august
2 013
Rex Surgical Specialists
Leaders in Effective and Long-Term Bariatric Treatment
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
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From the Editor
Multidisciplinary Fix Dramatic weight loss and reduction in chronic disease can be expected after bariatric surgery. But keeping the excess weight off after the first two years is much less certain. 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
This month’s cover story is on Rex Surgical Specialists, a practice that has raised the bar in bariatric care by giving patients multidisciplinary tools that empower them to develop healthy eating and lifestyle patterns. Patient care is led by the bariatric surgeon, who stay engaged with the specialized-care team and each patient before and after surgery. The program is now housed within the new Rex Bariatric Specialty Center, a standalone, state-of-the-art facility designed for patient comfort and support, with a classroom, demonstration kitchen and nutrition store. This issue of The Triangle Physician features a number of new and returning contributors, whose articles enlighten on a diverse array of relevant health care topics. Thanks to all for making this a great issue. Orthopedic surgeons Louis C. Almekinders and Sameer Mathur examine the surgical options of two common problems, joint and back pain, respectively. Marc Stevens discusses the need to maintain sufficient levels of essential vitamins to promote healing
Editor Heidi Ketler, APR
Contributing Editors Louis C. Almekinders, M.D. Douglas A. Drossman M.D. Bill Evans, M.P.H., M.C.H.E.S., C.H.C. Amanda Kanaan Sameer Mathur, M.D. Joe Reddy Marc S. Stevens, M.D., F.A.C.S., F.I.C.S. Michael J. Thomas, M.D., Ph.D. Photography Mark Jacoby
after surgery, especially among patient with diabetes.
Creative Director Joseph Dally
As a gastroenterologist and president of the Rome Foundation, Douglas Drossman advances
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awareness of how to improve the lives of people with functional gastrointestinal disorders in his concise overview. Endocrinologist Michael Thomas details hypothyroidism.
heidi@trianglephysician.com
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info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com
University of North Carolina assistant professor Bill Evans and marketing consultant Amanda Kanaan argue in favor of emerging health care roles that support improved relationships in the new Accountable Care Organization environment. Mr. Evans explains the skillset of the health education specialist. Ms. Kanaan discusses that of physician liaison. Returning practice management consultant Joe Reddy offers sage advice for late adopters on the inevitable electronic health record. In short: Don’t wait until the incentives end and the penalties kick in. You are invited to share your practice and professional news and contribute your medical perspective. It’s a no-cost way to connect with the more than 9,000-plus medical professionals throughout the Triangle. Cost-effective advertising in The Triangle Physician is another way to round out your multifaceted marketing mix. Feel free to contact me at heidi@trianglephysician.com for more information. With great respect and appreciation,
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.
2
The Triangle Physician
Category
COVER STORY
6
Rex Surgical Specialists
Leaders in Effective and Long-Term Bariatric Treatment
august 2 0 1 3
Vol. 4, Issue 7
FEATURES
9
DEPARTMENTS 11 Practice Marketing
Health Care Reform
The PCP-Specialist Disconnect: What’s the Solution?
12 Endocrinology
Help! Support Is Available to Guide Change in Skillset and Mindset Bill Evans of the University of North Carolina
The Many Aspects of Hypothyroidism
14 Orthopedic Surgery
Vitamin Supplementation Promotes Wound Healing in People with Diabetes
discusses the role of a health education specialist
16 Orthopedic Surgery
in improved outcomes.
18
Relieving Pain in the Aging Back
20 Gastroenterology
Orthopedic Surgery
Treating the Various Forms of Irritable Bowel Syndrome
21 Practice Management
Stage 2 for Specialists
Repairing Worn-Out Joints: Will It Ever Be a Reality?
22 Duke Research News
Dr. Louis C. Almekinders brings us up to date on
22 UNC Research News
the surgical options for this common problem among athletes and seniors.
More than $2 Million to Study Glucose Monitoring Is Awarded
23 Community Support
COVER PHOTO: From left to right: Peter Ng, M.D., Tricia Burns, P.A.-C., Lindsey Sharp, M.D., Dustin Bermudez, M.D.
Doctors Should Discuss Financial Concerns of Cancer Patients
Local Events Help STOMP the Monster
24 News
Welcome to the Area
august 2013
3
Cover Story
Rex Surgical Specialists Leaders in Effective and Long-Term Bariatric Treatment By Heidi Ketler
As obesity tightens its grip on the United
improvement in quality of life.
cational foundation and the practical tools to modify the lifestyle behaviors that led to
States, Rex Surgical Specialists stands as a center of excellence in bariatric surgery
“Patients may experience as much as an
their obesity. The national success rate for
and multidisciplinary care, providing a
83 percent resolution of diabetes and a
bariatric surgery reaches 85 percent at five
range of weight-management tools for
marked reduction in the amount of insulin
years after surgery, according Dr. Ng.
demonstrated long-term success.
needed. Some can stop taking insulin all together. This means a drastic reduction
The practice’s success is a reflection of a
considered
in the risk of eye, vascular and heart
unique and ambitious bariatric program
successful when excess weight is reduced
disease and, ultimately, improved quality
that addresses the many causes of a com-
by greater than 50 percent and the weight
and quantity of life,” says bariatric surgeon
plex disease. Treatment plans are custom-
loss is sustained for five years. Rex Surgical
Peter C. Ng, M.D.
ized to meet patient needs and are physi-
Weight-loss
surgery
is
cian directed across the care continuum
Specialist strives to achieve as close to 100 percent excess weight loss as possible
The real test of a bariatric weight-loss pro-
– from pre-surgery psychological assess-
for every patient. But just as important is
gram is long-term weight management,
ment, nutritional counseling and mentoring
the reduction or elimination of chronic
which can be difficult to attain or sustain
to post-surgery fitness training, continuing
conditions, including Type 2 diabetes and
for patients who don’t receive a solid edu-
education and ongoing support groups. “The surgery itself is the easy part compared to the challenge of helping a patient stay in that state of bariatric awareness,” says bariatric surgeon Lindsey S. Sharp, M.D. “We work with patients to help them achieve ‘mindful’ eating and living and maintaining that for the rest of their lives.” Drs. Ng and Sharp were recently joined by Dustin M. Bermudez, M.D. Drs. Sharp and Bermudez are fellowship-trained in advanced minimally invasive and bariatric surgery. Dr. Ng, also an expert in minimally invasive surgery, serves as a national preceptor in teaching singleincision and hidden-scar laparoscopic surgical techniques. The Rex Surgical Specialists bariatric team includes a dedicated physician assitiant, psychologist, dietitians and a registered nurse as bariatric coordinator.
Peter Ng, M.D., is a graduate of the Brody School of Medicine at East Carolina University, where he also completed post-graduate training in bariatric surgery. He is the medical director of the bariatric surgery division at Rex Surgical Specialists. Dr. Ng sees patients at Rex Surgical Specialists’ locations in Raleigh, Cary and Wakefield.
4
The Triangle Physician
Most other bariatric programs aren’t as allencompassing and specialized, because most insurance companies don’t require
it, says Dr. Bermudez. “Baseline criteria are often used to portray a program as one that embraces (a comprehensive) approach.” Rex Surgical Specialists has gone a step beyond. “We want to help patients understand that these disciplines are critical to their long-term success,” adds Dr. Ng. “We also are unique in that (our surgeons) see our patients post-operatively, so the referring physician doesn’t have to assume their bariatric care,” says Dr. Ng. The bariatric surgeons see a patient an average of six times during his or her year of surgery – three times pre-op. The physicians also lead support group meetings and educational sessions. “Even outside of coming to the office for a visit, our patients have access to a physician,” says Dr. Sharp. “You don’t see that level of support elsewhere.” Rex Surgical Specialists further elevated its commitment to treating obesity when it opened Rex Bariatric Center four months
Dustin Bermudez, M.D., is a graduate of Stanford University School of Medicine and East Carolina University’s minimally invasive and bariatric surgery fellowship program. He is the newest member of the Rex Surgical Specialists bariatric surgery division. Dr. Bermudez sees patients at Rex Surgical Specialists’ in Raleigh.
ago on Lake Boone Trail in Raleigh. Designed for patient comfort, the contem-
with obesity were on average $1,429 high-
revisional surgery and the most advanced
porary facility features spacious exam
er than those of normal weight.
technology, such as microlaparoscopy. The practice also is involved in clinical tri-
rooms, an education classroom, a state-ofthe-art demonstration kitchen and a nutri-
In 2010, more than one-third (35.7 per-
als to explore new techniques in bariatric
tion store.
cent) of adults in the United States and
surgery.
