june
2 013
Wake Forest Dermatology Offering a Thoughtful Approach to Skin 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
Pregnancy and Thyroid Disease HER and Meaningful Use
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COVER STORY
6
Wake Forest Dermatology Offering a Thoughtful Approach to Skin Care
june 2 0 1 3
Vol. 4, Issue 5
FEATURES
9
Endocrinology
Thyroid Disease in Pregnancy Requires Special Considerations Dr. Khushbu Chandarana explores the implications and treatment options.
10
Practice Management
Strategies for Meaningfully Using Your EHR
DEPARTMENTS 11 Men’s Health
19 UNC Research News
Statistics Mean Nothing to Patient on the Wrong End of Them
Fetuses Emit Hormone that Protects Mother from Preeclampsia
12 Women’s Health
20 UNC Research News
Uterine Fibroids: What Can a Woman Do?
14 Endocrinology Congenital Hypothyroidism
15 WakeMed News
21 Duke Research News
Trauma Center Designation Is Renewed
Persistent Pain Following Stressful Events May Have Neurobiological Basis
16 Duke Research News
22 Recognition
Duke Researchers Identify Mutations Associated With Nearsightedness
Joe Reddy offers sound advice for
17 Duke News
those sweating the details.
Kernodle Clinic Physicians Join Faculty Practice Group
COVER PHOTO: Patricia Matheis, M.D., takes a thoughtful approach to the skin care at Wake Forest Dermatology.
2
The Triangle Physician
- I npatients Who Have STEMI More Likely to Die Than Outpatients -M argaret Gourlay Wins Top 10 Clinical Research Achievement Award
-P aulson Returns to Chair Duke’s Department of Radiology -B reast Cancer Expert Named One of TIME’s 100 Most Influential People
23 Recognition
18 Duke Research News
Certified Physician Assistant Joins Wake Internal Medicine & Pediatrics
Family History May Mean Higher Levels of Alzheimer’s Pathology
24 News
Welcome to the Area
Category
june 2013
3
From the Editor
Thoughtful Examination Experienced practitioners don’t typically base a diagnosis on one test. They consider multiple variables, including family history and lifestyle factors; even their professional instincts come into play. 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
One’s skin is a fascinating health indicator, offering clues of what might be going on within, the focus of dermatologist Patricia Matheis’ medical practice. In this month’s cover story “Wake Forest Dermatology Offers a Thoughtful Approach to Skin Care,” you will learn what distinguishes Dr. Matheis in her mission to help patients achieve the healthiest skin possible, including those who seek cosmetic treatment. In this issue of The Triangle Physician introduces urologic oncologist Edward Rampersaud Jr., takes exception to the American Urological Association’s reassignment of PSA screening guidelines. In his column, he argues for the necessity of varied diagnostic tools to make the best, most-informed diagnoses. Endocrinologists Khushbu Chandarana and Julie Warren-Ulanch discuss the importance of early and accurate diagnosis and treatment of thyroid disease in pregnant women and newborns, respectively. Gynecologist Andrea Lukes returns to discuss uterine fibroids and
Editor Heidi Ketler, APR
heidi@trianglephysician.com
Contributing Editors Khushbu Chandarana, M.D. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Edward N. Rampersaud Jr., M.D. Joe Reddy Julia Warren-Ulanch, M.D. Photography Mark Jacoby Creative Director Joseph Dally
mark@jacobyphoto.com
jdally@newdallydesign.com
the promise of treatment advances, including one available through a study conducted at
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her practice.
info@trianglephysiciancom
Joe Reddy’s practice management expertise and understanding of meaningful use show
News and Columns Please send to info@trianglephysician.com
in his article, which addresses some of the complexity of complying with new reporting requirements. Also in this issue, be sure to read about the North Carolina Medical Board licensee contest and other incentives for keeping profiles polished on the board’s website. You might be surprised to learn what a popular fact-checking resource it is, with some 3,000 inquiring minds accessing its licensee information pages online each day.
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Many thanks to all of our contributors, whose expert medical perspectives bring breadth and depth to the pages of The Triangle Physician – an information and referral resource for the Triangle medical community. Each issue is distributed to the more than 9,000 physicians, physician assistants, nurse practitioners and practice and hospital administrators, among others. And “shelf life” very often is extended in office waiting rooms. For the thoughtful practitioner, referral decisions are not made lightly. Usually, they are based on a multitude of inputs, including patient feedback, collegial recommendation, personal observation and, perhaps, an article read or advertisement seen in The Triangle Physician. With deep respect and gratitude,
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.
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Cover Story
Wake Forest Dermatology
Offering a Thoughtful Approach to Skin Care Wake Forest Dermatology is a full-service dermatology practice
General and Surgical Dermatology
centered on thoughtful, compassionate care that helps patients of
Dr. Matheis’ thoughtful patient-care manner is reminiscent of a
all ages – including children – achieve the healthiest skin possible.
bygone era and complemented by her breadth of expertise in advanced medical and surgical dermatology and special interests
Treatment takes into account not only the condition of a patient’s
in pediatric skin care, skin cancer and immunology of the skin.
skin, but also contributing factors within his or her lifestyle, including nutrition and environment, as well as family history. Dis-
Her depth of knowledge in immunology fortifies her diagnos-
ease prevention and health promotion are always a part of the
tic and treatment expertise in numerous diseases and illnesses.
treatment and health plan.
Some of the most common are melanoma, moles and warts, blisters and lesions, acne and skin rash.
“My patient-centered approach to care emphasizes direct, oneon-one interaction, so I have no physician extenders, with whom
Wake Forest Dermatology diagnoses and treats patients of all ages
I share responsibilities,” says Patricia Matheis, M.D., the practice
with common and complicated skin conditions. Services include:
owner. “I give patients the time and attention needed to under-
• Mole and skin cancer evaluation and treatment;
stand the various internal and external influences on their skin’s
• Women’s personalized skin care and evaluation;
health.”
• Acne treatments, including isotretinoin (Accutane); • Psoriasis treatment, including the use of systemic biologic
As a measure of her patient’s gratitude, Dr. Matheis was recog-
agents;
nized last Sept. 10 as a Patient’s Choice physician, an independent
• Eczema treatment, including new therapies and emollients:
designation that is based on achieving patient ratings with near
• Hair-loss treatment;
perfect scores. Only 5 percent of active physicians in the United
• Vitiligo treatment;
States were accorded this honor by their patients in 2012.
• Wart treatment, including occlusion, salicylic acid, cryotherapy, electrosurgery, laser surgery and prescription medications; • Minor surgical procedures, including treatment of moles, cysts and skin tags; • Removal by excision, cryosurgery, electrosurgery or other methods of benign and malignant growth removal, including basal cell carcinoma, squamous cell carcinoma and melanoma; and • Preventive skin care for aging and sun damage. Wake Forest Dermatology services also extend to the elimination of spider veins using sclerotherapy.
Screening and Dermoscopy Medical treatment begins with a thorough evaluation of a patient’s family and medical history and a detailed full-skin examination. Dr. Matheis is experienced in the use of the dermascope to more The dermascope is a specialized tool that has gained enthusiasm in dermatology for its ability to increase detection of mutated moles by their appearance.
6
The Triangle Physician
accurately diagnose malignant skin lesions.
Psoriasis Psoriasis is a condition that goes through cycles of improving and worsening, and at times, can be uncomfortable and painful. The scaling and unpleasant appearance of psoriasis lesions (especially if left untreated) can cause embarrassment and be a significant source of anxiety or depression. Psoriasis can interfere with sleep and make everyday tasks difficult. The condition can also be complicated by joint pain and swelling and other chronic medical conditions. Laser technology has improved during recent years so it is more effective and better tolerated than previously, mostly requiring only topical anesthesia. There are numerous cosmetic applications and differing devices used. The pulsed-dye laser is effective at reducing pigmented lesions.
“Ongoing evaluation and treatment are important lifestyle choices for those suf-
“The accuracy of dermoscopy increases
a patient’s control, new treatments help
up to 20 percent in the case of sensitiv-
minimize adverse symptoms. To follow
ity and up to 10 percent in the case of
are descriptions of the most common
Hair Loss
specificity, compared with naked-eye ex-
conditions and represent the broad range
Androgenic alopecia, or male and female
amination,” says Dr. Matheis. “This helps
of services available at Wake Forest Der-
pattern baldness, is an inherited tendency
to reduce the frequency of unnecessary
matology.
for follicles to stop producing new hairs.
surgical excisions of benign lesions.”
fering from psoriasis,” says Dr. Matheis.
The hair-growing tissue’s sensitivity to horAging
mones is thought to be the cause. A num-
Digital dermoscopy images can be stored
Natural aging normally begins in one’s
ber of treatments are available to reduce
and compared to images obtained in
mid-20s and is continuous. Extrinsic fac-
the hair loss and restore the hair-growing
follow-up visits. “Suspicious changes in
tors that prematurely age skin are sun
follicles.
lesions are an indication for excision,”
exposure, repetitive facial expressions,
says Dr. Matheis. “Skin lesions that appear
gravity, sleeping positions and smoking.
