The Triangle Physician April 2010 by TTPLLC

APRIL 2010

Womenâ&#x20AC;&#x2122;s Wellness Clinic Excellence in Gynecology and More

Also in this Issue

Autism Spectrum Disorders Tubal Ligation Reversal

To learn more about autism spectrum disorder and the Autism Society of North Carolina, contact us at 1-800-442-2762, or visit our website at www.autismsociety-nc.org

Rinkside, Vancouver. Bedside, Duke. Duke’s Fraser Leversedge, MD, takes care of of Olympic hockey players and is here to give you gold medal care the rest of the year. What is your role with the Vancouver Olympics? I am a site physician for the ice hockey venue, so I treat the orthopaedic injuries of the athletes from all countries. I had a similar role at the basketball venue at the Olympic Games in Athens—an exciting experience filled with many inspiring moments courtside and in the medical room. Back home at Duke, what is your specialty? I’m a hand and arm surgeon. I treat conditions from the fingertip to the shoulder including trauma, fractures, arthritis, nerve and tendon damage, sports injuries, pediatric and congenital disorders, and microvascular reconstruction. Has your work with athletes taught you about teamwork? Absolutely! But really, there’s no better place to learn about teamwork than at Duke Orthopaedics. I collaborate on a daily basis with colleagues who specialize in hand and arm surgery and in other specialties from sports medicine to pediatric neurology. Whether an injury affects an Olympic athlete, a student athlete, or a “weekend warrior,” we have an extensive team of specialists to provide comprehensive care, whether it requires surgery or conservative management. In addition to collaboration, what else do you think distinguishes Duke Orthopaedics? At Duke patients have access to some of the best surgeons in the world and the most advanced technology and treatments. People come from all over the country to receive care here, and we take on some of the most complex cases. At the same time, I think you’ll be impressed with our emphasis on patientcentered, compassionate care for all injuries; no matter how simple or complex the injury, we recognize the importance of helping our patients return to an active, healthy lifestyle. Duke University Medical Center is ranked #6 in the nation for orthopaedics by U.S.News & World Report.

Duke Orthopaedics dukehealth.org

888-ASK-DUKE

Contents

COVER STORY

Women’s Wellness Clinic Excellence in Gynecology and More

FEATURES

AUTISM SPECTRUM DISORDERS

Recognizing the Signs and Knowing the Correct Approaches. April is National Autism Awareness Month, a time that highlights the need for everyone to become more aware of autism spectrum disorders (ASDs) and the special challenges they can bring to everyday life.

APRIL 2010

VOLUME 1

ISSUE 3

TUBAL LIGATION REVERSAL

DEPARTMENTS 12 FERTILITY Advanced Fertility Options:

Preventing Genetic Disease through Embryo Biopsy

Regret Turns to Hope

13 ELECTROPHYSIOLOGY Takotsubo Cardiomyopathy

Tubal ligation is the second most frequent

17 AUTISM Finding Better Ways

birth control method, chosen by more than 12 million American women. While tubal sterilization is considered a permanent form of contraception, many women regret their decision and would like to have their fertility restored.

to Treat Patients with Autism

18 AUTISM

Living with Autism

19 PHLEBOLOGY

Ever Notice Shin Discoloration? Start Taking a Closer Look!

20 WOMEN’S HEALTH An Integrative Approach to

Perimenopause and Menopause

23 NUTRITION Chocolate Milk,

So Good and So Good for You

24 NEWS

Welcome to the Area Events & Opportunities New and Relocated Practices

25 PHYSICIAN PROFILES

Neuroradiology at Wake Radiology

26 PRACTICE MANAGEMENT

Understanding Fee Schedules in Physician Practices

27 INSURANCE

Is Your Umbrella Ready for a Rainy Day?

29 GOOD BUSINESS COVER PHOTO: Front row, left to right – Amy Stanfield, M.D., F.A.C.O.G.; Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G. PHOTO BY JIM SHAW Second row, left to right – Juliette Eck, RN; Atiya Sherwani; Terry Allen; Tara Whitted, CNA.

The Triangle Physician | APRIL 2010

Your Blogging Colleagues

32 LOCAL INTEREST

Discover Historic Wilmington

FEBRUARY 2010 | The Triangle Physician

From the Editor

pring is a time of hope and renewal in the natural environment, and the human spirit responds in-kind at the sight of buds and blossoms. While it’s Triangle Physician’s mission to bring you news each issue of promising medical developments that restore health and hope, the cover story for April is especially apropos.

In this issue, you will read how Drs. Andrea Lukes and Amy Stanfield at Women’s Wellness Clinic are leading clinical trials and advances in gynecology. Their ongoing research is bringing hope to women who have long suffered from gynecological problems that disrupt their reproductive system’s natural rhythms and greatly impact their quality of life. Drs. Lukes and Stanfield also discuss the role of other physicians as the first point of contact to help female patients understand that abnormal periods are just that, and no longer need to be tolerated. In the column “An Integrative Approach to Perimenopause and Menopause,” Dr. Stanfield describes how integrative medicine is effective in the relief of perimenopausal and menopausal symptoms. Multifaceted treatments recommendations involve nutrition, exercise and stress reduction, as and nutritional and botanical supplements. Dr. Stanfield also reports on hormone therapies and new clinical research findings that clarify the benefits of HT on cardiovascular health. In this issue of Triangle Physician, contributor Dr. William Meyer of Carolina Conceptions offers fascinating insight into preimplantation genetic diagnosis in preventing inherited disease before an embryo is implanted. In another article, Dr. Gary Berger of Chapel Hill Tubal Reversal Center reviews studies that show the need for greater awareness of the benefits of cost-effective out-patient tubal ligation reversal. As always, this issue has breadth and depth. In light of National Autism Awareness Month in April, we explore autism spectrum disorders, with an enlightening Q&A about the complexities and opportunities for those affected. There is an informative piece about the nutritional value of milk vs. other drinks marketed to children. Finally, we get insurance advice on umbrella coverage for those rainy days. Now, let’s all hope the economy heals and jumps back to life with the crocuses and daffodils! As we anticipate better days, keep in mind that an effective marketing strategy is essential and your marketing message on the pages of Triangle Physician goes a long way. So until next time, think spring!

Editor Mark Westphal

mark@trianglephysician.com

Contributing Editors Heidi Ketler heidi@trianglephysician.com Gary S. Berger, MD; Laura Buxenbaum, MPH, RD, LDN; Susan L. Kennedy, MD; Lindy McHutchinson, MD; William Meyer, MD; Sameh K. Mobarek, MD; MD; John Reidelbach; Mike Riddick; Amy Stenfield, MD, FACOG Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Dan Early Van Early

dan@trianglephysician.com van@trianglephysician.com

Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com The Triangle Physician is published by Early Design Group 982 Trinity Road | Raleigh, NC 27607-4940 Subscription rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Tucson, AZ 85726 Every precaution is taken to insure the accuracy of the articles published, The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography.

Mark Westphal Editor

Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.

The Triangle Physician | APRIL 2010

From the Cover

Women’s Wellness Clinic Provides Excellence in Gynecology and More.

The Women’s Wellness Clinic is a unique blend of old-fashion personalized care and the latest technology and research. This results in compassionate and state-of-the-art care for women of all ages. Further, the entire staff is female. This unique clinic is headed by two highly engaged, specialized physicians. Both are investigators in a variety of clinical trials, which offer up-to-date health options. After just a brief time spent with the staff, patients realize they are receiving the highest quality clinical care. The attitude of physicians, nurses, research team and the front office personnel is that This approach sets them apart from most and is one of the many reasons the Women’s Wellness Clinic provides

“the best of care.”

The Triangle Physician | APRIL 2010

to care for women.”

it is a “privilege

For those suffering from heavy menstrual bleeding (HMB), Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G., and partner Amy Stanfield, M.D., F.A.C.O.G., and their medical staff can bring the latest diagnostic and treatment options. Their approach begins with determination of the cause(s) of HMB. Next, the staff spends time educating women on the various treatment options. One popular choice of management includes in-office treatment using a variety of endometrial ablations – including NovaSure® (www.NovaSure.com), Thermachoice III® (www.gynecare.com/thermachoice) and Her Option® cryoablation (www.heroption.com). HMB is one of the most common gynecological problems, affecting as many as 1 in 4 women. “Heavy periods can impact a woman’s daily activities, from soiling clothing and embarrassment, avoiding social and family events, missing work and more,” says Dr. Lukes. “Many women do not realize the variety of options now available. A hysterectomy will cure the problem—but there are many effective and safe alternatives to hysterectomy today that allow women other options. For instance, in addition to the endometrial ablation, there is a new medication that is now FDA approved called Lysteda®. This medication is non-hormonal and taken only during the days of heavy bleeding, when someone is motivated to do something.” Dr. Lukes was the lead principal investigator in the United States for new medical clinical trials evaluating Lysteda, or tranexamic acid. She and co-investigators presented early data in 2009. In addition, this year Dr. Lukes will give two oral presentations at the American Congress/College of Obstetrics and Gynecology (ACOG) in May 2010. “The choice of researchers to give oral presentations at

PHOTO BY JIM SHAW

reas of expertise include: heavy periods, irregular periods, uterine fibroids, anemia, alternatives to hysterectomy (including endometrial ablation), vulvar and vaginal infections, and the latest on sexual health, contraception, infertility, menopause and hormone replacement. In addition, beginning March 2010, Dr. Amy Stanfield has launched a comprehensive Integrative Health Program (detailed later in article).

Physicians at the Women’s Wellness Clinic engage patients of all ages.

national ACOG meetings is quite prestigious and reflects the top-quality research done at the Women’s Wellness Clinic,” says Dr. Lukes. “I enjoy clinical research—and my training at Duke University and the University of North Carolina Chapel Hill prepared me well. This drug will be widely used once launched early this year. It has been used for over four decades outside the United States and is over the counter in areas of Europe.” Dr. Lukes’ partner, Dr. Stanfield, has completed the most prestigious fellowship in integrative medicine from the University of Arizona. She agrees with Dr. Lukes: “Women first want to understand why they are having heavy periods. And I emphasize eating well and supplementing with certain foods rich in iron, which can improve a woman’s response to treatment.” BACKGROUND INFORMATION Both Dr. Amy Stanfield and Dr. Andrea Lukes are board certified in obstetrics/gynecology and both were trained here in North Carolina. They remain close colleagues, despite slightly different views on college basketball: one for University of North Carolina (Dr. Stanfield) and one for Duke University (Dr. Lukes). Dr. Lukes received her bachelor’s degree in religion from Duke University in 1988, followed by a combined medical degree and master’s

degree in statistics from Duke University in 1994. She completed her Ob/Gyn residency at the University of North Carolina in 1998. During her 10 years on faculty at Duke University Medical Center, she co-founded and served as director of Gynecology for the Women’s Hemostasis and Thrombosis Clinic. While at Duke University, she had research support from the National Institute of Health (NIH) and the Center for Disease Control (CDC ), and many clinical trials were sponsored by industry—both pharmaceutical and medical-device companies. After early success at Duke University, Dr. Lukes left her academic position in 2007 to begin Carolina Women’s Research and Wellness Center (CWRWC). The success of CWRWC has continued to grow and now includes collaboration with a growing number of physicians throughout North Carolina. Research areas concentrate on women’s health and have included clinical trials on heavy menstrual bleeding, uterine fibroids, endometrial polyps, human papillomavirus (HPV) vaccination, contraception, bone density, menopause and premenstrual syndrome. The group at CWRWC works closely with a number of disciplines, including Ob/Gyn, internal medicine, family practice, hematology, gastroenterology, psychiatry, psychology, dermatology, plastic surgery and others. APRIL 2010 | The Triangle Physician

PHOTO BY JIM SHAW

Atiya Sherwani and Dr. Lukes discuss in-office removal of uterine fibroids with the new MyoSure device.

