Florida Hospital Winter Garden - Florida MD Magazine

Florida Hospital Winter Garden - Florida MD Magazine

FEBRUARY 2016 • COVERING THE I-4 CORRIDOR COVER STORY: Florida Hospital Winter Garden Emergency Care and Outpatient Services to Enhance Quality of ...

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contents 6




Winter Garden is welcoming its newest resident – Florida Hospital Winter Garden, a community asset that will make emergency and outpatient services more accessible to those who live and work in historic and rapidly growing Winter Garden beginning this month. A hallmark of the new nearly 100,000-square-foot, three-story facility is the “offsite” emergency department, so called because it is not physically attached to a hospital. Instead, this emergency department is under one roof with life-enhancing outpatient services. Imaging, outpatient surgery, endoscopy suites, outpatient lab, , and women’s services will be complemented by a large multidisciplinary medical clinic on the third floor. “Our goal is to provide local access to the clinical expertise of Florida Hospital in order to keep as many patients as we can from having to travel outside of their community,” says Florida Hospital Winter Garden Administrator Amanda Maggard. “From the patients’ standpoint, they would much rather see their doctor in a community close to home and have access to the No. 1 hospital in the state without having to travel 20 minutes away, especially from an emergency standpoint.”



ON THE COVER: Florida Hospital Winter Garden


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am pleased to bring you another issue of FloridaMD. If you think about it, breathing is something we take for granted. We don’t consciously think about every breath we take. This is not the case for people with cystic fibrosis who struggle for each breath. The Cystic Fibrosis Foundation works to assure the development of the means to cure and control cystic fibrosis (CF) and to improve the quality of life for those with the disease. Please join me in supporting this wonderful organization and their mission to better the lives of millions of Americans. Best regards,

Donald B. Rauhofer Publisher

COMING UP NEXT MONTH: The cover story focuses on the Transcatheter Aortic Valve Replacement (TAVR) procedure at The Heart & Vascular Institute at Osceola Regional Medical Center. Editorial focus is on Men’s Health and Orthopaedics.

CYSTIC FIBROSIS FOUNDATION IS MAKING AN IMPACT The Cystic Fibrosis Foundation is the world’s leader in the search for a cure for cystic fibrosis. The Foundation funds more CF research than any other organization, and nearly every CF drug available today was made possible because of Foundation support. Based in Bethesda, Md., the Foundation also supports and accredits a national care center network that has been recognized by the National Institutes of Health as a model of care for a chronic disease. But what is Cystic Fibrosis? The genetic disease affects the lungs and digestive systems of tens of thousands of young people. One in 31 Americans, more than 10 million people, is an unknowing, symptomless “carrier” of the defective CF gene. Each time two carriers conceive, there is a 25 percent chance that they will have a child with cystic fibrosis. Through its unique venture philanthropy approach, the Foundation invests in promising CF research with leading pharmaceutical companies to accelerate treatment for this rare disease. The result is a robust pipeline of potential therapies, in various stages of development and testing, aimed at targeting the disease from every angle. Orkambi™ is the latest example of the CF Foundation’s innovative drug development model. Approved in 2015, this breakthrough therapy addresses the underlying cause of cystic fibrosis for nearly one-third of those with the disease. The science behind Orkambi™ and its predecessor, Kalydeco™, has opened new doors to research and development that may eventually lead to a cure for all people with CF. Although the outlook for a child born with CF today has improved tremendously over the years, it is not good enough. That’s why the CF Foundation holds fundraising events throughout the year to make sure momentum in CF research continues. This year, the Central Florida Chapter of the CF Foundation will host several events:

GREAT STRIDES: UCF – April 9, 2016, Brevard and Volusia County – April 16, 2016, Orlando – April 23, 2016 (greatstrides.cff.org) For more information and other events visit Orlando.cff.org or please contact Paul Gloersen (407) 339-2978 or [email protected] The Central Florida office of the Cystic Fibrosis Foundation is located at 1850 Lee Rd, Suite 111, Winter Park, FL 32789.



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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Sajid Hafeez, MD, Daniel T. Layish, MD, Daniel Landau, MD, Rajesh A. Shah, MD, Scott Silvestry, MD, Jason Zimmerman, Brock Magruder, Jeff Holt, Marni Jameson, Dorothy Mowbray, Corey Gehrold Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2012, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.


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Florida Hospital Winter Garden – Emergency

Care and Outpatient Services to Enhance Quality of Life

By Heidi Ketler Winter Garden is welcoming its newest resident – Florida Hospital Winter Garden, a community asset that will make emergency and outpatient services more accessible to those who live and work in historic and rapidly growing Winter Garden beginning this month. A hallmark of the new nearly 100,000-square-foot, three-story facility is the “offsite” emergency department, so called because it is not physically attached to a hospital. Instead, this emergency department is under one roof with life-enhancing outpatient services. Imaging, outpatient surgery, endoscopy suites, outpatient lab, , and women’s services will be complemented by a large multidisciplinary medical clinic on the third floor. “Our goal is to provide local access to the clinical expertise of Florida Hospital in order to keep as many patients as we can from having to travel outside of their community,” says Florida Hospital Winter Garden Administrator Amanda Maggard. “From the Guests are greeted in the main lobby.

patients’ standpoint, they would much rather see their doctor in a community close to home and have access to the No. 1 hospital in the state without having to travel 20 minutes away, especially from an emergency standpoint.” Florida Hospital was ranked No. 1 in the state by U.S. News & World Report for the third year in a row and recognized among America’s Best in nine specialties. Winter Garden resident and emergency medicine physician Ramon H. Nunez, MD, says a model for delivering emergency care and outpatient services makes sense for Winter Garden. He is now the medical director of the Florida Hospital Winter Garden emergency department. “We have seen the explosive growth of the central Florida corridor in terms of population, and many have experienced the logistical challenge of accessing health care, like when you have a sick baby and you call the doctor’s office and it’s swamped and overwhelmed,” he says. A seven-story, 200-bed community hospital and an additional 200,000 square feet of office space are possible for future expansion. According to Ms. Maggard, finalization of Phase II and the timeline will be based on the community’s growth and health care needs. Florida Hospital Winter Garden is located between State Road 535 and Daniels Road, just across from the Winter Garden Village at Fowler Groves. Phase I of the Florida Hospital Winter Garden campus broke ground Sept. 17, 2013.

PROVIDING LIFESAVING CARE While the offsite emergency department (ED) model is new to Florida Hospital and the central Florida region, it represents a growing trend. Florida Hospital Winter Garden is now among more than 20 offsite EDs throughout the state. The Winter Garden emergency department will operate like its hospital-based counterparts, providing thorough and timely diagnosis and treatment, 24 hours a day, seven days a week. Onsite imaging and lab departments will provide 24-7 support. Of the 27 total beds, eight are for 23-hour observation. PHOTO: PROVIDED BY FLORIDA HOSPITAL

The emergency department will be staffed by an elite corps of emergency medicine specialists who are primed and equipped for triage and treatment. Each member of the emergency care team must have had at least two years of experience. All are certified in chest pain and acute stroke. “They are the same individuals who staff all Florida Hospital emergency rooms in Orange, Osceola and Seminole counties,” says Dr. Nunez. Like other emergency departments, “we can take care of patients at Winter Garden with more complex diagnoses, up to 6 FLORIDA MD - FEBRUARY 2016

COVER STORY the progressive care-unit level, such as chest pain, transient ischemic attack, abdominal pain and syncope,” says Patricia Price, MSN, RN, who serves as the clinical leader for the Winter Garden campus. “Even coding patients can come to us.” Florida Hospital Winter Garden emergency department will be seeking accreditation as a “chest pain center” within its first few months of opening. That means it has a robust, detailed stabilization and transfer protocol that focuses on door to balloon times for the heart, of less than 90 minutes.


The Winter Garden ED also has strong working relationships with the emergency medical service ground and air transport agencies and a helipad onsite for air flight. With a critical care transport team onsite, stroke or STEMI (ST segment elevation myocardial infarction) patients en route to Florida Hospital Orlando are in competent hands. Direct communication between Florida Hospital Winter Garden and Florida Hospital Orlando will provide essential medical data. At Florida Hospital Winter Garden, “we are held to the same metrics of care for a patient having a heart attack or stroke – door-to-balloon or door-to-needle” – as a hospital-based emergency department, says Ms. Price. “Time saved by having this level of emergency care in your neighborhood is lifesaving.”

“INCUBATOR FOR INNOVATION” Clinical pathways within the Florida Hospital Winter Garden emergency department aim to optimize care and minimize costs. “We are implementing evidence-based pathways for evaluation of some of the most high-volume complaints in ways that will streamline some of the processes we have today,” says Dr. Nunez. “Think of our facility as an incubator for innovation. Once we

Utilized for both ER patients as well as outpatients, the facility boasts a Siemens MAGNETOM 3T MRI, the most advanced on the market.

fine-tune the processes and they become successful, I envision they will be implemented in other (Florida Hospital) facilities.”


All ER guest rooms are private, featuring ambient lighting and are pediatric friendly.

Florida Hospital Winter Garden emergency department patients also will benefit from care coordination beyond discharge, a service that traditionally serves inpatients. Likewise, Winter Garden’s coordination program is designed to expedite a patient’s return to health and minimize return visits to the ER or hospital. The care coordinator will become part of a patient’s health care team as soon as the patient enters the Winter Garden ED. The coordinator will help the patient manage follow-up care with community health care providers, including scheduling medical appointments and submitting prescriptions. Care coordination is among numerous concierge services available to enhance a patient’s Florida Hospital Winter Garden experience and is offered at no additional cost. FLORIDA MD - FEBRUARY 2016




Also available for ER and outpatients, is an ultra-fast, reduced-dose Siemens SOMATOM AS 128-Slice CT.

RAISING THE BAR There are several ways Florida Hospital Winter Garden is distinguishing its emergency department from others throughout Florida. It is the first in the state to offer a 23-hour observation, or “clinical decision,” unit onsite. Dr. Nunez explains the benefits: “In some cases patients who come into our emergency department may have problems that need additional treatment or symptoms that may not be completely resolved until treatment.” Asthma is one example. “The patient does not have respiratory failure, but may still be wheezing a little, and going home would represent a logistical problem for the family. Traditionally, we would admit the patient, which would come at a significant cost and inconvenience to family,” Dr. Nunez says. “The way around that is with the observation unit, where we have a board-certified therapist delivering high-quality care in an evidence-based fashion.” Florida Hospital Winter Garden will be the first among Florida’s freestanding emergency departments to have an onsite pharmacist, who will consult with patients on medication history and observe for potential interactions. Plans also are under way to provide patients with common prescriptions at discharge, so they don’t have to stop at the pharmacy on the way home. This will be a first in central Florida when launched in the coming months, according to Ms. Maggard. “Our Winter Garden emergency department is the first model of it’s kind that I know of in the whole state. None has this level of comprehensiveness in a single building,” Ms. Maggard says. 8 FLORIDA MD - FEBRUARY 2016

“The goal of our campus is to really be a pilot site around improving quality, enhancing the patient experience and reducing cost. For many patients, emergency services outside of a fully functioning hospital are an appropriate level of care. Physicians and patient advocates are interested in seeing how this campus does that,” she says.

