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The Raleigh Center for Weight Loss Surgery Experts in Laparoscopic Bariatrics 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
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Sleep Apnea and Cancer Easing the Stroke Burden
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Contents
COVER STORY
6
The Raleigh Center for Weight Loss Surgery
Experts in Laparoscopic Bariatrics june
2012
Vol. 3, Issue 6
FEATURES
12
Neurology
Obstructive Sleep Apnea Is Associated with a Higher Mortality from Cancer Dr. Paul Peterson reports on a recent human study that links sleep apnea to an elevated risk of cancer mortality.
14
Bariatric Surgery
DEPARTMENTS 14 Your Financial RX Market Gurus and 15 Minutes of Fame
15 Practice Management Rethinking the EHR Revolution
16 Women’s Health Vigilance Helps Protect Women from Advance of Ovarian Cancer
20 Neurology Stroke Threat Grows Despite Declining Mortality and Changing Care Patterns
22 Duke Research News - Statin Drugs Slow Benign Prostate Growth; Lifestyle Could Help Too - Cardio Fitness Levels May Affect Survival of Breast Cancer Patients
23 Duke News New Health Education Center Honors Philanthropist’s Lifelong Commitment
Obstructive Sleep Apnea: Effective Treatment Leads to Rapid Improvement
24 UNC News
Dr. Alfonso Torquati explores obesity, obstructive
Quest to Understand Hepatitis C and Liver Cancer Link Gets $2.35 Million
sleep apnea and the effectiveness of bariatric surgery as treatment. COVER PHOTO: Joseph C. Moran, M.D., F.A.S.M.B.S., stands with two of his bariatric surgery patients, Dylan McIntyre and Alison Stair. Photo by Jacoby Photography.
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Dr. Ned Sharpless Recognized as a Welcome Distinguished Professor
25 UNC Research News 26 UNC Research News - $900,000 Grant to Fund Use of Kinase Test in HER2-positive Breast Cancer - DNA Replication Protein also Has a Role in Mitosis and Cancer
28 News Welcome
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From the Editor
From the Editor
Eyes Wide Open 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
When faced with the likelihood of dying from a comorbidity of obesity or being overweight, such as heart disease, folks often turn to The Raleigh Center for Weight Loss Surgery, the focus of our cover story this month. Editor Heidi Ketler, APR
heidi@trianglephysician.com
Here, patients must accept that the medical procedures – gastric bypass or insertion of an adjustable gastric band, performed either laparoscopically or as an open surgery – are only 10 percent of the battle. The other 90 percent is dependent on proper nutrition and behavior modification. So in addition to a bariatric surgeon, the patient care team includes a psychiatrist and nutritionist, who specialize in weight loss. In this article, two patients share how weight-loss surgery freed them from the shackles of obesity, allowing them to see great results and experience improved health and quality of life. Also this month, we bring special attention to sleep and the growing awareness of its importance to overall health. Lack of quality sleep has been linked to serious disease. Addressing this subject are Dr. Alfonso Torquati, who reviews the risks of obstructive sleep apnea, diagnosis and treatment; and Dr. Paul Peterson, who discusses a recent study that links obstructive sleep apnea to an increased risk of cancer mortality.
Contributing Editors Larry B. Goldstein, M.D., F.A.A.N., F.A.H.A. Andrea S. Lukes, M.D., M.H.Sc Paul C. Peterson, M.D., F.A.C.E.P. Paul J. Pittman, C.F.P. Alfonso Torquati, M.D., M.S.C.I., F.A.C.S. Maryan Binkley Photography Mark Jacoby Creative Director Joseph Dally
mark@jacobyphoto.com
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Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com
Also contributing this month, neurologist Larry Goldstein explores the high incidence of stroke in North Carolina and efforts under way to minimize it. Gynecologist Andrea Lukes
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urges greater awareness of ovarian cancer and a pro-active approach to early detection. Finally, our resident financial planning expert, Paul Pittman, opens our eyes to the realities of investing and why a fickle global market makes fame for wealth managers so fleeting. And for those whose market is the Raleigh-Durham medical community, you need look no further than The Triangle Physician for a cost-effective medium to connect you with practice and health system leaders and administrations. Your news, commentary and, of course, advertising is always welcome. Respectfully,
Heidi Ketler Editor
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Cover
The Raleigh Center for Weight Loss Surgery Experts in Laparoscopic Bariatrics By Rory Cullen
Dylan McIntyre was at the end of his rope.
ended after I picked up the chicken wings,”
By the time he’d worked up the courage,
he says.
he’d developed a suite of comorbidities: sleep apnea, type 2 diabetes and danger-
For the first 20 years of his life, he’d been active and healthy. He ran, swam and
By his mid-30s, Mr. McIntyre had become
ously high blood pressure and cholesterol.
biked. He played sports and went to the
extremely obese. At 5 feet, 8 inches and
Medication was prescribed, but there was
gym. He was fit by any measure and had
more than 300 pounds, he knew he
little doubt that his habits were unsustain-
never struggled with his weight. But the
needed help but was reluctant to seek it. “I
able. “The doctor told me, ‘if you keep go-
pressures of adult life took their toll on
was afraid of going to the doctor, afraid of
ing this way, you’re going to die early.’”
his time – and his eating habits. “That all
what I might have,” he says. Motivated to change his life, Mr. McIntyre started exercising and eating right in 2008. Assiduous effort earned him an encouraging 60-pound drop in weight. “And then I gained 90 of it back,” he says. As with so many others, his initial enthusiasm was shattered when he couldn’t maintain his gains. Devastated, he let himself go. “A lot of this was mental, a lot. At that point I had basically given up.” It took a plaintive question from his daughter to snap him out of his despair. “We were watching a TV show,” he says. “It was something about obese people, and one of them had died. And my daughter turned to me and asked, ‘Daddy, if you keep getting bigger, are you going to die like that?’” Galvanized, Mr. McIntyre resumed his search for a solution. He’d investigated The Raleigh Center for Weight Loss Surgery once before, in 2007 – but his longtime reluctance to see a physician had precluded the five years of documented medical history required by his insurance provider. This time he was equipped with a different plan, and was able to take a fresh
Joseph C. Moran, M.D., F.A.S.M.B.S., poses in a day surgery suite at Rex Hospital in Raleigh, N.C.
6
The Triangle Physician
look at bariatric surgery.
Sandra Kelly, R.N., C.B.N., holds a Lap-Band model used as a patient educational tool.
The Raleigh Center for Weight Loss Surgery
Dr. Moran emphasizes the importance of the big picture: “In
Joseph Moran, M.D., F.A.S.M.B.S., is a godsend for Mr. McIntyre
helping our patients, 10 percent is surgery, and 90 percent is
and many like him. Dr. Moran completed his undergraduate work
proper nutrition and behavioral modifications, changes in routine
at SUNY-Stony Brook and medical school at the Ross University
and mindset.” The 90 percent number is often echoed by his
School of Medicine. He followed this with a five-year general sur-
patients and staff. Ashley House, P.A.-C., an assistant to Dr. Moran,
gery residency at St. Agnes in Baltimore and a two-year fellowship
underscores the importance of the post-surgical commitment:
in minimally invasive surgery.
“Surgery is just a small part – it’s about the amount of dedication that people put into it.”
Dr. Moran’s focus in bariatrics began in 2002, when he trained under the past president of the American Society for Metabolic
Significant weight loss is not something everyone can do, and Dr.
and Bariatric Surgery, Robert Brolin, M.D. “Working with him and
Moran has procedures in place to ensure that his patients have
looking forward, and seeing on the horizon this wave of obesity
realistic expectations and don’t presume the surgery alone to be
coming upon us … I saw an opportunity to do something for these
the cure. Before being scheduled for surgery, patients must pass a
people.”
rigorous screening process and get appropriate nutritional advice.
Arriving in North Carolina in 2004, Dr. Moran oversaw the
This is done through Tammie D. Moore, a psychiatrist and owner of
development of the bariatric surgery program at Rex Hospital,
Western Wake Counseling and Psychological Services, and Jennifer
among the very first bariatric programs in the Triangle area. In
Hunt, R.D., L.D.N., with Healthy Diets Inc., a private nutritional
2006, He opened his own practice, The Raleigh Center for Weight
practice. Both come to The Raleigh Center for Weight Loss Surgery
Loss Surgery (www.alasurgery.com) just across the street from Rex
twice weekly to treat Dr. Moran’s patients. Their onsite availability
and has since focused exclusively on minimally invasive bariatric
lends to patient convenience and fosters collaboration among all
surgery.
specialists involved in the patient’s care.
Immeasurably important to his and his patient’s success has been
The clinic encourages patients to begin making lifestyle changes
Dr. Moran’s profound understanding of the weight-loss process. “We
immediately. In addition to dietary concerns and exercise
have to take care of people who have these ingrained behaviors
recommendations, the clinic hosts regular support group meetings
and attitudes,” he says. “They deal with food addictions and other
to ameliorate the psychological and social issues that come with
problems emotionally, psychologically and socially.”
obesity and weight loss. “The support group is one of the ways we
June 2012
7
Front desk coordinator Rushmi Gross greets and assists all patients from their first visit to their five-year anniversary appointment.
try to get more personal with our patients,”
the weight.” But at 361 pounds, he still
GI tract serves to reduce the absorption of
says Mrs. House. Dr. Moran continues:
had a long way to go, and after careful
calories and nutrients from food, known
“We know our patients by name. We know
consideration he decided to proceed with
as malabsorption.
their families, we know their spouses. A
the surgery. The surgery also precipitates substantial
lot of times we’ve taken care of multiples within a family. Our patients recognize and
The Roux-en-Y procedure divides the
physiologic and neuroendocrinal changes.
appreciate that attention to detail.”
upper portion of the stomach from the
While not yet fully understood, they are
lower, creating a small, 1- to 2-ounce
known to offer considerable benefit
Roux-en-Y
“pouch” at the top and stapling both
to the patient by shifting the internal
Determined to succeed, Mr. McIntyre
portions of the stomach shut. The first
gastrointestinal
passed the screenings with flying colors
third of the small intestine is bypassed,
balance. Secretion of peptides promoting
and fully invested himself in his weight-
and the second third is connected to the
energy storage, such as ghrelin, is reduced,
loss journey, electing the Roux-en-Y
gastric pouch. The bypassed portions are
while peptides promoting oxidation of
laparoscopic gastric bypass surgery, one
left in place but are effectively removed
glucose, such as peptide YY 3-36, increase.
of two specialties offered by Dr. Moran.
from the gastrointestinal tract; all food
This results in increased metabolism and
In preparation for surgery, Mr. McIntyre
intake travels down the “Roux limb” to the
more energy, as well as neurological
went on a liquid diet to shrink his liver.
now Y-shaped configuration of the small
changes like different food preferences.
