Florida MD March/April 2022

MARCH/APRIL 2022 • COVERING THE I-4 CORRIDOR

Florida Vein Care & Cosmetic Center

EndoVenous Laser Treatment (EVLT) – A Minimally Invasive Option for Vein Disease

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ON THE COVER: Richard Bragg, MD, medical director for Florida Vein Care and Cosmetic Center in Lake Mary, Florida.

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WHEN SCOLIOSIS REQUIRES TREATMENT

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MORE CANNABIS DISPENSARIES = FEWER OPIOID DEATHS

COVERING THE I-4 CORRIDOR

 COVER STORY

Since 1999, EndoVenous Laser Treatment (EVLT) has become the therapy of choice for patients with painful and painless varicose veins. Now the standard of care and FDA approved, EVLT is minimally invasive, done in the doctor’s office in under an hour, requires no general anesthesia or stitches and provides immediate relief from symptoms. Patients return to normal activities right away. “Over the past 20 years, the demand for EVLT has skyrocketed 200 percent,” says Richard Bragg, M.D., medical director for Florida Vein Care and Cosmetic Center in Lake Mary, Florida. “The procedure has really directed patients away from stripping and ligation done in the hospital.”

According to the American College of Phlebology (ACP), more than 80 million Americans suffer from some form of venous disorders. Phlebology is the field of medicine that treats vein disease such as spider and varicose veins. Varicose veins occur when the one-way valves in the veins don’t function efficiently and the veins become visibly distended with blood. The condition can cause pain, heaviness and/or throbbing in the legs and are often a cosmetic embarrassment for the patient. Nearly 40% of women and 25% of men suffer from varicose veins. Heredity is the primary contributing factor for varicose veins. Other predisposing factors include multiple pregnancies, aging, leg injury and occupations that require standing for many hours. Spider veins are small, thread-like clusters of red, purple, and blue veins that are usually considered an aesthetic annoyance. They most commonly appear on the thighs, calves and ankles.

PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

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MARCH/APRIL 2022

DEPARTMENTS 2

FROM THE PUBLISHER

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DERMATOLOGY

8

PULMONARY

12

ORTHOPAEDIC UPDATE

14

PEDIATRICS

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MARKETING YOUR PRACTICE

FLORIDA MD - MARCH/APRIL 2022

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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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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: JJohn “Lucky” Meisenheimer, MD, Jason Malone, DO, Omar E. Beidas, MD, Mark A. Vollenweider, MD, MPH, Tabarak Qureshi, MD FCCP, 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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COVER STORY

Florida Vein Care and Cosmetic Center

EndoVenous Laser Treatment (EVLT) – A Minimally Invasive Option for Vein Disease

By Margaret M. Sloane, RN, BSN Since 1999, EndoVenous Laser Treatment (EVLT) has become the therapy of choice for patients with painful and painless varicose veins. Now the standard of care and FDA approved, EVLT is minimally invasive, done in the doctor’s office in under an hour, requires no general anesthesia or stitches and provides immediate relief from symptoms. Patients return to normal activities right away. “Over the past 20 years, the demand for EVLT has skyrocketed 200 percent,” says Richard Bragg, M.D., medical director for Florida Vein Care and Cosmetic Center in Lake Mary, Florida. “The procedure has really directed patients away from stripping and ligation done in the hospital.”

According to the American College of Phlebology (ACP), more than 80 million Americans suffer from some form of venous disorders. Phlebology is the field of medicine that treats vein dis-

ease such as spider and varicose veins. Varicose veins occur when the one-way valves in the veins don’t function efficiently and the veins become visibly distended with blood. The condition can cause pain, heaviness and/or throbbing in the legs and are often a cosmetic embarrassment for the patient. Nearly 40% of women and 25% of men suffer from varicose veins. Heredity is the primary contributing factor for varicose veins. Other predisposing factors include multiple pregnancies, aging, leg injury and occupations that require standing for many hours. Spider veins are small, thread-like clusters of red, purple, and blue veins that are usually considered an aesthetic annoyance. They most commonly appear on the thighs, calves and ankles.

Patients who come to Florida Vein Care and Cosmetic Center seeking relief for these conditions can expect Dr. Bragg and his

PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

This varicosed anterior thigh circumflex vein was removed by a phlebectomy using 3mm incisions. No sutures are required, and the after picture is 4 weeks post-op.

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COVER STORY

Immediately after endovenous laser treatment, patients walk for 20 minutes in the office on the treadmill. A post-op dressing and compression stocking is worn for 1 week after treatment.

healthcare team to provide a comprehensive three step process that includes consultation, treatment and follow up.

Consultation - The consultation phase consists of a careful medical history evaluation followed by an initial vascular exam known as a “Doppler,” a quick, painless, non-invasive test to determine the extent of the problem. During this time, Dr. Bragg enjoys getting to know his patients, answering questions, and exploring the many options available to treat varicose and spider veins. In some cases, additional diagnostic testing using an ultrasound is required in order to create an effective treatment plan. These painless diagnostics are conveniently performed by Dr. Bragg in the office.

Treatment - Florida Vein Care and Cosmetic Center offers a personalized treatment plan that includes safe, effective, state of the art procedures for varicose and spider veins. Dr. Bragg notes that he has seen an annual growth of 40% in his office over the past seven years and EVLT accounts for a large portion of that growth. EVLT has the same if not better results than vein stripping and ligation, once considered the gold standard for treatment of varicose veins. Clinical studies indicate that EVLT has a 95% initial success rate and excellent long term outcomes. Candidates for EVLT usually fall between the ages of 20-60 and must be able to walk immediately following the procedure.

Typically, EVLT uses laser energy to target a faulty valve at the saphenous femoral junction located in the groin. The saphenous vein runs up the inside of the leg. A small laser fiber is inserted at the knee and advanced up the leg to the groin using non-invasive ultrasound for accurate placement. As the laser is withdrawn, pulses of light cause the vein to heat up, collapse, and then seal itself. During the process, local anesthetic is delivered inside the vein so the patient doesn’t feel the heat. When the laser tip is withdrawn back to the knee, the

PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

All patients are screened with the bi-directional doppler to rule out saphenopopliteal junction incompetence prior to any treatment.