COMPREHENSIVE OUTPATIENT SERVICES When Florida Hospital Winter Garden opens, the community will have convenient access to the same leading-edge radiological expertise found throughout the Florida Hospital system. “We have one of the most advanced radiological departments in the state,” says Ms. Price. A team of board-certified radiologists and other imaging professionals on staff are equipped with a range of imaging technologies, including magnetic resonance imaging, computed tomography and ultrasound. The next-generation technology is faster, safer and more accurate, such as 128-slice CT and 3Tesla wide-bore MRI. Breast MRI and magnetic resonance angiography also are available. Each imaging modality is connected to Florida Hospital’s centralized data network that makes image review and storage, report generation, distribution of results and communication among medical professionals faster and more reliable, secure and costeffective. Florida Hospital Winter Garden also will open with an outpatient surgery and endoscopy center. The center, located on the second floor of the facility, will have two operating rooms and one endoscopy suite.

COVER STORY A large multispecialty clinic hosting primary care and specialty care physicians on the third floor will round out the offerings of the first phase of Florida Hospital Winter Garden. According to Dr. Nunez, the medical community has expressed “tremendous interest” in the multispecialty practice.

MEET DR. NUNEZ Dr. Ramon Nunez earned his medical degree from the University of Medicine and Dentistry of New Jersey. He is boardcertified in emergency medicine and has been a member of the Florida Hospital medical staff for 10 years. Dr. Nunez has served in various leadership positions since 2007. Most recently he was chair of emergency medicine at Florida Hospital Zephyrhills, where he helped launch its stroke and cardiac response program and worked on implementation of electronic medical records, among other projects. Prior to that, he worked as unit medical director in the Florida Hospital Kissimmee emergency department. Currently, he is focused on “standardization and implementation of evidence-based protocols, because really I think that’s one of the opportunities in health care to streamline processes, improve care and control costs,” he says. Dr. Nunez is looking forward to working “together in a collaborative way with institutions and physicians in ways that enhance

the quality of life in Winter Garden,” the community where he and his family live.

A MEMBER OF THE COMMUNITY Engaging the community in the design and planning of the hospital campus was of vital importance to Florida Hospital leadership. In 2014, the hospital created the Florida Hospital Winter Garden Community Advisory Council, a group made up of 30-plus residents, civic leaders and business owners. The council participated in all stages of planning and provided feedback on everything from physical design to clinical models and future planning. Input from the group led to inclusion in the Florida Hospital Winter Garden master plan of a community garden and greenway around the hospital. “We want our facility to be a place that fosters wellness and social connections,” says Ms. Maggard. “One of our goals is to be very connected in the community and to be improving wellness within the community as a whole. It’s a journey. It will take baby steps, which we will continue to take as the campus grows,” she says. Appointments for outpatient services at Florida Hospital Winter Garden can be made by calling (407) 303-1700. Scheduling online also is possible at www.floridahospital.com/ winter-garden. 


Two over-sized outpatient OR suites and an endoscopy suite are available on the second floor.




Planning for Psychiatric Care STORY By COVER Sajid Hafeez, MD no matter how well-thought out the basic plan of treatment, there will always be unforeseen factors and limitations that must be taken into consideration to create the best possible outcome for the patient. Limitations to ideal treatment come in many regularly seen forms: intellectual, emotional, chronological, financial, and environmental. A truly experienced treatment team has encountered these limitations time and time again and has developed their own preferred methods to help the patients navigate around these road blocks, as well as teaching them how to navigate them on their own once they discharge. Serving Central Florida Since 1982 While some patients may be highly intelligent and functioning, it may not necessarily be the case for all patients. UnfortunateOur physicians are Board Certified in Internal Medicine, ly, there are many who have not developed Pulmonary Disease, Critical Care Medicine, and Sleep Medicine the expanded reasoning so that they are adeSpecializing in: quately equipped to manage the stressors of • Asthma/COPD life. For some this might be educational, for • Sleep Disorders others it might be in relation to IQ level, or • Pulmonary Hypertension emotional readiness. It becomes important • Pulmonary Fibrosis for the therapists to understand the nature • Shortness of Breath of these limits so that they are able to adapt • Cough different therapeutic strategies to help the • Lung Cancer patients develop coping skills to manage • Lung Nodules these stresses. It might be a treatment plan • Low Dose CT - On Site that is more basic and focuses on simple • Clinical Research skills like expressing feelings in a different Daniel Haim, M.D., F.C.C.P. way, or using a context that the patient is Daniel T. Layish, M.D., F.A.C.P., F.C.C.P. more familiar with in order to draw a paralFrancisco J. Calimano, M.D., F.C.C.P. lel by example. In group therapy, this paFrancisco J. Remy, M.D., F.C.C.P. tient may also benefit from sessions with an Ahmed Masood, M.D., F.C.C.P. alternative group rather than a main group Syed Mobin, M.D., F.C.C.P. who may be talking about concepts over Eugene Go, M.D., F.C.C.P. that person’s head. Mahmood Ali, M.D., F.C.C.P. A frequent limitation is the outside enSteven Vu, M.D., F.C.C.P. vironment. Some patients, when admitted, Ruel B. Garcia, M.D., F.C.C.P. Tabarak Qureshi, M.D., F.C.C.P. seem perfectly stable and adjusted because Kevin De Boer, D.O., F.C.C.P. they are living in a highly controlled enviJorge E. Guerrero, M.D., F.C.C.P. ronment and able to leave the stressors of Roberto Santos, M.D., F.C.C.P. the real world on the other side of the door. Hadi Chohan, M.D. Without preparing them on how to handle Jean Go, M.D. these stressors, they may become rapid reGuillermo Arias, M.D. admissions quickly after being discharged. Erick Lu, D.O. While the treatment team has an influence of the patient, they typically have no influDowntown Orlando East Orlando Altamonte Springs ence over the patient’s outside factors. So it 1115 East Ridgewood Street 10916 Dylan Loren Circle 610 Jasmine Road is vitally important for the team to keep this 407.841.1100 | www.cfpulmonary.com | Most Insurance Plans Accepted into consideration when developing a last-

Author Alan Lakein once said, “Planning is bringing the future into the present so that you can do something about it now.” When it comes to acute psychiatric care, all members of the treatment team know their roles; they are experienced and are able to quickly assess and adapt general treatment plans to a wide assortment of clinical admitting diagnoses. In a perfect world, every patient could be admitted, stabilized, and sent home with no fear or relapse in 3 days time. However, the world is not perfect and

Central Florida Pulmonary Group, P.A.


BEHAVIORAL HEALTH ing plan. If patients lack transportation, they are unable to make appointments. If patients are being abused, and that situation is not dealt with appropriately, then nothing has changed. The treatment team will work with outside agencies such as protective services and caseworkers to enact a plan of action to manage these external influences. On a long enough time scale, any team could take a patient from unstable to stable. The trick is discerning what is most therapeutically needed into the reduced time frame that is covered by insurance. Many patients have limited funds or are lacking them all together. If finances are the impetus for their admission, adding to that debt in exchange for services becomes a risky gambit. The treatment team understands that accurate documentation allows the doctor more options to negotiate for coverage on behalf of the patient. In expressing the dire need of acute care and the likelihood of failure if cut short, the team is able to advocate for coverage and time, allowing the patient more opportunities to gain tools for success. Many times, the doctor may know that for the patient’s condition, a specific medication has a high degree of success. Yet, there is no purpose for the doctor to start the patient on a medication that he or she could not afford after discharge. So the doctor must have a general idea of which medications are covered by which insurance companies. Some will only authorize generic while others will only authorize brand medications. In truth, the generics and brand medications are not always the same as there are often different standards in clinical efficacy. So it isn’t as simple as saying “if not this, than that will work.” So the doctor must stay educated on the most recent studies and data of all medications if he or she is to provide the best care within the limitations. While there are times that many of these limiting factors can seem insurmountable, there is always a way around them. It just takes a seasoned team to know the hidden paths and tricks to help deliver the best route around them. So too does this experience in dealing with these limitations further allow the health care professionals further refine what is most appropriate for a successful stabilization. Sajid Hafeez, M.D., is a child and adolescent psychiatrist who is serving as a Medical Director of the Acute Care Baker Act Unit at the University Behavioral Center. He also served as the Center’s Medical Director of the long term Residential Units: ASAPP Unit (for adolescent boys with inappropriate sexual behaviors), Solutions Unit (for adolescent boys with behavior problems), Promises and Stars Unit (for adolescent females with behavioral problems as well as victims of sexual abuse), and Discovery Unit (for children ages 5-13 with behavioral as well as inappropriate sexual problems). In addition, Dr. Hafeez also Served as an Assistant Professor of Psychiatry at the University of Central Florida (Voluntary Position). He was also the Chief of the Adolescent Psychiatry Unit, an Attending Psychiatrist of the Comprehensive Psychiatry Emergency Program and of the Mobile Crisis Team at the Westchester Medical College. At Vassar Brother’s Medical Center in New York. Dr. Hafeez was the Director of Outpatient Child & Adolescent and Adult Psychiatric Clinic as well as Director of Consultation and Liaison Psychiatry. Dr. Hafeez received his adult Psychiatry and Residency Training at the University of Kansas Medical Center in Kansas City. He received his Child and Adolescent Psychiatry fellowship training at the New York Medical College New York and at Children’s National Medical Center of George Washington University in Washington, DC. Dr. Hafeez can be reached at 407-281-7000 or by visiting www. universitybehavioral.com. 



