Floridamd august 2014

AUGUST 2014 • COVERING THE I-4 CORRIDOR

The Florida Hospital Global Robotics Institute The Most Sought Out Robotic Treatment Center in the Country

SURGEONS PATIENTS RESULTS

WITHOUT

BORDERS SCARS DOUBT

Creighton D. Fiscina, MD; William L. Huether, III, MD, FACS; Nicole BaiRossi, MD, FACS; John W. Robertson, MD, FACS

Welcome Creighton D. Fiscina, MD, general surgeon, to extend the continuum of care.

The elite general surgeons at Advanced Surgical Care Specialists can properly diagnose, progressively treat and permanently solve both simple and complex surgical issues. Our team is at the forefront of the latest surgical techniques, including open, endoscopic, minimally-invasive laparoscopic, robotic and single-site incision procedures. Positive patient outcomes are among the best in the area, providing minimal pain, scarring and recovery time.

Providing a true continuum of care approach for physicians and their patients.

NEW Location: 661 E. Altamonte Springs Dr., Ste. 225, Altamonte Springs, FL 32701

FHMG-14-18782

4106 W. Lake Mary Blvd., Ste. 330, Lake Mary, FL 32746

407.833.9195 | www. AdvancedSurgeryDocs.com

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AUGUST 2014 COVERING THE I-4 CORRIDOR

 COVER STORY

Photo: DONALD RAUHOFER / FLORIDA MD

The Florida Hospital Global Robotics Institute is headquartered at Florida Hospital Celebration Health, a resort-style medical facility located in the Disney-planned town of Celebration. In 2008, Florida Hospital’s clinical services expanded with the launch of the Global Robotics Institute. The Global Robotics Institute and Dr Patel’s medical practice, the Center for Urologic Cancer, were created out of a growing need in Florida for care of urologic cancer patients.

The Institute is under the medical direction of Vipul Patel, MD, FACS. Dr. Patel is a Baylor College of Medicine trained physician, who completed his residency and fellowship programs at the University of Miami. Prior to coming to Florida Hospital, Dr. Patel was Director of Minimally Invasive Urologic Surgery at The Ohio State University. He now leads an experienced team at GRI; some of who have been collaborating for over ten years.

ON THE COVER: Vipul Patel, MD, FACS, Director of the Florida Hospital Global Robotics Institute

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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 five 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.”

24 Choosing the Best Embryo - Advances in Invitro Fertilization

PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

SPECIAL FEATURE 

DEPARTMENTS 2

FROM THE PUBLISHER

3

ORTHOPAEDIC UPDATE

9

HEALTHCARE LAW

10 PULMONARY & SLEEP DISORDERS 12 CANCER

26 Overtraining & Overuse in Young Athletes: How much is too much?

14 MARKETING YOUR PRACTice

29 CURRENT TOPICS

22 CARDIOLOGY

16 FINANCIAL UPDATE: Insurance•Benefits•Wealth MGMT.

FLORIDA MD - AUGUST 2014

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FROM THE PUBLISHER

I

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

Best regards, Donald B. Rauhofer Publisher

Coming UP Next Month: A profile on UCF Pegasus Health, the College of Medicine’s physician practice, that provides primary and specialty care to patients across the community ages 16 and up.

See how physicians who are teaching tomorrow’s healthcare leaders are also providing individualized, evidence-based care to patients.

Editorial focus is on Pediatrics and Autism.

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

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

Services are provided at UCP’s six campuses as part of their in-house educational program, as well as on-site outpatient therapy, summer enrichment and services at some local community facilities. Many education programs are free of charge for eligible children.

Therapy services most common funding sources are Medicaid, commercial insurances and private pay. You can positively impact the 65,000 Central Florida youth who have a least one disability by referring them to the ‘Experts for children with Special Needs.’ Learn more at www.ucpcfl.org.. 

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

Reprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products.

Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

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

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FLORIDA MD - AUGUST 2014

Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Troy Kishbaugh, JD, Julie Tyk, JD, Jennifer Thompson, Ashley Fialkowski and Kim Straw, Daniel T. Layish, MD, Eric M. Toloza, MD, T. Kevin Taylor, JD, Margaret M. Sloane, RN, Barry Weinstock, MD, Corey Gehrold, Mark P. Trolice, MD, Sarah R. Gibson, MD Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information.

Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762.

Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2012, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

ORTHOPAEDIC UPDATE

Patient Gains Mobility, Freedom After Anterior Approach Total Hip Replacement

By Corey Gehrold Joan Cozart, a Celebration resident, was at a loss for months after her accident. Her pain left her barely capable of walking and unable to do small things like showering and getting dressed without the aid of her husband.

What if that pain never went away? Cozart had a very real fear of just that, having to live the rest of her days in discomfort.

She was referred by a friend to visit Eric G. Bonenberger, M.D., a board certified and fellowship trained orthopaedic surgeon specializing in joint replacement at Orlando Orthopaedic Center.

Immediately upon meeting Dr. Bonenberger she was a fan of his and she knew he would be able to help her regain her mobility. After trying the conservative nonsurgical measures to treat the pain, he informed her the next step was an anterior approach total hip replacement.

“I was a 50-year-old woman feeling like I was 80-years-old,” she says. “[Since surgery], there’s been an amazing effect on my life. In a lot of ways I’d say I got back the life I had before I had surgery.”

What Makes the Anterior Approach Total Hip Replacement Special?

The biggest benefits to patients who undergo the anterior approach total hip replacement are a result of the procedure’s tissue sparing techniques when compared to traditional approach hip replacement procedures.

Benefits of the anterior approach total hip replacement for patients include: • Less pain • Faster recovery • Minimal movement restrictions following surgery • Increased mobility • Reduced scarring “Keeping the muscles intact can also help prevent joint dislocations,” explains Dr. Bonenberger. “The surgery can be completed faster than traditional hip replacement surgery as well, which helps reduce the risk for infection in the operating room.”

What is the key to the increased benefits of the anterior approach? Dr. Bonenberger explains it’s the approach itself that helps provide increased benefits for patient and surgeon alike.

“The surgery is done by making a single, small incision on the anterior, or front, portion of the hip instead of at the back or on the side,” he explains. “This alleviates much of the pain typically associated with the procedure because the muscles and tendons are gently spread to the side (tissue sparing).”

During surgery, Dr. Bonenberger says the hip is exposed in such a way that neither the muscles nor the tendons are detached from the bone, which helps reduce pain and speed recovery time.

“We enter the body much closer to Eric G. Bonenberger, the hip joint, thus placing less tissue MD between the skin and the hip bone,” he explains. “Using a computerized preoperative digital template along with intraoperative radiographs helps ensure the hip is well balanced, stable and that the implants are aligned with preciJoan Cozart says she got her life back following her anterior approach total hip sion.” replacement at Orlando Orthopaedic Center.

Joan is appreciative for the results of her surgery. “It’s the small things, like, literally being able to put on socks, shave my legs or wash my feet in the shower. On top of that, I have a six-year-old grandson who danced around me the first time he saw me after my surgery and I could walk normally” she says.

Luckily for patients, more than 90 percent of Dr. Bonenberger’s hip replacement patients are candidates for this minimally invasive procedure.

Recovering from an Anterior Approach Hip Replacement Physical rehabilitation following the anterior approach hip surgery spans several weeks.

“Patients are able to get up and are walking later in the day following surgery,” says Dr. Bonenberger. “Most patients progress to a cane in as little as one to two weeks.”

Many patients are walking independently in two to three weeks and are able to perform normal activities shortly thereafter.

As for Cozart, she has completed her rehabilitation and couldn’t be happier with the results following her anterior approach hip replacement at Orlando Orthopaedic Center.

She says, “Hands down, Dr. Bonenberger is my first referral if it’s a hip, but anyone else I would feel comfortable recommending Orlando Orthopaedic Center for their needs.”

To watch Joan discuss her experience with Dr. Bonenberger and Orlando Orthopaedic Center visit OrlandoOrtho.com.

About Dr. Bonenberger: Eric G Bonenberger, M.D. Is one Of Central Florida’s original direct anterior hip replacement surgeons. He has performed this operation for more than 8 years and is one of the highest volume anterior approach specialists in Florida.  FLORIDA MD - AUGUST 2014

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COVER STORY

The Florida Hospital Global Robotics Institute The Most Sought Out Robotic Treatment Center in the Country

By Ashley Fialkowski and Kim Straw The Florida Hospital Global Robotics Institute is headquartered at Florida Hospital Celebration Health, a resort-style medical facility located in the Disney-planned town of Celebration. In 2008, Florida Hospital’s clinical services expanded with the launch of the Global Robotics Institute. The Global Robotics Institute and Dr Patel’s medical practice, the Center for Urologic Cancer, were created out of a growing need in Florida for care of urologic cancer patients.

The Institute is under the medical direction of Vipul Patel, MD, FACS. Dr. Patel is a Baylor College of Medicine trained physician, who completed his residency and fellowship programs at the University of Miami. Prior to coming to Florida Hospital, Dr. Patel was Director of Minimally Invasive Urologic Surgery at The Ohio State University. He now leads an experienced team at GRI; some of who have been collaborating for over ten years.

This unique institute prides itself on patient care. It offers a concierge environment, which caters to the needs of patients from their initial call to their post-operative follow up visits.

Each patient is treated as an individual and care is personalized to their specific medical history and needs.

Photo: DONALD RAUHOFER / FLORIDA MD

Dr. Patel operating on the da Vinci robot.

4 FLORIDA MD - AUGUST 2014

Institutes such as GRI have helped Florida Hospital gain national recognition. For two consecutive years, the U.S. News & World Report has ranked Florida Hospital as the #1 hospital in the state, one of the best hospitals in the nation overall, and received specific recognition for their urology programs.

