The Triangle Physician August 2010 by TTPLLC

AUGUST 2010

Vascular Access Center of Durham Interventional Nephrology and Peripheral Artery Disease Care

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

Also in this Issue Children’s Vision Care Haitian “Eye M.D.” Initiative

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

What’s new in cancer treatment

With over 200 published papers, he wrote the book on gynecologic cancer Andrew Berchuck, MD, director of the Duke Division of Gynecologic Oncology, talks about the latest research in ovarian and other cancers. What’s the latest news in gynecologic cancer? It is a very exciting time in cancer research. We’re learning new things about the molecular origins of the disease that will lead to better prevention and treatment. For example, it’s been shown that about 15 percent of ovarian cancers occur in women who inherit mutations in the BRCA1 or BRCA2 genes. If testing shows that a woman carries the mutation she may then choose to have her ovaries removed to prevent cancer, which is rarely detected early. Which means that even if ovarian cancer is in your genes, it doesn’t have to be in your future? That’s right. The chance to intervene before a woman develops cancer is the holy grail of oncology that we strive for. What other dramatic changes have you witnessed in your career at Duke? Most patients with gynecologic cancers undergo surgery as part of their treatment. Today we can perform most cancer surgeries with minimally invasive laparoscopic or robotic techniques that use tiny incisions. Recovery times are remarkably shorter and cosmetic results are superior. Being able to offer surgical approaches that make the experience of having a gynecologic cancer more bearable for women has been incredibly gratifying. Many academic physicians don’t spend their entire career at one institution. What has kept you at Duke for 21 years? It is a pleasure to work alongside many of the best and the brightest on a daily basis. Duke has created an environment in which clinician-scientists can be productive in their quest to provide the best possible care, while also striving to create new knowledge and treatment paradigms. And from a quality of life perspective, this a terrific place to live and work. I kiss the ground every time my plane touches down at Raleigh-Durham International Airport. Nationally recognized physicians at Duke Comprehensive Cancer Center treat nearly 6,000 new patients per year, combining cutting-edge research with compassionate care.

cancer.duke.edu

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5991PE_Berchuck_TriPhys.indd 1

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Contents

COVER STORY

PHOTO BY JIM SHAW

Vascular Access Center of Durham Enhancing Care for Dialysis and PAD Patients

FEATURES

Ophthalmology

AUGUST

2010 VOLUME1 ISSUE7

DEPARTMENTS 13 Phlebology Bulging Varicose Veins Are a Medical Problem

Ophthalmology

16 Neurosurgery Building Blocks for Spinal Fusion

Battle to Catch Lazy Eye Early Wages On

U.S., Latin American Eye M.D.s Help Rebuild Haitian Eye Care

19 Business Management

If the condition is not caught by age nine or 10, there is minimal chance for vision improvement in the affected eye. Blindness can occur.

Donations are being collected, and “Eye M.D.s” and other medical experts are being placed where they are needed.

22 Ophthalmology

Accurate Reimbursement Analysis Boosts Income

Early Diagnosis of Harlequin Eye and Other Craniosynostoses Is Key

24 Insurance Coverage Protects Against Identity Theft

25 Hospital News Raleigh Orthopaedic Uses New Gene Test for Scoliosis Severity

26 Women’s Health Hair-Removal System for Men and Women Is Pain Free and Permanent

28 Ophthalmology New Training Program Has Eyes on Sharpening Important Learning Tool

30 News Welcome to the Area, New and Relocated Practices, Upcoming Events and Clinical Trials

31 Hospital News Rex Healthcare Gets OK to Build Cancer Hospital

32 Cardiology COVER PHOTO: Dipen S. Parikh, MD: Photo by Jim Shaw.

The Triangle Physician

BNP Is a Valuable Congestive Heart Failure Test

From the Editor

Ever-evolving medical community This issue’s cover story on Dr. Dipen Parikh and Vascular Access Center of Durham offers evidence that the order of medical disciplines is not static, but evolving to meet anticipated need for care. In this case, interventional nephrology has emerged to provide specialized care for patients with end-stage renal disease, specifically the multitudes who receive hemodialysis. The focus of the interventional nephrologist is to assure hemodialysis patients have well-functioning venous accesses, the portal through which their blood is cleansed. The subspecialty has emerged in response to a growing need. The prevalence of patients with kidney failure is expected to increase 60 percent in the next 20 years, according to data from the United States Renal Data System. This is largely attributed to the bulging population of aging baby boomers. Improved care of dialysis and chronic kidney disease patients also is viewed as a contributing factor. Throughout this issue of The Triangle Physician are references to efforts to ensure that early-childhood vision exams are performed thoroughly and consistently. Leading the way is Prevent Blindness in North Carolina. Also at the forefront are ophthalmologists Timothy Jordan and Michael Brennan. Dr. Jordan reports on the “battle” to save the eyesight of children with amblyopia (“lazy eye”) and strabismus (eye crossing), respectively. Dr. Brennan is on the ground in Haiti helping to rebuild the infrastructure for quality eye care. Radiologist Catherine Lerner explains some of the subtleties of accurately diagnosing craniosynostoses, which include “harlequin eye.” On the business-management front, beware of identity theft. Mike Riddick discusses coverage that minimizes the damage. Also, John Reidelbach provides counsel on reimbursement analysis, with the start of a two-part series. In this issue, Dr. Dennis Bullard discusses the best bone-grafting materials for successful spinal fusion. Dr. Mateen Akhtar explains the value and limitations of B-type natriuretic peptide levels to help identify congestive heart failure. Dr. Lindy McHutchison reinforces that the condition of bulging varicose veins is a medical problem usually covered by insurance companies. As always, we extend our appreciation to the more than 8,000 M.D.s, D.Os, P.A.s and N.P.s, and their indispensable support staff who read The Triangle Physician and provide health care in our region that evolves to stay second to none.

Heidi Ketler Editor

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Mateen Akhtar, M.D.; Dennis E. Bullard, M.D., F.A.C.S.; Catherine B. Lerner, M.D.; Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G.; Lindy McHutchinson, M.D.; John J. Reidelbach; and Mike Riddick Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Joseph Dally

jdally@newdallydesign.com

Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com

The Triangle Physician is published by New Dally Design 9611 Ravenscroft Ln NW, Concrd, NC 28027

Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401 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. 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

On the Cover

Vascular Access Center of Durham

PHOTO BY JIM SHAW

Interventional Nephrology Enhances Care for Dialysis and Peripheral Artery Disease Patients

p Vascular access procedure being performed.

ver the past 10 years, the discipline of interventional nephrology has developed to take advantage of the nephrologist’s unique and intimate knowledge of dialysis patients, as well as to provide a comprehensive service uniquely dedicated to enhancing care for the growing numbers of patients with end-stage renal disease (ESRD). The United States Renal Data System estimates that the prevalence of ESRD will

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increase about 60 percent, from 506,000 in 2006 to more than 785,000 by 2020. Most ESRD patients are treated by hemodialysis. For it to be successful, it is critical to have a functioning vascular access – their lifeline for receiving renal replacement therapy.

appropriately to maintain adequate clearances and ultrafiltration. Nephrologists involved in the subspecialty typically require an additional 12 to 24 months of dedicated didactic and procedural training focused on vascular access management.

This is the focus of the interventional nephrologist, who is trained to use the latest state-of-the-art imaging, diagnostic and interventional services to ensure the dialysis patient’s vascular access functions

“As the prevalence of end-stage renal disease increases, an interventional nephrologist is becoming an increasingly important member of the health care team involved in caring for patients with ERSD,” says Dipen S.

Dipen S. Parikh, M.D., attended the Texas Academy of Mathematics and Science for high school, and subsequently graduated from Johns Hopkins University in Baltimore, Md. His medical training at the University of Texas Medical School (at Houston) was followed by a residency in internal medicine. He completed a nephrology fellowship at Duke University Medical Center. Dr. Parikh currently works with the Fistula First National Vascular Initiative (Network 6), the Duke Clinical Research Institute and Emory University on clinical research projects to help improve vascular access outcomes for hemodialysis patients. He is a member of the American Society of Nephrology, the Renal Physicians Association, the American Society of Diagnostic and Interventional Nephrology, and the National Kidney Foundation. Dr. Parikh specializes in all aspects of hemodialysis vascular access maintenance.

Parikh, M.D., an interventional nephrologist and medical director with Vascular Access Center of Durham.

timely treatment of vascular access failures to limit the use of temporary or tunneled dialysis catheters and reduce unnecessary hospitalizations.3 “That’s where the interventional nephrologist plays a pivotal role. There is just a large demand, so having interventional nephrologists, like Dr. Parikh, to fill the gaps in care, as well as train additional interventional nephrologists, will be helpful,” says Uptal D. Patel, M.D., assistant professor of medicine and pediatrics at Duke University School of Medicine. Dr. Patel’s research focuses on health care systems and their impact on outcomes among patients with renal disease. He also works to identify and implement clinical strategies that may facilitate patients’ access to quality health care. Interventional nephrology procedures are minimally invasive and typically performed in an outpatient setting. By providing

The United States Renal Data System estimates that the prevalence of end-stage renal disease (ESRD) will increase about 60 percent, from 506,000 in 2006 to more than 785,000 by 2020. Many of the current vascular access-related dilemmas for patients with ESRD include dialysis access procedure delays, temporary dialysis catheter use, possible detrimental effects of missed dialysis treatments, increased health care costs and unnecessary hospitalizations. In fact, morbidity related to vascular access is the leading cause of hospitalization among patients who receive chronic hemodialysis.1 Furthermore, hospital admission for a dialysis patient often results in at least one missed outpatient dialysis session and incurs average costs of more than $8,000 for an inpatient access procedure. Indeed, vascular access-related costs account for up to 25 percent of all endstage renal disease Medicare costs, totaling up to $1.5 billion annually.2 Consequently, the National Kidney Foundation and the “Fistula First” National Vascular Initiative Program recommend

expeditious care in a cost-effective and safe manner, patients that need vascular access interventions have fewer missed outpatient dialysis treatment sessions and require fewer hospitalizations. Ultimately, such management may help improve the quality of life of patients with ESRD, while reducing overall health care costs.

