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Rex Neurosurgery & Spine Specialists Rex Healthcare Expands Neurosurgical Services with a New Practice and Three of the Triangle’s Top Neurosurgeons
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Also in This Issue
Autism Fecal Incontinence
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COVER STORY
6
Rex Neurosurgery & Spine Specialists Rex Healthcare Expands Neurosurgical Services with a New Practice and Three of the Triangle’s Top Neurosurgeons
AP r i l 2 0 1 3
Vol. 4, Issue 3
FEATURES
12
Urogynecology
New Treatment Is More Reason to Ask Women About Bowel Control Problems Dr. Catherine Matthews urges awareness of a condition that impacts quality of life and requires improved treatment.
15
Neuropsychiatry
Autism Awareness Is Needed to Help Remedy Public Misconceptions Dr. Sandeep Vaishnavi discusses social cognition dysfunction, promising research and possible treatments. COVER PHOTO: Grant Buttram, M.D., Robert Lacin, M.D. and Robin Koeleveld, M.D. bring over 50 years of combined experience to Rex Neurosurgery & Spine Specialists, now open on Lake Boone Trail in Raleigh.
DEPARTMENTS 9 Community Service
18 Duke Research News
Stomp the Monster: Local NonProfit Takes Financial Burdens Off of Cancer Patients
Obesity in Dads May Be Associated with Offspring’s Risk of Disease
10 Endocrinology
19 UNC Research News
Incidence and Advances in Diagnosis and Treatment of Thyroid Nodules
Research Needed on Interventions for Children Exposed to Traumatic Events
11 Practice Marketing
20 UNC Research News
Patient Communications: An Integral Part of Your Marketing Strategy
Steroids Help Reverse Process Involved in Rapid Bone Loss
16 Duke Research News
Promising Stem Cell Blood Test May Be a Sight-Saving Breakthrough
Bullied Children Can Suffer Lasting Psychological Harm as Adults
17 Duke Research News Growth Factor Aids Stem Cell Regeneration After Radiation Damage
22 UNC Research News
24 News
- Carolina Endocrine Open House - Welcome to the Area and Upcoming Events April 2013
3
From the Editor
Brains with Heart This month’s cover story in The Triangle Physician on Rex Neurosurgery & Spine Specialists does an excellent job of introducing the new practice and conveying the world-class, comprehensive care now
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
available. Its leading men, however, hardly need an introduction. Grant Buttram, M.D.; Robin Koeleveld, M.D.; and Robert Lacin, M.D., have been performing back, neck, cranial and peripheral nerve procedures for many years as partners with Raleigh Neurosurgical Clinic. Perhaps most compelling within the article is the genuine compassion and professional enjoyment that shines through in quotes and the powerful effect that has on boosting the patient confidence. “We are all great surgeons, but we are also great doctors; we don’t just operate with our hands, but with our hearts and brains, as well,” says Dr. Lacin. This month’s columnists personify brains with heart. Urogynecologist Catherine Matthews enlightens readers on the prevalence of fecal incontinence – the causes, the urgent need to develop better treatment options and the hope offered by a clinical trial now under way. Sandeep Vaishnavi explores the growing spectrum of autism disorders and
Editor Heidi Ketler, APR
heidi@trianglephysician.com
Contributing Editors Amanda Kanaan Catherine A. Matthews, M.D. Michael J. Thomas, M.D., Ph.D. Sandeep Vaishnavi, M.D., Ph.D. Photography Mark Jacoby Creative Director Joseph Dally
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promising cognitive neuroscience research. Readers of The Triangle Physician will remember the January cover story on Carolina Endocrine P.A., the practice of Michael Thomas. This month, Dr. Thomas returns with a comprehensive overview of the diagnosis and treatment of malignant and benign thyroid
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nodules. His column informs, while reinforcing his expertise and concern that patients receive the most appropriate and high-quality patient care. Practice marketing expert Amanda Kanaan returns every issue to share the latest best practices. This issue she conveys tips for maintaining cost-effective communication with
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existing patients, who are an important referral source. Indeed, heart and soul are alive and well in the Triangle. So consider sharing instances where yours has shined through, either in a column or news release, which The Triangle Physician publishes at no charge to the contributor. Advertising also makes a lot of sense, with our highly competitive rates and exclusive coverage area. So if your marketing brains want to turn your practice message into referrals and clients, put The Triangle Physician’s brawn to work for you. Contact me at heidi@trianglephysician.com. With gratitude and respect for all you do,
Heidi Ketler Editor
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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. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. 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.
Cover
Rex Neurosurgery & Spine Specialists Rex Healthcare Expands Neurosurgical Services with a New Practice and Three of the Triangle’s Top Neurosurgeons Rex Healthcare has expanded its neu-
Grant Buttram Jr., M.D.; Robin Koeleveld,
patients with brain and spine cancers. “I
rological services with the addition of a
M.D.; and Robert Lacin, M.D., have been
really enjoy all aspects of general neuro-
new practice consisting of three of the
performing back, neck, cranial and pe-
surgery, but particularly like the challenge
Triangle’s top neurosurgeons. The newly
ripheral nerve procedures at Rex Hospital
of spine and brain tumor surgeries. In
established Rex Neurosurgery and Spine
for many years as partners with Raleigh
fact, one of my motivations in starting this
Specialists opened its doors this January,
Neurosurgical Clinic. Now as partners of
practice was the opportunity to perform
enhancing care for patients with routine
Rex Neurosurgery and Spine Specialists,
more brain tumor surgeries, in conjunc-
and complex spine problems, brain tu-
these leading neurosurgeons will have the
tion with both Rex Cancer Center and the
mors and other neurological ailments. Al-
unique ability to collaborate with the on-
UNC Department of Neurosurgery,” says
though the practice itself is new, the phy-
cologists at Rex Cancer Center, as well as
Dr. Koeleveld.
sicians share almost 50 years of combined
specialists at the University of North Caro-
experience and are well renowned in the
lina Department of Neurosurgery.
Dr. Buttram says working with cancer patients offers some of the most gratifying
region for offering the latest neurosurgical techniques combined with compassion-
The collaboration with Rex Cancer Cen-
experiences of his career. “I perform mis-
ate patient care.
ter will enhance treatments available for
sion work in Nicaragua and these patients, just like cancer patients, are so pleasant to work with, because they expect nothing yet appreciate everything.” By collaborating with Rex Cancer Center and the UNC Department of Neurosurgery, Rex Neurosurgery and Spine Specialists is able to provide more patients in Wake County and across Eastern North Carolina with greater access to comprehensive neuro-oncology treatments, novel therapies and clinical trials, including personalized, genetic medicine. “This partnership allows Rex Healthcare to expand the neuro-oncology services
Grant Buttram Jr., M.D., earned undergraduate degrees in animal science and chemistry, as well as a master’s degree in physiology from North Carolina State University. He graduated from East Carolina University School of Medicine and completed his internship, residency and fellowship at University of Tennessee at Memphis/Semmes-Murphey Neurologic & Spine Institute. Dr. Buttram completed a fellowship in complex and minimally invasive spine surgery, and his specialties include: general neurosurgery; brain, spine and spinal cord tumors; complex spine instrumentation; cervical and lumbar spine disease; minimally invasive spine techniques; peripheral nerve disorders; and scoliosis.
6
The Triangle Physician
we provide by offering patients three disciplines – medical oncology, radiation oncology and neurosurgery – all in one location and without leaving Wake County,” says Linda Butler, M.D., chief medical officer of Rex Healthcare. The new practice
ed morbidity, i.e. a muscle-sparing technique versus muscle dissecting. Dr. Buttram, who completed a fellowship in complex and minimally invasive spine surgery at the renowned SemmesMurphey Neurologic and Spine Institute at University of Tennessee at Memphis, says there are many benefits to this technique. “Less muscle trauma means less blood loss, a lower risk of infection, less cost and a faster return to work for patients,” says Dr. Buttram, who trained under Dr. Kevin Foley – considered the pioneer of minimally invasive spine surgery. Robin Koeleveld, M.D., earned his undergraduate degree in chemistry from Harvard University. He graduated from the Columbia University College of Physicians and Surgeons and completed his internship and residency at Tufts-New England Medical Center. Dr. Koeleveld completed post graduate training in cervical, lumbar and thoracolumbar spine stabilization, and his specialties include: general neurosurgery, aneurysms, brain tumors and spine surgery.