Between this and the new habits he was
intestine.
of
energy
Gastric bypass has been performed for
learning from the support groups, he lost 15 pounds right before surgery.
regulators
The procedure allows for a multifaceted
more than 30 years in the United States and
approach to weight loss: the stomach
is highly effective – when combined with
For a moment, he almost had second
pouch is restrictive, acting as a control
appropriate lifestyle changes, patients can
thoughts. “I was thinking, ‘do I really
on the patient’s portion sizes, limiting the
expect to lose between 50 percent and 75
need this?’ Lots of my friends were telling
amount of food he can consume in one
percent of their total excess body weight
me just to eat right and exercise to lose
sitting and increasing satiety. The shorter
within 18 months, with a further period of
8
The Triangle Physician
complications during and after surgery. This minimally invasive approach, wherein the surgery is performed through incisions less than a centimeter in length, is safer for the patient and takes around 75 minutes to complete. Most patients remain in the hospital for 24 to 48 hours, and return to normal activities within two weeks. However, Dr. Moran notes that certain patients are poor candidates for the laparoscopic approach. For patients with excessive scar tissue or when complications during the operation result in an inability to clearly see the internal organs or excessive bleeding, Dr. Moran will convert the surgery to a conventional open gastric bypass. Mr. McIntyre’s hospital stay was a little longer than the average, lasting three days, but the results were as impressive as they were fluctuation lasting between 18 months and two years. For many,
rapid. Within a week, he was able to go off his diabetes and blood
this quickly removes the physical barriers to exercise and activity,
pressure medications. His high cholesterol medication and sleep
putting the active lifestyle they need within reach. The National
apnea was, likewise, eliminated within the month.
Institutes of Health recommends this procedure for patients with a body mass index (BMI) of 40 or more or 35-40 with comorbidities.
“My wife could finally sleep at night,” he laughs. He went from averaging 3,500 calories per day to 1,200. “I’m eating to live now,
Dr. Moran prefers to perform the procedure laparoscopically
not living to eat,” he says.
to shorten the period of convalescence and reduce the risk of
Jennifer Hunt, R.D., L.D.N., of Healthy Diets Inc. examines the nutritional values of supplements recommended for bariatric surgery patients.
june 2012
9
Practice administrator Meredith Ledford updates the “Patient Manual” used as a guide and resource to patients before, during and after surgery.
Today, Mr. McIntyre is down to 211 pounds.
her efforts, she couldn’t seem to get any
Like the Roux-en-Y, the procedure is
He goes on long bike rides with his family
farther. Seeing a commercial for the LAP-
recommended for patients with a BMI of
and has regained all the mobility and
BAND® System, Mrs. Stair’s search for
40 or more or 35-40 with comorbidities.
activity he had once thought unattainable.
more information eventually led her to The
With accompanying lifestyle changes, the
The secondary benefits from his education
Raleigh Center for Weight Loss Surgery.
LAP-BAND® System can result in loss of 50 percent to 60 percent of excess body
at The Raleigh Center for Weight Loss Surgery are evidenced in his healthier
She was immediately impressed with Dr.
weight within two years, with a three-to-
family. “I haven’t cooked fried food in three
Moran. “He’s serious, but I like that. I didn’t
four-year period of fluctuation following.
years … my children are healthy, and my
want the warm-and-fuzzies,” she says. “I’d
wife is losing weight too.”
rather have a doctor who takes it seriously.
The minimally invasive surgery takes about
Dr. Moran was very knowledgeable. He
half an hour and is typically performed as
Lap-Band®
wanted me to be informed and to know
an outpatient procedure. Recovery is swift,
In contrast to Mr. McIntyre, Alison Stair had
what it would take to get to a healthy weight
with most patients returning to normal
always struggled with her weight.
and a healthy lifestyle.” With Dr. Moran’s
activities within a week.
expert counsel, she elected to have the “I’ve yo-yo’d my entire life,” she says. At just
LAP-BAND® surgery.
Compared to the Roux-en-Y and other conventional bariatric procedures, the
5 feet, 3 inches, she weighed 308 pounds at age 25. She suffered from sleep apnea
The LAP-BAND® device comprises an
LAP-BAND® is less invasive, much easier
and high blood pressure. “I had trouble
inflatable silicone band, 2 centimeters
to reverse and doesn’t modify the GI tract.
putting on pants,” she laughs. But she was
to 3 centimeters in diameter, connected
The device can be adjusted as required,
determined to live the active life she’d
by a thin tube to a subdermal port. The
providing easy flexibility unmatched by
always dreamed of.
band is placed around the upper part
other procedures.
of the stomach, creating a gastric pouch She changed her habits. She stopped
and restricting food intake. The port is
However, weight loss from the LAP-BAND®
smoking,
and
sutured to the abdomen, and allows for the
is considerably more gradual compared to
dramatically reformed her diet. In just six
restriction of the band to be adjusted with
other bariatric procedures and requires
months she’d lost 70 pounds. But for all
saline injections.
regular follow-up visits for adjustment –
10
started
The Triangle Physician
exercising
initially, every few weeks, and as needed
Changing Attitudes
out, she’s a new woman. Two, that the
once the patient’s weight stabilizes.
Dr. Moran’s endeavors to develop an
heart can’t tolerate the procedure. Before
accurate understanding of the risks
patients go into surgery, I make sure they
The LAP-BAND® System is a relatively
and
surgery
can tolerate it. Three, the idea that people
recent innovation, gaining United States
extend beyond his patients; despite its
who get bariatric surgery want an easy way
Food and Drug Administration approval
effectiveness, there remains an air of
out.”
in 2001, but there are few surgeons more
diffidence surrounding these procedures.
experienced in its use than Dr. Moran. As
“I used to feel that bariatric surgery was
Dr. Moran elaborates: “People hear horror
a proctor for Allergan, the manufacturer
a last resort, something done when
stories or bad outcomes. They’re very
of the LAP-BAND® System, Dr. Moran has
everything else had failed,” says Dr. Joseph
small in number but they tend to grab the
provided instruction to other surgeons on
Falsone, M.D., F.A.C.C., a cardiologist at
headlines, the attention of the media, a lot
performing the procedure laparoscopically.
Wake Heart and Vascular who provides
more easily than the success stories.”
benefits
of
weight-loss
pre-surgical cardiac clearance to Dr. Mrs. Stair’s story is testament to the
Moran’s patients. “Initially, I would say 98
The national mortality rate for the Roux-
effectiveness of the system – when
percent of physicians were against these
en-Y is 0.05 percent; for the LAP-BAND®,
combined with dedication. After receiving
procedures.”
0.005 percent. Dr. Moran’s personal mortality/morbidity rates are far below
the LAP-BAND® in March 2008, she’s down to 135 pounds and no longer suffers
Dr. Falsone believes that opposition
the national averages. “The risk is very
from sleep apnea or high blood pressure.
to bariatric surgery stems from poor
low. They’re very safe and well-tolerated
“I went from barely able to put on pants
knowledge regarding its safety and efficacy.
procedures,” he says.
to running a 10k,” she says. “It was so
“There are several misconceptions. One,
rewarding to be able to set goals and meet
that it’s horribly dangerous. That’s just not
In several cases, failing to consider bariat-
them. Realistically, I would not be able to
true. I sent Dr. Moran a patient who had
ric surgery may be the more dangerous ap-
be where I am without the band.”
suffered multiple heart attacks. Six months
proach. Dr. Falsone highlights the enormity
Ashley House, P.A.-C., meets with a patient three weeks after Roux-en-Y gastric bypass surgery to discuss her progress.
June 2012
11
of the situation facing some of his patients.