Patient Perspectives Education Promotes Improved Outcomes Robert Newton, 39, whose kidneys were removed because of polycystic kidney disease, recently experienced the benefits of interventional nephrology care. After increasing problems with blood flow during hemodialysis, he was referred in March to Dipen S. Parikh, M.D., an interventional nephrologists at Vascular Access Center of Durham. There, Dr. Parikh performed angioplasty, macerated and lysed thrombi and, ultimately, augmented Mr. Newton’s arterio-venous fistula. “I get a lot better blood flow now. After seeing Dr. Parikh, clearances have improved and the dialysis treatment is better,” says Mr. Newton. He also appreciates the education Dr. Parikh regularly provides before and after each case by explaining anatomy, physiology and reviewing images/films. “I learn a lot about my disease and the whole vascular side of things,” he says. Dr. Parikh also delivers regular educational presentations to dialysis technicians and nurses, primary care physicians and clinical nephrologists.

Friendly Atmosphere Minimizes Aprehension Robert Thorpe, a 64-year-old retired staff sergeant, was diagnosed with kidney failure in March 2009. The idea of hemodialysis frightened him, but Mr. Thorpe’s fears were eased from the moment he met Dr. Parikh.

“With the goal of optimal care for patients who require a functional access for hemodialysis as their top priority,” Dr. Patel says, “the interventional nephrologist may provide more timely care.

“From the first day I walked in there, it’s been like family. They treat you so nice, very nice,” says Mr. Thorpe. “They are such wonderful people there. (Dr. Parikh) comes out in the lobby, and explains what he is going to do and what is going to take place before he takes you back. I have only nice things to say about the whole staff.”

The hemodialysis lifeline Hemodialysis, an artificial blood-cleaning process, is the most common method of treating advanced and permanent kidney failure. It requires the establishment of a vascular access through which blood is removed, processed and returned.

Although kidney failure and dialysis have required adjustments, Mr. Thorpe is more confident and less fearful about his vascular access since visiting Dr. Parikh and the Vascular Access Center of Durham.

AUGUST 2010

PHOTO BY JIM SHAW

p Patient checking in at the Vascular Access Center of Durham.

The creation of the vascular access has progressed considerably since its origins. In 1948, Nils Alwall, M.D., first reported the creation of an arterio-venous shunt for dialysis. Subsequently, he used such shunts, made of glass, to treat 1,500 patients in renal failure between 1946 and 1960. During the 1960s, Belding Scribner, M.D., and Wayne Quinton, M.D., modified the glass shunts by making them from Teflon and connected the Quinton-Scribner shunts to a short piece of silicone elastomer tubing. In 1962, Dr. Scribner started the worldâ&#x20AC;&#x2122;s first outpatient dialysis facility in Seattle, Wash.

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The arterio-venous fistula (AVF) remains the preferred access to hemodialysis, showing better survival and lower complication rates than graft and catheters. For instance, people with a fistula have a 50 percent lower mortality rate than those with a catheter.4 Creation of an AVF is dependent on, but not limited to, the integrity of the peripheral and central veins, surgical expertise, established clinical nephrology care, timely vein mapping and patient co-morbidities, according to Dr. Parikh.

A fistula is an opening or connection between any two parts of the body that are usually separate, for example, a hole in the tissue that normally separates the bladder from the bowel. While most kinds of fistula are a problem, an AVF is useful because it causes the vein to grow larger and stronger, making repeated needle insertions for hemodialysis treatments easier. If a fistula is not possible, a graft or venous catheter may be needed. A graft is created using a synthetic tube that connects an artery to a vein.

PHOTO BY JIM SHAW

p Pre-procedure evaluation and examination.

A temporary tunneled or non-tunneled central venous catheter is an immediate option that can be used when the need for hemodialysis is urgent. However, catheters are not ideal for permanent access because of the possible complications associated with long-term use. Specialized hemodialysis vascular access care All types of hemodialysis vascular access can have complications that require treatment or intervention. Once poor vascular access function is determined, Dr. Parikh advises that early intervention typically prevents the escalation of such abnormalities. “Scheduled physical exams and monitoring during dialysis treatments may enable early detection of possible abnormalities. Dialysis centers and clinical nephrologists often do a great job of this,” states Dr. Parikh. ”Managing and maintaining appropriate vascular access in dialysis patients requires a team effort.

Clinical nephrologists, dialysis center staff and nurses, social workers, surgeons and interventionalists all play a vital role.” Fistula maturation procedures The time period from AVF creation and the first cannulation (and use for successful dialysis) is referred to as the maturation time of the fistula. Augmenting the fistula by expanding distinct sections of the fistula, redirecting blood flow, and/or removing accessory and collateral veins may expedite the maturation process. Successful early fistula maturation enables the patient to use the fistula for dialysis sooner, helping to prevent unnecessary complications of temporary catheter use. Thrombolysis/thrombectomy Despite excellent care and observation, arterio-venous grafts and (less often) fistulas may develop thrombi for various reasons. Percutaneous thrombi removal may occur via multiple (and possibly a combination)

of methods involving aspiration and balloon thrombectomy, pharmacological thrombolysis and/or mechanical thrombectomy. Tunneled catheter placement, exchange, and removal Dialysis catheters are typically placed in the large central veins (typically the internal jugular or femoral veins), and subsequently

p Dr. Dipen S. Parikh is medical director of Vascular Access Center of Durham. AUGUST 2010

PHOTO BY JIM SHAW

p Peripheral artery disease screening being performed on a symptomatic patient.

used for dialysis. Ultrasound or fluoroscopic guidance is often required for the procedures. The Vascular Access Center of Durham provides the full range of tunneled and non-tunneled catheter services. â&#x20AC;&#x153;Although fistulas have also been associated with improved long-term survival, roughly two-thirds of incident patients start hemodialysis with a catheter,â&#x20AC;? says Dr. Parikh, who researches strategies to expedite fistula creation or graft placement in dialysis patients. p F istula maturation, with images shown pre-procedure (left) and post-procedure (right). The image at left shows a fistula that has not matured properly.

The Triangle Physician

Increasing awareness about underdiagnosed peripheral artery disease Peripheral arterial disease generally results from atherosclerosis (hardening of the arteries), leading to impaired circulation to the extremities and other vital organs. Peripheral artery disease affects 10 percent to 25 percent of patients aged over 55 years, and 70 percent to 80 percent of affected individuals are asymptomatic.5 Despite the prevalence and cardiovascular risk implications, less than 25 percent of PAD patients are undergoing treatment.6 “Peripheral artery disease is responsible for significant morbidity and death in the ESRD population,” Dr. Parikh says. In fact, numerous studies suggest PAD may be significantly more prevalent in the ESRD population than among the general population.7 For example, the incidence of non-traumatic, lower-extremity amputation among patients with ESRD is approximately 10 times higher than that among patients not requiring dialysis, even after accounting for diabetes mellitus.8 As a result, Dr. Parikh is currently working on a large-scale project

with the National Kidney Foundation to better understand the relationship between PAD and chronic kidney disease. Established risk factors for PAD in the general population include increased age, hypertension, hyperlipidemia, smoking, diabetes mellitus and coronary artery disease. The challenge is PAD does not always cause recognizable symptoms, and those who experience symptoms, such as pain or cramping in the legs, often attribute them to aging or normal fatigue. Claudication, defined as reproducible ischemic muscle pain, is one of the most common manifestations of peripheral vascular disease. Claudication occurs during physical activity and is relieved after a short rest; pain develops because of inadequate blood flow. Other symptoms include: abnormal sensation (numbness, tingling, coldness) and/or non-healing or poorly healing ulcers or sores on the legs or feet. Often, PAD can be treated with lifestyle changes. Smoking cessation, a structured exercise program and preventive foot care

may provide considerable symptomatic relief and prevent further progression of the disease. Interventional procedures may benefit patients with symptoms refractory to lifestyle changes or medical management. Percutaneous transluminal angioplasty procedures utilize fluoroscopic guidance imaging to efface stenotic or narrowed arterial circulation pathways. Occasionally, stents may be used to prevent re-occlusion. Angioplasty and/or stent placement is a minimally invasive treatment that does not require surgery, just a nick in the skin the size of a pencil tip. Peripheral arterial interventions provided at Vascular Access Center of Durham include: • Non-invasive screening and diagnosis of peripheral artery disease • Peripheral angiograms • Peripheral artery angioplasty • Peripheral artery stent placement Visit www.vascularaccesscenters.com, then click on Clinical Services and Peripheral Arterial Disease to download a questionnaire that can shed light on one’s PAD risks.

p Back to front, left to right: David Honeycutt, R.N.; Jim Altrichter, R.N.; office administrator Tracey Glasscock; Dipen S. Parikh, M.D.; and Mario Accardo, R.T. AUGUST 2010

Entering an emerging subspecialty “While I was fascinated by nephrology and was always interested in procedures, my excellent clinical and research mentors at Duke helped me gain an appreciation for the intricacies and complexities of appropriate vascular access for dialysis patients,” says Dr. Parikh.

Thinking about Relocating or Expanding?

