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AUGUST 2012 • COVERING THE I-4 CORRIDOR

Global Pioneer in Robotic Microsurgery Treatments for Male Infertility,

Testicular and Groin Pain

Winter Haven Hospital Robotics Institute:

Sijo Parekattil, M.D.

Meet the surgeons of Florida Hospital Orlando. Since 2000, they’ve performed more gynecologic oncology surgeries than any other hospital in the state. Using a multi-disciplinary approach, they’ve revolutionized surgical robotics for our patients while teaching these skills to surgeons at other hospitals. With clinical outcomes and survival rates among the best in the nation, Florida Hospital Orlando continues to be a national destination for gynecologic oncology surgery.

To refer a patient, call Denise Cochran, MSN, ARNP-BC at (407) 303-5909 or visit www.FloridaHospitalGYNCancer.com today.

Meet the surgeons who don’t just

specialize in gynecological oncology,

they revolutionize it.

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CANCER-12-8922 Florida MD August-GYN ONC/2.indd 1 8/7/12 9:47 AM

FLORIDA MD - AUGUST 2012 1

contents AUGUST 2012CENTRAL FLORIDA EDITION

5 COVER STORY

DEPARTMENTS

3 FOR YOUR ENTERTAINMENT

22 DOCTORS SHOUlD WORk TOGETHER TO IMPROVE CARE DURING PATIENTS’ MOST VUlNERAblE TIME

28 ORTHOPAEDIC COMMUNITY lAUNCHES AGGRESSIVE RISk MITIGATION PROGRAM

30 CURRENT TOPICS

32 ADVERTISERS INDEX

Male Infertility and chronic groin or testicular pain are conditions that are difficult for most patients to discuss openly and require the care and support of a specialized urologist – an Andrologist. Central Florida men are lucky to have the only dual fellowship trained Andrologist and Robotic Microsurgeon, Sijo Parekattil, MD in the area. Dr. Parekattil provides cutting edge diagnostic and therapeutic options for patients in our local area and from around the globe.

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Dual Fellowship trained Andrologist & Robotic Microsurgeon, Sijo Parekattil, MD.

2 FROM THE PUblISHER

10 MARkETING YOUR PRACTICE

12 PUlMONARY AND SlEEP DISORDERS

14 PHARMACY UPDATE

16 bEHAVIORAl HEAlTH

18 ORTHOPAEDIC UPDATE

19 CANCER

21 MEDICAl MAlPRACTICE EXPERT ADVICE

23 DIGESTIVE AND lIVER UPDATE

FLORIDA MD - AUGUST 2012

FROM THE PUblISHER

Publisher: Donald Rauhofer

Photographer: Donald Rauhofer / FloridaMD, Mike Potthast / Potthast Studios, Dawn Erikson / Winter Haven Hospital

Contributing Writers: Nancy DeVault, Benito M. Torres, DO, Victor Mikhael, MD, Tabarak Qureshi, MD, Jill Weinstein, RPh, James D. Huysman, Psy.D, Matt Gracey, Jennifer Thompson, Corey Gehrold, Tiffany Little, PharmD Candidate, Fraser Cobbe

Designer: Ana EspinosaFlorida 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 621586, 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.

ADVERTISE IN FlORIDA MDFor more information on advertising in Florida MD, call Publisher Donald Rauhofer at(407) 417-7400,fax (407) 977-7773 or [email protected]

Email press releases and all otherrelated information to:[email protected]

PREMIUM REPRINTSReprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products. Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

IIam pleased to bring you another issue of Florida MD Magazine. It’s hard to imag-ine anyone who is not familiar with the March of Dimes and the work they do to

always reinventing themselves to create new programs and services. Coming up next month is the annual March for Babies. It’s a wonderful team-building opportunity for

-tions on how you and your family can join the march or how to form a team for your whole practice. I hope to see some of you there.

Warm regards,

Donald B. RauhoferPublisher/Seminar Coordinator

FROM THE PUBLISHER

ADVERTISE IN FLORIDA MDFor more information on advertising in the Florida MD Central Florida Edition,call Publisher Don Rauhofer at(407) 417-7400,fax (407) 977-7773 or

www.floridamdmagazine.com

Send press releases and all other related information to:Florida MD MagazineP.O. Box 621856Oviedo, FL 32762-1856

PREMIUM REPRINTSReprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, ser-vices and medical products. Increase your brand exposure with high quality, 4-color reprints to use as brochure

pieces, and trade show handouts. Call Florida MD for printing estimates.

Publisher: Donald RauhoferAssociate Publisher: Joanne MagleyPhotographer: Tim Kelly / Tim Kelly Portraits, Donald Rauhofer / Florida MD Magazine Contributing Writers: Joanne Magley, Sam Pratt RPh, Mitchell Levin, MD, Jennifer Thompson, Vincenzo Giuliano, MD, David S. Klein, MD, Stephen P. Toth, CLU, Jennifer Roberts

Florida MD Magazine is published by Sea Notes Medical Seminars, PA, 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 Magazine cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2010, Sea Notes Medical Seminars. All rights reserved. Reproduction in whole or in part without written permission is prohibited.

Steps for New Users: 1. Go to marchforbabies.org2. Click JOIN A TEAM3. Search for your team name in the

search box.4. Click on your team name5.

password for future reference.

Some keys to success: Ask your friends, family and colleagues to support you by

reason why people do not donate is that no one asked them to give (don’t be shy)! Emailing them is an easy way to ask.

You’re done! Your personal page has been created for you and you are ready to begin fundraising!

Join more than a million people walking in March of Dimes, March for Babies and raising money to help give every baby a healthy start! Invite your family and friends to join you in March for Babies, or even form a Family Team. You can also join with your practice and become a team captain. Together you’ll raise more money and share a meaningful experience.

When Saturday, April 24th7am Registration 8am Walk

WhereLake Lily Park, Maitland

For more information on March for Babies please call:Phone: (407) 599-5077Fax: (407) 599-5870Central Florida Division341 N. Maitland Avenue, Suite 115Maitland, FL 32751

2 FLORIDA MD MAGAZINE - MARCH 20102

I am pleased to bring you another issue of Florida MD. Since nurses play such an integral

role in healthcare and are sometimes not recognized to the extent they should be (my Mom

was a nurse), I wanted to be sure everyone of you saw the ad running in this month’s issue on

page 15 promoting the March of Dimes Nurse of the Year Award. The inaugural Nurse of the

Year awards ceremony will take place November 10, 2012 at the Walt Disney Dolphin and

Swan Resort to celebrate nurses and recognize them for their tireless work and commitment

to providing care, comfort, and support to patients. Nurse of the Year will feature a cocktail

reception, seated dinner, and an award presentation in 15 categories ranging from Advance

Practice to Student Nurse. There is a banner ad on the FloridaMD.com website that clicks

through to a nomination form. The deadline for nominations is September 3rd so there’s no

time to lose. I’m sure all of you know a nurse (s) that deserves this honor.

Best regards,

Donald B. Rauhofer

Publisher

Coming next month: The cover story focuses on the opening of the new Nemours Hospital in Orlando. There is also a special feature about the new women’s center at Heart of Florida Regional Medical Center in Davenport. Editorial focuses on Pediatrics and Autism.


FOR YOUR ENTERTAINMENT

The Orlando Philharmonic Celebrates A Spectacular 20th Anniversary Season

The Orlando Philharmonic celebrates its 20th Anniversary Season this year. The Focus Series, a 4-concert chamber music series, re-turns with a variety of musical offerings sure to please Central Florida’s classical music lovers. This popular series is held in the Margeson Theater, located in the John & Rita Lowndes Shakespeare Center, at 812 E. Rollins Street, in Orlando’s Loch Haven Park.

The Focus Series programming features music from Haydn, to Bach and from Tchaikovsky to Borodin, Dvorak and more. The concerts are presented on Mondays at 7:00 p.m. in the Margeson’s intimate, theater-in-the-round setting. The Focus Series opens on October 22, 2012 and runs through April 22, 2013.

Included on the series are:

MonDAY, october 22 • 7 pM • HAYDn: MAD ScIentISt

Dirk Meyer, guest conductor

Haydn enjoyed the perfect musical laboratory in Esterhazy. His prince loved music and generously funded an exceptional orchestra. Haydn’s experiments could be outlandish, but they changed the course of musical history.

Program includes excerpts from Haydn’s greatest symphonies, including the ‘Farewell’ symphony, Symphony No. 49, ‘La Passione,’ and Symphony No. 102, one the finest of all examples of the Classical symphony.

MonDAY, DeceMber 10 • 7 pM • bAcH’S coFFee HoUSe

Christopher Wilkins, conductor

Zimmerman’s Coffee House was Bach’s musical home for secular music. There he performed his Brandenburg concertos, orchestral suites, secu-lar cantatas and music by others he admired, including Vivaldi and Telemann.

Program includes Bach’s Brandenburg Concertos No. 1 and 5, and an excerpt from his ‘Coffee Cantata,’ as well as music Bach might have led at Zimmermann’s by Telemann, Locatelli and Vivaldi.

MonDAY, FebrUArY 18 • 7 pM • tHe SLAVIc SoUL

Christopher Wilkins, conductor

Slavic music has a unique warmth and depth of feeling. It is often inspired by folk music, and has been made famous by generations of great string virtuosi who have championed it. Tchaikovsky, Borodin and Dvořák lead the way.

Tchaikovsky | Suite No.1 – Marche miniature

Tchaikovsky | Andante cantabile

Liadov | Eight Russian Folk Songs (excerpts)

Borodin (arr. Sargeant) | Nocturne

Koussevitzky | Concerto for Double Bass

Dvorak | Romance

To subscribe to any of the 2012-13 Season Series above which are presented at the Bob Carr Performing Arts Centre, or the 4-concert Focus Series (a chamber series) presented at the Margeson Theater, call the box office at (407) 770-0071, or find more details about the artists, dates, times and programming at www.OrlandoPhil.org.


ROBOTICS INSTITUTE

AN AFFILIATE OF THE UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE AND SHANDS HEALTHCARE

Sijo Parekattil, MD, has performed more robotic microsurgical procedures than any other surgeon in the world. He has pioneered new treatment options for Male infertility and Chronic Testicular or Groin Pain.

Well done to the “Team” & Sijo Parekattil, MD on over

1,000lives touched and cared for.

WWW.ROBOTICMICROSURGERY.ORG

For more information call (863) 292-4652


COVER STORY

Winter Haven Hospital Robotics Institute:

By Nancy DeVault, Staff Writer

Male infertility and chronic groin or testicular pain are condi-tions that inflict a great deal of angst and frustration for patients. There is a great deal of difficulty and trepidation in openly dis-cussing these issues. The effective care and management of these patients requires a sensitive, dedicated multi-disciplinary team approach led by a specialized type of urologist – an Andrologist. Sijo Parekattil, MD is the only dual fellowship (Cleveland Clinic Foundation) trained andrologist and robotic microsurgeon in the country and is the Director of Urology and Robotic Surgery at Winter Haven Hospital. He is also a Clinical Assistant Professor at the University of Florida. Dr. Parekattil is an award winning researcher, innovator and physician who has earned numerous honors including America’s Top Urologists (2009).

MAlE INFERTIlITY, VASECTOMY REVERSAl & GROIN / TESTICUlAR PAIN PROGRAM

Male Infertility

In 2010, Dr. Parekattil established the Winter Haven Hospital Robotics Institute, in affiliation with the University of Florida, with the launch of the male infertility and groin / testicular pain program. According to Dr. Parekattil, approximately fifteen percent of all couples trying to conceive a child face fertility issues. Among those, up to fifty percent of conception problems may be attributed to male infertility factors. He reports the causes of male infertility can range from genetic and physiologic issues to environmental causes. To find the most appropriate solutions, the Male Infertility Program at Winter Haven Hospital offers a comprehensive diagnostic workup as well as a full array of treatment options to ultimately achieve conception. For Dr. Parekattil, helping couples achieve a successful pregnancy is one of the most rewarding aspects of his work.

