j u ly 2 0 1 4
The Cancer Center at Maria Parham Medical Center
Delivers Community-Based World-Class Care
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
Also in This Issue
Communication Tips Administrative Leadership
now 87% Smaller
The Reveal LINQ Insertable Cardiac Monitor is a revolutionary system that transforms your ability to diagnose and treat even the most difficult-to-detect cardiac arrhythmias.
SMALL: 87% smaller than Reveal速 XT ICM, with 20% more data memory. SIMPLE: Simplified insertion procedure with <1 cm incision provides the most discreet cardiac monitoring option, with minimal scarring for greater patient acceptance.
CONNECTED: Only wireless insertable cardiac monitoring system that continuously
collects and trends data for up to 3 years, with automatic Medtronic CareAlert速 Notifications.
PRECISE: Clinically actionable, easy-to-read Medtronic CareLink速 reports reduce the
data management burden.
Shift into small at RevealLINQ.com
Innovating for life.
Ann Lee was feeling overwhelmed. Following a cervical polyp removal and biopsy, her Ob/Gyn had recommended a full radical hysterectomy. He also advised having a breast lesion removed. On top of that, she was told she needed an umbilical hernia repaired. Ann was concerned about multiple procedures and hospital stays, as well as all the recovery time that would interfere with her daily routine of caring for her two-year-old granddaughter, Payton. Then her Ob/Gyn told Ann about his experience with Johnston Health’s daVinci robotic surgery suite and how her hysterectomy could be done as an outpatient procedure with only a few small incisions.
Her surgeon said he could remove her appendix during the procedure, as well as the breast lesion. He then contacted her general surgeon and they arranged to coordinate the hernia repair at the same time.
“I could not be happier with the outcome!” says Ann. “I was up and back home the same day and actually able to watch over my granddaughter the next day. Within a few days, I was fully caring for her. I am thankful that Johnston Health has the daVinci capability and that my doctors were so considerate and so thorough.”
If You Have A Patient Who Could Benefit From The Less Invasive Procedures & Quicker Recovery Times Of Our daVinci Robotic System Contact Johnston Health Or Visit Us Online! 509 N. Bright Leaf Blvd. Smithfield, NC
919-934-8171
www.johnstonhealth.org
COVER STORY
6
The Cancer Center at Maria Parham Medical Center
Delivers Community-Based World-Class Care
j u ly 2 0 14
Vol. 5, Issue 4
FEATURES
9
Patient Relations
10 Tips for Improved Patient Communication â&#x20AC;&#x201C; Part II Dr. Douglas Drossman offers strategies for greater patient involvement in the management of their chronic disease.
10
DEPARTMENTS 12 Womenâ&#x20AC;&#x2122;s Health Genetic Testing for Breast and Ovarian Cancers Offers Benefits
14 Dermatology
Psoriasis: A Systemic Disease
15 Duke Research News
Heart Imaging Complexity in Children May Raise Lifetime Cancer Risk
16 Duke Research News
New Gamma and Neutron Imaging Techniques Deemed Safe in Simulations
17 WAKEMED NEWS
Practice Management
Could Your Practice Benefit from a Change in Administrative Leadership?
Donald Gintzig Assumes Helm
18 UNC Research News
Increased Mucins Pinned to Worsening Cystic Fibrosis Symptoms
19 UNC Research News
Discovery of Enzyme Role May Lead to Better Therapies for Various Cancers
20 UNC Research News
Margie Satinsky encourages careful and honest prac-
tice evaluation and taking the necessary steps
21 News
to achieve great leadership.
Clinical Tool Is First to Evaluate Violence Risk in Military Veterans
Welcome to the Area
COVER PHOTO: Standing in front of the linear accelerator at The Cancer Center at Maria Parham Medical Center (radiation oncology) are, from left: Dianne B. Dookhan, M.D., pathologist with Raleigh Pathology Laboratory Associates; Kulbir K. Sidhu, M.D., radiation oncologist with the Duke Oncology Network and The Cancer Center at Maria Parham Medical Center; Adrian M. Ogle, M.D., urologist; David Mack, M.D., medical oncologist with the Duke Oncology Network and The Cancer Center at Maria Parham Medical Center; John Faulkner, M.D., primary care physician with Four County Primary Care; and Bob F. Noel Jr., M.D., generalsSurgeon with Northern Carolina Surgical Associates.
2
The Triangle Physician
From the Editor
No Place Like Home This month, our cover story features The Cancer Center at Maria Parham Medical Center, a Duke Medicine affiliate that brought to Henderson in 1990 the most advanced technologies and specialized practitioners. Just this past March, the leadership and medical
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
staff achieved the voluntary Commission on Cancer (CoC) accreditation, underscoring their commitment to delivering world-class care to north-central North Carolina and Southside Virginia. Read on about a cancer care center that elevates quality of life for patients and their families living in this rural place.
Also in this issue, Dr. Douglas Drossman offers strategies for effective patient communications in the last of his two-part series. Dr. Andre Lukes discusses genetic testing for breast and ovarian cancers and the benefits to the patient of being informed. On the practice management front, Margie Satinsky outlines the questions whose answers may suggest the need to elevate administrative leadership and the strategies for doing so.
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Laura Briley, M.D. Douglas A. Drossman, M.D. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Margie Satinsky, M.B.A. Creative Director Joseph Dally jdally@newdallydesign.com
Advertising Sales info@trianglephysiciancom
Summer is a time for vacations, when we can get away and, hopefully, recharge. If your time away is restorative, your relaxed alpha brainwaves just might lead to inspired thinking about your practice and your referral base.
If so, it may lead you to consider the many opportunities to increase awareness via The Triangle Physician, a cost-effective vehicle for delivering key messages straight to a very key audience â&#x20AC;&#x201C; the medical community throughout the eastern half of North Carolina. Your medical news and expert perspective runs at no cost, space permitting. Other opportunities for high-profile visibility include a practice profile on the cover and advertising at competitive rates.
There really is no better way to communicate with the medical community here at home. For more information, contact me at heidi@trianglephysican.com.
Hereâ&#x20AC;&#x2122;s wishing you a summer with opportunities to unwind and reflect.
With great appreciation,
Heidi Ketler Editor
4
The Triangle Physician
News and Columns Please send to info@trianglephysician.com
The Triangle Physician is published by: New Dally Design Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. 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.
www.kendallmurphyphotography.com kendall@kendallmurphyphotography.com Maternity
Children
Newborns
Families
KendallPhotography_FP_AD_June14.indd 1
â&#x20AC;&#x153;Grow With Meâ&#x20AC;? packages
Boudoir
Business Professionals
6/10/14 9:24 PM
Cover Story
The Cancer Center
at Maria Parham Medical Center Delivers Community-Based World-Class Care The Cancer Center at Maria Parham Medi-
oped a consistent and effective communi-
nurses, radiation technologists, social
cal Center, a Duke Medicine affiliate, has
cation model that benefits each and every
workers, clerical personnel and even pa-
long provided a level of cancer care be-
cancer patient.
tient navigators, who are there to escort the cancer patient through the entire pro-
yond that typically seen at a rural hospital. Of course, it does help when the institute
At The Cancer Center at Maria Parham
cess. This multidisciplinary partnership
it’s affiliated with, the Duke Cancer Insti-
Medical Center, patients needing both dis-
results in improved patient care.
tute, has been ranked among the top cen-
ciplines of cancer therapy are seamlessly
ters in the nation for cancer services, ac-
seen by radiation and medical oncologists.