Contact information Vascular Access Centers has locations in nine states and the District of Columbia. The Vascular Access Center of Durham offers hemodialysis fistula and graft interventions, complete catheter services and peripheral arterial disease screening and treatment. Hours are Monday through Friday from 8 a.m. to 5 p.m. For more information, call (919) 251-6605 or visit the practice website at www.vascularaccesscenters.com.

References 1. Centers for Medicare and Medicaid Services: 2007 Annual Report EndStage Renal Disease Clinical Performance Measures Project. Baltimore, MD, Department of Health and Human Services, Centers for Medicare & Medicaid Services, Center for Beneficiary Choices, 2007. 2. USRDS: the United States Renal Data System. Am J Kidney Dis. Jan 2010;55(1 Suppl 1):S1-S420. 3. Charmaine E. Lok, “Fistula First Initiative: Advantages and Pitfalls,” Clin J Am Soc Nephrol 2: 1043-1053, 2007. 4. (Dhingra RK, et al. Kidney Int 60:1443-1451, 2001). 5. “Peripheral Artery Disease Prevention and Prevalence.” Peripheral Artery Disease. Your Health Encyclopedia. Nov 1 2007. 6. Sharrett AR. “Peripheral Artery Disease Prevalence,” Peripheral Artery Disease. Armenian Health Network. 7. Hiatt W, Hong S, Hamman R. “Effect of Diagnostic Criteria on the Prevalence of Peripheral Artery Disease.” Circulation 1995; 91: 1472-1479. 8. E ggers PW, Gohdes D, Pugh J: Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int 56: 1524–1533, 1999.

The Triangle Physician

Main St., Holly Springs

11,200 sq. ft. Office Building Can be divided into 4 units Parking lot expansion in July Remodeling begins in July Elem. & Middle Schools nearby FOR INFO:

1-919-924-1883 www.OmniBusinessPark.com www.Hollyspringsnc.us/ecdev

Bulging Varicose Veins Are a Medical Problem By Lindy McHutchinson, M.D.

The superficial venous system in the leg serves as a reservoir. When these veins have reflux causing leg symptoms, minimally invasive procedures are used to effectively treat the unhealthy veins by closing or eliminating them thus, alleviating many leg symptoms. Bulging varicose veins are usually caused by the medical condition chronic venous insufficiency, and treatment is covered by most insurance plans, including Medicare. Bulging varicose veins, or BVV, are large superficial veins that bulge beyond the usual surface of the skin. In addition to being unsightly, BVV symptoms include tired, achy, heavy, swollen legs. The superficial venous system in the leg serves as a reservoir. When these veins have reflux causing leg symptoms, minimally invasive procedures are used to effectively treat the unhealthy veins by closing or eliminating them thus, alleviating many leg symptoms.

When venous reflux is present, venous pooling and congestion occur in the great and small saphenous veins. This pooling and increased pressure cause affected veins to distend and enlarge to accommodate the increased blood volume. With time, the chronically dilated and distended saphenous veins progressively utilize and recruit adjacent branches, which eventually dilate and distend, and like the Mississippi River, become ribbon-like down the leg. This phenomena is called chronic venous insufficiency. Venous reflux is diagnosed with duplex ultrasound performed by a trained venous ultrasonographer in the vein clinic setting.

Phlebology Dr. Lindy McHutchinson began training with notable physicians in the field of phlebology, first at Duke University as an observational fellow with Dr. Cynthia Shortell, chief of vascular surgery at Duke. Subsequently, she completed an extended clinical preceptorship with Dr. John Mauriello, fellow of the American College of Phlebology and nationally known educator in the field. She also trained with Dr. John Kinglsey in Birmingham, Ala., another nationally known phlebologist. Today, Dr. McHutchinson is medical director of Carolina Vein Center, a practice dedicated to the treatment of chronic venous insufficiency and other conditions associated with venous disease. To learn more about venous disease, visit www.carolinaveincenter.com.

Duplex means “two,” so first, the direction of venous flow is evaluated in the saphenous veins, and second, the veins in the legs are “mapped.” Treatment may begin with conservative management that includes prescription compression stockings, leg elevation, avoiding hot tubs and baths (to decrease venous dilation), and exercise (to help “pump” blood out of the leg). Often, however, relief is only temporary. Definitive treatment involves first treating the underlying source of reflux in the saphenous veins with endovenous laser ablation. Subsequently, BVV can be treated either with ambulatory phlebectomy (AP), which is a micro-extraction of the bulging vein segments, using local anesthesia or traditional injection sclerotherapy. Both are equally effective and depend on the treating physician’s expertise and recommendation. At Carolina Vein Center, BVVs are typically treated with AP, a simple, office-based procedure, and most patients return to normal activity the same or following day.

Normal leg veins work against gravity, using one-way flow valves that take blood via antegrade flow back to the heart. If valves are damaged, abnormal or absent, blood flows retrograde toward the feet. This unhealthy, retrograde flow is called venous reflux. The leg has two vein systems, deep and superficial. The two main “trunks” of the superficial system are the great saphenous vein and the small saphenous vein.

p Symptomatic bulging varicose veins.

p After ambulatory phlebectomy. AUGUST 2010

Ophthalmology

Lazy Eye Battle to catch

By Timothy D. Jordan, M.D.

early wages on

It always amazes me when a child with treated amblyopia improves from 20/400 to 20/20.

lthough you won’t read or hear much about the amblyopia battlefield, it is a fight families and their doctors have been waging for years. Now, I am glad to report that children across our state have benefitted from the diligent efforts of health teams that focus on finding amblyopia early and starting therapy upon discovery. The incidence of amblyopia, or “lazy eye,” has been reported to be between 2 percent to 4 percent of children in North America. Amblyopia is suppression of normal vision development typically from one of the following causes: • Ocular misalignment or strabismus, • Uncorrected refractive error, • Other eye disorders that block or distort a clear image transmission from the eye to the brain. A hidden refractive error with pronounced hyperopia, myopia and/or astigmatism in the weaker eye (anisometropia) leads to suppressed vision development. If not caught by age nine or 10, there is minimal chance for vision improvement in the affected eye. It is, of course, preferred to catch amblyopia at a much younger age, since young children have a faster and more substantial response to therapy.

The Triangle Physician

Dr. Timothy Jordan completed his medical education at Baylor College of Medicine and his ophthalmology residency at Medical College of Virginia. His pediatric ophthalmology fellowship was served at the James Hall Eye Center in Atlanta with Dr. Zane Pollard. His current practice of pediatric ophthalmology and strabismus started in 1998 after joining Raleigh Ophthalmology. He has served as a longstanding board member of Prevent Blindness North Carolina.

Unsuspected problem When amblyopia is suspected and confirmed by exam, parents are often dismayed to see the level of visual impairment in one eye when their child’s visual acuity is tested in the office. Some dense amblyopia can decrease vision so that counting fingers is possible only at 1 foot to 2 feet, or worse.

It is difficult to reconcile for parents who had no suspicion that any vision problems were present. Occasionally they find out when their child states, “Mommy, that’s my bad eye... . It’s always been like that.” This scenario most often occurs because there are no visual symptoms, because of the help of one normal-sighted eye. In contrast, when pediatricians or families observe eye crossing in a child, the assistance of an eye care specialist is usually sought. Strabismus has a variety of forms that respond to treatment, including glasses, orthoptic exercises, patching, eye drops and strabismus surgery. Many studies concur that when these therapies start shortly after strabismus is noticed, there is a much greater chance for successful outcomes. Unfortunately, even with strabismus, some families delay care, hoping the child will outgrow the cross. Also, small unnoticed strabismus can delay therapy and cause significant amblyopia.

Accurate screenings It is imperative that accurate, sensitive visual screening be performed at least by age three. If vision screeners have the proper training, their work can literally save vision for multitudes of children. Here in North Carolina, organized efforts to screen children for eye disease have met with great success. Pediatricians, primary care physicians and other health care professionals are performing an invaluable service in screening for vision trouble during routine well-child visits. Prevent Blindness North Carolina also has been instrumental in using photoscreening techniques for preverbal children in preschools and health centers around the state. Photoscreening uses a camera to record any abnormal light reflections off the back of the eye. The resulting photos are reviewed to detect significant refractive error, strabismus, media opacity within the eye, pupil abnormalities or ptosis. Treatment of amblyopia Once a child is suspected of having risk factors for amblyopia, a comprehensive eye exam is recommended. Treatment is directly aimed at eliminating or reducing the underlying source of amblyopia. The mainstay of therapy for amblyopia is occlusive patching of the normal sighted eye. For anisometropia and certain types of strabismus, correction is with eyeglasses. It always amazes me when a child with treated amblyopia improves from 20/400 to 20/20. Of course parents deserve much of the credit for their persistence in helping their child complete the therapy, which sometimes lasts several months. Educating the family about the condition is critical for achieving success with treatment. While your own practice may have little to do with eye health, if you happen to encounter a child who might have an eye problem, ask the parents if they have taken their child to the eye doctor. Your sensitivity to this issue could save vision for that child’s entire life!

AUGUST 2010

Neurosurgery

Building Blocks for

Spinal Fusion By Dennis E. Bullard, M.D., F.A.C.S.

