Stephen L. Houff, MD Stephen L. Houff, MD - AkronCantonMDNews

Cleveland/Akron/Centon Edition | March-April 2009 VOL. 13, NO. 2Exploring the LinkBetween Genes and Healthat Akron Children’sREVIEW ONLYEasy Access to GeneralSurgery at Euclid,Marymount, Hillcrest andFairview Hospitals© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Pediatric MIS: On theCutting Edge at RainbowSpecial SectionsMen’s HealthMinimally InvasiveSurgeryStephen L.Houff, MDLeading the HospitalistMovement at HMG

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all about George.REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Yes, George. Our patient.We believe in putting patients first, plain and simple. In fact, in most of theemergency departments we staff, the patient actually sees a physician before theysee a nurse. This innovative program results in the patient being satisfied, efficiencysoaring and profitability increasing. As a physician group that staffs hospitalemergency departments with unparalleled patient care, you can be assured thepatient is our highest priority. It’s not about us... it’s all about George.www.emp.com4535 Dressler Road NW, Canton, Ohio 44718800.828.0898CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 1

from the publisherSixteen years ago, before the advent of the hospitalist movement, no one could havepredicted that hospitalist medicine would become the fastest growing specialty in the US.According to estimates related to a 2007 study by the American Hospital Association,there are now approximately 28,000 hospitalists, and that number is expected to swell to50,000 within the next few years.Dr. Stephen Houff was at the forefront of the hospitalist movement in 1993 when heimplemented a single-site hospitalist program at The Ohio State University Hospitals East.Seven years later, he established Hospitalists Management Group (HMG), a nationwideprovider of turnkey hospitalist services. Headquartered in Canton, Ohio, HMG is the largestequal-equity ownership hospitalist group in the country with more than 300 physiciansserving 40 healthcare systems in 15 states. And it continues to grow. Read all about it inthe cover story of this issue of M.D. News.In our Special Section on Minimally-Invasive Surgery (MIS), you’ll find a feature storyabout Rainbow Babies & Children’s Hospital’s Pediatric MIS Center, where improvedtechniques and technology enable endoscopic procedures to be successfully performed onthe tiniest of patients, even those under 5 kg. Dr. Todd Ponsky directs this Center.In the MIS Special Section, you’ll also find a story about the Cleveland Clinic Departmentof Surgery. Several years ago, when Ohio began losing its surgeons to more physician-friendlystates, Cleveland Clinic began taking steps to maintain and expand its General SurgeryDepartment at four regional hospitals: Fairview, Hillcrest, Euclid and Marymount. Today,nine general surgeons provide services at these hospitals.Akron Children’s Hospital is the focus of our third feature story. When Akron Children’sGenetic Center was established in 1977, few people truly understood or appreciated thebenefits of genetic testing. Today, hundreds of patients across all age groups utilize thescreening, diagnostic, treatment and educational services of the Center which is directedby Dr. Mohamed Khalifa.We hope you’ll enjoy these and the dozens of other articles — clinical, business and lifestyle— in this issue of M.D. News. All were contributed by local physicians and professionalswho are an important part of the Cleveland/Akron/Canton healthcare industry.Do you have comments or suggestions for future stories or articles? If so, give me a callor send me an e-mail. As always, your input is welcomed and very much appreciated.Cleveland/Akron/Canton EditionPublisher: Jan RaabePhotographers: Joe Smithberger, North Canton;Jamie Janse, CantonWriters: Robert Janek; Liz Meszaros; AlexStrauss; Martha Bethea, CPA; Ron Pavlovic, CPA;Joseph Feltes; Paul Guerra, AIF; Richard Weidrick,CPA; Raymond Latiano, CFP; Nathan Vaughan;Matthew Hunt; Larry Stern, MD; Eric Espinal, MD;Matthew Demore III, DPM; Dann Granzhorn, MD;Gil Peleg, MD; David Perse, MDM.D. News is published by Sunshine Media, Inc.8283 N. Hayden Rd., Ste 220Scottsdale, AZ 85258(480) 522-2900 | sunshinemedia.comCEO: David McDonaldPresident: Tony YoungChief Financial Officer: Webster AndrewsFounder: Robert J. BrennanVice President of Market Development: Ken MinnitiPublisher Development Manager: Teri BurkeDirector of Publisher Development: Howard LaGraffeMarket Development Specialists: Elisha Davis,Stephanie MichaudManager of Sales Administration: Cindy MaestasVice President of Creative Services: Tyler HardekopfProduction Manager: Tanna KempeEditorial Manager: Shannon WisbonProduction Specialist Manager: Brenda HolzworthCreative Services: Kenny Bump, Kristy Carns,David Drew, Gerry Dunlap, Breanna Fellows,Kristen Gantler, Amelia Gates, Tess Kane,Courtney Littler, Lana May, Jodi Nielsen, Si RobinsController: Darrell DragooFinancial Services: Lori Elliott, Allison Jeffrey,Sharon Lardeo, Christian WilliamsManager of Human Resources: Carrie HildrethManager of Information Technology: Eric HibbsREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Jan RaabePublisherAlthough every precaution is taken to ensureaccuracy of published materials, M.D. News cannotbe held responsible for opinions expressed or factssupplied by its authors. Copyright 2009, SunshineMedia, Inc. All rights reserved. Reproduction inwhole or in part without written permissionis prohibited.Advertise in M.D. NewsFor more information about advertising in theM.D. News Cleveland/Akron/Canton edition,call 330-499-5332or fax 330-497-0570Contact InformationGreater Cleveland/Akron/Canton M.D. News6864 Mapleridge NWCanton, OH 44718jraabe@mdnews.comPostmaster: Please send notices on Form 3579 toP.O. Box 27427, Tucson, AZ 85726.05-7372 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

contents VOL.13, NO. 2MARCH-APRIL 2009 44 COVER STORYSTEPHEN L. HOUFF, MDSixteen years ago, before the advent of thehospitalist movement, no one could havepredicted that hospitalist medicine wouldbecome the fastest growing specialty inthe US — no one, perhaps, exceptDr. Stephen Houff. Dr. Houff isthe founder and president/CEO ofHospitalists Management Group (HMG),the largest equal-equity ownershiphospitalist group in the country.11Special Section:Minimally-Invasive Surgery11 surgery featureMINIMALLY INVASIVEPEDIATRIC SURGERYAt UH Rainbow Babies & Children’sHospital’s Minimally Invasive SurgeryCenter, endoscopic procedures are beingsuccessfully performed on the tiniestof patients — under 5 kg. Establishedin 2006 with funding provided by theCleveland Foundation, the Center ison a mission: to develop a nationallyrecognized center of excellence inpediatric MIS.19 hospital featureEASY ACCESS TOGENERAL SURGERY ATEUCLID, MARYMOUNT,HILLCREST ANDFAIRVIEW HOSPITALSAccess to surgical care is a growing concernacross the country. Several years ago, inan effort to better serve Northeast Ohiocommunities, Cleveland Clinic begantaking steps to maintain and expandthe Department of General Surgery atFairview, Hillcrest, Euclid and MarymountHospitals. The result? Improved access andshorter wait times for patients.25 special featureEXPLORING THE LINKBETWEEN GENES ANDHEALTH AT AKRONCHILDREN’SWhen the Genetic Center at AkronChildren’s Hospital was established in1977, few people truly understood theways in which genetics would begin tochange the face of medicine. Today,genetic knowledge and screening inmedicine as it relates to health is morereadily appreciated and utilized forpatients across all age groups.30Special Section:Men’s Health30 featureMEN’S HEALTHTwo things men need to be on thelookout for: osteoporosis (not just awoman’s concern) and prostate cancer.Read on about the underdiagnosis ofosteoporosis in men and new studies thatexamine the efficacy of prostate cancerpreventive treatments.ON THE CoverStephen L. Houff, MDDEPARTMENTSREVIEW ONLY44 local docs innational news46 hospital rounds© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.192511Photo © Smithberger Photography, North CantonCLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 3

coverstoryStephen L. Houff, MDLeading the Hospitalist Movement at HMGBy Robert JanekPhoto © Smithberger Photography, North CantonSixteen years ago, before the advent of the hospitalist movement,no one could have predicted that hospitalist medicine would becomethe fastest growing specialty in the US. According to estimates relatedto a 2007 study by the American Hospital Association (AHA),there are now approximately 28,000 hospitalists — more than thenumber of neurologists or gastroenterologists — and that numberis expected to swell to 50,000 within the next few years.Stephen L. Houff, MD, was at the forefront of the hospitalistmovement in1993, when he implemented a single-site hospitalistprogram at The Ohio State University Hospitals East. Seven yearslater, he established Hospitalists Management Group (HMG), anationwide provider of turnkey hospitalist services. Headquarteredin Northeast Ohio, HMG is the largest equal-equity ownershiphospitalist group in the country with more than 300 physiciansserving 40 healthcare systems in 15 states. Its mission is to deliverincreased healthcare value to patients, hospitals and payers throughclinical excellence and innovation.HMG’s executive team includes (L-R) David Berkey, vice president of business development;Linda Ellis, chief operating officer; Stephen Houff, MD, president/CEO; Martin Fallon, vicepresident and general counsel; and Mark Valentine, chief financial officer. Missing from thegroup photo is Ronald Casey, MD, HMG’s chief clinical officer.“We’re a total outsource solution for hospitals that want a rapidlysuccessful hospitalist program,” said Dr. Houff. “We custom-designeach hospitalist program, recruit and train the physicians, andadminister of all of the practice management, credentialing, thirdparty contracting, human resources, billing, coding, compliance,marketing … everything that a hospitalist program needs to besuccessful.”Board certified in Internal Medicine, Dr. Houff completed hisundergraduate and medical school education at The Universityof Maryland. In addition to serving as the first hospitalist at TheOhio State University Hospital East, he was chief of staff, memberof the Board of Trustees, chairman of the Quality ManagementCommittee and Physician Peer Review, and member of the MedicalExecutive Committee, Clinical Resource Evaluation Policy Groupand Intensive Care Quality Management Committee.Today, in addition to leading HMG as its president/CEO, Dr. Houffserves on the Workforce Task Force of the Society of HospitalistMedicine and is a founding member of thePhoenix Group, a think tank comprised ofleaders of the largest private hospitalist companiesin the nation. He is also a member ofthe editorial board of Today’s Hospitalist andis a frequently quoted authority and commentatoron hospitalist medicine.“More than half of American hospitals— 58 percent according to the Society ofHospital Medicine (SHM) — and virtuallyall of the country’s leading hospitals haveembraced hospitalists,” said Dr. Houff.“In addition, the SHM reports that manyof the nation’s largest managed care programs,including Humana, Kaiser, Aetna,PacifiCare, and Cigna, are supportive ofhospitalist programs.”Several factors contribute to this. Chiefamong them are reduced hospital costs andimproved quality of care.REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.reduced costs,improved careA study, which appeared in the Winter2008 issue of Human Resource Management,4 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

explored the differences between hospitalistand traditional models of careby measuring performance outcomes inmore than 6,000 cases over a two-year periodat a community hospital. Comparedto the traditional approach, researchersfound that the hospitalist model decreasedthe average length of patient stay (LOS)by about half a day and reduced costs tothe hospital by $655 per patient. They alsofound that hospitalists reduced the risk ofre-admitting a patient by 41.8 percent,a key measure of quality performancein hospitals.HMG’s performance outcomes areeven better. In 2008, HMG experienced agreater than one day LOS reduction at eachof their current practice sites, resulting in acost per case reduction of $850 per patient.Readmission rates were reduced by more than half when comparedto primary care control groups.“We’re currently providing services at University MedicalCenter (UMC) in Las Vegas, NV, which is the county hospitalfor Clark County and the primary teaching hospital forthe University of Nevada School of Medicine. UMC is a veryhigh acuity facility with a Level I trauma center, and it has avery high rate of uninsured patients,” said Dr. Houff, citingan example. “Within the first 18 months that we operateda hospitalist program at this safety net hospital, we broughtMedicare length of stay down by over two days. That has had atremendous impact on the hospital finances and allowed themto continue their mission.”Additional HMG program benefits include:• 24/7/365 onsite presence which expands access to physician careand improves hospital throughput;• Procedurally competent hospitalists who can manage patientairways, intubate and place central venous catheters andarterial lines;• Physician supported Rapid Response Teams;• Interdisciplinary care team participation that incorporates carecoordination and discharge planning;• Post-discharge follow-up call program to ensure patient satisfactionand compliance;• Vacation and after hours coverage of private attending patients;and• Preadmission testing and medical co-management for surgicalpatients.Hospital clients realize financial gains, as well. “One of ourclient hospitals reported a $1,200 per patient improvementin contribution margin for the hospitalist service dischargescompared to inpatients managed by their local primary careHMG’s president and CEO, Dr. Houff, is a frequent lecturer and often quoted nationalauthority on Hospitalist Medicine.physicians,” said Dr. Houff. “Multiply that figure by 2,500 dischargesper year, and you can see the enormous financial powerof dedicated management of hospital inpatients.”unique programs, unique modelsHaving executed 40 programs in a variety of hospital settings— rural and urban, large and small, academic and community —Dr. Houff and his leadership team bring a significant base of knowledgeand national experience to each hospital they serve.“We start by having our operations team meet with key leadersat the hospital to identify their hospitalist program goals and alignour program objectives with those of the hospital and its medicalstaff,” said Dr. Houff. “Then we recruit — usually from outsidethe service area, so we add to instead of delete from the hospital’sphysician base — and we extensively train those physicians toachieve the specified goals.”At The Ohio State University (OSU) Hospitals East, a highlyevolved HMG program provides comprehensive hospitalistservices 24/7 in addition to staffing a Long Term Acute CareHospital, a VA disability-testing clinic and a pre-admissionmedical evaluation service. HMG physicians also provide medicalco-management for the hospital’s orthopedic surgeons, andthe hospital utilizes a closed intensive care unit model whichincorporates the HMG hospitalists and OSU medical schoolpulmonary, critical care faculty members. Both services havedemonstrated outstanding patient outcomes as reported by theUniversity Healthcare Consortium (UHC). In fact, of the UHC’s97 academic medical schools and 153 affiliated hospitals, OSUHospitals East had the lowest mortality rates for inpatients andorthopedic patients in 2007.What really differentiates HMG from many other hospitalistorganizations, however, is its unique physician ownership modelREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Photo © Smithberger Photography, North CantonCLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 5

Photo © Jamie Jansen Photography, CantonHeadquartered in Northeast Ohio, HMG is the largest equal-equity partnership hospitalistgroup in the country with more than 300 physicians serving 40 healthcare systems in 15states.and its benefits to hospital clients in attracting and keepinghigh quality, well-trained hospitalists. Unlike most hospitalistcompanies, HMG is a physician-managed equal equity group.“Our physicians become equity owners after three years withouta ‘buy in.’ Being an owner and having a stake in the company, alongwith the reward system we have in place, gives our physicians theincentive to take it to the next level for their patients and hospitalpartners,” said Dr. Houff.HMG’s equity ownership program also aids physician retention.Nationwide, there is an average hospitalist turnover ofmore than 30 percent. However, HMG’s turnover is less than15 percent for all of its hospitalists and less than 3 percent forequity partners.“The Achilles’ heel of hospitalist medicine is excessive physicianturnover,” explained Dr. Houff. “HMG has an excellentrecruitment and retention strategy that has largely eliminatedthis issue as a concern for us and for ourhospital clients. We have stable physiciangroups who are committed to health systemneeds, and that’s what really drivesour programs.”best practicesAccording to Dr. Houff, all physiciansreceive comprehensive orientation andongoing training to ensure they understandtheir hospital clients’ clinical andquality objectives and can embrace thebehaviors and the best practices that willoptimize these endpoints by managing inpatientstay, improving inpatient mortalityratio, reducing related re-admissions,and improving the content of physiciandocumentation which optimizes hospitalreimbursement. He emphasized the importanceof medical informatics and theefforts and advances that HMG has madeas an organization in gathering, analyzingand reporting data for its hospital clients.“We live in a world now that is so dominated by publiclyreported data that hospitals are looking for a partner who understandsit, embraces it, and has an ability to impact outcomes,”Dr. Houff said. “So, in addition to putting together a serviceplan and meeting with the hospital on a regular basis to see thatwe’re exceeding expectations, we’re also generating reports forthe hospital that help them analyze return on investment andother important practice metrics including service volumes, coremeasures, quality endpoints, etc.”The reality of the current economic environment for hospitals,he explained, is that they have to be very careful about how theyspend their dollars.“We have a cost effective, proven solution that will deliver asignificant return on investment for our client hospitals throughenhancements in reimbursement, reductions in cost per case and significantimprovement in patient satisfactionand publicly reported quality endpoints,” hesaid. “Our national health system is headedtowards paying for quality and our programsare set up with that in mind. What’sbest for the patient is ultimately best for thehealth system.”REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.HMG Case StudiesPatient Satisfaction on Inpatient Units1st Qtr (Pre)4th Qtr (Post)Press Ganey Indicators % Rank % RankTime physician spent with you 79 97Physician concern for your worries 63 97Physician kept you informed 51 95Friendliness/courtesy of physician 37 92Skill of physician 26 87For more information about establishing ahospitalist program in your hospital, or to inquireabout becoming a hospitalist, call HMG at 330-492-6400 or toll free at 1-866-464-7497. n6 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

