November
2 013
Cary Gastroenterology Associates
Safeguarding Patient Health with Quality, Comprehensive Care
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
Autism Warning Signs Osteoarthritic Hand
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COVER STORY
6
Cary Gastroenterology Associates Safeguarding Patient Health with Quality, Comprehensive Care
November 2 0 1 3
FEATURES
9
Psychiatry
DEPARTMENTS 10 Practice Management
20 Community Support
Myself: Together Again Advances Awareness of Breast Reconstruction
The Clock Is Ticking
12 Women’s Health
Autism Spectrum Disorder: Early Intervention Is Important, Know the Early Warning Signs Dr. Linmarie Sikich reports on the STORY study, which is seeking children 18-60 months old and not yet diagnosed.
11
Vol. 4, Issue 10
Women May Be Able to Delay Having Children by Freezing Eggs
Update on Treatment for Patients with Osteoarthritis of the Hand Dr. John Erickson discusses the nonsurgical and surgical options, including the effectiveness of thumb carpometacarpal joint arthroplasty.
14 Gastroenterology Functional Vomiting Syndromes
15 Duke Research News HPV Vaccines May Not Equally Help African-American vs. White Women
16 Duke Research News Orthopedic Surgery
21 UNC Research News
Spinal Fusion Material Increases Risk of Benign Tumors, Not Cancer
17 Duke Research News
-F indings Indicate Moderate Exercise Does Not Increase Knee Osteoarthritis -F indings Suggest New Route to Better Fragile X and Autism Treatments
22 UNC Research News Study Provides Strongest Clues for Causes of Schizophrenia
23 UNC Research News Molecular Findings Could Lead to New Therapies for Treating Septic Shock
Inducing and Augmenting Labor May Increase Risk of Autism
24 News
18 Duke News
25 Rex News
Vice Dean Sally Kornbluth Is Elected to Prestigious Institute of Medicine
19 WakeMed News
Gintzig named Interim President/CEO
Welcome to the Area
-C ancer Care Practice Opens in Garner -N ational Hospital Reports Give Rex Top Marks for Quality and Safety
COVER PHOTO: The physicians with Cary Gastroenterology Associates are (from left, standing) Michael J. Brody, M.D.; Michael G. DeLissio, M.D.; Stephen J. Furs, M.D.; Jeevan J. Pai, M.D.; and Michael R. Pike, M.D.; and (sitting) Juliana Miller, M.D.; and Shannon Scholl, M.D.
2
The Triangle Physician
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Now Referring Doctors And Their Patients Have The Advantage Of A Rheumatology Specialist Here, Close To Home.
Anshul M. Rao, MD, of Clayton, a rheumatologist, is seeing adult patients at offices in the Medical Arts Pavilion on the campus of Johnston Medical CenterSmithfield and at the Johnston Professional Plaza on the campus of Johnston Medical Center- Clayton. Dr. Rao is a graduate of the University of Toledo Medical College. In 2012, he completed a fellowship in rheumatology at University Hospitals Case Medical Center in Cleveland, Ohio. He practiced one year in neighboring Wayne County, before joining us here at Johnston Health. Dr. Rao’s objective is to offer a myriad of treatments that allow patients to maintain and A short continue their quality of life. time If you have patients who you think could benefit ago, from seeing Dr. Rao, call for an appointment Caleb 919-934-3022 Thornhis coastal
ton feared carefree days of fishing might be over. One evening, Caleb’s heart rate suddenly became extremely elevated, and his family wisely called 911. A few minutes later he was rolled into Johnston Medical Center - Smithfield, one of Johnston Health’s two accredited Chest Pain Centers. He was quickly Healing Neighbors - It’s What We Do. It’s Who We Are! diagnosed with AtrialIt’s Fibrillation, aHealing condition that, Neighbors... What WeTwo Do -Accredited It’s Who WeChest Are!Pain Centers Healing Neighbors... What We Do - It’s Who We Are!It’s SMITHFIELD CLAYTON left untreated, could lead to stroke and other Mon. Wed. Fri. Tues. & Thur. complications. He was given treatment that converted 507 N. Bright LeafMedical Blvd. Center 2076 Johnston HwyMedical 42W Center Johnston Suite 100Smithfield Suite Clayton 330 509 N. Bright Leaf Blvd. 919-934-8171
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From the Editor
Quality Shines 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
Cary Gastroenterology Associates’ dedication to patient-focused, quality care shines through in this month’s cover story.
This year it opened a new full-service office in Holly Springs for added convenience. It also opened Cary Gastroenterology Women’s Center for GI Health to exclusively care for conditions unique to females. And Blue Cross Blue Shield gave Cary Gastroenterology Blue Select Tier 1 status for clinical quality, cost efficiency and accessibility. These are just a few examples, so read more beginning on page 6.
Also this month, gastroenterologist Douglas Drossman starts a two-part series on functional vomiting syndromes. Two new contributing editors broaden awareness of the important issues and information related to their specialty areas. Orthopedic surgeon John Erickson outlines options for alleviating symptoms of the osteoarthritic hand. Psychiatrist Linmarie Sikich urges medical practitioners to be aware of the early
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors John M. Erickson, M.D. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Linmarie Sikich, M.D. Joe Reddy Creative Director Joseph Dally jdally@newdallydesign.com
Advertising Sales info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com
warning signs of autism spectrum disorder.
The Triangle Physician is published by: New Dally Design
Dr. Andrea Lukes returns with the latest on egg banking, now available for healthy
Subscription Rates: $48.00 per year $6.95 per issue
women who choose to delay having children. Practice management expert Joe Reddy is back with a reminder about the ICD-10 conversion deadline, Oct. 1, 2014, and the obstacles medical practices will need to hurdle before then.
Thanks to the all who contributed to making this a great issue of The Triangle Physician for our more than 9,000 readers – physicians, physician assistants, nurse practitioners, office administrators and other medical professionals within this region. Contact me at heidi@trianglephysician.com to learn about opportunities to showcase the qualities that distinguish you and your practice.