Minimally invasive spine surgery differs from traditional, open spine surgery in that it only requires a small incision, muscle dilation and the use of microsurgi-
also now allows the hospital to provide
Dr. Koeleveld adds that each of the three
cal techniques to access, view and repair
the community with 24/7 neurosurgical
surgeons enjoys his specialty so much
spinal deterioration or damage. Muscle
coverage for emergency situations.
that patients take notice, and it actually
dilation involves the use of small tubular
becomes a source of comfort for them as
retractors that are inserted sequentially –
they recognize the passion each doctor
smaller to larger – through the muscle to
has for his craft.
gently and gradually separate, rather than
Skilled Surgeons, Compassionate Doctors Although it’s important to provide the pa-
cut or strip the muscles that surround the
tients of Wake County greater access to
Dr. Buttram says his practice philoso-
spine. The system’s retractor tubes main-
the latest in neurosurgical care, what re-
phy revolves around taking conservative
tain the opening while the surgeon uses
ally makes Rex Neurosurgery and Spine
measures to ensure patients only pursue
specially designed surgical tools to reach
Specialists unique are the surgeons them-
surgery if absolutely necessary – an ap-
and remove spinal elements that are caus-
selves. Each boasts an impressive resume
proach most surgeons aren’t known for.
ing pain.
with training from some of the top aca-
“I like to see people get better without
demic centers in the world. But ask any of
surgery if possible,” says Dr. Buttram, who
Minimally invasive spine surgery can be
them why they love what they do, and it
usually puts his patients through a series
utilized to treat chronic back and neck
all comes back to the patients. “We are all
of conservative therapies first before even
pain, and pain in the arms and legs as-
great surgeons, but we are also great doc-
considering surgery.
sociated with degenerative disc disease
tors; we don’t just operate with our hands,
and structural pathology. Unless it’s an
but with our hearts and brains, as well,”
From physical therapy, epidural steroid in-
extensively complex procedure, most
says Dr. Lacin, who believes that having
jections and traction to chiropractic treat-
spine conditions can be treated with
a close relationship with the patient and
ment and even acupuncture, Dr. Buttram
minimally invasive approaches, accord-
being able to counsel the family is part of
would rather see his patients try and fail
ing to Dr. Buttram.
what makes a great surgeon.
these initial therapies than head straight to surgery without being given another
Dr. Koeleveld seconds this notion: “These
option.
patients are among the most grateful and
Common Spine and Neurological Conditions The physicians at Rex Neurosurgery and
rewarding patients you can imagine. They
Minimally Invasive Spine Surgery
Spine Specialists treat more than 600
come to us very apprehensive and scared.
When most think of the phrase “minimally
forms of neurologic conditions that im-
We have the opportunity to counsel the
invasive,” they relate it to smaller surgical
pact patients in such ways as decreased
family and help them deal with the ill-
incisions. In this case, minimally invasive
mobility, difficulty speaking or learning or
ness.”
spine surgery refers to the approach-relat-
challenges with memory or mood.
April 2013
7
Neurological Conditions • Aneurysms • Carpal tunnel syndrome • Brain and pituitary tumors • Nerve disorders and injuries • Cerebral hemorrhage • Hydrocephalus • Radiculopathies • Trigeminal neuralgia • Vascular abnormalities of the brain
Spine Conditions • Disc disease • Neck and low back pain • Spinal cord tumors • Scoliosis • Vascular abnormalities of the spine Robert Lacin, M.D., graduated from the University of Lausanne Medical School in Switzerland. He completed his internship at St. Vincent’s Hospital in New York and residencies at Northwestern Memorial Hospital and Duke University Medical Center. Dr. Lacin completed fellowships at Lausanne Medical School and New York University Medical Center. His special interests include: general intracranial surgery; decompressive and reconstructive spine surgery; and decompressive and reparative peripheral nerve surgery.
The physicians at Rex Neurosurgery and Spine Specialists value their relationships with referring doctors and therefore are happy to accommodate patients that need to be worked into their schedules.
Some of these conditions can be difficult
• Reduced bladder control, or sexual dis-
“Anytime a physician needs a patient seen
to diagnose because they may present
turbance, associated with the above.
right away, they can just call us, and we’ll
as normal signs of aging. One condition
get them in either the same or next day,”
in particular that is sometimes misdiag-
Early diagnosis and treatment is important
nosed early on is cervical spondylotic my-
for CSM in order to help slow symptom
elopathy, or CSM.
progression. Cervical spine X-rays may
If the referral is of an urgent nature, Dr.
not provide enough information to con-
Lacin says he likes to involve the referring
CSM is the most common spinal cord dis-
firm CSM, but it may rule out other condi-
doctor. “I will personally call the referring
order in persons more than 55 years of
tions.
doctor if the patient has an urgent condi-
age in North America and perhaps in the
says Dr. Koeleveld.
tion to have them participate in the pa-
world. The aging process results in degen-
The best diagnostic test for CSM is mag-
erative changes in the cervical spine that,
netic resonance imaging, since they will
in advanced stages, can cause compres-
show the tight spinal canal and pinching
From minor procedures to more complex
sion of the spinal cord.
of the spinal cord. Surgery can be per-
spine surgeries and brain tumor resec-
formed to remove the pressure from the
tion, the physicians at Rex Neurosurgery
Signs of CSM:
spinal cord and prevent progression of
and Spine Specialists care for the full
• Deterioration of fine motor skills (such
symptoms.
range of patients’ needs by offering world-
as handwriting or buttoning a shirt). • Gait disturbance (bilateral uncertainty
tient’s care,” says Dr. Lacin.
class care close to home. “Because the symptoms of CSM can present so slowly or just seem like typical
Rex Neurosurgery and Spine Specialists
• Heavy feeling in the legs.
signs of aging, it’s important for patients to
is located at 4207 Lake Boone Trail, Suite
• Unable to walk at a brisk pace.
have an MRI early on, so the diagnosis is
220, across the street from the Rex Well-
• Feelings of numbness, tingling, pins
made as soon as possible and the symp-
ness Center on Lake Boone Trail in the
toms don’t progress,” says Dr. Koeleveld.
Rexwoods II building. To learn more, visit
when walking blindfolded).
and needles or shooting pain in the arms and/or legs when bending
www.rexneurosurgery.com. For referrals,
the head backward or far forward
To follow are other common conditions
(known as Lermitte’s phenomenon).
for which physicians refer to Rex Neurosurgery and Spine Specialists.
8
The Triangle Physician
call (919) 784-1410.
Community Service
STOMP the Monster
Local Non-Profit Takes Financial Burdens Off of Cancer Patients STOMP The Monster is a charitable organization providing financial and personal support for cancer patients, their families and caregivers when they need it most: during their battle with the disease. Recently, the motivated and dedicated group extended its great works to North Carolina. In October 2012, STOMP The Monster North Carolina was formed after chapter co-founder Susan Blumenthal, a physician’s assistant in a Cary oncology office, saw firsthand how easy it was for cancer patients to slip into financial distress. “I felt my patients had enough to deal with,” said Ms. Blumenthal. “To see them struggle with paying for medications – or worse, their family’s groceries – was just heartbreaking. Some didn’t have jobs or care for their children. They shouldn’t have those extra stresses while fighting the battle of their lives.” Working with her friend Andi Sawin, a founding board member of STOMP The Monster based out of New Jersey, Ms. Blumenthal brought the successful organization to the Triangle. STOMP The Monster was founded in 2010 by Seth Grumet of Marlboro, N.J., after he underwent his own treatment for Hodgkin’s Lymphoma. According to a press advisory, “when Mr. Grumet endured extensive testing, surgeries and chemo therapy, he saw
how quickly this monstrous disease could turn one’s world upside down. He was fortunate to have family and friends supporting him through this most difficult time, but he realized not every cancer patient is so fortunate. He saw so many struggling with financial and household hardship on top of their health issues.” Motivated by his 10-year-old daughter’s mantra to “stomp his cancer monster,” Mr. Grumet came up with a plan to raise money for these fellow cancer patients in need. Since then, STOMP The Monster of New Jersey and North Carolina has assisted 400-plus patients in five states with medical bills, prescriptions, utility bills, rent, gas, food, childcare, to name a few, anything that will help make their life easier. STOMP The Monster NC is a volunteeroperated organization that hosts events around the Triangle and seeks charitable contributions to fulfill local patient requests for assistance. All donations received stay in North Carolina and approximately 95 percent of the money raised goes directly to the patients. The advisory listed a few examples of how STOMP The Monster NC has helped North Carolinians: • K.F. is a 33 year old from Cary, N.C., with metastatic gastric cancer. She has been undergoing treatment for the past year
and is unable to work. She lives alone with support of her family but cannot pay all her bills. STOMP The Monster NC is paying her car and homeowners’ insurance for the next year to take away the stress of making those monthly payments. • R.B. from Garner, N.C., is 38 years old with colon cancer. He is a husband and father of three young children – one who was born during his second month of chemotherapy. Early in his treatment he was out of work, but he returned to work the night shift to help pay for his treatment and care for his family. STOMP The Monster NC paid off Mr. Brown’s medical bills and provided a holiday gift card to help make the season a little nicer for his family. • S.B. is a 54 year old from Raleigh, N.C., undergoing aggressive chemotherapy and radiation protocol for colon cancer. Both she and her husband are unemployed. She is fortunate to have COBRA insurance, but struggles with the premiums and additional medical expense from three hospitalizations and two surgeries. STOMP The Monster NC provided financial assistance to pay for her pathology bills, co-pays for radiological studies, and co-pays for her chemotherapy.
