november 2016
Carolina Spine Center
Creating a Positive Experience for Those with Spine Pain
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 Merger Shakeup Psoriasis Strides
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T
From the Editor
Game Changer Carolina Spine Center, this issue’s cover story, thrives on positivity and good humor, a game-changing attitude. If it doesn’t attract
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
clients or personnel, it certainly is part of the formula for keeping them. The positive, can-do spirit of practice founder, interventional spine physiatrist Paul Singh, has enabled him to provide life-enhancing spine care to patients in underserved and larger metropolitan areas at the same time! This attitude runs throughout the practice, strengthening teamwork and enhancing patient care. Louis Torres, who also is an interventional spine physiatrist, recently joined Dr. Singh and his medical team. Skill areas for both physicians include minimally invasive, X-ray-guided pain-relief procedures. Dr. Singh has special expertise in cervical transforaminal epidural steroid injections. Dr. Torres brings expertise in musculoskeletal ultrasounds, which will be provided in the near future.
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Laura D. Briley, M.D. Marni Jameson Carey Margie Satinsky, M.B.A. Creative Director Joseph Dally jdally13@gmail.com
Advertising Sales info@trianglephysiciancom
Currently, the Carolina Spine Center staff is seeing Cary patients at Total Joint Care, while its new location is under construction. The new Cary office will
News and Columns Please send to info@trianglephysician.com
open this coming January. The Carolina Spine Center staff also sees patients in its Rockingham, N.C., office.
The Triangle Physician is published by: New Dally Design
Also in this issue of The Triangle Physician dermatologist Laura Briley explores
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advances in treating psoriasis. Physician advocate Marni Jameson Carey discusses the hospital merger arguments that helped reverse a court decision and may have far-reaching implications. Practice consultant Margie Satinsky
Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
reviews two aspects of patient portals, functionality and Health Insurance Portability and Accountability Act privacy and security issues. Consider submitting your medical insight or practice news to complement the editorial content of upcoming issues of The Triangle Physician. We will run it as space allows, at no cost. Or considering featuring your practice on the cover of an upcoming issue, a game-changing marketing strategy, if you consider that this magazine reaches more than 9,000 professionals in the Raleigh-Durham medical community. Articles that enlighten readers about a practice’s strengths typically lead to increased referrals. Contact info@trianglephysician.com for more information.
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.
With gratitude for all you do,
Heidi Ketler Editor
2
The Triangle Physician
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.
Table of Contents
4
COVER STORY
Carolina Spine Center
Creating a Positive Experience for Those with Spine Pain n ovember 2016
V o l . 7 , I ss u e 1 0
FEATURES
7
Physician Advocacy
8 Practice Management Patient Portals and
Independent Doctors Help FTC Win Appeal to Stop Hospital Merger Marni Carey discusses arguments in a trade association amicus brief that resonated with the court.
10
DEPARTMENTS HIPAA Compliance
11 News Antibody Shown to Soothe Raging, Nerve-Driven Poison Ivy Itch
Dermatology
Expanded Treatment Improves Overall Health of Patients with Psoriasis
11
12 News Botox May Beat Neural Stimulation for Urge Incontinence, But Has Risks
Laura Briley explores the benefits of advanced medications and
13 News
their broader quality-of-life significance.
Welcome to the Area
november 2016
3
Cover Story
Carolina Spine Center Creating a Positive Experience for Those with Spine Pain Having an optimistic attitude, creating a
miles from his home in Cary and a place
my upbeat demeanor reminded a patient
positive culture and connecting with oth-
he had never been to. At the same time,
of Aziz Ansari, an actor and comedian
ers have been core values of interventional
Richmond County hospital administra-
who was raised in Bennettsville.”
spine physiatrist Paul G. Singh, M.D., since
tors tasked him with starting an additional
establishing Carolina Spine Center in 2009.
practice in Bennettsville, S.C.
