December 6, 2019

TIME = VISION

By Alan L Wagner MD, FACS, FICS

 

Stop, Drop, and Roll. Apply direct pressure to a wound. Thirty chest compressions before two rescue breaths. Sixty minutes “door to needle” within 240 minutes of symptoms with an ischemic stroke.

Here’s another rule everyone should know: 97 minutes until irrevocable loss of vision with a Central Retinal Artery Occlusion (CRAO). Blindness at six hours!

The retina, highly specialized brain tissue, is one of the most metabolically active parts of our body. Most think of changes in vision as non-emergent, or something that goes along with age.

Yet we recently received a “semi-urgent” referral of a 72-year-old female with an acute loss of vision for three hours in her non-dominant left eye. A painless change, without systemic complaints. She carried the diagnosis of a possible retinal detachment. Could we please see her later in the afternoon, or tomorrow?

We had her come in directly. She had a CRAO. An evolving ischemic stroke of the eye! Our emergent intervention restored blood flow, and she got her sight back. Few are as fortunate.

A CRAO usually presents as painless, acute and with profound loss of vision (visual acuity of barely counting fingers to no light perception). The U.S. incidence of a CRAO is 1.9/100,000.

The cause of the CRAO is usually a thromboembolus. It lodges where the central retinal artery, a division of the internal carotid artery, enters the optic nerve adjacent to the globe. Only if the thrombus/embolus can be dislodged, or lysed, will vision recover. Retinal recovery depends upon age and pre-existing conditions.CRAOs may be associated with: carotid artery disease, atherosclerosis, valvular heart disease, myxoma, atrial fibrillation, hypertension, smoking, IV drug abuse, oral contraceptives, sickle cell disease, homocystinuria and pregnancy. Most patients are in their 60s, with men at greater risk than women. Arteritic causes are rare (<5%).  

A macular cilioretinal artery is present in 15 to 30 percent of the general population. It spares the central 5º– 10° of the visual field, maintaining its flow during a CRAO. These fortunate patients experience an acute loss of their peripheral vision. If a CRAO develops in the non-dominant eye possessing a cilioretinal artery, a constrained “tunnel vision” is discovered when the dominant eye is covered.

 If a CRAO is suspected, immediate referral to an eye surgeon is crucial, because time equals sight!

There is no definitive treatment for a CRAO. Removing fluid from the eye, vasodilators, and lytic therapy are options. Reducing intraocular pressure abruptly allows the systemic blood pressure to better push the embolus “downstream”, sparing more retina. Similarly, drops or systemic mannitol can be employed. Thrombolytic therapy and vasodilators have had mixed results. Carotid ultrasound, echocardiogram and Holter monitor are standards of care for primary testing, identifying the most likely origin of the thromboembolus.  A CRAO, or branch retinal artery occlusion, BRAO, can be associated with increased mortality.  The American Academy of Ophthalmology recommends emergent referral to the emergency room, and the Neurology service, following initial treatment for CRAO/BRAO. The highest window for risk of a stroke is within seven days of presentation of a CRAO/BRAO. That risk remains elevated for the first 30 days.Close follow-up by both the surgeon and medical team is of paramount importance to optimize the patient’s success and survival, and to avoid complications.  

Remain suspicious of, and sensitive to, reported vision loss.

Alan L. Wagner, MD, FACS founded the Wagner Macula & Retina Center in 1987. A Board-certified ophthalmologist specializing in vitreoretinal surgery, Dr. Wagner received his medical degree from Vanderbilt University School of Medicine. He completed his residency in Ophthalmology at EVMS, and furthered his training as the Dyson Fellow in vitreoretinal disease and surgery at Weill Cornell University Medical Center.  wagnerretina.com

Side Summer 18

Summer 2018 Issue
Family and Internal Medicine
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Physician Spotlight 

 

James G. Dixon, MD
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Margaret M. Gaglione, MD, FACP
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J. Matthew Halverson, DO, FAAFP
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Good Deeds

John D. Sheppard, MD, MMSc
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Tonia Yocum, PA-C
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Treating the Spine
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Physician Spotlight

J. Abbott Byrd, III, MD, FAAOS
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Jeffrey R. Carlson, MD
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Mark Bradley Kerner, MD
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Dean B. Kostov, MD
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Antonio Quidgley-Nevares, MD
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H. Sheldon St. Clair, MD
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Good Deeds

Donna Talbott, NP
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Advanced Practice Provider

In Memoriam:
Angela Marie, Galdini, MD
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Past 2016 Board

AbuhamadAlfred Abuhamad, MD
Obstetrics & Gynecology

Dr. Abuhamad serves as the Vice Dean for Clinical Affairs and the Mason C. Andrews Professor and Chair, Department of Obstetrics and Gynecology at EVMS. He is Board Certified in Obstetrics & Gynecology and Maternal-Fetal Medicine. He is the current president of the Society of Ultrasound in Medical Education, and the National Council of Safety in Women’s Healthcare and past president of the American Institute of Ultrasound in Medicine.