Chronic Thromboembolic Pulmonary Hypertension By Daniel T. Layish, MD There are several categories of pulmonary hypertension. WHO Group I includes patients with idiopathic pulmonary hypertension, familial pulmonary hypertension, drug and toxin related (fen-phen) portopulmonary hypertension, HIV related pulmonary hypertension and pulmonary arterial hypertension associated with connective tissue disorders (such as scleroderma). WHO Group II pulmonary hypertension is often referred to as pulmonary venous hypertension. This includes patients with left ventricular systolic or diastolic dysfunction or valvular heart disease. Essentially, the WHO Group II category includes patients who have an elevated pulmonary capillary wedge pressure and/ or elevated left ventricular end diastolic pressure. WHO Group III pulmonary hypertension consists of patients with COPD, interstitial lung disease, or other conditions in which hypoxia causes vasoconstriction. The remainder of this article will focus on WHO Group IV pulmonary hypertension (chronic thromboembolic pulmonary hypertension or CTEPH). Although WHO Group IV patients are relatively rare, it is crucial to identify them because this is the only type of pulmonary hypertension which is potentially surgically curable. After acute pulmonary embolism, most patients will recover and have normal pulmonary hemodynamics, gas exchange, and exercise tolerance. It is believed that 1-4% of patients with acute pulmonary embolism will go on to develop CTEPH within two years. It is not clear why some patients with acute pulmonary embolism develop CTEPH. Risk factors include hypercoagulable states, myeloproliferative syndromes, splenectomy and chronic indwelling central venous catheters. Patients with CTEPH present with dyspnea, which can have a gradual onset. Many patients with CTEPH will not have a known previous diagnosis of acute pulmonary embolism. As with other patients with pulmonary hypertension, patients with CTEPH may not show findings on physical exam until pulmonary hypertension is in the late stages. Findings include a right ventricular lift, jugular venous distention, fixed splitting of the second heart sound, hepatomegaly, ascites, and peripheral edema. Patients with CTEPH may have “flow murmurs” heard over the lung fields because of turbulent flow through partially obstructed or recanalized pulmonary arteries. These tend to be accentuated during inspiration. Acute pulmonary embolism is the trigger for CTEPH. In some patients this triggers a small vessel vasculopathy (for unclear reasons) that contributes to the extent of pulmonary hypertension. This may explain why up to 35 percent of patients who undergo succesful pulmonary thromoendarterectomy can have some degree of postoperative pulmonary hypertension. Although VQ scanning has become less commonly used for diagnosis of acute pulmonary embolism this remains the initial imaging study of choice in patients with pulmonary hyperten12 FLORIDA MD - FEBRUARY 2016

sion to separate “small vessel” variants (Idiopathic pulmonary arterial hypertension) from “large vessel” disease (CTEPH) A normal VQ scan essentially excludes the diagnosis of CTEPH. A scan with one or more mismatched segmental defects is suggestive of the diagnosis. However, it is important to note that VQ scan can often understate the extent of central pulmonary vascular obstruction. Once the VQ scan is found to be abnormal then further testing should be undertaken (such as CT angiogram and/or pulmonary angiography). The angiographic findings in CTEPH are distinct from those of acute pulmonary embolism. They can include pouch defects and pulmonary artery webs. Patients with severe pulmonary hypertension have been found to tolerate performance of angiography as well as VQ scan without significant complication rate. The surgery for CTEPH is quite different from surgical intervention for an acute pulmonary embolism. Surgery for CTEPH is called a pulmonary thromboendarterectomy (PTE), which requires median sternotomy and cardiopulmonary bypass. It requires an often tedious intimal dissection of fibrotic recannalized thrombus from the native pulmonary arterial wall. IVC filter placement is usually recommended before pulmonary thromboendarterectomy. These patients can have a complicated postoperative course and this type of surgery is only done at a few specialized centers in the country. The center which is best known for this type of surgery is the University of California (San Diego). Patients who have undergone PTE are typically maintained on lifelong anticoagulation. To be a candidate for this surgery, a patients must have central, surgically accesible chronic thromboemboli. A significant postoperative complication is pulmonary artery steal, which refers to redistribution of pulmonary arterial blood flow from well-perfused segments into the newly opened segments resulting in ventilation perfusion mismatch and hypoxia. This redistribution of flow resolves over time. Approximately, 30% of PTE patients can develop reperfusion pulmonary edema. The perioperative mortality of pulmonary thromboendarterectomy can be in the range of 2-3% in experienced centers. Outcome is clearly better in high voluime centers (more than fifty PTE surgeries/year). Approximately 5000 thromboendarterectomy procedures have been performed worldwide, 3000 at UCSD alone. Surgery for CTEPH is clearly the best therapeutic option. However, there are some patients with CTEPH who are inoperable or who have persistent or recurrent pulmonary hypertension after undergoing pulmonary thromboendarterectomy. There is now a medical therapy available for these patients. Riociguat (Adempas) was approved by the FDA in October 2013. It is a member of a new class of compounds-soluble guanylate cyclase stimulators. In the multicenter study by Ghofrani et al that was published in the New England Journal of Medicine in July 2013,

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

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

Example of chronic clots removed during pulmonary thromboendarterectomy.

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

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



HIPAA, Data Privacy, and National Trends in Data-Breach Litigation By Jason Zimmerman and Brock Magruder The Ninth Judicial Circuit’s Complex Business Litigation Court recently dismissed with prejudice a class-action data-breach lawsuit against a hospital based on alleged violations of the Health Insurance Portability and Accountability Act (HIPAA) and state law contract claims. In 2011, the hospital fired three employees who improperly accessed patient files to send contact information to a third-party chiropractor. A criminal prosecution followed, and pursuant to HIPAA, the hospital notified its patients whose private information was potentially disclosed. Nevertheless, two patients brought a class action lawsuit asserting various breaches of legal and contractual duties despite the fact that no identity theft or other harm occurred. The hospital successfully dismissed the claims as the plaintiffs were not actual victims of identity theft, and the complaint improperly attempted to enforce HIPAA through a private right of action. These creatively plead data-breach cases are increasingly common in today’s technology driven economy, which dramatically increases exposure to highly-regulated and data-rich sectors like the health care industry. Recent federal cases out of the Seventh and Ninth Circuit have even recognized standing for plaintiffs who have not yet suffered damages related to lost or stolen data. See Remijas v. Neiman Marcus Grp., LLC, 794 F.3d 688 (7th Cir. 2015) and In re Adobe Sys., Inc. Privacy Litig., 66 F. Supp. 3d 1197 (N.D. Cal. 2014). Those cases acknowledged a data-breach victim’s standing to pursue a lawsuit absent allegations of actual damages in the form of identity theft or financial fraud – a novel premise for the recovery of damages in data-breach cases. Of course, these federal-standing cases do not affect Florida’s common-law pleading requirements, hence the above-referenced hospital’s success in Florida state court. Moreover, the Eleventh Circuit has not yet ruled on the issue, and Florida law still generally requires a showing of actual damages to sustain a claim in data-breach cases. With the ever increasing danger of accidental data breaches and targeted hacking, hospitals and other custodians of regulated private information would do well to keep their data protection policies up to date, and educate their employees on the importance of data security.


Jason Zimmerman

Brock Magruder

Jason Zimmerman and Brock Magruder practice in GrayRobinson’s commercial litigation department focusing on data-breach litigation and HIPAA privacy-related issues. You can reach them at 407-843-8880 or at [email protected] and [email protected]


Florida Hospital Pepin Heart Institute

Watchman Device Outperforms Blood Thinners in Reducing Stroke Mortality 3 FLORIDA MD - FEBRUARY 2016 15


Florida Hospital Pepin Heart Institute Watchman Device Outperforms Blood Thinners in Reducing Stroke Mortality

By Heidi Ketler


Florida Hospital Pepin Heart Institute in Tampa is among the first in Florida to offer patients with non-valvular atrial fibrillation a first-of-its-kind, proven alternative to long-term warfarin therapy for stroke risk.

• CHADS2 score ≥ 2 or CHA2DS2-VASc score ≥ 3 • A formal shared decision making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. The shared decision making interaction must be documented in the medical record. • Suitability for short-term warfarin but deemed unable to take long term oral anticoagulation following the conclusion of shared decision making as LAAC is only covered as a secondline therapy to oral anticoagulants. Despite the proven efficacy of long-term anticoagulation therapy to reduce the rate of stroke or embolism in patients, about 40 percent of AF patients who are candidates for anticoagulaKenneth Yammamura, MD, Electrophysiology

The Watchman Left Atrial Appendage Closure (LAAC) System – approved March 13, 2015, by the United States Food and Drug Administration – is a permanent, catheter-delivered heart implant designed to close the left atrial appendage (LAA). The device is implanted at or slightly distal to the ostium of the LAA, which is believed to be the source of more than 90 percent of stroke-causing clots in patients with non-valvular atrial fibrillation (AF or AFib). The occlusion prevents migration of thrombus, thereby reducing the risk of stroke. Most patients are able to discontinue the use of oral anticoagulants 45 days after implant. “In appropriate AF patients, the Watchman device is equal to or better than blood thinners in reducing the risk of stroke and at the same time reduces the risk of bleeding associated with blood thinners,” says Kenneth Yamamura, M.D., an electrophysiologist who is one of only two physicians in Tampa specially trained to implant the Watchman device at Florida Hospital Pepin Heart Institute. Clinical trials evaluating the Watchman LAAC have shown that it can reduce stroke risk by 36 percent and mortality at four years by 56 percent. “Over time it’s going to be even better,” says Dr. Yamamura. “If you figure you implant the device in a 65 year old who will live another 15 years, the reduction keeps getting more significant.” The Centers for Medicare & Medicaid Services (CMS) provides the following indications for Watchman implantation: • Non-valvular atrial fibrillation (NVAF) 16 FLORIDA MD - FEBRUARY 2016


Implanting the Watchman LAAC device is a minimally invasive procedure that usually lasts about an hour.

ON THE COVER (PREVIOUS PAGE): Florida Hospital Pepin Heart Institute is the first in Tampa to implant the Watchman Left Atrial Appendage Closure device help prevent stroke in patients with atrial fibrillation.

tion go untreated. Reasons for not taking anticoagulation medication include concerns about the bleeding side effects and/or a desire to forgo the necessary lifestyle compromises – dietary restrictions and frequent monitoring. Other patients have contraindications that prevent longterm anticoagulation use. “This highlights the need for additional treatment options,” says Dr. Yamamura. He describes a 72-year-old female patient who after AF diagnosis was prescribed warfarin and had an ablation that achieved normal heart rhythm. Then she had a life-threatening episode of bleeding that required five liters of blood, so anticoagulation therapy was discontinued. “Even though she had just one AF episode, she may still be at risk of stroke,” he says. “I think she is a perfect candidate” for the Watchman device. Many AF patients cannot tolerate long-term anticoagulation therapy because of comorbidities with symptomatic bleeding. For example, “there is a large population, especially here in Tampa, that is suffering from digestive disorders – such as diverticulitis and other causes of intestinal bleeding – and at the same time has AFib,” says interventional cardiologist Asad Sawar, M.D., who also performs the Watchman procedure at Florida Hospital Pepin Heart Institute. He and Dr. Yamamura have assumed the lead in performing the Watchman LLAC implant. The first patients at Florida Hospital Pepin Heart Institute are scheduled for the procedure this month. The Watchman device is delivered by catheter into the right atrium, then across to the left atrial appendage.