A Focus on Education and Global Impact: GRI’s Global Reach Dr. Patel has traveled the world extensively to perform live surgery demonstrations and train physicians in the field of minimally invasive robotic surgery. He and members of his team travel on

COVER STORY a monthly basis to perform lectures and surgeries internationally. His insight has impacted programs in England, Australia, Russia, Japan, Korea and Brazil, amongst many others.

Photo: PROVIDED BY FLORIDA HOSPITAL GLOBAL ROBOTICS INSTITUTE

In addition, Dr. Patel has received honorary professorships from Korean University, the Asian School of Urology, and the University of Lima. He also holds academic titles with the University of Milan, University of Central Florida, Nova Southeastern University, University of the State of Rio de Janeiro and Federal University of the State of Rio de Janeiro.

In July 2012, Dr. Patel received a distinguished international honor as an inductee to the Russian Academy of Science (RAS). Others in the past who have received this honor are globally recognized physicians, such as Dr. Michael DeBakey and Dr. James Watson. Among countless contributions to the field of prostate care, in 2008, Dr. Patel and his team formed and trained the Russian robotic surgery team and subsequently performed the first robotic prostatectomy in Russia.

In addition to teaching around the world, Dr. Patel has hosted and trained fellows from all over the world including Italy, Brazil, Korea, Chile, Israel and Venezuela.

Dr. Patel and his team recently celebrated the completion of his 7,5000 surgery.

“The Global Robotics Institute is a professional experience that changes your life. Dr Patel boosts your surgical skills and supports your career whenever and wherever you want to setup your program. When you have been a GRI Fellow, you will always feel as a part of the Team! The best team!” said Dr. Bernardo Rocco, a previous fellow who now helps to run a prestigious robotic program in Milan, Italy.

Mr. Oscar ‘The Big O’ Robertson and Dr. Patel go one on one with prostate cancer.

Patient Centric Approach

Photo: PROVIDED BY FLORIDA HOSPITAL GLOBAL ROBOTICS INSTITUTE

All types of patients come to the GRI, including NBA legend Oscar Robertson, known to fans as The Big O. He learned he had “The Big C (cancer)” after taking the simple diagnostic screening called prostate-specific antigen (PSA).

“Despite a lack of symptoms, my PSA rating had jumped from 3.9 to 5.3,” recalls 73-year-old Robertson. “When you learn that you have cancer, you look to find the best doctor for treatment.

And the best truly means the most experienced — and that is exactly what Dr. Patel offered me.”

The Big O is now three years out from surgery and enjoying life.

He has become a big advocate of cancer screening and education.

Robertson has joined the board of directors of the International Prostate Cancer Foundation and is a very active member, lending his celebrity as one of the faces of the cause.

Brett Troia, an avid Ironman competitor, learned he had prostate cancer at the young age of 41. “Even though cancer runs in my family, the news was devastating,” he said. Despite his diagnosis, a mere few months after treatment Brett was back to FLORIDA MD - AUGUST 2014

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COVER STORY new cases and 29,480 deaths attributed to prostate cancer, in the year 2014.

Is The Second Leading Cause of Cancer Death In Men Really Not Important?: PSA in Prevention & Detection Photo: DONALD RAUHOfer / Florida MD:

In this fight, screening and early detection are instrumental in overcoming mortality. Prevention and treatment are historically dependent upon consistent testing practices and early diagnosis leads to survival rates over 90%.

Dr. Patel’s OR team at work.

competition, not only performing at his best but logging some of his best times to date.

Outcomes “The Global Robotics Institute has a 99% patient satisfaction rating. We are in the medical practice of treating and curing patients, so of course, quality patient care is the key,” says Dr. Patel.

“Seeing the improvements to a patient’s health is what makes it all worthwhile.”

“Each surgery is customized in relation to the patients’ progression of cancer, but our approach to treating prostate cancer always aims to achieve the ‘trifecta’ result,” says Dr. Patel. “First and foremost, the robotic prostatectomy removes the cancer. Our focus also includes a priority to quickly regain urinary continence and sexual function. This trifecta approach centers on the patient being able to resume a normal, healthy life free of cancer, following a short recovery. In robotic surgery experience equals outcomes.

Having performed 7,500 robotic prostatectomies we rely on our experience daily to improve the outcomes going forward.”

Always a step ahead, the team now aims to achieve the ‘pentafecta’. In addition to the outcomes of the trifecta, the pentafecta results include no post-operation complications and negative surgical margins. This is the ultimate goal for each patient.

Continued Belief Early Detection Saves Lives — The Stats: According to the American Cancer Society almost 30,000 men die from prostate cancer each year making it the leading cause of cancer related death amongst men in the United States. The disease strikes 1 in 7 men and proves to be fatal for 1 in 36 diagnosed. According to the National Cancer Institute at the National Institutes of Health, the United States is estimated to see 233,000 6 FLORIDA MD - AUGUST 2014

Enter PSA, or Prostate-Specific Antigen - a substance produced by the prostate gland and key marker of significant prostate diseases. Assessing the levels of this substance, in men, helps to diagnose prostate cancer and ultimately save lives.

PSA Screening Since its inception in the early 1990s, this simple blood test has been used for routine screening and detection of prostate cancer.

This test has resulted in a consistent, yearly reduction in the death rate associated with prostate cancer, as well as providing valuable insight needed to provide comprehensive patient care.

Since the advent of PSA screening there has been a 40% reduction in prostate cancer mortality. Despite this proven validity, the PSA screen has in the recent years emerged as a focus for much controversy. In May 2012, the U.S. Preventive Services Task Force (USPSTF), a government advisory panel, suggested that doctors stop using the PSA test as a means to screen men for prostate cancer. Their opinion was that screenings did not save lives but actually may cause harm.

The Controversy Clarified When the USPSTF issued its recommendations against PSA screening the urologic community expressed its outrage. These new recommendations issued a Grade D rating for PSA-based screening, with the USPSTF discouraging its use in the practice of prostate cancer diagnosis. Urology physicians argue that these recommendations were made after a review and interpretation of available data that was both flawed and short term.

This creates a topic of grave concern in the urologic community; such recommendations pose a great disservice to men.

The Fight for a Resolution Leaders throughout the urologic community including the American Urological Association (AUA), the American Cancer Society and Dr. Patel have joined together in opposition, vocal-

COVER STORY Photo: PROVIDED BY FLORIDA HOSPITAL GLOBAL ROBOTICS INSTITUTE:

izing the shear importance of PSA screening for men - the only widely available test for prostate cancer. As one of the world’s foremost prostate cancer surgeons, Dr. Vipul Patel has intently assumed responsibility in urging the USPSTF to recant such negative recommendations.

By way of an online petition, Patel encouraged and urged supporters to engage by voicing concern at www.change.org. To date, 5,711 electronic signatures have been collected, over half of the desired 10,000 signatures, a number Dr. Patel believes will stage a successful stance for proposed legislation. His position, highlighted below, hinges on the belief that what is ultimately most important is forward movement & knowledge of this formidable disease.

“Though I enjoy taking care of prostate cancer patients, like any surgeon, I truly would love to be out of business one day, simply because we’ve identified a cure. PSA is a big part of that course, in addition to research and education. I am in the business of saving lives, and hopefully prevention will one day overcome intervention.” - Dr. Patel.

According to Patel, to discourage screenings would more than likely reverse any gains made in cancer cure rates to this point.

This will cause devastating results in the forward movement of research and treatment of prostate cancer.

“Men diagnosed early with prostate cancer have greater than a 90% chance of cure. This ill-advised recommendation could mean a death sentence for thousands of men around the world. Whereas, I believe that every man deserves the right to know if he has cancer,” - Dr. Patel.

Dorsal vein ligation.

This further supports the importance of PSA testing as it leads to detection of prostate cancer and provides the patient time to make informed decisions on their health.

To universally dismiss the PSA test before a suitable alternative to prostate cancer diagnosis is available would simply be an injustice to all men and their families.

South Carolina Senator Nikki Setzler honors Dr. Patel for his work in the effort to beat prostate cancer.

On March 12, 2013, exciting progress was made in the fight for change to these negative PSA recommendations. The South Carolina House passed a resolution to petition U.S. Congress to retract the USPSTF recommendations against PSA screening. With continued support of the movement, positive changes appear to be on the horizon.

A Reason to Recant Photo: PROVIDED BY FLORIDA HOSPITAL GLOBAL ROBOTICS INSTITUTE

The argument is simple; the decision to be tested for prostate cancer is an individual decision with no single standard that applies to all men - nor should there be. When used and interpreted appropriately, PSA testing provides critical information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. The benefits must not be discounted!

The importance of PSA testing is also strongly supported in a recent article published in the New England Journal of Medicine. According to this study conducted over a 23 year span following 695 men with prostate cancer, it was determined that there was a significant reduction in deaths after radical prostatectomies were performed verses men who only prescribed by watching waiting.

FLORIDA MD - AUGUST 2014

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COVER STORY Learning More For more information on the Florida Hospital Global Robotics Institute, Dr. Vipul Patel or questions regarding prostate cancer, please call the Global Robotics Institute at (866) 923-2863. You can also read more about GRI at globalroboticsinstitute.com and by visiting GRI’s Facebook page at facebook.com/celebrationgri.

Dr. Patel’s office is located at 410 Celebration Place, Suite 200, Celebration, FL 34747.  FLORIDA HOSPITAL CANCER INSTITUTE GUIDELINES

WHAT EVERY MAN SHOULD KNOW psa testing explained WHO SHOULD BE SCREENED? At 40, men with life expectancy greater than 10 to 15 years should consider screening.

Additionally, doctors should begin speaking with men about screening according to these

RISK CATEGORIES

VERY

(men with more than one first degree relative — father, brother, son — diagnosed with prostate cancer): Conversation at age 40

HIGH

(men of African American descent and/or those with a single first degree relative diagnosed before age 65): Conversation at age 45

HIGH RISK:

RISK:

What is the International Prostate Cancer Foundation (IPCF)?

Founded by Dr. Patel with the mission of ending prostate cancer, the IPCF funds research efforts, provides education regarding prostate cancer and promotes prostate cancer screening worldwide.