A Lifelong Journey
move rapidly through the small intestine,
“I take care of some very sick people. A lot
The stories of Mr. McIntyre and Mrs.
leading to abdominal cramps, nausea and
of them have high cholesterol and diabetes
Stair are uplifting, but Dr. Moran and his
diarrhea.
and some have had heart attacks. It gets to
staff are emphatic about articulating the
the point where this person is either going
realities of long-term weight loss. “They’re
With less of the small intestine to absorb
to lose weight or die.”
patients for life,” says Mrs. House. The
essential nutrients, patients of the Roux-
psychological and dietary counseling
en-Y procedure need to take supplementary
Many of Dr. Falsone’s patients have
continue for months and require studious
vitamins. Regular exercise is a must, and
benefitted greatly from bariatric surgery.
effort.
many patients continue attending support group meetings even after meeting their
After witnessing Dr. Moran’s expertise
goals.
firsthand, Dr. Falsone now regularly
Patients must change not only what they
refers patients to The Raleigh Center for
eat, but how they eat – how many times
Weight Loss Surgery. “Dr. Moran does
they chew, how much fluid they imbibe,
It’s truly challenging, and not every patient
fantastic with my high-risk patients. I’ve
how rapidly they finish their meals.
has the willpower. But dedication, not
seen the success of these surgeries, seen
Missing the mark often leads to vomiting
perfection, is the requirement. “Everyone
my patients come back so much better …
or “dumping syndrome,” wherein the
can fall off,” says Mrs. House. “What’s
They’re living longer, healthier lives.”
undigested contents of the stomach
important is to get them back on track.” The clinic offers services specifically for those who have “fallen off.” “Do the research, understand that your lifestyle is going to change and that you have to put in the effort,” advises Mrs. Stair. “Some people lose only 20 pounds because they don’t change their eating habits.” Mr. McIntyre adds, “It’s a lifetime journey, especially in the first year. You have to remember that this is a tool to help you lose weight – if you look at it that way, you will be successful.” Like his patients, Dr. Moran is optimistic about the future. In addition to the Rouxen-Y and the LAP-BAND® procedures, he’s considering offering another, the sleeve gastrectomy, in which up to three-fourths of the stomach is removed outright. Adding this procedure would enable him to more effectively meet the needs of extremely obese patients who may not be able to safely undergo gastric bypass. But for his hundreds of patients struggling with weight gain or diabetes, he’s already proven to be pivotal in changing their lives. “My only regret is in not telling my friends about this sooner,” notes Mr. McIntyre. “It’s such a great tool for someone who has
The Raleigh Center for Weight Loss Surgery staff work closely with patients and providers alike to ensure a seamless experience.
12
The Triangle Physician
struggled with their weight for their whole life,” says Mrs. Stair. “I love my lifestyle now.”
Neurology
Obstructive Sleep Apnea Is Associated with a Higher Mortality from Cancer By Paul C. Peterson, M.D., F.A.C.E.P.
Obstructive sleep apnea is a very prevalent
proangiogenic mediators, such as vascular
condition that induces or aggravates car-
endothelial growth factor, in tumor cells.
diovascular, metabolic and neurocognitive disorders. According to a new study, sleep
Moreover, tumor progression could be
apnea is associated with an increased risk
enhanced by external growth factors
of cancer mortality.
reaching the cancer cells, in particular those systemically induced by hypoxia
Obstructive sleep apnea (OSA) is well
and hence circulating in the blood. This
known to be associated with increased
pathway could be of particular relevance
risks of hypertension, cardiovascular
in OSA since patients with this sleep
disease,
breathing
cerebrovascular
disease,
depression and early death. Additionally,
disorder
exhibit
increased
proangiogenic factors in blood.
obstructive sleep apnea is common among patients with Alzheimer’s disease,
The Wisconsin Sleep Cohort is a longitudi-
with prevalence rates reported to be
nal, community-based epidemiology study
greater than 40 percent in those patients
of sleep apnea and other sleep problems
who are institutionalized.
that began in 1989 as a random sample of Wisconsin state employees. The partici-
Animal studies that have previously
pants underwent overnight sleep studies
been performed provide support for a
among other tests at four-year intervals.
hypothesis of causal link between OSA and
Dr. Paul Peterson is the medical director of the Sleep Laboratory and Stroke Center Program at Duke Raleigh Hospital and a physician with Duke Neurology of Raleigh. After earning his medical degree from the University of Texas Medical Branch at Galveston in 1995, he completed an initial residency in emergency medicine at San Antonio Uniformed Services Health Education Consortium in 1999 and a second residency in neurology at Duke University Medical Center in 2006. He completed a fellowship in sleep medicine and electroencephalography at Duke in 2007. Dr. Peterson is a member of several professional societies, including the American Academy of Sleep Medicine, the American Headache Society and the American Academy of Neurology, and he is a member and fellow of the American College of Emergency Physicians.
cancer. The recent study examining 22-
After adjustment for age, sex, body mass
year mortality data on 1,522 subjects from
index and smoking, the researchers in
the Wisconsin Sleep Cohort Wisconsin
the newly published study found that
supported the hypothesis. It showed a
both all-cause and cancer mortality were
nearly five times higher incidence of solid
associated with the presence and severity
Thus, in the first large, published,
organ cancer deaths in patients with severe
of obstructive sleep apnea in a dose-
population-based
obstructive sleep apnea compared to those
dependent fashion. Those participants
sleep apnea was found to be associated
without the disorder.
with severe obstructive sleep apnea died
with an elevated risk of cancer mortality.
of cancer at a rate of 4.8 times higher than
Additional studies will be needed to
people with no sleep apnea problems.
replicate and expound upon the results.
intermittent hypoxemia, which occurs in
The
after
If the association between obstructive
obstructive sleep apnea and promotes
excluding 126 subjects in the study who
sleep apnea and cancer mortality is
angiogenesis (increased vascular growth)
had used continuous positive airway
validated in further studies, the diagnosis
and, thereby, tumor growth. It has
pressure (CPAP), which is a treatment for
and treatment of obstructive sleep apnea in
been suggested that over-expression of
obstructive sleep apnea. The association
patients with solid organ cancer might be
hypoxia-inducible factor-1-alpha caused
was also stronger among non-obese
indicated to prolong survival.
by tissue hypoxia triggers upregulation of
subjects than obese subjects.
The putative mechanism suggested by
sample,
obstructive
prior animal studies is believed to be associations
were
similar
June 2012
13
Your Financial Rx
Market Gurus and 15 Minutes of Fame By Paul J. Pittman, C.F.P.
Every decade spawns market gurus who
present events and discounted future
make a few correct calls, get massive media
events) that it is impossible to develop
attention, then fizzle out. In the 1960s,
a mathematical model to predict stock
we had Gerry Tsai, Fred Carr and other
prices.
mutual fund gunslingers. In the 1970s, we
2. There are so many diverging opinions
had Joe Granville and Henry Kaufmann.
on stocks that at any given point in
In the 1980s, it was Robert Prechter and
time, there are buyers who believe in a
Elaine Garzarelli. The 1990s brought us the
price increase and sellers who believe
high-flying internet stock managers. Today,
in a price decrease. Since there’s no
Nouriel Roubini and Meredith Whitney are
reason to believe that the buyers are
all the rage. But, eventually, they all return
smarter than the sellers, or vice-versa,
to earth.
then at any given instant, the expected
“Instead of trying to hit home runs, we look for singles and doubles. This strategy may not put us on the cover of Money Magazine, but it may help us methodically meet our clients’ objectives.”
Paul Pittman is a Certified Financial Planner™ with The Preferred Client Group, a financial consulting firm for physicians in Cary, N.C. He has more than 25 years of experience in the financial industry and is passionate about investor education. He is also a nationally sought-after speaker, humorist and writer. Mr. Pittman can be reached at (919) 459-4171 and paul.pittman@ pcgnc.com. Send an e-mail to receive Mr. Pittman’s Weekly Market Commentary. born. But, the odds will eventually catch up with them, hence the fizzle. You can’t consistently and accurately interpret market-moving information. Even if you knew one day in advance what the
Why do all the gurus eventually stumble?
change in a stock’s price is zero. There
non-farm payroll numbers were going to be
They stumble because it is very difficult
are just as many buyers as sellers, and
or whether the Fed was going to change
to consistently pick winners, and it is very
neither one have better information.
interest rates, it would still be difficult to
difficult to accurately interpret market-
3. If you agree with No. 2 above, then
profitably trade with that information. The
moving information. Let’s look at these two
the mathematical expected return to a
problem is we would have to know what
issues in a little more detail.
speculator is zero – a “fair game.”
“the market” was expecting, how “the
4. If you agree with Nos. 2 and 3, then the
market” interpreted the information and
You can’t consistently pick winners. We all
market believes that the current stock
how quickly “the market” assimilated it.
try, and billions of dollars a year are spent
price is the true price. If the market
That’s impossible to do without surveying
on market research, trying to uncover the
didn’t believe that, then it would quote
every market participant. Even if you did
next big winner. Is that rational?
another price that is either higher or
that survey, their minds could change
lower.
before you could react.
In his book entitled Capital Ideas, Peter Bernstein reflects on The Theory of
According the Bachelier, a stock’s price
In the end, we’re back to the basics. Instead
Speculation, the doctoral dissertation of
will change only when there’s a good
of trying to hit home runs, we look for
French mathematician Louis Bachelier
reason for it to change, such as new
singles and doubles. This strategy may not
in the 1900s. Bachelier used complicated
information. Unfortunately, nobody knows
put us on the cover of Money Magazine,
mathematical formulas in an attempt to
whether this new information will cause
but it may help us methodically meet our
explain why the stock market behaves as it
the price to go up or down; hence, we have
clients’ objectives.
does. His conclusions, can be summarized
a 50/50 chance of an up or down move.
as follows:
And, probability theory says under those
Remember the mantra: “It’s Not What You
1. There are so many factors that influ-
conditions, one out of 1,000 will make 10
Make, It’s What You Keep.” Have a great
ence stock prices (e.g., past events,
accurate calls in a row; hence, a guru is
summer.
14
The Triangle Physician
Practice Management
Rethinking the
EHR Revolution By Maryan Binkley
For years, experts have pointed to electron-
ly dictate their exam notes into a phone sys-
ware automatically parses the document
ic health records as a cure for many of the
tem or digital recorder now have to log into
for discrete data, which is automatically
problems hindering our health care sys-
a computer and scroll through extensive
uploaded to the appropriate field of the
tem, including the inability of physicians to
lists of checkboxes for each patient they
EHR. The provider receives all of the struc-
quickly access a patient’s history.
see. The required computer interaction
tured data needed to meet Meaningful Use
limits their mobility, and if the computer
requirements, but also retains access to the
In terms of making information more read-
is in the exam room, their interaction with
note in narrative form. Further enhancing
ily available, new federal incentives to sub-
the patient, causing dissatisfaction from
the documentation process, mobile appli-
sidize the upfront costs of electronic health
both parties. Physicians who use front-end
cations are becoming increasingly robust
records (EHRs) are a welcome develop-
voice recognition fare only marginally bet-
and look to be a viable means to simplify-
ment. A recent report projects a robust
ter, as they’re required to immediately cor-
ing a clinician’s workflow.
