Tampa Bay Medical News April 2014

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By LyNNE JETER

TAMPA—A few dozen approved surgeons specializing in gastro-esoph-ageal refl ux disease or gas-tro-intestinal surgery across the nation are offering a revolutionary procedure for patients with gastro esopha-geal refl ux disease (GERD). It’s so new; many primary care physicians and some

specialists aren’t aware of it as an option.

“The FDA approved the LINX Refl ux Management Sys-tem two years ago, but when the New England Journal of Medicine published an article discussing the effi cacy of the system … then healthcare providers, patients and the media took notice,” said Gopal Grandhige, MD, a board-certifi ed, Yale fellowship-trained, laparoscopic general

surgeon with Suncoast Surgical Associates in Tampa, director of the Tampa Bay Refl ux Center, and a LINX-approved surgeon.

Torax Medical opted to launch the pro-cedure nationwide at approved centers, one or two per state. The company develops and markets products designed to restore human lower esophageal sphincter function via its technology platform, Magnetic Sphincter Augmentation (MSA), which uses attraction forces to augment weak or defective sphinc-ter muscles to treat GERD that often irritates the esophagus, causes heartburn and other

Refl ux KOTorax Medical rolls out LINX procedure for GERD patients to select specialists

Dr. Gopal Grandhige

By LyNNE JETER

Editor’s note: Medical News’ series on The Villages’ goal as a national healthcare model continues this month with Jeff Lowen-kron, MD, CEO of the USF Physicians’ Group.

THE VILLAGES – When Jeff Lowenkron, MD, joined USF Health in January 2012 after working in the mid-Atlantic states for 17 years, refi ning ways for an integrated care delivery model to succeed, it seemed like a natural fi t for him to mold the nation’s fi rst true university-community partnership.

“It still does,” said Lowenkron, CEO of the USF Physicians’

USF Physicians’ Group CEO explains how The Villages’ model is setting a new standard of care

Becoming America’s Healthiest Hometown

Addressing Obstacles on the Road to Diabetes Control What is the best way to get … and keep … diabetic patients actively engaged in the lifelong self-management of their condition?

... page 8

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By JEFF WEBB

SARASOTA - When Joelle Angsten began working at Tidewell Hospice in 2006, time was not on her side. She was coming off seven years in primary care practice, first at First Physicians Group and then at the North County Health Center, and she had three children , 10, 7 and 2, who needed more of her time.

“I loved my primary care practices in internal medicine and pediatrics, and I really loved my patients and families. … I never planned to leave,” said Angsten. She learned of an opportunity at Tidewell Hospice that seemed ideal. “I started out working Thursday-Sunday twice a month. It worked very nicely because it allowed me to volunteer in school and devote more time to my children,” she said. “It was the schedule that really sold me at first. I had no idea I’d learn to love it as much as I do,” said Angsten who was selected in August to become chief medical officer at Tidewell, an independent, not-for-profit organization that serves patients with advanced illness. Tidewell cares for more than 8,000 patients every year, both in private homes and at its eight facilities in a four-county area that includes, Sarasota, DeSoto, Manatee and Charlotte.

“I’d always been intrigued by hospice (and) once I practiced that way for a while I realized it was something I was meant to do. I love the back-to-basics approach of end-of-life care. … And I practice with the best nurses, social workers, chaplains and others who make up our care teams. They taught me everything I know about relieving suf-fering with respect for the whole person,” said Angsten, 44.

Becoming CMO at Tidewell “came out of the blue. It wasn’t something I was contemplating at all. But my predeces-sor (Stephen Leedy, MD) had been work-ing with me to build my skill set for some time. If I’m prepared at all to do this job, it’s because of him (and) a very large group of colleagues who have been very support-ive during my transition into the role,” said Angsten.

One person who has furthered that support system is Elizabeth Bornstein, an oncology-certified licensed clinical social worker at the Sarasota Memorial Hospital Institute for Cancer Care. “We have shared a lot of experiences professionally (and) as working mothers,” said Angsten.

“Dr. Angsten is an incredible, com-passionate, well-versed physician and an exceptional patient and family advocate. She really understands those dealing with advanced or life-limiting illnesses,” said Bornstein. “She is is able to make you feel like she has all the time you need. It’s quite refreshing to meet a physician who doesn’t seem rushed or scattered. She is genuinely present and gives all she can. … There isn’t

a better physician to have on your team than Joelle Angsten,” said Bornstein.

Angsten’s job is mostly administrative, but she said she “makes a point of keeping myself active clinically. I still have my black bag and I see patients as often as I can. This keeps me grounded. Connecting with pa-tients makes sure that I remember why I work so hard on quality measures and bud-gets and staffing and everything else.”

Some of the patients Angsten has a spe-cial connection to are children. “I promote a program within Tidewell which is entirely mission-driven. Our Children’s Services program provides many supportive ser-vices to patients and families regardless of ability to pay. Many people do not realize that children in our community succumb to illness, too, though thankfully far less fre-quently than adults do. However, children are also affected by loss, sometimes pro-foundly, and we provide services to those children in our community in partnership with area schools,” she said.