Created with help from a team of expert doctors, prostate cancer patients, and community leaders, the spirit of the foundation is from within: a culmination of the inspirational ideas and the challenges faced by men with prostate cancer.

Having treated over 7,500 men, Patel along with the IPCF, have learned from the experiences of these men that a monumental challenge lies ahead: eradicating the cancer while preserving their quality of life. What makes IPCF unique is that it is lead by doctors that work with these patients on a daily basis. These men have searched their souls seeking support, inspiration and compassionate care - and it is this that IPCF ultimately seeks to fulfill.

Screenings should include a PSA and DRE. For men whose life expectancy is less than 10 to 15 years, screenings should not be offered.

“Our mission functions through three pillars: clinical research, education for both patients and physicians, and the recommendation and availability of global screenings.” - Vipul R. Patel, MD, IPCF Founder and Chairman

Blueprint for Men’s Health — A GRI Survivorship Program

To get involved in the fight against prostate cancer or learn more about prostate cancer, please visit the International Prostate Cancer Foundation at www.fightingprostatecancer.com.

AVERAGE RISK:

Conversation at age 50

Always an innovator, Patel has recently created Blueprint For Men’s Health – A GRI Survivorship Program, which caters to the families and patients of prostate cancer survivors. The Blueprint for Men’s Health program is a guide for patients to achieve a healthy lifestyle and an enhanced quality of life. It is a dynamic personalized health care plan, specifically focused on survivorship, evolving from a comprehensive, multidisciplinary assessment of the patient’s disease, the surgical treatment provided and their individualized needs as they develop over time.

It encourages the patient to self-manage and adjust to the results of surgical or medical intervention and the required ongoing follow-up. For more information on this program, visit globalroboticsinstitute.com/blueprint.

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International Prostate Cancer Foundation 52 Riley Road, Suite 322, Celebration, FL 34747 (407) 301-4299 info@ipcfund.org Website: FightingProstateCancer.com (translatable to Português & Español) Blog: endprostatecancer.wordpress.com Online: General, monthly, planning giving, matching, in honor/memory gifts can be made (through PayPal) at FightingProstateCancer.com.

Healthcare Law

Federal Sunshine Act Open Payments Program

By Troy Kishbaugh, JD and Julie Tyk, JD The Physician Payment Sunshine Act (“Sunshine Act”) is a provision of the Affordable Care Act. Starting in 2014 a publicly available federal website, “Open Payments” will display information about payments and other transfers of value from manufacturers and group purchasing organizations (GPOs) to individual physicians (including medical doctors, doctors of osteopathy, dentists, chiropractors, podiatrists, optometrists and others) and teaching hospitals.

According to the Centers for Medicare & Medicaid Services (CMS) “Open Payments is a national disclosure program that promotes transparency by publishing the financial relationships between the medical industry and healthcare providers (physicians and hospitals) on a publicly accessible website developed

by CMS.”

Troy A. Kishbaugh , JD

Julie Tyk, JD

For more information on the Open Payments Program, please contact Troy A. Kishbaugh or Julie A. Tyk with GrayRobinson’s Health Care Practice Group.

Troy A. Kishbaugh, JD, BCS, is an equity shareholder and Chair of the Health Care Practice Group with GrayRobinson P.A. Troy focuses his practice in the area of health care law which includes, medical/health corporate law issues, Medicare/Medicaid, fraud and abuse, false claims,

Applicable manufacturers and applicable GPOs began collecting the required data on August 1, 2013. Information posted will include detailed information about payments and other “transfers of value” worth over $10 from manufacturers to physicians. There are 14 categories of payments and transfers of value to physicians including, without limitation: consulting fees, compensation for speaking or other services, travel, food, entertainment, gifts, honoraria, royalties or licenses, charitable contributions, education, and current or prospective ownership or investment interests. Manufacturers as well as GPOs are required to report to CMS on interests held by physicians and their immediate family members.

billing and reimbursement, corporate compliance, PPACA,

CMS has announced that most of the data will be released on the public website on September 30, 2014, and once annually thereafter. The initial data release will cover industry payments from August 1, 2013 through December 31, 2013.

P.A. Julie concentrates her practice in peer review, medical

Initial registration for physicians and teaching hospital representatives for the Open Payments system became available on June 1, 2014 and is available at https://portal.cms.gov/wps/portal/unauthportal/registration. The Open Payments review and dispute process began on July 14th and ends August 27, 2014.

According to CMS “the review, dispute and correction process allows physicians and teaching hospitals to review and initiate any disputes regarding the data reported about them by applicable manufacturers and applicable GPOs before CMS makes the information public on September 30, 2014.”

ry surgical centers, nurses and other health care providers

Individual physicians and teaching hospitals will be responsible for checking their information posted on the site and for contacting manufacturers to address any discrepancies. Physicians and teaching hospitals will need to register with the site to preview their information and, if needed, work with manufacturers to correct payment information. CMS has stated that it “will not mediate any dispute.”

HIPAA, health information technology, EMTALA, Stark, self-disclosure and exclusions, and daily hospital operational issues. He may be contacted by calling (407) 2445673; troy.kishbaugh@gray-robinson.com or by visiting www.gray-robinson.com.

Julie A. Tyk, JD, is an attorney in the Health Care Practice and Litigation Practice Groups with GrayRobinson, malpractice, transportation litigation and insurance defense. She has represented physicians, hospitals, ambulatoacross the state of Florida. She may be contacted by calling (407) 244-5694; julie.tyk@gray-robinson.com or by visiting www.gray-robinson.com.



Coming UP Next Month:

A profile on UCF Pegasus Health, the College of Medicine’s physician practice, that provides primary and specialty care to patients across the community ages 16 and up. See how physicians who are teaching tomorrow’s healthcare leaders are also providing individualized, evidence-based care to patients. Editorial focus is on Pediatrics and Autism.

FLORIDA MD - AUGUST 2014

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PULMONARY AND SLEEP DISORDERS

Pulmonary Manifestations of Rheumatoid Arthritis

By Daniel T. Layish, MD Rheumatoid arthritis (RA) is a systemic autoimmune process classically known for chronic symmetrical erosive synovitis. It is generally progressive. Lungs are the site of a myriad of nonarticular manifestations of RA. Other non-articular manifestations can include subcutaneous nodules, vasculitis, pericarditis, mononeuritis multiplex, and episcleritis.

Pleuropulmonary manifestations of RA include: 1. RA associated interstitial lung disease (ILD) 2. Pulmonary nodules 3. Large and small airway obstruction 4. Pleural disease 5. Vascular disease (including vasculitis and pulmonary hypertension).

In addition, pleuropulmonary infections can occur (related to RA itself as well as drug-induced immunosuppression) and druginduced pulmonary toxicity can occur related to medication use to treat rheumatoid arthritis. Furthermore, in a given patient, multiple pleuropulmonary syndromes can overlap (for example interstitial lung disease and pleural thickening). Prevalence of RA associated respiratory disease is difficult to estimate because of variations in study population and different techniques utilized to detect disease (HRCT versus pulmonary function tests versus autopsy, etc). In many cases, pleuropulmonary involvement can be subclinical, which further complicates epidemiologic assessment. Overall, the most common pleuropulmonary manifestations of RA appeared to be interstitial lung disease (ILD) and pleural disease.

RA related ILD can include various histologic patterns including nonspecific interstitial pneumonia (NSIP), usual interstitial pneumonia (UIP), organizing pneumonia (OP), lymphocytic interstitial pneumonia (LIP), desquamative interstitial pneumonia (DIP), and acute interstitial pneumonia (AIP). Patients with RA related ILD that are most likely to benefit from aggressive immunosuppression include younger patients, patients with histopathologic patterns other than UIP, and/or evidence of physiologic and/or radiographic progression over the proceeding three to six months.

Pleural disease is most common in patients with longstanding RA, but can precede joint disease. It is more common in men and coexists with rheumatoid nodules and ILD in up to 30% of patients. RA related pleural disease can often be subclinical. It can include exudative inflammatory pleural effusions. Rheumatoid nodules can develop necrosis and cavitation and rupture into the pleural space with creation of a bronchopleural fistula. Other manifestations include chyliform or “cholesterol” pleural effusion as well as “trapped lung.” Empyema also needs to be considered 10 FLORIDA MD - AUGUST 2014

in the differential diagnosis of these immunocompromised patients when they present with a pleural effusion.

Upper airway obstruction can occur in RA because of cricoarytenoid arthritis, less common causes include vasculitis involving the recurrent laryngeal or vagus nerves, which can then cause obstruction due to vocal cord paralysis.

Upper airway disease is more common in women and in longstanding RA. Unfortunately, symptoms of upper airway obstruction can often be absent until significant airway obstruction occurs and the patients can present with stridor. It is important to remember that because RA can be complicated by cervical spine instability, intubation should be performed by highly experienced clinicians with care to avoid excessive neck flexion.

Small airway dysfunction is known to occur in up to 24% of non-smokers with RA. Small airway abnormalities can be seen on HRCT in many patients who did not have physiologic evidence of airway obstruction. This phenomenon is of unclear clinical significance. Obliterative bronchiolitis (OB) is a rare (and usually fatal) condition characterized by progressive concentric narrowing of membranous bronchioles. OB has been associated with both RA itself and drugs utilized in the treatment of RA. OB appears to be more common in women.