Vasectomy Reversal

Until the recent use of robotics, Dr. Parekattil says surgical treatments for male infertility had remained unchanged for de-cades. Over the past several years, Dr. Parekattil has conducted a controlled trial to analyze robotic assisted vasovasostomy (RAVV) and vasoepididymostomy (RAVE) in comparison to standard microsurgical vasovasostomy (MVV) and vasoepididymostomy (MVE). His findings, to be published in the September issue of the Journal of Reconstructive Microsurgery, illustrated that the robotic assisted procedures decreased operative duration and im-proved the rate of recovery of post-operative total motile sperm counts. This is the first prospective cohort database study of its kind clearly showing advantages to the use of robotics in micro-

surgical vasectomy reversal and congenital obstruction recon-struction. Optimum outcomes for vasectomy reversals are typi-cally achieved within three years of the initial vasectomy; however Dr. Parekattil has achieved favorable results in patients thirty years out from their vasectomy procedure. Patients and their surgeon can also pre-operatively use the Vasectomy Reversal Predictor, an algorithm developed by Dr. Parekattil that calculates the likeli-hood of requiring a more complex vasectomy reversal called va-soepididymostomy (www.roboticinfertility.com). Dr. Parekattil was the first to perform this kind of complex bilateral vasectomy reversal robotically in 2007, and continues to achieve an impres-sive ninety-seven percent success rate for bilateral vasovasostomy (vasectomy reversal) cases.

Groin or Testicular Pain

In addition to male infertility interventions, Dr. Parekattil regularly treats chronic groin and/or testicular pain, a symptom identified in about 100,000 men annually. “This type of pain is

Sensitive, dedicated multi-disciplinary team approach for patients.

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Global Pioneer in Robotic Microsurgery Treatments

Cutting Edge Advances for Male Infertility and Testicular or Groin Pain.


“The groin and/or testicular pain treatment goal is to desensi-tize the problematic nerves which may start with physical therapy, pain management and non-invasive urology treatment options. When these fail, we have developed a targeted robotic assisted microsurgical denervation procedure to target these nerves in a minimally invasive manner without affecting the bulk of the nerves and function of the spermatic cord and testicle. In 2008, we performed the first such successful procedure for the treatment of this condition. It’s an effective fifteen to thirty minute outpa-tient procedure.” describes Dr. Parekattil. Dr. Parekattil has now performed over 400 of these procedures since then: 85% of these patients have a fifty percent or greater reduction in pain and 72% have complete elimination of pain. Female patients with groin pain are also treated.

SIjO PAREkATTIl, MD: CENTRAl FlORIDA‘S ANDROlOGIST AND GlObAl RObOTIC MICROSURGEON

Dr. Parekattil is pioneering the use of robotic assisted treatments in microsurgical urologic procedures. He has published well over one hundred scientific abstracts, delivered over a hundred presen-tations at major meetings, nearly thirty peer reviewed publica-tions and three medical books: Robotic Prostate Cancer Surgery (2010), Male Infertility: Contemporary Clinical Approaches, Andrology, ART & Antioxidants (2012), and TeleMicrosurgery (late 2012). His educational path began with electrical engineer-ing when he began college at the age of 15. After completing his

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COVER STORY

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Dual Fellowship-trained Andrologist & Robotic Microsurgeon, Sijo Parekattil, MD.

attributed to hypersensitive nerves in the groin, perhaps activated from a prior trauma to the area. It’s difficult to treat this dysfunc-tion because unlike a tumor, we are not removing a mass, but instead working to eliminate pain by targeting specific nerves. We have developed a unique Winter Haven Groin Pain Classification System to identify the type, location and potential root cause of the pain,” he explained. This group is also the first to identify three specific nerve fiber branches of the ilioinguinal and genitofemoral nerves in the spermatic cord that have Wallerian degeneration as a possible cause for this pain. This work was recently presented by Dr. Parekattil as a key plenary session presentation at the Annual 2012 American Urology Association Meeting in Atlanta.

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The Morrison Family: Successful vasectomy reversal 19 years after vasectomy.

The Winter Haven Hospital Robotics Institute provides global patient service.

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bachelor’s of engineering degree at the University of Michigan, he became interested in the world of medicine and decided to apply for medical school. This has given him a unique background to be able to apply his engineering knowledge in the area of robotic surgery.

“I was working with various chips and microscopes and thus my interests evolved into surgical techniques incorporating tech-nology, robotics and microsurgery. I knew I wanted to invest in developing solutions and apply my skills to the unique tools of urology,” explains Dr. Parekattil. He completed his urology resi-dency training at Albany Medical Center, followed by two fellow-ships at the Cleveland Clinic Foundation in Laproscopy/Robotic Surgery and Male Infertility/Microsurgery. Dr. Parekattil says his motivation within ‘this less sexy medical field’ is in part due to his extensive training and background, but more so due to his own personal experience. “I’ve been on the receiving end of such care, so I can relate to my patients, especially since many forgo medical intervention due to fear of broaching the topics of male infertility and groin or testicular pain.”

WINTER HAVEN HOSPITAl RObOTICS INSTITUTE – A GlObAl lEADER

The Winter Haven Hospital Robotics Institute has pioneered cutting edge treatment procedures using an advanced one-of-a-kind five arm robotic unit to perform urology related microsur-geries. The initial financial investment of is up to eight or ten times the expense of conventional equipment. However, Dr. Parekattil feels that the benefits of using the robotic equipment

so positively impact both the medical team and the patient that it outweighs the increase in investment. “We have improved mag-nification (up to twenty times) and have two additional camera views (three views compared to one with standard microscopy). One of the camera views allows us direct communication to work in unison with the lab. We’re able to work more efficiently as a team since we can also use 3 instrument arms, instead of just two, thus reducing reliance on a skilled assistant. Surgeon tremor and fatigue is eliminated. Most importantly, patients experience an improved result, which is our first priority. The improved surgi-cal efficiency has actually led to decreased out of pocket costs to the patient.” Additionally, the Winter Haven Hospital Robotics Institute offers some new imaging technology for patients: the smallest Doppler and ultrasound technology available for refined diagnostic assessment.

RObOTIC ASSISTED MICROSURGICAl & ENDOSCOPIC SOCIETY (RAMSES®)

Medical advances through robotic assisted surgery are on the rise worldwide, especially among microsurgeons who prac-tice urology, plastics, reconstructive and hand surgery. In 2010, the Robotic Assisted Microsurgical and Endoscopy Society (RAMSES®) was founded with an international board of directors (www.roboticmicrosurgeons.org). The mission of RAMSES® is to further develop and study surgical outcomes and establish best practice guidelines regarding management of conditions utilizing robotic assisted microsurgery. Dr. Parekattil is one of the found-ing board of directors for this society.

ENHANCING NURSE AND SURGICAl TRAINING FOR RObOTIC ASSISTED SURGERY

Dr. Parekattil has performed a total of over one thousand ro-botic assisted surgeries, serving patients seeking these effective high-tech treatments from throughout the United States and many countries abroad. He has performed more robotic assisted microsurgical procedures than any other surgeon in the world.

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COVER STORY

RAMSES® board of Directors (left to right): Dr. Michael bednar (Chairman of Hand Surgery, loyola University), Dr. Sijo Parekattil

(Clinical Assistant Professor, University of Florida), Dr. Philippe liverneaux (Professor of Hand Surgery, University of Strasbourg, France),

Dr. jesse Selber (Assistant Professor, Plastic Surgery, MD Anderson)

Medical Textbooks by Dr. Parekattil

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COVER STORY

The comprehensive team performing the various complex ro-botic procedures is comprised of the surgeon, surgical assistant, anesthesiologist, operating room technician, and several nurses. The nursing team has always and will always continue to play an integral role in the robotics program. However, there has been a paucity of formal external credentialed operating room nurse or technician training for these team members. Due to this need, Winter Haven Hospital has recently aligned with Polk State College to offer the first of its kind robotic surgery certification course, especially designed for operating room nurses and techni-cians. Launched earlier this month and to be held quarterly, the course will offer “didactic hands-on, one-on-one training in the setup, operation, positioning and technical problem solving for robotic assisted surgical procedures.” The next upcoming session will be held in November 2012 (www.roboticnursing.org).

Continuing to establish themselves as the global leader in the expanding field of microsurgical robotics; Winter Haven Hospi-tal along with University of Florida examined alternative robotic microsurgical training models to decrease surgical learning curves for trainees. “Existing training models (rodent and cadaver) are quite tedious and expensive,” says Parekattil. “We have developed a Lego® construction model approach to create the challenge of using multiple robotic arms (at least three) to accurately build structures such as the Empire State Building with robotic assis-tance.” A small preliminary study actually demonstrated that this technique could provide an equivalent teaching model for the development of robotic assisted microsurgical skills. The program is in the process of enrolling a multi-institutional study to further assess this methodology.

RObOTIC ASSISTED SURGERY TRAINING TO INSPIRE OUR YOUTH

Dr. Parekattil is also engaging with those that might have just recently grown out of using these Lego® blocks simply for fun! Showcasing the da Vinci© Si High Definition Robotic Surgical System, Dr. Parekattil has launched a new program called “Schol-arobotics” (www.scholarobotics.org). This ‘hands-on’ and ‘sit-on’ educational experience is geared toward presenting students, par-ents and the community at-large with the basic concepts of ro-botic assisted surgery. Held in the Grande Lobby at Winter Haven Hospital, attendees can explore the da Vinci© Robot equipment and learn about the microsurgical tools utilized during robotic assisted microsurgery.

Another youth focused opportunity is the ScholaRobotics Academy, open to high school students who have an interest in a science career. This student internship program, sponsored by the Winter Haven Hospital Robotics Institute and Polk State College, offers dual enrollment college credit hours with exceptional expo-sure to research projects, science and technology labs, and robotic surgery studies. The highlight of this program is that these high school students get to learn actual robotic microsurgical skills and present a project on robotic microsurgery at the International Annual Robotic Assisted Microsurgical and Endoscopy Society (RAMSES®) meeting (www.roboticmicrosurgeons.org).

THE FUTURE OF THE WINTER HAVEN HOSPITAl RObOTICS INSTITUTE & CENTER FOR UROlOGY

The expert team at Winter Haven Hospital also includes Kevin Lee, M.D., a Urologic Surgeon specializing in aspects of female urology, kidney stones, male erectile dysfunction, incontinence and oncology. In addition, there are two fellows - Ahmet Gude-loglu, M.D., a Robotic Microsurgery Research Fellow; and Ja-min Brahmbhatt, M.D., a Robotic Microsurgery Clinical Fellow. Mathew Oommen, M.D. will join the Winter Haven Hospital Robotics Institute & Center for Urology this September. He will bring the very unique combination of being trained both as a Gynecologist as well as a Urologist, having completed two resi-dencies. He will offer focused specialty care to include robotics

Robotic advantages over standard microsurgery: Enhanced magnification, scaling of motion and elimination of tremor.

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WINTER HAVEN HOSPITAl RObOTICS INSTITUTE 200 Avenue F, n.e. • Winter Haven, FL 33881 • call for appointments: (863) 292-4652

Fax: (863) 292-4653 • email: [email protected] location:

199 Ave b n.W. Suite 310 • Winter Haven, Fl 33881

MAlE INFERTIlITY & TESTICUlAR/GROIN PAIN PROGRAM • Website: http://www.roboticinfertility.com

PROGRAMS robotic Surgery certification for nurses /techs • polk State college & Winter Haven Hospital

next session: november 2012 • register at: www.roboticnursing.org or call 863-292-3769

SCHOlARObOTICS ACADEMYA student Internship sponsored by Winter Haven Hospital Robotics Institute and Polk State College

For additional information, visit: www.scholarobotics.org or call (863) 293-1121 x1465

RAMSES® (Robotic Assisted Microsurgical & Endoscopy Society)Register for the 2nd Annual Meeting at CAMlS, Tampa, Nov 9-10th, 2012

Visit: www.roboticmicrosurgeons.org

COVER STORY

in female urology, incontinence and oncology. “Though our cur-rent patient population does include a small percentage of female patients diagnosed with groin pain, I anticipate that Dr. Oom-men’s emphasis on female urology will expand our reach among prospective female patients,” states Dr. Parekattil.

