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Tolnitch Surgical Associates Expertise, Collaboration Distinguish Region’s Premier Breast Specialists
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
Renovating an Icon Contraception
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w w w. j o h n s t o n h e a lt h . o r g
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The Triangle Physician
Category
COVER STORY
6
Tolnitch Surgical Associates Expertise, Collaboration Distinguish Region’s Premier Breast Specialists
m ay 2 0 1 3
10
Vol. 4, Issue 4
Medical Icon to Become Renewed Destination for Health Care
The Durham Clinic Building on Roxboro Street is being redeveloped to serve a new generation of health care
DEPARTMENTS 16 Practice Marketing
21 UNC Research News
Understanding May Lead to New Treatment of All MRSA Strains
patients.
I nternal Marketing: 3 Ways to Grow Your Practice from Within
18 News
FEATURES
12
Women’s Health
Understanding Contraception and the Effectiveness of IUDs and Skyla Dr. Andrea Lukes urges provider awareness of top-rated devices.
14
- Raleigh Orthopaedic Surgery Center Opens with New Outpatient Option - Barker Selected as a Master Instructor of Hip Arthroscopy
19 News Hospitals Test Ultraviolet Technology to Reduce Infections
Endocrinology
Diagnosis, Treatment and Management of Types of Differentiated Thyroid Cancer Dr. Michael Thomas explores the continuum of care.
New Look at Old Study Casts Doubt on Benefits of Vegetable Fats
23 Duke Research News
20 News
22 UNC Research News
- Dermatologist Joins Raleigh Practice - Rex Express Collects 110,000Plus Dosages in Operation Medicine Drop
- Discovery of More Genetic Variations for Ovarian Cancer Raises Hope - People with Depression May Not Reap Full Benefits of Healthy Behaviors
24 News
Welcome to the Area
COVER PHOTO: Foreground, from left: Gayle A. DiLalla, M.D., F.A.C.S.; Nancy Crowley, M.D., F.A.C.S.; and Lisa A. Tolnitch, M.D., F.A.C.S., are surrounded by their Tolnitch Surgical Associates staff.
may 2013
3
From the Editor
Delivering on a Promise We are fortunate to live in an age in which the promise of curing dreaded diseases, such as breast cancer, has never been greater. And now genomics is leading to an era of cancer treatment that is tailored to
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
the individualized nature of tumors and destined to be more effective. This month’s cover story is on Raleigh-Durham’s first surgical group specializing in breast care. In “Tolnitch Surgical Associates: Expertise, Collaboration Distinguish Region’s
Editor Heidi Ketler, APR
heidi@trianglephysician.com
Premier Breast Specialist,” readers can certainly understand why specialized care leads to better outcomes. The article is a portrait of an all-woman practice truly focused on every aspect of breast cancer – from the basics to the complex genetics, from the psychosocial to the financial. It offers compelling patient perspectives, and an update on Pretty in Pink, the non-profit organization founded by Dr. Lisa Tolnitch for uninsured and underinsured patients, that it is going above and beyond to deliver on its promise.
Contributing Editors Amanda Kanaan Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Michael J. Thomas, M.D., Ph.D. Photography Mark Jacoby Creative Director Joseph Dally
mark@jacobyphoto.com
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Also in this month’s issue, readers gain insight into the redevelopment of the iconic Durham Clinic Building off of Roxboro Street. Developer Dan Klausner envisions the Live Well North Durham facility as the gateway to a health care campus that is easy to navigate
info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com
and anchored by a Kerr Drug Store. Leasing opportunities are available. Gynecologist and columnist Andrea Lukes returns to urge awareness among providers of the effectiveness of contraception, citing intrauterine devices and the implant as most effective. Endocrinologist Michael Thomas details the diagnosis, treatment and management of differentiated thyroid cancer. Marketing specialist Amanda Kannan suggests ways practices can better market to their most powerful resource – current patients. The Triangle Physician is a great tool for reaching that other all-important market – referring medical providers. Each issue is delivered to more than 9,000 physicians, physician assistants, nurse practitioners and hospital and practice administrators. Our advertising rates are highly competitive, and we welcome your practice news and professional commentary at no charge. For more information on how The Triangle Physician can help you deliver on your health care promise, please contact me at heidi@trianglephysician.com. With gratitude and respect for all you do,
Heidi Ketler Editor
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Cover
Tolnitch Surgical Associates Expertise, Collaboration Distinguish Region’s Premier Breast Specialists It is estimated that one out of every eight women in America is
In 2011, the surgical practice joined Duke Cancer Institute and the
diagnosed with breast cancer, and the vast majority survive. In 2011,
Duke Division of Surgical Oncology. “Our decision to merge with
the number of breast cancer survivors – those being treated and
Duke was based solely on the fact that through this partnership our
those who were disease free – in the United States was 2.6 million
commitment to quality patient care will be enhanced by providing
and growing.
Raleigh and surrounding areas with access to the state’s top-ranked cancer program,” says Dr. Tolnitch. “We also feel strongly that a
This trend is evident in the Raleigh-Durham region, in large part
multidisciplinary approach to cancer can facilitate better care.”
because of breast care specialists like Tolnitch Surgical Associates. Tolnitch Surgical Associates was founded in 1991 by Lisa A. Tol-
The Duke partnership expands Tolnitch Surgical patients’ access to
nitch, M.D., F.A.C.S., as the region’s first surgical practice dedicated
clinical trial opportunities, developing therapies and other resourc-
to breast cancer.
es, such as genetic counseling and support groups for managing issues down the line, “even volunteer opportunities for the many
Research shows that those with breast cancer are more effectively
patients who turn around to give back,” says Dr. DiLalla.
treated by specialized physicians, according to Gayle A. DiLalla, M.D., F.A.C.S., of Tolnitch Surgical Associates. Dr. DiLalla and Nan-
In 2004, Wake Radiology Diagnostic Imaging opened a mammogra-
cy Crowley, M.D., F.A.C.S., are partners with Dr. Tolnitch.
phy and ultrasound suite within Tolnitch Surgical Associates. Since 2005, Tolnitch Surgical has hosted an open, in-office conference
Over the years, Tolnitch Surgical has formed partnerships to ad-
with Rex Healthcare pathology group and Wake Radiology to re-
vance collaboration among other breast care specialists and coor-
view cases.
dination of services. Tolnitch Surgical maintains relationships with radiation oncologists and medical oncologists locally and across the state. After a cancer diagnosis, an onsite consultation with a medical oncologist can be facilitated for patients in need of chemotherapy.
Risk Factors: Sex, Age and Heredity Although breast cancer strikes men and women of all ages, about 85 percent of cases occur in women who have no history of it in their family. Genetic mutations, which happen in specific cells during a person’s life, are more likely due to the aging process than to genetic inheritance. Research also suggests a combination of obesity and lack of exercise may contribute to breast cancer risks. About 5-10 percent of breast cancer cases is hereditary. A woman’s risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with Conferring on a case, Drs. Lisa Tolnitch, Gayle DiLalla and Nancy Crowley.