After working on the Children’s Team for a while, Angsten said she “started to find myself feeling very isolated from oth-ers – even other hospice colleagues. I knew I needed to figure out a way to deal with los-ing the children on my team. And I wanted to be able to do this work for a long time without it interfering with my professional or personal life.” She attended a colleague’s

lecture “about grief, love and loss. In it, she reminded me that everyone was someone’s precious child once. Grief and loss are not meant to be measured or compared. Each person has a unique story and deserves to be honored to the best of my ability regardless of their age,” said Angsten. That perspective has “enabled me to keep doing this work while maintaining my own personhood.”

Making the transition from primary care to the subspecialty of palliative medi-cine has been “an intensely satisfying expe-rience,” she said. “I found that the things I loved about medicine were still there and … the connections with your patients and wanting to do the best work that you can and to make their lives better was all still there, but more intense,” she said. “There’s only one chance you have to get someone’s death right, to make sure they have an op-portunity to finish and not be fearful or suf-fer. I can see how it’s all interlinked now, whether I’m wearing my administrative physician hat, or my internal medicine hat, or my pediatric hat. They’re all connected.”

It is “an exciting time to be in palliative

care,” Angsten said. “Now that it’s become a recognized medi-cal specialty … we’re leading the charge to provide excellent end-of-life care. We have this perfect storm of increase in evidence-based research and the challenge to do it

better,” she said. The demand for excel-lence is being driven by the baby boomer generation, Angsten said. “They are in-formation seekers, they tend to challenge authority … (Palliative care) challenges the status quo.”

Angsten said she is fortunate to come home at night to both her best friend and a colleague. “We never run out of things to talk about,” she said of husband Brian, an MD who is board-certified in pulmonary disease, internal medicine, critical care medicine and sleep medicine. “We know what a hard day at our work feels like. We can translate that and speak in shorthand at the end of the day.”

It helps, too, that the Angstens have help on the homefront. In fact, they have had that support for their children, now ages 17, 14 and 9, since they moved “back home” in 1999 from Michigan, which is

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Group, the healthcare practice that covers The Villages. “It’s really great fun. Much of the work that needs to happen to get the details to line up is not my day-to-day work. Many people from USF are working on our behalf at The Villages.”

When Lowenkron arrived in Tampa, The Villages’ care delivery model was still a diagram on paper.

“It would be refined on paper for an-other 10 months before the first primary care center opened, before the first con-tract was signed with United (Healthcare) for an open enrollment period,” he said. “This is an ongoing process of continuous learning and refining. In The Villages, they expect things to move very quickly.”

When Lowenkron explains how The Villages is on track to become “America’s healthiest hometown,” it’s a tall order without visualization.

“It’s like trying to describe Cirque de Soleil! When I made my first trip to The Villages in March 2012, the first thing I noticed was a bustling economy, despite the economic downturn,” he said. “A lot of people were congregating at town square. I’d never seen so many smiling faces and hand-holding.”

The new model of healthcare being implemented at The Villages was devel-oped in great interest from residents. Be-fore crafting a model, USF Health initiated the nation’s largest canvassing survey of its type, with an unprecedented response.

“What makes The Villages such a great place is the residents’ social connect-edness and willingness to work with us on a public health survey that provided us with a roadmap for what’s they’re looking for in a medical home,” he said.

Residents were mostly concerned about their care being fragmented, which left them with gaps in confidence and con-tinuity to assure them the ability to main-tain their active lifestyles, said Lowenkron.

“A common theme was seeing mul-tiple doctors who were telling them multiple things, with some conflicting in-formation,” he explained. “I’d hear, ‘some provider is sending me someplace with a specific question in mind and when I get there, the provider seems to want to an-swer a different question. When I ask one question, I often get two different answers and I can’t quite figure out the best way to go.’ That type of fragmentation is com-mon in a lot of areas around the country.”

The Villages’ healthcare network is more than a simple buddy system.

“That almost implies you’re linked to one neighbor, but you’re linked to many neighbors,” he said. “For example, a couple of groups asked me about specialty care, in particular whether we’d have an oncologist come in, or someone focused on multiple sclerosis. My answer was al-ways consistent: we need to take a look and understand the demand. If there’s enough demand, then yes, absolutely. I can’t tell you the time frame, but we defi-nitely will.”

The Villages’ 100-member Multiple Sclerosis (MS) Club was the first group to approach Lowenkron.

“They did their own informal survey that asked the question: if USF brought a specialist to The Villages, how many would see the doctor? Of those, 39 said absolutely, they’d see that doctor,” he said. “With that information, I can build a demand model for the number of appoint-

ments I’ll need to set aside for the year and have our MS expert come up to The Vil-lages. It’s not enough for a full-time job, but there’s enough work and interest from the people who are doing care delivery to manage the need. In a month or so, we’ll finalize how that process should work and get someone up there. That exemplifies one little piece.”

MS Club members also asked about the possibility of being included in clinical trials.

“Let’s say it turns out there’ll be a brand new potential treatment for MS,” Lowenkron said. “We could go to the club and tell them what we’re doing, ask if they’re interested, and they’d give us good, honest feedback. These are the types of opportunities you don’t get in many different places.”