April 2013
9
Endocrinology
Incidence and Advances in Diagnosis and Treatment of
Thyroid Nodules The advent of numerous imaging techniques, including neck ultrasound, carotid Doppler and neck computed tomography or magnetic resonance imaging, has led to an increase in the incidental discovery of subclinical thyroid nodules that were not previously noted on physical examination. Thyroid nodules are quite common, and the incidence increases with increasing age. The risk of a thyroid nodule-containing cancer is approximately 5-15 percent, depending on age, gender, family history or a history of neck irradiation. Size and number of nodules do not seem to influence the risk of thyroid cancer in any single nodule, although other sonographic features, such as irregular borders or microcalcifications, can increase the risk of a nodule being malignant. Initial evaluation of thyroid nodule(s) should include measurement of serum TSH (thyrotropin/thyroid stimulating hormone) to determine whether a patient is hyperthyroid. A suppressed TSH usually indicates hyperthyroidism, which may be associated with an elevated free T4 (thyroxine) and/ or Free T3 (triiodothyronine). Hyperthyroid nodular thyroid disease occurs with toxic multinodular goiter or hyperfunctioning (toxic) adenoma, whereas non-hyperthyroid nodular disease may occur in nontoxic multinodular or uninodular goiter, or autoimmune (Hashimoto’s) thyroiditis. If a patient has hyperthyroidism, a nuclear medicine thyroid scan may be performed to confirm the presence of hyperfunctioning, or “hot,” nodules or photopenic, or “cold,” nodules. “Hot” nodules are rarely malignant, whereas a “cold” nodule on hyperthyroid nuclear medicine scan carries an approximate 20 percent chance of malignancy and should be evaluated by
10
The Triangle Physician
fine needle aspiration (FNA) biopsy. Therapeutic options for toxic multinodular goiter and hyperfunctioning nodules include radioiodine (I-131) therapy, thyroidectomy or lifelong anti-thyroid drug therapy (e.g. methimazole). If a patient has a thyroid nodule and a normal or elevated TSH, then a FNA biopsy should be considered to see whether there is any evidence of malignancy. Thyroid nodules that are greater than 1 centimeter in size should be considered for FNA biopsy, whereas smaller nodules may be watched or biopsied, if they harbor any sonographic features worrisome for malignancy. FNA biopsy can be done under ultrasound guidance, particularly if the nodule is small. Three to four passes are often done, using a 25-27-gauge needle, and cellular aspirates are prepared on microscope slides or into saline solution for cytopathological analysis. The procedure usually takes less than 15 minutes, and complications are rare. FNA thyroid biopsy results usually fall into one of four broad categories: cancer; suspicious, e.g. follicular neoplasm; benign; or non-diagnostic. Patients with malignant thyroid nodules should undergo a total thyroidectomy, often with lymph node dissection, particularly if lymphadenopathy is noted on a pre-op ultrasound. Benign nodules may be followed sonographically to note whether there is any evolution or progression in size and may warrant re-biopsy, if a “false-negative” cytopathology result is suspected. Non-diagnostic FNA biopsies may be re-attempted. Suspicious nodules may need to be surgically removed for pathologic examination and definitive diagnosis, or some new molecular diagnostic tests (e.g. Veracyte Afirma, Asuragen mIRinformm) can further risk-stratify the
By Michael J. Thomas, M.D., Ph.D.
Dr. Michael Thomas of Carolina Endocrine P.A. graduated from the School of Medicine at West Virginia University in Morgantown, with a Doctor of Medicine and Doctor of Philosophy in pharmacology and toxicology. He completed his post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency, and fellowship in endocrinology. He was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. Dr. Thomas established Carolina Endocrine in the summer of 2005. He is board certified in internal medicine and endocrinology, and is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology (FACE) and has completed endocrine certification in neck ultrasound (ECNU). For more information and patient referrals and appointments call (919) 571-3661 or visit the practice website at carolinaendocrine.com
likelihood of malignancy vs. benign follicular lesions. Thyroid hormone suppressive therapy with levothyroxine may be considered, if the patient has any compressive symptoms (dysphagia, fullness, pressure) or cosmetic concerns, as long as the patient does not have a suppressed TSH. Levothyroxine dose is titrated upward to bring the TSH into the lower range of normal. Approximately, 50 percent of nodules may have some modest reduction in size (about 10-30 percent) over a period of several months, but therapy needs to be continued indefinitely or until the patient desires surgery. If the patient is asymptomatic, benign nodules may be monitored without therapeutic intervention.
Practice Marketing
Patient Communications
An Integral Part of Your Marketing Strategy By Amanda Kanaan
You may not traditionally think of patient communication tools such as blogs and e-newsletters as a marketing tactic, but staying top of mind with current patients is an integral part of attracting new business – not to mention it can also result in increased patient satisfaction. Doctors often tell me that one of their most fruitful sources of new patients is referrals from current patients. That means it’s important not to neglect your current patients when deciding where to spend your marketing dollars. The good news is that marketing to current patients is often the most costeffective form of marketing, because it can be achieved through strategies as simple as improved communications. Some examples of ways you can utilize these communications include: • Enhancing patient satisfaction by sending timely updates about early closings due to inclement weather, • Increasing repeat business by informing patients of other services your practice offers, or • Positioning yourself as the medical expert by sharing or commenting on recent health news and articles. To follow is a three-step process for communicating one message or article across three different channels to save time and costs when marketing to current patients. Step 1 – Write a Blog Post: I recommend that every practice incorporate a blog into their website. Most practices title their blog something along the lines of “News and Updates”
and will have their most recent posts listed on the homepage. It’s a quick and easy way to get a message to your patients, add fresh content to your site, feature services and even share educational articles. It’s also really good for your search engine optimization (SEO) efforts to enhance your Google rankings. The average blog should be about 400 words in order to get the full benefit from SEO. Read articles online to learn how to optimize your blog with proper keywords. Or you can always hire an SEO agency to do it for you. Step 2 - Social Media: Once you’ve written your blog news/ article, you can then post a link to the blog on your social media pages to act as a megaphone for announcing the message. Use social media to engage patients in the content and most importantly, get them talking about it. According to a Pew Internet Survey, 50 percent of all adults use social media; the fastest growing age segment of which is 50 to 64 years of age. This is one of your most affordable and effective tools to spread the word to your target audience. You can even ask your peers to post it as well. For instance, if you are an infertility clinic, ask the obstetrics clinics you’ve befriended on Facebook to post your blog link. Just be sure you’re willing to return the favor. Step 3 - E-Newsletter: So once you’ve written your blog and posted it on your social media channels, then the third step is to include it in an
Amanda Kanaan is the president of WhiteCoat Designs – a Raleigh-based medical marketing agency providing doctors with online marketing services as medical website design, search engine optimization (SEO), social media management, blog writing, graphic design, referring physician outreach and more. To contact Ms. Kanaan or to learn more about WhiteCoat Designs, visit www. whitecoat-designs.com.
e-newsletter to your patients. If you currently aren’t collecting e-mail addresses for patients, you should start. Email addresses are invaluable when it comes to using digital communications to stay top of mind with your patients. Not to mention, it’s something patients want. In fact, 65 percent of patients who use the Internet say they are willing to switch to a doctor using digital communications to engage them (Pew Internet Research Group, 2011). Using this three-step process, you can take just one piece of content and deliver it across various mediums to get the most impact for your efforts. While each of these methods is extremely inexpensive, I always caution practices against thinking they are free. There is definitely time involved to carry out this strategy, and we all know time is not free. However, as compared to relying on traditional snail mail, a digital approach is much more budget-friendly, time-sensitive and preferred by most patients.
April 2013
11
Urogynecology
New Treatment Is More Reason to Ask Women About
Bowel Control Problems By Catherine A. Matthews, M.D.
