march 2016
North Carolina Specialty Hospital Wound Healing and Hyperbaric Center Awarded 2015 Center of Distinction
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 New Dietary Guidelines Adrenal Incidentalomas
Johnston Health Has Become A Part Of UNC Health Care. Just As Exciting Is What We Are Becoming To Folks Throughout This Area...
“Johnston Health made my delivery special.”
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“Johnston Health is my amazing outpatient DaVinci robotic surgery!” Ann Lee Clayton, NC
For more information about the services available to physicians and your patients in our Smithfield and Clayton hospitals, visit us online at www.johnstonhealth.org Healing Neighbors - It’s What We Do. It’s Who We Are.
From the Editor
Community Assets This month’s cover story on North Carolina Specialty Hospital Wound Healing and Hyperbaric Center captures well the qualities that make it an asset to the medcial community. In addition to celebrating practice excellence, the article shares insights into the “specialized expertise” needed to assess and treat various wound etiologies. The reader also learns about some of the latest wound treatment technologies onsite, including negative pressure wound therapy, bioengineered tissue placement and hyperbaric oxygen therapy. At the NCSH Wound Health and Hyperbaric Center, the patient’s physicians become part of the multidisciplinary approach. Here patient education about prevention is just as important as the limb-saving treatment for such chronic conditions as diabetic foot ulcers.
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
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Marni Jameson Margi Satinsky, M.B.A. George Stamataros, D.O., F.A.C.E. Lindsay Wojciechowski, F.N.P.-C. Creative Director Joseph Dally jdally@newdallydesign.com
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The Raleigh-Durham medical community also has within it a virtuoso at explaining complex systems – practice management consultant Margie Satinsky. This month she begins a two-part series on the challenges of implementing an electronic health record system. Next month she will share tips for successful implementation. Also in this issue, endocrinologist George Stamataros discusses the process of determining if the chance discovery of an adrenal incidentaloma is benign or malignant. Nurse practitioner Lindsay Wojciechowski explores the recently released edition of the Dietary Guidelines for Americans and the shift in focus to health-promoting eating patterns. Marni Jameson, a dedicated advocate for independent physicians, reminds those considering hospital employment to be cautious. The Triangle Physician is a vehicle for communicating news and information to the more than 9,000 professionals throughout Raleigh-Durham. Just as important, the content often reflects the values that drive, as well as distinguish, one’s professional practice. Here at The Triangle Physician we revel in the role of producing a quality magazine for this great community, one that earns your time and interest. With great appreciation,
Heidi Ketler Editor
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Table of Contents Category
4
COVER STORY
North Carolina Specialty Hospital Wound Healing and Hyperbaric Center Awarded 2015 Center of Distinction marc h 2016
Vol. 7, Issue 3
FEATURES
7
DEPARTMENTS 8 PRACTICE MANAGEMENT
Nutritional Health
Understanding the New Dietary Guidelines Nurse practitioner Lindsay Wojciechowski explores the focus on health-promoting eating patterns over individual components.
10
Part I: Anticipating Problem Areas and Tips for Successful EHR Implementation
12 PHYSICIAN ADVOCACY
Sound to Good to Be True? Beware the Trojan Horse
13 DUKE RESEARCH NEWS Enrollment to Begin This Year for Study Aimed at Resolution of How to Manage Pre-Cancers of the Breast
Endocrinology
Diagnosing Adrenal Incidentalomas
14 DUKE RESEARCH NEWS Sildenafil May Relieve Dangerous Cold-Water Edema in Swimmers
Endocrinologist George Stamataros discusses diagnosis of what can
16 NEWS
be an elusive diagnosis, citing telltale signs of various tests.
Welcome to the Area
On the Cover: NCSH Wound Healing and Hyperbaric Center staff (clockwise from the top): Dana Perko, program director; Vincent Wilson, hyperbaric tech; Roberta Kunz, front-desk coordinator; Olivia Fuqua, R.N., case manager; Janice Harris, C.N.A.; Sue Weeks, M.D.; Woody Burns, M.D.; and Kelly Bennett, R.N., clinical nurse manager.
march 2016
3
Cover Story
North Carolina Specialty Hospital
Wound Healing and Hyperbaric Center Awarded 2015 Center of Distinction The North Carolina Specialty Hospital
Center was presented the 2015 Center
NCSH Wound Healing and Hyperbaric
Wound Healing and Hyperbaric Center in
of Distinction Award by Healogics for
Center provides care for all wound
Durham stands out among Triangle clinics
achieving outstanding clinical outcomes
etiologies. Given the increasing rates
dedicated to wound care.
for 12 consecutive months. During this
of diabetes and obesity, the majority
time period, the center earned a patient
of ulcers treated in wound clinics are
The Wound Healing and Hyperbaric
satisfaction rate of greater than 92 percent
diabetic foot ulcers (DFU) and venous
Center’s doors opened in February 2013, the
and a wound healing rate of at least 91
stasis ulcers (VSU). An estimated 6,500,000
brainchild of local plastic surgeon Edward C.
percent within 30 median days, among
Americans are affected by chronic ulcers,
Ray, M.D., and the product of collaboration
other quality outcomes.
approximately 2,000,000 of which are DFUs, and 600,000 of which are VSUs1.
among North Carolina Specialty Hospital, and
Healogics is affiliated with more than 780
Healogics, the nation’s largest provider of
centers, and the NCSH Wound Center was
“A chronic wound is a game changer for
advanced wound care services.
one of only 221 centers to achieve this
many people. It affects their psyche, it
honor.
affects their ability to participate in society.