In the United States, roughly 250,000 spinal fusions are done each year. 1A fusion is an attempt to use bone growth to stabilize an unstable portion of the spine. This can involve something as simple as attempting to stabilize a small joint in either the cervical or lumbar spine percutaneously all the way to a multilevel attempt at bone formation in a 360-degree fashion around the spine.

pain and loss of motion. The fusion may not restore normal movement, but the goal is to prevent abnormal, painful movement. The types of material used for bone formation need to be osteogenic, meaning they generate bone formation, and to have three specific properties to induce new bone growth: osteoconduction, osteopromotion

The spinal column is divided into the anterior column, consisting of the vertebral body and disc; the lateral column, consisting of both sides posteriorly with facet joints and lateral masses; and the posterior column, involving the lamina and spinous processes in the back of the spine. Movement occurs to different degrees in each of these columns depending upon their location. Spinal fusions are designed to stabilize and prevent excessive painful movement, and can cause nerve or spinal cord injury. Framework for bone growth The placement of metallic hardware – such as pedicle screws, facet screws, lateral mass screws, etc., and cages made of polyethylene carbon fiber or other non-reactive and permanent devices – are the stabilizing scaffold and are designed to hold the unstable spine in a stable enough position so bone growth can occur. If the bone growth of the fusion does not occur, then an optimal surgical result may be jeopardized. It is the bone growth itself that will provide the longterm stability and benefit to the patient. It is not always the case that fusion results in increased rigidity and loss of motion. In many cases appropriate anterior cervical fusions in the neck have resulted in improved range of motion of the neck. The same is generally true for fusions in the lumbar spine when instability is present, causing marked

directly inducing the bone growth. These often include aspiration of the patient’s own bone marrow and/or the patient’s own plasma. Osteoinduction refers to the primary growth of new bone within the fusion. The primary agents used for this are donor bone, demineralized bone matrix (DBM) and compounds called bone morphogenic proteins (BMP), which induce cells to differentiate into bone-forming cells. Auto-grafting materials For most surgeries, another way of looking at this is to talk about the bone-graft material being divided into: autograft, meaning the patient’s own bone, and allograft, meaning bone from a donor. This bone tissue has a high rate of fusion because it has virtually all of the components mentioned above. Unfortunately, the harvesting of this bone from the sites richest in bone-forming cells often results in a relatively painful surgical site. Generally, this is the hip and in many cases, patients will often complain of this pain for a long period of time. In larger, open procedures, where there is extensive bone removal, this may be less of an issue due to the nature of those surgeries.

and osteoinduction. Osteoconduction is the ability of the material used to provide a trellis or scaffold for the formation of new bone. Multiple materials, including a person’s own bone, donor bone and even coral or ceramics when combined with calcium compounds, can provide such a property. Osteopromotion refers to biologic materials that increase the bone growth by facilitating bone formation, while not

In our practice we tend to use minimally invasive approaches to the lumbar spine to avoid this, allograft from a bone bank and stem cells is used. This can either serve as a structural support or in certain cases help with osteoconduction. The use of stem-cell technology from adult organ donors has been a major advancement. These materials are harvested in a specific fashion from patients who have been extensively screened. This results in a viable cellular bone matrix, with adult stem cells and osteoprogenator cells in a demineralized Continued on pg. 18

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Triangle Neurosurgery, PA A Complete Spine Care Center Triangle Neurosurgery provides a unique blend of personalized attention to each patient with the latest advancements in state of the art technology. This results in compassionate and comprehensive care delivered through conservative management or surgery. Our emphasis is patient centered and we recognize the importance of helping patients return to an active and healthy lifestyle.

Dr. Dennis E. Bullard MD, FACS is a Board

in cervical spine surgery. He has been

Certiﬁ ed Neurological Surgeon and a Fellow

honored with the Patients’ Choice Award

in the American College of Surgeons. He is a

and has been elected continuously to the

neurosurgeon who has been practicing for

lists of America’s Top Rate Physicians and

28 years and is always striving for the most

Best Doctors in America. He is a member

current and effective care for his patients.

of the North Carolina Spine Society and elected to the International Who’s Who in

He is the recipient of the 2010 ﬁrst place

Medicine.

award given by the American Association of Neurological Surgeons for his research

1540 Sunday Drive, Suite 214, Raleigh, NC | P: 919-235-0222 | F: 919-235-0227

triangleneurosurgery.org

bone matrix. These compounds have been shown to be safe in extensive use throughout the body and appear to be extremely promising alternatives to either autograft or older allograft materials. In some situations where a large mass is needed, bone graft substitutes of plastic, ceramic or bioabsorable compounds can be used. These do not induce bone formation, but they do provide a structural support that allows other agents to induce formation within this larger structure. Latest findings Currently, the agents most commonly used for osteopromotion are the patientâ&#x20AC;&#x2122;s own bone marrow aspirates and platelet-rich gels. Both of these were initially felt to be promising in early trials, but have been somewhat inconsistent in larger studies, especially when used in the lumbar spine. Specifically, the platelet-rich plasma gels are now considered to be ineffective in promoting bone growth and in some studies have even been reported to interfere with bone growth.

shown, especially in the cervical spine, to be associated with significant immune reactions that can potentially be life threatening. Multiple studies have centered around trying to make these BMP products more contained or potentially less hazardous, but in the cervical spine they are not agents that should be routinely employed. In the lumbar spine, many surgeons report excellent results. Others, however, have noted the problems above to persist. The stem cell derivatives, such as Trinity Evolution, a viable preserved cellular bone matrix, have proven so far to be an excellent alternative and, to date, extremely successful. This material is taken from donor bone marrow and is extensively screened for potential transmission of infectious disease and is immunologically compatible. These contain adult mesenchymal stem cells (MSC) that have the ability to differentiate into bone, muscle, cartilage, tendon or ligaments, depending upon the environment. They also

have osteogenic progenitor cells, which can only evolve into bone cells. MSC has the added benefit of secreting chemicals known as cytokines that modulate immune reactions. These cellular properties appear to continue even after bone has begun to form. Trinity Evolution has been used in more than 3.5 million grafts since its development in 1987, with a high rate of success and a minimal complication rate. These cells do not stimulate an immune reaction when placed into surgical patients. The criteria for selection of donor patients is extremely strict and less than 40 percent of potential donors pass the initial set of criteria. In summary We try to always use the safest and most effective agents possible. Currently we believe stem cell technology, and Trinity Evolution in particular, are the best components available. Reference 1

nited Network for Organ Sharing and the U Musculoskeletal Transplant Foundation

Osteoinduction refers specifically to any material that causes bone cells to grow. Bone cells come from two sources: progenitor stem cells, which when stimulated form a bone-growing cell; and induction of mesenchymal stem cells to develop into viable, growing progenitor cells, and thus into bone. The most commonly used products for this, other than autologous bone, are demineralized bone matrix and certain BMP derivatives. Stem-cell preparations appear to have this property and do not appear to have the potential serious side effects that BMP products have. BMP materials are often extremely strong and can induce bone formation in areas where it is not desirable and extend it beyond the desired fusion site. They also have been

Trinity Evolution

Dr. Dennis Bullard is a board-certified neurological surgeon and a fellow of the American College of Surgeons. He graduated from St. Louis University Medical School in 1975. He completed his internship and residency at Duke University, and a fellowship in neurology at the National Hospital for Neurologic Disease in London. He was on the faculty at Duke University as an associate professor in neurosurgery from 1982 through 1987. Dr. Bullard has been in practice in Raleigh since 1987. He is a former chairman of the Joint Section on Tumors and the Stereotactic and Functional Section of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons. He has served as chairman of surgery and neurosurgery at Rex Hospital. His major interests are spinal problems with a special emphasis on the cervical spine and minimally invasive procedures for the lumbar spine. For more information, call (919) 235-0222 or visit www.triangleneurosurgery.org.

The Triangle Physician

Business Management

This is the first in a two-part series

Accurate reimbursement analysis boosts income By John J. Reidelbach

In initiating a reimbursement analysis, all cost factors of the practice must be taken into consideration to determine whether or not a specific plan reimbursement is covering the cost for services. The sole focus of a reimbursement analysis is to maximize physician incomes. Therefore, prevailing politics or social issues, while obvious in practice dynamics, is generally not considered in the development of observations and recommendations for a report of this nature. It is the responsibility of the physician management of the practice to weigh these factors and, ultimately, make these judgments based on the pure facts of the analysis. This analysis can serve as a measurement of the income “lost” to actions taken that are contrary to financially focused business decisions. For example, some practices believe in serving impoverished patients through state charitable programs, such as Medicaid. The services for these patients are reimbursed at below-market rates, displacing higher paying commercial patients. The impact of the social decision to see Medicaid patients has a real financial cost to the practice and can be quantified with a reimbursement analysis. When initiating a reimbursement analysis, one must use locally adjusted Medicare relative value units (RVUs) as a measurement of physician productivity throughout the analysis. While the Medicare system has its pitfalls and is prone to political and other non-market pressures, we believe that it is the most effective and easily understood measurement available today. Also, the site-of-service differential must be taken into consideration based on whether a procedure was performed in a facility or not. When comparing multiple years’ services to one another, one must always use the

correct year’s set of RVUs. Since Medicare changes annually, choosing one set will allow one to compare apples to apples, so you can observe real changes, excluding changes in Medicare rates. For example, when comparing 2008 services to 2009, you must assign 2008 RVUs to 2009 services so both years’ results can be examined relative to 2009 Medicare. As in many other types of business operations, production and capacity typically have relative pricing based on these factors. For example: If one was to purchase a fleet of vehicles for one’s business, chances are the pricing received for these vehicles would be better priced if only one vehicle was purchased. However, in health care provider services, this is not the case. For example: In most cases, payers such as Blue Cross Blue Shield, Cigna, United Health Care, etc., provide the largest capacity for most medical practices, yet it is not uncommon to find a smaller payer reimbursing at rates below the negotiated rates of these larger payers. Hence, this methodology should be approached for these services, as well.