Hospital physicians involved in any aspect
cording to U.S. News & World Report, and
As needed, surgeons, pathologists, urolo-
of cancer care at Maria Parham routinely
a leader in the southeast since 1993. But
gists, radiologists and other physicians on
attend tumor board meetings and planning
it goes much deeper – the medical staff
the hospital staff join the patient’s health
sessions. Along with determining optimal
at Maria Parham Medical Center and the
care team. This multidisciplinary approach
medical care, other patient needs are rec-
Duke oncologists at the center have devel-
continues with a support staff of registered
ognized and best solutions are discussed.
From left, David Mack, M.D., medical oncologist with the Duke Oncology Network and The Cancer Center at Maria Parham Medical Center, reviews a chart with Catherine Blankenship, R.N., B.S.N., C.H.C.A., director of The Cancer Center at Maria Parham Medical Center.
6
The Triangle Physician
This type of collaboration, along with an expansion of cancer-related diagnostic services offered at the hospital, allows most patients to receive the care they need here at home. Bob Noel Jr., M.D., a surgeon with Northern Carolina Surgical Associates, is one of the specialists who works closely with The Cancer Center at Maria Parham team. “We had a grass root effort by staff physicians and specialists to create the cancer committee and work toward accreditation as an ACS (American Cancer Society) cancer center. That includes ongoing participation in educational activities, such as tumor board and cancer program improvement activities, such as program and patient care quality analysis,” Dr. Noel says. The Cancer Center at Maria Parham Medical Center Earns
Physicist Qing Chen, R.S.O., D.A.B.R., (left) collaborates with chief therapist Anthony Kidd, C.M.D., R.T., (sitting) and radiation oncologist Kulbir K. Sidhu, M.D. All are members of the Duke Oncology Network and The Cancer Center at Maria Parham Medical Center medical staffs.
National Accreditation The Cancer Center at Maria Parham took
Hospital administration and our strong
that care as convenient as possible to the
another large step in distinguishing itself
clinical team have made the commitment
patient. One of the goals of the center
as a premier place to receive cancer care
to achieve and continue to challenge our-
when it was established in 1990 was to
when the Commission on Cancer of the
selves in how we provide multidisciplinary
eventually provide comprehensive care
American College of Surgeons granted it a
cancer care and awareness in our area.”
within one location. With the addition of
three-year accreditation with commendation in March.
on-board imaging, respiratory gating, comWhen patients receive care at The Cancer
puted tomography simulation and positron
Center at Maria Parham Medical Center,
emission tomography scanning, that goal
To earn voluntary Commission on Cancer
they also have access to information on
has been achieved for a majority of the
(CoC) accreditation, a cancer program
clinical trials and new treatments, genetic
cancer patients.
must meet or exceed 34 CoC quality care
counseling and patient-centered services,
standards, be evaluated every three years
including psycho-social support, a patient
“Most of our cancer patients can now re-
through a survey process and maintain lev-
navigation process and a survivorship care
ceive full-service cancer care right here at
els of excellence in the delivery of compre-
plan that documents the care each patient
Maria Parham,” says Ms. Blankenship.
hensive patient-centered care. Three-year
receives and seeks to improve cancer sur-
accreditation with commendation is only
vivors’ quality of life.
The center has undergone multiple face-
awarded to a facility that exceeds standard
lifts, including a major expansion of the
requirements at the time of its triennial sur-
“The CoC accreditation program brings
medical oncology department in 2010 that
vey.
new and evolving national standards for
nearly quadrupled the size of the unit.
cancer care to our attention quickly, al-
Each of the 12 patient spaces has a view
lowing for prompt incorporation into our
of an outdoor garden that allows natural
patient care plans,” says Dr. Noel.
light into the treatment room. The radiation
Catherine
Blankenship,
R.N.,
B.S.N.,
C.H.C.A., director of The Cancer Center at Maria Parham, says, “This achievement
oncology side of the center is currently
reflects the highest quality of cancer care
Excellent Technologies and
undergoing its own expansion with new
available anywhere. Our program not only
Facilities Improve Patient
treatment rooms, office space and wait-
met the standards to become accredited,
Convenience
ing areas being built to handle the ever-
but also exceeded the requirements to
An important aspect of providing high-
increasing patient volumes the center has
receive commendation in several areas.
quality cancer care is to make receiving
seen during the years.
JULY 2014
7
In the Hands of Well-trained Experts
“Maria Parham is fortunate to have not only
About Maria Parham Medical
As important as all of these new technolo-
a team of talented Duke oncologists but
Center, a Duke LifePoint Hospital
gies are, it is their use in the hands of
also a team of surgeons and specialists on
Maria Parham Medical Center, located in
well-trained, experienced physicians and
staff locally who work side by side with the
Henderson, is a regional hospital serving
staff that makes all the difference. Under
cancer team to provide excellent care here
the people of north-central North Carolina
the leadership of Duke medical oncolo-
in Henderson,” says Bob Singletary, chief
and Southside Virginia. As a Duke LifePoint
gist David Mack, M.D., and Duke radiation
executive officer of Maria Parham Medi-
Hospital, Maria Parham offers a combina-
oncologist Kulbir Sidhu, M.D., The Cancer
cal Center. “Our surgeons, specialists and
tion of Duke University Health System’s
Center at Maria Parham Medical Center
even our primary care physicians actively
world-renowned leadership in clinical
has seen consistent growth in the volume
participate in planning sessions and attend
excellence and quality care and LifePoint
of patients seeking medical and radiation
the tumor board sessions. This type of col-
Hospitals’ extensive resources, knowledge
cancer care. Working along with Drs. Mack
laboration makes for a continuity of care
and experience in operating community
and Sidhu are Duke oncologists Ivy Alto-
not seen in most facilities.”
hospitals.
The Cancer Center at Maria Parham Medi-
Maria Parham offers a wide range of ser-
cal Center is a testament to the way team-
vices and the latest technology to meet the
“Our goal has always been to provide
work between a world-renowned health
health care needs of the community. It is
world class, Duke-level cancer care at Ma-
care institution, like Duke Medicine, and
fully accredited by The Joint Commission
ria Parham, and we feel that we have done
a community-based hospital, like Maria
and Core Measure Sets. For more informa-
just that,” Dr. Mack says.
Parham, can create a special place where
tion about Maria Parham Medical Center,
patients can receive the quality, expertise
call (252) 438-4143 or visit the website at
and commitment they deserve.
www.mariaparham.com.
mare, M.D., (medical) and Nicole a. Larrier, M.D., M.S., (radiation).
Medical Oncology Treatment Room
8
The Triangle Physician
Gastroenterology
Part 2
10 Tips for Improved Patient Communication By Douglas A. Drossman, M.D.
It’s well recognized that good communi-
patient’s personal experience, understand-
cation skills are the cornerstone of an ef-
ing and interests in various treatments and
fective patient-provider relationship. The
then provide choices (rather than direc-
following outlines the final five elements
tives) that are consistent with the patient’s
toward reaching this goal. The first five ele-
beliefs. The patient needs to make the final
ments are outlined in last month’s issue of
decision in these options.