Accidental bowel leakage, or fecal incontinence, is a common but largely silent problem in women’s health. Embarrassment surrounding the condition and a lack of successful treatment options has limited public awareness and prevented patients and doctors from discussing the condition.
Forceps-assisted vaginal delivery is consistently identified as a major risk factor for anal sphincter injury, the muscle involved in voluntary bowel control. Many women who sustain a severe perineal laceration during vaginal childbirth may suffer from fecal urgency and accidental bowel leakage at a young age.
Recent general population surveys indicate the prevalence of fecal incontinence (FI) at 9 percent to 12 percent and in older women, as high as 24 percent.1,2,3 This translates into as many as 17 million women in the United States who are suffering from FI.
Women with irritable bowel syndrome (IBS) may also experience FI as one of the symptoms of their condition.
While traditionally thought of as a condition that only afflicts the elderly, perhaps the most surprising finding in recent studies is the high prevalence in younger women. The onset of symptoms often occurs in the 40s, 50s and 60s, and sometimes younger, with the average age of onset being 51. At any age, the condition is both physically limiting and emotionally devastating. Those afflicted are often forced to withdraw from social and professional activities and often face problems in their private personal relationships.
The damage that may lead to FI and other bowel control issues can involve the internal and external anal sphincters, pelvic floor muscles and associated nerves. Symptoms from damage sustained during childbirth may not manifest until later in life, when their emergence is possibly due to age-related changes in rectal sensation, compliance and volume, as well as general weakening of the sphincters and pelvic floor muscles. As the cause to FI is often complex and poorly understood, it has been difficult to develop effective treatments. Existing treatment options have had limited success, and include dietary modification with increased fiber, physical therapy, surgery and surgical device implants.
Cause and Treatment The causes of FI are likely multifactorial but are not completely understood. Many women with FI have a history of damage to the pelvic region caused by pregnancy and childbirth and additionally may have changes to the muscles in this area associated with aging.
12
The Triangle Physician
Dr. Catherine Matthews is an associate professor at University of North Carolina Department of Obstetrics and Gynecology and director of UNC Pelvic Health. She earned her medical degree from the University of Virginia, where she served as president of the medical honor society, Alpha Omega Alpha, and graduated valedictorian of her class. Dr. Matthews completed her residency and specialty training in obstetrics and gynecology and urogynecology at Virginia Commonwealth University Medical Center, where she served on the faculty from 2001-2010. Voted into “Best Doctors in America,� Dr. Matthews has dedicated her career to improving the quality of life for women who suffer from the potentially embarrassing conditions of urinary and bowel incontinence and pelvic organ prolapse. Dr. Matthews is nationally and internationally recognized for her expertise in robotic surgery for pelvic floor reconstruction and the repair of complicated genito-urinary fistulae. She also has an interest in the management of sexual dysfunction in postpartum women, anal sphincter repair and defecation disorders. For more informa-
Without good treatment options, many women with bowel control problems are resigned to coping with the condition in silence using products, such as pads and adult diapers.
tion visit www.UNCpelvichealth.org or call 919-966-2131.
New Investigational Option Recognizing the limitations of available treatments, I am a member of a select
group of physicians across the United States who are studying LivSure, a new intra-vaginal bowel control device developed for treating FI in women. It originated at Stanford University as part of a joint development effort between Stanford engineers and physicians.
April is Autism Awareness Month.
1 of every 70 North Carolina children will be diagnosed with a form of autism.
The investigational device is non-surgical and therefore avoids many of the risks and complications of more invasive treatments. Placed intra-vaginally, it resides in a similar position as a diaphragm. It consists of a flexible ring with an inflatable balloon that compresses the rectum through the vaginal wall. The device can easily be removed at any point, so patients can try the treatment as a first option with little long-term risk. Initial results from clinical evaluations have been promising. As overcoming social stigma regarding this distressing disease state is still an issue, improved efforts at disease identification are ongoing. Practitioners treating women with other pelvic floor disorders, namely urinary incontinence and pelvic organ prolapse, should be aware that fecal incontinence is a common comorbid medical condition. Many women may be too embarrassed to bring this to their health care provider’s attention, therefore routinely inquiring about it as a specific entity is paramount.
The Autism Society of North Carolina is your partner in improving patient care by providing training workshops for medical professionals. For more information, please visit www.autismsociety-nc.org or call 919-743-0204, ext. 1501.
Partnering with patients and providers for a healthier community.
References harucha et al. Prevalence and B burden of fecal incontinence: a population-based study in women. Gastroenterology 2005;129:42-49. 2 Varma et al. Fecal incontinence in females older than aged 40 years: who is at risk? Dis Colon Rectum. 2006 June; 49(6): 841-851. 3 Nygaard et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008; 300(11):13111316. 1
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14
The Triangle Physician
Neuropsychiatry
Autism Awareness Is Needed to Help Remedy Public Misconceptions By Sandeep Vaishnavi, M.D., Ph.D.
Autism is a neurodevelopmental disorder of increasing interest to the public, partly because of rising numbers. There has been a steady increase in the estimated prevalence of autism, now up to one out of every 88 live births in the United States. There is controversy as to whether this is truly an increase in the disease, or rather, if this is reflective of better surveillance or perhaps more liberal diagnostic criteria. Autism can be thought of as a spectrum of disorders, as opposed to a unitary disorder. There has been recent controversy with the upcoming publication of the updated Diagnostics and Statistics Manual (DSM-V), because Asperger’s Syndrome will be incorporated into the autism diagnosis. Currently, Asperger’s is listed separately. The updated DSM will reflect the current consensus in the field, which is that autism symptoms range from mild (like with Asperger’s) to severe, with intellectual disability and seizures. Autism spectrum disorders tend to have three core constellations of symptoms: dysfunction with social cognition, language abnormalities and repetitive thoughts and behaviors. Autism may be thought of at the most fundamental level as a disorder of social cognition. There is often poor eye contact, little interest in socializing with peers and more interest with things and machines than with people. Language difficulties are also part of autism spectrum disorders. People with severe autism may not develop language
at all. Those that do develop language may speak in a monotonous, robotic way. There is little inflection or prosody. Even mild autistic patients may have problems with the pragmatics of language, the social communication that language facilitates. For example, they may not evidence any interest in the thoughts or interests of others. They may tend to talk too much about particular interests of their own and not know when to stop talking. Finally, autism spectrum disorder patients may have repetitive thoughts and behaviors. They may have motor stereotyped behavior, such as toe walking, hand flapping or head banging. They may be preoccupied with narrow interests, such as train or plane schedules, or World Series statistics. Autistic patients may have an “obsessive need for sameness,” such that they cannot tolerate very well any deviation from their established routine. Mood and anxiety symptoms are quite commonly comorbid. Obsessive and compulsive symptoms are, as we have seen, often a key component of autism. These symptoms are amenable to treatment with medications. The core symptom of social cognitive dysfunction, though, is not treatable at this time. However, there are promising studies with oxytocin and arbaclofen for this core feature of autism. There is data that early intervention with intensive therapies can be helpful in modifying the severity or trajectory of the illness.
Dr. Sandeep Vaishnavi is the director of the Neuropsychiatric Clinic at Carolina Partners. He has been trained at Johns Hopkins and Duke Universities and is board certified in behavioral neurology and neuropsychiatry, as well as general psychiatry. His doctorate is in cognitive science, with specialization in cognitive neuroscience. For more information, visit www.carolinapartners.com or call (919) 929-9610 or (877) 876- 3783 toll free.
To diagnose autistic spectrum disorders properly, it may be helpful to refer to specialists, like neuropsychiatrists, who have training in aspects of both neurology and psychiatry. They can help in consulting for medication management as well. In some cases, agitation and aggression can be part of the clinical picture and so consultation for management can be helpful in those cases. General psychiatrists and neurologists also can help with diagnosis and management. There is much research on the neurodevelopmental basis of autism. Social cognition is a relatively new area of cognitive neuroscience research, and much needs to be learned about how our brains allow us to generally interact with others in a fluid, engaging way. Hopefully, this research will allow us soon to provide more help for the core symptoms of our autistic patients.