AdcockO.T. Adcock, Jr., RPh, MD
Registered Pharmacist/Family Medicine

Dr. Adcock is a Board certified Family Medicine physician in practice in Hampton for 32 years.  He currently serves as Associate Medical Director and Service Line Chief for Primary Care and Access for Riverside Medical Group.

AldridgeJohn W. Aldridge, MD, FAAOS
Orthopaedic Surgeon 

Dr. John Aldridge is Board certified orthopaedic surgeon with Hampton Roads Orthopaedics & Sports Medicine. He specializes in minimally invasive muscle sparing spinal surgery and total joint replacement surgery. Dr. Aldridge practices at both the Newport News and Williamsburg office locations of HROSM. In addition to his many interests in the field of orthopaedics, he also serves as a Lieutenant Colonel in the United States Army Reserves.

JohnsonBrian L. Johnson, MD
Dermatology

Dr. Johnson is the founder of The Virginia Dermatology & Skin Cancer Center.  He is a Fellow of the American Academy of Dermatology, American College of Mohs Surgery, and the American Society of Dermatologic Surgery. His emphasis is on the treatment of skin cancer using the Mohs Micrographic surgical technique, an advanced surgical procedure for the treatment of skin cancers.

McFarlandMark W. McFarland, DO
Orthopaedic Spine Surgery

Dr. McFarland practices at the Orthopaedic & Spine Center in Newport News and is Board certified In Orthopaedic Surgery and Fellowship trained in Spine Surgery.

Miles-ThomasJennifer Miles-Thomas, MD, FPM-RS
Urology

Dr.  Miles-Thomas is a urologist with The Devine-Jordan Center for Reconstructive Surgery and Pelvic Health-a division of Urology of Virginia, an Assistant Professor in the Department of Urology at EVMS, and the Medical Director for the Pelvic Health Center at Chesapeake Regional Medical Center. Dr. Miles-Thomas is Board certified and fellowship trained in urology. She is also Board certified in female pelvic medicine and reconstructive surgery.

HesedMugaisiHesed Mugaisi, MD

Dr. Mugaisi is a Board certified family medicine physician with Bon Secours Suffolk Primary Care.  He acquired his bachelor of medicine and bachelor of surgery from the University of Nairobi in Nairobi, Kenya and completed his family medicine residency at Group Health Family Medicine Residency Program affiliated with University of Washington in Seattle, WA.

Pagador16Jennifer F. Pagador, MD
Family, Bariatric and Age Management Medicine

Dr. Pagador is Medical Director of Seriously Weight Loss, LLC and Attending Physician at Revita Medical Wellness, specializing in medical weight loss and hormone optimization. Dr. Pagador is Board certified in family medicine.

RomashMichael M. Romash, MD
Board Certified Orthopaedic Surgeon

A Board certified lower extremity specialist practicing for over 30 years, Dr. Michael Romash is a Fellow of the prestigious American Orthopaedic Association and known as a pioneer in his field. Author of numerous medical journal articles and chapters in text books about foot and ankle surgery, he has developed treatments commonly used for various heel fractures.

SkaryakLynne A. Skaryak, MD
Thoracic Surgery

Dr. Skaryak is Director of Thoracic Surgery and Co-Director of Thoracic and Lung Health at Chesapeake Regional Medical Center.  She is Board certified in Thoracic Surgery.

Liability Risks of Telemedicine:

State Standards Among Considerations
By Dustin Shaver, Vice President of Risk Management at NORCAL Mutual Insurance Company

Telemedicine utilization growth continues at an impressive rate. According to the FAIR Health database (the largest repository of private healthcare claims), telemedicine use in the U.S. nearly doubled between 2007 and 2015. Over half of all U.S. hospitals now use some form of telemedicine, according to the American Telemedicine Association. Telemedicine is widely credited with improving patient access, cost efficiencies and quality of care. This and increasingly favorable state and federal telemedicine legislation may explain the rapid increase in its utilization. Despite the advantages, telemedicine has liability risks, such as privacy, security, patient confidentiality, credentialing and misdiagnosis due to a lack of continuity of care. Additionally, the soft skills that may come naturally in a personal patient encounter may need to be adjusted for electronic encounters. Telemedicine providers should evaluate their “webside” manner. For example, equipment needs to be positioned to simulate direct eye contact; active listening cues may need to be exaggerated; posture and facial expressions may need adjustment and sessions must be started and ended appropriately. Seemingly minor electronic communication strategies can significantly affect the success of a telemedicine encounter.