Follicular bronchiolitis (lymphoid hyperplasia of bronchus associated lymphoid tissue) can also occur in rheumatoid arthritis (either alone or in combination with NSIP). On HRCT, this can cause centrilobular or peribronchial micro-nodules (less than 3 mm) with branching linear structures, which can include bronchial dilation and bronchial wall thickening. Bronchiectasis has also been reported in up to 30% of patients with RA and can occur without evidence of ILD. Rheumatoid Nodules (CT Scan)

PULMONARY AND SLEEP DISORDERS Rheumatoid nodules are the only pulmonary manifestations specific for RA. Rheumatoid lung nodules occur more often in patients with a longer duration of disease and concomitant subcutaneous rheumatoid nodules. They are usually located in subpleural areas or interlobular septa, range in size from a few millimeters to several centimeters and may be single or multiple, solid or cavitary. Rheumatoid nodules can cause hypermetabolism on a PET scan (even in the case of nonmalignant rheumatoid nodules). Rheumatoid nodules can resolve spontaneously and complications such as bronchopleural fistula are infrequent.

Caplan’s syndrome refers to a combination of RA and occupational dust exposure (pneumoconiosis). This can cause rapid development of multiple basilar nodules with mild airflow obstruction. Caplan’s syndrome can also be complicated by the development of progressive massive fibrosis.

Drug-induced lung disease in the setting of RA is beyond the scope of this article, but drug reaction should be considered in the differential diagnosis of physiologic and radiographic abnormalities in patients with RA. RA can also cause thoracic cage abnormalities, which can impact pulmonary function.

RA appears to increase the risk of venous thromboembolic disease slightly (even after controlling for other risk factors).

There also appears to be a slightly increased risk of developing lung cancer in patients with RA when compared to the general population.

Rheumatoid Lung Nodules (Histopathology)

Primary pulmonary vasculitis is quite rare. Pulmonary hypertension can be related to underlying vasculitis. Clinical manifestations can be similar to those of idiopathic pulmonary arterial hypertension. Secondary pulmonary hypertension (WHO Group 3) can occur in the setting of RA related ILD. Given the multiple pleuropulmonary manifestations of RA, the monitoring and management of these patients can be quite challenging and often will involve close collaboration between a variety of specialists including a pulmonologist and a rheumatologist. Pulmonary infection can be a major contributor to morbidity and mortality in patients with RA. Vaccination against Pneumococcus and influenza should be considered in all patients with RA. Pneumocystis prophylaxis should be considered in some patients with RA (depending on their level of immunosuppression).

ORTHOPAEDIC SUBSPECIALTIES UÊ Ê Ê

Daniel Layish, MD, graduated UÊ "7 magna cum laude from Boston UniUÊ ""/ÊEÊ UÊ ÊEÊ7, -/ versity Medical School in 1990. He UÊ * then completed an Internal Medicine UÊ Residency at Barnes Hospital (WashUÊ- "1 , UÊ" " " 9 ington University) in St.Louis, MisUÊ* /, souri and a Pulmonary/Critical Care/ UÊ-*",/-Ê

UÊ* Ê / Sleep Medicine Fellowship at Duke UÊ* 9- Ê/ , *9 University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Codirector of the Adult Cystic Fibrosis SAME DAY, NEXT DAY APPOINTMENTS AVAILABLE Program in Orlando. Dr. Layish may OVIEDO SATURDAY WALK-IN CLINIC be contacted at 407-841-1100 or by NO APPOINTMENT NECESSARY | 9AM - 1PM Downtown Orlando | Winter Park | Sand Lake | Lake Mary | Oviedo | Lake Nona visiting www.cfpulmonary.com. 

HELPING YOUR PATIENTS

GET BACK TO WHAT THEY LOVE

REQUEST YOUR APPOINTMENT AT ORLANDOORTHO.COM 407.254.2500 FLORIDA MD - AUGUST 2014 11

CANCER

Robotic-Assisted Thoracic Surgery, Not Surgery by the Robot

By Eric M. Toloza, MD, PhD Traditional thoracic surgery involved large incisions in order to adequately expose the relevant chest cavity and visualize the target organ. For example, heart surgery, such as for coronary artery bypass grafting or cardiac valve surgery, or resection of mediastinal masses, such as thymectomies for thymomas, traditionally required a full sternotomy incision in order to adequately expose the pericardial cavity or the mediastinum, respectively, and to visualize the heart or the involved mediastinal structure, such as the thymus, respectively. Similarly, lung surgery, such as for lung cancer, traditionally required a large thoracotomy incision in order to expose the involved pleural cavity and to visualize the involved lung. These thoracotomy incisions usually involved division of both the latissimus dorsi and the serratus anterior muscles and often resection of the entire 5th rib to achieve this exposure. Although the cut edges of the latissimus dorsi and the serratus anterior muscles would subsequently be reapproximated with sutures, these muscles would never Surgeon’s Binocular View and Hand Controls at the VinciŽ regain their original strength due to denervation of the distal half of each Surgeon Console. (Photograph courtesy of Intuitive of these muscles. For esophageal surgery, the traditional incisions required Surgical Corporation.) both a large abdominal incision to expose and mobilize the stomach and a large thoracotomy incision to expose and resect the esophagus and to construct the gastric conduit. However, these large incisions are associated with significant morbidity, such as increased intraoperative bleeding, increased risk of infection, increased postoperative pain, increased narcotic-associated complications, longer hospital stays, and longer recovery periods.

In attempts to decrease these postoperative sequelae, approaches that utilized smaller incisions and that spared previously divided muscles were developed. Partial sternotomy techniques were developed for cardiac and for mediastinal surgery. Muscle-sparing thoracotomy techniques were developed, in which one or both of the latissimus and the serratus muscles were not divided and in which the 5th rib was not resected. In contrast to traditional thoracotomies, muscle-sparing approaches resulted in the patient eventually regaining full muscle strength, but these still relatively large incisions still resulted in significant postoperative pain and morbidity and in prolonged hospital stays and recovery periods. In addition, these smaller incisions, while still relatively large, decreased exposure of the relevant body cavity and visualization of the target organ during surgery.

With the development of video technology in order to improve visualization within the relevant body cavities and of target organs, surgical incisions were able to be further minimized in order to decrease postoperative sequelae even more. Initial success with minimally invasive pelvic and abdominal surgery, such as with laparoscopic hysterectomies in gynecology and with laparoscopic cholecystectomies in general surgery, respectively, were then translated to video-assisted thoracoscopic (VATS) procedures, including lung resections, esophageal resections, mediastinal resections, such as VATS thymectomies, and even many cardiac procedures, such as VATS mitral valve repair or replacement. Minimally invasive VATS surgical procedures have well-established advantages over traditional open thoracic surgery via thoracotomy, including less intraoperative bleeding, less need for perioperative blood transfusions, smaller surgical incisions, less postoperative pain, less need for postoperative narcotics, reduced exposure of internal organs, less perioperative inflammatory response, shorter hospital stays, shorter recovery times, faster return to routine activities of daily living, reduced infection risk, and less postoperative scarring.

Long narrow surgical instruments were developed in order to be able to reach the farthest recesses of the relevant body cavities through these small 12 FLORIDA MD - AUGUST 2014

CANCER diastinum during mediastinal lymph “keyhole” incisions, but use of these node dissection. For minimally invastraight non-articulating instruments was sive thoracic procedures, such as VATS akin to operating with chopsticks. While lobectomies or esophagectomies, these a few instruments with articulating tips advancements in instrumentation alhave been designed, articulation often lows for more precise hilar dissection required complicated controls, such as and less risk of intraoperative compliwheels and levers to realize the articulacations and less risk of conversion to tion. Moreover, use of these instruments open lung or esophageal resection via was counterintuitive, as need to move a large thoracotomy, in which case the the working internal end of the instrupatient loses the benefit of minimally ment in one direction required that the invasive surgery. Thus, robotic-assisted surgeon move the external handle of the surgery would allow minimally invainstrument in the opposite direction. For sive surgical procedures to be within example, to move the working internal reach of more thoracic surgeons, esend of the instrument up, surgeons must pecially those who are currently permove their hands down, and to move forming mainly open thoracic surgithe working internal end to the left, surcal procedures, and to be available to geons must move their hands to the right. more patients who would benefit from These shortcomings in surgical instruthe advantages of VATS surgery. For ments has limited the widespread adoponcologic procedures, robotic-assisted tion of VATS surgery, with less than 45% thoracic surgery improves mediastinal of all lobectomies in the United States lymph node dissection and improves being performed by VATS approach dedetection of mediastinal lymph node spite almost 20 years since the first VATS The da Vinci Robotic Patient Cart: (A) Holds up metastases,4 which translates to pato 3 surgical instruments and a video telescope; lobectomy in 1991 and with 80% of (Photograph courtesy of Intuitive Surgical tients with clinically occult pathologic VATS lobectomies being performed at Corporation.) and (B) Docks to the patient on the 1,2,3 stage-2 or stage-3 disease being able to specialized academic centers. operating room table, here during a typical right be offered the necessary adjuvant cheAddition of a robotic surgical system lung resection, with the robotic arms covered by motherapy or adjuvant chemotherapy plastic sleeves for sterility (Photograph by Eric M. (da Vinci®, Intuitive Surgical CorporaToloza, M.D.) with radiation therapy, respectively, tion, Sunnyvale, California) to VATS and which in turn would be expected to improve cancer-related surgical procedures corrects several of the shortcomings of VATS patient survival rates. After all, are not improved postoperative cameras and instruments. First, at the surgeon console, the robotic outcomes and improved survival rates our ultimate goals for our system’s binocular cameras provide the surgeon with a high-deficancer patients? nition, 3-dimensional view of the operating field, which provides References available upon request improved depth of perception compared to the 2-dimensional image provided by conventional VATS cameras. Second, the roEric Toloza, M.D., Ph.D., associate member of the Thobotic system computer translates the surgeons hand movements racic Oncology Program at Moffitt Cancer Center, received at the surgeon console to equivalent movements of the robotic his undergraduate degree in 1984 at the University of surgical instrument working tips within the patient, which is California, Los Angeles. He also received both his medical contrary to the popular misconception that the robot itself performs the surgery. The surgeon simply manipulates the hand degree and a Ph.D. from UCLA. Dr. Toloza is involve in controls within the surgeon console as he or she would control several lung cancer clinical research programs and has ausurgical instruments during a traditional open surgical procedure thored or co-authored numerous medical journal articles, via a full sternotomy or thoracotomy incision. When the surgeon needs to move robotic instrument working tips up, the surgeon moves the controls up, and when the surgeon needs to move the robotic instrument tips to the left, the surgeon moves the controls to the left. Moreover, the robotic system has the capacity to scale down the surgeon’s hand movements and to reduce any hand-related tremors. Third, the articulating robotic instrument working tips has the same or more degrees of motion than the human hand and improves the ability of the surgeon to complete surgical procedures that require operating around and behind structures, such as around the pulmonary artery and vein and around the bronchus within the pulmonary hilum during a lung resection, and within deep narrow spaces, such as within the me-

book chapters, and books. He is involved in the evaluation

and aggressive combined-modality treatment of all stages of lung cancer and mesothelioma, as well as in the evaluation and treatment of mediastinal and chest wall masses and also pulmonary metastases from a variety of primary extrathoracic malignancies. He is also one of only a few thoracic surgeons worldwide who is certified to perform robotic-assisted thoracic surgery for primary lung cancer, pulmonary metastases, and mediastinal masses.