6
The Triangle Physician
breast cancer.
comed by the staff. I was nervous, and they were very kind and professional. …I appreciated Dr. Tolnitch’s openness and felt very comfortable with her abilities.” Today, Ms. Anderson and her sister are cancer survivors. Brenda Caref has survived three separate breast cancer diagnoses. The first time she received the definitive news from Dr. Tolnitch, she was 44 and coming out of anesthesia after a biopsy. “I’ll never forget her words. She said, ‘I’m sorry, but you have Nikki Fonville, Patient Services Associate
breast cancer.’ I knew that this was going to be the start of a journey with her. She gave
Mutations of the BRCA1 and BRCA2 genes
says Dr. Tolnitch. “But we have a long way
me bad news, but I had a certain reassur-
are the most common. Affected women
to go” in understanding, both the science
ance that she would be there.”
have up to an 80 percent risk of develop-
and the psychosocial impact.
ing breast cancer during their lifetime. An
Ten years later, after a lumpectomy, an
increased ovarian cancer risk also is associ-
Tolnitch Surgical offers genetic testing to
oophorectomy, a mastectomy and recon-
ated with these genetic mutations.
high-risk patients. It also provides direct
struction, Ms. Caref is cancer free. Now her
access to Duke genetic counselors, who
concern is with her daughter. The mother
In men, about one in 10 breast cancers are
explain family history, genetic testing and
of three young children, living in Hunting-
believed to be due to BRCA2 mutations
available options, such as chemopre-
ton, W.V., was diagnosed in November with
and even fewer cases to BRCA1 mutations.
vention, prophylactic surgery to remove
stage 2 breast cancer.
breasts and/or ovaries and surveillance
Genetics: Treating Generations
with magnetic resonance imaging or ultra-
At that news, Ms. Caref contacted Dr. Tol-
Genomics – the study of complex sets of
sound to detect breast cancer early.
nitch, who promptly coordinated a team
genes, their expression and function – has
of breast cancer physicians – radiologist,
revealed that individual cancers contain
Patient Perspectives
medical oncologist, plastic surgeon. A
many different alterations. Therefore, can-
Veronica Anderson’s mother was 42 when
bilateral mastectomy and reconstruction
cer is not the same disease for every pa-
she died of breast cancer. At age 40, her sis-
followed. Today, Ms. Caref’s daughter is re-
tient, and a patient may be more or less
ter was diagnosed with breast cancer, and
ceiving aggressive chemotherapy.
likely to develop advanced disease or to
at age 44, Ms. Anderson was diagnosed
respond to certain therapies.
with ovarian cancer.
Pretty in Pink: Financial Safety Net and Much More
The findings are leading to genetic tests
Having survived ovarian cancer, she is now
Pretty in Pink Foundation was started in
that identify a patient’s risk for disease,
focused on her daughter’s pregnancy and
1994 by Dr. Tolnitch with a unique mis-
such as breast cancer, and help health
eager for the arrival of her granddaughter.
sion – to serve as an ally for uninsured and
care providers and patients better under-
So she decided to have genetic testing. “…I
under-insured men and women with breast
stand what treatments are most likely to
wanted to live! I was no longer willing to sit
cancer.
work or how likely a cancer is to spread or
back and wait for a diagnosis. I wanted to
return. Research continues at Duke Cancer
show my daughter that you can ‘take con-
Since then, it has far exceeded its goal to
Institute and other leading cancer research
trol’ of the situation.”
fund needed treatment for 10 breast cancer
centers with the hope of developing more sophisticated molecular diagnostic tools.
patients per year. As of press time, Pretty in After testing positive for the BRCA1 muta-
Pink has helped 1,518 eligible women and
tion, she selected Dr. Tolnitch to perform
men in 78 North Carolina counties, accord-
“I think the real key over the next decade
the prophylactic bilateral mastectomy.
ing to Executive Director Penny Lauricella,
or two will be designing both very individ-
“From the moment I walked into the (Tol-
M.H.A. Sights are now set on expanding
ual and cost-effective therapy for patients,”
nitch Surgical Associates) offices, I felt wel-
services nationally.
may 2013
7
ultrasound and ultrasound-directed core biopsy since the early 1990s. Stereotactic biopsy has been available in the office since 2004 and is accredited by the American College of Radiology. Sentinel node biopsy and sentinel lymph biopsy are performed in the operating room as outpatient surgery. Surgical Treatments Most patients can be treated with breast conservation therapy, so treatment of breast cancer has moved away from mastectomies and toward removing the tumor “Our friendly staff” is comprised of (from left) Vernita Harvey, Lena Tabb, Sue Seidel, Mary England, Rebecca Wolfgang and Nikki Fonville.
and a small area of surrounding breast tissue (lumpectomy). Breast conservation therapy is usually combined with radiation
Unlike most breast cancer non-profits, Pret-
ons,” the women and men receiving assis-
ty in Pink is a direct-service provider and
tance, and provide in-kind services.
focused on funding treatments, rather than
therapy of the breast. An effective treatment option for patients with early-stage breast cancer is the Mam-
to uninsured or underinsured breast can-
Services: Comprehensive Continuum of Care
cer patients (in North Carolina), chances
Tolnitch Surgical Associates’ reputation
volves implanting into a lumpectomy cavity
are you are doing so in partnership with
comes from specialized experience deliver-
a small balloon attached to a thin catheter.
Pretty in Pink,” Ms. Lauricella she says,
ing the most effective care across the con-
Inside the balloon is a tiny radioactive
adding that Pretty in Pink pays the Medi-
tinuum – from diagnosis and treatment, to
source that delivers radiation to the area
care allowable rate for services.
health management and prevention, to fi-
where cancer is most likely to recur.
research. “If you provide medical services
moSite Radiation Therapy System. It in-
nancial, even to psychological and spiritual. “The patient, who in many cases is already
Follow-Up Visits
seeing a physician, contacts us directly.
Services are patient focused and stream-
Patients often form a strong bond with
What they need are the funds to get in the
lined to be as timely and convenient as
their Tolnitch breast surgeon and choose
door to receive care,” says Ms. Lauricella.
possible for the patient. Often treatment
to continue seeing them for regular exams
after diagnosis can occur in a few weeks to
and mammograms. One of those patients
a few months.
is Susan Cashwell. “I regularly see Dr. Tol-
According to Ms. Lauricella, Pretty in Pink is working with a $1.5 million budget this
nitch. I just felt like I was in very capable
year, and the cost of treatment for one pa-
Mammography
hands (during breast cancer treatment),
tient can exceed $300,000. She says the 10
A Wake Radiology mammography and ul-
and that’s where I want to continue to get
to 15 applications that come in each day
trasound suite at Tolnitch Surgical Associ-
my care.” Ms. Cashwell, her sister and her
are forwarded to the organization’s medi-
ates is designed to provide the quickest di-
mother were treated for breast cancer by
cal review board. All the requests for help
agnostic turnaround available. Radiologists
Dr. Tolnitch, and all are cancer free.
keep the small, overachieving organization
specializing in breast care staff the suite
highly motivated.
two days a week, so an individual with an
For more information about Tolnitch Surgi-
abnormal mammogram can quickly re-
cal Associates, call (919) 782-8200 or visit
Ms. Lauricella and her staff share a long list
ceive further diagnostic tests, including ul-
www.carolinabreastcare.com. The practice
of responsibilities, including: negotiating
trasound and/or biopsy. Definitive results
is located at 2301 Rexwoods Dr., Suite 116
discounted rates with health care provid-
can be available within 48 hours.
in Raleigh 27607.
ministrators; raising funds through commu-
Biopsies
For more information about Pretty in Pink
nity events and grant writing on behalf of
The surgeons at Tolnitch Surgical Associ-
Foundation, call (919) 532-0532 or visit www.
individual patients; and working with large
ates have extensive experience with image-
prettyinpinkfoundation.org. Regional offices
and small companies that adopt “champi-
directed biopsy, having offered in-office
are located in Wilmington and Charlotte.
ers, even in rural areas, and insurance ad-
8
The Triangle Physician
Live Well North Durham
Medical Icon to Become Renewed Destination for Health Care By Heidi Ketler
A developer is breathing new life into the
Telephone in 1987, says Robert E. “Bob”
oncology, neurosurgery, neurology, gy-
Durham Clinic Building, an aging icon that
Price Jr., M.D., a retired neurosurgeon who
necology, general surgery, plastic surgery
has served the community for 25 years.
was one of the original physician owners.
and orthopedics. There was a master registration desk that serviced all the physicians and an optical shop onsite.