Physicians who adopt telemedicine also have administrative considerations that may pose a challenge and liability risk. For instance, professional licensure portability and individual state mandated practice standards present major challenges. There are significant differences among state telemedicine laws and the laws are constantly changing. In the 2016 legislative session, for example, over 150 telemedicine-related bills were introduced by 44 states. The issues addressed by these bills ranged from informed consent requirements to online prescribing parameters to Medicaid reimbursement. Physicians should be aware of the telemedicine laws in their own state and in the state of every patient in their telemedicine practice. Understanding the laws is paramount to understanding the medical liability risks that may be involved in the various different stages of providing telemedicine.

Medical professionals providing virtual visits must work harder to reduce practice liability exposures. To help enhance patient safety and reduce risk:

Understand that individual state telemedicine practice laws vary from state to state.

Consult with your healthcare business attorney as needed.

Check your professional licensure portability to ensure that you are licensed to practice in the jurisdiction where the patient resides.

Consult with your medical practice liability insurance company to ensure that your policy covers all jurisdictions where you plan to provide services.

Be aware of online prescribing regulations that vary across jurisdictions.

Comply with all applicable privacy and security standards for the secure transmission of protected health information between patient, provider and payers.

Standardize telemedicine patient visits to help minimize the potential for error and to support good communication practices.

Take care to ensure that the primary care physician and patient relationship is not fractured with ongoing use of telemedicine consultation.

Telemedicine is an emerging practice and the rising rate of adoption by both physicians and patients is an indication of its value. As with all advancement in the field of medicine, the advantages of adopting a new way of practice should be considered carefully and risks assessed. It is important to consult with your medical professional liability insurance provider on your individual policy to ensure you are adequately covered for the scope of practice, and consult with your business attorney as needed.

NORCAL Mutual has a team of risk management specialists available to consult and assist policyholders with the assessment of their practice and to help identify and address risk exposures. To learn more about managing telemedicine risk exposure, NORCAL policyholders can access the September 2016 Claims Rx entitled “Telemedicine Risk Management,” which is available through MyACCOUNT on the new MyNORCAL® mobile app.

This article is reprinted with the permission of NORCAL Mutual Insurance Company.
NORCAL Mutual Insurance Company. Liability Risks of Telemedicine: State Standards Among Considerations

Innovations in Breast Prostheses

By Teresa Kelly

For patients who do not choose breast reconstruction, or those with a failed reconstruction, breast prostheses can help recapture the look and feel a woman had prior to her lumpectomy, mastectomy, reduction or uneven reconstruction.

Breast07_16Conventional off-the-shelf breast forms are made of silicone, foam or fiberfill, and come in many shapes and sizes.  These forms tuck inside a special pocketed bra or camisole to keep the form in place.  Some styles come with adhesive backing that attaches to the chest wall for a very natural look and feel.

Custom breast forms can be fabricated to give a more natural appearance by matching the patient’s natural contours and skin color, resulting in a better fit and more symmetrical look.

Improved Fitting Results with 3D Laser Scanning.
Advances in technology are bringing changes to the world of breast prostheses.  One example is the FastScan system (http://fastscan.com), a portable 3D scanner that makes a digital scan of the chest in real time. This technology delivers great results for post-mastectomy fitting, as well as for lumpectomy and uneven/unbalanced reconstruction.

3D scanning gives precise imaging of the patient’s chest, as well as any remaining breast tissue.  The back side of the custom prosthesis is tailored to the exact dimensions of the surgery site as digitized by the scanner, providing the best possible fit.  This precise fit eliminates the need for a pocketed bra and gives women the freedom to wear off-the-shelf bras and swimsuits.

Custom Prostheses Give Patients More Color Options.

There are many companies that specialize in custom breast prostheses, offering patients breast forms that are lighter than traditional silicone off-the-shelf forms and available in a multitude of colors. These manufacturers can provide as many as 30 skin tone colors to choose from, ensuring a prosthesis that can match (or very closely match) a woman’s natural skin tone.  The results are a realistic appearance that is a unique duplicate of the patient’s natural breast.