John Reidelbach’s career in health care spans more than 20 years and all facets of administration within physician practices, hospitals and large health care insurers. He founded Physician Advocates Inc. in 1996. Today, he assists health care entities in all aspects of practice management, operation, strategic development and implementation, education, contract negotiations, data analysis and capital funding. His credentials include degrees in engineering and education, and a master’s in business administration. Mr. Reidelbach has designed several health care management entities, including independent physician associations, physician practice management companies, management service organizations and group practices. His experience includes developing equity ownership structures, financial incentives, network administration, and information systems selection and implementation. He also has developed detailed analysis tools for health care providers and product vendors. Mr. Reidelbach can be reached in North Carolina at (919) 321-1656 or in Atlanta at (404) 664-9060; and by e-mail to info@ mdpracticeadvice.com.

capacity. For example, if a practice has available appointments regularly, then any income generated would improve physician income, even if Medicaid is the payer. For most practices, however, the opposite is true; the opportunities lie with converting lower paying patients to higher ones.

One would think payer reimbursement should be primarily based on the volume that the payer is purchasing from the practice. As is commonly seen in day-to-day life, those businesses that purchase more of a product generally pay lower prices. Therefore, in theory, the larger capacity payers should extract the deepest discounts among commercial payers for most practices.

In initiating a reimbursement analysis, all cost factors of the practice must be taken into consideration to determine whether or not a specific plan reimbursement is covering the cost for services. Cost is defined to include physician income and retained earnings, or net income. Therefore, any increases in practice cost, either nominally or per RVU, is likely a very good result. One should also examine the practice’s operating expenses, as well, and the distinction between the two is made.

The opportunities to improve physician incomes are vastly different for practices with capacity than the majority of practices that consider themselves at or above

In our next writing, we will provide data examples, with explanations, of how this type of analysis will provide a practice with the tools to understand and negotiate reimbursements based on factual practice data. AUGUST 2010

Ophthalmology

U.S., Latin American

Eye M.D.s Haitian Help Rebuild Eye Care Dr. Michael Brennan, chair of the American Academy of Ophthalmology Task Force on Haiti Recovery, chats with a friend during one of his visits since the earthquake.

“About 5 feet from where I was working, I saw a Haitian ophthalmologist performing cataract surgery using an irrigation aspiration bottle and a 10cc syringe. It was a far cry from the outpatient surgical facilities we have in the States.” – Philip R. Rizzuto, M.D.

ore than six months after the devastating earthquake in Haiti, doctors and health officials there still struggle to provide quality trauma, disease, and eye and vision care. In response, eight United States ophthalmologists are working with the American Academy of Ophthalmology, the Pan-American Association of Ophthalmology (PAAO) and other partners to get crucial equipment and supplies to Haitian doctors. Through the academy’s Task Force on Haiti Recovery, sight-saving instruments and supplies valued at more than a half-million

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dollars have been shipped to date, and donation collection continues. The task force is led by former academy President Michael W. Brennan, M.D., of Burlington, N.C. Dr. Brennan is a military veteran with unique humanitarian experience in Iraq and Afghanistan. “Our task force continues to be actively engaged with our Haitian colleagues,” says Dr. Brennan. “In addition to collecting equipment and supplies, we’re helping place ‘Eye M.D.s’ (American Academy of Ophthalmology ophthalmologists)

and other medical experts where they’re needed. As Haiti rebuilds, public health and rehabilitative medicine volunteers are especially needed.” The academy’s task force was created within days of the quake, as reports came in from Haitian colleagues of destroyed offices and hospitals, shortages of supplies and equipment, and the challenges of treating quake-related eye injuries, such as eye socket fractures and corneal abrasions caused by falling debris, and infections that flourished in the unsanitary conditions.

Task force volunteers returned from Haiti bearing long lists of urgently needed supplies and equipment. The task force worked closely with PAAO and the Bascom Palmer Eye Institute of the University of Miami Health System on the donation drive, and leaders of the Haitian Society of Ophthalmology and the University of Haiti Eye Hospital are collaborating with the academy on distribution of the eye units and other materials. “The earthquake left many of our colleagues without the equipment and structure they need to provide proper patient care,” says David W. Parke II, M.D., chief executive officer of the academy. “I am proud of the ophthalmic community’s overwhelming response in this time of great need and of the academy’s role in the collaborative effort to rebuild the eye care system in Haiti.” Philip R. Rizzuto, M.D., was one of several ophthalmologists who went to Haiti to lend a hand. He described conditions in a blog post: “Haitian ophthalmologists Bridgette Hudicort and François Rocourt welcomed

me on arrival, and over the next five days we became friends and teammates. “On Monday, we restored a young woman’s sight by repairing her damaged eyelid. Two functional operating rooms had been set up in a lovely old motel spared by the earthquake, now called St. Damian Children’s Hospital. “Later we moved on to the university hospital, where eye surgeries were done under local anesthesia, with a desk lamp for illumination. About 5 feet from where I was working, I saw a Haitian ophthalmologist performing cataract surgery using an irrigation aspiration bottle and a 10cc syringe. It was a far cry from the outpatient surgical facilities we have in the States.” The Foundation of the American Academy of Ophthalmology also established a Disaster Relief Fund to provide ophthalmic resources and facilitate much-needed patient care. All funds collected will be used for Haitian recovery efforts.

“We are extremely satisfied with our partnership and look forward to continued productivity and collaboration throughout joint efforts still to come,” says` Frantz Large, M.D., president of the Haitian Society of Ophthalmology. “The academy’s efforts have been consistent since the disaster,” says Dr. Brennan. “From the immediate response and evaluation of needs to the subsequent facilitation and solicitation of supplies, we are proud to have been able to aid our colleagues in this trying time.” The American Academy of Ophthalmology is the world’s largest association of eye physicians and surgeons – Eye M.D.s – with more than 29,000 members worldwide. Eye health care is provided by the three “O’s” – opticians, optometrists and ophthalmologists. It is the ophthalmologist, or Eye M.D., who can treat it all: eye diseases, infections and injuries, and perform eye surgery. For more information, visit the Task Force on Haiti Recovery website at http://www.aao. org/haiti/task-force.cfm.

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AUGUST 2010

Radiology

Early Diagnosis of

Harlequin Eye and Other Craniosynostoses Is Key By Catherine B. Lerner, M.D.

Working as a team with referring clinicians, pediatric radiologists can facilitate the early detection of this important pediatric diagnosis.

linicians who care for children are often faced with the task of evaluating an infant for abnormal skull shape. This can be a sign of craniosynostosis, a congenital birth defect in which one or more of the fibrous sutures separating an infant’s skull bones close prematurely, before the brain is fully formed. When a baby has craniosynostosis, his or her brain can’t grow in its natural shape and the head is misshapen. The arrangement of the bones of an infant’s skull allows the head to pass through the birth canal and to grow with the brain in early infancy. While it’s normal for a baby’s skull to be slightly misshapen during the few days or weeks after birth, parents may notice that their baby is developing a persistent flat spot. Most cases of localized skull flattening are caused by deformational or positional plagiocephaly, particularly given the successful implementation of the American Academy of Pediatrics (AAP) “Back to Sleep” campaign. Since the AAP campaign, the incidence of sudden infant death syndrome (SIDS) in the United States has decreased by almost 40 percent, while the incidence of flattened-head syndrome has risen. While positional plagiocephaly often will correct itself with appropriate intervention, treating craniosynostosis usually involves surgery to separate the fused bones, and early detection is key. Types of craniosynostoses In general, true craniosynostosis is 10 times

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less common than positional plagiocephaly. Of the craniosynostoses, most involve just one suture and most occur as isolated events in families with no history of the condition and whose children with craniosynostosis are otherwise healthy. There are different types of craniosynostosis, and the suture involved determines the abnormal shape of the head. Sagittal synostosis (scaphocephaly) is the most common type. It affects the main (sagittal) suture on the very top of the head. The early closing forces the head to grow long and narrow, instead of wide. Babies with this type of craniosynostosis tend to have a broad forehead. It is more common in boys than girls. Frontal plagiocephaly is the next most common form, involving the closure of one side of the coronal suture, which runs from ear to ear on the top of the head. It is more common in girls. Metopic synostosis is a rare form of craniosynostosis that affects the metopic suture close to the forehead. The child’s head shape may be described as trigonocephaly, and the deformity may range from mild to severe. Also rare is lambdoid craniosynostosis, which involves the lambdoid suture that runs across the back of the skull between the occipital bone and the parietal bones. Premature fusion usually results in a flattening of the back of the head, with an

appearance that can be similar to positional plagiocephaly. Physical examination The suture most frequently involved by craniosynostosis is the sagittal suture (in 40 percent to 60 percent of cases), followed by the coronal suture (in 20 percent to 30 percent of cases). When coronal suture synostosis is unilateral, the result is one of the more recognizable clinical and radiographic presentations of craniosynostosis, that of the “harlequin eye” deformity of the orbit. The harlequin eye is meant to describe elevation of the ipsilateral lesser wing of the sphenoid, with posterior displacement or retraction of the superior and lateral rims of that orbit. A more common, and perhaps more challenging, clinical scenario is that of distinguishing between positional plagiocephaly and the unusual, but clinically important, lambdoid craniosynostosis. Both can cause occipitoparietal flattening, so evaluation begins with a physical examination for features that help differentiate the two. In positional plagiocephaly, when examining the infant from above, one sees frontal bossing and anterior displacement of the ear on the same side as the posterior (occipitoparietal) skull flattening. To the contrary, in the rare cases of lambdoid synostosis, one may see frontal and parietal bossing on the opposite side of the posterior (occipitoparietal) flattening, and the ear on the side of the occipitoparietal flattening may