The private practice associated with CWRWC is called the Women’s Wellness Clinic, and Dr. Lukes remarks with pride how fortunate it is to work with her partner, Dr. Stanfield. Dr. Stanfield has excelled in medicine. She completed both undergraduate and medical school at UNC, graduating in 1998. This was followed by her Ob/Gyn residency at the Carolinas Medical Center in Charlotte, N.C. She completed her residency training in 2002 and then went into private practice in Chapel Hill. After many years of successful private practice, she chose to enter a competitive fellowship in integrative medicine through the University of Arizona founded by the wellknown Dr. Andrew Weil. Having just finished her fellowship in December 2009, Dr. Stanfield began a comprehensive Integrative Health Program through the Women’s Wellness Clinic (www.cwrwc.com) . A pivotal element of integrative medicine is the partnership between the patient and practitioner in the healing process. A connection among all influences of health—including physical health and wellness, mind, spirit and community – is emphasized. Dr. Stanfield combines the best of conventional treatments with the latest alternative methods, which are unique within health care. As CWRWC director of integrative medicine, Dr. Stanfield manages research and clinical efforts relating 8

The Triangle Physician | APRIL 2010

to this specialized field of medicine. Both Drs. Stanfield and Lukes have been invited to write monthly articles on women’s health for Triangle Physician. Within this edition, Dr. Stanfield reviews some of the latest information on menopause. ENDOMETRIAL ABLATION As mentioned earlier, one of the most effective alternatives to hysterectomy is the endometrial ablation. Prior to undergoing an endometrial ablation, there are two require ments for women: 1) completion of their child bearing and 2) a normal endometrial biopsy. Although the evaluation of heavy periods and determining a cause is emphasized by Drs. Lukes and Stanfield, treatment options are usually what a woman desires. These physicians offer endometrial ablation as a first line of action. Dr. Lukes explains, “As long as someone has completed having children and has a normal endometrial biopsy—then they should consider an endometrial ablation. These are safe and effective for treatment of irregular or heavy periods.” Dr. Stanfield emphasizes,“We perform endometrial ablations all within the comfort of our office.” This quick, in-office, non-surgical treatment of the lining of the uterus results in 95 percent patient satisfaction. Often women

will completely stop their periods, with estimates ranging from 25 percent to 65 percent. Currently, Dr. Lukes is working with the CWRWC network of Ob/Gyn physicians to measure the impact on PMS symptoms in women with heavy menstrual bleeding who undergo NovaSure endometrial ablation. “We presented preliminary data at a recent meeting in November 2009 that showed women’s symptoms of PMS improved after a NovaSure endometrial ablation,” says Dr. Lukes. “Anecdotally, many physicians who use NovaSure have noted that not only do heavy periods improve, but often PMS symptoms improve. This is supported by our research,” says Dr. Stanfield.“These in-office endometrial ablations are a minimally invasive procedure that provide an alternative to hormone medications and/ or a hysterectomy. With such a high rate of success—95 percent—it surprises me how often women have not heard of this option.” MYOSURE® – The Latest in Removing Polyps and Fibroids In 2010, the Women’s Wellness Clinic began a clinical trial that involved an assessment of the new MyoSure® technology and associated in-office anesthesia protocol for removing endometrial polyps and uterine fibroids within the uterine cavity. “This has been particularly fun for me and my staff,” states Dr. Lukes, “I love hysteroscopy—which is when we use a narrow optic that is attached to a camera and inserted through the vagina and cervix, and into the uterine cavity. This allows us to see the uterine cavity. With the MyoSure device, we can now remove polyps and fibroids within the uterine cavity—and we do this all within the clinic. Our patients have tolerated this so well it’s hard to believe.” Information on the device can be found on the Web site for the Women’s Wellness Clinic at www.cwrwc.com. “Colleagues within the area will try this device and love it,” remarks Dr. Lukes, “and the staff at the Davis Ambulatory Surgical Center (DASC), through the Duke University Medical Center, have mastered how to set it up. They have been wonderful to work with on many cases—but now we are doing these within the clinic with only oral

Juliette Eck, RN, provides personalized care and helps with both clinical and research patients. PHOTO BY JIM SHAW

This device is designed to remove both endometrial polyps and uterine fibroids. Endometrial polyps arise from the lining of the uterus, or endometrium; whereas, uterine fibroids arise from within the muscle layers, or myometrium. Endometrial polyps are small, finger-like protrusions of tissue. As they grow, they become fragile and may bleed. For many women, uterine fibroids do not cause problems, but they can result in heavy periods or abnormal bleeding similar to endometrial polyps.

PHOTO BY JIM SHAW

pre-medication. Although many physicians will use it within an outpatient surgical center, such as DASC, I am impressed with the safety, effectiveness and impressive tolerability it offers for in-office use.”

When removal is recommended, the MyoSure device does this both safely and under direct visualization. As Dr. Lukes explains, “Not only does this new device offer effective removal within the office, it works while the physician is watching the polyp or fibroid. This is what separates it from the traditional surgical procedure—it separates the lesion from its base and removes it from the uterine cavity in one step. Whereas, the traditional two-step method separates it, but then lesion removal requires removal of the hysteroscope and use of a different device. This is more time consuming and it limits the amount of tissue that can be removed.”

There are currently only four physician practices in the United States using the MyoSure Tissue Removal Device. The Women’s Wellness Clinic is among them. “I do feel fortunate to be involved with this clinical trial and I was involved in evaluating the prototype devices,” remarks Dr. Lukes. “The commercial device is able to remove tissue with minimal cervical dilation and with minimal-to-no

Terry Allen oversees arrangements for surgeries and coordinates billing with Solutions4MDs. PHOTO BY JIM SHAW

Removing polyps and fibroids through the cervix is a preferred treatment because it allows improvement in bleeding, as well as potential of infertility treatments or recurrent miscarriages. Dr. Stanfield explains that “although we can’t guarantee an improvement in getting pregnant – we can safely perform this procedure with a minimally invasive procedure that likely improves infertility results.”

Tara Whitted, CNA, provides leadership on all office and clinic day-to-day operations.

APRIL 2010 | The Triangle Physician

PHOTO BY JIM SHAW

Dr. Lukes discusses the risks of hereditary breast cancer with a young patient.

patient discomfort. I look forward to the reaction of my colleagues when they begin using this device.” The MyoSure device uses a 6.25 mm hysteroscope. Its innovative design reduces the requirement for significant cervical dilation and makes fibroid and/or endometrial polyp removal possible in the office. The small-profile hysteroscope lights the way within the uterine cavity. The Myosure device then simultaneously cuts and removes the lesion using a port through the hysteroscope. The device is entirely mechanical and requires no highfrequency electrical energy. That means there is no risk of accidental burns, gas embolization and intact tissue margins on specimens. Additionally, sterile saline water is used for uterine distension, which is also different from older devices and once again provides an additional margin of safety. “This is cutting-edge, effective and safe gynecology,” says Dr. Lukes. Within the recovery room at the Women’s Wellness Clinic, both Tara Whitted, CNA, and Juliette Eck, RN, remark on the quick recovery. Tara Whitted notes that “Women have no complaints and leave with very minimal discomfort.” Juliette Eck is impressed with how well it is tolerated. “I have been surprised that women will watch the removal of a fibroid and then comment that they are not having any pain. One woman described it as a slight vibration.” 10

The Triangle Physician | APRIL 2010

Under the direction of Drs. Lukes and Stanfield, Women’s Wellness Clinic will be one of the leading sites in the United States to train physicians on the use of the MyoSure device. Dr. Lukes will present information on this system later in November 2010 at the AAGL (Association of Advanced Gynecologic Laparoscopy) meeting. PERMANENT BIRTH CONTROL For women who would like permanent birth control, the Women’s Wellness Clinic offers both ESSURE (www.essure.com) and ADIANA (www.adiana.com). Terry Allen, the current office manager, states, “We have not scheduled a traditional BTL (bilateral tubal ligation) or tubal ligation in over 18 months. The newer options of ESSURE and ADIANA are safer and actually more effective than tubals of the past.” The ESSURE procedure uses a soft, flexible micro-insert that is placed in the fallopian tube through the cervix. The micro-inserts work in tandem with the body to form a natural barrier that prevents sperm from reaching the egg. Following the procedure, most women resume their normal activities within one day. The newer ADIANA procedure uses a smaller insert that measures the same size as a grain of rice. Dr. Lukes notes that “Both devices offer reliable but permanent birth control. Women must be sure that they are done having children.”

“We do this within our clinic in a 10-to-15minute procedure. Most women are quite surprised at how easy it is done,” says Terry Allen. Permanent birth control within the clinic is an advantage to both patient and provider. SEXUAL DYSFUNCTION Drs. Lukes and Stanfield recently have taken on an initiative to address sexual dysfunction through the formation of an all-women academic group. “We are doing this for a number of reasons,” explains Dr. Lukes. “There are very few providers who deal with sexual dysfunction or do it with a multidisciplinary or integrated group. Thus, we founded the Women involved in Sexual Health Group or WiSH.” In addition to the two founding physicians, Dr. Tiffany Marum with Southwest Durham Family Practice (www. swdfm.com) and psychologist Dr. Sara Rosenquist (www.drsara.com) make up the core group. These individuals meet regularly to review the latest research and options for women and their partners. In February, Dr. Lukes presented data at the International Society for the Study of Women’s Sexual Health (ISSWSH). This data involved a survey done by the Ob/Gyn Alliance and the attitudes of Ob/Gyn physicians on a new treatment for vaginal laxity after vaginal delivery. She explains,“We surveyed colleagues about their attitudes towards sexual health. We found that many providers do not have time to address sexual health, but that many want to do this and many want more treatment options.” Early in March, Dr. Lukes joined experts from the United States at a meeting in Houston, Texas, to discuss the latest on HSDD, or hypoactive sexual dysfunction disorder. She explains, “This is a prevalent condition. Many women do not have a strong libido —and in many cases, something can be done. Next, I will present this information to the providers within WiSH. We help one another learn and stay up to date.” FAMILY HISTORY AND BREAST CANCER An important aspect of one’s health relates to family history. The staff at the Women’s

Wellness Clinic gives all patients a family history form that reviews cancer within the family. This is done to assess who may qualify for the latest genetic testing for the hereditary breast and ovarian syndrome (HBOC), called BRCAnalysis. “Women want to know if they are at increased risk for breast and ovarian cancer,” states Dr. Lukes. The hereditary screening form asks the most important family history questions. This is usually done before patients see the physicians, helping Drs. Lukes and Stanfield better decide who is appropriate to test.

CLINICAL RESEARCH As mentioned earlier in the article, with their clinical and research backgrounds, both Drs. Lukes and Stanfield have created a network of physicians within North Carolina who work with them on several clinical trials.