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Summa Health System toSell Operations of CFGHThe Summa Health System and CuyahogaFalls General Hospital Boards of Directorshave voted to approve the sale of the operationsof Cuyahoga Falls General Hospital(CFGH) and the lease of the facility andemployees to a joint venture between Summaand Western Reserve Hospital Partners(WRHP). As a result, the new entity, SummaWestern Reserve Hospital, LLC, will takeover operations at the hospital upon receivingregulatory approvals.The facility, to be renamed SummaWestern Reserve Hospital, will commenceoperations while construction of the planned100-bed, full-service community hospitalin northern Summit County is completed.Upon completion, the services and operationsof Summa Western Reserve Hospitalwill transfer to the new facility, allowingSumma to utilize the former CFGH campusto provide additional healthcare services thatbest serve the community.According to Summa spokespeople, thisjoint venture model will have no impacton current hospital operations until afterthe new facility’s planned opening in 2011.Plans for future use of the current CFGHfacility continue to be finalized. However,it is anticipated that it will be used as an agingin place campus to continue to providean increasing array of services to a growingsenior population. There are no plans toeliminate any employees as a result of thejoint venture.“The decision to transition Cuyahoga FallsGeneral Hospital comes following careful andthoughtful deliberation of how to best servethe residents of northern Summit and southernCuyahoga counties,” said Summa HealthSystem President and CEO Tom Strauss. “Bypartnering with Western Reserve HospitalPartners, we will ultimately provide a newfacility that will serve a growing populationin a more convenient location. Upon transitionto the new facility, it will allow Summato continue to utilize the current CuyahogaFalls General location for additional servicesin the future.”Summa and WRHP announced in January2008 plans to construct and jointly operatethe northern hospital. The facility will belocated off of Route 8 with Summa HealthDr. Andrew Fishleder NamedCEO of Cleveland Clinic Abu DhabiCleveland Clinic (USA) and MubadalaHealthcare (Abu Dhabi) have appointedAndrew Fishleder, MD, to hold the positionof Chief Executive Officer of Cleveland ClinicAbu Dhabi.Scheduled to open in 2011, the 360-bedmulti-specialty hospital will be a unique andunparalleled extension of the Cleveland Clinicmodel. The hospital is a vital part of MubadalaHealthcare’s strategy to build an integratedhealthcare delivery network.Dr. Fishleder assumed responsibility for theoverall operations of Cleveland Clinic Abu Dhabion January 1, 2009.As construction iscurrently underway,he is focusing on theimplementation ofthe systems, procedures,guidelines andstandards for the hospitalas an extensionof Cleveland Clinic’sAndrew Fishleder, MDmodel of medicineand clinical capabilities in the Middle East.Dr. Fishleder was instrumental inSystem and WRHP physicians sharing ownership.Site selection is in the final stages, but itis anticipated that the hospital will be locatedalong Seasons Road.“As physicians, we look forward to workingwith Summa Health System to continue to enhancecare for the community,” said WesternReserve Hospital Partners President RobertKent, DO. “Cuyahoga Falls General Hospitaland the new northern facility are very importantto us. Together with Summa, we willensure that the current location continues tothrive as we construct the new facility andthat we remain committed to providing theoutstanding care our patients are accustomedto, now and in the future.”Although required to be classified asfor-profit by law, Summa Western ReserveHospital will operate in a manner whichis consistent with Summa Health System’snot-for-profit mission. As part of this philosophy,the new hospital will adopt a charitycare policy consistent with Summa HealthSystem’s charity care policy, meaning allpeople will be treated regardless of theirability to pay. nREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.the development of Cleveland Clinic’sEducation Institute, which he recently ledas its Chairman. In addition, Dr. Fishlederserved as Executive Dean of the ClevelandClinic Lerner College of Medicine of CaseWestern Reserve University. Beginning hismedical career as a pathologist at ClevelandClinic in 1978, he has held various leadershipand executive positions, and serves asa member of the Cleveland Clinic’s Boardof Governors and has been a member of theinstitution’s Medical Executive Committeesince 1991. n8 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

financial planningGoodbye 2008! (Maybe)By Paul GuerraThe tremendous volatility of 2008 is officiallybehind us, and now investors begina new year with cautious optimism. A newadministration in the White House promiseshope and change while the actions onCapitol Hill continue to demonstrate thereality that significant change is still buta hope. Two issues earlier, we discussedthe reality that Congress would likely failto pass any legislation that was directedtoward solving the country’s economicwoes, but rather use the opportunity forpolitical posturing and payoffs. Now,months later, the same scenario is playingout over an economic “stimulus” bill thatdoes more to restructure the long termspending priorities of the governmentrather than to address the causes, effects,and possible solutions to the current economicdownturn.No Santa Claus: While investors andthe financial media excitedly awaited a“Santa Claus Rally,” the markets playedthe role of Scrooge, with the S&P 500 sufferinga total fourth quarter loss of 21.94percent. The Dow Jones Industrial Averagefared slightly better, declining “only” 18.39percent. These declines combined to make2008 the second worst year in the majormarket indices, topped only by the declinesexperienced in 1931.Evolving Policy Responses:Congress passed the Emergency EconomicStabilization Act in early October, authorizing$700 billion for the Troubled AssetRelief Program (TARP). They then failedto reach an agreement on a financial reliefpackage for the automakers formerlyknown as the “Big Three” after weeks ofcontentious debate. The White House didstep in and provided emergency bridgeloans to General Motors and ChryslerIronically, overwhelming pessimism has historicallyindicated a signal to the end of market downturn. Itis hard to argue that the environment today is anythingother than overwhelmingly pessimistic.to allow them to continue operationsthrough March 2009. Stay tuned formore discussions in this area during thefirst quarter of 2009 as the impact of the“band aid” wears off and the automakersfind themselves still struggling to turnprofitable in the 21st century using 20thcentury business models.Looking Ahead: A welcome rally inthe markets during the first few tradingdays of 2009 provided a brief respite forinvestors. However, the upswing provedshort-lived as the major indices reversedcourse and gave up ground throughoutthe month of January. Economic reportsin January revealed that businesses andconsumers remained under duress. As ofthis writing, unemployment is approaching8 percent, auto companies still reportdeclines (even Toyota has reported that2008 was their worst year since 1951),and banks still struggle to clear their balancesheets of bad loans and toxic assets.So, with all of this bad news, where is thesilver lining?Ironically, overwhelming pessimism hashistorically indicated a signal to the end ofmarket downturn. It is hard to argue thatthe environment today is anything otherthan overwhelmingly pessimistic. Themarkets also continue to trade in a relativelytight range that is characteristic of a“bottoming” process. Bad news (and thereis no shortage of such these days) no longerdrives the markets down to the extent thatwe observed in the second half of 2008.To the contrary, markets have lately beentaking very negative news in stride andmoving forward. Does this mean that theworst is over or that there is not furtherdownside possible in either the marketsor the economy? Hardly. Most marketexperts have given up trying to predictshort term trading ranges and bottomsand further negatives should be expected.However, it does appear at this point thatthe glass is certainly “half full.”So . . . What Do We Do? The environmentthat investors face today isone that the majority of us have neverexperienced and much of it is beyond ourcontrol. What we can control, however,is our commitment to saving and investinga portion of our current income ina diversified portfolio of assets. Reviewyour portfolio with an investment professionalto ensure that it is appropriatelyaligned with your goals, time horizon,and risk tolerance. The market turbulencewe have experienced over the pastyear represents an excellent opportunityto reevaluate one or all of these considerations.Most importantly, have faith inthe American spirit and resiliency andour history of overcoming hardship andemerging with strength and enthusiasm.In short, as with every challenge we havefaced in our 200+ years of history, thistoo will pass.Paul Guerra is an Accredited InvestmentFiduciary (AIF) and the president of BrookshireFinancial Group, Inc., in Canton. nREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 9

MetroHealth, Case Study DisclosesDangers of Hidden Food AdditivesResearchers from MetroHealth MedicalCenter and Case Western Reserve UniversitySchool of Medicine published a study in theFebruary 11, 2009 issue of the Journal of theAmerican Medical Association (JAMA) about thedangers of hidden phosphorus food additivesto kidney disease patients. Advanced kidneydisease patients have a list of foods they knowto avoid because they naturally contain ahigh level of the mineral phosphorus, whichis difficult for their compromised kidneysto expel. A great deal of processed and fastfoods, however, actually contains phosphorusadditives which can be just as dangerous forthese patients.High blood levels of phosphorus can leadto heart disease, bone disease, and evendeath among patients with advanced kidneydisease. This is why these patients must avoidUHCMC OffersAlternative toColonoscopyEXACT Sciences Corporation (NASDAQ: EXAS) and UniversityHospitals Case Medical Center (UHCMC) jointly announced inDecember that UHCMC has launched a program for stool-based DNA(sDNA) screening within its health care system at two sites comprisingfifteen physicians. For patients unwilling or unable to obtain a colonoscopy,sDNA screening will now be the preferred method of screeningoffered at the sites. UHCMC will evaluate program performance todetermine broader roll-out of sDNA screening system-wide.“Among our guiding principles is to pursue and implement breakthroughmedical advancements and practices to deliver superior clinicaloutcomes for our patients,” said Stanton Gerson, MD, Director, IrelandCancer Center of UHCMC, Director of Case Comprehensive CancerCenter, Case Western Reserve University. “Non-invasive sDNAscreening includes the Vimentin gene, a genetic locus discovered byDr. Sanford Markowitz of the Ireland Cancer Center and Case WesternReserve Medical School, a discovery that we believe can have a dramaticimpact on increasing screening rates and decreasing mortality.”Ohio and the bordering states of Indiana and West Virginia are amongthe ten states with the highest mortality rates from colorectal cancer inthe United States according to the American Cancer Society. nfoods with naturally high levels of phosphorus— such as certain meats, dairy products,whole grains, and nuts. The research teamdiscovered that it has become an increasinglycommon practice by food manufacturers toinclude phosphorus additives, such as sodiumphosphate or pyrophosphate, to processedfoods. The additives are used to enhance flavorand shelf life — particularly in meats, cheeses,baked goods, and beverages — and it is verydifficult for American consumers to knowwhether or not these additives are present inproducts, because they are not required to belisted on nutrition labels.The researchers found they were ableto significantly lower phosphorus levelsamong advanced kidney disease patientsonce they were taught to avoid foodscontaining phosphorus additives.The investigators randomly assigned 279advanced kidney disease patients receivingdialysis treatment to a control group that receivedusual care or to an intervention groupthat was taught to avoid additive-containingfoods when purchasing groceries or eatingat fast food restaurants. After three months,phosphorus levels declined two and a halftimes more in the intervention group than inthe control group (0.4 vs. 1.0 mg/dL).The study findings are most relevant to thehalf a million Americans with advanced kidneydisease and the 10 million more with moderatekidney disease. However, the study authorsnote that even people with normal kidneyfunction may be affected by these additivessince previous research has found that highphosphorus diets appear to lower bone densityand increase fracture risk as well. nREVIEW ONLYAkron Children’s CysticFibrosis Center toAdvance CF Research© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Akron Children’s Lewis H. Walker, MD, Cystic FibrosisCenter was recently accepted as one of the Cystic FibrosisFoundation’s “Therapeutic Development Network Sites” for 2009.The designation recognizes the center’s patient care, clinical andbasic science research, and quality improvement initiatives, andwill ensure that Akron Children’s CF patients have access toclinical trials and the latest drugs and nutritional supplementsin development.Cystic fibrosis is an inherited chronic disease that affects the lungsand digestive system of about 30,000 children and adults in theUnited States. Akron Children’s has 220 CF patients, ranging in agefrom newborns to adults in their 50s. Between 2006 and 2007, thenumber of Akron Children’s patients involved in CF-related clinicaltrials doubled from 38 to 76.In recent years, the center has also conducted quality improvementand care standardization studies that have received nationalattention. These studies have focused on improving the respiratoryfunction and nutrition of patients. n10 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

special section: surgery featureMinimally Invasive Pediatric SurgeryOn the Cutting Edge at RainbowBy Alex StraussEndoscopic tools and technology have evolved over the past 30years, resulting in less invasive methods of performing surgery. Withfurther miniaturization of these tools and the development of advancedtechniques during the current decade, many pediatric surgeons areroutinely performing minimally invasive surgeries (MIS) on babies andsmall children. Even neonates are now candidates for MIS.At UH Rainbow Babies & Children’s Hospital’s Minimally InvasiveSurgery Center, endoscopic procedures are being successfully performedon the tiniest of patients — under 5 kg. Established in 2006with funding provided by the Cleveland Foundation, the Center is ona mission: to develop a nationally recognized center of excellence inpediatric MIS utilizing the most innovative surgical techniques and cuttingedge technology in a unique setting to minimize the invasivenessof the entire surgical experience for children and their parents.“We strive to diagnose and treat children in the least painful andleast invasive way possible. This involves not only minimizing thesurgical scar but the emotional scar,” saidTodd Ponsky, MD, director of Rainbow’sMIS Center. “We focus on this from diagnosisthrough the post-operative period.”• develop educational programs to disseminate information aboutall of the above.In the past two years, since the establishment of the MISCenter, Dr. Ponsky and his surgical team have progressedfrom relatively routine procedures, like cholecystectomy, toperforming complex and intricate procedures, like Nissenfundoplication for reflux, through small incisions.“It is really amazing to see what has happened with the equipmentand techniques,” said Dr. Ponsky, who points out thatthe expertise available at Rainbow in MIS is superior. “Mostpediatric surgeons can do laparoscopic cholecystectomy thesedays, but there are few centers in the country that can offerthe wide array of MIS operations that we do, especially in theneonatal population.”These include general and specialized operations in theareas of ophthalmology, otolaryngology, thoracic surgery,REVIEW ONLYFellowship trained in both Pediatric Surgery and Minimally Invasive Pediatric Surgery, Dr. ToddPonsky leads a team of pediatric surgeons at Rainbow’s Center for Minimally Invasive Surgery.© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.a comprehensiveapproachWith the collaborative efforts of surgeons,radiologists, nurses, social workers,child life specialists, anesthesiologists, childpsychologists and psychiatrists, Rainbow’sMIS Center is truly comprehensive.Rainbow is also striving to:• become the leader in critically evaluatingand appropriately defining the roles ofnew MIS technology for children;• develop new minimally invasive therapiesand assess their safety and efficacy;• create clinical and basic science researchstudies to evaluate the value and outcomesof MIS techniques and stress-reducingstrategies; andPhoto © Smithberger Photography, North CantonCLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 11

Photo courtesy of UH Rainbow Babies & Children’s HospitalREVIEW ONLYWith the collaborative efforts of surgeons, radiologists, nurses, social workers, child life specialists, anesthesiologists, child psychologists andpsychiatrists, Rainbow’s MIS Center is truly comprehensive.neurosurgery, orthopaedics, dentistry, urology and plasticsurgery. Even the tiniest babies born with congenital deformitiesof the esophagus or intestines, can often undergo surgicalrepair at Rainbow through minimally-invasive “needle-scopic”incisions of 1 or 2 mm.“If we find there is anyone, anywhere in the world doing somethingthat we are not doing here, we send our practitioners to golearn from them,” said Dr. Ponsky. “We always want to make surethat we are offering the very latest, most advanced techniques toour patients.”Those techniques are being performed in eight state-of-theartoperating rooms in the Rainbow Prentiss Pediatric SurgeryCenter. These ORs are designed specifically to accommodatepediatric patients. They are also equipped with integratedcutting edge technology that allows surgeons to easily controlthe endoscopic cameras and lights for better visualization onhigh-definition monitors.“The cameras that we use have very high magnification, soeven though we are operating in a very small space (inside thepatient), we can actually see better than with traditional opensurgery,” said Dr. Ponsky. “And, of course, that is better forthe patient.”MIS advantagesThere are other advantages, as well. These include less pain, lesschance of infection and less blood loss. The hospital stay is shorter,scars are hardly visible and recovery is quicker.“In newborns, we know that making a big incision on the chestcan cause catastrophic problems with growth or even scoliosis,”Dr. Ponsky explained. “In these cases, having the option to performsurgery in a much less invasive way can be crucial.”In addition, babies who are in less pain breathe more normally andare less likely to develop post surgical pneumonia. But Dr. Ponskyis quick to add that not every type of surgery can or should be doneminimally invasively. He also points out that sometimes surgery isnot the only answer to a problem.“We’re learning that there are different modalities, such as drugtherapy, radiation and other therapeutic treatments that may be justas efficacious as surgery,” he said.He explained that it is still unclear what role MIS should play incancer treatment. Scar tissue in children who have had multiple operationscan also preclude the use of MIS techniques. And, becauseusing the laparoscope during an MIS procedure necessitates inflatingthe chest or abdomen with air, it is not always the best option forvery sick children who may not be able to tolerate insufflation.© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.12 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

“Our primary concern is for the patient’s safety,” said Dr.Ponsky. “We carefully evaluate each case and only attempt to doan operation with a minimally invasive technique when we aresure that it will be both safe and beneficial.”Dr. Ponsky also wants to make sure the surgical experience ismade gentler — for patients and their families.“Our goal is to take the anxiety out of surgery,” he said. “Weknow that it can be a high-stress situation for a parent to puttheir child in someone else’s hands to perform surgery. And theattitudes of the family affect the attitude of the child. So we makeevery effort to be in communication with the family to minimizetheir fear because we know that children who are less anxioustend to do better.”Towards this goal, doctors and staff have received specialtraining to foster effective communication with pediatric surgerypatients and their parents prior to the surgery. Before thescheduled surgery, patients’ families also receive a phone callfrom the nurse coordinator to answer any remaining questionsand help further allay fears. A collaborative team includingchild life specialists, social workers, and child developmentexperts is also available to guide parents and children throughthe process.Parents can usually remain with their child while anesthesiais induced by Rainbow’s board-certified pediatric anesthesiologists,specially trained to put patients at ease. During the surgeryitself, the nurse coordinator serves as liaison, keeping familiesinformed of the progress of the operation. Parents can even stayin communication with the surgical team during a procedurevia a pager messaging system. Afterwards during the recoveryperiod, family members are guided and supported.REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.education and researchAccording to Dr. Ponsky, Rainbow’s MIS Center is a worldleader in single-site surgery. This technique enables doctors toperform minimally invasive surgery through a tiny incision inthe navel to correct abdominal disorders. Currently, surgeonsat Rainbow are removing the appendix, gallbladder and spleenthrough one tiny incision hidden in the belly button. Dr. Ponskyand his colleagues are working in the laboratory to developother single site procedures, for example, for treating gastroesophagealreflux.As one of the only hospitals in the country performing thissingle-site surgery in children, Rainbow surgeons are trainingother surgeons from around the world with monthly courses onthis technique. Interested surgeons can also learn about otherMIS techniques from Rainbow’s specialists via interactive websymposiums which are offered throughout the year. The first,Scott Boulanger, MD, and Todd Ponsky, MD (top photo), performsingle-site surgery at Rainbow Babies & Children’s Hospital.Rainbow is one of only a few pediatric hospitals in the countrycurrently offering single-site surgery. This technique enablesdoctors to perform minimally invasive surgery through a tinyincision in the navel (middle photo), which is almost invisible uponhealing (bottom photo), to correct abdominal disorders. Currently,surgeons at Rainbow are removing the appendix, gallbladder andspleen through single-site surgery.Photos courtesy of UH Rainbow Babies & Children’s Hospital.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 13