Cosmetic Dermatology
unchanged over time are considered be-
For those who are bothered by visible
Wake Forest Dermatology offers complete
nign.”
signs of aging, a number of treatments are
cosmetic dermatology services and the
available.
latest treatment options. “Our philosophy
Comprehensive treatment plans also are
is to customize the treatment so patients
designed for prevention and early detec-
Acne
can achieve a more natural look that mini-
tion and typically include annual skin ex-
While the exact cause is unknown, acne
mizes their wrinkles and folds,” says Dr.
ams. “Many of my patients find it helpful
may be the result of a variety of factors,
Matheis.
to schedule their annual skin examina-
including heredity, hormones, stress, diet
tion at the beginning of the year or in the
and/or vitamin deficiencies, especially
The best results, she says, are obtained
month of their birthday.”
vitamin D. It is often the source of emo-
by combining cosmetic procedures with
tional distress, so the good news is there
healthy skin. “Success in improving the
are many new treatment options.
overall health of a patient’s skin relies on
Dr. Matheis also encourages patients to incorporate sun-protection measures into
careful examination, treatment expertise
their daily lives. That includes the regular
Keloid Scars
and a comprehensive understanding of
use of hats, sunglasses and ultraviolet-pro-
Keloid scars are excessively large and
available therapies.”
tective creams and even clothing.
form at the site of wounds or trauma, including ear piercings, vaccinations or
The following is an overview of some
Commonly Treated Skin Conditions
surgical sites. They are most common on
available
Wake Forest Dermatology offers hope for
the upper chest and shoulders. A variety
from Dr. Matheis are usually best made
patients suffering from skin conditions
of treatments are available to reduce the
once she develops a relationship with pa-
of all types. While contributing intrinsic
size of the scar and minimize associated
tients and better understands their goals
factors, such as heredity, may be out of
discomfort.
and budget.
options.
Recommendations
june 2013
7
into the offending muscles, allowing the skin
Latisse
to relax and the folds to soften or disappear.
Eyelash hypotrichosis is another name for having inadequate or not enough eye-
Fillers
lashes. Lattisse is the only prescription ap-
Juvéderm is a dermal filler designed to
proved by the United States Food and Drug
smooth out wrinkles and add volume to
Administration for growing eyelashes and
facial folds. It is a natural complex sugar
making them longer, thicker and darker.
that retains water and is found in all living organisms. It has been formulated to be
Latisse is believed to affect the growth
more comfortable to inject and to provide
(anagen) phase of the eyelash hair cycle
long-lasting correction.
by increasing the length of this phase and increasing the number of hairs in this
Examination of suspicious skin lesions is aided by use of high-intensity luminescence tools.
Restylane provides immediate and long-
growth phase. “Many people experience
lasting wrinkle correction. It is a safe, natural
significant benefit with the use of Lat-
cosmetic dermal filler. It can be used to re-
tisse,” says Dr. Matheis.
duce laugh lines, reduce forehead wrinkles and improve the appearance of the lips.
Career Highlights Dr. Matheis earned her bachelor’s degree
Chemical Peels
Radiesse is a dermal filler used for restor-
in nursing from Creighton University in
Chemical peels use a chemical solution
ing a natural, more youthful appearance
1988. She later pursued her interest in skin
to improve and smooth the texture of the
to folds and lines in the nasolabial folds
disease and skin surgery at the renowned
skin by removing outer layers of the skin
around the nose and mouth. It is made of
North Carolina Jaycee Burn Center in Cha-
that are damaged by age, sun and environ-
unique calcium-based microspheres in a
pel Hill; additionally she continued clini-
mental factors. The process is helpful in
natural gel that is injected into the skin.
cal research at the Shriners Burns Institute
treating individuals with facial blemishes,
The calcium helps to stimulate the growth
in Texas. While earning her medical doc-
wrinkles and uneven skin pigmentation.
of your own collagen, which over time re-
tor degree at the University of Colorado
In many cases chemical peels may be
builds the skin’s foundation and restores
Health Sciences Center, she conducted
used to control acne, treat pre-cancerous
its youth.
investigations into the genetics of skin
lesions and soften facial scarring.
cancer and the immunology of the skin. “Radiesse is typically longer lasting than
Microdermabrasion Microdermabrasion involves a gentle, gradual exfoliation of the skin’s surface cells, thereby reducing damage caused by age, heredity, sun and other environmental factors. It can minimize fine lines and wrinkles, improve acne scarring, lighten age spots and be performed on any part of the body. Microdermabrasion is performed in a series of treatments, and patients are able to immediately return to work and normal activity after each. Botox and Dysport Botox or Dysport may be the best solution for patients seeking an easy solution for smile lines, crow’s feet or frown lines on the face, forehead and glabella. Both are highly purified muscle relaxants that are injected
8
The Triangle Physician
other fillers on the market, lasting a year
After finishing her training at the Univer-
or longer,” says Dr. Matheis
sity of North Carolina in Chapel Hill, Dr. Matheis completed her internship in medi-
Beyond Skin
cine and residency in dermatology in 2006.
Sclerotherapy
A native of Omaha, Neb., Dr. Matheis is
Sclerotherapy is commonly considered
married with two children. In her spare
the best available treatment for spider
time she enjoys cycling, baking and par-
veins and has been in use for many years.
ticipating in church activities.
A small amount of chemical solution is in-
Physician Referrals Are Welcome
jected through a tiny needle directly into
Dr. Matheis serves as a consultant with
the faulty vein. The chemical irritates the
primary physicians to diagnose and man-
vein wall, causing it to close and eliminate
age skin disorders and recommends and
trapped blood.
administers treatment to counteract a defective response of the immune system.
Depending on the extent of the veins being treated, multiple sclerotherapy ses-
To refer a patient, call (919) 4880-0355.
sions may be needed to achieve full clear-
More information is available online at
ance, and some varicose veins issues may
wakeforestderm.com. Patients also have
require referral to a vein clinic due to their
access to a knowledge library and can
size and/or location.
schedule a consultation online.
Endocrinology
Thyroid Disease
in Pregnancy Requires Special Considerations By Khushbu Chandarana, M.D.
In general, thyroid disease is five times
or thyroid-stimulating immunoglobin (TSI)
more common in women than men. The
are very high. In low doses, anti-thyroid
coincident occurrence of thyroid disease
drugs are generally safe during breastfeed-
before, during and after pregnancy involves
ing, and mothers should take it in divided
special considerations for the health of the
doses immediately following each feeding.
infant and the mother.
Hypothyroidism Hyperthyroidism
The most common cause of hypothyroid-
Early pregnancy is associated with several
ism in women of childbearing age is auto-
hormonal changes that alter thyroid
immune (Hashimoto’s) thyroiditis. Recent
function and structure. Approximately
studies have shown that the presence of
10 percent of women may have a mildly
thyroid peroxidase (TPO) antibodies in
suppressed thyroid-stimulating hormone
euthyroid women is associated with an in-
(TSH) during the first trimester, especially
creased risk of miscarriage, particularly in
with hyperemesis gravidarum (“morning
the first trimester; and treatment with low-
sickness”). This cause of suppressed TSH
doses of levothyroxine may lower the mis-
needs to be distinguished from Graves’
carriage rate to that of unaffected women.
disease, which is the most common cause
Dr. Khushbu Chandarana performed her medical training at New York University School of Medicine. Her residency training was done at Robert Wood Johnson University Hospital in New Brunswick, N.J., and it was followed by a fellowship in diabetes, endocrinology and metabolism at New Jersey Medical School. Prior to joining Carolina Endocrine in May 2011, Dr. Chandarana worked in private practice in Hamilton, N.J. She is board certified in internal medicine and endocrinology and has also 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.
of clinically significant hyperthyroidism in
During the first 10-12 weeks of gestation, the
be safely performed during pregnancy;
pregnancy.
developing fetus is completely dependent
however, nuclear medicine studies are
upon maternal thyroid hormone levels for
contraindicated. If a thyroid FNA biopsy
Women who require therapeutic interven-
normal brain development. Untreated overt
reveals the presence of cancer or if a
tion during pregnancy are usually placed
maternal hypothyroidism is associated
nodule is found to be suspicious for
on anti-thyroid drugs (ATD). Propylthio-
with
fetal
malignancy, then the patient may elect
detrimental
effects
upon
uracil (PTU) is recommended to be used
neurocognitive development in addition to
to undergo surgical resection (usually
in the first trimester secondary to the tera-
an increased rate of miscarriage, low birth
during the second trimester) or may defer
togenic effect of methimazole (MMI). After
weight and pre-term delivery.
thyroidectomy until after delivery (in most cases). Women with thyroid cancer
the first trimester, consideration is given to switching to MMI in order to decrease the
These adverse outcomes may also be as-
who are on thyroid hormone suppressive
incidence of liver disease.
sociated with subclinical hypothyroidism,
therapy may require dose adjustment.
but the data is not as conclusive. Pregnant Both MMI and PTU can cross the placenta.
women with preexisting hypothyroidism
Post-Partum Thyroiditis
The goal is to maintain free thyroid levels
or newly diagnosed hypothyroidism re-
This is usually a painless, transient
at or just about the upper limit of normal,
quire careful monitoring and frequent ad-
disturbance in thyroid function that
while utilizing the smallest possible dose.
justment of thyroid hormone dose.
develops two to six months after delivery. Incidence is estimated to be anywhere
Graves’ disease may become quiescent during the latter part of the pregnancy, but may
Thyroid Nodules and Cancer
intensify two-to-three months post-partum.
