Florida MD September 2021

SEPTEMBER 2021 • COVERING THE I-4 CORRIDOR

Nemours Children’s Health: Building Central Florida’s Premier Pediatric Orthopedic Program

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SEPTEMBER 2021 COVERING THE I-4 CORRIDOR

 COVER STORY

Nemours Children’s Health has been caring for children and adolescents for more than 80 years. But in Central Florida, our footprint and services have grown exponentially during the past decade.

PHOTO: PROVIDED BY NEMOURS

There’s been a tremendous amount of change over the years since we first started seeing patients in Central Florida in 1997. Not only did we open Nemours Children’s Hospital in 2012, but we made a conscientious effort to extend our services out into local communities throughout Central Florida.

Previously, we were in agreements with other children’s hospitals to provide our surgical and inpatient care but having our hospital in Lake Nona has really changed the dynamics of our department and the care we can provide.

ON THE COVER: Nemours Children’s pediatric orthopedic surgeons performed over 1,200 procedures last year for a wide range of common to complex conditions.

3 SMOKING CANNABIS DOES NOT HARM YOUR LUNGS LIKE SMOKING TOBACCO

PHOTO: PROVIDED BY NEMOURS

16 UNDERSTANDING AUTISM

DEPARTMENTS 2

FROM THE PUBLISHER

8 PULMONARY 10 PHARMACY UPDATE 12 MARKETING YOUR PRACTICE 13 13 PEDIATRICS 15 DERMATOLOGY

FLORIDA MD - SEPTEMBER 2021

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FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. I can only imagine the emotional and physical trauma that a woman goes through when she has a mastectomy. The procedure affects not only her body, but her mind and her self-esteem. Now add in the inability to not be able to reconstruct her breasts and give that part of her life back, because she’s uninsured or under insured, and it becomes an unthinkable crushing blow. Fortunately there is My Hope Chest to help women who are unable to afford reconstructive surgery. 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

MY HOPE CHEST — Making Women Whole Again In 2010, more than 22,000 uninsured women lost their breasts to cancer and were left disfigured, deformed and feeling “less than whole.” How many years has this figure been growing?

Many organizations raise funds for research, education and “awareness” of breast cancer. Most have no idea there lies a huge gap in assistance for delayed reconstruction and co-pays for survivors wanting this surgery.

My Hope Chest is the ONLY national 501c3 non-profit organization focused on funding breast reconstruction for the uninsured and under insured survivors. Our services “pick up” where other breast cancer organizations leave off… providing the “final step in breast cancer treatment. ” My Hope Chest is about addressing the needs of survivors now. Through wonderful surgeon partnerships we are able to transform the lives of breast cancer survivors who otherwise have no hope of reconstruction.

We hope to hear from you to learn how we can work together to eliminate our wait list and take action to help every woman who desires reconstruction after mastectomy and feel restored in body, mind and spirit.

Wish List • Surgeons to create awareness for My Hope Chest and to identify new clients • Doctors of Distinction- Surgeon partners nationwide to join our program.

• Corporate partners, interested in Win-Win, Commercial- coventure marketing campaigns promoting their product or service by sharing our vision to make sure there is always coverage for reconstruction surgery.

For additional information on how you can help or refer a patient please go to www.MyHopeChest.org.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD, Daniel T. Layish, MD, Ramamoorthy Nagasubramanian, MD, Scott Bradfield, MD, MBA, Andy Kolb, MD, Naina Mehta, MD, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, Pragati Gusmano, ND, 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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Smoking Cannabis Does Not Harm Your Lungs Like Smoking Tobacco By Michael Patterson, NHA, OTR/L, CEAS A recent study published in the JAMA NETWORK asked the age-old question; Is there an Association between Marijuana Exposure and Pulmonary Function over 20 years? The study can be found via the link below: Association Between Marijuana Exposure and Pulmonary Function Over 20 Years | Adolescent Medicine | JAMA | JAMA Network What they discovered was that “occasional and low cumulative marijuana use was NOT adverse effects on pulmonary function”.

In other words, cannabis smoke – unlike tobacco smoke – doesn’t have such a drastic impact on lung function despite having some of the same chemical profile in smoke.

The study performed was called CARDIA, which is a longitudinal study designed to measure risk factors for coronary artery disease in a cohort of black and white women and men (n = 5115) aged 18 through 30 years and healthy at enrollment in 1985. Participants were sampled from 4 US communities without selection for smoking behaviors and comprise a broad crosssection of typical tobacco and marijuana use patterns.

Each study center (Oakland, Chicago, Minneapolis, and Birmingham), participants underwent a baseline examination and 6 follow-up examinations, with 69% retention at year 20. Pulmonary function testing was performed at years 0, 2, 5, 10, and 20. For this investigation, we included all visits for which pulmonary function, smoking behavior, secondhand smoke exposure, height, and waist circumference were available.

Current intensity of tobacco use (cigarettes smoked per day) was assessed at each examination. These data, along with baseline examination data on past years of smoking, were used to estimate cumulative lifetime exposure to cigarettes in terms of pack-years, with 1 pack-year of exposure equivalent to 7300 cigarettes (1 year × 365 days/y × 1 pack/d × 20 cigarettes/pack). Misclassification of smoking exposure by self-report, measured by comparisons with serum cotinine levels, is uncommon.