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COVER STORY

PR OO Bragg. A Sigvaris support stocking should be worn for one week

one week the treatment patientsmust mustschedule schedule aa brief brief follow-up after after the treatment andand patients follow-up appointment to evaluate the results of the procedure. appointment to evaluate the results of the procedure.

4 | REPRINTED FROM CENTRAL FLORIDA M.D. NEWS MAY 2007 6 FLORIDA MD - MARCH/APRIL 2022

407.805.8989 Office • 407.805.8833 Fax www.floridaveincare.com www.floridaveincare.com

PHOTO BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

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PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

and then seal itself. During the process, local anesthetic is delivered inside the vein so physician removes fromWhen the vein, the patient doesn’t feel theit heat. the applies a of tapeback along a Sigvaris lasersmall tip ispiece withdrawn to with the knee, the graduated compression stocking.

The patient physician removes it from the vein, applies is asked to get upofand in the office to a small piece tapebegin alongwalking with a Sigvaris check for bleeding and reduce the risk of clots. graduated compression stocking. The patient “With EVLT, there is reduced risk of anestheis asked to get up and begin walking in the sia, reduced risk of infection, reduced office to check for bleeding and reduce the cost and a oneEVLT, inch scar as isisthe case with vein risk instead of clots.of“With there reduced stripping, the patient has a tiny three risk of anesthesia, reduced risk of infection, millimeter incision the knee,” remarks Dr. Bragg. reduced cost and at instead of a one inch scar they canthefinally wear skirts as is “Female the case patients with veinsay stripping, patient without being embarrassed and teachers are has a tiny three millimeter incision at the amazed that their legs feel fine at the end of a knee,” remarks Dr. Bragg. “Female patients long day on their feet.”

Dr. Bragg has done over say they can finally wear skirts without being 1500 EVLT procedures since 2002. embarrassed and teachers are amazed that After procedure, Dr. their legs feelnearly fine at every the endEVLT of a long day Bragg points out that it is usually necessary on their feet.” Dr. Bragg has done over 1500 Dr. Bragg sees all patients in consultation. He explains venous anatomy, pathology and to have an ambulatory phlebectomy on the treatment options.

EVLT procedures since 2002. remaining bulging veins.

“This is a micro-surThe consultation, the in-office diagnostic ultrasound, and the After nearly every EVLT procedure, Dr. gical removal of surface varicose veins using aBragg smallsees veinallhook,” Dr. patients in consultation.

He explains venous anatomy, pathology and procedure is covered by most insurance plans.

Bragg points out that it is usually necessary says Dr. Bragg. “Phlebectomy is also done in the options. center under treatment to have an ambulatory phlebectomy on the Laser treatment holds great promise in the field of phlebology, local anesthesia through tiny incisions that require no stitches remaining bulging veins. “This is a microsays Dr. Bragg. Today, EVLT can be used on the greater sapheand leave nearly imperceptible scars.” After the vein has been reThe consultation, the in-officevein diagnostic ultrasound, and the procedure surgical removal of surface varicose veins nous vein, short saphenous and perforator veins.

These three moved, a bandage and stocking is worn for one week. is covered by most using a small vein hook,” says Dr. Bragg. “Phlebectomy is also done in the areas cause mostinsurance varicose plans. veins seen in the legs.

Sclerotherapy is used in treatment for spider and varicose veins Laser treatment holds great promise in theBachelor’s field of phlebology, says center under local anesthesia through tiny incisions that require no stitches Dr. Bragg received his pre-medical degree from and has been developed and refined by experts since its introducDr.Louisiana Bragg. Today, EVLT can be used on the greater saphenous vein, and leave nearly imperceptible scars.” After the vein has been removed, a State University in 1988. After graduating from Louition in Europe nearly a century ago. It’s become popular in the short saphenous vein and perforator veins. These threehe areas most bandage and stocking is worn for one week. siana State University Medical School in 1992, wascause selected United States in the past decade. Once diseased veins are identivaricose veins seen in the legs. at Florida Hospital’s Family Practice Sclerotherapy is used in treatment for spider and varicose veins and for internship and residency fied, a sterile solution of “sclerosing” material is injected microDr. Braggprogram. received his Bachelor’s degree from Louisiana has been developed and refined by experts since its introduction in Europe residency Hepre-medical remains board certified in family practice scopically into the vein altering the walls of the vein causing them State University inBragg 1988.isAfter graduatingwith fromthe Louisiana State University nearly a century ago. It’s become popular in the United States in the past medicine.

Dr. an instructor National Procedures to collapse and dissolve. The simple procedure is safe and virtually Medical School 1992, physicians he was selected internship residency decade. Once diseased veins are identified, a sterile solution of “sclerosing” Institute and inteaches whofor come to himand from aroundat painless and essentially improves the circulation in the legs by diFlorida Hospital’s Family Practice residency program.

He remains material is injected microscopically into the vein altering the walls of the the world injection sclerotherapy, ambulatory phlebectomy board and verting blood flow into nearby healthy veins. Treatment does not certified intechniques. family practice medicine.

Dr. Bragg isAmerican an instructor with of the vein causing them to collapse and dissolve. The simple procedure is safe EVLT An active member of the College prevent the development of more spider veins, but the removal National Procedures Institute and teaches physicians who come to him and virtually painless and essentially improves the circulation in the legs Phlebology, he volunteers many hours a year to educate physiof existing spider veins can dramatically improve the appearance from around the and worldlayinjection sclerotherapy, by diverting blood flow into nearby healthy veins. Treatment does not cians, nurses, people about venous ambulatory disease. phlebectomy of the area. Often, two or more sessions are required to achieve and EVLT techniques.