Dan Klausner, P.E., LEED A.P., of DKNC
“DKNC Ventures and Flagship Capital
Ventures is the visionary behind plans
Partners are making happen what we en-
for the renaissance of the respected mul-
visioned 26 years ago. We were trying to
“If a primary care physician had a patient
tispecialty group of physicians at 3901 N.
make that corner and that piece of prop-
that needed any kind of surgery, all they
Roxboro Street. The development encom-
erty a medical office complex, with a multi-
had to do was call Durham Clinic Build-
passes a full block bounded by Frasier and
disciplinary surgery clinic,” Dr. Price says.
ing,” says Dr. Price.
Newsom streets and Crabtree Avenue.
“We were ahead of the times.”
The project involves completely renovating
The Durham Clinic Building opened as
Many physicians with historical relevance
the original medical building, expanding
the community’s first multispecialty surgi-
in the Durham medical community prac-
onsite parking and enhancing the land-
cal group. In its glory days, it was one of
ticed in the Durham Clinic Building.
scaping. Concurrently, Klausner and his
the largest groups of its kind in Durham
investment partners, Flagship Capital Part-
County, according to Dr. Price, and the list
Dr. Price was the city’s first neurosurgeon.
ners, are focused on recruiting an internal
of physicians who practiced there reads
His partners were Bruce L. Kihlstrom,
medicine practice and a complementary
like a who’s who of pioneering surgeons
M.D., who now practices part-time at the
mix of high-level physicians.
in Durham.
Durham Veterans Administration Hospital;
Medical Icons Remembered
and Peter R. Bronec, M.D., who is on staff When construction is complete in the early
At its height, the Durham Clinic Building
at Durham Regional Hospital. Ng Weng,
third quarter, doors will open to the gate-
was home to nearly 20 physicians, repre-
M.D., Durham’s first neurologist, also is
way of a renewed health care destination,
senting ophthalmology, otolaryngology,
now retired.
Live Well North Durham. A Kerr Drug Store will anchor the new medical complex, adding convenience and value for patients. “The name ‘Live Well North Durham’ represents a paradigm shift in health care, one that focuses on the promotion of a healthy lifestyle and disease prevention,” says Klausner. He points to the 2017 opening of the Campbell University School of Osteopathic Medicine as a local response to this growing health care movement.
Living Up to a Progressive Purpose Klausner’s vision is as progressive as that of the Durham Clinic Building investors who purchased the property from General
10
The Triangle Physician
“What happened history-wise, multidisciplinary clinics didn’t do well, unless they were huge,” and subspecialty groups added to the competition. About five years ago, Hillandale Associates sold the Durham Clinic Building to Venture Equities, which then sold it to DKNC Ventures in 2012.
Entering a New Health and Wellness Era Live Well North Durham will serve new generations by offering a refreshing change – health care that is more convenient and personal. The high-quality medical complex will serve as a source of pride for its physicians and their patients. It is already established as a medical destination located on a main corridor, close to Durham Regional Hospital, the James E. Davis Ambulatory Surgery Center and Duke Medical Center, as well as I-85. A tasteful, yet distinctive contemporary façade will make Live Well North Durham easily recognizable. Ample onsite parking and a single-story medical building that doesn’t require elevators will add to ease The late ophthalmologist Arthur C. Chan-
cal center – which opened in 1985 about
dler Jr., M.D., was among the complement
a block away on East Carver Street – was
of prestigious Durham Clinic Building sur-
named for him.
of access. Inside Live Well North Durham, all 27,423 square feet will be fully renovated with new
geons. Dr. Chandler was second in command at the Duke Eye Center before join-
These and other Durham Clinic Building
ceiling tiles, lighting, paint, carpeting, fau-
ing the Durham Clinic Building group. He
physician owners invested in the long-
cets and fixtures, furnishings and artwork.
also was beloved as the “Voice of the Cam-
range plan for expansion of the entire
Amenities even include an onsite mobile
eron Indoor Stadium” at Duke University
block. It was a necessity in a highly com-
magnetic resonance pad and rooms with
for 40 years and the proud recipient of four
petitive health care market that favored
lead-lined walls for diagnostics.
NCAA Championship watches, presented
larger multispecialty groups or subspe-
by Coach Mike Krzyzewski.
cialty practices.
Leasing opportunities can accommodate users who require up to 11,000 square feet.
The late James E. Davis, M.D., general
As it turned out, the greatest hurdle was
Signage for the medical practices will take
surgeon and American Medical Associa-
the group of five homeowners on the block
advantage of traffic counts of 30,000 vehi-
tion past president (1982-1989), relocated
with the Durham Clinic Building. They
cles per day on Roxboro Road.
to Durham Clinic Building as a “profes-
were unwilling to sell, until much later. For details about joining the Live Well
sor emeritus” after his practice partner, surgeon Walter J. Loehr, M.D., retired. Dr.
“We couldn’t make it come together,” says
North Durham renaissance, contact Klaus-
Davis’ move to the Roxboro Street loca-
Dr. Price of the initiative he and his part-
ner at (919) 986-9944.
tion also was before the ambulatory surgi-
ners undertook as Hillandale Associates.
may 2013
11
Women’s Health
The Effectiveness of IUDs: and the new Skyla By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
to prevent pregnancy.
Women of all ages consider prevention
Implanon is the only implant available
of pregnancy. As health care providers,
in the U.S. An etonogestrel implant, the
we must provide women with accurate
single flexible rod is used for up to three
Skyla’s Advantages
information of what options are effective.
years.
The WHO rates Skyla as a top-tier
Of all pregnancies within the United States,
contraceptive option because there is less
approximately 50 percent are unintended.
Mirena is a hormone-releasing IUD placed
than one pregnancy per 100 women each
This underscores the importance that
within the uterus to prevent pregnancy
year.
providers
up to five years. It also is used to treat
understand
contraceptive
effectiveness.
heavy periods in women who choose
What sets Skyla apart from what is already
intrauterine contraception.
available? One difference is the length of
The World Health Organization (WHO)
time it is used. Skyla is used for three years
provides an informative chart (below) that
ParaGard is a non-hormonal, copper intra-
only. Skyla also is the smallest IUD on
highlights the efficacy of contraceptive
uterine contraceptive that can be used for
the market, which requires less cervical
options.
up to 10 years.
dilation and helps minimize discomfort
Other
than
permanent
sterilization, the intrauterine device (IUD)
during placement.
and the implant are the most effective
Skyla is approved by the U.S. Food
forms of contraception.
and Drug Administration as an IUD for
Many women are hesitant to consider the
the prevention of pregnancy for up to
IUD, because they perceive the placement
Top-Tier Contraception in the U.S.
three years. It is a hormone-releasing
to be painful. But this is not usually the
Three IUDs are available in the U.S.
system that is placed within the uterus
case at all. Most women have some discomfort with placement of any IUD, but this is usually only for three to five minutes. As I speak with women about Skyla, I explain that it is a small and flexible device (Tshaped) that contains a hormone. The hormone, a progestin called levonorgestrel, is slowly released into the uterus in small amounts and even smaller amounts enter the blood. Often the number of bleeding and spotting days can lessen per month with a significant proportion of women having no or very little bleeding at all. Also, within the clinical trials leading up to FDA approval
12
The Triangle Physician
of Skyla, 38.8 percent of women were
contraception.”