Triangle
Today,
Orthopaedic
the
North
Associates
Carolina
In the bigger picture, it can be a harbinger
Specialty
Hospital (NCSH) Wound Healing and
“It is an honor for our clinic to receive this
of things to come,” says Dr. Weeks. “We take
Hyperbaric Center is staffed by surgeon
award, and I think it reflects what a great
amputation-prevention very seriously. The
Walter Woodrow “Woody” Burns III, M.D.,
team we have at the wound clinic, including
five-year mortality rate for a diabetic patient
and interventional radiologist Susan “Sue”
the nurses and office staff. Everyone here
following a major amputation approaches
Weeks, M.D.
enjoys their job and works very hard to take
50 percent, so healing these wounds and
excellent care of our patients in a caring,
preventing future wounds is paramount to
Finishing its third year in operation,
friendly and respectful manner,” says Dr.
the overall health of the patient.
the Wound Healing and Hyperbaric
Burns. “The goal of the NCSH Wound Center is not just to heal the wound, but to help the patient develop strategies to avoid rewounding. It’s a part of helping them take charge of their life,” she says. Wound center patients are usually referred for wound care by their primary care provider or a specialist consultant. They also may refer themselves. Wounds of different etiologies need to be treated differently, and each wound is evaluated to identify the appropriate treatment plan. Most patients seen at the NCSH Wound Center have chronic wounds, which no longer follow the normal healing
Dana Perko Program Director addresses a question from a Hyperbaric Oxygen Therapy patient.
4
The Triangle Physician
cycle2.
Bioengineered tissues continue to evolve and are derived from human, animal and synthetic sources. These “skin substitutes,” also known as “bioactive alternative tissues” and “cellular- and tissue-based products,” can be highly effective when selected appropriately. They come in two general categories: dermal substrate replacement products and dermoinductive products. The former are used for wound-bed preparation to support the underlying dermal matrix, and the latter are used for wound closure. Available at NCSH Wound Healing and Hyperbaric Center, hyperbaric oxygen therapy is an advanced modality used to treat selective ulcerations and certain nonwound conditions.
Dr. Woody Burns discusses the healing progress of a patient’s wound.
Medicare acknowledges 15 indications A typical acute wound proceeds through
resonance
are
for HBO, including diabetic foot ulcers
four stages while healing: hemostasis,
obtained as indicated. Edema is improved
imaging
(MRI)
scans
with associated deep soft-tissue infection;
inflammation, proliferation and remodeling.
with compression wraps when possible,
abscess, or osteomyelitis; acute arterial
If adverse systemic or local influences affect
and offloading is addressed usually by
insufficiency; osteoradionecrosis, or soft
the wound, these influences can suspend
casting or orthotics.
tissue radionecrosis; chronic refractory
the wound in the inflammatory state,
osteomyelitis; crush injuries; necrotizing
leading to a chronic, nonhealing ulceration.
Patients return for frequent follow-up visits,
fasciitis; and preparation and preservation
If the negative influences can be identified
and each time the wound is re-assessed and
of compromised skin grafts. Commercial
and treated, the wound should return to the
treatment modified as indicated. Evidence
insurance will consider other indications
more “normal” healing cycle.
suggests a wound that does not decrease
for HBO that have been approved by the
50 percent in volume during the first four
Undersea and Hyperbaric Medical Society
To that end, during the initial visit,
weeks will be more difficult to heal, so it is
(UHMS), including idiopathic sudden
patients’ wounds are evaluated for a
the wound center’s goal to reach that initial
sensorineural hearing loss, compromised
multitude of adverse conditions, including
benchmark in wound healing . If a wound
flaps and “selected problem wounds.”
hypoperfusion, presence of non-viable
does not meet appropriate healing criteria,
The best clinical evidence (Level 1) exists
tissue, infection, inflammation, edema and
more aggressive therapies can be utilized,
for HBO treatment of ischemic, infected
undue pressure. Patient pain and systemic
including negative pressure wound therapy
(Wagner Grade 3 or higher) diabetic foot
illness are assessed.
(NPWT), bioengineered tissue placement
ulcers5.
3
and, in some cases, hyperbaric oxygen For lower-extremity ulcers the presence of
therapy (HBO).
PtcO2 is used to assess oxygenation of
adequate blood flow is assessed on initial
the periwound skin and as an indirect
exam by obtaining an ankle brachial (ABI)
Negative pressure wound therapy is a
measurement of microcirculatory blood
or toe brachial (TBI) index. If needed,
proven therapeutic option for healing
flow. This technology is an effective
further evaluation with arterial ultrasound
ulcerations, as it enhances local blood flow,
screening tool to identify patients at risk for
(US), transcutaneous oxygen measurement
decreases edema and facilitates growth of
wound-healing failure secondary to local
(PtcO2) or consultation by a vascular
granulation tissue across the wound bed4.
periwound hypoxia. It also helps to identify
specialist may be required to restore
A more recent development is that of the
patients most likely to benefit from HBO, as
adequate blood flow for healing.
single-use NPWT device, which allows
well as predict therapeutic response.
for single placement on a weekly basis in Non-viable tissue is debrided, and infection
patients whose wound characteristics meet
In addition to weekly wound care, patients
is
criteria.
undergo
treated.