April 2013
15
Duke Research News
Bullied Children Can Suffer Lasting Psychological Harm as Adults Bullied children grow into adults who are
A previous longitudinal study of bullied chil-
ed being bullied at least once; 887 said
at increased risk of developing anxiety dis-
dren, conducted in Finland, found mixed
they suffered no such abuse. Boys and
orders, depression and suicidal thoughts,
results, concluding that boys had few lasting
girls reported incidents at about the same
according to a study led by researchers at
problems, while girls suffered more long-
rate. Nearly 200 youngsters, or 9.5 percent,
Duke Medicine.
term psychological harm. That study, how-
acknowledged bullying others; 112 were
ever, relied on registry data in the health
bullies only, while 86 were both bullies and
The findings, based on more than 20 years
system that didn’t fully capture psychiatric
victims.
of data from a large group of participants ini-
records. Of the original 1,420 children, more than
tially enrolled as adolescents, are the most definitive to date in establishing the long-
Dr. Copeland and colleagues had a much
1,270 were followed up into adulthood.
term psychological effects of bullying.
richer data set. Using the Great Smoky
The subsequent interviews included ques-
Mountain Study, the research team tapped
tions about the participants’ psychological
Published online Feb. 20 in JAMA Psychia-
a population-based sample of 1,420 chil-
health.
try, the study belies a common perception
dren ages 9, 11 and 13 from 11 counties in
that bullying, while hurtful, inflicts a fleeting
western North Carolina. Initially enrolled in
As adults, those who said they had been
injury that victims outgrow.
1993, the children and their parents or care-
bullied, plus those who were both victims
givers were interviewed annually until the
and aggressors, were at higher risk for psy-
“We were surprised at how profoundly bully-
youngsters turned 16, and then periodically
chiatric disorders compared with those
ing affects a person’s long-term functioning,”
thereafter.
with no history of being bullied. The young people who were only victims had higher
said William E. Copeland, Ph.D., assistant clinical professor in the Department of Psychiatry
At each assessment until age 16, the child
levels of depressive disorders, anxiety dis-
and Behavioral Sciences at Duke University
and caregiver were asked, among other
orders, generalized anxiety, panic disorder
and lead author of the study. “This psycho-
things, whether the child had been bullied
and agoraphobia.
logical damage doesn’t just go away because
or teased or had bullied others in the three
a person grew up and is no longer bullied.
months immediately prior to the interview.
Those who were both bullies and victims had higher levels of all anxiety and depres-
This is something that stays with them. If we can address this now, we can prevent a whole
A total of 421 child or adolescent partici-
sive disorders, plus the highest levels of
host of problems down the road.”
pants – 26 percent of the children - report-
suicidal thoughts, depressive disorders,
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16
The Triangle Physician
Duke Research News generalized anxiety and panic disorder.
Jane Costello, Ph.D., associate director of re-
In addition to Drs. Costello and Copeland,
Bullies were also at increased risk for anti-
search at Duke’s Center for Child and Family
study authors include Adrian Angold, M.D.,
social personality disorder.
Policy. “Bullying, which we tend to think of
of Duke and Dieter Wolke, Dipl.-Psych.,
as a normal and not terribly important part
Ph.D., of the University of Warwick, Coven-
The researchers were able to sort out con-
of childhood, turns out to have the potential
try, England.
founding factors that might have contrib-
for very serious consequences for children,
uted to psychiatric disorders, including pov-
adolescents and adults.”
The work received support from the National Institute of Mental Health (MH63970,
erty, abuse and an unstable or dysfunctional home life.
Drs. Costello and Copeland said they would
MH63671, and MH48085); the National In-
continue their analysis, with future studies
stitute on Drug Abuse (DA/MH11301); the
“Bullying is potentially a problem for bullies
exploring the role sexual orientation plays
Brain and Behavior Research Foundation;
as well as for victims,” said senior author E.
in bullying and victimization.
and the William T. Grant Foundation.
Growth Factor Aids Stem Cell Regeneration After Radiation Damage Epidermal growth factor has been found to
regeneration after injury could benefit pa-
plants. One group received regular bone
speed the recovery of blood-making stem
tients who are undergoing bone marrow
marrow cells; a second group got bone
cells after exposure to radiation, according
transplantation, plus others who suffer
marrow cells from donors that had been
to Duke Medicine researchers. The finding
radiation injury from accidental environ-
irradiated and treated with EGF; a third
could open new options for treating can-
mental exposures, such as the Japanese
group got bone marrow cells from irradi-
cer patients and victims of dirty bombs or
nuclear disaster in 2011.
ated donors treated with saline.
nuclear disasters. The Duke researchers launched their inves-
The regular bone marrow cells prolifer-
Reported in the Feb. 3 issue of the journal
tigation using mice specially bred with de-
ated well and had the highest rate of en-
Nature Medicine, the researchers explored
letions of two genes that regulate the death
graftment in the recipient mice. But mice
what had first appeared to be an anomaly
of endothelial cells, which line the inner
that were transplanted with the cells from
among certain genetically modified mice
surface of blood vessels and are thought
irradiated/EGF-treated donors had 20-fold
with an abundance of epidermal growth
to regulate the fate of hematopoietic stem
higher engraftment rate than the third
factor in their bone marrow. The mice were
cells. Blood vessels and the hematopoietic
group.
protected from radiation damage, and the
system in these mice were less damaged
researchers questioned how this occurred.
when exposed to high doses of radiation,
Additional studies showed that EGF im-
improving their survival.
proved survival from a lethal radiation exposure, with 93 percent of mice surviving
“Epidermal growth factor was not known to stimulate hematopoiesis, which is the
An analysis of secretions from bone mar-
the radiation dose if they subsequently
formation of blood components derived
row endothelial cells of the protected
received treatment with EGF, compared to
from hematopoietic stem cells,” said se-
mice showed that epidermal growth factor
53 percent surviving after treatment with a
nior author John Chute, M.D., a professor
(EGF) was significantly elevated - up to 18-
saline solution.
of medicine and professor of pharmacol-
fold higher than what was found in the se-
ogy and cancer biology at Duke University.
rum of control mice. The researchers then
Dr. Chute said it appears that EGF works
“However, our studies demonstrate that
tested whether EGF could directly spur
by repressing a protein called PUMA that
the epidermal growth promotes hemato-
the growth of stem cells in irradiated bone
normally triggers stem cell death following
poietic stem cell growth and regeneration
marrow cultured in the lab. It did, with sig-
radiation exposure.
after injury.”
nificant recovery of stem cells capable of “We are just beginning to understand the
repopulating transplanted mice.
mechanisms through which EGF promotes
Hematopoietic stem cells, which constantly churn out new blood and immune cells,
Next, the Duke team tried the approach in
stem cell regeneration after radiation in-
are highly sensitive to radiation damage.
mice using three different solutions of cells
jury,” Dr. Chute said. “This study suggests
Protecting these cells or improving their
in animals undergoing bone marrow trans-
that EGF might have potential to acceler-
April 2013
17
Duke Research News ate the recovery of the blood system in
burg, Katherine Helms, J. Lauren Russell,
Heart, Lung and Blood Institute (HL-
patients treated with chemotherapy or ra-
Emma Fixsen, Mamle Quarmyne, Jeffrey R.
086998-01); the National Institute of Allergy
diation.”
Harris, Divino Deoliviera, Julie M. Sullivan,
and Infectious Diseases (AI-067798-06, AI-
Nelson J. Chao and David G. Kirsch.
067798-01); the National Institutes of Health
The study was funded by the National
Award; and Duke University.
(T32 HL0070757-33); the Barton Haynes
In addition to Dr. Chute, study authors include Phuong L. Doan, Heather A. Him-
Obesity in Dads May Be Associated with Offspring’s Risk of Disease A father’s obesity is one factor that may in-
Decreased DNA methylation at the IGF2
The researchers noted that the changes in
fluence his children’s health and potentially
gene has been associated with an in-
DNA methylation could have been a result
raise their risk for diseases like cancer, ac-
creased risk of developing certain cancers,
of something related to obesity, such as
cording to new research from Duke Medicine.
including colorectal and ovarian cancers.
eating a certain diet or having diabetes that
The study, which appears Feb. 6 in the jour-
“Our genes are able to adapt to our envi-
nal BMC Medicine, is the first in humans
ronment. However, we adjust in a way that
Additional research is under way to see if
to show that paternal obesity may alter a
may be problematic later,” said Cathrine
these changes in DNA methylation at the
genetic mechanism in the next generation,
Hoyo, Ph.D., M.P.H., a cancer epidemiolo-
IGF2 gene remain as the children grow
suggesting that a father’s lifestyle factors
gist at Duke Medicine and the study’s se-
older. Future studies may also determine
may be transmitted to his children.
nior author. “It is not a change in the se-
if certain interventions – similar to women
quence of the DNA itself, but how genes
taking folic acid while pregnant to prevent
“Understanding the risks of the current
are expressed. Some genes may get ‘shut
birth defects – can be used prior to or after
Western lifestyle on future generations is
off’ as a result of environmental trauma.”