12-percent growth rate for such systems
rect anything the software misinterpreted. Efforts to improve interoperability within
over the next few years. After a notoriously slow start for the technology, four of every
The quality of the document can also suf-
the industry continue to advance, sug-
10 physicians now utilize EHRs at their hos-
fer. The physician becomes the only set of
gesting a bright future for such interfacing.
pital or office.
eyes looking at information going into the
What’s becoming more apparent is that
record, making it harder to detect crucial
EHRs are not the solution to inefficiencies
Of course, adopting electronic records is
mistakes. When it comes to reviewing pa-
in health care, but rather part of the solu-
only step one. The real key to improving
tient information, because the information
tion. The sooner providers realize this, the
patient outcomes and gaining efficiencies
was entered into a one-size-fits-all template,
quicker we’ll see the real information revo-
lies in how EHRs are implemented. Clearly,
practitioners no longer have a narrative
lution we’ve been waiting for.
the industry is still finding its way in this
note they can look to for a clear under-
regard. Last year, a study of more than
standing of what previous medical person-
2,700 family physicians found that only 49
nel observed.
percent were satisfied in whole with their system.
EHR users do well by playing to the technology’s strengths. For a number of for-
While there’s no silver bullet to improving
ward-thinking facilities around the country,
the EHR experience, providers often ben-
this has meant integrating their EHR with
efit from taking a clear-eyed look at what
other software programs and building syn-
these systems can deliver. Many facilities
ergies between them. One promising trend
discover, only after an expensive rollout,
involves hospitals and clinics linking tran-
that electronic charts aren’t actually a pan-
scription management software with their
acea for their record-keeping challenges.
EHR system, creating a “hybrid” solution.
For instance, while physicians appreciate the ability to call up patient data instanta-
With the help of a software technology
neously, many are unenthused about not
known as “discrete reportable transcrip-
only how that information is initially cap-
tion,” doctors can realize the benefits of
tured, but also how it’s presented.
EHRs without giving up their ability to dictate patient notes. When the transcription-
Doctors who were previously able to quick-
ist types the note into the system, the soft
The Triangle Physician 2012 Editorial Calendar July
New Imaging Technologies Electronic Medical Records
August
Digestive Disease Computer Technologies
September
Sports Medicine – Physical Therapy
October
Breast Cancer – Reconstructive Surgery
November
Urology – Robotic Surgery
December
Pain Management June 2012
15
Women’s Health
Vigilance Helps Protect Women from Advance of
Ovarian Cancer By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G.
Women considering their cancer risks
Once diagnosed, the five-year relative sur-
disease is within advanced stages (Stage
often first think of breast cancer. Organi-
vival rate for ovarian cancer patients is only
III or IV), largely because the presenting
zations like Susan G. Komen for the Cure
46 percent – meaning that more than half
symptoms are ignored, overlooked or mis-
have done much to further education, and
of ovarian cancer diagnoses result in the
taken for a more common illness.
research of breast cancer and awareness is
death of the patient within five years. (As
at an all-time high.
a point of reference, the five-year relative
So what are the most common symptoms
survival rate for breast cancer patients is
of ovarian cancer?
Certainly these efforts deserve praise, but
about 89 percent.)
•A bdominal bloating or swelling; •P ressure or pain within the abdomi-
women should take care not to be blinded
nal, pelvic or back;
by the spotlight on the pink ribbon! Aware-
•E arly satiety (or feeling full sooner
ness is just as necessary in combating
than usual);
many other forms of cancer, including less
•N ausea, vomiting, gas, constipation
well-known threats, such as ovarian can-
or diarrhea;
cer, which frequently go overlooked.
•F requent urination; According to estimates from the National
•W eight gain;
Cancer Institute (www.cancer.gov/cancer-
•C hange in menopausal or postmenopausal bleeding.
topics/types/ovarian), in 2012 health care providers will diagnose 22,280 new cases of ovarian cancer, and the disease will
As with many cancers, early detection
Unfortunately, no routine screening test
be responsible for 15,500 deaths. Ovarian
improves treatment options and efficacy.
exists that reliably detects ovarian cancer
cancer accounts for only three percent of
Survival rates of women who discover
(Pap smears are useful in diagnosing cer-
annual new cancer cases in women and
and treat the cancer early, when it is still
vical cancer, but not ovarian cancer.), and
ranks ninth in overall frequency; however,
localized, are more than 90 percent, and
few women adequately understand their
it is the fourth-leading cause of cancer-re-
treatment is likely to be less invasive and
risk factors. Higher rates of the cancer are
lated deaths in women.
painful.
associated with nulliparity (not having chil-
The median age at diagnosis of ovarian
The challenge for women with ovarian can-
cancer (also known as Lynch syndrome
cancer is 60-64 years, although younger
cer and their health care providers comes
II), and a personal or family history of
women are also at risk. Despite advances
in recognizing and responding to the often-
breast, colon or ovarian cancer. A long his-
in cancer treatment and research during
subtle symptoms of the disease before it
tory of uninterrupted ovulatory cycles may
the last 40 years, the prognosis for ovarian
advances too far. More than half of ovarian
also increase a woman’s risk.
cancer remains grim.
cancer patients are diagnosed when the
dren), hereditary non-polyposis colorectal
e p o H 16
The Triangle Physician
Strength
Faith
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 co-founded and served as the director of gynecology for the Women’s Hemostasis and Thombosis Clinic. She left her academic position in 2007 to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head 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.
Fortunately, there’s a flip side to the coin – several protective factors for ovarian cancer have been identified. Multiparity (having many children), breast feeding and taking oral contraceptives are all associated with lower incidence of ovarian cancer. Women
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Toll Free: (866) 953-2828
Like breast cancer, ovarian cancer is associated with mutations in the BRCA1 and BRCA2 genes, and women with a family history of either are at increased risk for both. We encourage active screening for hereditary breast and ovarian cancer now at annual examinations. Currently, the testing for BRCA1 and BRCA2 are done by Myriad Laboratories (www.myriad.com). We encourage providers to become familiar with this screening, and we are happy to see women for screening and education regarding hereditary breast and ovarian cancer.
Treatment Center
Doctors can confirm the presence or absence of ovarian cancer by starting with a good history and physical, including a pelvic exam, then proceeding to a pelvic ultrasound and blood tests, specifically CA-125. The CA-125 is a substance that is found on the surface of ovarian cancer cells. Because elevated CA-125 levels may result from a variety of conditions, the test alone can-
HD Treatment Center of Raleigh is seeking part-time physicians to come join its team and share in the success of this new practice. HD Treatment Center of Raleigh is a specialty practice dedicated solely to the treatment of Hemorrhoidal Disease (HD). Only FDA cleared treatment regimens are used and our treatment procedures are performed in-office.
not confirm a diagnosis of ovarian cancer and is not an effective
We offer:
screening tool. However, the test’s results often prove helpful in
• Outstanding rate of pay • • Part-time and hours • • Flexible scheduling • • No on-call or inpatient/hospital work • • No administrative responsibilities • • All training done on site •
the evaluation of an ovarian cyst, and in monitoring the cancer after a diagnosis. If a provider is suspicious of ovarian cancer, we recommend referral to a gynecologic oncologist. While ovarian cancer is often stealthy, it is rarely silent. It is vitally important for every woman to be aware of her health risks and to address them proactively. Both women and health care providers need to have a high index of suspicion in the diagnosis of ovarian cancer. Educating yourself and your patients may prompt early evaluation and prove to be the difference between statistic and survivor.
This is an ideal part time position for any primary care or family physician or surgeon. If interested, please call (919) 861-9777 or send your CV to Dr. Lawrence Fusco at HD Treatment Center of Raleigh, 4601 Lake Boone Trail, Suite 1D, Raleigh, NC 27607 or by email to information@hdtreatmentcenter.com. Please visit our website at www.hdtreatmentcenter.com for additional information.
June 2012
17
Bariatric Surgery
Obstructive Sleep Apnea: Effective Treatment Leads to Rapid Improvement By Alfonso Torquati, M.D., M.S.C.I., F.A.C.S.
In the United States, obstructive sleep
of the pharyngeal airway during sleep.
apnea is most common in the fourth, fifth
Some patients with OSA end up awaken-
and sixth decade of life, affecting up to
ing from sleep to restore normal breath-
one in four men and one in nine women,
ing, which compromises nocturnal sleep
for an estimated total of 23 million affected
quality. The main clinical presentation of
individuals. Despite a recent increase
OSA is snoring, which is frequently asso-
in public and health care workers’
ciated with symptoms of daytime fatigue
awareness, this condition is still largely
and sleepiness.
underdiagnosed, leaving perhaps one in four people with obstructive sleep apnea
The most profound effects of OSA are
without a diagnosis.
on the cardiovascular system. Repeated nocturnal
hypoxemic activation
events and
elicit
Obstructive sleep apnea (OSA) is a medi-
sympathetic
cal condition that causes disruptions to
inflammatory mediator release that carry
systemic
breathing during sleep. Apnea is defined
over into the daytime. Complications of
as a temporary absence or cessation of
untreated OSA include increased risk of
breathing for more than 10 seconds. Usu-
premature death, myocardial infarction,
ally a person affected by obstructive sleep
arrhythmias, stroke and motor vehicle
apnea experiences repeated episodes of
accidents.
apnea because of a narrowing or closure
Dr. Alfonso Torquati is an associate professor of surgery at Duke University and co-director of the Duke University Center for Metabolic and Weight Loss Surgery, one of the top academic bariatric centers in the country. Dr. Torquati is a nationally recognized leader in bariatric surgery, with more than 14 years’ experience in performing bariatric procedures. He has given more than 100 presentations worldwide about bariatric surgery and published more than 60 peer-reviewed studies. His current research effort, funded by the National Institutes of Health, focuses on the role of bariatric surgery as treatment for obesity and related diseases. Dr. Torquati may be reached by calling (919) 470-7000 or (919) 470-7041.
