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M ay / j u n e 2 0 14

Granville Urology Associates Focusing on the Treatment of Female Incontinence

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 Endometriosis Melanoma

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COVER STORY

Granville Urology Associates Focusing on the Treatment of Female Incontinence

m ay / j u n e 2 0 14

FEATURES

Dermatology

New Advances in the Treating Endometriosis

Vol. 5, Issue 3

DEPARTMENTS 9 Gastroenterology

19 UNC Research News

10 Tips for Improved Patient Communication

New Pathogen-Identification Method Is Cheaper Than Conventional Tests

10 Practice Management Managing a Balanced Practice in Changing Times

13 Community Support

21 ECU Research News Fibrillation After Surgery May Be Predicted and Prevented

Triangle Goes Red for Women Luncheon

22 ECU News

risks, diagnosis and treatments

15 Practice Marketing

Brody Ranks Fifth on List of Top Family Physicians Producers

and upcoming clinical trials.

Blogging: Affordable, Effective Way to Boost Google Rankings

22 Duke News

16 Duke Research News

Duke Regional Hospital Names Katie Galbraith as President

Complications from Kidney Stone Treatments Are Common and Costly

23 WakeMed NEWS

Women’s Health

16 Duke Research News

Cary Women’s Pavilion & Birthplace Appoints Angela Newman as Director

Melanoma: Early Detection Is Key

Bullying May Have Long-Term Health Consequences

23 News

Lindsay Wojciechowski reviews

Dr. Gregory Wilmoth discusses the progression and asymptomatic nature of this deadly cancer.

18 UNC Research News

Welcome to the Area

Genetic Trigger for RSV-Induced Infant Hospitalizations Found

COVER PHOTO: Urologist Joseph C. Zola Jr., M.D., of Granville Urology Associates, specializes in treating women’s urologic issues.

The Triangle Physician

Ann Lee was feeling overwhelmed. Following a cervical polyp removal and biopsy, her Ob/Gyn had recommended a full radical hysterectomy. He also advised having a breast lesion removed. On top of that, she was told she needed an umbilical hernia repaired. Ann was concerned about multiple procedures and hospital stays, as well as all the recovery time that would interfere with her daily routine of caring for her two-year-old granddaughter, Payton. Then her Ob/Gyn told Ann about his experience with Johnston Health’s daVinci robotic surgery suite and how her hysterectomy could be done as an outpatient procedure with only a few small incisions.

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919-934-8171

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From the Editor

Ending Needless Suffering In this issue of The Triangle Physician, the cover story features urologist Joseph Zola, who discusses urinary incontinence, a common medical problem, especially in women. Despite the great discomfort and emotional distress – diminished selfT 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

esteem and sexuality – many who suffer from urinary incontinence put off treatment, often embarrassed and rationalize that it is something they just need to live with.

A specialist in the treatment of female incontinence, Dr. Zola is familiar and empathizes with the emotional barriers, and he shares his patient’s joy once their problem is corrected following proper treatment. In this article, he describes diagnosis and the range of options that can reverse unnecessary – and often silent – suffering.

Also in this issue, we welcome some first-time contributors. Nurse practitioner Lindsay Wojciechowski discusses endometriosis and its manifestations that can cause delayed

Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Douglas A. Drossman, M.D. Amanda Kanaan Margie Satinsky Gregory J. Wilmoth, M.D. Lindsay A. Wojciechowski Creative Director Joseph Dally jdally@newdallydesign.com

diagnosis. Dermatologist Gregory Wilmoth brings us up to date on melanoma. Practice management consultant Margie Satinsky gives a preview of her upcoming columns that will offer guidance on managing health care delivery in changing times.

Many thanks to our returning contributors. Gastroenterologist Douglas Drossman offers important tips for improving patient communication in the first of a two-part column. Marketing and social media consultant Amanda Kanaan explains the value of blogs to

Advertising Sales info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com

The Triangle Physician is published by: New Dally Design

physician practices and how to keep meaningful information flowing.

Subscription Rates: $48.00 per year $6.95 per issue

Contributors to The Triangle Physician make the most of an effective way to elevate

Advertising rates on request Bulk rate postage paid Greensboro, NC 27401

awareness of their expertise among referring physicians. You are welcome to take advantage of the opportunity to share your medical news and perspective, as well. It doesn’t cost anything. Just send us your news or submit a column.

The Triangle Physician is delivered to a very select group – the more than 6,000 medical professionals throughout eastern North Carolina. So advertising is a cost-effective way to reach those who may otherwise suffer needlessly – prospective patients. Please contact me at heidi@trianglephysician.com for details.

With deep appreciation and respect for all you do,

Heidi Ketler Editor

The Triangle Physician

Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.

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Cover Story

Granville Urology Associates

Focusing on the Treatment of Female Incontinence Granville Health System urologist Joseph

In a recent survey, the National Associa-

primary care physician if a referral to a

C. Zola Jr., M.D., with Granville Urol-

tion for Continence (NAFC) found that on

urologist could benefit more advanced or

ogy Associates, has a passion for treating

average, people were waiting seven years

complicated cases.

women’s urologic issues. Dr. Zola has ad-

before seeking treatment for their blad-

vanced training in the surgical correction

der control problem. Many people change

“Women living with these issues endure a

and medical treatments for female incon-

their lifestyle when their bladder habits

tremendous amount of discomfort. They

tinence.

begin to control their daily routines. They

really don’t have to live with incontinence,”

may stop visiting friends, exercising, travel-

said Dr. Zola. “I love it when they come in

ing or even engaging in sexual intercourse.

to see me and realize that it’s highly treat-

“Women are often reluctant to seek treat-

able.”

ment,” said Dr. Zola. “I want to bring incontinence out of hiding, because it does not

Patients will often seek treatment for incon-

have to be a part of a woman’s functional

tinence from their family physician. How-

Originally from northwestern New Jersey,

life.”

ever, patients should discuss with their

Dr. Zola obtained his undergraduate degree from the College of William and Mary. He completed his medical training at the Medical College of Virginia, where he was elected into the Alpha Omega Alpha honor medical society. Dr. Zola completed his surgical residency in urology at Thomas Jefferson University Hospital in Philadelphia, Pa., specializing in robotics, laparoscopic surgery and advanced endourology. He has a family friend who is a physician and athlete. After her first child was born, she found she was unable to run due to incontinence. She asked him about treatment options at a family gathering, and Dr. Zola found himself surrounded by other women with the same issues. He was astounded that so many women thought they had to live with incontinence, even with the wide variety of treatment options available. This experience opened his eyes to the extent of women’s incontinence and enlightened him on what women give up due to incontinence, like family vacations or hobbies. He encourages women – and his peers within primary care who treat

The Triangle Physician

them – to seek specialty urology care, as incontinence often requires specialty diagnostic testing and treatment. “I refer lots of my patients to Dr. Zola, particularly women suffering from incontinence,” said Christopher Sorrels, M.D., a primary care physician with Granville Primary Care in Oxford. “It’s rare to find a urologist who is as skilled in treating women’s urologic issues. In fact, the entire staff at Granville Urology Associates is fantastic to work with.” What Patients Should Expect in Evaluating Urinary Incontinence To determine the most effective urinary incontinence treatment for each patient’s condition, Dr. Zola offers individualized

Ruling Out Other Problems First

der can become hyper-reactive, sending

evaluations for urinary incontinence. The

Dr. Zola’s individualized evaluations deter-

strong signals to empty before the bladder

evaluation begins with a comprehensive

mine whether the patient is suffering from

is full. Nerve stimulation therapies “jam”

history and physical examination, includ-

a bladder function problem by first ruling

the pathways that transmit these abnormal

ing a pelvic examination.

out other urological issues such as:

messages.

• Infection To confirm the diagnosis, some of the di-

• Bladder stones

In percutaneous tibial nerve stimulation

agnostic tests mentioned below also may

• Tumors

(PTNS), a small acupuncture needle is

be ordered:

• Interstitial cystitis

placed in the ankle along the tibial nerve.

Urinalysis – A sample of urine is examined

• Outlet obstruction/stenosis

A handheld device connects to the needle to deliver mild electrical impulses to the

for the presence of infection, blood or other abnormalities.

In addition, other medical issues, such as

nerve. These travel up the tibial nerve to

Post-void residual urine measurement –

diabetes and polydipsia, as well as pos-

the sacral nerve plexus, which regulates

This test determines whether any urine

sible medication interactions, are consid-

the bladder. PTNS sessions are painless,

remains after the patient has tried to empty

ered.

last 30 minutes and are repeated weekly for 12 weeks. All sessions take place in a

the bladder completely.

medical office.