CWRWC is now enrolling for a study on birth control and bone density in teenagers, as well as a study on women who have osteoporosis and who have been taking alendronate. They will begin a study on migraines later this year. Their several trials on the HPV vaccine are currently closed for enrollment, but they are actively following over 40 women who have participated in their study on Gardasil®.

“I have worked at other clinical institutes, but think our current staff and location and research areas are the best around.”

According to Dr. Lukes, “up to 10 percent of all breast and ovarian cancers are part of a hereditary syndrome. In women who are carriers for BRCA1 or BRCA2 (the HBOC genes), there is marked increased risk in breast cancer. Compared to the general-population risk of 8 percent in women up to the age of 70, in women who test positive for BRAC1 or BRCA2, the risk for breast cancer is up to 87 percent by the age of 70 years. That is a significant increase in risk. What is exciting, though, is that in women who are positive, steps can be taken to decrease their own risks. More screening and surveillance can be done, such as with MRI. In addition, medications and surgeries can be used to help reduce their risk of both breast and ovarian cancer.” Dr. Stanfield explains that they also screen for hereditary colon cancer and the Lynch syndrome with COLARIS® and for melanoma with MELARIS®. “This is something we take pride in offering and we help assure that it is covered by insurance. We will only learn more and offer more genetic testing. Our American College of Obstetricians and Gynecologists recognized in 2009 that the Ob/Gyn provider should routinely offer screening to patients for hereditary breast and ovarian cancer. This means we should do it at annual exams.”

The CWRWC has conducted more than 10 Food and Drug Administration trials in less than two years. “I have been impressed with the amount of work our staff has done with clinical studies. Although I felt blessed to do research at Duke University, our staff here at CWRWC is able to perform clinical trials in a more effective manner. Thankfully, I learned from the best at Duke University and UNC. And now we have a dedicated research staff, led by Atiya Sherwani, who focuses on how to conduct studies the right way and also the most effective way.” Like the medical practice, their clinical research focuses on women of all backgrounds and all ages. The CWRWC staff maintains an up-to-date awareness of the latest research in women’s health and makes opportunities to participate available to patients seen at the Women’s Wellness Clinic. In addition, Atiya Sherwani advertises the various clinical trials through television, radio and posters, notifying the CWRWC research network and more. Atiya Sherwani explains further, “We are able to offer many exciting options to women and our experienced staff helps educate participants as to what they need to do for each particular study. Many girls and women enjoy being a part of innovative and leading research. We only choose clinical trials that our physicians believe in. I have worked at other clinical institutes, but think our current staff and location and research areas are the best around.”

Educators at heart, Drs. Lukes and Stanfield contribute their research findings and expertise through publications and presentations. Dr. Lukes presented in October 2009 at the Nurse Practitioners in Women’s Health conference on quality of life in women with heavy periods who were treated with Lysteda®. Dr. Lukes also will present findings this year at the American Congress/ College of Obstetricians and Gynecologists (ACOG), the National Medical Association (NMA) and the Association of Advanced Gynecologic Laparoscopists (AAGL). Finally, Dr. Lukes also continues to chair the Ob/Gyn Alliance (www.obgynalliance.com), an on-line network she founded that has grown to 8,000 Ob/Gyn physicians across the United States. The peer-to-peer network has the common goal of improving health care for women and enhancing practices by staying up to date on the latest medical news relating to primary care, new devices and tools, and research developments. Dr. Stanfield has been interviewed for topics relating to integrative health for the Ob/Gyn Alliance. Although membership is limited to only Ob/Gyn physicians,

the leadership provided by the staff at the Women’s Wellness Clinic “is impressive and distinguishes this unique team as one of the best in North Carolina,” says Dr. Lukes. APRIL 2010 | The Triangle Physician

Fertility

Advanced Fertility Options: Preventing Genetic Disease through

by William Meyer, MD Dr. Meyer received his medical degree from the University of Virginia in 1983. He completed an obstetrician/gynecologist residency at Emory University, and then went to Yale University Hospital, where he received advanced training through a reproductive endocrinology and infertility fellowship in 1990. He is board certified in both Ob/Gyn and Reproductive Endocrinology and Infertility. In 2006, Dr. Meyer formed Carolina Conceptions with Dr. Grace Couchman. Along with Dr. John Park, the three physicians comprise an experienced medical team offering exceptional success rates, innovative treatments and compassionate care to earn a reputation as one of the fastest-growing infertility clinics in the southeast. To learn more, visit www.carolinaconceptions.com.

Embryo Biopsy Recently two areas of in vitro fertilization (IVF)—egg freezing and preimplantation genetic diagnosis (PGD)—have dramatically changed the options physicians at Carolina Conceptions can offer their patients. While Carolina Conceptions offers both techniques, PGD, better known as embryo biopsy, has more well-defined uses and has rapidly changed our conception of disease prediction, detection and prevention. PGD is the newest of the reproductive technologies that allows for diagnosis of a disease even before the embryo is implanted back into the uterus. Couples who are carriers of diseases, such as cystic fibrosis, spinal muscular atrophy or familial cancers, now have the ability to prevent their children from inheriting such genetic disorders with the

Overall, Carolina Conceptions has currently performed 27 embryo transfers after PGD for such conditions as cystic fibrosis, spinal muscular atrophy, Trisomy 21 and Robertsonian, and various reciprocal chromosomal translocations in couples with repetitive miscarriages. A total of 14, or 55 percent, of the transfers have resulted in pregnancy. Currently, we have couples who are carriers of sickle cell, Tay-Sachs and specific single-gene mutations undergoing preparation for ovarian stimulation and IVF. One of our most recent PGD success stories comes from a couple in Macon, N.C., who discovered they were both carriers for spinal muscular atrophy. They spontaneously conceived their first child, who at six weeks of age was diagnosed with the fatal disease and subsequently passed away four months later. Together, the couple shared a 25 percent chance of having another affected child, a 50 percent chance of conceiving a carrier and a 25 percent chance of delivering a perfectly healthy baby. After being presented several options, the couple decided to pursue IVF with PGD at Carolina Conceptions. The couple conceived during each of the two attempts at IVF. They now have two healthy children: a 2-year old and 4-month old.

use of this micromanipulation technique. Carolina Conceptions performs embryo biopsy in our on-site lab after the cleaved embryo has been in culture media in a low-oxygen tension incubator for three days. At this time a single cell, or blastomere, is removed from the eight-cell embryo after using a laser to create an opening in the shell, or zona pellucida. With gentle traction the blastomere is squeezed through the aperture and then either fixed on a slide or suspended in a solution and sent for genetic analysis. Only the healthy unaffected embryos, now called a blastocysts, are placed back into the woman’s uterus under ultrasound guidance. Cystic fibrosis and spinal muscular atrophy are two of the most commonly inheritable diseases. It is estimated that 1 in 30 to 40 people

Although most diseases screened by PGD manifest themselves at birth

are carriers of either disease. Before PGD, couples in which both

or in early childhood, it is now possible to test for diseases that manifest

parents were carriers had several options. One was to try their luck by

themselves later in life. We have now expanded the use of PGD to

conceiving and then use antenatal testing to determine if the pregnancy

include BRCA1 and BRCA2 and the testing of genes like p53 mutations

was affected, and then the pregnancy could be terminated or carried

that may predispose one to familial cancers.

to term. Other options included doing no testing or using donor sperm. Currently, more than 3,000 IVF cycles have been accompanied by PGD In the last two years, Carolina Conceptions has performed eight cases

internationally, resulting in approximately 700 live births. With the

of PGD in couples who are carriers of either cystic fibrosis or spinal

completion of the human genome project, virtually any genetically

muscular atrophy. Currently, 6 out of the 8 couples have succeeded in

inherited disease can be identified in a single cell. So, the applications

delivering a healthy unaffected child.

of PGD appear endless.

The Triangle Physician | APRIL 2010

Electrophysiology

Takotsubo Cardiomyopathy:

The Broken Heart Syndrome

Certification: Testamur, ASEeXAM, 1998; American Board of Internal Medicine, Cardiology (Board Certified), 1997; American Board of Internal Medicine (Board Certified), 1993; FLEX, 1989; ECFMG, TOEFL, GRE, Master of Cardiology (Part I), 1988; Diploma of Internal Medicine, 1986 Specialty: Echocardiography, Echocardiography, Electrophysiology Wake Heart Center

by Sameh K. Mobarek, MD

Takotsubo cardiomyopathy mimics

acute left ventricular dysfunction, some patients

continuous telemetry monitoring and

acute coronary syndrome and is accom-

have pulmonary edema or cardiogenic shock.

administration of aspirin, anticoagulants with

panied by reversible left ventricular apical

Onset of signs and symptoms is usually

direct thrombin inhibition and or glycoprotein

ballooning in the absence of angiographi-

sudden and usually occurs after an emotional

IIb/IIa receptor inhibition, nitrates, b-blockers,

cally significant coronary artery stenosis. In

stressor such as the death of a loved one or

and diuretics. Once takotsubo cardiomy-

Japanese, “tako-tsubo” means “fishing pot

a physical stressor such as an asthma attack.

opathy is diagnosed, treatment is primarily

for trapping octopus,” and the left ventricle

A systematic review of 254 patients with

supportive. Complete reversal of contractile

of a patient diagnosed with this condition

takotsubo cardiomyopathy indicated that 27%

abnormalities and recovery with no treat-

resembles that shape. Takotsubo cardio-

had an emotional stressor, 39% had a physical

ment was also noted. Aspirin can be

myopathy, which is transient and typically

stressor, and 34% could not identify a stressor.

discontinued unless coronary disease or

precipitated by acute emotional stress, is

peripheral vascular disease is concomitant.

also known as “stress cardiomyopathy” or

distinguish the signs and symptoms of takot-

b-Blockers may be continued long-term to

“broken-heart syndrome.

subo cardiomyopathy from those of myocardial

protect against catecholamine sensitivity,

infarction caused by acute coronary throm-

which may predispose to this syndrome.

for about 1% of all acute myocardial infarctions.

bosis. Urgent cardiac catheterization is often

Heparin and coumadin should be used if

performed. A diagnosis of takotsubo cardio-

apical thrombus is present, or a severe apical

Takotsubo cardiomyopathy may account Most patients who have takotsubo car-

No way currently exists to immediately

diomyopathy are postmenopausal women. Cardiovascular risk factors are generally present to a lesser degree in patients with takotsubo cardiomyopathy than in patients with coronary artery disease.

Although the exact pathogenesis of

takotsubo cardiomyopathy remains unclear, various mechanisms have been proposed including coronary vasospasm of epicardial coronary arteries, myocardial injury due to microvascular spasm, and neurogenic stun-

Schematic representation of takotsubo cardiomyopathy (A) compared to the situation in a normal person (B).

ning of the myocardium.

myopathy is suspected when obstructive

defect makes thrombus formation likely.

Enhanced sympathetic activity appears

coronary disease is not present to explain the

to play a very important role in the patho-

patient’s degree of left ventricular dysfunction.

myopathy occur during the acute phase of

physiology of takotsubo cardiomyopathy.