The Triangle Physician. 9) Help the patient take responsibility. 6) Set realistic goals. Patients may come to
Many patients may respond to their illness
the doctor with expectations for a rapid diag-
by feeling helpless and dependent on the
nosis and cure. However, the clinician may
clinician thus abrogating their responsibil-
see this as a chronic disorder requiring ongo-
ity. However, patients with chronic illness
ing management. Therefore it helps to clarify
do better when they take responsibility for
and reconcile the patient’s goals.
their care. As an example, rather than asking the patient: “How is your pain doing?”
For example, the clinician might say: “I
one might say “How are you managing with
can understand how much you want these
your pain?” The former question suggests
longstanding symptoms to go away, but
the responsibility for pain management is
realistically we need to find better ways to
the physician’s, while the latter acknowl-
manage them, just like arthritis or migraine
edges the patient’s role.
headaches. If you could reduce your symptoms by 30 percent or 40 percent would
Another method includes offering any of
that help?”
the several treatment approaches with a discussion of their risks and benefits, so the
7) Reassure. Patients often fear serious
patient can make the choice.
consequences of their disease and may feel helpless, vulnerable to their condition and
10) Establish boundaries. For some pa-
out of control. Reassurance occurs by:
tients, it is important to establish and main-
• Identifying the patient’s worries and
tain “boundaries” related to frequent phone
concerns
calls, unexpected visits, a tendency toward
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 patientprovider relationship. Drossman Gastroenterology P.L.L.C. (www.drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management 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.
• Acknowledging and validating them
lengthy visits or unrealistic expectations
• Responding to their specific concerns
for care. The clinician needs to present
The
expectations in a way that is not perceived
information: 2012 David Sun Lecture:
It’s important to avoid premature or “false”
as rejecting or belittling to the patient yet
Helping Your Patient by Helping Yourself
reassurances (e.g., “Don’t worry, every-
is also consistent with personal needs. For
– How to Improve the Patient – Physician
thing’s fine.”) particularly before the medi-
example, if a patient calls by phone during
Relationship by Optimizing Communication
cal evaluation is completed.
off hours when not on call, the clinician can
Skills; Douglas A. Drossman, MD; Am
gently remind the patient that it would be
J Gastroenterol 2013; 108:521–528; doi:
8) Negotiate. The basis for patient-centered
better to have the discussion at their next
10.1038/ajg.2013.56; published online 19
care is that patient and physician must mu-
visit. Here it is important not to try to ad-
March 2013.
tually agree on diagnostic and treatment
dress the issue on the phone as that might
options. The doctor should ask about the
encourage further phone calls.
following
article
offers
more
JULY 2014
9
Practice Management
Could Your Practice Benefit from a Change in
Administrative Leadership? By Margie Satinsky
Managing a medical practice requires
Planning and Marketing
both strategic vision and operational
• Is there a strategic business plan that
skills. Ongoing changes in reimbursement,
guides the practice’s thinking and is
technology and the legislative landscape
regularly updated?
make the job challenging, regardless
• Is the practice well informed about
of the training and experience of the
demographic trends, community
individual responsible for the job.
dynamics, new laws and regulations and the competitive environment?
What’s the right administrative approach for your practice? There are big differences in the education and experience of an
• Is there a marketing plan that supports the strategic business plan?
Margie Satinsky is president of Satinsky Consulting, L.L.C., a Durham consulting firm that specializes in medical practice management. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century.
• Has the practice identified external
office manager, practice manager and
professionals who can help it
practice administrator.
accomplish its goals?
• Does the practice have and use a formal performance evaluation system? • Is there a formal orientation program
We recommend starting with the needs
Financial Management
of the practice, not with the availability
• Does the practice have both operating
• Is there a formal system for physician
of someone you know who might be
and capital budgets that support the
recruitment, hiring, orientation and
interested in making a job change or with
strategic plan?
performance?
a well-meaning but inexperienced relative who is willing to work for a low salary.
for all administrative and clinical staff?
• Is there a comprehensive revenue cycle management system that enables
Facilities
the practice to meet its financial goals?
• Does the current facility meet current
Ask the following questions about the
• Does the practice have a managed care
current management of the practice. If
strategy that helps it maximize revenue
the responses suggest a need for help,
and monitor actual vs. expected
Information Technology
develop a job description and recruit.
payments?
• Does the practice use information
Don’t put the cart before the horse!
• Is there a clear understanding of Accountable Care Organizations
What Does Your Practice Need?
(ACOs) and other value-based
Daily Practice Operations
methods of payment that encompasses
• Do the current methods for overseeing
how they work and how the savings/
daily practice operations meet
losses will be distributed?
the needs of patients, physicians, managers and staff? • Do staff members work as a team to identify and resolve operational problems on a timely basis? • Does the practice clearly communicate practice plans, policies and
administration and the direct provision of patient care? • Is every staff member trained to use the information technology solutions that are currently in place?
Human Resources
major changes in information
• Does the practice have a history of
technology, and if so, have decisions
high staff turnover?
already been made?
• Are responsibilities and accountabilities clear? • Does every employee have a clear job description and understand job
the information on a timely basis?
expectations?
The Triangle Physician
technology to support both
• Does the practice expect to make
procedures to all who need to know
10
and projected needs?
Quality Measurement and Improvement • Does the practice respond on a timely basis to patient complaints and
Establish a starting salary range with room
lowed by a written offer to your candidate
for growth. Advertise online and select the
of choice. A written employment contract
surveys for both patients and physician
health care management organizations
is optional. If you prefer to use this ap-
colleagues?
that can assist with recruitment. Two
proach, seek legal guidance.
questions about claims? • Does the practice use satisfaction
• Does the practice understand the
reliable resources are North Carolina
requirements of different systems
Medical Group Managers (www.ncmgm.
Conclusion
for measuring quality (e.g. Patient
org) and Medical Group Management
The best way to ensure outstanding
Centered Medical Home, Meaningful
Association’s
administrative leadership for your practice
Use)?
partner, HealtheCareers.com.
(MGMA)
administrative
is to start with your needs, develop a clear job description and then recruit. The best
• Does the practice use its software and reporting capabilities to profile
Conduct telephone interviews using a set
results come from taking the right steps in
the care provided to individuals and
list of questions and identify candidates
the right order.
groups of patien ts?
whom you would like to meet in person.
• Does the practice benchmark itself against acceptable standards and take
Following personal interviews, check ref-
For more information, visit
erences carefully. Make a verbal offer fol-
www.satinskyconsulting.com.
measures to improve the care that it provides? Legal and Regulatory Compliance • Does the practice have and use a compliance plan? • Is the practice compliant with the Health Insurance Portability and Accountability Act (HIPAA), Occupational Safety and Health Administration (OSHA) laws and regulations and other requirements? • Are annual coding audits included in the compliance program? Obtaining Outside Help When Needed • Does the practice know what it knows and where there are gaps in knowledge? • Does the practice engage external consultants to help with tasks that cannot be performed internally? • Does the practice manage the external consultants that it has identified as appropriate resources for the practice? Recruiting the Right Individual If the responses to the questions above suggest that your practice might benefit from a change in administrative leadership, develop a job description. Specify priorities, day-to-day responsibilities, reporting relationship, supervisory responsibility and required education and experience.