Dr. Catherine Lerner is a pediatric radiologist at Wake Radiology Pediatric Imaging Center. A native of Tallahassee, Fla., she received her medical training at Columbia University College of Physicians and Surgeons in New York and served her internship at St. Vincent’s Catholic Medical Center there. She completed a fellowship in pediatric radiology at Duke University Medical Center, where she was chief resident in diagnostic radiology. She is a cum laude graduate of Yale University, where she earned a bachelor of science degree in biology and a bachelor of arts degree in art history. She has authored articles appearing in Pediatric Radiology and the journal Cancer. Dr. Lerner is board certified in diagnostic radiology by the American Board of Radiology, and is a member of the Radiological Society of North America and the Society for Pediatric Radiology. She can be reached at (919) 782-4830.

be displaced posteriorly, toward the fusing suture. With lambdoid synostosis, one may also see a “mastoid bump” on the same side as the posterior flattening, as growth can still occur at the patent posterolateral fontanel. Pediatric radiolography When a clinician encounters an infant with abnormal skull shape or facial features that cannot be attributed to positional plagiocephaly, referral to a pediatric radiologist is an important next step. Working as a team with referring clinicians, pediatric radiologists can facilitate the early detection

If an abnormality is detected, a low-dose head CT tailored to the evaluation of craniosynostosis can be performed. With this head CT, the infant is assessed for additional abnormalities that could not be appreciated on skull radiographs, recognizing that more than one suture may be affected in a minority of patients. In addition, using the pediatric craniosynostosis protocol, threedimensional reconstructed images can be rendered to aid the surgeon in his or her treatment planning.

of this important pediatric diagnosis. A radiographic skull series serves as the appropriate screening study in evaluation of such infants. The pediatric radiologist evaluates the radiographs for any signs of craniosynostosis, such as increased sclerosis at the sutures, narrowing of a suture or loss of suture clarity, or frank bony bridging across a suture. In addition, if performed at a dedicated pediatric imaging center, the pediatric radiologist has the opportunity to examine the patient when indicated.

Early intervention Children born with craniosynostosis may have increased pressure on the brain and vision problems, low self esteem and behavioral problems. Long-term studies demonstrate that in addition to correcting functional problems associated with craniosynostosis, reconstructive surgery has a positive effect on the child’s self image and the ability to get along with his or her peers. Although there is no upper age limit to surgery, the ideal timing for surgery is prior to three months of age, when a less-invasive microscopic procedure can be performed. Also at this time, the bones of the skull are easier to work with and the covering of the brain, known as the dura, can make bone on its own. Moreover, the growing brain can continue to reshape the skull and face after the surgery. Children with multiple suture synostosis require emergency treatment in the first two weeks of life. Usually one surgery is required to correct children with simple craniosynostosis, although some may need minor alterations at four to five years of age. Children with craniofacial syndromes in addition to craniosynostosis require several surgeries on the skull to achieve a normal shape. Patients who have surgery usually do well, especially those with only one suture involved and those whose condition is not association with a genetic syndrome. References: Blaser SI. Abnormal Skull Shape. Pediatr Radiol (2008) 38 (Suppl 3):S488-S496. Kabbani H and Raghuveer TS. Craniosynostosis. Amer Fam Phys (2004) 69 (12): 2863-2870. AUGUST 2010

Insurance Mike Riddick is president of Riddick Insurance Group Inc., an independent insurance agency in Raleigh. For 10 years, he has been helping professionals protect their assets through insurance and financial planning. Riddick Insurance Group specializes in property, casualty, liability and life insurance planning for small business owners. Mr. Riddick can be reached at (919) 870-1910 or mike@ riddickinsurancegroup.com.

Coverage Protects Against

Identity Theft By Mike Riddick

With our economy struggling to recover, identity thieves are looking harder than ever for good information to steal.

veryday as you watch the news, listen to the radio or read the newspaper, you learn about identity theft and the billions of dollars it costs Americans every year. Recently, one Saturday morning my home phone rang and someone asked to speak to me, yet they weren’t looking for “me,” they were looking for someone else with a similar name who had put my home phone number on a series of loan and credit card applications. Needless to say, the person on the other end was disappointed to hear she had hit a dead end in her search. In 2010, an estimated 9 million Americans will have their identity stolen. Most victims will not know their identity has been stolen until they go to apply for credit. In other cases it can prevent someone from getting a job, new housing or educational loans, among many other issues. Identity thieves can steal your information many different ways, and every day they get more and more creative in the ways they steal. In most cases, it costs the victim hundreds or thousands of dollars to repair their status after an identity theft. The worst part is, if the thief has created fake IDs or social security cards, it could take years to get all the credit repaired, thus driving up the costs. Many people ask what they can do to be prepared and how insurance can help.

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For starters, my favorite website to go to for identity theft is the North Carolina Attorney General’s at www.ncdoj.gov. A very informative site, it offers clarification on top consumer myths, suggestions for protecting your credit, ways to order your free annual credit report, and instructions on how to freeze your credit and report scams to local authorities. ID theft policies There are three kinds of “policies” available that I personally recommend to protect against identity theft. First, most home insurance policies today offers an ID Theft rider. This rider generally costs about $25 annually. It will protect you against the costs associated with restoring your credit and ID. Most policies cap at an aggregate payout of around $25,000. Secondly, many business policies will offer an identity theft coverage rider. This rider covers both the business and its employees (with certain stipulations). It’s a little more expensive, but is a great way for a business owner to protect himself and his employees.

Lastly, prepaid legal is offering identity shield on many of its programs. Costing $10 monthly, the identity shield performs many of the functions that a home policy ID theft rider would cover. Although it’s a little more expensive, it gives you a little more coverage. With our economy struggling to recover, identity thieves are looking harder than ever for good information to steal. Be prepared, call your insurance agent and have identity theft coverage added to your policy. Its well worth the time and you’ll be glad you did it the day you have a claim.

Hospital News

Raleigh Orthopaedic Uses New Gene Test for Scoliosis Severity The Pediatric Spine Service at Raleigh Orthopaedic Clinic is offering a newly available gene test to determine how severe a child’s curvature may become. The test, called ScoliScore (DePuy Spine Inc.), was developed based on the gene profile of thousands of patients with scoliosis or spinal curvature. The test detects specific gene patterns found in patients with progressive curves. Positive findings are factored together to give a numeric value, the child’s “ScoliScore.” “A child with a low ScoliScore value is very unlikely to have progression of her curve, even as she grows,” says Keith Mankin, M.D., F.A.A.P., chief of the Raleigh Orthopaedic Clinic Pediatric Service Unit. “A higher score may mean that the curve is going to progress quickly and may need more aggressive treatment.” The test is easy and painless: A saliva sample is collected in the clinic and sent off for evaluation. According to DePuy Spine, it is most effective in children between the ages of nine and 13 who have curves under 25 degrees.

of pioneering broad range of products and solutions across the continuum of orthopaedic and neurological care. These companies are unified under one vision – Never Stop Moving™ – to express their commitment to bringing meaningful, innovative, shared technology and quality care to patients throughout the world. Visit www.depuy.com for more information. About Raleigh Orthopaedic Clinic Raleigh Orthopaedic Clinic (ROC) is Wake County’s largest and oldest orthopaedic practice.

It is part of the DePuy companies of Johnson & Johnson, which are proud of their heritage

The Athletic Performance Center, a division of ROC, provides sports physical therapy and sports performance-enhancement services for healthy and injured athletes. ROC is the official sports medicine provider of the Carolina Hurricanes, North Carolina State University, the Carolina Ballet and multiple high school sports programs in Wake County.

The orthopedic surgeons of ROC are ROC has offices in Raleigh, North Raleigh, fellowship trained in their respective Cary and Garner. Complete practice subspecialty areas, which include: foot and information is available at ankle, hand and wrist, spine, hip, shoulder www.raleighortho.com. NEWSOURCE-JUN10:Heidi 12:57 PM Page 1 and elbow surgery, total joint8/5/10 replacement,

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“ScoliScore represents an exciting new vista in scoliosis treatment,” says Dr. Mankin. “The test can give peace of mind to parents and children, as well as providing definitive answers as to what treatments may be necessary. Also, as we get more information, our understanding of the causes and treatments of scoliosis will continue to expand.” About DePuy Spine DePuy Spine Inc. has worked and partnered with leading clinicians, researchers and thought leaders to develop products to treat spine disorders for more than 20 years.

sports medicine and pediatric orthopedic care. Ancillary services include physical therapy, magnetic resonance imaging, radiology, shock wave therapy, and orthotics and pedorthics.

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Maybe it’s happiness in a child’s eyes. Whatever the desired outcomes, count on us to ensure your key messages have the 20/20 clarity to deliver.

AUGUST 2010

Women’s Health

Hair Removal System for Women and Men Is Pain Free & Permanent

By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G

arolina Women’s Research and Wellness Center is now offering Alma Laser’s next-generation PainFree, Hair-Free hair removal system for men and women at its Women’s Wellness Clinic near the Streets of SouthPoint. Laser hair removal is the process of removing unwanted body hair. Alma Laser permanently and painlessly removes hair using IN-Motion technology, featuring a patented DualChill treatment tip that keeps the surface of the skin cool and comfortable.

The Triangle Physician

“Many women and men have unwanted hair, and don’t realize how simple and safe permanent hair removal can be,” says Dr. Amy Stanfield, M.D., F.A.C.O.G.. “One recent patient remarked after her treatment in our office, ‘I wasn’t sure I really believed you when you said it wouldn’t hurt, but that was the smartest thing I’ve done.’ She plans to bring her husband next month to remove unwanted back hair.” During laser hair removal, the light from the laser is absorbed by melanin within the

hair shaft. The increase in temperature of the hair follicle thermally destroys the cells responsible for re-growth of hair. Dr. Stanfield and partner Dr. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G are fully trained and qualified to provide treatments and limit adverse reactions.” “The wavelength, pulse duration and power of the light are set to ensure destruction of the hair,” says Dr. Stanfield. “Importantly, the settings should not be too high or the skin can be burned or blistered.”