Newly discovered thyroid nodule presents
from 3-15 percent.
a unique challenge during pregnancy.
This condition is characterized by a
Infrequently, the transplacental passage of
History, physical exam and ultrasound
thyrotoxic phase, followed by a hypothyroid
maternal antibodies can lead to transient
characteristics of a nodule can help with
phase, each of which may last for several
neonatal hyperthyroidism (about 2-5 per-
risk stratification.
weeks or months. About 10 percent of women with post-partum thyroiditis will
cent), particularly if titers of thyroid-stimulating hormone receptor antibody (TRAb)
Fine-needle aspiration (FNA) biopsy may
remain permanently hypothyroid. june 2013
9
Practice Management
Strategies for Meaningfully Using Your EHR By Joe Reddy
Is your electronic health record helping
tion (GPRO) for PQRS requirements. If you
you obtain the available cash incentives by
missed the Jan. 31 requirement to register,
qualifying for meaningful use?
you will have another opportunity sometime this summer through Oct. 15.
Electronic health record (EHR) dissatisfaction is on the rise even with incentive
The PQRS incentive/penalty for GPRO is
payouts exceeding $12 billion. As many as
based on submission of data via registry or
39% of clinicians have buyer’s remorse and
completion of the GPRO web interface. EPs
would not recommend their EHR to a col-
reporting individually will enjoy the benefit
league.
of having PQRS “baked in” the Stage 2 MU
Joe Reddy is the owner of RevMedRx, a North Carolina-based 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.
requirements that a qualified EHR should So do you accept the pain until you go
be leading you through. Therefore, you
numb or start over a little more educated?
should be able to get credit for both, with-
Moreover, the Centers for Medicare &
out two separate tracking records. There are
Medicaid Services (CMS) audits reveal
approximately 300 ambulatory MU program
that many providers struggle to document
EHR vendors. Only a few dozen of them are
meaningful use (MU)?
CMS-approved direct submitters for MU and PQRS, making it even easier to attest.
It’s hard to imagine how simple some of the challenges appear. For instance, some
Planning for Stage 2 and Beyond
EHRs don’t provide a functional audit log
We don’t know yet which EHR vendors
that allows necessary documentation for
will be certified for Stage 2. We can expect
designating attestation periods.
it to be less than those currently certified for Stage 1, largely due to the investment
On the positive side, there’s also some incentive to get engaged sooner rather than later. In fact, it’s not too late to begin and attest Stage 1 this year and still claim a total of up to $39,000 over the next several years and avoid the first-year PQRS penalty. This is not difficult if you are with the right vendor.
For 2014 Only The Centers for Medicare & Medicaid Services recently announced that all providers, regardless of their meaningful use stage
required.
are only required to demonstrate MU for
what you have and the functionality that’s
We also can expect some vendors to pass
reporting period. For Medicare providers,
currently available. Often this discovery is
along some of those costs to you in “fees.”
achieved only by comparison in today’s
You know what I’m talking about, if you’re
market.
working with one of them now, as you get
Given the technology advances even in the past year, it’s important to understand
your checkbook ready for your ICD-10 up-
a three-month electronic health record this three-month reporting period is fixed to the calendar quarter for eligible professionals in order to align with the PQRS. This one-time, three-month reporting period is
grade
being permitted so all providers who must
core and menu objectives as they were in
In 2014, a Stage 2-certified vendor will be
have adequate time to implement their new
Stage 1. For ambulatory-eligible profession-
required, even if you are still attempting to
als (EPs), Stage 2 requires reporting on 17
successfully attest for Stage 1. It would be
core objectives and three of the six menu
prudent to review vendors by comparison
objectives. In addition, EPs also must report
shopping before you progress much further
on one measures group or three individual
along this timeline.
Understanding MU Reporting Stage 2 MU measures are comprised of
measures as part of the Physician Quality Reporting System (PQRS).
By 2016, the PQRS penalties peak at 2%. The EHR penalties begin in 2015 and increase by
Beginning in 2013, two or more EPs in a
1 percent per year until 2019, maxing out at
group practice could register or self-nomi-
5%. That’s a 7% exposure in Medicare revenue
nate for the Group Practice Reporting Op-
penalties in 2019.
10
The Triangle Physician
upgrade to 2014-certified EHR technology system. Finding efficiency equals survival for clinicians as they navigate these re quirements.
Stay Tuned There is some congressional discussion on Stage 2 qualification extensions. Just don’t get your hopes up for the early-adopter incentives to be extended as well.
Men’s Health
Statistics Mean Nothing to the Patient On the Wrong End of Them By Edward N. Rampersaud Jr., M.D.
My father, a family physician, called me
instead, to whom treatment is offered.
Dr. Edward Rampersaud is a urologic oncologist and assistant professor of surgery for the Section of Urologic Oncology at the Duke Cancer Institute. He earned his medical degree from Duke University, where he also completed his urology residency and research fellowship. He then completed a Society of Urologic Oncology fellowship at the Institute of Urologic Oncology at University of California, Los Angles. His clinical and research interests focus on kidney cancer and other malignancies of the upper retroperitoneum. For more information on Dr. Rampersaud visit www.dukehealth.org/physicians/edward-nrampersaud-jr. He can be reached at (919) 681-8760 or edward.rampersaud@duke.edu. To schedule a patient appointment, call (919) 668-8108.
from New York one year ago to ask, “So we shouldn’t get PSAs anymore?” The
Kidney cancer has been the focal point of
news was breaking in May 2012 that the
my clinical and research efforts for several
United States Preventative Task Force
years now. I perform complex partial and
(USPTF) had chosen the week of the
radical nephrectomies; and the topic of
American Urological Association (AUA)
competing risks and over-treatment has
national meeting to announce that they
begun to touch even kidney cancer, the
would be assigning Grade D recommen-
most lethal of genitourinary malignancies.
dations to population-based PSA screening. This occurred on the backs of two
As the number of partial and radical ne-
randomized trials, of debatable design,
phrectomies has risen during the last 20
attempting to measure the impact of PSA
years, the annual death rate for kidney
screening.
cancer has not appreciably diminished. While this is certainly a multifactorial
Still, as the AUA Guidelines Panel mud-
event well beyond the scope of this edi-
dled through the data to construct its own
torial, it leads us to question the natural
set of guidelines , I cannot help but won-
history of small renal masses (SRMs), as
der why so much of the focus has been
we do not fully understand their biology.
1
on detection rather than treatment. Why would we not want to know more clinical
With the increasing prevalence of cross-
information upon which to base an even
sectional imaging obtained for any num-
more-informed decision?
ber of reasons comes the diagnosis of the incidentally discovered SRM. In the
While it is becoming clearer to me that we
last couple of years, centers have begun
have likely been over-treating men with
publishing their experiences of patients
low-risk prostate cancer, it is not at all evi-
with SRMs (usually less than 4 centime-
dent that men with intermediate or high-
ters in diameter) that have been placed
risk prostate cancer are not better served
on active-surveillance regimens. I, also,
by its detection and aggressive treatment.
believe that not every SRM needs to be
We cannot ignore the fact that remains
treated and have instituted a formal active-
– prostate cancer is still the second lead-
surveillance program for the appropriate
ing cause of cancer-related death in men
patients.
The phrase “art and science of medicine” describes the integration of two folds of a profession that at its skin appear to be distinct and separate, but actually meld together into one. Fallibility applies to both evidence and anecdotal experience. However, we must use the available information – our experiences and abilities and the uniqueness of each individual patient – all combined to make the best and most-informed decision possible. Guidelines and best-practice statements are well-intended and important; but we should never forget about common sense,
each year. Nothing is worse than objectifying a paThe rate of death from prostate cancer has
tient by quoting a statistic – only to find
decreased by 20-30 percent in the PSA era,
out later that very patient is part of the mi-
and there are many possible explanations
nority contingent you originally described
for this phenomenon. As we continue to
to them. Even if the chance of the “bad”
observe, most men die with prostate can-
thing were 1 percent, for the patient to
cer, not of it. Perhaps the focus should not
whom it occurred, the chances were 100
be about narrowing the band of patients
percent after-the-fact.
intuition and the wisdom gained through actual experience that truly make us doctors and advocates of individual people. Reference
www.auanet.org/education/guidelines/
1
prostate-cancer-detection.cfm
on whom prostate cancer is detected, but
june 2013
11
Women’s Health
Uterine Fibroids
What can Women Do? By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
Uterine fibroids are remarkably common.
The options for treatment of fibroids are
One study by radiologists found that by age
growing. Certainly a hysterectomy is the
50 years, 80 percent of African-American
classic “cure.” Importantly, a woman does
women have fibroids and 70 percent of
not have to remove her ovaries (source
Caucasian women have fibroids.
of estrogen and progesterone, or female hormones) when she has a hysterectomy.