According to Dr. Singh, these same quali-
“Starting one office was a challenge, but
in which the board “was incredibly kind
ties that define his practice today were de-
another at the same time in a different
to assist me with a financial grant for pro-
veloped early on in his medical practice.
state, was an even tougher task,” said Dr.
viding medical care in their underserved
He had accepted the opportunity to build
Singh. “I was fortunate in that after work-
region.”
a practice in Richmond County, N.C., 100
ing in Bennettsville for a period of time,
The patient, a member of the hospital board, was inspired to initiate a meeting
Dr. Paul Singh performs a lumbar transforaminal epidural to ease nerve inflammation and associated pain.
4
The Triangle Physician
The years went by. “Patients in the area ap-
Positive Practice Culture
One-on-one review of imaging and edu-
preciated my care and commitment, and
In order to provide a positive patient ex-
cation during patient visits also are key
I found that my time there deepened my
perience, Dr. Singh believes that it starts
to patient satisfaction. “I have found that
fulfillment in medicine.” In 2011 Dr. Singh
with the staff and how they feel about the
people appreciate seeing the imaging of
returned to Cary, where he developed
practice they work at.
their spine and understanding it as I see it relate to their spine health and issues,”
a working relationship with Cary Orthopedics, while also continuing to operate
“I have been fortunate that the staff mem-
Carolina Spine Center in Rockingham, N.C.
bers I work with are people I genuinely re-
says Dr. Singh.
spect, care about and enjoy working with.
The Medical Team of
In June 2016, Dr. Singh decided to ex-
They are my friends, and I fully accept that
Carolina Spine Center
pand Carolina Spine Center to Cary and
the practice functions because of their
Dr. Singh works with a capable, compas-
forged a partnership with Total Joint
dedication. What we do for people, we do
sionate team.
Care, the office of orthopedic surgeon
together, but in large part because they
Stephen G. Struble, M.D. Dr. Singh and
make it happen,” says Dr. Singh.
Louis Torres, M.D., joined the practice in July as a fellowship-trained, interven-
his team are currently serving patients at Total Joint Care, while the new office for
“I have been fortunate in not losing any
tional spine physiatrist after recently
Carolina Spine Center is under construc-
staff member for a better employment
completing fellowship training. “Having
tion in Parkway Professional Park in Cary.
opportunity in the seven years I’ve prac-
Dr. Torres join the team has been incred-
He expects to be treating patients at the
ticed. Their well-being and happiness
ible – he’s great with patients and skilled
new location in January 2017.
mean a lot to me, and I am committed to
in procedures. He’s truly been a great
them as they are committed in creating a
friend and fun to share a laugh with. We
Interventional Spine Care Services
positive culture. The staff thrives on the
share thoughts about how to help pa-
Dr. Singh is board-certified in physical
autonomy to provide excellent care to all
tients and often see them together. He’s
medicine and rehabilitation and is fel-
those we serve, which contributes to our
made his time with the practice enjoy-
lowship trained in interventional spine
progress,” says Dr. Singh.
able for all of us.”
diagnosis and rehabilitation of musculo-
When working with patients, it’s important
Dr. Torres is competent in all interven-
skeletal injuries.
to Dr. Singh to understand each patient as
tional procedures and has extensive
care. As a physiatrist, he is trained in the
a person and not as a symptom or diagno-
training and ability in musculoskeletal
Rigorous fellowship training and nine
sis. “Having empathy and connecting to
ultrasound, a service Carolina Spine Cen-
years of experience in interventional
people’s lives is the best aspect of my job
ter intends to provide in the near future.
spine care have given Dr. Singh skill in
and what keeps the day fun.”
the use of minimally invasive, X-ray-guided procedures that provide pain relief for those with painful spinal disorders. “One particular area of procedural expertise that I have developed is cervical transforaminal epidural steroid injections that deliver corticosteroid directly around an inflamed nerve in the cervical spine.” These elective procedures often decrease, and even resolve, longstanding pain in the neck and back and can at times prevent or delay the need for surgical intervention. “Because of our ease and efficiency with fluoroscopic injections, we are able to accommodate people’s need for sameday service,” says Dr. Singh.
november 2016
5
Meet the Physicians Paul G. Singh, M.D.
Paul G. Singh is
Neema Patel, N.P.,
but our plan is to be more accessible for
works
with
patients by the new year,” says Dr. Singh.
Singh
in
Dr. Cary
and Rockingham.