An active member of the American prevent the development of more spider veins, but the removal of existing Dr. Bragg’s main office is located at 580 Rinehart RoadCollege in Lakeof optimum results.

Phlebology, he volunteers many hours a year to educate physicians, nurses, spider veins can dramatically improve the appearance of the area. Often, Mary, Florida.

His other locations are at 7009 Dr. Phillips Blvd.

For tiny veins on the legs, face or chest, a laser procedure usand lay people about venous disease. two or more sessions are required to achieve optimum results. and at 10902 Dylan Loren Circle in Orlando. ing a high energy light source can be used. The laser light passes Dr. Bragg’s main office is located at 580 Rinehart Road in Lake Mary, For tiny veins on the legs, face or chest, a laser procedure using a high For more information log on to www.floridaveincare.com through the skin without damaging it and selectively targets the Florida. His second office is at 7009 Dr. Phillips Blvd. in Orlando. For energy light source can be used. The laser light passes through the skin or to schedule an appointment, call the office at (407) 805spider vein. The light is absorbed by the red blood cells in the information log on to www.floridaveincare.com or to schedule an without damaging it and selectively targets the spider vein. The light is 8989.  vein. The resulting heat causes the walls of the vein to seal to- more appointment, call the office at (407) 805-8989. absorbed by the red blood cells in the vein.

The resulting heat causes the gether and disappear. Laser light treatment may be used in conwallsjunction of the vein to seal together and disappear. Laser light treatment may with sclerotherapy. be used in conjunction with sclerotherapy.

When considering treatment options, Dr. Bragg ensures that When considering treatment options, Dr. Bragg ensures that his his patients understand the risk and limitations and that patients patients the risk and limitations and that patients have realistic haveunderstand realistic expectations for outcomes. expectations for outcomes.

Follow-Up - Follow-up is an important component of Dr. Follow-Up - Follow-up is an important component of Dr. Bragg’s Bragg’s care management plan. Unlike with vein stripping and 580580 Rinehart LakeDr.Mary, 32746 RinehartRoad, Road, Suite 110 •7009 PhillipsFL Blvd., care management plan. Unlike with vein stripping and ligation which ligation which requires bed rest and limited activities, patients 110 Suite 240 requires rest andnon-surgical limited activities, patients are whoexpected undergo non-surgical 7009 Dr.Suite Phillips Blvd., Suite 240 • Orlando, FL 32819 whobed undergo treatments to get movLake Mary, FL 32746 Orlando, FL 32819 treatments are expected to get moving.

“We want our patients to walk 30ing. “We want our patients to walk 30-40 minutes a day for up to 10902 DylanOffice Loren Circle • Orlando, FL Office 32825 407.805.8989 407.352.9877 40 minutes a day for to threeresolution weeks to facilitate resolution of thesays treated three weeks to up facilitate of the treated veins,” Dr. 407.805.8833 Fax 407.351.0755 Fax veins,” says Dr. Bragg. A Sigvaris support stocking should be worn for

DERMATOLOGY

Not All Basal Cell Carcinomas Are Created Equal

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. 

Nodular basal cell carcinoma.

FLORIDA MD - MARCH/APRIL 2022

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PHOTO: JOHN MEISENHEIMER, VII PHOTO: JOHN MEISENHEIMER, VII

Occasionally a patient will tell me their “doctor friend” recommended that they don’t need treatment for a basal cell carcinoma because it will never hurt you. “Doc, he said it’s only a basal cell carcinoma.” Dermatologists fully recognize this as a genuinely cringe-worthy statement. You don’t need to see too many people missing various parts of their facial anatomy to know this advice is blatantly wrong. Even in this modern time of medical miracles, people still die from neglected basal cell carcinomas. When pressed for the name of their “doctor friend,” it usually comes up as I don’t remember their name, or it ends up being “Doctor Google.”

It is true a superficial basal cell carcinoma on the torso probably would take years and years for it to cause any sort of significant morbidity to a patient. But, on the other hand, even a small basal cell on the torso will continue to grow if left untreated slowly. What might have been a simple, inexpensive procedure now, a decade later, has turned into a monster of aggravation, discomfort, and cost.

Although metastatic disease risk is low with basal cell carcinomas, it is certainly not zero. Several people die each year from basal cell carcinoma. Even more, patients can have disfiguring bouts with cancer losing various parts of anatomy such as nose, ears, eyes, etc. What a lot of patients and even some physicians are not aware of is that not all basal cell carcinomas are created equal. There are several different histologic growth patterns. These Infiltrative Basal Cell carcinoma of the forehead. varying histologic types can each behave differently and require different treatment plans.

As mentioned before, a superficial basal cell carcinoma is probably not going to cause a great deal of physical damage unless neglected for long periods. There are other types of basal cell carcinomas; morpheaform and sclerosing basal cell carcinomas with infiltrating growth patterns. These cancers left untreated can cause a significant amount of morbidity in shorter periods measured in months, not years. Aggressive basal cell cancers can also become neurotropic, meaning that they “wrap” around a nerve and can track down its length. Neurotropism can be particularly dangerous, especially if Pathology of an infiltrative this is on the face and affecting a nerve that happens to pass through basal cell carcinoma. a foramen into the brain. Clearly, not a good scenario.

Superficial Multifocal BCC. Basal cell carcinomas, limited to the skin, tend to be very amenable to treatment in a variety of different ways. Even as a Mohs surgeon I can think of at least half a dozen different ways that I have treated basal cell carcinomas. Not all basal cell carcinomas need Mohs surgery. Each case of basal cell carcinoma should be evaluated individually and in consideration as to the best method of treatment based on its histologic growth pattern, location, and physical condition of the patient.

The great news about basal cell carcinoma, even though it is the most common type of skin cancer and millions are treated each year, only a tiny percentage of these end up causing death in paNeurotropic basal cell carcinoma. tients. When someone says I would much rather have a basal cell Sclerosing basal cell carcinoma. carcinoma than a melanoma, there is a caveat; if you die from a basal cell carcinoma, you are just as dead as if you were to die from melanoma. Happily, most of the time, with early diagnosis and treatment, you don’t have to die from either. Basal cell carcinoma is called cancer for a reason. Give it its respect that it is due, or otherwise, you may regret saying, “oh, you don’t have to worry about it, it’s only a basal cell carcinoma.”