As a clinician, I divide the problems of
If a woman is motivated to avoid a
fibroids into two broad categories: bulk
hysterectomy, then what can she do?
symptoms and bleeding symptoms. The bulk symptoms are due to fibroids that
The
minimally
grow to be large. Symptoms may include
for
pressure, a feeling “fullness,” back pain,
myomectomy with MyoSure, laparoscopic
fibroids
invasive
include:
treatments
hysteroscopic
urinary urgency, constipation, etc. The
myomectomy (removal of the fibroid, not
bleeding symptoms range from heavy
the uterus), uterine fibroid embolization
periods to abnormal bleeding.
(performed by radiologists), the new
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.
Drug Administration for cyclic heavy
HALT procedure (radiofrequency energy
menstrual bleeding (HMB). A large
Despite enormous efforts to understand
administered to fibroids) and ExAblate
proportion of women with HMB treated
why
our
(magnetic resonance imaging-focused
with Lysteda had uterine fibroids. An
understanding is still lacking. Even so,
energy to fibroids), as well as medications.
advantage to this medication is that it is
women
develop
fibroids,
nonhormonal, taken only during the days
women seem to find it reassuring that they are so common, so as a clinician, I
Medications for heavy periods related to
a woman has bleeding (up to five days),
start there.
fibroids include Lysteda, a medication
and it does not impact fertility.
approved by the United States Food and The Institution Review Board-approved advertisement on the Elagolix study at the Women’s Wellness Clinic.
Do Heavy Periods associated with
Uterine Fibroids
Affect You?
Uterine fibroids symptoms can affect any woman, anytime, anywhere. If you’re at least 20 years old and have heavy periods associated with uterine fibroids, you may qualify for this oral investigational medication research study. As a participant, you will receive all study-related care and investigational medication at no cost. If uterine fibroids affect your life, consider volunteering.
Call 919-251-9223
www.fibroidstrial.com Women's Wellness Clinic
12
The Triangle Physician
Elagolix is a medication under evaluation
which is taken daily, essentially stops
treatments for uterine fibroids and about
and available through a new study being
bleeding by suppressing ovarian function.
the Women’s Wellness Clinic can be found online at www.cwrw.com.
conducted at Carolina Women’s Research and Wellness Center. The oral medication,
More
information
about
the
latest
Statewide
Medical Board Contest Challenges Licensees to Polish Their Profiles The North Carolina Medical Board has
LI categories that must be reported include:
Information reported in optional licensee
launched its first-ever contest to promote
• Basics, such as the licensee’s current
information categories must be accurate
broader licensee participation in the op-
practice address and telephone number.
and relevant to each individual category
tional content listings offered through the
• Where applicable, such information as ac-
for which information is provided. Winning
board’s popular licensee information pages.
tions by out-of-state medical boards and
entries will be determined at the sole discre-
other regulatory agencies, certain crimi-
tion of the NCMB Public Affairs Department.
All licensed physicians and physician assis-
nal convictions and information about
tants have licensee information (LI) pages,
certain malpractice payments.
How to Enter
which include required and optional infor-
Visit www.ncmedboard.org, and click on
mation. The NCMB reports that not all li-
The NCMB also offers licensees the op-
“Update Licensee Info Page” in the green
censees are taking advantage of the opportu-
portunity to provide information in many
Quick Links box on the right. Log in and
nity to market themselves and their practice
optional categories, including “practice phi-
provide content for applicable optional cate-
through optional information categories.
losophy,” memberships in professional soci-
gories (practice philosophy, memberships,
eties, non-English languages spoken by the
languages spoken, etc.) Verify all informa-
Consider that, according to NCMB, the pub-
licensee and/or in the office, public service,
tion is accurate.
lic accesses these pages up to 3,000 times
participation in Medicare and Medicaid and
each day, most often by clicking on the
more! This information is of great interest to
When finished, let the board know in an e-
“Look Up a Licensee” tool, the most popu-
current and prospective patients. – in fact,
mail to: forum@ncmedboard.org. Include
lar feature on the board’s website.
according to NCMB, patients contact the
full name. Entrants must complete updates
board to ask why there is no information in
by end of business July 1.
To further incent licensees to maintain their
these categories.
Prizes
NCMB website profiles, the board is challenging licensees to polish their optional content,
Contest Details
Depending on the number and quality of
and the winner will be featured in an upcom-
The North Carolina Medical Board will ac-
entries, the NCMB’s Public Affairs Depart-
ing medical board promotional campaign!
cept entries to its Licensee Information
ment will select up to 10 licensees, who will
Challenge through July 1. Its goal is to en-
be offered the opportunity to be featured in
LI pages date back to the 1990s, when NCMB
courage more licensed physicians and phy-
an upcoming NCMB public awareness cam-
began posting basic licensee information
sician assistants to provide optional content
paign. Examples of upcoming campaigns
online as part of its ongoing commitment to
for their licensee information pages.
include print media/display advertisements,
public protection and transparency. In 2000,
radio spots and/or video public service an-
the board became one of the first medical
Rules
nouncements. Winners also will be featured
regulators in the country to begin posting
Licensed physicians and physician assis-
in The Forum.
public board actions on the web. The most
tants must:
recent enhancements to online licensee
• Have an active license,
Questions?
information came in 2009, when the board
• Practice medicine at least part time,
Contact Jean Fisher Brinkley, Director, Pub-
implemented changes to North Carolina law
• Have no history of public discipline for at
lic Affairs at jean.fisher@ncmedboard.org or
that significantly expanded the types of in-
least 10 years.
(919) 326-1109, ext. 230.
formation it is required to collect and report regarding its licensees.
june 2013
13
Endocrinology
Congenital Hypothyroidism Hypothyroidism is a common condition
thyroid), or only partially formed. These
to develop over the course of a lifetime,
cases are most often sporadic, and com-
but it is also a condition babies can be
prise the majority of cases of congenital
born with. As it is common (1 in 3000-4000
hypothyroidism, at 80-90%. Future babies
newborns), cost-effective to diagnose and
born to the same parents are not at any
treat, and a preventable cause of mental
higher risk to have the same problem. The
retardation, it is of the utmost importance
other way a baby can be hypothyroid is to
to address it early. Here, we’ll review
have a defect or deficient enzyme along
the causes, diagnosis, treatment, and
the pathway that takes precursors and cre-
management of this disease.
ates thyroxine. Another way to say this is there is a slow or broken machine along
Signs and symptoms of hypothyroidism
the factory that takes building blocks and
in a baby can be quite hard to detect,
creates the final product. This form of hy-
and devastating to miss. For this reason,
pothyroidism comprises the other 10-20%
in 1974, the United States began pilot
of congenital hypothyroidism, and is au-
programs for newborn screening. This
tosomal recessive. Future babies born to
is a special test for infants at twenty-four
the same parents have a 25% chance of be-
hours of life. A heel stick is performed,
ing normal, 50% chance of being a carrier,
and blood is collected onto a piece of
and 25% chance of being affected.
filter paper to be screened for diseases for
By Julia Warren-Ulanch, M.D.
Julia Warren-Ulanch is a board-certified adult and pediatric endocrinologist. She is a graduate of Texas A&M University, who travelled to the University of Michigan for residency in internal medicine and pediatrics. She went on to the University of Pittsburgh, where she completed her training as a fellow in adult and pediatric endocrinology. Dr. Warren-Ulanch is board certified and has Endocrine Certification in Neck Ultrasound (ECNU). Now an associate at Carolina Endocrine, P.A., she enjoys serving pediatric and adult patients with general endocrinology issues. For more information and patient referrals and appointments, call (919) 571 3661 or visit the practice website at carolinaendocrine.com.
which early intervention is available and
Once confirmed with repeat blood
life-changing. Amongst those conditions
testing, determining the cause of the
of water, levels can be normalized quickly.
tested is congenital hypothyroidism. The
hypothyroidism is important to provide
Infants on a soy formula may require
outcome for babies is best if treatment
implications for the patient (more severe
more, as absorption is impaired.
is started within 14-21 days of life. In
cases are at higher risk for developmental
the State of North Carolina, the test for
delay) future pregnancies. A nuclear
While no parent wants their newborn
hypothyroidism includes both thyroid
medicine test to image the thyroid with
afflicted with any problems, congenital
stimulating hormone (TSH) and thyroxine
technetium can be done quickly to
hypothyroidism is treatable with daily
(T4). Using the values of these tests,
assess the presence and location of the
hormone
infants are classified as normal, borderline
thyroid. As soon as the test is complete,
close
(TSH<20 and T4<5, TSH 20-29.9 and T4
replacement can begin. If levothyroxine
Endocrinologist, we can assist these
<12.9, or TSH 30-39.9) or hypothyroid (any
is started quickly at a dose of 10-15ug/kg/
babies to develop to their full intellectual
TSH>40uIU/mL). Those with borderline
day, and dosed in water or a small amount
potential.
replacement.
monitoring
with
Along a
with
Pediatric
or hypothyroid results are sent a letter within a week notifying the pediatrician that further testing is in order. The common causes of congenital hypothyroidism fall into two major categories: athyreosis and dyshormonogenesis. Infants can be born without a thyroid altogether, a gland in the wrong location (usually the base of the tongue, or lingual
14
The Triangle Physician
The Triangle Physician 2013 Editorial Calendar July Imaging Technologies Psoriasis, Medical Insurance
October Cancer in Women, COPD - Lung Health Medical Software - EMR
August Orthopedics, Gastroenterology Medical Real Estate
November Alzheimerâ&#x20AC;&#x2122;s Disease Diabetes, Financial Planning
September Atrial Fibrillation Urology, Web Design
December Pain Management, Spine Disorders Practice Management
Wake News
Trauma Center Designation Is Renewed The North Carolina Office of Emergency
in the state. In this capacity, it provides
a leader in this field,” said William “Bill” K.