JULY 2014
11
Women’s Wellness
Genetic Testing for Breast and Ovarian Cancers Offers Benefits By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
Seven percent of breast cancer and 11-
population, up to 50 percent versus 2 per-
15 percent of ovarian cancer cases are
cent. Similarly the risk of breast cancer by
caused by BRCA1 or BRCA2 genes.
age 70 for those with the BRCA mutation compared to the general population is up
Fortunately, genetic testing is available
to 87 percent versus 8 percent.
for hereditary breast and ovarian cancer (HBOC) syndrome. Myriad offers a test
This highlights that age is a risk, but a wom-
called BRACAnalysis. The Centers for Dis-
an with the BRCA mutation has a markedly
ease Control and Prevention (CDC) offers
higher risk than a woman in the general
the Know:BRCA tool, which can help a
population. Further, second breast can-
woman understand her risk of having this
cers (after a primary cancer) and ovarian
gene mutation. Further, reliable informa-
cancer are more common in women with
tion for providers is available at both orga-
BRCA mutation compared to the general
nizations’ websites: www.myriad.com and
population.
www.cdc.gov/cancer/breast. Who Should Be Tested? Health care providers can and should
There are clear risk factors that support
screen women for risks and identify who
testing. Specifically, if a woman has:
should receive genetic testing. One of the
• Breast cancer at age 50 or younger.
best graphs highlighting the difference be-
• Ovarian cancer at any age.
tween the general population and those
• Ashkenazi Jewish descent and a person-
with BRCA mutations is below from the
al or family history of breast, ovarian or
Myriad website at www.myriad.com.
pancreatic cancer.
The graph shows that a woman with the
In terms of family history, the following
BRCA mutation has a higher risk of breast
supports testing:
cancer by age 50 compared to the general
• Two breast cancers in the same person
After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position (2007) to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.
or on the same side of the family. • Triple negative breast cancer at any age in the family. • Pancreatic cancer and an HBOCassociated cancer (breast, ovarian and pancreatic) in the same person or on the same side of the family. • Breast cancer in three or more on the same side of family. • BRCA1 or BRCA2 mutation in the family. The Hereditary Cancer Quiz can be found at www.hereditarycancerquiz.com. Also, the CDC and the National Cancer Institute have tools. Our clinic uses the one from Myriad.
12
The Triangle Physician
Women’s Wellness Why Should Those at Risk Be Tested?
BOTOX® COSMETIC • COOLSCULPTING® • FACIAL FILLERS • MICRODERMABRASION • AND MORE
Your Skin Needs a
Testing enables a woman at risk for the HBOC
BOUNCER
syndrome to make informed decision. If she is found to be positive, then she may benefit from cancer-reducing measures,
Improve the security of your skin with stateof-the-art skin care services from our boardcertified Dermatologists specializing in:
such as semiannual clinical breast exams, annual mammograms and annual breast
• SKIN CANCER SCREENING & TREATMENT • MOH’S MICROGRAPHIC SURGERY • PEDIATRIC & ADULT GENERAL DERMATOLOGY • ACNE TREATMENT • COMPREHENSIVE DIAGNOSIS OF SKIN DISEASES
magnetic resonance imaging screening at age 25, chemoprevention (tamoxifen) and potentially bilateral mastectomy. Also, if a woman has had a cancer and is tested and found to be positive, she could potentially prevent a second cancer.
Our advanced therapies provide you with the ultimate defense for prevention and early detection of skin cancer!
Knowing one’s own risk also may indicate the risks of relatives, including one’s children.
We are Skin Protectors. Make an appointment today! SKIN CANCER CENTER 919-782-2152
Available Genetic Testing Evaluation and counseling is available
SKIN RENEWAL CENTER 919-863-0073
by calling the Women’s Wellness Clinic
southernderm.com
at (919) 251-9223. Both Duke University Health System and the University of North Carolina Health Care offer testing, as well
ACNE • MOHS SURGERY • SKIN CANCER • PSORIASIS • ECZEMA • DERMATITIS • ALOPECIA DER131_AD_Triangle Physican 1_3.indd 1
6/23/14 10:20 AM
as many other private practice facilities.
55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514
Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.
919.929.7990
www.drossmangastroenterology.com
Breast Cancer Facts •O ne in eight women will be diagnosed with breast cancer in her lifetime. In the United States, more than 220,000 women are diagnosed each year with breast cancer and over 40,000 will die from breast cancer. •B reast cancer is more common in white women compared to other races. • S even percent of breast cancer cases
Drossman Gastroenterology
are hereditary. •E arly menstruation (before age 12) and late menopause (after 55) are associated with breast cancer. • L ifestyle choices do matter; a sedentary lifestyle increases one’s risk of breast cancer. •O ther risk factors include: being overweight or obese, frequent consumption of alcohol and taking combined hormone replacement therapy (HRT).
JULY 2014
13
Dermatology
Psoriasis A Systemic Disease By Laura Briley, M.D.
Our skin is our largest organ. It covers ap-
ing in severe pain, stiffness and inflamma-
proximately 18 square feet of the human
tion in and around the joints.
body and serves both as a protective layer that keeps invaders out and an expansive
“We’ve moved from rub-on medications
sensor packed with nerves that keep the
to highly effective photo light therapy to a
brain in touch with the outside world.
half-dozen very effective biologic medica-
The health of our skin is often a barometer
tions,” says Laura Briley, M.D., of Southern
for overall health, providing practitioners
Dermatology Skin Cancer & Skin Renewal
with vital diagnostic data.
Center in Raleigh.
Just a few decades ago, both doctors
Some biologics target T cells, the “gener-
and patients thought of psoriasis, the red
als” of the immune system that recognize
scaly patches that affect nearly 7.5 Ameri-
bacteria and viruses and coordinate an
cans, as a problem on the skin and not
immune response. In psoriasis, however,
as a systemic issue. We now know that
certain T cells are mistakenly activated
psoriasis is a systemic disease that can go
and migrate to the skin. Once in the skin,
deep into the body and the joints, with co-
they begin to act as if they are fighting an
morbidities linked to greater risks of heart
infection or healing a wound, which sets
disease, depression, obesity and diabetes.
off a chain of events that leads to the rapid
Some 10-30 percent of people with psoria-
growth of skin cells, causing lesions to
sis also develop psoriatic arthritis, result-
form. Certain biologic medications treat
Dr. Laura Briley, a board-certified dermatologist at Southern Dermatology Skin Cancer Center & Skin Renewal Center in Raleigh, specializes in dermatologic surgery and cosmetic dermatology, among other specialties. She earned her bachelor of science degree from Wake Forest University and her medical degree from The Brody School of Medicine at East Carolina University. She completed her internship at Roger Williams Medical Center in Providence, R.I., and residency at The Brody School of Medicine at East Carolina University. Dr. Briley is a member of the American Academy of Dermatology, American Medical Association and Alpha Omega Honor Society.
psoriasis by preventing the activation or migration of T cells or by reducing the number of psoriasis-involved T cells in the body. “We most often prescribe biologics for people with moderate to severe psoriasis and psoriatic arthritis. Often they work well for people who have not responded to other conventional treatments or cannot tolerate the side effects of some medications,” notes Dr. Briley. Not all patients will be able to tolerate biologics, however. Patients with liver problems can’t take the medication methotrexate, and those with a history of skin cancer are at risk with photo light therapy. Additionally, patients with active infections may not be eligible for some biologics.
