IT’S BEEN A TRYING YEAR for doctors and patients alike, with the pandemic still in full swing at the beginning of 2022. By year’s end the medical landscape reflected the triple whammy of flu, COVID, and RSV, a respiratory virus particularly problematic in children. In spite of adversity, doctors in the New Orleans area marched on, giving excellent care, and providing patients with the latest and greatest innovations in their respective specialties. Our readers, once again, weighed in with their picks for the best of the best in 24 different subspecialties. Following is a small sampling of the more than 120 doctors who made the list and discussed their thoughts on the current state of medicine with Inside New Orleans magazine.
Detective work is the name of the game for doubleboard certified allergist and immunologist Dr. Irum Qureshi, whose practice is centered in Covington. Beyond treating her patients for everything from asthma to chronic coughs, her modus operandi is to dig beyond the symptoms to find the underlying causes of any malady.
“Rather than putting asthma patients, for example, on steroid inhalers for the rest of their lives, I try to go beyond the obvious to get to the real culprit which is causing the problematic symptoms,” explained Qureshi.
“So, if I’m targeting an allergen, my job is to delineate whether it’s a chemical entity, a food allergen, an environmental toxin, or other causes of the troubling symptoms in my patients.”
“You want to provide the sort of care that doesn’t lead to the exacerbation of symptoms or that can lead to emergency room visits in the future for side effects caused by years of steroids. Osteoporosis and osteopenia are just some of the many unfortunate results from years of corticosteroids. I want patients to be aware of the many different modalities of treatments that better target the precise causes of their problems, and stay away from endless treatment with drugs that have long-term consequences.”
When it comes to our skin, the largest organ of the body, doing damage can start very early and have lasting effects. According to The Skin Surgery Centre’s Dr. Keith LeBlanc, Jr., a dermatological specialist known as a Mohs surgeon, most skin cancers that you get as an adult are actually due to sun exposure received from birth to ten years of age. So, if you’re debating about putting sunblock on your young child, there’s no question it’s important.
LeBlanc, who doesn’t practice general dermatology, is involved in the very specialized arena of removing cancerous lesions, the most common of which are basal cell carcinomas. This type of skin cancer is more prevalent than breast, prostate, lung and colon cancer combined. Mohs surgery, which Dr. LeBlanc performs exclusively, involves cutting away thin layers of skin, which are examined closely in a lab for any signs of cancer. The process keeps going until all margins are clear and there is no sign of cancer. This can translate to one level or multiple levels, depending upon how deep the cancer goes beneath the skin’s surface.
“Not every cancerous lesion requires Mohs surgery,” says LeBlanc. “Appropriate use criteria dictates whether to do Mohs, or not. Size matters … 3mm on an arm doesn’t qualify, but on the nose or eyelid, it does. So, the anatomical location, your family history, and the size of the cancerous lesion are all relevant.”
LeBlanc only performs Mohs surgery on lesions of 7mm or more. On the arm that still doesn’t qualify, but on the face, it would. Lesions are categorized as high, medium, or low-level conditions. High is on the face, hands, feet and genitalia. Medium would be the front of the leg between the knee and ankle, as well as cheeks, scalp and neck. Everywhere else is a low-level condition. But, it’s important to remember that a very large lesion on a low-level anatomical area will still need Mohs surgery to eliminate the cancer. Cutting away large swaths of skin can often mean reconstruction of the area, and every case is different.
“Certainly, the size of the defect matters,” recounts LeBlanc. “Some lesions will heal on their own. But, if I have to plane off the end of someone’s nose, it may not be cosmetically appealing. A patient may need a skin flap or a graft from another part of his/her body. The choices for reconstruction depend on the individual Mohs surgery that’s been done. My goal is to return the patient to as normal a look postoperatively as possible.”
Up to 5% of the population will develop some form of skin cancer over his or her lifetime, whether it’s a basal cell, squamous cell, or melanoma. Over the age of 65, one has a 50% chance of getting skin cancer. But, everyone over the age of 18 should have a general dermatologist do a thorough body check for any unusual lesions, and if something looks suspect, a biopsy can be done. If the result indicates some type of cancer, a referral to a board-certified Mohs surgeon like Dr. LeBlanc is often in order.
Dr. Brobson Lutz, one of our Leading Doctors of 2022, has been in practice long enough to have been part of some watershed moments in public health. In 1982 he found himself on the frontlines during the AIDS epidemic. As the former New Orleans Director of Health in 2005, he set up shop on the streets of the French Quarter to treat those suffering from the after-effects of Hurricane Katrina. Having been a part of an earlier bronchitis study at Tulane University, when Covid-19 hit New Orleans, he was all too familiar with the effects of a respiratory virus on those with pre-existing conditions and compromised immune systems. He has been a myth-buster since his early days in internal medicine and infectious diseases.