The Winter Haven Hospital Robotics Institute will be relocat-ing to a new 7,200 square foot clinical space on September 1, 2012 in the 610 Corporation/Inland Fiber and Data building in downtown Winter Haven. 1,000 square feet of this clinic space is dedicated to a one-of-a-kind “robotics research and education center”– to facilitate training and education for the robotics nurs-ing and ScholaRobotics programs. “In our new medical facility, we’ll have access to the LambdaRail – one of the world’s fastest Internet network links. This will allow expansion of our global outreach programs by enhancing communication with patients and providing educational webcasts for the robotics medical community,” says Dr. Parekattil. In fact, the Winter Haven Hos-pital Robotics Institute is slated to host a live webcast to present a robotic assisted microsurgery case during the next Robotic As-sisted Microsurgical & Endoscopy Society (RAMSES®) meeting. Hundreds of international microsurgeons from diverse medical fields will attend the conference to be held November 9-11, 2012 at the CAMLS center at University of South Florida in Tampa. Plans are already underway for Dr. Parekattil and his team to also broadcast for the 2013 meeting, to be held at the IRCAD facil-ity in Strasbourg, France, and the 2014 meeting planned for Sao Paolo, Brazil. “Winter Haven Hospital may be perceived by some as a small, community hospital, but our Robotics Institute is truly a global leader in building the movement of robotic assisted mi-crosurgery,” says Dr. Parekattil.

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Dr. Parekattil with future scientists, engineers and health care providers.

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3D Rendering of the new Winter Haven Hospital Robotics Institute.


Potential Patients Are Interacting With Your Social Media Accounts – Now What?By Jennifer Thompson, President of Insight Marketing Group

By now, we hope your office as set up the social media chan-nels that make sense for you. Whether that’s Facebook, Twitter, Google+ or YouTube, ideally you’ve set up your profile and you’re interacting with the 91 percent of online adults who use social media regularly, according to Hubspot. A client of ours recently asked a question that’s often overlooked so we thought we’d share our answer to, “What do I do when someone comments on my practice’s Facebook page?”

Now, for the purpose of this article, we’re going to expand Fa-cebook to include any of the social sites and share some of the tips and ideas we use to respond to patients when they interact with us in the social media world.

PHASE #1 – HAVE A CONTENT PlANThe whole point of interacting with patients online isn’t to

make you feel good about how many people you know (really, we don’t care). The point of interacting with patients in an on-line or social environment is to generate leads, cultivate potential patients and ultimately put their butts in your exam rooms. To do that you’ll want to create a two-phase plan that accomplishes a few key things. Creating the content plan will also help you craft responses and prepare when someone interacts with your practice’s social media profiles. Phase one should include creating a content and publishing plan that:

• Builds Off of Quality Content – The more quality content you have posted on your blog and you share through your so-cial channels, the better your chance for increasing your or-ganic page rank thereby showing up higher in search engines and ultimately garnering more clicks.

• Positions You as an Expert – That same content will also help position you as a leading expert in whatever your specialty is in the area. If you’re everywhere and you answer lots of questions, you must know what you’re talking about, right?

• Engages Your Audience – By providing this relevant, useful content you’ll also be engaging your fans/followers/patients/haters/etc.

Now, of course those are just the broad strokes of what the first phase plan should entail. We’ll cover more of what your plan should entail in future writings.

As you come up with your content, make a note of questions, answers and references you came across while writing. That way, if it’s ever asked, you can produce everything you need to respond quickly.

For phase two, you need to create a plan for responding when your audience becomes engaged. Remember, the more engage-ment you create from your content, especially on social sites, the

better traffic potential for your web-site.

PHASE 2 When someone finally posts or

comments on something you’ve posted, what do you do? The obvious answer is to respond, duh. But, how do you respond? Here are a few tips:

• Be Timely – You have a very small window to respond to a comment to show your appreciation toward a positive com-ment or answer a negative comment. You want to show pa-tients that you care what they have to say and you appreciate the fact that they took time out of their day to interact with you. As for how long you have, if the shoe was on the other foot, how long would you want to wait to get a response? That’s your answer. It should be within a few days at the absolute lat-est.

• Be Positive No Matter What – You can curse out the patient all you want behind closed doors, just make sure you get all that anger out of your system before you start typing. Being snarky, short, condescending or worse will do you no good and it will destroy your reputation. We’ve seen case studies where it happens. Take a chill pill. Because you’re a doctor, get it? Any-way, If you can rise above the comment, those who read your response will also be inclined to trust your word a bit more. It was recently reported by SocialMediadd that 70 percent of consumers trust social media reviews from strangers. That’s a huge number, and it’s exactly why you need to respond and respond well to negative reviews. Although there may be no way to stop people from posting negative reviews, no matter how good of a job you can do, you can mitigate their damage with a proper response.

• Have a Few Responses Ready – It would be handy (and a real timesaver) if you had a few canned responses already created. Did someone post on your Facebook page asking for medi-cal advice? No problem, copy and paste your previously typed response detailing that you can’t give medical advice via the internet but you would be happy to schedule an appointment for them in your office. The same survey mentioned above also reported that 61 percent of users rely on user reviews before making a decision, no matter what the review is. Your respons-es can also play into if a user sees you’re honest, transparent and friendly. All things they’d want in their new physician.

• Always Brand Yourself – Remember, your name or your prac-tice name is a brand. You have standards to uphold and you want to be seen in a certain light – all the time. Your responses

MARkETING YOUR PRACTICE


MARkETING YOUR PRACTICE

should always fall in line with those standards. In other words, if you’re rushed or aren’t sure what to say, revisit the post when you have a moment.

By interacting with patients, increasing your engagement levels and ultimately growing your office’s brand in the social marketplace, you’ll see increased leads and quantifiable benefits that you can’t really match anywhere else, especially for the relatively low cost of main-taining these pages or paying a group to do it for you.

MARkETING YOUR MEDICAl PRACTICE: A QUICk REFERENCE GUIDEAre you ready to finally start marketing your practice? Visit www.InsightMG.com to learn how you can order your copy of

“Marketing Your Medical Practice: A Quick Reference Guide” by Jennifer Thompson and Corey Gehrold on Amazon. Encapsu-lating their real world medical marketing knowledge and expertise, this easy-to-read book gives you all the tips and tricks you’ll need to start marketing your practice today in a fast, fun and friendly format – just like the articles in this series. To learn more, visit www.InsightMG.com.

lOOkING FOR MORE INFORMATION? Contact Jennifer Thompson today for a free consultation and marketing overview at 321.228.9686 or e-mail her at [email protected].

Jennifer Thompson is president of Insight Marketing Group, a full-service healthcare marketing group focused on digital and social media administration, referral and partnership development, creative services and graphic design, online reputa-tion management/development and promotional products. She is co-author of Marketing Your Medical Practice: A Quick Ref-erence Guide and an avid Twitter user, regularly posting medical practice marketing tips, articles and more at www.Twitter.com/DrMarketingTips. You can learn more about her and her company at www.InsightMG.com.


Two Convenient Locations: East Orlando: 10916 Dylan Loren Circle Altamonte Springs: 610 Jasmine Road

407.581.1444 phone | www.cfpulmonary.com | Most Insurance Plans Accepted

WE KNOW THE SCIENCE OF

...REST ASSURED Comprehensive High Quality Care In the Field of Sleep Medicine

Specializing in: Sleep Apnea Restless Leg Syndrome Insomnia Narcolepsy Snoring All Other Sleep Disorders

Our Board Certified Sleep Specialists:

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

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

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

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

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

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

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


PUlMONARY AND SlEEP DISORDERS

sleep, the more agitated one becomes and the less able one is to fall asleep. Persons with a conditional arousal response typically sleep better away from their own bed and usual rou-tines. Stress symptoms, environmental factors, and life changes are often associated with precipitating psychophysiological insomnia. Polysomnographic findings will show increased sleep latency, or increased wake after sleep onset, increased N1 and decreased slow wave sleep

PARADOXICAl INSOMNIA: (SlEEP STATE MISPERCEPTION, PSEUDO-INSOMNIA)

Paradoxical insomnia is a complaint of severe insomnia that occurs without evidence of objective sleep disturbance and with-out the level of daytime impairment associated with the degree of sleep deficits reported. The complaint of decreased sleep time or no sleep is accompanied with extensive awareness of either the environment or mental processes consistent with wakefulness. Like other patients with insomnia, paradoxical insomnia is re-ported with daytime symptoms related to sleep complaints. The severity of nocturnal complaints are not matched by evidence of pathological sleepiness, marked performance decrements and other functional impairments during the day that may result from marked sleep deprivation. This condition is found in less than 5 % of population. It is more common in young and middle aged adults (with a preponderance in women). Polysomnographic findings fail to show sleep deficits and standard sleep parameters are similar to those of individual without sleep complaints.

INSOMNIA DUE TO MENTAl DISORDER (PSYCHIATRIC INSOMNIA)

Essential feature is insomnia caused by underlying psychiatric or mental disorder. The insomnia is viewed as a symptom of the underlying mental disorder and shares a course with that disorder, however the insomnia constitutes a distinct complaint and focus of treatment. In some cases the underlying mental disorder may become more apparent only after specific questioning. Mood and anxiety disorders may underlie this insomnia. It effects less than 3% of the population, mostly young to middle aged adults and is more common in women. Polysomnographic findings include increased sleep latency with decreased sleep efficiency, increased N1 and N2 sleep with decreased N3 and REM sleep.

INSOMNIA DUE TO DRUG OR SUbSTANCE USE (SUbSTANCE INDUCED SlEEP DISORDER)

Insomnia due to substance or drug use is a suppression or dis-ruption of sleep caused by consumption of a prescription medica-tion, recreational drug, caffeine, alcohol or food item. Sleep dis-turbance may result from substances that act as CNS stimulants or depressants. Stimulants that commonly lead to sleep difficulty include caffeine, amphetamines and cocaine. Side effects of pre-

INSOMNIA

Insomnia is defined by a repeated difficulty with sleep initia-tion, duration or quality of sleep (despite adequate time and op-portunity to sleep), resulting in daytime impairment. In adults, insomnia complaints are related to difficulties in initiating and maintaining sleep. Concerns about extend periods of nocturnal wakefulness or insufficient amount of nocturnal sleep accompany these complaints. In children, insomnia is usually reported by parents and characterized by bedtime resistance, inability to sleep or both.

In milder cases, daytime symptoms may include fatigue, irrita-bility, decreased mood, general malaise and cognitive impairment. Chronic insomnia in adults may impair social and vocational functioning and reduce quality of life. In children it may lead to poor school performances. Physical symptoms may include head-aches, muscle tension and gastrointestinal complaints. Insomnia is a symptom that may arise from primary medical illnesses, sub-stance use and or abuse, other sleep and mental disorders.

Definition of a sleep wake disturbance in a patient with in-somnia is a complex task since it may be multifactorial and fre-quently there may be a confluence of factors that may result in insomnia.

ACUTE INSOMNIA: (ADjUSTMENT INSOMNIA)

The essential feature of acute insomnia is associated with an identifiable stressor. The sleep disturbance is usually of short duration, typically a few days to weeks. Adjustment insomnia is acute in onset and lasts no more than three months. The sleep disturbance is expected to resolve when the specific stressor re-solves or the individual adapts to that stressor. Stressors that have been identified include interpersonal relationships, occupational stress, bereavement, diagnosis of a medical condition, personal losses, visiting or relocation to a new location. Change or stress with an emotional tone may precipitate acute insomnia. Indi-viduals with a prior history of insomnia are predisposed to devel-oping further episodes. Polysomnographic findings may include prolonged sleep latency, increased number and frequency of awakenings, short overall sleep time and reduced sleep efficiency. Latency to REM sleep is prolonged and percentages of stages N3 and REM reduced.