Radiographs
or
magnetic
concommitant
HBO
therapy
march 2016
5
and are seen each week to assess clinical response. Each HBO treatment takes about two hours, and patients typically undergo 20 to 40 treatments during a four-to-eightweek period depending on their indication. During this treatment, the patient is slowly brought to a pressure of 2 atmospheres absolute, which is the equivalent of 33 feet of sea water. One-hundred percent oxygen flows into the single-person chamber in order to hyperoxygenate the blood. This pressure and oxygen concentration causes increased diffusion of oxygen into the plasma, which has been shown to increase tissue oxygenation, improve cell
North Carolina Specialty Hospital Wound Healing and Hyperbaric Center facility
metabolism, increase collagen deposition, improve edema, increase extracellular matrix proteins, improve bacteriocidal activity and decrease exotoxin effects, as well as enhance antibiotic action. HBO has been shown to enhance growth factors, increase angiogenesis, decrease inflammation and increase stem cell mobilization. Overall, HBO has been shown to decrease risk of major amputation and to be a cost-effective adjunct to standard therapy (6,7). The advantages a wound center can offer are numerous. Studies have shown that centers specializing in wound care, by adhering to evidence-based clinical practice guidelines, are able to achieve higher healing rates, demonstrate faster healing times and deliver more cost-effective care. The North Carolina Specialty Hospital Wound Healing and Hyperbaric Center focuses on the wound, employing the latest technological advances to heal the wound and helping the patient identify behaviors that can be modified to help avoid recurrent wounding. In the case of diabetic foot ulcers, this might include appropriate longterm orthotic use, diabetic shoes and daily foot checks. Long-term use of compression, treatment of abnormally refluxing veins and protection from leg trauma resulting from venous stasis ulcerations may be enough to
6
The Triangle Physician
The NCSH Wound Center is located at
avoid future venous stasis ulcerations.
4315 Ben Franklin Blvd., Durham, NC 27704. Providing care for these patients often
Office hours are from Monday-Friday,
requires a multidisciplinary approach. An
8 a.m. to 5 p.m. For more information call
important function of the wound center
(919) 595-8490.
is to coordinate each patient’s care plan with his or her primary care physician
References
and specialists who may be involved in
(1) Sen CK, Gordillo GM, Roy S, et al. “Human
the treatment of each patient, such as
Skin Wounds: A Major and Snowballing Threat to
those specializing in vascular surgery,
Public Health and the Economy.” Wound Repair
orthopedics, podiatry, infectious disease,
Regen. 2009; 17(6):763-771.
endocrinology and plastic surgery.
al. “Definitions and guidelines for assessment
A graduate of Duke University, Dr. Weeks completed
medical
school
and
(2) Lazarus GS, Cooper DM, Knighton DR, et
her
residency and fellowship at the University of North Carolina (UNC) at Chapel Hill. She is
of wounds and evaluation of healing.” Wound Repair Regen. 1994;2:165-70. (3) Snyder RJ, Cardinal M, Dauphinee DM, et al. “A post-hoc analysis of reduction in diabetic foot ulcer size at 4 weeks as a predictor of
a board-certified interventional radiologist
healing by 12 weeks.” Ostomy Wound Manage.
and serves as medical director of the NCSH
2010;56(3):44-50.
Wound Center as well as the Triangle
(4) Miller C. “The History of Negative Pressure
Orthopaedic Associates Vein Clinic.
Wound Therapy (NPWT): From “Lip Service” to the Modern Vacuum System.” J Am Coll Clin
Dr. Burns is a graduate of Davidson College
Wound Spec. 2012; Sep; 4(3): 61-62.
and completed his medical training at
(5) Weaver LK. UHMS Hyperbaric Oxygen
Wake Forest University and residency at
Therapy Indications. 2014 (13):25.
UNC. A board-certified general surgeon, he practices wound care full-time. Kelly Bennett is a certified wound care nurse and the center’s clinical nurse coordinator. She
graduated
School of Nursing.
from
UNC-Greensboro
(6) Roeckl-Wiedmann I, Bennett M, Kranke P. “ Systematic review of hyperbaric oxygen in the management of chronic wounds.” Br J Surg. 2005 Jan;92(1):24-32. (7) Guo S, et al. “Cost-effectiveness of adjunctive hyperbaric oxygen in the treatment of diabetic ulcers”. Int J TechnolAssess Health 2003;19(4):731-737.
Nutritional Health
Understanding the
New Dietary Guidelines By Lindsay Wojciechowski, F.N.P.-C.