16.9 percent of children and adolescents
Obesity’s Impact
were obese, according to the CDC. Self-
Weight-loss operations alter the anatomy
Obesity is a source of great suffering, ill
reported state statistics from the CDC indi-
of the digestive tract to create restriction
health and earlier mortality.
cated that nearly one-third (29.1 percent)
(the sense of fullness) and, in some cases,
of adults in North Carolina are obese. The
reduce calorie absorption and affect hun-
Those with a body mass index of more
statistics show a disproportionately high
ger hormones. While proven safe, weight-
than 30 are considered obese. Beyond
prevalence of obesity in lower-income
loss surgery carries unique risks and
the emotional and physical distress, obe-
communities and communities of color
benefits, and the Rex Surgical Specialists
sity significantly increases the risk of
across the United States.
bariatric team works closely with patients to help them understand the options and
such chronic conditions as heart disease, stroke, Type 2 diabetes and certain types
“If current rates continue, it’s predicted
of cancer. It is the second-leading cause of
that half of adults in America will be obese
preventable death behind smoking.
by 2040, so we’re really facing an epidem-
Laparoscopic
ic,” says Dr. Ng.
Roux-en-Y
determine the one that’s best for them. gastric
gastric
bypass
bypass)
(or
involves
partitioning the stomach into two parts:
According to the Centers for Disease Control and Prevention, medical costs associ-
Surgical Weight-Loss Options
a small functioning upper “pouch” and a
ated with obesity in 2008 were estimated
Rex Surgical Specialists offers a diverse
disconnected lower “remnant” stomach.
at $147 billion. The medical costs of those
range of bariatric procedures, including
The pouch limits the amount of food
august 2013
5
consumed. A length of small bowel is
Lap-Band System (or adjustable gas-
Long-term weight loss on average is 85
attached to reestablish the digestive tract.
tric banding) is a less-invasive option that
percent of excess weight. The duodenal
involves the application of an inflatable
switch also has a track record as the most-
With gastric bypass, rapid weight loss typi-
band around the upper stomach to create
effective metabolic operation for treating
cally occurs in the first six to nine months
a pouch. When appropriately tightened,
diabetes mellitus (91 percent).
with continued significant weight loss for
the band restricts the flow of food through
18 to 24 months when patients follow the
the pouch and stimulates surrounding
Like all weight-loss programs and diets, in-
recommended lifestyle changes. Clinical
nerves to produce the feeling of fullness
dividual weight loss after bariatric surgery
studies show weight loss averages about
sooner. Weight loss averages between 45
varies depending on starting weight, age
70 percent of excess weight.
percent of excess weight. Long-term stud-
and sex.
ies show most patients maintain weight Laparoscopic sleeve gastrectomy (or
loss three to eight years after surgery.
vertical sleeve gastrectomy) involves
Multidisciplinary Care “Surgery is only a tool. Beating food ad-
creation of a small narrow stomach to re-
Bilio-pancreatic diversion with duode-
diction requires more than having the sur-
duce caloric intake and create an earlier
nal switch (or the duodenal switch) in-
gery,” says dietician Mary Gray Hutchison,
sense of fullness after eating. This proce-
volves two bariatric techniques: a vertical
M.P.H., R.D. L.D.N. “Psychological prepa-
dure removes 80 percent of the stomach
gastric sleeve attached to a distal intestinal
ration, nutritional education, regular exer-
and offers neurohormonal changes that
roux-en-Y bypass. During this operation,
cise and long-term follow-up play equally
help to reduce the feeling of hunger.
approximately 80 percent of the stomach
important roles in achieving and maintain-
is removed. The effectiveness of the pro-
ing a healthy weight.”
Clinical studies show weight loss averages
cedure is based on a combination of re-
around 65 percent of excess weight within
striction, fat malabsorption and hormonal
Throughout the weight-loss journey, pa-
the first 24 months.
effects that reduce hunger, increase satiety
tients partner with various specialists on
and decrease insulin resistance.
the bariatric team. It begins with psychological assessment and two pre-op visits with a psychologist and nutritional counseling and a minimum of three visits with a registered dietician. Patients also participate in the pre-op mentoring program and support groups. After surgery, exercise at least four times a week for 45 minutes is important to achieve weight-loss goals, and physical trainers at Rex Wellness Centers have the expertise to help bariatric patients exercise safely and stay motivated. Post-op support groups and continuing education also are available to help patients stay on track. Ms. Hutchison explains why patients often struggle to maintain their weight loss at the three-to-five-year mark. The first year after bariatric surgery is called the “honeymoon period.” This is when patients experience the most weight loss. Patients who have not “bought into” the need to maintain healthy lifestyle changes for a lifetime
Lindsey Sharp, M.D., graduated medical school at Tufts University and completed his fellowship in bariatric and advanced minimally invasive surgery at Duke University. He is the medical director of bariatric surgery at Rex Hospital. Dr. Sharp sees patients at Rex Surgical Specialists’ locations Raleigh, Cary and Garner.
6
The Triangle Physician
are more likely to go back to their previous problematic eating patterns.
School and completed his general surgery residency at University of Pennsylvania Hospital in Philadelphia. He completed his fellowship training in minimally invasive and bariatric surgery at East Carolina University and the Vidant Medical Center in Greenville, N.C. He is also bilingual and speaks fluent Spanish. Dr. Ng completed his undergraduate degree at Davidson College. He earned his medical degree from East Carolina University Brody School of Medicine, where he completed his general surgical residency and specialty post-graduate training in laparoscopic bariatric surgery. Dr. Sharp earned his undergraduate degree at Duke University. He completed his medical degree and surgical training at Emory University in Atlanta and returned to Duke for a fellowship in bariatric and advanced minimally invasive surgery. Mary Gray Hutchison, N.P.H., R.D., L.D.N., is a graduate of NC State University with an advanced degree from the University of North Carolina at Chapel Hill. She provides nutrition counseling for patients at Rex Surgical Specialists before and after bariatric surgery as part of the comprehensive approach to successful surgical weight loss.
Referring Physicians “We encourage referring physicians to participate in the bariatric care of their patient
ate substitutions. They also glean powerful
to the extent that they feel comfortable,”
“Patients who are truly successful are pa-
tips – such as taking a two-minute break
says Dr. Ng.
tients who have gotten in control of their
halfway through a meal.
‘head hunger,’ as well as their physical
“At the same time, we look for the opporBuy-in is important, says Ms. Hutchison.
tunity to work with the primary care physi-
“As awareness grows self-efficacy im-
cian, who can monitor co-morbidities after
Mindful Awareness
proves daily, so they feel better about the
surgery and better manage medications,”
“Eat to live, don’t live to eat.” It’s a favorite
decisions they’ve made and the willpower
says Dr. Sharp. “We need their medical ex-
saying of Dr. Sharp. And it’s a mindset most
they’re able to use to avoid the overeating
pertise, so it’s really a partnership in taking
Americans would do well to embrace.
that used to get them in the past.”
care of the bariatric patient.
“The reality of our culture is that when
Meet the Bariatric Surgical Team
“Most importantly, we want to serve both
we’re sad or happy, we turn to food or drink. Everything in our culture to some
“I became a bariatric surgeon because
tients to expertly meet their surgical, nu-
extent has a connection to food,” says Dr.
of the dramatic benefits that can result –
tritional and psychological needs for a
Ng. “So we teach patients how to manage
from the improvement in one’s outlook on
lifetime of success.”
this in a healthy way.”
life, to the improvement in one’s medical
hunger,” Ms. Hutchison says.
referring physician and our bariatric pa-
condition and increased life expectancy,”
The Bariatric Center is located at 4207
At the start of their weight-loss journey,
says Dr. Bermudez. “The operations are of
Lake Boone Trail, Suite 210 in Raleigh,
patients are introduced to the principles
great interest to me, and I enjoy working
near Rex Hospital and across the street
of “mindful eating” – such as eating only
with bariatric patients and the close, long-
from Rex Wellness Center of Raleigh on
to satisfy hunger and only when one can
term relationships that develop.”
Lake Boone Trail. For more information,
give it full attention. They are educated on practical applications – such as appropri-
visit www.rexbariatrics.com or call (919) Dr. Bermudez attended Stanford Medical
784-SURG (7874). august 2013
7
Health Care Reform
Help!
Support Is Available to Guide Change in Skillset and Mindset By Bill Evans, M.P.H., M.C.H.E.S., C.H.C.