Current intensity of marijuana use (episodes in the last 30 days) was also assessed at each examination. Using baseline examination data on past lifetime exposure to marijuana, current intensity of marijuana use, and another question designed to assess number of joints or filled pipe bowls smoked per episode we calculated total lifetime exposure to marijuana joints in joint-years, with 1 joint-year of exposure equivalent to 365 joints or filled pipe bowls smoked (1 year × 365 days/y × 1 joint/d), as described previously.

The 5115 CARDIA participants recruited in 1985-1986 contributed 20 777 total visits that included pulmonary function testing. Of these, 959 visits were excluded for lack of complete information on smoking behavior, 114 for lack of height or waist measurements, and 1 for an unknown visit date, leaving 19 703 visits (95%) with complete data from 5016 participants (98%).

Participants contributed 3.9 visits/participant on average; attrition was more common in tobacco smokers but not associated with marijuana use. FEV and FVC varied across participants, increased slightly with age through the late 20s, and declined slowly thereafter.

More than half of participants (54%; mean age at baseline, 25 years) reported current marijuana smoking, tobacco smoking, or both at 1 or more examinations. Smoking patterns differed by race and sex, with black women most likely to smoke tobacco only, white men most likely to smoke marijuana only, and black men most likely to smoke both. Tobacco smokers tended to have lower education and income and to be slightly shorter and less active, whereas marijuana smokers tended to be taller and more active. The median intensity of tobacco use in tobacco smokers was substantially higher (8-9 cigarettes/d) than the median intensity of marijuana use in marijuana smokers (2-3 episodes in the last 30 days). Although marijuana and tobacco exposures were strongly correlated, our sample included 91 participants with no tobacco exposure and more than 10 joint-years of marijuana exposure (contributing 153 observations of pulmonary function), 40 (56 observations) of whom had more than 20 joint-years of exposure.

The findings suggest that occasional use of marijuana for these or other purposes may not be associated with adverse consequences on pulmonary function. It is more difficult to estimate the potential effects of regular heavy use, because this pattern of use is relatively rare in our study sample; however, our findings do suggest an accelerated decline in pulmonary function with heavy use and a resulting need for caution and moderation when marijuana use is considered.

ANALYSIS

While this study is good news, smoking cannabis for medical purposes is not the most efficient way to consume medicine. A lot of cannabinoid effects are lost when cannabis is burned to be smoked. A similar, but better way to consume cannabis is via vaporizer or vape pen. The cannabis not being burned but heated into a vapor, which maintains all of the cannabinoids in order to be available for absorption into the body. Furthermore, more accurate dosing of cannabis can be found via edibles or tinctures, which allow a patient to have a measured amount of cannabinoids (THC, CBD, THCA, CBG, CBN, etc.) to build confidence and certainty in the reaction of cannabis medicine on the body.

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.  FLORIDA MD - SEPTEMBER 2021

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COVER STORY

Nemours Children’s Health –

Building Central Florida’s Premier Pediatric Orthopedic Program By: John Lovejoy, III, MD, Chair of Orthopedics, Nemours Children’s Health Nemours Children’s Health has been caring for children and adolescents for more than 80 years. But in Central Florida, our footprint and services have grown exponentially during the past decade.

There’s been a tremendous amount of change over the years since we first started seeing patients in Central Florida in 1997.

Not only did we open Nemours Children’s Hospital in 2012, but we made a conscientious effort to extend our services out into local communities throughout Central Florida.

HOSPITAL IMPACT Previously, we were in agreements with other children’s hospitals to provide our surgical and inpatient care but having our hospital in Lake Nona has really changed the dynamics of our department and the care we can provide.

PHOTO: PROVIDED BY NEMOURS

We have outstanding access to operating rooms and leadingedge technology. The hospital also supports us as a department with clinic space and inpatient services, which makes for a more seamless process. And when it comes to our offsite outpatient clinics, it’s easy to get patients back to the hospital, when necessary, for emergent or nonemergent treatment. Combine all of

that with the support of our foundation, and it gives us the flexibility and some opportunities that might be more challenging in a different situation.

CARE CLOSER TO HOME It became more apparent as our organization grew its reputation and awareness that we were drawing patients from all across Florida. But we knew that families in Central Florida really wanted more expert care closer to home whenever possible.

As an orthopedics department, we developed a thoughtful plan to see how we could grow and expand our presence in the region. This resulted in a combination of projects with some of our internal Nemours Children’s programs like other surgical specialties and our primary care offices. Our organization as a whole looked at opportunities to partner with other organizations in the communities we serve as well. Through that approach we ended up with seven locations for orthopedics in Central Florida, with our services really anchored at Nemours Children’s Hospital in Lake Nona.

We believe it’s really important to get into the neighborhoods where our patients live. As an organization, we want to be a part of the communities around CenNemours Children’s has grown its orthopedics and sports medicine program to now include a compretral Florida. When you’re there hensive team of pediatric orthopedic surgeons, sports medicine physicians and physician assistants in person, it’s easier to truly bealong with additional support staff to offer a full range of expert care throughout Central Florida. come part of the community. For the day-to-day visits or follow up visits, people prefer to have those appointments closer to home.

Without these services located in neighborhoods, it leaves communities vulnerable. In some cases, we need to bring families to our hospital in order to provide them with the highest level of care and ensure the best outcomes. Then we can give them the opportunity to have follow up visits at a clinic near where they live. I think that’s really beneficial for the families we serve.

In several of the areas that we provide care, we continue to grow our services. We might start out FLORIDA MD - SEPTEMBER 2021

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COVER STORY seeing patients one or two days a week at a location, but then we can expand as the demand increases.