Another benefit of a custom prosthesis is the ability to custom contour nipples and areolas.  These are fabricated to match the desired size, color and shape of the remaining nipple and areola.  Semi-custom nipples and areolas can also be fabricated for post-bilateral reconstruction patients.

What to Expect from Insurance.
Insurance coverage can vary, but most typically cover:

A minimum of two, and up to 12, special mastectomy bras (with prostheses pockets) on a yearly basis

One light weight prosthesis every six months

A new, silicone prosthesis every one to two years

Some insurance companies also provide benefits for custom breast prosthesis.  The mastectomy practice will contact each patient’s insurer to determine her eligibility and allowances, as well as any out-of-pocket expenses.  Most plans typically allow lifetime benefits, no matter the length of time since the surgery; patients should be advised to continue to utilize these benefits.

More Choices = Happier Patients = Better Outcomes.

Living with mastectomy or lumpectomy is challenging on many levels.  Giving a woman a piece of her femininity back can provide huge rewards in her mental and physical health.  Advances in technology are extending beyond the hospital walls to after care, bringing devices that can make life more enjoyable and meaningful for patients.  This result is happier patients with better outcomes.

TeresaKellyTeresa Kelly is the Manager of Silhouette Mastectomy Boutique for breast cancer patients, featuring undergarments for women who have undergone mastectomy, with or without reconstruction.   silhouettemb.com

2016 Advisory Board

AbuhamadAlfred Abuhamad, MD
Obstetrics & Gynecology

Dr. Abuhamad serves as the Vice Dean for Clinical Affairs and the Mason C. Andrews Professor and Chair, Department of Obstetrics and Gynecology at EVMS. He is Board Certified in Obstetrics & Gynecology and Maternal-Fetal Medicine. He is the current president of the Society of Ultrasound in Medical Education, and the National Council of Safety in Women’s Healthcare and past president of the American Institute of Ultrasound in Medicine.

AdcockO.T. Adcock, Jr., RPh, MD
Registered Pharmacist/Family Medicine

Dr. Adcock is a Board certified Family Medicine physician in practice in Hampton for 32 years.  He currently serves as Associate Medical Director and Service Line Chief for Primary Care and Access for Riverside Medical Group.

 

AldridgeJohn W. Aldridge, MD, FAAOS
Orthopaedic Surgeon 

Dr. John Aldridge is Board certified orthopaedic surgeon with Hampton Roads Orthopaedics & Sports Medicine. He specializes in minimally invasive muscle sparing spinal surgery and total joint replacement surgery. Dr. Aldridge practices at both the Newport News and Williamsburg office locations of HROSM. In addition to his many interests in the field of orthopaedics, he also serves as a Lieutenant Colonel in the United States Army Reserves.

JohnsonBrian L. Johnson, MD
Dermatology

Dr. Johnson is the founder of The Virginia Dermatology & Skin Cancer Center.  He is a Fellow of the American Academy of Dermatology, American College of Mohs Surgery, and the American Society of Dermatologic Surgery. His emphasis is on the treatment of skin cancer using the Mohs Micrographic surgical technique, an advanced surgical procedure for the treatment of skin cancers.

McFarlandMark W. McFarland, DO
Orthopaedic Spine Surgery

Dr. McFarland practices at the Orthopaedic & Spine Center in Newport News and is Board certified In Orthopaedic Surgery and Fellowship trained in Spine Surgery.

 

Miles-ThomasJennifer Miles-Thomas, MD, FPM-RS
Urology

Dr.  Miles-Thomas is a urologist with The Devine-Jordan Center for Reconstructive Surgery and Pelvic Health-a division of Urology of Virginia, an Assistant Professor in the Department of Urology at EVMS, and the Medical Director for the Pelvic Health Center at Chesapeake Regional Medical Center. Dr. Miles-Thomas is Board certified and fellowship trained in urology. She is also Board certified in female pelvic medicine and reconstructive surgery.

HesedMugaisiHesed Mugaisi, MD

Dr. Mugaisi is a Board certified family medicine physician with Bon Secours Suffolk Primary Care.  He acquired his bachelor of medicine and bachelor of surgery from the University of Nairobi in Nairobi, Kenya and completed his family medicine residency at Group Health Family Medicine Residency Program affiliated with University of Washington in Seattle, WA.