Cystoscopy – An examination of the inside

Urge Incontinence

of the bladder with a small viewing tele-

Sometimes referred to as “overactive blad-

scope called a cystoscope.

der” or “spastic bladder,” urge inconti-

Sacral Neuromodulation Therapy

Stress test – To find out whether stresses

nence is an involuntary loss of urine that

(Interstim)

on the bladder cause leakage, the patient

usually occurs when a person has a strong,

Sacral neuromodulation therapy also uses

may be asked to cough, stand or do other

sudden need to urinate. Urge incontinence

electrical impulses applied directly to the

activities while their bladder is full.

is not a disease, but a sign that there is an

sacral nerves. Wires are threaded through

Urodynamic testing – These tests examine

underlying problem.

openings in the pelvic bones along the sacral nerves. This is done in an operating

bladder and urethral sphincter muscle function by inserting a small tube into the

How Is Urge Incontinence Treated?

room using local anesthesia. The wires are

bladder or examining the bladder with

Percutaneous Tibial Nerve Stimulation

attached to a small external generator. If

X-rays. Through several such tests, it can

(PTNS)

a two-week test using the external device

be determined whether the patient has

Normal voiding depends not only on the

shows improvement in symptoms, a per-

normal bladder sensation and capacity

normal function of organs and muscles

manent device, called Interstim, is implant-

and whether the bladder fills and empties

but also on nerves that deliver appropriate

ed under the skin. This procedure requires

normally.

signals regarding urination. In urge incon-

general anesthesia.

tinence, the nerves regulating the blad

may/June 2014

Botox Bladder Injections Botulinum toxin A, better known as Botox, is used to treat patients with urge incontinence that does not improve with medications or other conservative therapies. It works by paralyzing bladder muscles, which helps decrease unwanted bladder contractions. Maximum relief is usually seen seven days after injection and normally lasts six to 12 months. Repeat injections are often needed. Stress Incontinence Urinary stress incontinence occurs when an activity, such as coughing or sneezing, causes a small amount of urine to leak from the urethra. Stress incontinence is the most common type of incontinence suffered by women, especially older women. In addition, women who have given birth are more likely to have stress incontinence. How Is Stress Incontinence Treated? Transvaginal Mesh/Sling The female mid-urethral sling is a minimally invasive, outpatient procedure to treat stress urinary incontinence. This surgery has been performed since the 1960s and has been shown to be safe and effective. The sling lies under the urethra acting as a “hammock,” which maintains urethral support and keeps it closed during abdominal pressure increases (as with a cough, sneeze or athletic activity), preventing loss of urine. Transvaginal mesh insertion is a short (15-30 minute) outpatient surgery done under general anesthesia, spinal anesthesia or under

The procedure to inject Macroplastique can be performed in an

sedation with local anesthesia. A 2-3-centimeter incision is made

outpatient clinic or hospital in approximately 30 minutes. Prior to

in the vagina, as well as two smaller incisions just above the pubic

the procedure, the doctor gives the patient an antibiotic to reduce

bone or in the inner thigh just beside the labia. In some cases only

the risk of infection. Upon the start of the procedure, the doctor

a single vaginal incision is made. The sling, made of surgical mesh

administers anesthetic in the tissues near the bladder to reduce

(polypropylene), is then placed under the urethra and brought out

discomfort.

through the mini incisions using specially designed instruments. The sling is then adjusted to the proper tension (no pressure on the

A cystoscope is used during the procedure to view the urethra and

urethra) and then buried under the skin incision. Patients usually

bladder while injecting Macroplastique into the surrounding ure-

go home within a few hours after surgery.

thral tissue. The physician fills the bladder to halfway with water or saline to better view the area. The optical instrument is removed

Macroplastique

after the injection, and the treatment is complete.

Macroplastique is a less-invasive option for adult female stress urinary incontinence (SUI), primarily due to intrinsic sphincter deficiency (ISD). An injectable, soft-tissue urethral bulking agent, Macroplastique is made up of two parts – the water-soluble gel

What a Patient Can Expect After the Procedure • To stay at the treatment facility until the numbness from the anesthetic is gone and they can urinate on their own.

(polyvinylpyrrolidone) that is absorbed and removed from the

• To receive a prescription for antibiotics to prevent infection.

body in urine and the artificial rubber-like, silicone elastomer im-

• To resume her normal daily activities and return to work

plant material (cross-linked polydimethylsiloxane) that is perma-

within a few days.

nent and not absorbed by the body. It is this permanent material that causes the bulking effect around the urethra after implantation.

For More Information or to Schedule an Appointment Dr. Joseph Zola Jr. is available for consultation and accepting pa-

Macroplastique is injected into the tissues surrounding the urethra.

tients at Granville Urology Associates, 102 Professional Park Drive,

The increased “bulk” allows the urethra to close more effectively

Suite C, Oxford, NC 27565. Appointments can be made by calling

and prevents urine from leaking.

(919) 690-0435. For more information, visit ghshospital.org/urology.

The Triangle Physician

Gastroenterology

Part 1

10 Tips for Improved Patient Communication By Douglas A. Drossman, M.D.

Health care providers spend the majority

3) Elicit the patient’s “agenda”

of their time communicating one-on-one

The clinician needs to identify how the

with their patients. It’s widely recognized

patient understands the illness from their

that good communication skills are the

personal and sociocultural perspective.

cornerstone of an effective patient-provid-

Several questions can be routinely asked

er relationship.

to understand the patient’s agenda: “What brought you here today?” “What do you

This article is the first in a two-part series

think you have?” “What worries or con-

discussing 10 key elements toward reach-

cerns do you have?” “What are your

ing this goal. I’m presenting methods of

thoughts of what I can do to help?”

communication that we have found to be helpful in interactions with our functional

4) Offer empathy

gastroenterology patients. These tips can

Empathy means to demonstrate an under-

be applied to communication with pa-

standing of the patient’s pain and distress,

tients in primary care and other subspe-

while maintaining an objective and obser-

cialties as well.

vant stance. An empathic statement would be: “I can see how difficult it has been for

1) Listen actively

you to manage with your symptoms” or “I

The clinical data is obtained through an

can see how much this has affected your

active process of listening, observing and

life.”

facilitating. This is different from some social situations where a “collective mono-

5) Validate the patient’s feelings

logue” occurs. Here, the one person hard-

Patients may experience shame or embar-

ly listens to the other and rather waits for a

rassment when about to disclose person-

moment to communicate their ideas. With

ally meaningful information. The clinician

active listening questions are constructed

needs to provide an air of acceptance and

based on what the patient says, rather

seek to validate the patient’s feelings. For

than from any personal agenda.

example, a validating statement to a patient who is feeling shamed by others who

Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation. org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www.drossmancenter.com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patientprovider relationship. Drossman Gastroenterology P.L.L.C. (www.drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.

2) Stay attuned to questioning style

say the problem is due to stress would

and non-verbal messages

be: “I can see you are upset when people

Often, it’s not what you say, but how you

say this is due to stress, and you know it’s

How to Improve the Patient-Physician Re-

say it that makes the difference. For exam-

real.”

lationship by Optimizing Communication

ple methods that engage the patient in the

Skills; Douglas A. Drossman, MD; Am

care process include: good eye contact, af-

The remaining five communication tips

J Gastroenterol 2013; 108:521–528; doi:

firmative nods and gestures, a partner-like

will be presented in the second part of this

10.1038/ajg.2013.56; published online 19

relationship, closer interpersonal distance

series. For additional information, see the

March 2013.

and a gentle tone of voice.

following article: 2012 David Sun Lecture: Helping Your Patient by Helping Yourself –

may/JUne 2014

Practice Management

Managing a Balanced Practice in Changing Times By Margie Satinsky

Within the past year, four physicians have

stopped at the conclusion of your formal

contacted me for help in setting up a new

training, and you should be continuing to

private practice, and several more who

add to your knowledge base.

are already in practice have requested guidance in improving their existing

The increasing availability of online

practices.

information offers many tools to help you diagnose, prescribe, treat and refer when

appropriate.

There

Margie Satinsky is president of Satinsky Consulting, L.L.C., a Durham consulting firm that specializes in medical practice management. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century.

We’ve always maintained that balance is

elsewhere

the key to success in both new and estab-

are many reliable ways to quantify and

lished practices. Understanding that the

evaluate the quality of the care that

important aspects of practice manage-

you provide so you can better manage

ment are patient care, structure/manage-

specific populations. Do you know what

ment/governance, practice operations

to measure, how to do it and how to use

Like every business, you need a formal

(including information technology), plan-

the results?

budget and financial projections. They

ning and marketing, financial manage-

become the benchmarks against which

ment, human resources and compliance,

The way in which you organize and

you measure what you earn and spend.

how can you best maintain balance within

manage your practice sets the stage. If

Amazingly, not all physicians think

and between all of these important func-

you obtained good legal advice and have

budgets and benchmarks are important;

tions?

in place the written legal documents

some prefer to “wing it” – risky business

that

in my opinion.

support

your

decisions,

you

As we all know, balance depends not

should be well positioned to tackle the

only on inner capabilities, but also on the

many challenges that lie ahead. If the

What’s your payer mix? Do you regularly

ways in which we respond to a shifting

managerial roles and responsibilities of

revisit those managed care contracts that

and unpredictable external environment.

physicians and your practice manager or

are negotiable? When payers ask you to

How do we maintain a steady course

office manager are clear, you are more

demonstrate value, can you? If you are

and a thriving medical practice when we

likely to accomplish your goals. If you

part of an Accountable Care Organization

can’t control changes in health policy,

regularly engage in a formal strategic

(ACO), do you understand how it works

reimbursement and other variables?

business-planning process and create a

and can help you? If you are a primary

supporting budget, you’ll have a roadmap

care practice, do you qualify for Patient-

In a series of articles that will appear in

to follow. If you have a marketing strategy

Centered Medical Home (PCMH)? Have

The Triangle Physician in 2015, we’ll select

that relates to your business plan, you can

you applied for Meaningful Use and other

specific topics within each of these five

promote the excellent care and service

financial incentives that are available to

important categories. Here’s a preview.

that you provide.

you?

