Floridamd September 2014

SEPTEMBER 2014 • COVERING THE I-4 CORRIDOR

UCF Pegasus Health:

New College of Medicine Physicians Practice Offers Primary, Specialty Care Under One Roof

WE’RE GETTING BIGGER AND

BETTER.

Announcing Extension of Pediatric Services at Osceola Regional Medical Center Now partnering with Pediatrix Medical Group to provide onsite pediatric care to admitted children and newborns – 24/7.

Pediatrix Medical Group also specializes in caring for hospitalized pediatric patients at Arnold Palmer Hospital for Children and newborns at Winnie Palmer Hospital for Women & Babies.

Osceola Regional Medical Center Pediatric Services • • • •

Pediatric Emergency Services with Board Certified Pediatric ER Physicians Only Neonatal Intensive Care Unit (NICU) Level II (2) in Osceola County Nationally Recognized Hospital-Based Board Certified Pediatricians - New Tenured Team of Local Pediatric and Family Practice Physicians

For information about our services, FREE physician referral and healthcare questions, please call Consult-A-Nurse® Toll Free – 24/7 at: 1-800-447-8206

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FLORIDA MD - SEPTEMBER 2014

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contents 6

SEPTEMBER 2014 COVERING THE I-4 CORRIDOR

 COVER STORY

Photo: DONALD RAUHOFER / FLORIDA MD

As the physician practice of UCF’s new College of Medicine, UCF Pegasus Health keeps clinical faculty at the top of their patient care game by, as the physicians say, “practicing what we teach.”

For the past two years, UCF Pegasus Health has been seeing patients 16 and older from across the community. The practice is located at Quadrangle and University boulevards, just two blocks from UCF’s main campus. In the spring of 2015, UCF Pegasus Health will open a second location in Orlando’s Medical City.

UCF Pegasus Health includes primary care physicians and specialists in cardiology, endocrinology, rheumatology, nephrology, geriatrics, adolescent medicine and sports medicine.

Photo: provided by UCF College of Medicine

ON THE COVER: Dr. Maria Cannarozzi, board certified internist and medical director of UCF Pegasus Health, reviews treatment options with a patient during a well woman exam.

27 IR’S RELENTLESS ASSAULT ON LIVER TUMORS 29 HIDING IN PLAIN SIGHT– POSTPARTUM DEPRESSION 31 NEMOURS HOSPITALISTS STORY 32 Two New Residencies Open at Osceola Regional Medical Center

DEPARTMENTS 4

FROM THE PUBLISHER

11 BEHAVIORAL HEALTH 13 HEALTHCARE LAW 14 CANCER 16 PULMONARY & SLEEP DISORDERS 19 ORTHOPAEDIC UPDATE

20 MARKETING YOUR PRACTice 22 ALLERGY 24 DIGESTIVE & LIVER UPDATE 26 FINANCIAL UPDATE: Insurance•Benefits•Wealth MGMT. 2

FLORIDA MD - SEPTEMBER 2014

FLORIDA MD - SEPTEMBER 2014

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FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. Because of the tragic death of comedian Robin Williams, there’s been a lot of discussion in various media about depression. One of the least understood is postpartum depression. Ironically, it causes what should be a joyous time for a new

mother to be quite the contrary. Hope’s Bridge was created to help these new mothers by serving as a link to helpful resources and treatment plans in our community. I have asked them to share information about their program that some of your patients or their families may find very useful. Until next month…

Best regards,

Donald B. Rauhofer Publisher

Coming UP Next Month: The cover story focuses on Moffitt Cancer Center in Tampa.

Editorial focus is Cancer and Dermatology.

Hope’s Bridge The number of new mothers experiencing postpartum mood complications is high, yet few community resources are available to provide comprehensive support to these women and their families. Hope’s Bridge was born out of this need to serve these clients.

Its vision is to advocate, educate and provide support pertaining to postpartum wellness, while destigmatizing and demystifying the myths surrounding mood disorders. The program serves as a link between the client and resources within the community (e.g. therapists, doulas, psychiatrists, etc.). For example, it provides individual support based on an in depth assessment and a treatment plan. This treatment plan may include personal support and the above mentioned community resources. The key is to provide a safety net for the mother and family to help them recover from the effects of these mood complications. Hope’s Bridge is currently in the process of creating a support group for new mothers and a lecture series featuring various professionals speaking on different topics of postpartum wellness.

Hope’s Bridge also recognizes the role of the provider working with a new mother and family. Understanding the impact of postpartum wellness is critical in assisting the family during the postpartum period. The practitioner may be the first one to be able to recognize the symptoms of postpartum mood disorders as well to provide education and support toward prevention, treatment and recovery. Hope’s Bridge is available for consultation for providers who are interested in learning more about perinatal mood disorders and postpartum wellness. Furthermore, we are continually seeking resources in which to refer to our clients. If you provide a postpartum related service, we would love to speak with you further about partnering with your organization. Please contact Nancy Layish, LCSW, ACSW at nrlayish@aol.com or visit www.hopesbridge.net. 

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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.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Wendy Sarubbi, Srinivas Seela, MD, Damon Reed, MD, Brian Montague, MD, Christopher Ramsey, PhD, Jamie Huysman, PsyD, Nancy Layish, LCSW, Jennifer Thompson, Corey Gehrold, S. Kyle Taylor 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.

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.

FloridaHospital.com/USNews FLORIDA MD - SEPTEMBER 2014 MKTGPR-13-16418

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COVER STORY

UCF Pegasus Health: New College of Medicine

Physicians Practice Offers Primary, Specialty Care Under One Roof

By Wendy Sarubbi As the physician practice of UCF’s new College of Medicine, UCF Pegasus Health keeps clinical faculty at the top of their patient care game by, as the physicians say, “practicing what we teach.”

For the past two years, UCF Pegasus Health has been seeing patients 16 and older from across the community. The practice is located at Quadrangle and University boulevards, just two blocks from UCF’s main campus. In the spring of 2015, UCF Pegasus Health will open a second location in a joint facility with Florida Hospital in the Gateway Building at Orlando’s booming Medical City.

“UCF Pegasus Health is a state-of-the-art, multi-specialty group practice where faculty members who are teaching M.D. students the latest in medicine and are researching current issues in medicine are seeing and caring for patients in our community,” explains Dr. Deborah German, vice president for medical affairs and dean of the UCF College of Medicine. “At UCF Pegasus

Health, the clinical experts training the next generation of health leaders are taking care of people like you and me.”

Primary, Specialty Care Under One Roof UCF Pegasus Health includes physicians practicing primary care (internal and family medicine) and specialists, all under one roof. Current specialties include cardiology, endocrinology, rheumatology, nephrology, geriatrics, adolescent medicine and sports medicine. And the practice is looking to increase the number and specialties of its faculty physicians. UCF Pegasus Health recently earned a three-year echocardiography accreditation in adult transthoracic and adult stress testing from the Intersocietal Accreditation Commission (IAC). Under the leadership of board certified cardiologist and faculty physician Dr. Bernard Gros, UCF Pegasus Health’s cardiology lab performs echocardiograms, cardiac stress tests and also can fit patients with Holter monitors.

Photo: provided by UCF College of Medicine

Cardiologist Dr. Bernard Gros in UCF Pegasus Health Cardiology lab doing a stress test.

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Photo: provided by UCF College of Medicine

COVER STORY

Dr. Mariana Dangiolo, geriatric and family medicine specialist goes over test results on an Ipad with the patient.

Other diagnostic services are also available. The practice’s inhouse radiology center provides DEXA scans for existing patients with X-ray services coming soon. The clinic has a procedure room for biopsies and minor surgical procedures. Medical staff members draw physician-ordered blood work right at the UCF Pegasus Health facility. The blood work is analyzed off-site, but patients do not typically have to travel to an outside lab location to have their blood work done.

“Our goal is to provide seamless care to our patients,” said Dr. Maria Cannarozzi, who is board certified in internal medicine and pediatrics and also serves as medical director of the practice. “We teach together and practice together. We show the same teamwork to our patients that we show in how we train UCF’s medical students – our community’s health leaders of tomorrow.”

Patients challenged by multiple health problems show the power of UCF Pegasus Health’s teamwork approach. For example, a patient with hypertension, which has led to kidney and heart damage, can have his or her primary care and healthcare oversight from one of the practices internal medicine specialists. Meanwhile, the same patient can get coordinated kidney and cardiac treatment from Drs. Gros and board-certified nephrologist Dr. Abdo Asmar – all at the same healthcare location. If that patient develops arthritis down the road, one of UCF Pegasus Health’s two rheumatologists can provide additional coordinated care.

“With primary care physician and specialists under one roof, you don’t have to run around town so much trying to get well,” said Dr. Joyce Paulson, one of the practice’s board-certified internal medicine specialists. “Inside UCF Pegasus Health we don’t

have barriers to teamwork.”

Committed To Community Education As College of Medicine faculty members, UCF Pegasus Health physicians are also committed to health education for the entire Central Florida community: • The practice continues to hold seminars and other events for patients and non-patients alike. Recent public sessions included “The Art and Science of Healthy Women,” where about 65 women learned about preventative healthcare, and topics from diabetes to dementia, from six UCF Pegasus Health female physicians. The doctors, who are wives, mothers, daughters and career women, said they understood the challenges of staying healthy as they care for everyone else. As Cannarozzi said, the goal of the session was not to preach but to provide information on “what it takes to be a healthy woman in today’s hectic world.” Later, a “Live Smart for Your Heart” event featured advice from three faculty physicians on simple lifestyle changes that can reduce the risk of heart disease. More than 50 people attended and learned about topics ranging from monitoring high blood pressure at home to whether low-dose aspirin therapy works for everyone.

• UCF Pegasus Health recently began offering therapeutic yoga instruction for people with specific conditions – including diabetes, hypertension and arthritis.

• In partnership with UCF’s Department of Psychology, UCF Pegasus Health holds support groups for diabetics and caregivers. The caregiver events are led by Dr. Daniel Paulson, a FLORIDA MD - SEPTEMBER 2014

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Photo: DONALD RAUHOFER / FLORIDA MD

COVER STORY

“Inside UCF Pegasus Health we don’t have barriers to teamwork,” says Dr. Joyce Paulson (right), a board certified internal medicine specialist shown coordinating care with Dr. Neha Bhanusali, a board certified rheumatologist at the practice.

UCF assistant professor of psychology, and include information on improving communication, understanding difficult behaviors and increasing pleasant events for both the caregiver and patient. The UCF caregiver program was established to meet community needs. As Americans care for a rapidly aging population, approximately 43.5 million people have assumed caregiver roles for aging family members and another 14.9 million are caring for people with Alzheimer’s disease or dementia. Research shows that when caregivers attend organized support groups run by trained professionals, they can double the amount of time a senior with dementia can stay at home, rather than be cared for through an outside and often more costly program. Research also shows that support groups bring increased peace-of-mind to families trying to accommodate their loved one’s wishes.

• This year, the practice is also beginning an inaugural Fall Lecture Series that will include topics such as “Couch Potato to 5K,” cyber security for yourself and your children, and crime prevention/personal safety taught by members of UCF’s Police Department.

• The practice produces weekly health tips that are emailed for all UCF faculty and staff. Those health tips are also shared with UCF Pegasus Health patients and area businesses, neighborhood associations and community groups.

