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JANUARY 2015 • COVERING THE I-4 CORRIDOR

Get Back on Your Feet with

Orlando Foot and Ankle Clinic

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contents 4

JANUARY 2015 COVERING THE I-4 CORRIDOR

 COVER STORY

Photo: DONALD RAUHOFER / FLORIDA MD

Craig C. Maguire, DPM, opened a single podiatric office in Orlando over thirty-five years ago. Today, Orlando Foot and Ankle Clinic has grown to seventeen locations in Orange, Osceola, Lake, Brevard and Seminole Counties. “Dr. Maguire is retired now,” says Greg Renton, chief executive officer, “but even back then he had a vision to provide foot and ankle care in locations convenient for patients of all ages, including children.”

David B. Moats, DPM, was the second physician to join the practice. “Our goal has always been to be the most surgically innovative -- and technologically advanced -- group of foot and ankle surgeons in Florida,” he says. “Our practice philosophy is to put patients first through good communication and advanced treatment protocols.

ON THE COVER: Amber M. Shane, DPM, FACFAS, medical director of the Ambulatory Ankle and Foot Center of Florida, preparing to perform surgery on a torn Achilles’ tendon.

Photo: DONALD RAUHOFER / FLORIDA MD

17 One Small Antitrust Case, One Giant Step for the Future of Independent Doctors

DEPARTMENTS 2

FROM THE PUBLISHER

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HEALTHCARE LAW

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PULMONARY & SLEEP DISORDERS

11 CANCER 13 ORTHOPAEDIC UPDATE 14 FINANCIAL UPDATE: Insurance•Benefits•Wealth MGMT.

15 MARKETING YOUR PRACTice 19 DIGESTIVE AND LIVER UPDATE

FLORIDA MD - JANUARY 2015

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FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. and I hope your new year is happy, healthy and prosperous.

The emotional and physical trials and tribulations of parents and families with a child who is mentally and/or physical disabled. Where can they go and who can help them and their child? Since 1955 UCP of Central Florida has offered support, therapy and education for thousands of children with a wide range of disabilities. They continue to grow and provide much needed services. Please join me in supporting this wonderful organization.

Best regards,

Donald B. Rauhofer Publisher

Coming UP Next Month: The cover story focuses on Central Florida Cardiology Group. Editorial focus is on Cardiology, Heart Disease and Stroke.

UCP of Central Florida UCP of Central Florida is a not-for-profit charter school and pediatric therapy center providing support, education and therapy services for children, with and without disabilities, ages birth through 21. More than 3,000 children and their families receive services annually. There are seven campuses located throughout Central Florida in three counties – Orange, Osceola and Seminole.

The charter schools serve students of all abilities including children with cerebral palsy, Down syndrome, autism, spina bifida, speech delays, visual impairments and other developmental delays. UCP now embraces an inclusion education model allowing all children – with and without disabilities – to learn, grow and excel together in the same setting. Research illustrates that inclusion education strengthens socialization skills, test scores and acceptance of others for both students with and without special needs.

For more information, go to www.ucpcfl.org.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Ann Alexander, Hadi Chohan, MD, Jennifer Thompson, Donna Ingles, Julie Tyk, JD, Corey Gehrold, S. Kyle Taylor, Marni Jameson Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information.

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Healthcare Law

2014 Year-End Roundup There has been shortage of significant cases affecting medical malpractice claims in Florida this year, so with 2015 just around the corner I thought we would roundup the news highlights from the past twelve months.

Caps on Pain and Suffering Damages in Medical Malpractice Death Cases Ruled Unconstitutional On March 13, 2014, the Florida Supreme Court issued its longawaited ruling in the McCall vs. United States. Michelle McCall died while in the care of military medical personnel shortly after the birth of her son. A wrongful death lawsuit alleging medical malpractice was filed in which the woman’s parents and her newborn son were the only claimants. The non-economic award of $2 million was reduced to $1 million when the caps described in §766.118, Florida Statutes were applied. On appeal, the U.S. 11th Circuit, federal constitutional arguments were rejected, but four questions regarding state constitutional claims were certified to the Florida Supreme Court.

The Florida Supreme Court found that, in wrongful death cases, the caps on non-economic damages enacted in 2003 violate the equal protection provision of the Florida Constitution. The caps remain in place in cases involving non-lethal injury. The ruling will affect wrongful death cases currently in litigation as well as those yet to be filed. As stated above, the McCall decision is currently limited only to wrongful death cases. Proponents of the decision believe that this decision may signal the Court’s reasoning that all caps are unconstitutional including personal injury caps. However, defenders of the caps argue that the Court may have preserved the caps on personal injury by acknowledging that “the legal analysis for personal injury damages and wrongful death damages are not the same.” The future of medical malpractice caps should become clearer as the Florida Supreme Court heard oral argument this past summer in Miles v. Weingard, a case challenging the retroactivity of the caps.

Health Care Providers and their Attorneys can have Direct Access to Patients’ Protected Health Information in Malpractice Cases On October 10, 2014, the U.S. Court of Appeals for the Eleventh Circuit in Murphy v. Dulay, decided that a Florida law allowing prospective defendants in medical malpractice cases to obtain records directly from other health care providers and to interview them about patient care and treatment is fully compliant with the Health Insurance Portability and Accountability Act (HIPAA), under certain conditions.

The statute in question took effect on July 1, 2013. The statute requires a prospective plaintiff who intends to file a malpractice claim to provide an “Authorization for Release of Protected Health Information” to any health care provider they intend to sue, in addition to other statutory requirements. The Authorization provides access to medical records and allows malpractice defendants and their attorneys to have direct contact with certain health care providers who have knowledge relevant to the alleged injuries during both the presuit investigation and during litigation.

By Julie Tyk, JD

Health care providers and their legal counsel should develop a strategy on how to utilize these additional discovery methods with an eye toward remaining in compliance with this new law.

Hospital Incident Report Not Patient Safety Work Product On July 30, 2014, Judge Wallace in Charles v. Southern Baptist Hospital of Florida, Inc. d/b/a Baptist Medical CenterSouth, Case No. 2012-CA-002677, ordered Baptist Hospital to produce documents the hospital claimed were patient safety work product. The order expressed a very restrictive view of patient safety work product.

In Charles, Baptist Hospital argued that, regardless of the purpose behind the collection of information, the only information not privileged under the Patient Safety Act was information provided to a government entity. The court rejected this argument.

In its analysis, the court noted that under the Patient Safety Act, certain categories of information are expressly excluded from being patient safety work product, including information that is collected, maintained, or developed separately, or that exists separately, from a Patient Safety Evaluation System. The court found that Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state. The court further noted that Florida requires hospitals to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities. Therefore, the court held that the information required to be gathered under Florida law, whether reported or not, is precluded from being protected patient safety work product under the Patient Safety Act. The hospital is currently appealing this order in the First District Court of Appeals.