Medical
has
sophisticated and multidisciplinary care
Atkinson, Ph.D., M.P.H., M.P.A., F.A.C.H.E.,
renewed the WakeMed Trauma Program’s
and serves as a regional referral site for the
president and chief executive officer of
designation as a Level 1 trauma center.
most critically injured.
WakeMed Health & Hospitals.
Level I is the highest designation awarded
“This re-designation exemplifies WakeMed’s
Osi Udekwu, M.D., serves as WakeMed’s
to trauma centers, and the renewal is for a
commitment to trauma care and validates
trauma director.
four-year period.
our expertise, experience and teamwork as
Services
(NCOEMS)
Following a comprehensive site visit and indepth examination of all processes related to WakeMed trauma services, the state cites zero deficiencies. In addition to strong leadership, vision and commitment to trauma, the report cited WakeMed’s robust trauma program staff, including clinical team members, physicians, researchers and support staff. It also cited: • Collaboration among area EMS providers, trauma service, emergency department and all the subspecialty team members who care for trauma patients; • Disaster preparedness program; • State-of-the-art
equipment,
training
techniques and facilities, including the Center for Innovative Learning and simulation trainings; • Staff involvement in trauma system endeavors
and
regional
system
development; • WakeMed’s physician assistant residency program; and • Commitment
to
injury
prevention,
education and outreach. WakeMed’s trauma program has reportedly seen a 93 percent increase in trauma patients in the past decade. Last year, more than 3,200 patients were treated there, making it one of the busiest trauma centers in North Carolina. WakeMed first earned designation as Wake County’s only Level I trauma center in 2006. Today, it is one of six Level I trauma centers Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
june 2013
15
Duke Research News
Duke Researchers Identify Mutations Associated With Nearsightedness Mutations in a gene that helps regulate
international research team.”
Pharmacology and Cancer Biology at Duke, said the finding suggests that different
copper and oxygen levels in eye tissue are associated with a severe form of
In this study, Dr. Young and her colleagues
kinds of mutations in the SCO2 gene result
nearsightedness, according to a study
sought to identify these genetic factors by
in different diseases. Dr. Thiele, an expert in
published in the American Journal of
studying families with high-grade myopia.
copper metabolism who was not involved
Human Genetics May 2.
They performed next-generation deep
in the research, noted that another SCO2
sequencing on four relatives from an
gene mutation is responsible for a lethal
Nearsightedness – also known as myopia –
11-member American family of European
form of cardiomyopathy.
is the most common human eye disease in
descent. “This is a fascinating finding, and it points
the world. It occurs if the eye is too long or the cornea has too much curvature, which
Analyzing DNA extracted from blood and
to the relevance of copper metabolism to a
keeps light entering the eye from focusing
saliva, the researchers identified mutations
spectrum of different human diseases,” Dr.
correctly.
in the SCO2 gene in common among family
Thiele said.
members with high-grade myopia, but High-grade myopia, a more severe form
absent in those family members with no
Since normal copper metabolism is
of nearsightedness, affects up to 2 percent
myopia. They confirmed four mutations in
important for eye health, future research
of Americans and is especially common
the SCO2 gene in an additional 140 people
may focus on whether copper deficiency
in Asian populations. Individuals with
with high-grade myopia.
could place someone at higher risk for nearsightedness.
high-grade myopia are at an increased risk for other serious eye problems,
Once the researchers identified the
including retinal detachment, cataracts and
mutations in DNA samples, they turned
“Our findings, plus information from the
glaucoma.
to human eye tissue and verified that the
literature, suggest that copper deficiency
SCO2 gene was expressed in areas of the
could predispose people to develop
eye connected to nearsightedness.
myopia,” Dr. Young said. “While this wasn’t
Studies suggest that myopia is caused by a
directly tested in this study, it’s possible that
combination of environmental factors, such as large amounts of reading and genetics.
To further support their findings, they
our diets – which are deficient in a number
Nearsightedness runs in families, but little
performed an experiment in which mice
of minerals and vitamins – play a role, and
is understood about genetic factors that
were made nearsighted in one eye by
it may be something as easy as taking a
cause it.
wearing a strong lens. Collaborators at Duke-
supplement with copper that helps thwart
NUS, the Singapore Eye Research Institute
the development of myopia.”
In recent years, researchers have reported
and Yong Loo Lin School of Medicine at
several genes or locations of genes
the National University of Singapore found
Dr. Young noted that multiple factors
associated with myopia and have continued
that SCO2 gene expression decreased in
are likely responsible for developing
to search for additional clues.
the nearsighted eye, suggesting that SCO2
nearsightedness,
may play a role in the development of
additional research. She hopes to continue
nearsightedness.
by studying animal models with SCO2
“This is the first time a gene mutation
and
this
warrants
mutations to better understand the gene’s
for autosomal dominant nonsyndromic
connection with nearsightedness.
high-grade myopia in Caucasians has
In the body, the SCO2 gene helps
been discovered,” said senior author
metabolize copper, an element important
Terri Young, M.D., M.B.A., professor of
for regulating oxygen levels in eye tissue.
In addition to Dr. Young, co-authors include
ophthalmology, pediatrics and medicine
Increased stress brought on by too much
Khanh-Nhat Tran-Viet, Caldwell Powell and
at the Duke Eye Center, Duke Center for
oxygen may alter the eye’s development
Erica Nading of Duke; Yi-Ju Li of Duke, Duke-
Human Genetics and the Duke-National
and function.
NUS and Yong Loo Lin School of Medicine at the National University of Singapore
University of Singapore Graduate Medical School (Duke-NUS). “Our findings reflect
Dennis J. Thiele, Ph.D., George Barth
(NUS); Steve Rozen and Thomas Klemm of
the hard work and collaboration of our
Geller professor in the Department of
Duke-NUS; Veluchamy A. Barathi of Duke-
16
The Triangle Physician
Duke News NUS, Singapore Eye Research Institute
Oklahoma/Dean McGee Eye Institute;
The research was supported by the National
and Yong Loo Lin School of Medicine at
Georg Schneider of the Agency for Science
Institutes of Health, the Lew Wasserman
NUS; Candace Ho of the Singapore Eye
Technology and Research in Singapore and
Award from Research to Prevent Blindness
Research Institute; Sebastian Maurer-Stroh
Institute of Science and Technology Austria;
Inc., a Duke-NUS core grant, the Toulouse
of the Agency for Science Technology
Ravikanth Metlapally of the University of
Hospital Young Researcher Fellowship, the
and Research and Nanyang Technological
California, Berkeley; Seang-Mei Saw of the
Fondation pour la Recherche Médicale,
University in Singapore; Vincent Soler of
Yong Loo Lin School of Medicine at NUS;
Fondation de France and the National
the Université Paul Sabatier in France;
and Liang Goh of Duke-NUS and the Yong
Medical Research Council of Singapore.
Tammy Yanovitch of the University of
Loo Lin School of Medicine at NUS.
Kernodle Clinic Physicians Join Faculty Practice Group The physicians of Kernodle Clinic Inc., a
same time, access and coordination of care
Carolina, with more than 40 physicians at
multispecialty medical practice serving the
will be streamlined, where needed, with
four locations in Alamance County. Kernodle
Triad region, have joined Private Diagnostic
Duke specialty and subspecialty programs
Clinic provides services in many specialties
Clinic, Duke Medicine’s physician practice
and faculty.
including internal medicine, family medicine, pediatrics,
organization.
obstetrics
and
neurology,
gynecology,
Kernodle providers and patients also will gain
cardiology,
This affiliation, effective Aug. 1, ensures that
access to Duke Medicine’s new state-of-the-
podiatry, rheumatology, gastroenterology,
orthopedics,
current and future Kernodle Clinic patients
art electronic health record technology.
endocrinology,
pulmonology,
sports
medicine, physiatry, physical therapy and
will continue to receive their medical care locally from their existing Kernodle
Founded in 1949, Kernodle Clinic is one of
physicians and other local providers. At the
the largest multispecialty practices in North
general surgery.