The Villages’ first primary care cen-ter opened in early 2013. The urgent care center opened later in the year. Since then, two primary care centers have opened, and two are scheduled to open soon. About three dozen primary care physicians have been hired, with more slots being filled as the need demands it.

Lowenkron called the model “a pa-tient-centered medical home on steroids.”

“It’s a risk-bearing model,” he ex-plained. “There’s great evidence that an integrated pathology-supported system works. It’s being built on the back of the community at the community’s request, specialty by specialty from the ground up, in a way there’s good alignment. There’s philosophical integration and engagement to help build the system and to match up and link to our programs at USF. How do we ensure that people have the right care philosophy long-term? With patients as

the center of all we do, geared toward not only committing to value, but also to be measured on performance, it’s an exciting concept. It gives you a model built around community needs.”

Becoming America’s Healthiest Hometown, continued from page 1

symptoms. Left untreated, reflux could lead to serious complications, such as esopha-gitis, stricture, Barrett’s esophagus and esophageal cancer.

“Torax Medical has been extraordinarily concerned with patient outcomes and patients’ well-being by only releasing the LINX device to centers that do a lot of reflux work, in order that the proper evaluation and appropriate patients are chosen for this minimally invasive procedure,” said Grandhige.

The LINX System’s new device is a quarter-sized flexible band of magnets en-cased in tiny titanium beads. The magnetic attraction between the beads helps keep a weak esophageal sphincter closed to prevent reflux. Implanted around a weak sphinc-ter just above the stomach, the minimally invasive procedure typically takes less than an hour to complete. Most patients even go home the same day of the procedure.

“The force of swallowing breaks the magnetic bond to allow food and liquid to pass through, and then the magnetic attrac-tion closes the lower esophageal sphincter back to form a barrier,” said Grandhige.

A procedure developed in the 1990s called the laparoscopic Nissen fundoplica-tion currently is the most common proce-

dure performed for heartburn. “The problem with the procedure is

that each surgeon performs it differently because it’s best used for a completely dys-functional sphincter,” said Grandhige. “In this procedure, the top part of the stomach – the fundus – is wrapped around the lower esophagus to improve the reflux barrier. In patients who have severe reflux, this pro-cedure works very well and has minimal side effects of bloating and dysphagia. The problem with the Nissen fundoplication is that it works too well in those patients with mild to moderate reflux, and these patients may report gas bloating because of the de-creased ability to belch.

The LINX Reflux Management sys-tem standardizes the surgery, leading to more reproducible results, he said.

Three years after sphincter augmenta-tion with the LINX System, the majority of treated patients were able to substantially reduce or resolve their reflux symptoms, while also eliminating their use of reflux-related medications, according to the New England Journal of Medicine summary.

In 100 percent of patients, severe re-gurgitation was eliminated, and nearly all patients (93 percent) reported a sig-nificant decrease in the need for medi-

cation. Ninety-four percent reported satisfaction with their overall condition after having the LINX System procedure, compared to 13 percent before treatment while taking medication.

“Surgical options such as the Nissen fundoplication offer a static solution to the treatment of reflux which is required in late-stage disease,” said Grandhige. “The LINX procedure is dynamic because opening and closing simulates the normal sphincter, except you’re keeping it closed so you don’t have reflux. Now we have a

choice for patients that we can tailor-make the surgical approach to this problem.”

The Tampa Bay Reflux Center offers three procedures for reflux: one endoscopic (incision-less) procedure and two laparo-scopic procedures.

“By offering various options, we’re able to tailor an appropriate treatment for our patients, without pigeon-holing all pa-tients into one option,” said Grandhige.

Like Nissen fundoplication, the proce-dure is done laparoscopically through five small punctures in the abdomen.

“Once we’re in the OR, we can decide which procedure the patient is better suited for, depending on anatomy,” he said. “For example, the LINX procedure cannot be done if the patient has a hiatal hernia larger than three centimeters.”

Another patient benefit is a quicker return to eating solid food.

“We try to get LINX patients to eat regular food right away to train the device,” he said. “With the Nissen procedure, they’re on a prescribed diet for at least two weeks.”

Because the procedure is new, insur-ance coverage varies by provider and is usually approved on a case-by-case basis, but Medicare has started to approve a por-tion of the procedure.

Florida LINX-Approved Surgeons:Florida Hospital Celebration Health James C. Rosser, MD

Florida Hospital Orlando Steve Eubanks, MD

Mayo Clinic in Florida, Jacksonville Kenneth R. Devault, MD C. Daniel Smith, MD

Tampa Bay Reflux Center Brandon, Tampa, & South Tampa Gopal Grandhige, MD

Reflux KO, continued from page 1

PhysicianSpotlight

Joelle Angsten, MDwhere the couple completed their medical residencies after meeting, marrying and earning their MDs from the University of Miami School of Medicine in 1995.

Angsten’s family moved to Sarasota when she was a toddler, and now “We live right around the corner from my parents. That was by design,’ Angsten said. “We’re pretty much at their house or they’re at ours.”