“As physician educators, we want to teach our patients so they are empowered and active in their own healthcare,” explains As8 FLORIDA MD - SEPTEMBER 2014

mar, an award-winning teacher at the College of Medicine and at Cook County Hospital in Chicago, where he served as chief resident. “We know that wellness and disease are consistently tied to lifestyle choices. So our goal is to give our patients support in a range of topics -- medicine, psychology, exercise, stress management -- to make them as healthy as they can be.”

Incorporating Patient Care, Research As an academic medical practice, UCF Pegasus Health has strong ties to the latest in medical research. The medical school includes UCF’s Burnett School of Biomedical Sciences, which focuses its scientific research on cancer, cardiovascular, neurodegenerative and infectious diseases.

Ph.D. scientists, graduate students and post-doctoral students are increasingly working with clinical faculty to identify disease and prevention trends in an effort to increase scientific discoveries from lab bench to patient bedside. In fact, the new UCF Pegasus Health practice at Lake Nona’s emerging Medical City will have an inflammatory disease focus – with clinicians such as endocrinologists, rheumatologists and gastroenterologists working with Burnett School researchers to find better treatments for patients suffering from inflammatory diseases.

UCF Pegasus Health physicians are also involved in research.

For example, Asmar was recently named to the editorial board of the American Journal of Kidney Diseases (AJKD), one of the top three international journals on the topic. As part of his editorial

COVER STORY work, he is compiling and detailing peer-reviewed research on kidney disease and treatment and condensing it faster use on the journal’s blog. He is also interviewing research authors across the globe on their scientific discoveries. In addition, clinical-researchers at UCF Pegasus Health are seeking opportunities to engage in such clinical trials.

Second Location Coming Soon The UCF College of Medicine is working to complete construction on its second UCF Pegasus Health Location, in the Gateway Building on Narcoosee Boulevard in the heart of Orlando’s booming Medical City.

The Gateway location is expected to open in the spring of 2015. UCF’s goal is to provide patient care and research in inflammatory diseases, including rheumatology, endocrinology and dermatology and to incorporate treatment with inflammatory disease research being done at the college’s Burnett School of Biomedical Sciences.

The expansion is part of the economic development brought about by the Medical City at Lake Nona, which is anchored by the new medical school and is expected to generate 30,000 jobs and more than $7.8 million in annual economic impact by the year 2017. Medical City currently also houses the Sanford-Burnham Medical Research Institute, Nemours Children’s Hospital, the Orlando VA Medical Center, set to open in 2015, and a University of Florida research facility.

Health IT Focus UCF Pegasus Health is also committed to secure electronic health records that can improve patient care and make communication between patient and physician easier and faster. Most physicians at the practice have attested to Meaningful Use Part 1 and are on their way to attesting to Part 2. Eight current physicians were named Meaningful Use Vanguards (MUVERS) for their leadership in electronic records by UCF’s Regional Extension Center for Health IT. In April, the practice launched a secure new web-based portal for patients to communicate with medical staff, review prescriptions and lab results and verify appointments. The portal also allows the practice to notify the patient when it’s time for preventative care measures like annual physical exams and cancer screenings.

“We strive to provide healthcare in a way that fits our patients’ busy lives,” said Dr. Leonardo Oliveira, who is board certified in internal medicine and sports medicine and also serves as UCF Pegasus Health’s director of quality and safety. Oliveira has spearheaded the practice’s electronic health record implementation.

“Physicians want to practice at the top of their license and do the best for their patients. We really think that the use of electronic health records helps us provide great quality care and decrease costs for our patients.”

Dedicated To Public Service In addition to caring for their own patients, the UCF Pegasus

Photo: provided by UCF College of Medicine

Dr. Leonardo Oliveira, sports and internal medicine specialist, and team physician for University High at UHS football game.

FLORIDA MD - SEPTEMBER 2014

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COVER STORY Health physicians are also focused on the community’s health. Their public service efforts are many:

• Dr. Lisa Barkley, board certified in family, adolescent and sports medicine, serves as the UCF College of Medicine’s assistant dean of diversity and inclusion and recently received a Blueprint Award from the city of Orlando for her leadership and a national “Diversity Visionary Award” from INSIGHT Into Diversity magazine. She serves on a variety of community boards, including the United Way, Healthy Eatonville and the Central Florida Partnership on Health Disparities. Working with UCF medical students, Barkley has provided health screenings and support to underDr. Abdo Asmar, a board certified nephrologist who was chief resident at Chicago’s Cook County Hospital, talks with a patient. served communities at events like the Zora Neale Hurston Festival, the Black Men’s Health Summit, the Caribbean Health Summit and back-to-school health fairs.

• Asmar was elected to the Board of Directors of the National Kidney Foundation (NKF) of Florida. As part of his service, he volunteers at the NKF’s Kidney Early Evaluation Program (KEEP), which targets individuals with an increased risk of developing kidney disease in underserved areas of the state.

Quality care for patients and improving the health of the greater Orlando community are the prime focus for the new practice– and one that is strengthened as UCF Pegasus Health matures and grows. As it begins its third year and grows to serve patients throughout the community, UCF Pegasus Health remains committed to providing innovative, personalized care as College of Medicine faculty physicians “practice what we teach.” 

3400 Quadrangle Blvd • Orlando, FL 32827 (407) 266-3627 • ucfpegasushealth.org 10 FLORIDA MD - SEPTEMBER 2014

UCF Pegasus Health is the College of Medicine’s physician practice and offers the following specialties and procedures: • • • • • • • • • • • • • •

Internal medicine Family medicine Cardiology Endocrinology Geriatrics Adolescent Medicine Rheumatology Sports Medicine Nephrology Echocardiograms Cardiac stress tests Holter monitors DEXA scans Injections for sports injuries and chronic inflammatory disease management • Blood draws at time of appointment

Photo: provided by UCF College of Medicine

• Oliveira, who did his sports medicine fellowship at the Cleveland Clinic, is the team physician for Orlando’s University High School.

He continues to work at University High and around the community to raise awareness of the dangers of concussions – to athletes and non-athletes alike.

Behavioral Health

There’s a Lot to Celebrate this Month, COVER STORY So Get Ready to Get Your Party On! September honors and acknowledges two things that are very close to my heart…Recovery and Healthy Aging.

By James D. Huysman, PsyD, LCSW If you are physician or an allied health professional, remember that the month of September is an important one for your patient. Anyone who has salvaged their life from “a seemingly hopeless state of mind and body” deserves to be congratulated this month. Recovery Month is most often associated with drug and alcohol addiction and there will be many events to raise awareness about the problem of addiction in the USA today. In our offices, make sure to assess and identify addicts for care diligently and please make it a protocol.

However, I’d like to paint a broader stroke and lend support to the concept of “recovery” as a universal human experience this month. Throughout our lives we “recover” from many things too numerous to mention here. Often we see that the only way to recover is the 12 Steps and for many that is true. But it is also true that “all paths lead to the righteous.”

Your patients may be caregivers as well! They may be experiencing a loss and grieving or an impending loss. You, as their physician need to be aware! The loss of a friend or loved one can be a game changer as it pertains to their medical health or even their likelihood of ending up in an emergency room. That is the power of how behavioral health intersects with medical care.

Know that your patient and/or their caregivers are struggling.

Complete acceptance of the situation is not always easy, but it is an important part of the process, as they grieve and as you care for them. You, as a professional, could grieving for yourself unconsciously. We should not be immune to the feelings of those we care for.

Whether the loved one lives or passes on, caregiving inevitably changes a person because of the extraordinary intimacy of it.

Make sure to tell them to take some time for themselves to reflect and recover throughout this sacred journey as it unfolds. Sharing can be powerful and comforting at the same time. Knowing how they feel bonds in a very special way.

The other celebration this month revolves around the notion of living long enough to come to terms with the fact that you are aging. That’s right, it’s Healthy Aging® Month.

Healthy Aging® Month is an annual observance month designed to focus national attention on the positive aspects of growing older. The mission of Healthy Aging® Month is to encourage local level Healthy Aging® events that promote taking personal responsibility for one’s health… be it physically, socially, mentally or financially.

Think it’s too late to “reinvent” yourself? Think it is too late for your patient to reinvent themselves? Think again.

According to Carolyn Worthington, editor-in-chief of Healthy Aging® Magazine and executive director of Healthy Aging®, it’s never too late to find a new career, a new sport, passion, or hobby. Worthington is the creator of September is Healthy Aging® Month, an annual health observance designed to focus national attention on the positive aspects of growing older. Now in its second decade, Worthington says September’s Healthy Aging® Month provides inspiration and practical ideas for adults, ages 50-plus, to improve their physical, mental, social, and financial well-being.

I speak for UnitedHealth at the AARP Conferences and I am just jazzed to be a part of their” Life Reimagined Campaign.” It is the perfect combination of recovery and health again. In the spirit of Worthington’s words, a powerful program awaits you and all you have to do is go to lifereimagined.aarp.org.

The following tips are good advice for your patients and their caregivers of all ages as we reimagine our lives and celebrate National Recovery Month. They both go hand in hand. But of course, first use the combination of these two events in September to jumpstart their new viewpoint! And by the way, walk the walk as well. Nothing is more powerful than the “power of attraction.”

You and your patients can get your life in gear, with a little jump start.

The four key things to remember are: 1) Be Here Now – Do not beat yourself up over the past. Reframing how and why we hot here and understanding that everything happens for a reason is a conversation to have with you, a great therapist or a safe place to laugh and cry!

2) Today is the First Day of the Rest of Our Lives. No matter what age we are, we always know that this is the premise of the Life Reimagined Campaign 3) “A journey of a thousand miles begins with a single step.” That is straight out of the powerful Eastern voice of Lao Tzu. Just think, Lao Tzu’s wisdom was so powerful that it was said Confucius actually travelled to meet him. That about says it all!

4) Build on successes. Do not run when things start to get good or wait for the other shoe to drop. We actually deserve the success and need to build on it hour by hour and day by day.

Of course, that is my rendition of 4 steps but of you are so inclined the number 4 is very lucky indeed. Make sure to run out and grab a copy of “The Four Agreements” by Dr. Miguel Ruiz and savor its words. It is so easy to read but like any self-help measure, needs to be implemented on a consistent basis.

FLORIDA MD - SEPTEMBER 2014 11

Behavioral Health If we can do that, just feel how we change and the world around us adjusts to that change. I am so happy Recovery Month and Healthy Aging® Month are happening together. September is a great month to make sure your patients and their family caregivers are aware as well.

Don’t take my effort in combining these two, feel free to make these two events this month work specifically for you and when you do get back to me so I can share your efforts with everyone I come in contact with, jhuysman@wellmed.net.

Dr. James Huysman, PsyD, LCSW, aka Dr. Jamie, is a fierce advocate of patient-centered healthcare. He is a popular conference speaker and media guest on caregiver burnout, compassion fatigue and addictions and healthcare reform. Dr. Jamie blogs for Psychology Today and sat on the NASW committee to establish national protocols for certification and standardization of caregiving practices. He writes for Florida MD and Today’s Caregiver magazines. He co-founded the Leeza Gibbons Memory Foundation and created the signature programming for its psychosocial drop-in model, Leeza’s Place, opening 8 national locations, each with a different funding partner, in a four year period. He co-wrote the acclaimed book, Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One with Memory Loss, with Gibbons and Dr. Rosemary Laird. He currently works as Vice President of Provider Relations and Government Affairs for WellMed Medical Management in Florida, a UnitedHealthcare company. 