Patient care is the No. 1 priority for every

Financial management has multiple

Do you, your practice or office man-

practicing physician. You chose medicine

components. The ultimate goal is to

ager and your CPA regularly review both

as a career so you can help patients by

maximize the revenue that you receive for

monthly financial statements and infor-

providing

the care you provide and to manage your

mation from your practice management

money wisely.

system? Or are you one of those practices

clinically

appropriate

and

safe care. Your learning should not have

The Triangle Physician

that naively ask one question at the end of

responsibility on your part, not removing

other external programs. For example,

each month: “Did we gross more revenue

a task from your full plate and ceasing

the passage of the HIPAA Final Omnibus

this month than last?”

to manage it. Outsiders do best when

Rule in 2013 made many changes in both

insiders provide guidance and feedback.

privacy and security. Do you know what changed, and did you update all of your

Practice operations have a major impact

HIPAA materials?

on each patient’s experience as well as on

With respect to your internal workforce,

clinician productivity. When did you last

do you have a formal orientation process,

step back and analyze your workflow?

a written employee handbook, a standard

Compliance doesn’t occur when trouble

performance evaluation system and ac-

comes; it prevents problems before they

These days, your patients wear their

cess to good legal counsel when you

arise.

consumer hats in your office as well as

need it? Articles to come will explore in greater

at the car dealer, and they turn a critical eye not only toward clinical outcomes but

Compliance is another vital aspect of

depth the opportunities for effective

also toward the administrative aspects of

practice management. We’re talking about

practice management.

your practice. How pleasant are the staff

coding compliance, OSHA, HIPAA and

members who answer the phone? How easily can patients get appointments? Are the office hours convenient for patients who work? Do patients have long waits in the reception area before being escorted back to an exam room? Is it easy to obtain results and have follow-up conversations with you and other clinicians? Many patients are facing increased financial responsibilities. Do you provide accurate estimates of the cost of care and clear answers to questions about billing and collections? Do you have a secure patient portal that works efficiently for patients who choose to use it, and do you have good ways of communicating with patients who don’t like electronic communication? Excellence in human resources applies to your internal workforce as well as to external professionals to whom you outsource work. Examples may include your attorney, CPA, IT software company, IT support vendor, billing and collections, professional employer organization (PEO), and perhaps a practice management consultant who provides help on specific projects. As the challenges of practice management increase, more practices are realizing that they may not be able to do everything internally.

But

outsourcing

means

may/June 2014

Women’s Wellness

New Advances in the Treating of Endometriosis By Lindsay A. Wojciechowski

Many women may not know they have

usually laparoscopy but also laparotomy.

endometriosis; whereas, others learn they

At the time of surgery, the presence of en-

have it at an early age. This disorder im-

dometrial glands and stroma at “extrauter-

pacts between 6-10 percent of women in

ine” defines this disorder. In other words,

their reproductive years (Giudice LC).

endometriotic lesions or endometrium-like tissue is found outside the uterus.

Endometriosis is a benign disease that is

Lindsay A. Wojciechowski is a nurse practitioner and consultant to the Women’s Wellness Clinic and the Carolina Women’s Research and Wellness Center (CWRWC). She has worked as a clinical nurse practitioner for Triangle Family Practice at Duke University Medical Center since 2006. She also has lectured and taught courses at the Duke University School of Nursing. Ms. Wojciechowski’s focus is on women’s health and family medicine, and she also is the lead medical writer for the Women’s Wellness Clinic.

prone to recurrence. Symptoms may over-

Unfortunately, there is a typical delay in di-

lap several other disorders. So it’s impor-

agnosis of eight to 11 years from presenta-

tant for clinicians to consider this potential

tion due to the variety of clinical manifesta-

diagnosis and avoid possible delays.

tions (Giudice LC, Kao LC).

Common symptoms of endometriosis

What has been of interest to us is that no

(Schenken, et al) include pain with men-

correlation exists between the frequency

strual bleeding (dysmenorrhea), pelvic

and severity of symptoms (pain and infer-

pain, pain with intercourse (dyspareunia)

tility) with the amount of disease or type

and/or infertility. Less common symptoms

of endometriotic lesion. In other words, a

include abnormal uterine bleeding (heavy

woman may have evidence of just a small

periods or bleeding at abnormal times),

amount of lesions at the time of surgery

the vast majority of women but is used on

constipation, bowel pain and dysuria, low

but experience intense and debilitating

a temporary basis (usually for about one

back pain or chronic fatigue.

pain. In contrast, a woman may be having

year). Also, nonsteroidal anti-inflammatory

surgery for a reason unrelated to endome-

drugs as well as stronger pain medications

Risk Factors

triosis when a large amount of endome-

should be provided.

Health care providers should be aware

triosis and scarring is incidentally found.

of certain risk factors for endometriosis.

Why this is true is still not known, but it is

Clinical Trials

For instance, women are more likely to

important to share with patients who have

Health care professionals at the Women’s

have endometriosis if they have never had

endometriosis.

Wellness Clinic have been fortunate to be involved in studies relating to endometrio-

children (nulliparous), if they had early menarche (started period early), had late

Treatment

sis, and we encourage patients and pro-

menopause, had short menstrual cycles or

The main treatments of endometriosis in-

viders to call us for more information. We

had prolonged menses. Müllerian anoma-

clude medical therapy that slows or stops

recently ended enrollment using a medica-

lies (Missmer et al) also increase risk.

the progression of the disease. The most

tion called elagolix, which is an oral go-

common first-line approach is the use of

nadotropin-releasing hormone antagonist

Some factors decrease risk or are protec-

progestin-only medications (Aygestin or

(see www.clinicaltrials.gov).

tive. Protective factors include multiple

Provera) as well as many of the available

births, extended lengths of breast feeding

combined oral contraceptive pills.

Later this summer, we expect to begin a new study on endometriosis with a medi-

and late-onset menarche, specifically periods beginning after the age of 14 (Treloar

The most aggressive form of treatment is

cal therapy that will improve pain associ-

et al).

with

hormone

ated with endometriosis. Such new ad-

agonists (Depo Lupron). This medica-

vances are important to evaluate given the

Diagnosis

tion essentially causes “menopause,” or

limited options available to clinicians for

The gold standard for establishing a diag-

a hypoestrogenic state, through pituitary

the control of symptoms relating to endo-

nosis of endometriosis remains surgery,

suppression. In our experience, this helps

metriosis.

The Triangle Physician

gonadotropin-releasing

Women’s Wellness References • Schenken RS, Barbieri RL, Falk SJ, Pathogenesis, clinical features, and diagnosis of endometriosis, Up-to-Date, Topic 7384, Version 15.0. • Giudice LC. Clinical practice. Endometriosis. N Engl J Med. 2010;362(25):2389-98.

• Giudice LC, Kao LC. Endometriosis. Lancet 2004;364(9447):1789-99. • Treloar SA, Bell TA, Nagle CM, Purdie DM, Green AC, Early menstrual characteristics associated with subsequent diagnosis of endometriosis, Am J Obstet Gynecol. 2010;202(6):534.31.

• Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL, Malspeis S, Willett WC, Hunter DJ, • Reproductive history and endometriosis among premenopausal women, Obstet Gynecol. 2004;104(5 Pt 1):965.

Community Support

Triangle Goes Red for Women Luncheon By Margie Satinsky

More than 300 women from across the Triangle attended the American Heart Association’s Triangle Goes Red for Women Luncheon, education expo and silent auction May 9, raising more than $185,000 for heart disease research specific to women. According to the AHA, one in three women will lose their life to heart disease. The keynote speaker was Susan Gravely, chairwoman and chief executive officer of Vietri. Event sponsors were Allscripts, BlueCross BlueShield of NC and WakeMed.

Tara Wind, a dietician with WakeMed, talks to luncheon guests about how to reduce salt and sugar in their diet.

Bhavani Balaravi, M.D., a cardiologist with WakeMed Faculty Physicians-Raleigh Cardiology, answers guests’ questions about heart disease prevention and treatment.