Angsten says the whole clan, which in-cludes two younger sisters who also live and work in Sarasota, gets together often at her parent’s home to break bread over spaghetti or share “eggplant parmesan so good it will make you cry. … You can actually taste the love in it and you can tell when mom’s cooking (her homemade tomato sauce) be-cause of how many cars there are in the driveway,” she laughed, noting the irony that her mom is actually Irish-German who learned to cook Italian from a neighbor.

Angsten said it is a priority for her fam-ily to dine together every night, even if it is at the ballpark, where her son plays and her husband coaches Little League. “One of Brian’s mentor’s told him long ago that if he made it a point to be home for dinner every night, he would never regret it. It’s re-ally worked for us.”


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SURGICAL WEIGHT LOSS: Get Back To

A Healthier, Happier YOU!

bar • i •at • ric (noun) -a branch of medicine that deals with the control and treatment of obesity and related diseases.

FREE Educational SeminarsA Support group is available and free on the same night as our seminars.

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Seminars are presented by our Bariatric & General Surgeons to register for a seminar, call 1-855-BARIATRic (855-227-4387)

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By WENDy R. LEVINE

In an effort to keep up with cutting edge technology (pun intended) physicians at the Heart and Valve Institute at Bra-denton’s Blake Medical Center (BMC) re-cently began implementation of the Sapien Transcatheter Aortic Valve Replacement (TAVR) for patients experiencing severe senile aortic valve stenosis.

Approved by the U.S. Food and Drug Administration in 2011, TAVR is the first artificial heart valve that can replace an aor-tic heart valve without open-heart surgery. The Sapien TAVR is made of cow tissue and polyester supported with a stainless steel mesh frame.

While there are 155 hospitals in the country offering this procedure, BMC is the only hospital in Manatee County per-forming TAVR surgery. After a $6 million investment and months of preparation, the TAVR team performed their first heart valve implant on December 5, 2012 and as

of February 26, 2014, they have performed 71 TAVRs with excellent outcomes.

Developing the TAVR program at BMC involved a tremendous amount of planning, preparation, education training and demonstrated expertise and skill in per-forming the TAVR procedure. Becoming a TAVR site required strict adherence to an extensive number of regulations mandated by the Centers for Medicare Services (CMS).

Senile aortic valve stenosis is a progres-sive, age-related disease caused by calcium deposits on the aortic valve that cause the valve to narrow. As the heart works harder to pump enough blood through the smaller valve opening, the heart eventually weak-ens, which can lead to problems including chest pain, fainting, irregular heart rhythms, heart failure or cardiac arrest

Although open-heart aortic valve re-placement surgery is the gold standard treatment for severe symptomatic aortic valve stenosis, open-chest surgery is some-times contraindicated because of a patient’s age, history of heart disease, frailty or other health issues.

According to BMC’s interventional cardiologist Enrique Rivera, MD approxi-mately 7 percent of Americans age 65 and older have aortic valve disease and “it is

likely 50 percent of these people will not survive beyond two years after the onset of symptoms.” These symptoms may include chest pain and/or tightness, heart palpita-tions, shortness of breath and fatigue.

“Advanced age, severe aortic valve dis-ease symptoms and symptoms from other health conditions can even completely in-capacitate people, eliminating quality of life,” said Rivera, adding, “these patients are often too sick or too weak to undergo open surgery to replace their diseased valve – the preferred method. TAVR can be a life changing option for these types of patients.”

If after a comprehensive evaluation by an interventional cardiologist and car-diothoracic surgeon it is determined that a patient is a candidate for TAVR, the proce-dure is performed under general anesthesia. This less invasive procedure can be per-formed through two different approaches – transfemoral (through an incision in the leg) or transapical (through an incision in the chest between the ribs).

In any event, the TAVR procedure requires a multi-disciplinary team of inter-ventional cardiologists, cardiac surgeons, anesthesiologists, cardiac catheter lab nurses and staff.

At BMC the heart team utilizes the

transfemoral procedure enabling the place-ment of a balloon-expandable heart valve into the body via a delivery catheter. The catheter, which is slightly wider than a pen-cil, and the Sapien TAVR are inserted into the femoral artery through a small cut in the leg and threaded to the site of the diseased valve. The heart valve is then released from the delivery catheter and expanded with a balloon and is immediately functional.

The most common serious and poten-tially life-threatening side effects in patients receiving the TAVR include death, stroke, perforation of the blood vessels, ventricle or valvular structures, damage to the conduc-tion system in the heart, significant bleeding and leaks around the new valve.

Because of other medical issues 70 year-old Sharon Rayle of Bradenton was not a candidate for the conventional open heart surgery. She opted to have the TAVR procedure at BMC on August 21, 2013 and in her own words is “doing amazingly well.”

Sharon indicated that prior to surgery she was in pretty bad shape since her valve was almost closed. “I was very short of breath and slept a lot.” Today, she goes to cardiac rehab twice a week and is happy her quality of life has improved because she can breathe better and doesn’t sleep as much.

TAVR Comes to Bradenton’s Blake Medical Center


SURGICAL WEIGHT LOSS: Get Back To

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bar • i •at • ric (noun) -a branch of medicine that deals with the control and treatment of obesity and related diseases.

FREE Educational SeminarsA Support group is available and free on the same night as our seminars.