The 2015-2020 Dietary Guidelines for
Currently, average Americans consume
Americans, Eighth Edition, released by
25 teaspoons (about 13 percent of daily
the United States government on Jan.
caloric intake) of added sugar, no doubt
7, places a focus on health-promoting
contributing
eating “patterns” over individual dietary
epidemic.
to
the
current
obesity
components. The new guidelines do not restrict total Every five years the U.S. Department
fat intake but recommend consumption of
of Health and Human Services and the
saturated fats to be less than 10 percent of
U.S. Department of Agriculture publish
caloric intake. They emphasize replacing
key
saturated fats with unsaturated fats, like
a
recommendations healthy
lifestyle
for
that
achieving reflect
the
olive oil, avocados, nuts and fatty fish.
current body of scientific evidence on
Lindsay Wojciechowski is a nurse practitioner and consultant to the Women’s Wellness Clinic and the Carolina Women’s Research and Wellness Center (CWRWC). She worked as a clinical nurse practitioner at Triangle Family Practice from 2006 until 2014 and has assisted with nursing courses at the Duke University School of Nursing. Ms. Wojciechowski’s focus is on women’s health and family medicine. She is the lead medical writer for the Women’s Wellness Clinic. She currently practices in Milwaukee, Wis.
nutrition, food and health. Physicians are
Historically, the misunderstood fear of fats
encouraged to educate themselves on the
has contributed to the high-carbohydrate
recommendations, individualizing them to
diet of most Americans, inadvertently
help support healthy eating patterns for all
increasing the rate of obesity and diet-
With
of their patients. There is no one-size fits
related diseases, like diabetes. Saturated
Americans overweight and nearly half
all eating plan.
fats (found in butter, whole milk, red
afflicted with diet- and obesity-related
meat, etc.) are known to increase serum
diseases, it is not surprising that these new
The new edition emphasizes regular
cholesterol, whereas unsaturated fats are
guidelines advocate for a diet high in fruits
consumption
linked with health benefits.
and vegetables, emphasizing
of
adequate
essential
nutrients and foods that reduce the risk of
approximately
two-thirds
of
the importance of whole
obesity and chronic disease (both all too
Keep in mind that all saturated fats are
grains, lean meats,
prevalent in our society). Compared to the
not created equal. For example, highly
seafood, legumes, nuts
recommendations in 2010, there are some
praised coconut oil contains lauric acid, a
and low-fat dairy
noteworthy changes.
saturated fat that has been linked to several
products.
health benefits. White starchy foods take the biggest hit in the new guidelines and at least half of
The new guidelines no longer restrict
consumed grains are encouraged to be
cholesterol intake. This isn’t to suggest that
whole ones.
dietary cholesterol is not important, but that current research shows saturated fat
Daily added sugar is now limited to less
to be more negatively impactful on serum
than 200 calories per day (approximately 12
cholesterol levels than dietary cholesterol.
teaspoons) or less than 10 percent of daily caloric intake. This is roughly equivalent
For the first time since the 1980s, moderate
to one 16-ounce sugary beverage. Added
daily coffee consumption can be part of a
sugars include corn sweetener, corn syrup,
healthy diet. Moderate alcohol (preferably
high-fructose corn syrup, honey, sucrose,
in the form of red wine) can also be
raw sugar and dextrose. Natural sugar from
included; up to one drink a day for women
milk and fruit are excluded from these
and two for men.
limitations.
march 2016
7
Practice Management
Part 1: Anticipating Problem Areas and Tips for Successful
EHR Implementation Margie Satinsky, M.B.A.
Finally – you’ve made a decision on
deal with both the workforce and with
purchasing or replacing your electronic
patients. In many instances, what appears
health records software. Postpone the
to be resistance on the part of a clinician or
sigh of relief until you’ve tackled the next
administrative staff member is a learning
challenge – implementation.
difficulty in disguise. Remember that each person learns in different ways. Some of
This is the first article in a two-part
us are visual learners, and others are more
series that explores the challenge of
“hands on.” One-size training won’t fit all,
implementing a new electronic health
so make sure the training meets each user
records (EHR) system or replacing the
at a comfortable place.
one you already have. The second part of this series will cover implementation tips and appear in next month’s issue of The Triangle Physician. Common Problems with Software Implementation
Margie Satinsky is president of Satinsky Consulting LLC, a Durham consulting firm that specializes in medical practice management. She has helped many physicians start new practices, assess the wisdom of affiliating with a larger health care system and improve their current practices. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www. satinskyconsulting.com.
Let’s start with five common problems that frequently occur during software
this method has its place, particularly
implementation
as a resource for ongoing continuing
and
strategies
for
overcoming each one.
education after a system has gone live. Prior to go-live, we prefer onsite training
Letting the vendor run the show. The
or a combination of onsite and web-based
vendor knows the software that you’ve
training. Both of these options allow
chosen, but successful implementation
Neglecting to ask about hardware
depends on the development of a
requirements.
collaborative
All
vendors
practice-vendor interactions.
provide
relationship
specific hardware requirements. Not all
Setting unrealistic expectations. Soft-
between vendor and practice. Come with
practices pay attention, only to discover
ware implementation is a process, not
an open mind, be ready to learn, ask many
during implementation that they need to
an act. Practices that expect a perfectly
questions and strive to make the solution
upgrade existing hardware or purchase
smooth ride without bumps in the road
meet your needs and priorities. Polite
new hardware to make the new software
are setting themselves up for disappoint-
assertiveness works better than passivity
work. Pay close attention to details before
ment. Focus on establishing a trusting
or hostility.
implementation begins.
working relationship with the vendor, so
working
together you can identify and address implementation
Depending on web-based training to
questions and issues when they arise. Ven-
involves both technology and people.
save a dime. Many vendors offer web-
dor sales, implementation and technical
Software has many capabilities, but it
based training as an economical method
support staff deserve respect, not anger
doesn’t manage people. It’s your job to
for keeping the cost down. We think
and negativity.