14
The Triangle Physician
Duke Research News
Heart Imaging Complexity in Children May Raise Lifetime Cancer Risk percent for complex imaging.
Children with heart disease
patients who get frequent
are exposed to low levels
studies as part of their care,
of radiation during X-rays,
we wanted to better under-
“Clinicians need to weigh the risks and
which do not significantly
stand the risk associated
benefits of different imaging studies, in-
raise their lifetime cancer
with repeated exposure.”
cluding those with higher radiation exposure,” Dr. Hill said. “We’re not proposing
risk.
However,
children
who
undergo
repeated
Dr. Hill and his colleagues
eliminating complex imaging – in fact,
complex imaging tests that
studied a group of 337 chil-
they’re critically important to patients
deliver higher doses of ra-
dren ages six and younger
– but we can make significant improve-
diation may have a slightly
who had one or more sur-
ments by prioritizing tests and simply
increased lifetime risk of
geries for heart disease
recognizing the importance of reducing
from 2005 to 2010. During
radiation exposure in children.”
cancer, according to re-
Kevin D. Hill, M.D., M.S.
searchers at Duke Medicine.
the five-year study period, the children received an average of 17 im-
The findings, published June 9 in the
aging tests, each as part of their medical
American Heart Association journal Cir-
care before and after their surgeries.
culation, represent the largest study of cumulative radiation doses in children with
In order to estimate the amount of radia-
heart disease and associated predictions
tion delivered in the tests, the researchers
of lifetime cancer risk.
used a combination of existing data on radiation levels, as well as simulations that
Children with heart disease frequently
calculated radiation doses using child-
undergo imaging tests, including X-rays,
sized “phantoms,” or models, to estimate
computed tomography scans and cardiac
radiation exposure.
catheterization procedures. The number of imaging studies patients are exposed
The researchers found that most children
to depends on the complexity of their dis-
had low exposure to radiation, amounting
ease, with more serious heart conditions
to less than the annual background expo-
typically requiring more testing.
sure in the United States. However, certain groups of children, particularly those with
Although children benefit from advanced
more complex heart disease, were ex-
imaging procedures for more accurate
posed to higher cumulative doses from re-
The researchers also noted that lifetime
diagnosis and less-invasive treatment, the
peated tests and high-exposure imaging.
cancer risk was increased among girls and children who had imaging tests done
increase in radiation has potential health risks.
Abdominal and chest X-rays accounted
at very young ages. Girls had double the
for 92 percent of the imaging tests, but
cancer risk of boys because of their in-
“In general, the benefits of imaging far
only 19 percent of the radiation exposure.
creased chances of developing breast and
outweigh the risks of radiation exposure,
Advanced imaging (CT and catheteriza-
thyroid cancers.
which on a per-study basis are low,” said
tion) made up only 8 percent of imaging
senior author Kevin D. Hill, M.D., M.S., an
tests performed, but accounted for 81 per-
In addition to Dr. Hill, authors include Ja-
interventional cardiologist and assistant
cent of radiation exposure.
son Johnson, Christoph Hornik, Jennifer Li, Daniel Benjamin Jr., Terry Yoshizumi,
professor of pediatrics at Duke University School of Medicine.
The researchers estimated the average
Robert Reiman and Donald Frush. The
increase in lifetime cancer risk to be 0.07
study was supported by the National In-
“We know that each of these individual
percent, with the risk increase ranging
stitutes of Health (UL1TR001117) and the
tests carries a small amount of risk, but for
from 0.002 percent for chest X-rays to 0.4
Mend a Heart Foundation.
JULY 2014
15
Duke Research News
New Gamma and Neutron Imaging Techniques Deemed Safe in Simulations Gamma and neutron imaging offer possible improvements over existing techniques such as X-ray or computed tomography, but their safety is not yet fully understood. Using computer simulations, imaging the liver and breast with gamma or neutron radiation was found to be safe, delivering levels of radiation on par with conventional medical imaging, according to researchers at Duke Medicine. The findings, published in the June issue of the journal Medical Physics, will help researchers move testing of gamma and neutron imaging into animals and later humans. Conventional medical imaging tools – including X-ray, ultrasound, CT and magnetic resonance imaging – detect disease by finding the anatomy, or shape and size, of the abnormality. When using these tools to screen for cancer, a tumor must be large enough to be detected, and if found, a surgical biopsy is generally required to determine if it is benign or malignant. Duke researchers are working to develop imaging technologies to detect disease in its earliest stages, much before the tumors grow large enough to be detected using conventional methods. Two imaging techniques they are researching are neutron stimulated emission computed tomography and gamma stimulated emission computed tomography. Research has shown that many tumors have an out-of-balance concentration of trace-level elements naturally found in the body, such as aluminum and rubidium. These elements stray from their normal concentration levels at the earliest stages of tumor growth, potentially providing an early signal of disease. The neutron and gamma imaging methods measure the concentrations of elements in the body, determining molecular properties without the need for a biopsy or injection of contrast media. The goal is for these tests to be able to distinguish between benign and malignant lesions, as well as healthy tissue. “Gamma and neutron imaging may eventually be able to help us to detect cancer earlier without having to perform an invasive biopsy,” said Anuj Kapadia, Ph.D., assistant professor of radiology at Duke University School of Medicine and the study’s senior author. Gamma and neutron imaging may also have applications for patients undergoing cancer treatment. Patients currently wait weeks or months to see if their cancer is responding to a particular treatment and shrinking in size, but gamma and neutron imaging may
16
The Triangle Physician
Simulated three-dimensional dose measurements of the breast (top) and abdomen/liver (bottom) show the dose imparted by gamma and neutron imaging to the whole body. The dose is shown on a red and yellow color map, where yellow shows maximum dose. (Credit: Duke Medicine)
Duke Research News be able to tell if a treatment is working
breast using neutron and gamma imaging.
est amount of radiation given its location in
earlier by detecting molecular changes di-
They found that the majority of radiation
the direct path of the beam. Further work
rectly within the tumor.
was delivered to organs directly within the
is needed to reduce and better target gam-
radiation beam, and a much lower dose
ma radiation doses in liver scans.
While improved diagnostic tests would
was absorbed by tissue outside of the ra-
provide clinicians with useful tools, one
diation beam.
“The results show that despite the use of a highly scattering particle, such as a neu-
ongoing question is the safety of gamma and particularly neutron radiation. Upon
In simulated breast scans, the radiation
tron, the dose from neutron imaging is on
entering the body, neutrons scatter con-
was almost entirely limited to the area of
par with other clinical imaging techniques
siderably, with the possibility of reaching
the breast being scanned. The dose to the
such as X-ray CT,” Dr. Kapadia said. “Neu-
several vital organs. Thus, researchers
breast accounted for 96 percent of the ra-
tron and gamma radiation may become vi-
have been concerned about how much
diation in neutron scans and 99 percent
able imaging alternatives, if further testing
radiation is absorbed in the targeted organ
in gamma scans. The heart and lungs re-
proves them to be safe and effective.”
versus surrounding tissue. For instance, in
ceived less than 1 percent of the radiation
a breast scan, how much radiation is deliv-
dose.