PHOTO: JOHN MEISENHEIMER, VII

PHOTO: JOHN MEISENHEIMER, VII

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

PULMONARY

What’s New in the Treatment of Mild Obstructive Sleep Apnea and Primary Snoring?

By Tabarak Qureshi, MD FCCP

THE FIRST FDA-AUTHORIZED DAYTIME THERAPY: EXCITEOSA® SNORE... SNORE… SNORE… We all know of someone who snores, but when people are informed of their snoring, the typical response is denial and disbelief. The truth of the matter is that snoring is extremely common, but most people don’t understand why it happens.

Snoring is generated when the upper airway/pharyngeal muscles relax and as air flows through a relaxed posterior airway. In some people with a crowded posterior airway, these sounds and vibrations result in mild obstructive sleep apnea (OSA), which is identified by having an AHI (apnea hypopnea index) between 5-15 events/hour. The repeated airway obstructions result in sleep disruption, blood pressure swings, and recurrent nocturnal asphyxia and hypoxia resulting in increased sympathetic nervous system activation during sleep. Traditionally, there has not been any significant treatment modality for primary snoring. Mild OSA has been treated primarily with auto-CPAP/PAP or mandibular advancement devices along with lifestyle modifications (weight loss, drinking, and smoking cessation). The most notable change is noted in the upper airway and the genioglossus muscle.

This collapsibility is higher in mild OSA compared to primary snoring. In non-snorers, there is an ability to prevent collapsibility of the upper airway and have functional mechanisms that prevent collapse.

The genioglossus is considered the largest muscle of the airway and the most important dilatory muscles during sleep onset. With sleep onset, there is rapid reduction in pharyngeal and tongue muscle contractility. Over time the respiratory stimulus and genioglossus activity progressively increase during stable non-REM sleep. However, a notable number of individuals fail to effectively increase genioglossus activity or achieve inadequate tongue muscle activation to overcome the obstruction prior to the arousal. Therefore, there is a failure of the tongue muscles to generate an appropriate protective response from a neural drive or responsiveness perspective.

The first proof of concept of daytime stimulation of the tongue was presented by Wiltfang in 1999 (28). He demonstrated using a TENS like stimulation during daytime for two weeks resulted in a significantly reduced respiratory disturbance index (RDI), from 13.2/hour to 3.9/hour, oxygen desaturation index improved as did minimum oxygen saturation from 75% to 88%. In another prospective placebo controlled randomized trial of daytime tongue stimulation vs TENS type stimulation the number of snoring epochs decreased significantly (from 63.9±23.1 epochs per hour to 47.5±31.2; P<.05).

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EXCITEOSA®: The eXciteOSA device targets the intrinsic and extrinsic pharyngeal and tongue muscles by delivering neuromuscular electrical stimulation to the tongue with the purpose of increasing muscle responsiveness and preventing excessive relaxation. The device has three components: 1. Washable flexible electrode mouthpiece with an electrode array that fits onto the tongue.

2. Rechargeable control unit that attaches to the mouthpiece via a USB connection.

3. Smartphone App that manages the functions of the device.

The mouthpiece is placed in the mouth, on the tongue with the two electrodes located above and two below the tongue.

Therapy consists of a series of pulse bursts with rest periods for 20 minutes during the wakefulness state for a period of 6 weeks.

With daily use of eXciteOSA, the tongue muscle function improves to prevent the backward collapse of the tongue and hence obstruction of the airway.

CLINICAL TRIALS DATA The original trial was a prospective multicenter trial of individuals with primary snoring or mild OSA. Snoring was assessed by the bed partner reporting on a visual analog scale-VAS (ranging from 1-10, 10=unbearable snoring). The snorers sleep quality was recording using the Pittsburgh Sleep Quality Index (PSQI) pretreatment (2 weeks before start of therapy), during treatment phase (6 weeks recorded in last two weeks) and post treatment (2 weeks after stopping therapy). 27 individuals completed the trial (8 women and 19 men), average age 44 years (age range 2568 years), BMI 29.7 (range 20.7-35) and AHI 9 (range 2.5-15).

PULMONARY Eight primary snorers and 19 had mild OSA. Results revealed bed partner reported snoring reduced by 52% (p<0.001) with over 80% declaring a reduction of >40%. The change remained statically significant for primary snores and mild OSA patients (VAS reduction 6.6 to 3.6 p<0,001).

Another multicenter clinical trial was undertaken at London University hospital along with other sites in Europe. The objective was to validate the objective measures and assess the reproducibility of the subjective outcomes of the previous study. This was cohort of mild OSA (HST using WatchPAT®) and primary snorers. Two consecutive night studies were conducted before and after the 6-week period. This was supplemented with partner VAS, Epworth Sleepiness Scale (ESS), and PSQI. 125 patients were recruited and 115 (50 primary snorers and 65 mild OSA patients) completed the trial. The average age was 46 (range 24-79 years), 73 males and 42 females, average BMI 27 (range 20-34). For the study population the mean objective percentage of sleep time snoring at >40dB, reduced significantly by 41% (p<0.001). 90% of the participants recorded an objective reduction in their snoring. Clinically significant reduction in snoring time was also reported at snoring intensities of 45dB and 50dB with an improvement of 52% (p<0.001) and 54% (p<0.001) respectively. In mild OSA, 79% showed an average reduction in AHI of 52% (p<0.001) and the post therapy AHI normalized to 4.95. Statistically significant improvements were noted in ESS and PSQI scores as well (p<0.001).