Asad Sawar, MD, Interventional Cardiology

Dr. Yamamura suspects that future trials may result in a loosening of the requirement for warfarin after Watchman implantation. The medication is taken to diminish the slight risk of blood clot formation on the Watchman device. He says a small study indicated no difference in outcomes among those taking warfarin and those who did not. Despite the strong evidence of medical benefit, physicians are not likely to recommend Watchman implantation over oral anticoagulation as a first course for AF treatment. If, on the other hand, “a patient with AFib is not able to use blood thinners then the Watchman is the way to go,” says Dr. Sawar. The challenge for the future is that as the population ages the risk of stroke increases and treatment using blood thinners decreases because of the risk of falls and injury. “To have this device implanted in already is a benefit. As the population ages, I think it’s a huge benefit moving forward,” says Dr. Yamamura.


SAFETY AND EFFICACY OF WATCHMAN IMPLANTATION Implantation of the Watchman device is an hour-long procedure under anesthesia. The device is guided from the femoral vein in the upper leg into the heart using a delivery catheter. The implant is introduced into the right atrium and passed into the left atrium through a patent foramen ovale in the atrial septum. The Watchman is then fed through the delivery catheter to the LAA, where it opens like an umbrella and is permanently affixed. Once in place, a thin layer of tissue grows over the Watchman device in about 45 days, permanently sealing off the LAA. As with any surgical procedure, the Watchman implant has its risks. Acute procedural complications are mainly related to transseptal puncture and device implantation. They include air embolism, pericardial effusions/cardiac tamponade and device embolization. FLORIDA MD - FEBRUARY 2016 17

SPECIAL FEATURE Risks have been greatly reduced over time as a result of numerous technical and procedural enhancements. For example, transesophageal echocardiography guidance and pressure monitoring help ensure a safe transseptal puncture before advancing the sheath. Extended follow-up trial results indicate hazard ratios for the composite endpoint of major bleeding, pericardial effusion and device embolization dropping from 2.85 at the original 600-patient-year follow-up to 1.53 at 1,500 patient-years. “Another important part of Watchman trials is that strokes occurring soon after the procedure were minimal compared to the control group whose strokes were huge,” Dr. Yamamura says. To prevent the minimal risk of thrombus, patients take aspirin and warfarin for the first 45 days after Watchman implantation. This is followed by clopidogrel and aspirin for six months. “Here at Florida Hospital, we have had the advanced training, we have experience in transseptal puncture and structural heart interventions and we have the necessary experience in managing and preventing complications to minimize the risks,” says Dr. Sawar. “As an electrophysiologist, I perform multiple ablations a week that take place in the left transseptal junction. Because I deal with this region on a daily basis, I am familiar with it,” Dr. Yamamura says.


Non-valvular AF is the most common sustained cardiac arrhythmia, currently affecting 1-2 percent of the general population, or more than five million Americans. Prevalence increases with age. AFib is caused by chaotic electrical signals that make the upper chambers of the heart (the atria) quiver instead of contracting properly. During AFib blood pools in the atria, which can allow a clot to form. If a blood clot breaks free, it can enter the bloodstream and cause a stroke. People with AFib have a stroke risk that is five times higher than people who do not have AFib. “Stroke from AF tends to be disabling and potentially fatal, because the left atrial appendage can form a large blood clot that ultimately blocks blood vessels in the brain,” says Dr. Yamamura. “The clot is less likely to cause a TIA (transient ischemic attack) and more likely to be life threatening.” In fact, 70 percent of AF-related strokes result in death or permanent disability.


“We have extensive experience and expertise in treating AFib, and the Watchman device offers another option in our integrated and comprehensive approach to therapy,” says Dr. Sawar. Standard AF treatment encompasses either rate control and/ or rhythm control strategies, accompanied by antithrombotic therapy based on an individual’s stroke risk and ongoing monitoring inmost cases. Medical treatment should be complemented by healthy adjustments to one’s lifestyle, particularly in terms of proper diet and body weight as well as appropriate amounts of sleep. Pharmacological agents for slowing the heart rate, such as Þ-blockers, are currently recommended as the first course of therapy. Returning the heart to normal sinus rhythm is typically 18 FLORIDA MD - FEBRUARY 2016

achieved using antiarrhythmic drugs, electrical cardioversion or ablation therapy. While rate and rhythm control therapies relieve AF symptoms, such as palpitations, shortness of breath and fatigue, they don’t reliably prevent thromboembolic events. The vitamin-K-antagonist warfarin is the most commonly prescribed medication to prevent strokes. In use for more than 50 years, warfarin has been shown to prevent two out of three strokes compared to no treatment in patients with AF. Newer anticoagulants – dabigatran, rivaroxaban, apixaban and clopidogrel – are just as effective as warfarin in preventing thromboembolic events. In addition, they have the advantage of eliminating the dietary concerns and the need for regular blood monitoring that come with warfarin. While major bleeding and associated complications remain with the newer medications, they are somewhat less than with warfarin. In most cases, says Dr. Sawar, the risk of bleeding associated with anticoagulation use is minor and presents as bruising or minor nosebleeds. About 1-2 percent of people on anticoagulation will develop more serious bleeding that may require a blood transfusion and the interruption of blood-thinning medication. The HAS-BLED bleeding-risk scoring system assesses the oneyear risk of major bleeding associated with oral anticoagulation: H – Hypertension, with uncontrolled blood pressure more than 160 mmHg. A – Abnormal kidney function, including patients who have had a transplant. – Abnormal liver function. S – Stroke, including TIA. B – Bleeding that has been serious. L – Labile INRs (international normalized ratios) that range from 2.0 to 3.0 in those taking warfarin. In people who are not taking a blood thinner, blood clots with INR of about 1.0. To reduce the risk of a stroke in atrial fibrillation the blood needs to be 2-3 times thinner than normal. E – Elderly, age 65 years and older. D – Drug use, including regular use of aspirin or pain killers. – Alcohol intake above recommended daily amount. Each factor is assigned one point, including a point for each of the two factors in A and D, for a total maximum HAS-BLED score of nine. Patients who have a high risk of bleeding (score of three or greater) and are taking anticoagulation should undergo regular clinical review. The scoring system also is able to discriminate the risk for intracranial hemorrhage (ICH), a lethal bleeding side effect of anticoagulants and the cause of up to 10 percent of strokes. Most recent studies show the risk of ICH in patients taking anticoagulation medication is about 0.2-0.4 percent per year or slightly higher. While not trivial, this is substantially lower than the 5 percent annual risk of ischemic stroke in the vast majority of AF patients who are not anticoagulated. Studies also have shown that the risk of ICH with the newer oral anticoagulants may be less than half of that with warfarin. “To have a device that’s capable of preventing not only the embolic stroke but hemorrhagic stroke by eliminating the need for



ADVANCING CARDIOVASCULAR MEDICINE Florida Health Pepin Heart Institute is on the cutting edge of cardiovascular medicine in the Tampa Bay area. Dr. Sawar list a number of firsts: • First in Florida to introduce the AngioVac System, therapy for patients suffering from illiofemoral deep-vein thrombosis and massive swelling in the legs. • First in Tampa Bay to offer subcutaneous implantable defibrillators for the treatment of ventricular tachyarrhythmias. • First south of Boston to establish a formalized pulmonary embolism response team.

A collaborative survey between the National Stroke Association, Heart Rhythm Society and Boehringer Ingelheim uncovered a critical need to improve communication and education about the link between atrial fibrillation and the devastating impact of stroke. Dr. Sawar agrees, “We need to get the word out, so people better understand their risks of stroke.” The medical community can help increase awareness of the risk factors, which include age over 60, high blood pressure, diabetes, excess weight and existing heart disease. Sleep apnea is another. While not completely understood, there is increasing recognition of the influence of long-term, untreated sleep apnea on a number of impairments, including cardiovascular conditions like high blood pressure, stroke and AFib. Gender is another risk factor. “We probably need to be emphasize blood thinners and the Watchman implant for women, because we know they are at higher risk of stroke due to AF than men,” says Dr. Yamamura. “We’re still appropriately treating only about 60 percent of AFib patients with anticoagulation. If there is one clear message to convey it is – whether we treat the patient with the Watchman device or Florida Hospital Pepin Heart Institute, located at Florida Hospital Tampa, is a free-standing cardiovascular institute providing comprehensive cardiovascular care. anticoagulation, physicians need to do a better job of treating patients with AF.” “These are things I have been personally involved in,” he says. “Among patients with AF who are not on anticoagulation ther“They are in addition to all the other things that all the other apy, some will have a stroke during the early monitoring period Pepin Heart Institute doctors are doing.” after diagnosis. A majority will have a stroke within a few years For instance, cardiologist Charles Lambert, M.D., medical of diagnosis. A small percent will not have a stroke for 10 to 15 director of Florida Hospital Pepin Heart Institute, is leading years after. Based on the annual 5 percent rate for stroke among an innovative Parachute clinical research trial on a therapeutic untreated AF patients, within the next 20 years almost all will implant for congestive heart failure patients who have no viable have a stroke,” says Dr. Sawar. treatment options. It is one of 12 active clinical research trials at In other words, he adds: “Those with atrial fibrillation who Pepin Heart Institute that enable patients to receive leading-edge are not taking blood thinners are a time bomb. Their 5 percent cardiovascular medicine without leaving Tampa Bay. risk of stroke is much greater than their risk of getting into a car “We are excited to offer this one-of-a-kind treatment at Florida wreck.” Hospital Pepin Heart Institute,” said Thomas Nicosia, Assistant The challenge facing physicians is that patients with AF ofVice President of Cardiovascular Services at Florida Hospital ten don’t experience symptoms. Patients need to understand that Tampa. “For more than 20 years, Pepin Heart has been at the AFib symptoms are subtle and may include paroxysmal or persisforefront of innovative cardiovascular care. The Watchman is antent fluttering or thumping in the chest, dizziness and shortness other example of how we’re bringing the latest technology, proceof breath. dures, and expertise to the Tampa Bay community.” AFib is diagnosed by reviewing medical and family histories, For more information about Watchman device implantacompleting a physical exam and conducting diagnostic tests and tion, comprehensive AFib treatment, clinical trials or other procedures. If someone has AFib, it is important for him or her to cardiovascular services at Florida Hospital Pepin Heart Instidiscuss with a physician treatment options that can help reduce tute, call (813) 554-3278.  the risk of stroke.


warfarin, is a huge step in our treatment of AF,” says Dr. Yamamura.



10 Tips to Creating Engaging Video Content Without Knowing What You’re Doing By Jennifer Thompson We know the future of web content is all video. By 2017, video will account for 69 percent of all consumer Internet traffic, according to Cisco. So, how can you capitalize on this trend and put your medical practice ahead of the curve? The best way is to start creating engaging video content today. Not sure how? Don’t worry, we’ve got you covered.