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Join Us at the Symposium for Multidisciplinary Management of Liver Metastases Our faculty will discuss the roles of systemic therapy, surgery and locoregional treatments, including new and emerging options such as targeted biologic agents, advanced resection techniques, Yttrium 90 radioembolization and combination therapies.

Faculty:

George Fisher, MD, PhD Stanford, CA

Rafael Blanco, MD Tampa, FL

Brian Montague, MD Tampa, FL

Dhirash Jeyarajah, MD Dallas, TX

Fred M. Moeslein, MD, PhD Baltimore, MD

Kelly VanEpps, MD Tampa, FL

Saturday, October �

7am-3pm | $25 Embassy Suites Downtown Convention Center* | 513 S. Florida Ave., Tampa *Overnight stay optional. Discounted room rate of $139 per night applied upon booking directly with Embassy using hotel code BPM

�.� CMEs provided upon completion To register or for more information: StJosephsIR.org or (���) ���-���� Education grant provided by Sitex Medical, Inc.

12 FLORIDA MD - SEPTEMBER 2014

BC1403793_0814

Healthcare Law

Medical Technology Patents Affected by U.S. Supreme Court

By Christopher Ramsey, PhD Several recent decisions by the U.S. Supreme Court affect the extent to which two important classes of medical technology inventions are patentable: those inventions that involve (1) natural products or (2) natural processes. By themselves, natural products and processes have never qualified as patentable subject matter, while isolated natural products and practical applications of natural process have been patentable. Many patented blockbuster drugs and medical treatment methods are derived from natural products or the body’s natural processes.

The well-publicized gene patent debate concerns patents on isolated human genes and methods of using them to detect a person’s genetic disposition to diseases such as breast cancer. In Association for Molecular Pathology v. Myriad Genetics, 133 S.Ct. 2107 (2013), the Supreme Court recently decided that isolated human genes cannot be patented because isolating genes from their natural environment is not an act of invention.

The United States Patent and Trademark Office (USPTO), the government agency responsible for examining patent applications, applies the Myriad gene patent case to all natural products, such as proteins and other naturally occurring molecules.

For now, people will not be able to patent natural products in the U.S. merely by identifying a use for them and isolating them from nature. Instead, for natural products to qualify as patentable subject matter, the isolated natural products will need to be combined with other materials or modified so that they are not just isolated copies of their natural selves.

tions. Their fate, in other words, will lie as a matter of wordsmithing, but not be based on the overall subject matter the patents describe.

Inventions involving naturally-derived products or natural processes are still patentable, but the Supreme Court has made it more difficult. Patent practitioners must artfully draft patents to ensure that inventions are precisely defined to fit within these new boundaries of what is patentable subject matter.

Christopher M. Ramsey, Ph.D. practices intellectual property law and is a registered patent attorney at GrayRobinson, P.A. in Orlando, FL. He advises clients on patent, trademark, and copyright issues. Chris is a Ph.D. chemist. His research is published in more than twenty peer reviewed articles. For additional information, Chris can be reached at 407-244-5686; christopher.ramsey@grayrobinson.com; or by visiting www.gray-robinson.com. 

In Mayo v. Prometheus, 132 S.Ct. 1289 (2012), the Supreme Court decided that a diagnostic method for determining the best dose of the drug thiopurine for a given patient was not patentable subject matter. The method involved the steps of: (a) administering a drug that produced a particular metabolite in the patient’s body and (b) determining the amount of metabolite the patient produced. The amount corresponded to the dose of thiopurine the patient needed.

Prior to the Mayo decision, this method would have been patentable subject matter because the “administering” and “determining” steps were not part of the body’s natural metabolic processes – they required human involvement. The Supreme Court concluded, however, such steps were just routine physician activities. Accordingly, after Mayo, a method involving a natural process cannot be patented just by practically applying the natural process using routinely-performed steps.

These Supreme Court decisions do not signify the end of patenting naturally-derived products or practical applications of natural process, although they will adversely affect certain patents that issued prior to the date of these decisions. For the patents that will be adversely affected, the problem will often be a matter of how those patents define their respective invenFLORIDA MD - SEPTEMBER 2014 13

CANCER

Moffitt Doctor Spearheads Sunshine Project, Pediatric Cancer Foundation Lab

By Damon Reed, MD and Sarah Breseman The Pediatric Cancer Foundation (PCF) is a nonprofit organization dedicated to funding research to eliminate childhood cancer. PCF was founded by two mothers who met in the waiting room of a Tampa pediatric oncology clinic in 1991. Its focus is to fund research to find less toxic, more targeted therapies by partnering with leading hospitals nationwide. This innovative collaboration is known as the Sunshine Project and it aligns parents, patients, community members, clinical and translational researchers and physicians across the country towards fighting childhood cancer.

Each year, approximately 12,600 children are diagnosed with cancer. For a family receiving this devastating news, the initial shock is only the beginning of the long, rough road that lies ahead of them. While significant progress has been made overall for young patients with cancer, there remain difficulties treating patients with rare cancers, high-risk cancers, and cancers with metastatic spread.

Many of these patients will experience the heartbreak of exhausting all options and known therapies.

Despite many efforts at institutions, there remains significant need for new and innovative combination therapies.

Wouldn’t it be great if the leaders in the fight against childhood cancer could unite behind the common goal of destroying this terrible disease? The Pediatric Cancer Foundation recognizes this need, and is working together in partnership with Moffitt Cancer Center to eliminate childhood cancer.

The Sunshine Project, administered at Moffitt, capitalizes on the strengths of doctors and researchers to streamline the process and accelerate the development of new treatments. This unique collabMelissa Helms , Dr. Damon Reed, Dr. Diana Yu, Elliot Kahen and Nancy Crane. Melissa is the orative model optimizes the significant founder of the Pediatric Cancer Foundation and Nancy is the executive director of the Pediatric clinical research resources at Moffitt, Cancer Foundation. which allow coordination of the 13 other sites that enroll pediatric patients. These sites include: • All Children’s Hospital Johns Hopkins Medicine, St. Petersburg, Fla. • Children’s Hospital of Los Angeles, Los Angeles, Calif.

• Connecticut Children’s Medical Center, Hartford, Conn.

• Holtz Children’s Hospital at the University of Miami, Miami, Fla. • Johns Hopkins Medicine, Baltimore, MD • Arnold Palmer Hospital for Children, Orlando, Fla. • Montefiore Medical Center, Bronx, NY • Nationwide Children’s Hospital, Columbus, Ohio • Nemours Children’s Clinic, Jacksonville, Fla. • Nemours/Alfred I duPont Hospital for Children, Wilmington, Del. • Primary Children’s Medical Center, Salt Lake City, Utah • UF Health Shands Children’s Hospital, Gainesville, Fla., and • Tampa General Hospital Children’s Medical Center, Tampa, Fla. 14 FLORIDA MD - SEPTEMBER 2014

CANCER The Pediatric Cancer Foundation funds basic science, translational research, and clinical trials. They are also funding peerreviewed grants across its member institutions in the fall of this year. These innovative projects consist of translatable hypotheses with plans to incorporate this work into the next generation of Sunshine Project trials.

Spearheaded by Damon Reed, M.D., director of the Adolescent and Young Adult Program and medical director of the Sarcoma Department at Moffitt, the Sunshine Project is making great strides in terms of innovation and trial accrual, continually growing in terms of patients treated. Current initiatives and Phase I clinical trials include: • Relapsed Acute Lymphoblastic Leukemia Trial (ALL): ALL is the most common cancer in children. Metformin is a medication frequently used to treat Type II diabetes. The combination of metformin and chemotherapy is a new way to target resistant leukemia cells. This trial will determine if combining metformin with chemotherapy is safe and effective at treating leukemia. (NCT01324180) • VIT and Metformin in Relapsed or Refractory Solid Tumors Trial: Solid tumors account for 60 percent of all childhood malignancies. Unlike other childhood cancers, minimal improvement in survival has been seen in children with solid tumors over the past twenty years. These disappointing results have prompted the Pediatric Cancer Foundation to find new agents in the fight against this disease. (NCT01528046) • Topotecan & Sorafenib in Relapsed or Refractory Solid Tumors Trial: Topotecan is a chemotherapy drug that has been used safely for over a decade in children with anti-cancer activity in leukemias, solid tumors and brain tumors. Sorafenib is from a newer class of targeted chemotherapy drugs. The activity and safety data of single use Sorafenib has shown in multiple pediatric research models to be effective in targeting cancer cells. Therefore, the combination of these two agents was tested along with numerous others in sarcoma models and found to work well together to kill cancer cells. (NCT01683149)

Pediatric Total Cancer Care Program: • In 2013, the Pediatric Cancer Foundation opened the first pediatric blood and tissue banking program in Florida to further personalized medicine for children with cancer.

Pediatric Cancer Foundation’s Sunshine Project Research Laboratory at Moffitt Cancer Center • In 2013, the Pediatric Cancer Foundation opened a new Sunshine Project research laboratory at Moffitt. The focus is to create a system to rapidly evaluate many FDA approved and actively evaluated agents which can then immediately be translated into Sunshine Project Phase I clinical trials. Current work focuses on osteosarcoma, Malignant Peripheral Nerve Sheath Tumor and Alveolar Soft Part Sarcoma.

The Sunshine Project prides itself on being quickly adaptable and willing to innovate. In 2013-14, the Pediatric Cancer Foundation donated more than $1 million to the Sunshine Project. By

relying on the cooperative efforts of this team of principal investigators from leading institutions, this novel approach holds great promise and has been steadily increasing in terms of numbers of institutions and active research programs supported by this effort.

An annual retreat is held in Tampa, where these researchers and doctors come together to evaluate the Sunshine Project’s progress and determine future project goals, prioritize clinical trials and fund translational research efforts.

This synergistic joint effort aims to provide an example of an improved, collaborative method for successful research. Childhood cancer occurs frequently and strikes at random, sparing no ethnic group, socioeconomic class or geographic region. And survival comes at a cost. The Pediatric Cancer Foundation and Moffitt will continue to work together through the Sunshine Project to eliminate childhood cancer. To learn more about the Pediatric Cancer Foundation’s Sunshine Project, please visit www. fastercure.org.

Damon Reed, M.D., is the medical director of the Sarcoma Department and leader of the Adolescent and Young Adult Program at Moffitt Cancer Center. Reed received his undergraduate degree at the University of Dayton and attended medical school at Case Western Reserve University School of Medicine in Cleveland, Ohio. He completed his residency in Pediatrics at Boston Children’s Hospital, Boston, Mass., and then completed his fellowship in Pediatric Hematology/Oncology at St. Jude Children’s Hospital in Memphis, Tenn. Reed is board certified in pediatrics and pediatric hematology/oncology. His interests include care of the Adolescent and Young Adult Oncology patient, translational research, and developing novel therapies, Sarah Breseman is with the Pediatric Cancer Foundation, Community Outreach. She may be contacted at Sbreseman@fastercure.org or 813-269-0955.  FLORIDA MD - SEPTEMBER 2014 15

PULMONARY AND SLEEP DISORDERS

Shift Work Sleep Disorder

By Daniel T. Layish, MD Optimal sleep and wakefulness requires proper alignment between an individual’s intrinsic circadian rhythm and their desired sleep wake schedule. The word circadian comes from the Latin “circa” meaning “about” and “dian” meaning “day.” Our intrinsic circadian rhythm is controlled by an internal clock in the hypothalamus (suprachiasmatic nucleus). The hypothalamus receives signals from the retina that entrain the circadian rhythm to the light dark cycle. The circadian rhythm affects the timing of sleep.