Forgetting
8
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march 2016
9
Endocrinology
Diagnosing Adrenal Incidentalomas By George Stamataros, D.O., F.A.C.E.
The incidentally discovered adrenal mass is
ducing tumor that can cause marked fluc-
a common radiologic finding, typically wit-
tuations in blood pressure and heart rate.
nessed on a computed tomography scan or
(See Table I). While adrenal carcinoma is
magnetic resonance imaging scan that was
relatively rare, there are other malignancies
performed for some other clinical reason.
found in the adrenal gland, such as metastatic lung cancer.
Endocrine evaluation of adrenal masses is necessary to establish whether an adrenal
Certain radiologic features, such as density
lesion is benign and/or functional (i.e., pro-
on computed tomography (CT) scan can
ducing hormones). The overall incidence
predict whether a tumor is likely to be be-
of adrenal “incidentalomas” increases with
nign or malignant. Unenhanced CT lesions
age, but is estimated to be between 2-4 per-
that have a Hounsfield unit value less than
cent of the adult population, depending
10 are likely to be benign adrenal adeno-
on the demographic background and the
mas. Similarly, enhanced CT lesions that
imaging study. Typically, these lesions are
display greater than 50 percent washout at
greater than 1 centimeter and may be unilat-
10 minutes after washout are likely to be be-
eral or bilateral.
nign. In either of those instances, repeat adrenal imaging at six to 12 months can deter-
The vast majority of adrenal lesions are
mine if an adrenal mass is radiographically
benign, with less than 1 percent being ma-
stable. The presence of calcium deposits in
lignant. Generally, nodules greater than 4-5
an adrenal lesion can suggest granuloma-
centimeters in size should be considered
tous disease (e.g., tuberculosis).
for surgical excision (to rule out malignancy); however, it is important to exclude
Adrenal incidentalomas are usually non-
pheochromocytoma, a catecholamine-pro-
functional, but approximately 5 percent
George Stamataros was born in Queens, N.Y., and grew up near Princeton, N.J. He completed his undergraduate studies at Rutgers University with a focus in biological Sciences. He earned his medical degree from the University of Medicine and Dentistry of New Jersey and completed his graduate medical training in internal medicine and subspecialty training in endocrinology at UMDNJ-Robert Wood Johnson Medical School in New Brunswick, N.J. Dr. Stamataros is board certified in internal medicine and endocrinology. He has worked in private practice in New Brunswick for three years before relocating to North Carolina. He was active in teaching medical students and served as a director at Somerset Medical Center. Dr. Stamataros is also a member of the American Association of Clinical Endocrinology and Endocrine Society. Dr. Stamataros now practices at Carolina Endocrine P.A., 3840 Ed Drive, Suite 111, Raleigh, NC 27612. He can be reached by calling (919) 571-3661 or sending an email to gstamataros@ carolinaendocrine.com.
Table I – Types of Hormonally-Active Adrenal Tumors Syndrome
Initial Screening Diagnostic Test(s)
secrete hormones. The type of hormones
Pheochromocytoma
Serum metanephrines, 24-hr. urine catecholamines (VMA, metanephrine of Epi/Norepi)
tumor is arising from the adrenal medulla
Corticosteroid
Cushing’s Syndrome
Overnight dexamethasone suppression test, 24- hr. urine Free cortisol, midnight salivary cortisol
Aldosterone
Primary Hyperaldosteronism
Serum aldosterone/renin ratio, saline suppression test
Androgens
Androgenization, early puberty
DHEA, Testosterone
Hormone
Catecholamine
In evaluating for catecholamine-producing tumors (pheochromocytoma), serum metanephrines and/ or 24-hour urine catecholamines (VMA, metanephrine, epi/norepi) are measured. When suspecting Cushing’s Syndrome, we proceed with an overnight dexamethasone suppression test, 24-hour urine-free cortisol or midnight salivary cortisol. To evaluate for aldosterone excess (primary hyperaldosteronism), serum aldosterone/renin ratio and saline suppression tests are performed. In assessing for androgenization or early puberty, DHEAs and testosterone are typically measured. Reference: Young, WF, Jr., N Engl J Med 2007; 356:601-610
10
The Triangle Physician
being produced depends on whether the (catecholamines) or the adrenal cortex (steroid hormones). Therefore, functional adrenal incidentalomas typically secrete hormones that may produce clinical syndromes in one of four broad categories: catecholamine excess, corticosteroid excess, aldosterone excess and adrenal androgen excess. (See Table I). History and physical examination findings can help guide the evaluation. Reviewing the reason for the imaging study might suggest associated parts of a syndrome.