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
june 2013
17
Duke Research News
Family History May Mean Higher Levels of Alzheimer’s Pathology Close family members of people with
Duke
trainee
people with a positive family history may
Alzheimer’s disease are more than twice
Erika J. Lampert, Mr. Doraiswamy and
also have higher levels of Alzheimer’s
as likely as those without a family history
colleagues analyzed data from 257 adults,
pathology earlier, which could be a reason
to develop silent buildup of brain plaques
ages 55 to 89, both cognitively healthy and
why they experience a faster cognitive
associated
with varying levels of impairment. The
decline than those without a family history,”
participants were part of the Alzheimer’s
Ms. Lampert said.
with
Alzheimer’s
disease,
according to researchers at Duke Medicine.
neuroscience
research
Disease Neuroimaging Initiative, a national The study, published online in the journal
study working to define the progression of
The findings may influence the design of
PLOS ONE April 17, confirms earlier findings
Alzheimer’s through biomarkers.
future studies developing new diagnostic tests for Alzheimer’s, as researchers may
on a known genetic variation that increases one’s risk for Alzheimer’s and raises new
The researchers looked at participants’ age,
choose to exclude those with a positive
questions about other genetic factors
gender and family history of the disease,
family history – a group that has historically
involved in the disease that have yet to be
with a positive family history defined as
volunteered to participate in studies to
identified.
having a parent or sibling with Alzheimer’s.
better understand the disease – as healthy
This information was compared with
controls, given that they are more likely to
An estimated 25 million people worldwide
cognitive assessments and other biological
develop Alzheimer’s pathology.
have Alzheimer’s disease, and the number
tests, including APOE genotyping, magnetic
is expected to triple by 2050. More than 95
resonance
measuring
“Our study shows the power of a simple
percent of these individuals have late-onset
hippocampal volume and studies of three
one-minute questionnaire about family
Alzheimer’s, which usually occurs after
different pathologic markers (Aβ42, t-tau,
history to predict silent brain changes,” Mr.
the age of 65. Research has shown that
and t-tau/Aβ42 ratio) found in cerebrospinal
Doraiswamy said. “In the absence of full
Alzheimer’s begins years to decades before
fluid.
understanding of all genetic risks for late-
imaging
scans
onset Alzheimer’s, family history information
it is diagnosed. As expected, the researchers found that a
can serve as a risk-stratification tool for
Family history is a known risk factor and
variation in the APOE gene associated with a
prevention research and personalizing
predictor of late-onset Alzheimer’s disease,
greater risk and earlier onset of Alzheimer’s
care.” He encouraged those with a known
and studies suggest a two- to four-fold greater
was overrepresented in participants with a
positive family history to seek out clinical
risk for Alzheimer’s in individuals with a
family history of the disease. However, other
trials specific to preventing the disease.
mother, father, brother or sister who develop
biological differences also were seen in
the disease. These first-degree relatives share
those with a family history, suggesting that
In addition to Ms. Lampert and Mr.
roughly 50 percent of their genes with another
unidentified genetic factors may influence
Doraiswamy,
member of their family. Common genetic
the disease’s development before the onset
Kingshuk Roy Choudhury, Christopher A.
variations, including changes to the APOE
of dementia.
Hostage and Jeffrey R. Petrella.
heritability of Alzheimer’s, but the disease’s
Nearly half of all healthy people with a
Funding for the study was provided in part
other genetic roots are still unexplained.
positive family history would have met
by the Alzheimer’s Disease Neuroimaging
study
authors
include
gene, account for around 50 percent of the
the criteria for preclinical Alzheimer’s
Initiative, a public-private partnership created
“In this study, we sought to understand
disease based on measurements of their
with $60 million in grants from the National
whether simply having a positive family
cerebrospinal fluid, but only about 20
Institute on Aging, the National Institute of
history, in otherwise normal or mildly
percent of those without a family history
Biomedical Imaging and Bioengineering,
forgetful people, was enough to trigger silent
would have met such criteria.
the Food and Drug Administration, private pharmaceutical companies and non-profit
buildup of Alzheimer’s plaques and shrinkage of memory centers,” said senior author P.
“We already knew that family history
organizations. Trainees in Mr. Doraiswamy’s
Murali Doraiswamy, M.B.B.S., professor of
increases
lab are supported by the Wrenn Clinical
psychiatry and medicine at Duke.
Alzheimer’s, but we now are showing that
18
The Triangle Physician
one’s
risk
for
developing
Research Scholars Fund.
UNC Research News
Fetuses Emit Hormone that Protects Mother from Preeclampsia In a study using mice, researchers from
“We really don’t know that a pregnant
By
the University of North Carolina School
woman is going to get preeclampsia until
adrenomedullin, the research could pave
of Medicine found that the hormone
she has it,” said Dr. Caron. Because the
the way to new methods for detecting and
adrenomedullin plays a crucial role in
condition has numerous risk factors
preventing preeclampsia. For example,
preventing the pregnancy complication
and causes, it’s difficult for doctors to
adrenomedullin levels could potentially
preeclampsia. They also found that
know which patients are at highest risk.
be used as a biomarker, or early indicator,
this hormone protects women from
“Identifying molecules that could predict
to identify which patients might be
preeclampsia when emitted by the
preeclampsia would be really important.”
predisposed to the condition. “Having
the
key
role
of
a biomarker would be wonderful – it
fetus, during the most critical times in pregnancy.
identifying
The researchers studied mice that were
could allow the physician to manage a
genetically
woman differently in the early part of her
programmed
to
produce
pregnancy,” said Dr. Caron.
“We’ve identified the fact that the baby
either reduced or increased levels of
is important in protecting the mom from
adrenomedullin. The study revealed that
preeclampsia,” said the study’s senior
in a normal pregnancy, the fetus secretes
As a next step, the researchers plan to
author, Kathleen M. Caron, Ph.D., assistant
adrenomedullin into the placenta during
build upon their mouse studies to examine
dean for research at the UNC School of
the second trimester, signaling special
patterns of adrenomedullin levels and
Medicine and an associate professor
cells called “natural killer cells” to help
preeclampsia in pregnant women.
in the Department of Cell Biology and
dilate the mother’s blood vessels and
Physiology. “If the baby’s cells are not
allow more blood to flow to the growing
This paper was published online on May 1
secreting this hormone, the mother’s
fetus.
in the Journal of Clinical Investigation and appears in the June print edition.
blood vessels don’t undergo the dilation The study is one of the first to identify an
that they should.”
important chemical message sent from
The study’s co-authors include: Manyu
Preeclampsia affects roughly one in 15
fetus to mother in the womb. Scientists
Li, Nicole M.J. Schwerbrock, Patricia M.
pregnancies. An important characteristic
understand more about the mom’s side
Lenhart, Kimberly L. Fritz-Six, Mahita
of the condition is that blood vessels in
of the “chemical conversation” that goes
Kadmiel, Kathleen S. Christine, Scott T.
the placenta fail to enlarge, or dilate, to
on between mother and baby, but much
Espenschied, Helen H. Willcockson and
accommodate increased blood flow to
of the hormonal signaling in the placenta
Christopher P. Mack of UNC; and Daniel
the fetus. Untreated, it can threaten the
remains a mystery.
M. Kraus of Duke University Medical Center.
life of both mother and baby.
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june 2013
19
UNC Research News
Inpatients Who Have STEMI More Likely to Die Than Outpatients between Jan. 1, 2007 and July 31, 2011, com-
Researchers have found that the chances
er than people who suffer a STEMI outside
of surviving an ST elevation myocardial in-
the hospital. But even after adjusting the
pared to 227 patients with outpatient STEMI
farction while being treated in the hospital
statistical analysis to account for this, there
treated at UNC Hospitals during the same
for something else is greater than for those
were important differences in survival, Dr.
time period. UNC Hospitals earned the
who have this kind of a heart attack outside
Stouffer said.
American Heart Association’s Gold Level Performance Achievement Award in 2012
the hospital and are quickly brought to the According to a UNC press advisory, another
for its care of STEMI patients and has a very
possible explanation: Hospital emergency
active STEMI program. Further research is
The study is the first to systematically ex-
departments are trained to react very quick-
needed to determine the inpatient STEMI
amine outcomes among hospital inpatients
ly when a patient with a suspected STEMI is
survival rates at hospitals that have not
who have an ST elevation myocardial in-
brought in. For that reason, the time from a
achieved such AHA recognition.
farction (STEMI). It was published April 4
STEMI outpatient’s arrival to treatment with
in the Journal of the American Heart Asso-
angioplasty, referred to as “door-to-balloon
Nationwide, there are approximately 11,000
ciation.
time,” averages about 45 minutes at UNC
cases of STEMI a year among hospital inpa-
Hospitals.
tients, which would translate into approxi-
emergency department for treatment.
mately 4,300 deaths based on extrapolating
“We found that the survival rate for outpa-
data from this study.
tients brought to UNC Hospitals for STEMI
“In contrast, when patients who are in the
treatment was slightly more than 96 per-
hospital for a non-cardiac condition have a
cent,” said George A. Stouffer, M.D., distin-
STEMI, the onset is not usually heralded by
First author of the study is Xuming Dai,
guished professor in the University of North
chest pain and thus health care providers
M.D., a fellow in interventional cardiol-
Carolina School of Medicine and senior au-
may not suspect that a coronary artery has
ogy at UNC. The other authors are Joseph
thor of the study. “But the survival rate for
occluded. As a result, the time it takes for
Bumgarner, M.D.; Andrew Spangler, M.D.;
inpatients who suffered a STEMI was much
restoration of coronary blood flow for inpa-
Dane Meredith, M.P.H.; and Sidney C. Smith
lower, only 60 percent.”
tients is much slower and more variable,”
Jr., M.D., professor of cardiology at UNC
Dr. Stouffer said.
and a past president of the American Heart Association.