At the University of North Carolina at
created training programs specifically
Greensboro we have met with several
geared to emphasize patient behavioral
senior leaders in major health systems
change in physician practice settings.
around the state during the past few months, and they all say the same thing,
Health
“Help! We can’t solve today’s problems
grounding in behavioral theory with
education
specialists
offer
with yesterday’s tools, with a new
a social-ecological approach to one’s
reimbursement structure through the
health. They recognize the effects of an
Affordable Care Act.”
individual’s relationships with family and
Bill Evans is an assistant professor in the Department of Public Health Education at the University of North Carolina-Greensboro. For practices interested in health coach training, he can be reached at wmevans@uncg.edu or (336) 334-3796.
friends; affiliations with institutions, such When I speak to physicians and nurses
as the workplace and places of worship;
(physicians, physician assistants, nurse
in Patient Centered Medical Homes, they
and their broader community, such as
practitioners, nurse navigators, nurses,
are striving to meet the new demands of
organizations; and the laws or policies
certified
“pay for performance” and are working
that affect their lives, such as whether
workers, etc.) on new skills that will help
to retool their approach to practice. But
sidewalks are in their neighborhoods.
patients reach optimal outcomes.
all come to: “We don’t yet have the skills
For once, the incentives are aligned to
It starts with the co-creation of an alliance
to change behavior.” Therein lies the
include such a skillset on the medical
with the patient and being grounded in
multimillion-dollar misstatement.
team. But at UNCG, we recognize that the
the application of behavioral theory. If the
supply of health education specialists in
relationship with and accountability to the
You can’t easily change someone’s
this new role is low, so we are working
patient isn’t there, practices will have little
behavior. Think about when someone has
diligently to train our undergraduates,
success.
told you that you have to do something.
master in public health students and even
Your first reaction usually is resistance.
doctoral students for this new role in
Peeling back the layers of the onion may
medical settings.
bring some tears as practices work to
medical
assistants,
social
there is a common conclusion they have
That is the issue we’re facing in moving
adjust to new patient care skills, but in the
from a prescriptive model of medicine to
In the meantime, we also recognize
a participatory approach, where centrally
that there are already clinical personnel
the patient has to find the means,
in
motivation or inspiration to better manage
settings
that
their diabetes, congestive heart failure,
simply
need
lower their cholesterol or adhere to their
training
and
medication schedule to maintain proper
retraining
blood pressure ratios.
become better
medical
prepared
to to
In the Department of Public Health
help patients
Education at UNCG, we recognized this a
on their journey to
couple of years ago and started to facilitate
improved outcomes. So, we
trainings to begin to ramp up health
are also working to meet these
education specialists to accept new roles
demands around the state by
in physician practice settings. We have
training existing medical staff
9
The Triangle Physician • august 2013
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Practice Marketing
The PCP-Specialist Disconnect:
What’s the Solution? By Amanda Kanaan
In the past, primary care doctors and spe-
son for referral to the specialist, but only
cialists had the opportunity to interact fre-
34.8 percent of specialists said they regu-
quently in the hospital setting. For many
larly receive such information. On the flip
reasons (including the advent of hospital-
side, 80.6 percent of specialists reported
ists), that interaction rarely happens any-
regularly sending consultation results to
more. It’s not uncommon for a primary
the referring PCP, but only 62.2 percent of
care doctor to send patients to a special-
PCPs said they received such reports, ac-
ist whom they’ve never met before. When
cording to the 2008 study funded by Rob-
referring a patient, the skills, training and
ert Wood Johnson Foundation involving
experience of the specialist are of course
4,720 practicing physicians.
important, but much can be gained in terms of quality of care through improved
The study found that physicians who did
communication among providers.
not receive timely communication regarding referrals and consultations were more
The relationship between primary care
likely to report that their ability to provide
and specialty practices is invaluable. For
high-quality care was threatened.
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. meaningful relationships between PCPs
the primary care doctor, it can mean better communication on mutual patients;
As
Organizations
and specialists by facilitating meetings,
the ability to call for a clinical consult
(ACOs) begin to form, many believe the
communicating with all staff in the refer-
when needed; and the confidence to tell
solution to this lapse in communication
ring office and sharing clinical education.
your patients being referred that they will
is linking all practices in the ACO to the
This is what ultimately brings value to the
be in good hands. For specialists, it can
same electronic health record. However,
relationship between PCP and specialist
mean getting the proper records needed
that only satisfies the medical records
in order to grow loyal referral bases.
once the patient is referred; better com-
portion of this dilemma. True quality of
munication with PCPs on treatment plans;
care comes not just through medical re-
Currently, physician liaisons are usually
and an increased number of patient refer-
cords but by way of strong relationships
a service provided by specialists in the
rals.
with practices (not just between doctors,
community who want to increase refer-
but among the staff members – including
rals. However, in the near future these liai-
nursing and administration).
sons may be employed by ACOs and even
The breakdown in communication be-
Accountable
Care
Independent Practice Associations (IPAs)
tween PCPs and specialists was analyzed
to bring their networks together.
in a national study by researchers at the
The answer to this may seem unorthodox
Center for Studying Health System Change
to some and yet obvious to others – a
(HSC), which revealed that primary care
physician liaison. Part marketing, part cus-
Hospital systems have been relying on
and specialist physicians have decidedly
tomer service and part clinical, the role
physician liaisons for years to ensure
different views about how often their col-
of the physician liaison is to visit medical
high-quality service and increase refer-
leagues communicate.
practices in the community in order to
rals. Now, more and more private physi-
bring physicians together and to educate,
cians are relying on this tactic to enhance
For instance, 69.3 percent of PCPs re-
serve and promote services. The goal of
communication with PCPs and ultimately
ported regularly (“always” or “most of the
the liaison is not to drop off brochures
grow their practices through new patient
time”) sending a patient’s history and rea-
and bagels to win referrals, but to build
referrals.
august 2013
11
Endocrinology
The Many Aspects of
Hypothyroidism By Michael J. Thomas, M.D., Ph.D.
Hypothyroidism is a common condition
vain’s), post-partum or silent (“painless”)
that results when the thyroid is unable
thyroiditis may cause transient hyperthy-
to produce enough thyroid hormone
roidism followed by temporary or perma-
(thyroxine, T4, and/or tri-iodothyronine,
nent hypothyroidism. Loss of functional
T3). Onset can occur at any age, but in-
thyroid tissue, such as surgery or radioac-
creases with age. Hypothyroidism is more
tive iodine, can render a person perma-
common in women with a prevalence ap-
nently hypothyroid. Congenital thyroid
proaching about 2 percent in some age
agenesis/dysgenesis may be identified on
groups (compared with 0.1 percent for
neonatal screening and requires prompt
men). Congenital hypothyroidism is one
treatment to prevent cretinism (mental re-
of the most common defects present at
tardation and growth failure).
birth (about 1 in 5,000 births). Interference with thyroid hormone proThyroid hormone production is regulated
duction can be drug-induced. Iodine and
by a hormone from the anterior pituitary,
lithium inhibit thyroid hormone secretion.
thyroid stimulating hormone (TSH). TSH
Overtreatment with thionamides used
acts on thyroid follicular cells and stimulates
in hyperthyroidism can also produce
several facets of thyroid hormone produc-
hypothyroidism. Amiodarone, an anti-
tion and promotes thyroid growth. There is
arrhythmic containing iodine, can block
negative feedback regulation of TSH by T4
production of thyroid hormone. Congeni-
and T3 at both the level of the pituitary and
tal defects in T4 biosynthesis or maternal
at the level of the hypothalamus.
treatment with antithyroid drugs or iodine deficiency can cause congenital hypothy-
Primary hypothyroidism occurs with thy-
roidism with a goiter.
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. Dr. Thomas was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. He established Carolina Endocrine in the summer of 2005. Board certified in internal medicine and endocrinology, Dr. Thomas 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.
roid gland failure, resulting in low-serum T4 and elevated TSH levels. The most
Secondary hypothyroidism – low TSH,
common cause of primary hypothyroid-
usually with low free T4 (FT4) levels - is
ism
overlooked in the elderly.
(“Hashimoto’s”)
usually the result of pituitary/hypotha-
Low thyroid hormone levels can explain
thyroiditis. High titers of anti-thyroid anti-
lamic dysfunction due to tumors, trauma,
some of the symptoms of hypothyroid-
bodies (thyroid peroxidase and/or thyro-
surgery or irradiation. TSH deficiency oc-
ism: decreased metabolic rate leads to
globulin antibodies) are common, though
curs when the anterior pituitary is unable
cold intolerance and modest weight gain;
they may be low in elderly patients. T4/T3
to produce adequate amounts of TSH to
and the failure to metabolize glycosami-
synthesis is gradually impaired, prompt-
stimulate T4/T3 production, whereas hy-
noglycans results in their accumulation in
ing a compensatory rise in TSH, with a
pothalamic defects lead to TRH (thyrotro-
subcutaneous tissue, causing non-pitting
“subclinical” phase that may precede the
phin releasing hormone) deficiency.
edema (myxedema).
is
autoimmune
onset of clinical hypothyroidism.
Clinical Presentation
Thyroid size is variable, ranging from en-
Autoimmune thyroid failure is usually pro-
The clinical spectrum of hypothyroidism
largement (goiter), which may be seen in
gressive and chronic, although occasional
is broad, ranging from “subclinical” with
autoimmune thyroiditis and iodine defi-
recovery to normal and sometimes hy-
no manifestations to profound hypothy-
ciency, or normal size, small or absent, as
perthyroid states can occur. Other types
roidism and, rarely, myxedema coma. The
seen in post-procedural hypothyroidism or
of thyroiditis, such as painful (DeQuer-
onset of symptoms can be insidious and
congenital thyroid agenesis/dysgenesis.