Oral pooling of saliva was most common side effect, with a

been known to activate motor units that are not otherwise activated. NMES has been shown to change the myofibrillar protein expression to induce a phenotype shift from fatigue prone to fatigue resistant with the strengthening of the cytoskeleton. NMES has been shown to result in metabolic shift from glycolytic to oxidative profiles, increasing intracellular defense against harmful oxygen species, reverse the degeneration of pre and postsynaptic tongue neural morphology associated with ageing and a shift to a higher contractile tension. eXciteOSA offers a simple and effective method of addressing the above-mentioned process and has been shown to benefit individuals with primary snoring and mild OSA. eXciteOSA provides a targeted retraining tool to stimulate the tongue and the biggest dilatory muscle of the airway – the genioglossus muscle.

The clinical trial demonstrated significant reductions in all of the relevant objective measures, 90% of the study population showed reduction in snoring, 79% of the mild OSA population showed a 50% reduction in AHI and ODI resulting in reduction in ESS and PSQI. Tongue muscle training using eXciteOSA has proven to be effective in reducing multiple indices associated with sleep disordered breathing. Additional studies have been published and accepted for publication and currently underway. eXciteOSA provides a “no nighttime wearable” safe option of therapy for patients and overcomes many of the risks and disadvantages of currently available treatment options.

For more information on this novel daytime therapy option, visit the eXciteOSA website: eXciteOSA.com or email info@signifiermedical.com.

Bibliography available upon request.

Tabarak Qureshi, MD FCCP practices at Central Florida Pulmonary Group. He is Chairman-Division of Pulmonary Medicine at AdventHealth, Director of ICU AdventHealth Altamonte Springs and Director of the Sleep Lab at Central Florida Pulmonary Group. 

small percentage reported tongue discomfort, tooth discomfort, filling sensitivity, gagging, metallic taste and jaw tightness. Prevalence of these symptoms reduced in the six weeks of therapy.

DISCUSSION AND CONCLUSION Daytime neuromuscular electrical stimulation (NMES) therapy for correction of nighttime airway obstruction is a novel, innovative and probably unconventional therapeutic strategy. The ability to control nighttime sleep disordered breathing without wearing a nighttime device makes this an attractive treatment modality. NMES involves the application of electrical current to induce muscle contractions and has been shown to activate the muscle to a greater extent than voluntary muscle actions. It has

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9

When Scoliosis Requires Treatment

By José Herrera-Soto, MD

ABOUT SCOLIOSIS Scoliosis affects an estimated 2 to 3 percent of the U.S. population, both children and adults. But because scoliosis tends to progress as a child develops, this abnormal C- or S-shaped curvature of the spine is most often diagnosed in children between the ages of 10 and 15. A vast majority of cases, up to 85 percent, are classified as idiopathic, and less than 10 percent of children experience any back pain or other symptoms. In fact, it is often during a routine physical exam or Adam’s forward bend test that a spine curvature or rib hump is discovered.

Scoliosis tends to be passed down to children through genetics.

Although parents may not have had scoliosis as a child, it may have occurred in other family members or gone undiagnosed.

Whether a documented family history of scoliosis is present or not, a child having scoliosis is no one’s fault; scoliosis itself is not preventable.

The biggest risk associated with scoliosis is significant curve progression over time. Referral to a specialist ensures a full orthopedic and neurologic evaluation as well as diagnostic imaging tests to determine the exact location and extent of the curvature in order to develop a customized treatment plan. With about 1,800 visits in 2019, the Scoliosis Center at Orlando Health Arnold Palmer Hospital for Children cares for children across the full scoliosis spectrum, including idiopathic, congenital, neuromuscular and syndromic scoliosis from early-onset to adolescent diagnoses.

TREATMENT THERAPIES Only a small percentage of children with scoliosis — about 30 percent — will require treatment such as physical therapy or bracing, and an even smaller number — about 10 percent — will require surgery. The standard determination of severity in scoliosis is measured in terms of the degree of curvature. Spinal curves measuring less than 25 degrees generally do not require treatment.

For these patients, ongoing observation with regular checkups is recommended to watch for any progression of disease.

If the curvature increases over time or presents at 25-45 degrees, nonsurgical treatment encompassing physical therapy, bracing and casting options — used individually or in combination — can help to slow or prevent disease progression. A growing child often can overcome minor spinal curvatures and deformities through these less invasive options; for major deformities, these treatments provide ongoing care until the child is older and showing signs of skeletal maturity needed for surgery.

The Schroth Method is a relatively new type of physical therapy, which began in Germany and has continued to develop as its use around the world has grown. The Scoliosis Center at Orlando Health Arnold Palmer is one of the few centers in Florida that has a specialist trained in this unique treatment option. The Schroth Method focuses on customized posture, positioning and 10 FLORIDA MD - MARCH/APRIL 2022

breathing exercises, as well as on activities of daily living and self-image, and is often used in conjunction with bracing. Some studies have found that this treatment option has a positive effect on a child’s sense of well-being and perception of curve improvement, leading to better patient engagement and thus, better outcomes.

If a patient is still skeletally immature but has progressed to a point that physical therapy and/or bracing is ineffective, growing rods become the next course of treatment. Conventional growing rods are surgically inserted either in the lumbar spine or ribs, based on the type of instrumentation used, or a hybrid. Proven to be a very effective treatment, the growing rods are surgically changed or lengthened approximately every six months. Some patients may benefit from a system called MAGEC® (MAGnetic Expansion Control), which utilizes innovative magnet technology. Once the adjustable growing rods are surgically inserted, the lengthening can be done as an in-office procedure using an external remote controller to operate a motor inside the rods to lengthen them as needed. This method can be especially effective for debilitated or very weak patients, reducing the potential risks of repetitive surgeries and anesthesia.

When the angle of curvature is more than 50 degrees, surgical correction is recommended, as studies have shown that deformity over 50 degrees will continue progressing. Spinal fusion is a major surgery, performed to correct the curvature permanently.