Dr. Singh and Dr. Torres plan to introduce
“Neema is wonder-
to the practice proven, emerging thera-
diana, where he
ful with people,
peutic options for those with spine and
completed his un-
she
musculoskeletal pain.
dergraduate stud-
at summarizing a
ies at the University of Notre Dame.
person’s medical history and pertinent
All the while, patients can count on the
details, which allows me to focus on the
same uplifting practice spirit. “I believe
person and their spine. She is very detail
that as long as we continue to make the at-
oriented and meticulous and conscien-
mosphere positive and one where people
cine and Science/Chicago Medical
tious in her care. I am fortunate to have
want to work and receive care, it’s going
School and completed his residency
her as a friend and colleague.”
to be a fun journey to help patients who
originally from In-
He earned his medical degree at Rosalind Franklin University of Medi-
is
amazing
need our services,” says Dr. Singh.
at Rush University Medical Center in Chicago. He completed a fellowship in Interventional Spine at the University of Pennsylvania. Dr. Singh has been in practice for nine years and
Ava White, N.P., also works with Dr. Singh in Rockingham. Ava has over 30 years of
Contact Information
experience as a medical provider, and
Patients are being accepted at both con-
“her greatest strength is her ability to re-
venient Carolina Spine Center locations:
late to patients as people,” Dr. Singh says.
• 115 Parkway Office Court, Suite 101,
enjoys spending time with his family and playing tennis.
Cary, N.C., 27518 (currently the office The Future of Carolina Spine Center It is an exciting time for Carolina Spine
Louis A. Torres, M.D. Originally
from
Chicago, Louis A. Torres
attended
of Total Joint Care) • 809 S. Long Drive, Suite G, Rockingham, N.C. 28379.
Center. With a new office under construction, the hope is to increase access to
For more information and to schedule
care in Cary and continue to deliver care
an appointment, call (910) 997-3733.
in Rockingham.
The fax number is (910) 997-3707. Visit
Northwestern Uni-
the Carolina Spine Center website at
versity, where he
“We are currently available Mondays and
competed on the collegiate swim
Wednesdays in Cary at Total Joint Care,
www.carolinaspinecenter.com.
team while completing his undergraduate studies. He earned his medical degree at Ross University School of Medicine in Dominica and completed his residency in physical medicine and rehabilitation at MedStar Georgetown University Hospital/National Rehabilitation Hospital in Washington, D.C. He completed a fellowship in Interventional Spine and Sports at OSS (Orthopedic and Spine Specialists) Health in York, Pa. Dr. Torres says he has enjoyed the transition to the Triangle area, and he and his wife are looking forward to raising their young children here. The Carolina Spine Center medical team treats patients with personalized, leading-edge care in an upbeat, positive way.
6
The Triangle Physician
Physician Advocacy
Independent Doctors Help FTC Win Appeal to Stop Hospital Merger By Marni Jameson Carey
In a legal victory announced in late Sep-
they can negotiate higher reimbursements,
tember that many believe will help slow
which drives up health care costs.
the unhealthy wave of hospital mergers in
Marni Jameson Carey is the executive director of the Association of Independent Doctors. You may reach her at (407) 571-9316 or marni@aid-us.org. Visit www.aid-us.org for more information.
America, the Federal Trade Commission
Meanwhile, AID and other health care
successfully put the brakes on a merger
insiders are awaiting the outcome of an-
under way in Central Pennsylvania between
other merger decision in northern Illinois.
Penn State Hershey Medical Center and Pin-
AID filed a second amicus brief on behalf
nacleHealth System. The decision came
of the FTC to prevent the merger of Advo-
from the U.S. Court of Appeals for the Third
cate Health Care and NorthShore Univer-
Circuit.
sity HealthSystems, a proposed $7 billion
Leaders in the health care industry are
merger. That case, which is pending, is with
watching these decisions closely, as they
The Association of Independent Doctors, a
the U.S. Court of Appeals for the Seventh
will set the tone for future hospital mergers,
national trade association based in Winter
Circuit.
he said. AID is a three-year-old nonprofit with members in 30 states coast to coast.