In addition to Dr. Kapadia, authors include Matthew D. Belley and William Paul Segars
ered unnecessarily to the heart or lungs? When imaging the liver in simulation, the
of Duke Medicine. The study was support-
Using detailed computer simulations, Dr.
neutron scan imparted the highest radia-
ed by the National Institutes of Health (R01-
Kapadia and his colleagues estimated the
tion dose to the liver, while in the gamma
EB001838, T32-EB007185).
radiation dose delivered to the liver and
scan, the stomach wall absorbed the great-
WakeMed News
Donald Gintzig Assumes Helm Donald R. Gintzig
physician engagement, fiscal stewardship
assumed the role
and the health of our community,” said
Mr. Gintzig, a retired rear admiral in the
of
William H. McBride, chair, WakeMed
United States Navy, held positions of
and
Board of Directors. “We believe Donald
increasing responsibility throughout his
executive
is the right leader to ensure WakeMed
military career, during which he oversaw
officer May 27,
remains the preferred provider of health
more than 150,000 navy personnel (active
after serving in
care in Wake County and is able to deliver
and reserve), 40 military treatment
the interim role
upon its vitally important mission for
facilities and 200-plus clinics and budgets
since
years to come.”
of more than $7 billion.
from multiple well-qualified candidates
“I am humbled and honored to be chosen
Mr. Gintzig began his career in private
following
WakeMed
president chief
Donald R. Gintzig
October.
He was selected nationwide
to lead this extraordinary organization
sector health care in 1983 and has served
search. The search process was led by
which is devoted to improving the
as CEO for not-for-profit, faith-based
a nine-person committee and included
health and wellbeing of our community
and for-profit health systems, including
input from more than 400 internal and
while building upon the legacy of those
United Health Group, Minneapolis, Minn.;
community-based stakeholders.
preceding me,” said Mr. Gintzig. “Our
St. Thomas Health Services, Nashville,
patients and their families dignify us by
Tenn.; and The Pottsville Hospital and
“In addition to having the right credentials,
choosing us at times when they are most
Warne Clinic, Pottsville, Pa.; among
Donald’s leadership style has proven
vulnerable, and WakeMed is blessed to
others. He earned both his undergraduate
to be a good fit with the culture of our
have an exceptionally talented team of
and graduate degrees from George
organization. He has demonstrated an
physicians, volunteers, caregivers and
Washington University, Washington, D.C.
outstanding commitment to WakeMed’s
support associates who embody our
mission, patient and family-centered care,
mission every day.”
an
inclusive
JULY 2014
17
UNC Research News
Increased Mucins Pinned to Worsening Cystic Fibrosis Symptoms University of North Carolina School of Medicine researchers have provided the first quantitative evidence that mucins – the protein framework of mucus – are significantly increased in cystic fibrosis patients and play a major role in failing lung function. The research, published June 2 in the Journal of Clinical Investigation, shows that a three-fold increase of mucins dramatically increases the water-draining power of the mucus layer. This hinders mucus clearance in the CF lung, resulting in infection, inflammation and ultimately lung failure. “Our finding suggests that diluting the concentration of mucins in CF mucus is a key to better treatments,” said Mehmet Kesimer, Ph.D., associate Mehmet Kesimer, Ph.D. professor of pathology and laboratory medicine and co-senior author of the JCI paper. Ashley Henderson, M.D., assistant professor of medicine and co-first author of the JCI paper, added, “We think this study shows why nebulized hypertonic improves Ashley Henderson, M.D. saline the hydration of the CF airway, improves the patient’s mucus clearance and, in so doing, increases lung function.” The UNC study also casts further doubt on a controversial 2004 study that disputed the theory that mucins play a major role in CF.
18
The Triangle Physician
This work, a collaboration of 13 UNC scientists, is part of an extensive UNC lung research program based in the new Marsico Lung Institute, which is led by Richard Boucher, M.D., co-senior author of the JCI paper. “This paper points to a therapeutic strategy to rectify this problem of mucus clearance and provides signposts, or biomarkers, to guide development of novel therapies,” said Dr. Boucher, the James C. Moeser Eminent Distinguished Professor of Medicine. Also, by measuring mucin concentration in patient mucus, doctors could learn whether therapies are working and to what degree. Scientists and doctors have known for a long time that failing to clear mucus is the major reason why CF patients face chronic lung infection and inflammation. But the mechanisms of this failure have not been well understood. Normally, when humans breathe, the mucosal layer of our lungs trap the contaminants – dust, pollutants, bacteria – naturally found in air. Then, epithelial cells brush the mucus up and out of our lungs. In people with cystic fibrosis, though, this process doesn’t work as well because they lack a properly functioning CFTR gene. They continually battle infections and must work hard to clear mucus from their lungs. This is where mucins come into play. Mucins give mucus its gel-like thickness and elasticity. “Without mucins, mucus would have the viscosity of blood,” Dr. Kesimer said. “The vast majority of mucus is water, but 30 to 35 percent of the remaining solid material is made up of mucins. They form a network of bonds that serves as a framework.” This is why Dr. Kesimer and his UNC mentor, the late John Sheehan, Ph.D., Distin-
guished Professor of Biochemistry and Biophysics, suspected that something must happen to mucins in the CF lung. They and others knew that CF mucus is typically drier than normal mucus. Back in 2004, however, other researchers used a standard immunologic analysis to show that mucins were decreased in CF secretions. They suspected DNA was the main culprit that caused problems in CF mucus. Dr. Sheehan and Dr. Kesimer were skeptical, as was Dr. Henderson, a clinician who saw CF patients and had been a research fellow in Dr. Sheehan’s lab. They set out to conduct various novel experiments to physically measure the amount of mucins in CF secretions and normal mucus. In one experiment, they used a technique called size exclusion chromatography: In a column, they added custom-made beads that had small pores. Smaller proteins could enter the pores while mucins could not. Through this separation, Dr. Kesimer and Dr. Henderson’s team isolated the mucins and simultaneously measured their concentration using a refractometer. By using sputum samples from CF patients, the researchers found that CF mucus contained three times as many mucins than did normal samples. They also conducted experiments to show that mucin overabundance led to a six-fold increase of the pressure between the mucus layer and the ciliated layer. This finding affirms the CF disease model that UNC researchers published in the journal Science in 2012. In essence, in a CF patient, the increased osmotic pressure of the concentrated mucus layer crushes the ciliated cells so that mucus is not cleared. The lung becomes a breeding ground for bacteria. This leads to more mucins, more mucus, inflammation and subsequently lung failure.
UNC Research News Moreover, Dr. Kesimer’s team showed precisely why the 2004 research was flawed. Those researchers used a classic antibody-based immunologic technique called a western blot, which measures the expression of a given protein – in this case mucins – based on an antibody response to that protein. But, as Dr. Kesimer pointed out, antibodies must latch onto proteins at specific sites on the proteins’ surfaces. When Dr. Kesimer conducted the western blot, he got the same result as the 2004 researchers. But then he used a technique called mass spectrometry to find that CF secretions are full of proteases – enzymes that
break down molecules. The mass spectrometry showed that the proteases degraded the mucins, essentially “erasing” many of the sites where antibodies could bind without disrupting the structural integrity of mucins. “For that reason, we saw less antibody response using the western blot,” Dr. Kesimer said. And so it looked as if there were fewer mucins. “But by using more accurate methods, we clearly saw the increase of mucins. In fact, we’ve analyzed many samples of sputum from patients with other chronic pulmonary diseases and we saw the increase in mucins in them, as well.”