TIPS FOR CREATING ENGAGING VIDEOS You know how they say a picture is worth a thousand words? Well, one minute of video is worth 1.8 million words, according to Forrester Research. Kind of a big difference. Oh, and seven in 10 people view brands in a more positive light after watching interesting video content from them, according to Axonn Research. The key phrase there is “interesting”. Marketing your practice in a video can be as simple as a patient testimonial or an ask the doctor series answering common health questions. Videos should be educational and/or emotional and contain a message that connects with the viewer quickly. Here are tips to help your practice create engaging videos: • Connect to patients’ emotions. One of the main drivers of video storytelling is human emotion. Healthcare practices are filled with compelling, human interest stories from patients and staff. Share them. Don’t focus on the procedure side of a testimonial, instead discuss the fact the patient is able to walk again and visit with their grandchildren. • Consider your patients and potential audience. Ensure the video is going to be relevant to them and that it’s not just something you or your doctors would be interested in. In other words, don’t get too technical and put yourself in the patient’s shoes when planning or asking questions. • Make professional quality videos. Advances in technology have driven the costs of video production down. A video will represent your brand and you will want viewers to know that your brand is professional. If you don’t have the means or knowledge to make a professional video, hire someone to do it for you. If your videos look amateurish, what does that say about your quality of care? • Get b-roll for your videos. Even if it’s only two minutes in length, make sure there is plenty of broll footage to keep the segment interesting. Staring at someone for two minutes straight is boring (and creepy). • Have a consistent video structure.Make sure your video has a clear beginning, middle and end. If necessary, create a storyboard ahead of time that describes exactly how your video should be 20 FLORIDA MD - FEBRUARY 2016

filmed and edited together. Keep this structure on all relevant videos so your videos have a “brand” and “identity” that can be felt in each. • State your video’s purpose. Make sure your viewers know within the first 10 seconds why they should keep watching. Focus on the outcome. Most patients don’t care what it takes to get there, just how long it takes to recover and what they will experience when healed. • Choose one topic. Focus on one topic per video and delivering that idea well. • Consider the length. Most viewers will only watch a video for about two minutes. Try to keep videos less than 5 minutes no matter what. • Share your videos on social media. Promote your video on Facebook, Twitter, in email blasts and on other social media channels your practice engages in. When you promote your video, make it easy for patients to share it. • Put your video on your website. You worked long and hard to create your masterpiece, so make sure it lives on past your social post. Embed your video on your website so patients can view it indefinitely. There you have it. Follow these tips and you should be well on your way to creating quality video to attract and retain more patients for your medical practice. Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better. 


The Race Against Arthritis: One Man’s Total Hip Replacement Experience By Corey Gehrold Douglas Hagopian has always had a need for speed, so it’s only natural he was drawn to racing dirt bikes, racecars and anything else with a motor. If you’ve ever seen a motocross event, you know it can take a toll on a racer’s body - even on their best day. Over the years, after his fair share of motocross events, Hagopian developed advanced arthritis in his hips. Not only did he feel the symptoms of arthritis (joint stiffness, pain, swelling and tenderness), he also had difficulty walking. One day, while struggling to keep up with his friends during a round of golf, he decided it was time to seek help. That’s when he reached out to Orlando Orthopaedic Center’s Travis B. Van Dyke, M.D., a board certified orthopaedic surgeon specializing in sports medicine, trauma, and joint replacement of shoulder, knee and hip. When Dr. Van Dyke and Hagopian met, they discussed his condition and evaluated his treatment options. When nonsurgical treatment, such as pain management and physical therapy, stopped working, the duo began to discuss the possibility of surgery. Together, they decided anterior hip replacements in both hips were Hagopian’s best option to get back to the lifestyle he wanted.

believe,” says Hagopian with a smile. “At three weeks I was playing golf.” WHAT ARE THE RESULTS OF AN ANTERIOR TOTAL HIP REPLACEMENT?

Travis B. Van Dyke, MD

After surgery and recovery, most patients should experience little to no hip pain. For Hagopian, he says his hip pain was completely gone - and faster than he ever thought possible. “There’s no other word to describe it. It was just gone,” he says. “I was amazed. I joke it was as if David Copperfield, the magician, operated on me because it’s nothing short of magic.” Hagopian encourages anyone considering the surgery to go through it sooner rather than later. “It’s been 14 weeks since I’ve had the surgery on my left hip and 9 weeks since the surgery on my right hip,” says Hagopian.“I’m back to working out, golfing and riding my motorcycle.I feel 20 years younger. It’s great.” 

“In hindsight, I should have had this surgery ten years ago,” he says. “I wish I would have known having this surgery was going to be this easy and only take a short period of time.” WHAT IS AN ANTERIOR TOTAL HIP REPLACEMENT?

During total hip replacement, the damaged bone and cartilage are removed, cleaned and replaced with a durable prosthetic. The anterior surgical approach uses a minimally invasive incision on the front (anterior) of the hip. In this approach, the surgeon is able to move the muscles aside rather than cutting through them. By not cutting through muscles and tissues, there is less damage and trauma allowing for a quicker recovery time. WHAT IS THE RECOVERY PROCESS OF AN ANTERIOR TOTAL HIP REPLACEMENT?

In most cases, patients get back to their usual activities within several weeks. After surgery, the patient will typically walk later that day and spend one night recovering in the hospital. “For several weeks following surgery, the patient will undergo physical therapy to improve strength and range of motion,” says Dr. Van Dyke. “As they continue the healing process, they’ll be required to use a cane or walker as they move closer and closer to returning to normal function.” Typically, patients are able to return to work within a few weeks and are fully healed within eight to 12 weeks. “When I went in for hip replacement surgery on my left hip, Dr. Van Dyke said to me I’d be walking without a walker in two weeks and in four weeks I’d be playing golf. I found that hard to FLORIDA MD - FEBRUARY 2016 21


Next-Day Appointments Help Patients Navigate Potential Cancer Diagnosis By Daniel Landau, MD According to the American Cancer Society, an estimated 1.6 million Americans were diagnosed with cancer last year. Though millions battle this disease every year, the process for receiving a cancer diagnosis is still harrowing and fraught with anxiety for most patients. When a GP tells his or her patients that they need to be referred to an oncologist, the first reaction is fear and uncertainty. Waiting adds to this anxiety. In some countries, the wait is too long. In the UK, for example, the government has set targets so that patients with suspected cancer must see a specialist within 14 days after referral. It also sets targets so that patients wait no longer than two months between the date a hospital receives an urgent referral for suspected cancer and the date they begin treatment. One Canadian study involving men with prostate cancer indicated that 70 percent of patients felt their care had been delayed due to the health care system or factors related to their physicians. Longer waits for diagnosis and treatment are also associated with added distress for patients and their families and may be correlated with a worse prognosis, the study found.

NEXT-DAY APPOINTMENTS: FASTER ACCESS TO SPECIALISTS, PEACE OF MIND FOR PATIENTS When cancer is suspected, it’s critical to see a doctor as soon as possible. At UF Health Cancer Center – Orlando Health, we don’t want anyone to have to live with the fear of a diagnosis a moment longer than necessary. It’s why we’ve begun to offer next-day appointments for any new patient who calls in or who receives a referral from his or her doctor. Upon calling us, patients are offered a next-day appointment with one of our specialists. The specialist will arrange for imaging tests and other necessary blood work. However, there are frequent occasions where the workup happens immediately. For example, I recently met with a young woman who had a large abdominal mass that her doctor noticed after a CT scan for another purpose. Because she came to me so quickly, I was able to set her up to meet with me, a surgical specialist and a radiation specialist — all within one The Endo-Surgical Center of Florida's day. We were able to put together informaoperating suite is now available for lease.  tion to come up with a definitive plan almost instantaneously, whereas she couldn’t get an appointment with anyone else for essentially weeks after the scan was done. ESCF's operating suite is larger than a standard operating room and fully equipped to offer surgeons top-quality equipment to perform well. It has 5 preoperative unit and a 5 postanesthesia care unit with an efficient scheduling system to optimize your time.

Located in East Orlando, with easy access to highways 408 and 417. Lease Contact: Director of Operations Noemi Madera at 407-506-0006 or email her at [email protected] 22 FLORIDA MD - FEBRUARY 2016

Since we launched the program, we’ve heard several stories from patients about how being able to see a specialist as soon as possible made them feel more in control and better able to cope with a potential diagnosis — whether it was a malignancy or benign. Some patients have come to us to see a hematologist after a referral from their GP. They’ve scheduled next-day appointments, and in some cases, received a diagnosis of severe anemia rather than cancer. You can’t imagine the peace of mind a patient in this situation has after quickly getting this diagnosis. Next-day appointments also have helped several patients receive an earlier cancer diagnosis. This can be lifesaving for many people, especially those with a diagnosis like acute myeloid leukemia, which doesn’t have any tests that can detect the cancer early.

CANCER RESULTS OF NEXT-DAY APPOINTMENTS We’ve seen that next-day appointments have been successful in helping patients see a specialist or doctor more quickly, get an earlier diagnosis of their condition and earlier treatment plans. We also believe that these appointments allow patients to have better outcomes and a better experience. Roughly 67 to 75 percent of patients being referred to the UF Health Cancer Center – Orlando Health are offered next-day appointments. Of patients who are offered an appointment, approximately 67 percent of them accept, which speaks to the fact that diagnostic delays are sometimes patient-driven and that we in the medical community need to make patients more comfortable with seeing a doctor. However, patients who do come in for a next-day appointment have faster access to a specialist, less worry and anxiety and a quicker diagnostic workup. We’ve also had patients come to the clinic, undergo a bone marrow biopsy and initiate chemotherapy before they were able to get in to see another physician. The turnaround time in this situation is remarkable, but for many patients it can make a big difference in their prognosis and approach to treatment.

LOOKING TO THE FUTURE When a primary care doctor tells a patient that there is a lump that needs to be biopsied or that the results of a blood test may indicate cancer, patients are unsure of what is happening and want answers quickly. Patients tell us that seeing a specialist right away allows a weight to be lifted off their shoulders — even when they are unsure of their diagnosis and are awaiting test results. Next-day appointments have an impact far beyond a patient’s initial visit. If a patient is symptomatic and does have cancer, we may be able to detect it early because of these appointments. This expands a patient’s treatment options and potential survivorship. It also has an impact on patients with advanced cancers. I frequently meet patients in our next-day program who have very aggressive cancers, including testicular cancer or lymphomas. When I get these patients, I do whatever test I can instantaneously and have treatment started within days of our appointment. This can make a huge difference with aggressive malignancies that can grow and spread by the day. Our goal with next-day appointments is to help every patient who comes into our center feel empowered and to ease some of their worry and anxiety, regardless of their diagnosis. We know that this program will save many lives — in fact, we’re already starting to see the results. We will continue to offer next-day appointments, but it’s our hope that more patients beyond the current 67 percent take advantage of this program. Doing so could be lifesaving. New patients who need next-day appointments can call 321.843.7770 to schedule a visit with a specialist or fill out the form on the UF Health Cancer Center – Orlando Health website to request an appointment.