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Cover Story
Cary Gastroenterology Associates Safeguarding Patient Health with Quality, Comprehensive Care By Heidi Ketler
Cary Gastroenterology Associates has
seen that rare disease before or tried one of
lege of American Pathologists (CAP) certi-
thrived for 30 years, keeping pace with
the newer medications before you have. A
fied – the highest level of certification pos-
advances in medical care that improves
good variety (of expertise and experience)
sible. A recent CAP inspection found no
patient comfort, outcomes and access.
is helpful,” says Michael J. Brody, M.D.
deficiencies.
This past April, it expanded services to
The practice’s high-quality standards are
“One of the greatest ‘behind-the-scenes’
residents of southern Wake County, open-
complemented by those at Raleigh Endos-
benefits of having a full-time, dedicated pa-
ing the South Wake Center for GI Health, a
copy Center in Cary, where Dr. Brody is
thologist onsite is the personal interaction
full-service practice in Holly Springs. The
medical director, and at WakeMed Cary
between the physician and Dr. Samala,”
location saves those in need of GI consul-
Hospital. The two state-of-the-art medical
says Dr. Furs. “Working together, Dr. Sa-
tation from having to travel to Cary or Ra-
facilities provide Cary Gastroenterology
mala and the physician team provide the
leigh. It’s conveniently located across from
physicians with quality endoscopy suites
highest quality care in a very efficient and
Rex Healthcare of Holly Springs.
for examining, diagnosing and document-
compassionate manner.”
ing abnormalities through inspection, Cary Gastroenterology Women’s Center
specimen collection and therapeutic in-
Dr. Brody points to the quality of the prac-
for GI Health in Raleigh opened in May.
tervention.
tice staff at each location, from the front
It is the only woman-specific GI practice,
desk to the nurses and physicians. He
with an all-female staff, outside of the aca-
notes that there are no physician extend-
demic-provider realm.
ers on staff. All patients are seen by one of the physicians.
Today, Cary Gastroenterology is comprised of eight physicians, with diverse
Cary Gastroenterology Associates also ac-
expertise to treat and manage the broad
tively participates in clinical trials, increas-
array of digestive system disorders. Each
ing patient access to the latest in treat-
physician works at multiple locations
ment, while assisting in the pursuit of new
throughout the week.
understanding about illness. A number of clinical trials are under way for eligible pa-
“We have a well-balanced medical staff, which provides a nice complement of ex-
Gastroenterologist Juliana Miller (pictured) leads Cary Gastroenterology’s Women’s Center for GI Health with colleague Dr. Shannon Scholl.
tients who wish to participate. Specialized Care for Women
perience, including newer physicians who bring a fresh, state-of-the-art perspective,”
The complete range of endoscopic tech-
While each Cary Gastroenterology physi-
says managing partner Stephen J. Furs, M.D.
nologies
flexible
cian sees both male and family patients,
sigmoidoscopy, upper endoscopy and
the Women’s Center for GI Health is re-
For instance, Shannon Scholl, M.D., has
colonoscopy, as well as such specialized
served for women and their unique health
an additional year of fellowship training in
procedures as capsule endoscopy, esoph-
care needs. Dr. Scholl and Juliana Miller,
hepatology. She trained with leaders in the
ageal and anorectal manometry, pH moni-
M.D., head this location.
fields of transplant hepatology, Barrett’s
toring, placement of percutaneous feeding
esophagus and irritable bowel syndrome,
tubes and IV medication infusions.
available
includes
colitis.
“Dr. Scholl and Dr. Miller focus on, and understand how, disease impacts wom-
as well as Crohn’s disease and ulcerative Clinical outcomes within Cary Gastroen-
en’s bodies differently, which leads to im-
terology are positively impacted by an
proved care for women,” says Dr. Furs.
“It’s nice having multiple partners to help ad-
onsite, physician-directed lab that delivers
dress patient needs. If you have a question,
quality results faster and more efficiently.
Take, for instance, women’s increased inci-
you can run it by a partner who might have
Pathologist Sujana Samala, M.D., is Col-
dence for gallstones. Women are twice as
6
The Triangle Physician
likely as men to get gallstones, especially
ing Meaningful Use and quality care out-
H. pylori causes the most cases of
during fertile years when female hormones
comes from the beginning, so I think the
gastritis, when the stomach lining
are at work. Risk factors include multiple
combination of our offices and the Raleigh
(mucosa) becomes inflamed, producing
pregnancies, oral contraception and es-
Endoscopy Center, we’re hitting all those
less acid and enzymes and mucus.
trogen replacement therapy, in addition to
points,” says Dr. Brody.
According to the Centers for Disease Control, in industrialized countries like the
weight gain, cigarette smoke and alcohol. Full-Service Practice –
U.S., 20-50 percent of the population may
The women’s GI center is specially de-
From Esophagus to Rectum
be infected with H. pylori.
signed to offer an inviting, unrushed envi-
Cary Gastroenterology Associates is a full-
ronment where patients may feel more at
service practice, with the expertise to treat
The most common diagnostic test for gas-
ease to express their concerns.
disorders of the entire digestive – from the
tritis is endoscopy with a biopsy of the
esophagus to the colon/rectum.
stomach. A combination of antibiotics and other medications are prescribed to kill
“We look for esophageal motility disorders
the bacteria and stop pain and ulceration.
– people with swallowing issues that may be more than anatomic. When we look at
Peptic ulcer disease occurs when diges-
reflux, we go beyond heart burn into other
tive acids damage the walls of the stomach
issues of reflux, like LPR (laryngopha-
or duodenum. Again, H. pylori is the most
ryngeal reflux disease), which may have
common cause. Another cause is long-
symptoms outside of the esophagus,” says
term use of nonsteroidal anti-inflammatory
Dr. Brody.
medicines, such as aspirin and ibuprofen. While stress and spicy foods do not cause ulcers, they can make them worse.
Esophageal Disorders Gastroenterologist Michael Delissio has special interests in colon diseases, peptic ulcers, gastroesophageal reflux and clinical research.