Diagnosis is confirmed by observation of the

illness. Late complications are rare because

Triggering factors, such as intense emotion-

typical octopus pot morphology of the left

the syndrome is reversible and the damage

al stress, are frequently seen in patients with

ventricle. Identification of a triggering

is not permanent. The reported complica-

this syndrome. Excessive levels of catechol-

emotional or physical stressor is considered

tion rate is about 19%. Heart failure and

amines have been observed in patients with

supportive of but not necessary to the diag-

pulmonary edema occur in 3% to 46% of

takotsubo cardiomyopathy.

nosis. An echocardiogram must be obtained

patients, and mortality rates are 1% to 3%.

within days or weeks after the acute phase

of acute coronary syndrome, usually chest pain,

to confirm that abnormalities have reversed.

lent, with complete resolution in all reported

dyspnea, ST-segment changes on ECGs, and

cases, there are no data in the literature

elevated levels of cardiac biomarkers. Degree of

management of coronary ischemia and pul-

regarding long-term outcome in patients who

symptom severity varies widely. Because of

monary edema. This management includes

have experienced takotsubo cardiomyopathy.

Patients have signs and symptoms suggestive

Immediate treatment should include

Most complications of takotsubo cardio-

Although short-term outcomes are excel-

APRIL 2010 | The Triangle Physician

Autism

Autism Spectrum Disorders provided by The Autism Society

The Autism Society, the nation’s leading grassroots autism organization, exists to improve the lives of all affected by autism. We do this by increasing public awareness about the day-to-day issues faced by people on the spectrum, advocating for appropriate services for individuals across the lifespan, and providing the latest information regarding treatment, education, research and advocacy. For more information, visit www.autism-society.org.

April is National Autism Awareness Month, a time that highlights the need for everyone to become more aware of autism spectrum disorders (ASDs) and the special challenges they can bring to everyday life. Awareness of these challenges can be especially important for health service professionals who may not have had previous experience with ASD. Recognizing the signs and knowing the correct approaches can assist all involved.

WHAT IS AUTISM? Autism is a complex neurodevelopmental disability that typically appears during the first two years of life and affects a person’s ability

Also, the National Institute of Child Health and Human Development (NICHD; www.nichd.nih.gov) lists five signs of autism that

to communicate and interact with others. Autism is defined by a

parents and pediatricians should look for in children:

certain set of behaviors and is a “spectrum disorder” that affects

• Does not babble or coo by 12 months

individuals differently and to varying degrees. The U.S. Centers for

• Does not gesture (point, wave, grasp) by 12 months

Disease Control and Prevention recently found that one in 110

• Does not say single words by 16 months

American children have an ASD.

• Does not say two-word phrases on his or her own by 24 months • Has any loss of any language or social skill at any age

Though there is no cure, autism is treatable. Children do not “outgrow” autism, but studies show that early diagnosis and intervention lead to

Recognizing the signs and knowing the correct approaches can help

significantly improved outcomes.

ensure that the person with autism is provided appropriate services during his or her visits with you. Keep in mind that an individual

People on the autism spectrum may:

with ASD may not be able to communicate his or her symptoms (e.g.,

• Not understand what you say

gastrointestinal pain) or medical needs, or understand the need

• Appear deaf

for care.

• Be unable to speak or speak with difficulty • Engage in repetitive behaviors • Act upset for no apparent reason • Appear insensitive to pain • Appear anxious or nervous • Dart away from you unexpectedly • Engage in self-stimulating behaviors, such as hand flapping 14

The Triangle Physician | APRIL 2010

Some individuals with autism may have additional medical problems that should be considered, such as a seizure disorder or a gastrointestinal condition. The Autism Society was recently involved in producing a consensus report on autism and GI disorders that included a set of recommendations for doctors; for more information, please visit www.autism-society.org/Pediatrics2010GIReport.

HOW IS AUTISM DIAGNOSED?

Following are tips that may assist you in conducting

There are no medical tests for diagnosing autism. An accurate diagnosis

examinations:

must be based on observation of the individual’s communication, behavior and developmental levels. However, because many of the behaviors associated with autism are shared by other disorders, various medical tests may need to be ordered to rule out or identify

1. Obtain as much information from a care provider as possible, including functioning level and what will make the individual feel more secure or calm.

other possible causes of the symptoms being exhibited.

2. Speak slowly and use simple language; avoid medical jargon.

Research indicates that early identification is associated with

process. Terms may need to be changed if a person is not able to

dramatically better outcomes for individuals with autism. The earlier

understand. Repeat simple questions if necessary.

a child is diagnosed, the earlier the child can begin benefiting from

3. Presume the person’s competence. If they cannot speak, this does

one of the many specialized intervention approaches to treatment and

not mean they will not understand you and comprehend what you

education. The American Academy of Pediatrics recommends that

say. Adjust your language level as necessary.

all children be screened for autism by their family pediatrician twice

4. Whenever possible, avoid physical contact. If it is necessary, explain

by the age of 2, at 18 months and again at 24 months. For more

what you will be doing prior to doing so. Allow patients time to

information about the AAP guidelines, visit www.aap.org.

process what you are explaining to them and ensure they understand,

HOW DO I INTERACT WITH SOMEONE WHO HAS AUTISM? Though autism is commonly associated with children, it is a lifelong condition, and as the prevalence increases, medical professionals should expect to serve adults as well as children with ASDs in the course of their careers. Medical professionals should be aware that because it is a spectrum disorder, no two people with ASD are the same; some individuals

However, do use age-appropriate phrases during the initial assessment

if possible, before proceeding. Due to receptive and expressive language delays, this may require more time than is typical. 5. If unable to speak, make sure individuals have a method of communication familiar to them, such as a communication device, paper and pen, picture symbols, etc. 6. If a person becomes fixated on an object or has the need to perform self-stimulating activities or body movements, do not interrupt unless necessary. This may be a way for the person to calm down and self-regulate sensory needs.

may be highly verbal while others are nonverbal, have above-average intelligence or cognitive limitations (intellectual disabilities), and may respond differently to sensory stimuli. During instances of heightened anxiety or when they do not know what is expected of them, individuals with ASD may also lose some of their abilities more readily. Providing reassurance will assist in alleviating the individual’s anxiety and discomfort; however, the characteristics of autism may pose challenges to providing medical care. Many individuals on the autism spectrum have sensory issues that could affect their ability to be treated. For example, tactile hypersensitivity may mean the person is unable to have adhesive products applied. Individuals with visual sensitivities may react to fluorescent lighting often found in hospitals. Providing simple explanations prior to each step in treatment will assist in calming the individual. Knowledge of the individual’s method of communication is vital. Some individuals with ASDs are nonverbal, and even those who are verbal may process and communicate information in different ways. Communicating with someone who knows the individual well, such as a parent or other caregiver, is key to understanding his or her specific use of communication traits. AUTISM RESOURCES, American Academy of Pediatrics: www.aap.org; (847) 434-4000; Autism Society: www.autism-society.org; (800) 328-8476; National Institute of Child Health and Human Development: www.nichd.nih.gov; (800) 370-2943

APRIL 2010 | The Triangle Physician

Women’s Health

Regret Turns to Hope with

Tubal Ligation Reversal by Gary S. Berger, MD

Dr. Gary S. Berger is a reproductive surgeon and the medical director of Chapel Hill Tubal Reversal Center, Chapel Hill, NC.

Tubal ligation is the second most frequent birth control method, chosen by more than 12 million American women. Each year 650,000 female sterilizations are performed in the United States. While tubal sterilization is considered a permanent form of contraception, many women regret their decision and would like to have their fertility restored. The most common reason for this is remarriage. In the 1995 National Survey of Family Growth, women who reported having a tubal ligation were asked, “As things look to you now, if your tubal ligation could be reversed safely, would you want to have it reversed?” 1 Nearly 25 percent of women with a tubal ligation expressed a desire for reversal of the operation on the part of herself, her husband or partner, or both. In the U.S. Collaborative Review of Sterilization (CREST), women were interviewed for up to eight to 14 years after the sterilization operation.2 At each interview, they were asked, “Do you still think tubal sterilization as a permanent method of birth control was a good choice for you?” Overall, 13 percent of women said they did not think the tubal ligation was a good choice. The percentage expressing regret in CREST was 20 percent for women aged 30 years or younger at the time of sterilization compared with 6 percent for women older than 30 years at the time of tubal ligation. For women under age 25, the rate was 40 percent. The regret rate was higher for women who were not married at the time of their tubal ligation or when tubal ligation was performed less than a year after delivery. Women who had experienced changes in marital status were three times more likely to seek information about tubal ligation reversal than those whose marital status had not changed. It appears, however, that only a small percentage of women who regret having a tubal ligation 16

The Triangle Physician | APRIL 2010

Tubotubal Anastomosis After opening the blocked ends of the remaining tubal segments, a narrow flexible stent is gently threaded through their inner cavities or lumens into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes. The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscularis and serosa, while avoiding the mucosa of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the tube.

and would like to have it reversed undergo tubal reversal surgery. One reason is the lack of insurance coverage for sterilization reversal. Another is that many women receive inaccurate information about tubal reversal, such as: • Tubal ligation cannot be reversed; • The only treatment option is in vitro fertilization (IVF); or, • Tubal sterilization reversal is a high-cost in-hospital operation. There are no national statistics available on the number of women having tubal ligation reversals. Locally, more than 8,000 tubal reversal operations have been performed at Chapel Hill Tubal Reversal Center, where the procedures are performed as outpatient surgery. Analysis of the outcomes of tubal ligation reversal is made possible with a database started in 2000 at the center. It now includes more than 5,000 patients and is the largest study population of this kind. The database shows that 2 out of 3 women have become pregnant after their reversal procedures. It also finds that pregnancy rates vary with age and tubal ligation method. Women under age 30 with tubal clip procedures had a 90 percent pregnancy rate,

which fell to 31 percent for those 40 and older having had tubal coagulations. The success of tubal anastomosis is directly linked to surgical experience. Since the advent of assisted-reproductive technology, surgical training has markedly declined and there remain few fellowship programs in the United States with meaningful numbers of surgical cases. A recent study found that most of the current reproductive endocrinology and infertility fellows performed less than 10 procedures and 35 percent of program graduates performed no surgical tubal reversals in the previous year.3 The primary benefit of tubal reversal surgery is that it has a high cumulative pregnancy rate because conception is a possibility in every subsequent ovulation cycle. Tubal ligation reversal avoids the increased risk of multiple pregnancy associated with IVF (35 percent) and other risks of gonadotropin stimulation of the ovaries. The primary risk of tubal reversal is the long-term risk of ectopic pregnancy (10-15 percent). Although tubal sterilization is meant to be permanent, the reality is that it can be reversed through cost-effective outpatient surgery.

References: (1) Surgical Sterilization in the United States: Prevalence and Characteristics, 1965-95. Vital and Health Statistics Series 23, No. 20, National Center for Health Statistics. (2) Hillis, S.D.; Marchbanks, P.A.; Tylor, L.R.; et al. Poststerilization Regret: Findings from the United States Collaborative Review of Sterilization. Obstet Gynec 1999 93(6): 889-95. (3) Armstrong, A.; Neithardt, A.B.; Alvero, R.; et al. The role of fallopian tube anastomosis in training fellows: a survey of current reproductive endocrinology fellows and practitioners. Fertil Steril. 2004 82(2):495-7.

Autism

Better Ways to Treat Patients with Autism Finding

Imagine trying to treat a patient who can’t

communicate with you. Perhaps this person can’t speak or describe their level of pain accurately. They may have sensory issues and heightened anxiety that can make a trip to the doctor’s office intolerable. Perhaps the office lights are too bright, the waiting room too crowded or too loud. For patients with autism

this is often the case and providing medical care, even a routine check up, can be challenging.