Go Red Luncheon guests from WakeMed enjoy the program and a heart-healthy lunch. There are (from bottom left) Julianne Macie, Breanna Bouchard, Andi Curtis, Tara Wind, Stacy Kropp, Kelly Washington, Ginger Bryan and Andrea Lee.

may/June 2014

Dermatology

Melanoma:

Early Detection Is Key Melanoma – It’s among the deadliest

patients is nine months.

of all the skin cancer strains. According to the American Cancer Society’s 2014

The scary thing about melanoma is that it

estimates, melanoma rates are steadily

is almost always completely asymptomatic.

rising. Approximately 76,100 new mela-

It doesn’t bleed, doesn’t hurt and generally

nomas will be diagnosed this year, while

doesn’t bother people. The misconception

9,710 people are estimated to die of the

that most people have about melanoma is

disease. That’s one United States citizen

that it’s usually big and bleeding.

every hour. Fifty years ago, we were taught that melaGenetics is a significant factor in develop-

nomas were very large. Now we’re taught

ing melanoma. A person who has a first-

that melanoma is commonly tiny, perhaps

degree relative with a history of melanoma

6 millimeters – about the size of the eraser

will have a dramatically increased risk to

on a pencil.

develop melanoma. A great majority of cases of melanoma are diagnosed in fair-

The good news is, if melanoma is detected

skinned people, most of whom report

early, where it’s less than .75 millimeters

some kind of sunburn in their past.

thick, there is a very high cure rate. In fact, the five-year survival rate for melanoma

Risk also increases with age; the average

when it’s detected early approaches 99

age at the time melanoma is found is 61.

percent.

However, it is not uncommon for those younger than 30, particularly young women, to develop melanoma. It’s one of the most common cancers in young adults, according to the American Cancer Society. The most common melanoma is the superficial-spreading melanoma, which typically starts in a pre-existing mole, and accounts for approximately 70 percent of all cases. This type of melanoma travels along the top layer of the skin for a fairly long time before penetrating more deeply. The vast majority of melanomas are removed in the earlier stages of the growth. The more serious problem comes when melanoma completes its horizontal growth and becomes invasive. Melanoma tumors can produce metastases. Once metastatic, the mean survival for

The Triangle Physician

By Gregory J. Wilmoth, M.D.

Dr. Gregory Wilmoth, a board-certified dermatologist at Southern Dermatology & Skin Cancer Center in Raleigh, specializes in Mohs surgery and skin cancer reconstruction, among other specialties. He earned his bachelor of science degree in chemistry from the University of North Carolina at Chapel Hill and his medical degree from Bowman Gray School of Medicine, Wake Forest University. He completed his internship at North Carolina Baptist Hospital and residency at Mayo Clinic, Rochester, Minn. Dr. Wilmoth is a fellow of the American Society for Mohs Surgery. He is a member of the American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Academy of Dermatology, American Medical Association and the North Carolina Medical Society.

Practice Marketing

Blogging:

Affordable, Effective Way to Boost Google Rankings By Amanda Kanaan

When I mention the word “blog” to most

something none of your patients want to

medical practices, I see practice manag-

read.

ers and physicians alike begin to cringe. Don’t worry, blogging doesn’t mean taking

How often should we blog?

an hour out of your day to share life les-

In a perfect world, we would all blog a

sons. Instead, I’m referring to writing short

couple times a week but that’s just not fea-

patient education articles that are relevant

sible for most small businesses, especially

to the keywords you are trying to rank for

medical practices. Most practices realisti-

on Google. Below is a guide to blogging

cally aim for one blog a week or one blog

and why it’s so important.

a month at minimum. Any less frequent than one blog a month and your efforts

Do I really need to blog?

will be futile.

Yes, if you want to attract more new pa-

Amanda Kanaan is the founder and president of WhiteCoat Designs – a Raleigh-based medical marketing agency providing doctors with medical website design, search engine optimization (SEO), mobile and responsive websites, social media management, graphic design, physician liaison consulting and more. To learn more about WhiteCoat Designs, visit www.whitecoatdesigns.com.

tients online; 80 percent of Internet users

What should I write about?

search online for health information and

You want to try and strike a balance be-

What if I don’t have time to write blogs?

44 percent of those are looking for treat-

tween relevant practice news/information

One idea to share the demands of blog writ-

ment and/or a provider. If your practice

and good quality educational content

ing is to ask each provider in your group

doesn’t have a great website that is easily

(one serves Google’s purposes and the

to take turns writing blogs. If your practice

found online then you are missing out on

other serves patients’ needs). Sure, every

has no desire to write blogs, consider hir-

patients. Blogs are a very effective search

once in a while you’ll need to just write

ing a freelance medical writer (one who

engine optimization (SEO) tactic, since

a short announcement about how your

has experience in SEO if possible, so they

they add relevant content to your site and

hours have changed or an event you’re

can optimize the blogs for you). There are

keep it fresh with new information.

hosting but for SEO purposes, the longer,

plenty of affordable freelance writers out

information-rich articles are most effective.

there that charge anywhere from $50-$200 a blog depending on how long/involved

How many words do the blog articles have to be?

If you have the luxury of an SEO agency

the article is. They will usually give you a

Google does not give a black-and-white

that can perform keyword research for

quantity discount as well, if you commit to

answer to this one; however most SEO

you, then you know exactly what keywords

ongoing articles.

agencies will tell you to shoot for around

to write about. Let’s say one of those key-

400-600 words. (There has been more re-

words is “robotic surgery.” Knowing that is

Website blogging is an affordable and ef-

cent arguments for longer articles if the

a popular search term, it would behoove

fective SEO tactic to boost your rankings

topic warrants it.) Google has made a shift

you to write various blog articles about ro-

in Google and also a great way to maintain

during the last couple years away from

botic surgery to help Google understand

ongoing communications with patients.

stand-alone keywords and towards quality

that your website is a relevant source of

Whether you do it yourself or hire a medi-

content. That means it’s vital that you write

information for this topic. Just make sure

cal writer, I would highly suggest this tac-

a quality article about a topic relevant to

that your blog is built into your actual web-

tic to any medical practice that wants to

your website rather than a keyword-stuffed

site and isn’t a separate URL, or you won’t

increase their online footprint and attract

article with no substance; the latter is also

reap the SEO benefits from Google.

more new patients online.

may/June 2014

Duke Research News

Complications from Kidney Stone Treatments Are Common and Costly Despite their overall low risk, procedures to

window of observation than had previously

of treatment but also the financial difficulties

treat kidney stones lead to complications that

been studied. According to the analysis,

from time off work due to pain and treat-

require hospitalization or emergency care for

patients who had their surgery at hospitals

ment.”

one in seven patients, according to research-

that did high volumes of the procedure were

ers at Duke Medicine.

much less likely to have complications.

Dr. Scales said the public policy implications are also important, particularly in the cur-

These complications are costly. Patients who

When complications occurred, they were

rent environment in which health costs are

have an unplanned visit face an average cost

least common following shock wave litho-

increasingly scrutinized.

of nearly $30,000, depending on the type of

tripsy, affecting 12 percent of patients. Those

procedure and the subsequent care.

treated with ureteroscopy, the second most

“Reducing unplanned emergency visits and

common procedure, had slightly more un-

hospitalizations associated with kidney stone

planned visits, with 15 percent of patients.

treatments could result in significant cost sav-

“Our findings provide a good starting point

ings if the causes can be identified and ad-

to understand why these complications are

dressed,” Dr. Scales said.

happening and how they can be prevented,

Costs for complications of nephrolithotomy

because the costs to patients who suffer

were highest, averaging over $47,000 when

complications and to the health care system

an unplanned emergency visit occurred.

He said understanding why complications

are substantial,” said lead author Charles D.

Unplanned shock wave lithotripsy visits aver-

occur and how they can be avoided will be

Scales Jr., M.D., M.S.H.S., assistant professor

aged more than $32,000.

important next steps.

of surgery at Duke. Dr. Scales said further research is needed

In addition to Dr. Scales, study authors in-

Dr. Scales and colleagues, publishing April

to understand why the different procedures

clude Christopher S. Saigal, Janet M. Hanley,

28 in the journal Surgery, analyzed the out-

resulted in different complication rates and

Andrew W. Dick, Claude M. Setodji and Mark

comes of more than 93,000 privately insured

costs, but noted that patients may be unpre-

S. Litwin.

patients who underwent treatment for kidney

pared for complications arising from mini-

stones. Procedures included shock wave lith-

mally invasive treatments.

The National Institute of Diabetes and Digestive and Kidney Diseases and the Urologic

otripsy, ureteroscopy or percutaneous nephrolithotomy – the main interventions gener-

“From the patient perspective, an unplanned

Diseases in America Project provided fund-

ating an estimated $10 billion annual tab for

emergency department visit or hospital ad-

ing for the study (HHSN276201200016C).

kidney stone disease in the United States.

mission after a low-risk ambulatory proce-

Scales also received support from the Robert

dure is a significant event,” Dr. Scales said.