FLORIDA MD - AUGUST 2014 13

Marketing Your Practice

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

By Jennifer Thompson

Take advantage of back to school time by promoting select services at your practice.

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

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

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

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

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

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

Here’s how to reach them.

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

Step one is determining your concept and step two is applying Create something that will capture the attention of your target audience: the parents.

14 FLORIDA MD - AUGUST 2014

to the medium of your choosing.

Choose your message carefully for your collateral. You’ve only got one shot to engage the parent of your target patient, so it better be good. Your concept should be kid-focused and easy to read.

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

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

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

2. Repurpose Content Do you already have content from previous back to school seasons? How about general patient education pieces or news items about what you do?

Content creation. Caption: Rework content you have already created with a back to school theme and put it on your website.

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

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

Marketing Your Practice 3. Put Together a Resource Center on Your Website Can you modify your website? Even if you can only create a news (blog) post, put something together to act as a “resource center” for back to school season. If you can change out image sliders and create pages, that’s great. Do that, too.

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

What should your resource center include?

• Any relevant content you have (see no. 1 and 2 above) • Helpful links (perfect if you don’t have the content – link to a reputable website or news outlet that does) • Videos of your physicians discussing procedures, trends, topics and things to be aware of this time of year (or general procedures that could be applied to a younger population) • New patient forms • Appointment request information Rework content you have already created with a • A motivating call to action back to school theme and put it on your website.

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

Even with little to no budget, you can create momentum around back to school time to build your medical practice and find new patients in your community. Now get to work before you’re late for class.

Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better. 

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

Specializing in:        

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

Our physicians are Board Certified in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Sleep Medicine Daniel Haim, M.D., F.C.C.P.

Eugene Go, M.D., F.C.C.P.

Andres Pelaez, M.D., F.C.C.P.

Daniel T. Layish, M.D., F.A.C.P., F.C.C.P.

Mahmood Ali, M.D., F.C.C.P.

Jorge E. Guerrero, M.D., F.C.C.P.

Francisco J. Calimano, M.D., F.C.C.P.

Steven Vu, M.D., F.C.C.P.

Neveen A. Malik, D.O., F.C.C.P.

Francisco J. Remy, M.D., F.C.C.P.

Ruel B. Garcia, M.D., F.C.C.P.

Roberto Santos, M.D.

Ahmed Masood, M.D., F.C.C.P.

Tabarak Qureshi, M.D., F.C.C.P. Timur Graham, M.D.

Syed Mobin, M.D., F.C.C.P.

Kevin De Boer, D.O., F.C.C.P.

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

407.841.1100 phone | www.cfpulmonary.com | Most Insurance Plans Accepted FLORIDA MD - AUGUST 2014 15

Financial Update: Insurance • Benefits • Wealth Management

Market Review

By T. Kevin Taylor, JD, LLM

If you don’t have to return to work until Monday 9/08/14, then you may be one of the 535 members of Congress that are now on recess until the week after the Labor Day holiday. Upon their return to Washington, the 435 House members and 33 Senators that are up for re-election will have just 57 days until the 11/04/14 mid-term voting takes place. Democrats are hoping to avoid the performance of the Republicans in the 2006 mid-terms (i.e., 6 years after President Bush took office) when the party not in control of the White House picked up 30 House seats and 6 Senate seats (source: Congress).

As had been expected, the Federal Reserve announced on 7/30/14 that its monthly asset purchases will be $25 billion going forward, the 6th reduction since December 2013 when purchases were $85 billion a month. The Fed is on track to end its “printand-purchase” policy at its late October 2014 meeting. When the current program was announced by the Fed on 9/13/12, then Chairman Ben Bernanke anticipated running with the strategy “as long as necessary,” stating at the time that interest rates will be kept at historically low levels through at least the middle of 2015 (source: Federal Reserve).

The government reported strong +4.0% growth in the US economy during the 2nd quarter (i.e., quarter-over-quarter change expressed as an annualized number), the largest increase over the previous quarter’s result in 14 years. This caused the bond market to react negatively (i.e., prices down and yields up), anticipating that the huge jump in the economy may push the Fed into earlier action than had been expected. But the nation’s jobs report at week’s end (gain of +209,000 new hires) was far from robust and quickly dampened the heady expectations of premature Fed rate hikes (source: BTN Research).

Notable Numbers for the Week: 1. FIFTY YEAR BOND? - The US government is soliciting indications of interests in Treasury bonds with maturities longer than 30 years. Mexico offered a 100-year bond in March 2014 (source: BTN Research).

2. A BETTER WAY - Almost 3 in 4 Americans (72%) that have inherited assets from deceased parents plan on handling the disposition of their wealth differently than the way their parents transferred assets (source: UBS).

3. MOST ARE UNPREPARED - Just 5% of Americans currently on Medicare have retirement savings of at least $1.11 million. 50% have savings less than $61,400 (source: Kaiser Family Foundation).

4. IMPACTING THOUSANDS – The city of Detroit filed for 16 FLORIDA MD - AUGUST 2014

Chapter 9 bankruptcy protection on 7/18/13. Judge Steven Rhodes will preside over the city’s bankruptcy trial, scheduled to begin on 8/21/14 (source: The Detroit News).

Securities offered through NFP Securities, Inc., Member FINRA/SIPC. NFP Securities, Inc. is not affiliated with The Vaughn Group, Inc. This material represents an assessment of the market and economic environment at a specific point in time and is not intended to be a forecast of future events, or a guarantee of future results. Forward-looking statements are subject to certain risks and uncertainties. Actual results, performance, or achievements may differ materially from those expressed or implied. Information is based on data gathered from what we believe are reliable sources. It is not guaranteed by NFP Securities, Inc. as to accuracy, does not purport to be complete and is not intended to be used as a primary basis for investment decisions. It should also not be construed as advice meeting the particular investment needs of any investor. The indices mentioned are unmanaged and cannot be directly invested into. Past performance does not guarantee future results. The S&P 500 is an unmanaged index of 500 widely held stocks that is generally considered representative of the US stock market. Copyright © 2014 Michael A. Higley. All rights reserved.

Kevin is a principal at The Vaughn Group, Inc. and manages the wealth management department. Before becoming a financial advisor, Kevin practiced law in Orlando, focusing on tax, estate, and asset protection planning for ultra-high-net-worth families. As a financial advisor, he has presented educational seminars and made presentations to the Florida Bar Association, regional Estate Planning Councils, the National Association of Retired Employees, the Arthritis Foundation, and the National Business Institute.

Kevin graduated from the University of Florida with a B.A. in Economics, a J.D. with Honors, and a Masters of Laws in Taxation. He can be reached via email at kevin@ vaughngroup.com or by phone at (407) 872-3888. The Vaughn Group, Inc.’s offices are located at 1407 E. Robinson St., Orlando, FL 32801. 

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

AUGUST 2014 • COVERING THE I-4 CORRIDOR • SPECIAL FEATURE

Florida Vein Care & Cosmetic Center

EndoVenous Laser Treatment (EVLT) – A Minimally Invasive Option for Vein Disease FLORIDA MD - AUGUST 2014

3

SPECIAL FEATURE

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 five 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.

18 FLORIDA MD - AUGUST 2014

SPECIAL FEATURE

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 physi-

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.

FLORIDA MD - AUGUST 2014 19

PR OO Bragg.after A Sigvaris support should be worn forfollow-up one week one week the treatment and stocking patients must schedule a brief after the treatment and patients must schedule a brief 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 20 FLORIDA MD - AUGUST 2014

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

PHOTO BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

F

PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES

DQG WKHQ VHDO LWVHOI 'XULQJ WKH SURFHVV ORFDO SPECIAL FEATURE anesthetic is delivered inside the vein so the patient doesn’t feel the heat. When the cian removes it from the vein, applies a small laser tip is withdrawn back to the knee, the piece of tape along with a Sigvaris graduated physician removes stocking. it from the vein, applies compression The patient is asked to D VPDOO SLHFH RI WDSH DORQJ ZLWK D 6LJYDULV get up and begin walking in the office to check JUDGXDWHG FRPSUHVVLRQ VWRFNLQJ 7KH SDWLHQW for bleeding and reduce the risk of clots. “With LV DVNHG WR JHW XS is DQG EHJLQ ZDONLQJ WKH EVLT, there reduced risk of LQ anesthesia, reRIÂżFH WR FKHFN IRU EOHHGLQJ DQG UHGXFH WKH duced risk of infection, reduced cost and inULVN stead RI FORWV (9/7 UHGXFHG of aÂł:LWK one inch scarWKHUH as isLV the case with vein risk stripping, of anesthesia, reduced risk of infection, the patient has a tiny three millimereduced cost and at instead of a one inch scar ter incision the knee,â€? remarks Dr. Bragg.