PSYCHOPHYSIOlOGICAl INSOMNIA (CHRONIC INSOMNIA, PRIMARY INSOMNIA)

Features of psychophysiological insomnia includes heightened arousal and learned sleep preventing associations that result in a complaint of insomnia and decreased functioning during wakeful periods. The physiological arousal may be related to emotional reactions that do not meet criteria for separate disorders. Mental arousal with a typical complaint of a “racing mind” is character-istic. A cycle develops in which the more the individual strives to

“I Can’t Sleep”By Tabarak Qureshi, MD


PUlMONARY AND SlEEP DISORDERS

scription medications (including certain antidepressants, antihypertensive medications, corticosteroids, antiparkinsonian drugs, etc) can lead to insomnia. Alcohol is commonly used as a sleep aid, however it can actually lead to restless and fragmented sleep. Polysomno-graphic findings include increased sleep latency and arousals with decreased total sleep time and reduced REM sleep.

INSOMNIA DUE TO MEDICAl CONDITIONS:

Insomnia caused by a coexisting medical condition may involve sleep initiation or maintenance, or over all poor quality of sleep. Obstructive lung disease may be characterized by difficulty initiating sleep, fragmented sleep associated with respiratory distress. Several neurological disorders any cause insomnia because they lead to fragmented sleep patterns, subjective sleep concerns and disruption of sleep wake cycles. The insomnia usually begins near the time of onset or with significant progression of the underlying disorder and waxes and wanes with fluctuation with the disorder. No significant polysomnographic findings occur in this type of insomnia.

bEHAVIORAl INSOMNIA OF CHIlDHOOD: (CHIlDHOOD INSOMNIA)

The essential feature is difficulty falling asleep, staying asleep or both that is related to an identified behavioral etiology. Sleep onset association type is characterized by child’s dependence on specific stimulation, objects or settings for initiating sleep or returning to sleep after awakening. This may be associated with daytime behavioral problems, limit setting difficulties in the day, or both. It occurs in 10-30% of the childhood population. In addition, this leads to poor parental nighttime sleep and associated daytime impairment. Developmental issues like childhood milestones and separation anxiety may predispose a child to develop sleep problems.

SlEEP ONSET ASSOCIATION TYPE:

A type of behavioral insomnia that is characterized by reliance on inappropriate sleep associations, and usually presents with frequent nighttime awakenings. In this disorder, the process of falling asleep is associated with a specific form of stimulation (rocking or watching television, etc), object (bottle) or setting (specific room, bed). As this disorder is prevalent in younger children, it is defined as a disorder only if the associations are problematic (long car rides).

lIMITED SETTING TYPE:

This involves refusing or stalling to go to sleep. If sleep is enforced it comes quickly, otherwise onset is delayed. The bedtime problems usually occur as parents do not set specific bed time, limits and managing behavior. However normal and prolonged separation anxiety may trigger behavioral insomnia in children.

TREATMENT

Treatment for insomnia is multifaceted. A thorough evaluation with sleep history is the corner stone. Sleep hygiene measures, Behavioral treatment (stimulus control, sleep restriction, progres-sive muscle relaxation, etc) and pharmacological therapy(sedative hypnotics, etc) are ways by which there can be improvement in sleep times and in turn functional capacity of the patient.

Tabarak Qureshi, MD, graduated from Baqai Universi-ty Medical School in 2000. He then completed an Internal Medicine Residency as well as a Pulmonary/Critical Care Fellowship at Detroit Medical Center (Wayne State Uni-versity) in Detroit, Michigan. Dr. Qureshi then went on to complete a Sleep Medicine Fellowship at Detroit Receiving Hospital (Wayne State University) in Detroit, Michigan. Since 2009, he has been a member of the Central Florida Pulmonary Group. Currently he serves as the Sleep Lab Medical Director for Physician Associates of Florida and as an Assistant Professor for the University of Central Flor-ida School of Medicine.

Dr. Qureshi may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com.


PHARMACY UPDATE

The Enhanced Drug Delivery System – IontophoresisBy Jill Weinstein, RPh and Tiffany Little, PharmD Candidate

Electricity is a familiar and powerful energy source that we have learned to harness over the centuries from light bulbs to the ever-popular electric cars; the opportunities with electricity are boundless. Electricity provides us with a unique drug delivery sys-tem called iontophoresis. Iontophoresis has been described as a penetration enhancer, an electromotive drug administration tech-nique (EMDA), but most commonly a needle-less injection. This drug delivery system is a topical product that gently pushes the drug through the skin at the site of application via electrostatic repulsion. Iontophoresis has a positive (anode) and a negative (cathode) end, a drug that is positively ionized is placed on the anode side, and the same is done to the cathode with a negatively charged drug. An electrical power source, such as a battery, acti-vates the reaction initiating a process similar to putting two mag-nets together on the same side. The like charges repel one another. The resulting electrostatic repulsion is so forceful that the drug is painlessly repelled into the skin.

The benefits: Iontophoresis is an inventive way to get drug into the body without the need of an invasive procedure. By absorb-ing the drug in this manner patients are able to avoid painful injections since the drug is repulsively driven into the skin. This topical administration technique enhances drug delivery without the worries commonly seen with oral therapy. Iontophoresis solu-tions are placed directly at the site, bypassing the stomach and liver which assists in reducing absorption issues, drug-drug inter-actions, food-drug interactions, and first pass effect. Side effects are minimized from this administration technique because the product is placed at the local site of action resulting in reduced systemic exposure. This electromotive dosage form is convenient and allows for better compliance in therapy for the patient.

The applications: This drug administration technique can target a variety of disease states; however the drugs used have to be ion-ized water-soluble drug molecules with the correct polarity and molecular size for skin penetration. Thus, many variables need to be taken into consideration when determining the proper drug solutions for the patient. This localized treatment can be used to decrease inflammation, provide analgesia, remove scar tissue and adhesions, treat heel spurs or other calcifications, and help allevi-ate gout. The individual drug solutions placed in the electrodes are determined based on patient specific needs. For example, drug solutions containing corticosteroids can be used to decrease in-flammation. Studies have been done to treat many different in-flammatory processes through iontophoresis. A study in patients with juvenile idiopathic arthritis (JIA) found dexamethasone iontophoresis to be a safe and effective initial treatment of tem-

poromandibular joint involvement in JIA. Stefanou et al. conducted a prospective, randomized study evaluating the effects of iontophoresis delivery of dexamethasone versus corticosteroid injection therapy on patient outcomes. The study concluded that corticosteroids may be considered a treat-ment option for patients with lateral epicondylitis, because of the short-term benefits found in the iontophoresis group’s grip strength and how unrestricted return to work was found to be significantly better.

Lidocaine, commonly used as a local anesthetic can provide pain relief and analgesia. When used with iontophoresis it was found to produce blood vessel dilation and topical anesthesia that permeates the skin several millimeters. These successes have led to the use of other ionized drugs to target different disease states such as pain, gout, calcifications and scar tissue removal. The drugs used with iontophoresis continue to grow as different drugs are applied using this technique.

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The available positive and negative drug solutions can be formulated in different ways; either with preservatives as found in manufac-tured products or without preservatives as formulated by a compounding pharmacy. Retail pharmacies can offer drug products needed for iontophoresis but the majority contains preservatives. These preservatives pose two distinct problems. First, some patients can be hypersensitive to preservatives contained in the manufactured product leading to local skin allergic reactions. Second, iontophoresis drug solution products with preservatives can cause ionic competition and reduce the amount of active drug ions delivered through the skin. Preservative-free iontophoresis drug solutions are available, but must be compounded. This is beneficial because it allows the preservative-free iontophoresis drug solutions to be tailored and customized for the patient.

Compounding pharmacists can assess the patient’s disease condition and needs, communicate a recommendation to their health care provider on appropriate drug solutions, and formulate a custom preservative-free iontophoresis drug solution. These customized com-pounded drug solutions are a great resource for patients and providers who need treatment therapy options. Please contact Pharmacy Specialists at (407) 260-7002 to speak with one of our compounding pharmacists and see how we can be of service to your patients!

References available upon request.

Tiffany Little, PharmD Candidate University of Florida is currently on rotation at Pharmacy Specialists. Jill Weinstein, RPh, graduated from Uni-versity of Florida and is the clinical pharmacist who does hormone, nu-trition and weight loss consultations at Pharmacy Specialists. Pharmacy Specialists is proud to be the only pharmacy in all of Central Florida and one of only 129 pharmacies in the country that are accredited by the Pharmacy Compounding Accredita-tion Board (PCAB). We meet or ex-ceed ALL standards for sterile as well as non-sterile compounding and we are the only USP 797 and USP 795 validated compliant pharmacy in all of central Florida. Currently, Sam Pratt, RPh at Pharmacy Specialists is the only Full Fellow of the Inter-national Academy of Compounding Pharmacists in the Central Florida area. Call Pharmacy Specialists to check with a clinical pharmacist for suggestions and recommendations. For additional information please call (407)260-7002, FAX (407) 260-7044, Phone (800) 224-7711, FAX (800) 224-0665.

PHARMACY UPDATE

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NOMINATE AN OUTSTANDING NURSEMarch of Dimes Nurse of the Year will honor the

contributions of nurses working in Orange, Seminole and Osceola counties who have demonstrated extraordinary

patient care, compassion, and service.

working together for stronger, healthier babies

What are the categories?The Nurse of the Year awards will be presented in 15 categories

during an evening celebration at the Walt Disney World Dolphin and Swan Resort on Saturday, November 10, 2012. Categories range from Advance Practice to Student Nurse.

Who can nominate a nurse?Anyone can! Patients, co-workers, supervisors, health

professionals, and self-nominations are also encouraged.

What is the deadline?September 3, 2012

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What Does the Affordable Care Act (ACA) Mean for Healthcare Professionals?By James D. Huysman, Psy.D., LCSW

What does the Affordable Care Act (ACA) mean for profes-sionals that work with patients/clients and their caregivers? That seems to be the question on our minds since the Supreme Court upheld the legislation.

As we trudge the road less taken to find our place in the new or-der of healthcare made possible by the ACA, there are surely more questions than answers at this point. Without combing through the thousands of pages to dissect the ACA, let’s concentrate on what we know about it.

The Affordable Care Act is a federal statute signed into law in March 2010 as a part of the healthcare reform agenda of the Obama administration. Minus the political dramas and traumas around it, it was designed to address the three-legged dilemma we see in healthcare today: cost, access and quality. It means that healthcare delivery is boldly going where it has not gone before.

Before you can say “Beam me up, Scotty,” the 2014 rollout will be upon us. Healthcare professionals are going to be asked to do even more in the years ahead. We need to be prepared and we need to ramp up quickly. We also need to look to integrate be-havioral health in primary care clinics to more effectively provide access, quality and cost efficiencies.

The next two years of ramp up will mean we will do more with less and facing burnout in the process. Unfortunately, our health-care system is already inundated with caregiver burnout and com-passion fatigue as the current fee for service world drives more and more traffic to physicians’ offices and emergency rooms. Feel like you’re being asked to “change a tire on a fast moving vehicle”? You’re not alone.

The two questions I get asked most often from healthcare pro-fessionals in my national travels are “What is burnout and how does it differ from compassion fatigue?” And “When I find out which one I am challenged with, what can I and my agency do to deal with it?”

By definition, caregiver burnout is the intensive progression of your many professional first-responder stresses - physical, emo-tional, financial, psychological, and social - to the point that you feel totally “burned out” or physically, emotionally, and mentally exhausted.

Compassion Fatigue is the byproduct of that burned-out state of mind, exacerbated by untreated secondary traumatic stress re-sulting in detachment, fatigue, emotional distress, or apathy. It is

a definite condition that can lead to our demise long before our patients/clients if we are not careful.

So what can be done about it? Quite simply, you must “Take your oxygen first!” I am not being cavalier when I say that; I’m actually quite serious. There would be nothing more powerful, no better example of healthcare reform, than for our healthcare workforce to be in touch with its own wellness. Already, it is no coincidence that our industry is the highest utilizing industry of healthcare services of all.

Taking care of yourself and knowing you are worth it is the first step. I suggest that you have a rotating ‘mental health’ day to relax, reflect and recharge. Making “me” time is a great way to alleviate stress. Call a friend and brainstorm a day where you can play “hooky.” Sometimes the process is as important as the product.

Find things you can do to blow off steam and have fun together as a group outside of your work environment. Massage, tai chi, Pilates and just going out to a movie and dinner can make all the difference in the world. Spending time with one or more friends who understand you is a powerful thing to make routine.