Leading the Way Another hallmark for Cary Gastroenterology Associates is its classification as a Blue
Common conditions affecting the esophaA patient’s breath, blood or stool can be
gus include: • Dysphagia: Difficulty swallowing.
tested for signs of infection. Peptic ulcer
• Barrett’s esophagus: Esophagus that is
also can be confirmed with biopsies taken from the stomach during endoscopy.
damaged by stomach acid. • Hiatal hernia: When part of the
Select Tier 1 provider within the new Blue
stomach pushes up through the
Celiac disease, a condition that can be
Cross and Blue Shield of North Carolina
diaphragm.
inherited by those with first- and second-
• Gastroesophageal reflux (GERD):
degree relatives with celiac disease,
When a muscle at the end of the
causes the body’s immune system to re-
Tier 1 represents the hospitals and select-
esophagus does not close properly, al-
spond to gluten (a protein found in wheat,
ed specialists that receive top rating for
lowing stomach contents to leak back,
rye and barley) by creating antibodies that
clinical quality outcomes, cost efficiency
or reflux, into the esophagus.
attack the small intestine. These antibod-
“tiered benefit” health plan.
and accessibility. Consumers pay less outof-pocket costs when visiting a Tier 1 pro-
• Esophageal cancer: Relatively uncom-
ies damage the villi of the small intestine, so nutrients cannot be absorbed into the
mon in the United States.
body.
vider compared to a Tier 2 provider. Left untreated, swallowing and esophageal “We try to be on the forefront of trends in
disorders can lead to more serious prob-
Left untreated, celiac disease can lead to
an evolving health care environment, like
lems, such as esophageal cancer. Early
such serious health problems as Type I
meaningful use, documentation, good
diagnosis and intervention are important.
diabetes and multiple sclerosis, neurological conditions, like epilepsy and mi-
quality care and cost-efficient care,” says Dr. Brody. “It’s important to be on the fore-
Stomach/Intestinal Disorders
graines, and intestinal cancers. Treatment
front and be a leader, rather than trying to
Stomach problems can frequently be re-
includes a strict gluten-free diet.
catch up.”
lieved with over-the-counter medicines and lifestyle changes, such as avoiding
Colorectal Disorders
“From the office standpoint, we intro-
fatty foods or reducing stress. Other prob-
According to the International Foundation
duced the electronic medical record early
lems like gastritis, peptic ulcers and celiac
for Functional Gastrointestinal Disorders,
on. We have been on the forefront of meet-
disease require medical attention.
functional gastrointestinal and motility dis-
november 2013
7
orders are the most common GI disorders
The diagnostic tools include blood and
Blood tests help assess liver inflammation
in the general population.
stool tests, colonoscopy or sigmoidos-
and liver function, as well as other indica-
copy, barium X-ray, computerized axial
tors of disease and extent of disease. Imag-
tomography and capsule endoscopy.
ing studies may be used to visualize the
Functional gastrointestinal disorders are
liver and nearby organs that may be dis-
classified according to the international Rome criteria. The most common and best
In many people with IBD, medicines can
eased. A liver biopsy may be considered
studied among this broad range of disor-
control symptoms. But for people with
to confirm diagnosis.
ders are functional dyspepsia, affecting
severe IBD, surgery is sometimes needed. Timely and accurate management of liver
mainly the upper gut, and irritable bowel syndrome (IBS) affecting the intestine.
Advanced Liver Disease Expertise
disease and disorders is crucial to rebuild-
Cary Gastroenterology Associates’ exper-
ing the liver and overall health. If left un-
According to IFFGD, IBS is the most fre-
tise encompasses management of liver
treated, almost any type of liver disease can
quent reason for consultation with a gastro-
disease, a broad term that covers viral
lead to cirrhosis – late-stage liver disease.
enterologist in the U.S., with overall preva-
hepatitis, nonalcoholic fatty liver disease,
lence ranging from 3-25 percent. Unlike
autoimmune liver diseases, genetic liver
Advancing Colon Cancer
inflammatory bowel disease, IBS does not
disease and liver cancer.
Awareness
cause inflammation or damage in the intestines, although symptoms can be similar.
Colon cancer is often preventable with Classic symptoms of liver disease include:
routine screening and 90 percent curable when detected early. Yet, it is the second leading cause of cancer deaths in the U.S., with 54,000 each year. Colon cancer equally affects men and women, primarily those 50 and older. Even though having a family history increases the risks for developing colon cancer, the majority of colon cancers appear in people without a family history of the disease. Routine colon cancer screening for those with average risk should begin at age 50.
Gastroenterologist Jeevan Pai has general interests in gastroesophageal reflux disease, colon cancer screening, clinical research and capsule endoscopy.
For people with a family history of colon cancer or polyps, screening is recommended at age 40 or younger. African-American women are at an increased ethnicity risk and should begin screening at age 45.
Inflammatory bowel disease (IBD)
nausea, vomiting, right upper-quadrant
comprises ulcerative colitis and Crohn’s
abdominal pain and jaundice (yellow dis-
disease. Ulcerative colitis affects the top
coloration of the skin due to elevated bili-
Cary Gastroenterology Associates actively
layer of the large intestine. Crohn’s disease
rubin concentrations in the bloodstream).
participates in the mission to fight colon
can affect all layers of the intestinal wall.
Fatigue, weakness and weight loss also
cancer with its presence at numerous
may occur.
community events. One of its favorite is the annual 5K “Get your rear in Gear.”
IBD is thought to be genetic and caused by an improper immune system reaction to
Diagnosis involves a patient history. A thor-
normal bacteria in the digestive tract. The
ough physical examination is necessary,
Cary Gastroenterology welcomes the op-
main clinical features are fever, abdominal
as liver disease can have physical findings
portunity to partner with referring physi-
pain, diarrhea, rectal bleeding, weight loss
that affect almost all body systems, includ-
cians. Call the Cary office at (919) 816-4948,
and malnutrition.
ing the heart, lungs, abdomen, skin, brain
the Holly Springs office at (919) 285-2801
and cognitive function and other parts of
or Raleigh office at (919) 787-1644. All of-
the nervous system.
fices are listed on Intelligent Care Coordi-
Diagnosis requires differentiating symptoms that are similar to other problems.
8
The Triangle Physician
nator patient referral system.
Psychiatry
Autism Spectrum Disorder Early Intervention Is Important, Know the Early Warning Signs By Linmarie Sikich, M.D.
Autism spectrum disorders are neurode-
include some of the following:
velopmental disorders defined by impair-
• S eldom makes eye contact.
ments in social communicative function-
•R arely responds to a smile by smiling.
ing, restricted interests and repetitive
•R arely responds to his or her name or
behaviors that significantly impair function-
to the sound of a familiar voice.
ing throughout life and result in high social
• S eldom points to show you something.
and medical costs.