Wood Johnson Foundation Clinical Scholars

The researchers included emergency depart-

“Kidney stones are excruciatingly painful

program and U.S. Department of Veterans Af-

ment visits or hospital admissions within 30

and primarily affect people who are of work-

fairs.

days of the original procedure – a longer

ing age. These patients face not only the cost

Bullying May Have Long-Term Health Consequences Bullied children may experience chronic,

the University of Warwick, the University of

marker of inflammation, provide a potential

systemic inflammation that persists into

North Carolina at Chapel Hill and Emory Uni-

mechanism for how this social interaction

adulthood, while bullies may actually reap

versity, was published online in the Proceed-

can affect later health functioning,” said Wil-

the health benefits of increasing their social

ings of the National Academy of Sciences the

liam E. Copeland, Ph.D., associate professor

status through bullying, according to re-

week of May 12.

of psychiatry and behavioral sciences at Duke University School of Medicine and the

searchers at Duke Medicine. “Our findings look at the biological conThe study, conducted in collaboration with

The Triangle Physician

sequences of bullying, and by studying a

study’s lead author.

Duke Research News Earlier studies have suggested that victims

levels as adults than the other groups. In fact,

of childhood bullying suffer social and emo-

the CRP levels increased with the number of

tional consequences into adulthood, includ-

times the individuals were bullied.

cess aside from bullying others.” The researchers concluded that reducing bullying, as well as reducing inflammation

ing increases in anxiety and depression. Yet, bullied children also report health problems,

Young adults who had been both bullies and

among victims of bullying, could be key tar-

such as pain and illness susceptibility, which

victims as children had CRP levels similar to

gets for promoting physical and emotional

may extend beyond psychological outcomes.

those not involved in bullying, while bullies

health and lessening the risk for diseases as-

had the lowest CRP – even lower than those

sociated with inflammation.

“Among victims of bullying, there seems to

uninvolved in bullying. Thus, being a bully

be some impact on health status in adult-

and enhancing one’s social status through

In addition to Dr. Copeland, study authors in-

hood,” Dr. Copeland said. “In this study, we

this interaction may protect against increases

clude E. Jane Costello of Duke, Dieter Wolke

asked whether childhood bullying can get

in the inflammatory marker.

and Suzet Tanya Lereya of the University of Warwick in the United Kingdom, Lilly Sha-

‘under the skin’ to affect physical health.” While bullying is more common and per-

nahan of the University of North Carolina at

Dr. Copeland and his colleagues used data

ceived as less harmful than childhood abuse

Chapel Hill and Carol Worthman of Emory

from the Great Smoky Mountains Study,

or maltreatment, the findings suggest that

University.

a robust, population-based study that has

bullying can disrupt levels of inflammation

gathered information on 1,420 individuals

into adulthood, similar to what is seen in

The study was supported by the Nation-

for more than 20 years. Individuals were ran-

other forms of childhood trauma.

al Institute of Mental Health (MH63970, MH63671, MH48085 and MH080230), the Na-

domly selected to participate in the prospective study, and therefore were not at a higher

“Our study found that a child’s role in bully-

tional Institute on Drug Abuse (DA/MH11301,

risk of mental illness or being bullied.

ing can serve as either a risk or a protective

DA023026), the Brain & Behavior Research

factor for low-grade inflammation,” Dr. Cope-

Foundation, the William T. Grant Founda-

Participants were interviewed throughout

land said. “Enhanced social status seems to

tion and the Economic and Social Research

childhood, adolescence and young adult-

have a biological advantage. However, there

Council (ES/K003593/1).

hood, and among other topics, were asked

are ways children can experience social suc-

about their experiences with bullying. The researchers also collected small blood sam-

55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514

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919.929.7990

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ples to look at biological factors. Using the blood samples, the researchers measured Creactive protein (CRP), a marker of low-grade inflammation and a risk factor for health problems including metabolic syndrome and cardiovascular disease. “CRP levels are affected by a variety of stressors, including poor nutrition, lack of sleep and infection, but we’ve found that they are also related to psychosocial factors,” Dr. Co-

Drossman Gastroenterology

peland said. “By controlling for participants’ pre-existing CRP levels, even before involvement in bullying, we get a clearer understanding of how bullying could change the trajectory of CRP levels.” Three groups of participants were analyzed: victims of bullying, those who were both bullies and victims, and those who were purely bullies. Although CRP levels rose for all groups as they entered adulthood, victims of childhood bullying had much higher CRP

may/June 2014

UNC Research News

Genetic Trigger for RSV-Induced Infant Hospitalizations Found Researchers at the University of North

and its effect on epithelial-cell shedding

rus, she saw infected cells ball up and puff

Carolina School of Medicine have pin-

that makes RSV by far the most common

out of the airway epithelium. “The cells in-

pointed a viral protein that plays a major

cause of bronchiolitis in otherwise healthy

fected by PIV3 expressing the NS2 gene of

role in making respiratory syncytial virus

young children. The finding was years in

RSV looked exactly like RSV-infected cells,”

the most common cause of hospitalization

the making.

said Dr. Liesman, who was a UNC graduate student as the time.

in children under one year of age. “It was a real struggle to put our finger on The discovery, published April 8 in the

differences between RSV and other com-

Drs. Pickles and Liesman then used their

Journal of Clinical Investigation, is the first

mon respiratory viruses that might account

reengineered PIV expressing RSV NS2 in

step toward identifying better diagnostics

for the increased disease caused by RSV,”

animal models to provide more clinical

and potential treatments for an infection

Dr. Pickles said. “We compared the abil-

relevance for their findings. They found

that strikes nearly all children before they

ity of RSV and parainfluenza virus (PIV3)

that infection of the narrowest airways of

reach the age of three and causes severe

– another common virus in children that

the lung by PIV3 alone caused moderate

disease in 3 percent of infected children.

causes much less severe airway disease –

levels of inflammation, but after infection

to infect and cause inflammatory respons-

by PIV3 expressing RSV NS2, the epithelial

Respiratory syncytial virus (RSV) infection

es in a cell culture model of human epithe-

cells lining the narrow airways were shed

leads to the hospitalization of between

lial cells, which compose the lining of the

rapidly into the airway lumen. The shed-

75,000 and 125,000 babies under one year

lung airway. But comparing these conse-

ding occurred at such a great rate that the

of age in the United States every year. Glob-

quences of infection did not provide hints

shed cells obstructed the airway lumen,

ally, RSV is the second-leading cause of

as to why RSV and PIV3 produced such dif-

resulting in excessive inflammation.

infant mortality due to infectious disease

ferences in disease severity. We did notice,

behind only malaria.

though, that the epithelial cells infected by

Dr. Pickles said that these findings in ani-

RSV looked very different during infection

mal models were almost identical to what

compared to those infected by PIV3.”

has been found in human infants who had

“We’ve known for a

died because of RSV infection. “I’m con-

long time that RSV has

Raymond Pickles, Ph.D.

an increased propen-

While the PIV-infected epithelial cells re-

vinced that the RSV NS2 gene is a major

sity, compared to other

tained their natural elongated, columnar

driver for the well-recognized increased

respiratory viruses, for

shape, the same cells infected with RSV

ability of RSV to cause lung disease, es-

causing obstruction and

balled up and puffed out of the airway epi-

pecially in the extremely narrow small air-

inflammation in the nar-

thelium, causing the infected cells to ac-

ways of human infants,” he said.

rowest airways of the in-

cumulate in the lumen of the airway. “We

fant lung, leading to severe bronchiolitis,”

hypothesized that since RSV and PIV3 are

Dr. Pickles is now on the trail of a human

said Raymond Pickles, Ph.D., associate

very similar viruses these different effects

biomarker that would tell doctors if an RSV-

professor of microbiology and immunolo-

must be due to differences in the types of

infected infant is at greater risk of develop-

gy and senior author of the JCI paper. “But

genes that RSV expresses,” Dr. Pickles said.

ing severe lung disease. A biomarker would be key in the development of a needed diag-

what we’ve now shown is that RSV has an increased ability to cause airway obstruc-

There aren’t many genes in RSV, and by

nostic tool and would aid clinical trials that

tion because, during an RSV infection, the

generating mutant viruses in the labora-

aim to develop anti-RSV therapeutics.

virus expresses a specific RSV-encoded

tory, Dr. Pickles’ team found that a specific

non-structural protein, or NS2, in epithelial

RSV gene – the NS2 gene – was responsible

Michelle Hernandez, M.D., a pediatric im-

cells, causing the cells to shed from the air-

for the balling up of RSV-infected airway

munologist at UNC, said, “When young chil-

way lining and into the airway lumen. This

cells. In experiments led by Rachael Lies-

dren arrive at the hospital with an RSV infec-

leads to obstruction of airflow in the small

man, Ph.D., the researchers decided to en-

tion, it’s challenging and frustrating to guess

airways and overwhelming inflammation.”

gineer PIV3 to express the RSV NS2 gene.

which children you can safely send home

When Dr. Liesman infected human airway

versus those you should admit to the hos-

cells in the lab with this re-engineered vi-

pital because they might require supportive

According to this study, it’s this NS2 protein

The Triangle Physician

UNC Research News care in an intensive care unit. Any information that will help us make these decisions not only helps us ensure that we provide the best care for these kids, but also helps us use health care resources more wisely.” Using animal models, Dr. Pickles has found candidate molecular biomarkers that indicate if the epithelial cells in the tiniest airways are expressing the RSV NS2 protein. He is now initiating studies to look for the same biomarkers in human infants infected with RSV. “If we can find biomarkers informing us that the most vulnerable parts of the lung have already been infected by RSV, then it could be possible to identify much more

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said it may be possible to suppress the

Dr. Pickles added that suppressing the ef-

tic Fibrosis and Pulmonary Research and

ability of NS2 to shed the airway epithe-

fects of the RSV NS2 protein may also allow

Treatment Center. Dr. Liesman is now a

lial cells. Thwarting this shedding effect

the immune system more time to deal with

postdoctoral fellow in the Pickles lab.

wouldn’t stop infection or stifle the typical

the RSV infection before the small airways

symptoms of RSV infection, but it might

become clogged with cells shedding from

Other authors of the JCI paper include Ur-

limit the virus’s ability to spread into the

the lining of the airway. He said, “These

sula Buchholz, Ph.D., and Peter Collins,

tiniest airways, which are the most likely to

are questions we are aiming to answer in

Ph.D., at the National Institutes of Health;

be obstructed by cells shed during infec-

studies already underway.”