While this case may not set any official precedent, this order will be part of the ongoing discussion about Patient Safety Organization protections. Organizations that have established a Patient Safety Evaluation System for reporting to a Patient Safety Organization should explore any state-mandated safety and quality regulations to ensure the collection of such information is conducted in harmony with the Patient Safety Evaluation Systems to ensure proper protection as patient safety work product.

The Medical Malpractice Defense Team at GrayRobinson is committed to assisting clients in navigating this development and other changes as they happen. Please feel free to contact us at your convenience.

Julie A. Tyk, JD, is an attorney in the Health Care Practice and Litigation Practice Groups with GrayRobinson, P.A. Julie concentrates her practice in peer review, medical malpractice, transportation litigation and insurance defense.

She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida. Call her at (407) 244-5694; julie.tyk@grayrobinson.com or visit www.gray-robinson.com.  FLORIDA MD - JANUARY 2015

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COVER STORY

Get Back on Your Feet with Orlando Foot and Ankle Clinic

By Ann Alexander Your feet. Where would you be without them? If you think about it, your feet have a pretty important job. Not only do they get you places, your feet support the weight of your entire body.

They are your base of operations.

novative -- and technologically advanced -- group of foot and ankle surgeons in Florida,” he says. “Our practice philosophy is to put patients first through good communication and advanced treatment protocols.”

The feet (and their mechanical neighbors, the ankles) are complicated structures composed of 26 bones, 33 joints and an abundance of muscles, tendons and ligaments. So where do you turn when your feet and ankles get you down?

So what is a podiatrist?

Orlando Foot and Ankle Clinic, the largest podiatry group in Central Florida.

Craig C. Maguire, DPM, opened a single podiatric office in Orlando over thirty-five years ago. Today, Orlando Foot and Ankle Clinic has grown to seventeen locations in Orange, Osceola, Lake, Brevard and Seminole Counties. “Dr. Maguire is retired now,” says Greg Renton, chief executive officer, “but even back then he had a vision to provide foot and ankle care in locations convenient for patients of all ages, including children.”

David B. Moats, DPM, was the second physician to join the practice. “Our goal has always been to be the most surgically inAmber M. Shane, DPM, FACFAS, medical director of the Ambulatory Ankle and Foot Center of Florida, preparing to perform surgery on a torn Achilles’ tendon.

A podiatrist is more than just a foot doctor. Podiatrists are surgically trained specialists who perform procedures from simple callus repair to complex surgeries such as ankle fusions and reconstruction. Additionally, the nineteen podiatrists who now make up Orlando Foot and Ankle Clinic, fit orthotic inserts, prescribe custom shoes and assist patients with gait patterns. “In other words,” states Dr. Moats, “if it’s below the knee, we can take care of it.”

Oh, my aching feet!

Foot and ankle problems can affect any person, and Orlando Foot and Ankle Clinic is equipped to treat everyone from toddlers to seniors. “We see patients from age two years and up,” says Renton, “but our typical patients are females between the ages of thirty-eight through sixty-five years.”

Why? People who are on their feet all the time -- or those constantly on the go – usually find themselves with an increasing number of problems. Besides overuse, other factors that may contribute to poor foot health include: • Tight shoes and super-high heels Shoes that do not fit properly (or do not provide good support) often cause issues with the toes, feet, knees and back – issues such as bunions, nerve damage, osteoarthritis, plantar fasciitis and low back pain.

• Age Another important factor in foot health is advancing age. Years of wear and tear can affect the feet, and so can certain diseases and poor circulation. Elderly individuals sometimes also have difficulty with foot hygiene or trimming toenails properly.

• Obesity causes added stress to bones of the feet and ankles.

Photo: DONALD RAUHOFER / FLORIDA MD

• Diabetes leads to circulation problems, which may result in circulatory problems, foot wounds and difficulties healing.

First steps to foot health To appropriately treat any medical condition, the first step is a proper diagnosis. Orlando Foot & Ankle Clinic is like a diagnostic one-stop-shop; each clinic location offers multiple diagnostic services so that all of your diagnostics can be handled at a single location. Orlando Foot and Ankle Clinic provides advanced imaging technology such as magnetic resonance imaging (MRI), 4 FLORIDA MD - JANUARY 2015

COVER STORY digital x-rays, ultrasounds and Doppler machines. “Our practice is still the only podiatric practice to offer a foot and ankle MRI system,” says Dr. Moats. Results are interpreted by a radiologist who specializes in podiatric imaging.

Once a diagnosis is made, the proper treatment can be prescribed. In addition to more common foot problems such as bunions, ingrown toenails, corns and calluses, Orlando Foot and Ankle physicians offer services for: • Heel pain and spurs • Sprains and fractures • Plantar fasciitis • Diabetic foot wounds • Achilles tendon and other ligament problems • Arthritic foot and ankle care • Ankle reconstruction and total ankle replacement • Flat foot reconstruction • Tendon transfers for drop foot or congenital deformities • Arthritis management techniques such as platelet rich plasma treatments

Ambulatory Ankle and Foot Center of Florida (AAFCF) In keeping with their tradition of innovative, quality care and convenience for patients, Orlando Foot and Ankle Clinic expanded their services to include the Ambulatory David B. Moats, DPM, medical director at Orlando Foot and Ankle Clinic, performing the Ankle and Foot Center of Florida (AAFCF) cutting edge MLS Laser Therapy treatment on a patient. The procedure is performed at the Kissimmee and East Orlando locations.

-- a free-standing outpatient surgery center located in downtown Orlando. Besides board certified podiatThe Ambulatory Ankle and Foot Center of Florida performs ric surgeons, the ambulatory center is staffed by registered nurses outpatient surgeries that do not require an overnight stay. Proce(RNs), medical assistants (MAs) and certified scrub techs -- all dures include: precisely trained in foot and ankle care. Amber M. Shane, DPM, • Surgery for ankle or joint problems and heel pain FACFAS acts as the medical director at the center.

• Endoscopic procedures for plantar fasciitis “To maintain our high standards of efficiency and accuracy, our • Arthroscopic procedures for ankle arthritis and ankle cartilage equipment is specific to foot and ankle surgery,” says Dr. Shane. damage “Our staff also has a concentrated focus, which enables them to provide individualized care. They know what each patient needs • Toe and bunion reconstruction before, during and after surgery.” Nurses provide written and ver• Tendon and ligament repair bal instructions post-operatively; they also follow-up with each “Patients benefit from outpatient surgery at the Ambulatory patient for a status update and to answer any questions about Ankle and Foot Center of Florida because of our convenient, easy their recovery. access… and they can go home the same day,” states Dr. Shane.

Each nurse is also certified in Advanced Cardiac Life Support (ACLS).