•D oes not wave goodbye or raise arms
The prevalence of autism spectrum disor-
•D oes not make noises to seek attention.
ders (ASDs) has been progressively increas-
•R arely initiates or responds to cuddling.
ing and is more common than childhood
• S eldom imitates movements and facial
cancer, cystic fibrosis and multiple sclerosis
expressions others have expressed.
combined. It is estimated nationally that 1
•R arely plays or shares interest and en-
to be picked up.
out of every 88 children has an ASD. Evidence also suggests that the prevalence rate in North Carolina is even higher than the na-
joyment with others. • Seldom asks for help or things they want.
tional average, at 1 in 70 (Centers for Disease
• Slow to develop or use language.
Control and Prevention, CDC).
• Uses language you would expect of a much older person.
Overall, research has shown that early in-
The director of the ASPIRE Program, Dr. Linmarie Sikich earned her medical degree and completed a postdoctoral research fellowship in psychiatry at Washington University. She did her psychiatry residency at Yale University. Since joining the University of North Carolina (UNC) faculty, she also has pursued an interest in early onset psychotic illnesses. Today, the majority of her work is focused on evaluating and developing treatments for both disorders using standard efficacy measures, effectiveness measures that also consider the tolerability and acceptability of treatments, neurocognitive outcomes and biomarkers. Dr. Sikich’s research is funded by the National Institute for Child Health and Human Development (NICHD) and the National Institute for Mental Health (NIMH), the Foundation of Hope and Autism Speaks. She also participates in industry-sponsored trials of novel treatments for autism and schizophrenia. Dr. Sikich serves on the research advisory board for the Autism Treatment Network, the data and safety monitoring board of the NICHD Rare Diseases Clinical Research Network and the UNC Biomedical Institutional Review Board.
tervention can greatly improve the lives of
The American Academy of Pediatrics cur-
people with ASD and increase their inde-
rently recommends that all children be
pendence as adults and should be initiated
screened for possible ASD at 18 and 24-30
as early as possible, perhaps even before a
months of age during routine examina-
formal diagnosis is given. The majority of
tions. It is important for all providers who
early-intervention programs are designed
see children to be aware of and educated
to promote positive changes in the core
about these early warning signs of autism.
symptoms of preschool children with ASD.
Pediatricians, family practitioners, emer-
studies that enroll patients with ASDs. One
gency room physicians and specialists
research study, called STORY, is specifically
Eleven early-intervention programs have
alike should learn to recognize the early
seeking children ages 18-60 months who
reported significant acceleration of devel-
symptoms of ASD and DD.
are suspected of having an ASD or a developmental delay but have not yet been
opmental rates, IQ gains, language gains and improved social behavior. Overall, the
The ASPIRE Program at UNC Chapel Hill
diagnosed. The goal of the STORY research
goal of early detection is to ensure early
conducts thorough, multidisciplinary eval-
study is to develop a blood test that screens
intervention in order to improve functional
uations of children and adolescents with
for a potential ASD or DD to facilitate earlier
independence of the individual with ASD
suspected ASDs or DDs. The ASPIRE pro-
diagnosis and therefore earlier intervention.
or other developmental disabilities (DD).
gram also works with families to identify
Similar interventions also help children
the most appropriate resources for early
Evaluations completed as part of a research
with other sorts of developmental disabili-
intervention and to develop and test new
study are offered at no cost.
ties like speech delays or intellectual dis-
interventions for children and adolescents
abilities.
with ASD and DDs.
Possible early signs of autism (infants, tod-
In addition to clinical evaluations, the AS-
out ASPIREs website at www.med.unc.
dlers and pre-school-aged children) can
PIRE Program conducts multiple research
edu/psych/research/aspire.
To make a referral, call (800) 708-0048 or send an e-mail to aspire@unc.edu. Check
november 2013
9
Practice Management
The Clock Is Ticking By Joe Reddy
As a gentle reminder, the countdown to-
spective pilot organizations.
ward the ICD-10 conversion has begun. Unlike many new program rollouts, Oct. 1,
From a financial impact, ICD-10 coding will
2014 is a “go-live” date with no grace peri-
be akin to you doing the taxes for your own
od. Proper planning is critical to the finan-
practice. Moreover, we’re assuming every-
cial health of your practice. Much more
thing will work smoothly on the payer’s
robust documentation will be required as
end.
appropriate justification of the true depth of care and accurate reimbursement ac-
Given the money at risk, it’s well advised to
cording to the new code set.
study up or outsource the coding work to a professional firm. At minimum, an external
Status
coding audit of your practice is in order.
The unfamiliar ground and increased la-
You may also find money currently being
bor on chart notes will likely decrease the
left on the table.
Joe Reddy is the owner of RevMedRx, a North Carolinabased revenuecycle management company. RevMedRx offers sophisticated, yet affordable, solutions to today’s complex practice management needs with a focus on efficiency and cash-flow optimization. Joe Reddy can be reached at joe.reddy@ revmedrx.com. To learn more, visit www.revmedrx.com. Reference Point
number of patients you can fit into a day.
When Canada implemented ICD-10 in
It’s estimated that less than 40 percent of
Observers agree that finding or training
2002, coder productivity dropped by half
today’s documentation is ready for the
qualified coders could be challenging and
and only rebounded to three-quarters of its
transition. And that’s just the beginning
expensive. With 11 months until the imple-
pre-ICD-10 level a year later. Many experts
of the challenge. At the recent Medical
mentation deadline, few coders have the
anticipate a similar effect in the United
Group Management Association (MGMA)
needed ICD-10 skill sets. And it’s still dif-
States.
meeting, a North Carolina Healthcare In-
ficult to determine how many coders will
formation and Communications Alliance
be needed. Not to mention, it’s sometimes
Decisions
director suggested the results of the initial
challenging to get economies of scale and
How are you going to handle the inevitable
testing of coding were “scary.”
efficiency managing a coding staff for less
denials and backlogs? Which ball is your
than 100 providers. The MGMA recom-
eye on: Affordable Care Act, Meaningful
I would have to agree at rates of 55-63
mends that medical practices plan for 16
Use or ICD-10? As I mentioned in a previ-
percent accuracy. The productivity also
to 24 hours of training for clinical staff and
ous editorial on ICD-10, you may want to
dropped from four or more charts per hour
40 to 60 hours for coding staff if you keep
consider getting a line of credit for the
to an average of two per hour. These were
the coding in house.
transition if you don’t have enough cash to
the results of the best coders from the re-
cover your existing overhead.