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Metabolic andBariatric Surgery

TAMPA– Lithium, one of the oldest and most widely used drugs to treat neu-ropsychiatric illnesses, such as bipolar dis-order, has a serious drawback – toxicity. In a continued effort to find a safer form of lithium, researchers at the University of South Florida (USF) have discovered that lithium salicylate, an alternative salt form, might be the answer.

Researchers found that oral lithium salicylate produced steady lithium levels up to 48 hours in rats, without the toxic spike associated with the rapid absorption of current FDA-approved lithium carbon-ate. They concluded that lithium salicylate could be more effective than lithium car-bonate, yet without accompanying risks of toxicity, a potentially important devel-opment in the next generation of lithium therapeutics.

Their study results, “Plasma and Brain Pharmacokinetics of Previously Un-explored Lithium Salts,” appeared in a re-cent issue of RSC Advances, the journal of the Royal Society of Chemistry.

While lithium carbonate has been very effective for the treatment of mania in bipolar disorder, and credited for re-

ducing suicides in depressive phases of the disease, patients who take lithium carbon-ate are often noncompliant because of adverse effects, including hand tremor, diarrhea, vomiting, weight gain and de-creased thyroid function. New drugs – as effective as lithium carbonate, but without toxicity – haven’t been forthcoming.

“Despite its narrow therapeutic win-dow and the emergence of proprietary alternatives, U.S. FDA-approved lithium therapeutics are still regarded as the ‘gold

standard’ for the treatment of the manic phase of bipolar disorder,” said study lead author Adam J. Smith, PhD, a neuro-scientist at the Center of Excellence for Aging and Brain Repair, Department of Neurosurgery, at USF Health. “Our previous research suggested that re-en-gineering lithium therapeutics by crystal engineering might produce better perfor-mance with reduced toxicities.”

Crystal engineering is the design and synthesis of molecular solid crystal struc-

tures with desired properties using inter-molecular interactions, Smith said.

For their latest study published in RSC Advances, researchers tested two previously untested salts of lithium – salic-ylate and lactate – both of which are struc-turally different from lithium carbonate. In laboratory rats, they found that lithium salicylate and lithium lactate exhibited “profoundly different pharmacokinetics” when compared to the FDA-approved and widely used lithium carbonate.

“To our knowledge, this is the first pharmacokinetic study of lithium sa-licylate and lithium lactate in laboratory animals,” Smith said, noting that phar-macokinetics is the way the body absorbs, distributes and gets rid of a drug.

The findings support earlier sugges-tions that an ideal lithium preparation would be one that would both “flatten” high blood level peaks and also slow declining blood concentrations, the re-searchers report.

“This is exactly the pharmacokinetic profile produced by lithium salicylate in our study,” said senior author Doug Shytle, PhD, also of the Center of Excel-lence for Aging and Brain Repair at USF Health. “Remarkably, lithium salicylate

Exploring Safer Lithium Therapy USF Health researchers release preclinical study on toxicity, discovery of viable option



ALL-NEW SHOW LIVE ORCHESTRA

“The conductor is fabulous, the orchestra was fabulous—so, so wonderful... the composers, the people that did some of the work to bring this music together, mixed with the [dance] perfectly... the music, the conductor is

the best I’ve ever heard.”— Rick Crompton, musical conductor

“Many artists in the world admire Shen Yun’s quality. It is the highest form of dancing art that mankind could

possibly achieve. I am beyond admiring it!”— Joseph Kuo Nan-Hong, celebrated director and

producer, known as the godfather of films in Taiwan

“My overall impression is that it is beyond anything I can put into words. It’s the most amazing, uplifting, spiritual journey... it transcends you to a higher state of

consciousness. Amazing!”— Margaux Brooks, executive film producer

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APRIL 22-23 Two ShowsTwo ShowsTwo ShowsTwo ShowsTwo ShowsTwo ShowsTwo ShowsTwo ShowsTwo ShowsTwo ShowsVan Wezel Hall, Sarasota

5,000 Years of Myths & Legends Come Alive Don’t Miss This Extraordinary Event

“I’ve seen many Chinese performances. I was touched by some of the performances and concerts, but I was never moved so deeply as I was today… The programs stirred me again and again. I was constantly trying to keep myself contained, but in the end I couldn’t control myself. I cried...”

— Dr. Thomas Weyrauch, author and China expert

Presented by Florida Falun Dafa Association

“I was moved to tears a few times. It was very uplifting. They use their costumes brilliantly with their movement.

I’ve never seen anything like that before.”— Carol Miller, former Ballet teacher

“The dancers are some of the most phenomenal, especially the male dancers are absolutely amazing... it resonates through you, no matter you are 5 or 65, it was

just an amazing show.”— Jessica Black, Miss USA 2010

Shen Yun Symphony OrchestraOctober 27 Van Wezel Hall

After Shen Yun performing arts shows on APR 22-23, Shen

Yun’s symphony orchestra will return to Sarasota

for one concert

By CINDy SANDERS

What is the best way to get … and keep … diabetic patients actively engaged in the lifelong self-management of their condition?