Endocrinology Determining whether it might have been
ing’s syndrome) is usually screened with an
ics, which should be discontinued for about
noted (perhaps overlooked) on a previous
overnight dexamethasone suppression test:
four weeks before attempting to interpret
imaging study can help establish stability
administration of 1 milligram dexametha-
the ARR.
or growth. Reviewing physical biochemical
sone at 11 p.m., the night before an 8 a.m.
clues for functionality might include hyper-
cortisol. The normal physiologic response
ARR values greater than 20 suggest the pres-
tension, anxiety/depression, body habitus,
is suppression of serum cortisol to less than
ence of primary hyperaldosteronism, al-
diabetes mellitus, hypokalemia, changes in
1.8 micrograms per deciliter. This test has a
though additional confirmatory endocrine
hair/skin texture or masculinization/acne.
very low false-negative rate but frequently
testing is needed to establish this diagnosis.
can yield false positives in very heavy in-
Hypokalemia is often seen in primary hy-
Laboratory evaluation includes either se-
dividuals, people under excessive physio-
peraldosteronism. Sometimes, a saline-sup-
rum metanephrines and/or 24-hour urine
logic or emotional stress or deviations from
pression test can determine if aldosterone
catecholamines (either vanillylmandelic
clinical protocol. In those instances, a 24-
is suppressible. Additional diagnostic con-
acid (VMA)/metanephrines or epineph-
hour, urine-free cortisol may be preferred.
firmation usually requires bilateral adrenal
rine/norepinephrine) to rule out the most
Again, elevations in cortisol production can
vein sampling in order to establish whether
serious functional tumor, pheochromocy-
include a variety of environmental stressors,
a gradient exists, suggesting a unilateral
toma. Elevated serum metanephrines have
which need to be further evaluated by more
aldosterone-producing tumor or bilateral
a false-positive rate as high as 10 percent,
specific diagnostic tests.
nodular adrenal hyperplasia.
several minutes or if there is significant
Pituitary adrenocorticotrophin hormone
Finally, adrenal tumors can infrequently
needle stick trauma during phlebotomy.
(ACTH) in the presence of cortisol-produc-
cause hirsutism, and sometimes virilization
However, a normal serum metanephrine
ing adrenal tumors is typically suppressed.
in women, and less commonly, premature
has a very low false-negative rate (less than
In hypertensive or hypokalemic patients,
pubertal problems in children and adoles-
1 percent), which can be further monitored
the aldosterone/renin ratio (ARR) can be
cents. Once size, functionality and stability
by follow-up surveillance and/or a 24-hour
measured usually in the morning, after the
of adrenal incidentalomas have been ex-
urine catecholamine.
patients have been upright for at least two
cluded, then patients may forego any fur-
hours. However, these results cannot be in-
ther diagnostic or therapeutic intervention
terpreted in patients who are taking diuret-
or undergo periodic follow-up surveillance.
particularly if the patient is not supine for
Evaluation of corticosteroid excess (Cush-
march 2016
11
Physician Advocacy
Sound to Good to Be True?
Beware the Trojan Horse By Marni Jameson
Many of you will be approached, if you
3. Who controls the decisions? A CIN board
haven’t already, by one or more hospitals
will make every decision, action and deter-
inviting you to join their clinically integrated
mination for the network, including terms
network.
and conditions of contracts with payors. Look closely at the agreement to see how
Though not new ventures, clinically inte-
this board is formed and who appoints its
grated network (CINs) have become more
members. Although this board must be “phy-
popular as a result of Obamacare, which fu-
sician led” by definition, the CIN will likely
els the alignment of doctors and hospitals in
remain under the hospital’s control.
ways that allegedly reduce cost, waste and
Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at (407) 865-4110 or marni@aid-us.org.
doctors’ efficiencies by combining them with hospital inefficiencies, which indepen-
inefficiencies. How that gets achieved is de-
4. How do independent doctors get pro-
dent doctors can’t control, the new dynamic
batable, but CINs are an attempt.
tected? The hospital will likely make sure
also dilutes any gains independent doctors
employed doctors dominate the CIN board
realize by becoming more efficient.
These networks include both hospital-em-
and thus influence the decisions and votes
ployed doctors and independent ones, who
of those employed board members. Sure, a
8. How will joining the CIN impact your over-
don’t want to work for the hospital.
few token independent doctors may be on
head? Your overhead costs will likely go up.
the board, but they won’t form a majority.
As an independent provider, you will still pay
At the Association of Independent Doctors,
for your current overhead – such as electron-
we have had an opportunity to review privi-
5. What about your existing contracts? A
ic medical records, administrative, billing
leged documents that list the terms of agree-
close reading of the agreements reveals that,
and collection costs. Plus you will subsidize
ment for several networks and urge caution.
theoretically, the CIN could force doctors to
the same costs for the CIN.