Photo © Smithberger Photography, North CantonIn Rainbow’s surgical research lab, pediatric surgeons are working to develop new MISmethods. The lab, which is one of the largest animate research facilities in the nation, is alsoutilized for MIS training offered to surgeons around the world.which was presented last January, focused on repairing pediatrichernias minimally-invasively.“We believe that we have a responsibility to educate othersin this and other techniques for the benefit of pediatric patientseverywhere,” said Dr. Ponsky.Recognizing that research will be another key to moving thefield of minimally invasive surgery forward, Dr. Ponsky and hiscolleagues are involved in multiple projects. With the help of arecently hired MIS research coordinator, the Rainbow SurgicalSpecialists have authored over 30 manuscripts in the last six monthsthat have been submitted or accepted for publication in majorsurgical journals.Dr. Ponsky is also leading the way in his own research on theuse of NOTES — Natural Orifice Transluminal EndoscopicSurgery — in children. The scarless surgery uses natural orifices,such as the mouth, to access organs and structures in theabdomen and intestines. In addition, Rainbow’s MIS Center isestablishing a database of minimally invasive pediatric proceduresand their outcomes from centers around the country. As a nationalrepository for such information, Rainbow hopes to helpsurgeons everywhere better understand the risks and benefits ofnew procedures.In an effort to reach out not only to other surgeons, but tomore patients throughout the region, Rainbow MIS surgeonsare now seeing patients at several University Hospitals HealthCenters, specifically in Landerbrook/Mayfield Heights, Mentor,Twinsburg, Strongsville, and Westlake. They also performMIS procedures at ambulatory surgery centers including ZeebaSurgery Center in Beachwood, UHSurgical Center in Westlake, and WrightSurgery Center in South Euclid. Dr.Ponsky expects the number of outpatientsites and MIS offerings to grow, providingpediatric patients and their families moreconvenient access to advanced surgicalcare.a cutting-edgecommitmentAs tools and techniques improve,Dr. Ponsky expects his team will continueto stay on the cutting edge. Currently,they are “pushing the envelope” in the developmentof several new technologies.Dr. George Thompson and his team ofpediatric orthopedic surgeons are workingon cutting-edge techniques that willminimize the invasiveness and maybe even the need for majorspine surgery for scoliosis. Dr. Faruk Orge is also on the cuttingedge with new minimally invasive ophthalmic surgical techniquesfor children.“We have been applying to the FDA for approval of new devicesfor children who have debilitating diseases, such as diaphragmparalysis,” said Dr. Ponsky. “One of our surgeons developed adiaphragm pacer several years ago, and we are hoping to be ableto use this in children. If it is approved, we will be one of the firsthospitals offering this option for our young patients.”Another device for which Dr. Ponsky hopes to obtain FDA approvalwould help children with digestive disorders. Referred toas the ‘gastric pacer,’ this device would facilitate the movementof food through the digestive tract.All in all, Dr. Ponsky is excited to see the ongoing evolutionof MIS technology and techniques for pediatric patients. Andhe’s delighted to be part of an institution which is so proactivein this area.“Rainbow has made a commitment to being on the cuttingedgeof innovative care for children and is setting the standardfor pediatric hospitals, not just nationally but internationally,” hesaid. “I’m very proud to be a member of such an advanced groupof surgeons and such a forward thinking institution.”REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.For more information about the Center for Minimally Invasive Surgeryat Rainbow Babies & Children’s Hospital and a complete list of MISprocedures performed, call 216-844-RAINBOW (844-7246) or visitwww.rainbowbabies.org/tinyscars. n14 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 15

special section: misLaser Promotes Ulcer HealingBy Larry A. Stern, MDFor nearly one million American adults,venous leg ulcers represent a painful anddebilitating disease. The vast majority of legulcers are due to venous disease, and up tohalf of individuals with untreated varicoseveins will develop an ulcer. Risk factors associatedwith venous disease include familyhistory, increasing age, obesity, pregnancy,and prolonged standing.Varicose veins are often associated withaching, heaviness, itching, and swelling. Overtime, the symptoms may worsen to includeeczematous skin changes, pigmentation, atrophyblanche, and ulceration. The skin changesand ulceration are characteristically locatedjust proximal to the medial malleolus, whichimplicates venous disease involving the greatsaphenous vein. Cutaneous manifestationsmay occur in other distributions, however,depending upon the pattern of the superficialor perforator vein disease.In the evaluation of varicose veins andvenous ulcerations, venous duplex ultrasoundis the diagnostic modality of choice.Ultrasonography allows for the assessmentof venous patency, as well as venous valvularfunction. In a typical examination, the deepand superficial venous system is visualized,as well as perforator veins. Valves are positionedat intervals in the venous system, andare designed to allow flow of blood upwardtoward the heart, preventing flow in thereverse direction. In individuals with severevenous disease, the valves become dysfunctional,or incompetent, and the normalefficient flow of blood becomes stagnant.This results in venous hypertension anddilatation, and results in an inflammatoryprocess which leads to the extravasation offluid and cellular components.Traditional conservative treatmentmethods have included measures designedto diminish venous pressure and aid venousreturn to the heart. These measures includeleg elevation, avoidance of idle standing andsitting, and weight control. Exercise andambulation are encouraged, as the contractingfoot and calf muscles during activityserve as a pump to enhance venous return tothe heart. Additionally, graduated compressionstockings or compression wraps areutilized to improve venous hemodynamicsand minimize lower extremity edema.Unless contraindicated, compression of30-40 mm Hg is utilized.It has long been known that proceduresdesigned to treat varicose veins must addressthe underlying cause of venous hypertensiondue to incompetence of the venous valves.The valvular incompetence is most oftenidentified in the saphenous veins, which areanatomically a part of the superficial systemof veins. The great saphenous vein, whichis the longest of the superficial veins in thelower extremity, courses from the groin tothe ankle on the medial aspect of the leg. Thesmall saphenous vein is located posteriorly inthe calf between the popliteal space and theankle. Procedures intended to treat varicoseveins, therefore, must include elimination ofthe saphenous veins if valvular incompetenceis demonstrated. In the past, it was necessaryto physically remove the diseased saphenousvein from the leg in a procedure known as“stripping,” which required incisions, wassomewhat painful, and involved a significantperiod of convalescence.In recent years, new minimally-invasivetechniques have emerged in the treatmentof unsightly varicose veins. A procedureknown as endovenous laser ablation hasbeen shown to be as effective as thetraditional vein stripping procedure, butrequires no incisions and is associated withlittle or no discomfort. The procedure canbe performed in the office setting usinglocal anesthesia and mild sedation, withreturn to normal activity within a day ortwo. The procedure involves placement ofa long, slender laser fiber within the dysfunctionalvein using only a small needle.The procedure is performed using ultrasoundimaging to guide the placement ofthe laser fiber and the anesthetic. The laseris used to generate heat which creates athermal effect, thereby sealing the veinshut and arresting blood flow through thediseased vein. Venous blood flow then isautomatically rerouted through alternatehealthy pathways. When treating varicoseveins, additional adjunctive proceduresare sometimes necessary.Venous ulceration is a manifestation ofadvanced venous disease. Traditionally, venousulcers require many months to achievehealing, and recurrences are common.Customary treatment protocols includecompression, a variety of topical preparations,and serial debridements.Recent research has documented therole of endovenous laser ablation in thetreatment of venous ulcers. Clinical studieshave shown that the use of endovenouslaser ablation in the presence of saphenousvein incompetence significantly decreasesulcer recurrence. Additionally, emergingevidence suggests that endothermal ablationtechniques can significantly enhanceand expedite the healing of existing venousulcerations.In summary, the advent of minimallyinvasiveoutpatient endovenous ablation hasrevolutionized the treatment of varicoseveins in recent years. Evidence is now accumulatingthat these procedures also promotevenous ulcer healing as well as decrease ulcerrecurrence. Armed with this information,wound care specialists now have an additionalalternative in the comprehensiveapproach to ulcer management.Dr. Larry Stern is a board certified surgeonand phlebologist, and the medical director of theVein Specialty Center. He is affiliated with theHyperbaric Medicine and Wound Healing Centerat Wooster Community Hospital. nREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.16 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

Minimally InvasiveSurgery for Lung CancerBy Eric A. Espinal, MD, FACC, FACS, FACCPLung cancer remains a leading cause of death in the United States andworld-wide. With over 200,000 new cases diagnosed in 2008 alone, itwill be responsible for more deaths than breast cancer, prostate cancer,and colorectal cancer — combined. Because 1 in 13 males (and 1 in 16females) will be afflicted with this disease, it is a major health concernfor all medical professionals.Although prevention efforts have resulted in a decline in the numberof smokers in the United States, over 17.4 billion packs of cigaretteswere sold in 2007. According to the American Heart Association,25.9 million men (23.9%) and 20.7 million women (18.1%) weresmokers in 2007. With such strong predominance in our society, mostmedical professionals feel that the greatest advances in the treatmentof lung cancer will result from strategies aimed at early detection oflung cancer. Unfortunately, the majority of patients who are currentlydiagnosed with lung cancer are not candidates for curative resectionbecause they present in more advanced stages of the disease. Nearly70% of those diagnosed last year were in the latter stages of disease,when cure rates are quite low. Two large trials will release resultswithin the next 2 years — The National Lung Screening Trial and TheInternational Early Lung Cancer Action Program. Hopefully, theselarge trials will help guide lung cancer specialists in determining themost efficacious ways of detecting lung cancer early so that greatercure rates can be achieved.Currently, the best chance for cure from lung cancer is an operationthat achieves complete anatomic resection of the tumor and samplingof associated lymph node stations. Although recommendations areindividualized to a patient’s specific situation, the most common operationperformed for primary lung cancer is a lobectomy. A commonapproach to this operation has traditionally involved a thoracotomy,which consists of cutting muscle fibers and gaining access to thehemithorax by spreading the rib cage.More recently, less invasive approaches to lung cancer surgeryhave been associated with equivalent efficacy and cure rates. Musclesparing“mini-thoracotomies,” thoracoscopic lobectomy, and roboticlobectomy are approaches gaining favor with surgeons and patients.In fact, thoracoscopic lobectomy has been successfully performedworld-wide and is an accepted oncologic approach for patients withnon-small cell lung cancer. Single and multi-institutional studieshave demonstrated that thoracoscopic lobectomy is not only a safeand feasible technique but is also associated with several advantagescompared with conventional thoracotomy, including shorter length ofhospitalization and chest tube duration, decreased postoperative pain,improved preservation of pulmonary function, reduced inflammatoryresponse, and fewer overall complications [1-11]. This approach hasbeen shown to be particularly useful for elderly patients who may befrail or have poor performance status[2,5,12,13]. In addition, recentstudies show greater facilitation of the delivery of chemotherapy afterspecial section: misthoracoscopic lobectomy [14]. Thus, it is possible that improved deliveryof postoperative chemotherapy may improve outcomes.Although thoracoscopic lobectomy has been a successful approachto lung cancer over the past decade, its widespread use has grown at aconservative rate. A major reason is its steep learning curve. Althoughvisualization is typically excellent, dexterity can be limited withexisting “straight-stick” thoracoscopic technology. As a result, manysurgeons find dissection to be challenging. New surgical robot technologyrecently introduced into the surgical arena provides a numberof technical advantages over standard thoracoscopy. First, threedimensionalvisualization of the operative field provides an importantadvantage during operative dissection. In addition, the articulatedinstrumentation provides much more dexterity to facilitate carefuldissection around delicate structures. In addition, robotic dissectionmore accurately parallels the surgeon’s open operative experience.Not all patients are candidates for robotic lung surgery. In somesituations, palpation of the lung could be important in determiningSee Next PageREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 17

Minimally Invasive Foot Surgeryfor Chronic Plantar Heel PainBy Matthew DeMore III, DPM, FACFASOne of the more common approaches tochronic plantar heel pain secondary to plantarfasciitis is the Endoscopic Plantar Fasciotomy.Plantar fasciitis is described as inflammationat the origin of the plantar fascia. The mostcommon complaint is post static dyskinesia orpain after periods of rest. Most patients sufferingfrom this describe pain with the first stepsin the morning or after sitting for a period oftime then resuming weight bearing.Endoscopic Plantar Fasciotomy would beclassified as a minimally invasive procedure.It is normally performed on patients whohave not responded to a prolonged courseof conservative care as most of the literatureidentifies a 70% success rate with conservativecare. The procedure itself is done on anout patient basis under MAC anesthesia inmost cases. Local anesthesia is utilized in theContinued from Page 17extent of resection – this can only be done by the human hand. In addition,chest wall involvement is considered a relative contraindicationto robotic lung resection. Fortunately, for those patients not eligiblefor the robotic procedure, the advancements in minimally invasivesurgery still make it possible for them to experience a successful lungcancer operation.Dr. Eric Espinal is director of the Institute of Minimally Invasive Therapeuticsat Summa Health System and associate clinical professor of Surgery atNEOUCOM. nReferences1. Daniels LJ, Balderson SS, Onaitis MW, D’Amico TA. Thoracoscopic lobectomy:a safe and effective strategy for patients with stage I lung cancer AnnThorac Surg 2002;74:860-864.2. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frailand high-risk patients: a case control study Ann Thorac Surg 1999;68:194-200.3. McKenna RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy:experience with 1100 cases Ann Thorac Surg 2006;81:421-426.4. Nagahiro I, Andou A, Aoe M, et al. Pulmonary function, postoperativepain, and serum cytokine level after lobectomy: a comparison of VATS andconventional procedure Ann Thorac Surg 2001;72:362-365.5. Nomori H, Horio H, Naruke T, Suemasu K. What is the advantage of athoracoscopic lobectomy over a limited anterior thoracotomy procedure for18 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009surgical area, as well.Two 1.5 cm. incisions are created, oneon the medial aspect of the foot just distalto the identification of the plantar medialtubercle of the calcaneus and one laterallyto allow for passage of the cannula. Care istaken to avoid the Sural nerve laterally. Oncethe cannula is in place an endoscope is passedthrough the lateral opening and positionedto allow visualization of the entire plantarfascia. The foot is maximally dorsiflexed anda cutting blade is inserted into the cannulamedially. In most cases the medial band andsometimes a portion of or the entire centralband are identified and transected allowingseparation of the two ends. Photos of theprocedure are also taken via the endoscope.The lateral band of the fascia is preserved toavoid instability of the lateral column of thespecial section: misfoot and subsequent calcaneal-cuboid jointsyndrome. The cannula is then removed andwhile the foot is again placed in a dorsiflexedposition, the plantar medial arch is palpatedto ensure release. The medial and lateral incisionsare closed with non-absorbable sutureand remain for 7-14 days.The post operative course for this surgerydepends on the surgeons’ preference. Thisranges from immediate weight bearing in asurgical shoe to a non-weight bearing statusfor up to two weeks followed by protectedweight bearing in a CAM walker. Results forthis procedure have been proven excellentwith return to normal pain free activity in6-8 weeks.Dr. Matthew DeMore is an associate professorand chairman of the Department of Surgery at OhioCollege of Podiatric Medicine. nREVIEW ONLYspecial section: mislung cancer surgery? Ann Thorac Surg 2001;72:879-884.6. Onaitis MW, Petersen PR, Balderson SS, et al. Thoracoscopic lobectomy is asafe and versatile procedure: experience with 500 consecutive patients AnnSurg 2006;244:420-425.7. Petersen RP, Pham DK, Toloza EM, et al. Thoracoscopic lobectomy: a safeand effective strategy for patients receiving induction therapy for non-smallcell lung cancer Ann Thorac Surg 2006;82:214-219.8. Roviaro G, Varoli F, Vergani C, Maciocco M. Video-assisted thoracoscopicsurgery (VATS) major pulmonary resections: the Italian experience SeminThorac Cardiovasc Surg 1998;10:313-320. Swanson SJ, Herndon J, D’AmicoTA, et al. Results of CALGB 39802: feasibility of VATS lobectomy for lungcancer Proc Am Soc Clin Oncol 2002;21:290a.9. Walker WS, Codispoti M, Soon SY, et al. Long-term outcomes followingVATS lobectomy for non-small cell bronchogenic carcinoma Eur JCardiothorac Surg 2003;23:397-402.10. Yim APC, Wan S, Lee TW, et al. VATS lobectomy reduced cytokine responsescompared with conventional surgery Ann Thorac Surg 2000;70:243-247.11. Koizumi K, Haraguchi S, Hirata T, et al. Lobectomy by video-assisted thoracicsurgery for lung cancer patients aged 80 years or more Ann Thorac CardiovascSurg 2003;9:14-21.12. McKenna RJ, Fischel RJ. VATS lobectomy and lymph node dissection orsampling in eighty-year-old patients Chest 1994;106:1902.13. Arriagada R, Bergman B, Dunant A, et al. Cisplatin-based adjuvant chemotherapyin patients with completely resected non-small-cell lung cancer NEngl J Med 2004;350:351-360.© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.