Alan Proia, M.D., Ph.D., at Duke University; and John DeVincenzo, M.D., at the Univer-

tion. This would lead to a less severe infection and fewer hospitalizations.

Dr. Pickles is a member of the UNC Cys-

sity of Tennessee.

New Pathogen-Identification Method Is Cheaper Than Conventional Tests Researchers at UNC Health Care have

found to take much less time. In most cas-

said, “I don’t like to use

found that using a new method for identify-

es, lab technologists identified a pathogen

the word ‘revolutionize,’

ing bacteria and fungi in patient specimens

in about an hour; test results from conven-

but this technology has

led to a 92 percent cost reduction in the

tional molecular methods take at least a

revolutionized our lab.

reagents needed to run clinical microbiol-

day and often longer.

We can diagnose infection

ogy tests. Peter H. Gilligan, Ph.D., director of the During the year-long study, the new tech-

Clinical Microbiology-Immunology Labo-

nology – called MALDI-TOF MS – also was

ratories at UNC Hospitals in Chapel Hill,

Peter H. Gilligan, Ph.D.

efficiently

and treat patients much quicker, both of which

help decrease health care costs.” may/June 2014

UNC Research News Dr. Gilligan, a professor

taled $118,260 for one year. That’s a savings

“For a microbiology lab, that’s a lot of mon-

of pathology and labo-

of 82 percent.

ey,” Dr. Gilligan said. “It was a big commitment, which told us that the hospital had

ratory medicine in the

Anthony Tran, Dr.P.H.

UNC School of Medi-

Dr. Tran said, “We estimate that because

faith we could ultimately save money and

cine, and clinical micro-

of the reduced cost of reagents and time

most importantly improve patient care.”

biology fellow Anthony

saved for lab technologists, the upfront

Tran, Dr.P.H., presented

cost of the MALDI-TOF instrument will be

Dr. Gilligan added, “I can’t stress enough

their findings at the 2014

offset in less than three years from pur-

that the savings are really in efficiency. Our

chase.”

lab’s workload is increasing all the time,

General Meeting of the American Society

but we’re not hiring new technologists.

for Microbiology in Boston May 18. MALDI-TOF MS stands for Matrix-Assisted

So somehow we had to become more ef-

From April 1, 2013 to March 31, 2014, Drs.

Laser Desorption Ionization-Time of Flight

ficient and smarter. This technology allows

Gilligan and Tran led a cost-analysis study.

mass spectrometry. It analyzes proteins

us to do that. Getting results sooner saves

The lab used the MALDI-TOF MS to iden-

from incubated specimens and identi-

everyone time. If a doctor knows sooner

tify specific microorganisms from 21,930

fies the specimens by comparing them to

what’s going on with a patient, then the

samples from patients at UNC Hospitals.

known microorganisms in a database. The

doctor can narrow the therapeutic options

Specimens consisted of enteric pathogens,

technology came into clinical microbiol-

faster than before.”

enterococci, gram negative non-glucose

ogy use within the past five years. Dr. Gilli-

fermenters, staphylococci, streptococci

gan’s lab was one of the first in the country

The new technology also has helped Dr.

and yeast.

to acquire MALDI-TOF MS in 2012 and was

Gilligan’s lab identify some pathogens that

the first lab in North Carolina to use it.

lab technologists would not have typically considered the cause of infection. One of

Traditionally, clinical microbiologists use various reagents that require different

Two companies – Bruker Corp. and bio-

them is the bacterium Corynebacterium

amounts of time to determine what patho-

Mérieux Inc. – have developed slightly

kroppenstedtii, which has now been impli-

gens are contained within a given sample.

different versions of the technology. Spear-

cated in beast abscesses.

Often, doctors and patients would need

headed by Melissa Miller, Ph.D., associ-

to wait between 24 and 48 hours to get a

ate director of the Clinical Microbiology-

“This is a big deal,” Dr. Gilligan said. “Doc-

result from Dr. Gilligan’s lab. The cost of

Immunology Laboratories, Dr. Gilligan’s

tors would see patients with chronic infec-

identifying 21,930 organisms would have

team tested both company’s instruments

tions, and no one knew what caused them.

cost $84,491 in reagents alone.

prior to his and Dr. Tran’s recent study and

Now we know, and we can treat patients

found that each provided results as good

much more effectively than before.”

With MALDI-TOF, Dr. Gilligan’s team has

as or better than conventional methods. This study was conducted entirely by

results often within an hour, depending on the type of organism. And the cost of

UNC Hospitals purchased the MALDI-TOF

the staff at the Clinical Microbiology-

materials was $6,469 for one year. That’s 92

MS in 2012 for approximately $250,000 from

Immunology Laboratories, which is part

percent less than the cost of conventional

bioMérieux due in part because of the

of the McLendon Clinical Laboratories at

reagents.

company’s location in north Durham and

UNC Hospitals in Chapel Hill.

UNC Health Care’s previous collaborations The cost savings, when calculated to in-

with the company.

clude time spent by lab technologists, to-

The Triangle Physician 2014 Editorial Calendar

July Sports medicine Rheumatology

September Bariatrics Neonatology

November Urology ADHD

August Gastroenterology Nephrology

October Cancer in women Wound management

December Otorhinolaryngology Pain management

The Triangle Physician

ECU Research News

Fibrillation After Surgery May Be Predicted and Prevented Researchers at the Brody School of Medi-

heart surgery from 2010 to 2012.

cine at East Carolina University have locked in on an enzyme they think will

“What we found is that the enzyme re-

help tell which patients are likely to suffer

sponsible for metabolizing epinephrine

atrial fibrillation, a common postoperative

and dopamine, monoamine oxidase, is a

complication following mitral valve sur-

strong predictor of whether a person will

gery, cardiac bypass surgery or both.

have atrial fibrillation after heart surgery,” said Ethan J. Anderson, Ph.D., a scientist

In a related study, they have shown that

and assistant professor of pharmacology

prescribing concentrated fish oil supple-

at the Brody School of Medicine and pri-

ments before the surgery might decrease

mary investigator on the study. “In other

activity of this enzyme and boost several

words, we believe we have discovered

to a 2010 study. The result is more post-

beneficial properties in the heart, poten-

enzymes that will predict, with very high

operative complications, including stroke,

tially decreasing incidence of postopera-

degree of certainty, whether a patient is at

longer hospital stays and subsequent in-

tive atrial fibrillation.

risk of developing A-fib.”

crease in the costs.

The discovery could help reduce com-

Once researchers identified patients likely

“Post-op atrial fibrillation continues to be

plications that include stroke, reduce the

to develop fibrillation, the companion

one of the biggest, if not the biggest, post

length of time patients spend in the hos-

study investigated the impact of prescrib-

op complication for patients undergoing

pital following surgery and reduce treat-

ing relatively high doses of fish oil to them

open heart surgery,” said Alan P. Kypson,

ment costs.

two to three weeks before surgery. They

M.D., a cardiothoracic surgeon at the East

Dr. Ethan Anderson is the primary investigator of the study.

found the fish oil triggered increased pro-

Carolina Heart Institute at ECU. “It ac-

The enzyme research, “Monoamine Oxi-

duction of key anti-inflammatory and an-

counts for an average of at least two days

dase is a Major Determinant of Redox Bal-

tioxidant enzymes, which helped protect

extra in the hospital, costing about $6 bil-

ance in Human Atrial Myocardium and is

them from post-surgery complications,

lion worldwide.”