The individual or institution that comes up with a definitive answer to that question will surely be remembered in the history books in the same manner as Jonas Salk. After all, diabetes is a pervasive condi-tion of epidemic proportions in much of the world. According to the latest statistics from the National Institutes of Health, 25.8 mil-lion Americans have diabetes … roughly 8.3 percent of the nation’s population. Ad-ditionally, it is estimated another 79 million American adults have prediabetes, putting them at high risk for developing the condi-tion without active intervention to stop the progression toward disease.

Keenly aware of the toll diabetes takes on the body, healthcare providers routinely talk to patients about the threat of comor-bid conditions ranging from heart disease, stroke and kidney disease to blindness and amputation. Yet, there continues to be a disconnect from what a patient seemingly hears and understands in the office and what actually transpires on a daily basis.

“We talk about diabetes all day long with patients, but they have to go about their business of living with the disease,” noted Eliz-abeth S. Halprin, MD, associate director of Adult Diabetes at Joslin Diabetes Center, an af-filiate of Harvard Medi-cal School.

A recent study con-ducted by Joslin researchers looked at ob-stacles present among patients with poorly controlled diabetes. Halprin, a board certified endocrinologist and instructor at Harvard Medical School, said the reasons for poor management vary hugely and are specific to individuals and their own per-sonal circumstances. Are there financial is-sues that make office visits cost prohibitive? What about transportation or geographic barriers that make it difficult to get to an appointment? Perhaps an individual is working multiple jobs or caring for every-one else in the family with little time left over to address their own needs.

Halprin said the study also revealed

Addressing Obstacles on the Road to Diabetes Control


Dr. Elizabeth S. Halprin

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some interesting perceptions about the healthcare system and providers. “They find the whole healthcare system imper-sonal,” she said of the study participants. “They think we’re not listening and that we suggest things that aren’t practical.”

To a physician, telling a patient to ‘in-crease physical activity’ seems like a highly appropriate, straightforward step toward better diabetes management. To a patient who struggles financially, a gym member-ship is out of the question and strolling through an unsafe neighborhood could be more dangerous to their health than the disease, itself.

“Diabetes is a very time consuming disease to have, but it’s also a very time con-suming disease to treat,” Halprin pointed out. “The healthcare system doesn’t always permit the time for exploring and looking at each person’s individual needs.”

To address that, Joslin is investigating the addition of care coordinators to work with high-risk patients. The coordinator becomes the point person who initiates a follow-up call after an appointment to see if the patient understood recommenda-tions and to make sure prescriptions are being filled. The coordinator might also reach out to remind the patient when it is time for their diabetic eye or foot exam. This is the individual who is more likely to know about medication assistance pro-grams, area outlets for safe activity, and other resources to overcome obstacles.

Although the concept isn’t novel in healthcare, it is one that has been difficult to fund under the current payment system. Changes in reimbursement models, such as the patient-centered medical home, make it more feasible to add a care coor-dinator to the team approach that Halprin used at Joslin. In addition to the physician, the team includes a nurse practitioner, nu-tritionist, exercise physiologist, registered nurse, psychiatrist and diabetes educator. Through a joint project with Beth Israel Deaconess Medical Center, Joslin has launched the Diabetes Practice Liaison Program to share collaborative strategies with primary care providers and their of-fice staff in the region.

Just as one provider doesn’t hold all the answers, it’s unlikely one approach will meet everyone’s needs.

Halprin pointed to another study among Joslin’s older patients that had en-couraging outcomes. “A highly structured education program with specific tasks and cognitive behavior strategies resulted in better A1c control, which was maintained for at least a year,” she noted of the in-tervention that worked well with older patients up to age 75. However, she con-tinued, that program didn’t show the same promise among middle-aged patients.

Race and ethnicity are also important variables in how information is received, perceived and acted upon. Joslin has ini-tiatives for Asian, African-American and Latino patients that take into account so-cial and cultural traditions. Considering the risk of diagnosed diabetes in compari-

son to non-Hispanic whites is 18 percent higher among Asian Americans, 66 per-cent higher among Latinos, and 77 per-cent higher among non-Hispanic blacks, reaching these specific populations in a meaningful way is critical.

Halprin, a member of Joslin’s Latino Diabetes Initiative, noted there is a support group that meets regularly at the diabetes center to knit and chat. A staff psychologist joins the group to guide conversation and answer questions.

“They bring food so that’s an oppor-tunity to discuss what is a good choice or a not-so-good choice,” Halprin said. “Nu-trition is a huge part of diabetes care, but it’s also a huge part of the Latino culture,” she noted, adding nutritionists on staff try to make suggestions that are culturally ap-pealing or that revamp traditional meals to lighten the carbohydrate load.

Additionally, education classes are conducted in Spanish and materials have been translated. Providers with the Latino program also are piloting group medical visits with four-eight participants. All of these efforts combine to make the health-care clinic less intimidating and more welcoming of natural conversation and questions about living with diabetes.

In fact, Joslin hosts a number of pro-grams in a group setting including DO IT, a four-day intensive outpatient program de-signed for those who have gotten off track with their self-management; Why WAIT, a combined weight reduction and manage-ment program with a focus on nutrition, physical activity and behavioral support; and interactive games like CarbChallenge where participants test their knowledge of carbohydrate containing foods.