Part of the difference is explained by the fact that people who suffer a STEMI while
These results are based on 48 cases of
hospitalized are, as a group, older and sick-
STEMI among inpatients at UNC Hospitals
Margaret Gourlay Wins Top 10 Clinical Research Achievement Award For leading a study that
England Journal of Medicine in January 2012,
“Dr. Gourlay’s study has proven to be very
was the first to define ap-
calculated time estimates that doctors can
influential in the field of bone and mineral
propriate bone density-
use for bone density screening in primary
research, and it has the potential to change
screening intervals for
care practice, based on a woman’s first bone
the way doctors order bone density tests,”
older women, Margaret
density T-score at age 65 or older. The study
said Eugene P. Orringer, M.D., a professor
Gourlay, M.D., M.P.H., of the University of
found that when women had good T-scores
of medicine at UNC who nominated her for
North Carolina School of Medicine has
on their first test, it took about 15 years for
this award.
been honored with a Top 10 Clinical Re-
10 percent of them to develop osteoporo-
search Achievement Award from the Clini-
sis. But women with lower T-scores on their
“The results should help doctors target the
cal Research Forum.
first test developed osteoporosis sooner – it
bone density screening, so that they test
took about one to five years for 10 percent of
patients with lower T-scores and thinner
them to develop osteoporosis.
bones more frequently. The results also
Dr. Gourlay’s study, published in the New
20
The Triangle Physician
Category UNC Research News mean that older women with very good
light up more of these beacons for the mil-
tigious and acclaimed academic medical
bone density on their first test don’t need
lions who look to us for help.”
centers and health care systems. Its goal is to sustain and expand a cadre of talented,
tests to be performed nearly as often as was originally thought,” Dr. Orringer said.
Dr. Gourlay, an assistant professor in the
well-trained clinical investigators at all stage
Department of Family Medicine in the UNC
of career development and support nurtur-
“These achievements are beacons of hope
School of Medicine and an adjunct assis-
ing environments and comprehensive re-
that show what can be accomplished when
tant professor in the UNC Gillings School
search capabilities within academic institu-
our nation’s researchers are given the free-
of Global Public Health, and the other win-
tions. Its mission is to provide leadership
dom and resources to tackle tough clinical
ners were honored April 18 during the Clin-
to the national clinical and translational re-
problems,” said National Institutes of Health
ical Research Forum annual meeting and
search enterprise and promote understand-
Director Francis S. Collins, M.D., Ph.D. “The
awards dinner in Washington, D.C.
ing and support for clinical research and its impact on health.
opportunities for advancing clinical research have never been better. So, we at NIH
The Clinical Research Forum is an organi-
look forward to doing everything we can to
zation comprised of the nation’s most pres-
Persistent Pain Following Stressful Events May Have Neurobiological Basis A new study led by University of North
to the body’s response to stressful events.
have no idea what the biologic mecha-
Carolina School of Medicine researchers
The study evaluated whether the HPA axis
nisms are that cause chronic pain. Chron-
is the first to identify a genetic risk factor
influences musculoskeletal pain severity
ic pain after these events is common and
for persistent pain after traumatic events,
six weeks after motor vehicle collision
can cause great suffering, and there is an
such as motor vehicle collision and sex-
and sexual assault.
urgent need to understand what causes chronic pain, so that we can start to de-
ual assault. Its findings revealed that variation in the
velop interventions.”
In addition, the study contributes further
gene encoding for the protein FKBP5,
evidence that persistent pain after stress-
which plays an important role in regulat-
This study is an important first step in de-
ful events has a specific biological basis.
ing the HPA axis response to stress, was
veloping this understanding, he said.
A manuscript of the study was published
associated with a 20 percent higher risk of
online in the journal Pain April 29.
moderate to severe neck pain six weeks
“In addition, because we don’t under-
after a motor vehicle collision, as well as
stand what causes these outcomes, indi-
“Our study findings indicate that mecha-
a greater extent of body pain. The same
viduals with chronic pain after traumatic
nisms influencing chronic pain devel-
variant also predicted increased pain six
events are often viewed with suspicion, as
opment may be related to the stress
weeks after sexual assault.
if they are making up their symptoms for financial gain or having a psychological
response, rather than any specific injury caused by the traumatic event,” said
“Right now, if someone comes to the
reaction,” Dr. McLean said. “An improved
Samuel McLean, M.D., M.P.H., senior au-
emergency department after a car acci-
understanding of the biology helps with
thor of the study and assistant professor
dent, we don’t have any interventions to
this stigma.”
of anesthesiology. “In other words, our
prevent chronic pain from developing,”
results suggest that in some individuals
Dr. McLean said. “Similarly, if a woman
The study was conducted by a multidisci-
something goes wrong with the body’s
comes to the emergency department af-
plinary team of investigators from 13 insti-
‘fight or flight’ response or the body’s re-
ter sexual assault, we have medications to
tutions. Co-lead authors on the study were
covery from this response, and persistent
prevent pregnancy or sexually transmit-
Andrey Bortsov, M.D., Ph.D., assistant re-
pain results.”
ted disease, but no treatments to prevent
search professor in the UNC Department
chronic pain.
of Anesthesiology; and Jennifer Smith, B.S., a UNC medical student and former
The study assessed the role of the hypothalamic-pituitary adrenal (HPA) axis, a
“This is because we understand what
physiologic system of central importance
causes pregnancy or infection, but we
Doris Duke fellow.
june 2013
21
Recognition
Paulson Returns to Chair Duke’s Department of Radiology Erik Paulson, M.D., is returning to the Duke University School of Medicine as chairman of the Department of Radiology, after serving as professor and chairman of the Department of Diagnostic Radiology at MD Anderson Cancer Center.
and his collaborative spirit make him an exceptional leader for the department of radiology,” said Nancy C. Andrews, M.D., Ph.D., dean of Duke University School of Medicine. “I am thrilled that Erik is returning to Duke to take on this important role.”
Dr. Paulson was educated and trained at Duke, and spent 20 years as a faculty member with increasing responsibilities and leadership roles. Before joining MD Anderson in 2012, he was named Duke’s division chief of abdominal imaging in 2001 and vice chairman of the Department of Radiology in 2009.
A highly regarded expert in cross-sectional imaging of the abdomen, Dr. Paulson has built an academic career around clinically driven research. His academic interests include cross-sectional imaging of the liver, assessments of computed tomography (CT) technology and new image-guided interventions. Recent work focuses on advanced CT methods and reducing the radiation patients receive during CT scans.
“Dr. Paulson’s knowledge of Duke and of the national and international radiology landscape, his commitment to excellence
Dr. Paulson’s work reflects his collaborative approach to clinical care and research. His contributions to peer-reviewed publications, his clinical practice and his leadership in professional societies have earned him respect within and beyond radiology circles. “I am committed to listening, learning and navigating progress within Duke radiology,” Dr. Paulson said. “My goals are to maintain areas of excellence, introduce new initiatives to meet evolving demands, address the impacts of a changing health care environment and nurture collaboration that is essential for clinical and research excellence in a major medical center.”
An author on more than 176 publications,
Breast Cancer Expert Named One of TIME’s 100 Most Influential People Kimberly Blackwell, M.D., a clinical oncolo-
targeted therapy, and chemotherapy to im-
contributions to improving breast cancer
gist at Duke Cancer Institute and one of the
prove survival rates with fewer unpleasant
care.
country’s leading breast cancer research-
side effects. The treatment for advanced
ers, is included in this year’s roster of TIME
HER-2 positive breast cancer was approved
“Being recognized by TIME not only reflects
magazine’s 100 most influential people.
by the United States Food and Drug Admin-
my work, but the thousands of patients who
istration earlier this year.
have bravely participated in the clinical trials that allow us to move the field of breast
Dr. Blackwell was the only cancer specialist named to the TIME list, which recognizes
Dr. Blackwell served as the principal inves-
cancer therapy forward,” Dr. Blackwell
activism, innovation and achievement,
tigator on the pivotal TDM-1 study. Previous-
said. “Although TIME is recognizing me as
along with political leaders, such as Presi-
ly, she was a leader in the development of
an individual involved in some of the excit-
dent Barack Obama, first lady Michelle
the breast cancer drug treatment lapatinib.
ing breast cancer therapies that have been developed in the last five years, it is really
Obama and New Jersey Gov. Chris Christie; activist Aung San Suu Kyi; and celebrities
A professor of medicine and director of
an acknowledgment of the patients and the
Justin Timberlake, Beyoncé and Jay Z.
the breast cancer program at Duke Cancer
scientists who have been instrumental in
Institute, Dr. Blackwell treats patients at the
this important pursuit.”