Hooks or screws are placed into the vertebral column, which are then attached to rods that are maneuvered and rotated to straighten the spine. Orlando Health Arnold Palmer performs about 150 spinal surgeries annually, providing patients with a more functional spine and symptom relief. A multidisciplinary approach includes a dedicated team of specialists utilizing advanced technology, such as spinal cord monitoring and fluoroscopy to aid in the placement of instruments and devices. Ongoing follow up with the patient occurs every six months or yearly, depending on the age and the degree of severity.

A NEW SURGICAL TREND Orlando Health Arnold Palmer also will soon be participating in a study of a new procedure known as vertebral body tethering (VBT), becoming one of only a handful of centers in Florida to offer this surgical option. Guided by very specific indications of bone maturity and curvature, this procedure harnesses the growth potential on the concavity of the spine while holding or limiting the growth on the convexity. So, as the concavity catches up with convexity in height, the spine straightens. With access through a minimal incision in the chest, anchors are placed on the front of the spine, anchoring the growth centers. But because it is not a fusion, the spine can continue to move in a

normal range of motion. This allows for correction of the spine slowly, as the spine matures and grows.

THE TAKEAWAY When a child is diagnosed with scoliosis, many parents are understandably worried about how this diagnosis will affect their child’s health and future. This type of response is normal. Referral to a specialty center to learn more about the science behind scoliosis and its treatments can help patients and families feel less anxious. While scoliosis requires monitoring with a specialist and — depending on its severity — possible life adjustments, it is a manageable condition with positive outcomes, with kids able to compete in sports, play with their friends and enjoy a fun, carefree childhood.

José Herrera-Soto, MD, is a pediatric orthopedic surgeon at Orlando Health Arnold Palmer Hospital for Children. Board certified in orthopedic surgery, Dr. Herrera-Soto sees patients at the Orlando Health Arnold Palmer Center for Orthopedics.

He specializes in treating congenital, neuromuscular and idiopathic scoliosis, kyphosis and other spinal conditions as well as hip preservation surgery and hip conditions. He is also involved in the design and development of implants for the correction of spinal deformities. Dr. Herrera-Soto earned his medical education from the University of Puerto Rico School of Medicine.

He also completed his residency at the University of Puerto Rico and a fellowship in pediatric orthopedic surgery at Cincinnati Children’s Hospital Medical Center. 

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FLORIDA MD - MARCH/APRIL 2022 11

ORTHOPAEDIC UPDATE

Targeted Muscle Reinnervation for Relief from Phantom Limb Pain

By Justin W. Zumsteg, MD At Orlando Health Jewett Orthopedic Institute, surgeons are successfully employing targeted muscle reinnervation (TMR) as an advanced microsurgical pain-management option for amputees and others facing limb loss.

More than 80 percent of the 2 million Americans living with limb loss suffer chronic pain following amputation, known as phantom limb pain (PLP). This painful sensation feels like it is coming from the limb that is no longer there. PLP occurs when nerves cut during amputation try to regenerate. In the absence of a clear path for regrowth, a clump of scarred nerve endings, or neuroma, forms. This changes the electrical signals that are being conducted to the brain, and sometimes there is spontaneous activity in that nerve that automatically generates signals to the brain that can be interpreted as pain.

PLP can be very frustrating and even disabling for some patients because, not only are they dealing with the psychological and emotional loss of a limb, they also are still experiencing pain from something that is no longer there. Often, PLP also can interfere with wearing a prosthesis, which then in turn can impede with recovering function and getting back to normal life. So, having a more effective way to treat or prevent that neuropathic pain from even developing is vital to helping patients get back to doing the activities they want to do and improve their quality of life.

Traditionally, surgeons have performed traction neurectomy during amputation as a surgical treatment for symptomatic neuroma. TMR uses microsurgery to reroute severed nerves from an amputated limb to new targets in muscles that remain but are no longer needed after amputation. This reconnection reduces the chance of a neuroma forming and PLP developing. By giving the cut nerve somewhere to go and something to do, it is able to regenerate in a more organized fashion, which prevents the signaling of pain to the brain.

For instance, if someone has a below-knee amputation, all the muscles that control the ankle and the toes are no longer necessary. So, we take a cut nerve and plug it into a nerve going into one of the muscles that controls the ankle or foot. That cut nerve, rather than forming a big, disorganized neuroma, now seems to have some organized growth as it grows into the motor nerve and then into the denervated muscle. And by having the organized growth of the nerve that’s been cut, it seems to both prevent the neuroma from forming and the phantom limb pain from developing.

This novel procedure can be performed at the time of amputation to prevent PLP or it can be done post-amputation to treat chronic pain that already has developed. When performed as part of an amputation, a microsurgeon joins the team, working in tandem to reconnect the severed nerves during one procedure.

For patients with prior upper- or lower-extremity amputation 12 FLORIDA MD - MARCH/APRIL 2022

who experience phantom limb pain or residual nerve pain, TMR can be considered even several years after surgery.

Probably more than 85 percent of the TMR cases I currently perform are for patients who have already had an amputation and have PLP, and I have done the surgery in patients as far as 10 years out from their amputation. And all patients have had improvement in or elimination of their neuropathic pain.

TMR also can improve an amputee’s control of an advanced prosthesis called an advanced myoelectric prosthesis. By reassigning the nerves that once controlled the arm and hand, or leg and foot, to a different muscle, TMR surgery provides more opportunity for the prosthesis to detect the electrical signal generated by the patient’s nerves, which can then be transmitted to a myoelectric prosthesis via Bluetooth, providing improved control of their prosthesis with resulting increased movements and more intuitive handling.

More than 185,000 amputations are performed annually in the United States as treatment for an injury, disease or infection.

Complications from vascular disease, diabetes and peripheral arterial disease (PAD) account for more than half of all surgical amputations. Another 45 percent are due to trauma. Candidates for TMR include patients suffering from chronic nerve pain post amputation or those slated for amputation who want to prevent phantom limb pain. Orlando Health surgeons, highly skilled in trauma surgery as well as both upper- and lower-extremity limb loss, are offering TMR as part of a multidisciplinary care program to help amputees regain control of their lives.