What may sound like a great deal on the sur-
terminate contracts they have with payors
face bears closer inspection.
and prohibit doctors from negotiating future
9. Who owns your patients’ data? Once you
payor contracts, especially if those existing
join a CIN, the hospital will have access to
Before you agree to participate in any CIN,
contracts include beneficiaries covered by
your patients’ demographics and health in-
consider these 10 points.
the CIN’s contracts. Independent doctors
formation and could data mine the records.
may not have the option to get paid at the
Even if you leave the network, they will have
1. Who benefits? Ask what is in this for the
more favorable rates they have negotiated on
your patients’ information.
hospital? Clearly, the hospital can negoti-
their own. Again, the CIN negotiates these
ate very effectively for themselves and their
contracts, not you.
employed physicians. So why now does the
10. Show me the papers. Be wary of hospitals that arrange lots of meetings for doctors
hospital want independent doctors to enroll?
6. How could joining impact your fees? The
telling them why they should join the CIN,
What is in it for you? If you think the hospi-
CIN board could also negotiate higher re-
but have no operating agreements available
tal is going to negotiate better rates for you,
imbursement rates for the hospital and the
for review. Without the paperwork, the agree-
jump to No. 5.
hospital’s employed physicians and pay for
ment is just talk. That talk likely portrays the
that by lowering reimbursement rates to in-
CIN as a win-win for doctors and hospitals
dependent physicians.
alike, but the devil is in the details. Be highly
2. History and track record. When was the last time an arrangement the hospital pre-
suspicious of any agreement that the hospi-
sented truly benefited independent doctors
7. What’s the payoff if you’re more efficient
tal wants you to “hurry up” and sign without
in the long run? Why is this any different? Be
than the pool? When has a hospital ever got-
allowing time for your attorney or certified
suspicious.
ten more efficient as it grew? Just as hospi-
public accountant to review it. In short, be-
tals’ bundled payment programs neutralize
ware the Trojan horse.
12
The Triangle Physician
Duke Research News
Enrollment to Begin This Year for Study Aimed at Resolution of How to Manage Pre-Cancers of the Breast The first large United States study aimed
ers have questioned whether those treat-
Women with a DCIS diagnosis who par-
at resolving an ongoing debate about the
ments are necessary in all cases, given
ticipate in the study will be randomized to
best way to treat an early sign of breast
that DCIS lesions do not grow rapidly or
receive one of two treatment approaches:
cancer will launch later this year under
spread in the majority of women with the
The current standard of care consisting of
the direction of a Duke Cancer Institute
diagnosis. Treatment can result in side ef-
surgery and radiation therapy or careful
investigator.
fects, including long-term pain and altered
monitoring with mammograms and physi-
body image, along with significant finan-
cal exams every six months.
The study, entitled COMET (Comparison
cial costs to both patients and the health
of Operative to Medical Endocrine Thera-
care system. Actively monitoring many of
“Anyone whose DCIS progresses would be
py) for low-risk ductal carcinoma in situ,
these patients has been recommended as
immediately treated with standard thera-
received funding through a $13.4 million,
an alternative, if research demonstrates it
py,” Dr. Hwang said. “When detected early
five-year award from the Patient-Centered
is safe and effective.
in this way, the outlook for long-term survival and even a cure is excellent.”
Outcomes Research Institute (PCORI), an independent, nonprofit organization au-
“This will be a definitive clinical trial that
thorized by Congress in 2010 to support
will help set the course for future DCIS
Dr. Hwang said the study would provide
research that enlightens health care deci-
treatment,” said Dr. Hwang, who has been
data about the best candidates for active
sions.
a leading voice in the national debate
surveillance and create a repository of im-
E. Shelley Hwang, M.D.
calling for a more informed approach to
aging and cell samples to advance knowl-
Principal investigator E.
treating DCIS. “It is based on what we are
edge into the molecular biology of DCIS
Shelley Hwang, M.D.,
discovering about the tremendous variety
and what fuels or deters its growth.
chief of breast surgery
we see even in one disease, such as DCIS,
at the Duke Cancer In-
and how we must design our future treat-
The study also is designed to collaborate
stitute and vice chair of
ments to more precisely reflect those dif-
closely with a similar trial that was initiated
research in the Duke
ferences.”
last year in Europe, providing the ability to combine findings that will then strengthen
University Department
the statistical conclusions globally.
of Surgery, will lead the
Dr. Hwang will work with co-principal in-
study through the cooperative group, The
vestigators Alastair M. Thompson, M.D.,
Alliance for Clinical Trials in Oncology.
from The University of Texas MD Ander-
“This study will provide so many answers
son Cancer Center and Ann H. Partridge,
to questions that are critical to resolve,” Dr.
The research will focus on ductal carcino-
M.D., from Dana-Farber Cancer Institute,
Hwang said. “One of the key features is the
ma in situ (DCIS), which is a small cluster
partnering with The Alliance for Clinical
assessment of patient-reported outcomes
of abnormal cells in the breast ducts that
Trials in Oncology.
with each approach, as we believe how patients view their disease and their care
has not spread to surrounding tissue. Identified via mammography and other screen-
The study will enroll 900 patients diag-
must be central to any advances in cancer
ing technologies, DCIS is currently diag-
nosed with low-risk DCIS from 100 cancer
treatment.”
nosed annually in about 60,000 women in
centers throughout the U.S., with enroll-
the U.S., and is generally treated similarly
ment slated to begin later this year. The
The funding award for the DCIS study has
to other more advanced breast cancers
trial will take four years to accrue all pa-
been approved pending completion of
with surgery and radiation therapy.
tients, with follow-up and analysis to con-
a business and programmatic review by
tinue for at least five years.