Since 1970, the Autism Society of North Carolina has provided information, resources, and advocacy. Since its inception the Society has helped tens of thousands of families across North Carolina each year. Today the Society

In a survey of North Carolina physicians

is recognized as a national leader in serving

conducted by ICARE Partnership, 44% of respondents reported having a “poor” comfort level treating patients with autism. Considering

individuals,riddick families and professionals insurance group ad.pdf 12/28/2009

7:13:50 PM

coping with Autism Spectrum Disorder. The

Autism Society of NC is the best source of assistance for autism issues for children and adults in the state. For more information about services or to schedule training, contact Shelley Moore at 1-800-442-2762 extension 1116 or via email at smoore@autismsociety-nc.org. Visit the organization’s website at www.autismsociety-nc.org.

the incidence of autism is now at 1 in 110 births, it is critical that the medical community be better informed. We know that individuals with autism often receive inadequate care partly because of the lack of understanding many physicians have about the nature of the disorder. Families often avoid seeking care for a child with autism because of the trauma associated with the visit. As a result, medical C

conditions can be missed leading to more serious health complications in the future.

Individuals with autism need and deserve

better access to medical care.

In Wake County a grant from the John Rex

Endowment allows the Autism Society of

CMY

North Carolina to offer physician training to K

pediatricians. The Society has resources that can help physicians better recognize and help individuals with autism and their families. Simple inexpensive changes can be made to better serve this population. Sometimes it’s a matter of asking for certain information on an intake form, or offering a quieter waiting area. “Tool kits” are available that include information and resources about autism. APRIL 2010 | The Triangle Physician

Autism

Living with by Susan L. Kennedy, MD This issue of Triangle Physician is

I accept that diagnosis, and we’ll just

devoted to autism, a topic that deserves

take it a step at a time.” In our own case,

great attention and one that is close to

we don’t like that Chris has autism,

home. My husband, Carroll C.

but we have learned to manage it in a

Overton, MD, and I have three

way that our whole family can be happy.

wonderful children: Katie, 18 months, John, 10, and Chris, 12, who is autistic.

It’s important not to lose perspective

Chris is in the middle of the autism

on the good things in life, and there are

spectrum in terms of functioning; he

a lot of beautiful things about a child

does not have the conversational

with autism. We have learned to value

language skills and is not typical

the little things—the bright moments,

socially, but he can communicate with

being together as a family, the progress Chris has made, and the silly

simple three- to five-word sentences. He knows thousands of words and he can read,

speech therapist, Tracy Vail of Let’s Talk in

things Chris does that make us all smile. Most

write, and use the computer.

Raleigh. She helped me hire college students,

important, Chris is a happy child.

At the time of Chris’s diagnosis, when he was 18 months old, I felt overwhelmed and devas-

and we trained them to do the therapy. Chris has responded well, and we know without the therapy there is a good possibility that Chris

On a day-to-day basis, our house can be quite busy, but we have a lot of help, a very organized

would not communicate at all.

schedule and at the end of the day, everyone’s

But one of the most difficult aspects of having

One of the challenges of having a child with

as hard if not harder than I do with our family,

a child with autism is that no one knows the

autism, or any chronic illness, is managing the

and we’re totally a tag team. If I’m taking

cause, no one knows what treatment is right,

rest of your life and finding balance in your

Chris to the mall (he loves to go there for Dots

and no one knows the outcome. Basically,

life. Yes, we have a son with autism, but autism

ice cream), my husband might be with John

tated. I just wanted to do whatever I needed to do to help him, and I wanted to do it fast.

needs seem to get met. My husband works

hitting golf balls. Most Saturdays we try to go

“Okay, I accept that diagnosis, and we’ll just take it a step at a time.”

out alone together. Again, it is all about balance and getting everyone’s needs met. Having a child with autism has changed our family immensely and has grounded us about what’s really important in life. It takes away our vanity, and we realize that the things that

you are given a devastating diagnosis—and

does not control or imprison our family. I have

no one can tell you what to do about it.

impress most—fancy cars, houses, etc.—are

one instruction with therapists. We set up the

two other children who need attention, a wonderful husband, and a great career. In so many ways, having a career and being a physician helped me put this diagnosis in perspective, and at the same time it has made me a better physician. In my practice, I have met many amazing patients, some of whom have had medical conditions that are very difficult to deal with. The patients who inspire

program ourselves with the help of Chris’s

me the most are the ones who say, “Okay,

true success.

help Chris, we found all sorts of programs and treatments. Luckily, as physicians, we could distinguish valid ideas from sheer craziness. We ultimately selected a verbal behavior program, which is based on intensive one-to-

The Triangle Physician | APRIL 2010

are our relationships with family and friends and being real. As a physician, this has taught me a greater compassion for others and their struggles. Most of all, I’ve found that each of us has his or her own struggles, and it is how we choose to deal with those issues that makes us at peace with ourselves, which I believe is

When my husband and I searched for ways to

actually superficial fluff. What really matters

Phlebology

Ever Notice

Shin Discoloration? Start Taking a Closer Look!

by Lindy McHutchinson, MD

Although hyperpigmentation of the lower leg

Why pigmentation? Because of gravity,

may initially seem a cosmetic issue, hyperpig-

venous reflux (retrograde blood flow) is a

mentation is usually a physical sign of severe

principal contributor to venous pooling and

underlying Chronic Venous Insufficiency

venous congestion. This chronic pooling leads

(CVI). The skin changes of CVI are important

to eventual venous hypertension, which is

for physicians to recognize, because they are a warning signs for things to come! CVI skin changes, including hyperpigmentation (early

left: Lower leg hyperpigmentation, a skin change from CVI. right: Severe skin changes of CVI â&#x20AC;&#x201D; lipodermatosclerosis characterized by hyperpigmentation and fibrosis.

thought to then cause a localized leukocyte activation resulting in tissue inflammation. This inflammation is ultimately responsible for

stage skin changes) and lipodermatosclerosis (late stage skin changes)

further tissue damage including, stasis dermatis, hyperpigmentation,

can be predictors of looming venous ulcers. CVI is considered a

lipodermatosclerosis, fibrotic changes and ultimately, venous ulcers.

medical problemâ&#x20AC;&#x201D;evaluation and treatments are covered by most insurance companies, including Medicare.

Treatments are targeted at decreasing the venous pressure either by

CVI is result of chronic venous reflux in leg veins. What is venous

treatment (closing the veins via endovenous laser ablation and/or

reflux? Normal leg veins work against gravity utilizing one way flow valves taking blood via antegrade flow back to the heart. If valves are genetically abnormal or absent, damaged or malfunction, blood flows retrograde toward the feet. This unhealthy, retrograde flow is called venous reflux. Venous reflux is diagnosed with duplex ultrasound performed by a trained vascular ultrasonographer in the vein clinic setting.

conservative treatment (Rx compression stockings) or definitive chemical sclerotherapy). Usually, a combination of these treatments is necessary for long term successful treatment. Reducing the venous hypertension may improve the skin changes, however, many of the more advanced skin changes are considered permanent. Learn more about venous disease at www.carolinaveincenter.com. Dr. Lindy McHutchison at the Carolina Vein Center treats Chronic Venous Insufficiency and other conditions associated with venous disease.

APRIL 2010 | The Triangle Physician

Women’s Health

An Integrative Approach to

by Amy Stanfield, MD, FACOG

Perimenopause and Menopause Menopausal symptoms such as hot flashes, night sweats, and vaginal dryness significantly affect 4 out of 5 women entering menopause.

Perimenopausal and menopausal women also commonly experience decreased libido and sleep disturbances, which can be debilitating and can lead to other problems, such as fatigue, irritability and mood swings. Treatment of perimenopausal and menopausal symptoms benefits from an integrative medicine approach. When evaluating a perimenopausal patient, it is vital to obtain a complete history, including the patient’s symptoms, health habits, risk assessment for future diseases, and level of mental and emotional stress. While a physical exam is always performed and thyroid disease often needs to be ruled out, laboratory testing of specific hormone levels is not recommended. In my practice, treatment for perimenopausal and menopausal symptoms begins with

fats and processed foods. Specific food triggers,

they are very safe and likely have benefits

such as hot foods, spicy foods and alcohol, and

beyond menopausal symptoms.

environmental factors, such as stress and warmer surroundings, should also be discussed.

Black Cohosh Black cohosh has been used for many years

I recommend that my menopausal patients eat

in Europe for menopausal symptoms and is

whole foods that contain soy, such as edamame,

recommended by the World Health Organi-

miso soup, tempeh and tofu, (rather than soy

zation for this indication. Scientific evidence is

or isoflavone supplements). Soy contains phytoes-

encouraging, though study results have been

trogens, and most of the current research is

mixed with some showing benefit and others

focusing on the benefits of the isoflavones

no benefit over placebo. I have found that for

genistein and daidzein. Potential benefits of a

many women this herb is very helpful for

diet rich in soy foods are positive lipid effects,

menopausal symptoms. It can be purchased

specifically lowering of triglycerides and LDL,

over the counter as Remifemin or as a dried

and an increase in HDL. For women with a

herb in capsule form from health food stores

personal history of breast cancer, I would

or online. Dosing ranges from 40-60 milligrams

not encourage soy in their diet until further

daily. I typically recommend a starting dose

research is done.

of 40 milligrams twice daily and think 20 milligrams twice daily is too low of a starting

Ground flax seeds may also be beneficial for

dose. Black cohosh is quite safe, but should be

hot flashes. A small study in 2007 found that two

avoided in patients with a personal history

tablespoons of ground flax seed twice daily

of breast cancer or liver disease.

reduced the frequency and intensity of hot flashes. Larger studies will need to confirm

Hormone Therapy

these results, but fresh ground flax seeds have

Menopausal hormone therapy, or HT, is a

other health benefits and are a safe option to

complicated topic for both patients and phy-

try for menopausal symptoms.

sicians. In its 80-year history doctors have alternatively embraced and rejected HT. In the

nutrition, exercise and stress reduction recom-

Exercise

mendations, followed by nutritional and

decades prior to the release of the Women’s

Discussing exercise is equally important.

Health Institute study data in July 2002, HT

Although there is no clear data that suggests

was recommended for all menopausal women

exercise reduces menopausal symptoms, there

to protect against cardiovascular (CV) disease.

is plenty of research to support the fact that

After the results of the Heart and Estrogen/

regular exercise reduces the risk of breast cancer,

Progestin Replacement Study, or HERS, and

heart disease and osteoporosis. Furthermore,

WHI trials, HT was no longer recommended

exercise improves a patient’s overall sense

for improving cardiovascular health. Since

of wellbeing. Stress reduction in the form of

2002, HT use has been limited to treatment

breathing and relaxation techniques, yoga and

of menopausal symptoms at the lowest dose

meditation may be helpful. For women who

for the shortest period of time with ongoing

are open to and interested in these modalities,

periodic assessment.

botanical supplement recommendations. These treatments are often effective for relief of mild to moderate symptoms, though in more severe cases hormonal therapy or other prescription medications are often needed. Nutrition Nutrition is an important component of integrative medicine, and emphasis is placed on a diet rich in whole foods and low in saturated 20

The Triangle Physician | APRIL 2010

Dr. Amy Stanfield is board certified in obstetrics/gynecology. Having completed a fellowship in integrative medicine through the University of Arizona, she now leads a comprehensive integrative health program at the Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Center (www.cwrwc.com).