Access to surgical care is a growing concern across the country.This is especially true in Ohio where decreasing reimbursementscompounded with the rising costs of practicing medicine aredriving surgeons out of smaller community hospitals and evenout of the state.Several years ago, in an effort to better serve Northeast Ohiocommunities, Cleveland Clinic began taking steps to maintainand expand the Department of General Surgery in four regionalhospitals: Fairview, Hillcrest, Euclid and Marymount. The result?Improved access and shorter wait times for patients requiringgeneral surgery services.Today, nine of 15 Cleveland Clinic general surgeons offer convenientaccess to surgical care at these hospitals. They are Drs. TimothyBarnett, Brent Bogard, Karen Draper, John Dorsky, Kenneth Lee,James Malgieri, Richard Niemczura, William O’Brien, and AndrewSmith. All are board-certified, highly trained surgeons with strongties to the hospitals and the communities they serve.general ‘specialists’The physicians affiliated with the Cleveland Clinic Departmentof General Surgery at Euclid, Marymount, Hillcrest and FairviewHospitals provide a full range of procedures for both evaluationand treatment. These include a wide range of general surgeryprocedures, including: appendectomy, cholecystectomy, laparoscopicand open hernia repair, soft tissue and lymph nodebiopsy, antireflux procedures, exploratory surgery, intestinalsurgery, endocrine surgery, dialysis catheter placement, andlipoma excision.Together with other general surgery colleagues at the MainCampus, they also provide services in the following areas:• Surgical management of hepatobiliary and pancreatic diseases,including gallbladder disease, cancer, portal hypertension, infections,abdominal disease, small and large intestine cancer, stomachcancer, and cystic diseases;• Laparoscopic surgery, including hernia repair, adrenalectomy,antireflux surgery, lymph node biopsy, splenectomy, digestivedisease surgery, surgery for achalasia, diagnostic laparoscopy andother advanced procedures; and• Endoscopic evaluation and surgical treatment of upper gastrointestinaland small bowel disorders, including ulcers, hiatal hernia,achalasia, Barrett’s esophagus, gastritis, GI bleeding, gastroparesis,gastroesophageal reflux disease (GERD) as well as endoscopicretrograde cholangiopancreatography (ERCP).hospital featureEasy Access to General Surgery atEuclid, Marymount, Hillcrest andFairview HospitalsBy Robert JanekIn 2008, more than 4,500 procedures were performed bythe nine general surgeons at Euclid, Marymount, Hillcrest andFairview Hospitals.general surgery at Euclid HospitalRichard Niemczura, MD, is a member of the Cleveland ClinicDepartment of General Surgery at Euclid Hospital. A Northeast Ohionative, Dr. Niemczura is a graduate of John Carroll University, CaseWestern Reserve University School of Medicine, and the UniversityHospitals’ General Surgery residency program. He has practiced atEuclid Hospital since 1977.Located on Lake Shore Boulevard overlooking Lake Erie,REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 19Photo by Tom Merce, Cleveland Clinic Center for Medical Art and Photography

Euclid Hospital has 371 beds and is home to one of the region’sleading rehabilitation centers. It serves residents of northernCuyahoga County.“Euclid is a community hospital that has kept up to date. Thesupport staff is well trained, and they take excellent care of patients,”said Dr. Niemczura.A wide variety of surgical services are offered at Euclid Hospital’sSurgery Center, where 10 surgical suites and procedure roomsare equipped with state-of-the-art technology, including the latestendoscopic and laparoscopic equipment. In 2007, Euclid Hospitalgeneral and specialty surgeons performed more than 2,600 inpatientsurgeries and 3,800 outpatient surgeries, many of which were donelaparoscopically.“Almost all gallbladder surgeries and appendectomies and one-thirdto one-half of inguinal hernia repairs are done laparoscopically,” saidDr. Niemczura.at Marymount HospitalWilliam O’Brien, MD, offers general surgery services at bothMarymount and Hillcrest Hospitals. A graduate of the Medical Collegeof Wisconsin, Milwaukee, Dr. O’Brien completed a general surgeryresidency at the former Mount Sinai Medical Center in Cleveland. Hisspecial interests include gastrointestinal surgery, breast surgery, thyroid/parathyroid surgery, and laparoscopic surgery.“I’ve been at Marymount for 18 years and watched it grow. It offersa wonderful community setting for general surgery and for healthcareoverall,” said Dr. O’Brien.Located in Garfield Heights, Marymount is a full-service, 322-bedhospital which serves southern and southeastern Cuyahoga Countyand neighboring communities. Inpatient and outpatient surgicalservices are provided at the hospital where nine ORs and procedurerooms are equipped with state-of-the-art lasers, endoscopes, laparoscopesand other technology for both traditional open and minimallyinvasive procedures.Outpatient surgery is also performed at the Marymount SurgeryCenter on Transportation Boulevard, just off of I-480. This CenterREVIEW ONLYRichard Niemczura, MD, is a member of the Cleveland ClinicDepartment of General Surgery at Euclid Hospital where he has beenon staff since 1977.includes eight ORs. Recovery rooms and waiting areas for patients’families are also located within this Center.“The facilities and particularly the staff are outstanding. They arevery caring and terrific to work with, from the patients’ standpointas well as from the physicians’,” said Dr. O’Brien.© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Photo by Tom Merce, Cleveland Clinic Center for Medical Art and PhotographyPhoto by Neil Lantzy, Cleveland Clinic Center for Medical Art and PhotographyWilliam O’Brien, MD, offers general surgery services at both Marymount and Hillcrest Hospitals.at HillcrestAt Hillcrest Hospital in Mayfield Heights,Dr. O’Brien is joined by three more generalsurgeons: James Malgieri, MD, John Dorsky,MD, and Karen Draper, MD. Hillcrest is afull-service 424-bed hospital which servescommunities on Cleveland’s eastside andparts of Lake and Geauga Counties.Dr. Malgieri earned his medical degreefrom Georgetown University School ofMedicine in Washington, DC. He completeda surgery internship and a general surgeryresidency at University Hospitals and joinedHillcrest Hospital in 1984. Gastrointestinalsurgery, breast surgery, thyroid/parathyroidsurgery and laparoscopic surgery arehis specialty interests.“Dr. Dorsky and I have worked togetherat Hillcrest since the late 1980s,” said20 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

Dr. Malgieri, who also sees patients at Solon Family Health Center.“A graduate of Cornell University Medical College, he completedsurgery internship and residency programs at North Shore UniversityHospital in Manhasset, New York.”Dr. Dorsky’s special interests include gastrointestinal surgery, breastsurgery, thyroid/parathyroid surgery, and laparoscopic surgery.Three years ago, Dr. Draper was recruited from an academicallyaffiliated private practice in Kentucky to join the group. She graduatedfrom Michigan State University College of Human Medicine inEast Lansing and completed general surgery internship and residencyprograms at Michigan State University Kalamazoo Center for MedicalStudies. Dr. Draper also received fellowship training in laparoscopicsurgery at Vanderbilt University Medical Center in Nashville. Inaddition to general and advanced laparoscopic surgery, her specialtyinterests include breast surgery.“The four of us all perform the entire breadth of surgical procedures,including endocrine surgery, colon surgery, laparoscopic surgery andbreast procedures,” Dr. Malgieri said. “Really the only surgery wedon’t do is liver surgery, which we refer to the hepatic specialists atCleveland Clinic’s main campus, and some of the specialized colonand rectal procedures such as those for IBD (inflammatory boweldisease), which we refer to the Colorectal Surgery Department.We really have a depth of experience to take care of virtually everyother surgery at Hillcrest.“The hospital has all of the subspecialty physicians and services thatwe require to take care of even the sickest patients And that includesICU specialists, pulmonary specialists, cardiologists, gastroenterologists,neurologists …” he said. “We certainly have state-of-the-artfacilities with 18 ORs, and once the new construction is completedin 2010 we’ll have 21.”at FairviewFairview Hospital’s Surgery Center includes 13 operating suitesand procedure rooms. Located on the hospital’s Lorain Avenuecampus, the Center is equipped with all of the latest technology forboth inpatient and outpatient surgery. Outpatient surgery is alsooffered at Fairview’s Ambulatory Surgery Center located withinthe Westlake Family Health Center campus on Columbia Road.Brent Bogard, MD, Timothy Barnett, MD, Andrew Smith, MD,and Kenneth Lee, MD, are the Cleveland Clinic general surgeonsat Fairview. All except Dr. Lee completed their general surgeryresidencies there.“I graduated from Case Western Reserve University School ofMedicine and completed my general surgery internship and residencyat University Hospitals, and I’ve been at Fairview Hospitalever since,” said Dr. Lee, whose special interests include laparoscopicsurgery, hernia repair and surgery for gastrointestinal andbreast disorders. “Dr. Bogard and I have been partners for morethan eight years.”Dr. Bogard has practiced at Fairview since 1994. A graduate ofUniversity of Texas Health Science Center at San Antonio, he beganhis career at Fairview with Dr. James Magisano who was one of theMembers of the Cleveland Clinic Department of General Surgery at Hillcrest Hospital include (L-R) William O’Brien, MD, Karen Draper, MD,John Dorsky, MD, and James Malgieri, MD.REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Photo by Neil Lantzy, Cleveland Clinic Center for Medical Art and PhotographyCLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 21

Photo by Tom Merce, Cleveland Clinic Center for Medical Art and PhotographyREVIEW ONLY(L-R) Kenneth Lee, MD, Andrew Smith, MD, Timothy Barnett, MD, and Brent Bogard, MD, comprise the Cleveland Clinic Department ofGeneral Surgery at Fairview Hospital.first surgeons on the Westside of Cleveland to perform laparoscopicsurgery. Dr. Bogard’s specialty interests include laparoscopic antirefluxprocedures and the surgical treatment of hernias, thyroid andparathyroid disorders.Gastrointestinal surgery and breast surgery are the specialty interestsof Dr. Barnett, who joined Dr. Bogard and Dr. Lee at Fairviewseven years ago. Dr. Barnett is a graduate of The Ohio State UniversityCollege of Medicine.Dr. Smith is the newest member of the group. A graduate ofLoyola University Stritch School of Medicine in Chicago, he joinedthe other three surgeons at Fairview Hospital in 2003. His specialinterests include laparoscopic surgery, hernia repair, surgery for breastdisorders and gastrointestinal surgery.“We all do the full range of general surgery at Fairview,” saidDr. Lee, who pointed out that Drs. Bogard and Smith also see patientsat Westlake Family Health Center. “There are definitely some cases thatare more rare and more highly specialized thatwe refer to our colleagues at the downtown© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Cleveland Clinic Department of General Surgery at Euclid,Marymount, Fairview and Hillcrest HospitalsEuclid Hospitalwww.euclidhospital.orgRichard Niemczura, MD216.692.1500Marymount Hospitalwww.marymounthospital.orgWilliam O’Brien, MD216.518.3650Fairview Hospitalwww.fairviewhospital.orgTimothy Barnett, MDBrent Bogard, MDKenneth Lee, MDAndrew Smith, MD440.673.0100Hillcrest Hospitalwww.hillcresthospital.orgJohn Dorsky, MDKaren Draper, MDJames Malgieri, MDWilliam O’Brien, MD440.449.1101www.clevelandclinic.org/general_surgerySolon Family Health CenterJames Malgieri, MD440.519.6800Westlake Family Health CenterBrent Bogard, MDAndrew Smith, MD440.899.5555Cleveland Clinic campus. And sometimes itworks in reverse — they refer cases to us.They send patients out our way if they feelcertain cases can be better handled in thecommunity closer to the patient’s home.”The benefit, according to all of the generalsurgeons at the four regional hospitals, ispatient convenience.“What we are striving to provide out herein the suburban hospitals is obviously thevery best surgical care as well as easy accessfor the patients,” said Dr. Lee.For more information about Cleveland Clinic’sDepartment of General Surgery, visit clevelandclinic.org/general_surgery.n22 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 23

The Elms.Where girls become confident women leaders.All-Campus Open HouseHigh School(All-girls grades 9-12)7th Grade Visitation DayApril 24, 2009 9am - 1pmPlease call 330.867.0918 to register100% College AcceptanceClass of 2008 earned over $2.1 millionin scholarships for college. ($120,000 avg per student)12 AP ClassesLeadership Development CurriculumMiddle School(All-girls grades 7-8)Earn High School creditsSmall class sizesPersonal Leadership Development ProgramElementary School(All-girls grades 1-6)April 26, 20091pm - 3pmREVIEW ONLYNew Performing Arts StudioScheduled completion dateMarch 2009© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Small class sizesEncourage leadership skills across curriculumBefore and After School Care availableHot Lunch programNewly renovated theaterPeek at Pre-KMarch 26, 2009 & April 21, 20099am - 10amPlease call 330.864.7210 to registerKindergarten & Pre-K(Co-ed K & Pre-K)Teacher to Student ratio 1:12 (PK), 1:15 (K)Teach pre-literacy skillsBefore and After School Care availableHot Lunch programNew Gymnasium & Walking TrackScheduled completion dateApril 2009www.TheElms.orgElementary, Kindergarten & Preschool1290 W. Market St. Akron, Ohio 44313330.864.7210High School & Middle School1375 W. Exhange St. Akron, Ohio 44313330.867.091824 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

special featureExploring the Link Between Genesand Health at Akron Children’sBy Alex StraussWhen the Genetic Center at Akron Children’s Hospital wasestablished in 1977, few people truly understood the ways inwhich genetics would begin to change the face of medicine.But Haynes Robinson, MD, the Center’s only pathologist atthat time, understood. And he began consulting with patientsusing the limited scientific knowledge available regardinggenetically-determined diseases.“Thirty two years ago, it was an awkward thing for a pathologistto see patients, because they were trained in laboratory work, notpatient care,” said Mohamed Khalifa, MD. “Fortunately, AkronChildren’s had the foresight to be supportive of Dr. Robinson’s efforts,and the center began to expand.”Today, the Genetic Center includes five board-certified clinicalgeneticists, eight genetic counselors and two nurse coordinators.Dr. Khalifa, who is board certified in clinical, biochemical, andmolecular genetics and in pediatrics, is the Center’s director.Dr. Robinson is the co-director of the Fetal Treatment Center ofNortheast Ohio, which is part of the Genetic Center.The medical staff also includes Thaddeus Kurczynski, MD,Catherine Ward-Melver, MD, and Kurt Wegner, MD, who is basedat Akron Children’s Mahoning Valley. Each year, the team servesthe screening, diagnosis, treatment and education needs of hundredsof patients across all age groups.“We not only serve as a resource for other specialists andMohamed Khalifa, MD, is director of Akron Children’s Genetic Center where genetic screening, diagnosis, treatment and education is providedeach year for hundreds of patients across all age groups.Photo © Smithberger Photography, North CantonCLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 25

Photo © Smithberger Photography, North CantonThrough preconception planning, geneticists and counselors can identify familial riskof certain types of conditions and help couples understand the odds of their child beingaffected. Shown here with Dr. Khalifa is genetic counselor Connie Motter.departments in the hospital, but also provide genetic services foradult hospitals and the public,” said Dr. Khalifa. “People are justbeginning to appreciate the increasing importance of geneticknowledge and genetic contribution to medicine as it relates totheir health. The more we know, the more we can do to anticipateand prevent diseases, diagnose and manage birth defects, and tailortreatments to the individual patients’ needs.”Virtually all diseases and conditions that affect humans have agenetic component. “Even things we used to think were purelyenvironmental are affected by a person’s genetic makeup, such asthe ways in which the body reacts to and recovers from diseases,and even trauma,” said Dr. Khalifa.Speaking to physicians and other groups, Dr. Khalifa frequentlytakes this message into the community.“I use the example that two people can sit in the same room withsomeone who sneezes and one will develop the flu and the other onewon’t,” he said. “There are many factors that may account for this,but one of them is the fact that our genetic makeup is different, andthe way we react to the same environmental factor is different.”Preconception PlanningSome of the most important genetic testing done at the GeneticCenter is testing which takes place prior to or in the early stages ofpregnancy to detect problems. Through preconception planning, geneticistsand counselors can identify familial risk of certain types ofconditions and help couples understand the odds of their child beingaffected. Once a couple has conceived, prenatal testing can identifygenetic abnormalities in time to safely interact and to prepare.“The importance of understanding family history cannotbe overstated,” said Dr. Khalifa, who adds that history-takingoften reveals risks other than the one for which the patient wasoriginally referred.26 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009Women, who have learned throughultrasound of a pregnancy abnormalityor who have a family history ofgenetic disease, make up almost half of thecenter’s patients.When prenatal genetic testing revealsa significant problem, the patient may bemanaged by the Fetal Treatment Centerof Northeast Ohio for more personalizedtreatment (see related story).Prenatal and NewbornScreeningMany patients referred to the GeneticCenter are identified through routinematernal screening. Advanced geneticblood testing means all women can nowbe safely screened for common chromosomalabnormalities that used to be testedonly in mothers of advanced maternal age(over 35).“This level of testing used to require an amniocentesis,” explainedDr. Khalifa. “Because of the risks associated with that test, we used toreserve it only for older mothers or those at higher risk. Even then, wewere only catching about 20 percent of Down syndrome cases.”With a newer, more advanced biochemical test and ultrasound, upto 92 percent of Down syndrome cases can now be detected. Thetest can also reveal the severe chromosomal abnormality, Trisomy18, and almost 90 percent of spina bifida cases.By law, all newborns are currently screened for 32 metabolicdisorders, some of which require immediate intervention. Wheregenetic information is concerned, knowledge is power.“A good example is phenylketonuria (PKU). As long as we identifythis genetic problem at birth and put these children on a special diet,they can have normal, healthy lives. But if it is not caught very early,these children can end up with severe mental retardation.”When a baby tests positive for a metabolic disorder, the MetabolicDisorder Clinic serves as a resource for patients and their doctors.Located within the Genetic Center, this clinic provides ongoingevaluation, testing and treatment.Akron Children’s also offers a number of other clinics and programsfocusing on specific disorders including:• Cystic fibrosis• Craniofacial problems• Down syndrome• Fragile X• Myelodysplasia• Sickle cell• Skeletal dysplasia• Cancer geneticsSatellite clinics are held regularly in Medina, Millersburg, Cantonand Mansfield. The Mansfield site offers additional genetic services,monthly pediatric/adult clinics, and weekly prenatal appointments.