(Obstet
Gynecol
nulliparous, or had never had children.
2012;120:127-8) This is quite important for
This is important to consider and a fact
providers to understand.
that is reassuring to teenagers and their The failure rate in this study among
parents.
participants who used pills, patch or Realistically, however, many obstetricians
ring was 4.55 per 100 participant-years
and gynecologists (including myself)
compared to 0.22 for those who used
are comfortable using the Mirena in
DMPA
nulliparous
are
acetate, or Depo Provera) and 0.27 for
reluctant because Mirena labeling states it
those who used an IUD or implant. These
is to be used for contraception in women
findings were supportive by prior studies.
women.
Yet,
many
(depot
medroxyprogesterone
who have had one child. The ParaGard is approved for use in nulliparous women.
As providers care for teenagers and women
who
seek
contraception,
Clinical Studies Prove IUD’s Effectiveness
remember that the IUD and implant are
An important landmark study was
options for IUDs have expanded.
the most effective forms. Thankfully,
published by Brooke Winner, M.D., New
The Women’s Wellness Clinic welcomes
England Journal of Medicine in which
the opportunity to educate women and
“participants using oral contraceptive
providers about options for contraception.
pills, a transdermal patch or a vaginal
Call (919) 251-9223 for more information.
and
colleagues
within
the
ring had a risk of contraceptive failure that was 20 times as high as the risk
Disclosure: Dr. Lukes is a speaker for Bayer
among those using long-acting reversible
Pharmaceutcals.
After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position (2007) to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.
COME OUT your family.your future. You didn’t choose breast cancer. It chose you. Being diagnosed with breast cancer forces you to make a lot of choices. For many women that includes having to choose between getting proper medical treatment or putting food on the table. We are the Pretty In Pink Foundation and we’ve made it our mission to ensure that no woman has to choose between her family or her future. Visit us online at www.prettyinpinkfoundation.org or call (919)532-0532.
may 2013
13
Endocrinology
Diagnosis, Treatment and Management of Types of
Differentiated Thyroid Cancer By Michael J. Thomas, M.D., Ph.D.
thyroid nodule, using ultrasound guidance.
Approximately 56,640 Americans were
Follicular and papillary thyroid cancer can
diagnosed with thyroid cancer in 2012, with
be classified as “differentiated” and have a
three out of four of those cases occurring
more favorable prognosis than medullary
Papillary thyroid carcinoma may reveal
in women, and about 1,780 died as a result.
and undifferentiated types.
nuclear inclusions or grooves and nuclear overlap, in addition to “psamomma bodies”
Table 1 – Staging System for Differentiated Thyroid Cancer
(small calcifications within thyroid follicular cells). Follicular thyroid carcinoma cannot
T1
Tumor ≤2 cm
T2
Tumor >2, ≤4 cm
alone; cytopathology usually identifies
T3
Tumor >4 cm, or minimally invasive
a suspicious aspirate as a “follicular
T4
Tumor of any size, invading local tissues/structures
neoplasm,” based on cellularity, scant/
N0
No metastatic cervical lymph nodes
structures. About 25 percent of follicular
N1
Metastatic cervical lymph nodes (N1a medial/ N1b lateral to carotid)
neoplasms are either follicular carcinoma
NX
Not assessed at time of surgery
or papillary thyroid carcinoma follicular
M0
No distant metastases
M1
Distant metastases
MX
Distant metastases not assessed
be definitively diagnosed by FNA biopsy
absent colloid and absence of papillary
variant. The remainder of these lesions is usually benign follicular adenomas. For most thyroid cancers, total thyroidec-
Patient Age <45
Patient Age ≥45
Stage I
Any T, any N, M0
T1, N0, M0
Stage II
Any T, any N, M1
T2, N0, M0
Stage III
Stage IV
T3, N0, M0
tomy is recommended, sometimes with lymph node dissection. Thyroid cancer is staged either using the TNM (tumor, nodal metastasis and distant metastasis) or the American Joint Committee on Cancer stag-
T1-3, N1a, M0
ing system, summarized in Table 1. Staging
T1-3, N1b, M0
determines prognosis and post-operative
T4, N1a-b, M0
management and surveillance. Generally,
Any T, any N, M1
most patients with Stage I through Stage III do well, and even many Stage IV patients
Thyroid cancer is the most common
The most common presentation for patients
do reasonably well, although morbidity and
endocrine malignancy. The majority of
with thyroid cancer is the incidental
mortality increase with worsening stages.
thyroid cancers are either papillary or
discovery of a painless thyroid mass noted
follicular, with several various subtypes.
on self, or physical, exam or imaging study.
Post-operatively,
Medullary and anaplastic thyroid cancer
Diagnosis is usually made by performing a
of radioiodine (I-131) therapy should
account for less than 5 percent of cases.
fine-needle aspiration (FNA) biopsy of the
be assessed. I-131 can be used to ablate
14
The Triangle Physician
the
possible
benefits
normal thyroid remnant or treat residual or recurrent thyroid cancer. I-131 also can be used to identify the presence or location of local or distant metastasis on a nuclear medicine whole body scan. I-131 is administered when levels of thyroid stimulating hormone (TSH) are very high, which can be accomplished using recombinant
TSH
(Thyrogen),
which
obviates the need for thyroid hormone withdrawal and hypothyroidism. Patients may enhance the effectiveness of I-131 therapy by following a low-iodine diet for 10-
Dr. Michael Thomas of Carolina Endocrine P.A. graduated from the School of Medicine at West Virginia University in Morgantown, with a Doctor of Medicine and Doctor of Philosophy in pharmacology and toxicology. He completed his post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency, and fellowship in endocrinology. He was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. Dr. Thomas established Carolina Endocrine in the summer of 2005. He is board certified in internal medicine and endocrinology, and is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology (FACE) and has completed endocrine certification in neck ultrasound (ECNU). For more information and patient referrals and appointments call (919) 571-3661 or visit the practice website at carolinaendocrine.com
14 days prior to I-131 therapy. Side effects of I-131 therapy include nausea (though emesis is uncommon) and sialoadenitis (salivary gland pain and swelling), dry mouth and dysguesia (abnormal taste sensation). There is a slight increase risk of secondary cancers with repeated high doses of I-131 therapy, including cancers of the salivary gland, stomach, bladder and bone marrow (leukemias). Women must not receive I-131 if pregnant or lactating and should delay family planning for at least six months. Men are counseled to delay fathering children for at least three months. Long term, most patients are placed on thyroid hormone suppressive therapy (levothyroxine)
to
keep
their
TSH
suppressed. Serial neck ultrasounds can be periodically performed to identify recurrent disease in cervical lymph nodes. Thyroglobulin, a protein that is exclusively produced by thyroid tissue, is a useful tumor marker post-operatively. An elevated or rising serum thyroglobulin may indicate recurrent disease. Unfortunately, up to 20 percent of thyroid cancer patients have antibodies to thyroglobulin in their serum, which renders the measurement of thyroglobulin uninterpretable. Thyrogen, is a useful diagnostic and therapeutic agent that facilitates radioiodine uptake and may also be used to stimulate serum thyroglobulin levels. Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
may 2013
15
Practice Marketing
The Power of
Internal Marketing
3 Ways to Grow Your Practice from Within By Amanda Kanaan
Although the word “marketing” may evoke visions of print ads and television spots, when it comes to growing your practice don’t forget your most powerful resource of all – current patients (i.e. walking and talking billboards). The goal of external marketing (such as advertising) is to get patients to your door, however it is internal marketing that not only pulls them through the door but keeps them knocking time and again. Internal marketing is a strategy that focuses on maximizing patient retention through consistent communication and, of course, good patient care. Since acquiring new patients is much more costly than retaining current ones, it’s important to treat your patients as valuable customers. Here are three ways to grow your practice from within. 1. Stay Top of Mind. You’ve probably heard the saying “out of sight, out of mind.” Staying top of mind with patients is the best way to keep them (a) thinking about you so there’s a greater chance they’ll come in for more than the once-a-year visit and/or (b) talking about you so they’re more likely to make a referral. For good or for bad, we’ve entered an age in medicine where patients will Google just about anything. In fact, 59 percent of adults in the United States searched online for health information in the past year, according to a 2012 study by Pew Research Center. Because patients
16
The Triangle Physician
are so digitally savvy (also known as epatients), this presents a unique opportunity for doctors to now communicate with patients in a way that’s convenient, cost-effective and timely. Social media is one example of how practices can take advantage of this epatient revolution. Use social media to stay top of mind with patients by posting links to educational articles, helpful health tips and practice news. E-newsletters can be used in the same way. The point is to find ways to keep your patients connected beyond the waiting room. 2. Give Patients a Reason to Come Back. Communication tools like social media and e-newsletters are also a great way to spread the word about new or existing services within your practice. When it comes to marketing, if you’re not saying it, then you’re not doing it. That means, if you aren’t telling patients about your other services then they probably don’t know they even exist. Sometimes patients need a service but don’t realize your practice performs it (such as mole removals at a family practice), and sometimes you offer a service that patients don’t know they need (such as NovaSure at an OB/GYN practice). This is when you have to put on your marketing hat and take the opportunity to upsell patients on other services you offer.