To date, over 20,000 patients have had surgery at the AmbuFLORIDA MD - JANUARY 2015

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Photo: DONALD RAUHOFER / FLORIDA MD

• Cartilage replacement

COVER STORY

Photo: DONALD RAUHOFER / FLORIDA MD

• Extracorporeal shock wave therapy (or ESWT) is a nonsurgical treatment that uses short bursts of energy waves to treat chronic foot and ankle problems. This treatment has actually been in use for nearly twenty-five years -- but it was originally utilized to break up kidney stones. Now ESWT is found to be a positive alternative treatment for foot and ankle problems such as plantar fasciitis and Achilles tendonitis.

Because it is non-invasive, the procedure is done quickly and patient recovery time is minimal.

Biff Kramer, DPM, laser specialist at Orlando Foot and Ankle Clinic, performing our state of the art QClear laser treatment on a patient. The procedure is offered at five of the seventeen clinic locations.

latory Ankle and Foot Center of Florida; in fact, two-thirds of the surgeries performed by the group’s physicians are done at this facility.

Some foot and ankle surgeries must be done at a hospital for various reasons such as a patient’s age (a child, for example) or because of insurance requirements or pain management needs that require an overnight hospital stay.

“Whether the surgery is done at the Ambulatory Ankle and Foot Center of Florida or at a hospital,” Dr. Shane says, “our surgeons can perform any type of foot and ankle surgery -- from the simple to the complex.”

Advancement in foot and ankle care Technology is constantly advancing, and Orlando Foot and Ankle Clinic is keeping pace.

Explains Dr. Moats, “Over the years, our doctors have been the first to utilize a number of advanced methods of treatment for our patients. For example, we were the first to use extracorporeal shock wave therapy and the first for endoscopic plantar fasciotomies. We also introduced Central Florida to Topaz treatments.

Most recently,” he continues, “our own Christopher Reeves, DPM, FACFAS was the first in the area to perform total ankle implants for severe arthritis.”

6 FLORIDA MD - JANUARY 2015

• The Topaz procedure is another innovative treatment offered by the Orlando Foot and Ankle Clinic. This treatment utilizes radio frequency waves to restore circulation and promote the natural healing of chronic foot and ankle problems. The Topaz technique is an outpatient procedure that is completed in less than 30 minutes.

• Orlando Foot and Ankle Clinic initially brought the Cool Breeze laser system to Central Florida patients. Since then the clinic has upgraded to the latest in laser technologies with the purchase of the Light Age Q-Clear system. The Q-Clear laser utilizes infrared light to treat toenails that are yellowed and disfigured by fungus. The treatment eliminates the need for medication and there are no side effects. Patients are treated quickly and with no pain.

• Additionally, Orlando Foot and Ankle Clinic has introduced MLS laser therapy for patients with chronic pain. “We are very excited to have this newest technology,” says Dr. Moats. “It is a pain-free treatment, given in the office, with no patient downtime. The results are truly amazing.” MLS laser therapy treats patients with conditions such as diabetic neuropathy, tendon injuries and plantar fasciitis. Precisely focused light energy stimulates damaged cells to repair themselves. The procedure is quick (generally about 8 minutes) -- and so are the results.

In fact, many patients experience relief after just a few treatments.

Several Orlando Foot and Ankle Clinic locations also offer physical therapy services. Physical therapy may be prescribed to help you regain mobility and strength, particularly after muscle or tendon injuries, broken bones or surgery. Physical therapists

COVER STORY will work with your podiatrist to develop a plan of care for your recovery and return you to full functioning.

Foot care for all ages Foot problems are not just for adults -- even little ones can experience foot and ankle issues. Common problems for children include pediatric flatfoot and heel pain.

Until about the age of five, while little bones are still forming, the feet are composed of cartilage. Parents should make every effort to protect tiny feet and prevent injury. In addition to her duties as medical director of the Ambulatory Ankle and Foot Centers of Florida, Dr. Amber Shane also acts as a national spokesperson for the profession. She was recently featured on a local network television program with shoe-shopping tips for parents. Her words of advice? Developing feet need support, and properly fitting shoes are essential to foot health for growing youngsters. Shoes can be flexible during the first months when a baby is crawling, but should become more rigid and supportive as

the child begins to grow and walk. “I don’t recommend flip-flops for young feet,” adds Dr. Shane. “Sandals in the Florida heat are okay, but they should have straps across the back and front to keep the shoe on the foot.”

The elderly frequently encounter podiatric problems as well, – simply from the years of wear and tear on their feet and ankles.

However, proper care might help minimize some of the most common problems experienced by seniors. In addition to regular visits to a podiatrist to maintain healthy feet, a few suggestions to prevent some of the most common problems include: • Avoid walking barefoot • Keep your feet clean and dry • Trim your toenails straight across to help prevent ingrown toenails • Try not to sit with your knees crossed – this simple habit will help improve circulation in your legs and feet

Photo: DONALD RAUHOFER / FLORIDA MD

Paul B. Thurston, DPM performs a routine foot exam on a patient. Dr. Thurston works at two of the seventeen clinic locations.

FLORIDA MD - JANUARY 2015

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Photo: DONALD RAUHOFER / FLORIDA MD

COVER STORY

Dr. Shane, performing surgery on a torn Achilles tendon at Orlando Foot and Ankle Clinic’s free-standing outpatient surgery center. Just one of the many surgeries offered.

• Always seek help for chronic foot and ankle pain, injuries or wounds

CONTACT INFORMATION

Over 35 years ago, Dr. Craig C. Maguire brought podiatric care to Central Florida. His vision was to ensure that foot care was available and convenient to patients across the area. Today, Orlando Foot and Ankle Clinic locations reach in every direction from their center in Orlando – with an office to the north in Lake Mary to as far south as their newest location in Poinciana; from their eastern office in Melbourne to their western location in Clermont. By offering ever-advancing technology in diagnostic and treatments methods, coupled with individualized care plans and patient education, Orlando Foot and Ankle Clinic honors Dr. Maguire’s original mission.

To make an appointment call 407-423-1234 or go online to www.orlandofoot.com.

“Our wonderful technology continues to improve the quality of medicine we are able to provide,” observes CEO Greg Renton, “and we’re not done yet.” Dr. Moats agrees. “It’s evident that all Orlando Foot & Ankle Clinic doctors are dedicated to providing the highest standard of care with the most advanced technology available,” he says. “That is our commitment to this community.

We will continue to strive for the best outcomes and satisfaction for our patients. You can count on that.” 

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Orlando Foot and Ankle Clinics can be found in the following locations: Altamonte Springs • Apopka Clermont • Downtown Orlando Dr. Phillips • East Orlando Kissimmee • Lake Mary Lake Nona • Melbourne Merritt Island • Ocoee Oviedo • Poinciana St. Cloud • Waterford Lakes Winter Park

PULMONARY AND SLEEP DISORDERS

The Importance of the Right Heart Catheterization By Hadi Chohan, MD It was while watching sailboats float one summer day in the late 1960s on the Santa Monica beaches that Dr.Jeremy Swan and Dr.Willam Ganz got the idea of “floating” a balloon-tipped catheter through the right heart chambers into the pulmonary vasculature to record pressures. The Swan-Ganz (SG) catheter, also known as a pulmonary artery (PA) catheter or right heart catheterization (RHC), has revolutionized care in cardiology, pulmonary, and critical care medicine.