12
The Triangle Physician
Differential Diagnosis
along with possible imaging of the pitu-
in patients with persistent fatigue, depres-
Hypothyroidism is accurately diagnosed
itary/hypothalamus.
sion or cognitive problems despite normalization of thyroid function tests is con-
with thyroid function tests. TSH and either a free T4 or estimated by a free T4 index
Management
troversial, and most carefully controlled
(FTI, the product of a total T4 and percent
Levothyroxine (L-T4) is the drug of choice.
studies have failed to show any benefit.
of T3 uptake, a crude estimate of thyroid
L-T4 has supplanted desiccated thyroid
hormone binding proteins) are main labo-
extract, which has variable potency/pu-
Adjust the maintenance dose for primary
ratory tests used in the initial evaluation of
rity. L-T4 is converted to T3, producing
hypothyroidism to normalize the TSH lev-
hypothyroidism.
normal plasma levels of both T4 and T3.
el. Because of T4’s long half-life and the
Depending on the degree of hypothyroid-
delayed fall of chronically elevated TSH
Serum T3 measurements are rarely helpful
ism, LT4 replacement doses of 100-125 µg
levels, dose adjustments are made no
in the diagnosis of hypothyroidism, since
per day (~1.6 mcg/kg/day) are common,
more often than five to six weeks. Avoid
T3 levels fluctuate greatly in circulation.
but depend on age. Elderly or cardiac pa-
over treatment, since it is associated with
Abnormal thyroid function tests need to
tients usually start therapy with smaller
accelerated loss of bone mass and higher
be distinguished from a condition termed
doses (25-50 µg per day) and increase
prevalence of arrhythmias. After normal-
“non-thyroidal illness,” or “euthyroid sick
gradually to avoid aggravating myocardial
ization of thyroid function tests, annual
syndrome.”
ischemia.
thyroid tests can be performed to ensure
Changes in T4 (and T3) during acute ill-
Tri-iodothyronine (T3) is used infrequent-
ness do not necessarily indicate abnormal
ly for therapy, due to its short half-life and
In patients with secondary hypothyroid-
thyroid function, because TSH levels are
slightly higher cost. Similarly, combina-
ism, TSH is not regulated normally and
usually normal and these tests usually
tion T4/T3 preparations offer no phar-
cannot be used to adjust the dose. T4 or
normalize after the underlying illness re-
macologic advantage, since T4 naturally
free T4 levels should be maintained within
solves. This biologic effect may represent
undergoes deiodination in peripheral tis-
the normal range.
an adaptive stress response.
sues. The role for low supplements of T3
stability.
An elevated TSH level confirms primary hypothyroidism which may require treat-
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ment, depending on degree and etiology of the findings. Subclinical hypothyroidism (an increased TSH with normal T4 levels) is common, occurring in about 7.5 percent of women and about 3 percent of men. Treatment of subclinical hypothyroidism is controversial, however, and low doses of thyroid hormone can be tried to normalize thyroid function tests and ascertain improvement of a non-specific
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symptom (e.g. fatigue). Measurement of anti-thyroid antibodies may suggest the diagnosis of autoimmune thyroiditis and can reveal the likelihood that subclinical hypothyroidism might progress to overt hypothyroidism. Secondary hypothyroidism is less common and has a low TSH and low FT4 on laboratory testing. Assessment of other pituitary hormones should be performed,
4441 Six Forks Rd. Suite 106-293 • Raleigh, NC 27609 • Phone: (800) 845-6090
august 2013
13
Orthopedic Surgery
Vitamin Supplementation Promotes Wound Healing in People with Diabetes By Marc S. Stevens, M.D., F.A.C.S., F.I.C.S.
It’s not uncommon for diabetic patients
digestive system by keeping glucose lev-
facing surgery to say “I can’t have surgery,
els stable.
because I won’t heal.” This is certainly not the case.
Adults with a value below 170-250 pg/mL are considered deficient in B12. Elevated
Diabetes is a disease that affects the small
blood homocysteine or methylmalconic
blood vessels and the function of the im-
acid levels may suggest a B12 deficiency.1
mune cells when the blood sugar is high. With proper nutrition and blood sugar
Symptoms of vitamin B12 deficiency are
management, it is very safe for diabetics to
megaloblastic anemia, fatigue, weakness,
undergo knee replacements, abdominal
constipation, loss of appetite and weight
surgery and many elective procedures.
loss. Additional symptoms include difficulty maintaining balance, depression,
Because diabetes often causes nutritional
confusion, dementia, poor memory and
deficiencies, people with diabetes must
soreness of the mouth and tongue.
supplement for these nutritional losses. Changes in diet or medications can initi-
Specifically for diabetics, neuropathy is a
ate this nutritional loss. So it is critical
common complication, with damage oc-
that diabetics who undergo surgery work
curring in the skull, spine and vital organs.
closely with their doctor to manage their
Diabetics with neuropathy experience
blood sugar and vitamin supplementation
pain, tingling and numbness in their arms,
– a vital part of overall recovery.
hands, legs and feet, resulting in sores. If B12 deficiency is not remedied, perma-
In my practice, I have found that educating
Dr. Stevens is board certified in orthopedic surgery and has advanced training in wound care, trauma and critical care, and undersea and hyperbaric medicine. He earned his medical degree in 2000 from Creighton University School of Medicine in Omaha, Neb., and completed his residency in orthopedic surgery at the University of Arkansas for Medical Sciences in Little Rock. Before moving to North Carolina, Dr. Stevens practiced several years in Little Rock, where he was named Physician of the Year in Arkansas and listed among America’s Top Orthopedic Surgeons. He also has published many papers and has been an international lecturer. He is a member of the Johnston Health medical staff and Triangle Orthopaedic Associates and can be reached at (919) 934-1094. present for calcium to build strong bones.
nent nerve damage can occur.
patients on the importance of essential vi-
A deficiency of vitamin D also hinders
tamins and helping them identify vitamin
Vitamin B12 supplementation can have a
blood sugar levels, making it more diffi-
deficiencies have made an overwhelming
positive impact in overcoming deficien-
cult to control diabetes. Additionally, it in-
difference in their successful recovery af-
cies in the body and can be taken orally
creases the incidence of infection, muscle
ter surgery and overall daily health.
or by injections if the body is unable to
weakness and falls, defects in the skeletal
absorb B12 due to medications or other
mineralization process, bone discomfort
medical complications.
and aches and pains in the joints and
The following essential vitamins are often deficient in people with diabetes.
muscles.
Vitamin D Vitamin B12
One of the complications diabetics face is
The major source of vitamin D is exposure
Vitamin B12 is essential in the formation
the loss of bone density, so a deficiency of
to sunlight, leading to a major seasonal
of red blood cells, neurological function
vitamin D puts them at greater risk of frac-
variation in circulating 1,25(OH)2D in the
and DNA synthesis. It also supports the
tures or osteoporosis. Vitamin D needs to be
blood stream.2
14
The Triangle Physician
The few foods that naturally contain sig-
Researchers have an increased interest
er medical management combined with
nificant amounts of vitamin D include fatty
in the role of magnesium in preventing
nutritional management can help over-
fish, such as salmon, mackerel and her-
and managing disorders such as diabetes.
come these hurdles.
ring, along with fish oils, such as cod liver
Low levels of magnesium can cause insu-
oil. Farm-raised fish tend to have 100-250
lin resistance and are frequently seen in
IU of vitamin D per 100g serving, versus
individuals with Type 2 diabetes.
500-1,000 IU for the same-sized serving of wild-caught fish. Some foods are forti-
Foods high in magnesium are rice, wheat
fied with vitamin D, such as milk, some
and oat bran and certain herbs, seeds and
juice products, some breads, yogurts and
nuts. The recommended daily allowance
cheeses.
of magnesium is 400mg.
Supplementation of vitamin D is usually
Someone with diabetes mellitus is always
necessary for most individuals to achieve
at risk for wounds and slow healing. Prop-
References IH Office of Dietary Supplements. (2011). N Dietary Supplement Fact Sheet: Vitamin B12. 2 Holick, M.F. & Chen, T.C. (2008). Vitamin D deficiency: A worldwide problem with health consequences. American Journal of Clinical Nutrition, 87(Suppl.), 1080S-1086S. 3 Holick, M.F. (2006). High prevalence of vitamin D inadequacy and implications for health. Mayo Clinic Proceedings, 81(3), 353-373. 4 NIH Office of Dietary Supplements. (2011). Dietary Supplement Fact Sheet: Vitamin D. 1
the optimal intake. The recommended 3
daily intake of vitamin D For healthy adults is 600 IU.4
Vitamin E Vitamin E acts as a powerful antioxidant, protecting cells against the damaging effects of free radicals containing an unshared electron and is also intimately involved with healthy immune function. It promotes eye health and can prevent hardening of the arteries by controlling cholesterol levels. The risk of heart disease, stroke and heart attack can all be linked to deficiencies in vitamin E levels. Foods containing ample amounts of vitamin E are nuts, seeds and vegetable oils. The synthetic form of alpha-tocopherol is found in supplements as dl-alpha-tocopherol, which has only half of the bioactivity as naturally occurring vitamin E.