Remember, we do sacred work. We have patients and families who depend on us. We owe it to them and to ourselves to be the best we can possibly be. Understand that the process of progres-sive wellness is a marathon and not a sprint.

Will changing our mindset and that of our current health cul-ture be easy? No, change never is. Progress may be chaotic and slow. So we have a choice: We can sit back and allow the change to happen (or not) around us OR we can look toward being part of a collaborative solution. The change begins with us!

The ACA affords us an opportunity to integrate a patient-centered approach to health and wellness; one that makes each individual a partner in that effort. It focuses us on the concept of prevention and even allows us to introduce what have been cat-egorized as “alternative” modalities into the mainstream of 21st century medicine. It also opens the door to embracing palliative care as a process that includes the caregiver, and so much more.

The French dramatist Eugene Ionesco said, “Art requires that one place everything in doubt all over again”. What an appropri-ate metaphor for finding the positive in accepting and molding the impact of the ACA. The ACA is not perfect but it can be a

bEHAVIORAl HEAlTH


What Does the Affordable Care Act (ACA) Mean for Healthcare Professionals?

process that, if we are up to the challenge, will direct us more to becoming real partners in the continuum of care.

Now is the time to re-evaluate our own goals and protocols: How do we plan to be included in the process? How can we be better partners? Who should we be in touch with that we are not?

Perhaps the most important question of all is for each of us to ask ourselves, “What kind of healthcare delivery and support system do I want in this country for my-self, my kids and my grandkids? Now that’s something to think about!

Dr. James D. (Jamie) Huysman,

Psy.D., LCSW began his career serv-

ing in vice presidential roles at free-

standing psychiatric and chemical

dependency treatment centers. Sub-

sequently he was called upon to in-

tegrate behavioral healthcare with

medical services in the same capacity

at several national medical surgical

hospital groups. Today, he is part of

the WellMed Medical Management

team that advocates for and inte-

grates behavioral health into primary

clinic settings to create better qualita-

tive outcomes and care efficiencies.

He received his Masters in Social

Work from Barry University and

Psy.D. from California Southern

University. He is also certified as an

addictions professional and compas-

sion fatigue therapist.

A popular and engaging speaker,

Dr. Huysman keeps an active sched-

ule presenting on a variety of relevant

topics for professional caregivers and

service providers around the country.

He can be reached at drj@drjamie.

com or through his website www.

drjamie.com.

bEHAVIORAl HEAlTH

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State Concussion law Creating Changes for Pediatricians,General Practice PhysiciansBy Corey Gehrold

On April 27, 2012, Governor Rick Scott signed Florida’s youth-concussion law, making Florida the 38th state to have such a law. The law sets tougher restrictions to prevent youth athletes who have experienced a concussion from returning to their sport too soon.

The law could create numerous challenges for pediatricians and general practice physicians who are now required to either pro-vide medical clearance for the concussed athlete or refer them to another practitioner who is able to test and clear the patient before they could return to on-the-field action, either in practice or in a game.

“This law emphasizes the importance of concussion manage-ment,” says Randy S. Schwartzberg, M.D., a board certified or-thopaedic surgeon specializing in sports medicine at Orlando Orthopaedic Center. “And we support it for taking a step in the right direction.”

The law requires athletic trainers and coaches to take an ath-lete out of a game or practice immediately following a suspect-ed head injury. The player is then required to receive clearance from a doctor before returning to practice or to play in another game. Another provision of the law mandates that parents sign a concussion-information form before their child can participate in school sports.

Orlando Orthopaedic Center’s Michael D. McCleary, M.D., is a primary care sports medicine fellowship trained physician with the ability and necessary equipment to easily, safely and quickly manage concussions in athletes of all sports.

“By requiring athletes suspected of having a concussion to be evaluated and cleared by a medical professional before return-ing to play allows for proper evaluation and treatment,” Dr. Mc-Cleary says.

Dr. Schwartzberg adds, “An estimated 140,000 high school athletes suffer concussions annually nationwide and, unfortu-nately, many return to play before they have fully recovered.”

“In fact, I am a proponent of preliminary baseline and follow-up testing before and after a concussion, respectively, so all symp-toms and signs can be assessed as accurately as possible,” he adds. Orlando Orthopaedic Center is able to perform such tests at their five office locations thanks in part to the ImPACT program.

The computer-based ImPACT test essentially tests an athlete’s

ability to recall and process informa-tion to help Dr. McCleary measure the brain’s functional level, which may be abnormal with a concus-sion, even where no obvious symp-toms are perceived. Concussions may lead to social development issues, dampen learning abilities and cause mood swings in young individuals. In some cases they may result in permanent brain damage or death.

“Once the diagnosis is estab-lished, treatment consists of physical and mental rest to allow for proper brain function to be restored,” says Dr. McCleary. “After the athlete’s symptoms have resolved, we repeat the ImPACT test to confirm that full neurologic function has re-turned to baseline.”

Both physicians recommend athletes taking a baseline Im-PACT test at their schools or at Orlando Orthopaedic Center prior to the season that is truly representative of the individual so there is a record to compare if a concussion does occur. If not, their results are compared to “norms” of individuals based on age, gender, academic level and several other factors.

“There is a lot of misunderstanding of these injuries by ath-letes, coaches, and even physicians, so treatment by a medical professional that has an understanding of the most current man-agement guidelines is essential for quality outcomes,” says Dr. McCleary.

Orlando Orthopaedic Center launched a “Same Day, Next Day” campaign this year wherein anyone attempting to schedule an appointment will be seen at one of their five offices within two business days. This quick turnaround time may be the difference in getting athletes back to the sport they love quicker while mini-mizing consequences that could result from a concussion.

To learn more about what Orlando Orthopaedic Center can do to evaluate and clear your student-athlete patients that may have had a concussion, visit www.OrlandoOrtho.com/Concus-sions.

Randy S. Schwartzberg, MDBoard Certified in

Orthopaedic Surgery; Board Certified in Sports Medicine; Specializing in

Sports Medicine, Knee and Shoulder Surgery

ORTHOPAEDIC UPDATE

Michael D. McCleary, MD Specializing in Sports

Medicine andMusculoskeletal Medicine


MARkETING YOUR PRACTICECANCER

Cancer Pain: New Interventional Options, better ResultsBy Benito M. Torres, DO

important.”

Therapeutic nerve blocks are gain-ing increasing adoption rates due to effective outcomes as noted by Dr. Dilling. In addition to intrathoracic blocks, celiac plexus blocks are extremely worthwhile for patients with locally advanced pan-creatic cancer. This outpatient procedure can provide significant relief to those pancreatic cancer patients with disease infiltrating the celiac plexus region. Selective diagnostic nerve blocks can also be used as a short-term bridge to a longer-term solution such as radiofrequency ablation (RFA) or cryoablation.

Interventional options have truly expanded over the past 10 years. Since the 1990s, vertebroplasty and kyphoplasty have in-creased as effective treatments for pathologic compression frac-tures. Indications for this procedure include an acute compres-sion as evidenced by contrast-enhanced MRI. These procedures involve the injection of a cement formulation into the vertebral body to provide strength to the weakened bone. These procedures provide structural support to the bone and also provide pain relief by a mechanism that is thought to be secondary to thermoabla-tion of nerve endings. Contraindications include patients with spinal cord compression or epidural disease. The most commonly treated types of cancer include breast, prostate, and lung. Pain relief can be immediate. Studies have shown that more than 80 percent of treated patients have improvement or complete pain

relief. The procedure is often combined with external beam radiation for synergistic tumor control.

Additional options for localized pain include the integration of neurostimulation. These procedures involve the implantation under the skin of a pulse generator unit that looks like a pacemaker. These techniques, called spinal cord stimulation and pe-ripheral nerve stimulation, are particularly useful for patients with neuropathic pain who have often failed other treatment.

Some patients may be more appropriate candidates for an intrathecal (IT) infusion of opioid analgesics. These drugs can be delivered via a tunneled percu-taneous catheter or an implanted infusion pump. These IT systems are capable of delivering higher doses of opioid analgesics more focally without the attendant peripheral side effects. These pumps are

All too often, pain becomes a clinically significant problem at some point in a patient’s cancer journey. Up to 70 percent of patients who die of prostate or breast cancers have bone metas-tases. Although less common, patients with kidney, thyroid and lung cancers also can have disease that involves the bone and can cause pain, fractures, hypercalcemia, and compression of the spi-nal cord or peripheral nerves.

Narcotic analgesics are effective but are often associated with side effects such as constipation, nausea and central nervous sys-tem effects. In this setting, interventional options may offer pa-tients a better alternative.

At Moffitt Cancer Center, our team of interventional pain specialists can offer additional options to our patients who are often already receiving multimodality care. Our services, however, are often underutilized because clinicians are not always aware of the full range of our state-of-the-art options.

“Lung cancer patients often have chest wall pain,” notes Thomas Dilling, a Moffitt thoracic radiation oncologist. “This can be a clinical problem when they are receiving radiotherapy and have to place their arms over their head for 20 minutes a day on the treatment table for seven weeks. Those patients I have referred for nerve blocks have been more compliant with their treatment and required less pain medications. As residency program director, I think ensuring that our trainees understand the physiology of pain and understand the range of therapies available is critically

Paddle Lead

Implanted Pulse

Generator

Fig. 1 showing an implanted spinal cord stimulator with a percutaneously placed paddle lead in the epidural space.

Continued on page 20


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CANCER

capable of delivering highly potent therapy, on the order of a fac-tor of 1:300 compared with oral medications. One such location where these pumps can be particularly effective is in the pelvis, where local recurrences of cancer can cause painful infiltration of the sacral plexus.

Cancer patients can develop painful side effects from treat-ment, as well as from metastases. Modern chemotherapy is as-sociated with significantly improved outcomes but can cause pe-ripheral neuropathy, which can have a profound negative effect on the patient’s quality of life. One new indication that many oncologists are not aware of is the application of topical creams to cause thermal ablation of the nerve endings on the patient’s feet. In our practice, referrals for this procedure are increasing because oncologists are seeing the improved performance status of their patients. The treatment is outpatient and involves the in-office application of a specially formulated cream that will produce the desired effect in one treatment. The application is well tolerated with good efficacy.

All of these new options for pain are a tribute to the fact that patients are living longer with more effective cancer treatments. This improvement in outcomes is shining the spotlight on quality of life. Better interventional pain options are translating to better daily functioning and less pain. If novel cancer therapies continue to improve and cancer can ultimately become a chronic disease,

then interventional options will continue to offer patients hope for living better despite their malignancy.

Benito M. Torres, D.O., is an expert in pain manage-ment with specialization in the field of interventional pain medicine. He has offices at the Moffitt location adjacent to USF/Busch Gardens as well as the new facility adjacent to International Plaza Mall. He has extensive experience in the procedures listed in this article and is accepting new patients. He can be contacted at (813) 745-2390 or www.moffitt.org. New patients to Moffitt can also be scheduled through the New Patient Appointment Center at (813) 745-3980.



MEDICAl MAlPRACTICE EXPERT ADVICE

How Will ObamaCare Affect the Malpractice-Insurance Industry?By Matt Gracey of Danna-Gracey – The Malpractice Insurance Experts

Q. How will ObamaCare affect the malpractice-insurance industry, since tort reform was not a part of the plan?

A. Already we are seeing doctors either sell out to hospitals or join mega groups. Many of those hospitals’ doctors enjoy sovereign immunity, as do VA doctors and many other public-hospital doctors. Many of the mega groups, at least in South Florida, do not require or even encourage their doctors to be insured, nor do most any hospitals in Florida these days. So where does that leave the mostly insured solo and small-practice doctors in the liability-claims arena? Well, just like the insured- versus uninsured-patients issues, eventually the insureds will carry a much heavier risk load than the uninsured because they are carrying risk for themselves and for every other doctor without coverage to whom they are at all connected in a patient’s care.

In my opinion, this will lead to more cries of “class warfare” as those small-practice doctors get sued more often just because they are still trying to responsibly stand. Layer on top of that some 30 million new patients in the system and I predict that malpractice insurance for the smaller doctors could increase to unaffordable levels. So, what happens then? Either the government comes up with an “all must be insured” solution, like ObamaCare has done on the patient level, or we must pass serious, effective tort reform that stops the frivolous suits cold and efficiently helps injured patients without giving away a huge portion of the claims payments to “frictional costs,” that nice way to say plaintiff-attorney’s big fees. I hope many of our leaders start connecting these dots soon.