DV LV WKH FDVH ZLWK YHLQ VWULSSLQJ WKH SDWLHQW “Female patients say they can finally wear skirts has awithout tiny three millimeter incision at teachers the being embarrassed and are NQHH ´ UHPDUNV 'U %UDJJ Âł)HPDOH SDWLHQWV amazed that their legs feel fine at the end of a VD\ WKH\ FDQ ÂżQDOO\ ZHDU VNLUWV ZLWKRXW EHLQJ long day on their feet.â€? Dr. Bragg has done over embarrassed and procedures teachers aresince amazed that 1500 EVLT 2002.

WKHLU OHJV IHHO ¿QH DW WKH EVLT HQG RI procedure, D ORQJ GD\ Dr. Bragg After nearly every RQ WKHLU IHHW ´ 'U %UDJJ KDV GRQH RYHU points out that it is usually necessary to have Dr. Bragg sees all patients in consultation. He explains venous anatomy, pathology and EVLT since 2002. anprocedures ambulatory phlebectomy on the remaining treatment options.

After nearly every EVLT procedure, Dr. removal bulging veins. “This is a micro-surgical Dr. Bragg sees all patients in consultation.

He explains venous anatomy, pathology and %UDJJ WKDW LW veins LV XVXDOO\ The consultation, the in-office diagnostic ultrasound, and the of SRLQWV surfaceRXW varicose usingQHFHVVDU\ a small vein hook,â€? says Dr. Bragg. treatment options. to have an ambulatory phlebectomy on the procedure is covered by most insurance plans. “Phlebectomy is also done in the center under local anesthesia UHPDLQLQJ EXOJLQJ YHLQV Âł7KLV D PLFUR through tiny incisions thatLV require no stitches and leave nearly Laser treatment holds great promise in the field of phlebology, 7KH FRQVXOWDWLRQ WKH LQ RIÂżFH GLDJQRVWLF XOWUDVRXQG DQG WKH SURFHGXUH VXUJLFDO UHPRYDO RI scars.â€?

VXUIDFH YDULFRVH YHLQV imperceptible After the vein has been removed, a bandage says Dr. Bragg. Today, EVLT can be used on the greater saphenis covered most saphenous insurance plans.

XVLQJ D VPDOO YHLQ KRRN ´ VD\V 'U %UDJJ ³3KOHEHFWRP\ LV DOVR GRQH LQ WKH and stocking is worn for one week. ous vein,byshort vein and perforator veins. These three /DVHU WUHDWPHQW JUHDW SURPLVH LQ the WKH ¿HOG FHQWHU XQGHU ORFDO DQHVWKHVLD WKURXJK WLQ\ LQFLVLRQV WKDW UHTXLUH QR VWLWFKHV Sclerotherapy is used in treatment for spider and varicose veins areas cause most KROGV varicose veins seen in legs. RI SKOHERORJ\ VD\V 'U %UDJJ 7RGD\ (9/7 FDQ EH XVHG RQ WKH JUHDWHU VDSKHQRXV YHLQ and leave nearly imperceptible scars.�

Afterby theexperts vein hassince beenits removed, a and has been developed and refined introducDr. Bragg received his pre-medical Bachelor’s degree from saphenous vein and perforator veins. These three areas cause most EDQGDJH DQG VWRFNLQJ LV ZRUQ IRU RQH ZHHN tion in Europe nearly a century ago. It’s become popular in the short Louisiana State University in 1988. After graduating from LouiYDULFRVH YHLQV VHHQ LQ WKH OHJV Sclerotherapy treatment spider and varicose veins and United Statesisinused theinpast decade.forOnce diseased veins are identisiana State University Medical School in 1992, he was selected 'U %UDJJ UHFHLYHG KLV SUH PHGLFDO %DFKHORUÂśV GHJUHH IURP /RXLVLDQD KDV EHHQ GHYHORSHG DQG UHÂżQHG E\ H[SHUWV VLQFH LWV LQWURGXFWLRQ LQ (XURSH fied, a sterile solution of “sclerosingâ€? material is injected microfor internship and residency at Florida Hospital’s Family Practice 6WDWH 8QLYHUVLW\ LQ $IWHU JUDGXDWLQJ IURP /RXLVLDQD 6WDWH 8QLYHUVLW\ QHDUO\ D FHQWXU\ DJR ,WÂśV EHFRPH SRSXODU LQ WKH 8QLWHG 6WDWHV LQ WKH SDVW scopically into the vein altering the walls of the vein causing them residency program. He remains board certified in family practice GHFDGH 2QFH GLVHDVHG YHLQV DUH LGHQWLÂżHG D VWHULOH VROXWLRQ RI ÂłVFOHURVLQJ´ to collapse and dissolve. The simple procedure is safe and virtually 0HGLFDO 6FKRRO LQ KH ZDV VHOHFWHG IRU LQWHUQVKLS DQG UHVLGHQF\ DW medicine. Dr. Bragg is an instructor with the National Procedures PDWHULDO LV LQMHFWHG PLFURVFRSLFDOO\ LQWR WKH YHLQ DOWHULQJ WKH ZDOOV RI WKH painless and essentially improves the circulation in the legs by di- )ORULGD +RVSLWDOÂśV )DPLO\ 3UDFWLFH UHVLGHQF\ SURJUDP +H UHPDLQV ERDUG Institute and teaches physicians who come to him from around YHLQ FDXVLQJ WKHP WR FROODSVH DQG GLVVROYH 7KH VLPSOH SURFHGXUH LV VDIH verting blood flow into nearby healthy veins. Treatment does not FHUWLÂżHG LQ IDPLO\ SUDFWLFH PHGLFLQH 'U %UDJJ LV DQ LQVWUXFWRU ZLWK WKH the world injection sclerotherapy, ambulatory phlebectomy and andmember teaches of physicians who come to him prevent the development of more spider veins, but the removal National DQG YLUWXDOO\ SDLQOHVV DQG HVVHQWLDOO\ LPSURYHV WKH FLUFXODWLRQ LQ WKH OHJV EVLT Procedures techniques.Institute An active the American College of of existing spider veins dramatically improve the appearance IURP DURXQG WKH ZRUOG LQMHFWLRQ VFOHURWKHUDS\ DPEXODWRU\ SKOHEHFWRP\ E\ GLYHUWLQJ EORRG Ă€RZ LQWR can QHDUE\ KHDOWK\ YHLQV 7UHDWPHQW GRHV QRW Phlebology, he volunteers many hours a year to educate physiof the area. Often, two or more sessions are required to achieve DQG (9/7 WHFKQLTXHV DFWLYH about PHPEHU RI WKH $PHULFDQ &ROOHJH RI SUHYHQW WKH GHYHORSPHQW RI PRUH VSLGHU YHLQV EXW WKH UHPRYDO RI H[LVWLQJ cians, nurses, and lay$Q people venous disease. optimum results.

3KOHERORJ\ KH YROXQWHHUV PDQ\ KRXUV D \HDU WR HGXFDWH SK\VLFLDQV QXUVHV VSLGHU YHLQV FDQ GUDPDWLFDOO\ LPSURYH WKH DSSHDUDQFH RI WKH DUHD 2IWHQ Dr. Bragg’s main office is located at 580 Rinehart Road in Lake For tiny veins on the legs, face or chest, a laser procedure us- and lay people about venous disease.

WZR RU PRUH VHVVLRQV DUH UHTXLUHG WR DFKLHYH RSWLPXP UHVXOWV Mary, Florida. His other locations are at 7009 Dr. Phillips Blvd. ing a high energy light source can be used. The laser light passes 'U %UDJJœV PDLQ RI¿FH LV ORFDWHG DW 5LQHKDUW 5RDG LQ /DNH 0DU\ )RU WLQ\ YHLQV RQ WKH OHJV IDFH RU FKHVW D ODVHU SURFHGXUH XVLQJ D KLJK and at 10902 Dylan Loren Circle in Orlando. through the skin damaging it andSDVVHV selectively targets the )ORULGD +LV VHFRQG RI¿FH LV DW 'U 3KLOOLSV %OYG LQ 2UODQGR )RU HQHUJ\ OLJKW VRXUFH FDQ without EH XVHG 7KH ODVHU OLJKW WKURXJK WKH VNLQ For more information log on to www.floridaveincare.com spider vein. The light is absorbed byWKH theVSLGHU red blood cellsOLJKW in the PRUH LQIRUPDWLRQ ORJ RQ WR ZZZ ÀRULGDYHLQFDUH FRP RU WR VFKHGXOH DQ ZLWKRXW GDPDJLQJ LW DQG VHOHFWLYHO\ WDUJHWV YHLQ 7KH LV or to schedule an appointment, call the office at (407) 805vein. The resulting heat causes the walls of the vein to seal to- DSSRLQWPHQW FDOO WKH RI¿FH DW

DEVRUEHG E\ WKH UHG EORRG FHOOV LQ WKH YHLQ 7KH UHVXOWLQJ KHDW FDXVHV WKH 8989. î Ž gether and disappear. Laser light treatment may be used in conZDOOV RI WKH YHLQ WR VHDO WRJHWKHU DQG GLVDSSHDU /DVHU OLJKW WUHDWPHQW PD\ junction with sclerotherapy.

EH XVHG LQ FRQMXQFWLRQ ZLWK VFOHURWKHUDS\ When considering treatment options, Dr. Bragg ensures :KHQ FRQVLGHULQJ WUHDWPHQW RSWLRQV 'U %UDJJ HQVXUHV WKDW that KLV his understand patients understand risk and and limitations andhave that realistic patients patients the risk andthe limitations that patients have realistic expectations for outcomes. expectations for outcomes.