conception to prevent irregular methyla-
was not measured in this study.
tion profiles.
important,” said molecular biologist Adelheid Soubry, Ph.D., a postdoctoral associ-
To gather data on newborn health out-
ate at Duke Cancer Institute and the study’s
comes, the researchers followed families
“This study is an important start in looking
lead author. “The aim of this study was to
enrolled in the Newborn Epigenetics Study
at the effects of environmental exposure on
determine potential associations between
(NEST), a research program developed by
children, not only through the mother but
obesity in parents prior to conception and
Dr. Hoyo and funded by the National Insti-
also through the father,” said Dr. Soubry.
epigenetic profiles in offspring, particularly
tutes of Health to test the influence of en-
“Although we cannot define at this point
at certain gene regulatory regions.”
vironmental exposures on genetic profiles
which obesity-related factor may cause
in newborns.
an epigenetic effect, we measured in this study a significant association between
Researchers looking at health outcomes in newborns have historically focused on
Researchers gathered information about
paternal obesity and aberrant methylation
pregnant women. Studies have shown that
the mothers and fathers using question-
profiles in the offspring.”
nutrition and environmental factors during
naires and medical records. They then
pregnancy can affect children’s health and
examined DNA from the umbilical cords
In addition to Drs. Soubry and Hoyo, study
may raise their risk of chronic diseases.
of 79 newborns to determine potential as-
authors include Joellen M. Schildkraut,
However, little has been done to uncover
sociations between the offspring’s DNA
Amy Murtha, Frances Wang, Zhiqing
how paternal factors can affect children.
methylation patterns and parental obesity
Huang, Autumn Bernal, Joanne Kurtzberg,
before conception.
Randy L. Jirtle, and Susan K. Murphy.
mine associations between obesity in par-
DNA methylation at the IGF2 gene in the
The study was supported by National Insti-
ents and changes in DNA methylation at
offspring of obese fathers was significantly
tutes of Health (R21ES014947, R01ES016772,
the insulin-like growth factor 2 (IGF2) gene
lower than in the children of fathers who
R01DK085173, R25CA126938-01A2), the
among offspring. DNA methylation regu-
were not obese. This suggests that paternal
American Cancer Society (ACS-IRG 83-
lates the activity of certain genes, which
obesity may be associated with an increased
006), Fulbright and the Fred and Alice
can reflect a higher risk for some diseases.
risk of children developing certain cancers.
Stanback Foundation.
The Duke research team sought to deter-
18
The Triangle Physician
UNC Research News
Research Needed on Interventions for Children Exposed to Traumatic Events About two of every three children will
study that met the criteria for inclusion in
ply don’t have much of an evidence base
experience at least one traumatic event
the review. Only a few psychotherapeu-
to be able to recommend best treatment
before they turn 18. Despite this high rate
tic treatments showed possible benefits
practices.”
of exposure, little is known about the effec-
for children exposed to
tiveness of treatments aimed at preventing
trauma. The most prom-
“These findings serve as a call to action:
and relieving traumatic stress symptoms
ising interventions were
psychotherapeutic intervention can provide
that children may experience after such
school-based
psycho-
some benefit to children exposed to trau-
therapy interventions that
matic events, but far more research is need-
included cognitive behav-
ed to make definitive conclusions,” said
ior therapy. These inter-
Adam J. Zolotor, M.D., M.P.H., a family physi-
idence-based Practice Center and Boston
ventions were associated with changes in
cian at the University of North Carolina and
Medical Center.
symptoms of post-traumatic stress, anxiety,
a co-author of the review. “Because trauma
events, according to researchers at RTI International, the University of North Carolina School of Medicine, the RTI-UNC Ev-
Adam J. Zolotor, M.D., M.P.H.
depression and anger.
is a common and costly source of child-
The article, published today in the journal
The review did not find
hood psychological distress, it is critical to
Pediatrics, summarizes the results of a sys-
evidence of effectiveness
understand effective forms of treatment.”
tematic review of clinical interventions for
for any of the pharmacologic interventions.
children under age 18 exposed to at least one traumatic event, such as an accident,
Valerie FormanHoffman, Ph.D.
The authors recommend immediate attention from funding agencies, clinicians, re-
“The current body of
searchers, policymakers and other public
or political instability. Child abuse and ne-
evidence provides only a little insight into
health authorities to support further, well-
glect were not included in this research;
best practices in treating children exposed
designed research that can broaden the ev-
a separate review covers interventions for
to trauma, some of whom already have
idence base. They suggest that future stud-
these types of traumas. The United States
symptoms,” said Valerie Forman-Hoffman,
ies expand their examination of the impact
Agency for Healthcare Research and Qual-
Ph.D., a research epidemiologist at RTI
of trauma interventions to a wider range of
ity funded the review.
International and lead author of the study.
outcomes, such as risk-taking behaviors
“This is particularly discouraging given re-
and suicidality and focus on longer-term
After reviewing 6,647 abstracts, the inves-
cent shootings at schools and other places
indicators of development and functioning.
tigators found 21 trials and one cohort
where children have been victims. We sim-
natural disaster, community violence, war
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february/march 2013
19
UNC Research News
Steroids Help Reverse Process Involved in Rapid Bone Loss New research in animals triggered by a
process. A report of the new findings ap-
M.D., assistant professor in the departments
combination of serendipity and counterin-
pears online Feb. 5 in the journal PLOS ONE.
of Medicine and Cell Biology and Physiol-
tuitive thinking could point the way to treat-
ogy at UNC.
ing fractures caused by rapid bone loss in
Osteoporosis, or the loss of bone mass, is
people, including patients with metastatic
a major public health problem in the west-
“While little is known about the biology of
cancers.
ern world and commonly results in hip and
rib fractures, we have identified a molecu-
spine fractures. “But rib fractures are the
lar mechanism that could have important
A series of studies at the University of North
most common and yet most unreported os-
implications for the treatment of fractures
Carolina School of Medicine found that ste-
teoporotic fractures and also occur in many
in cancers and other conditions often asso-
roid drugs, known for inducing bone loss
cancers, such as breast cancer, malignant
ciated with rapid bone loss,” said Dr. Deb,
with prolonged use, actually help suppress
melanoma and myelomas that metastasize
who also is a member of UNC’s McAllister
a molecule that’s key to the rapid bone-loss
and spread to the ribs,” said Arjun Deb,
Heart Institute and Lineberger Comprehensive Cancer Center. The UNC researcher indicated that his lab arrived at the study “via serendipity.” From stromal cells of adult mice, they had deleted a gene called beta catenin. These cells, also known as fibroblasts, form the connective tissue of almost all organs in the body. The Deb lab was working on the molecular regulation of these cells. But something “amazing” occurred, Dr. Deb said. Following beta catenin deletion, the mice died within three weeks. The researchers looked at the functioning of every organ – heart, kidney, lung, spleen – wherever this gene could possibly be expressed. All appeared normal, except lung function. “With just a whiff of anesthesia, their blood oxygen saturation dropped precipitously. This was a first clue of a problem in the respiratory system of these animals.” But the lungs looked absolutely fine under the microscope. Dr. Deb then turned to UNC’s Department of Physics and Astronomy, which had developed a novel contactless fiber-optic displacement sensor for monitoring respiration during mouse computed tomography scans. In association with the department of radiology and the Biomedical Research Imaging Center at UNC, three-dimensional
20
The Triangle Physician
lung reconstruction revealed profound lung
vived,” Dr. Deb said. “And after 80 days,
“From that perspective, these studies are
collapse on one or both sides.
we saw that the ribs showed evidence of
interesting and challenge the existing para-
repair; they were able to form new bone.
digm that steroids are drugs that cause
This was a puzzle. “How can an animal
And when we looked at new CT lung scans,
bone loss. They do, but in rapid bone loss
with normal lung tissue under a micro-
the lungs were expanded and the ribs con-
from aggressive osteoclast overactivity, ste-
scope have lung collapse and respiratory
tained far less numbers of osteoclasts.”
roids may be helpful. That’s the principle
problems?” Dr. Deb wondered whether the chest wall could be the culprit.
message of this story.” As to mechanism, Dr. Deb said that a molecule in bone called rank ligand (RANKL)
Study co-authors were JinZhu Duan, Yueh
CT scans of the chest wall in these animals
is important for osteoclast formation. “We
Lee, Corey Jania, Jucheng Gong, Mauricio Ro-
revealed multiple spontaneous fractures af-
found that steroids were suppressing
jas, Laurel Burk, Monte Willis, Jonathon Ho-
fecting multiple ribs. The affected ribs had
RANKL to the extent that RANKL levels in
meister, Stephen Tilley and Janet Rubin. The
60-70 percent less bone compared to nor-
these animals were the same as healthy
study was funded by the National Institutes of
mal ribs. Essentially the bony rib cage had
animals.”