The indications for a RHC to be performed have changed over the last fifteen years. RHC is often performed in the evaluation of advanced heart failure, heart and lung transplantation, and in the evaluation of pulmonary hypertension. In critical care medicine, the use of PA catheters has been reduced dramatically. Much of this is related to multiple large studies that showed outcomes did not improve (and may even worsen) in the care of critically ill patients who undergo RHC. Whether this is related to varying expertise and comfort levels with adequate catheter placement and data interpretation is open to debate. However, RHC is still considered in the evaluation of “mixed” shock states where it is unclear whether a cardiogenic or septic cause may be the leading etiology. A RHC can be performed if noninvasive tests do not clarify the etiology or if the patient does not respond to empiric therapy.

The RHC allows direct evaluation of the central venous, right ventricular, and pulmonary artery pressures. Measurements of the pulmonary capillary wedge pressure (PCWP) or the pulmonary artery occlusion pressure (PAOP) allows an indirect or surrogate evaluation of the left atrial pressure (see Figure 1 on following page). Calculations can be used to determine the pulmonary vascular resistance, cardiac output, and cardiac index via thermodilution through a thermistor or using the Fick formula.

The RHC is a crucial step in the evaluation of patients with pulmonary arterial hypertension. The World Health Organization has divided the etiologies of pulmonary hypertension by pathophysiology into five broad groups (See Table 1 on next page.) The majority of cases of pulmonary hypertension are secondary to left heart diseases such has congestive heart failure and valvular diseases (WHO Group 2) or chronic pulmonary diseases (WHO Group 3). Though the prevalence of idiopathic pulmonary arterial hypertension (PAH) may be low, the increasing recognition of liver and autoimmune diseases as well as the prolonged latency of anorexi-

gen-induced PAH is likely to increase the number of individuals diagnosed with this disease.

Since the introduction of Epoprostenol (Flolan®) in 1996, the pharmacological therapies available in our armamentarium to treat pulmonary hypertension have increased dramatically over the last eighteen years. In the past year alone, three new medications have been approved for treatment of Group 1 PAH as well as one specifically for chronic thromboembolic pulmonary hypertension (CTEPH; WHO Group 4).

With more treatment options, the responsibility to adequately characterize the disease has increased. It is well known that the echocardiogram is the best screening test in pulmonary hypertension but not as the sole diagnostic test. Echocardiograms can both underestimate and overestimate right heart pressures. The right heart catheterization is crucial in the evaluation of not only the pressures but an assessment of the pulmonary vascular resistance and cardiac output. Also, the pulmonary wedge pressure allows a differentiation between pulmonary hypertension secondary to elevated left heart pressures versus intrinsic pulmonary disease.

The pulmonary vascular resistance allows both an initial evalua-

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PULMONARY AND SLEEP DISORDERS

tion and a prognostication of the risk of right ventricular failure for patients with pulmonary hypertension. This also provides an assessment of the degree of vascular remodeling in the pulmonary vasculature. The cardiac output often correlates with the patient’s functional class and degree of cardiac decompensation secondary to the disease process.

Table 1, ABOVE: Updated Clinical Classification of Pulmonary Hypertension (Nice, France 2013) Figure 1, LEFT: Waveforms obtained from right heart catheterization (Courtesy of Pulmonary Hypertension Association)

As more pulmonary hypertension is identified on echocardiograms, it is important for patients to be referred to a pulmonary hypertension specialist for further evaluation. This allows a thorough assessment of the patient’s risk factors for other causes of pulmonary hypertension and the need for a potential right heart catheterization for further information and data. With better characterization of patients with pulmonary hypertension and newer treatment options, the quality of life and exercise capacity can be improved for these patients.

Hadi Chohan, M.D attended medical school at St. George’s University in Grenada, West Indies and completed an internship and residency in Internal Medicine at East Carolina University Brody School of Medicine in Greenville, North Carolina. He then went on to obtain further fellowship training in Pulmonary/Critical Care Medicine at Virginia Commonwealth University/Medical College of Virginia in Richmond, Virginia. Dr. Chohan joined Central Florida Pulmonary Group in 2014. He may be contacted at (407) 841-1100. 

10 FLORIDA MD - JANUARY 2015

CANCER

The Link between Cancer and Infections: Moffitt Cancer Center’s Approach to Better Understanding and Preventing Cancer

By Donna Ingles The Center for Infection Research in Cancer (CIRC) at Moffitt Cancer Center is a global leader in research focused on infections that cause cancer. With strategic partners across the United States and around the world, CIRC’s clinicians and scientists tackle challenges in identifying new infectious agents that play a role in various cancers and developing strategies for prevention, early detection and treatment. Moreover, CIRC integrates research faculty and clinicians from all of Moffitt research programs, with interests that include cancers related to human papillomavirus (HPV), hepatitis B and C, HIV/AIDS, polyomaviruses, H. pylori, and others.

low rates of HPV vaccine uptake in Florida, and the correspondingly high rates of HPV-related cancers among men and women in Florida. Working with U.S. Congresswoman Kathy Castor’s HPV Action and Awareness Coalition, Dr. Giuliano, Dr. Susan Vadaparampil and other CIRC members are working to initiate a national discussion of ways to prevent these cancers among future generations through vaccination.

One of CIRC’s cornerstones is the pursuit of novel, highrisk research ideas that have the potential to result in significant changes to clinical and public health practice. CIRC pilot project grants, awarded competitively on an annual basis to Moffitt investigators, support these initiatives. For example, anal cancer, caused by HPV, can potentially be prevented through early detection and treatment of pre-cancerous lesions. In a novel approach that combines new imaging technologies with infection status of the tumor, Drs. David Shibata and Erin Siegel have partnered with Moffitt’s imaging specialists to validate a novel non-invasive early detection intervention that, if successful, will change routine clinical practice in the prevention of anal cancer. Other currently supported research projects include identifying oncogenic viruses that cause a subset of ovarian cancers shown to have molecular characteristics consistent with an infectious etiology, determining

Although current research shows that 1 in 5 cancers worldwide are caused by infectious diseases, experts believe this proportion is considerably higher. “As research progresses, we learn of newly identified infectious agents that are leading causes of specific cancers. As such, the percent of cancers caused by infections may actually be much higher than what we know today,” said Dr. Anna Giuliano, founding director of CIRC. In addition to multiple effective methods for prevention of infection-related cancers, cancers caused by certain infections may be more responsive to treatment. “This opens up new avenues for less invasive cancer treatment, providing superior outcomes with higher quality of life for the patient,” GiuDr. Anna Giuliano, director of Moffitt’s Center for Infection Research in Cancer, discusses research with Drs. liano added.