Recent evidence suggests that OSA has strong association with obesity,
Diagnosis and Treatment
diabetes,
hypertension
Polysomnography plays a prominent role
and cardiovascular disease. Therefore,
in the evaluation of sleep disorders and
the prevalence of OSA has the potential
diagnosing OSA, since the disorder cannot
to increase substantially in the coming
be correctly suspected on the basis of
years, secondary to the obesity epidemic
interview and physical examination alone.
dyslipidemia,
facing our society. Continuous positive airway pressure Primary prevention interventions are
(CPAP) is used as first-line treatment if
aimed at the known risk factors for OSA
symptoms and disease are severe. The
and include:
effectiveness of CPAP in eliminating
• Losing weight, reducing alcohol or
obstructive sleep apnea has been proven
sedative use, stopping smoking;
by a number of randomized clinical trials.
• Optimizing treatments for conditions that may exacerbate OSA (e.g. asthma,
of life and to decrease fatigue during
allergic rhinitis);
daytime in patients with intermediate and
• Assessing one’s risk for cardiovascular disease and diabetes.
18
The Triangle Physician
CPAP therapy is likely to increase quality
severe OSA.
NEWSOURCE-JUN10:Heidi
8/5/10
12:57 PM
Page 1
Weight loss should be recommended for all overweight and obese patients with OSA, as it results in improvement of the condition. A study from Paul E. Peppard,
Do They Like What They See?
Ph.D., and collaborators reported that a 10 percent weight loss predicted a 26 percent decrease in the severity of sleep apnea.
Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.
Considering that medical weight loss usually fails to provide long-term results, bariatric
surgery
should
be
highly
considered in patients affected by OSA
Our services range from consultation, to design, to creation and implementation of strategic plans.
and with body mass index greater than 35 (Class 2 obesity). The 2004 Buchwald meta-analysis of the impact of bariatric surgery on weight loss in patients with four comorbidities (diabetes, hyperlipidemia, hypertension
newsource & Associates
and OSA) reviewed 136 studies involving 22,094 patients. The mean percentage of excess weight loss was 61.2 percent in all patients, and OSA was completely
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resolved in 85.7 percent of patients. In one of the largest series measured by polysomnography before and after bariatric
surgery,
K.L.
Haines
and
collaborators confirmed that bariatric surgery results in significant improvement
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of OSA and parameters of sleep quality in obese patients. The above mentioned studies and many others clearly support the role of bariatric surgery in treating OSA in obese adults. Bariatric surgery is effective because weight loss has been shown to be rapid, significant and durable. Other methods of weight loss are less effective in resolving OSA, because weight loss is not as significant and rapid as with bariatric
Financial Rx for Physicians:
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For more information on weight-loss
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surgery at Duke, visit the website at www.dukehealth.org. To schedule an appointment for a patient at the Durham clinic, call (866) 637-0711 and select option one; or at the Raleigh Clinic, call (919) 862-2715.
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June 2012
19
Neurology
Stroke Threat Grows Despite Declining Mortality and Changing Care Patterns By Larry B. Goldstein, M.D., F.A.A.N., F.A.H.A.
In January 2000, the United States Depart-
stroke death rate in the state has declined
North
Carolina
ment of Health and Human Services, in
over recent years, in 2008 it remained
implementation funding from the CDC
conjunction with voluntary health organi-
above the national average and above
National
zations including the American Heart As-
the Healthy People 2010 target. Stroke-
Prevention Program since 1998. The
sociation, launched Healthy People 2010,
related direct costs in North Carolina are
program aims to facilitate and implement
a program aimed at improving Americans’
estimated at $1.05 billion annually.
cardiovascular
health and decreasing disease-related
With more than 75 percent of strokes
Hypertension, the single most important
Heart
has
received
Disease
preventive
and
basic Stroke
programs.
treatable stroke risk factor, is one target.
It is a leading cause of adult disability and a major cause of cognitive impairment, and was responsible for $73.7 billion in direct and indirect medical costs in 2010.
Reflecting the program’s success, a recent report indicates that more than 94 percent of North Carolina adults had their blood pressure checked by a health care professional within the prior two years, with the state having the fourth-
morbidity through a variety of popula-
being first events, much of the reduction
highest rate of blood pressure screening
tion-based initiatives. A target 25 percent
in stroke mortality in the country has
nationally.
reduction in stroke mortality was set, a
been attributed to improved prevention.
goal that was actually achieved in 2006.
Following a healthy lifestyle is arguably
Recognizing the burden of heart disease
By 2008, stroke deaths had declined by
the most important stroke preventive
and stroke in the state, the North Carolina
34 percent. Due to a combination of lower
measure. Those who have an 80 percent
legislature established the Justus-Warren
mortality and a reclassification of respira-
lower risk of stroke as compared to those
Heart Disease and Stroke Prevention Task
tory diseases in national statistics, in 2010
who do not.
Force in 1995. Comprised of members of the legislature, medical and public health
the Centers for Disease Control reported that stroke had fallen from the country’s
Healthy lifestyle recommendations in-
professionals, heart attack and stroke
third- to its fourth-leading cause of death.
clude not smoking; following a healthy
survivors,
diet, such as the DASH (Dietary Ap-
leaders and other stakeholders, the task
Despite these encouraging statistics, stroke
proaches to Stop Hypertension) eating
force helps to coordinate multiple private,
remains a major public health problem. It
plan; engaging in at least 30 min per day
is a leading cause of adult disability and
of at least moderate physical activity, such
a major cause of cognitive impairment,
as brisk walking; maintaining an optimal
and was responsible for $73.7 billion in
body weight (body mass index less than
direct and indirect medical costs in 2010.
25 kg/m2); and not consuming alcohol
The impact of stroke is particularly high in
to excess. Health care providers need to
North Carolina. Situated in the country’s
reinforce these lifestyle recommendations
“Stroke Belt,” North Carolina has the sixth-
with their patients. The American Heart
highest stroke death rate in the country,
Association (mylifecheck.heart.org) has
with rates disproportionately high in the
tools to help people optimize their cardio-
eastern part of the state. Although the
vascular health.
20
The Triangle Physician
business
and
community
Dr. Larry Goldstein is professor of medicine (neurology) at Duke University and the Durham Veterans Affairs Medical Center and director of the Duke Stroke Center. He has published nearly 600 journal articles and other professional papers and chaired or been a member of several national guideline committees. He served as chairs of the ASA Advisory Committee and the Leadership Committee of the AHA Stroke Council, and was a member of the AHA National Board of Directors. He is a member of the editorial boards of several medical journals and was a member or chaired review panels for granting agencies, the Food and Drug Administration and CMS-Centers for Medicare & Medicaid Services. Locally, he served as a member of the Board of Directors and president of the AHA Mid-Atlantic Affiliate and is a member of the North Carolina Stroke Advisory Council.
federal and state-funded activities in heart disease and stroke prevention. In 2007, the legislature also established a Stroke Advisory Council to report to the task force. This was based on national data showing that stroke care was poorly coordinated and research data showing geographic disparities in stroke treatment capabilities across the state. In parallel with these activities, the American Heart Association
improvement registries and programs. Both North Carolina’s Collaborative Stroke Registry (part of the CDC’s Paul Coverdell Stroke Registry) and the AHA Get with the Guidelines program provide hospitals with comparative quality metrics (many of which are also required for Primary Stroke Center certification). Participation in Get with the Guidelines is associated with improvements in a variety of quality indicators. Despite these advances in prevention and the organization of stroke care in North Carolina, considerable hurdles remain. A survey found that less that 18 percent of adults in the state know all the symptoms of stroke and indicate they would call 911 if they thought someone was having a stroke. Another study found that those at highest risk (the elderly and African Americans) were the least knowledgeable. The risk of stroke doubles with every decade of age over 55 years. As the average age of the population of the country continues to rise, the burden of stroke is expected to dramatically increase in coming years. The impact may be blunted by more effective prevention combined with better public education and enhanced organization of care. The 2010 goals have now been replaced by 2020 goals – to improve cardiovascular health and further reduce cardiovascular and stroke-related death. The health care community will all need to work together to achieve these goals.