Amanda Kanaan is the president of WhiteCoat Designs – a Raleigh-based medical marketing agency providing doctors with online marketing services as medical website design, search engine optimization (SEO), social media management, blog writing, graphic design, referring physician outreach and more. To contact Ms. Kanaan or to learn more about WhiteCoat Designs, visit www. whitecoat-designs.com.
You already have a captive audience in your current patients so take the opportunity to better communicate your services. Patients need to hear a message several times before they commit it to memory so don’t make the mistake of sharing your message only once. 3. Make it a Positive Experience for Patients. OK, so you probably knew this one was coming… the patient experience. It’s obviously a waste of money to implement an internal marketing plan, if you have no hope of retaining patients because their experience at your office was negative. From the way your staff answers the phone to the color of your walls, it’s all part of the patient experience. Your staff needs to understand that they are not just part of the administrative or clinical departments, but they are also an essential part of marketing. I’ve seen far too many great doctors lose patients
due to poor staffing choices. Your patients can be one of the best sources of ideas to make your practice better. Whether the ideas come from patient surveys, your social media page or even online review sites, take the feedback to heart and be open to change. Customer service is the new public relations. That means that by responding to complaints online with practical solutions, patients will be far more impressed that you took action than the fact that the complaint happened in the first place.
Partnering with patients and providers for a healthier community.
Meet Cheryl and Cherye
Lost: 80 lbs Found: Life is Good!
A good marketing strategy starts from the inside out. By incorporating the three approaches above, you’ll create an effective internal marketing strategy that will enhance the ROI (return on investment) on your external marketing campaigns, thereby making the most impact on the growth of your practice.
Joseph C. Moran, MD, FASMBS 2801 Blue Ridge Road, Suite 101 Raleigh, NC 27607
P: 919.781.0815 F: 919.781.0816
www.alasurgery.com
Expert, cost effective and timely care is what Carolina Endocrine has to offer your patients. • Neck Ultrasounds (ECNU certified) • Fine needle aspiration biopsies • Nuclear medicine studies • Pediatric Endocrinology
All in one convenient location at 3840 Ed Drive, behind Rex Hospital.
919-571-3661
www.CarolinaEndocrine.com Dr. Michael Thomas, Ph.D. Dr. Julia Warren-Ulanch Dr. Khushbu Chandarana Courtney Kovalick, PA-C Eileen Andres, PA-C
may 2013
17
News
Raleigh Orthopaedic Surgery Center Opens with New Outpatient Option The new Raleigh Orthopaedic Surgery Cen-
Hadley Callaway, M.D., president of Raleigh
known for their excellent care and experi-
ter is a one-stop outpatient facility offering a
Orthopaedic Clinic. “It will be a destination
ence working together on what we anticipate
wide range of orthopedic care and services
for comprehensive orthopedic care.”
will be a new model for outpatient surgery centers,” said Steve Burriss, Rex’s chief oper-
involving knees, feet, shoulders, hips, wrists Raleigh Orthopaedic Surgery Center is locat-
and more.
ating officer.
ed at 3001 Edwards Mill Road, between DuThe 27,707-square-foot surgery center – a
raleigh Road and Wade Avenue, near Rex’s
Raleigh Orthopaedic Clinic is Wake County’s
joint venture between the private physicians’
main Raleigh campus. It is located on the first
largest and oldest orthopedic practice. Its or-
group Raleigh Orthopaedic Clinic and Rex
floor of a four-story, 98,000-square-foot build-
thopedic surgeons are fellowship trained in
Healthcare – was created to provide a wide
ing that will serve as the new home for Ra-
their respective subspecialty areas, which in-
range of orthopedic services, including sur-
leigh Orthopaedic Clinic’s main offices later
clude: foot and ankle, hand and wrist, spine,
gery, digital X-ray, magnetic resonance imag-
this summer.
hip, shoulder and elbow surgery, total joint replacement, sports medicine and pediatric
ing, physical therapy and urgent care in an outpatient setting. It houses four operating
According to a press advisory, the surgery
rooms and two procedure rooms.
center will initially create about 30 full-time jobs. “We are excited to have two organizations
Barker Selected as a Master Instructor of Hip Arthroscopy
Joseph U. Barker, M.D.
For the third consecu-
A fellowship-trained orthopedic surgeon in
tive year, Joseph U.
sports medicine, Dr. Barker’s areas of exper-
Barker, M.D., of Raleigh
tise include shoulder, hip and knee arthrosco-
Orthopaedic
Clinic
py and cartilage restoration. He has a clinical
was selected by the Ar-
interest in the treatment of young adults with
throscopy Association
hip pain.
of North America to be an associate master in-
structor of arthroscopy.
The American Orthopaedic Society for Sports Medicine (AOSSM) recently recognized Dr. Barker for his basic science research on hip
Dr. Barker was selected to instruct the recent
arthroscopy. The paper he co-authored was
hip arthroscopy course in Chicago, Ill., in Feb-
named AOSSM’s 2011 winner of the Aircast
ruary. The Arthroscopy Association of North
Award for Basic Science.
America course involved teaching orthopedic surgeons from around the world the fun-
For details, visit www.josephbarkermd.com or
damentals of hip arthroscopy. It emphasized
call (919) 863-6808 for appointments.
techniques on how to perform hip arthroscopy, labral repairs, impingement surgery and gluteus medius repairs.
18
The Triangle Physician
Complete practice information is available at www.raleighortho.com.