Park, Fla., helped the FTC achieve the victory, which has nationwide ramifications.
In 2015, the number of hospital transac-
AID filed a friend-of-the-court opinion, also
tions grew by 18 percent from the pri-
known as an amicus brief, on behalf of
or year and by 70 percent from 2010,
the FTC arguing that if the hospital were permitted to merge, competi-
according to Becker’s Hospital
tion would be reduced and costs
Review. The Affordable Care Act is driving much of this consoli-
would go up considerably.
dation by reinforcing the notion that there is safety in size.
In siding with the FTC, the appeals court reversed a lower
Like all hospitals seeking to
court’s order that would have allowed the merger to proceed while
merge, these entities promised
the government agency looked into
that together they would lower prices by creating greater efficien-
the potential negative impacts.
cies. However, studies prove other-
But the verdict did more than slow the
wise: Consolidation unilaterally raises
merger down pending the analysis: After
prices.
losing the appeal, the two hospital systems decided to abandon their merger plans altogether.
“The FTC wasted no time letting the Sev-
We are proud to be a part of a decision that
enth Circuit know about the Third Circuit
is not only healthy for the citizens of central
Studies repeatedly show that when hos-
win,” said attorney Charles Artz of Har-
Pennsylvania but also for all of America. We
pitals consolidate, they harm communi-
risburg, Pa., who filed the amicus brief on
hope the Seventh Circuit also views the Il-
ties by forming monopolies. Because they
behalf of AID.
linois hospitals merger with the same clear headedness.
have more bargaining power with insurers,
november 2016
7
Practice Management
Patient Portals and HIPAA Compliance By Margie Satinsky, M.B.A.
A patient portal that allows patients to
pliance. At the June 2016 NCHICA Confer-
communicate securely with your practice is
ence on Managing Security & Privacy in an
an effective way to actively involve patients in
Environment of Increased Risk & Threats,
their own health. A growing body of evidence
portal compliance issues were a significant
demonstrates that patients who are actively
concern. We’ll share the highlights with you.
involved in their own health and in the care they receive have better outcomes and less
Patient Requests for Information
costly care than patients who are uninvolved.
HIPAA grants patients the right to access their protected health information (PHI)
In this article we’ll review two important as-
in a “designated record set” or snapshot of
pects of patient portals, functionality and
the complete medical record. Here’s the
Health Insurance Portability and Accountabil-
reasoning behind the concept:
ity Act (HIPAA) privacy and security issues. Patients don’t always need the entire medical
Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She has helped many physicians start new practices, assess the wisdom of affiliating with a larger health care system and improve their current practices. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www.satinskyconsulting.com.
With respect to functionality, a patient portal
record. More often than not, they need infor-
can enhance patient engagement by creat-
mation related to a specific visit, condition,
to PHI – including but not limited to PHI that
ing an easy and secure way to communicate
test result or situation. Patients also have the
is available through the patient portal – to
electronically. Although not all portals offer
right to request that their information be sent
others. Covered entities are required to ask
the same options and not all providers use
in a particular electronic format, provided that
each patient to sign an authorization to use
all of the options available to them, here are
it is “readily producible.” An example might
and disclose PHI. That form might include a
the most common:
be a thumb drive. The covered entity retains
specific item about portal access.
• Exchange secure email with the health
the right to deny access to the requested infor-
care team • Request (and sometimes make) non-urgent appointments
mation for numerous reasons, among them
Covered
the potential to endanger the life of the patient
precautions to protect portal access. They
entities
can
take
additional
or another individual.
might require that portal registration be done in the office and/or under the supervision
• Receive appointment confirmation and Given these rules, the covered entity must
of staff. They also might require that every
• Request prescription refills
recognize that a patient may request more
portal user, including patients and others
• Check benefits and coverage
than he/she might automatically receive
authorized by patients, register separately
• Update contact information
through the portal. The patient also may
in order to track portal usage. And finally,
• Download (and sometimes fill out and
request information in a format other than
they can confirm portal signup by a method
return) forms for patient demographic
what appears in the portal. Finally, not all
called out-of-band communication, i.e. by
information and medical history
patients use the portal, so the covered entity
sending an email to verify that portal signup
must offer other options.
has occurred.