John Greene and Lary Robinson.

Ongoing CIRC projects include basic science investigations into new infectious causes of cancer and clinical trials for new vaccines and therapeutic interventions.

CIRC is also spearheading a number of education projects, including efforts to educate physician providers, parents and other members of the community on the benefits of vaccine protection. One such project, funded as a result of recommendations by President Obama’s Cancer Panel, focuses on ways to improve the very FLORIDA MD - JANUARY 2015 11

CANCER the role of human herpesvirus 6 in Hodgkin’s lymphoma, and studying cutaneous viral infections in non-melanoma skin cancers.

Monthly CIRC meetings feature experts from around the world who share their recent research progress in infection-related cancers and discuss new ideas with CIRC members. The collaborations stemming from these meetings have already resulted in a number of grant applications focused on cancers that are of national and global importance. Dr. Jamie Morano, an infectious disease physician, is currently pursuing a grant to fund research related to hepatitis C-related hepatocellular carcinoma, and Drs. Domenico Coppola and Jose Pimiento were recently awarded a pilot grant from Moffitt’s Integrative Mathematical Oncology Workshop to determine optimal screening paradigms for gastric cancer caused by Helicobacter pylori. Drs. Coppola and Pimiento will be collaborating with colleagues in Colombia, where this cancer (and the causative infection) are highly prevalent and of primary concern.

Targeted faculty recruitment continues to add to the CIRC ranks at Moffitt. The latest addition is Dr. Christine Pierce Campbell, an epidemiologist who is focused on building a new area of research at Moffitt to study the microbiome. Dr. Pierce Campbell’s most recent grants include a study of immune markers of head and neck cancer related to infection and another study assessing changes in the oral microbiome post-treatment. This latter project may aid in explaining differences in disease-free survival in these infection-related cancers, allowing clinicians to better determine optimal treatment courses for each patient. Other CIRC faculty and staff recruitments, as well as expansion of dedicated research laboratories to study infection-related cancers in 2015 and beyond will continue to expand and shape this Center of Excellence at Moffitt.

For more information and the latest developments from Moffitt’s Center for Infection Research in Cancer: www.Moffitt.org/CIRC. Donna Ingles is Research Project Manager at the Center for Infection Research in Cancer at Moffit Cancer Center. Ms. Ingles received an MS in Medicinal Chemistry from the University of Kansas in 2008, with research focused on the synthesis of Hsp90 inhibitors. She accepted a job at Moffitt Cancer Center as a Research Associate in Drug Discovery in 2009, specializing in protein chemistry and structural biology in the laboratory of Dr. Ernst Schonbrunn. In 2012, Ms. Ingles transitioned to Moffitt’s Center for Infection Research in Cancer, where she currently works as a Research Project Manager under the direction of Dr. Anna Giuliano. She also completed an MPH degree in Epidemiology and Global Communicable Diseases from the University of South Florida in 2014. Ms. Ingles may be contacted at Donna.Ingles@Moffitt.org. 

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ORTHOPAEDIC UPDATE

Epidural Steroid Injections Help Relieve Pain Without Surgery

By Corey Gehrold When visiting with a pain management physician in Orlando, treatment may include physical therapy, therapeutic modalities, prescription medication and/or interventional pain management consisting of epidural steroid injections.

Although some consider epidural steroid injections a “last resort” of sorts in the pain management subspecialty, patients report high satisfaction and effectiveness ratings.

“I compare it to putting the water where the fire is,” says Matthew R. Willey, M.D., a Board Certified Physical Medicine and Rehabilitation Physician specializing in Interventional Pain Medicine at Orlando Orthopaedic Center. “I would rather target the medication right at the pain generator rather than prescribe the medication orally, only to have a fraction of the medication reach the problem area.”

What is an Epidural Steroid Injection?

An epidural steroid injection is a minimally invasive procedure used by pain management physicians to relieve both spine and extremity pain caused by disc herniation, disc degeneration, spinal stenosis, and inflamed nerve roots.

“The medication is delivered to the inflamed spinal nerve through the epidural space,” explains Dr. Willey. The epidural space is the area between the protective covering of the spinal cord (the dura) and the bony elements that form the spinal canal. The injection includes a corticosteroid (betamethasone or triamcinolone typically) and a numbing agent (bupivacaine or lidocaine).

“Corticosteroids reduce inflammation and have the potential to work very well when delivered directly to the site of pain,” says Dr. Willey. “Often times patients report near immediate pain relief following the procedure. If only mild relief is achieved, we may schedule one or two more injections to achieve maximum effectiveness.”

He continues, “It is important to remember, however, that an epidural steroid injection is only a method of delivering medication. It will not change lumbar spinal anatomy or increase abdominal muscle strength. Therefore, we must have close working relationships with both our spine surgery and physical therapy colleagues should additional treatment be needed.”

Dr. Willey that epidural steroid injections are often combined with physical therapy or home exercise programs to strengthen the back and core musculature, and to help prevent future pain.

How is an Epidural Steroid Injection Performed?

Once an epidural steroid injection has been decided as the next course of treatment for patients, they are briefed on what to expect the day of the procedure. For Dr. Willey and his fellow pain management physician Daniel M. Frohwein, M.D., the epidural steroid injection will take place at the Orlando Orthopaedic Cen-

Matthew R. Willey, MD

A rendering of an epidural needle injecting anesthetic into the lumbar spine.

ter Outpatient Surgery Center just south of downtown Orlando.

Using a fluoroscope (a special type of X-ray), the physician directs a hollow needle through the skin and into the epidural space. There are two techniques used to access the epidural space, either an interlaminar or a transforaminal approach.

The interlaminar approach advances a needle between the lamina of two vertebrae at the target location, through the ligamentum flavum, and into the posterior epidural space.

The transforaminal approach aims to place the needle in opening of the neural foramen. This approach allows placement of medication into the anterior epidural space and closer to the spinal nerve roots. In both scenarios, contrast dye is used to confirm proper spread of medication.

Most patients remain awake during the procedure and typically feel more pressure than pain. Some patients elect mild or even heavy conscious sedation for comfort. Once the needle is in place and the steroid medication is delivered, the needle is removed and patients are moved to a recovery area and cleared to leave shortly thereafter.

The entire procedure typically takes less than 20 minutes.

How Effective is an Epidural Steroid Injection?

Unfortunately there is not a “standard” amount of time a patient will feel relief following their epidural steroid injection. Pain relief may last for several weeks, or it may last for several years.