“There really isn’t anything else like this in Raleigh or even across North Carolina,” said
orthopedic care.
The Triangle Physician 2013 Editorial Calendar June Men’s Health Vascular Diseases Medical Collections July Imaging Technologies Psoriasis Medical Insurance August Orthopedics Gastroenterology Medical Real Estate September Atrial Fibrillation Urology Web Design October Cancer in Women COPD - Lung Health Medical Software - EMR November Alzheimer’s Disease Diabetes Financial Planning December Pain Management Spine Disorders Practice Management
News
Hospitals Test Ultraviolet Technology to Reduce Infections Hospitals within the Duke Infection Con-
According to the advisory, Tru-D automat-
questionable outcomes of lesser advanced
trol Outreach Network are participating in
ed dose-delivery system accurately and
and disruptive strobe light offerings.”
an infection-reduction study funded by the
silently measures and delivers the lethal
Centers of Disease Control and Prevention.
UV dose required to break apart the DNA
The SmartUVC technology is reportedly the
of bacteria, virus and spores and render
only ultraviolet disinfection device support-
The two-year study is measuring the effec-
the bacteria harmless. Its UV technology is
ed by multiple, independent peer-reviewed
tiveness of using advanced, no-touch envi-
able to disinfect line-of-sight and shadowed
studies. “Tru-D’s advanced, environmentally
ronmental ultraviolet disinfection technol-
surfaces from a single placement within a
friendly germicidal disinfection system has
ogy to reduce infections.
room, “overcoming human error, such as
moved disinfection of rooms and equipment
missed and difficult-to-reach surfaces, im-
to a much higher level than can be achieved
The nine participating hospitals are: Ala-
proper chemical applications and unreli-
through manual, chemical cleaning alone,”
mance Regional Medical Center, Duke
able ‘blind-dose guessing’ associated with
said Tru-D spokesman Chuck Dunn.
University Hospital, North Carolina Memorial Hospital at UNC, Rex Healthcare, High Point Regional Hospital, Durham Regional Hospital, Duke Raleigh Hospital, Durham Veterans Administration Medical Center and Chesapeake Regional Medical Center in southeastern Virginia. The CDC study is focusing on four specific pathogens that persist in the hospital environment: MRSA, VRE, C. difficile and acinetobacter. Patients that present symptoms for these pathogens are traditionally placed on contact precautions, and special chemical cleaning procedures are used to disinfect the environmental surfaces after the patient is discharged. According to a press advisory, the product Tru-D SmartUVC was selected for the study because clinical research has shown more than a 99.9 percent reduction of C. difficile spores using Tru-D’s Sensor360 technology. Elimination of surface contamination within patient rooms is a critical and essential practice in the reduction of hospital-acquired infections (HAIs). It also is an important target for hospitals, as associated costs are often non-reimbursed. Yet, facilities are faced with the challenge of eliminating infection-causing germs that are increasingly resistant to chemical cleaners and antibiotic therapies.
may 2013
19
News
Dermatologist Joins Raleigh Practice Lynn Cheng, M.D.
Lynn Cheng, M.D., a boardcertified dermatologist and fellow of the American Academy of Dermatology, recently joined The Dermatology Center of Raleigh.
Dr. Cheng earned her medical degree from Duke University School of Medicine in Durham and completed an internship in pediatrics at the University of North Carolina at Chapel Hill and a residency in dermatology at the Medical College of Wisconsin in Mil-
waukee. She earned a bachelor of science degree with honors from the Pratt School of Engineering at Duke University. Prior to joining The Dermatology Center of Raleigh, Dr. Cheng was in private practice for several years in Wisconsin. She has a special interest in pediatric dermatology, expertise in medical and surgical dermatology and is fluent in Mandarin Chinese. “I am very pleased to be welcoming an experienced colleague who truly shares my
practice philosophy of providing a highlevel of personalized patient care in our unique integrated health and fitness setting,” said Carol A. Trakimas, D.O., practice founder, president and medical director. The Dermatology Center of Raleigh is located at the American Institute of Healthcare & Fitness in North Raleigh. For more information, visit www.tdcor.com or call (919) 573-9030.
Rex Express Collects 110,000-Plus Dosages in Operation Medicine Drop Rex Express Care helped collect more than 110,000 dosages of expired and unwanted medications on Saturday, March 23, helping to reduce the risk of accidental poisoning and other problems. In conjunction with Safe Kids North Carolina and local police departments, Rex Healthcare hosted operation Medicine Drop at Rex Express Care locations in Cary, Holly Springs, Knightdale and Wakefield. There, co-workers and local law enforcement received and properly discarded the over-thecounter and prescription medications.
The event at Rex Healthcare of Holly Springs also featured a demonstration by the Holly Springs Police Department K-9 unit and a car seat installation station.
North Carolina has some of the highest numbers of deaths from unintentional poisoning, and the majority of these are due to over-the-counter or prescription medica-
“We participate in Operation Medicine Drop because ensuring that expired and unwanted medications are disposed of properly helps to keep kids safe and protects our environment,” said Beth Mills, a pharmacist with Rex Healthcare. “The turnout across all locations was exceptional, and we were excited to surpass our dosage collection total from last year’s event.”
Scott Christofferson, Pharm.D., emergency medicine pharmacy team leader; and Courtney Bradley, Pharm.D. candidate, both with the UNC Eschelman School of Pharmacy, complete a rotation at Rex Express Care of Cary’s event.
Cary Endocrine & Diabetes Center, P.A.
CEDC provides diagnosis and treatment for patients with hormonal and metabolic disorders including: diabetes, lipid disorders, PCOS, thyroid disorders, osteoporosis and other bone disorders, pituitary disorders, adrenal disorders, and sex hormone disorders.
Celebrating our first year in Cary!
Sung-Eun Yoo, MD
Endocrinologist Diplomat, American Board of Endocrinology, Diabetes and Metabolism Diplomat, American Board of Internal Medicine Endocrine Certification in Neck Ultrasound (ECNU) Certification in the International Society for Clinical Densitometry (ISCD)
On-Site Services: • Thyroid, parathyroid and neck ultrasound • Ultrasound guided FNA • DEXA bone density scans and interpretation • Osteoporosis therapy • Comprehensive diabetes management including diabetes education, insulin pump therapy, and continuous glucose monitoring • LabCorp in-house Introducing Jeanne Hutson, NP-C Board Certified in Advanced Diabetes Management
Cary Endocrine & Diabetes Center, P.A. • 103 Parkway Office Court, Suite 202 • Cary, NC 27518 • 919-378-2332 • www.caryendocrine.com
20
The Triangle Physician
UNC Research News tions. Reported data shows that from 1999 to 2010 the number of deaths from unintentional poisonings increased more than 300 percent in North Carolina. Since 2010, Operation Medicine Drop has collected more than 30 million dosages of medication at
1,000 events across the state. Safe Kids North Carolina is one of more than 450 coalitions affiliated with Safe Kids Worldwide, an organization whose mission is to prevent accidental childhood injury,
the leading killer of children age 14 and younger. There are 38 Safe Kids coalitions covering 66 counties in North Carolina. For more information, visit rexhealth.com or ncsafekids.org.