After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/ gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thombosis Clinic. She left her academic position in 2007 to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head the Women’s Wellness Clinic, the private practice associated with CWRWC. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.

Usually between three to six laser treatments are needed because body hair is in different phases of growth. Only hairs that are in the anagen (growth) phase are destroyed.

“Most of us feel more confident and attractive when our skin is healthy and smooth,” says Dr. Lukes. “So we work with our patients to make the latest technology affordable, safe and effective.”

“We started offering aesthetic treatments because people want them – including myself and my staff,” she says. “We are focused on safety and good results, and we work with our patients to make treatments affordable.”

“Even with one treatment, though, patients have a noticeable reduction in hair growth,” says Dr. Stanfield. “After several treatments, almost all hair is eliminated.”

IN-Motion technology features a patented DualChill treatment tip that keeps the surface of the skin cool and comfortable. The laser treatments also help treat pseudofolliculitis barbae (PFB), when hair is shaved and begins to grow back, curling into the skin instead of straight out of the follicle. This creates itchy red skin, and the inflamed areas can become infected. In individuals of African descent, keloid scarring can occur. “This is a treatable medical condition, but many women and men do not realize that laser treatment will improve PFB,” says Stanfield. “Once the hair is removed, the bumps improve and the skin becomes smooth.” AUGUST 2010

New Training Program Has

Eyes on Sharpening Important Learning Tool

It is estimated that 1 in 20 preschoolers have an undiagnosed vision problem.

very August, teachers and parents both begin tireless preparations to welcome a new batch of students – kindergarteners. Classrooms are stocked and readied, while parents and children begin the search for supplies and the perfect lunch box. However, families can often neglect one of the greatest tools for early learning – healthy vision. It is estimated that 1 in 20 preschoolers have an undiagnosed vision problem. A quality vision screening can indicate early signs of problems, allowing families time to access professional eye care before lasting damage occurs. However, screening protocols can often vary from setting to

The Triangle Physician

setting making it difficult to ensure every child’s screening is optimal.

Family Practice also will engage these providers in the project.

Refreshing providers, enforcing the law With the support of the United States Centers for Disease Control and Prevention, Prevent Blindness North Carolina (PBNC) and Duke University are collaborating on an exciting project aimed at eliminating some of these variations.

Vision screening is required as part of Medicaid well-child visits and mandated for all children entering kindergarten by North Carolina’s Commission on Early Children Vision law. This module will refresh providers’ skills, while reinforcing the law.

The project’s latest endeavor includes developing an online training module providing credit toward American Board of Pediatrics Maintenance of Certification Part 4 (Performance in Practice). A reciprocal agreement with the American Board of

Under the direction of Duke University pediatric epidemiologist Dr. Alex Kemper, this performance-improvement module will roll out in North Carolina by the end of 2010, followed by national distribution. How it will work Participants will begin by collecting baseline data on current methods of vision screening

in preschoolers ages three to five. They also will receive education on the importance and rationale for preschool vision screening. The second step includes completion of an online training session of appropriate tools and processes for screening children. Providers are then given access to office tools to assist in tracking outcomes and recording vision screening results. Finally, providers will participate in a series of quality-improvement activities to increase the rate and completeness of preschool vision screening. Those who successfully complete participation will receive Part 4 Maintenance of Certification credit from the American Board of Pediatrics. Active participation in quality-improvement activities – a factor in the project’s design – has been shown to be much more efficient at changing practice behaviors.

the state’s certification program that trains more than 7,000 volunteer screeners. This workforce screens more than 530,000 children grades K-6 annually in all 100 North Carolina counties. PBNC has been providing training sessions to pediatrician offices in recent years. In 2009, the organization began a working relationship with Community Health Centers and federally qualified health centers training staff on pediatric and adult-vision screenings. For more information about these programs, contact PBNC at (919) 755-5044.

Big picture According to vision industry statistics, 80 percent of children diagnosed with a learning disability have an undiagnosed vision problem and 70 percent of juvenile delinquents also have visual problems. In recent months, the importance of healthy childhood vision has been given national attention thanks to discussions relating to health care reform. Provisions in the reform will include vision services for children beginning in 2014, although the specifics of these services have yet to be determined. The importance of early vision was illustrated by a recent quote from President Obama: “No child should be falling behind at school because he can’t hear the teacher or see the blackboard. I refuse to accept that millions of our kids fail to reach their full potential because we fail to meet their basic needs.” A recent article in The American Prospect draws the connection between health care reform efforts and better education outcomes, particularly in literacy. The article simply states, “The health care reform bill has the potential to make children healthier and, as a result, better learners.” Prevent Blindness North Carolina operates Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

AUGUST 2010

News Welcome to the Area

Upcoming Events

Tahanie Abu Ahmed , MD

Douglas Joseph Hartz , MD

Jeremy Walter Shaw , MD

Wake Health Services, Inc., Raleigh

Radiology UNC Hospitals, Chapel Hill

Duke Eye Center, Durham

Megan Marie Adamson , MD

Mir Rauf Subla , MD

September 11, 2010

The Gail Parkins Memorial Ovarian Awareness Walk & 5K Run Location: Sanderson High School - Raleigh, NC

Family Medicine Duke University Hospitals, Durham

Thomas Walter Hash , MD Duke University Hospital, Durham

Cardiology Duke University Hospitals, Durham

5500 Dixon Drive, Raleigh, NC 27607

Tariq Ahmad , MD

Masanori Hayashi , MD

Alison Evelyn Sweeney , MD

Internal Medicine Duke University Hospitals, Durham

Pediatrics Duke University Hospitals, Durham

8:00 am Registration Opens 8:30 am Run starts

Kadry Raji Allaboun , MD

Diane Michelle Howell , MD

Dina Marie Trobbiani , MD

Pediatrics UNC Hospitals, Durham

Pediatrics UNC Hospitals, Chapel Hill

Pathology, Durham

Dunya Mary Atisha , MD

Janice Hsiao-Lun Jou , MD

Duke University Hospital, Durham

Matthew John Volk , MD Internal Medicine Duke University Hospitals, Durham

Aysel Atli , MD Physical Medicine and Rehabilitation

Internal Medicine UNC Hospitals, Chapel Hill

Thuy L. Vu , MD Duke University Hospital, Durham

Diagnostic Radiology UNC Hospitals, Chapel Hill

Hematology and Oncology, Internal Medicine Duke University Hospitals, Durham

Keith Jeffrey Mathers , MD

Jennifer Azbell Walker , MD

Natalie McCarter Bowman , MD

Stephanie Brigitte Mayer , MD

Prateeti Prabhaker Khazanie , MD

Elizabeth Sun-Mee Bigger , MD

UNC Hospitals, Chapel Hill

Jared B. Bowns, MD Neuroradiologist, Emergency Medicine Radiologist WakeMed Health & Hospitals, Raleigh

Duke Eye Center, Durham

Duke University Hospital, Durham

Kate Lawrence Mitchell , MD Internal Medicine Duke University Hospitals, Durham

Scott Matthew Moore , MD General Surgery UNC Hospitals, Chapel Hill

Mary Fox Braithwaite , MD Pediatrics Wake Teen Medical Services, Raleigh

Angel Aleatha Brown , DO Family Practice UNC Hospitals, Chapel Hill

William John Bulsiewicz , MD UNC Hospitals, Chapel Hill

Stephanie Ming-Way Chia , MD Child Neurology Durham

Deborah Collins , MD Family Practice UNC Hospitals, Chapel Hill

Philip John DiGiacomo , MD Emergency Medicine UNC Hospitals, Chapel Hill

Todd Andrew Dorfman , MD UNC Hospitals, Chapel Hill

Scott Meacham Duncan , MD Radiology Duke University Hospitals, Durham

Emily Dawn Eads , MD Radiology Duke University Hospitals, Durham

Gretchen Marie Foltz , MD Radiology UNC Hospitals, Chapel Hill

Daniel Eric Forsha , MD Pediatrics Duke University Hospitals, Durham

Paul Sang Do Hahn , MD Duke Eye Center, Durham

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Internal Medicine Duke University Hospitals, Durham

Danielle L. Wellman, MD

Siobhan Marie O’Connor , MD

Pediatrics UNC Hospitals, Chapel Hill

Waleska Michelle Pabon-Ramos, MD Jill M Pappalardi , MD

New and Relocated Practices Raleigh Neurology Associates’ Durham office has relocated to a new building in Durham. Our new Durham address is: 4111 Ben Franklin Boulevard, Durham, NC 27704. Phone and Fax numbers remain the same (phone: 919719-8834 / fax: 919-855-0953).

Punitha Ida Rathnam , MD Act Medical Group, Goldsboro

Adrienne Phillips Ray , MD Anesthesiology UNC Hospitals, Chapel Hill

Richard Youshin Ro , MD Diagnostic Radiology, Raleigh

Lisa Jeannette Rose-Jones , MD Internal Medicine UNC Hospitals, Chapel Hill

Paul Christopher Rossi , DO Emergency Medicine CIGNA, Raleigh

Joseph Kamel Salama , MD Duke University Hospital, Durham

Emil Anthony Ty Say , MD Ophthalmology UNC Hospitalsm Chapel Hill

Kristin Marie Schroeder , MD Pediatrics UNC Hospitals, Chapel Hill

9:00 am – Registration begins 10:30 am – Start walking for a cure! Please note: Walk is slightly hilly at the end. http://www.ovarianawareness.org/ September 26, 2010

2010 Start! Triangle Heart Walk Time: TBD Location: RBC Center, 1400 Edwards Mill Rd. Raleigh, NC 27607 http://starttriangle.org/

Do you have patients with any of these problems?