“Although we can’t predict how long pain relief will last, we do know that a majority of patients experience reduced pain and improved function in very short order,” says Dr. Willey. “At times, the response can be quite miraculous. Other times, we see only limited improvement. Much of that depends on the specific anatomy, individual physical condition, and, what I hypothesize, a large genetic component.”  FLORIDA MD - JANUARY 2015 13

Financial Update: Insurance • Benefits • Wealth Management

Notable Numbers

By S. Kyle Taylor

The S&P 500 gained +13.7% (total return) in 2014, its 11th positive year in the last dozen years (2003-2014). The ongoing bull market (which began after stocks bottomed on 3/09/09) is 70 months old this week and has gained +244% from its bear market low. Interest rates surprised most bond market veterans as rates fell throughout the year. The yield on the 10-year Treasury note, which ended 2013 at 3.03%, finished 2014 at 2.17%. The biggest tumble during 2014 belonged to the price of a barrel of oil which dropped 50% from its 2014 high to finish the year at $53.27 a barrel (source: BTN Research).

The 114th session of Congress begins its 2-year run this week.

For the first time since 2000, a Democrat will occupy the White House (President Obama) while Republicans will be in charge of both the Senate (57-43 majority) and the House (247-188 majority). The tension between the political parties will be put to the test in the first week as legislation that would approve the Keystone XL pipeline will be the topic of a 1/07/15 Senate committee hearing. Incoming Majority Leader Mitch McConnell (R-KY) has pledged to put the bill to a vote, a statute that the White House has indicated it will most likely veto (source: BTN Research).

The makeup of the voting members of the Federal Open Market Committee (FOMC) changes every January. The 4 exiting members this year (Kocherlakota, Fisher, Plosser and Mester) are considered to be 3 “hawks” and 1 “dove.” “Hawks” are inclined to raise interest rates due to worries about future inflation. “Doves” are inclined to maintain low interest rates to spur hiring. The 4 new voting members this year (Lockhart, Williams, Lacker and Evans) are considered to be “doves” or centrists, a change in the FOMC’s composition that will play into the central bank’s decision-making in 2015 (source: Fed).

Notable Numbers for the Week: 1. UP vs. DOWN - The split between “up” and “down” days for the S&P 500 over the last 50 years (i.e., 1965-2014) is 53% “up” and 47% “down.” The split during 2014 was 57/43 (source: BTN Research).

4. EURO - Lithuania became the 19th country to join the Eurozone on 1/01/15. When the Euro was launched on 1/01/99, there were 11 countries that used the Euro as their common currency (source: BTN Research).

Securities and Investment Advisory Services offered through NFP Advisor Services, LLC, Member FINRA/SIPC. NFP Advisor Services, LLC 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 Advisor Services, LLC 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 © 2015 Michael A. Higley. All rights reserved.

S. Kyle Taylor is a principal at The Vaughn Group, Inc. and manages the wealth management department. As an independent financial advisor, he focuses on helping his clients understand the importantce of developing a strategic, long-term wealth plan.

Kyle believes that wealth management is a process and a partnership built on trust and integrity. He approaches that process by gaining clarity about a client’s current situation – identifying core values, defining future goals, and developing a flexible strategy that allows them to reach their objectives.

Kyle graduated from the University of Florida with a B.A. in Finance and also attended the College for Financial Planning. He can be reached via email at kyle@ vaughngroup.com or by phone at (407) 872-3888. The

2. INSIDE THE INDEX - 176 of the 500 individual stocks (i.e., 35% of the stocks) in the S&P 500 gained at least +20%.

122 stocks (i.e., 24% of the stocks) finished the year with a stock price lower than where it started the year (source: BTN Research).

Vaughn Group, Inc.’s offices are located at 1407 E. Rob-

3. MISSED THEM - The total return for the S&P 500 was a gain of +13.7% (total return) in 2014. If you missed the 5 best percentage gain days last year, the +13.7% gain falls to a +3.2% gain (source: BTN Research).

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14 FLORIDA MD - JANUARY 2015

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Marketing Your Practice

3 Trends that Will Change the Way You Market Your Practice in 2015

By Jennifer Thompson Being nose deep in the world of medical marketing allows us to gain a unique perspective on what’s going on, what you should be aware of and how to market your practice better with less work.

In 2014 we saw three big trends that helped shape the world of medical marketing and what to expect in 2015: • Newsletters– Why they’re still successful with patients and how you can produce a successful piece every time.

• Appointment Request Forms– How they can boost business, erase headaches and save you time and money.

• Reputation Management– Why it matters more than ever to have a handle on your office’s online rating profiles.

Newsletters

Contrary to what you may hear, newsletters – both in print and online – are not dead. In fact, they’re very much alive. Some of the ways they thrive are: • Printed for distribution • Online in the form of a series of blog posts on your website • An email to your email database Content is king in today’s world of inbound-driven marketing, sure. That’s why we’ve used the demand for custom content creation in the form of patient testimonials and ongoing patient education to generate a traditional paper newsletter to be used for field-level direct to consumer marketing and physician-tophysician marketing. In many cases the newsletter has become the main marketing piece for the practice, often replacing the practice brochure.

With online consumption and requests for information, we’ve

been successful in increasing brand awareness and promoting positive online reviews in monthly patient e-newsletters sent directly to patient inboxes.

In 2014, this has been an effective and cost efficient method for delivering value to the doctors we work with.

Patients like them in-hand because it’s like reading a pretty magazine / patient education brochure. They like them online because it’s relevant information and announcements delivered right to their inbox. In short: they work.

In 2015, we expect this trend to grow even more while picking up some serious momentum along the way.

Appointment Request Forms

One of the biggest things we’ve seen this past year has been the desire for appointment request forms on websites. Whether we’re building a new site for clients or just retrofitting a current site with a button in the header or navigation bar, we’ve done a ton of these this year.

The reason? Well, there’s actually a few reasons but one of the main ones is just that patients LOVE them. For one of our clients, they’re getting between 300-500 appointment requests through their site alone they weren’t getting before we put the button there. Granted, some of these appointments would’ve called in… but some wouldn’t. As a result of the button, we’ve seen total appointments year-to-date go up when comparing numbers preand post-button on their site.

Another added benefit is that you save a bunch of time and effort with this system. Think about it. Let’s say even 200 of those appointments were phone calls previously. You’re paying someone to answer the phone and take time out of their day to field those calls. Now you don’t have to.

The patient fills out a request, the website generates an email and your staff confirms the appointment with a quick email or FLORIDA MD - JANUARY 2015 15

Marketing Your Practice phone call back to the patient saying, “You’re all set.” Think of the time saved just there alone.

Not to mention, patients can make these requests any day at all hours of the night and there’s no need to come in the next day to a dozen messages and waste an hour trying to transcribe and understand what they said, call them back, hear the whole story again and find a spot for them.

Reputation Management The early part of 2014 saw a rise in the consciousness of online reputation management, specifically in doctors paying attention to what their patients were saying about them online (whether true or not unfortunately).