For these outpatient clinics, we are in locations that can provide the most impact. We started caring for patients in Central Florida at our clinic in downtown Orlando, but then added services in Lake Mary, Melbourne and Winter Garden. Then our Lake Nona outpatient clinic on Narcoossee Boulevard was our first really specialized clinic offering dedicated fracture and sports medicine services five days a week to help fill those specific care needs. We also have a partnership with Lakeland Regional Health to provide pediatric orthopedic care for kids, along with other pediatric services, at their facility.

This growth has truly helped increase our overall presence throughout Central Florida as well as our dramatically increasing our patient access.

PHOTO: PROVIDED BY NEMOURS

We had around 10,500 patient visits in 2014 and we’re now projected to conduct around 35,000 patient visits in 2021.

PARTNERING WITH THE COMMUNITY As we build upon our services within our walls, our team continues to look for ways to partner with other types of organizations to help strengthen our presence in local communities. That often means providing our expertise to groups that share our same goals in improving the lives of children and adolescents.

We are thrilled to serve as an official Medical Services Provider of the USTA National Campus which is located just down the road from our hospital in Lake Nona. Our sports medicine physicians are able to provide on-site care along with preventive and educational support for their athletes. We also work with Nona Soccer Academy as their medical partner and provide health care support to some of our local schools.

BUILDING SUCCESS WITH STAFFING As part of our continued growth, we’ve enjoyed the ability to recruit an outstanding team. Our staff of providers was comprised of only three physicians and three physician assistants early on. Over the years, we’ve been able to grow that to seven surgeons, three non-operative sports medicine physicians, and nine PAs, including a PA who is dedicated to providing a reduction clinic in our hospital’s emergency department Monday through Friday. This is combined with a full complement of support staff to allow us to better serve the needs of our patients and their families across Central Florida.

IMPROVING ACCESS AND SERVICE OPTIONS FOR FAMILIES All of this growth and expansion has allowed us to not only increase our access, but it has also allowed us to expand the subspecialties in pediatric orthopedics that we are now able to offer.

We have specifically recruited specially trained physicians that give us the opportunity to improve our offerings in areas like sports medicine, spine, complex hip, limb reconstruction, tumor, foot and ankle, and a variety of other areas that were underrepresented.

6 FLORIDA MD - SEPTEMBER 2021

Nemours Children’s has focused on enhancing its subspecialty care offerings throughout the years, including program areas like its spine center, to better serve families throughout Central Florida.

We also looked for some opportunities outside of our organization, so we developed a partnership with a private practice that specializes in hand and now we’re able to have their surgeons come to our facility on a monthly basis and perform complex hand procedures. This gives us the ability to serve yet another segment of the pediatric orthopedic patient population in the Central Florida.

EDUCATION AND RESEARCH Other areas that have dramatically changed over the years for us is our involvement in academics and research. In 2018, we were able to create the opportunity to have HCA residents complete rotations at Nemours Children’s Hospital. We also started a Fellowship program at our hospital. We were able to graduate our first orthopedic Fellow in June and have others lined up for next two years and continue to match for following years.

We have significantly expanded our involvement in research.

Six of our faculty members are very actively involved in research and we have two grants in the department now. We have also grown the research infrastructure that supports our work, including the recruitment of a new research director.

WORKING WITH REFERRING OFFICES For our referral base, we want them to know we’re here in their communities as a resource. We’re here to listen to their concerns and problems and we’re accessible to them. They can also get to know our local doctors that service their area, so they’ll have a

COVER STORY point person to go to when they need them. Our goal is to work with primary care providers – or other referring physicians – as partners in caring for their patients to ensure they receive the best care available to them.

Overall, we’ve seen a dramatic change over the last decade. We’ve gone from being a small number of individuals providing a very select service at a single outpatient location to a full-blown department able to provide service to a catchment area of over 2.2 million. We’ve seen our volumes triple in that time and really generated some financial and operational success for our department.

Throughout this process, the priority for our orthopedics department has always remained the same: to build a true center of excellence. Our goal Nemours Children’s continues to grow its presence within the communities it serves is to ‘provide an elite level of care and customer by partnering with local organizations including the USTA National Campus and Nona Soccer Academy, among others. service to patients in need of pediatric orthopedic services in and around Central Florida,’ so the focus is centered around patients and their families.

For us, that focus breaks down into three categories: Associates – having the right team in place and being dedicated to recruitment and retention Quality – having superior outcomes that are the highest quality not only in the region but in the country Customer Service – providing care in a way that is appealing to families and meets their needs while being as convenient as possible for them We always strive to provide the highest level of care with the best customer service and some of the best outcomes with the lowest complications based on national metrics. We have been on a mission to really redefine how pediatric orthopedic care is provided in Central Florida. It hasn’t been perfect, and we’ve had to learn along the way, but we have not deviated from that underlying goal of building a true center of excellence for pediatric orthopedic care.

2020 NEMOURS

BY THE NUMBERS 28,694 Total outpatient visits 1,282 Total surgical cases 193 Spinal procedures 1.1% Infection rate for all orthopedic procedures 14 Peer reviewed articles 14 Book chapters 14 National presentations

Every day our team comes into work wanting to be the best they can be. As families experience that, they realize what that care should look like now. It’s a dynamic process and we are constantly looking for ways to do it better. We are constantly trying to understand what needs we aren’t meeting well enough so we can redirect our efforts and resources to help meet those needs.