Health and the Ellison Medical Foundation.
disappeared within three weeks, said Dr. Deb, and he immediately realized that the animals were dying from respiratory failure because the frail chest wall was unable to support respiration. Bone mass is usually maintained by a close functional coupling of osteoblasts (cells that form bone) and osteoclasts (cells that resorb bone). The study team found a huge infiltration of osteoclasts into the animals’ ribs. Other bones, including the spine and femur, also showed some resorption but not as dramatic as in the ribs. And when drugs, such as bisphosphonates, commonly used to preserve bone mass in humans were given to the animals, their survival was prolonged only briefly. This led the study team to think that the osteoclast formation was so aggressive that the body was unable to form new bone to keep pace with the bone loss. In conditions such as rheumatoid arthritis and other problems involving inflammation, many types of inflammatory cells promote bone resorption, which led the researchers to see if treatment with corticosteroids might be helpful in these animals. And it was: a 30-40 percent increase in bone mass, compared to animals that did not get steroids. They also found 60-70 percent of the ribs were preserved. “Notably, 75 percent of the animals surWomens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
April 2013
21
UNC Research News
Promising Stem Cell Blood Test May Be a Sight-Saving Breakthrough A study led by researchers at the Univer-
ing of this event, we have no way of prevent-
ARCA, a new technology capable of mea-
sity of North Carolina is the foundation for
ing it,” Dr. Chavala said.
suring rare cell populations reliably, was better suited as a diagnostic blood test. This
a promising new blood test to detect the Currently, no test is available to predict the
technology is currently being used in clini-
more serious form, which can lead to blind-
conversion from dry to wet ARMD. How-
cal practice for cancer patients, so the tech-
ness.
ever, a paper by the study authors and
nology can be readily adopted for macular
published online Jan. 24 in the journal
degeneration patients.
progression of macular degeneration to its
Age-related macular degeneration (ARMD)
PLOS ONE describes how it could be ac-
is the most common cause of central vision
complished.
The study compared traditional FACS and ARCA in 23 subjects with age-related mac-
loss in the western world, according to a press advisory. Those affected by macular
The ability to predict the conversion from
ular degeneration, both dry and wet. The
degeneration find many daily activities,
dry to wet age-related macular degenera-
samples were “masked” so that no one
such as driving, reading and watching tele-
tion is one of the most coveted achieve-
involved in the sample assessments at the
vision, increasingly difficult.
ments in vision science, according to Dr.
two labs where the analyses were done
Chavala. “A clinical test that predicts im-
knew the type of macular degeneration the
In the United States as many as 11 million
pending conversion is the first step in de-
patients had.
Americans have some form of macular de-
veloping treatments to prevent the switch to
generation, including both early and later
wet macular degeneration.”
“We found a promising trend favoring the ARCA technology in detecting a higher
stages of the “dry” and wet” forms. The eye condition deteriorates the macula, the cen-
In the study, the researchers used the Cell
number of EPCs in the wet macular degen-
tral area of the retina, causing blind spots
Search system, an FDA-approved technolo-
eration group compared to the dry. And
and blurred or distorted vision.
gy for automated rare cell analysis (ARCA),
that trend was not observed with traditional
which Dr. Chavala and colleagues applied
FACS,” Dr. Chavala said. “We were sur-
“People with macular de-
to the identification and analysis of endo-
prised that we needed to analyze relatively
generation start out with
thelial progenitor cells (EPCs).
few patients to detect this trend.”
can detect with a simple
These cell types are rare compared to other
“Our ‘proof of concept study’ suggests that
dilated eye exam,” said
blood cells. EPCs are a stem cell subset that
the ARCA technology could be a powerful
Sai H. Chavala, M.D., di-
gives rise to the endothelium found in the
tool for monitoring progression in macular
the dry type, which we
Sai H. Chavala, M.D.
rector of the Laboratory
inner lining of blood vessels. EPCs are liber-
degeneration. Further study is required to
for Retinal Rehabilitation and assistant pro-
ated from the bone marrow and circulate
validate this test for detecting and prevent-
fessor of ophthalmology and cell biology
in the blood in response to signals for new
ing the conversion from dry to wet macular
and physiology at the UNC School of Medi-
blood vessel growth.
degeneration.
Previous studies using fluorescence activat-
“The next step is to do a prospective study
cine. Dr. Chavala practices at the Kittner Eye Center at UNC Health Care in Chapel
ed cell sorting (FACS), or flow cytometry,
in a greater number of subjects having the
have demonstrated that EPCs are elevated
known criteria that puts them at higher risk
“But about 20 percent of patients at some
in patients with wet macular degeneration
of progressing from dry to wet macular de-
time in their life will develop wet macular
compared to patients with the dry type.
generation,” Dr. Chavala said.”
degeneration, which is characterized by
However, FACS measurements are subject
blood vessels that grow under the surface
to substantial variability between observ-
Co-authors include lead author Emil An-
of the retina. These abnormal vessels can
ers, along with an element of subjectivity
thony T. Say, M.D., at UNC Kittner Eye
leak blood and fluid, which causes irre-
when measuring rare cell populations chal-
Center; Alex Melamud, M.D., Retina Group
versible damage to the cells of the retina
lenging its clinical use.
of Washington, Washington, D.C.; Denise
Hill and New Bern.
Ann Esserman, Ph.D., UNC Gillings School
leading to irreversible vision loss. Since we don’t have a way to predict the precise tim-
22
The Triangle Physician
Dr. Chavala and colleagues thought that
of Global Public Health; and Thomas J.
UNC Research News Povsic, M.D., Ph.D., Duke University Medi-
Foundation, Hope for Vision and Research
a patent surrounding this technology and is
cal Center in Durham.
to Prevent Blindness grants.
founder of Serrata L.L.C., a company that plans to market diagnostic testing for ocular
Support for the study came from the Adler
Disclosure Statement: Dr. Chavala has filed
disease.
New Chemical Probe Is Tool to Study Malignant Brain Tumor Domains development, especially in the case of cancer.
tary, Dr. Frye outlined the qualities that make
While many chemical probes work through
a good chemical probe. To Dr. Frye, a good
the inhibition of enzyme activity, L3MBTL3
chemical probe must be highly selective to
functions as a mediator of protein-to-protein
enable specific questions to be asked and it
interactions, which have been historically
must function as well in a cell as in the test
difficult to target with small, drug-like mol-
tube, providing clear quantitative data with a
ecules. The researchers found three to four
well-understood mechanism of action in ei-
further disease subtypes within TN tumors,
ther situation. It also must be available to all
with more than 75 percent of the tumors fall-
academic researchers without restrictions on
ing into the basal-like subtype.
its use. The Frye lab fulfills this criterion with its commitment to provide researchers with
The chemical probe UNC1215 will be used to investigate the function of malignant brain tumor (MBT) domain protein, L3MBTL3, and study its role in different signaling pathways and disease.
In an article published as the cover story
Further research is needed to identify the distinct biomarkers shared by the expanded
UNC1215 is already available through com-
subtypes of TN cancers. The ultimate goal will
mercial vendors, as well.
be to target the individual biomarkers of these subtypes and create therapies that target their individual biology, according to Dr. Perou.
This research was supported by National Institutes of Health grants (RC1GM090732 and R01GM100919) and the University Cancer Re-
of the March 2013 issue of Nature Chemical Biology, Lindsey James, Ph.D., research as-
“Many people believe that protein-protein
sistant professor in the lab of Stephen Frye,
interactions are difficult to target. Often they
Fred Eshelman distinguished professor in
have a large surface area, so it is hard for
the UNC School of Pharmacy and member of
small molecules to go in and intervene,” said
the UNC Lineberger Comprehensive Cancer
Dr. James.
Center, announced the discovery of a chemical probe that can be used to investigate
Almost 40 percent of the genes that drive
the L3MBTL3 methyl-lysine reader domain.
cancer can be mapped to dysfunction with-
The probe, named UNC1215, will provide re-
in signaling pathways. In the last five years,
searchers with a powerful tool to investigate
chemical probe development has allowed
the function of malignant brain tumor (MBT)
researchers to make fundamental observa-
domain proteins in biology and disease.
tions of the role of these pathways in cancer development, as well as pointing to potential
“Before this there were no known chemical
targets for new therapies. Each of the com-
probes for the more than 200 domains in the
plex interactions within the signaling path-
human genome that recognize methyl lysine.
ways represents a potential point where a
In that regard, it is a first-in-class compound.
therapy can be applied, and the probes allow
The goal is to use the chemical probe to un-
researchers to interact with these processes
derstand the biology of the proteins that it
at the molecular level and observe the over-
targets,” said Dr. James.
all effect of their perturbation on the disease state.