Understanding May Lead to New Treatment of All MRSA Strains In the last decade, a new strain of MRSA has emerged that can spread beyond hospital walls, putting everyone at risk of contracting the dangerous bacterial infection. This particular strain of MRSA – known as USA300 – contains a chunk of genes not shared by any other strains, though it is unclear how this unique genetic material enables the bacteria to survive and persist in the community. Now, research from the University of North Carolina School of Medicine has pinpointed a gene that causes the infection to linger on the skin longer than other strains, allowing it to be passed more readily from one person to the next. The gene makes this strain of MRSA resistant to specific compounds on the skin called polyamines that are toxic to other forms of the bacteria. In uncovering this property, researchers have identified a novel target for developing new treatments against methicillin-resistant Staphylococcus aureus, particularly the USA300 strain that accounts for the vast majority of MRSA skin and soft-tissue infections seen in emergency rooms. “The problem is by the time you figure out how one strain comes into dominance, it often fades away and a new strain comes in. But because these compounds occur naturally and are so toxic, we still think they can lead to treatments that are effective against all MRSA. We will just have to put in a little extra work to block the gene and make this particular strain of MRSA susceptible to polyamines,” said senior study author An-
thony Richardson, Ph.D., assistant professor of microbiology and immunology at the UNC School of Medicine. The UNC study, published Jan. 16 in the journal Cell Host & Microbe, follows an attribute of MRSA previously unexplored by other scientists – its sensitivity to the naturally occurring compounds called polyamines. Polyamines are critical to wound repair, because they are anti-inflammatory and promote tissue regeneration. Scientists first observed that MRSA infections were killed by polyamines in the 1950s, but no one followed up until recently, when Dr. Richardson decided to twist this scientific observation into a treatment option.
Cell nuclei are stained magenta and polyamine producing macrophages are blue. The host is attempting to wall off the infection by laying down a surrounding layer of collagen (gold) and other matrix proteins. Source: Richardson lab, UNC.
He and his colleagues tested hundreds of MRSA strains and found that all of them except one – USA300 – were sensitive to polyamines. When they looked to see what was different about this particular strain, they found that it contained a chunk of 34 genes, called the arginine catabolic mobile element (ACME), that none of the other
strains possessed. Then the researchers mutated each of these genes, one by one, until they created a strain that could be killed off by the polyamines. To confirm that they had the right gene, the researchers added a normal, nonmutated version of the gene – named SpeG – to other strains of MRSA and showed that it could make them resistant to these compounds. Finally, Dr. Richardson wanted to know if the gene exerts the same effects in the context of a real infection. Using mouse models of MRSA infection, he and his colleagues showed that the presence of the SpeG gene helped the potent USA300 strain to stay on the skin for anywhere from a day to a week, giving the infection time to spread to the next host. “Previously, the field tried to understand MRSA by focusing on attributes that we already knew were important, such as the amount of toxins or virulence factors a given strain makes. Those elements may explain why the disease is so bad when you get it, but they don’t explain how a particular strain takes over. Our work uncovers the molecular explanation for one strain’s rapid and efficient spread to people outside of a crowded hospital setting,” said Dr. Richardson. The research was funded by the National Institute of Allergy and Infectious Diseases. Study co-authors from UNC include Lance R. Thurlow, Ph.D.; Gauri S. Joshi, Ph.D.; Justin R. Clark; Jeffrey S. Spontak; Crystal J. Neeley; and Robert Maile, Ph.D. may 2013
21
UNC Research News
New Look at Old Study Casts Doubt on Benefits of Vegetable Fats A new analysis of data missing from a study
59 years who had recently had a coronary
all the evidence). This also showed no evi-
that ended more than 40 years ago casts
event, such as a heart attack or an episode
dence of benefit and suggested a possible
doubt on current dietary advice about veg-
of angina. Participants were randomly di-
increased risk of cardiovascular disease,
etable fats and heart health.
vided into two groups.
emphasizing the need to rethink mecha-
The clinical trial published in the British
The intervention group was instructed to re-
Journal of Medicine shows that replacing
duce saturated fats (from animal fats, com-
The researchers conclude that recovery
saturated animal fats with omega-6 polyun-
mon margarines and shortenings) to less
of these missing data “has filled a critical
saturated vegetable fats (PUFAs) is linked
than 10 percent of energy intake and to in-
gap in the published literature archive” and
to an increased risk of death among pa-
crease linoleic acid (from safflower oil and
that these findings “could have important
tients with heart disease.
safflower oil polyunsaturated margarine) to
implications for worldwide dietary advice
15 percent of energy intake.
to substitute omega-6 linoleic acid (or poly-
nisms linking diet to heart disease.
Nutrition epidemiologist and study co-au-
unsaturated fatty acids in general) for satu-
thor, Daisy Zamora, Ph.D., is postdoctoral
rated fatty acids.”
researcher in the Program on Integrative Medicine in the Department of Physical
Co-authors of the study along with Dr. Zamo-
Medicine & Rehabilitation at the Univer-
ra are Christopher E. Ramsden, U.S. Nation-
sity of North Carolina School of Medicine.
al Institutes of Health (NIH); Katourah R.
“These findings highlight the need to re-
Faurot, UNC; Boonseng Leelarthaepin, Uni-
evaluate worldwide dietary advice to sub-
versity of New South Wales, Australia; Sha-
stitute omega-6 PUFAs for saturated fats,”
ron F Majchrzak-Hong, NIH; Chirayath M.
she said.
Suchindran, UNC Gillings School of Global Public Health; Amit Ringel, NIH; John M.
The most common dietary PUFA in western diets is omega-6 linoleic acid; concentrated
Oil extracted from safflower seeds are used mainly in margarine and cooking oil. Image source: USDA.
Davis, University of Illinois at Chicago; and Joseph R. Hibbeln, NIH. Ramsden, Zamora, and Faurot also are affiliated with the Pro-
sources of these fats are safflower oil, corn oil, soybean oil, sunflower oil and cotton-
Safflower oil, a concentrated source of
gram on Integrative Medicine, Department
seed oil.
omega-6 linoleic acid, provides no omega-3
of Physical Medicine and Rehabilitation, at
PUFAs, typically associated with fish oils.
UNC School of Medicine.
oleic acid on deaths from coronary heart
The control group received no specific di-
Funding for the study came from the Na-
disease and cardiovascular disease has
etary advice.
tional Institute on Alcohol Abuse and Alco-
An in-depth analysis of the effects of lin-
holism (NIAAA), a component of the U.S.
not previously been possible because data from the Sydney Diet Heart Study – a ran-
Both groups had regular assessments and
National Institutes of Health; and The Life
domized controlled trial conducted from
completed food diaries for an average of 39
Insurance Medical Research Fund of Aus-
1966 to 1973 – was missing.
months. All non-dietary aspects of the study
tralia and New Zealand.
were designed to be equal in both groups. But now, a team of researchers from the
**FREE CME Event**
United States and Australia have recovered
The results show that the omega-6 linoleic
and analyzed the original data from this
acid group had a higher risk of death from
trial, using modern statistical methods to
all causes, as well as from cardiovascular
compare death rates from all causes, in-
disease and coronary heart disease, com-
Selection and Management of Weight Loss Surgery Patients A Comprehensive Guide for Primary Care Physicians June 15, 2013
cluding cardiovascular and coronary heart
pared with the control group.