Justin W. Zumsteg, MD, is a board-certified orthopedic surgeon with the Orlando Health Jewett Orthopedic Institute, where he specializes in upper-extremity surgery. After earning his medical degree from the University of Michigan Medical School, Dr. Zumsteg completed an orthopedic surgery residency at Vanderbilt University Medical Center, followed by a fellowship in hand, upper-extremity and microvascular surgery at the renowned Indiana Hand to Shoulder Center. His work has been published in multiple peer-reviewed journals and presented at several regional and national meetings. With a particular interest in peripheral nerve surgery, Dr. Zumsteg is committed to staying current in new technologies and techniques, and to date has performed more than 30 targeted muscle reinnervation surgeries. 

More Cannabis Dispensaries = Fewer Opioid Deaths By Michael Patterson, NHA, OTR/L, CEAS A recent study in the British Medical Association Journal (BMJ) shows increasing access to marijuana dispensaries is associated with a significant reduction in opioid-related deaths. (link below) Association between county level cannabis dispensary counts and opioid related mortality rates in the United States: panel data study | The BMJ Researchers reviewed opioid mortality and cannabis dispensary prevalence in 23 US states from 2014 to 2018. The study concluded that counties where the number of legal marijuana shops increased from one to two experienced a 17 percent reduction in opioid-related fatalities. Increasing the dispensary count from two to three was linked to an additional 8.5 percent decrease in opioid deaths.

is expected to exceed 70,000 people, and opiates are legal via prescription.

Society is tired of being lied to about cannabis. They are tired of politicians protecting the illegality of cannabis, and pharmaceutical companies pitching drugs that have side effects worse than the disease or condition for treatment. As more and more facts and data emerge on the positive benefits to society and health that cannabis offers, the legalization trend of cannabis will continue in the USA and globally.

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+

“Higher medical and recreational storefront dispensary counts are associated with reduced opioid related death rates, particularly deaths associated with synthetic opioids such as fentanyl.” Per the study, it’s a finding that “holds for both medical and recreational dispensaries.”

years experience in: Cannabis-Hemp investment, Law,

“While the associations documented cannot be assumed to be causal, they suggest a potential association between increased prevalence of medical and recreational cannabis dispensaries and reduced opioid related mortality rates,” the researchers wrote.

“This study highlights the importance of considering the complex supply side of related drug markets and how this shapes opioid use and misuse.”

subject matter expert in the Global Cannabis and Hemp

“Our findings suggest that increasing availability of legal cannabis (modeled through the presence of medical and recreational dispensary operations) is associated with a decrease in deaths associated with the T40.4 class of opioids, which include the highly potent synthetic opioid fentanyl. This finding is especially important because fentanyl related deaths have become the most common opioid related cause of death.”

ANALYSIS This study is one of many that continues to demonstrate that cannabis is a benefit to society not a detriment. Most states that have legal medical cannabis programs allow use of cannabis as a substitute for the use of opiates.

Opiate addiction and deaths in the USA have destroyed countless lives, families, and communities. The lies regarding the safety of opiate use by Pharmaceutical companies are now coming out in litigation across the country by US States demanding restitution from the many effects of the opioid plague.

There has never been a single recorded death in human history associated with the use of cannabis, and it is still illegal based on US federal law. Meanwhile, the opiate death toll for 2020

Regulation, Compliance, Operations, & Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, & Healthcare Analytics. He is a 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 - MARCH/APRIL 2022 13

PEDIATRICS

Pediatric Limb Length Discrepancies By: Jason Malone, DO Q: HOW COMMON ARE PEDIATRIC LIMB LENGTH DISCREPANCIES?

done for leg difference of 2-5 cm.

A: Limb length discrepancies are very common. Up to twothirds of the population have a leg length difference of less than 2 cm (0.79 inch). Luckily, most people do not have symptoms unless the difference is greater than 2 cm.

Q: HOW LONG DOES THE PROCESS TAKE?

Q: WHAT ARE CAUSES OF LIMB LENGTH DISCREPANCIES?

A: Limb length discrepancies can be categorized into two major groups: congenital and acquired.

Congenital causes range from longitudinal deficiencies such as congenital short femurs, proximal focal femoral deficiencies, tibia hemimelia, fibular hemimelia, hemihypertrophy, unilateral clubfoot, skeletal dysplasias, and hip dysplasia. Acquired causes range from idiopathic, paralytic disorders such as cerebral palsy or polio and physeal injury from trauma, infection or tumors.

Q: WHAT TECHNIQUES DO YOU USE TO TREAT THESE PATIENTS?

A: Symptomatic leg length differences less than 1 cm can be treated with a shoe insert. A difference greater than 1 cm can be addressed with nonsurgical treatment with a customized shoe lift.

However, some patients or families do not wish to use a brace or shoe insert for the rest of their life.

Leg differences can be treated with a shortening procedure on the long side or a lengthening procedure on the short side or a combination of the two. Shortening procedures are smaller surgeries that are quicker to recover from but do lead shorter stature. Lengthening procedures are classically done for differences greater than 5 cm but many deformity specialists are now treating smaller leg length differences down to 3 cm in skeletally mature patients.

Q: HOW DOES THE PROCESS WORK?

A: Limb Lengthening procedures were first described by Dr. Gavriil Ilizarov in the 1950s. He called the process distraction osteogenesis. The process entails making a fracture in a bone, having the patient rest for 5-7 days, then distracting the bone ends about 1 mm per day. The bones can be distracted with an external fixator, a mechanical intramedullary nail, and soon with an expanding plate. We can safely lengthen a bone about 5 cm per treatment.

External fixators are better for legs that have an associated large deformity or children with open growth plates. Intramedullary nails are better tolerated but can only be placed in the femur of children at least 8 years old once the growth plate is closed in the tibia. The new lengthening plates that should be out in the summer of 2021 will allow us to lengthen internally even when a child has an open growth plate.

Shortening procedures usually are done in growing children.