Associated with Postoperative Atrial Fi-

including atrial fibrillation. Dr. Anderson added that the research

brillation,” is published in the March issue of the Journal of the American Heart Asso-

“If we have a way of identifying high-risk

could be a springboard to establishing

ciation. It was funded by a $400,000 grant

patients, we can get in front of it,” Dr. An-

other enzymes as risk predictors for vari-

from the National Institutes of Health.

derson said. “Preventing this in the first

ous cardiovascular diseases.

place would mean they’d have decreased The study that looked at treating patients

postoperative stay in the hospital, have

Dr. Kypson was co-primary investigator

with fish oil prior to surgery was pub-

less complications and less cost.”

on the enzyme research. Jimmy T. Efird, Ph.D., M.Sc., director of epidemiology re-

lished online March 5 in the journal Antioxidants & Redox Signaling. It was funded

The study is an example of the emerging

search at the heart institute and professor

by the National Institutes of Health and a

field of biomarkers, or biological proper-

of public health, performed the statistical

$160,000 grant from GlaxoSmithKline, the

ties that can be used as an indicator of

analysis of the project. Graduate student

maker of Lovaza, a prescription-strength

a particular disease state or some other

Timothy Darden performed much of the

fish oil supplement. The pharmaceutical

physiological state of an organism or as a

work in Dr. Anderson’s laboratory. Saame

firm also supplied the fish oil capsules for

predictor of a likely response to a drug.

Raza Shaikh, Ph.D., assistant professor of biochemistry and molecular biology at

patients. Postoperative atrial fibrillation affects up

ECU, was a member of the research team

In the enzyme study, scientists examined

to half of bypass and heart valve surger-

for the fish oil study, and his laboratory

human heart tissue samples obtained

ies and is expected to continue rising due

performed the experiments looking at the

from approximately 250 patients during

to the aging patient population, according

fish oil in the heart tissue.

may/June 2014

ECU News

Brody Ranks Fifth on List of Top Family Physicians Producers The Brody School of Medicine at East Carolina University has again been honored as one of the top producers of family physicians in the nation. The American Academy of Family Physicians Top 10 Award annually honors medical schools that – during a consecutive three-year period – graduated the greatest percentage of students who chose firstyear family medicine residency positions. Brody School of Medicine ranked fifth on this year’s list, reflecting an average of 18.6 percent of ECU medical students entering family medicine during the last three years. No other North Carolina medical school received the award. “With the anticipated changes that are predicted in the provision of health care services, this confirms that the Brody School of Medicine is as relevant as when it was established four decades ago,” said

Paul Cunningham, M.D., F.A.C.S., dean of the Brody School of Medicine. “The formula for our success has been carefully forged over these many decades, and I salute all of our faculty who have served in this mission with passion and capability.” Between 1999 and 2009, East Carolina sent a higher percentage of its medical graduates into training as family physicians than any other school in the country. “For the past five years, we have seen growth in student interest in family medicine,” said AAFP President Reid B. Blackwelder, M.D. “Much of the credit for that increase goes to the medical schools that have actively supported family medicine as the comprehensive, challenging and professionally fulfilling specialty that it is.” This is the eighth consecutive year of recognition for ECU’s medical school, according to the ECU Department of Family

Medicine records. Top 10 recipients were announced May 5 during the Society of Teachers of Family Medicine Annual Spring Conference in San Antonio, Texas. Approximately one in four of all office visits are made to family physicians, according to AAFP data. That totals nearly 214 million office visits each year – nearly 74 million more than the next largest medical specialty. At a time when the nation is facing a shortage of primary care physicians, AAFP leadership believes filling the family physician workforce pipeline is vital to the health of Americans. Founded in 1947, AAFP represents 115,900 physicians and medical students nationwide. It is the only medical society devoted solely to primary care. More information is available online at www.aafp.org.

Duke News

Duke Regional Hospital Names Katie Galbraith as President Katie Galbraith, MBA, assumed the position of president of Duke Regional Hospital May 1.

tal, which reflects the hospital’s role within Duke University Health System.

Ms. Galbraith served as Duke Regional interim president since Sept. 30, 2013, and formerly as the hospital’s vice president. She succeeds Kerry Watson, who left Duke Regional in 2013 after a decade of leadership within the Duke University Health System.

“I am honored to lead the dedicated team of physicians, staff and volunteers at Duke Regional Hospital who strive to provide the best possible care to our patients each day,” Ms. Galbraith said. “Duke Regional’s vision is to become the best community hospital in North Carolina, and we are committed to serving our community while offering our patients the expertise and quality of Duke’s health system.”

A seasoned health care executive, Ms. Galbraith has had various posts at Duke Regional since 2001, from marketing and business development to hospital operations. She was part of the leadership team overseeing the 2013 renaming of Durham Regional Hospital to Duke Regional Hospi-

The Triangle Physician

In addition to her work at Duke Regional, Ms. Galbraith served as the president of the board of directors of Lincoln Community

Health Center from 2010-2013. She was the public relations manager for Duke Children’s Hospital & Health Center prior to joining Duke Regional and has also worked as a newspaper reporter and freelance writer. Ms. Galbraith graduated with a bachelor’s degree in journalism from Northwestern University and a master of business administration from Elon University. She is a member of the American Hospital Association’s Society for Healthcare Strategy & Market Development and the American College of Healthcare Executives.

WakeMed News

Cary Women’s Pavilion & Birthplace Appoints Angela Newman as Director Angela Newman, M.S.N., R.N., C.M.S.R.N., has accepted the position of director of the Women’s Pavilion & Birthplace at Cary Hospital after serving as the interim director since October. Since joining WakeMed in 1998, most of Ms. Newman’s career has been at Cary Hospital. In addition to her work with the Women’s Pavilion & Birthplace, she

istration at the University of North Carolina at Chapel Hill, her bachelor’s degree in health promotions at Appalachian State University and her associate’s degree in nursing at Caldwell Community College.

served in leadership roles with WakeMed’s Medical-Surgical and Medical Day Treatment units. She also continues to lend her expertise to many system-wide quality and service improvement initiatives. Ms. Newman earned her master’s degree in nursing admin-

Angela Newman, M.S.N., R.N., C.M.S.R.N.,

News Welcome to the Area

Physician

Sarah Bass Carroll, MD

Andrew Joseph Donohoe, MD

Ryan Michael Garcia, MD

Internal Medicine

Hospitalist; Internal Medicine

Hospitalist

UNC Hospitals Chapel Hill

4210 Brenmar Lane Durham

Robin Lee Casey, MD

Ann Le Dorsey, MD

Orthopedic Surgery, Trauma; Orthopedic, Hand Surgery; Plastic and Reconstructive Surgery; Plastic Surgery; Plastic Surgery Within the Head and Neck; Plastic Surgery/ Hand Surgery

Addiction Psychiatry; Alcohol and Drug Abuse; Child and Adolescent Psychiatry; Geriatric Psychiatry; Psychiatry; Psychoanalysis; Psychosomatic Medicine

Family Medicine; Family Practice; Urgent Care

Samantha Lynne Cunningham, DO

Anthony Francis Oliva, DO Administrative Medicine; Family Medicine

833 Calico Creek Dr Garner Joel Andrew Virkler, DO Orthopedic Sports Medicine; Orthopedic Surgery; Orthopedic Surgery, Adult Reconstructive

Triangle Orthopaedics, P.A. Durham Scott Sina Abedi, MD Diagnostic Radiology

UNC Hospitals Chapel Hill Andrew Patrick Ambrosy, MD Cardiology; Hospitalist; Internal Medicine

Duke University Medical Center Durham Armando Diego Bedoya, MD Internal Medicine; Pulmonary Disease and Critical Care

Duke University Hospitals Durham Joshua Norstrom Berkowitz, MD Internal Medicine; Pediatrics

UNC Hospitals Chapel Hill William Michael Bullock, MD Anesthesiology

Duke University Hospitals Durham Sara Tavernier Burgardt, MD Internal Medicine

UNC Hospitals Chapel Hill Bari Marissa Eberhardt Byrd, MD Obstetrics and Gynecology

UNC Hospitals Chapel Hill

UNC Hospitals Chapel Hill Cameron Frank Cavola, MD Maxillofacial Surgery

Capital Oral & Facial Surgery Holly Springs Ian Joseph Chaves, MD Radiology

Division of Musculoskeletal Imaging Durham Earl Michael Chester, MD Diagnostic Radiology; Radiology

Duke University Hospitals Durham Jeannie Collins, MD Addiction Psychiatry; Geriatric Psychiatry; Psychiatry; Psychiatry, Geriatric; Psychosomatic Medicine

UNC Hospitals Chapel Hill James Gregory Cox, MD Zirconia

Duke Urgent Care Raleigh Amanda Leigh Elliott, MD Internal Medicine; Urgent Care

Duke University Hospitals Durham Clayton Tyler Ellis, MD Abdominal Surgery; Colon and Rectal Surgery; Critical Care Surgery; General Surgery; Surgery; Surgery (general); Surgery - Surgical Critical Care; Surgical Oncology

UNC Hospitals Chapel Hill

Hospitalist; Internal Medicine

Duke Regional Hospital-Hospital Medicine Program Durham

Preston Robert Tisch Brain Tumor Ctr Durham Graydon Samuel Goodman, MD Emergency Medicine

UNC Hospitals Chapel Hill Jegan Gopal, MD Abdominal Surgery; General Surgery; Surgery

Duke Univ Med Ctr, Deparment of Surgery Durham Dilraj Singh Grewal, MD Ophthalmology