Pagador16Jennifer F. Pagador, MD
Family, Bariatric and Age Management Medicine

Dr. Pagador is Medical Director of Seriously Weight Loss, LLC and Attending Physician at Revita Medical Wellness, specializing in medical weight loss and hormone optimization. Dr. Pagador is Board certified in family medicine.

 

RomashMichael M. Romash, MD
Board Certified Orthopaedic Surgeon

A Board certified lower extremity specialist practicing for over 30 years, Dr. Michael Romash is a Fellow of the prestigious American Orthopaedic Association and known as a pioneer in his field. Author of numerous medical journal articles and chapters in text books about foot and ankle surgery, he has developed treatments commonly used for various heel fractures.

SkaryakLynne A. Skaryak, MD
Thoracic Surgery

Dr. Skaryak is Director of Thoracic Surgery and Co-Director of Thoracic and Lung Health at Chesapeake Regional Medical Center.  She is Board certified in Thoracic Surgery.

 

Emeritus Board

EmmertitisDocs

 

Bradley R. Prestidge, MD

Regional Medical Director 
for Radiation Oncology
Bon Secours Cancer Institute at DePaul

PrestidgeFullIn November of 2012, when Bon Secours Virginia broke ground on the Bon Secours DePaul Medical Plaza, it was with the vision of establishing a comprehensive cancer institute, which would place state-of-the-art technology in the hands of cancer experts, enabling them to address the unique needs of patients battling cancer.  Less than a year later, Dr. Bradley Prestidge, a world-renowned radiation oncologist, came to DePaul with his own particular vision: a comprehensive suite in which to treat cancer patients with the specialized radiation technique known as brachytherapy.

Thus he had a hand in the design of the brachytherapy suite at the DePaul Cancer Institute; a hand so large, in fact, that he says the architects often tried to look the other way when they saw him coming.   He’s only half joking, but the result is clear: “Very few centers have the efficiency and the capability we have at DePaul,” Dr. Prestidge says.  “We can do many things that can be done in an operating room there.  It’s completely shielded behind a three-ton door, so we can administer brachytherapy in the same room after we perform our procedures, without ever having to wake and move the patient.  I specifically asked for that before I came here.”

In some centers, he explains, it can take as much as a day to complete a treatment, because the anesthetized patient is taken to one room to have the radiation applicators placed, awakened to get on a gurney and taken for a CT scan so the computer plan can be completed.  The patient is then brought back into the original room for treatment.  At DePaul, it’s all done in the brachytherapy suite, and treatment be completed in as little as an hour.

Brachytherapy wasn’t new to Hampton Roads when Dr. Prestidge came to DePaul, but he quickly learned that one vital application of the modality wasn’t being offered: high dose rate brachytherapy for patients with non-melanoma skin cancers like squamous cell carcinoma and basal cell carcinoma.  In Hampton Roads, with its welcoming climate, beaches and outdoor activities, these cancers are commonly diagnosed.  He began reaching out to dermatologists and plastic surgeons to explain the benefits of brachytherapy as an alternative for their more complex cases, which can require extensive surgeries.

“Using an intraoperative 3-D computer plan, we put a single, highly radioactive source, not much larger than a quarter inch, on the end of a cable that goes down a tube into an applicator placed into or on the tumor,” Dr. Prestidge explains.  “The applicators are specifically shaped, molded to the area of the cancer – often the ear or the nose.”  That single, highly radioactive pellet comes down through a catheter into the applicator, either inside or on the surface of the skin, and sits there for a number of seconds while the computer moves it to different positions inside the applicator to deliver the dose.  When the dose is delivered, the source is retracted into the shielded after-loader, and the treatment is done.  Patients leave with no radiation in their body.

It’s a highly effective therapy, Dr. Prestidge says, which he also employs for breast, prostate, cervical, esophageal and rectal cancer cases.  And he emphasizes, “The Cancer Institute is very comprehensive in terms of all its radiation modalities.  I think we’re on par with most any academic radiation department in a university center.  We also do external beam, stereotactic radiosurgery, stereotactic body radiation.  And we just opened the infusion center in September.”

Many cancer patients in Hampton Roads have historically felt the need to travel to Duke or Johns Hopkins, but we have world class cancer care available here.

Temp

covers_Winter_2015Winter 2015 Issue

Cancer

View Winter 2015 issue Click Here

 

Physician Spotlight

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Robert M. Palmer, MD, MPH

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Teresa L. McConaughy, MD
and Paul E. Evans, III, MD

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Marissa Galicia-Castillo, MD

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