Matt Gracey, Jr. is a medical malpractice insurance specialist with Danna-Gracey, an independent insurance agency based in downtown Delray Beach with a statewide team of specialists dedicated solely to insurance coverage placement for Florida’s doctors. To contact him call (800) 966-2120, or email: [email protected].

Pathology Lab Results — Patient: SP Age: 63 Sex: Male Before Diet After DietLipid Panel Result 08/28/2009 Ref Range Result 09/20/2010Cholesterol H 278 (80-199)mg/dL 180Triglycerides H 199 (30-150)mg/dL 82HDL Cholesterol 51 (40-110)mg/dL 55LDL Cholesterol H 187 (30-130)mg/dL 109VLDL Cholesterol 40 (10-60)mg/dL 16Risk Ratio(CHOL/HDL) H 5.5 (0.0-5.0)Ratio 3.3

Body Scan Results Tissue Fat % Tissue (g) Fat (g) Lean Muscle (g)8/26/10: 26.3% 83,019 21,864 61,1559/24/10: 21.1% 78,045 16,449 61,596Please Note: Gain of 441g of muscle and a fat loss of 5,415g in 30 days! Individual results may vary.

For information call 407-260-7002 or email [email protected].

START WEIGHT SEPT. 2010: 207 LBS. • END WEIGHT DEC. 2010: 166 LBS.


The stage after a hospital stay is a particularly precarious time for patients. During these times, responsibility for care shifts from the hospitalist to patients, their families and primary care physi-cians. There is a period of time (between discharge and the first post-acute PCP visit) when patients and caregivers are left to their own devices when it comes to tracking new medication regimens, beginning new therapies and tracking symptoms to determine if their condition is worsening. It’s estimated that approximately 20% of patients experience Adverse Drug Events (ADEs) dur-ing this time of transition. Half of these ADEs and other types of medical errors could be prevented (or their impact decreased) with appropriate communication between the hospital care team and the patient and his or her primary care physician. There are several challenges contributing to the breakdown in communica-tion that promotes ADEs and medical errors.

The first challenge is the “planned discontinuity of care” be-tween the hospitalist and the PCP. Often times, discharge sum-maries don’t contain the necessary information a PCP needs to pick up the care where the hospitalist left off. And most of the time, discharge summaries are not available to the PCP at the time of the patient’s first post-acute visit. Including the necessary elements in the discharge summary (primary diagnosis, results of diagnostic tests, pending lab or diagnostic tests, hospital course, follow up recommendations, etc.) and its timely delivery (before the first post-acute visit) are critical factors in overcoming the challenges posed by physician discontinuity during this time of transition.

Another important challenge is that posed by modifications and inconsistencies in patients’ medication regimens. Often times many changes are made to the patient’s healthcare routine when transitioning from the inpatient to the outpatient setting. For example, medication dosages may be altered to accommo-date changes in condition, some medications may be discontin-ued and new therapies may be started. It’s important to obtain accurate medication history by assimilating data from multiple sources of information (involving the patient, the family/care-giver, prescription bottles, and any obtainable medical records) during the admission process, so that proper education can take at discharge and during the transition period.

Perhaps the most important, but often overlooked, challenge is that many patients (particularly self-pay patients and/or with-

out a PCP relationship) never make it to a post-acute primary care provider visit after they’ve been discharged from the hospital. The reasons range from transportation and mobility challenges to appointment scheduling difficulties to financial considerations. None of the challenges mentioned above can be addressed if there is an inaccessibility of primary care for patients in transition.

There is a national trend towards facilitating a safe Transition of Care for patients as they move from the inpatient to the out-patient setting. Hospitalists should strive to extend their role beyond the discharge process as meaningful participants in the promotion of safe and efficient transitions. CFIM’s Transition of Care Program engages community physicians to facilitate post-acute primary care visits for self-pay patients and for those with-out an established PCP relationship.

As part of the program, CFIM facilitates an appointment for a post-acute visit with a community physician and provides a dis-charge summary. In turn the community physician provides a Post Discharge Evaluation (PDE), physical exam, and medica-tion reconciliation and ensures that the patient understands their medication regimen, red flags to look for, what to do next, and the self-care particulars of their condition. The community physi-cian may also offer transportation as well as establish special lower fees for Program patients that need such accommodations.

With the Transition of Care Program, CFIM aspires to ensure a smooth and safe transition from the inpatient setting to the next level of care for patients under our care. We also seek to mea-surably reduce readmissions to the inpatient and to improve the patient experience. By working together, inpatient and outpatient doctors can indeed improve care and outcomes for patients dur-ing their most vulnerable time.

Community doctors can learn more about Transitions of Care and CFIM’s program at 407-647-2346.

Doctors Should Work Together to Improve Care During Patients’ Most Vulnerable TimeBy Victor Mikhael, MD

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DIGESTIVE AND lIVER UPDATE

INTRODUCTION — Natural orifice transluminal endoscop-ic surgery (NOTES) is an emerging field within gastrointestinal surgery and interventional gastroenterology in which the surgeon accesses the peritoneal cavity via a hollow viscus and performs diagnostic and therapeutic procedures. NOTES is evolving rap-idly, presenting seemingly limitless possibilities for innovation, technique, and device development.

EXPERIMENTAL EVOLUTION AND DEVELOPMENT — The concept of flexible transluminal endoscopy, a term used before NOTES was coined, was first developed by a multicenter team of investigators (the Apollo Group) in the late 1990s . The publication of the initial animal studies generated a wave of enthusiasm and many centers began experiments of their own, using the NOTES approach for a variety of operations ]. These have ranged from diagnostic explorations of the peritoneal cavity to complex organ resections including pancreatectomy, splenec-tomy, and nephrectomy ].

The initial approach was transgastric, but more recently NOTES has been performed through several other orifices, re-sulting in transcolonic, transvaginal, and transurethral/transcystic approaches. The approach has also been extended from the peri-toneum to other compartments in the body, such as transesopha-geal approaches to the mediastinum and heart, transgastric intra-uterine interventions in pregnant animals, and novel approaches to the vertebral column .

Given this flurry of activity and mounting enthusiasm, in 2005 the American Society of Gastrointestinal Endoscopy (ASGE) and the Society of Gastrointestinal Endoscopic Surgeons (SAGES) came together in a consortium (the Natural Orifice Surgery Con-sortium for Assessment and Research, or NOSCAR (www.noscar.org)) to provide consensus and guidelines on how best to bring this procedure to the clinical mainstream. In the last few years, an increasing number of NOTES procedures in humans have been performed. However, technological limitations of the cur-rent flexible platforms have been a major challenge, limiting the adoption of this approach (to date) to a few major medical cen-ters. Nevertheless, while it is still too early to predict its ultimate role and value, it is clear that NOTES has dramatically altered our perceptions of how to approach gastrointestinal surgery.

A strong argument can be made that NOTES has been instru-mental in the resurgence of lesser invasive surgical techniques, such as single-incision laparoscopic surgery, which for some may represent a bridge to NOTES . Furthermore, developmental ef-forts in NOTES have resulted in numerous advanced surgical and endoscopic technologies that are now being applied in con-

Natural Orifice Transluminal Endoscopic Surgery (NOTES)

ventional laparoscopic and endoscopic techniques. PREMISE AND PROMISE OF NOTES — Interventions in

the peritoneal cavity were historically performed by laparotomy. In the late 1980s and 1990s, laparoscopic surgery became widely popularized as a less invasive, cosmetically more appealing ap-proach, and it is now commonplace in general surgery.

At the same time, there has been a dramatic increase in the complexity of endoluminal gastroenterologic procedures. These approaches differ significantly in the kind of access and viewing perspective they provide and the types of therapeutic maneuvers they enable.

Although NOTES procedures have been successfully (and ap-parently safely) reproduced in animal models, most investigators who have tried to implement NOTES in humans have encoun-tered technical difficulties and sometimes even ethical challenges. These issues appear to be lessened by implementation of hybrid approaches, using a combination of laparoscopic, intraluminal, and transluminal (NOTES) procedures . However, the ultimate goal of NOTES is to eliminate the laparoscopic component alto-gether and perform surgery using access provided by the “natural orifices” only (ie, the mouth, vagina, anorectum, or urethra).

Enthusiasm for these approaches stems from several reasons :• Thehypothesisthata“hole”inaviscusisbettertoleratedby

the body than that in the abdominal wall, potentially leading to fewer complications such as ileus, pain, adhesions, and her-nias when compared with laparoscopic surgery.

• Eliminationofanexternalscartherebyleadingtobettercos-metic outcomes (which to some patients may be the most im-portant advantage).

• Betteraccesstocertainareasintheperitonealcavityorincer-tain patients, such as those who are severely obese.

• Thepotentialforshorterhospitalizationsandreducedhealth-care costs.The evolution of laparoscopy was driven by patients, surgeons,

and industry demand. A similar phenomenon may be evolving with NOTES. In a survey study of 100 patients considering lap-aroscopic cholecystectomy, 80 percent of respondents reported a theoretical preference for NOTES, based mainly upon the as-sumption that it would lead to less pain and fewer external scars . For those who preferred laparoscopic cholecystectomy, the most common reason was its proven safety and effectiveness. With re-gard to the choice of orifice used, both men and women preferred the mouth over the rectum or vagina. However, these outcomes were sensitive to the perceived risk. Thus, if the complication rate

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of NOTES was projected to double that of the laparoscopic ap-proach, the preference for NOTES declined to 15 percent.

However, these views are already evolving. A survey of 300 women revealed that at least three-fourths of them would not favor NOTES via a transvaginal approach over laparoscopic cholecystectomy. A possible reason for this was that many of the women, especially younger nulliparous women, expressed con-cerned about future sexual function . Patients in general may not fully understand the complexity of these approaches. Further, even with proper education and informed consent, opinion on the acceptability of the technique will also be influenced by cul-tural and geographic variations.

TECHNICAL CONSIDERATIONS — Most of the NOTES procedures in humans that have been performed have pushed the limits of currently available endoscopes and endoscopic accessories, leading to procedures that are far more complex, lengthy, and potentially riskier than they need to be. This is one reason why it is presently difficult, if not impos-sible, to directly compare laparoscopic and NOTES approaches. Fortunately, a number of platforms and tools are emerg-ing that may render such studies feasible in the near future. Furthermore, even if they are not implemented for NOTES, these tools will help advance more con-ventional approaches, thus moving the whole field forward .

The key technical elements in a NOTES procedure are access via a hollow viscus, performance of the desired maneuver once in the target cavity, and closure of the port upon exit. Many technical varia-tions have been described for gaining safe access to the peritoneal cavity via a hollow viscus such as the stomach, but it is now generally accepted that a minimal inci-sion (eg, using a needle-knife or sphinc-terotome) followed by balloon dilation is preferred.

Although the endoscope can be in-serted directly through the newly created stoma, some form of overtube is generally used to allow multiple entries and com-plex maneuvers. Choosing which viscus to use for access is determined, at least in part, by the location of the target organ and the potential for visualization and ap-propriate triangulation to the target.

As a general rule, the transgastric ap-proach is best for lower abdominal and pelvic targets, whereas a transvaginal or transcolonic approach provides much

straighter access to upper abdominal targets such as the gallblad-der. This is important because many of the current instruments in use today are difficult to maneuver when the endoscope is ret-roflexed. When this general rule is not followed, spatial orienta-tion during NOTES procedures can be very challenging to the surgeon. These technical constraints limit certain procedures to certain points of natural entry.

Another major set of limitations stems from the design of the contemporary flexible endoscopes, which were not intended to serve as a platform for complex surgical techniques. They do not provide the rigidity and ability to triangulate that is desirable in most instances . Technological advances, however, have a tremen-



dous potential to transform this platform and make it capable of much more sophisticated maneuvers.