Magnesium Magnesium is needed for more than 300 biochemical reactions in the body and is an essential mineral in the regulation and improvement of blood sugar control. It helps maintain normal muscle and nerve function, keeps heart rhythm steady, supports a healthy immune system and keeps bones strong. Magnesium also plays a role in the secretion and function of insulin by opening cell membranes for glucose and helps the body to digest, absorb and utilize proteins, fats and carbohydrates. Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
august 2013
15
Orthopedic Surgery
Relieving Pain in the
Aging Back
By Sameer Mathur, M.D.
The aging population presents a unique challenge in the sense that the majority of people above the age of 65 will have disc degeneration, spinal stenosis and spinal instability. Back pain is a common complaint that af-
back and leg pain can occur secondary to
fects more than 80 percent of Americans.
a disc herniation, while in the older popu-
Most people will miss work or have to visit
lation it is more likely to be spinal stenosis.
their physician due to back pain. Osteoporotic compression fractures are Couple the prevalence of back pain with
unique to people over the age of 65. Spi-
the growth of the aging population and a
nal instability (spondylolisthesis) is more
health care crisis occurs. The older pop-
prevalent as well. However, all age groups
ulation (persons 65 years or older) rep-
share muscle deconditioning, poor pos-
resents 12.9 percent of the Unites States
ture and over-use as a cause for back pain.
population, about one in every eight Americans. By 2030, there will be about 72.1 mil-
Diagnosis
lion older persons, more than twice their
The diagnosis of spinal pathology is based
number in 2000.
upon a thorough history, accurate physical examination and radiographic imaging.
As a spinal surgeon, my office is routinely
Dr. Sameer Mathur, a board-certified orthopedic spinal surgeon with Cary Orthopaedic Spine Specialists, earned his undergraduate and medical degrees at the University of Pennsylvania. He completed a spinal reconstructive fellowship at RUSH Medical Center in Chicago and was awarded research fellowships at the National Institutes of Health and the Dana Farber Cancer Institute (Harvard Medical School). Dr. Mathur was an assistant professor at the University of North Carolina, Chapel Hill, where he conducted research in spinal trauma and genetics of scoliosis. After joining Cary Orthopedic, he started the Center for Minimally Invasive Spine Surgery. Dr. Mathur treats a wide array of spinal pathology from herniated discs to complex adult deformity. He is particularly interested in using the latest minimally invasive techniques to treat compression fractures (kyphoplasty), cervical stenosis, disc herniations and spinal instability. For more information visit mathurspinesurgery.com.
filled with people in their 60s, 70s and
The aging population presents a unique
even 80 who are very active (including an
challenge in the sense that the majority of
82-year-old triathlete). They suffer from back
people above the age of 65 will have disc
I usually start with a comprehensive physi-
pain and/or sciatica just as their younger
degeneration, spinal stenosis and spinal
cal therapy program and a short course of
counterparts and don’t want to be told they
instability.
anti-inflammatory medications. If physical
are “too old� to have spinal surgery.
therapy is ineffective and the patient has In my practice, I always examine the pa-
radiculopathy (pain in a corresponding
Over the past several years, there has been
tient first to determine what level I feel is
dermatome and myotome), I recommend
a paradigm shift in spinal surgery with the
involved and proceed with treatment after
a lumbar epidural injection.
advent of minimally invasive surgical pro-
reviewing magnetic resonance imaging
cedures. A significant portion of my spine
findings.
Minimally Invasive Spine Surgery
ing population with less-invasive surgical
Treatment
If non-operative treatment modalities fail to
techniques.
In my practice less than 10 percent of pa-
provide relief, we offer minimally invasive
tients, whether young or above 65, are of-
surgical options.
practice has evolved into treating the ag-
Causes of Back Pain
fered surgical intervention. The majority
The etiology for back and leg pain are
of patients improve with physical therapy,
Compression Fractures: Acute compres-
somewhat different in the older and young-
injections and oral anti-inflammatory medi-
sion fractures are treated with a procedure
er populations. In the younger population,
cations.
called a kyphoplasty. Under IV sedation, a
16
The Triangle Physician
balloon catheter is introduced via a portal and inflated creating a void. Subsequently, the liquid polymer poly (methyl methacrylate) is placed through the same portal into the vertebral body. The surgery is performed on an outpatient basis with instant relief of pain. Lumbar Spinal Stenosis or Disc Herniation: Surgery can be performed using
Partnering with patients and providers for a healthier community.
tubular retractors and a microscope to relieve pressure on a nerve. This is done on an outpatient basis with minimal blood loss.
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Scoliosis: We are able to treat adult scolio-
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sis with a minimally invasive lateral fusion and percutaneous pedicle screws. The lateral fusion can restore spinal balance, and the screws secure the individual vertebral
Joseph C. Moran, MD, FASMBS 2801 Blue Ridge Road, Suite 101 Raleigh, NC 27607
bodies. In the past, this surgery was performed via a large open incision with sig-
P: 919.781.0815 F: 919.781.0816
nificant blood loss. Now the same surgery
www.alasurgery.com
can be done with minimal muscle dissection and nominal blood loss.
Expert, cost effective and timely care is what Carolina Endocrine has to offer your patients. • Neck Ultrasounds (ECNU certified) • Fine needle aspiration biopsies • Nuclear medicine studies • Pediatric Endocrinology
All in one convenient location at 3840 Ed Drive, behind Rex Hospital.
919-571-3661
www.CarolinaEndocrine.com Dr. Michael Thomas, Ph.D. Dr. Julia Warren-Ulanch Dr. Khushbu Chandarana Courtney Kovalick, PA-C Eileen Andres, PA-C
august 2013
17
Orthopedic Surgery
Repairing Worn-Out Joints Will it Ever Be a Reality? By Louis C. Almekinders, M.D.
O
ver one-third of us suffer from “worn-out joints,” or osteoarthritis, in this country. Conservative estimates indicate that more than 25
million Americans are looking for treatment of painful joints due to loss of cartilage in one or more joints. For the medical world, this results in more than seven million ambulatory visits. For the country as a whole, it has been estimated that this results in over $13 billion in job-related costs. It seems clear that this is a significant health and economic problem. Therefore, good treatment solutions would be expected to result in measurable improvements in quality of life and potentially decreased cost to our society. When patients are being told their joint pain is due to loss of cartilage or osteoarthritis, I frequently get the response: “Can’t you just squirt something in there that restores this problem?” The constant barrage of medical one-liners in our media has left many with the impression that a little “stem cell therapy” is a reality for many conditions including osteoarthritis. Unfortunately, we are a long way from truly repairing worn-out human joints with cartilage restoration. As we are obligated to practice evidencebased medicine, we should continue to look critically at newer treatment methods before we universally recommend them to patients. Our medical literature does lend support to cartilage restoration of smaller defects (2-5 square centimeters or less). Since the 1990s, the use of such surgical techniques as microfracture marrow stimulation, chondrocyte implantation and osteochondral transfer have shown to result in acceptable levels of improvements for many active patients with small defects. However, this is clearly not the answer for diffuse defects that we generally see in osteoarthritis. Injection treatments with hyaluronic acid and autologous platelet-rich plasma have more recently been touted as potential answers. As we look critically at injection therapy, we must be realistic with patients and explain that these methods have not conclusively been shown to improve joints with osteoarthritis and in some studies were no better than placebo treatment. To date, no basic science research has resulted in any type of stem cell option that is close to clinical implementation for osteoarthritis. Prosthetic joint replacement surgery, for better or worse, remains our main treatment option for worn-out joints. Although it does not truly repair a joint, it continues to reduce pain and restore function to a
18
The Triangle Physician
Dr. Louis Almekinders is a native of the Netherlands, where he attended Erasmus University (Rotterdam, the Netherlands) for both undergraduate and medical studies. After graduation, he moved to the United States. While in North Carolina, he completed a residency in orthopedic surgery and a research fellowship at Duke University Medical Center. In 1989 he joined the faculty of the Department of Orthopaedic Surgery of the University of North Carolina at Chapel Hill. In the ensuing 14 years, Dr. Almekinders worked as a team physician for the varsity athletic teams and became a tenured, full professor at UNC. In addition, he spent a considerable time in basic, orthopedic research focusing on acute and chronic soft-tissue injuries. In 2003, Dr. Almekinders cofounded the North Carolina Orthopaedic Clinic. He is a clinical professor in the Division of Orthopaedic Surgery at Duke University and remains active in teaching and conducting clinical research.