PCORI staff and issuance of a formal award contract.
In recent years, physicians and research-
march 2016
13
Duke Research News
Sildenafil May Relieve Dangerous Cold-Water Edema in Swimmers Swimmers and divers who are prone to a sudden and potentially life-threatening form of pulmonary edema in cold water could benefit from a simple and readily available dose of sildenafil, according to findings from a small study by Duke Health researchers. The drug – best known as Viagra – is normally used for treatment of male impotence but also for pulmonary arterial hypertension. It dilates blood vessels, giving it the potential to ease an abrupt cold water-induced constriction of blood vessels in the arms and legs that can lead to blood pooling in the heart and lungs. Athletes and others with this condition – called swimming-induced pulmonary edema, or SIPE – cough up blood, labor to breathe and have low blood-oxygen typically brought on by swimming or
Duke researcher Anne Cherry, M.D., works with a participant during a study on swimming-induced pulmonary edema at the Duke Hyperbaric Center. Credit: Duke Health
scuba diving, usually in cold water. Often the symptoms dissipate during the next 24 hours, but the condition can be seri-
published online February 16 in Circula-
water exercise, confirming that SIPE is
ous and even fatal, and medical attention
tion: Journal of the American Heart Asso-
a form of pulmonary edema caused by
is recommended. Many don’t know they
ciation.
high pressure in the blood vessels within
are prone to the problem, until they are in the water and quickly develop symptoms.
the lungs. Dr. Moon and colleagues studied these responses in 10 athletes who had expe-
When the SIPE participants were given
“During immersion in water, particularly
rienced the condition while exercising
sildenafil and then performed the same
cold water, susceptible people have an
or competing in triathlons. During a care-
underwater exercise, the pressures were
exaggerated degree of the normal redis-
fully monitored test in Duke’s hyperbaric
no longer as elevated.
tribution of blood from the extremities to
center, the researchers had the partici-
the chest area, causing increased pres-
pants exercise under water in a dive pool
“This is a small study, but also very inten-
sure in the blood vessels of the lungs and
that recreated the conditions of a swim
sive with direct, accurate pressure mea-
leakage of fluid into the lungs,” said Rich-
that could trigger the SIPE response.
surements,” Dr. Moon said. “It appears
ard Moon, M.D., an anesthesiologist and
that the drug, which dilates the blood
medical director of the Duke Center for
They compared those participants with
vessels, could be creating more capacity
Hyperbaric Medicine & Environmental
20 others who did not have a history of
in the blood vessels in the arms and legs,
Physiology.
SIPE. None of the participants in either
reducing the tendency for blood to redis-
group had heart abnormalities, but the
tribute to the thorax and therefore reduc-
“Some cases of SIPE appear to have been
SIPE-susceptible athletes had higher pul-
ing the high pressure in the pulmonary
the result of cardiac problems,” said Dr.
monary arterial pressure and pulmonary
vessels.”
Moon, who was lead author of the study
artery wedge pressure during the under-
14
The Triangle Physician
Duke Research News One study participant, triathlete Katherine Calder-Becker, said her bouts with
MOHS MICROGRAPHIC SURGERY • EXCISIONAL SURGERY • CRYOSURGERY
problems during training in swimming
“She wanted to move on with her life.”
pools but then experienced debilitating
I REFERRED HER TO SOUTHERN DERMATOLOGY
SIPE threatened to end her competitive career. She said she would have no
shortness of breath and distress during the swim portions of competitions in colder open water. She coughed up blood and was once hospitalized. Ms. Calder-Becker, 51, was diagnosed with SIPE and enrolled in studies at Duke in 2011. Afterward, she consulted
WI
her cardiologist and was prescribed a low dose of sildenafil that sheBAY15001 takes RADAR: shortly before competitions. Ad: Version
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lons since I started taking sildenafil, including five ultra events that require 10-kilometer swims,” Ms. Calder-Becker said. “I have not had an incident since then. I didn’t want to give up racing –
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petitions – so it has meant everything to me to continue.” Dr. Moon said larger studies are needed to replicate the results and learn more about possible adverse side effects of the drug. He also said research is ongoing to further illuminate the causes of SIPE and potential ways of diagnosing it early. In addition to Dr. Moon, study authors include Stefanie D. Martina, Dionne F. Peacher, Jennifer F. Potter, Tracy E. Wester, Anne D. Cherry, Michael J. Natoli, Claire E. Otteni, Dawn N. Kernagis, William D. White and John J. Freiberger.
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News Welcome to the Area
Physicians
Sara Abbott, MD Anatomic and Clinical Pathology; Blood Banking, Blood Banking/ Transfusion Medicine; Cytopathology; Dermatopathology; Forensic Pathology; Hematology Pathology; Immunopathology; Medical Microbiology; Molecular Genetic Pathology; Neuropathology
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Chapel Hill
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University of North Carolina Hospitals Chapel Hill
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