Camille Ehre, Ph.D., a research associate at the UNC CF Research Center/ Marsico Lung Institute, is co-first author of the paper. Other authors of the paper, all of whom conducted this research while at UNC, include Brian Button, Ph.D., Lubna Abdullah, Ph.D., Li-Heng Cai, Ph.D., Margaret Leigh, Ph.D., Genevieve DeMaria, Ph.D., Hiro Matsui, Ph.D., Scott Donaldson, Ph.D., C. William Davis, Ph.D., and John Sheehan, Ph.D. The National Institutes of Health and the Cystic Fibrosis Foundation funded this research.
Discovery of Enzyme Role May Lead to Better Therapies for Various Cancers Twelve years ago, University of North Carolina School of Medicine researcher Brian Strahl, Ph.D., found that a protein called Set2 plays a role in how yeast genes are expressed – specifically how DNA gets transcribed into messenger RNA. Now his lab has found that Set2 is also a major player in DNA repair, a complicated and crucial process that can lead to the development of cancer cells if the repair goes wrong. “We found that if Set2 is mutated, DNA repair does not properly occur” said Dr. Strahl, a professor of biochemistry and biophysics. “One consequence Brian Strahl, Ph.D. could be that if you have broken DNA, then loss of this enzyme could lead to downstream mutations from inefficient repair. We believe this finding helps explain why the human version of Set2 – which is called SETD2 – is frequently mutated in cancer.”
The finding, published online June 9 in the journal Nature Communications, is the first to show Set2’s role in DNA repair and paves the way for further inquiry and targeted approaches to treating cancer patients. In previous studies, including recent genome sequencing of cancer patients, human SETD2 has been implicated in several cancer types, especially in renal cell carcinoma – the most common kind of kidney cancer. SETD2 plays such a critical role in DNA transcription and repair that Dr. Strahl is now teaming up with fellow UNC Lineberger Comprehensive Cancer Center members Stephen Frye, Ph.D., director of the UNC Center for Integrative Chemical Biology and Drug Discovery (CICBDD); Jian Jin, Ph.D., also with the CICBDD; and Kim Rathmell, M.D., Ph.D., an associate professor in the department of genetics. Their hope is to find compounds that can selectively kill cells that lack SETD2. Such personalized medicine is a goal of cancer research at UNC and elsewhere.
In recent years, scientists have discovered the importance of how DNA is packaged inside nuclei. It is now thought that the “mis-regulation” of this packaging process can trigger carcinogenesis. This realm of research is called epigenetics and at the heart of it is chromatin – the nucleic acids and proteins that package DNA to fit inside cells. Proper packaging allows for proper DNA replication, prevents DNA damage and controls how genes are expressed. Typically, various proteins tightly regulate how these complex processes happen, including how specific enzyme modifications occur during these processes. Some proteins are involved in turning “on” or turning “off” these modifications. For instance, protein and DNA modifications involved in gene expression in kidneys must at some point be turned off. In 2002, Dr. Strahl found that Set2 in yeast played a role as an off switch in gene expression – particularly when DNA is copied to make RNA. Now, Dr. Strahl’s team found that Set2 also regulates how the broken strands of DNA – the most severe
JULY 2014
19
UNC Research News form of DNA damage in cells – are repaired. If DNA isn’t repaired correctly, then that can result in disastrous consequences for cells, one of them being increased mutation that can lead to cancer. Through a series of biochemDeepak Jha ical and genetic experiments, Deepak Jha, a graduate student in Dr. Strahl’s lab, was able to see what happens when cells experience a
break in the double-strand of DNA. “We found that Set2 is required when cells decide how to repair the break in DNA,” said Mr. Jha, the first author of the Nature Communications paper. He said that the loss of Set2 keeps the chromatin in a more open state – not as compact as normal. This, Dr. Strahl said, leaves the DNA at greater risk of mutation. “This sort of genetic instability is a hallmark of cancer biology,” Mr. Jha said. Dr. Strahl and Mr. Jha said they still don’t know the exact mechanism by which Set2 becomes mutated or why its mutation affects its function. That’s the subject of
their next inquiry. They are now collaborating with Dr. Rathmell and Ian Davis, also members of UNC Lineberger Comprehensive Cancer Center, to study how the human protein SETD2 is regulated and how its mutation contributes to cancer. “We think this work will lead to a greater understanding of cancer biology, and open the door to future therapeutic approaches for patients in need of better treatment options,” Dr. Strahl said. This research was funded through a grant from the National Institutes of Health.
Clinical Tool Is First to Evaluate Violence Risk in Military Veterans A new five-question screening tool can help clinicians identify which veterans may be at greater risk of violence, according to a new study led by a University of North Carolina researcher.
Eric Elbogen, Ph.D., research director of the Forensic Psychiatry Program in the UNC School of Medicine and psychologist in the United States Department of Veterans Affairs.
The study, published online by the American Journal of Psychiatry, is based on a national survey sample of veterans combined with a smaller, in-depth assessment sample. The screening tool, called the Violence Screening and Assessment of Needs (VIO-SCAN), asks veterans about financial stability, combat experience, alcohol misuse, history of violence or arrests and probable posttraumatic stress disorder (PTSD), plus anger. The screening tool can be viewed in the text of the article at http://ajp.psychiatryonline.org/data/Journals/AJP/0/appi.ajp.2014.13101316.pdf.
On the VIO-SCAN, veterans give yes-or-no answers to questions such as, “Did you personally witness someone being seriously wounded or killed?” and “Have you ever been violent towards others or arrested for a crime?” The answer to each question is scored as either O or 1. The score for each answer is combined to yield an overall score, ranging from 0 to 5, with O indicating generally lower risk and 5 indicating generally higher risk.
“When we hear about a veteran being violent, there is a knee-jerk reaction that it stems from PTSD. The VIO-SCAN shows that PTSD is relevant to screening risk but is only the tip of the iceberg. Non-PTSD factors need to be looked at, such as alcohol abuse or past criminal behavior, just like in civilians,” said study lead author
20
The Triangle Physician
“We believe this screening tool will provide clinicians with a rapid, systematic method for identifying veterans at higher risk of violence. It can help prioritize those in need of a full clinical workup, structure review of empirically supported risk factors and develop plans collaboratively with veterans to reduce risk and increase successful reintegration in the community,” Dr. Elbogen said.
However, Dr. Elbogen cautioned, the VIOSCAN is not intended to be a comprehensive assessment of whether a veteran will or will not be violent. Instead, it is a screen identifying whether a veteran may be at high risk and thereby require a full clinical workup to make a final risk judgment. Co-authors of the article are Michelle Cueva, Ph.D., at UNC; H. Ryan Wagner, Ph.D., Mira Brancu, Ph.D., and Jean C. Beckham at the Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center and Duke University; Shoba Sreenivasan, Ph.D., at the Greater Los Angeles Veterans Affairs Forensic Outreach Services, and Lynn Van Male, Ph.D., at the Veterans Health Administration Office of Public Health. The study was funded in part by the National Institute of Mental Health; the Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Office of Mental Health Services; and the Office of Research and Development Clinical Science and Health Services, Department of Veterans Affairs.