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level that is appreciated by most patients undergoing this procedure. The basic idea of joint arthroplasty components has not changed since their inception, but many design and fixation changes allow the surgeon to choose from an array of partial and complete replacements. I find it important to stress to patients with osteoarthritis that joint replacement does not make a joint normal. Therefore, it is important to not jump to replacement surgery at the first signs of arthritis. However, advanced arthritis after failed attempts
at
conservative
treatment
generally makes for a thankful patient after successful arthroplasty surgery. The Centers for Medicare & Medicaid Services has formalized this approach by now requiring documentation of failed conservative
treatment.
If
performed
correctly and the patient adheres to the rehabilitation protocol, joint arthroplasty remains one of the most cost-effective medical treatments in all of medicine.
august 2013
19
Gastroenterology
Treating the Various Forms of
Irritable Bowel Syndrome By Douglas A. Drossman M.D.
Irritable bowel syndrome affects about 10
by abnormal motility or uncoordinated
percent of all adults and, thus, represents a
contractions that can lead to diarrhea,
large portion of patient care visits.
constipation or bloating. Also, visceral hypersensitivity or lower pain threshold
Patients with irritable bowel syndrome (IBS)
of the nerves can produce the abdominal
experience a combination of persistent and
discomfort or pain that is characteristic of
recurrent abdominal pain that is associated
IBS. Abnormal motility, stress or infection
with abnormal bowel habit. The pain often
can lead to this visceral hypersensitivity.
begins after eating and typically is relieved af-
Finally, dysfunction of the brain’s ability to
ter a bowel movement. Other possible symp-
regulate visceral (intestinal) activities can
toms include bloating, passage of mucus and
play a role in IBS.
a feeling of incomplete emptying.
Range of Treatment Options Diagnosing Symptoms
The most frequently seen group of IBS pa-
The Rome Foundation has established
tients has mild symptoms. They are seen
symptom-based criteria (Rome III) to en-
in primary care practices, usually maintain
able greater precision in making a diag-
normal daily activities and have little or no
nosis of IBS and reducing unneeded diag-
psychosocial difficulties. These patients
nostic testing. Key features of these criteria
may experience a flare in their symptoms
include abdominal discomfort or pain that
at times of increased stress. Treatment in-
is associated with:
volves education, reassurance and dietary
• Increased frequency and looser bowel
or lifestyle changes. Prescription medica-
movement – IBS-D (diarrhea prominent)
tions or psychological treatments usually
if occurrence is greater than 25 percent
are not needed for mild IBS.
of the time; or,
Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation.org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www. drossmancenter.com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patient-provider relationship. Drossman Gastroenterology P.L.L.C. (www. drossmangastroenterology.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management of GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.
• Decreased frequency and harder stool –
A smaller proportion of patients have mod-
IBS-C (constipation prominent) if occur-
erate symptoms that are usually intermit-
rence is greater than 25 percent of the
tent, although at times are disabling. Symp-
have severe symptoms. They are mostly
time and pain is relieved with a bowel
toms may produce emotional distress and
seen in a referral center and frequently
movement.
greater physiological gut reactivity. Treat-
have severe, often constant, pain and psy-
• Presence of both looser and harder
ments for these patients involve gut-acting
chological distress, including depression
stools – IBS-M (mixed) if occurrence is
pharmacological agents, like anticholiner-
and anxiety. They also may have other
greater than 25 percent of the time.
gics, antidiarrheals and chloride channel
psychosocial difficulties, like a history of
Symptoms should be present for six
activators, depending on the predominant
sexual/physical abuse or maladaptive cop-
months and criteria should be met for
symptom.
ing styles. In these cases, antidepressant medications, like tricyclic antidepressants
three months to be confident in an IBS diagnosis.
Understanding the Root of Symptoms
If the symptoms are more persistent, treat-
and serotonin–norepinephrine reuptake
ment may also include low-dose tricyclic
inhibitor, and possibly mental health re-
antidepressants and/or psychological treat-
ferral are needed. For these patients, the
ments, like cognitive behavioral therapy.
physician-patient relationship is an important tool to provide psychosocial support
IBS symptoms may have any of several underlying causes. First, IBS can be caused
20
The Triangle Physician
Finally, a very small proportion of patients
through brief, regular visits.
Practice Management
Stage 2 for Specialists By Joe Reddy
Inevitably and for various reasons, there
different vendor than the referring provider.
will be a certain percentage of late adopters of electronic health record (EHR)
The patient portal is also a requirement in
technology. If you happen to fall into this
Stage 2. This is not just for patient access of
group, it’s possible you have overlooked a
records. The patient must also be able to
potential consequence beyond the missed
transmit that information directly from the
incentive payments and pending penalties.
online portal to another provider.
Meaningful use (MU) Stage 2, which many
As many of a specialist’s patients come by
practices will be attempting to attest to in
way of referral, these are important issues.
2014, has a number of additional require-
By not engaging EHR and MU in a timely
ments. One optional menu objective from
manner or at all, you could be limiting your
Stage 1 that is now a required core objec-
referring base of physicians. You could be-
tive in Stage 2 involves transitions of care.
come a less attractive professional partner, if it’s more difficult to work with you.
Physicians transitioning or referring patient care to another setting or provider
Joe Reddy is the owner of RevMedRx, a North Carolinabased revenuecycle management company. RevMedRx offers sophisticated, yet affordable, solutions to today’s complex practice management needs with a focus on efficiency and cash-flow optimization. Joe Reddy can be reached at joe.reddy@ revmedrx.com. To learn more, visit www.revmedrx.com.
a year or two out, but if engaging EHR is inevitable, why delay with incentives now and
Understandably, the potential impact may be
penalties pending? Something to consider.
must transmit a summary of care record to the next provider. Medicare and Medicaid providers must exchange information electronically for more than 50 percent of
The Triangle Physician 2013 Editorial Calendar
patient referrals and transitions of care.
September Atrial Fibrillation Urology, Web Design
November Alzheimer’s Disease Diabetes, Financial Planning
October Cancer in Women, COPD - Lung Health Medical Software - EMR
December Pain Management, Spine Disorders Practice Management
Of this 50 percent, more than 10 percent must be transmitted through certified EHR technology (CEHRT). Moreover, providers must transmit at least one summary of care record to a provider using CEHRT from a
Cary Endocrine & Diabetes Center, P.A.
CEDC provides diagnosis and treatment for patients with hormonal and metabolic disorders including: diabetes, lipid disorders, PCOS, thyroid disorders, osteoporosis and other bone disorders, pituitary disorders, adrenal disorders, and sex hormone disorders.
Celebrating our first year in Cary!
Sung-Eun Yoo, MD
Endocrinologist Diplomat, American Board of Endocrinology, Diabetes and Metabolism Diplomat, American Board of Internal Medicine Endocrine Certification in Neck Ultrasound (ECNU) Certification in the International Society for Clinical Densitometry (ISCD)
On-Site Services: • Thyroid, parathyroid and neck ultrasound • Ultrasound guided FNA • DEXA bone density scans and interpretation • Osteoporosis therapy • Comprehensive diabetes management including diabetes education, insulin pump therapy, and continuous glucose monitoring • LabCorp in-house Introducing Jeanne Hutson, NP-C Board Certified in Advanced Diabetes Management
Cary Endocrine & Diabetes Center, P.A. • 103 Parkway Office Court, Suite 202 • Cary, NC 27518 • 919-378-2332 • www.caryendocrine.com
august 2013
21
Duke Research News
Doctors Should Discuss Financial Concerns of Cancer Patients Most cancer patients would like to talk about the cost of their care with their doctors, but often don’t because they fear the discussion could compromise the quality of their treatment, researchers at Duke Cancer Institute report.
Of patients with the highest degree of financial distress – determined by a gauge commonly used in the financial planning field – 61 percent said they wanted to discuss treatment costs with their doctors, but only 25 percent had done so.
Yet many patients who do broach the subject of finances believe it helps decrease costs.
“There’s a real disconnect,” Dr. Zafar said. “Even people with the highest needs aren’t bringing up costs as part of the decision-making process.”
Those findings, from a survey of 300 insured patients treated at Duke and affiliated clinics in rural North Carolina, suggest that doctors can play a role in easing financial worries just by taking the problem into account. “We wanted to know whether patients wanted costs to impact their treatment decision,” said Yousuf Zafar, M.D., M.H.S., assistant professor at Duke and lead author of the study slated for presentation June 3 at the 2013 Annual Meeting of the American Society of Clinical Oncology in Chicago (ASCO Abstract #6506). “We know many patients are burdened by outof-pocket costs, but we know little about how those costs impact decision making.” Dr. Zafar said 57 percent of the participants in the Duke survey said they wanted to talk about treatment costs with their doctors, but only 19 percent actually had that conversation.