Our mission is to take care of all of the kids in Florida who seek out our help – even the ones who never step inside one of our buildings.

Call (407) 650-7715 or visit Nemours.org to find out more or schedule an appointment.  FLORIDA MD - SEPTEMBER 2021

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PHOTO: PROVIDED BY NEMOURS

DIRECTION OF THE DEPARTMENT

PULMONARY AND SLEEP DISORDERS

Chronic Thromboembolic Pulmonary Hypertension

By Daniel T. Layish, MD There are several categories of pulmonary hypertension.

WHO Group I includes patients with idiopathic pulmonary hypertension, familial pulmonary hypertension, drug and toxin related (fen-phen) portopulmonary hypertension, HIV related pulmonary hypertension and pulmonary arterial hypertension associated with connective tissue disorders (such as scleroderma).

WHO Group II pulmonary hypertension is often referred to as pulmonary venous hypertension. This includes patients with left ventricular systolic or diastolic dysfunction or valvular heart disease. Essentially, the WHO Group II category includes patients who have an elevated pulmonary capillary wedge pressure and/ or elevated left ventricular end diastolic pressure. WHO Group III pulmonary hypertension consists of patients with COPD, interstitial lung disease, or other conditions in which hypoxia causes vasoconstriction. The remainder of this article will focus on WHO Group IV pulmonary hypertension (chronic thromboembolic pulmonary hypertension or CTEPH). Although WHO Group IV patients are relatively rare, it is crucial to identify them because this is the only type of pulmonary hypertension which is potentially surgically curable.

After acute pulmonary embolism, most patients will recover and have normal pulmonary hemodynamics, gas exchange, and exercise tolerance. It is believed that 1-4% of patients with acute pulmonary embolism will go on to develop CTEPH within two years. It is not clear why some patients with acute pulmonary embolism develop CTEPH. Risk factors include hypercoagulable states, myeloproliferative syndromes, splenectomy and chronic indwelling central venous catheters. Patients with CTEPH present with dyspnea, which can have a gradual onset. Many patients with CTEPH will not have a known previous diagnosis of acute pulmonary embolism. As with other patients with pulmonary hypertension, patients with CTEPH may not show findings on physical exam until pulmonary hypertension is in the late stages.

Findings include a right ventricular lift, jugular venous distention, fixed splitting of the second heart sound, hepatomegaly, ascites, and peripheral edema. Patients with CTEPH may have “flow murmurs” heard over the lung fields because of turbulent flow through partially obstructed or recanalized pulmonary arteries. These tend to be accentuated during inspiration.

Acute pulmonary embolism is the trigger for CTEPH. In some patients this triggers a small vessel vasculopathy (for unclear reasons) that contributes to the extent of pulmonary hypertension.

This may explain why up to 35 percent of patients who undergo succesful pulmonary thromoendarterectomy can have some degree of postoperative pulmonary hypertension.

Although VQ scanning has become less commonly used for diagnosis of acute pulmonary embolism this remains the initial imaging study of choice in patients with pulmonary hyperten8 FLORIDA MD - SEPTEMBER 2021

sion to separate “small vessel” variants (Idiopathic pulmonary arterial hypertension) from “large vessel” disease (CTEPH) A normal VQ scan essentially excludes the diagnosis of CTEPH. A scan with one or more mismatched segmental defects is suggestive of the diagnosis.

However, it is important to note that VQ scan can often understate the extent of central pulmonary vascular obstruction. Once the VQ scan is found to be abnormal then further testing should be undertaken (such as CT angiogram and/or pulmonary angiography). The angiographic findings in CTEPH are distinct from those of acute pulmonary embolism. They can include pouch defects and pulmonary artery webs. Patients with severe pulmonary hypertension have been found to tolerate performance of angiography as well as VQ scan without significant complication rate.

The surgery for CTEPH is quite different from surgical intervention for an acute pulmonary embolism. Surgery for CTEPH is called a pulmonary thromboendarterectomy (PTE), which requires median sternotomy and cardiopulmonary bypass. It requires an often tedious intimal dissection of fibrotic recannalized thrombus from the native pulmonary arterial wall. IVC filter placement is usually recommended before pulmonary thromboendarterectomy. These patients can have a complicated postoperative course and this type of surgery is only done at a few specialized centers in the country. The center which is best known for this type of surgery is the University of California (San Diego). Patients who have undergone PTE are typically maintained on lifelong anticoagulation. To be a candidate for this surgery, a patients must have central, surgically accesible chronic thromboemboli. A significant postoperative complication is pulmonary artery steal, which refers to redistribution of pulmonary arterial blood flow from well-perfused segments into the newly opened segments resulting in ventilation perfusion mismatch and hypoxia. This redistribution of flow resolves over time. Approximately, 30% of PTE patients can develop reperfusion pulmonary edema.

The perioperative mortality of pulmonary thromboendarterectomy can be in the range of 2-3% in experienced centers. Outcome is clearly better in high voluime centers (more than fifty PTE surgeries/year). Approximately 5000 thromboendarterectomy procedures have been performed worldwide, 3000 at UCSD alone.

Surgery for CTEPH is clearly the best therapeutic option.