News Welcome to the Area
Physicians
Jeremy Andrew Halbe, MD
Behrouz Namdari, MD
Aaron Thomas Trimble, MD
Hospitalist; Internal Medicine
Neurology
Duke Hospital Medicine Durham
Psychiatry
Internal Medicine - Critical Care Medicine; Pulmonary Disease, Internal Medicine
Nicole Marie Gill, DO Carolina Headache Institute Chapel Hill Leah Rebecca Goodson-Gerami, DO
John Carroll Haney, MD Cardiovascular Surgery; Thoracic Surgery
Obstetrics and Gynecology
Duke Medicine Durham
Womenâ&#x20AC;&#x2122;s Healthcare Associates Jacksonville
Andrew Zachary Heling, MD
Misha Oswald Harrell, DO Aerospace Medicine
Seymour Johnson AFB 4th Medical Group Goldsboro Scott Julius Noorda, DO Family Medicine - Geriatric Medicine, Sports Medicine
Doctors Making Housecalls Durham Christele Behalal-Bock, MD Rheumatology, Internal Medicine
Durham Stephanie Davis Cardella, MD Hospitalist; Internal Medicine
University of North Carolina Hospitals Chapel Hill
Neonatal-Perinatal Medicine; Pediatrics
University of North Carolina Hospitals Chapel Hill Heather Sue Hoff, MD Gynecology; Gynecology/Oncology; Obstetrics; Gynecologic Surgery; Gynecology - Endocrinology/Infertility; Gynecology - Gynecologic Oncology; Gynecology - Reproductive; Obstetrics
UNC Reproductive Endocrinology Chapel Hill Thomas Patrick JensenII, MD Addiction Psychiatry; Alcohol and Drug Abuse; Child Psychiatry; Neurology/ Psychiatry
Person County Family Medical Center Roxboro Allen Manuel Joseph, MD Diagnostic Radiology
Marcela Carolina Castillo, MD Obstetrics and Gynecology
UNC Dept of Obstetrics & Gynecology Chapel Hill
Pinehurst Matthew Douglas Kalp, MD
Ophthalmology Duke Eye Center Durham
Laura Caitlin Page, MD Pediatrics
Duke University Medical Center Durham Roma P Patel, MD Ophthalmology
Duke University Durham Carrie Monica Polin, MD Anesthesiology Durham Pinakpani Roy, MD Angiography; Interventional Radiology; Diagnostic Radiology; Diagnostic Roentgenology Radiology; Interventional and Vascular Radiology
Duke Neurology/DUMC Durham
UNC Medical Center Chapel Hill
University of North Carolina Hospitals Chapel Hill
Diabetes; Endocrinology, Internal Medicine; Internal Medicine; Internal Medicine Endocrinology, Diabetes &amp; Metabolism
Cary
Duke Eye Institute Durham
Division of Endocrinology Durham
Brett L MacLean, MD
Rebecca Kay Simpkin, MD
Pediatrics
Pediatrics
Pulmonary Disease and Critical Care, Internal Medicine
Duke University Hospitals Durham
Anna Langley, PA Duke University Hospital Durham Dermatology; Laboratory; Dermatology Pediatric - Dermatology
Wilson
Evan Silverstein, MD
Raleigh Deesha Dhaval Mago-Shah, MD Pediatrics
Duke University Hospitals Durham
Sandhills Pediatrics Inc Southern Pines Julia Anne Marsh Sung, MD Infectious Diseases, Internal Medicine; Internal Medicine
Kirk Joseph MatthewsJr, MD
Duke University Hospitals Durham
Gynecologic Surgery; Obstetrics and Gynecology
Sara Tarjan, MD
Wilkerson Obstetrics & Gynecology Raleigh Margaret Kathryn McGinn, MD Internal Medicine
Carrboro Marcus Muehlbauer, MD Gastroenterology, Internal Medicine
University of North Carolina Hospitals Chapel Hill
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
Family Medicine
Ophthalmology
Coral Xantia Giovacchini, MD
UNC Hospitals Chapel Hill
Obstetrics and Gynecology
General Practice; General Surgery
University of North Carolina Hospitals Chapel Hill
Emergency Medicine; Pediatric - Emergency Medicine
Jennifer Thomas Sandbulte, MD
Thersia Jeane Knapik, MD
Ophthalmology; Pediatric Ophthalmology
Aaron Edward Wiener, MD
Duke University Hospitals Durham
David Andrew Dâ&#x20AC;&#x2122;Alessio, MD
Kevin Ray Gertsch, MD
Duke University Hospital Durham
Internal Medicine
Duke University Hospitals Durham
Duke Neurosurgery Durham
Rheumatology, Internal Medicine
Jennifer Anne Rymer, MD
University of North Carolina Hospitals Chapel Hill
Critical Care; Neurological Surgery, Pediatric
Sara Dana Wasserman, MD
Philip George Reasbeck, PA
Radiology
Monica Ann Selak, MD
Neurological Surgery
Peter Edward Fecci, MD
Boone Dermatology Clinic Boone
Adam Thomas Ryan, MD
WakeMed Raleigh
Pediatrics
Department of Orthopaedics University of North Carolina at Chapel Hill
Dermatology
Critical Care Surgery
Emergency Medicine
Isaac Obiri Karikari, MD
Orthopedic Surgery; Orthopedic, Hand Surgery
Brittain Hammill Tulbert, MD
University of North Carolina Hospitals Chapel Hill
University of North Carolina Hospitals Chapel Hill
Shelby Ann Kaplan, MD
Mark Stephen Connelly, MD
Reid Wilson Draeger, MD
University of North Carolina Hospitals Chapel Hill
Neurology; Vascular Neurology
Garrick Chak, MD Ophthalmology; Pediatric
Duke University Hospitals Durham
Emergency Medicine
University of North Carolina Hospitals Chapel Hill Brian David Thorp, MD Head and Neck Surgery; Otolaryngic Allergy; Otolaryngology; Otolaryngology - Neurotology; Otolaryngology - Plastic Surgery Within the Head; Neck; Otolaryngology - Sleep Medicine; Otology; Otorhinolaryngology; Pediatric Otolaryngology; Rhinology
University of North Carolina Hospitals Chapel Hill
2014 Editorial Calendar August Gastroenterology Nephrology September Bariatrics Neonatology October Cancer in women Wound management November Urology ADHD December Otorhinolaryngology Pain management JULY 2014
21
3D MAMMOGRAPHY WE’RE TALKING WAY BETTER IMAGING, EARLIER DETECTION, FEWER FALSE POSITIVES AND LESS CHANCE OF A CALL BACK. END OF DISCUSSION.
3D MAMMOGRAPHY • GREATER ACCURACY • REDUCED ANXIETY • NOW AT WAKE RADIOLOGY Let’s have a frank discussion. You can’t treat what you can’t detect. And 3D mammography, along with your regular 2D exam, is revolutionizing breast cancer detection. How? By significantly improving clarity for earlier detection and fewer false positives. Which, of course, reduces recall rates and the anxiety that comes with additional tests. To learn more about 3D mammography or to schedule an appointment, visit wakerad.com. Like we said, you can’t treat what you can’t see. And now we’re seeing better than ever. Wake Radiology | North Hills Breast Center | 919-232-4700 | wakerad.com Daily, evening and Saturday appointments | 20 minutes from check-in to exam completion