The Triangle Physician 2013-2014 Editorial Calendar December Pain Management, Spine Disorders Practice Management
10
January Diabetes Endocrinology
April Pediatrics Infectious disease
July Sports medicine Rheumatology
October Cancer in women Wound management
February Cardiology Ophthalmology
May Women’s health Neurology
August Gastroenterology Nephrology
November Urology ADHD
March Orthopedics Hematology
June Cancer in men Pulmonary
September Bariatrics Neonatology
December Otorhinolaryngology Pain management
The Triangle Physician
Orthopedic Surgery
Update on Treatment for Patients with
Osteoarthritis of the Hand By John M. Erickson, M.D.
Osteoarthritis is a common, progressive
ry medications (NSAIDs), hand therapy mo-
degenerative joint disorder that can cause
dalities and activity-modification education.
pain, impaired mobility and decreased health-related quality of life. As our popula-
The use of oral glucosamine and chondroi-
tion ages, there has been increased public
tin sulfate supplementation is also gaining
interest in effective treatment options for
acceptance for use in patients with hand
osteoarthritis.
OA. A recent randomized, controlled trial showed a significant improvement in hand
Total joint arthroplasty (joint replacement)
function, pain scores and morning stiffness
is a well-established surgical option for pa-
in patients in the treatment group compared
tients with advanced degenerative disease
to placebo. These supplements are avail-
of the knee and hip joints. Lower-extremity
able over the counter and are not subject to
joint replacement has demonstrated most-
United States Food and Drug Administration
ly good-to-excellent outcomes in the or-
oversight.
thopedic literature, resulting in pain relief, functional improvement and high satisfaction for many patients.
Dr. John Erickson is a hand and upperextremity surgeon at the Raleigh Hand Center. He is board certified in orthopedic surgery and completed additional fellowship training in hand and upper-extremity surgery at Vanderbilt University. Dr. Erickson earned his medical degree from the University of Texas Southwestern Medical Center in Dallas and completed his orthopedic surgery training at the University of Michigan Hospitals in Ann Arbor. He has a special interest in sports injuries, wrist fractures and hand tumors. For more information, call (919) 872-3171 or visit www.raleighhand.com.
Public awareness of lower-extremity osteo-
This procedure was first reported in the
arthritis (OA) treatment has increased as
1940s and has a long track record of favor-
advancements in joint replacement surger-
able results. Several 10-year outcomes stud-
ies have been reported. In contrast, the
ies have demonstrated that CMC joint sur-
treatment options for patients with hand
gery provides long-lasting pain relief for the
and wrist OA are often misunderstood by
majority of patients.
the general public. Often patients say, “I didn’t know there was anything that could
During this outpatient procedure, the tra-
be done for arthritis in my hands” or “I
pezium bone at the base of the thumb
thought I just had to live with my arthritis
metacarpal is removed, which eliminates Other remedies patients often try prior to
the “bone-on-bone” grinding characteris-
consulting a physician are herbal supple-
tic of OA pain. Typically a tendon from the
While it is true there is currently no cure
ments, topical ointments, antioxidant diets,
patient’s forearm is used to fill the trapezial
for degenerative joint disease, there are
warm water soaks and paraffin wax kits,
void and support/cushion the base of the
many non-surgical and surgical treatments
which may or may not provide durable
thumb metacarpal.
that effectively relieve symptoms. In our
symptom relief.
pain.”
Most patients report improved hand func-
practice, the emphasis is always on the most conservative and least invasive ap-
When conservative treatment fails to satis-
tion, decreased pain and satisfaction with
proach when possible.
factorily improve symptoms, there are well-
the long-term results. However, this proce-
established surgical interventions available
dure is not a “quick fix,” as recovery can
Most patients improve with conservative
to many patients. For example, thumb car-
take three months or more to achieve full
care, and therefore do not undergo surgery.
pometacarpal (CMC) joint arthroplasty is a
benefit. The risks and benefits of thumb
Effective non-surgical options include off-
commonly performed surgery for patients
CMC joint surgery are carefully assessed for
the-shelf and custom splints, corticosteroid
with debilitating basilar thumb arthritis
each patient, and not all patients are candi-
injections, oral and topical anti-inflammato-
pain.
dates for surgery.
november 2013
11
Women’s Health
Women May Be Able to Delay Having Children by Freezing Eggs By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
Many women now delay having children
topic. Recently, I was able to communicate
for varying reasons: careers, school, travel,
about egg banking with one such expert,
and more. There are many exciting things
Jennifer Mersereau, M.D., of UNC Fertility.
to do in life and with effective contracep-
She explained that egg banking “is a great
tion; women can potentially control when
option to try to extend the ‘reproductive
they get pregnant.
window’ for young women whose life circumstances will result in delayed attempts
Unfortunately, age can have a negative
for pregnancy.”
impact on a woman’s ability to become pregnant. A woman who may delay hav-
The technology of egg banking relies on
ing children to go to graduate school, to
cryopreservation. This technology refers to
further her career or to travel may find that
the “cooling of cells and tissues to sub-zero
when she is ultimately “ready,” she then
temperatures in order to stop all biologic
has difficulty becoming pregnant. This usu-
activity and preserve them for future use.”1
ally relates to age. The peak age of fertility for women is age 24.
Interestingly, this technology dates back to 2500 BC when early civilizations used
So what options are available to help wom-
cold temperatures for medicinal purposes.
en overcome the “negative impact” of age?
Initial techniques damaged cells due to ice
One new and exciting option for women is
formation or excessive dehydration. More
elective egg freezing or egg banking. This
recently, “slow-freeze,” or vitrification, has
has been done for many years for women
been developed that prevents the forma-
who have cancer or terminal illnesses.
tion of ice. It is this technology that is used
It works, but has not been available to
to freeze eggs, embryos and ovarian tissue.
healthy women until recently.