There is also a homeostatic sleep drive, which controls sleep intensity, and it is determined by how long an individual has been awake.

Shift work sleep disorder is a recurrent or persistent mismatch between a person’s habitual sleep wake schedule and their endogenous circadian rhythm. Shift work sleep disorder can be associated with insomnia or excessive sleepiness (or both). The conventional time cues (zeitgeber = “time giver” in German) of sunlight and social activities are frequently out of phase with the altered sleep schedule in an individual with shift work sleep disorder. Many shift workers revert back to their traditional daytime schedule during non-work days. By definition, the course of shift work sleep disorder parallels the period of the shift work and remits with termination of shift work. An individual with shift work sleep disorder may use a large porSLEEP FACTORS tion of their free time for recovery of sleep, which may have negative social consequences such as marital discord and impaired social relationships. Shift work sleep disorder tends to be more common after age 50. Between 5 and 8% of the population is exposed to night work on a regular or periodic basis.

Shift work sleep disorder is usually a clinical diagnosis. A formal sleep study (polysomnogram) may be helpful to exclude other etiologies of a patient’s symptoms. The sleep study should ideally be performed during the regular hours of sleep of the individual having the study. To diagnose shift work sleep disorder one must exclude any other medical or psychiatric conditions which could account for the symptoms. In addition, the symptoms should not meet criteria for any other sleep disorder which can produce insomnia or excessive daytime sleepiness (such as Jet-lag syndrome). Women appear to be slightly more prone to developing shift work sleep disorder. Interestingly, women tend to quit their shift work less often than men. The occurrence of shift work sleep disorder may vary depending upon the speed and direction of shift rotation. It may also vary depending upon a patient’s di16 FLORIDA MD - SEPTEMBER 2014

urnal preference. It appears to be less common in individuals who identify themselves as “night owls.” Individuals with shift work sleep disorder have been found to have higher rates of peptic ulcer disease as well as more sleepiness related motor vehicle accidents. Other consequences of this disorder include absenteeism from work, higher rates of depression and missed family and social activities as well as chronic fatigue and poor work performance. There have also been studies which link shift work sleep disorder to glucose intolerance as well as higher risk for alcohol and substance use. Sleep diaries can be CIRCADIAN FACTORS

SHIFT WORK COPING ABILITY

ENVIRONMENTAL FACTORS

helpful in assessing patients with shift work sleep disorder. Actigraphy can be useful as an adjunct to history, physical exam and sleep diary. Actigraphy recording should consist of at least three consecutive 24-hour periods. Circadian rhythm markers (such as core body temperature monitoring or timing of melatonin secretion) are more difficult and typically are not used in routine clinical settings.

Treatment for shift work sleep disorder can include exposure to bright light in the work place as well as administration of wake promoting agents during evening work hours. Other treatments include scheduled napping as well as hypnotic agents to improve daytime sleep. Maintaining a regular sleep wake schedule during both work and non-work days is also recommended (as well as minimizing light or noise in the bedroom and allowing sufficient time in bed for sleep during the daytime). Other recommendations include limiting light exposure by using dark sunglasses during the morning trip home from work. The timing of light

PULMONARY AND SLEEP DISORDERS

FLORIDA MD - SEPTEMBER 2014 17

PULMONARY AND SLEEP DISORDERS therapy is critical. The American Academy of Sleep Medicine recommends light exposure before the core temperature is reached in an individual with a morning/evening/night schedule (versus administrating light therapy after core temperature in an individual with a night/evening/morning schedule). Studies have utilized various light intensities from 2350 to 12,000 lux. Some but not all studies of bright light therapy have also restricted daytime light exposure. Different schedules of light exposure have also been used. Melatonin has both sleep promoting (hypnotic) and phase shifting properties. Melatonin (when given to night workers before their daytime sleep) may enhance daytime sleep and appears to have no effect on subsequent nighttime alertness. In a study published by Czeisler in The New England Journal of Medicine in 2005, modafinil resulted in decreased accidents/near accidents during the commute home (versus placebo). Treatments for shift work sleep disorder can include modafinil (Provigil) as well as armodafinil (Nuvigil). These medications are non-amphetamine stimulants believed to act on the hypothalamus, although their exact mechanism of action is unknown.

Shifts can be permanent, fixed or rotating. Shift can rotate forward (clockwise) (from morning to evening to nighttime) or backward (from night to afternoon to early morning shift). Rotating shifts seem to cause more sleep difficulties than permanent shifts and counter clockwise rotation affects sleep wake activities more than clockwise rotation. The speed of rotation and the length of the shift may also impact an individual’s symptoms.

It appears that workers on permanent night shifts sleep one to four hours less than day workers and individuals on rotating shifts sleep about two hours less than day workers. There are several factors involved in this. Shift workers must try to sleep at a time when their circadian/wakefulness drive is exerting pressure on them to remain awake. The desire to spend time with family or take care of household or social obligations is also a facMeet Our tor. Environmental factors such as noise and light may also be obstacles to sleep quality for shift workers.

work than men).

In general, the circadian clock adjusts better to clockwise rotation because it is naturally easier to delay sleep to a later hour.

Typically, longer shifts (such as 10-12 hours) cause more sleepiness than eight hour shifts. Women doing shift work tend to get less sleep than men when they are not working because of their persistent family and social obligations. Overall, night and rotating shift workers comprise approximately 6% of all workers. About 1% of the working population in the United States is believed to suffer from shift work disorder. Increased awareness of this disorder should allow more individuals to receive proper diagnosis and therapy.

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He currently serves as Medical Director of the Intensive Care Unit, Respiratory Therapy and Pulmonary Rehab at Winter Park Memorial Hospital. Dr. Layish may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com. 

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Table 1: Factors influencing the effect of shift work on sleep and wakefulness • Type of shifts (permanent, rotating).

• Duration of shifts.

• Speed of rotation (slow or fast).

• Direction of rotation (clockwise or counter clockwise).

• Social and family disruption.

• Exposure to natural or artificial light.

• Existing health problems.

• Age (over 50 is more adversely affected than younger individuals) • Gender (female shift workers seem to have more difficulty coping with shift 18 FLORIDA MD - SEPTEMBER 2014

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ORTHOPAEDIC UPDATE

Hands-On: Patient is Pain-Free Again Following Excision Arthroplasty of the Thumb

By Corey Gehrold Gardening. Golfing. Even putting away the dishes became difficult for Marilyn several years ago, and that’s when she decided to seek out a hand specialist in Orlando. Today, she is back doing what she loves, and she owes it all to a missing bone.

Marilyn has always had a love of writing; so, when it became too painful for her to put pen to paper she scheduled an appointment with Alan W. Christensen, M.D., a hand specialist at Orlando Orthopaedic Center.

After their initial consultation, Dr. Christensen suggested several options to help relieve her pain, offering the pros and cons for each option.

faces of the CMC joint.

Alan W. Christensen, MD

“An excision arthroplasty will alleviate pain while allowing the thumb joint to retain a level of movement,” he says. “This is unlike a fusion surgery which binds the joint together and causes it to be immobile.”

Recovering from an Excision Arthroplasty Following surgery, Dr. Christensen performs a follow up in five

Together, the duo decided excision arthroplasty was the best way to give Marilyn back the function she wanted.

“I really appreciated how honest he was, and he even told me to go home and do research on my own before making a decision,” she says. “I trusted his judgment and went ahead and did [the surgery] and it has been great.”

In fact, Marilyn was playing golf again just five weeks after her procedure.

“Surgery really has made a profound impact on my life,” she says. “[It] really helped me be able to function.”

Marilyn was back to writing and playing golf without pain just a few weeks after an excision arthroplasty procedure from Dr. Christensen at Orlando Orthopaedic Center.

What is an Excision Arhroplasty?

Essentially, an excision arthroplasty removes the trapezium, a small bone situated between the two large bones at the base of the thumb, and replaces it with a piece of tendon, preventing the surfaces of the joints from rubbing together. When these joints rub together, there’s a sudden, intense pain, making it difficult to perform even menial tasks like typing or holding a glass of water.

The result of surgery?

“The tendon provides soft tissue that forms a sort of false joint to maintain the thumbs ability to move,” says Dr. Christensen.

“This false joint alleviates the pain by preventing the surfaces of the joints from being rubbed together.”

He says the problem arises when the carpometacarpal (CMC) joint of the thumb becomes attached to the trapezium bone in the wrist. The CMC joint is what allows a person to move the thumb to the palm.

to seven days to check on healing. Patients will wear a thumb brace for four to six weeks to give the hand time to heal. Patients are then directed to attend physical therapy sessions for several weeks as they begin to regain strength, range of motion and motor abilities in their hand.

“The pain level now compared to before I had surgery is as different as night and day,” says Marilyn. “I’m back writing full-time and playing golf and it has really made a big difference.”

Dr. Christensen notes that full recovery may take up to four months in some patients, but many begin going back to their regular activities much sooner.

“For me this surgery was fantastic,” says Marilyn. “I love the results.” 

The goal of the 90-minute excision arthroplasty procedure is to ease the pain where those two joint surfaces now rub together.

The tendon forms a soft tissue “spacer” that will separate the surFLORIDA MD - SEPTEMBER 2014 19

Marketing Your Practice

FAQ: How Can I Get More Patients in the Door?

By Jennifer Thompson, Co-founder, DrMarketingTips.com Do you want to know a few easy ways to get more patients in the door?

Are you wondering how you can fill appointment slots with little to no marketing budget?

Most medical practices ‘do’ marketing for one reason – to get more patients in the door. So to help you, we’ve put together a list of the questions we get most often and our answers.

What can I do to increase referrals at my office immediately?

Take a look at where you are getting your best referrals now and work to strengthen those existing relationships. We see so many offices that assume they will always continue receiving referrals from their trusted referral partners, but it’s important to remember that relationships take work.

You must continue to connect with people. Always assume that there is someone else out there trying to earn the same business that you already have and it’s up to you to continue cultivating those relationships – doing everything you can to ensure those referral sources are still strong. In other words, don’t forget about them. Come up with small ways to show your appreciation to your referral partners.

What’s the biggest trend you see coming this year for medical marketing?

Online rating websites are going to be huge. Over 70% of all new patients are going to the internet first to find out about your office and the physicians within it.

If you do a Google search of your practice, take a look at where a lot of the results are coming from. You’ll see your website, maybe some ads and then online physician rating sites populate much of the rest of the list.

Smart practices need to be proactive in making sure that the information on physician rating sites is correct and that you have a policy in place for responding and reacting to negative comments.

Any opportunity you get to humanize your doctors should be taken.

In your experience, what works best to grow a practice with a very limited budget?