In late 2013 and early 2014 we received more and more requests to speak at various trade organizations on the subject of online reputation management. It’s like the physician community woke up to the fact that more and more consumers were airing their grievances online and they needed to at the very least put a system in place for monitoring it.

This will matter more in 2015 than ever before for practices of every size.

In 2014 we’ve seen more and more a need to monitor daily what is being said about our clients. And, although we’ve been on the lookout for an automated system for improving this activity, we’ve yet to find something to our satisfaction and to the satisfaction of the men and women we work with.

This year we’ve spent an exhaustive amount of time claiming physician profiles only to find ourselves reclaiming them weeks later. HealthGrades.com alone now represents more than 100 million online reviews and that number continues to grow daily. On top of that, site like RateMDs.com and Vitals.com continue to show up near the top of the first page of search results.

Bring on 2015 As they say, the only constant is change. If you don’t change the way you market your practice to take advantage of these new marketing initiatives, your competitors will.

Looking for more ways to attract and retain more patients? Check out DrMarketingTips.com for free articles, webinars, ebooks, audio blogs and more for your practice.

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. 

16 FLORIDA MD - JANUARY 2015

One Small Antitrust Case, One Giant Step for the Future of Independent Doctors

By Marni Jameson On the other side of the country, in the unassuming state of Idaho, a health-care antitrust case is being decided. Its outcome will have a ripple affect across America.

The pending verdict has captured the nation’s attention because the U.S. Court of Appeals’ imminent decision may deem unlawful a situation that is common in many American cities -- specifically the merging of hospitals and certain medical groups.

The case involves St. Luke’s Health System and its acquisition of Saltzer Medical Group.

The Nampa County practice was Idaho’s largest independent medical group before it sold out to the hospital system in winter of 2013, for just under $30 million, according to court documents.

Like many hospitals that acquire medical practices, St Luke’s claimed that the merger would be better for the patient community as it would help “integrate care” and “enhance efficiencies.”

However, St. Alphonsus Medical Center down the street disagreed and argued that St. Luke’s acquisition created a monopoly that reduced competition, sent costs sky-rocketing and limited patient access and choice. Indeed, the purchase gave St. Luke’s 80 percent of the primary care doctors in Nampa and significant bargaining leverage over health insurers, according the Idaho Statesman.

The Federal Trade Commission joined St. Alphonsus and filed suit against St. Luke’s claiming that the merger violated antitrust laws. Last fall, the U.S. District Court for Idaho agreed and ordered the parties to unwind the merger.

St. Luke’s refused, and appealed the decision.

Orlando Group Steps In That’s when a small but fast-growing national association of independent doctors with roots in Central Florida got involved.

Orlando has felt firsthand the negative imFLORIDA MD - JANUARY 2015 17

pacts these mergers have on costs, care and communities. The region has two of the nation’s largest health systems, which are rapidly buying up medical groups to secure market share.

A major national insurance company, which supports the preservation of independence of doctors, reached out to the Association of Independent Doctors for help.

With members in nine states, A.I.D. is the only trade association representing the interests of independent doctors on the national stage.

“The resources from our growing membership allowed us to hire attorneys from a top Washington law firm to write the amicus brief affirming the district court’s decision,” said , A.I.D. founder Tommy Thomas, a certified public accountant in Winter Park.

Thus, A.I.D. filed an amicus brief (a friend of the court opinion) in August asking the higher court to uphold the lower court’s decision. The legal brief eloquently argues and clarifies the reasons Americans need independent doctors, and why hospital-doctor consolidations are bad for patients, communities and the nation’s health-care system.

“This is a giant step forward in the fight for independent doc-

tors,” said Thomas.

In addition to A.I.D., the following groups also filed compelling briefs supporting the lower court’s decision: attorneys general from 16 states, a group of economics professors, America’s Health Insurance Plans, and Catalyst for Payment Reform.

Idaho Attorney General Lawrence Wasden thanked A.I.D. for its involvement, saying he believed the organization’s brief would have a “persuasive impact” on the appeals court, which as of press time was still deliberating.

If the U.S. Court of Appeals for the Ninth Circuit agrees with the lower court and orders the acquisition to be unwound, St. Luke’s won’t be the only hospital affected. Health systems across the nation will be on notice: Buying up market share to the point of creating a monopoly in the community not only increases health-care costs and is bad for patients, but it is also against the law.

“People who work in health-care antitrust law think the ruling could spur more lawsuits from the FTC as it seeks to unwind similar hospital-doctor mergers,” The Idaho Statesman reported.

We’ll soon find out.

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Digestive and Liver Update

Abdominal Pain: Gastroparesis

By Harinath Sheela, MD Gastroparesis (delayed gastric emptying) is a common cause of nausea, vomiting, and other upper gut symptoms in patients referred to gastroenterologists. The true prevalence of gastroparesis is unknown. It is estimated to occur in 20–40% of patients with diabetes mellitus, primarily those with long duration of type 1 diabetes mellitus with other complications. Delayed gastric emptying may also be present in 25%–40% of patients with functional dyspepsia, a condition affecting approximately 20% of the US general population.

The etiology of gastroparesis is multifactorial; the main categories are diabetic, idiopathic, and postsurgical. Diabetic gastroparesis is believed to represent a form of neuropathy involving the vagus nerve. Hyperglycemia itself can also cause antral hypomotility, gastric dysrhythmias, and delayed gastric emptying in some patients. Idiopathic gastroparesis is present in many patients with functional dyspepsia and may in some cases occur after a viral infection.

Diagnosis of gastroparesis The diagnosis of gastroparesis is based on the presence of appropriate symptoms/signs, delayed gastric emptying, and the absence of an obstructing structural lesion in the stomach or small intestine.

Symptoms of gastric dysmotility Clinical symptoms that suggest gastroparesis include nausea, vomiting, and postprandial abdominal fullness. In contrast, dyspepsia refers to a symptom complex of chronic or recurrent upper abdominal pain or discomfort that may have associated symptoms of early satiety, nausea, and postprandial fullness/bloating.

There is overlap of the symptoms of gastroparesis and functional dyspepsia. Idiopathic gastroparesis may be one of the causes of functional dyspepsia.

The differential diagnosis of nausea and vomiting is extensive and includes a broad range of pathologic and physiologic conditions affecting the gastrointestinal tract, the central nervous system, and endocrine/metabolic functions. Assessment of the patient begins with a careful history aimed at understanding the patient’s symptoms. Vomiting needs to be differentiated from regurgitation, rumination, and even bulimia; the duration, frequency, and severity of symptoms together with a description of their characteristics and the nature of any associated symptoms should be delineated. The physical examination should be directed toward any consequences or complications of vomiting and identification of any signs that may point to the cause of the symptoms.

Evaluation for gastroparesis Gastric emptying scintigraphy of a radiolabeled solid meal is the best accepted method to test for delayed gastric emptying.