Daniel Landau, MD, is board-certified in internal medicine, medical oncology and hematology for the Medical Oncology and Hematology Specialty Section at UF Health Cancer Center – Orlando Health. He has been with Orlando Health for 7 years. Dr. Landau received his medical degree from the University of South Florida College of Medicine, where he also completed his residency. Dr. Landau completed his medical oncology and hematology fellowship at MD Anderson Cancer Center Orlando, serving as chief fellow. Dr. Landau has been recognized as a top oncologist by SmartestOncologist.com three consecutive times. He is currently a member of the American Society of Clinical Oncology and the American Society of Hematology. To schedule an appointment with Dr. Landau, please call 321.841.7219. 




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Florida Hospital Implants First Rightsided Percutaneous Heart Assist Device, Impella RP In Central Florida By Rajesh A. Shah, MD and Scott Silvestry MD The Cardiovascular Institute at Florida Hospital Orlando is the first hospital in Central Florida to implant the Impella RP™, the only right sided percutaneous (through the skin) assist device on the market, to treat right-sided heart failure. The Impella RP is part of the Impella platform which includes the World’s Smallest Heart Pump manufactured by Abiomed. The unique device addresses an unmet need of treating patients who develop acute right heart failure or decompensation following left ventricular assist device implantation, myocardial infarction, heart transplant, or open-heart surgery. The Impella RP System is indicated for providing circulatory assistance for up to 14 days in pediatric or adult patients with a body surface area ≥ 1.5 m2 who develop acute right heart failure or decompensation following left ventricular assist device implantation, myocardial infarction, heart transplant, or open-heart surgery. The device does not require an open surgical procedure for insertion, and it can provide up to four liters per minute of hemodynamic support. The Impella RP catheter delivers blood from the inlet area, which sits in the inferior vena cava, through the cannula to the outlet opening near the tip of the catheter in the pulmonary artery. Traditional treatments for right ventricular issues are limited. Many patients who experience right-sided heart dysfunction have exhausted interventional options and require invasive surgery but are at high risk for complications. Florida Hospitals’ multidisciplinary team — including Rajesh Shah MD, Scott Silvestry MD and Donald Botta MD — led a collaborative heart team in the catheterization lab during the first implantation at Florida Hospital. For the first time in history we have the ability to percutaneously support the right ventricle. Previous techniques involved either a version of total cardiopulmonary bypass (ECMO) or surgical RVAD. The the impella RP revolutionizes the support of the right ventricle in such cases as myocardial infarction and post heart surgery right ventricular failure. We are privileged to be able to offer this therapy here at Florida Hospital Orlando for patients –

SCOTT SILVESTRY MD-SURGICAL DIRECTOR OF THORACIC TRANSPLANT Our community of patients and partners deserve the best therapies available. This powerful new addition to our catheterization lab and surgery suite provides an entirely new benefit enabling our staff to treat high-risk patients with right-side heart failure minimally invasively,” said Rajesh Shah MD, ACS Medical Director, Florida Hospital Orlando. 24 FLORIDA MD - FEBRUARY 2016

Rajesh A. Shah, MD, FACC- ACS Rajesh A. Shah, MD is Program Medical Director at Florida Hospital Orlando – specializing in Interventional Cardiology and Advanced Heart Failure Therapies. Dr. Shah also has an integral role within the Heart Transplant program. He is Board Certified Cardiovascular Disease, Interventional Cardiology and Nuclear Medicine. Dr Shah practices at Orlando Cardiac and Vascular Specialists, 251 Maitland Ave. Scott Silvestry MD Suite 116, Altamonte Springs, FL 32701. He may be contacted by calling (407) 915.5643 Scott Silvestry MD,- Surgical Director of Thoracic Transplant, Florida Hospital Orlando – Dr. Silvestry joins the Florida Hospital Transplant Institute from Washington University School of Medicine, where he served as associate professor and the surgical director of the cardiac transplantation and ventricular assist division of cardiothoracic surgery. He has extensive research and publication experience in advanced heart failure, heart transplantation and cardiac disease. Dr. Silvestry received his medical degree from the University of Pennsylvania. He completed both his cardiovascular and thoracic surgery fellowship and cardiac transplantation and ventricular assistance advanced fellowship at Duke University in Durham, North Carolina. The Florida Hospital Transplant Institute is located at 2415 North Orange Avenue, Suite 700 Orlando, FL 32804, (407) 303-2474, (866) 913-7851.  Team: Rajesh Shah MD, Scott Silvestry MD, Simon Shakkar MD, Nipun Arora MD, Rohit Bhatheja MD (Not pictured: Donald Botta MD)


Practice Business Plans – A Blueprint for Future Success! By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank When consulting with my healthcare clients around the thought of starting up or expanding a current practice, I explain one of the key essential first steps is creating a plan prior to applying for financing.

licensing fees and professional services; and working capital— that is, the cash you need to cover operating expenses before your practice sees income.

Striking out on your own in a private practice or growing the one you have is a challenging prospect. While you can’t predict the future, you can plan for it with a well-crafted business plan, which acts as a blueprint for financial and legal planning. Here’s a look at the basic elements: 1, 2

3. Financing: Finally, your practice plan should outline where funds will come from. Sources include personal investment, loans from friends and family, equipment financing and leasing and, of course, traditional bank loans, mortgages or lines of credit.

Executive Summary: This should encapsulate the highlights of the plan, including an abbreviated practice description, an overview of financing requirements and a mission statement.

While you may need a business plan to meet the requirements of financial institutions and investors, you’ll also find that it crystallizes your own ideas about your practice. By periodically reviewing and updating your plan, you’ll have a living, breathing document that provides a road map for your practice’s growth and a touchstone when making critical decisions.

Practice Description: Here you can go into greater detail with a practice history (if already in existence) and/or the professional background of the principals. Introduce your management team, key personnel and professional advisors, and describe the legal structure of the practice, which includes your insurance coverage. Market Research: This opens with a description of the market you are entering: demographics, growth projections, etc. Include a detailed profile of the patients you plan to serve, and describe the competitive landscape, along with the advantages you bring to the table. Marketing Plan: If you plan to market your practice, how will you do so? Consider professional referral networks, an online presence and a marketing budget. Operations: This is the basics of the practice, including location and premises, hours of operation, equipment and supplies needed, staffing plan and compensation. Financial Forecast: This section takes the descriptive parts of the plan and converts them into dollars and cents. It consists of three basic parts: 3 1. Cash Flow Projection: Cash is your practice’s lifeblood, and this document shows when you expect money to come in and go out. Understand that this is not the same as income and expense: Consider the time it takes to receive reimbursement for services, what your anticipated insurance rejection rate will be and other factors that may impact when cash will be available. Your analysis should be monthly for the first 12 months, and, optionally, annually for the following four years. 2. Capital and Operating Expenses: This is the total amount you need to start your practice or other project. It includes capital expenses such as real estate, renovation and equipment purchases; one-time startup costs such as security deposits,

Contact your trusted healthcare business professional advisor for the guidance and support that you need to create and maintain your plan for the best chance of reaching your goals. IMPORTANT LEGAL DISCLOSURES AND INFORMATION: 1 - http://www.sba.gov/category/navigation-structure/starting-managing-business/ starting-business/writing-business-plan/ess 2- http://academy.clevelandclinic.org/Portals/40/LHC%20Bus%20Plan%20 Article.pdf 3 - http://www.sba.gov/content/financials

Jeff Holt is a Senior Healthcare Business Banker and V.P. with PNC Bank’s Healthcare Business Banking and is a Certified Medical Practice Executive. He can be reached at (352) 385-3800 or [email protected]

Sea Notes Photography Donald Rauhofer – Photographer Head Shots • Brochures • Meetings Events • Portraits • Arcitectural

4O7-417-74OO FLORIDA MD - FEBRUARY 2016 25

Medical Office Resources of Florida: On-Call 24/7 For Florida Healthcare Professionals By Dorothy Mowbray, M.O.R.O.F. Media Committee Chair and Board Member You take care of your patients, but who takes care of your practice? Keeping up with all the new government regulations and requirements, of which each comes with its own fines for non-compliance, has become its own full-time job. It’s no wonder that many independent practitioners are opting to sell their practices to the big medical groups. This too comes with its own challenges as physicians trade the freedom of running their own practice for the confines of being an employee, doing as instructed by their employer instead of calling their own shots! Neither situation is right or wrong, but rather, a matter of preference. For those healthcare professionals who also desire to independently own their practice, Medical Office Resources Of Florida (M.O.R.O.F.) was created as a local medical resource. Not a clinical resource, but rather a resource that brings all the aspects of running a profitable healthcare business together through one unified source. Membership includes doctors, nurses, office managers, medical associations, and professionals who support the healthcare industry. Even if you aren’t a member, resources are available online 24 hours a day, 7 days a week, 365 days a year. “M.O.R.O.F. is designed to help keep the independents, independent!” says Chuck Wright, the president of the group The www.mor-of.net website with links to the MOROForlando YouTube channel is a tremendous resource, with every presentation videotaped and archived. Each 45 to 60 minute presentation is further divided into an itemized list of 2 to 3 minute subtopics so you can easily listen to just the parts of each presentation that specifically answer your question. Each sub-topic is listed on the M.O.R.O.F. website with direct links to YouTube channel video. Or, if you are on the MOROForlando YouTube channel, just click on the “Show More” text under the main video to see the itemized sub-topic list. For example, discover “Common Myths about Physician Burn-out” presented by Dr. Herdley Paolini last fall. Learn “Why medical data is so valuable to criminals. Some of the itemized segments will give you a legal view, a banking view and an IT view. These views correspond with the three experts on the panel. The second part of this presentation, “Why Everyone Must Be Compliant” helps you better understand the four major rules within HIPAA? And What’s a Breach? And now in Florida, there’s FIPA compliance! Have problems with ICD-10 implementation? Check out the video that addresses questions like, “Where do you find the ICD10 exclusions that automatically prevent insurance from paying?” This video is dated 9-24-2015, but is still applicable for anyone having issues now or until the ICD-10 transitional grace period ends. Curious about the Growing Popularity of Integrative Medicine? Hear from Dr. Robinson and how UFHealth Cancer Center is implementing many aspects of integrative medicine into their Oncology treatments to treat the whole patient. These and many other health topics are presented by local experts at monthly M.O.R.O.F. breakfast meetings. Ken Peach will be the guest speaker Thursday, Feb. 25, 2016. He’ll be discussing Networks: The Future of Healthcare Delivery. Massive consolidation is occurring in health care. Insurance companies are merging with other insurance companies. As we have seen in this market, independent hospitals are joining health systems. Even independent physician offices are forming entities to give them more of a voice in this rapidly changing environment. Elsewhere in both the U.S. and Europe, networks are being assembled as a means of improving care coordination, the quality of patient care, and the cost of providing that care. In many ways, networks are enablers of The Triple Aim, an objective of the federal government and many health systems to deliver population health, improved experience of care, and lower per capita cost. Come learn about the elements found in new and existing local networks and a peer into the future of Central Florida health delivery! Remember that if you can’t make the meeting in-person, subscribing to the MOROForlando YouTube channel will quickly provide you a The cover story focuses on the local resource for all past and future presentations like this!