In her commentary, Sherry Lansing, the
Duke Cancer Institute, focusing on com-
former chairman and chief executive offi-
plex breast cancer cases that include those
A full list of the TIME 100 most influential
cer of Paramount Pictures and co-founder
involving women under age 40. A national
people appeared in the April 29 issue of the
of Stand Up to Cancer, cited Dr. Blackwell’s
and community leader, she has served on
magazine, which is currently online at time.
work on TDM-1. Dubbed a “smart bomb,”
numerous cancer advisory panels, includ-
com/time100.
the treatment combines Herceptin, a gene-
ing as a Komen Scholar for distinguished
22
The Triangle Physician
Recognition
Certified Physician Assistant Joins Wake Internal Medicine & Pediatrics Jessica Hedrick, PA-C., has joined Wake Internal Medicine & Pediatrics in North Raleigh. In practice since 2006, Ms. Hedrick has been with the Wake Internal Medicine Consultants
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family of practices at Rx Urgent Care since 2009. She graduated from the University of North Carolina at Wilmington cum laude with a bachelor of arts degree in chemistry. She completed her physician assistant master of science degree at South University in Savannah, Ga. She has earned certification from the National Commission on Certification of Physician Assistants (NCCPA) and is licensed by the North Carolina Medical Board.
4441 Six Forks Rd. Suite 106-293 • Raleigh, NC 27609 • Phone: (800) 845-6090 NEWSOURCE-JUN10:Heidi 8/5/10 12:57 PM Page 1
“Ms. Hedrick has been a great asset to our Rx Urgent Care division and we are very pleased to have her in the North Raleigh offices,” said
Do They Like What They See?
Arvind Jariwala, M.D., practice president. “Her experience, compassion and relational skills are a great fit with our philosophy of providing convenient and exceptional medi-
Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.
cal care.” In addition to Wake Internal Medicine & Pediatrics, Wake Internal Medicine Consultants is
Our services range from consultation, to design, to creation and implementation of strategic plans.
comprised of Wake Gastroenterology, Wake Women’s Health and Rx Urgent Care. Twenty-four physicians provide a comprehensive range of health care services, including primary care and specialty diagnosis and treatment in cardiology, gynecology, pulmonary medicine, sleep medicine, pediatrics and gastroenterology.
newsource & Associates
Same-day appointments are offered for most specialties. Call (919) 781-7500. Complete practice information is available at www.
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wakeinternalmedicine.com.
june 2013
23
News Welcome to the Area
Physicians Eric Todd Lee, DO Neurology; Neuromuscular Medicine
University of North Carolina Hospitals Chapel Hill
Michael Thomas Durheim, MD
Mallory Jean McClester, MD
Alyssa Ann Williams, MD
Internal Medicine; Pulmonary Disease and Critical Care
Family Medicine
Psychiatry
University of North Carolina Hospitals Chapel Hill
University of North Carolina Hospitals Chapel Hill
Duke University Hospitals Durham
Amber Marie Huffman Gaught, MD
Benjamin Aaron Alman, MD
Physical Medicine & Rehab - Pain Medicine
Orthopedic Surgery, Pediatric
University of North Carolina Hospitals Chapel Hill
Duke Orthopaedics Durham
Ahmad Moustafa Aouthmany, MD Emergency Medicine; Internal Medicine; Pediatrics; Diagnostic Radiology; Nuclear Medicine; Nuclear Radiology
Duke University Hospitals Durham
Daniel Lee Gilstrap, MD Duke University Hospitals Durham
Maria Olivares, MD
Brad Patrick Barnes, MD
UNC Hospitals Chapel Hill
University of North Carolina Hospitals Chapel Hill
Brian Barrett, MD
Matthew Robert Kappus, MD Gastroenterology, Internal Medicine
Duke Gastroenterology Durham
Anne Christine Kelly, MD
Anesthesiology
University of North Carolina Hospitals Chapel Hill
Jessica Beierle Boyer, MD
Crysten Brinkley Kragel, MD
Emergency Medicine
Neurology
Wake Emergency Physicians Cary
Duke University Dept of Neurology Durham
Joseph McNeill Bumgarner, MD
Ginger Nichole Locklear, MD
Internal Medicine
University of North Carolina Hospitals Chapel Hill
Nathaniel James Coleman, MD Internal Medicine - Endocrinology, Diabetes & Metabolism
UNC-Chapel Hill Endocrinology Chapel Hill
Stephen James Dolgner, MD Internal Medicine; Pediatrics
Durham
Emergency Medicine
Duke University Medical Center Durham
Events
Pediatrics
University of North Carolina Hospitals Chapel Hill
Kevin Alan Paduchowski, MD Emergency Medicine
University of North Carolina Hospitals Chapel Hill
Neha Jadeja Pagidipati, MD
Pediatrics
University of North Carolina Hospitals Chapel Hill
Paul Bryan Maloof, MD
June 3, 5:30-7:30 p.m.
Look Good Feel Better is a free American Cancer Society program that teaches women beauty techniques while they undergo chemotherapy and radiation treatments. Participants receive a free cosmetics kit and instruction by beauty professionals. Location: North Conference Room, Durham Regional Hospital Registration: Call (919) 470-7168
Kavita Dali Patel, MD
Stroke Support Group June 10, 1-2:30 p.m.
Duke University Hospitals Durham
Karl Martin Schweitzer Jr, MD Orthopedic Surgery; Orthopedic, Ankle Foot
Duke University Hospitals Durham Internal Medicine
University of North Carolina Hospitals Chapel Hill
Duke University Hospitals Durham
Duke Health Center Durham
Margaret Marie, MD
Gaurav Vij, MD
Psychiatry
Hospitalist; Internal Medicine; Radiology; Neuradiology
Weight Loss Surgery Support Group June 25, 6-7 p.m.
This weight-loss surgery support group encourages discussion on topics related to adjustment before and after weight-loss surgery. June’s session is entitled “Physical Activity 101.”
Andrew Robert Spector, MD
Orthopedic Surgery; Orthopedic, Ankle Foot
The mission of this support group is to help educate the stroke survivor, caregiver and community about stroke prevention and stroke disabilities. This group meets the second Monday of each month. Location: Durham Regional Hospital, private dining room C
Lee Brinkley Sigmon, MD
Internal Medicine - Sleep Medicine; Neurology
Fairway Center Raleigh
Look Good Feel Better
Duke University Hospital Durham
Cardiovascular Disease, Internal Medicine
Family Medicine
Psychiatry
Duke University Hospitals Durham
Mark Salvatore Ritchie, PA
Matthew David Oettinger, MD UNC Hospitals Family Medicine Chapel Hill
University of North Carolina Hospitals Chapel Hill Adolescent & Young Adult Medicine; General Practice; Hospitalist; Adolescent Medicine; Internal Medicine; Pediatrics
Durham Regional Hospital Durham
Pulmonary Disease and Critical Care, Internal Medicine
Pediatric: Cardiology, Gastroenterology, Hematology-Oncology, Infectious Diseases, Pulmonology; Pediatrics - Developmental - Behavioral; Adolescent Medicine; Critical Care Pediatrics; Pediatric - Nephrology
Internal Medicine, Geriatric
Physician Assistants
Internal Medicine; Hospitalist
Family Medicine
Margaret Sandbank Hall, MD
Charles Adrian Austin III, MD
Dustin Lee Norton, MD
Location: Duke Center for Metabolic and Weight Loss Surgery Durham Clinic, 407 Crutchfield St., Durham 24404. Register for these events online at www. durhamregional.org/events or by calling (919) 403-4374, unless otherwise noted.
Duke University Hospitals Durham
Orthopedic Specialists welcomes the following people:
Ashley Mason, PA-C
Justin Scruggs, MD
Albert Harris, MD
Jon Verceles, PA-C
Katie Truscello, PA-C
Michelle Fegeley, PA-C
Shannon Poplstein, PA-C
Triangle Ortho welcomes the following people:
Bryan Stanislaus PA-C
24
Courtney Jordan, PA-C
The Triangle Physician
Jennifer Chazan, PA-C
Kelly Egbert, PA-C
Kim Jones, PA-C
Rosie Polinsky, PA-C
Ruth Berger, PA-C
Sue Weeks MD
Woody Burns III MD
“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
The No-Excuse Mammogram. Saturday and evening appointments where your patients live, work and play in the Triangle. An annual screening mammogram only takes 20 minutes, from check-in to exam completion. That’s the convenience of Wake Radiology, where we specialize in state-of-the-art digital mammography as well as comprehensive women’s imaging. It‘s easy for patients to schedule this important exam, because many of our nine breast imaging offices throughout the Triangle are open evenings and Saturdays, and walk-ins are welcome at all locations. Wake Radiology is in-network with most insurance plans and offers financial assistance or payment plans to those who need it. If your patients have celebrated 40 birthdays or more, encourage them to safeguard their health by calling 919-232-4700 or going online to schedule their annual screening mammogram today. Wake Radiology. Excellence in breast imaging.
Wake Radiology is a 2013 Year-Round Sponsor Wake Radiology is the only multi-site freestanding imaging provider in the Triangle to earn the prestigious American College of Radiology (ACR) designation of Breast Imaging Center of Excellence (BICOE). Nine convenient Triangle locations Raleigh | West Raleigh | Morrisville | Chapel Hill | Cary North Raleigh | Garner | Wake Forest | Fuquay-Varina
wakerad.com
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Comprehensive Breast Imaging Centers