“Diabetes can be a very isolating con-dition,” Halprin said. “It’s good for people to be in a group and know other people are struggling with similar issues.”

What’s good for patients is also good for providers. Halprin’s colleague, Robert Gabbay, MD, the chief medical officer for Joslin Diabetes Center, is slated to give the keynote speech at The American Journal of Managed Care annual meeting. “Patient-Centered Diabetic Care: Putting Theory into Practice” is the 2014 theme of the April 10-11 conference in Princeton, N.J.

“Our meeting will occur as the first waves of newly insured consumers are ac-cessing the healthcare system, including many who will learn for the first time they have diabetes or other cardiometabolic conditions,” said Brian Haug, president of AJMC. “This is an important time for healthcare professionals to be engaged with leaders in this field.”

By working collaboratively, utilizing diverse technologies and education offer-ings, and leveraging the theories embed-ded in new reimbursement models, the hope is patients and providers will work together to overcome the obstacles to ef-fective diabetes self-management.

Addressing Obstacles on the Road to Diabetes Control, continued from page 8


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Teaching Hospital Approved For Highly Specialized Adult Kidney Transplant Program

Largo Medical Center is proud to an-nounce it has been approved to offer one of the most highly specialized adult kidney transplant programs on the west coast of Florida.¬† The program will serve the state’s Transplantation Area 2 comprised of 13 counties*.

Anthony Degina, Largo Medical Cen-ter, Chief Executive Officer said that one benefit to opening the program at the hospital is that it breaks down realistic geographic barriers for the millions of people in the service area who currently must travel a longer distance for kidney transplant services

Other benefits Degina mentions is that it equates to more access, energy and fo-cus on transplantation and expertise with-in the community, meaning:

• there will be an increase in local pub-lic organ donation education,• increased awareness will assist in in-creasing the number of potential donors,• there will be reduced wait times for patients on multiple wait lists,• there will be shorter travel times for transplant candidates in greater Pinel-las County and beyond.During the 4th quarter of 2013, Largo

Medical Center filed a kidney transplant program letter of intent and application. This month Florida’s Agency for Health Care Administration (AHCA) granted the hospital’s certificate of need request. The program is expected to be operational in 2015. Largo Medical Center is one of only eight hospitals statewide approved to pro-vide kidney transplant services.

Northside Hospital Welcomes Jayme Chancellor, MBA, as COO

Northside Hospital is pleased to an-nounce the appointment of Jayme Chan-cellor as Chief Operating Officer. Jayme has been with the HCA West Florida di-vision in different capacities since 2005, including Process Improvement Engineer and Director of Management Engineer-ing. Her most recent title was Vice Presi-dent of Performance Improvement.

Jayme holds a Bachelor’s degree from the University of South Florida, and an MBA from the University of Tampa. She also holds a green belt in Six Sigma and is certified in Lean process improvement. Jayme’s first day at Northside was March 3. She is married with one child.

Lakewood Ranch Medical Center Announces New Board of Governors Members

William “Will” C. Rob-inson, Jr., Representative W. Gregory “Greg” Steube and Larry Wade have been named to the Board of Governors of Lakewood Ranch Medical Center. The 120-licensed bed hospi-tal opened in 2004 and is owned by a subsidiary of Universal Health Services, Inc., headquartered in King of Prussia, Pennsylvania.

William “Will” C. Rob-inson, Jr. is a Principal at the law firm of Blalock Wal-ters, P.A. in the areas of Real Estate, Land Use, Local Government and Business.

Will represents commercial and resi-

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GrandRounds

produced elevated levels of lithium in the blood and brain 48 hours after the dose, but without the sharp peaks that contrib-ute to the toxicity problems of lithium in the currently used form.”

That 48-hour window, said research-ers, represents a critical difference between lithium salicylate and current FDA-ap-proved lithium therapeutics. If these preclin-ical results hold true in humans, this would allow for a less frequent dosing regimen and possibly fewer troublesome side effects that plague conventional lithium therapy.

“Psychiatry has long struggled with the fact that, while lithium is highly ef-fective for treating bipolar disorder, the narrow therapeutic window and side ef-fect profile often makes lithium both dif-ficult and sometimes dangerous to work with clinically,” said Todd Gould, MD, of the Department of Psychiatry at the University of Maryland, an expert in the mechanisms of lithium and the neurobiol-ogy of bipolar disorder. “The pharmaco-kinetic data by Dr. Smith and colleagues suggests that lithium salts other than the commonly used lithium carbonate may have a broader therapeutic window and potentially fewer side effects. Studies in humans will be needed to confirm safety and demonstrate that the pharmacoki-netic profile observed in rats is similarly observed in humans.”

USF researchers expect to soon con-duct the experiments required to support early clinical trials.

Exploring Safer Lithium Therapy, continued from page 7

Greg Steube

Will Robinson


dential real estate developers, corpora-tions, businesses and individuals. His practice involves real estate conveyances, land development and permit approvals and leasing.

Will earned his J.D. from Stetson Uni-versity College of Law and B.A. in Finance with a Certificate in Internal Relations at the University of Notre Dame. He is mem-ber of the Twelfth Circuit Judicial Nomi-nating Commission.