/American Stroke Association published a white paper outlining the components of stroke systems of care. Based on recommendations from this report, Brain Attack Coalition criteria and AHA/ASA guidelines, the Joint Commission began to certify primary stroke centers (PSCs), hospitals organized and capable of providing coordinated acute stroke care. There are currently 13 such hospitals in the state. Studies now show that care in PSCs is associated with higher rates of treatment with intravenous tissue plasminogen activator (tPA, the only FDA-approved treatment for selected patients with acute ischemic stroke), as well as improved patient outcomes. To maintain certification, hospitals must regularly report on a variety of stroke-related quality metrics and have biannual site visits. Non-PSC hospitals are now being linked via telemedicine to hospitals having stroke expertise, extending treatment to otherwise underserved areas of the state. This is particularly important as the provision of tPA is time sensitive; the longer the interval between symptom onset and treatment, the less likely the patient will benefit. In 2010, the North Carolina Office of Emergency Medical Services required that each EMS provider have a triage plan for patients with likely stroke to reduce treatment delays. The effectiveness of the program is currently under study. Many hospitals are now participating in stroke-related quality
June 2012
21
Duke Research News
Statin Drugs Slow Benign Prostate Growth; Lifestyle Could Help Too Statins drugs prescribed to treat high
Enlarged prostate, diagnosed as benign
“We don’t yet understand the mechanisms
cholesterol also may work to slow benign
prostate hyperplasia, causes urinary prob-
that might be causing this,” Dr. Muller
prostate growth in men who have elevated
lems that can escalate to bladder and kid-
said. “Some have suggested that statins
PSA levels, according to an analysis led
ney damage. Up to 90 percent of men over
may have anti-inflammatory properties,
by researchers at Duke University Medical
the age of 70 have some symptoms associ-
and inflammation has been linked to pros-
Center.
ated with enlarged prostate, according to
tate growth, but this needs further study.”
the National Institutes of Health. Dr. Muller said the findings in the current
The finding, presented at the annual meeting of the American Urological As-
Dr. Muller and colleagues used data gath-
research also suggest that lifestyle choic-
sociation, provides additional insight into
ered for an unrelated, large trial testing
es, such as diet and exercise, may not
the effects statins have on the prostate.
a drug called dutasteride, which can be
only affect cholesterol, but also prostate
Previous studies at Duke and elsewhere
used to treat prostate enlargement. From
health.
had found a link between the cholesterol
that trial, the researchers culled data for
drugs and lower levels of PSA, a protein
more than 6,000 men, including 1,032 who
“Prostate enlargement was once con-
produced by the prostate that is often ele-
also took statins.
sidered an inexorable consequence of aging and genetics, but there is growing
vated by cancer or by non-lethal prostatic Men on statins were older on average
awareness that prostate growth can be
than non-users, but had a similar prostate
influenced by modifiable risk factors,” Dr.
In the current finding, prostatic growth
volume. At two years, prostate growth
Muller said. “In this context, the role of
rate diminished among men with elevated
was less for the men in the study who
blood cholesterol levels and cholesterol-
PSA levels who took statins, although that
took a statin drug, regardless of whether
lowering drugs, such as statins, warrants
effect was relatively small and tapered off
they had been randomly assigned to take
further study.”
after about two years.
dutasteride or a dummy pill. In men who
diseases.
took both a statin and dutasteride pill,
In addition to Dr. Muller, study authors
“Given that benign prostate growth is an
prostate growth was 5 percent less than
included Leah Gerber; Daniel Moreira;
important health problem in the United
in untreated men. For those taking a statin
Gerald Andriole; J. Kellogg Parsons; Neil
States and elsewhere, and will be a larger
and a dummy pill, prostate growth was 3.9
Fleshner; and Stephen Freedland.
problem as the population ages, it’s impor-
percent less. The study was funded by GlaxoSmith-
tant to understand and treat its causes,” said Roberto Muller, M.D., a urology fellow
Those reductions, however, did not per-
at Duke and lead author of the study.
sist after two years.
Kline, which markets dutasteride.
Cardio Fitness Levels May Affect Survival of Breast Cancer Patients Women receiving care for breast cancer
tial evidence that poor cardiopulmonary
people who do not have cancer; however,
have significantly impaired cardiopulmo-
function may be a strong predictor of sur-
relatively little research has been done as-
nary function that can persist for years
vival among women with advanced breast
sessing the clinical importance of these
after they have completed treatment,
cancer.
tests in patients with cancer,” said Lee Jones, Ph.D., associate professor at Duke
according to a study led by scientists at “We know that exercise tolerance tests,
and lead author of the study. “Our work
which measure cardiopulmonary func-
provides initial insights into the effects a
The findings, reported online in the Jour-
tion, are among some of the most impor-
cancer diagnosis and subsequent therapy
nal of Clinical Oncology, also provide ini-
tant indicators of health and longevity in
may have on how the heart, lungs and rest
Duke University Medical Center.
22
The Triangle Physician
Duke Research News of the body work together during exer-
ment called VO2-peak, the gold standard
it with exercise training. Although we cur-
cise.”
assessment of cardiopulmonary function
rently do not know if improving fitness in
that athletes use to measure fitness levels
cancer patients is associated with longer
and design training programs.
survival, our data provides initial evi-
Treatment regimens for breast cancer
dence to pursue this question.”
have saved lives, contributing to a decline in death rates of about 2.2 percent a year
The researchers found that women with
since 1990, according to a Duke press re-
breast cancer, regardless of treatment
Dr. Jones said the findings of this study
search. But successful treatments often
status, had significantly worse cardiopul-
indicate exercise may be a good interven-
come at a heavy price to the cardiopulmo-
monary function than healthy women of
tion for cancer patients both during and
nary system, including the lungs, heart,
the same age who were sedentary. Even
after therapy. His team at Duke has several
blood and skeletal muscle.
among patients who had completed can-
studies under way examining the effects
cer therapy years previously, cardiopul-
of exercise training on women with breast
Certain types of chemotherapy can impair
monary function levels were markedly
cancer, plus patients with other cancers.
the heart’s pumping function, reduce the
impaired, suggesting that fitness levels
ability of red blood cells to carry oxygen
may not recover after therapy. More strik-
In addition to Dr. Jones, study authors
throughout the body and diminish the
ing, approximately a third of women in
from Duke include Whitney E. Hornsby,
ability of muscle cells to work efficiently.
the study had a cardiopulmonary function
April D. Coan, James E. Herndon II and
Patients also may experience secondary
score below the threshold that suggests
Pamela S. Douglas.
effects of therapy, becoming less active
people can function independently – do
and gaining weight, which can also impair
household tasks, walk up and down stairs
Authors from the University of Alberta, in
cardiopulmonary function.
or walk a half mile.
Edmonton, Alberta, Canada, include: Kerry S. Courneya, John R. Mackey, Edith N.
To begin to understand the direct and
Among the patients with advanced breast
Pituskin and Mark Haykowsky. Hyman B.
indirect effects of therapy on breast can-
cancer, median survival was significantly
Muss is from the University of North Caro-
cer patients, Dr. Jones and his colleagues
longer for women with higher cardiopul-
lina at Chapel Hill; Jessica M. Scott is from
examined cardiopulmonary function at
monary function. Median survival was
NASA Johnson Space Center in Houston,
rest and during exercise in 248 women in
36 months in high-fitness patients vs. 16
Texas.
various stages of treatment for breast can-
months in the low-fitness patients. Dr. Jones is supported by grants from the
cer. All completed a carefully controlled cardiopulmonary exercise test on a sta-
“Fitness level may be an important bio-
National Institutes of Health. The authors
tionary bike, which escalated until the pa-
marker of survival among cancer pa-
reported no conflicts of interest.
tients reached maximum exertion. At that
tients,” Dr. Jones said. “But the beautiful
point, the researchers took a measure-
thing about fitness is that we can improve
Duke News
New Health Education Center Honors Philanthropist’s Lifelong Commitment constant reminder, now and in the future.”
Duke University’s Board of Trustees has
school’s missions of research, education
approved naming the school of medicine’s
and patient care was always a source of
new Center for Health Education in
inspiration to our faculty and students,”
According to Victor J. Dzau, M.D., chan-
honor of the late Mary Duke Biddle Trent
says Nancy C. Andrews, M.D., Ph.D., dean
cellor for health affairs and chief executive
Semans, a philanthropist with a lifelong
of the Duke University School of Medicine.
officer of Duke University Health System,
commitment to the University.
“It is fitting that Duke Medicine’s new
Mary Semans “was a close friend who rep-
home for health education be named in
resented the very heart and soul of Duke
her honor so that her legacy will be a
Medicine. She will always have a presence
“Mary Semans’ unwavering support for the
June 2012
23
Duke News on the university campus, and naming the
one of the largest private foundations in
The new Center for Health Education,
Center for Health Education in her honor
the country. Mrs. Semans was a trustee
currently under construction, was initially
befits the legacy she has left the medical
of The Duke Endowment for 55 years and
funded with $35 million from The Duke
center.”
served as its first female chairman from
Endowment. When it is completed in late
1982-2001.
fall 2012, the five-story, limestone-andglass facility will be centered at the heart
Mrs. Semans, who died Jan. 25 at the age of 91, had deep roots with the university.
“Mother loved Duke Hospital and the Duke
of the medical campus. It will feature high-
Her grandfather, Benjamin Newton Duke;
Medical Center and we are so pleased
tech teaching and learning opportunities,
his brother, James B. Duke; and their
that her memory will be kept alive for the
including an entire floor of simulation
father Washington Duke, were the chief
future medical students and leaders who
laboratories, flexible classroom space,
benefactors of Trinity College, which later
will pass through these halls,” said Mary
teaching labs and event space. Classes
became Duke University. In 1924, James B.
Jones, Mrs. Semans’ daughter.
will begin in the new building in January 2013.