There are three things we think work really well here.

First, strengthening existing personal relationships is always huge as we mentioned earlier.

Next, your practice should have a strong internet presence with a sound social media strategy. You should have a dynamic, 20 FLORIDA MD - SEPTEMBER 2014

informational website that allows patients to not only get to know what you are capable of as an office, but also who you are as people. Your practice is a business like anywhere else; and you do more business with people you trust or like.

Lastly, we suggest marketing to your existing patients. You’ve already got the captive audience, so you might as well use them.

Consider sending out newsletters, fliers, postcards (whatever you can afford, really) in an effort to get them to recommend you or come back themselves.

How important is my office staff to help grow my practice?

Extremely important! Your staff is what you will be judged on by your patients as they are typically the first and last touch points. It’s as simple as being greeted with a smile. Even in this technology forward day and age, it’s still important to put on a happy face and put your best foot forward.

It goes a long way, especially when so many businesses lack customer service.

Do contests and giveaways work to help me grow my practice?

Not really, no. They can help you gain some followers on Facebook and Twitter, but as far as actually growing your practice, not so much. Unless, of course, you’re giving away a prize big enough to get you an inordinate amount of publicity – something a seasoned professional would know all about.

I don’t collect e-mail addresses from all patients. Should I? What should I do with them?

Collecting email addresses is an easy way to build a strong, accurate customer database. Have a plan for communicating your marketing messages to your patient database, be that e-mail newsletters, appointment reminders or even birthday messages.

Remember, if you’re on a limited budget, marketing to your existing patients is a great way to stay top of mind and grow your practice. This goes without saying, but if you’re collecting email addresses for marketing purposes, you must also have an opt-in field on the form you collect them.

How often should I update my practice’s website?

It depends.

You should be making changes to your website on a very regular basis – adding practice events, open-houses, speaking engagements, testimonials, etc. The more you make changes to your website, the higher you will most likely be in search engine rankings (there’s more to it than that, but it helps).

Marketing Your Practice That said, integrating a focused social media plan is a great way to strengthen your web presence without having to constantly update your main website that will have a similar effect.

What type of print advertising really makes a difference to my bottom line?

As always, it depends on your target audience. Who are you trying to reach? Where are they receiving their media? We always say we want to put ourselves in front of the best eyes possible, not necessarily the most. Meaning, it’s better to have the right audience, even if it’s smaller. If they are all potential targets, the size difference is irrelevant. Best of all, those smaller distribution sizes usually mean cheaper ad rates and potential bonuses for advertising (such as event sponsorship and content opportunities).

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Want more free medical marketing resources? Check out DrMarketingTips.com for articles, webinars, video tutorials, audio blogs, forums and more.

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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. 

Coming UP Next Month: The cover story focuses on Moffitt Cancer Center in Tampa. Editorial focus is Cancer and Dermatology.

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 - SEPTEMBER 2014 21

ALLERGY

Understanding and Managing Pediatric Food Allergy

By Jessie Rosenberg Hoang, MD and Steven Rosenberg, MD One of the greatest fears a parent may face is whether their child can become seriously ill if he/she comes in contact with a food, such as peanuts, to which their child is allergic. Television and newspapers report numerous stories of a child having to be rushed to an emergency room for treatment because the child was exposed to a food at home, at a friend’s house, or in a restaurant, that resulted in an allergic (anaphylactic) reaction. Food allergies are a growing problem for pediatric patients and their families.

While the incidence of food allergies in the general population is about 2%, there is a much higher incidence in pediatric patients with approximately 6-8% of children manifesting some type of sensitivity to a food. Most of these pediatric sufferers are under the age of 5 years. It is estimated that one quarter of households in the United States alter their dietary habits to some extent to accommodate a family member with a presumed food allergy. The manifestations of food allergic reactions range from mild throat and skin irritation to life-threatening anaphylaxis.

Food allergy is by far the most common cause of anaphylaxis seen in the emergency department. An estimated 30,000 emergency department visits and 200 deaths each year are attributed to food-induced anaphylaxis. Of anaphylaxis induced by food allergy, peanuts and tree nuts account for 80%. Trends have shown that the prevalence of peanut allergy has actually doubled within the last decade. Food allergy is very prevalent in children with eczema. It is estimated that 35% of children with moderate to severe eczema have IgE mediated food allergy that may be a triggering factor in their exacerbations.

Although awareness of food allergies in the population has increased, considerable confusion still exists in regard to defining it. The layperson often has only a limited understanding of the term and will refer to any form of food intolerance as an allergy.

In many cases a parent may attribute the fact that a child simply does not like a food to the child having an allergy to it. Parents, nutritionists, and even physicians implicate “allergies” for behavioral problems such as Attention Deficit Disorder, poor performance at school, and even Autism. However to date, no study has been able to elicit a definite relationship between food allergy and any of these syndromes listed above.

When by careful history it is established that the child is indeed having a reaction to a food, it then must be determined if the reaction is Type I or IgE mediated (anaphylactic), induced by a non-IgE mediated reaction (anaphylactoid), or non-immune related (idiosyncratic reaction). Examples of idiosyncratic reactions to foods include individuals who develop headaches (Migraines) after eating foods rich in additives such as nitrites. Type I or IgE mediated reactions can be detected by skin or RAST testing. The diagnosis of non-IgE mediated reactions cannot be detected by conventional allergy testing. The only means to make a diagnosis 22 FLORIDA MD - SEPTEMBER 2014

Jessie Rosenberg Hoang, MD

Steven Rosenberg, MD

in respect to non-IgE dependent food allergy is by oral provocation challenge, usually done in an office or hospital setting. Oral provocation challenge testing while effective, is time-consuming and not without risk.

Chicken, eggs, cow’s milk protein, peanuts, tree nuts, fish, and soy protein cause the vast majority of food reactions in children living in the United States. Delaying exposure to these foods may delay the development of clinical atopy, and decrease the severity of the allergic (atopic) state in children. However no study to date have been able to demonstrate that delaying the introduction of these foods will completely prevent the allergic state in infants, children, and adults.

Breastfeeding, regardless of the mother’s diet has been proven to be beneficial to the health of the infant. Exclusive breastfeeding for at least 6 months compared with cow’s milk protein formula feedings provides a long-term protective effect on the development of respiratory allergy in the pediatric patient. In subgroups of neonates with a family history suggestive of allergy (atopy), it has been demonstrated that early exposure to cow’s milk protein compared with breast milk increased the risk of developing eczema by age 18 months. The best recommendations for mothers of high-risk infants at this time are to breastfeed for at least 4-6 months.

When it is time for the parents to consider adding solid foods to the high-risk infant’s diet, the least allergenic foods should be given first. Cow’s milk protein should not be added until 9-12 months, eggs at 12 months, and peanuts, nuts, and fish at 3 years.

Adding solid foods to the infant’s diet in the first 4 months of life is not recommended and has been shown to predispose high-risk infants to eczema. It should be stressed that many children, despite preventive efforts, will still develop food allergies and clinical atopy.

Allergic disease has many different manifestations in children.

Symptoms seen in IgE dependent food reactions include oralpharyngeal irritation with pruritus, urticarial (hives), angioedema (swelling), laryngeoedema, bronchospasm, and gastrointestinal symptoms such as diarrhea, vomiting, pain, and cramping. We have recently seen a new syndrome, Eosinophilic Esophagitis that can present with dysphagia. The most feared consequence of IgE dependent food allergy is anaphylaxis or a generalized allergic reaction that can be life-threatening.

The diagnosis of food allergy is dependent upon a careful history, physical examination, and laboratory tests. The history

ALLERGY should be a means in which the physician, patient, and family can begin to identify the foods in question which are thought to be triggering factors. At times the physician may request that the family keep a detailed dietary history. For a definitive diagnosis of IgE dependent food allergy skin or RAST testing should be done. Skin tests are highly reproducible, they have a positive predictive value around 50%, and their negative predictive value is greater than 95%. It is important to note that a positive skin or RAST test alone does not establish the diagnosis of food allergy.

To make the diagnosis of IgE dependent food allergy the presence or absence of positive tests should correlate with the patientâ&#x20AC;&#x2122;s history. When there is a question, the physician may then proceed to oral provocation challenge testing to the food(s) in question.

Because of this when there is any doubt in regards to food intolerance/allergy, referral to a physician who specializes in food allergy such as an Allergist/Immunologist would be of benefit.

The prognosis for children who suffer from certain food allergies is generally good. Many patients diagnosed with anaphylaxis to milk, wheat, eggs, and soybean will outgrow their clinical sensitivity. An estimated 50% of cases resolve by 18 months and 90% by 36 months. Children who develop food sensitivity after age 3 are less likely to lose their food sensitivity. However in the case of sensitivity to peanuts, tree nuts, fish, and shellfish the chances of the child going into remission are significantly less, and in fact, the sensitivities to these foods may persist into adult life.

Peanut/Tree Nuts are responsible for the majority of food-induced anaphylaxis cases seen in the emergency department in the United States. It is important for physicians to educate families about the management of peanut/tree nut allergy. Specifically, physicians should teach their patients to read food labels to see if peanuts or tree nuts have been added. Generally if a member of the family is allergic to peanuts/tree nuts, these foods should not be kept in the home. If they are in the home, they should have brightly colored warning labels and be out of reach of the pediatric patient. Restaurants and carry-out establishments should be contacted ahead of time and asked if they use peanuts, tree nuts, or cold-pressed peanut oil in their cooking. The treatment of choice for anaphylaxis is injectable epinephrine. Because of this an Epi-Pen should be carried at all times by the patient, and if necessary a school-nurse. Many schools will establish peanut/ tree nut free areas in the school cafeteria. Some airlines are no longer serving peanuts to their passengers. The growing consensus is that an Epi-Pen should be available in all schools and even in restaurants.

ment modalities. While Immunotherapy has been found to be effective for the treatment of asthma and pollinosis, current studies do not reveal any benefit to the use of allergy injections for food allergy. Other treatment modalities such as food drops have also not been shown to be of any benefit. Hopefully in the future, agents such as Xolair (omalizumab) may be of benefit to reduce or eliminate an individualâ&#x20AC;&#x2122;s sensitivity to foods. Because of the difficulty in making a diagnosis and the serious implications of food, allergy referral to a physician specialist in the field of Allergy/Immunology will be of much benefit in the diagnosis and management of the child with food sensitivity.

Jessie Rosenberg Hoang graduated with a Bachelor of Science degree from Cornell University. She attended medical school at St. Georges University, Grenada where she graduated with a MD. Jessie Rosenberg Hoang is currently a pediatric resident at the University of Maryland Medical Center, Baltimore, Maryland.

Steven Rosenberg has been in private practice in the Central Florida area for over 30 years. His practice, Allergy and Asthma Associates of Central Florida specializes in Pediatric and Adult Allergy, Asthma, and Immunology.

Dr. Rosenberg and his associates, Carlos Jacinto, MD, and Harleen Anderson, MD, have offices in the Dr. Philips, Winter Park, Altamonte Springs, and Viera. î Ž

Be sure and check out our

website at www.floridamd.com!

It is important to recognize that these changes and restrictions require a lot of work by the family and can cause considerable stress and frustration. In peanut allergic patients, it is often not necessary to restrict other legumes. However, tree nuts are universally restricted due to cross-reactivity unless a particular nut has been individually tested and found to be safe for the patient.