Follow-Up - Follow-up an important component of Dr. Follow-Up )ROORZ XS LV DQ isLPSRUWDQW FRPSRQHQW RI 'U %UDJJÂśV Rinehart Road, Phillips Blvd., care management plan.YHLQ Unlike with DQG veinOLJDWLRQ stripping and FDUH Bragg’s PDQDJHPHQW SODQ 8QOLNH ZLWK VWULSSLQJ ZKLFK 580580 Rinehart Road, Suite 110 •7009 LakeDr.Mary, FL 32746 Suite 110 Suite 240 ligation which requires bed rest and limited activities, patients UHTXLUHV EHG UHVW DQG OLPLWHG DFWLYLWLHV SDWLHQWV ZKR XQGHUJR QRQ VXUJLFDO 7009Lake Dr.Mary, Phillips Blvd., Suite 240Orlando, • Orlando, FL 32819 FL 32746 FL 32819 who undergo non-surgical treatments are expected to get movWUHDWPHQWV DUH H[SHFWHG WR JHW PRYLQJ Âł:H ZDQW RXU SDWLHQWV WR ZDON 407.805.8989 Office 407.352.9877 Office ing. “We want ourtopatients to walk 30-40 minutes day up to 40 minutes a day for up three weeks to facilitate resolutiona of thefor treated 10902 Dylan Loren Circle • Orlando, FL 32825 407.805.8833 Fax 407.351.0755 Fax three weeks to facilitate resolution of the treated veins,â€? says Dr. YHLQV ´ VD\V 'U %UDJJ $ 6LJYDULV VXSSRUW VWRFNLQJ VKRXOG EH ZRUQ IRU

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FLORIDA MD - AUGUST 2014 21

CARDIOLOGY

Robotic Technology Advances Cardiology Procedures

By Barry Weinstock, MD Part of the excitement of being in the medical field is keeping pace with advancements in technology and procedures. Finding new ways to provide better care and treatment, while improving patient safety and outcomes, is an ongoing initiative for physicians.

As an interventional cardiologist, I am always excited by new technologies that dramatically alter the way that we practice. One such innovation is a vascular robotic system for percutaneous coronary intervention (PCI) procedures, a technology that has piqued my interest and that of interventional cardiologists across the country. I recently attended a medical conference at which I was able to “test drive” a new robotic system designed for the catheterization lab. PCI procedures, which typically utilize balloon angioplasty and stenting, are performed to restore blood flow in obstructed coronary arteries. Robotic-assisted systems allow physicians to perform the procedure from within a radiation shielded “cockpit,” rather than standing next to the patient in close proximity to the x-ray source. The cockpit contains monitors that are positioned much closer to the physician than those found in the cath lab. This set-up enhances visualization of the procedure while a control console for the physician enables operation of the bedside-mounted robotic arm.

• Increasing patient and physician radiation exposure during the placement of additional stents • Decreasing procedure profitability, since reimbursement is the same whether one or two stents are used in the procedure.

Corindus Robot

The CorPath System can advance or retract guide wires and position balloons and stents with movements as small as a millimeter, a degree of precision difficult to replicate with “manual” control. With such precision required, it’s no surprise that up to 47 percent of stents are sub-optimally placed using traditional methods, and these procedure variations can have a big impact, such as:

Aside from the enhanced accuracy, an additional benefit of using the robotic-assisted system is that it dramatically reduces radiation exposure for the physician and potentially for the patient, as well. In traditional PCI procedures, fluoroscopy is used to visualize the movements of guide wires, balloons and stents.

A cardiologist might be exposed to 10 or 20 minutes (or more) of radiation per procedure, which certainly creates a significant lifetime occupational risk since a busy cardiologist may perform 10,000 or more PCI procedures during his / her career. Also, the cockpit’s radiation shielding eliminates the need for physicians to wear the heavy and cumbersome lead aprons used in traditional PCI procedures to protect themselves from radiation exposure.

Performing procedures from the cockpit reduces the physical fatigue that results from prolonged standing and leaning over the patient during the procedure. Lower back problems are virtually indigenous to high volume interventional cardiologists often necessitating a reduction in procedure volume or even complete discontinuation of the performance of catheterization procedures. It stands to reason that without the discomfort and weight of lead aprons, physicians using robotic technology will be able to focus more of their attention on performing the procedure perfectly while simultaneously avoiding fatigue, injury and exposure to radiation.

• Elevating the risk of target vessel revascularization in the patient, which may require a revised procedure in the future

Corindus conducted a series of clinical trials of CorPath in 2010 and 2011. The CorPath PRECISE Study was sponsored

The robotic-assisted system that I “test drove” is called the CorPath Vascular Robotic System, from Corindus Vascular Robotics.

There are multiple benefits to using a robotic-assisted system versus a traditional procedure done manually. The CorPath System allows for measurement of coronary anatomy which the physician can use to select the optimal length stent. Such precision has been found to reduce the average number of stents per procedure by eliminating the occasional implantation of a stent that is too short to fully cover the diseased segment (thus requiring an additional stent). Choosing a stent that is unnecessarily long can also be problematic due to inadvertent coverage of side branches, a problem that may also be avoided with the CorPath system.

22 FLORIDA MD - AUGUST 2014

CARDIOLOGY

by Corindus under Investigational Device Exemption approval from the FDA to obtain 510(k) clearance. The study was a prospective, multicenter, non-randomized study which enrolled 164 patients at nine clinical trial sites. The study showed that robotic-assisted angioplasty can be performed safely and effectively.

Recently, data was published in a single-site study that compared the cases from the PRECISE trial to 80 cases performed on patients that would have qualified for inclusion in the trial but were treated using traditional methods. This small study demonstrated strong trends suggesting that robotic PCI can decrease radiation to the patient along with reducing the volume of contrast media used. Reduced contrast media usage can decrease the risk of contrast-induced nephropathy, a worsening or cessation of renal function following contrast administration. CorPath’s ability to reduce contrast media usage would certainly be a welcome “side effect” of robotic system use.

Corindus Screens

In the future, I anticipate that the capabilities of the CorPath System and other robotic systems will evolve, making them progressively more and more useful for interventional procedures. Although limited to coronary interventional procedures at present, I envision expanded use of such systems in the future for other types of procedures, including peripheral vascular and carotid stent procedures or even more complex procedures such as endovascular aneurysm repair procedures or percutaneous valve procedures. Certainly, electrophysiology procedures, such as atrial fibrillation ablations, and complex peripheral vascular procedures, which often require very prolonged radiation times, will be prime targets for sophisticated robotic systems. It will be exciting to watch the development of such systems in the years to come. Don’t be surprised if you walk into the cath lab one day and see your cardiologist sitting down at what looks like a video game console… performing a complex intervention in somebody’s heart!

References available upon request..

Barry S. Weinstock, MD, practices at Florida Heart & Vascular Center in Leesburg. He may be contacted at (352) 7286808 or by visiting www.flheartcenter. com. 

FLORIDA MD - AUGUST 2014 23

Choosing the Best Embryo Advances in In-vitro Fertilization

By Mark P. Trolice, MD

REPRODUCTIVE GENETICS In 1990, cells from an early developing embryo were removed and analyzed for the male Y- chromosome, thus preimplantation genetic diagnosis (PGD) was born. Over 20 years later, PGD has advanced to allow the identification of many genetic disorders as well as a complete chromosome analysis (karyotype). PGD is the general term for embryo genetic testing and includes identification of single gene diseases as well as comprehensive chromosome screening (CCS) or karyotype. The current designation of terms defines PGD for gene disorders and PGS (preimplantation genetic screening) for CCS. This breakthrough in IVF has profound implications which I will explore in this article.

PGD is the general term representing the analysis of cells removed either from an egg’s polar body (byproduct of an oocyte meiotic division) or from an embryo for the purpose of identifying gene disorders or for CCS. While originally showing promise, polar body biopsy has not given consistent and reliable results.

Further, embryo testing had traditionally occurred on day 3 of development where the embryo is comprised of only six to eight cells. Unfortunately, studies have shown day 3 biopsy results are

subject to validity concerns (e.g. allele dropout) and also reduces the subsequent ability for the embryo to implant by 40%. So, the standard of care today for embryo testing is a biopsy at the blastocyst stage on day 5 of embryo development where the embryo consists of more than 100 cells. Studies have not shown an increase in birth defects or damage to the embryo following biopsy.

Once embryo cells are removed and shipped to the specialized genetic laboratory the results are returned in several days.

Once the embryo passes day five of development in a fresh IVF cycle, there is a lack of synchrony with the lining of the uterus (endometrium) as well as an inability to maintain the growing embryo in the laboratory culture. Rarely, the genetic laboratory performing the analysis is at the same location as the IVF center, so most programs offer the patient a two-step process: the embryos are immediately frozen following biopsy then once the genetic information is returned, the patient undergoes a frozen embryo replacement (FER) the following month. Fortunately, due to advances in freezing using a process called vitrification,

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FER cycles allow for similar pregnancy rates as fresh cycles. If one focuses only on CCS cycles, then FER cycles may actually result in a higher pregnancy rate.

2. Metabolomics - By analyzing culture media surrounding the embryos, metabolic by-products of the embryo are tested from using biomarkers to assess embryo viability.

A summary of PGD options:

WHAT’S NEXT? Technology will continue to advance to

1. PGD is utilized to avoid transmitting lethal genetic mutations when the couple are both carriers of the same single gene defect, eg, cystic fibrosis, sickle cell anemia, Tay Sach’s, hemophilias.

2. PGS refers to embryo analysis for CCS including gender. Patients who utilize PGS are those with unexplained recurrent miscarriage (RM), women over 35 years of age, and couples desiring family balancing by selecting the gender of the offspring.

This technology can also reduce the risk of multiple gestation through the enhanced selection of only one normal embryo.

optimize pregnancy success with IVF, namely a healthy single live birth.

Mark Trolice, MD is the Director of Fertility CARE - The IVF Center located in Winter Park, FL, the most comprehensive and successful fertility center in central FL, specializing in infertility diagnosis & treatment. http://www.myfertilitycare.com; 407-672-1106 or 866-9FERTILITY. î Ž

CHOOSING THE BEST EMBRYO The three most important factors determining a successful outcome from IVF are the three E’s: 1) Endometrium - the lining of the uterus to develop and secrete proteins for implantation; 2) Embryo transfer - the ability for the physician to carefully, atraumatically, and accurately transfer the embryo into the optimal location in the uterus; 3) Embryo - the genetic and structural integrity of the embryo to develop and communicate with the endometrium for implantation.