Emerging data, such as that from the WHICACS (Coronary Artery Calcification Study), suggests that HT may in fact be cardioprotective if initiated at the time of menopause and not years later, as was done in the earlier

Estrogen is by far the best treatment for the

hyperplasia and cancer. I occasionally use

vasomotor symptoms of hot flashes and night

bioidentical testosterone for women with

sweats. When prescribing estrogen, I encourage

decreased libido as well. Finally for women

my patients to use a transdermal patch or

with contraindications to HT or who are not

cream to avoid the first-pass effect on the liver.

comfortable taking HT, other prescription

There is evidence from observational studies

medications can be helpful, such as gabapen-

that using oral estrogen increases the risk of

tin, venlafaxine, paroxetine and clonidine.

blood clots, particularly in overweight and obese women.

Menopause is a normal and natural part of aging and it is experienced differently by

For patients affected primarily by vaginal

every woman. For women having difficult

dryness and pain with intercourse, topical

symptoms common during the transition af-

vaginal estrogen is best. The addition of bi-

fecting their quality of life, there are ways to

oidentical progesterone in oral form is nec-

cope and feel better. I enjoy assisting women

essary for women who have not undergone

through this transformation and helping

hysterectomy to protect against uterine

women live their fullest and healthiest life.

WHI study. This is referred to as the “timing hypothesis,” and would explain the conflicting results through the years regarding the potential benefit and risk of HT on cardiovascular health. Two ongoing trials, the ELITE and KEEPS studies, to be completed respectively in 2010 and 2012, hopefully will shed light on whether HT has beneficial effects on cardiovascular health when initiated at the start of menopause. The ELITE study also will examine bioidentical progesterone and estrogen. It will be interesting to see that data, as well, in light of the popularity of bioidentical hormones in our culture today. For patients who are candidates for HT—those with no personal history of breast cancer, blood clots, CV disease or stroke and those who choose to use HT (after discussing the risks and benefits of treatment)—I prefer bioidentical hormones. These hormones are an exact match to our body’s own estrogen and progesterone, meaning their chemical structure is identical, hence the term “bioidentical.” Bioidentical hormones can be obtained at regular pharmacies or as non-patented formulations from compounding pharmacies. Though there is no data to prove that bioidentical estrogens are any safer than non-bioidentical estrogens, there is data to suggest that bioidentical progesterone may be better tolerated and have a safer cardiovascular and breast profile than synthetic progestins. APRIL 2010 | The Triangle Physician

Adding Chocolate to Milk Doesn’t Take Away Its Nine Essential Nutrients All milk contains a unique combination of nutrients important for growth and development - including three of the five “nutrients of concern” for which children have inadequate intakes. And, flavored milk accounts for less than 3.5% of added sugar intake in children ages 6-12 and less than 2% in teens.

Reasons Why Flavored Milk Matters kids love the taste!

Milk provides nutrients essential for good health and kids will drink more when it’s flavored.

nine essential nutrients!

Flavored milk contains the same nine essential nutrients as white milk - calcium, potassium, phosphorous, protein, vitamins A, D and B12, riboflavin and niacin (niacin equivalents) and is a healthful alternative to soft drinks.

helps kids achieve 3 servings!

Drinking low-fat or fat-free white or flavored milk helps kids get the 3 daily servings* of milk recommended by the Dietary Guidelines for Americans.

better diet quality!

Children who drink flavored milk meet more of their nutrient needs; do not consume more added sugar, fat or calories; and are not heavier than non-milk drinkers.

top choice in schools!

Low-fat chocolate milk is the most popular milk choice in schools and kids drink less milk (and get fewer nutrients) if it’s taken away. These health and nutrition organizations support 3-A-Day of Dairy, a science-based nutrition education program encouraging Americans to consume the recommended three daily servings of nutrient-rich low-fat or fat-free milk and milk products to improve overall health.

www.nationaldairycouncil.org/childnutrition

©National

Dairy Council 2009®

RefeReNCes: 1. 2. 3.

4. 5. 6. 7.

NPD Nutrient Intake Database; 2 years ending Feb. 2009. Johnson RK, Frary C, Wang MQ. The nutritional consequences of flavored milk consumption by school-aged children and adolescents in the United States. J Am Diet Assoc. 2002;102(6):853-856. National Dairy Council and School Nutrition Association. The School Milk Pilot Test. Beverage Marketing Corporation for National Dairy Council and School Nutrition Association. 2002. http://www.nutritionexplorations.org/sfs/schoolmilk_pilottest. asp (Accessed January 4, 2009). NICHD. For Stronger Bones….for Lifelong Health…Milk Matters! Accessed Sept 7, 2009 via http://www.nichd.nih.gov/ publications/pubs/upload/strong_bones_lifelong_health_mm1.pdf HHS, Best Bones Forever. Accessed Sept 7, 2009 via http://www.bestbonesforever.gov/ Frary CD, Johnson RK, Wang MQ. Children and adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. J Adolesc Health 2004;34(1):56-63. American Academy of Pediatrics, Committee on School Health. Soft drinks in schools. Pediatrics 2005; 113152-154.

8. 9. 10. 11. 12. 13.

United States Dept. of Health and Human Services, United States Dept. of Agriculture and United States Dietary Guidelines Advisory Committee, 2005 Dietary Guidelines for Americans. (6th ed. HHS publications, 2005, Washington D.C.) Greer FR, Krebs NF and the Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children and adolescents. Pediatrics 2006; 117:578-585. Murphy MM, Douglas JS, Johnson RK, Spence LA. Drinking flavored or plain milk is positively associated with nutrient intake and is not associated with adverse effects on weight status in U.S. children and adolescents. J Am Diet Assoc 2008; 108:631-639. Johnson RK, et al. Dietary Sugars Intake and Cardiovascular Health. A Scientific Statement From the American Heart Association. Circulation. 2009; 120:1011-1020. ENVIRON International Corporation. School Milk: Fat Content Has Declined Dramatically since the Early 1990s. 2008. Patterson J, Saidel M. The Removal of Flavored Milk in Schools Results in a Reduction in Total Milk Purchases in All Grades, K-12. J Am Diet Assoc. 2009; 109,(9): A97.

* Daily recommenDations - 3 cups of low-fat or fat-free milk or equivalent milk products for those 9 years of age and older and 2 cups of low-fat and fat-free milk or equivalent milk products for children 2-8 years old.

Nutrition

Chocolate So Good and Milk So Good for You by Laura Buxenbaum, MPH, RD, LDN

Milk rules in the world of nutrient-rich

“When sodas replace milk in the diet, it’s hard

beverages. It far exceeds all other beverages,

for children to get the key nutrients they need

including juices, in delivering a powerful

for growth and development,” says Dr. Stewart

package of protein, calcium, vitamins, minerals

Gordon, chief of pediatrics of the Louisiana

and electrolytes. Yes, milk is the champion

State University Health Sciences Center at Earl

over even the sports drinks in all nutrients.

K. Long Medical Center in Baton Rouge, LA.

The key is to get children to drink the milk.

“Low-fat and fat-free flavored milk are good beverage choices for children because they

“The emerging science shows that a whopping

are packed with calcium, vitamin D and

70 percent of children and adolescents are

potassium, and have fewer added sugars than

deficient in vitamin D. Low levels of vitamin D

the soft drinks they are replacing.”

have been linked to higher blood pressure, heart disease and diabetes in adults. Three

The Journal of the American Dietetics

8-ounce glasses of low-fat milk provide 75

Association (June 2002) reported that children

percent of the daily vitamin D requirements,”

who consumed flavored milk in school had

explains Dr. Douglas Gregory, past president

products, the quality of children’s and

higher total milk intake and lower soft drink

of the Virginia Academy of Pediatrics.

adolescents’ diets improves, and in the case

and fruit drink intake. Flavored milk contains

of flavored milks, no adverse effects on weight

an additional 60 calories per 8 ounces from

status were found.”

the addition of sweeteners. This is less than

Soft drinks and sports drinks (which have no nutritional value) are aggressively marketed

half as much added sweetener as is found

to children and sold in schools. Flavored milk,

The American Medical Association reports

in fruit drinks and soft drinks. Additionally,

such as low-fat chocolate milk, is very popular

a meta-analysis of 23 studies performed over

flavored milk did not increase total sugar

with children and is an excellent way to get

a 12-year period concluded that sugar intake

intake as a result of lowering intake of soft

children to drink milk when they might otherwise

does not affect children’s behavior and does

drinks and fruit drinks.

choose sodas instead. However, critics of

not contribute to hyperactivity. In the case

flavored milk voice concerns about high fructose

of hyperactivity, the caffeine in chocolate milk

corn syrup used as a sweetener, and also the

is negligible—the same as decaffeinated tea—

added calories and impact on body weight.

and should not be cited as the cause.

A review of the scientific literature indicates that chocolate milk consumed in moderation does not cause overweight, obesity or hyperactivity in children. The American Heart Association’s scientific statement, Dietary Sugar Intake and Cardiovascular Health, states, “When sugars are added to otherwise nutrientrich foods, such as sugar-sweetened dairy

MILK MATH Drink Type

Protein, calcium and other nutrients,

milk has more of everything good. Do the math! Milk Has More of Everything Good.

Calories (per 8 oz.)

Protein (grams) Calcium (grams)

Low-fat 160 9 300 chocolate milk

Other Nutrients

D, potassium, B12, riboflavin, niacin, phosphorous

Fruit punch

120

Vitamin C

Soft drinks

100

Sports drinks

Riboflavin, Vitamin B 12

APRIL 2010 | The Triangle Physician

News Welcome to the Area

Events and Opportunities April 7, 2010

KATHLEEN BONCIMINO , MD

ELIZABETH NUNNERY PAVLISKO, MD

Physical Medicine and Rehabilitation, Internal Medicine North Carolina

Pathology Duke University Hospitals, Durham

ELIZABETH LOUISE BOSWELL, MD

DUYKHANH THI PHAM, MD

Pathology Duke University Hospitals, Durham

Thoracic Cardiovascular Surgery, General Surgery Duke University Medical Center, Durham

MICHELE ROBERTS CASEY, MD Falls Pointe Medical Group Medical School | University of North Carolina at Chapel Hill Internship and Residency | Wake Forest University Baptist Medical Center

THOMAS DAVID FISHER, MD Radiology

INAM RASHID, MD Falls Pointe Medical Group Medical School | King Edward Medical University Internship and Residency | Family medicine at Wake Forest University Baptist Medical Center in Winston-Salem, NC Diplomate of the American Board of Family Medicine

LESLIE ROBINSON, MD Falls Pointe Medical Group

AVROM LOUIS KURTZ, MD Neurology University of North Carolina Hospitals, Chapel Hill

SALLY METCALF LAMBETH, MD

Medical School | University of North Carolina at Chapel Hill Residency | Family medicine at Wake Forest University Baptist Medical Center in 1998

Internal Medicine

MARC LESSIN, MD

ANDREW RYAN, MD

Pediatric Surgery, General Surgery Chapel Hill, NC

Radiology University of North Carolina Hospitals, Chapel Hill

CHRISTOPHER KIRK LIPPINCOTT, MD

SEIN YIN SEE, MD

Internal Medicine North Carolina

Nephrology, Internal Medicine Raleigh

CHRISTOPHER BOYD LOONEY ,MD Radiology Duke University Hospitals, Durham

JO-ANN EUDORA LYNCH, MD Cardiovascular Disease, Internal Medicine Raleigh

BECKY ALISON MILLER ,MD Infectious Diseases, Internal Medicine Duke University Hospitals, Durham

BENJAMIN NICHOLAS MORRIS, MD Anesthesiology - Critical Care Medicine North Carolina

SOE NYUNT, MD Internal Medicine North Carolina

MO NICA OEI, MD Falls Pointe Medical Group Medical School | University of Illinois at Chicago Residency | Family medicine at UCLA Certification | Family Medicine and is fluent in Mandarin Chinese and Medical Spanish

DONNA E. SHARPE, MD Surgery / Otolaryngology-Head and Neck Surgery Duke Otolaryngology of Durham Medical School | MD, Mount Sinai School of Medicine of New York University, 1993 Residency | General Surgery, Medical College of Georgia, 1993-1994; Otolaryngology-Head and Neck Surgery, Medical College of Georgia, 1994-1998

NATIONAL START! WALKING DAY Lace up your sneakers and take a walk to celebrate National Start! Walking Day. Walking has been proven to lower heart disease risk and improve wellness. For free walking resources visit StartWalkingNow.org or contact the AHA at 919-463-8353.