Every person should have a primary treating physician, or internist, who has an overall picture of the health of the patient and who can order tests to determine such critical elements of health such as cholesterol, blood sugar, and various blood counts. These internists, many of whom specialize in infectious diseases, also order outpatient procedures like mammograms and colonoscopies, which can prevent diseases from occurring down the road.
“I think Louisiana gets a bad rap, because our city’s wonderful food is often blamed for high cholesterol. But the truth of the matter is that both high cholesterol levels and high blood pressure, which accounts for hypertension, are largely genetic,” explained Lutz. “Certainly, we want to eat healthy and exercise, but those will only change blood pressure and cholesterol numbers about 10% of the time.”
As distressing as the pandemic has been, Lutz believes we as a country have learned so much since the onset of Covid-19. We have figured out how to do rapid testing with home kits, and he’s looking forward to those same sorts of test kits on the horizon for both the flu and RSV. “Of course,” he notes, ”getting anything approved by the FDA is akin to flying a kite in a hurricane.”
Referring to screening tests for cancer, he weighed in with an opinion that many might find interesting. “At the moment, those tests cost between $600 and $1000, and are not covered by insurance,” said Lutz. “I’ve seen a lot of false positives, which then need to be chased with CT scans and blood work just to confirm the results. Right now, I don’t recommend them.”
What he does recommend in the way of screening tests are mammograms, tests for colorectal cancers, which can include the non-invasive DNA stool specimen tests like Cologuard, a PSA test for men, which can detect prostate cancer early, a complete blood count (CBC), a liver enzyme panel, and a check of creatinine levels, which can detect kidney disease. He’d also like to see screenings for hepatitis C, which, left undetected, can lead to very serious problems down the road.
Now a concierge doctor with Signature MD in New Orleans, Lutz believes it’s the best way for him to give his patients the time that they require.
“People who engage in jarring sorts of activities or heavy lifting cause more wear and tear on the spine and surrounding apparatus,” explained Thomas, ”especially if they’re overweight.”
“Most problems show up around middle age or later, but when a number of younger patients in their twenties began to need discectomies, because their discs were herniated, it turned out there was a common denominator in their activities. A form of high intensity interval training known as CrossFit which involves jumping on trampolines and lifting with weights, was causing a torquing of the spine. The exercises have now been modified to avoid injuries.”
According to Thomas, herniated discs usually resolve on their own, because they contain a lot of water and have the ability to shrink back to their former positions. However, he notes, if the disc doesn’t resorb, the nerve remains chronically inflamed, and the patient fails conservative therapy, it could be time for further action. That can include a discectomy or microdiscectomy where a piece of the offending disc is removed, or a laminectomy, which treats moderate spinal stenosis by removing bone spurs and tissues associated with arthritis of the spine. This enlarges the narrow spinal canal and relieves pressure on the spinal cord or nerves. More complex problems may require a spinal fusion, connecting two or more bones using metal hardware like plates, screws, and rods to immobilize specific levels of the spine causing pain.
“We are always making advances in the field of neurosurgery,” noted Thomas. “We continue to use assisted robotics for the placement of hardware, and there are currently biologics and stem cell therapies in clinical trials that remove pain from discs and increase disc volume. We are now attempting to intervene earlier in the degenerative process.”
“And, let’s remember that contraceptive methods aren’t just used for birth control,” said obstetrician and gynecologist Rebecca Perret of Crescent City Physicians at Touro Infirmary. “It also provides help for those with heavy cycles, fibroids, endometriosis, and polycystic ovary syndrome. Contraception is now recognized as a tool to help preserve future fertility, which is often an overlooked factor.”
For decades, the only way to detect chromosomal abnormalities was with amniocentesis or chorionic villi sampling, both considered invasive procedures. With the advent of non-invasive prenatal testing, in which fetal cells can be taken from the mother’s blood, invasive procedures are no longer necessary.
In years past, there wasn’t much talk of post-partum depression after mothers gave birth. In fact, many mothers were reluctant to discuss such feelings. Now, patients are screened for post-partum blues, depression, and anxiety as part of their visit to Dr. Perret’s office after the baby is born. “Some form of post-partum depression/anxiety can affect 40% of new mothers,” explained Perret. “Reassuring patients that most cases usually resolve over time is important, but sleep strategies, nutrition, and exercise should also be addressed. For some patients, referral to a mental health provider may be warranted.”