As children grow, the Genetic Center can also assist pediatriciansin determining the cause of developmental delays or in complementingcare for children with birth defects or genetic disorders.Genetic Testing for AdultsPregnant women are not the only adults served by the specialistsat Akron Children’s Genetic Center. Patients whosefamily histories put them at risk for hereditary cancers such asbreast or ovarian or those at risk of other genetic diseases suchas Huntington’s Chorea, adult onset neurodegenerative diseases,and hemochromatosis are candidates for evaluation, testing andcounseling services offered through the Hereditary CancerProgram and Adult Genetics Program.“Genetics now extends into every area of medicine, crossingall specialty boundaries,” said Dr. Khalifa. “Our biggest challengeat the Center is getting physicians to understand what wedo and recognizing who should be referred to us. The wholeidea of using genetics in cancer or in adult onset diseases is toidentify patients before they develop the disease when treatmentis most effective.”Most physicians and patients are well aware of the link betweenbreast cancer and the genes known as BRCA I and II. But whatis less commonly understood is that the BRCA genes can alsoput patients at risk for ovarian and other cancers. In addition,about 10 percent of colon cancers are known to have a geneticcomponent. Patients identified early as carrying genetic risks,can take steps to stay healthy, including lifestyle modifications,prophylactic surgery, or regular monitoring to catch disease inits most treatable stage.“People are beginning to understand this and we are gettingmore referrals into our Hereditary Cancer Program all the time,”said Dr. Khalifa.But the response has been slower for certain other hereditaryadult onset diseases, such as hemochromatosis, a disease thatcauses slowly progressive organ damage due to excess iron.Although hemochromatosis is one of the most common hereditaryAkron Children’s Genetic Center includes five board-certified clinical geneticists, including (L-R) Haynes Robinson, MD, Mohamed Khalifa,MD, and Catherine Ward-Melver, MD. Not pictured are Thaddeus Kurczynski, MD, Ph.D, and Kurt Wegner, MD.Photo © Smithberger Photography, North CantonCLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 27

diseases, with an estimated one in eight people a carrier of thegene, the center sees about only one case a year.“We can determine whether someone has it with a simple bloodtest. If it is identified early, these patients can be almost completelycured with treatment,” said Dr. Khalifa. “It is the responsibility ofthe primary care providers to determine who is at risk for thesediseases and refer them for genetic testing.”Changing theFace of MedicineThere are only 1,700 certified clinical geneticists and 2,100genetic counselors practicing in the United States today, farfrom enough to meet the growing need for genetic information.Dr. Khalifa predicts that primary care physicians will have toincrease their own understanding of genetics, and he expectsthe Genetic Center will play an even greater role in educatingthem and their patients.“In medicine it used to be that we waited for something tobreak and then we went in and fixed it. But we are now beginningto practice ‘preemptive medicine,’ anticipating whatproblems might arise, based on genetic make-up, and workingto prevent them,” he explained. “Genetics is leading medicinedown this path.”Dr. Khalifa believes the practice of genetics will also pave the wayfor more individualized delivery of care. This is already evident inthe way in which dosing of the drug Coumadin is closely linked toan individual’s metabolism.“This drug has a very wide dose margin with the highest doseclose to 120 times the lowest dose. Too much drug will causebleeding and death, too little will cause clots and stroke. It takes ahematologist an average of seven days to find the right dose. But, ifthey use a genetic test, they can virtually remove the guess workand shorten that time to just one or two days.”Given that almost two million new patients are put on this bloodthinner every year, Dr. Khalifa points out that shortening the timeit takes to decide on proper dosing could save more than a billiondollars by avoiding complications currently caused by extra daysof improper dosing.Other new drugs have been developed as a direct result of geneticresearch. Trials conducted at multicenters, including Akron Children’sGenetic Center, helped lead to FDA approval in 2007 of a new drugthat may lessen the need for dietary restriction in PKU patients.Ongoing research, being conducted in conjunction with anEnglish team, includes a study of common genetic traits in theAmish population.“For me, one of the most exciting things about the field of geneticsis that we are not only helping individual patients, but we arehelping whole families,” said Dr. Khalifa. “That, and the fact thatit is never boring. The field is changing so rapidly. At the GeneticCenter, we have to stay on our toes all the time.”For more information about Akron Children’s Hospital’s Genetic Center,call 330-543-4139. n28 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009History-taking and documentation, as shown on this “pedigree,”often reveal risks other than the one for which the patient wasoriginally referred.The Fetal Treatment Center of Northeast OhioThe Fetal Treatment Center of Northeast Ohio is apartnership among Akron Children’s Hospital, Summa Health Systemand Akron General Medical Center with offices located in all threehospitals. Here, geneticists, obstetricians, neonatologists and otherspecialists from a variety of pediatric and adult disciplines worktogether as a team to provide complete care for fetal patients andtheir families. This centralized approach improves timeliness inidentifying birth defects, improves communication amongspecialists, reduces confusion for families, and ensures the bestpossible outcomes.“Genetics plays a major part in the Fetal Treatment Center,” saidDr. Haynes Robinson, one of the Center’s co-directors. “Once theperinatologists identify an anatomic abnormality, our job is to helpestablish a specific diagnosis — a syndromic diagnosis or geneticdiagnosis. Once we do that, we try to develop an optimal plan ofprenatal and post-natal care for the baby. Our second task is toexplain to the family whether or not it’s hereditary, whether or notthey’re at risk in future pregnancies, and what they can do abouttheir risks.”In addition to diagnosis, services provided by the Fetal TreatmentCenter include:• Genetic counseling and education by center staff to help parentsunderstand prenatal tests, diagnosis and treatment options at allpoints in fetal care.• Case management and care coordination by a case manager whois the central contact person for families and who coordinates thecommunication among the pediatric specialists who will care forthe newborn and the entire Fetal Treatment Center team.• Family counseling regarding recurrence risks and what measuresparents might be able to take to prevent problems in futurepregnancies. Birth defects are also monitored on a local, state andnational basis.• Yearly updates on fetal medicine for the local and state medicalcommunity.“The kinds of treatments we perform are primarily medicaltreatments. For example, we’ve had a number of babies in needof transfusions in utero because of a disorder that destroys redblood cells. We currently have a fetus with an arrhythmia who isbeing treated in utero,” said Dr. Robinson. “For invasive prenataltreatments, such as for spina bifida, we collaborate with five or sixuniversity hospitals across the nation which offer prenatal surgery.”Photo © Smithberger Photography, North Canton

UHCMC study paves wayfor breast cancer vaccine trialResearch out of the Ireland Cancer Center of University HospitalsCase Medical Center (UHCMC) has found that the vast majorityof triple negative breast cancers express the MUC-1 target. Thefirst-of-its-kind finding has paved the way for an upcoming vaccinetrial for patients with early stage triple negative breast cancerthat could potentially prevent recurrence of this aggressive typeof breast cancer.Joseph Baar, MD, PhD, director of Breast Cancer Research atthe Ireland cancer Center, and colleagues analyzed 53 tumors anddetermined that 92 percent of them expressed MUC-1. Thesefindings support their theory that this MUC-1 protein on breastcancer cells could be a target for a novel vaccine using the patient’simmune system to target and kill cancer cells. These findingswere presented at the San Antonio Breast Cancer Symposium inDecember.A grant from the National Cancer Institute and the AvonFoundation allowed Dr. Baar to begin the vaccine trial in January forwomen with early stage triple negative breast cancer to determine ifthis vaccine can stimulate the immune response against MUC-1. Ifsuccessful, a later study would determine whether the generation ofthis immune response leads to an increase in patients’ relapse-freesurvival rates. The vaccine will be given following standard therapyof surgery, radiation and chemotherapy.recent researchCleveland Clinic finds way to removetherapeutic body protein for MS treatmentCleveland Clinic researchers have discovered a way to try to combat arare, but serious, side effect of a drug used to treat multiple sclerosis (MS).The monoclonal antibody natalizumab helps treat MS by inhibiting whiteblood cells from entering the brain and attacking nerves. A small number ofpatients taking natalizumab have suffered a rare, but serious, infection calledPML (progressive multifocal leukoencephalopathy).The study, which was published in the February 3rd issue of Neurology, themedical journal of the American Academy of Neurology, examined 12 MSpatients taking natalizumab. Results of the study showed that researcherswere able to “clean” natalizumab from the patient’s blood during a two-weekperiod. Results also showed that blood cleaning, or plasmaphereisis, canquickly remove natalizumab from the blood, allowing a patient’s immunesystem to re-establish itself, if necessary, to fight the PML infection.“Our study shows that we can remove a therapeutic protein from the bodyand improve immune function, which may convert PML into a manageablecomplication of treatment with natalizumab,” said Robert Fox, MD, medicaldirector of Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatmentand Research. “Emerging evidence suggests that heightened awareness andclinical vigilance have been successful in diagnosing PML earlier than everbefore, and early discontinuation, coupled with plasma exchange, may improvepatient outcomes.”Dr. Fox conducts research for Biogen Idec. He is also a paid speaker and consultantfor the company. nREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED. CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 29

special section: men’s feature healthMen’s HealthBy Liz MeszarosResearchers have shown — consistently — that many of the majorhealth risks faced by men can be treated effectively and even prevented.Thus, the importance of consistent and appropriate medical careand regular screening tests in men is of paramount importance.Unfortunately, the social environment has geared the male psycheto pay less attention to physical health than females do. In moderntimes, this translates — among other characteristics — to a greaterinclination to engage in risky behaviors and to avoid seeking medicalhelp. Men tend to smoke and drink more than women, and to ignoreand bottle up stress caused by work and financial problems.These tendencies and lifestyle choices can combine into a disastrousmix for men’s physical health and well-being. This month, M.D. Newswill focus on two issues that clinicians should be aware of as theycare for their male patients. The first, prostate cancer, is one of thetraditional primary concerns of clinicians and their male patientpopulation. The second issue is one that may not make an appearanceon the “traditional” list of male risk factors — osteoporosis.Nevertheless, researchers have now shown that men as well as womenare at risk for this potentially debilitating disease.CONSIDER OSTEOPOROSIS RISKS IN MEN, TOOMany physicians may not be aware of the fact that men, especiallyolder men, may be at risk for osteoporosis.In May 2008, the American College of Physicians (ACP) developedguidelines for the screening for osteoporosis in men. 1 The primaryrecommendation is that clinicians periodically perform individualizedassessment of risk factors for osteoporosis in older men. According tothe review these guidelines were based on, 2 the risk factors includeincreased age, low body weight, weight loss, physical inactivity,prolonged corticosteroids use, previous osteoporotic fracture andandrogen-deprivation therapy.“The emerging data about the under diagnosis of osteoporosis inAccording to researchers, many of the conditions and diseases thataffect men can now be treated effectively, and even prevented, withproper attention and screening.30 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009men, plus the results of osteoporosis treatment trials showing benefitsin men, contributed to the decision to develop these guidelines,” saidPaul Shekelle, M.D., Ph.D., senior author of the study the guidelineswere based upon, and co-author of the guidelines themselves.Recommendation two from the ACP is that clinicians obtaindual-energy X-ray absorptiometry for those men at increasedrisk for osteoporosis and who are candidates for drug therapy.Recommendation three states that the ACP recommends furtherresearch to evaluate osteoporosis screening tests in men.“Osteoporosis, while traditionally thought of as a disease of women,also affects many men. As clinicians, we need to be vigilant aboutscreening men who might be at risk for osteoporosis and fractures,” saidHau Liu, M.D., M.B.A., M.P.H., lead author of the review the guidelineswere based upon. “Prior research has shown that male osteoporosis issignificantly underdiagnosed and undertreated,” she added.Dr. Shekelle agreed: “Osteoporosis is not just a women’s healthissue; osteoporosis also occurs in men and can have similar, if notworse, health consequences. I strongly doubt that most men, orindeed many men at all, are aware of their risks for osteoporosis.And, the data about underdiagnosis would suggest that not all cliniciansare aware.”“Physicians can routinely evaluate their patients for osteoporosis,including assessing key risk factors such as increased age, low bodyweight and history of prior fractures. Patients at risk for osteoporosisand fracture should be screened with a bone density [DXA] scan,”concluded Dr. Liu, who is Co-Director, Chronic Care Management,and Associate Chief, Endocrinology and Metabolism, at the SantaClara Valley Medical Center, San Jose, CA. She is also clinical assistantprofessor at Stanford University Medical Center.Dr. Shekelle, who is a staff physician at the VA Greater Los AngelesHealthcare System, explained the risk factors for male osteoporosis.“Beyond certain special populations — such as men who have to takelong-term steroids as treatment for chronic conditions such as rheumatoidarthritis, or men who are undergoing androgen-deprivationtherapy as treatment for prostate cancer — a surprisingly goodestimate of the risk of osteoporosis can be made simply by knowinga man’s age and weight. The older a man is, the more likely he is tohave osteoporosis, and men who weigh less are more likely to haveosteoporosis, particularly men who lose a great deal of weight,” hetold M.D. News.To combat osteoporosis, clinicians should advise their patients to“eat a well-balanced diet that contains adequate calcium and vitaminD and get regular physical exercise,” concluded Dr. Shekelle.REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.PROSTATE CANCERThe number of deaths from prostate cancer has declined recentlyin the United States (see sidebar). Nevertheless, prostatecancer remains one of the most common cancers affecting Americanmen. In 2008, there were approximately 186,000 new cases and

29,000 deaths from prostate cancer, making it the second leadingcause of cancer death in this country.Effective preventive therapies for prostate cancer would have considerablepublic health benefits, and previous observational studies hadassociated intake and serum levels of vitamins E and C with reducedrisk of certain cancers.Unfortunately, two recent studies have found that supplementsthought to be helpful in the prevention of prostate cancer are notso. The first of these studies, the largest cancer chemopreventiontrial ever conducted, found that supplementation with vitamin E orselenium — alone or in combination — was not associated with alower risk of prostate or other cancers. 3“Prostate cancer is the most common nonskin cancer in the UnitedStates and the cause of a significant amount of anxiety and treatmentrelatedmorbidity. An effective, nontoxic way to prevent prostatecancer would be a major public health benefit,” Eric A. Klein, M.D.,one of the co-authors of this study, told M.D. News. “When used asprescribed in SELECT (Selenium and Vitamin E Cancer PreventionTrial), neither selenium nor vitamin E prevent prostate cancer, anyother cancer or cardiovascular disease.”For this study, researchers included 35,533 men, aged 50 years orolder, from the United States, Canada and Puerto Rico. Participantsrandomly received one of four interventions, with a minimum followupof seven years. These interventions included selenium (200 µg/d),vitamin E (400 IU/d), selenium plus vitamin E or placebo.Data showed that there were no statistically significant differencesin the absolute numbers or five-year incidence rates of prostate cancerdiagnoses between the four groups. In the group that receivedselenium, there were 432 cases of prostate cancer (five-year rate =4.56%); in the group that received vitamin E, 473 cases (4.93%);in the selenium plus vitamin E group, 437 cases (4.56%); and in theplacebo group, 416 cases (4.43%).According to Dr. Klein, clinicians must take other steps to reducethe risks of prostate cancer. “Recognize the risk factors, which includeage, race and family history; discuss the potential benefits ofyearly screening with PSA and DRE; and offer the use of finasteride,which was shown in the Prostate Cancer Prevention Trial to reducethe risk of developing prostate cancer by 25% regardless of baselinerisk factors,” he said.“Americans spend billions of dollars per year on supplements onthe belief that they are beneficial for health and preventing disease,even in the absence of scientific trials that prove benefit. SELECTdemonstrates that neither selenium nor vitamin E prevent prostateor other cancers or major cardiovascular disease,” said Dr. Klein,who is Interim Chair, Glickman Urological and Kidney Institute,Director of the Center for Clinical and Translational Research andprofessor of surgery at the Cleveland Clinic in Ohio.According to another recent major cancer-prevention study, longtermsupplementation with vitamins E or C does not reduce the riskof prostate or other cancers. 4 Because of the public health implicationsof these results, they were released early online by the Journal of theAmerican Medical Association.“Vitamins E and C are among the most widely used supplements.Previous data suggested a role for both in prevention ofchronic diseases, but we must rely on large trials for definitiveresults. This study was designed to explore the role of vitamins EThe National Prostate Cancer Coalition recommends beginningannual prostate cancer screenings starting at age 50, and youngerfor African-Americans and those with a family history of the disease.and C on both cancer and cardiovascular disease prevention,” saidJ. Michael Gaziano, M.D., M.P.H., lead author of the trial.For the Physicians’ Health Study II, a randomized, placebocontrolledtrial, 14,641 male physicians aged 50 years or older wereincluded, of whom 1,307 had a previous history of cancer. Thesesubjects were randomized to receive individual vitamin E supplementsevery other day (400 IU), and vitamin C daily (500 mg).During an average follow-up of eight years, 1,943 cases of cancerwere confirmed, and 1,008 cases of prostate cancer. Comparedwith placebo, vitamin E had no effect on either the incidence oftotal cancer or prostate cancer. There were also no significanteffects of vitamin C on total cancer or prostate cancer. Neithervitamin had significant effects on site-specific cancers, includingcolorectal, lung, bladder and pancreatic cancers. Stratification byvarious cancer risk factors showed no significant modification ofthe effect of vitamin E on prostate cancer risk, or vitamin E or Con total cancer risk.“Our study does not support a role of vitamin E or C in the preventionof cancer or heart disease,” concluded Dr. Gaziano. “There arebeliefs among patients and doctors alike that certain supplements mayreduce the risk of cancer, but there are no definitive trial data thatsupport this belief. For cancer in general, physicians should counselpatients about the usual risk factors, such as smoking, obesity andlack of exercise,” he told M.D. News. Dr. Gaziano is an epidemiologistat Brigham and Women’s Hospital and VA, in Boston. ■REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.References1. Qaseem A, Snow V, Shekelle P, et al. Screening for osteoporosis in men: AClinical Practice Guideline from the American College of Physicians. AnnIntern Med. 2008;148:680-4.2. Liu H, Paige NM, Goldzweig CL, et al. Screening for osteoporosis in men:a systematic review for an American College of Physicians Guideline. AnnIntern Med. 2008 May 6;148(9):685-701.3. Lippman SM, Klein EA, Goodman PJ, et al. Effect of selenium and vitaminE on risk of prostate cancer and other cancers: The Selenium and Vitamin ECancer Prevention Trial (SELECT). JAMA published online December 9,2008.4. Gaziano JM, Glynn RJ, Christen WG, et al. Vitamins E and C in the preventionof prostate and total cancer in men: The Physicians’ Health Study IIrandomized controlled trial. JAMA, published online December 9, 2008.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 31