Why? Some responded that they were embarrassed; others didn’t think it was something the doctor could help with or should worry about. But many – 28 percent - said they wanted the best possible care regardless of cost. Dr. Zafar said other studies have shown that patients fear receiving less-optimal treatments if they raise concerns about costs. “We found that when patients did talk about costs with their doctors, many felt they gained something from the discussion – that their expenses were reduced,” Dr. Zafar said. “This suggests that the perceived barriers to the cost conversation aren’t real, and we need to do more to foster a dialogue around these issues.” Dr. Zafar said doctors should have tools to identify the patients who need help, so they can direct to them to the appropriate resources.
“Patients rely on oncologists to help with treatment decision making. A core tenet of shared decision-making is considering patients’ values and preferences,” Dr. Zafar said. “Without considering costs to the patient as part of the treatment process, we have to ask: Are we really taking all patient preferences into account? “With today’s evolving health insurance landscape, cancer treatment-related costs to patients are more important than ever,” Dr. Zafar said. “These data are particularly interesting and liberating, as they indicate a two-way interest in cost discussions. As providers, our team is convinced that cost discussions with our patients is important, and knowing that patients want to have these discussions should give us confidence in making this a routine practice.” In addition to Dr. Zafar, study authors include Amy P. Abernethy, James A. Tulsky, Peter A. Ubel, Deborah Schrag, Christel Rushing, Fumiko Chino, Jonathan Nicolla, Ivy Altomare, Greg Samsa and Jeffrey M. Peppercorn. The study was funded by the Duke Cancer Institute Cancer Control Pilot Studies Award, the Duke Clinical Research Institute Comparative Effectiveness Research KM1 Award and an American Cancer Society Mentored Research Scholar Grant.
UNC Research News
More than $2 Million to Study Glucose Monitoring Is Awarded Re-
2 diabetes using oral medications. The
patients with Type 2 diabetes treated in a
search Institute has approved a research
three-year project will focus on assess-
community-based clinic setting.
award to the University of North Carolina
ing the impact of three different types
School of Medicine to study the role of
of blood sugar, or glucose, home-testing
Katrina Donahue, M.D., M.P.H., associate
glucose monitoring in patients with Type
approaches on outcomes important to
professor of family medicine, and Laura
The
22
Patient-Centered
The Triangle Physician
Outcomes
UNC Research News Young, M.D., Ph.D., assistant professor of
The researchers stated that this impor-
The UNC study is one of 51 projects total-
medicine, will lead the research project.
tant, patient-centered project will help
ing more than $88.5 million approved for
Both are members of the North Caro-
patients and those who care for them
funding by PCORI’s board of governors
lina Clinical and Translational Institute,
make better, evidence-based decisions
May 6. All were selected through a highly
academic home of the National Institutes
about whether or not blood glucose
competitive review process in which
of Health Clinical and Translational Sci-
monitoring can improve the outcomes
scientists, patients, caregivers and other
ence Awards (CTSA). John Buse, M.D.,
they value most. They also said the re-
stakeholders helped choose more than
Ph.D., professor of medicine and dep-
sults will shape future decision-making
400 applications for funding. Proposals
uty director of the CTSA, will lead the
in diabetes-care practice and guidelines.
were evaluated on the basis of scientific merit, how well they engage patients and
stakeholder advisory team comprising patients and community members, as
The study is part of a portfolio of patient-
other stakeholders, their methodologi-
well as representatives from industry,
centered research that addresses the
cal rigor and how well they fit within the
advocacy groups and state government.
PCORI national research priorities and
PCORI national research priorities, ac-
The contract from the Patient-Centered
will provide patients with information
cording to the press advisory.
Outcomes Research Institute (PCORI) is
that will help them make better informed
for $2,090,699.80.
decisions about their care.
“Given the time and resource-intensive
According to a UNC press advisory,
new round of funding follows PCORI’s
nature of glucose self-monitoring, to
“UNC is well placed to manage the study
initial approval of $40.7 million in sup-
test or not to test is a critically important
because of the collaborative network
port for 25 projects under the institute’s
question facing the millions of patients
and research infrastructure provided by
national research priorities. All awards in
living with non-insulin-treated Type 2
the National Institutes of Health CTSA,
this most recent round of funding were
diabetes,” said study leaders Drs. Dona-
as well as UNC’s well-known work in the
approved pending completion of a busi-
hue and Young in a written statement.
area of patient-centered care.”
ness and programmatic review by PCORI
The awards are part of PCORI’s second cycle of primary research funding. This
staff and issuance of a formal award con-
“Patients often receive mixed messages
tract.
about blood glucose self-monitoring. We
Dr. Donahue practices in the UNC Family
are excited that PCORI has recognized
Medicine Center, a National Committee
the lack of consensus around the utility
for Quality Assurance-certified patient-
For more information about
of glucose monitoring in patients with
centered medical home. Study partici-
PCORI’s funding announcements, visit
Type 2 diabetes not treated with insulin.”
pants will come from counties in central
www.pcori.org/funding-opportunities.
North Carolina, through partnerships with the UNC Physician Network practices.
Community Support
Local Events Help STOMP the Monster The nonprofit STOMP the Monster North Carolina hosts events to raise awareness and funds for cancer patients, their families and caregivers to assist them during their battle with the disease. In addition to the events represented here, the organization helped run the bike check-out station for athletes during the IRONMAN 70.3 in Downtown Raleigh June 2.
Debbie Ross (center) stands with Brittani Boehlke, M.S., PA-C; and Mark L. Graham II, M.D., of Waverly Hematology Oncology during the STOMP the Monster Wine Tasting/Silent Auction May 11 at the Halle Cultural Art Center in Apex.
From left, Gini Hyman and Susan Blumenthal, PA-C, of Waverly Hematology Oncology enjoy an evening of painting at the Heart-full Art fundraiser June 3 at Artistic Abandon, where artist-owner Emily Page presented 50 percent of the proceeds, totaling $562.50, to the nonprofit STOMP the Monster NC. august 2013
23
News Welcome to the Area
Physicians Zachary Ian Love, DO Orthopedic Surgery; Adult, Reconstructive, Pediatric, Trauma, Ankle Foot, Hand Surgery, Sports Medicine Department of Orthopaedic Surgery Durham
Dina Marie Randazzo, DO Neurology Duke University Hospitals Durham
Parvish Pradip Shah, DO Diagnostic Radiology; Radiology Department of Radiology Durham
Kendall Denise Jefferson Agochukwu, MD Pediatrics Sandhills Pediatrics Southern Pines
Andrew Robert Paul Barina, MD Diagnostic Radiology Duke University Hospitals Durham
Ali Bourguet-Vincent, MD Pediatrics Duke University Hospitals Durham
Eric Chiane Chu, MD Hospitalist; Internal Medicine Duke Raleigh Hospital Raleigh
Craig Ashley Cook, MD Psychiatry Chapel Hill
Natasha Tania Cunningham, MD Internal Medicine; Psychiatry; Psychosomatic Medicine Duke University Hospitals Durham
Anthony James Dedousis, MD Psychiatry University of North Carolina Hospitals Chapel Hill
Michael Dean Deel, MD Pediatric Hematology-Oncology; Pediatrics Duke University Durham
Priyank Kishorkumar Desai, MD Internal Medicine - Critical Care Medicine; Pulmonary Disease Boice-Willis Clinic Rocky Mount
Wei Duan-Porter, MD Internal Medicine Durham VA Medical Center Durham
Stephen Tyler Elkins-Williams, MD Critical Care Surgery; Plastic & Reconstructive Surgery; Abdominal Surgery; General Surgery; Trauma Surgery; Colon and Rectal Surgery Univ of North Carolina Hospitals Chapel Hill
Returi Priti Rao Elkins-Williams, MD Pediatrics Cornerstone Pediatric & Adolescent Medicine Cary
24
The Triangle Physician
Diana Terry Feldstein, MD
Nicole Helene Odom, MD
Internal Medicine Carrboro
Child Neurology; Clinical Neurology, Neurophysiology UNC Hospitals Chapel Hill