Authorization to Access Information through the Patient Portal
Patient Restrictions on Using and
What about authorization to access informa-
Patients have the right not only to authorize
tion through the patient portal? In some in-
access to their PHI, be it available or not on
In our experience, portal functionality re-
stances, only the patient accesses the portal.
the patient portal. That same authorization
ceives far more attention than portal com-
In other instances, the patient gives access
to use and disclose PHI gives patients the
reminders
• View patient balance and pay bills online • View normal test results • Obtain visit summary information • Obtain patient education materials recommended by the practice
8
The Triangle Physician
Disclosing PHI
Practice Management opportunity to restrict the sharing of their PHI by category of information (e.g., behavioral health, HIV status, pregnancy) and by the patient’s relationship to an individual (e.g., spouse, parent, child). Patients who pay out-of-pocket for a service also have the right to request that information on the care delivered not be sent to an insurer. Given these patient rights, covered entities must be able to segregate specific information, so it remains outside of the “designated record set.” It’s best to work with the software vendor(s) to determine the best method to segregate information upon patient request. Suggested Action Steps Here are four proactive steps that covered entities can take to ensure their patient portal meets HIPAA compliance requirements. • Include the patient portal in the security risk analysis that is performed each year in order to identify and correct any problems.
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• Finally, audit the use of the portal on a regular basis in order to identify suspicious patterns and correct problems. The print version of the October issue of The Triangle Physician included an article on changes in Medicare reimbursement that was written prior to CMS’ issuance of the Final Rule on Oct. 14, 2016. The Final Rule made important changes in clinician eligibility for participation, timing and weighting of quality measures. For an updated article, please contact margie@satinskyconsulting.com, and we’ll provide a PDF of the corrected information. We apologize for the inconvenience.
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Physician Advocacy
Expanded Treatment Improves Overall Health of Patients with Psoriasis By Laura D. Briley, M.D.
During the past 15 years, targeted treatment
for psoriasis, such as Cosentyx, Otezla and
approaches and medications with fewer
Taltz, are now available.
side effects have expanded the options for patients with severe psoriasis.
When treating a psoriasis patient it is important to consider the presence of associated
The goal of treatment in most autoimmune
diseases, such as heart disease, obesity, dia-
diseases is to suppress the immune system
betes and depression. Many patients also
from attacking the body. In the past,
have arthritis, which limits their ability to
medications for psoriasis suppressed the
lead a healthy, active lifestyle.
entire immune system, but now treatments target the part of the immune system that is
Compounding
over active. This leads to fewer side effects
emotional toll of being shunned by those
the
challenges
is
the
and greater tolerability.
who wrongly believe that the scaling plaques of psoriasis are contagious. Patients
Dr. Laura Briley specializes in general adult and pediatric dermatology, dermatologic surgery, cosmetic dermatology and skin cancer. She graduated from Wake Forest University and earned her medical degree from the Brody School of Medicine at East Carolina University. She completed her internship at Roger Williams Medical Center in Providence, R.I., and her residency at the Brody School of Medicine. Dr. Briley is a member of the American Academy of Dermatology, American Medical Association and Alpha Omega Alpha Honor Society.
Methotrexate, Soriatane and Cyclosporine
frequently describe being brought to tears
used to be some of the only options for pa-
in situations where people don’t want to
tients with severe psoriasis who failed ultravi-
touch them and otherwise make them feel
olet light therapy and topical corticosteroids.
dirty or contaminated. All of these issues
Regular primary care visits are needed to
However, all of these medications have seri-
can lead to severe depression, alcoholism
coordinate care provided by cardiology,
ous side effects, such as deleterious effects
and substance abuse.
rheumatology, dermatology and nutritional providers. Stress reduction and assessment
on liver, kidneys and blood pressure. With treatment, clearing the skin and help-
of mental health is essential. As these pa-
Biologic medications, such as Enbrel,
ing the joints can enable individuals with
tients are on medications that suppress the
Humira and Stelara, have proven over time
psoriasis to lead healthier lives and greatly
immune system, it is important that they not
to have milder side effects that are well
reduce the emotional burden. Management
delay normal skin cancer screenings.
tolerated. Excitingly, even more medications
of the comorbidities requires a team of health care providers.