The final and perhaps most important technical challenge is to close the resultant viscerotomy in a secure, reliable, and safe manner. Indeed, a wider adoption of NOTES is critically depen-dent upon the safe and reliable closure of the viscerotomy and in-fection rates that are comparable if not better than conventional techniques. (See ‘Limitations’ below.) From this perspective, the transvaginal route is easier to secure after exit, although theoreti-cal long-term consequences, such as dyspareunia and infertility, need to be considered.

lIMITATIONSBacterial contamination, peritonitis, and abscess formation —

There will be some degree of bacterial contamination of the peri-toneal cavity due to the viscerotomy and prolonged manipulation in the peritoneal cavity. A quantitative bacteriologic study in pigs showed a 20 to 40 percent incidence of abscesses and 40 to 60 percent incidence of significant contamination of the peritoneal fluid following NOTES, even in the absence of a leak. Although the abscesses were generally small, these studies suggest that bac-terial infection is a potential threat that needs to be addressed carefully in clinical applications of NOTES.

Thus far, in most clinical reports of natural orifice surgery, even though postoperative infections remain a great concern, there have been relatively few infections reported . A prevailing challenge is to develop an affordable, efficient, and high-level of disinfection or sterilization process for complex fi-beroptic endoscopic systems such as those that are utilized in NOTES.

Effects on the immune system and other physiological effects — A num-ber of animal models have been created to assess the physiologic, biochemical, and neurohormonal impact of NOTES access and manipulation. One report found that circulating levels of cytok-ines such as IL1 beta, IL6, and TNF-alpha were similar in animals immedi-ately following a sham operation, open exploration, laparoscopy, or transgastric NOTES. However, in the late postop-erative period, there was a substantial decrease in TNF-alpha levels compared with the open and laparoscopic groups. The clinical significance of these obser-vations remains unknown.

Another concern with a NOTES procedure is the possibility of over-in-sufflation of the peritoneal cavity and subsequent decreased venous return to the heart . Over-insufflation is prevent-ed during laparoscopy by using pressure sensors, which are not currently avail-

able with standard endoscopy systems. There have been animal reports of successful monitoring of intra-abdominal pressures through the endoscope during NOTES; however, these findings have not been replicated in human studies .

Inability to deal with major complications — Major bleed-ing, laceration, perforation of neighboring organs, and other complications occur with any major abdominal surgery, whether it is done via NOTES or any other access. However, it would be far more difficult to rapidly address these complications with a NOTES approach, given the limited range of instruments avail-able for use through the flexible endoscope. Such complications would in all likelihood require conversion to a laparoscopic or open approach.

Complications have been reported to occur in 5.5 to 9.6 per-cent of procedures in different NOTES registries, with complica-tions related to a transgastric approach being the most common. Reported complications include bleeding, bowel injury, biliary leaks, biliary fistulae, esophageal injury, and peritonitis. No mor-tality has been described, at least in the most current medical lit-erature. Again, developments such as flexible endoscopic suturing devices may ameliorate some of these issues.

Training and credentialling — Many surgeons are not com-fortable using flexible endoscopic instruments as their use requires a very different set of manual skills, hand-eye coordination, and perception than what most surgeons were trained in. Although this situation is changing as surgery programs increase flexible en-

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doscopy training, this issue will likely remain a major limitation to the rapid adoption of NOTES or NOTES-like procedures. At the same time, very few gastroenterologists have both the skill set and the inclination to enter the peritoneal cavity. Even if they do, it is unlikely that they will be given credentials to perform these procedures by either their institutions or national boards. Overcoming these challenges will require a large, concerted ef-fort involving investigators and agencies overseeing training and credentialing.

Economic limitations — The implementation of NOTES demands formidable financial resources above and beyond those required for technology development. NOTES procedures are generally far lengthier than laparoscopic procedures, but lack established reimbursement codes that can provide appropriate compensation for the effort involved ]. This may limit NOTES techniques mainly to academicians, as private practitioners may find the opportunity cost prohibitive.

HUMAN EXPERIENCE — Since the inception of NOTES, several hundred human cases using NOTES have been reported and published, including 572 cases from a German registry and 362 cases from a Brazilian registry . However, only a handful of cases have been purely NOTES, requiring no laparoscopic instru-mentation.

Transvaginal NOTES — Presently, the transvaginal NOTES approach has been the most common and successful. Vaginal sur-gery and organ retrieval through the vagina have been reported for many years and demand very little in terms of infrastructure and highly-trained expertise. Closure of the vaginal entry is far less complex than any other NOTES entry. Also, the flexible vag-inal walls allow extraction of even large organs. Its relative safety makes this approach more attractive than many other NOTES approaches; however, it is an option in women and requires that gastrointestinal specialists enter the world of gynecological sur-gery.

Most reports of transvaginal NOTES have utilized rigid instru-mentation, either entirely or in addition to flexible endoscopy. There has been concern about the safety of using flexible endos-copy clips, especially for cholecystectomy. Such an argument has been the rationale for some to use conventional clips and, conse-quently, hybrid techniques.

Transvaginal NOTES has been used for several operations oth-er than cholecystectomy and appendectomy in humans. Other procedures have included sleeve gastrectomy, colon resections, and even abdominal wall hernia repair.

One account of the first 14 months of the German NOTES Registry reported a total of 572 target organs in 551 patients, of which cholecystectomy was the predominant operation (85 per-cent.) The approach used was a transvaginal hybrid procedure. Complications occurred in about 3 percent, with conversions to laparoscopy or open surgery in about 5 percent. The conversion rate was dependent upon institutional case volume, obesity, and age.

Remaining challenges with this technique include potential dyspareunia, infertility, and a need to cannulate the bladder, which could potentially result in urinary infections, among the other potential complications previously described.

Transgastric NOTES — Unlike the transvaginal approach, en-try through the stomach demands a much higher degree of tech-nological sophistication, especially for closure. A growing number of devices have been created for this purpose. Most have been utilized only in animal or cadaver models, and their results have been increasingly promising. Thus far, closure of the gastric access site in human NOTES has required laparoscopic assistance.

Flexible endoscopic platforms are a must for this approach; however, all cases require some degree of hybridization. Proce-dures performed via a transgastric approach include appendec-tomy and cholecystectomy. Cancer staging and the retrieval of dislodged percutaneous endoscopic gastrostomy tubes have also been reported. The frequency and severity of complications with the transgastric route are higher than those experienced with the transvaginal approach. While the transgastric approach seems ap-plicable to nearly all patients, only relatively small specimens may be conducive to extraction through the mouth.

Miscellaneous Approaches — Hybrid NOTES techniques have been successfully implemented in transcolonic, transesopha-geal, and transurethral/transcystic approaches. One novel tech-nique that is not transluminal but involves entry through natural orifices is the management of achalasia by per oral endoscopic myotomy (POEM) and over 50 cases have been successfully performed, of which at least 33 have been published. Advanced surgical procedures, such as sigmoidectomy for cancer, have been performed with a micro-assisted laparoscopy natural orifice sur-gery (MANOS) approach, but not yet using a true NOTES tech-nique. Transanal endoscopic microsurgery has also been extended at times to transluminal resections .

IMPLICATIONS BEYOND THE PROCEDURE ITSELF — Even if NOTES procedures are not widely adopted, a ma-jor benefit may be to embolden endoscopists to be more aggres-sive even with intraluminal procedures, with the knowledge that limited perforation of the gut may have no ill effects, if repaired promptly. This will allow endoscopists to expand their therapeu-tic techniques to include resection of larger and deeper mucosal lesions, and to take full-thickness biopsies. A further benefit will come from the technological spin-offs from instrument develop-ment for NOTES. Many of these should be readily adaptable to intraluminal applications, enabling newer procedures. Finally, the advent of NOTES will have significant implications for the training of both gastroenterologists and surgeons, and has the po-tential for changing the way gastroenterology will be practiced in the future .

SUMMARY AND RECOMMENDATIONS• Natural orifice transluminal surgery (NOTES) is a rapidly

evolving set of techniques by which intraabdominal opera-tions are performed without any transabdominal incisions.


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• Potentialadvantagesareeliminationorreductionofcomplications,suchassurgicalwoundinfections,abdominalwallhernias,andabdominal wall pain.

• Thereismuchmorethatneedstobelearnedaboutthisprocedure,includingtheriskofperitonealcontamination.

• Atpresent,NOTESshouldbeconsideredexperimentalandshouldbeperformedonlyinaresearchsetting.

• ChallengesforthescalableadoptionofNOTESseemmuchmoreformidableandcomplexthanoncethought.Whilethereturnofinvestment on tangible clinical data and improved outcomes has been modest, there has been tremendous technological development of advanced surgical platforms applicable to endoscopic surgery and gastroenterology.

Harinath Sheela, MD moved to Orlando, Florida after finishing his fellowship in gastroenterology at Yale University School of Medicine, one of the finest programs in the country. During his training he spent signifi-cant amount of time in basic and clinical research and has published articles in gastroenterology litera-ture.

His interests include Inflamma-tory Bowel Diseases (IBD), Irritable Bowel Syndrome (IBS), Hepatitis B, Hepatitis C, Metabolic and other liver disorders. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endos-copy (ASGE) and the American As-sociation for the Study of Liver Dis-eases (AASLD) and Crohn’s Colitis foundation (CCF). Dr. Sheela is a Clinical Assistant Professor at the University of Central Florida School of Medicine. He is also a teaching at-tending physician at Florida Hospi-tal Internal Medcine Residency and Family Practice Residence (MD and DO) programs.

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Delray Beach: 800.966.2120 • Orlando: 888.496.0059 • Miami: 305.775.1960 • Jacksonville: [email protected] • www.dannagracey.com

Some two years ago Orthopaedic Surgeons across Florida de-cided to stand together and assume more responsibility in the medical liability insurance arena. The concept was simple – the Florida Orthopaedic Society and Bones Society of Florida would develop a Risk Purchasing Group that would provide its mem-bers with buying power in the marketplace. Once purchasing in-surance together, the organization could actively engage industry partners to develop a better understanding of the risk inherent in the practice of orthopaedics and apply risk analysis and risk mitigation techniques that will make our individual members more efficient professionals. Today, the Florida Orthopaedic Risk Purchasing Group (FORPG) has fundamentally changed the game of medical liability insurance for orthopaedic surgeons in the state.

As of February 2011, of the 900 or so active members of the Florida Orthopaedic Society, nearly 1/3 are members of the Flor-ida Orthopaedic Risk Purchasing Group. The buying power of our group has not only driven down premiums for our members, but has forced the competition to lower their rates too, benefit-ting even non member surgeons. Given the cyclical nature of the insurance industry, the organization is aware that difficult times are certain to ap-pear again. When that next tight malprac-tice cycle rolls around, standing together in unity will prove the far wiser, and more profitable, course of action.

FORPG membership benefits may begin with stable, lower premiums, but that is just one part of the picture. The organization created an active Claims Review Commit-tee made up of member orthopods across the state, representing the best and bright-est in almost every subspecialty. When a claim is filed against an FORPG member, an anonymous summary of the case file is brought to this committee for review. The entire group of doctors, not just one reviewer, discusses the issues involved and offers recommendations on the defensibil-ity of the suit. No other insurance carrier offers such a depth of orthopaedic specific experience and knowledge when it comes to defending claims.

A third area where the FORPG has made a difference is in the crucially important area of political advocacy. Keenly aware that it is the politicians who must eventu-ally reform our broken medical liability sys-tem the FORPG has endorsed an aggres-

sive education and awareness campaign for our elected leaders. Armed with the knowledge provided by the development of the purchasing group, the leadership of the FORPG is engaged in efforts to seek targeted reforms to the tort system in Florida that may deliver more reasonable and effective protections for physi-cians and patients.

The final component of the organization is the Risk Manage-ment Committee. Charged with distribution of risk mitigation strategies to the members of the FORPG, the Committee re-cently unveiled its first publication. Information is power, and by understanding the types of issues that are giving rise to claims against our members, we can further reduce our group’s risk pro-file, thus allowing us to deliver better quality care and hopefully steer clear of the courtroom.

While the FORPG has made great strides in the initial years of existence there is great promise for the future.

Fraser Cobbe is the Executive Director of the Florida Or-thopaedic Society and the Bones Society of Florida. He can be reached at 813-948-8660 or [email protected].