However, there are some patients with CTEPH who are inoperable or who have persistent or recurrent pulmonary hypertension after undergoing pulmonary thromboendarterectomy. There is now a medical therapy available for these patients. Riociguat (Adempas) was approved by the FDA in October 2013. It is a member of a new class of compounds-soluble guanylate cyclase stimulators. In the multicenter study by Ghofrani et al that was published in the New England Journal of Medicine in July 2013,

PULMONARY AND SLEEP DISORDERS 261 patients were randomized prospectively to receive riociguat versus placebo. Riociguat was shown to significantly improve exercise capacity and pulmonary vascular resistance. Side effects include systemic hypotension. Prior smaller studies have also shown some benefits to medical therapy in CTEPH (inoperable or with post-operative PH) with oral agents such as bosentan and sildanefil, inhaled iloprost and subcutaneous treprostinil. Medical therapy has also been used as a “bridge” before PTE. Although relatively rare, CTEPH is an important cause of PH since it is potentially curable with pulmonary endarterectomy. This surgery should only be performed in very experienced, specialized centers. PTE surgery should always be the treatment of choice for CTEPH. However, medical therapy can have a role as a bridge to PTE,in patients who are not surgical candidates or in those who have persistent pulmonary hypertension despite undergoing PTE. I would like to express my gratitude to Dr. Peter Fedullo (University California San Diego) for his review of this manuscript and providing the photographs.

Pulmonary angiogram showing lack of blood flow to the right middle lobe and the right lower lobe from CTEPH.

Example of chronic clots removed during pulmonary thromboendarterectomy.

Example of the large perfusion defects seen on V/Q scan in a patient with CTEPH.

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



FLORIDA MD - SEPTEMBER 2021

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COVER STORY

PHARMACY UPDATE

HDL: The Wolf in Sheep’s Clothing

By Pragati Gusmano, ND and Juan Lopez, PharmD, FAPC High-density lipoprotein (HDL) is largely considered cardio protective - it is our “good” cholesterol, after all. Emerging research suggests it’s not that simple. HDL can be “good”, but it depends heavily on how well the HDL particle functions within the body.

If the HDL function is not optimal, it can cause damage to arteries rather than protecting them.

The main function of HDL is collecting excess cholesterol and bringing it to the liver to be recycled or eliminated, a process known as reverse cholesterol transport. Reverse cholesterol transport is vital to cardiovascular health; well-functioning HDL is critical to reducing the formation of arterial plaques that can lead to heart attacks and stroke.

In addition to reverse cholesterol transport, HDL has an antioxidant effect that reduces the oxidation of LDL. Oxidized LDL is a contributing factor to the development of arterial plaque and coronary heart disease.

WHAT IS HDL? HDL is a particle, made up of a phospholipid shell that contains lipids, such as cholesterol. HDL particles are embedded with many different proteins, which are vital for the effective function of HDL. When the proteins are damaged or oxidized, HDL dysfunction comes into play and HDL becomes compromised. The two proteins that we look at most often are PON and apoA1.

Lifestyle changes should be the first course of action in supporting HDL function. Key changes include smoking cessation, increasing movement and eating a Mediterranean style diet, which is naturally rich in fruits and vegetables that contain several phytonutrients shown to support HDL function.

In addition to lifestyle, plant bio-actives are a powerful way to mitigate the factors that can damage the proteins on the surface of HDL.

POMEGRANATE, LYCOPENE, AND QUERCITIN In clinical studies, pomegranate polyphenols have been shown to increase PON expression and reduce oxidative stress within 4-6 weeks. Both of these factors can improve HDL function.

Lycopene has demonstrated the ability to protect the central components of HDL. Clinical studies have shown that lycopene supplementation can reduce levels of the pro-inflammatory marker SAA, which can interfere with HDL function. Lycopene has the ability to increase expression of the protein PON, which is critical for HDL anti-oxidant properties. Further, lycopene has the ability 10 FLORIDA MD - SEPTEMBER 2021

to improve reverse cholesterol transport, the key function of HDL. Quercetin has been shown to increase the proteins on the surface of HDL, apoA1 and PON, promoting the heart healthy benefits of HDL. Quercetin also plays a role in the expression of enzymes that support the transport of cholesterol to and from HDL particles .

We know that HDL has an important role in cardiovascular health, but we reap the most benefit from this particle when it is functioning well. Oxidative stress, inflammation and glucose can all damage HDL. The good news is that lifestyle factors and plant bio-actives can serve to protect HDL function and improve dysfunction.

REFERENCES AVAILABLE UPON REQUEST.

Pragati Gusmano, ND is a functional medicine practice consultant for Metagenics. Juan Lopez, PharmD, FAPC, is a personalized medicine pharmacist with Pharmacy Specialists Compounding Pharmacy in Altamonte Springs, FL. For more information on how personalized nutritional support can help you, please call 407-260-7002, or email us at Info@ MakeRx.com. 

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MARKETING YOUR PRACTICE

What Does Your Branding Say About Your Medical Practice?

By Sonda Eunus, MHA, CMPE Your brand is the identity that you create for your practice. It is crucial to identify the core values that you want your brand to represent, because this is how it will be perceived by your target audience and the community at large.

Here are some questions to consider when building your brand: • How do you want your practice to be perceived?

• What core values do you hold most important to your WHY? • What does your brand look like? Colors, fonts, and shapes matter.

• What does your brand sound like?

When choosing your brand colors, be aware of the following color associations: • Red — Red stands for passion, excitement, and anger. It can signify importance and command attention.

• Orange — Orange stands for playfulness, vitality, and friendliness. It is invigorating and evokes energy.

• Yellow — Yellow evokes happiness, youth, and optimism, but can also seem attention-grabbing or affordable.