Duke Eye Center Durham

David Fleischman, MD

Johanna Kate Halfon, MD

Ophthalmology

Obstetrics and Gynecology

Duke University Eye Center Durham

Duke University OBGYN Durham

Christopher Scott Forsythe, MD

Elizabeth Merkle Hankollari, MD

Emergency Medicine

Hospitalist

UNC Hospitals Chapel Hill Stephen Andrew Gaeta, MD Cardiology; Cardiovascular Disease, Internal Medicine; Internal Medicine

Marin Elyse Darsie, MD

Duke University Medical Center Durham

Emergency Medicine; Neurological Surgery, Critical Care

Jared Robert Gallaher, MD

UNC Hospitals Chapel Hill

Neurology

Faye Rachel Farber, MD

Mary Elizabeth Currie, MD Pediatrics

Duke University Hospitals Durham Ashley Parham Ghiaseddin, MD

General Surgery

UNC Hospitals Chapel Hill

Anna Elise Teeter Dolgner, MD

Duke Hospital Durham Elisabeth Ann Heiser, MD Pediatrics

Goldsboro Pediatrics Goldsboro Alison Claire Herndon, MD Pediatrics

UNC Hospitals Chapel Hill Benjamin Michael Heyman, MD

Hospitalist; Internal Medicine; Pediatrics

Internal Medicine

UNC Hospital Chapel Hill

Duke University Hospital Durham

may/June 2014

News Welcome to the Area Nicholas Holdgate, MD

Michael Steven McGrath, MD

Lindsay Anne Magura Rein, MD

A.B.M Enayet Ullah, MD

Internal Medicine; Rheumatology

Orthopedic Sports Medicine; Orthopedic Surgery; Orthopedic Surgery, Adult Reconstructive; Orthopedic Surgery, Trauma

Hematology and Oncology, Internal Medicine

Internal Medicine

Duke University Hospitals Durham

I.M. Family Care Smithfield

Ashley Marie Rietz, MD

Emily Beth Vander Schaaf, MD

Family Medicine

Pediatric - Allergy/Immunology; Pediatric Critical Care Medicine; Pediatric Dermatology; Pediatric Emergency Medicine; Pediatric Rehabilitation Medicine; Pediatric Transplant Hepatology; Pediatrics

Duke Rheumatology and Immunology Durham Damon Eugene Houghton, MD Internal Medicine

University of North Carolina Chapel Hill Jennifer Rebecca Hughes, MD Pediatrics

Capitol Pediatrics Raleigh Julia Terese Hughes, MD Endocrinology, Internal Medicine; Gastroenterology, Hematology and Oncology, Infectious Diseases, Integrative Medicine; Critical Care Medicine

UNC Hospitals Chapel Hill Sanaz Javadi, MD Diagnostic Radiology; Nuclear Radiology; Radiology; Vascular and Interventional Radiology

Duke University Medical Center Durham

Duke University Medical Center Durham Deana Helen Miller, MD Pediatrics

Duke University Hospitals Durham Diane Lee Miller, MD Emergency Medical Services

UNC Hospitals Chapel Hill Aaron Philip Mitchell, MD Internal Medicine

Durham VA Medical Center Durham Clare Kelleher Mock, MD Hospitalist; Internal Medicine

Duke hospital medicine Durham Paul Nabeel Mogannam, MD Radiology

Cary

Malav Joshi, MD

Elizabeth Smith Nicholson, MD

Ophthalmology

Psychiatry

Duke Eye Center Durham

UNC Hospitals Chapel Hill

Lauren Ann Kilpatrick, MD

Nathan Coleman Nussbaum, MD

UNC Family Medicine Chapel Hill James Spencer Clayton Ronald, MD Angiography; Interventional Radiology; Body Imaging; Diagnostic Radiology; Diagnostic Roentgenology Radiology; Diagnostic Ultrasound; Interventional and Vascular Radiology; Neuroradiology; Nuclear Radiology; Pediatric Radiol

Duke University Hospitals Durham Dermatological Immunology; Dermatology Pediatric - Dermatology; Dermatopathology

Duke University Hospitals Durham Joseph John Rubelowsky, MD

Rebecca Eli Sadun, MD Internal Medicine; Pediatric Rheumatology; Pediatrics; Rheumatology, Internal Medicine

Duke University Hospitals Durham

Bryant G Oliverson, MD

Goldsboro Neurological Surgery Goldsboro

Neurological Surgery

Anesthesiology; Critical Care Medicine

Radiology

Duke University Hospitals Durham

Lauren Dalya Schiff, MD

Omobonike Oyindasola Oloruntoba, MD

University of North Carolina Obstetrics and Gynecology Chapel Hill

Norman Paul Litchfield, MD Psychiatry

Duke University Hospitals Durham Jeffrey Kyle Longnion, MD Anesthesiology; Anesthesiology - Pain Medicine; Anesthesiology Pain Management; Pain Management; Pain Medicine; Surgical Critical Care

Duke University Hospitals Durham Nicole Elizabeth Lopez, MD Abdominal Surgery; General Surgery; Surgery; Surgical Oncology

UNC Hospitals Chapel Hill

Duke University Hospitals Durham Leybelis Padilla, MD General Practice; Internal Medicine

UNC Hospitals Chapel Hill Jacquelyn Knupp Patterson, MD Adolescent Medicine; Critical Care Pediatrics; Neonatal-Perinatal Medicine; Pediatric Emergency Medicine; Pediatrics

UNC Hospitals Chapel Hill Morgan Uriah Amanda Patterson, MD Psychiatry

UNC Hospitals Chapel Hill

Kashif Mazhar, MD Otolaryngic Allergy; Otolaryngology Plastic Surgery Within the Head &amp; Neck; Otolaryngology - Sleep Medicine; Otology; Otorhinolaryngology; Pediatric Otolaryngology

Carolina ENT Raleigh Jennifer Jo McEntee, MD Hospitalist; Internal Medicine; Pediatrics; Public Health

Duke Hospital Medicine Durham

The Triangle Physician

Brett Thomas Phillips, MD Abdominal Surgery; Colon and Rectal Surgery; Critical Care Surgery; Facial Plastic Surgery; Head and Neck Surgery; Maxillofacial Surgery; Pediatric Surgery; Reconstructive Surgery; Plastic Surgery/Hand Surge

Duke University Medical Center, Division of Plastic and Reconstructive Surgery Durham

Apex David Lloyd Wells II, MD Maxillofacial Surgery

Nu-Image Surgical Center Raleigh

Duke University Hospitals Durham

Victoria Rene Samuels, MD

Gastroenterology, Internal Medicine; Internal Medicine

Lynne Beth Willing Weisberg, MD

Shaina Marissa Willen, MD

Duke University Hospitals Durham

9619 Allsbrooke Drive Raleigh

WakeMed Health & Hospital Raleigh

Wake Speciality Physician-Carolina Cardiovascular Surgical Associates Raleigh

UNC School of Medicine Chapel Hill

Emergency Medicine

Hospitalist; Internal Medicine; Pediatrics

Thoracic Cardiovascular Surgery; Thoracic Surgery; Vascular Surgery

Hematology and Oncology, Internal Medicine; Hospitalist; Internal Medicine

Christine Thomas Knettel, MD

Paul VanSweden, MD

Psychiatry

Leah Scanlin Ronald, MD

Otorhinolaryngology; Pediatric Otolaryngology

Rebecca Yasmin Klinger, MD

UNC Hospitals Chapel Hill

Obstetrics; Gynecologic Surgery

Gary Robert Schooler, MD Pediatric Radiology; Radiology

Duke Univ Medical Center Durham Michael I Seider, MD Ophthalmology

Duke University Health System Durham Jennifer Irene Sherwin, MD Pediatrics

Durham Brianne Jo Steele, MD Emergency Medicine

Duke University Medical Center, Dept of Emergency Medicine Durham

Pediatrics

John Howard Williams, MD Emergency Medicine; Internal Medicine

Raleigh Nicholas Graham Wysham, MD Pulmonary Disease and Critical Care, Internal Medicine

Duke University Hospitals Durham Sunny Yadav, MD Hospitalist

Chapel Hill Michael Kuo-Pin Yu, MD Neuroradiology; Radiology, Neuradiology

Duke University Hospitals Durham Paul Eric Zimmerman, MD Hospitalist; Internal Medicine

Durham Regional Hospital-Hospital Medicine Durham Moboluwade Duduyemi AbeLathan, PA Dermatology; MOHS-Micrographic Surgery

Raleigh Skin Surgery Center Raleigh Rebecca Boyle, PA Blood Banking/Transfusion Medicine; Hospice and Palliative Medicine; Medical Oncology; Neoplastic Disease

Durham VA Medical Center Durham

Bryan Dwayne Stup, MD

Cara Lee Gambill, PA

Pediatrics

Orthopedic, Hand Surgery

Goldsboro Pediatrics Goldsboro

Duke Orthopaedics Durham

Arturo Suarez, MD Anesthesiology - Critical Care Medicine

Duke University Medical Center Durham Elizabeth Anne Foard Tucker, MD Pediatrics

UNC Hospitals Chapel Hill

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