After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position (2007) to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.
How Is Egg Banking Done? However, in October of 2012 the Practice
Egg banking works in a way similar to in vi-
Since this is a relatively new procedure,
Committee of the American Society for
tro fertilization. A woman is given medica-
precise predictions on the chance of future
Reproductive Medicine (ASRM) lifted the
tions that initiate the development of mul-
pregnancy can be challenging. Pregnancy
“experimental” label from the technique
tiple eggs over a single cycle. The number
rates are likely higher in younger women
of egg freezing. Thus, it is now available
of eggs that an individual develops varies
who bank eggs. Also, the more eggs a
to healthy women by some reproductive
widely. (The range is from three to 30.)
woman can bank, the better, given she will have more potential attempts to conceive.
specialists. Younger women (less than 35 years) tend
Jennifer Mersereau, M.D.
12
Although I am a
to make more eggs compared to older
One recent study conducted in Spain
member of ASRM
women. These eggs are then removed in
(2010)2 evaluated IVF with egg donors
and a practicing ob-
a surgical procedure (anesthesia is used)
(young women producing eggs to anony-
stetrician/gynecolo-
that involves using a needle attached to an
mously donate to another couple). They
gist, I rely on our
ultrasound probe and placed within the va-
found that the technology of egg freez-
many experts in the
gina. The eggs are aspirated or suctioned
ing had advanced so well that pregnancy
Triangle
medical
from the ovaries. Once removed, they are
rates with frozen eggs were as good as
community to help
evaluated microscopically, and the healthi-
with fresh (non-frozen) eggs. This is good
guide us on this
est eggs are frozen in liquid nitrogen.
news for women who want to delay child
The Triangle Physician
bearing – the technology shows promise, though there are not many studies look-
Services
ing at pregnancy rates for women in their
• iClaim • EMRx • ChoicePay • AutoCard • QuickCollect
30s who are banking eggs. Other Considerations
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Another consideration is that some women may choose to bank eggs at a young age and later conceive on their own with a partner rather than use their banked eggs. For this reason, banking eggs can be viewed as an insurance policy that may or may not be needed. Currently, egg banking is usually not covered by insurance and can cost several thousand dollars. Women who are interested in learning more should speak to a fertility specialist to discuss the likelihood of future pregnancy in her specific scenario. Dr. Mersereau works with a talented team at UNC Fertility, which has opened a new location in Raleigh (877-338-4693).
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www.revmedrx.com/quickcollect.php 4441 Six Forks Rd. Suite 106-293 • Raleigh, NC 27609 • Phone: (800) 845-6090
Her expertise in this area is invaluable to women, so I encourage both health care
55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514
Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.
919.929.7990
www.drossmangastroenterology.com
providers and patients to learn more. Recently, I asked a 30-year-old single woman if she had considered preserving her eggs. She had never heard of this, but her reaction was “absolutely, I haven’t met the perfect one.” This illustrates the exciting real-life potential for this technology. Although there is no guaranteed method to stop the “ticking biological clock,” egg banking may be one of the best methods available.
Drossman Gastroenterology
1
The Practice Committees of the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology, “Mature oocyte cryopreservation: a guideline,” Fertility and Sterility, vol. 99, No. 1, January 2013. This article focused on freezing eggs, or egg banking.
2
C obo A, Meseguer M, Remohi J, Pellicer A, “Use of cryo-banked oocytes in an ovum donation programme: a prospective randomized, controlled, clinical trial” Human Reproduction, Vol.25, No.9 pp2239-2246, 2010.
november 2013
13
Gastroenterology
Functional Vomiting Syndromes
This is the first in a two-part series on functional vomiting syndromes.
By Douglas A. Drossman, M.D.
Vomiting as an occasional symptom is
abdominal ultrasound, computed tomog-
an adaptive physiological process where
raphy, magnetic resonance or endoscopy,
the body seeks to rid itself of offending
depending on the clinical situation.
substances that have been ingested. It may also occur in the setting of an acute illness,
When the vomiting occurs recurrently and
such as a gastroenterentitis, or as part of a
seemingly without clear recognition of
more chronic condition, such as a bowel
cause, a variety of functional gastrointes-
obstruction. Because of neurological links
tinal syndromes are to be considered, in-
to emotional centers, vomiting can occur
cluding functional vomiting, gastroparesis
during intense emotional distress.
and cyclic vomiting syndrome. Today we will discuss functional vomiting.
The differential diagnosis of recurrent vomiting can include endocrine or meta-
Functional vomiting has been defined by
bolic disorders (pregnancy, diabetes and
the Rome III criteria and must include all
hyperthyroidism); infections (both gastro-
of the following:
intestinal and systemic, nongastrointestinal); bowel obstruction, including Crohn’s
1) On average one or more episodes of vomiting per week.
disease; and other sources of bowel ob-
2) Absence of criteria for an eating
struction, central nervous system disor-
disorder, rumination or major
ders (migraine and increased intracranial
psychiatric disease, according to
pressure), seizure disorders, psychiatric
DSM-IV. 3) Absence of self-induced vomiting
disorders or medication.
and chronic cannabinoid use and The
diagnostic
evaluation
includes
absence of abnormalities of the
taking a careful medical history seeking
central nervous system or metabolic
to identify the potential structural or
diseases to explain the recurrent
metabolic causes, as noted above. One
vomiting.