The most challenging aspect of IVF is to determine which embryo is optimal for transfer. In the past, the gold standard method of embryo selection was grading the embryo by appearance (morphology). In fact, only 50% of embryos will be accurately selected by an embryologist to be chromosomally normal when morphology is compared with PGS results.

Despite the higher pregnancy rate potential following PGS, the holy grail of embryo selection remains elusive, because the chromosomal content of the embryo is not the only determining factor for successful implantation.

In addition to PGS, other methods to determine the optimal embryo to improve pregnancy rates, reduce the number of embryos transferred and reduce multiple gestation are: 1. Time-lapse photography - repetitive photographs of the embryos every five minutes while they are in the incubator. This technology has been shown to increase the ability to predict which embryos will develop to the blastocyst stage but has not yet been determined to improve live birth rates.

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FLORIDA MD - AUGUST 2014 25

Overtraining & Overuse in Young Athletes: How Much is Too Much?

By Sarah R. Gibson, MD As parents, physicians and coaches, we all want our young athletes to succeed and do their best. However, sometimes this desire to help young athletes reach their full potential and athletic goals can result in overtraining and overuse injuries of their growing muscles and bones. Overtraining a child or adolescent athlete’s body may not only hurt their athletic career, but could also result in lasting health problems.

curs. They are usually located near the ends of the long bones in children and adolescents. The growth plates help determine the future length and shape of the mature bone. When growth is complete—usually during adolescence—the growth plates close and are replaced by solid bone.

What is overtraining and overuse?

Overtraining and overuse are two terms that go hand in hand.

Overtraining is, as it sounds, when an athlete trains for a certain sport in excess or performs a certain movement or activity too many times without enough recovery time in between. As a result, the athlete may develop an overuse injury from repetitive stress on a particular muscle, ligament or bone. The tissues may get inflamed, stretched or may even break. For example, a young gymnast who repeatedly performs hyperextension activities may develop a stress fracture in their spine or a young, an overtrained swimmer may see signs of rotator cuff tendonitis. A relatively well-known overuse injury is Little League elbow – which occurs in young baseball players who are throwing or pitching too much.

An unfortunate trend Overtraining and overuse injuries in young athletes are not only becoming more common, but they are also being seen at younger ages. In fact, over 50 percent of all injuries seen in pediatric sports medicine are related to overuse. Many primary physicians are now seeing chronic tendonitis and stress fractures in athletes below the age of 10 – which was unheard of in the past.

The statistics are alarming. According to The Journal of Sports Science and Medicine, almost one-third of young athletes are overtraining and putting unnecessary harm on their developing bodies.

Overtraining in developing athletes can occur in males and females and in any sport. There is a higher incidence rate in individual sports (48 percent) compared with team sports (30 percent) and less physically demanding sports (18 percent). One of the major reasons for the increase in overtraining and overuse injuries is that more children are participating in year-round training and competition in a single sport. However, even young athletes that play different sports in different seasons may still be at risk for overuse injuries, especially if their chosen sports emphasize the use of the same body part. For example, a young athlete who plays tennis, volleyball and swims may still be at risk for overuse injuries in their shoulder since all of these sports put a high demand on that body part.

The importance of growth plates The growth plate, or physis, is an area where bone growth oc26 FLORIDA MD - AUGUST 2014

Wrist x-rays of a young fencer who developed left wrist pain while training for the national championships. Overtraining had caused irritation of the growth plate in his left distal radius, which is seen as widening of the growth plate on this x-ray (arrow).

Athletes are at risk of growth plate injuries when their growth plates are still open. For most girls, growth plates usually close from age 14 to 16; while for most boys they close from age 16 to 18. It is very important for parents and young athletes to understand that even though they might have the energy and stamina to push themselves, their bones may not be able to endure the stress like adult bones can. Growth plates are the “weak link in the chain” – weaker than the surrounding ligaments, tendons and bone - and therefore will often be where the injury occurs. If pushed too far, the athlete is at-risk for a growth plate injury.

Various factors can put young athletes at increased risk for injury. These include: poor coordination; open growth plates; muscle and tendon tightness secondary to growth spurts; and the fact that growing cartilage may be more vulnerable to stress.

The injury of growth plates might not just keep an athlete out for a season, but can cause long-term effects. If stressed or injured, growth plates can close prematurely, resulting in permanent developmental issues, such as crooked or uneven limbs. It is imperative for parents, coaches and primary physicians to protect their growing athlete’s growth plates by not overtraining and pushing them too hard.

Signs and Symptoms At first, an overuse injury will present as pain in the affected area after physical activity. If the young athlete continues to push through the pain, they may progress to also having pain in the affected area during activity, but initially this is not severe enough to restrict their performance. However, if they continue to perContinued on page 28

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form the activity the pain may worsen to the point that it does limit their performance. The last, and most severe, stage in overuse injuries is when the athlete has pain that limits their performance and continues to bother them even at rest.

Prevention Although there are no scientifically determined guidelines, parents, coaches and physicians can take steps to help prevent overtraining in young athletes. Rest is very important, and some sports, like baseball, have outlined specific guidelines like pitch counts that should be adhered to in order to minimize the risk of overuse injuries.

The American Academy of Pediatrics Council on Sports Medicine recommends the following: 1) Limit any single sporting activity to a maximum of 5 days per week 2) Take at least one day off per week from all sports and organized athletic activities 3) Take at least three months off per year from any particular sport Also, apply the 10% rule to training: Do not increase the amount or intensity of training by more than 10 percent per week. Additionally, coaches can incorporate drills that put less stress on the body, such as water running for a track athlete. Making sure that the athlete has proper form can also be critical. Lastly, it is important to keep workouts interesting and fun with ageappropriate games and training and to focus on wellness and teaching young athletes to be in tune with their bodies so they know when to slow down or alter their training methods.

Sarah Gibson, MD is an expert in pediatric sports medicine. Before joining the Department of Orthopedics at Nemours Children’s Hospital in September 2013, she was in private practice in Fort Lauderdale, Fla. Dr. Gibson earned her medical degree at the University of South Alabama College of Medicine in Mobile. She completed a combined residency and internship in internal medicine at the Medical University of South Carolina in Charleston. Dr. Gibson then relocated to Boston for a residency in physical medicine and rehabilitation at Spaulding Rehabilitation Hospital, a teaching hospital of Harvard University, and a fellowship in primary care pediatric sports medicine at Harvard’s pediatric teaching institution: Boston Children’s Hospital. In addition to her clinical work with children, Dr. Gibson is a guest lecturer, researcher and published author. An athlete since childhood, she has provided medical care for a long list of teams and sporting events.

Dr. Gibson is board-certified by the American Academy of Physical Medicine and Rehabilitation.  28 FLORIDA MD - AUGUST 2014

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CURRENT TOPICS

Top Global Medical Institutions Convene at Nicholson Center to Improve Robotic Surgical Training Fifteen leading hospitals participate in Fundamentals of Robotic Surgery validation trial for final step in developing standardized robotic training curriculum With an overarching goal to improve patient outcomes and equip surgeons with optimal, standardized training curriculum, the Institute for Surgical Excellence (ISE) hosted a two-day kick off meeting at the world-renowned Florida Hospital Nicholson Center with fifteen of the world’s leading medical institutions to conduct its Fundamentals of Robotic Surgery (FRS) validation trial.

“Our mission is to ensure that physicians who utilize cutting-edge surgical technologies deliver the highest quality of care and improved outcomes for their patients, “ said ISE board member Dr. Jeffery Levy. “The FRS represents a revolutionary step towards achieving this goal.”

“We are incredibly proud to be a partner in leading these efforts to create an extensive online curriculum and a unique and innovative testing device for robotic surgeons. This week begins the final step of validating these products with fifteen of the world’s best medical colleges,” said Dr. Roger Smith, Chief Technology Officer for the Florida Hospital Nicholson Center. “The cooperation of these professionals has been truly impressive. All of them are focused on reaching this milestone in improving robotic surgical outcomes.”

FRS institution representatives practice hands-on curriculum using the Nicholson Center simulation equipment surgery.

The kick off meeting included hands-on simulation sessions in Nicholson’s state-of-the-art labs combined with an overview of the study requirements and concluded with a luncheon featuring remarks from Susannah Randolph, district director for Congressman Alan Grayson.

“Congressman Grayson was proud to have helped secure $4.2 million in federal grant money to fund a Global Center of Excellence in Medical Robotics and Simulation at the Nicholson Center for Surgical Advancement (NCSA),” said Randolph. “This weekend’s gathering of top robotic surgeons as part of the Institute for Surgical Excellence’s FRS validation study is revolutionary for the field. Congressman Grayson is thrilled that the funding that the NCSA received is being leveraged to insure that the future of robotic surgery and training for new surgeons will reach new heights.”

The FRS was established with a grant from the U.S. Department of Defense and Intuitive Surgical and has been working for over two years to develop a curriculum that imparts critical knowledge necessary to perform robotic surgery and evaluates a surgeon’s proficiency in understanding and performing fundamental skills and tasks. The validation study is the final, and most critical step in completing and vetting the program.

About the Institute for Surgical Excellence The Institute for Surgical Excellence (ISE) is a 501(c)(3) public non-profit organization dedicated to improving surgical care and patient outcomes. ISE’s mission is to support the implementation of safer solutions to complex surgical interventions, often involving the application of emerging technologies. ISE utilizes a systems-based approach to bring together key stakeholders to identify issues, set clearly defined goals, facilitate collaboration, assess and fill gaps, and better inform healthcare consumers. For more information about ISE, visit www.surgicalexcellence.org. 

FLORIDA MD - AUGUST 2014 29

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