Peripheral Arterial DiseaseBy Dann Ganzhorn, MDPeripheral Arterial Disease (PAD) is frequentlyseen as a co-morbidity for patientsreceiving hospice care. The goal of treatmentfor patients with end stage PAD is to relievetheir suffering from chronic, unrelentingpain. This may significantly enhance theirquality of living at the end of life — an importantconsideration for hospice patients.Pain management primarily involves opioidswith methadone being a good choice due toits inherent neuropathic coverage, low costand long half life, which necessitates lessfrequent dosing, an important factor at theend of life.PAD occurs when a disease causes obstructionto arterial blood flow — excludingthe coronary and cerebral vessels — and isoften caused by atherosclerosis. PAD affectsapproximately 20 percent of adults over age55 and is a powerful indicator for futuremyocardial infarction, stroke and vascularrelated deaths. It becomes more prevalent aspatients age, and the major risk factors aresmoking, hypertension and diabetes. Otherimportant factors include hyperlipidemia andhyperhomocysteinemia.Only about 20 percent of people with PADpresent typical symptoms such as impairedwalking, pain while at rest, ulcerations organgrene. Another third have atypical exertionalsymptoms including muscle pain inthe affected limb that does not go away withcontinued walking and is relieved with rest.Approximately five to ten percent of patientswith asymptomatic PAD develop symptomsover five years. A minority of patients withintermittent claudication develop critical legischemia leading to rest pain, ulcers and ultimatelygangrene. Diabetics have the highestrisk for ischemic changes.The differential diagnoses for claudicationinclude non-vascular causes such as arthritis,special section: men’s healthrestless legs syndrome, peripheral neuropathies,spinal stenosis and intervertebral discdisease. Vascular etiologies include arterialembolism, thromboangiitis obliterans anddeep vein thrombosis. Classic physical findingsinclude hair loss, atrophic skin (shinyand thin), dependant rubor, arterial bruits,diminished or absent pulses, ischemic tissueulceration and gangrene.Diagnosis is typically made by assessingthe ankle-brachial index (ABI). This is doneby measuring the systolic pressure in theankles for the dorsalis pedis and posteriortibial arteries using Doppler ultrasound. Theratios for each side of the body are calculatedby dividing the higher ankle pressure in eachleg by the arm pressure in each arm. A ratioof 0.91 to 1.3 is normal, 0.41 to 0.9 indicatesmild to moderate arterial disease and 0.0 to0.4 is indicative of severe PAD.When warranted and indicated, aggressiveREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.32 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

special section:men’s healthinterventions involving both non-pharmacologicaland medications should be undertaken.Patients that meet the criteria for PAD shouldbe treated as aggressively as if they hadsymptomatic coronary artery disease.Non-pharmacological interventions tomodify risk factors include the following:1. Smoking cessation is the dominant modifiablerisk factor for PAD and is dosedependant. Physicians should advise patientsquit and may recommend the useof nicotine replacement step down treatments,and/or oral medications.2. Exercise significantly improves walkingtime and ability. It is more effective thanangioplasty and antiplatelet therapyfor patients with stable claudication.Effectiveness may not be seen for atleast six months. This therapy remainsthe primary treatment of choice forimpaired walking.3. Weight loss may not affect the incidenceof PAD directly, but does affect diabetes,blood pressure and other cardiovascularrisk factors.Pharmacological interventions include:1. Statin drugs which reduce/retard athelerosclerosisprogression. The goal oftreatment is LDL cholesterol of lessthan100 mg/dL and serum triglyceridelevel of less than 150 mg/dL.2. Aggressive management of diabetes withglycemic control. It is estimated that eachone point decrease in the HgbA 1C is associatedwith a 28 percent decrease in theincidence of PAD.3. Blood pressure control to less than or equalto 130/80 with an emphasis toward use ofan ace inhibitor.4. Antiplatelet therapy:a. Aspirin (ASA) has not been shown toimprove impaired walking but delays therate of progression, reduces graft failuresand need for surgical interventions.b. Clopidogrel (Plavix) has FDA approvalfor prevention of ischemic events in patientswith PAD and maybe more effectivethan ASA alone.c. Cilostazol (Pletal) has been shown toimprove claudication but correct dosingis important. It should not be used if heartfailure is present.REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.See Next PageCLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 33

Prostate Cancerand Metabolic SyndromeBy Gil Peleg, MDProstate cancer is the leading cancer diagnosisand second leading cause of cancerrelated mortality for men in the U.S. In2007, prostate cancer was diagnosed inapproximately 220,000 men, and about27,000 deaths were attributed to this disease.The greatest risk factor for prostatecancer is increasing age. Additional riskfactors include African-American race,positive family history, diet high in animalfat and red meat consumption. The probabilityof being diagnosed with prostatecancer is one in 10,373 for men aged 40 andyounger, then increases with age to one in39 at 40 to 59 years, one in 14 at 60 to 69years and one in 7 at 70 to 79 years.The incidence of prostate cancer is increasing.Treatment modalities include expectantmanagement, surgery, radiation and androgendeprivation. Localized prostate canceris preferentially treated with prostatectomyand/or radiation therapy. In recurrent ormetastatic prostate cancer, androgen-deprivationtherapy with bilateral orchiectomyor with gonadotropin-releasing hormoneContinued from Previous Pagespecial section:men’s healthAspirin remains the antiplatelet drug offirst choice. Clopidogrel may be superiorto ASA and should be considered as an alternativemedication. Other experimental/investigational agents for PAD includenaftidrofuryl (Nafronyl), Ginkgo Biloba,propionyl levocarnitine, various prostaglandinand hyperbaric oxygen.As our population ages, the incidence andburden of PAD will undoubtedly increase,causing significant morbidity and mortality,making it vital that doctors are awareof the assistance hospice can provide forthis disease.Dr. Dann Ganzhorn is a Medical Director atHospice of the Western Reserve. nspecial section: men’s healthagonists is utilized. Alternatively, radiationtherapy may be used alone, or together, withandrogen-deprivation therapy to palliatesymptoms. Men at risk for prostate cancerrepresent the same population of men whoare at risk for metabolic syndrome, diabetesmellitus and coronary artery disease.Androgen-deprivation therapy results inprofound hypogonadism and is responsiblefor adverse consequences such as increasedbody mass index, increased fat mass andreduced lean body mass. This increase in fatmass is secondary to the deposition of bothsubcutaneous and visceral fat, resulting inabdominal obesity. The increase in visceralfat results in elevated levels of adipokines,which, in turn, is responsible for causinginsulin resistance and type 2 diabetes mellitus.Mean body weight has been shownto increase up to 3.1 percent and fat contentup to 20 percent, after 12 months ofandrogen-deprivation therapy. Lean bodymass was shown to decrease up to 3.8 percent,and muscle strength, osteoporosis,sexual dysfunction and poor quality of life.This male hypogonadism has emerged as anindependent risk factor in the developmentof metabolic syndrome.The metabolic syndrome is a group of conditionsthat increase the risk for heart diseaseand diabetes. These include hypertension,high fasting blood sugar level, high triglyceridelevels, low HDL level and abdominalobesity. In patients without prostate cancerwith hypogonadism, testosterone therapyhas reversed some of these changes.Non prostate cancer related deaths nowexceed prostate cancer related mortality inmen with prostate cancer. Cardiovasculardisease is the single most common causeof non prostate cancer related deaths inthis population. The major risk factors forcoronary artery disease (CAD) in men includesage > 45 yrs, positive family history,elevated low-density lipoprotein cholesterol(LDL) level, low high-density lipoproteincholesterol (HDL) level, hypertension,diabetes and tobacco use. The metabolicsyndrome (syndrome X) is a known causefor increased cardiovascular mortality. Theprevalence of metabolic syndrome amongthe adult U.S. population is between 22percent and 24 percent. In patients treatedwith androgen-deprivation therapy, the ratewas much higher — 55 percent. Men withmetabolic syndrome are three times morelikely to die of coronary heart disease andother cardiovascular diseases even afteradjustment for other risk factors.Additionally, there is an association reportedbetween the metabolic syndromeand prostate cancer. In multiple Finnishstudies, metabolic syndrome was found topredict prostate cancer, associating insulinresistance and prostate cancer. The associationbetween metabolic syndrome andrisk of prostate cancer was stronger amongoverweight and obese men with a body massindex ≥ 27 kg/m 2 than in lighter men.Reports suggest that diabetes mellitus isnegatively associated with prostate cancer.The care of patients with prostate cancertreated with hormone manipulation shouldinclude evaluation for the metabolic syndrome,diabetes mellitus and cardiovasculardisease. Treatment of these comorbiditiesaccording to accepted guidelines may resultin improved survival and quality of life.Addressing these issues is also important formale patients without prostate cancer, as itmay decrease the risk of prostate cancer.Dr. Gil Peleg is a medical oncologist, withspecial interests in GI malignancies and breastcancer, at University Hospitals Ireland CancerCenter at Southwest General. He is board-certifiedin internal medicine and medical oncology.A member of the American Society of ClinicalOncology, Dr. Peleg also serves on SouthwestGeneral’s Pharmacy and Therapeutics Committeeand on the Cancer Committee. nREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.34 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

special section: men’s healthDiabetic Foot UlcersBy David F. Perse, MDAccording to the American DiabetesAssociation, 23.6 million people inthe United States — or 8 percent ofthe population — have diabetes. Theincidence of diabetes is increasing atalarming rates as the number of obeseAmericans escalates. One in threeAmericans born in 2000 is expectedto develop the disease, according tothe Centers for Disease Control andPrevention (CDC).Diabetes treatment is particularlyburdensome to the U.S. healthcare system,costing an estimated $174 billionin 2007. The CDC reports the averagemedical expenditures for people whoare diagnosed with diabetes are 2.3times higher than for the non-diabeticpopulation.Foot problems that result fromcomplications of diabetes — poorcirculation, neuropathy and infection— are the leading cause of hospitalizationfor Americans with diabetes.Approximately 15 percent of peoplewith diabetes develop chronic ulcers ofthe feet and legs, and 12 to 24 percent ofthese require amputation. About 71,000nontraumatic lower-limb amputationswere performed on people with diabetesin 2004, according to CDC data.People who have diabetes — type1 (insulin-dependent) or type 2(non-insulin-dependent) — have agreater-than-average chance of developingfoot infections. The risk of infection isgreatest for people over the age of 60 whohave one or more of the following:• Poorly controlled diabetes• Neuropathy• Laser treatment for changes in theretina• Vascular or kidney diseaseFoot ulcers occur more often in diabeticsbecause the disease causes changes tothe nervous system and poor circulation.The nerves that control sweating nolonger perform, causing the skin of thefeet to become very dry and cracked.Calluses occur more frequently and buildup faster. If not trimmed regularly, thecalluses can turn into ulcers.People who have diabetes may not feeldiscomfort or pain in their feet untilweakness, fever or other symptoms ofsystemic infection appear. Because ofthis, minor irritations occur more often,heal more slowly and are more likely toresult in serious health problems.Once a diabetic patient develops a footulcer, he or she should seek immediatemedical treatment. It is necessary todetermine whether the bone of the foothas become infected. A wound samplewill be cultured and an appropriateantibiotic prescribed.Other treatment options include thefollowing:• Debridement to remove dead tissuefrom the wound• Specialty dressings and wraps tailoredto the stage of the wound• A cast or special shoes to protect thefoot• Hyperbaric oxygen therapy to increasethe amount of oxygen in the patient’sblood to help wounds heal• Bio-engineered tissue substitutes thatclosely resemble human skin in structure,function and handling• Vacuum-assisted closure• Platelet technologies• Surgery to increase blood flow to thefootIf diabetic foot ulcers are treatedproperly and the patient practices goodfoot care, the prognosis is generallyoptimistic. Without appropriate treatment,diabetic foot ulcers can lead toserious illness, gangrene, amputationand even death.Dr. David Perse is president of LutheranHospital and medical director of the LutheranHospital Wound Healing Center in Cleveland,Ohio. The Wound Healing Center offerscomprehensive treatment for wounds includingthree hyperbaric oxygen chambers. Dr. Perseis board-certified by the American Board ofSurgery and the National Board of MedicalExaminers. His specialties include general andlaparoscopic surgery, surgical endoscopy andwound management. nREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Achieving Effective Self-Care BehaviorAll medical practitioners are remindedto examine the feet of diabetic patients atevery office visit. Patients with diabetesshould be encouraged to improve theirself-care behaviors to help prevent theoccurrence of foot infections, as follows:• Control blood glucose and do not allow itto get too high.• Avoid smoking.• Keep blood pressure and cholesterolunder control.• Exercise regularly to stimulate blood flow.• Wear prescribed footwear for walking.• Keep feet clean, dry and warm.• Check feet daily for blisters, scratches,open sores or skin that is hard, broken,inflamed, feels hot or cold to the touch.• Dry feet carefully after bathing, applyinga thin coat of petroleum jelly to preventdry skin from cracking.• Seek professional help for foot and nailcare.• Do not neglect an ulcer should onedevelop.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 35

Fasten Your Seatbelt, Pop a Dramamine, andPrepare for a Ride in the Brave New WorldBy Joseph J. FeltesTom Daschle’s recent, unceremoniouswithdrawing of his nomination forSecretary of the Department of Health andHuman Services (paying taxes can be sopesky), coupled with continuing economicwoes that demand immediate attention,may retard, but will not stop, PresidentObama’s pledge to bring about sweepinghealth care reform.As physicians brace themselves to meetthe challenges of what promises to be aBrave New World (where memories fromMedicine’s Golden Age grow increasinglyfaint), they also need to prepare to help shoulderthe economic consequences brought aboutby profligate Wall Street practices, whichhave led to bailouts and mind-boggling deficitstimulus packages.Physicians Squeezedfrom Both SidesWhat does this all mean? Though mycrystal ball has become somewhat cloudy,it is certainly clear enough to predict thatCMS likely will ratchet provider reimbursement,and the Office of Inspector Generallikely will continue stepped-up enforcementefforts to combat fraud and abuse with theaim of restoring money to a Medicare Trustthat continues to face mounting financialdifficulties.I am hardly prescient. Just look at whatthe Inspector General stated in its AnnualPerformance Report for Fiscal Year 2008: “Ata time when the [300+] programs administeredby HHS are becoming increasinglyimportant to all Americans, it is essential thatmeaningful actions are taken to enhance theeconomy, efficiency, and effectiveness of HHSprograms… [W]e must continue to vigilantlymonitor HHS programs and operations to ensurethat valuable taxpayer resources are notbeing diminished by fraud, waste and abuse.”And that was from the Inspector GeneralPresident Bush appointed. Can we reallyexpect any less “vigilance” under a PresidentObama appointed Inspector General?The OIG’s success rate over the yearshas been impressive. In Fiscal Year 2008,it recovered $1.33 billion in audits and covered$2.35 billion more in civil settlementsor court-ordered payments. What is evenmore impressive is the OIG’s return oninvestment, which measures its efficiency.In Fiscal Year 2005, for every dollar spent,REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.36 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

the OIG recovered $11.60. In Fiscal Year2008, the rate of return jumped to $17 forevery $1 spent in audit, investigation andenforcement activities.Each year, the OIG publishes its WorkPlan, which lays out practices on its radarscreen. The Work Plan for Fiscal Year 2009identifies among those potential targets:(1) physician coding of place of serviceon Medicare Part B claims for servicesperformed in ambulatory surgical centersand hospital outpatient departments; (2)evaluation and management (E&M) servicesprovided by physicians and reimbursed aspart of the global surgery fee; (3) actualpractice expenses of selected specialties; (4)appropriateness of Medicare payments tophysicians for colonoscopy services; (5) “incidentto” services physicians bill to Medicarethat they do not perform personally, butwhich are performed by non-physician staffmembers [this one merits particular attentionin a world where physician extenders are beingutilized with greater frequency—a trend thatis likely to continue]; (6) appropriateness ofMedicare payments for sleep studies; (7) longdistance physician claims requiring a faceto-facevisit; (8) review of high utilizationof ultrasound; (9) physician reassignmentof benefits; and (10) accuracy of Medicarepayments for services billed using unlistedprocedure codes.Physician OfficeCompliance ProgramsI feel compelled to reach out to all physiciansreading this article who, by now, haveclimbed up on top of the highest piece offurniture in your office. Don’t jump. Stickwith me as I try to talk you down. There stillare effective measures physicians can take thatdon’t involve leaving the practice to sell fruitydrinks at a Caribbean resort.Several years ago, the OIG publishedCompliance Guidelines for Individual and SmallGroup Physician Practices. Now, perhaps morethan ever, it is important to review theseGuidelines and either institute or review andupdate your practice’s compliance program.Doing so not only minimizes the chances thatphysicians will receive an unfriendly knock onthe door by those wearing badges, but theseguidelines also will help prepare physiciansto meet future challenges health care reformpromises to bring.Compliance Guidelines for individualand small group practices consist of sevencomponents: (1) conducting internalmonitoring and auditing; (2) implementingcompliance and practice standardsbuilt around risk areas; (3) designating acompliance “contact” person [either internalor external]; (4) conducting appropriatetraining and education for staff, particularlythose who bill; (5) responding appropriatelyto detected problems and correcting them;(6) developing open lines of communication,urging employees to speak up if theybelieve there is a problem; and (7) enforcingdisciplinary standards to assure that stafffollow the law.Assuring that the staff prepare billsremain current and conducting periodicaudits by external reviewers will help minimizeerrors and could help optimize properpayment of claims. This has been a goodprescription for preventive medicine in thepast, and it will continue to serve physicianswell in coping with the Brave NewWorld ahead.Joe Feltes is an attorney and member of theHealth & Medicine Practice Group of Buckingham,Doolittle & Burroughs. He is the managing partnerof Buckingham Canton. nREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 37