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 patient-provider relationship. Drossman Gastroenterology P.L.L.C. (www. drossmangastroenterology.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management of 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.
where he or she received chemotherapy).
should identify the circumstances of the vomiting, i.e., after a meal (and how long
Criteria must be fulfilled for the last three
Often these are associated with anxiety-
after a meal); during emotional distress;
months with symptom onset at least six
inducing conditions, though the circum-
and whether there are other symptoms that
months prior to diagnosis.
stances may not be apparent to patient or
include abdominal pain, fever and nausea and if so which symptoms occurred first.
the health care provider. Generally patients Functional vomiting is often considered
with functional vomiting do not lose weight,
as a behavioral, stress-induced condition-
unless the vomiting occurs so frequently as
A physical examination should evaluate for
ing response, though the stressor may
to impair nutritional intake. In these rare sit-
signs of dehydration, weight loss or muscle
be unrecognized and possibly encoded
uations, dehydration and metabolic imbal-
wasting and abnormal physical features,
from earlier experiences. Examples would
ance may occur. Routine diagnostic studies
such as an abdominal mass. Routine stud-
include being in situations (by visual or
are negative except for any metabolic con-
ies would include complete blood count;
emotional cues) that remind the individ-
sequences of the vomiting.
sedimentation rate, or C-reactive protein;
ual of an earlier noxious experience (e.g.,
complete metabolic panel; lipase; and
childhood abuse, smelling a noxious sub-
In Part 2 of this editorial, we will discuss
in most cases some type of imaging that
stance previously experienced and condi-
gastroparesis and cyclic vomiting syn-
may include a flat plate of the abdomen,
tioned, a patient walking into the hospital
drome.
14
The Triangle Physician
Duke Research News
HPV Vaccines May Not Equally Help African-American vs. White Women Two subtypes of human papillomavirus
searchers enrolled 572 participants – 280
ous cervical abnormalities and 88 (15 per-
(HPV) prevented by vaccines are half as
African-American women and 292 non-
cent) had advanced precancerous cervical
likely to be found in African-American
Hispanic white women – who came for
abnormalities. Seventy-three percent of the
women as in white women with precancer-
additional testing after receiving abnormal
women infected with HPV were infected
ous cervical lesions, according to research-
Pap test results.
with multiple HPV subtypes.
Of the 572 participants, 245 (43 percent)
When the researchers looked at the spe-
The findings, presented on Oct. 28 at the
had no precancerous cervical abnormali-
cific strains of HPV, they found that white
12th annual International Conference on
ties, 239 (42 percent) had early precancer-
women and African-American women
ers at Duke Medicine.
Frontiers in Cancer Prevention Research, hosted by the American Association for Cancer Research, suggest that AfricanAmerican women may be less likely to benefit from available HPV vaccines to prevent cervical cancer. HPV is a common sexually transmitted infection with more than 40 subtypes. The virus causes nearly all cases of cervical cancer, which begin as precancerous cervical abnormalities. Two vaccines currently available to young women prevent infection by HPV 16 and HPV 18, the HPV strains responsible for about 70 percent cervical cancers. “Screening programs for cervical cancer are known to work well, with around 90 percent of sexually active women getting screened through Pap tests,” said senior author Cathrine Hoyo, Ph.D., M.P.H., associate professor of obstetrics and gynecology at Duke University School of Medicine. “The question is, if screening rates are comparable in African-American and white women, why are the rates of cervical cancer and mortality higher among African-American women when we have a program that works so well?” Dr. Hoyo and her colleagues sought to better understand these disparities by determining if African-American and white women in the United States are infected with the same subtypes of HPV. The reWomens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
november 2013
15
Duke Research News were often infected with different subtypes.
the same subtypes of HPV with the same
in larger populations. Drs. Hoyo and Vidal
The most frequent HPV subtypes detected
frequency, the vaccines aren’t helping all
and their colleagues are also continuing the
among white women with early precancer-
women equally.”
research to define epigenetic marks that can be used to predict which precancerous cer-
ous cervical abnormalities were 16, 18, 56,
vical abnormalities will advance.
39 and 66, while HPV subtypes 33, 35, 58
A new HPV vaccine targeting nine HPV
and 68 were the most common ones de-
subtypes (6, 11, 16, 18, 31, 33, 45, 52 and 58)
tected in African-Americans.
is currently being tested in phase III trials.
In addition to Drs. Hoyo and Vidal, study
While the new vaccine may help prevent
authors from Duke include Fidel Valea,
In those with advanced precancerous
additional HPV infections by covering new
Anne Ford, Francine Overcash and Susan
cervical abnormalities, HPV 16, 18, 33, 39
subtypes, it may not address the disparities
K. Murphy of the Department of Obstetrics
and 59 were the most common genotypes
found in this study.
and Gynecology; Rex Bentley and Katherine Grant of the Department of Pathology;
detected in white women, whereas HPV 31, 35, 45, 56, 58, 66 and 68 were the most
“The most disconcerting part of this new
and Maggie Gradison and Kimberly S. H.
prevalent in African-American women.
vaccine is it doesn’t include HPV 35, 66
Yarnall of the Department of Community
and 68, three of the strains of HPV of which
and Family Medicine. Jennifer S. Smith of
“Compared with white women, we saw
African-American women are getting the
the Department of Epidemiology at Gillings
that African-American women had about
most,” Dr. Hoyo said. “We may want to
School of Global Public Health at the Uni-
half as many infections with HPV 16 and
rethink how we develop these vaccines,
versity of North Carolina at Chapel Hill also
18, the subtypes that are covered by HPV
given that African-Americans tend to be
contributed to the research.
vaccines,” said Adriana Vidal, Ph.D., as-
underrepresented in clinical trials.” The research was supported by the Na-
sistant professor of obstetrics and gynecology at Duke University School of Medicine
The researchers noted that while these find-
tional Cancer Institute (R01CA142983 and
and the study’s first author. “Since African-
ings are compelling, the results are prelimi-
R01CA142983-02S1). The authors reported
American women don’t seem to be getting
nary and the studies should be replicated
no conflicts of interest.