April 16 and 17, 2010

CME: 2ND ANNUAL EMILY BEREND ADULT RECONSTRUCTION SYMPOSIUM A comprehensive hip and knee course presented by Adult Reconstruction, Division of Orthopaedic Surgery, Duke University Medical Center • Lectures on hot topics in hip and knee arthroplasty and live video demonstrations on the latest operative techniques • Visiting professor Adolph V. Lombardi, MD, FACS Friday, April 16, 2010 (Knee session) Saturday, April 17, 2010 (Hip session) Duke University Medical Center Register and get more information at cmetracker.net/DUKE/Courses.html This activity has been approved for AMA PRA Category 1 credit.TM Sponsored by Duke University School of Medicine

May 7, 2010

TRIANGLE GOES RED FOR WOMEN LUNCHEON Crabtree Marriott, Raleigh 919-463-8307 www.trianglegoesred.org Celebrate the power of women to join together in the fight against their No.1 killer — heart disease. Enjoy heart health seminars, networking, a healthy lunch and powerful keynote address.

SARAH ELLEN VOLK, MD Psychiatry University of North Carolina Hospitals, Chapel Hill

JAMES GRIER WALLACE JR., MD Family Practice, Public Health University of North Carolina Hospitals, Chapel Hill

CAROLYN ANNE WIECH ,MD Emergency Medicine University of North Carolina Hospitals, Chapel Hill

New and Relocated Practices

STACEY SHEASLEY O’NEILL, MD Pathology University of North Carolina Hospitals, Chapel Hill

JOHN ANTHONY PAPALAS III, MD Anatomic Pathology Duke University Hospitals, Durham

FALLS POINTE MEDICAL GROUP WakeMed North Healthplex Physicians Office Pavilion 10010 Falls of Neuse Road, Suite 103 Raleigh, NC 27614 Office: (919) 848-9451, Fax: (919) 848-9758 Opening April 12, 2010

The Triangle Physician | APRIL 2010

Physician Profiles

Neuroradiology at Wake Radiology PHILIP R. SABA, MD

MICHAEL L. ROSS, MD

Dr. Philip Saba & Dr. Michael Ross are co-directors of Wake Radiology’s neuroradiology section. Meet these interesting men behind the reports.

Ask neuroradiologist Philip Saba, MD, what drives him, and he doesn’t

For Ross, (who joined the practice in 1990) as a youngster, there

hesitate with the answer. It’s the mystery of the brain, which has held

wasn’t one defining moment when he decided to become a doctor.

a fascination for him since childhood.“

The challenge is to wrap your head around the concept that your brain is simply a lump of tissue—which grossly looks so simple—yet what goes on in there is beyond anything that I think we’ll ever completely comprehend,” he says. His fascination with the biology of the brain drew him first to psychiatry, and he was a third-year resident before changing to radiology because he enjoyed the faster pace and the broad variety of cases. Neuroradiology was exactly the right fit, confirmed by a two-year fellowship in one of the nation’s premier programs. “You want that fellowship to go on forever. That was a very rich experience.” These days, Saba’s time outside the office centers around his family, which includes his wife, Yvette Figueroa, MD, a psychiatrist and clinical associate at Duke University School of Medicine, and their three children, ages 8, 10, and 11. His avocation is singing and playing piano and acoustic guitar; he played in bands with his colleagues during med school and residency (think Elvis Costello, U2, Nirvana, and classic rock), and today he has a small recording studio at home. His faith is an overarching theme in his life, and Saba is a strong Christian, who participates in a weekly Bible study. On his reading table: always, the Holy Bible, and next to it, an ever-growing pile of magazines and

There was his father. “It was watching my dad. I so admired him,” Ross says. “His story is amazing. We are Jewish, and he grew up in Nazi Germany and went to medical school there. When he came to the US in 1938, he hardly knew anybody, he didn’t speak the language well, and yet he thrived in Chicago, as a general practitioner with a private practice of patients who came from humble beginnings. I was impressed with his humanity in serving his patients. It was so appealing to me to experience that satisfaction he had in treating patients.” Today that satisfaction comes through neuroradiology. “I love the anatomy and the logic of how the central nervous system works,” he says. “Since I started out, I’ve seen a revolution in imaging modalities with CT and MRI. It continues to be a thrill, our ability to visualize these abnormalities. The more elegant our imaging, the more helpful we can be to clinicians.” Does he have an unforgettable case? “Each time we serve a

patient well, that becomes my best case.”

The thread of family runs true through Ross’s life, and he is devoted to his son and daughter, both in their 20s, and his wife, Elizabeth Ross, Assistant Consulting Professor in the Doctor of Physical Therapy in

medical journals that he wishes he had the time to read.

the Duke University School of Medicine, a breast cancer survivor of

Saba, who joined Wake Radiology in 2001, co-directs the neuroradiology

she teaches Duke medical students the psychosocial aspects of care.

section of eight subspecialists who supervise and interpret all brain and spine MRIs and nearly every CT of the head, neck, or spine performed at Wake Radiology’s offices and the hospitals where they practice.

a decade who was so impressed by her own patient experience that

In his spare time, Ross is active in the Jewish community, and he enjoys exercising and traveling. He spent a week volunteering to consult in the radiology department of a hospital in Riga, Latvia. History is another avocation, and his reading table holds Team of Rivals by Doris Kearns Goodwin. APRIL 2010 | The Triangle Physician

Practice Management

Understanding Fee Schedules in Physician Practices

by John Reidelbach

John J. Reidelbach, founder of Physician Advocates, Inc. (PAI), has degrees in Engineering, Education, an MBA and more than twenty years experience in healthcare. Mr. Reidelbach has developed several healthcare management entities to include IPAs, PPMCs, MSOs and group practices. He is experienced in providing assistance to healthcare entities in all aspects of practice management, operation and strategic development and implementation, education, contact negotiations, data analysis and capital funding.

Payers provide Explanation of Benefits (EOBs)

Given that practices typically do not review

that reimburse at the Usual and Customary

their fee schedules, if payers are reimbursing

(UC) standard, but what does this mean? UC

at a rate of 85% or greater against your fee

standards can be a standard fee based on the

schedule we would advise an analysis and

into consideration any utilization of procedures,

payer data statistics that is determined on

an upward adjustment to your existing fee

which could affect the example up or down.

the basis of claims data that they process, not

schedule. You should base your rationale

on what the geographic representation is for

for this fee schedule adjustment on “dollars

Another important factor in analyzing your

your practice and zip code area. In addition,

left on the table”. One may assume that if

fee schedule is to assure that you only have

even if the payer reimburses on a UC

most service fees are paid at 85% or greater

one fee schedule loaded on your practice

standard that they dictate, should we accept

of your fee schedule, chances are that some

management system. Some practices utilize

this as the standard for the industry and

procedures are reimbursed at rates equal to

multiple fee schedules within their practice.

service we provide. The answer is, “No”, not if

your fee schedule. In the event that proce-

Posting multiple fee schedules on your

your practice has a process to examine,

dures are reimbursed at your charge master,

practice management system may cause

monitor and adjust fee schedules based on

you are falling into the payer contract terms

issues in the event of an audit, based on the

the experience of your practice’s geographic

and provisions.

example provided above. If there are multiple

location and patient demographics.

fee schedules loaded and you are selected for Most terms within payer contracts are:

When was the last time your practice analyzed your fee schedule? If your practice is similar

Example Only:

a payer audit revealing that the practice was paid 70% of charges based on a higher fee

“Payer will reimburse based on agreed fee

schedule than another that you have loaded

to what we see in the rest of the industry, it

schedule or at seventy percent (70%) of

on your system, the payer will adjust to the

has been more than five years. We suggest that

billed charge”.

lower of the two fee schedules and the prac-

you analyze your charge master annually.

tice will owe a refund to the payer.

Have you ever noticed that the cost of goods

In the event that fee schedules are based on

and services you purchase seems to increase

a previous five-year value than any proce-

The monitoring and analysis of fee schedules

on an annual basis? The reason for this is that

dures not identified in a contract, you will

should be an annual objective of all practices,

normal consumer services and products are

be paid at 70% based on the identified fee

no matter the contract or the reimbursement.

adjusted at least annually or sooner based on

of the practice, which could be costing the

Furthermore, we recommend that you

the cost to provide these products and services

practice lost revenue.

perform reimbursement analysis to assure

and to assure continued profitable operations.

proper reimbursement from contracted

Medical practices are no different, as they are

In the event you are a practice that has not

payers such that fee schedule adjustments are

providing services and products to consumers,

reviewed your fee schedule annually and you

compliant with the terms of contracts agreed

albeit through contracts in most cases. None-

are subject to a percentage of reimbursement

to by your practice.

theless, your practice should monitor and

based on fee schedule charges, you could be

analyze your charge master with regularity.

losing revenue. For example: If 2% of your fees

We acknowledge that there are a number of

Costs for practices increase annually as well,

are paid at a percentage of fee charge, and you

entities that provide various data and positions

such as compensation of employees, supplies,

are charging $1,000,000.00 per year, this could

on what a fee schedule should equate to

insurance, etc. To determine proper overhead

equate to $20,000.00 per one percent of pay-

within a practice. Practices should remember

and cost increases one must analyze the revenue

ment of charges being paid on a percentage

that these are mere tools and recommenda-

to determine if the service cost should increase.

of fee schedule. This example does not take

tions, and not mandated standards.

The Triangle Physician | APRIL 2010

Mike Riddick is the president of Riddick Insurance Group Inc, an independent insurance agency in Raleigh, NC. For 10 years, Mike has been helping professionals protect their assets through insurance and financial planning. The motto of Riddick Insurance Group is to help clients protect their standard of living by being better protected today and better prepared for tomorrow. Riddick Insurance Group specializes in helping small business owners with property, casualty, liability, and life insurance planning.

Is Your Umbrella

Ready for a Rainy Day?