Food allergy in the pediatric population can be difficult to diagnose and manage. While there is ongoing research in the field, other than dietary elimination, there are no other effective treatFLORIDA MD - SEPTEMBER 2014 23

Digestive and Liver Update

Celiac Disease, Clinical Symptoms, Pathophysiology, Diagnosis and Treatment By Srinivas Seela, MD Celiac disease is an autoimmune disease caused by the ingestion of gluten. Classically, it presents with diarrhea and failure to thrive within the first couple of years of life. Diagnosis is based on abnormalities of small intestinal biopsy. However, screening for celiac disease can be initially performed using serologic markers with very high sensitivity and specificity for disease such as IgA antibodies to tissue transglutaminase (TG). With the advent of rapid screening methods and increased awareness of celiac disease, an increasing number of individuals who are otherwise asymptomatic (or have subclinical symptoms) are being diagnosed.

The clinical manifestations of celiac disease that have been identified are extensive and varied and are no longer isolated to the gastrointestinal tract. Celiac disease has been associated with many other autoimmune conditions including autoimmune thyroid disease and type 1 diabetes.

Celiac (SEE-lee-ak) disease is a digestive condition triggered by consumption of the protein gluten, which is primarily found in bread, pasta, cookies, pizza crust and many other foods containing wheat, barley or rye. Celiac disease is characterized by smallintestinal mucosal injury and nutrient malabsorption in genetically susceptible individuals in response to the dietary ingestion of wheat gluten and similar proteins in barley and rye. People with celiac disease who eat foods containing gluten experience an immune reaction in their small intestines, causing damage to the inner surface of the small intestine and an inability to absorb certain nutrients.

Celiac disease can cause abdominal pain and diarrhea. Eventually, the decreased absorption of nutrients (malabsorption) that occurs with celiac disease can cause vitamin deficiencies that deprive your brain, peripheral nervous system, bones, liver and other organs of vital nourishment.

No treatment can cure celiac disease. However, you can effectively manage celiac disease by changing your diet.

Clinical Symptoms: There are no typical signs and symptoms of celiac disease. Most people with the disease have general complaints, such as: 1 Intermittent diarrhea 2 Abdominal pain 3 Bloating Sometimes people with celiac disease may have no gastrointestinal symptoms at all. Celiac disease symptoms can also mimic those of other conditions, such as irritable bowel syndrome, gastric ulcers, Crohn’s disease, parasite infections and anemia.

Celiac disease may also present itself in less obvious ways, including: 1 Irritability or depression 24 FLORIDA MD - SEPTEMBER 2014

2 Anemia 3 Stomach upset 4 Joint pain 5 Tiredness 6 Muscle cramps 7 Skin rash 8 Mouth sores 9 Dental and bone disorders (such as osteoporosis) 10 Tingling in the legs and feet (neuropathy) Some indications of malabsorption of nutrients that may result from celiac disease include: 1 Weight loss 2 Diarrhea 3 Abdominal cramps, gas and bloating 4 General weakness and fatigue 5 Foul-smelling or grayish stools that may be fatty or oily 6 Stunted growth (in children) 7 Osteoporosis

Another gluten-related condition Dermatitis herpetiformis is an itchy, blistering skin disease that also stems from gluten intolerance. The rash usually occurs on the torso, scalp and buttocks. Dermatitis herpetiformis can cause changes to the lining of the small intestine similar to that of celiac disease. However, it may not produce noticeable digestive symptoms. This disease is treated with a gluten-free diet, in addition to medication to control the rash.

Pathogenesis: Disease pathogenesis involves interactions among environmental, genetic, and immunological factors. Although celiac disease is predicted by screening studies to affect approximately 1% of the population of the United States and is seen both in children and in adults, 10%–15% or fewer of these individuals have been diagnosed and treated. Celiac disease (CD) is characterized by small-intestinal mucosal injury and nutrient malabsorption. It is activated in genetically susceptible individuals by the dietary ingestion of proline- and glutamine-rich proteins that are found in wheat, rye, and barley and are widely termed “gluten” (1). Although approximately 1% of the population of the United States is affected by CD, most affected individuals remain undiagnosed.

This probably reflects the fact that patients with CD can manifest a spectrum of intestinal and/or extraintestinal symptoms and, in some cases, they can be relatively asymptomatic, with their disease first being detected by antibody screening because they were identified as being at high risk of developing CD (for example, by being a family member of an affected patient. Presumed disease is best detected by serologic screening for the presence of

Digestive and Liver Update IgA antibodies specific for tissue TGase, and this should be followed by biopsy of the mucosa of the small intestine to establish a definite diagnosis. Life-threatening complications, although relatively rare, can include the development of refractory CD and enteropathy-associated T cell lymphomas (EATLs).

Acquired T cell–mediated immune mechanisms and innate immune mechanisms have an important role in the pathogenesis of CD.

Extra-Intestinal manifestations: We will use the phrase extra-intestinal manifestations of celiac disease to refer to conditions that are associated with celiac disease and are at least partially responsive to a gluten free diet. The distinction from conditions that are associated with celiac disease can be difficult and categorization is not necessarily exact.

Arthritis involving both the peripheral and axial skeletal has been reported in as many as 25% of patients presenting with celiac disease. More recent reports suggest a much lower proportion of subjects with celiac disease presenting with arthritis (1%). Neurologic and psychiatric disorders including depression, anxiety, irritability, peripheral neuropathy, cerebellar ataxia and migraines have all been reported

Serologic Testing:

to alternative treatments for this disease.

Srinivas Seela, 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 a significant amount of time in basic and clinical research, and has published articles in Gastroenterology literature.

His interests include advanced and therapeutic endoscopic procedures, colorectal cancer screening, Gastro Esophageal Reflux Disease (GERD), metabolic and other liver disorders.

Dr. Seela is board certified in both Internal Medicine and Gastroenterology. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE), the American Association for the Study of Liver Diseases (AASLD), and Crohn’s Colitis Foundation (CCF).

In addition to being an Assistant Professor at the University of Central Florida School of Medicine, he is also a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Residence (MD and DO) programs. Dr. Srinivas Seela is a gastroenterologist at Digestive and Liver Center of Florida. Contact information 407-384-7388. 

Serologic testing can be performed in subjects in whom the diagnosis of celiac disease is entertained, such as those with malabsorption and vitamin or mineral deficiencies, osteoporosis/osteopenia, infertility or other clinical symptoms. It can also be used to screen individuals considered to be Major Services include: at high risk for celiac disease, such as those • Allergy Injections with type 1 diabetes or first-degree relatives • Allergy Testing of an affected individual. Finally, serologic • Asthma Therapies testing can also be used to monitor therapy • Flu Shots (during Flu season) as antibody levels are expected to decline • Pulmonary Testing with treatment.

Treating Central Florida for over 25 years

There are multiple antibodies found in celiac disease, but endomysial (EMA) and TG IgA autoantibodies are the most sensitive and specific . Antibodies to TG IgA is now considered to be the single best test for the diagnosis of celiac disease , and is gradually replacing EMA testing due to high sensitivity and specificity, ease of use, and quantitative capability. Other autoantibodies, including anti-gliadin antibodies are much less specific and are generally not used

Treatment: Although most individuals respond to treatment with a “gluten”-free diet (GFD), which is the only currently accepted therapy, recent advances in our understanding of the immunopathogenesis of CD might lead

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FLORIDA MD - SEPTEMBER 2014 25

Financial Update: Insurance • Benefits • Wealth Management

Market Review

By S. Kyle Taylor

The stock trading week was historic, but few traders were there to see it. In what is always one of the lightest trading weeks of the calendar year, the S&P 500 set all-time closing highs on 4 of 5 trading days, giving the 57-year old index 32 record closes for the year (above and beyond the 45 record closes achieved in 2013).

The S&P 500 had its first close ever above 2000 (set on 8/26/14) and finished the week up +9.9% YTD (total return) through Friday 8/29/14. August, the worst performing month on average for the stock index since 1990, turned in a stellar +4.0% gain, its best result in 14 years (source: BTN Research).

The USA initially announced its plan of “quantitative easing” (QE) in November 2008. At that time, no central bank in the world had ever attempted a strategy of “printing money” and “purchasing bond assets” in an effort to drive down domestic interest rates to stimulate a declining economy. Nearly 6 years later, the GDP of the United States grew by a strong +4.2% in the 2nd quarter 2014. The European Central Bank, after seeing their collective Eurozone economies grow by just +0.2% in the 2nd quarter, is now considering its own version of QE (source: BTN Research).

The Federal Reserve has not shied away from discussing an October 2014 ending of QE, a conversation that logically should move domestic interest rates higher. But someone forgot to tell the bond market about that discussion. On Friday (8/29/14), the yield on the 10-year Treasury note closed at 2.35%, within 1 basis point (i.e., 0.01%) of its lowest close of the year and down 68 basis points since the end of 2013. At 4.10%, the average 30-year fixed rate mortgage is at its lowest level of the year (source: Freddie Mac).

Notable Numbers for the Week: NEW vs. OLD - The median sales price of a new home sold nationwide during July 2014 was $269,800. The median sales price of an existing home sold nationwide during July 2014 was $222,900. Thus, the premium paid for a new home vs. an existing home was +21% (source: Census Bureau, NAR).

HIRING FOLKS - 47 of 50 states have increased the number of people employed in their states over the trailing 12 months, i.e., 2nd quarter 2013 to the 2nd quarter 2014 (source: Rockefeller Institute).

RIGHT NOW - Nearly 3 in 5 American retirees (58%) worked full-time until their retirement, then stopped working and have not and do not anticipate ever working again (source: Federal Reserve).

JUST THE BIGGEST - Although 1,395 insured US commercial banks and savings institutions had some level of derivatives activity in the first quarter 2014, just 4 banks are responsible 26 FLORIDA MD - SEPTEMBER 2014

for 92% of all derivatives business (source: Office of the Comptroller of Currency).

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 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.

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.

Mr. Taylor 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 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!

IR’s Relentless Assault on Liver Tumors

By Brian Montague, MD

Interventional Radiology’s ever-growing arsenal of tumor-destroying weapons allows precise, powerful, and targeted ablation therapies.

We are amidst a very exciting time in oncology. Advances in chemotherapy have been nothing short of phenomenal, and new surgical techniques are allowing more and more patients to be safe resection candidates. But one of the most exciting advances in oncology has been the emergence and progression of minimally invasive targeted tumor therapies, especially those performed by Interventional Radiologists (IRs). These technologically advanced treatments propel cancer therapy into a whole new dimension, particularly involving malignant liver tumors. IRs can combine clinical and technical expertise with advances in technology to obtain high level tumor responses safely, quickly, and effectively. The result: patients are living longer, have a better quality of life, and are happier.

Image guided, minimally invasive targeted tumor therapy now plays a fundamental role in the treatment process of many cancer patients. Nowhere in the body does this hold true more than the liver. As the incidence of both primary and metastatic liver tumors continues to grow, so does our ability to treat patients who otherwise would not have options for longer-term survival and good quality of life.