Duke established The Duke Endowment,
UNC News
Dr. Ned Sharpless Recognized as a Wellcome Distinguished Professor “Ned”
“In addition to his accomplishment in fun-
North Carolina, where he studied math-
Sharpless, M.D., profes-
damental research, Dr. Sharpless is an ex-
ematics as an undergraduate. He gradu-
sor
Norman
E.
and
emplar of a new breed of entrepreneurial
ated with honors and distinction from
genetics and associate
researcher. He has gathered intellectual
the UNC School of Medicine, followed
of
medicine
director for translational
property from his UNC work and created a
by internal medicine training at Massa-
research at UNC Lineberger Comprehen-
UNC start-up, G-Zero. The company is de-
chusetts General Hospital and Harvard
sive Cancer Center, has been appointed
veloping agents that can be used to mini-
Medical School in Boston. He completed
the Wellcome Distinguished Professor in
mize the toxicity of chemotherapy and be
his hematology and oncology training at
Cancer Research.
used as radioprotectants in the case of
the Dana-Farber Cancer Institute, also at
human exposure to accidental radiation,”
Harvard Medical School. After finishing
Mr. Roper added.
his clinical training, Dr. Sharpless com-
The professorship was established by the
pleted a research postdoctoral fellowship
University of North Carolina School of Medicine in 1988 with gifts from the Bur-
“Simply put, Ned is one of the outstanding
at the Dana-Farber Cancer Institute, prior
roughs Wellcome Fund and the William
clinician scientists in the nation. His ex-
to joining the faculty at Harvard Medical
A. Smith Trust of Wadesboro, N.C. The
traordinary mastery of clinical medicine,
School in 2000. Dr. Sharpless returned to
gifts were supplemented by the state Dis-
high-level knowledge of molecular genet-
UNC in 2002.
tinguished Professors Endowment Trust
ics and animal modeling and passion for
Fund to create the endowed professor-
improving the lot of cancer patients are a
In addition to his clinical work as a physi-
ship.
rare combination. He meets anyone’s defi-
cian, Dr. Sharpless runs a 17-person basic
nition of a rising star in medical oncology
science laboratory that studies cancer
“Dr. Sharpless is an outstanding clinician,
and meets all of the criteria for appoint-
and aging. He is co-leader of the Molecu-
teacher and scientist. He is among this
ment to a distinguished professorship.
lar Therapeutics Program, co-founder and
institution’s most sought-after teachers
Ned’s work will make a difference for
co-director of the UNC Mouse Phase I Unit
and mentors and his laboratory is one of
cancer patients worldwide,” said Shelley
and associate director of The UNC Center
the most innovative and productive in his
Earp, M.D., director of UNC Lineberger
for Aging and Health. He has authored
field,” said William L. Roper, M.D., M.P.H.,
Comprehensive Cancer Center.
more than 90 original reports, reviews and book chapters and is an inventor of
dean of the UNC School of Medicine and chief executive officer of UNC Health Care
Dr. Sharpless, a Greensboro native, was
System.
a Morehead Scholar at the University of
24
The Triangle Physician
10 patents.
UNC News Dr. Sharpless’ lab has received support
the 2007 recipient of the Jefferson Pilot
by supporting research and other scien-
from the Sidney Kimmel Foundation for
Award, the 2009 recipient of the Hettle-
tific and educational activities. Through
Cancer Research; the American Federa-
man Prize for Scholarly Achievement, a
its programs, BWF seeks to accomplish
tion of Aging Research; the William Guy
2010 recipient of a Glenn Award for Re-
two primary goals: to help outstanding
Forbeck Research Foundation; the Golf-
search in Biological Mechanisms of Ag-
scientists early in their careers develop as
ers Against Cancer Foundation; the Breast
ing and a 2012 Triangle Business Journal
independent investigators and to advance
Cancer Research Foundation; the Paul
Health Care Hero.
fields in the basic medical sciences that are undervalued or in need of particular
Glenn Foundation; and the Ellison Medical
encouragement.
Foundation. He is supported by a Clinical
He is a member of the American Society
Scientist in Translational Research Award
of Clinical Investigation (ASCI), the na-
from the Burroughs-Wellcome Fund.
tion’s oldest honor society for physician-
The William A. Smith Trust is a charitable
scientists, and has been elected to serve
foundation chartered in 1934 under the
on the ASCI council from 2011 to 2014.
will of William Smith, a resident of An-
He is on the scientific advisory board of
sonville. The foundation is primarily inter-
several scientific foundations and is an associate editor of Aging Cell and Impact
The Burroughs Wellcome Fund (BWF) is
ested in funding educational projects in
Aging and is deputy editor of the Journal
an independent private foundation estab-
Anson County but occasionally extends
of Clinical Investigation. Dr. Sharpless was
lished to advance the medical services
its interests beyond that area.
UNC Research News
Quest to Understand Hepatitis C and Liver Cancer Link Gets $2.35 Million Does hepatitis C cause liver cancer due
medicine and microbiology and immu-
recently developed mouse model that
to inflammation associated with the
nology and a member of UNC Lineberger
develops a human immune response to
disease, or does the virus interact with
Comprehensive Cancer Center, the Cen-
HCV (hepatitis C virus) and human liver
host cells in a different way to promote
ter for Translational Immunology and the
diseases when infected with HCV. The
the development of cancer?
UNC Center for Infectious Disease. His
project will combine the expertise of
laboratory’s recombinant DNA virus tech-
the Su group in human immunology and
Two University of North Carolina scien-
nology will help the team understand how
humanized mouse models with that of the
tists have received $2.35 million to com-
genetic changes in hepatitis C virus may
Lemon group in HCV viral genetics and
bine the power of technologies developed
affect disease progression, including liver
liver cancer to elucidate mechanisms of
in each of their laboratories to answer this
cancer.
HCV-induced liver cancer,” said Dr. Su.
The researchers are both principal
“A number of studies have documented
Lishan Su, Ph.D., is a professor of
investigators on the five-year grant from
that inflammation plays a role in liver
microbiology
immunology
the National Cancer Institute, a member
cancer. But there is evidence that there is
and a member of UNC Lineberger
institute of the National Institutes of
more to the story of virus-cell interaction
Comprehensive Cancer Center and the
Health.
in the development of cancer. We believe
question.
and
that the virus is interacting specifically
UNC Center for Infectious Disease. His team has developed a laboratory model of
“Chronic hepatitis C infection is now
with host cell tumor suppressor pathways
hepatitis C that more faithfully replicates
the leading cause of hepatocellular
to promote cancer, and we want to
the course of the disease in humans,
carcinoma (HCC) in the United States,
understand what drives this progression
both in terms of inflammation, immune
but how it causes liver cancer is not
from infection to cancer in order to figure
response and other factors, according to
well understood because of the lack of a
out how to stop it,” said Dr. Lemon.
a university press release.
small animal model for hepatitis C. This
Stanley M. Lemon, M.D., is a professor of
multi-PI (multiple-principal investigators)
According to the Centers for Disease
project will allow us to further refine a
Control and Prevention, hepatitis C is
June 2012
25
UNC Research News the most common chronic blood borne
individual research awards. Additionally,
thirds of these cases.
more than one PI on individual grants was
infection in the United States, affecting approximately 3.2 million people. The
Editor’s Note: The National Institutes of
a major recommendation of the 2003 NIH
disease accounts for the deaths of more
Health allows multiple program director/
Bioengineering Consortium Symposium
Americans each year than HIV/AIDS.
principal investigator (PD/PI) research
on Catalyzing Team Science. NIH says its
Liver cancer is the third leading cause
as part of its NIH Roadmap initiative.
multiple-PD/PI policy offers approaches
of death from cancer worldwide and the
According to the NIH website, the NIH
to maximize the potential of team science
ninth leading cause of cancer deaths in
multiple-PD/PI
efforts and does not replace the traditional
the United States. Chronic hepatitis virus
response to a federal-wide directive to
infections account for more than two-
formally allow more than one PD/PI on
initiative
also
is
in
single-PD/PI model.
$900,000 Grant to Fund Use of Kinase Test in HER2-positive Breast Cancer Susan G. Komen for the Cure has award-
cancers eventually become resistant.
cancers. Several HER2-targeted drugs are in clinical use and many more are in de-
ed a grant of almost $900,000 to Lisa A. Carey, M.D., and Gary Johnson, Ph.D., to
Dr. Johnson, who is the Kenan distin-
velopment. But we don’t know who needs
research clinical applications for the first
guished professor and chair of the de-
which targeted drug and why, who needs
broad-based test for protein kinase activa-
partment of pharmacology in the UNC
dual HER2-targeted therapy and what oth-
tion and response to inhibitory drugs in
School of Medicine and a member of
er strategies might be needed to best treat
HER2-positive breast cancer.
UNC Lineberger Comprehensive Cancer
HER2-positive breast cancer.”
Center, worked with his team to develop Kinases are proteins expressed in human
a test that can measure both the presence
The team will use the test developed in Dr.
tissues that play a key role in cell growth,
and activity of 60-70 percent of all kinases
Johnson’s lab as part of a clinical trial led
particularly in cancer. Of the 518 known
simultaneously, allowing investigators to
by Keith Amos, M.D., assistant professor
human kinases, about 400 are expressed
see how cancers evade treatment with
of surgical oncology, to understand the
in cancers, but which ones and how many
kinase inhibitors, so they can combine
kinome activation state before and after
are actually active in tumors has been diffi-
drugs to block resistance.
treatment with kinome-targeted drugs to determine how and why the tumors “re-
cult to measure. Tremendous efforts have been made to develop kinase inhibitors as
Dr. Carey, who is Preyer distinguished
program” in response to various HER2-
cancer treatments, which have resulted in
professor of breast cancer research and
targeted therapies. Their goal is to define
key drugs such as Herceptin, Tykerb and
medical director of the UNC Breast Cen-
the best combinations of therapies and to
Gleevec. However, in spite of the effective-
ter, says, “HER2-positive breast cancers
develop selection strategies for individual
ness of this class of cancer drugs, most
comprise about 20 percent of all breast
patients.