Identity Theft —FTC’s Red Flag RulesBy Martha S. Bethea, CPA, and Ronald F. Pavlovich, CPABy May 1, 2009 creditors who maintaincovered accounts must establish a programto prevent identity theft. What could thishave to do with a medical practice? Underthe FTC regulation a creditor is defined asan entity that regularly extends, renews,continues credit or arranges for the extensionof credit. A covered account is definedas a consumer account designed to permitmultiple payments or transactions, or anyother account for which there is a reasonablyforeseeable risk of identity theft. Underthese broad definitions, a majority of medicalpractices would be considered a creditorwho maintains covered accounts.The FTC Red Flag Rules require thata creditor develop an identity theft programthat contains reasonable policies andprocedures to• Identify relevant patterns, practices, andspecific forms of activity that are “red flags”signaling possible identity theft,• Detect these patterns or “red flags,”• Respond to those detected “red flags” toprevent and mitigate identity theft, and• Ensure the program is updated periodicallyto reflect changes in risks.Administration of such a program shouldinclude• Obtaining approval of the program by theentity’s board of directors or board committee,• Involvement of the board or senior managementdesignee(s),• Training of staff, and• Exercising oversight of any service providerarrangements.The program may be based on the relativerisk of identity theft within the creditor’slocations and customer population.So, what could medical identity theft looklike? One example would be the unauthorizeduse of a stolen insurance card, insurancenumber, name and/or social security numberto obtain medical services or products withoutthe victim’s knowledge. Another would bethe use of this form of identity theft to obtainmoney by falsifying medical claims or medicalrecords to support such claims.Examples of “red flags” in the health caresetting would include• Contact from a patient based on a billfor service or product that the patientdenies receiving, from a health careREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.See Next Page38 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

NEOUCOM AnnouncesNew Board of TrusteesThe Northeastern Ohio UniversitiesColleges of Medicine and Pharmacy(NEOUCOM) recently announced theappointment of eight new members to itsBoard of Trustees. They are Mr. Steve Cress;Dr. Eric Kodish; Dr. Chander Kohli; Ms.Judith Barnes Lancaster; Dr. Dianne BitonteMiladore; Dr. Anil Parikh; Dr. Steve Schmidtand Mr. Gary Shamis.Ohio Governor Ted Strickland appointedthe new Board of Trustees following hisendorsement of House Bill 562, which alsogained approval from Ohio Board of RegentsChancellor Eric D. Fingerhut and the OhioGeneral Assembly.Mr. Cress has served as president and CEOof Mid’s Pasta Sauces in Navarre, Ohio, since1997. He is the chairperson of the Board ofTrustees for NEOUCOM.Dr. Kodish is the F. J. O’Neill Professorand chairman of the Department of Bioethicsat the Cleveland Clinic Foundation. He’sprovider the patient never patronized,or for an Explanation of Benefits forservices never received;• Post office address discrepancy notice;• Insurance denials because maximumbenefits have been used or the lifetimemaximum has been reached;• Any dispute by a patient claiming to be avictim of identity theft;• The presentation of an insurance numberwithout an insurance card or documentationof insurance; or• Any notice or inquiry from an insurancefraud investigator.Application of the FTC requirementswould require that you1. Identify the red flags applicable to yourpractice and establish a system to detectthese red flags;2. Establish a program to respond to thedetection of the red flags from both thepractice and the victim’s perspective,including defining;also professor of Pediatrics at the LernerCollege of Medicine of Case WesternReserve University.Dr. Kohli is director of Neurological Surgeryat St. Elizabeth’s Hospital and clinical professorof Neurological Surgery at NEOUCOM.Ms. Lancaster is an attorney servingas Special Counsel to the Ohio AttorneyGeneral. She practices privately in Canton,Ohio, and is principal and president of GlobalManagement Group, Inc., a sports and entertainmentcompany. She is president-elect ofthe NEOUCOM Board of Directors.Dr. Bitonte Miladore is a life-long residentof the Youngstown area, who received herMD degree as a member of the charter classof NEOUCOM. She has been very activeat NEOUCOM, where she has served as aclinical faculty member, a member of theAdmissions Committee, the Academic ReviewCommittee, and the Clinical CompetencyAssessment Medical Advisory Board.• What the practice does when a patientclaims fraud in medical billing or records;• What to do when a practice is notified thata patient received bills for services they didnot receive;• What to do with an altered patient record;• What to do when the practice uncoversfraud;• How the practice works with patients tocorrect medical identity theft, correctrecords and limit future damage;• How the practice handles police reports andrequests for investigation by the victim ofidentity theft; and• How the practice trains and monitors staffto ensure the application of the program.3. Respond to “red flags” and takes stepsto prevent or mitigate identity theft.While HIPAA extends rights to patientsconcerning their medical records, itdoes not address identity theft. HIPAApolicies are not adequate for preventionDr. Parikh has operated a private practicein psychiatry in Fairlawn, Ohio, since 1987and teaches psychiatry residents at AkronGeneral Medical Center. He is board certifiedin psychiatry, geriatric psychiatry, addictionpsychiatry, forensic psychiatry, pain managementand psychosomatics.Dr. Schmidt is director of Summa HealthSystem’s Division of Surgical Research. Healso serves as chair of Summa’s TraumaResearch Committee and is an associateprofessor of Physiology at NEOUCOMand a member of the graduate faculties atKent State University and The Universityof Akron.Mr. Shamis is the firm managing directorof SS&G Financial Services in Cleveland.In 2008, he was named Ernst & YoungEntrepreneur of the Year for Northeast Ohioin the financial services category. He is chairmanemeritus of The Leading Edge Allianceand founder of The Advisory Board. nREVIEW ONLYContinued from Previous Pageand mitigation of identity theft. Separateand independent policies and proceduresneed to be in place concerning correctingfraudulent information in a medicalrecord and mitigating identity theft.4. Ensure your “red flag” policy is periodicallyreviewed and updated to reflect changesin risk.The American Medical Association andMedical Group Manager Association alongwith many other healthcare organizationscontinue their efforts to obtain clarificationand guidance from the FTC on the applicationof the Red Flag Rules to health care providers.The May 1, 2009 deadline (extended fromNovember 1, 2008) is rapidly approaching,and your practice needs to have its policiesand procedures in place.Martha S. Bethea, CPA, is the director in chargeof the Medical Practice Management Group of CBIZMHM, LLC. Ronald F. Pavlovich, CPA is seniormanager of the Medical Practice ManagementGroup of CBIZ MHM, LLC. n© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 39

Ready Yourself for Our New DealBy Richard Weidrick, CPA/PFSTax returns have been filed and we have thefirst 90 days or so of the new administrationbehind us. New programs and initiatives havebeen brought forward and the bail-out effortcontinues. Funding for these efforts comesfrom where? Unfortunately the reality is thatyou can expect to do the heavy lifting overthe next 8 years.The average reader of this magazine willexperience the following:1. An increase of the top ordinary incometax rates to 40+%.2. A repeal of the preferential capital gain ratefrom 15% back to being taxed at 28% oreven at ordinary income tax rates.3. An increase of the $106,800 wage limitfor social security tax purposes subjectingmore of your dollars to the 6.2% tax and apotential removal of the cap completely.4. A repeal of the preferential rate for domesticdividends from 15% to ordinaryincome tax rates.5. An increase in estate taxes.Find a comfortable pair of boots becausethe unprecedented transfer of wealth andincome that is going to occur has foot soldiers….youand you. The benefactors willbe the less fortunate, the less educated and alltoo often the less motivated. State and federalgovernments are set to expand (already one ofthe biggest employers in Ohio) and will playa bigger role in our lives.So now you know what the future lookslike. The following are a few suggestions onwhat can be done to minimize the impact ofour generations “new deal”:We Can KeepYour Practice HealthyGrow your business your way with Physician-based accounting.Weidrick, Livesay, Mitchell & Burge’s is staffed with experienced accountingprofessionals with a focus on physician practices. We specialize in physician-basedbusiness accounting to help doctors achieve their potential and remain successful.Controlling overhead, managing collections, personal taxes and retirement planningfor our clients means you are free to concentrate on your specialties...your patients, your practice, your family.Call us today to find out what we can do for you!WEIDRICK, LIVESAY,MITCHELL & BURGE, LLCC ERTIFIED PUBLIC ACCOUNTANTS1. Bunch income into early years especially2009. The common thinking isthat the Bush tax cuts will be left toexpire in 2010 which translates intoan increase in the top rates of at least5%. The sky is the limit after 2010 andsome clients are remembering top taxrates of 80% before Ronald Reaganbecame President.2. Continue putting money into tax deferredvehicles such as retirement accounts,real estate and annuities. By deferringthe taxation of any appreciation you areanticipating being in a lower tax bracketduring retirement.3. Maximize employer reimbursementopportunities by having expenses2150 North Cleveland-Massillon Road • Akron, Ohio Akron: 330-659-5985 Medina: 330-722-5249See Next PageREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.40 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

Ohio Supreme CourtModifies the BelvedereTest for Piercing theCorporate VeilBy Nathan D. Vaughan, Esq. & Matthew R. Hunt, Esq.One of the major advantages of incorporatinga business is the creation of a“corporate veil.” If the corporate veil ispierced, the shareholders will be held personallyliable for the corporate obligationsat issue.Recently, the Ohio Supreme Court inDombroski v. WellPoint, Inc. modified the 3part test for piercing the corporate veil.The original test was created in BelvedereCondominium Unit Owners’ Assn. v. R.E. RoarkCo., Inc. In Belvedere, the Ohio SupremeCourt held that a plaintiff can pierce thecorporate veil when:1. Control over the corporation by thedefendant is so complete that the corporationhas no separate mind, will, orexistence of its own;2. Control over the corporation by thedefendant is exercised in such a manneras to commit fraud or an illegal actagainst the person seeking to disregardthe corporate entity; andContinued from Previous Pagereimbursed out of production or beforetaxes. This reduces the overall amountssubject to the higher tax rates.4. Be pro-active and consult your advisors toensure you are doing everything you canto reduce your income and estate taxes.The next several years will not be easy,but with a little maneuvering they canbe survived.Rich Weidrick is a CPA and a principal ofWeidrick, Livesay, Mitchell & Burge, LLC,in Akron. nlegal ease3. Injury or unjust loss resulted to theplaintiff from such control and wrong.Since the announcement of the Belvederetest, Ohio Courts have disagreed whetherthe second prong would be satisfied upon ashowing of unjust and inequitable acts or ifthe plaintiff is required to show fraudulentor illegal conduct.In Dombroski, Kimberly Dombroski wasdeaf in both ears and her treating physiciandetermined it was medically necessary toreceive a cochlear implant. After the implant,Ms. Dombroski regained hearing inher left ear, but remained deaf in her rightear. As a result, her treating physician determinedit was medically necessary to install asecond cochlear implant. Ms. Dombroski’sinsurance company, Community InsuranceCompany (“CIC”), determined that the secondimplant was “investigational” and thusnot covered under her health insurance. Asa result, Dombroski filed suit alleging badfaith and breach of contract against CIC andits parent company. Dombroski sought topierce the corporate veil to hold the parentcompany, the shareholder, liable for CIC’stort of bad faith. The trial court dismissedthe action, but the 7th District Court ofAppeals reversed citing case law that heldunjust and inequitable conduct was sufficientto satisfy the second prong.However, the Ohio Supreme Courtoverturned this decision and concludedthat unjust and inequitable acts were insufficientto satisfy the second element ofthe Belvedere test. Further, the Court heldthat “ . . . piercing the corporate veil is the‘rare exception’ that should only be ‘appliedin the case of fraud or certain otherexceptional circumstances.’” The courtrecognized “[a]dding unjust or inequitableconduct to the second prong of theBelvedere test significantly increases thenumber of cases in which a Plaintiff couldpierce the corporate veil.”The Supreme Court did not stop bymerely determining that unjust or inequitableacts were insufficient to satisfy thesecond prong, but further modified the secondprong to allow piercing upon a showingof fraud, an illegal act or a similarlyunlawful act. The Supreme Court madeclear that piercing the corporate veil is onlyavailable “ . . . in the event that egregiouswrongs are committed by shareholders.”The Supreme Court instructed lowercourts to “apply this limited expansioncautiously toward the goal of piercing thecorporate veil only in instances of extremeshareholder misconduct.” Ultimately, theSupreme Court reinstated the trial court’sdismissal holding that even under the newlyrevised second prong of Belvedere, “[i]nsurerbad faith is a straightforward tort [and] doesnot represent the type of exceptional wrongthat piercing is designed to remedy.”NOTE: This general summary of the lawshould not be used to solve individual problemssince slight changes in the fact situation mayrequire a material variance in the applicablelegal advice.Nathan D. Vaughan and Matthew R. Huntare attorneys with the law firm Krugliak Wilkins,Griffiths & Dougherty Co., LPA in Canton. nREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 41

Life Insurance: A SoundFinancial StrategyBy Raymond N. Latiano, CFP, CLU, ChFCWhile the ’90s were a time of economicprosperity and wealth accumulation formany, the 2000’s have reminded peopleof the importance of diversification andprotection. Certainly, economic andworld events have caused many of us torefocus on a larger and more challengingfinancial picture. And, wisely, manyfinancial professionals are preaching theneed for diversification as a means of bettermanaging risk. But how many of them aresuggesting that their clients take a secondlook at an old reliable tool — life insurance— as an essential element for a soundfinancial strategy?Arguably, the biggest issue with lifeinsurance is the tendency to oversimplifythe whole process of buying it. It’s eitherterm or permanent, some “experts” willsay. Furthermore, these same experts willoften advise that term is the only way to gofor everyone.Truth is, buying life insurance cannot bereduced to a simple either/or decision. It ismuch more than a simple commodity; it’snot like buying a book online or using thelatest technology tool. And it will dependupon each person’s circumstances.There are issues of:• How much insurance you need and howlong you’ll need it; and• How the actual contract is designed: whattypes or combination of types are best foryour needs; how your insurance needsmight change over time; the extent towhich you are prepared to pay premiumsover an extended period.It follows that the life insurance policy aperson owns should reflect that individual’sunique needs — there are no one-size-fitsallsolutions when preparing for financialsecurity. For some this could mean termArguably, the biggest issue with life insuranceis the tendency to oversimplify the wholeprocess of buying it. It’s either term or permanent,some “experts” will say. Furthermore, these sameexperts will often advise that term is the only wayto go for everyone.life insurance; for others, it could meanpermanent life insurance. For others, still,it could mean a blended policy of both termand permanent insurance, or a combinationof several types.Whenever you get into the issue ofterm or permanent, it’s important tounderstand the fundamentals. Withpermanent insurance, the insuranceproceeds are paid to your beneficiarieswhenever you die, as long as the premiumscontinue to be paid. Permanentinsurance has level premiums and a cashvalue that grows on a tax-deferred basis.Term insurance, on the other hand,provides a payout only if you die withina certain period of time. The premiumstypically increase each time you renewyour policy and it has no cash value.Initially, the premium for term insuranceis considerably lower than that of apermanent policy. But, in the long-run,the net cost may eventually be lower withthe permanent plan.Life insurance should be consideredthe foundation and most conservativeelement of any personal plan — themoney that absolutely has to be there,no matter what the economic cycle orclimate. Furthermore, choosing the rightamount of insurance is more importantthan finding the right kind. After that,the type you buy depends on your timetableand budget.A good financial representative willmake sure you consider life insurance aspart of your overall financial strategy. Thisis someone who can help you understandyour insurance needs and help identifywhich products offer innovative solutionsin a particular situation. Rather than pusha product, a good financial representativewill do these things:REVIEW ONLYRe-examining the Role ofLife Insurance• Ask questions about your goals and objectivesand your long- and short-termneeds.• Analyze the information to determine thefeasibility of these goals, objectives andneeds.• Make a recommendation to help meetyour financial goals.• Provide good service year after year, byletting you know how your plan is performingrelative to your objectives – it’sa long-term relationship.© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.This article was prepared by NorthwesternMutual with the cooperation of Ray Latiano.Mr. Latiano is a financial representative withNorthwestern Mutual Financial Network themarketing name for the sales and distributionarm of The Northwestern Mutual LifeInsurance Company, Milwaukee, Wisconsin,its affiliates and subsidiaries. He is based inCanton, Ohio. n42 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

Want to increase patient referrals?Gain the attention of physicians in the Cleveland/Akron/Canton area through M.D. NEWS!Published every other month, M.D. NEWS offers the opportunity to• Promote your services through display advertising, and• Show your expertise through editorial.Call us today at 330-499-5332 to learn how you can gain the attention (and the patientreferrals) you want.REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Coming up in the M.D. NEWS May-June issueWomen’s Health Special Section of ads and articlesDo you diagnose or treat one of these?arthritis hernias menstrual disorders pelvic disorderscancers high risk pregnancies menopause sports injuriesdiabetes incontinence obesity strokedepression infertility orthopaedic problems TIAheart disease joint problems osteoporosis urogyn disordersOr do you offer other services for women such as plastic surgery or cosmetic procedures,estrogen replacement therapy, or birth control methods — temporary or permanent?If you have expertise in any of these areas, you’ll want to be included.For information, call 330-499-5332 or 1-877-499-5332or e-mail jraabe@mdnews.com