This is done through a timed epiphysiodesis. I prefer to perform a percutaneous epiphysiodesis as it leaves small scars and is associated with less complications than other techniques. This is 14 FLORIDA MD - MARCH/APRIL 2022

A: Distraction osteogenesis is a long process. After the initial surgery we wait about a week for the bony callus or regenerate to develop. We then lengthen 1 mm per day. Then the bone takes about 8-12 weeks to fully heal the regenerate. A large 5 cm lengthening can take about 100 days to fully heal.

Q: WHAT ARE THE POTENTIAL COMPLICATIONS INVOLVED?

A: Distraction osteogenesis is safe if performed and monitored by an experienced physician, but it can also be associated with multitude problems. The bones, tendons, muscles and neurovascular structures are growing faster than the body is used to growing, so patients can develop joint contractures, joint dislocations and nerve stretch. We combat this by using nighttime braces, starting physical therapy right away, and stopping the lengthening process if any major complication develops. We can also lengthen more in the future. You also have your standard complication that can happen with any orthopedic procedure such as infection, nonunion, malunion or hardware failure.

An epiphysiodesis can also have its complications such as fracture at the physis, continue growth, angular deformity if the entire growth plate is not fully removed and continues to grow, not timing the surgery right and not achieving the desired correction or even overcorrecting and needing to perform an epiphysiodesis on the contralateral side.

Q: WHEN SHOULD A CHILD SEE A SPECIALIST TO ADDRESS THE DISCREPANCY?

A: A child should see a pediatric orthopedic surgeon specialized in deformity correction when they have a congenital leg length difference, when they have a physeal injury, or an idiopathic leg length difference that is symptomatic or over 2 cm.

Q: ARE YOU CURRENTLY DOING ANY RESEARCH IN THE FIELD?

A: I just finished a research paper looking through a nationwide database from 1997-2016 on trends in femoral lengthenings in pediatric patients. What we found are that most of the surgeries are performed in large urban teaching hospitals. The South does more lengthenings than any other region in the country. The surgery has become safer over the years with shorter hospital stays but like most of medicine, the costs have risen substantially through the years. We currently have the paper submit for publication.

Jason Malone, DO, is a fellowship-trained pediatric orthopedic surgeon at Nemours Children’s Health who specializes in treating limb length discrepancies and deformities. Call (407) 650-7715 for more information. 

PEDIATRICS

9-year-old boy had a physeal injury to his left tibia. He sustained a 5 cm leg length difference with a flexion deformity of his knee. He had a projected leg length difference 9.6 cm.

He was treated with a hexapod external fixator to lengthen his leg 5 cm and correct his deformity.

16-year-old boy with an idiopathic 4 cm leg length difference, right genu valgum and an osteochondroma.

He was treated with a lengthening intramedullary nail, acute correction of his knee dormity and excision of his osteochondroma.

The tibia is now healed right before the external fixator is removed.

The femur is now healed right before the nail was removed.

FLORIDA MD - MARCH/APRIL 2022 15

MARKETING YOUR PRACTICE

Is Your Online Reputation Costing You Patients?

By Sonda Eunus, MHA, CMPE What does your online reputation say about your practice? If you have a negative online reputation, you are missing out on new patients every day. Most medical practices now get the majority of their new patients through Google and other search engine queries, such as “Pediatrician in Orlando”. If your practice appears in these searches, the most common next step for a potential new patient would be to check out your reviews – what are other patients saying about your practice? It has been reported that 90% of consumers read online reviews before visiting a business and that online reviews influence 67% of purchasing decisions (Bright Local). For this reason, it is incredibly important to pay attention to the rating and reviews that your practice has on search engines, social media platforms, and local online business directories.

However, despite the importance of cultivating a positive online reputation, only 33% of businesses report actively collecting and asking for reviews (1). One great process to set in place at your practice is asking for patient reviews after each patient visit. It can be as simple as training your front office staff to ask each patient how their visit went while checking them out, and if they receive favorable feedback then they can ask the patient to please leave a review on Google or Facebook about their experience. If they receive negative feedback, this feedback should be taken very seriously, and management should be notified as soon as possible so that the issue can be mitigated before the patient decides to post a negative review.

Setting up an automated text or email campaign that asks each patient for their feedback after their appointment is also a great way to improve your online reputation as well as to correct any issues that may be occurring at your practice. When you receive feedback from patients, you are then able to prompt them to leave a public review on Facebook, Google, Yelp, Healthgrades, or other applicable review platforms. However, you must be aware that legally, you are not allowed to only direct people with favorable feedback to leave reviews, which is known as review-gating – so if you are implementing an automated system like this, just make sure that you are aware of this limitation. There are online reputation management platforms which allow you to customize the messages that people see when they leave negative feedback as opposed to positive feedback, but both of those messages must still offer the option to leave a public review. However, if you create your message in such a way as to communicate to the patient who may leave negative feedback that you are working hard on resolving the issue and that someone will be in touch shortly, that may prevent them from leaving a public negative review.

When you receive a public review on Google, Facebook, or other review sites, make sure that you respond to it – either by thanking them for a good review or by asking them to contact you to discuss how you can improve their experience. Do not argue or try to defend yourself online – try to speak about it with them privately, fix the issue, and ask them to remove the review if possible.

When you receive great reviews, make sure to cross-share them on 16 FLORIDA MD - MARCH/APRIL 2022

your various social media platforms. You should also create a “Reviews” page on your website and add all great reviews to this page. This instantly adds credibility to your website.

Finally, make sure that when you look over the feedback and reviews that you receive, you are paying attention to what the negative reviews are saying – this is a great opportunity to identify current process challenges and improve your patients’ experience at your practice. Need help managing your practice’s online reputation? Visit www.lms-plus.com to see how Leading Marketing Solutions can help.

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.



2022

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.

JANUARY –

Digestive Disorders Diabetes

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

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Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

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Allergies Pulmonary & Sleep Disorders

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

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FLORIDA MD - MARCH/APRIL 2022 17

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