• Green — Green evokes stability, prosperity, growth, and a connection to nature.

• Light Blue — A light shade of blue exudes tranquility, trust, openness. It can also signify innocence.

• Dark Blue — Dark blue stands for professionalism, security, and formality. It is mature and trustworthy.

• Purple — Purple can signify royalty, creativity, and luxury.

• Pink — Pink stands for femininity, youth, and innocence. It ranges from modern to luxurious.

• Brown — Brown creates a rugged, earthy, old-fashioned look or mood.

• White — White evokes cleanliness, virtue, health, or simplicity. It can range from affordable to high-end.

• Gray — Gray stands for neutrality. It can look subdued, classic, serious, mysterious, or mature.

• Black — Black evokes a powerful, sophisticated, edgy, luxurious, and modern feeling. (www.99designs.com)

WHAT IS YOUR BRAND’S PERSONALITY? Think of your Business brand as a person. What is this person’s personality like? How does he or she dress, talk, and act in public? Here are just a few examples of a personality that your brand 12 FLORIDA MD - SEPTEMBER 2021

may have: • • • •

Serious and Professional Warm and Friendly Cool and Quirky Funny and Playful

However, you choose to represent your brand, make sure that it is authentic to who you are. For example, if you are playful and like to crack jokes, infuse your marketing with humor and you will find that people respond positively to jokes, memes, and quotes that are applicable to them. For example, for pediatric practices, we have found that moms just can’t get enough of memes that make fun of their kids! You can add some (goodnatured) jokes and memes to your social media posts and you will see some great engagement.

Similarly, if you want your brand to be viewed as serious and professional, you will want to consistently share valuable and informative content that educates your audience. You can choose to do so by looking for speaking opportunities to help build credibility and position you as the expert in your field, making educational videos and sharing them on your website, Youtube, and social media, or by writing educational articles and contributing to reputable publications.

If you’re going for warm and friendly, you will want to be seen engaging with your social media followers, being active in Facebook groups and other online groups, hosting community events, supporting great causes, etc.

If cool and quirky is your thing, you want to stand out from your competitors. You can use some colors that are not typical for your industry, create and share some fun videos, such as “funny (HIPAA-compliant) things that patients say”, paint your waiting room to inspire awe upon arrival, etc.

Keep in mind that for any brand personality, it is important to keep it consistent across your website content, social media posts, marketing materials, and any other communication that you may have with your audience.

Sonda Eunus is the Co-Founder of Pro Medical Marketing – an Internet Marketing Agency specializing in Medical practices. She has a Masters’ in Healthcare Management and is a MGMA Certified Medical Practice Executive. She has been heavily involved in operating her family’s Pediatric practices from an early age. She is passionate about helping medical practices grow and does so by sharing her experience in her writing, speaking, and consulting. Learn more about Sonda and Pro Medical Marketing at www.promedicalmarketing.com. 

PEDIATRICS

Increasing Awareness Broadens Access for Childhood Cancer and Sickle Cell Patients

By Ramamoorthy Nagasubramanian, MD Treatment of childhood cancer is one of the great success stories of modern medicine. Often touted as an example of medical advances made possible through research, a pediatric cancer diagnosis that once meant a fatal prognosis is now survivable for 80 percent of patients.

Despite these advancements, cancer remains the leading cause of death by disease among children. What’s more, all pediatric cancers combined receive only 4 percent of U.S. federal cancer research funding.

This past September was Childhood Cancer Awareness Month and Sickle Cell Awareness Month, reminding us to take stock of our current situation and to raise awareness of these conditions.

IMPROVING ACCESS TO ADVANCE HEALTH Having access to care for any medical need is important. But for patients who need the pediatric-focused, specialized treatment that childhood cancer requires, it can take on even deeper significance.

When one considers that society’s most underserved children — from racial and ethnic minority groups — remain more likely to die of childhood cancer than their non-minority peers due to lack of access to care, this is unacceptable.

At Nemours Children’s Health, our Hematology-Oncology team has found that by working together we can better impact two common goals: To find a cure and to reduce the side effects of childhood cancers and sickle cell disease to help all children not just live, but live longer and with a better quality of life — today and for many tomorrows.

HELPING TO HEAL THOUSANDS EACH YEAR Helping all children live longer and with a better quality of life requires that we deliver equitable care.

Our program treats 6,000 pediatric cancer patients in Florida and Delaware each year, and many enroll in the latest clinical trials sponsored by the National Cancer Institute to help children with conditions like: • solid tumors • sarcomas • neuroblastomas • blood disease and blood cancers The volume of patients, coupled with decades of experience, means that more kids are receiving life-saving care and having better outcomes.

Today, our program boasts the nation’s second largest pediatric clinical trial program of its kind and is one of only two pediatric programs nationwide to be recognized as a National Cancer Institute Community Oncology Research Program (NCORP).

REDUCING DISPARITIES IN CLINICAL TRIAL ACCESS AND RESEARCH PARTICIPATION To create a more equitable care environment for patients, we have worked intentionally to identify and minimize all barriers to research and clinical trial participation. To measure the impact of these efforts, our program tracks and reports weekly on three essential data elements: 1. Total clinical trial enrollments 2. Clinical trial enrollments across racial and ethnic groups and compared to population estimates 3. Screen failures (eligible but not enrolled) across racial and ethnic groups, as well as primary language spoken Our objective is to enroll all eligible patients on available clinical trials, inclusive of Therapeutic and Non-Therapeutic trials (e.g., symptom management and cancer prevention trials). We measure our program against national benchmarks published each year in the Children’s Oncology Group Report Card.