Patient education is a key component in care. The better a patient’s understanding of their skin condition and related health issues, the more empowered they can be to take charge of their own health. Only with proper understanding can one be convinced to adopt a healthier lifestyle. Proper treatment of the skin and joints often can result in the patient becoming more active and feeling less depressed. Awareness of the comorbidities of psoriasis can help elevate the priority one gives to stress reduction, a healthy diet and regular screenings.
10
The Triangle Physician
News
Antibody Shown to Soothe Raging, Nerve-Driven Poison Ivy Itch Scientists at Duke Health and Zhejiang Chinese developed
Medical a
University
strategy
to
stop
have the
uncontrollable itch caused by urushiol, the oily sap common to poison ivy, poison sumac, poison oak and even mango trees. The team found that by blocking an immune system protein in the skin with an antibody, they could halt the processes that tell the brain the skin is itchy. The hope is the model could lead to potential treatments for people who are allergic to poison ivy – an estimated 80 percent of the population. The research was done in mice and is
A fluorescence microscope image shows the skin of a healthy mouse (left) and skin from a mouse with a poison ivy rash (right). Interleukin-33, shown in green stain, is a protein that acts directly on the nerves, telling the brain the skin is extremely itchy. Credit: Sven-Eric Jordt/Duke Health
severe itching doesn’t go away with
found they could also alleviate itch by
antihistamines, because it arises from a
blocking a receptor for IL-33, called ST2.
different source, Dr. Jordt said. “There could be translational significance
described in the Nov. 7 Proceedings of the Dr. Jordt and collaborators determined
here,” Dr. Jordt said. “So our next step will
the itch is triggered by interleukin 33
be to look at human skin to see if we see
For most people, contact with poisonous
(IL-33), a protein in the skin involved in
the same activity and the same pathways.
plants is painful but not life threatening.
immune response.
We will also look at anti-inflammatory
National Academy of Sciences.
drugs that are already approved to see if
Still, there are significant health care costs associated with more than 10 million
All people have IL-33 in their skin, but
people in the United States affected
the protein is elevated in people who
each year, said senior author Sven-
have eczema and psoriasis, Dr. Jordt
In addition to Dr. Jordt, study authors
Eric Jordt, Ph.D., associate professor of
said. The protein is known for inducing
include Boyi Liu, Yan Tai, Satyanarayana
anesthesiology at Duke.
inflammation, but these new experiments
Achanta, Melanie M. Kaelberer, Ana I.
show the protein also acts directly on the
Caceres, Xiaomei Shao and Jianqiao Fang.
they have the potential to alleviate itch.”
“Poison ivy rash is the most common
nerve fibers in the skin, exciting them and
allergic reaction in the U.S., and studies
telling the brain that the skin is severely
The research was supported by the
have shown that higher levels of carbon
itchy.
Duke Anesthesiology DREAM Innovation Grant (2015-DIG LIU), Zhejiang Chinese
dioxide in the atmosphere are creating a proliferation of poison ivy throughout
The researchers used an antibody to
Medical
the U.S. – even in places where it wasn’t
block IL-33 and found that it not only
(722223A08301/ 001/004), the National
growing before,” Dr. Jordt said. “When
reduced inflammation, but also cut
Natural Science Foundation of China
you consider doctor visits, the costs of
down scratching in mice with poison
(81603676) and three National Institutes of
the drugs that are prescribed and the lost
ivy rashes. An antibody that counteracts
Health: the National Center for Advancing
time at work or at school, the societal
human IL-33 is currently being evaluated
Translational Sciences (UL1 TR001117),
costs are quite large.”
in humans through a Phase 1 clinical trial
the National Institute of Environmental
to determine its safety and potential side
Health Sciences (R01 ES015056, U01
effects.