M.O.R.O.F. meets the fourth Thursday of each month from 7:30 a.m. to 9 a.m. at the Venue On The Lake at the Maitland Civic Center. The address is 641 South Maitland Ave., Maitland, FL 32751. Healthcare professionals are always welcome as guests. RSVP at www.mor-of.net.  26 FLORIDA MD - FEBRUARY 2016

Transcatheter Aortic Valve Replacement (TAVR) procedure at The Heart & Vascular Institute at Osceola Regional Medical Center. Editorial focus is on Men’s Health and Orthopaedics.

One Piece of Advice Can Help Your Patients Cut Healthcare Costs by up to Half or More — New Online Tool Helps Patients and Doctors Find Independent Doctors By Marni Jameson Right after the question, “Can you help me get better?” comes this concerned question from patients to their doctors: “How much will it cost?” Many providers don’t realize that the single best way to help patients save significantly on health-care costs – without sacrificing quality – is to refer them to an independent doctor. That single decision can save patients up to half or more on their out-of-pocket costs -- and many thousands of dollars should they need hospitalization. That’s because patients who go to independent doctors don’t get saddled with facility fees. These are often substantial additional charges that hospitals layer in and that are of no value to the patient. Hospital administrators will say they need to charge these fees to cover their overhead, which is understandable when you consider how much their numbers have grown compared to doctors over the past 40 years:

So hospitals charge facility fees that can double or even multiply costs by five times. Now, the difference between a $70 doctor visit and a $140 visit may not seem like much, but watch how this compounds. These added facility costs increase exponentially when the hospital-employed primary care doctor refers his or her patient to a

hospital-employed specialist, who sends the patient to a hospitalowned imaging center and then to a hospital-owned surgery center – all of which charge as much as two to five times more than independently owned centers. Patients aren’t the only ones who pay. We all pay, of course. Workers pay in the way of higher premiums, and taxpayers pay through higher taxes needed to fund Medicare and Medicaid.

NEW ONLINE TOOL HELPS But here’s one bright spot. Because knowing which doctors are independent and which work for hospitals isn’t always clear, and changes rapidly, the Association of Independent Doctors -- a nonprofit organization dedicated to promoting price transparency in health care -- has created a new online tool that can help doctors refer patients to independent doctors in the area. The online directory of independent doctors (www.aid-us.org/ directory) offers an easy-to-search database of independent doctors listed by specialty. While not every independent doctor is on the list, many are. However, just as important as using this tool to help refer patients in the most cost-effective direction is letting them know about an important question that they need to ask their doctors: Are you independent or hospital employed? That one question puts a lot of power – and dollars -- back in consumers’ hands. To help your patients avoid these snowballing costs, help them make that first healthy decision -- to see an independent doctor. Marni Jameson is the executive director of the Association of Independent Doctors, a national nonprofit dedicated to helping reduce health-care costs by helping consumers, businesses and lawmakers understand the value of keeping America’s doctors independent www.aid-us.org.  FLORIDA MD - FEBRUARY 2016 27

Healthcare Provider Liability Insurance Primer By Bill Gompers Healthcare providers, by the nature of their business, always face liability risks. Although many of these risks can be lessened through implementation of risk-management practices, they can rarely be eliminated. Thus, it is prudent to implement a liabilityinsurance program that addresses the healthcare provider’s needs and ensures your peace of mind should the unexpected event(s) occur. The following is a listing of the liability coverages that comprise the inventory selected by many healthcare providers:c • Professional Liability Insurance (Medical Malpractice) • Commercial General Liability Insurance • Workers’ Compensation Insurance • Cyber Liability Insurance • Regulatory Liability Insurance • Employee Benefits Liability Insurance • Employment Practices Liability Insurance Below is a brief description of these liability coverages: Professional Liability Insurance (Medical Malpractice): Provides indemnity and expense protection for errors and omissions emanating from professional mistakes. These include professional negligence, provision of services that are below the prevailing standard of care, and misrepresentation. Policy terms and conditions are not standardized and must be reviewed closely. Some key components to look for are incident-sensitive trigger, defense outside limits, prior-acts coverage, and coverage for ancillary personnel and medical-director duties. Commercial General Liability Insurance: Provides indemnity and expense protection for incidents, including third parties, arising from negligence causing bodily injuries, property damage, and personal injuries that your business caused. This includes slips and falls and loss of or damage to property. Workers’ Compensation Insurance: Covers medical and rehabilitation costs and lost wages for employees injured at work. Florida, along with most states (with a few exceptions), essentially requires employers to purchase an insurance policy to handle their statutory obligations to workers who are injured or made ill due to a workplace exposure. Typically, workers’ compensation covers medical expenses, lost earnings, disability payments, funeral expenses, and legal fees. Cyber Liability Insurance: Offers financial protection when a data breach, theft of data, or cyber-attack compromises valuable 28 FLORIDA MD - FEBRUARY 2016

or private information. Coverages can include crisis management, multimedia liability, and security and privacy liability. Coverage can also protect you with regards to privacy regulatory defense and penalties as well as privacy breach and network asset protection. Cyber extortion and cyber terrorism coverages are also desirable attributes of many policies. Regulatory Liability Insurance: In today’s rapidly changing regulatory environment many operators are choosing this coverage to provide reimbursements for regulatory fines, penalties, claims expenses, and shadow-audit expenses resulting from regulatory proceedings. Desirable policies include coverage for allegations of billing errors resulting from ZPIC, RAC, and other similar audits; fines and penalties; as well as defense of EMTALA and STARK violations. Employee Benefits Liability Insurance: Covers an insured in the event of a claim that arises out of errors and/or omissions in the administration of a benefit plan. These can include failing to advise an employee of a benefit program; failure to enroll, terminate, or cancel an employee in the plan; and administering improper advice in regards to the benefits. Employee benefits programs can include group life insurance, group health insurance, profit-sharing plans, employee stock plans, workers’ compensation, unemployment insurance, and COBRA. Employment Practices Liability Insurance: Protects your business against the high cost of lawsuits due to discrimination, harassment, wrongful termination, and other potential charges stemming from employment practices. This coverage can cover your business from the cost of legal defense, settlements, and other court fees when faced with an allegation of violating a person’s or group’s civil rights or failing to provide a fair, acceptable environment for them to complete their work. Navigating the various types of coverages can be a challenge. Avoiding potential gaps and needless overlapping can be crucial to your operations and bottom line. Thus, professional guidance is often the best route to take, by conducting a review of all alternatives with your liability-insurance consultant. Bill Gompers is a medical malpractice insurance specialist with Danna-Gracey, an independent insurance agency specializing in medical malpractice and workers compensation insurance for Florida’s medical community., 305.775.1960, 888.777.7173; [email protected]



Pelvic Floor Dysfunction By Sergio Larach, MD Many people don’t feel comfortable talking about personal topics like pelvic floor disorders and symptoms such as incontinence. But these are actually very common medical problems that can be treated successfully. Millions of people have the same issues, but many don’t seek treatment and compromise their quality of life. Treatment can have a dramatic effect on pelvic floor dysfunction Pelvic floor dysfunction refers to a wide range of issues that occur when muscles of the pelvic floor are weak, tight, or there is an impairment of the sacroiliac joint, lower back, coccyx, or hip joints. Tissues surrounding the pelvic organs may have increased or decreased sensitivity or irritation resulting in pelvic pain. Many times, the underlying cause of pelvic pain is difficult to determine. Pelvic floor dysfunction may include any of a group of clinical conditions that includes urinary incontinence, fecal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction and several chronic pain syndromes, including vulvodynia. The three most common and definable conditions encountered clinically are urinary incontinence, anal incontinence and pelvic organ prolapse. It is estimated that at least one-third of adult women are affected by at least one of these conditions. Furthermore, statistics show that 30 to 40 percent of women suffer from some degree of incontinence in their lifetime, and that almost 10 percent of women will undergo surgery for urinary incontinence or pelvic organ prolapse. 30 percent of those undergoing surgery will have at least two surgeries in trying to correct the problem

WHAT IS PELVIC FLOOR DYSFUNCTION? For most people, having a bowel movement is a seemingly automatic function. For some individuals, the process of evacuating stool may be difficult. Symptoms of pelvic floor dysfunction include constipation and the sensation of incomplete emptying of the rectum when having a bowel movement. Incomplete emptying may result in the individual feeling the need to attempt a bowel movement several times within a short period of time. Some times use of digital help during the evacuation for support of the pelvic floor. Residual stool left in the rectum may slowly seep out of the rectum leading to reports of bowel incontinence. Constipation is not about frequency (or infrequency) of bowel movements, but rather chronic constipation is a “symptom complex.” The process of defecation (having a bowel movement) requires the coordinated effort of different muscles. The pelvic floor is made up of several muscles that support the rectum like a hammock. When an individual wants to have a bowel movement the pelvic floor muscles are supposed to relax allowing the rectum to empty. While the pelvic floor muscles are relaxing, muscles of the abdomen contract to help push the stool out of the rectum. Individuals with pelvic floor dysfunction have a tendency to contract

instead of relax the pelvic floor muscles. When this happens during an attempted bowel movement, these individuals are effectively pushing against an unyielding muscular wall. Chronic constipation may be associated with normal or slow stool transit time, functional defecation disorder (dyssynergic defecation) or a combination of both. With slow-transit constipation, there is a prolonged delay in the transit of stool through the colon. Dyssynergic or outlet obstruction (also called pelvic floor dyssynergia) is characterized by either difficulty or inability to expel the stool. With pelvic floor dysfunction (dyssynergic defecation), the muscles of the lower pelvis that surround the rectum (the pelvic floor muscles) do not work normally. A third type of constipation occurs with irritable bowel syndrome (IBS) where constipation alternates with bouts of diarrhea.