Nicole Elizabeth Frederick, MD Hospitalist; Internal Medicine Durham VA Medical Center Durham
Jesse Aaron Goldstein, MD Plastic Surgery; Hand Surgery UNC Division of Plastic Surgery Chapel Hill
Elizabeth Anne Greig, MD Internal Medicine UNC Internal Medicine Clinic Chapel Hill
Lars Johannes Grimm, MD Diagnostic Radiology; Radiology; Vascular and Interventional Radiology Duke University Hospitals Durham
Sinisa Haberle, MD Radiology; Diagnostic Radiology Duke University Hospitals Durham
Jacob Cameron Hartz, MD Pediatrics Duke University Hospitals Durham
Toma Samantha Omonuwa, MD
Vanessa Teaberry Schroder, MD
James Anthony Wrzosek, MD
Abdominal Surgery; Critical Care Surgery; Surgery - Surgical Critical Care; General Surgery Duke University Hospitals Durham
Ophthalmology Raleigh Eye Center Raleigh
Diagnostic Radiology; Vascular and Interventional Radiology Duke University Hospitals Durham
Deepti Sharma, MD
Pretesh Ramanlal Patel, MD
Family Medicine; Family Practice 313 Stromer Drive Cary
Radiation Oncology Duke University Medical Center Durham
Vaishali Patel, MD Internal Medicine Duke University Hospitals Durham
Bhavik Natvar Patel, MD Diagnostic Roentgenology Radiology Duke University Medical Center Durham
Marc Steven Piper, MD Internal Medicine University of North Carolina Hospitals Chapel Hill
Hospitalist; Internal Medicine Cary
Shraddha Sharma, MD
Holly Clare Simpson, MD Ophthalmology TEI Management Raleigh
Stephen George Stahr, MD Dermatology University of North Carolina Hospitals Chapel Hill
Eryn Kathleen Stansbury Clipp, MD Obstetrics and Gynecology Westside Ob/Gyn Burlington
Christina Pernia Prather, MD
Shannon Tew, MD
Anesthesiology Pain Management University of North Carolina Hospitals Chapel Hill
Hospitalist; Internal Medicine; Geriatrics; Hospice and Palliative Medicine University of North Carolina Hospitals Chapel Hill
Reena Mary Thomas, MD
Jeffrey Javidfar, MD
Erin Colleen Regan, MD
Gregory Dennis Jackson, MD
Surgery; Thoracic Surgery Cardiothoracic Surgery Training Program Durham
Xiaoyin Jiang, MD Pathology Duke University Hospitals Durham
Aliiah Vernee Jourdain, MD Emergency Medicine Duke University Hospital Durham
Eun Lee Langman, MD Radiology; Diagnostic Radiology Duke University Hospitals Durham
O’Nisha Shanette Lawrence, MD Psychiatry University of North Carolina Hospitals Chapel Hill
Jason Michael Long, MD Thoracic Surgery 1204 Salem Lane Chapel Hill
Mahendra Mangray, MD Internal Medicine; Nephrology Carolina Kidney & Vascular, PA Goldsboro
Douglas Scott Maxey, MD Anesthesiology, Pain Medicine Chapel Hill
Alicia Kate McFarren, MD Pediatric Hematology-Oncology Pediatric Blood and Marrow Transplant Program Durham
Joshua Aaron Bradley Moore, MD Internal Medicine Vidant Medical Center, GME Greenville
Pediatrics Jeffers, Mann & Artman Pediatrics Raleigh
John Keith Roberts, MD Nephrology, Internal Medicine Duke University Hospitals Durham
John Woodson Roberts, MD Southern Pines
Thomas Walker Robinson, MD Pediatric Sports Medicine; Pediatrics Durham
Brittany Page Rodgers, MD
Anesthesiology; Critical Care Medicine; Pain Management Duke University Hospitals Durham Internal Medicine Duke University Hospitals Durham
Syreeta Alston Tucker, MD Obstetrics and Gynecology Vidant Medical Center, GME Greenville
Jonas Alexander Vanags, MD
Physician Assistants Kathryn Renae Andrukonis, PA
Wake Forest Emergency Physicians Burlington
Adam Benjamin Brewer, PA Orthopedic Sports Medicine; Orthopedic Surgery Wake Forest
Lori Ann Brooks, PA Internal Medicine; Preventive Medicine/Occupational; Public Health & General; Urgent Care; Urology; Diabetes; Family Medicine - Geriatric Medicine; Infectious Diseases Butner Federal Correctional Complex Butner
Paulina Jude Collier, PA Orthopedic Sports Medicine; Orthopedic Surgery; Adult Reconstructive, Pediatric, Trauma, Ankle Foot Triangle Orthopaedic Associates, PA Durham
Rachel Griffin, PA Chapel Hill
Jerald Dean Grissom Jr, PA Cardiology; Hospitalist Durham VAMC Cardiology 111A Durham
Terry Daniel Henges, PA
Neurology Duke University Medical Center Durham
Dermatology 891 Willow Drive Chapel Hill
Divya Vodikad Jaiprakash, MD
Lauren Simpson Miglarese, PA
Internal Medicine Cary
Family Medicine; Family Practice/ Geriatric Medicine; Hospitalist; Internal Medicine Raleigh
Psychiatry University of North Carolina Hospitals Chapel Hill
Michael Healy Ward, MD
Jason Alexander Watts, MD
Urgent Care
Kristen Marie Rogers, MD
Internal Medicine Duke University Hospitals Durham
Renee Shopshire, PA
Pediatrics University of North Carolina Hospitals Chapel Hill
Ewa Dominika Ruel, MD Endocrinology, Internal Medicine Duke University Medicine, Division of Endocrinology, Diabetes and Metabolism Durham
Roberto Sanchez Gutierrez, MD Family Medicine; Hospitalist Alamance Regional Medical Center Burlington
Zachary W Sandbulte, MD
Emergency Medicine Chapel Hill
Sarahn Malena Wheeler, MD Obstetrics and Gynecology Duke University Medical Ctr Durham
Laura Marie Willing, MD Psychiatry University of North Carolina Hospitals Chapel Hill
Megan Elaine Wilson, MD Internal Medicine; Pediatrics; Hospice and Palliative Medicine Duke University Health System Durham
Family Medicine; Sports Medicine University of North Carolina Hospitals Chapel Hill
Amberly Kay Windisch, MD
Lucy Marie Schenkman, MD
William Asher Wolf, MD
Obstetrics and Gynecology Duke University Hospitals Durham
Urological Surgery; Urology UNC School of Medicine Chapel Hill Internal Medicine; Gastroenterology University of North Carolina Hospitals Chapel Hill
Muna Odeh, PA
Administrative Medicine; Gastroenterology, Internal Medicine; General Practice Durham VA Medical Center Durham
Margaret Anne Tyma, PA Adolescent & Young Adult Medicine; Family Medicine; Family Practice; Emergency Medicine; Family Practice/ Sports Medicine; Internal Medicine; Pediatrics; Urgent Care NC Neuropsychiatry Raleigh
“More than a doctor. Like a friend.”
Trust. WHV provides comprehensive heart services to prevent, diagnose and treat a full range of cardiovascular-related conditions. As heart specialists we are committed to providing access to quality care throughout Central and Eastern North Carolina. As part of UNC Health Care / Rex Healthcare, we can tap into the most up-to-date research and expertise, providing our patients with access to clinical trials and new therapies, resulting in the best cardiovascular care in the area.
Experienced Cardiologists J. Tift Mann, III, MD, FACC (retired) Michael Zellinger, MD, FACC William N. Newman, MD Gregory C. Rose, MD, FACC Joel E. Schneider, MD, FACC Eric M. Janis, MD, FACC R. Lee Jobe, MD, FACC Randy A.S. Cooper, MD, FACC Robert B. Wesley, II, MD, FACC Joseph M. Falsone, MD, FACC Kevin R. Campbell, MD, FACC Benjamin G. Atkeson, MD, FACC Ravish Sachar, MD, FACC
Locations in North Carolina
Benson Clayton Clinton
Goldsboro Knightdale Lillington
Arthur Y. Chow, MD, FACC Christian Gring, MD, FACC Matthew A. Hook, MD, FACC Andrew C. Kronenberg, MD, FACC Mateen Akhtar, MD, FACC Richard J. Pacca, MD, FACC Waheed Akhtar, MD, MRCP, FACC Malay Agrawal, MD, FACC Sunil P. Chand, MD, MRCP, FACC Paul A. Perez-Navarro, MD, FACC Sidharth A. Shah, MD Ashley M. Lewis, MD
Louisburg Raleigh Rocky Mount
Cardiovascular Services General Cardiology Echocardiography Nuclear Cardiology Interventional Cardiology Carotid Artery Interventions Cardiac Catheterization Cardiac CT Angiography and Calcium Scoring Electrophysiology and Cardiac Arrhythmia Peripheral Vascular Interventions Pacemakers / Defibrillators Stress Tests Holter Monitoring Lipid (Cholesterol) Clinics
Smithfield Wake Forest Wilson
When it comes to your cardiovascular care – We know it by heart.
1.800.WHV.2889 (800.948.2889) | www.WHVheart.com
Advanced Medical Imaging for Your Patients 19 Convenient Triangle Area Locations
True subspecialized diagnostic and interventional radiology Established in 1953, Wake Radiology is the leading provider of outpatient medical imaging for families in the Triangle. Our more than 50 radiologists are recognized experts, subspecialty trained and certified by the American Board of Radiology. As a longtime leader in low-dose imaging of children and adults, our commitment to minimize radiation exposure while maintaining high quality imaging is at the corner of what we do. We are proud to be the first outpatient 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 studies and the first in Wake County to offer dedicated pediatric imaging services. Plus, we operate the region’s only freestanding Positron Emission Tomography (PET-CT) facility. 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 • MRI and Low-dose CT • 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
Comprehensive Outpatient Imaging Services