DNA Replication Protein also Has a Role in Mitosis and Cancer The foundation of biological inheritance
hallmark of the genomic instability seen
cell cycle, mitosis. The finding presents
is DNA replication – a tightly coordinated
in most birth defects and cancers.
a possible explanation for why so many cancers
process in which DNA is simultaneously
possess
not
just
genomic
copied at hundreds of thousands of
University of North Carolina School of
instability, but also more or less than the
different sites across the genome. If
Medicine
usual 46 DNA-containing chromosomes.
that copying mechanism doesn’t work
that a protein known as Cdt1, which is
as it should, the result could be cells
required for DNA replication, also plays
The new research, which was published
with missing or extra genetic material, a
an important role in a later step of the
online ahead of print by the journal Nature
26
The Triangle Physician
scientists
have
discovered
UNC Research News Cell Biology, is the first to definitively show
Cdt1 function had been blocked did not
Dr. Cook says cells that make aberrant
such a dual role for a DNA replication
undergo mitosis properly.
amounts of Cdt1, like that seen in cancer, can therefore experience problems in
protein. Once the researchers knew that Cdt1
both replication and mitosis. One current
“It was such a surprise, because we thought
was involved in mitosis, they wanted to
clinical trial is actually trying to ramp up
we knew what this protein’s job was – to
pinpoint its role in that critical process.
the amount of Cdt1 in cancer cells, in the
load proteins onto the DNA in preparation
They further combined their genetic,
hopes of pushing them from an already
for replication,” said Jean Cook, Ph.D.,
microscopy and computational methods
precarious position into a fatal one.
associate professor of biochemistry and
to demonstrate that without Cdt1, Hec1
biophysics and pharmacology at the
fails to adopt the conformation inside
The research was funded by the National
UNC School of Medicine and senior study
the cells necessary to connect the
Institutes of Health. Study co-authors
author. “We had no idea it also had a night
chromosomes with the structure that pulls
from UNC were Dileep Varma; Srikripa
job in a completely separate part of the
them apart into their separate daughter
Chandrasekaran; Karen T. Reidy; and
cell cycle.”
cells.
Xiaohu Wan.
The cell cycle is the series of events that take place in a cell leading to its growth, replication and division into two daughter cells. It consists of four distinct phases: G1 (Gap 1), S (DNA synthesis), M (mitosis) and G2 (Gap 2). Dr. Cook’s research focuses on G1, when Cdt1 places proteins onto the genetic material to get it ready to be copied. In this study, Dr. Cook ran a molecular screen to identify other proteins that Cdt1 might be interacting with inside the cell. She expected to just find more entities that controlled replication and was surprised to discover one that was involved in mitosis. That protein, called Hec1 for “highly expressed in cancer,” helps to ensure that the duplicated chromosomes are equally divided into daughter cells during mitosis, or cell division. Dr. Cook hypothesized that either Hec1 had a job in DNA replication that nobody knew about, or that Cdt1 was the one with the side business. Dr. Cook partnered with Hec1 expert Edward “Ted” D. Salmon, Ph.D., professor of biology and co-senior author in this study, to explore these two possibilities. After letting Cdt1 do its replication job, the researchers interfered with the protein’s function to see if it adversely affected mitosis. Using a high-powered microscope that records images of live cells, they showed that cells where
Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
June 2012
27
News Welcome to the Area
Physicians Sarah Lucille Larson, DO
Anatomic and Clinical Pathology Duke University Hospitals, Durham
Mashael Saleh Al-Hegelan, MD
Pulmonary Disease and Critical Care, Internal Medicine; Critical Care-Internal Medicine; Critical Care Medicine; Internal Medicine; Pulmonary Disease Duke University Hospitals Durham
Amanda Marshburn Allen, MD
Internal Medicine University of North Carolina Hospitals Chapel Hill
Arghavan Almony, MD
Ophthalmology Carolina Eye Associates, P.A. Southern Pines
Kristen Beth Barrio, MD
Emergency Medicine University of North Carolina Hospitals Chapel Hill
Tania Beatriz Beltran Papsdorf, MD
Neurology University of North Carolina Hospitals Chapel Hill
Richard Alan Bloomfield, Jr., MD
Internal Medicine; Pediatrics University of North Carolina Hospitals Chapel Hill
Brittany Andriot Chapman, MD Neurology
University of North Carolina Hospitals Chapel Hill
Michael Rene Contarino, MD
Internal Medicine; Pediatrics University of North Carolina Hospitals Chapel Hill
Stephanie Ane Crapo, MD
Emergency Medicine University of North Carolina Hospitals Chapel Hill
Nell Brock Pollard Johnson, MD
Obstetrics and Gynecology University of North Carolina Hospitals Chapel Hill
Theresa Ann Kallman, MD
Lauren Alexandra McQueen, MD Critical Care Medicine; Anesthesiology Duke University Hospitals, Durham
Suhail Kamrudin Mithani, MD
Pediatrics 200 Towne Ridge Lane, Chapel Hill
Hand Surgery; Plastic and Reconstructive Surgery Duke South Clinics, Durham
David Edward Karol, MD
Priyesh Ashok Patel, MD
Internal Medicine; Psychiatry; Addiction Psychiatry; Administrative Medicine; Alcohol and Drug Abuse Duke University Hospitals Durham
Jacqueline Farber Kerkow, MD Pediatrics Duke University Hospitals Durham
Brendan John Kiel, MD Anesthesiology 3305 Magical Pl Raleigh
Internal Medicine Duke University Hospitals, Durham
Emily Marie Patel, MD Obstetrics and Gynecology Duke University, Durham
Diagnostic Radiology Duke University Hospitals Durham
Nicholas John Kuntz, MD Urology Duke University Hospitals Durham
Sean Michael Lee, MD
Abdominal Surgery; Colon and Rectal Surgery; Critical Care Surgery; General Surgery; Surgical Oncology; Vascular Surgery Duke University Hospitals, Durham
Ashley Moore Lewis, MD
Cardiology; Cardiovascular Disease, Internal Medicine Wake Heart and Vascular, Cary
Kara Alina May McElligott, MD Gynecologic Oncology; Obstetrics & Gynecologic Surgery; Obstetrics and Gynecology Duke University Hospitals, Durham
Anesthesiology University of North Carolina Hospitals Chapel Hill
Ramesh Srinivasan, MD
Hand Surgery; Orthopedic Surgery; Orthopedic, Hand Surgery Durham
Ashley Goodwin Sutton, MD
Pediatrics University of North Carolina Hospitals Chapel Hill
Michael John Sylvia, MD
Critical Care Pediatrics; Internal Medicine University of North Carolina Hospitals Chapel Hill
Fernanda Patricia Payan Schober, MD
Internal Medicine University of North Carolina Hospitals Chapel Hill
Elliot Jay Pearson, MD
Alison J Kim, MD
Justin Lee Rountree, MD
Testier Testiest, MD
University of North Carolina Hospitals Chapel Hill
Tung Thanh Tran, MD
Pediatrics Division Offices, Durham
Neurology Duke University Medical Center Durham
Zachary Eric Potter, MD Neurology UNC Chapel Hill Chapel Hill
Kiran Venkatesh, MD
Edward Nandlal Rampersaud, MD Urological Surgery Duke University Division of Surgery Durham
Kristoff Rewi Reid, MD
Hospitalist; Internal Medicine Durham Regional Hospital, Durham
Amy Hooks Wallace, MD
Gynecology/Oncology; Obstetrics and Gynecology Duke University Hospitals, Durham
Adult Reconstructive; Orthopedic Surgery, Pediatric; Orthopedic Surgery, Trauma; Orthopedic, Ankle Foot Duke Univ Dept of Orthopaedic Surgery, Durham
Michael Jan-Chi Wang, MD
Zachary Martin Robertson, MD Ophthalmology Kittner Eye Center Chapel Hill
Internal Medicine; Psychiatry; Psychosomatic Medicine Duke University Medical Center Durham
John James Rommel, MD
Yongqin Wu, MD
Cardiology; Internal Medicine University of North Carolina Hospitals Chapel Hill
Neurology; Vascular Neurology University of North Carolina Hospitals Chapel Hill
Jason Allen Webb, MD
Neurology University of North Carolina Hospitals Chapel Hill
Adam Cory Creech, MD Internal Medicine WakeMed Hospital Raleigh
Zubin John Eapen, MD
Cardiovascular Disease, Internal Medicine Duke University Div of Cardiology Durham
Paul Douglas Evans, MD
Diagnostic Radiology; Vascular and Interventional Radiology; Radiology Duke University Hospitals Durham
Kathryn Louise Everton, MD Radiology Duke University Hospitals Durham
Nicholas Gregory Heyne, MD
Psychiatry University of North Carolina Hospitals Chapel Hill
Arun Laxminarayan Jayaraman, MD
Anesthesiology Duke University Hospitals Durham
28
The Triangle Physician
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When it comes to your cardiovascular care – We know it by heart. To learn more, visit our website www.WHVheart.com or call us at 1-800-WHV-2889 (800-948-2889).
DIAGNOSTIC IMAGING | PEDIATRIC IMAGING | SPORTS IMAGING | NEURORADIOLOGY ADVANCED BREAST IMAGING | INTERVENTIONAL RADIOLOGY | ONCOLOGIC IMAGING
Since 1953, Wake Radiology has been a leader in diagnostic imaging in the Triangle and beyond. We bring to you and your patients the most advanced imaging technologies available, delivered with the reassurance and compassion that are at the heart of health and healing. We have 18 outpatient imaging locations throughout the Triangle—many offering studies on evenings and Saturdays, including screening mammography, CT, Ultrasound, and MRI exams. Wake Radiology’s 55 subspecialty trained radiologists diagnose injury and illness quickly, while working with you and your staff to ensure the best possible outcome. So, the next time your patients require medical imaging think of Wake Radiology, where outstanding imaging is backed by expertise, convenience, and compassion. Wake Radiology. Here when you and your patients need us. Wake Radiology is the only multi-site outpatient imaging service provider in the Triangle to receive the American College of Radiology’s designation of Breast Imaging Centers of Excellence. Scan now to request a Screening mammogram with your smartphone.
Express Scheduling 919-232-4700 | Chapel Hill Area Express Scheduling 919-942-3196 | wakerad.com
©2012 Wake Radiology. All rights reserved.
©2011 Wake Radiology. All rights reserved. Radiology saves lives.
Advanced Imaging For The Entire Family.