What we’ve learned along the way is that by understanding the factors that contribute to underrepresentation in research and clinical trials, clinicians can create targeted strategies to increase engagement.

For example, by translating our research consent forms into different languages common in our catchment areas, we have been able to eliminate patient screening failures due to language barriers. This is especially relevant considering that half of our clinical trial enrollments identify as Hispanic or non-white, a significant proportion of whom required consent in a language other than English.

SPECIAL FOCUS ON SICKLE CELL TREATMENT Another area related to the delivery of equitable pediatric care pertains to sickle cell disease, a genetic condition affecting the red blood cells that disproportionately impacts Black children and families. Roughly 3,000 children are born with sickle cell disease in the U.S. each year.

Since sickle trait usually doesn’t cause illness, many parents are FLORIDA MD - SEPTEMBER 2021 13

PEDIATRICS unaware that they have sickle cell trait. If two parents both have sickle cell trait, then there is a 25 percent chance that their children can be born with sickle cell disease.

Our Hematology-Oncology program is poised to lead the field of sickle cell care and research. For our work, we’ve been awarded a $10.6-million, 5-year grant from the Center of Biomedical Research Excellence (COBRE).

Through the grant, our program joined Christiana Cares to form the Delaware Comprehensive Sickle Cell Research Center. This center studies the laboratory, clinical and psychosocial sequelae of sickle cell disease and trains future researchers and doctors to improve the care and outcomes for children with sickle cell disease worldwide.

For pediatric cancer and sickle cell patients, increasing awareness of the unique challenges they face in treatment and beyond is an important step to garner more advocacy and support for programs and research.

To learn more about our efforts, please visit Nemours.org/CancerResearch.

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DERMATOLOGY

Merkel Cell Carcinoma, the Other Skin Cancer By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII When you mention skin cancer to the general public or even to the medical community, most folks think of the three big celebrities: basal cell carcinoma, squamous cell carcinoma, and melanoma. I like to refer to having occurrences of all three types of skin cancer in one patient as hitting the trifecta of skin cancer; unfortunately, there is no big payout with this trifecta. Excessive sun exposure is typically the common denominator. What is less known is there are other cancers of the skin besides the big three, and these can kill you as well. What I like to call “the fourth skin cancer” is the Merkel Cell Carcinoma. Not as famous as the big three, but Merkel cell carcinoma still should be treated with respect when it makes it rare appearances.

Merkel Cell carcinoma, like other skin cancers, has a predisposition for appearance in sun-exposed areas such as the face or sometimes the hands or digits. They usually do not appear in younger individuals and tend to arise more frequently in those with immunodeficiency. Merkel cell carcinomas present as a nonspecific papule or nodule. Because it can initially be misdiagnosed as a benign cyst, the actual pathology of the tumor may be delayed. Additionally, Merkel cell carcinoma is typically asymptomatic in the beginning, and this also adds to delay in diagnosis as many patients are not concerned until the fast-growing tumor reaches a large size.

The problem with Merkel cell carcinoma is that it is a highly aggressive type of skin cancer, and like melanomas, with enough growth and time, it can metastasize. Merkel cell carcinomas are treatable, and the treatment of choice is excision, the earlier, the better. Once a Merkel cell carcinoma has metastasized, it becomes a problematic tumor to treat, although new therapies are available that hold some promise. Recent studies suggest that 97% of Merkel Cell carcinomas have a common virus expression (Merkel cell polyomavirus).

How this oncovirus may cause, Merkel cell carcinoma is currently unknown. Fortunately, patients that have Merkel cell carcinoma are not infectious.

If you observe a growth on the skin and you think to yourself, well, it doesn’t look like a basal or squamous cell carcinoma or melanoma; therefore, it’s probably benign always think of the other skin cancer, Merkel cell carcinoma. Happily, I have not had any of my patients that have had a trifecta of skin cancer also get Merkel cell carcinoma. In this scenario, I would have to name it the superfecta of skin cancer and not a title I would want to bestow on anyone.

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. 

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FLORIDA MD - SEPTEMBER 2021 15

Understanding Autism

By Naina Mehta, MD We hear more about autism these days, leading many people to conclude that there are more and more cases each year. In fact, today we estimate that one in 54 children may be diagnosed as autistic, compared to one in 150 children back in 2000 and just one in 2,000 children in the 1980s. Is the incidence of autism really more than doubling every 20 years?

As a neurodevelopmental pediatrician, I don’t believe the incidence of autism is truly increasing exponentially, but it is our screening and diagnosis of autism that has been expanding. We define autism as a developmental disorder characterized by difficulty in social interaction and communication associated with restricted or repetitive patterns of thought and behavior.

Currently there is no medical test to diagnose autism, such as a blood test. But our screening processes and diagnostic tools have expanded. Often, the first step in diagnosing a child with autism lies with the pediatrician. They assess the child soon after the first birthday to see if they’re meeting milestones and interacting appropriately. If the physician or family suspects autism, the child is referred to a specialist for an official diagnosis, based on an evaluation using the Diagnostic and Statistical Manual of Mental Disorders, fifth addition (known as the DSM-5). In the state of Florida, this diagnosis must be made by a specialist – a developmental pediatrician, a neurologist, a psychologist or a psychiatrist, in order for the insurance companies to provide approval for the appropriate therapy, applied behavioral analysis (ABA), that the child needs.