Representative W. Gregory‚ Greg Steube proudly serves House District 73 in the Florida House of Representatives. District 73 includes parts of the counties of Sarasota and Manatee and is one of the fastest growing districts in the State of Florida in both size and population.

Rep. Steube attended the University of Florida where he was inducted into the University of Florida’s Hall of Fame as an undergraduate and earned a B.S. degree with honors in Animal Science with a mi-nor in Agricultural Law. Following his un-dergraduate studies, the Representative attended UF’s Levin College of Law and earned his Juris Doctorate in 2003.

After law school Rep. Steube enlisted in the U.S. Army and spent one year in the infantry and three years in the U.S. Army JAG Corps as a criminal Trial Coun-sel, Chief of Detainee Operations, Legal Assistance Attorney, and Administrative Law Attorney. He served as a Captain in the JAG Corps during Operation Iraqi Freedom. He has received numerous awards and commendations for his ser-vice to his country.

Currently, Rep. Steube is an attorney with Becker and Poliakoff and works in the firm’s Business Litigation Practice Group. He practices in the areas of Government Law, Real Estate and Corporate Litigation, Condominium and Home-owner Litigation, Probate Litigation, and Family Law. He is also a Florida Supreme Court Certified Circuit Civil Mediator.

Larry Wade is an active member of the Lakewood

Ranch Community currently serving on the planning committee of the Dick Vitale V Foundation Gala and the Inter Collegiate Clay Court Classic. He is also a member of the Board of Directors of the North Valley Bank in Zanesville, Ohio.

While in Ohio, Mr. Wade was a mem-ber of the Board of Directors of Zanes-ville Good Samaritan Hospital, Zanes-ville Downtown Association, Chamber of Commerce, Catholic Social Services, Muskingum County Convention Facilities Authority and the Men’s Retailer Associa-tion of America. He was also a member of the Rotary Club, Ohio State University’s President’s Club, Paul Harris Fellow and Campaign Chairman of the United Way twice in 1978 and 1988. He was named Outstanding Citizen of Southeastern Ohio in 1979 and won the Kiwanis Community Service Award.

Moffitt Cancer Center Graduate Student Awarded Joanna M. Nicolay Melanoma Foundation Scholarship

The Joanna M. Nicolay Melanoma Foundation presented Inna Fedorenko, a graduate student in Moffitt Cancer Center’s Cancer Biology Ph.D. program, with the 2014 Research Scholar Award. Fedorenko is one of five students nation-wide receiving this award, which includes $10,000 in grant support for melanoma research.

Although there has been great prog-ress in developing targeted treatments for melanoma, most patients eventually fail therapy. The research being done by Fedorenko and Moffitt aim to personalize therapy through use of novel proteomic technologies. Their insights could lead to new clinical trials that will directly benefit melanoma patients in the future.

The foundation’s Research Scholar Award program was initially piloted with the Johns Hopkins Sidney Kimmel Cancer Center in 2006, and expanded nationally to benefit the broader academic, scien-tific, clinical, and patient communities and encourage more students to choose

melanoma research as their professional career path.

Edward White Hospital Promotes Roger Haney to VP of Operations

Edward White Hospital is pleased to announce the promotion of Roger Haney to Vice President of Operations. Roger currently serves as the Vice President of Human Resources. He has been with

HCA for more than 6 years, having previ-ously worked at Regional Medical Center Bayonet Point and Englewood Commu-nity Hospital.

Roger holds a Bachelor’s Degree in Hotel, Restaurant and Institutional Man-agement and a Master’s Degree in Indus-trial and Labor Relations from Indiana Uni-versity of Pennsylvania. He is married with two children.

GrandRounds

Match Day Held at USF

Of the 121 USF Health medical students par-ticipating in Match Day, March 21 at Skipper’s Smokehouse, 39 percent will stay in Florida, with 30 percent of the class matching at the USF Health Morsani College of Medicine. Other students scattered across the country, going everywhere from Massachusetts General Hospital to UCLA Medical Center.

U.S. Rep. Kathy Castor, left, flashes the “Go Bulls” sign as Alicia Billington, recipient of the first match letter, finds out she’ll be doing a residency in plastic surgery at her first choice — the USF Health Morsani College of Medicine. Before the USF Health Match Day celebration began, Congresswoman Castor announced the introduction of proposed legislation to support more residency training slots. Billington, right, is one of the nation’s leading student advocates for increased graduate medical education funding.

USF senior medical student Lowell Dawson and his wife brought their three daughters, dressed in child-size white lab coats, to Match Day. With cues from Dawson whispered in her ear, 5-year-old Aniya announces that dad will be training as an interventional radiologist at USF.

After Danielle Kurant opened her envelope, she faced the camera and shouted to her friend watching the livestream of USF Health Match Day: “Get my room ready. I’m coming to UVA!” That’s the University of Virginia in Charlottes-ville, VA, where Kurant will specialize in pathol-ogy. Holding the microphone is Steven Specter, Associate Dean for Student Affairs at the USF Health Morsani College of Medicine.

Larry Wade

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Tampa Bay Medical News April 2014