One of the most promising new, targeted liver therapies is yttrium-90 radioembolization. Currently in practice at St. Joseph’s Hospital in Tampa, this procedure employs the use of very selective angiography, requires minimal sedation, and is performed on an outpatient basis. A tiny catheter, called a microcatheter, is advanced under fluoroscopic guidance into the hepatic arteries that are feeding the tumor. The treatment takes advantage of the fact that all liver tumors are supplied exclusively by the hepatic artery, whereas normal liver is supplied mainly by the portal vein. This fundamental provides IRs with the proverbial ‘silver bullet’: a therapy that provides an extremely intense tumor ablative dose, while essentially uneffecting normal liver tissue.

Once the microcatheter is advanced into the target vessel, millions of microscopic spheres coated with yttrium-90, a beta emitter, are infused through the catheter and lodged in

the tumor capillary bed. The range of activity of the yttrium-90 is on the order of a millimeter, so the tumor gets intensely radiated and the remaining liver is mostly unharmed.

This therapy works well for every liver tumor, independent of relative radiosensitivity, due to the profound radiation dose the tumor receives. Yttrium-90 radioem-

FLORIDA MD - SEPTEMBER 2014 27

bolization has been proven to be effective as first line therapy or in patients with failed first, second or multiple lines of chemotherapy; prolonging survival with minimal impact on patient quality-of-life.

The procedure is very safe, with low risks of cholecystitis (1%), gastroduodenal ulcer formation (3%), radiation pneumonitis, and liver failure (both much less than 1%).

and induce profound hypertrophy of the normal liver. For example, we have seen the lateral left lobe of the liver hypertrophy from 15% (not enough residual viable liver) to 40% (enough normal liver to survive after extended right and middle hepatic resection).

We look forward to further collaboration with surgery to facilitate tumor resection, as this technique is very promising.

A very unique aspect of our practice is that we are one of the very select few groups in the state with an Interventional Radiology authorized user (AU); there are only a handful of IRs to have been given AU status in the state of Florida. This status is designated by the state of Florida to prescribe and administer the yttrium therapy, based on very specific and rigorous training requirements. Although the angiography portion of the procedure must be performed by interventional radiologist, the actual dosing, dose administration and clinical evaluation for radiotherapy has been traditionally performed by non-IR physicians unfamiliar with angiography/embolization techniques and specific patient evaluation and follow up relative to these procedures. Having an IR AU helps provide a unique, comprehensive approach to patient care. This provides unprecedented continuity, with the interventional radiologist performing the full clinical evaluation, dosing, dose calculations, and entire procedure. We strongly believe that this translates into better continuity of care, higher patient satisfaction, improved follow up, and overall better outcomes.

IRs love what we do, and for many of us interventional oncology is at the top of the list. We thoroughly enjoy collaborating with medical oncologists, surgical oncologists, and radiation oncologists to offer individualized oncologic patient care that improves survival, decreases morbidity, improves quality of life, and enhances the overall patient experience. But most of all, we love our patients and their families; with the opportunity to be a part of their most crucial time in life.

But IRs don’t just have one arrow in the quiver; we can target many other tumors in the body. We employ numerous additional technologies, combined with our expertise with image guided procedures, to further target tumors, including thermal and electrical ablation devices: cryoablation, radiofrequency ablation/microwave ablation, and irreversible electroporation. Virtually all liver tumors can be treated using IR methods, and we often employ a combination of ORTHOPAEDIC SUBSPECIALTIES therapies for optimal outcomes. Some of our UÊ Ê Ê

most recent and exciting discoveries in IR UÊ "7 have shown synergistic effects of combining UÊ ""/ÊEÊ thermal ablation with embolization, signifiUÊ ÊEÊ7, -/ cantly expanding tumor ablation zones and UÊ * tumor cell kill rates by reducing what we call UÊ UÊ- "1 , the ‘tumor vascularity heat sink’ effect.

Brian Montague, M.D. is an interventional radiologist at St. Joseph’s Hospital in Tampa and is part of experienced radiology team that includes Troy Woeste, M.D., Matthew Berlet, M.D., Peter Bernstein, M.D., Kelly VanEpps, M.D. and Glenn Stambo, M.D. In addition to numerous cancer therapies, other procedures performed by this highly specialized team include arterial and venous angioplasty/stenting, uterine fibroid embolization, varicose vein ablation, peripheral vascular disease treatment, hemodialysis intervention, stroke intervention and more. For additional information please visit Stjosephsir.org. 

HELPING YOUR PATIENTS

GET BACK TO WHAT THEY LOVE

IRs also work very closely with other specialties to facilitate tumor therapies. We are now able to augment liver cancer surgery by converting patients, who otherwise would be unresectable, to surgical resection candidates.. In order for a liver tumor patient to be resectable, they must have enough normal liver left after surgery to survive. We can now increase the amount of residual normal liver (called the ‘future liver remnant’) by ablating the segments/lobe of the diseased liver using portal vein embolization or supratherapeutic Yttrium-90 radioembolization. These techniques cause atrophy of the diseased liver, 28 FLORIDA MD - SEPTEMBER 2014

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Hiding in Plain Sight – Postpartum Depression

By Nancy Layish, LCSW, ACSW

OVERVIEW: Postpartum depression (PPD) is a form of depression that develops following childbirth and impacts functioning to various degrees depending on severity. Onset is usually from the first few weeks postpartum up through the first year. Postpartum depression and a condition known as the “Baby Blues” may be confused. The differences between the “Baby Blues” and PPD are the duration, intensity, and severity of the symptoms. Approximately 80% of new mothers experience what is known as the “blues” (with symptoms such as lack of sleep, exhaustion, and a roller coaster of emotions), usually due to a hormonal imbalance.

However, these symptoms typically peak around two weeks and then disappear. Some mothers react more strongly than others to the changes in hormone levels, be it post-partum or even postweaning.

Unlike the blues, postpartum depression/anxiety symptoms persist and become more severe. Mothers often report feelings of worthlessness, guilt, despair, difficulty concentrating, or other similar feelings when depressed. Appetite and sleep patterns can be disrupted and a mother coping with postpartum depression may not be able to experience pleasure or interest in the baby or her family. Anxiety symptoms often accompany the depression. She may also have a difficult time adjusting to her new life as a mother while grieving the loss of her old identity and lifestyle. Many times, the mother may feel isolated due to lack of support. In some cases, a mother may have thoughts of wanting to hurt herself or her baby. Immediate help is required in these particular situations.

RISK FACTORS Multiple factors are believed to contribute to PPD. Medical issues, such as hormonal changes and/or a thyroid imbalance, play a role; psychosocial factors do, too. The latter may include a lack of social support, substance abuse issues, breastfeeding issues, birth defects, etc. A family history of anxiety or depression can also contribute. When doing an evaluation for postpartum depression, it is incumbent for the practitioner to assess for all of these factors. A spectrum of PPD exists (ranging from mild to severe), and if left untreated can become more severe. Approximately 20% of new mothers experience PPD, and it can affect any mother regardless of age, race, or income.

MYTHS AND STIGMAS It is unlikely that a mother will admit to depression and anxiety. Instead, she may say something like “I cry almost every day, I don’t see a way out, everything looks hopeless,” or “It feels like I am a bad mother--I should have never had this baby.” Many new mothers are ashamed or embarrassed to admit to feeling

depressed and/or anxious for fear of judgment or for fear of an authoritative figure deeming her unfit and taking her baby away. Unfortunately, these fears leave the mother in a state of isolation and silence.

Postpartum depression is shrouded in myths and stigmas hindering the understanding, creation, and accessibility of resources.

This is due, in large part, to the societal expectation that a new mother should be happy about her baby or that after a brief transition following the birth, she should be able to adjust fairly smoothly to her new role. The cultural expectation that motherhood will come naturally is personified and reinforced by media representations of the perky mom with her happy baby. Furthermore, the media’s portrayal of postpartum depression and other perinatal mood complications is usually negative. Media coverage is further intensified when there is a tragic outcome. For all these reasons, greater compassion, understanding, and support are crucial to break through the barriers of these stigmas. Isolation only exacerbates the depression and impairs the mother and family’s well being.

THE IMPACT OF POSTPARTUM DEPRESSION ON FAMILIES: A cycle of perpetual negative reinforcement and isolation exists which leads to a continued deterioration of coping skills and a likely increase of family conflict. Postpartum depression has a ripple effect influencing the mother’s ability to bond with her baby, as well as adversely affecting her relationship with her partner or other family members. Oftentimes, the partner feels bewildered by the mother’s symptoms, is unsure of what to do, and/ or feels helpless. S/he, however well intentioned, may expect the mother to “just snap out of it,” unable to understand that what she is experiencing is out of her control. The impact of untreated postpartum depression on the child could include low birth weight, disruption of the bonding process, insecure attachments, and social/behavioral problems in the older child. Early intervention and treatment is crucial to improve the outcome of the entire family unit.

SCREENING AND TREATMENT: A mother experiencing postpartum depression needs to understand that she is not alone, it is not her fault, and (with help) she will get better. Screening for PPD is crucial for identifying risk factors as early as possible. Ideally, screening would begin during pregnancy and occur during regular intervals during the postpartum period. It is the hope that in the future every hospital and birth center will have a screening protocol in place. The Edinburgh Postnatal Depression Scale (EPDS) (1) is an example of a widely used screening tool that is adaptable in many languages and is easy to administer and score. Please note that the FLORIDA MD - SEPTEMBER 2014 29

EPDS is a screening tool only - it does not assess the severity of the symptoms, nor is it a diagnostic tool. Follow up with the clinician is necessary to make an accurate diagnosis. Also, if the mother answers anything other than a zero on question number 10 (harm-related question), an immediate referral for further assessment and intervention is mandated.

The good news is that effective treatment for postpartum depression is available. Treatment includes individual counseling, support groups (face to face or online), one-to-one peer support, medication, or a combination of these. Individual counseling provides a trusting, supportive atmosphere where the mother can open up about her experience, focus on her strengths, and work on solutions to improve coping skills. Support groups are very powerful in that the mother can identify with others experiencing similar circumstances. This is a powerful affirmation that she is not alone. Several online support groups are available, making it a cost effective option and allowing the mother to participate from home. One-to-one peer support involves individuals, such as postpartum doulas, parent mentors, or other volunteers, communicating with the mother on a regular basis.

Finally, medication may also be a very helpful option in reducing depression and anxiety symptoms, thus increasing coping skills. However, many mothers are hesitant to consider medication for fear of stigma or how it will affect them or their babies.

The decision to take medication is a personal one, and the risks and benefits of medication for the mother and her baby need to be carefully considered. The mother will need to be referred to a physician for further information and a medication evaluation.

Resources, such as Lactmed, are available to help mothers and physicians evaluate pharmaceutical options.

POSTPARTUM DEPRESSION AND BREASTFEEDING: Mothers with PPD may feel that this condition is a contraindication to breastfeeding. However, it may be a situation where the mother needs to understand issues such as the use of medication, getting enough sleep, and family interactions, then figure out a strategy to meld these factors with breastfeeding. The interplay of these factors may or may not impact an individual mother’s decision whether or not to begin or continue to nurse.

Mothers with PPD may ask the following: “Can I breastfeed while taking a particular antidepressant/ anti-anxiety medication?”

“How can I maximize the amount of sleep I am getting while continuing to breastfeed?” “ I can’t/don’t wish to continue to breastfeed...am I a bad mother?”