HOW IS PELVIC FLOOR DYSFUNCTION DIAGNOSED? The diagnosis of pelvic floor disorder starts with a careful history regarding an individual’s symptoms, medical problems and a history of physical or emotional trauma that may be contributing to their problem. Next the physician examines the patient to identify any physical abnormality. A dynamic MRI and a defecating proctogram are studies commonly used to demonstrate the functional problem in a person with pelvic floor dysfunction. During this study, the patient is given an enema of a thick liquid that can be detected with x-ray. A special x-ray video records the movement of the pelvic floor muscles and the rectum while the individual attempts to empty the liquid from the rectum. Normally the pelvic floor relaxes allowing the rectum to straighten and the liquid to pass out of the rectum. This study will demonstrate if the pelvic floor muscles are not relaxing appropriately and preventing passage of the liquid. These tests are also useful to show if the rectum is folding in on itself (internal rectal prolapse). Many women have outpouching of the rectum known as a rectocele. A rectocele is a bulging of the front wall of the rectum into the back wall of the vagina. Rectoceles are usually due to thinning of the rectovaginal septum (the tissue between the rectum and vagina) and weakening of the pelvic floor muscles. This is a very common defect; however, most women do not have symptoms. There can also be other pelvic organs that bulge into the vagina, leading to similar symptoms as rectocele, including the bladder (i.e., cystocele) and the small intestines (i.e. enterocele). Usually a rectocele does not affect the passage of stool. In some instances, however, stool may become trapped in a rectocele causing symptoms of incomplete evacuation. The defecating proctogram or dynamic MRI helps to identify if liquid is getting trapped in a rectocele when the individual is trying to empty the rectum. Continued on page 30 FLORIDA MD - FEBRUARY 2016 29

DIGESTIVE AND LIVER UPDATE HOW IS PELVIC FLOOR DYSFUNCTION TREATED? Pelvic floor dysfunction due to non-relaxation of the pelvic floor muscles may be treated with specialized physical therapy known as biofeedback. With biofeedback, a therapist helps to improve a person’s rectal sensation and pelvic floor muscle coordination. There are various effective techniques used in biofeedback. Some therapists train patients by teaching them to expel a small balloon placed in the rectum. Another technique uses a small probe placed in the rectum or vagina or electrodes placed on the surface of the skin around the opening to the rectum (anus) and on the abdominal wall. These instruments detect when a muscle is contracting or relaxing and provide visual feedback of the muscle action. This visual feedback helps the individual to understand the muscle movement and aids in improving muscle coordination. Approximately 75% of individuals with pelvic floor dysfunction experience significant improvement with biofeedback. It is very important to have a good bowel regimen in order to avoid constipation and straining with bowel movements. A high fiber diet, consisting of 25-30 grams of fiber daily, will help with this goal. This may be achieved with a fiber supplement, high fiber cereal, or high fiber bars. In addition to augmenting fiber intake, increased water intake (typically 6-8 glasses daily) is also highly recommended. This will allow for softer stools that do not require significant straining with bowel movements, thereby reducing your risk for having a bulge associated with a rectocele. The surgical management of rectoceles should only be considered when symptoms continue despite the use of medical management and are significant enough that they interfere with activities of daily living. There are abdominal, rectal, and vaginal surgeries that can be performed for rectoceles.

Patient Assistance Resources

Rectal prolapse is a condition in which the rectum (the lower end of the colon, located just above the anus) becomes stretched out and protrudes out of the anus. Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage, resulting in leakage of stool or mucus. While the condition occurs in both sexes, it is much more common in women than men. There are many different ways to surgically correct rectal prolapse. Abdominal or rectal surgery may be suggested. An abdominal repair may be approached laparoscopically in selected patients. The decision to recommend an abdominal or rectal surgery takes into account many factors, including age, physical condition, extent of prolapse and the results of various tests. If a patient has pelvic health issue, don’t hesitate to learn more about treatment options, seek out an expert evaluation, at our center, we have state-of-the-art technology for physiologic testing and a multidisciplinary approach to patients with complex pelvic floor disorder

BOWEL INCONTINENCE–WHAT IS INCONTINENCE? Incontinence is the impaired ability to control gas or stool. Its severity ranges from mild difficulty with gas control to severe loss of control over liquid and formed stools. Incontinence to stool is a common problem, but often it is not discussed due to embarrassment.

WHAT CAUSES INCONTINENCE? There are many causes of incontinence. Injury during childbirth is one of the most common causes. These injuries may cause a tear in the anal muscles. The nerves supplying the anal muscles may also be injured. While some injuries may be recognized immediately following childbirth, many others may go unnoticed and not become a problem until later in life. In these ¬situations, a prior childbirth may not be recognized as the cause of incontinence.

The CF Foundation is committed to improving the lives of all people and families with CF. We can help you with: •Insurance coverage and benefits •Resources to pay for therapies and medications •Legal information •Other concerns Tell us your issue. We will help you find a solution. 888-315-4154 • [email protected] • www.cff.org


Anal operations or traumatic injury to the tissue surrounding the anal region similarly can damage the anal muscles and hinder bowel control. Some individuals experience loss of strength in the anal muscles as they age. As a result, a minor control problem in a younger person may

DIGESTIVE AND LIVER UPDATE become more significant later in life. Diarrhea may be associated with a feeling of urgency or stool leakage due to the frequent ¬liquid stools passing through the anal opening, If bleeding accompanies lack of bowel control, this may indicate inflammation within the colon (colitis), a rectal tumor, or rectal prolapse - all conditions that require prompt evaluation by a physician.

HOW IS THE CAUSE OF INCONTINENCE DETERMINED? An initial discussion of the problem with your physician will help establish the degree of control difficulty and its impact on your lifestyle. Many clues to the origin of incontinence may be found in patient histories. For example, a woman’s history of past childbirths is very important. Multiple pregnancies, large weight babies, forceps deliveries, or episiotomies may contribute to muscle or nerve injury at the time of childbirth. In some cases, medical illnesses and medications play a role in problems with control.

rectum, such as colitis, may contribute to anal control problems. Treating these diseases also may eliminate or improve symptoms of incontinence. Sometimes a change in prescribed medications may help. Your physician also may recommend simple home exercises that may strengthen the anal muscles to help in mild cases. A type of physical therapy called biofeedback can be used to help patients sense when stool is ready to be evacuated and help strengthen the muscles. Injuries to the anal muscles may be repaired with surgery. Some individuals may benefit from a technique that delivers electrical energy to the skin and muscles surrounding the anus which results in firming and thickening of this area to help with continence.

A physical exam of the anal region should be performed. It may readily identify an obvious injury to the anal muscles. In addition, an ultrasound probe can be used within the anal area to provide a picture of the muscles and show areas in which the anal muscles have been injured. Frequently, additional studies are required to define the anal area more completely. In a test called anal manometry, a small catheter is placed into the anus to record pressure as patients relax and tighten the anal muscles. This test can demonstrate how weak or strong the muscle really is. A separate test may also be conducted to determine if the nerves that go to the anal muscles are functioning properly.

WHAT CAN BE DONE TO CORRECT THE PROBLEM? Treatment of incontinence may include:
• Dietary changes
• Constipating medications
• Muscle strengthening exercises
• Biofeedback
• Surgical muscle repair
•. Sacral Neuromodulation ( Interstim)* Artificial anal sphincter After a careful history, physical examination and testing to determine the cause and severity of the problem, treatment can be addressed. Mild problems may be treated very simply with dietary changes and the use of some constipating medications. Diseases which cause inflammation in the FLORIDA MD - FEBRUARY 2016 31

DIGESTIVE AND LIVER UPDATE The InterStim® Therapy System is a surgically implanted device used to help a patient reduce the number of bowel accidents (fecal incontinence). The InterStim® Therapy System has several components: a neurostimulator which delivers an electrical pulse to the sacral nerve; an electrical lead that is implanted on a sacral nerve, and a programmer that is used to control the electrical pulse delivered by the neurostimulator. The neurostimulator and the lead are permanent implants. At this moment, the Interstim therapy is the most effective procedure for the treatment of this condition and it is become widely utilized after a trial period for each patient.The trial period give an immediate result of effectiveness of the therapy with minimal risk for the patient. In certain individuals that have nerve damage or anal muscles that are damaged beyond repair, an artificial sphincter may be implanted. The artificial sphincter is a plastic, fluid filled doughnut that is surgically implanted around the damaged anal sphincter. This artificial sphincter keeps the anal canal closed. When an individual wants to have a bowel movement, the fluid can be pumped out of the doughnut to allow the anal canal to open. In extreme cases, patients may find that a colostomy is the best option for improving their quality of life. If a patient has pelvic health issue, don’t hesitate to learn more about treatment options, seek out an expert evaluation, at our center, we have state-of-the-art technology for physiologic testing and a multidisciplinary approach to patients with complex pelvic floor disorder. REFERENCES AVAILABLE UPON REQUEST

Sergio Larach, MD completed his fellowship at the University of Texas Medical School. He is board certified in colon and rectal surgery. His interests include the whole spectrum of colorectal issues, and his addition to our practice will involve colonoscopies, anorectal diseases and pelvic floor evaluations. Dr. Larach is fluent in Spanish. He has held multiple professional appointments through his career, including Program Director of Orlando Health’s and Florida Hospital’s Colon and Rectal Fellowship Programs. Dr. Larach is currently a Clinical Associate Professor at University of Central Florida and Clinical Associate Professor at Florida State University. Dr. Larach has also published numerous articles on colon and rectal surgery, conducted clinical research, and authored book chapters in his specialty. He has been instrumental in the development of the TAMIS procedure for the treatment of rectal cancers. He is the Associate Director of International Advisory Affairs of the International Society of University Colon and Rectal Surgeons and is also a reviewer for the Surgical Endoscopy journal. To contact Dr. Sergio W. Larach, please call Digestive and Liver Center of Florida at 407-384-7388.  32 FLORIDA MD - FEBRUARY 2016



Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market. Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.


Digestive Disorders Diabetes


Cardiology Heart Disease & Stroke


Orthopaedics Men’s Health


Surgery Scoliosis


Women’s Health Advances in Cosmetic Surgery


Allergies Pulmonary & Sleep Disorders


Imaging Technologies Interventional Radiology


Sports Medicine Robotic Surgery

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

Cancer Dermatology

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

Please call 407.417.7400 for additional materials or information. FLORIDA MD - FEBRUARY 2016


She is why

She Is Why Life Is

life is

Amazing. Women are special.

That’s why we’ve created

a comprehensive network of care specializing in women’s unique healthcare needs, including a constellation of community hospitals, extended-care services and the new Florida Hospital for Women in Orlando. It’s special care for special people. Because women are one of the reasons


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