Marriott Raleigh City Center
disease. The authors then used the new data to upTheir analysis involved 458 men aged 30-
22
The Triangle Physician
date an earlier meta-analysis (a review of
The Duke School of Medicine designates this live activity for a maximum of 7.5 AMA PRA Category 1 Credit(s) TM. Contact: philip.clark@duke.edu
Duke Research News
Discovery of More Genetic Variations for Ovarian Cancer Raises Hope An international research collaboration has found five new regions of the human genome that are linked to increased risks for developing ovarian cancer. Duke Medicine researchers played a leading role in analyzing genetic information from more than 40,000 women. The findings are published in four studies, two appearing in the journal Nature Communications and two in Nature Genetics on March 27. The research is being published as part of a coordinated release of new data from the Collaborative Oncological Geneenvironment Study (COGS), an international effort to identify genetic variations that make certain people susceptible to developing breast, prostate and ovarian cancers. According to the National Cancer Institute, ovarian cancer accounts for 3 percent of all cancers in women and is the leading cause of death among cancers of the female reproductive system. This is due to the lack of early symptoms or effective screening tests. Inherited mutations in the BRCA1 and BRCA2 genes dramatically increase ovarian cancer risk. Genetic testing for BRCA1 and BRCA2 mutations can identify women who would benefit most from surgery to prevent ovarian cancer, but this is relevant to less than 1 percent of the population. Other genetic variants that are more common may also affect ovarian risk. The
Ovarian Cancer Association Consortium previously described six such genetic differences and now the COGS project has found five more. “Because ovarian cancer is relatively uncommon, it is critically important to identify subsets of women at increased risk,” said senior coauthor Andrew Berchuck, M.D., director of the division of gynecologic oncology at Duke Cancer Institute. “Although the common genetic risk variants for ovarian cancer discovered thus far are not strong enough to use in practice, this may become a reality as additional variants are discovered. This could facilitate development of ovarian cancer screening and prevention strategies directed towards women most likely to benefit.” “Our hope is that these genetic variants, along with established epidemiologic factors, such as reproductive history, will not only enhance our ability to predict which women are at increased risk for developing this highly fatal disease, but will also provide new insight into the underlying biology and pathogenesis of ovarian cancer,” said epidemiologist Joellen Schildkraut, Ph.D., director of the Cancer Control and Population Sciences program at Duke Cancer Institute. Dr. Schildkraut is a senior coauthor of one of the Nature studies and the principal investigator of the North Carolina Ovarian Cancer Study, one of the studies that contributed data to this discovery.
“Because of the large number of study subjects, we were able to determine that some genetic variants were important to specific subgroups of ovarian cancer, suggesting possible differences in the underlying cause of these subtypes,” Dr. Schildkraut said. Additional studies on the biology of these genetic variants could help researchers develop new tests to predict which women are at risk of developing ovarian cancer and potentially lead to therapies that better treat the disease. In addition to Dr. Berchuck and Dr. Schildkraut, Duke study authors include Rachel Palmieri Weber of the Department of Community and Family Medicine; and Edwin Iversen of the Department of Statistical Science and Cancer Prevention, Detection and Control Research Program. The studies were funded by the COGS project Ovarian Cancer Association Consortium, which is supported by the European Commission’s Seventh Framework Programme, the Ovarian Cancer Research Fund, the Wellcome Trust and the National Cancer Institute (R01-CA-114343, R01CA114343-S1 and U19-CA148112). A full list of researchers and their affiliations, as well as complete details of the funding of individual investigators and studies are provided in the manuscripts.
People with Depression May Not Reap Full Benefits of Healthy Behaviors Depression may inhibit the anti-inflammatory
cardio-metabolic risk marker C-reactive protein
“Our findings suggest depression not only di-
effects typically associated with physical activ-
(CRP) – points to another potential danger of
rectly affects an individual’s mental and physi-
ity and light-to-moderate alcohol consumption,
depression, which afflicts an estimated one
cal health; it might also diminish the health
according to researchers at Duke Medicine.
in 10 adults in the United States. Study results
benefits of physical activities and moderate
were published online March 26 in the journal
alcohol consumption,” said lead author Ed-
Brain, Behavior, and Immunity.
ward C. Suarez, Ph.D., associate professor of
The finding – based on measurements of the
may 2013
23
News psychiatry and behavioral sciences at Duke
through blood samples and evaluated the
dations to increase physical activity and ad-
Medicine. “This appears to be specific to in-
participants’ depressive symptoms, with 4.5
here to a Mediterranean diet that includes al-
flammation, which we know increases the risk
percent of the study group meeting the criteria
cohol consumption, clinicians may also need
for heart disease, so our findings suggest that
for depression.
to consider the mental state of their patients and specifically the presence of depressive
depression could be a complicating risk factor.” The researchers found that untreated depres-
symptoms.
CRP is a biomarker that predicts future risk of
sion hindered the anti-inflammatory effects of
heart disease and other chronic inflammatory
moderate alcohol consumption and exercise.
This combined approach could be especially
conditions. It may also play a role in the forma-
Participants who were physically active gener-
beneficial for primary care providers, who are
tion of plaque that builds up in arteries.
ally had lower CRP levels, with the exception
in a good position to both screen for depres-
of those who were depressed, who saw no
sive symptoms and measure CRP and cardio-
beneficial effect on CRP levels.
vascular risk. Early intervention – and perhaps
Physical activity and moderate alcohol con-
more aggressive treatment for depression –
sumption, defined as one drink a day for women and two a day for men, have each been
In addition, light-to-moderate alcohol con-
may benefit patients who do not see the ben-
shown to lower the risk of cardiovascular dis-
sumption was associated with lower CRP, but
efit of heart-healthy activities due to untreated
ease and type 2 diabetes. These behaviors also
only in men who were not depressed. Men
depression.
reduce inflammation, which is demonstrated
with symptoms of depression did not see the
through lower levels of CRP.
benefits of light-to-moderate alcohol consump-
“We’re not saying that exercise isn’t helpful
tion. Depression did not make a statistically
for those with depression; what we saw is that
In contrast, depression is associated with el-
significant difference among women who con-
depression has effects beyond what has previ-
evated CRP and increased risk of heart disease
sumed light to moderate amounts of alcohol,
ously been reported. Even if mental health im-
and type 2 diabetes.
nor those who didn’t drink or only drank in-
proves, the anti-inflammatory benefits of physi-
frequently.
cal activities may lag behind,” Dr. Suarez said. Future longitudinal studies could measure
In the current study, researchers gathered information from 222 nonsmoking, healthy
“This is a novel finding, and it seems to be
CRP levels among those with depression to
adults with no history or diagnosis of psychi-
specific to inflammation as measured by CRP,”
see if the anti-inflammatory effects of healthy
atric conditions. They recorded the amount
Dr. Suarez said, given that depression did not
behaviors catch up over time.
of alcohol the participants consumed, defin-
affect other health markers, such as fasting tri-
ing light-to-moderate drinking as about half a
glyceride and cholesterol levels.
In addition to Dr. Suarez, study authors include Nicole L. Schramm-Sapyta, Tracey V. Hawkins
drink per day for women and one daily drink
and Alaattin Erkanli.
for men. Participants reported their number of
Although preliminary, Dr. Suarez said the study
hours of physical activity (i.e., walking, play-
could guide health care providers on how best
ing tennis, and exercise classes) in the past
to reduce the risk of heart disease and type 2
The National Heart, Lung and Blood Institute
week. Researchers also measured CRP levels
diabetes. In addition to traditional recommen-
provided funding for the study (HL67459).
Welcome to the Area
Physicians
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Cary
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Raleigh
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Chapel Hill
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The Triangle Physician
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UNC Hematology/Oncology Fellowship Chapel Hill
Vascular Access Center of Durham Durham
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Pediatrics
Allergy and Immunology; Hospitalist; Internal Medicine
WakeMed Faculty Pediatrics Raleigh
University of North Carolina Hospitals Chapel Hill
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