Each day I meet customers from all different walks of life. Many of these customers are wealthy and many are not. As I meet with these customers, we talk about their potential exposures and whether they are insured properly to weather the storm of the potential hazards they come across on a daily basis. Did you know that more than 2.35 million people were injured in car accidents in 2008 and that every 12 minutes someone is killed in a car accident? Also, did you know that the leading cause of death for people ages 2 to 34 is auto accidents? Did you know that car accidents cost Americans more than $164 billion in 2008? I’m putting my last statistic in its own paragraph; it’s that important. Did you know that car accidents are the leading cause of disability each year across the United States? Many customers I meet with ask me what would happen if they severely injured another person in an accident. Then they ask me what would happen if someone was injured in their home. Then, the last one I really like, what would happen if I hit someone with a golf ball and hurt them while I’m playing golf? Obviously no one intends to cause a car accident, have someone injured at their home, or hit anyone with an errant drive, but they always ask what would happen. What would happen if I hurt someone in an accident and they could never work again? The answer to their question is always an uncertainty. However, one thing is for sure—if someone is hurt, there will be an amount paid out by either you or your

insurance company. An umbrella policy is the best way to protect you from those catastrophic losses and keep you from having to pay those amounts out of your own pocket if they surpass your current coverage amounts. An umbrella is a personal liability policy that provides an extra cushion of protection above and beyond the personal liability coverages on your current insurance policies. The protection can cover personal liability damages done by you, your pets or your dependents. It can cover you for liability with all of your belongings, including your home, cars, boat, second homes and rental homes. If you are a business owner, consider a business umbrella policy for your company. The same principles apply. Most umbrella policies start out with a basic coverage amount of $1 million and cost $100 to $200 annually. Umbrella coverage amounts can potentially go as high as $10 million or more. Often the insurance company will require that you have certain underlying coverage amounts on your home and car policies, which can also be a small added premium, but generally is less than a $100 annual increase for most customers. Not only does the insurance company provide you with the liability protection, but oftentimes will defend you, as well. We all know that legal defense costs can be very high. In closing I ask you this: Most of us work very hard to earn the belongings we have. Do you want to jeopardize those items to others when a small and easily affordable insurance policy can give you the buffer of protection you need? We all have those days when nothing goes as planned and everything comes crashing down. Will your umbrella be ready when you have your rainy day?

by Mike Riddick

Insurance

APRIL 2010 | The Triangle Physician

Add a pinch of spice,

a hint of laughter,

and a correct diagnosis,

and you’ll get Robert.

Robert suffered from unexplained fainting spells. His physicians couldn’t figure out why. To find answers, they implanted a Reveal® Insertable Cardiac Monitor (ICM) to see if his spells were heart rhythm related.

(Actual size)

The Reveal ICM is a long-term heart monitor that may help you rule in or rule out an abnormal heart rhythm as the cause of unexplained fainting spells. In Robert’s case, they were, and now he has a pacemaker. Possible risks associated with the implant of a Reveal Insertable Cardiac Monitor include, but are not limited to, infection at the surgical site, device migration, erosion of the device through the skin and/or sensitivity to the device material. Results may not be typical for every patient.

For more information, visit www.fainting.com.

Indications 9529 Reveal® XT and 9528 Reveal® DX Insertable Cardiac Monitors – The Reveal XT and Reveal DX Insertable Cardiac Monitors are implantable patient-activated and automatically activated monitoring systems that record subcutaneous ECG and are indicated in the following cases: • patients with clinical syndromes or situations at increased risk of cardiac arrhythmias; • patients who experience transient symptoms such as dizziness, palpitation, syncope, and chest pain, that may suggest a cardiac arrhythmia. 9539 Reveal® XT and 9538 Reveal® Patient Assistants – The Reveal XT and Reveal Patient Assistants are intended for unsupervised patient use away from a hospital or clinic. The Patient Assistant activates one or more of the data management features in the Reveal Insertable Cardiac Monitor: • To verify whether the implanted device has detected a suspected arrhythmia or device related event. (Model 9539 only); • To initiate recording of cardiac event data in the implanted device memory. Contraindications: There are no known contraindications for the implant of the Reveal XT or Reveal DX Insertable Cardiac Monitors. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated. Warnings/Precautions: 9529 Reveal XT and 9528 Reveal DX Insertable Cardiac Monitors – Patients with the Reveal XT or Reveal DX Insertable Cardiac Monitor should avoid sources of diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, therapeutic ultrasound and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing. MRI scans should be performed only in a specified MR environment under specified conditions as described in the device manual. 9539 Reveal XT and 9538 Reveal Patient Assistants – Operation of the Model 9539 or 9538 Patient Assistant near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device. Potential Complications: Potential complications include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin. See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.

Brief Statement

Good Business

Blogging Colleagues

Your

provided by the North Carolina Medical Society

The era of celebrity physicians and TV diagnoses has also spawned a generation of professional physician-bloggers, several of which sincerely stand out from the crowd with compelling questions, informed opinions, and thought-provoking perspective. And as more and more of your patients are spending time online—often researching information specifically about healthcare and local physicians—it’s worthwhile for our NC medical students and doctors alike to consider remaining apprised today’s more popular doctor-blogs. Here’s a snapshot of the most popular medical blogs on the Web—and if you’ve considered beginning a blog of your own to better connect with customers, these all serve as terrific reference points and examples of success. Grunt Doc (http://www.gruntdoc.com) – A former USMC Doctor, the Grunt Doc © ISTOCKPHOTO.COM/GELPI

recounts the stories—good and bad—he’s lived as attending EMD. Thought provoking, heart-warming, enraging and at times desperately sad, Grunt Doc spares no emotion when he tells the truth about what goes on behind closed hospital doors. KevinMD Blog (http://www.kevinmd.com/blog/) – A primary care doc in New Hampshire, Dr. Kevin Pho offers down to earth and realistic commentary which on medical news, legislation, and hot topics his views on CPR to commentary on Medicare and H1N1. Paging Dr. Gupta (http://pagingdrgupta.blogs.cnn.com/) – No stranger to the limelight, CNN’s Dr. Gupta offers a global context for developments in medicine and healthcare. Always an interesting perspective for NC doctors and medical students to explore. In the Pipeline (http://pipeline.corante.com) – Dr. David Lowe spends a great deal of time discussing drug development, the drug industry as well as looking at illnesses such as Alzheimer’s and Autism. Standing on the forefront of drug research, he provides a valuable perspective about the pharmaceutical industry in general. The North Carolina Medical Society (NCMS) began in 1849 when 25 physicians united to advance medical science and to raise the standards for their profession. Today, in our 160th year, we are more than 12,000 strong and champion the same goals and ideals. As the largest physician organization in the state, the North Carolina Medical Society devotes itself to representing the interests of physicians and protecting the quality of patient care. For more information, call (800) 722-1350 or visit us online at www.ncmedsoc.org.

APRIL 2010 | The Triangle Physician

0 10 M AY 1, 2 A L E I G H

DOWN

TOWN

e.org for

drid swalkan id .a w w o to w

ister toda

and reg ll details

Kay (left), diagnosed in 1986

walk

to create a world free of MS Join Walk MS by participating, volunteering and/ or recruiting others. Walk MS is a simple, but incredibly powerful way for the MS community to come together and create a world free of MS. REGISTER TODAY:

April 24, RBC Center walknct.nationalMSsociety.org 1-800 FIGHT MS APRIL 2010 | The Triangle Physician

Local Interest

Discover Historic

Wilmington

Cape Fear Museum of History and Science is the oldest history museum in North Carolina. Since its founding in 1898, the Museum has grown and changed. It began collecting confederate relics, and now collects images and artifacts that help us understand the history, science, and cultures of the region.

The Museum began in one room, staffed only by volunteers. It has evolved into a professionally run, American Association of Museums accredited institution, housing more than 50,000 objects. Visitors encounter the skeleton of a giant ground sloth, standing 17 feet tall in the

atrium. The bones were discovered in Wilmington during the 1991 construction of a retention basin. The long-term exhibit, Cape Fear Stories, takes visitors through time, from the age when Cape Fear Indians inhabited the region through present day. Enjoy the model of Civil War Wilmingtonâ&#x20AC;&#x2122;s waterfront, experience the dramatic Battle of Fort Fisher sound and light show, and walk through a classroom from the era of segregated schools. The Museum is also home to the Michael Jordan Discovery Gallery, an interactive exploration of the ecosystems of southeastern North Carolina. An ever-changing calendar of special exhibits, programs, and events offers something fun and educational for everyone throughout the year.

MUSEUM HOURS:

Tuesday-Saturday, 9a-5p and Sunday 1-5p. The Museum is open seven days a week between Memorial Day and Labor Day. Admission is $6 for adult and $3 for children with senior, student, and military discounts. For more information, call the Museum at 910.798.4350 or visit capefearmuseum.com. SPECIAL EXHIBIT: Going to the Movies runs through November 7, 2010. Experience the history of a century of movie-going in the Lower Cape Fear region. Explore where people went to the movies. Discover how the theater experience has changed over the years. Watch some of the first films local residents may have seen. Conservation Matters runs through September 6, 2010. Explore the art and science of artifact conservation. Discover what it is, who does it, and why it matters to museums. A selection of beautifully conserved furniture and other wooden objects from the Museumâ&#x20AC;&#x2122;s permanent collection are on display. Special exhibitions are free with Museum admission.

32 14

The 20102010 TheTriangle TrianglePhysician Physician | | APRIL FEBRUARY

YOUR LOCAL CARDIOLOGY PROFESSIONALS IN JOHNSTON COUNTY DEDICATED TO QUALITY, SERVICE, AND INTEGRITY Matthew S. Forcina, MD Electrophysiology

Mateen Akhtar, MD

Benjamin G. Atkeson, MD, FACC

Eric M. Janis, MD, FACC

Diane E. Morris, ACNP

Christian N. Gring, MD, FACC

Ravish Sachar, MD, FACC

2 LOCATIONS TO SERVE OUR PATIENTS Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7907 Fax: 919-989-3147

Wake Heart & Vascular Associates 2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326

Matthew A. Hook, MD, FACC

Nyla Thompson, PA-C

CARDIOLOGY SERVICES Coronary and Peripheral Vascular Interventions, Pacemakers/Defibrillators, Atrial Fibrillation Ablations, Echocardiography, Nuclear Cardiology, Vascular Ultrasound, Clinical Cardiology, CT Coronary Angiography, Stress Tests, Holter Monitoring, Cardiovascular Medicine, Echocardiography, Nuclear Cardiology, Cardiac Catheterization

THE HIGHEST QUALITY CARDIOVASCULAR CARE, CLOSE TO HOME.

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Dr. Scott L. Sailer, Radiation Oncologist

At Wake Radiology Oncology Services, we believe that combining patients’ advanced radiation therapies with exceptional care, compassion, and dignity makes the difficulties of cancer treatment a little easier to manage. Our skill in specialized treatments for breast, liver, head and neck, and other cancers has earned us national and international recognition. We’re at the forefront of cancer treatment — a position we’re committed to maintaining for our patients and our community.

Wake Radiology Oncology Services proudly celebrates 10 years as the Triangle’s first freestanding, full-service, outpatient radiation therapy center. It was also the first practice in Wake County to offer Intensity Modulated Radiation Therapy and now the first to offer ExacTrac® Image Guided Radiation Therapy.

300 Ashville Avenue, Ste 110 | Cary, NC 27518 | 919-854-4588 | wakerad.com

Wake Radiology Oncology Services. The Power of Hope.