Conventionally, the test is performed for 2 hours after ingestion of a radiolabeled meal. Shorter test durations are inaccurate for determining gastroparesis. For the test meal preparation, the radioisotope needs to be cooked into the solid portion of the meal. Performing the test for a longer duration, up to 4 hours, has been proposed to increase the yield in detecting delayed gastric emptying in symptomatic patients.

Breath testing can be used to measure gastric emptying using the nonradioactive isotope 13C to label octanoate, a mediumchain triglyceride, which can be bound into a solid meal. Studies have also reported labeling the proteinaceous algae (Spirulina) with 13C. By measuring 13C in breath samples, gastric emptying can be indirectly determined. The octanoate breath test has been used primarily for clinical research and pharmaceutical studies.

Antroduodenal manometry provides information about coordination of gastric and duodenal motor function in fasting and postprandial periods. Decreased antral contractility and origination of organized fasting migrating motor complexes in the small intestine rather than in the stomach are observed in gastroparesis.

With accurate stationary recording, a reduced postprandial distal antral motility index is correlated with impaired gastric emptying of solids. A normal study with a normal transit test result strongly suggests that antral motor dysfunction is not the cause of symptoms. Antroduodenal manometry may differentiate between neuropathic or myopathic motility disorders and may help to diagnose unexpected small bowel obstruction or rumination syndrome.

Treatment of gastroparesis Primary treatment of gastroparesis includes dietary manipulation and administration of antiemetic and prokinetic agents.

Dietary recommendations include eating frequent smaller-size meals and replacing solid food with liquids, such as soups. Foods should be low in fat and fiber content.

Antiemetic agents are administered for nausea and vomiting.

The principal classes of antiemetic drugs are antidopaminergics, antihistamines, anticholinergics, and more recently serotonin receptor antagonists. The antiemetic action of phenothiazine compounds is primarily due to a central antidopaminergic mechanism in the area postrema of the brain. Commonly used agents include prochlorperazine, trimethobenzamide, and promethazine.

Serotonin (5-HT3) receptor antagonists are helpful in treating or preventing chemotherapy-induced nausea and vomiting.

The sites of action of these compounds include the area postrema as well as peripheral afferent nerves. These agents are frequently used for nausea and vomiting due to other etiologies with little published evidence demonstrating their efficacy. These agents are best used on an as-needed basis.

FLORIDA MD - JANUARY 2015 19

Digestive and Liver Update Current prokinetic agents include metoclopramide and erythromycin, which can be administered orally or intravenously. Domperidone, a dopamine (D2) receptor antagonist, is not approved in the United States but is available in Canada, Mexico, and Europe.

Tegaserod, a partial 5-HT4 receptor agonist, enhances gastric emptying; however, no clinical trials have confirmed its efficacy in reducing symptoms in patients with gastroparesis.

Patients refractory to the initial treatment of gastroparesis can be difficult to manage. Treatment may involve switching prokinetic and antiemetic agents, combining prokinetic agents, injecting botulinum toxin into the pylorus, using gastrostomy/jejunostomy tubes, and implanting a gastric electric stimulator.

A treatment recently reported to be helpful for refractory gastroparesis is endoscopic injection of botulinum toxin into the pyloric sphincter. Botulinum toxin, which reduces the release of acetylcholine from cholinergic nerves, may relax pyloric sphincter resistance, allowing more food to empty from the stomach. In open-label trials, pyloric botulinum toxin has been reported to produce modest temporary symptom improvements in selected patients. To date, no placebo-controlled trials have been reported for this therapy of gastroparesis. Long-term control is not to be expected from this treatment.

Decompressing gastrostomy and feeding jejunostomy tubes are occasionally used when necessary. A jejunostomy tube may provide a route for administering enteral nutrition, hydration, and medications.

Gastric electric stimulation is an emerging therapy for refractory gastroparesis. There are several ways to stimulate the stomach by varying the electrical parameters. With gastric electrical pacing, the goal is to entrain and pace the gastric slow waves at a higher rate than the patient’s normal 3-cpm myoelectric frequency. One unblinded study in a small number of subjects has shown this to accelerate gastric emptying and improve dyspeptic symptoms. The second method is to use high-frequency stimulation at 4 times the basal rate (12 cpm). High-frequency gastric electric stimulation has been evaluated in several studies, showing an improvement in symptoms with only a modest change in gastric emptying. Studies to better evaluate the efficacy of gastric electric stimulation are ongoing. As this type of treatment evolves, further delineation of the overall effectiveness, the type of patient who will likely respond, optimal electrode placement, and stimulus parameters should be explored.

Celebrating our 40th Anniversary

Meet Our Principals — All working together for you!

• Corporate Retirement Plans • Complex Benefits Strategies • Individual and Family Estate Planning • HR and Benefits Compliance Solutions • Customized Insurance Products and Services • Financial Planning and Wealth Management

Hardy Vaughn, CLU, ChFC, CAP, MSFS*

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Experience. Knowledge. Strategy.

1407 E. Robinson Street Orlando, FL 32801 www.vaughngroup.com

Office: (407) 898-3911 Toll Free: (800) 940-0990

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*Securities and Investment Advisory Services may be offered through NFP Securities, Inc., Member FINRA/SIPC. NFP Securities, Inc. is not affiliated with The Vaughn S. Kyle Taylor* Group, Inc.

20 FLORIDA MD - JANUARY 2015

Harinath Sheela, MD moved to Orlando, Florida after finishing his fellowship in gastroenterology at Yale University School of Medicine, one of the finest programs in the country. During his training he spent significant amount of time in basic and clinical research and has published articles in gastroenterology literature. His interests include Inflammatory Bowel Diseases (IBD), Irritable Bowel Syndrome (IBS), Hepatitis B, Hepatitis C, Metabolic and other liver disorders. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE) and the American Association for the Study of Liver Diseases (AASLD) and Crohn’s Colitis foundation (CCF).

Dr. Sheela is a Clinical Assistant Professor at the University of Central Florida School of Medicine. He is also a teaching attending physician at Florida Hospital Internal Medcine Residency and Family Practice Residence (MD and DO) programs. 

2015

EDITORIAL CALENDAR

Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market.

Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics.

Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY –

Digestive Disorders Diabetes

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Imaging Technologies Interventional Radiology

AUGUST –

Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism OCTOBER –

Cancer Dermatology

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

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FLORIDA MD - JANUARY 2015 25

Florida Hospital is ranked the #1 hospital in the state of Florida for the second year in a row.

And ranked nationally in ten specialties.

Cancer

Cardiology & Heart Surgery

Diabetes & Endocrinology

Gastroenterology & GI Surgery

Geriatrics

Gynecology

Nephrology

Neurology & Neurosurgery

Pulmonology

Urology

We thank you for trusting us with your care.

We thank our clinicians for their commitment to excellence.

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