ES015674) and the National Institute of
Some symptoms of the fiery, blistering
University
Start-Up
Funding
Arthritis and Musculoskeletal and Skin
rash can be alleviated with antihistamines and steroids. But in recent years,
In an additional approach tested in the
Disease (R21 AR070554). The authors
scientists have determined that the most
mouse experiments, the researchers
declare no conflicts of interest.
november 2016
11
News
Botox May Beat Neural Stimulation for Urge Incontinence, But Has Risks bladder
The findings were published Oct. 4 in
The study involved 381
incontinence, the urge to urinate can come
the Journal of the American Medical
women from nine United
on suddenly and sometimes uncontrollably,
Association.
States medical centers that
When
women
suffer
from
recorded at least six ur-
leading to leakage. Patients looking for relief
gency incontinent episodes
can initially opt for first- and second-line
An injection of botulinum toxin in the
therapies, such as drinking fewer liquids or
bladder muscle works to address urgency
caffeinated beverages, pelvic floor muscle
urinary incontinence by relaxing the over-
days and had not improved with other treat-
training and medication.
active bladder muscles that cause the con-
ments.
Cindy L. Amundsen, M.D.
during three consecutive
dition. A sacral neuromodulation implant If those treatments prove inadequate,
does the same thing by sending electrical
The participants were randomly assigned
however, patients may seek more invasive
pulses to nerves in the spine.
to either receive sacral neuromodulation or a 200-unit injection of botulinum
options, including a form of nerve stimulation called sacral neuromodulation
“Urgency urinary incontinence is common,
toxin. After a trial period to test their
(an implanted device sold as InterStim) or a
with 17 percent of women over age 45 and
responsiveness to the therapies, 364
bladder injection of botulinum toxin, which
25 percent of women over age 75 suffering
women were enrolled and followed for six
is sold as Botox.
from it,” said Cindy L. Amundsen, M.D., the
months after treatment.
study’s lead author and the Roy T. Parker A head-to-head comparison of sacral
Professor of Obstetrics and Gynecology at
The study team analyzed the number of
neuromodulation and botulinum toxin led
Duke University School of Medicine. “That’s
urgency incontinent episodes on monthly
by a Duke Health researcher shows that
why it’s important for both patients and
“bladder diaries.” Participants who received
Botox provides more daily relief for women
health care providers to have information
botulinum toxin saw their number of daily
but might also be associated with more
that can guide their choice between these
urgency incontinent episodes decrease by
adverse events.
two therapies.”
3.9 on average versus 3.3 on average in the sacral neuromodulation group. The difference was statistically
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significant. Botulinum toxin participants also reported a greater reduction in bothersome symptoms, higher satisfaction with treatment and a greater likelihood of endorsing the treatment. Additionally, among participants who completed at least four monthly
diaries,
a
higher
percentage of botulinum toxin participants saw at least a 75 percent reduction in or complete resolution of urgency incontinent symptoms. However, the Botox patients also had three times the rate of urinary
12
The Triangle Physician
News tract infections. Some botulinum toxin
Amundsen said. “The information should
Yuko M. Komesu, Lily A. Arya, W. Thomas
participants also required intermittent self-
help guide care.”
Gregory, Deborah L. Myers, Halina M. Zyczynski, Sandip Vasavada, Tracy L. Nolen,
catheterization, although at lower rates than reported in previous studies using this dose.
While the study did not compare the cost
Dennis Wallace and Susan F. Meikle.
of the two treatments, Dr. Amundsen noted For the sacral neuromodulation partici-
that patients who receive botulinum toxin
The study was funded by the Eunice
pants, the most common adverse event was
may require additional injections as part
Kennedy Shriver National Institute of Child
removal or revision of the implant during
of continued treatment. Additionally, the
Health and Human Development and
the six months. This occurred at a low rate,
study only takes Botox into account, and
the National Institutes of Health Office of
similar to previous studies.
no conclusions can be drawn for other
Research on Women’s Health 3316.
botulinum toxin preparations that may be “This study is valuable because it is the first
used to treat urgency incontinence.
One co-author reported financial relationships with the commercial makers of both
randomized trial comparing the efficacy of two FDA-approved, third-line therapies
In addition to Dr. Amundsen, co-authors
InterStim and Botox. Full disclosures are
in a severely affected population,” Dr.
include Holly E. Richter, Shawn A. Menefee,
available in the study’s manuscript.
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