Wake Urological Associates, PA

Duke University Hospital, Durham

Body imaging and general diagnostic radiology. Raleigh Radiology

The Ovarian Awareness Walk 2-mile walk

Urology

UNC Hospitals, Chapel Hill

Kirk Peterson, MD

Educational Forum open to the public. 8:00 am Registration begins for forum and/or walk 9:30am Forum begins at Sanderson High School. Educational Forum presented by Duke and UNC GYN Oncologists. Once you are educated and know the symptoms, join us for the walk that helps raise money and awareness for ovarian cancer…

Clinical Trials.. Lisa Ann Whitehead , MD

Internal Medicine Duke University Hospitals, Durham

“It Whispers, So Listen”

Women’s Imaging Radiologist Wake Radiology, Raleigh

Internal Medicine Duke University Hospital, Durham

Pediatrics UNC Hospitals, Chapel Hill

North Carolina Div of Public Health, Raleigh

Justin David Westervelt , MD

Deborah Alissa Morris , MD

Scott Vincent Connelly , MD

Natalie Janine Miriam Dailey , MD

Pediatrics Duke University Hospital, Durham

5K Run

Moved to a New Practice WakeMed Health & Hospitals is proud to welcome

J. Duncan Phillips, MD, FACS, FAAP Surgeon-in-Chief of WakeMed Children’s Hospital and the Director of Pediatric Surgery for WakeMed’s physician practices.

James Zidar, M.D., Fellow with the American College of Cardiology and the Society of Coronary Angiography and Intervention Rex Heart & Vascular Specialists, Raleigh

Cory Adamson, MD, PhD, MHSc, MPH Surgery / Neurosurgery, Neurobiology Fellowship Neuro-Oncology Duke University Medical Center, Durham

Currently screening Do you have a sudden and urgent need to urinate? Do you have accidental loss of urine? If you are a male/female, 18 years of age and older you might be eligible to participate in a clinical trial study for Over Active Bladder conducted by Wake Urological Associates. For additional information and qualification criteria please call 919.782.1255 and ask for Clinical Trials Department or visit our web site www.Wakeurological.com

News

Rex Healthcare Gets OK to Build Cancer Hospital Plans to Expand Cancer Care Services for Wake County under way. The North Carolina Division of Health Service Regulation approved Rex Healthcare’s certificate of need application to build the North Carolina Cancer Hospital at Rex. The approval authorizes Rex Healthcare to establish a dedicated cancer care center in Wake County to provide area residents care closer to home. The new 70,000-square-foot hospital, projected to open in 2014, will be built in front of Rex’s current Cancer Center. It will house new cancer-care technological equipment and resources for patients, including garden spaces, a boutique and clinics. The hospital will work closely with Rex Surgical Specialists and Rex Thoracic Specialists to provide patients with quality surgical care. Patients will also have access to further oncology expertise through the hospital’s affiliation with UNC Health Care System and its North Carolina Cancer Hospital.

among the top five percent in the country. In 2008, Rex was listed as one of the nation’s 100 Top Hospitals by Thomson Reuters Healthcare. Rex also was named one of the top 100 (No. 9) Best Places to Work in Healthcare by Modern Healthcare magazine in 2009. Rex Healthcare is a member of UNC Health Care, a not-for-profit integrated health care system, with more than 4,600 employees and facilities in Apex, Cary, Garner, Knightdale, Wakefield and downtown Raleigh. Its main Rex Hospital campus in west Raleigh is a 665-bed facility (439 general acute beds and 226 skilled nursing) that treats more than 34,000 inpatients each year. Rex offers dedicated centers for cancer, heart and vascular, post-acute rehabilitation and skilled nursing care, same-day surgery, wellness and women’s care, plus dedicated services for pain management, sleep disorders, diabetes education, emergency services and stateof-the-art wound care.

“We are grateful that the state recognized the need for a comprehensive cancer-care center in our area,” says David Strong, president of Rex Healthcare. “As the population of Wake and surrounding counties continues to grow and age, we will now be better able to meet patients’ increasing needs for care with the North Carolina Cancer Hospital at Rex.” For more information about Rex Healthcare, visit rexhealth.com.

About Rex Healthcare Rex Healthcare, a private not-for-profit system founded in 1894, provides a variety of health care services throughout Wake County and has been ranked among the nation’s top hospitals. It is the first hospital in the Triangle and one of only 10 in North Carolina to receive Magnet Recognition, which places Rex nurses AUGUST 2010

Cardiology Dr. Mateen Akhtar is a board-certified cardiologist with Wake Heart & Vascular Associates. He sees patients daily in Clayton, Smithfield and Goldsboro. He welcomes new patient referrals and offers same-day appointments. He can be reached at (919) 989-7909 or by e-mail to mateenakhtarmd@gmail.com. By Mateen Akhtar, M.D., F.A.C.C.

The Use of

BNP Testing in Clinical Practice.

BNP testing is indicated in patients suspected of having CHF when the diagnosis is uncertain. A normal BNP level is particularly useful for excluding CHF due to its high negative predictive value.

eart failure is the leading cause of hospitalizations in patients over age 65. There are approximately 500,000 new cases of heart failure in America each year.

The diagnosis of congestive heart failure (CHF) often is not readily apparent since a number of other conditions can cause acute dyspnea, including myocardial ischemia, pulmonary embolism, asthma or chronic obstructive lung disease, anemia, anxiety and infectious diseases. CHF remains primarily a clinical diagnosis, based upon symptoms (dyspnea, orthopnea, edema, paroxysmal nocturnal dyspnea) and physical exam findings (jugular venous distention, edema, volume overload, pulmonary congestion), and is supported by echocardiographic evidence of systolic or diastolic dysfunction. B-type natriuretic peptide assay Assays for B-type natriuretic peptide (BNP) and its prohormone, NT pro-BNP, were first developed and tested as tools to help discriminate cardiac vs. non-cardiac causes of dyspnea. BNP is a natriuretic hormone secreted from the ventricles in response to increased stretch, volume expansion or pressure overload of the myocytes. BNP has been shown to have a sensitivity of 90 percent and a specificity of 74 percent for detection of CHF. BNP is elevated in systolic and diastolic dysfunction. Indications for BNP testing BNP has been shown to help discriminate between cardiac and noncardiac causes of acute dyspnea when the diagnosis is uncertain. One of the most useful clinical aspects of BNP is that it has a very high

The Triangle Physician

negative predictive value. The negative predictive value of a normal BNP for the diagnosis of heart failure is approximately 94 percent. Therefore in most clinical situations, a normal BNP essentially excludes significant CHF. BNP levels can also be useful in guiding inpatient or outpatient therapy of CHF. Of course, the use of serial BNP measurements to monitor the clinical course of a patient provides a more reliable guide to management than a single isolated measurement. BNP levels correlate with prognosis in CHF, as higher levels are associated with higher morbidity and mortality, including sudden cardiac death. Recent studies have shown that BNP can also serve as a prognostic marker for outcomes in acute coronary syndrome, heart failure and cardiac surgery. Limitations of BNP testing BNP may be elevated in several non-cardiac conditions, including renal failure, cirrhosis, pulmonary embolism, pneumonia, myocarditis and pulmonary hypertension. BNP levels may be falsely low in obese patients. BNP levels cannot distinguish systolic from diastolic heart failure. Some patients with chronic, severe CHF may have persistently elevated BNP levels, so monitoring levels in these patients may not be useful in guiding management. In conclusion, BNP is a quick, relatively inexpensive test that can aid in the diagnosis and prognosis of CHF. BNP testing is indicated in patients suspected of having CHF when the diagnosis is uncertain. A normal BNP level is particularly useful for excluding CHF due to its high negative predictive value. BNP levels also have prognostic and therapeutic monitoring value.

YOUR LOCAL CARDIOLOGY PROFESSIONALS IN JOHNSTON COUNTY DEDICATED TO QUALITY, SERVICE, AND INTEGRITY Ravish Sachar, MD, FACC Coronary and Peripheral Vascular Intervention

Mateen Akhtar, MD, FACC

Benjamin G. Atkeson, MD, FACC

Matthew A. Hook, MD, FACC

Eric M. Janis, MD, FACC

Matthew S. Forcina, MD

Christian N. Gring, MD, FACC

Diane E. Morris, ACNP

Nyla Thompson, PA-C

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

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, Cardiac Catheterization

THE HIGHEST QUALITY CARDIOVASCULAR CARE, CLOSE TO HOME.

We Know How To Exceed Your Imaging Expectations.

Dr. William G. Way Jr. | PET·CT Specialist

Wake Radiology’s PET·CT Services are ready when you and your patients need us. Patients and caregivers can pull right up to our door, with check-in just a few steps away. Our PET suite, with its glorious picture windows, is calming, and our experienced staff inspire confidence. You’ll have results in record time, and you’ll find us readily available for physician-decision support. One-call scheduling

makes us even more convenient—919-232-4700. Wake Radiology PET·CT Services. The future is now. If you haven’t received your PET·CT scheduling starter kit, please call us at 919-854-2190. 2010 YEAR-ROUND PARTNER

300 Ashville Avenue, Ste 180 | Cary, NC 27518 | Scheduling: 919-232-4700 | wakerad.com