With the advent of robotics now used in pelvic surgery, more complex cases can be completed in a less invasive manner, says Perret, with quicker recoveries for patients, in general.
“With treatment, we can lower the intraocular pressure in the eye,” explained Boyle. “This may involve eye drops, oral medications, and even lasers that can help slow the progression of the disease and prevent further vision loss. We can also do various types of surgeries which create more space for fluid to leave the eye. Now, the newer treatment for moderate glaucoma is a drug called Lumigan (which has been used cosmetically to grow eyelashes) that is placed in the front of the eye in the form of a slow release pellet that lowers pressure and lasts about a year. For most people, this is preferable to daily drops.”
Macular degeneration, which Boyle also treats, causes loss in the center of the field of vision. In dry macular degeneration, the center of the retina deteriorates, whereas wet macular degeneration means leaky blood vessels are growing under the retina.
“With dry MD, the treatment is eye vitamins, shown to be effective in a national study called AREDS (Age-Related Eye Disease Study), and involves supplements like vitamins C and E, copper, and zinc,” said Boyle. “With wet MD, we’re looking at medicines injected into the eye to slow the progression of the disease, by stopping the formation of new blood vessels and halting the ones that are already leaking.”
“RSV had been here since this past summer, but I think the reason for the surge in cases may be that kids were quarantined the previous year and had been wearing masks,” said Mark Morici, a pediatrician affiliated with Children’s Hospital of New Orleans. “Now kids are back in school and daycare, without the sort of preventive measures they had employed previously, and they are spreading germs. But, it’s important to note that while some of the kids with more serious RSV must be hospitalized, many are running and playing with the virus.”
Pediatricians treat a whole gamut of diseases. They are front and center in providing vaccines to growing children at different stages of their lives. Morici notes that there is a broader spectrum of vaccines these days than when we were kids. These include those for HPV, given at the age of 9, hepatitis A and B, and meningitis B at ages 11 and 16. There are also the Haemophilus influenzae type B vaccine (HIB) and the pneumococcal vaccine now in use.
Although better technology is certainly contributing to the miraculous ability we now have to save premature babies, not everything involves high-tech solutions. Something as simple as putting babies to sleep on their backs has gone a long way to prevent SIDS (Sudden Infant Death Syndrome). “We’re not absolutely sure of why the “back to sleep” movement has been successful,” said Morici, “but it may be that babies sleeping on their tummies are breathing in their own carbon dioxide. We now encourage parents to put their babies to sleep on their backs until they begin to roll over at about four to six months.”
Dr. Morici says times have changed. It’s not uncommon now for mothers to interview pediatricians before their babies are born to make sure they have found the right doctor for their child, both in terms of philosophy and personality. After all, pediatricians are with the child from the time they’re born until well into their teenage years.
“Our most common surgeries are for bunions, both those that cause pain and those that are strictly for cosmetic reasons, called Cinderella surgeries,” said Robinson. “But, of course, in my practice I also do a lot of traumatic surgeries where I’m literally putting a foot back together, much like the pieces of a puzzle.”
Robinson is often called upon to re-do other’s surgeries, and that can involve re-breaking a foot in order to realign the improperly healing bones. Her training at a trauma center in Miami prepared her for the kinds of surgeries that can run 4–6 hours in the operating room.
But, if you thought Botox and fillers were only for the face, think again. They also have uses for problems in the feet. “Some people’s feet perspire excessively, and for that we can inject botox,” recounted Robinson. “Botox has long had other uses aside from paralyzing muscles of the face to prevent active reinforcement of facial lines. It can also be used to block the nerve signals responsible for sweating, and it’s one of the ways we can help our podiatric patients.”
For those with particularly bony appendages, sometimes the balls of the feet do not have enough natural padding, and that’s where fillers come in, according to Robinson. Foot pad augmentation, as the procedure is referred to, seems to make walking much more comfortable for these patients.
It’s important to remember that your feet take the brunt of walking, running, and standing, so maintaining a healthy weight helps take the pressure off of your feet. Likewise, wearing shoes that fit well is ultimately very important. As Robinson notes, she may love ballet slippers, but they don’t give her feet adequate support, so she uses orthotics inside for extra cushioning.
As with most other specialties, the name of the game is to do less invasive surgeries with smaller incisions and local anesthesia whenever possible. The innovative strides in medicine are making all of this possible.