The bottom line is the well being of the mother and child.

In her article on breastfeeding and depression, Kathleen Kendall -Tackett points out the benefits of breastfeeding in a mother experiencing PPD (2). Lactation consultants, Breastfeeding USA Counselors, and educators can be extremely helpful and sup30 FLORIDA MD - SEPTEMBER 2014

portive in helping the mother with breastfeeding questions and issues. This support is crucial if a mother wants to continue to nurse, especially if she is having problems. In cases of severe PPD, early intervention with medical consultation is important for the health and safety of mother and baby. The risks of untreated PPD to the infant are documented.

As Katherine Stone states, “I know some mothers who suffered from PPD that felt incredible relief when they decided to stop breastfeeding, while others found their depression worsened. The decision to breastfeed (or not) is a very personal one. It is critical to recognize that breastfeeding is more important to some mothers than it is to others (whether that is biologically, intellectually, or emotionally determined). The relationship between PPD and sleep quality is critical. Unfragmented sleep is important in helping mothers to manage and overcome PPD. But if breastfeeding is highly valued to a particular mother (and to her mental health) and if the mother is breastfeeding successfully, then the sleep advice needs to be compatible with maintaining a healthy milk supply. Bad sleep advice could cause the mother’s milk supply to plummet and unnecessarily compromise her ability to breastfeed her baby.” (3) Whatever decision the mother chooses needs to be respectfully accepted without judgment.

CONCLUSION: In summary, postpartum depression is an issue that needs to brought “out of the closet.” So many new mothers experience it, yet it is an issue that is shrouded in secrecy and shame. The good news is that more attention is being focused on PPD. Increasing services for advocacy, education and resources is crucial if we are able to encourage the many mothers and families who require help to receive it without shame or fear of repercussion. The new mother needs to understand that she is not alone, not to blame, and with help will get better.

References available upon request.

Nancy Layish, LCSW, ACSW is a licensed clinical social worker in the Orlando area specializing in perinatal mood disorders such as postpartum depression (PPD) and anxiety.

Ms. Layish’s vision is to increase awareness of these disorders while destigmatizing them through education and advocacy; she is dedicated to serving the needs of mother and families experiencing these mood disorders and to educating providers within the community about the effects of PPD/anxiety on the patients a they see in their practices. Mrs. Layish is in the process of launching two programs to provide services in the Orlando and outlying areas: Hope’s Bridge is for mothers and families requiring support including assessment and treatment plans to effectively address the symptoms of PPD/ anxiety. The Mother’s Center will provide a support group for new mothers (tentatively in September 2014) as well as a lecture series of professionals speaking about postpartum wellness and related topics. She may be contacted at nrlayish@aol.com or by visiting www.hopesbridge.net. 

Nemours Children’s Health System Reaching More Families With Hospitalist Program

By Vonda Sexton, Managing Director, Strategy and Business Development When a child’s illness requires a hospital stay, keeping care local as long as possible is important to children and families.

The role of a pediatric hospitalist may not be familiar to many families but these physicians who focus on caring for acutely ill children while the child is hospitalized are becoming more common in Florida and are making specialized local care more possible. Nemours Children’s Health System and Wuesthoff Medical Center – Rockledge recently announced an agreement that places Nemours hospitalists at the Brevard County hospital starting on September 1st. In 2013, Nemours and Heart of Florida Regional Medical Center in Haines City announced a similar agreement that benefits families in Polk County.

“When a child needs to be hospitalized, it is best for the patient and family if the hospital is close to home,” says Ann Barnhart, CEO of Heart of Florida Regional Medical Center. “This agreement between Heart of Florida Regional Medical Center and Nemours Children’s Health System makes it easier for families in and around Polk County to spend time with their hospitalized child while being cared for by the physicians employed

by Nemours, an organization that solely focuses on the care of children.”

In Brevard County, the newly recruited Nemours pediatric hospitalists will provide on-site care to community-based pediatrician’s patients in the recently opened pediatrics wing at Wuesthoff Medical Center – Rockledge.

determine the safest and most necessary care for the child and family.”

Nemours has pursued these agreements with community hospitals based on the belief that as healthcare reform gains momentum, so does the demand to add greater value for patients, their families, and all partners in care.

“Hospitalists are essential to this new model, providing patients with the best care possible, in the least acute setting and at the lowest cost,” said Dr. David Bailey, President and CEO of the Nemours Foundation. “Beyond just providing care, they are important patient advocates, helping families navigate followup care, and communicating with the patient’s primary care physician, therapists and specialists to ensure the best possible outcomes after the patient leaves — and preventing costly readmissions. “ Outside of these agreements, Nemours Children’s Health System is growing rapidly in Central Florida. After opening Nemours Children’s Hospital in Lake Nona Medical City in October, 2012, the system now has 19 locations in the region including Nemours Children Primary Care, Nemours Children’s Urgent Care and Nemours Children’s Specialty Care.

Vonda Sexton manages and coordinates the strategic planning, business development strategies and referral relations functions for Nemours Children’s Hospital. Ms. Sexton works with various stakeholders to build stronger relationships and identify opportunities to expand pediatric health services throughout the region. 

“This is an exciting chapter in the future of healthcare for our county and its youngest residents,” said John Kennedy, MD, who cares for children and families at Pediatrics in Brevard. “Having Nemours Hospitalists available for patients within our community is an invaluable resource in Left to right: Jack Malizzi, Pediatric Unit Director, Wuesthoff Medical Center – Rockledge; Dr. Ruth the event of a childhood illness or Rodriguez , Hospitalist, Nemours Children’s Hospital; Roger Oxendale, CEO, Nemours Children’s Hospital; medical emergency.”

Tim Cerullo, CEO, Wuesthoff Health System; John Emery, Associate Administrator, Wuesthoff Medical Beyond pediatric hospitalists, the agreement also includes Nemours CareConnect, a technological link that allows Nemours specialists to remotely assess a patient at a community hospital through an iPad.

Center – Rockledge; Pam Carroll, Chief Nursing Officer, Wuesthoff Medical Center – Rockledge; Dr. Carolina Echeverri, Director of Community Hospital Medicine and Outreach, Nemours Children’s Hospital

“When our physicians have the opportunity to put their eyes on a patient, it will provide an added level of communication that you just cannot get over the phone,” said Lane Donnelly, MD, Chief Medical Officer of Nemours Children’s Hospital. “We think Nemours CareConnect allows care teams to better FLORIDA MD - SEPTEMBER 2014 31

Two New Residencies Open at Osceola Regional Medical Center Internal Medicine and OB/GYN Programs Address Florida’s Shortage of Graduate Medical Education

By Ejaz Ghaffar, MD and Mark Palazzolo, MD For a state whose constantly growing retirement-age population requires a high level of care, it’s surprising that Florida lags behind when it comes to equipping the next generation of doctors.

Fewer than 18 medical residents and fellows are on duty per 100,000 people, ranking the Sunshine State 42nd nationally.

Simply put, Florida has a shortage of graduate medical education programs, and there’s not enough quality training for physicians early in their careers.

At Osceola Regional Medical Center, a 321-bed HCA hospital in Central Florida, we’re setting out to change that.

On July 1, the hospital welcomed its first medical residents in internal medicine and obstetrics/gynecology. It’s a much-needed option for newly graduated physicians who, until now, might have been forced to travel elsewhere for their medical residency.

Partnering with the University of Central Florida College of Medicine and the Department of Veteran Affairs, 16 physicians have begun three-year internal medicine residencies at Osceola Regional. Our program, accredited by the Accreditation Council of Graduate Medical Education, is designed to eventually facilitate 60 residents annually.

In addition, four physicians have started a four-year OB/GYN residency, the first of its kind approved in the Southeast U.S. by the American Osteopathic Association.

Our transition to a teaching hospital is important on a number of levels.

• First and foremost, it’s just good medicine. Patients benefit because the academic environment encourages attending physicians to stay abreast of the latest medical developments.

Teaching hospitals also foster innovative solutions to patients’ problems through high-quality education and state-of-theart care.

• Second, it’s a substantial investment in the local community. Studies show that roughly 60 percent of doctors practice where they complete their residencies. Very soon, we expect our region to see an influx of more trained doctors who trace their career roots to Osceola County.

• Finally, it provides crucial training and Mark Palazzolo, MD leadership. As a teaching hospital, we offer residents opportunities to develop the clinical skills and knowledge they need to become highly qualified internists and OB/GYNs. Physicians-in-training work alongside staff members who model compassionate and ethical care, providing support and supervision to ensure patient safety. Our faculty serve not only as clinical instructors but also mentors to prepare students for Florida’s evolving healthcare needs.

As our nation faces a growing shortage of physicians, the work of teaching hospitals is more important than ever. According to the Association of American Medical Colleges, by 2015 the shortage will reach 62,900 doctors in all specialties, a number that climbs to 91,500 by 2020. In the next 10 years, one-third of physicians will reach age 60 (and likely retire).

Internal Medicine and OB/GYN GME residents with faculty and administrators at Osceola Regional Medical Center.

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Ejaz Ghaffar, MD

Of particular concern to the medical community is that Florida leads the nation with nearly 1 in 5 residents over the age of 65. Yet the United Health Foundation grades our state 28th overall for senior health, in part due to a shortage of specially trained primary care physicians and doctors.

Giving the doctors of tomorrow hands-on experience today is crucial for everyone’s health, regardless of age.

At Osceola Regional Medical Center, we’re excited about our new role, working alongside so many talented, aspiring minds in the fields of interInternal Medicine residents with faculty and administrators at Osceola Regional Medical Center. nal medicine and OB/GYN. All of our faculty and staff are proud of the 20 new physicians who have dedicated their lives to serving their patients and professions. We are honored to shape the future of healthcare in our diverse community by becoming a teaching hospital and instilling best practices into the next generation of doctors.

Mark R. Palazzolo, DO, is the director of Osceola Regional Medical Center’s OB-GYN residency program. He earned his medical degree from Michigan State University and is board-certified by the American Board of Obstetrics & GynecolOB/GYN residents with faculty and administrators at Osceola Regional Medical Center. ogy/Gynecologic Oncology.

Dr. Ejaz Ghaffar is the site director of the internal medicine residency at Osceola Regional Medical Center. He graduated from Khyber Medical College in Pakistan, completed his internship and residency at LaGuardia Hospital-Cornell University in New York, and is board-certified in internal medicine by the American Board of Internal Medicine. 

Osceola Regional Medical Center • 700 West Oak Street Kissimmee, FL 34741 • (407) 846-2266 • osceolaregional.com Highlights of the new residency programs at Osceola Regional Medical Center OB/GYN

• In-house, on-call attending 24/7

• Only OB/GYN residency program in the Southeast

• Robotic surgery training

• AOA accreditation under the Consortium for Excellence in Medical Education

Internal Medicine

• Nine doctors on teaching staff

• Ambulatory continuity experience in obstetrics and gynecology of one half-day per week throughout the residency

• Sponsored by the UCF College of Medicine

• Procedure workshops • Journal Club

• Block scheduling allows residents to focus on specific clinical practice without interruption

• Monthly tumor conference

• 21 doctors on teaching staff

• Training sites: ORMC, VA Hospital • 20 residents per year for a total of 60

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