In the past, a child may have been given the diagnosis of mental retardation, now more commonly known as intellectual impairment. In the case of a higher functioning child, the child may previously have been considered to be just quirky and different, and may have been diagnosed with the term Asperger’s. Today that same child may be considered autistic, based on the expanding criteria. A diagnosis of autism addresses a combination of two things: intelligence and behavior. The terms “high functioning” and “low functioning” refer to intellectual ability or intelligence.

The terms “low,” “moderate” and “severe” refer to their autistic behaviors. We see autistic people at all levels of intelligence and behavior. For instance, many may remember the character from the Rain Man film of the 1980s, who would be considered super high functioning for his intelligence – a savant even. Yet, his behavior was more severe.

While we don’t know what causes autism, we do know that boys are up to four times as likely to be diagnosed as girls. We also know that genetics are very much involved. In fact, parents with one autistic child are 10 to 20 percent more likely to have a second child diagnosed. If one identical twin is diagnosed as autistic, there is as high as a 90 percent chance the second twin is also autistic.

16 FLORIDA MD - SEPTEMBER 2021

As our screening and diagnostic tools for autism have expanded, our knowledge of treatment options for autism remains the same. Despite the numerous claims that there is a cure for autism, such as medications, mega-vitamins, gluten-free and casein-free diet, hyperbaric oxygen chambers or colonic cleanses, none have demonstrated success in curing or treating autism. After years of experience with autism, the medical community can say that behavioral therapy is the only treatment to have shown significant success.

It’s important to note that while medication may not be an effective treatment for autism, many people with autism have comorbid conditions, such as anxiety or depression, attention deficit hyperactivity, seizures, sleep issues and sometimes more significant behaviors of self-injury and aggression, where medications may have some benefit.

When it comes to treatment, we have seen significant success with applied behavioral analysis or ABA, an evidence-based treatment strategy used to reduce challenging behaviors and increase socially appropriate behaviors. ABA therapy is an intensive therapy administered by a board-certified behavioral analyst (BCBA)/ registered behavior technician (RBT) – up to 40 hours per week, which may be offered in the home or in a clinical setting. The therapy consists of an intensive, structured teaching program in which social and communication behaviors are broken down and rehearsed in their simplest elements. Other forms of therapy, such as floor time and circles of communication have also been shown to provide beneficial effects and can be practiced at home. Here the parent gets down at the child’s eye level and, through play, makes continuous social communication and interaction, back and forth, creating circles of communication which help the child understand that there’s a world out there in which he or she can interact.

Studies show that the earlier ABA therapy begins, the earlier we can see improvement. Our developmental window is the first six years of life. We see cases where treatment begins as early as 2 years of age and the child is ready for regular kindergarten by the age of 5 or 6. Sadly, the process of diagnosis and qualifying for treatment can be slow. In many cases, we see that it may take more than six months to see a specialist for a diagnosis and then up to a year to find availability with an ABA therapist, underscoring the need for early intervention. We recommend referring children to a specialist as early as possible to ensure that autism is diagnosed promptly and treatment may begin.

Special training is also available for parents and family mem-

bers, which I highly recommend. In fact, siblings often turn out to be the best therapists for their sibling with autism. So often children learn better from other children than an adult. Involving siblings in the therapy can also make the siblings feel more a part of the solution rather than resenting the autistic sibling for the extra attention required from parents. This special training for family members is an excellent tool to supplement ABA therapy or to be used while a family is awaiting ABA therapy approval or availability.

Autism is a fascinating field of study. We continue to learn more about the condition and ways to improve functionality. In fact, I’m currently working with a group of ear, nose and throat specialists, and gastroenterologists on a study to determine if nasopharyngeal microbiomes may be a marker for autism, advancing the thought that the olfactory nerve is the closest in proximity to brain tissue that can be easily accessible. This may provide evidence of changes within the brain, specific to children with autism, which can then be used a marker aiding in the diagnosis of autism. I look forward to learning more and to continuing my work serving autistic children and their families.

If you suspect a child has autism, consider scheduling an appointment with a specialist as early as possible to maximize treatment opportunities.

Naina Mehta, MD, is a neurodevelopmental

pediatrician

at the Orlando Health Arnold Palmer Hospital for Children

and Developmental Center. She

2021

is board certified in neurodevel-

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

Pediatric

Behavioral

Health

opmental disabilities. Dr. Mehta has co-published studies involving meditation, yoga and breathing practices for children and youth with ADHD and learning disabilities. She offers parents both personal experience and professional training in managing behavioral issues with their children. She is currently leading a research study with ENTs and gastroenterologists on nasopharyngeal microbiome as a possible autism marker.

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EDITORIAL CALENDAR

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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FLORIDA MD - SEPTEMBER 2021 17

ORTHOPEDICS CARE

Just for kids.

Kids and teens need prompt and innovative care specifically designed for their growing bodies.

We offer family-centered, kid-friendly care right here in Central Florida. Our expert team, including board-certified and fellowship-trained physicians, uses advanced technologies to diagnose and treat an extensive range of conditions through our highly specialized pediatric orthopedics programs.

From common to rare, we treat disorders and injuries involving bones, joints, muscles and nerves at Nemours Children’s Hospital, as well as our other specialty locations in: • Downtown Orlando • Lakeland

• Lake Mary • Melbourne

• Narcoosee Road • Winter Garden

Call 407.650.7715 to refer a patient.

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