Local Docs in National NewsPeter Degolia, MD, medical directorof Hospice and Palliative Care at SouthwestGeneral Medical Center published twoarticles in the January 2009 issue of ClinicalGeriatrics: “Geriatric Trauma: integratinggeriatric medicine consultation within atrauma service,” and “Moving geriatrictrauma toward better outcomes.”Henry B. Koon, MD, and AmitabhChak, MD, received 2008 Pilot AwardCore grants from the Clinical andTranslational Science Collaborative.Dr. Koon’s research will look for geneticmarkers that can predict if melanoma willspread through the lymph system. Workingwith Dr. Koon on the project are KordHonda, MD, etc. (See Ireland CancerCenter update.)Four Cleveland Clinic Lerner ResearchInstitute researchers recently receivedgrants totaling more than $2.3 million:Chris Eng, MD, PhD, chair, GenomicMedicine Institute, was awarded a totalof $250,000 over 1 year for “DifferentialBiallelic Expression of PTEN in Patientswith Heterozygous Germline (new) andGenes that Affect Mitochondrial Functionas Novel Mediators of Breast CancerSusceptibility (continuing).” Funded by theBreast Cancer Research Foundation.James Finke, PhD, Immunology, wasawarded $240,598 over 2 years for “Definingthe Mechanisms by which SunitinibRegulates T-regulatory and Myeloid DerivedSuppressor Cells in Renal Cell CarcinomaPatients Resulting in Improved T cellImmunity.” Funded by Pfizer, Inc.Neetu Gupta, PhD, Immunology,was awarded $115,875 over 1 year for“A Systems Biology Approach to EvaluateEzrin as a Therapeutic Target in BreastREVIEW ONLYJonathanCancer.” Funded by the U.S. Departmentof Defense.”Steven Leitman, MD, BiomedicalEngineering, was awarded $1,713,265over 5 years for “Molecular Mechanismsin Bone Resorption (R01).” Funded by theNational Institute of Dental & CraniofacialResearch/NIH.Three physicians from MetroHealthMedical Center recently received honorsfrom The American College of EmergencyPhysicians (ACEP). Louis S. Binder, MD,Thomas W. Lukens, MD, andJonathanSiff, MD, , were each named a “Hero ofEmergency Medicine.” The campaign, whichis part of ACEP’s 40th anniversary, recog-nizes emergency physicians who have madesignificant contributions to emergency medi-cine, their communities and their patients.Dr. Binder began his tenure atREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.44 | CLEVELAND/AKRON/CANTON M.D. NEWS MARCH-APRIL 2009

MetroHealth in 1999. His accomplishmentsas an educator earned him theCase Western Reserve University Schoolof Medicine’s annual Kaiser-PermanenteExcellence in Teaching Award in 2004.Dr. Binder has authored 56 peer-reviewedpublications and 145 scientific presentationsin a wide array of topics. He also is a professorat Case Western Reserve University.businessyoursDr. Lukens was among the foundingfaculty of the emergency medicine residencyat MetroHealth in 1991, and has assistedin the teaching of more than 125 emergencymedicine residents since that time.He was appointed to the medical team atMetroHealth in 1985. He is a long-timeACEP board member representing OhioACEP, and a member of several nationalACEP committees. Dr. Lukens co-foundedthe Northeast Ohio Society of EmergencyMedicine, a forum focusing on commongoals and education. He is an associate professorat Case Western Reserve University.by providing expert accounting servicesby minimizing your taxesby improving your profitabilityby maximizing your personal wealthby identifying tax planning opportunitiesREVIEW ONLYSince joining MetroHealth in 1997,Dr. Siff has helped spearhead a hospital-wideeffort to develop a policy andmethodology to create care plans forpopulations of emergency department patients,improving their care throughout theorganization. In 2007, Dr. Siff was the onlyemergency medicine physician appointed tothe Practicing Physicians Advisory Council,a national body which advises the Center forMedicare & Medicaid Services and the U.S.Department of Health and Human Serviceson physician regulatory policy. He also isan established member of ACEP’s NationalReimbursement Committee and chair ofOhio ACEP’s Reimbursement Committee.He is an assistant professor at Case WesternReserve University.ACEP is a national medical specialtysociety representing emergency medicinewith more than 26,000 members. ACEPis committed to advancing emergency carethrough continuing education, research andpublic education. Headquartered in Dallas,Texas, ACEP has 53 chapters representingeach state, as well as Puerto Rico and theDistrict of Columbia. nby developing an effective business planby providing you with an advantage© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.ACCOUNTING, TAX & CONSULTINGTO THE HEALTHCARE INDUSTRYTogether with Mayer Hoffman McCann,one of the Top Ten Accounting Providers in the NationCBIZ MHM, LLCwww.cbiz.com/cbizmhm-neohioCLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 45

What’s New at Area HospitalsAffinity Medical Center’s (Massillon)trauma center obtained Level III re-verificationfrom the Committee on Trauma(COT) of the American College of Surgeons(ACS). Established by the ACS in 1987, theCOT’s Verification/Consultation programfor Hospitals promotes the developmentof trauma centers in which participantsprovide not only the resources necessaryfor trauma care from the pre-hospital phasethrough rehabilitation to address the needsof all injured patients.Akron Children’s Hospital (ACH)and Aultman Hospital in Canton haveteamed up to offer the pediatric specialtyclinics several times a month at Aultman.Pediatric pulmonologists are available atAultman on the first and third Mondaymornings of each month to offer generalpulmonology services to infants, childrenand teens, including pulmonary functiontests, allergy skin tests and asthmaeducation. Patients requiring a multidisciplinarymedical team, such as thosewith cystic fibrosis, infants with apneaand those dependent on respiratory technology,will still need to schedule theirappointments at ACH’s main campus indowntown Akron. On the fourth Tuesdayof each month pediatric neurologists seepatients at Aultman from 8 a.m. to 4:30p.m. This includes patients with headaches,epilepsy, seizure disorders, headinjuries and neuromuscular disorders.Akron General Health System hasbeen honored by Modern Healthcare magazineas one of the nation’s most efficientintegrated health networks. Akron Generalwas the only system in Summit County, andone of only five in the state of Ohio, to makethe Top 100 list. In compiling its annualranking, Modern Healthcare used objective,comprehensive data gathered annuallyfrom integrated health networks across thecountry. The data included a wide range ofareas that demonstrated an organization’scommitment to integration throughout itsoperation. Surveyors examined criteria,such as the number of physicians employedby the system and the levels of integrationin medical care protocols, purchasing andcase management. Modern Healthcare alsoexplored the availability of programs indisease management and how integrateda system is in its information systems andmedical records.Alliance Community Hospital(ACH) has implemented the AllianceCommunity Medical Foundation, LLC(ACMF). ACMF is a partnership betweenAlliance Community Hospital and areaphysicians that is aimed at retaining thetop clinicians and medical services in theregion. It will enable physicians to focustheir attention on direct patient care, sincedaily business operations will be handled bythe Foundation.Aultman Hospital (Canton) recentlyreceived a grant from the March of DimesFoundation to expand capacity and increaseparticipation for the CenteringPregnancyprogram that helps uninsured and underinsuredexpectant mothers better understandprenatal care and take an active role in theirbabies’ development. The primary goal ofdecreasing preterm births is accomplishedby creating a fun, educational environmentthat encourages women to attendthe 90-minute appointments along side8-12 women with similar due dates. The5-year-old program has increase attendanceby 28 percent for these patients compared totraditional obstetric patients in the clinic.Cleveland Clinic researchers havedeveloped models, or “nomograms,” forpredicting success of kidney transplants. Aresearch team from the Glickman Urologicaland Kidney Institute at Cleveland Clinicanalyzed data from the United Networkhospital roundsfor Organ Sharing registry to determinekidney function in transplant patients afterone year and five years. The team used thedata to then determine which characteristicshave the most significant impact onoutcomes. Among the factors they analyzedwere a donor’s age, gender and the donor’ssize in comparison to the recipient. Theythen translated this information into chartsand tables that can be used in counselingrecipients about the kidney donor who willprovide the best match. Their study will bepublished in the March 2009 issue of TheJournal of Urology.Fairview Hospital recently receivedMagnet Status, the highest national awardfor nursing excellence, from the AmericanNurse Credentialing Center (ANCC).Magnet recognition serves as externalrecognition of exceptional care that isprovided to patients and their families.Only 5 percent of the hospitals in the nationhave received this recognition. TheANCC awarded Fairview Hospital thisaward after reviewing nearly 3,500 pages ofsubmitted documentation demonstratingachievements in patient care, nurse satisfaction,quality improvement and nursingresearch. This was followed by a three-dayon-site inspection by Magnet appraisersthat included visits to all patient care areas,all external Fairview Hospital sites,and interviews with hundreds of nurses,employees, physicians, Board Membersand community members.REVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.Marymount Hospital (GarfieldHeights) is reportedly the first communityhospital in northeast Ohio to install a multiaxisangiography system featuring robotictechnology. The new technology allowsfor greater ease in positioning patients, aswell as visualization of larger sections ofthe anatomy. It is the same angiographysystem used at Cleveland Clinic’s maincampus to help diagnose and treat vascular46 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

disease, including carotid artery disease,aortic aneurysms, circulatory conditions,and more. The angiography system wasinstalled in a spacious new suite, dedicatedexclusively to vascular procedures. In total,the multi-axis angiography system andnew vascular suite represent a $2.5 millioninvestment to Marymount Hospital’sclinical capabilities.Medina General Hospital’s PedsEmergency Department offers after-hours,pediatric medical care for children Mondaythrough Saturday 4-11 p.m. and on Sunday2-11 p.m. Decorated in a “rain forest” themewith jungle animal and safari truck examtables and supplied with DVD players tokeep children entertained or distractedduring procedures, the Peds ED is very kidfriendly.Seven board certified pediatriciansand a team of pediatric nurses staff the PedsED. With the availability of on-site lab andradiology services, they are able to care forover 95 percent of the patients who comethrough the door, including babies whoare a few days old through teenagers 17years of age.Mercy Medical Center (Canton) wasthe first in the Canton area to offer PET/CT scans via mobile service and now isthe only facility between Cleveland andColumbus to offer PET/CT scans on site,giving patients rapid access to neededtesting. For years, physicians have reliedon separate results from CT scans andPET scans to find and diagnose tumors.Mercy’s PET/CT unit combines PET andCT technology into a single imaging systemand superimposes the two scans, creating a“fused image” that pinpoints the cancerousareas in a patient’s body. This can lead toearlier detection and treatment.Parma Community GeneralHospital has a unique EmergencyDepartment (ED) process known as Docat the Door to make delivery of care quickerand more efficient, and patients love it. Forthe past three months, Press Ganey patientsatisfaction scores have been in the 90thpercentile. With Doc at the Door, a physicianassessment occurs within approximately 30minutes of the patient’s arrival. A preliminarydiagnosis and testing can be orderedby the physician before the patient is evenbrought back into an ED patient room.The physician heads a team, including anurse, paramedic and technician, who canperform EKGs, draw blood and start IVs.The ED recently completed renovation toremove registration areas near the waitingroom and replace them with more privatetriage rooms. Since patients are registeredat the bedside, separate registration suitesare no longer needed.Robinson Memorial Hospital’s(Ravenna) Visiting Nurse & HospiceDepartment was recently named to the2008 HomeCare Elite for the third consecutiveyear. This annual review identifiesthe top 25 percent of Medicare-certifiedagencies, ranked by an analysis of performancemeasures in quality outcomes,quality improvement and financial performance.The HomeCare Elite status isawarded by OCS, Inc., a data company thathelps healthcare organizations benchmarkand improve their quality of care, and byDON’T TRY TO PREDICT THE FUTURE ...PREPARE FOR IT. BrookshireF I N A N C I A L G RO U P, I NC .Lifetime wealth strategies and solutionsDecisionHealth, publisher of home care’smost respected independent newsletter,Home Health Line, and other publications foragency administrators.St. John West Shore Hospital’sDiabetes Education Program offers comprehensive,convenient diabetes care that isprovided through individual consultations,group education classes, support groups, andspecial community education programs. Itemploys the latest innovative teaching toolsto educate and motivate clients toward betterdiabetes self-management. The programwas awarded recognition status by theAmerican Diabetes Association (ADA),signifying the diabetes education servicesoccur in a high-quality, comprehensiveprogram that meets nationally establishedstandards. A physician referral is requiredfor individual and class diabetes education.Anyone is welcome to the diabetes supportgroup meetings.Sout hwe st G enera l He a lt hCenter’s new Orthopedic Joint Center(OJC) opened in November. It is the onlylocal orthopedic center focusing exclusivelyon knee and hip replacement. TheOJC offers a dedicated team of expertsWealth ManagementRetirement PlanningPersonal Trust ServicesEstate PlanningTHE MILLENNIUM CENTRE 200 MARKET AVENUE NORTH CANTON, OH 44702330-453-3991 info@brookshirefinancial.com www.brookshirefinancial.com hospital roundsREVIEW ONLY© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009 | 47

including board-certified orthopedicsurgeons, specially trained nurses andexperienced physical and occupationaltherapists; advanced technology; thelatest joint replacement surgery and recoverytechniques; and extensive patienteducation. Typically, patients that qualifyhave surgery on Monday or Tuesday andare discharged to home on Thursday orFriday. Previously, patients might remainin the hospital for up to eight days aftersurgery. The shorter hospital stay helpspatients recover more rapidly and returnto the activities of daily living sooner.Summa Akron City/St. ThomasHospitals’ DOVE (Developing Optionsfor Violent Emergencies) program hasbeen awarded the largest grant in its history— a two-year, $426,000 Byrne Grantfrom the US Department of Justice. Thisgrant will enable DOVE to expand itsclinical capacity on both campuses as wellas provide clinical and professional educationthroughout the communities servedby Summa hospitals to benefit victims ofacute sexual assault and domestic violence.DOVE provides specialized healthcare toadolescent and adult victims of acute sexualassault, domestic violence and elder abuseand neglect. No victim is ever charged forDOVE’s clinical services.Summa Barberton Hospital hasacquired two new LOGIQ 9 ultrasoundsystems, which allows for quick and precisegeneral ultrasound imaging for a variety ofapplications including abdominal, breastand vascular. This high-performance systemprovides high-definition images in 3D and4D, which provides clearer pictures to assistin early diagnosis and help patients betterunderstand what they’re seeing during anultrasound exam.Summa Cuyahoga Falls GeneralHospital (CFGH) celebrated the openingof its new Oncology and Infusion Center inJanuary. The Oncology and Infusion Centeris located on the western side of CuyahogaFalls General Hospital in the space thatwas formerly occupied by the hospital’semergency department and offer easy accessfor patients and their families. The center’sentrance is covered, and free, valet parkingis provided. The Oncology and InfusionCenter offers a variety of infusion servicesincluding chemotherapy, blood transfusionsand IV hydration.Summa Wadsworth-Rittman Hospitalrecently acquired the state-of-the-art system,Selenia digital mammography fromHologic. Digital mammography is differentfrom conventional mammography in howthe image of the breast is acquired and,more importantly, viewed. With digitalmammography, the radiologist can magnifythe images, increase or decrease the contrastand invert the black and white valueswhile reading the images. These featuresallow the radiologist to evaluate microcalcificationsand focus on areas of concern. TheWadsworth-Rittman Hospital Foundationpurchased the new mammography unitwith a grant received to develop women’shealth services, as well as proceeds fromthe annual Black Tie event held in Marcheach year.Union Hospital (Dover) has expandedits presence at the Oxford Medical Centerin Dover. Both the Union Hospital SleepDisorder Center and the CardiopulmonaryRehabilitation Department have moved tonewly remodeled facilities on the groundfloor of the building at 340 Oxford St. TheUnion Hospital Sleep Disorder Center hasdiagnosed and treated more than 10,000patients for sleep disorders. The sleep centerbegan in 1996 with one sleep study roomand has grown today to four sleep roomsand a state-of-the-art control room.U n iversit y Ho spit a l s C a s eMedical Center’s adult endoscopyunit is one of 56 units in the country tobe recognized by the American Societyfor Gastrointestinal Endoscopy (ASGE)for promoting quality in endoscopy. UHhospital roundsCase Medical Center is the only hospitalin Ohio to receive this elite honor. Thenew ASGE Endoscopy Unit RecognitionProgram honors endoscopy units thatfollow the ASGE guidelines on qualityassurance, privileging, endoscopyreprocessing and Centers for DiseaseControl infection control guidelines.ASGE, with nearly 11,000 membersworldwide, promotes the higheststandards for endoscopic training andpractice, fosters endoscopic research,recognizes distinguished contributionsto endoscopy, and is the foremost resourcefor endoscopic education.Special thanks to the hospital Public Relationsadministrators who submitted information for thiscolumn. To include your hospital’s news, add usto your press release list or e-mail informationto jraabe@mdnews.com. The deadline for theMay-June issue is April 3. nadvertisers’ indexREVIEW ONLYBrookshire Financial Group, Inc....47Buckingham Doolittle& Burroughs, LLP........................7CBIZ MHM, LLC...........................45Cleveland Foot & Ankle Institute....38Comprehensive PracticeResources...................................29Emergency Medicine Physicians.......1Hospice of the Western Reserve.....36Krugliak, Wilkins, Griffiths& Dougherty Co., L.P.A..............44Lutheran Hospital..........................15National City......... Inside Back CoverNEOUCOM....................................17Northwestern Mutual.....................37SouthwestGeneral.............. Inside Front CoverSumma Health System..... Back CoverThe Elms.......................................24University Hospitals.......................23U.S. Army.....................................32Visiting Nurse Association.............29Weidrick, Livesay, Mitchell& Burge, LLC.............................40Wooster Community Hospital.........33© 2008 SUNSHINE MEDIA, INC. UNAUTHORIZED USE OF THIS DOCUMENT IS STRICTLY PROHIBITED.48 | CLEVELAND/AKRON/CANTON m.d. news MARCH-APRIL 2009

MORE LOCAL HEALTHCARE CHOICESGet Summaexcellence closeto home.Summa’s large network of local communityhospitals provides easy access to excellent care. In fact,our Wadsworth-Rittman and Barberton Hospitals are justminutes away. Discover a Summa hospital near you! Akron City Hospital Barberton Hospital Cuyahoga Falls General Hospital Robinson Memorial Hospital St. Thomas Hospital Wadsworth-Rittman HospitalCOMING SOON! Summa’s Health Center at Lake MedinaEnjoy easy access to on-site diagnostics, physician offices, same-day surgery, oncology servicesand more at our state-of-the-art facility on Rt. 18, just west of I-71.www.summahealth.org