Chromatin regulatory pathways play a fundamental role in gene expression and disease
the L3MBTL3 probe free of charge on request.
In a 2008 Nature Chemical Biology commen
search Fund.
Vascular Access Center of Durham invites you to join us for our Open House Celebration! Date: Thursday, April 4, 2013 Time: 5:30pm – 7:30pm Location: 3624 Shannon Road, Suite 104
Please join us for wine & hors d’oeuvres as we welcome our new Medical Director, Dr. Harold Tate, MD. We look forward to seeing you there! Please RSVP by March 28th to:
Diane Beaudet dbeaudet@vascularcenters.com 919.943.1617 April 2013
23
News
Carolina Endocrine Open House
Welcome to the Area
Physicians
Michael Allen Evans, MD
Sarah Elisabeth Haley-Wien, DO
Johnston Memorial Hospital Smithfield
Emergency Medicine
FirstHealth Pinehurst
Michael Christopher Moore, DO Family Medicine; Urgent Care
Cary
Melanie Frances Barrett, MD Psychiatry
University of North Carolina Hospitals Chapel Hill
John Berry VII, MD Anesthesiology
University of North Carolina Hospitals Chapel Hill
Yijun Chen, MD Abdominal Surgery; Surgery
Duke Weigh Loss Surgery Center Durham
Emergency Medicine
Jonathon Porter Heath, MD Internal Medicine; Pediatrics
University of North Carolina Hospitals Chapel Hill
Pablo Fernando RecinosChavarria, MD Neurological Surgery, Pediatric
UNC Dept of Neurosurgery Chapel Hill
Mary Joyce Rico, MD Dermatology
Durham
Pinehurst
Raleigh Skin Surgery Center Raleigh
LaKesha Nicole Legree, MD
Lois Onkoba Wilkinson, MD
Scott David Long, PA
General Practice
Family Medicine; Geriatric Medicine; Internal Medicine; Occupational Medicine; Pediatrics; Preventive Medicine/Occupational; Emergency Medicine; Urgent Care
Anesthesiology
Durham
Charles Patrick McCormick, MD Internal Medicine; Psychiatry
Duke University Hospitals Durham
Knightdale
Jeanie Wang Yen, MD Physical Medicine and Rehabilitation
University of North Carolina Hospitals Chapel Hill
Dhipthi Mulligan, MD Psychiatry
Brittany Anne Davidson, MD
Duke University Hospitals Durham
Gynecology; Obstetrics
Atrium ObGyn Raleigh
24
The Triangle Physician
Kelly Elizabeth Jernigan, PA
University of North Carolina Hospitals Chapel Hill
Daniel Seoyjong Oh, MD
Philip Thiem Deibel, MD
Wilson Surgical Associates, P.A. Wilson
Child and Adolescent Psychiatry
Kelly Lynn Bombach, PA
Duke University Dept OB/GYN, Div GYN-Oncology Durham
Ruth Hinkle Huffman, PA
Internal Medicine; Nephrology
UNC Chapel Hill Gynecology/Oncology; Obstetrics and Gynecology - Critical Care Medicine
FastMed Urgent Care Clayton
Bryan Dorsey Smith, MD
Physician Assistants
Obstetrics & Gynecology - Endocrinology/ Infertility; Obstetrics and Gynecology
Family Practice; Urgent Care; Family Medicine
Lindsay Anne Kruska, MD
Duke University Hospitals Durham
Natalie Minns Crawford, MD
Crystal Marie Howell, PA
Radiation Oncology
Matthew David Pierson, MD Child Psychiatry; Psychosomatic Medicine
Margaret Faye Potter, PA Family Medicine; Hospitalist; Internal Medicine; Adolescent and Young Adult Medicine; Pediatrics; Obstetrics and Gynecology
Carolina Rehab Raleigh
Laura Elizabeth Smith, PA
Cary
Urgent Care of Smithfield Smithfield
Justin Wayne Bordeaux, PA Family Practice; Emergency Medicine
Nash General Hospital Rocky Mount
Melissa Guffey Potisek, MD
Elizabeth Aimee Crowgey, PA
University of North Carolina Hospitals Chapel Hill
NextCare Urgent Care Burlington
Family Medicine; Internal Medicine; Pediatrics; Family Practice
Duke University Hospitals Durham Anesthesiology
Dermatology
Urgent Care
Urgent Care of Smithfield, PA Smithfield
Urgent Care
Chad Ethan Tiller, PA Urgent Care; Emergency Medicine
Duke Urgent Care South Durham
“More than a doctor. Like a friend.”
We know it by heart.
Trust. WHV is an independent group of heart specialists with locations throughout Eastern North Carolina - ready to provide the care for your patient’s heart when and where they need it. We’ve been pioneering and delivering innovative cardiovascular care for over 25 years. Through our affiliation with UNC Health Care, our physicians can also tap into the latest research and expertise associated with a world-class academic institution. And this in turn allows all our patients to have more access to clinical trials and new therapies, resulting in the best cardiovascular care available in the area.
Cardiovascular Professionals in Johnston, Wayne and Wilson Counties Mateen Akhtar, MD, FACC Benjamin G. Atkeson, MD, FACC
Matthew A. Hook, MD, FACC Eric M. Janis, MD, FACC
Waheed Akhtar, MD, FACC Malay Agrawal, MD, FACC
Kevin R. Campbell, MD, FACC Randy A.S. Cooper, MD, FACC
Diane E. Morris, ACNP Ravish Sachar, MD, FACC
Sunil Chand, MD, FACC Paul Perez-Navarro, MD, FACC
Laura Davis, ANP-BC Christian Gring, MD, FACC
Nyla Thompson, PA-C
Joel Schneider, MD, FACC
Cardiovascular Services Echocardiography Nuclear Cardiology Interventional Cardiology Carotid Artery Interventions Cardiac Catheterization Cardiac CT Angiography and Calcium Scoring Electrophysiology and Cardiac Arrhythmias Peripheral Vascular Interventions Pacemakers / Defibrillators Stress Tests Holter Monitoring Lipid and Anti-Coagulation Clinics Vascular Ultrasounds / AAA Screening
WHV Locations in Johnston, Wayne and Wilson Counties 910 Berkshire Road
2076 NC Hwy 42 West, Suite 100
2605 Forest Hills Road South West
2400 Wayne Memorial Drive, Suite A
Smithfield, NC 27577 Phone: 919-989-7909 Fax: 919-989-3147
Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326
Wilson, NC 27893 Phone: 252-243-7049
Goldsboro, NC 27534 Phone: (919) 736-8655 Fax: (919) 734-6999
When it comes to your cardiovascular care – We know it by heart. To learn more, visit our website www.WHVheart.com or call us at 1-800-WHV-2889 (800-948-2889).
Advanced Medical Imaging for Your Patients 19 Convenient Triangle Area Locations
Established in 1953, Wake Radiology is the leading provider of outpatient medical imaging for families in the Triangle. Our 54 radiologists are recognized experts, subspecialty trained and certified by the American Board of Radiology. A longtime leader in low-dose imaging, we are committed to minimize patients’ radiation exposure while maintaining the highest quality. We are proud to be the only multi-site freestanding outpatient imaging provider in the Triangle to earn the American College of Radiology’s prestigious Breast Imaging Center of Excellence (BICOE) designation. Our group is also the only one to earn certification from the International Society for Clinical Densitometry (ISCD) for bone density screenings and the first in Wake County to offer dedicated pediatric imaging services. Our 19 outpatient offices provide easy access to a full range of imaging procedures including: • Screening and diagnostic mammography • PET-CT and nuclear medicine • Interventional radiology and vein care • Orthopedic and sports imaging • Low-dose CT and MRI • Pediatric imaging So the next time imaging is necessary for your patients, choose Wake Radiology. We are in-network with most insurance plans and offer financial assistance or payment plans to patients who need it.
Wake Radiology. Excellence in medical imaging.
Express Scheduling: 919-232-4700 Mon-Fri 7:30am-6:30pm Chapel Hill Scheduling: 919-942-3196 Mon-Fri 8:00am-5:00pm wakerad.com Wake Radiology has 19 convenient outpatient imaging locations in Raleigh | Cary | Garner | Wake Forest | Morrisville Fuquay-Varina | Chapel Hill
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