Orthopaedic Community launches Aggressive Risk Mitigation Program By Fraser Cobbe


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CURRENT TOPICS

Florida Hospital East Orlando Announces Plan to Expand The Emergency Department Will Double in Size and 40 New Patient Beds Will be Added

To better meet the needs of the growing East Orlando com-munity, Florida Hospital East Orlando has announced plans to expand its services including doubling the size of the emergency department as well as building out shell space on the fifth floor of its main patient tower to include 40 patient beds. The expansion will provide patients with better service, high-end technology, and create additional space for the growing demand of medical and surgical specialists close to home.

“As the East Orlando community has grown over the years, Flor-ida Hospital East Orlando has made enhancements to grow and expand in order to provide the best care possible in a convenient setting,” said Mike Thompson, administrator of Florida Hospital East Orlando. “Our goal is to provide patients with more efficient service and access to high quality medical care in their own back-yard.”

In 2011, the Florida Hospital East Orlando emergency depart-ment treated nearly 80,000 patients. As a result of the high de-mand for emergency care, the hospital plans to double the size of

its emergency department to 65 beds by adding 29 beds to its al-ready existing 36. Construction is scheduled to break ground later this year and will include access to the latest technology in hopes of treating patients quicker. The expansion of the emergency depart-ment is expected to take between 18 to 24 months.

The build out of the fifth floor of the main tower will add 40 new private patient beds to the hospital. This floor was originally built as shell space when the new patient tower opened in 2007.

“It has been part of our vision to expand the variety of surgical services offered at our hospital and these new patient beds will al-low us to treat even more patients,” said Thompson. “Over the past several years, Florida Hospital East Orlando has added a variety of additional surgical specialties including orthopedics, colorectal, urology and andrology. In the future, we hope to expand these ser-vices even further.”

The build out of the fifth floor is expected to take 12 months. These expansions will create approximately 75 construction jobs as well as new clinical jobs once the project is complete.

South Seminole Hospital Moves ‘Nursing Station’ Inside Patient RoomsNurses Begin Program in the Progressive Care Unit to Enhance Patient Care

Nurses at South Seminole Hospital are bringing patient care closer to the bedside by moving computer workstations inside each patient room. The computers serve as mini “nursing stations” allowing nurses to keep a closer watch on patients in their rooms while keeping a closer eye on the electronic information they need to provide patient care. The hospital implemented the program in the Progressive Care Unit – a 43 bed unit for patients with critical care needs.

Nurses agree the bedside nursing stations help them provide better care for patients.“Computers inside patient rooms help us recognize changes sooner and respond to needs sooner,” said

Kerry-Ann Farrow, RN, BSN, nursing operations manager, Intensive Care Unit/Progressive Care Unit. “Because electronic records are at our finger tips — medical histories, assessments, doctors’ orders, lab results, images, and lists of medications are readily available when making plan of care decisions.”

Valentina Duque, RN, clinical nurse I, adds, “The computer stations inside the room also make it easier for doctors to access what they need as well.”

Another benefit is the close proximity builds stronger relationships between the clinicians and pa-tients.

“Patients are more involved in their plan of care,” said Duque. “This helps patients have a better under-standing of their condition and treatment.”

The increased interaction helps nurses get to know patients and their families better, and leads to im-proved communication, quality standards and increased patient satisfaction.

Patients have also weighed in with positive responses and often wonder if the computer is for their use to check email or surf the web.

“Once they hear it is for us and why we have it in there room, they love it,” said Duque.Before the pilot, nurses would chart, give updates to the new shift and access patient information from the traditional nursing station

fixed at one end of the unit, move around computers on wheels or carry small sized laptops room to room. Though the portable computers offered benefits, the computers on wheels could be a challenge to push and pull along with other equipment, and the laptops had limita-tions with screen size and battery power.

“While there are good reasons to have a traditional nursing station and other equipment has helped, we find in the evolution of patient care and putting the needs of patients first, we need to look for ways that allow our nurses to provide patient care more efficiently and ef-fectively,” said Farrow. “In using and evaluating a new approach we have found a way to make difference in patient care.”

Continued on page 31


Florida Hospital Cancer Institute Presents latest in Cancer Research to Florida Clinicians Grant from the Florida Biomedical Research Program Will Fund Development of Innovative Methods for Novel Anti-Cancer Cellular Therapies

In addition to the patient care benefits, the in-room access means fewer steps for nurses, less time waiting for an available computer, less equipment to carry or push and more time to spend with patients. The close proximity also makes it easier to chart while providing care and easier to share updates with nurses during shift changes. The computer also increases access to patient care protocols and corporate policies and procedures.

CURRENT TOPICS

Breast and lung cancer research served as major topics of interest as health care providers from around the state recently gathered for the Florida Hospital Cancer Institute (FHCI) Best of ASCO 2012 in Central Florida. The meeting provided hematologists, medical oncologists, radiation oncologists and other clinicians a comprehensive summary of the information and data presented at the national American Society of Clinical Oncology (ASCO) 2012 Annual Meeting, the largest conference on cutting-edge research in oncology.

“Florida Hospital Cancer Institute has one of the largest clinical trials programs in Central Florida, participating in more than 100 clinical trials per year. We believe it is essential that oncologists everywhere have access to the latest research data if they are unable to attend the national meeting,” said Dr. Lee Zehngebot, director of clinical research at FHCI. “Our goal is to improve cancer care and prevention through a comprehensive presentation of pivotal data that will keep physicians informed and more knowledgeable in their practice.”

Hundreds of research findings are presented at the national ASCO meeting, but two studies in breast and lung cancer are mak-ing headlines.

ADVANCEMENTS IN bREAST CANCER: A new drug combination to target HER2 positive breast cancer

had been deemed a “smart bomb” treatment for patients who have become resistant to other forms of treatment. Research shows that a unique combination of a toxin, a chemotherapy drug too lethal to use on its own, delivered with an anti-body is directly attacking the cancer cells and leaving the healthy cells unharmed. “This approach has not been used before so it’s intriguing doctors because a toxin that should be so bad for the patient is effectively targeting only the

bad cancer cells with few side effects,” said Dr. David Molthrop, FHCI oncologist and breast cancer specialist. “It is giving patients who previously became resistant to treatment a new option and has implications for other forms of cancer down the road.”

ADVANCEMENTS IN lUNG CANCER:Five years ago, all lung cancers were treated the same with che-

motherapy. Now, clinical trials are giving doctors a better un-derstanding of the genetic markers that make up an individual’s tumor, leading to what you may have heard referred to as more “personalized medicine.” The ability to detect genetic mutations in tumors and create a targeted drug therapy specific to that mutation is changing the treatment of lung cancer. Many genetic mutations have been identified for lung cancer. At this year’s ASCO, the ros1 mutation was reported to predict dramatic benefit from a newly approved drug.

“When we are able to use a specialized drug that targets a specific genetic mutation or characteristics in a person’s tumor, that is what we call personalized medicine,” says Dr. Tarek Mekhail, medical director of the FHCI Thoracic Cancer Program. “Ros1 is respond-ing to a newer drug already available to doctors for treating other genetic markers. It will continue to be studied as the testing still needs to be standardized.”

The Best of ASCO also offered a discussion of data pertaining to melanoma, thoracic, kidney, lymphoma, myeloma and prostate research.

Presenters at the Best of ASCO included physicians from the Flor-ida Hospital Cancer Institute, Cleveland Clinic, Memorial Sloan-Kettering Cancer Center, Duke University Medical Center and Abramson Cancer Center at the University of Pennsylvania.

Florida Hospital has established the only lung transplant program in Central Florida. The addition of two world class physicians to the Florida Hospital team and the listing of the first patient to the lung transplant waiting list signals the first lung transplant in Central Florida is rapidly approaching.

The new lung transplantation program at Florida Hospital means patients in need of a lung transplant will no longer have to travel long distances to receive a life-saving organ. Typically, 10 to 20 patients each year have to leave Central Florida to receive lung transplant services in other parts of the state.

“In organ transplantation, much of the hard work for the patient comes after the surgery, with many follow up appointments and regu- Continued on page 32

Florida Hospital Establishes Only lung Transplant Program in Central Florida New Surgeon Joins the Florida Hospital Transplant Team and Lists First Prospective Lung Transplant Patient


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lation of medications,” said Dr. Andres Pelaez, Florida Hospital medical director of lung transplantation. “It is so important for patients and their families to get these services close to home so they can be near the team of experts that is familiar with their medical history.”

In 2010, Dr. Pelaez came to Florida Hospital from Emory University to establish the Florida Hospital lung transplant program. The latest addition to the Florida Hospital heart and lung transplant teams is Dr. Hartmuth Bittner, surgical director of the heart and

lung transplant program. Dr. Bittner has vast heart and lung transplant experience and comes from Germany where he was a Professor of Cardiovascular and Thoracic Surgery at the University of Leipzig.

CURRENT TOPICS

Drs. Bittner and Pelaez bring a combined 30 years of lung transplantation experience to the Florida Hos-pital team.

“Lung transplantation is the most advanced type of organ transplantation,” said Dr. Bittner. “It takes an experienced team of transplant physicians and clinical staff and years of organ transplant experience to suc-cessfully transplant a lung. While this is the start of a new program for this community, it places Central Florida patients in the hands of extremely experienced physicians and specialists.”

The Florida Hospital Transplant Institute per-formed Central Florida’s first kidney transplant more than 35 years ago and is the areas only trans-plant facility transplanting multiple organs; the pancreas, the liver, the kidneys, the heart and now the lungs. Approximately six months ago, Florida Hospital Transplant Institute performed the first heart transplant in Central Florida.

Dr. Hartmuth bittner and Dr. Andres Pelaez are the leaders of the newly

established lung transplant program at Florida Hospital Transplant Institute.

Florida Hospital Cancer Institute Receives Grant for New Cell Therapy ResearchThe Emergency Department Will Double in Size and 40 New Patient Beds Will be Added

The Florida Center for Cellular Therapy of the Florida Hospital Cancer Institute re-cently received a $374,000 grant to continue research in cellular therapy that could one day benefit cancer patients, especially ethnic minorities and the elderly.

Dr. Alicja Copik, research scientist at Florida Hospital Cancer Institute, applied for the grant in hopes of developing innovative cellular technology and then converting it into therapy that will help patients with leukemia. Dr. Copik’s research uses nanoparticle tech-nology to multiply a type of tumor-fighting white blood cells. This new technology could benefit minorities that experience difficulties finding a matching donor for bone marrow transplant and the elderly, for whom the transplant process is too problematic. The grant funds will be used within a three year period.

The funds awarded by the grant program will be used for research supplies, skilled re-searchers and equipment. This grant is seen as the next big stepping stone for this research at Florida Hospital Cancer Institute.

“Current biomedical research is expensive, but it is also one of the greatest investments that affect the future of society,” said Dr. Copik. “Without these funds, none of it is pos-sible and biomedical research would not move forward.” (Photo Dr Copik)

The grant, under the Bankhead-Coley Cancer Research Program, is called the New Investigator Research (NIR) grant. The grant application process is a competitive one; Dr. Copik’s team was one of 23 awardees out of 133 who applied to receive a grant from the Florida Biomedical Research Program. The applications undergo a peer review process by an extensive team comprised of experts in different research areas, professionals and one person representing the general public. These officials are chosen by the governor, president of the Senate, Speaker of the House of Representatives and three private philan-thropic organizations.

Dr. Alicja Copik

Our Hard Work in Achieving the Hospital Safety Grade

1 of 3 “A” HOSPITALS IN CENTRAL FLORIDAAs seen in the Orlando Sentinel

on June 6, 2012

Osceola Regional Medical Center700 West Oak Street Kissimmee, FL 34741(407) 846-2266

For more information on the Hospital Safety Score

or our services, please visitwww.osceolaregional.com.

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Winter Haven Hospital’s Robotics Institute and Center for Urology

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The Robotics Institute and Center for Urology Medical Director

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robotic micro-surgeries than any other center in the world.

Kevin Lee, M.D., F.A.C.S. received his medical degree and

completed his residency program at the University of Alabama.

Dr. Lee’s specialties include incontinence and erectile dysfunction.

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