Spinal Fusion Material Increases Risk of Benign Tumors, Not Cancer Using a certain bone-grafting material for
harmful effects, including increased rates
association between BMP use and can-
spinal fusion, one of the most common
of cancer when used in high doses, lead-
cer.”
procedures for people with painful ver-
ing to a decision by the United States Food
tebral deteriorations, does not appear to
and Drug Administration to reject approv-
Using national claims data from commer-
result in higher rates of cancer, according
al of the higher dosage formulation.
cial insurers, Medicaid and Medicare, Dr. Lad and colleagues conducted a large, ret-
to researchers at Duke Medicine. Although BMP is approved only for use in
rospective analysis of more than 4,600 pa-
However, the researchers found that the
the lower spine with anterior approaches
tients who had undergone spinal fusions
bone promoter known as recombinant
for surgery, it has been widely used “off-
with BMP and matched them against
human bone morphogenetic protein 2,
label” in cervical fusions, posterior lum-
similar patients who had the procedure
or BMP, is associated with a higher rate of
bar procedures and minimally invasive
without the bone growth material. They
benign tumors in the brain and nervous
approaches.
examined the association between BMP and the general risk of cancer, as well as
system. “Given the widespread use of BMP, there
the risk of developing cancer in different
Reported in the September print edition
has been a tremendous need for better
tissues.
of the journal Neurosurgery, the finding
data about its effects,” said lead author
provides a better understanding of the
Nandan Lad, M.D., Ph.D., assistant pro-
Overall, the Duke-led team found that 9.4
long-term outcomes of spinal fusions us-
fessor in the division of neurosurgery at
percent of spinal fusion patients receiving
ing BMP. Recent studies have suggested
Duke University School of Medicine. “Our
BMP developed malignant cancers, com-
that the growth factor is associated with
study is the largest to date examining the
pared to 8.4 percent of patients not receiv-
16
The Triangle Physician
Duke Research News ing the growth factor – a difference that
tem among patients receiving BMP may
“We believe this study is the first to spe-
was not statistically significant.
be caused by the large local dose of BMP
cifically investigate the association be-
that is administered to the spine, and war-
tween the use of BMP and cancer risk in
rants further study,” Dr. Lad said.
a systematic manner, and apply it to the
For benign tumors, there was a signifi-
general population of patients undergoing
cantly higher risk. After adjusting to better match patients in both groups to eliminate
Dr. Lad said findings should be viewed
spinal fusion in the United States,” Dr. Lad
selection bias, the researchers found that
with caution, noting the limitations of
said.
those who received BMP were 31 percent
the study include its retrospective de-
more likely to be diagnosed with benign
sign. However, the ethical and practical
In addition to Dr. Lad, study authors
tumors than those who did not receive
complications of prospectively enlisting
include Jacob H. Bagley, Isaac O. Kari-
the graft material. These tumors included
patients in a head-to-head comparison
kari, Ranjith Babu, Beatrice Ugiliweneza,
non-malignant growths in the brain and
of BMP against no growth factor made a
Maiying Kong, Robert E. Isaacs, Carlos A.
nervous system.
large, retrospective study the next-best ap-
Bagley, Oren N. Gottfried, Chirag G. Patil
proach. Dr. Lad said the study also relies
and Maxwell Boakye.
“While the absolute risks were small
on accurate and timely diagnoses of can-
overall, the increased risk for soft tissue
cer and benign tumors among the study
The study received support from the Na-
tumors and those lining the nervous sys-
population.
tional Cancer Institute (KM1CA156687).
Inducing and Augmenting Labor May Increase Risk of Autism Pregnant women whose labors are in-
previously suggested as a contributing
The findings suggest that among male
duced or augmented may have an in-
factor to autism development,” said lead
children, labor that was both induced
creased risk of bearing children with
author Simon G. Gregory, Ph.D., associate
and augmented was associated with a 35
autism, especially if the baby is male, ac-
professor of medicine and medical genet-
percent higher risk of autism, compared
cording to a large, retrospective analysis
ics at Duke. “However, these studies pro-
with labor that received neither treatment.
by researchers at Duke Medicine and the
duced conflicting results and consisted of
This estimated increase in risk accounted
University of Michigan.
a relatively small number of subjects. Our
for established maternal and pregnancy-
study is by far the largest one of its kind
related risk factors, such as maternal age
The findings, published in JAMA Pediat-
to look at the association between autism
and pregnancy complications.
rics on Aug. 12, do not prove cause and
and induction or augmentation.” While induced labor alone and augment-
effect, but suggest the need for more research, particularly as labor induction
In this study, the researchers looked at re-
ed labor alone were each associated with
and augmentation have been used more
cords of all births in North Carolina during
increased risk among male children, only
frequently in recent years.
an eight-year period and matched 625,042
augmentation was associated with in-
births with corresponding public school
creased risk among female children. The
Expediting deliveries has benefitted wom-
records, which indicated whether chil-
reason for the difference in findings be-
en with health conditions that pose a risk
dren were diagnosed with autism.
tween male and female children requires further investigation.
to them and their unborn children. Inducing labor (stimulating contractions before
Approximately 1.3 percent of male chil-
the onset of spontaneous labor) and aug-
dren and 0.4 percent of female children
Dr. Gregory said the increased risk asso-
menting labor (increasing the strength,
had autism diagnoses. In both male and
ciated with induction and augmentation
duration or frequency of contractions
female children, the percentage of moth-
is similar to other known risk factors for
during labor) have been shown to prevent
ers who had induced or augmented labor
developing autism, including a mother be-
complications, including stillbirth.
was higher among children with autism
ing older or a baby being born before 34
compared with those who did not have
weeks of age. Additional analysis suggests
autism.
that the absence of induction and aug-
“Inducing or augmenting labor has been
november 2013
17
Duke Research News mentation might eliminate two in every
(e.g., exogenous oxytocin and prostaglan-
“This is a provocative finding that calls for
1,000 autism cases among male children
dins),” Dr. Miranda said.
more research on the use of induction and augmentation during labor as a potential
born to induced or augmented mothers. In this study, researchers noted that chil-
risk factor for autism,” Dr. Halladay said.
Autism – a developmental disability that
dren later diagnosed with autism were
“The next step will be to understand why
can cause social, communication and
also more likely to undergo a birth char-
there is this association. Are there other
behavioral challenges – affects approxi-
acterized by fetal distress.
factors at play here that led to the need for induction, for example? More research is
mately one in 88 children in the United States. Researchers and families alike are
“The findings of this study must be bal-
needed before these results can be used
interested in understanding whether envi-
anced with the fact that there are clear
to inform clinical practice.”
ronmental factors may contribute to devel-
benefits associated with induction and
oping autism, particularly those that might
augmentation of labor,” said study author
The researchers noted that some informa-
affect the developing brain.
Chad A. Grotegut, M.D., assistant profes-
tion that could have benefitted their analy-
sor of obstetrics/gynecology at Duke
ses was not available, including detailed
“The scientific community has long looked
Medicine. “Labor induction, especially
data on the children’s autism diagnoses.
for environmental contributors to the rising
for women with post-date pregnancies or
No information was available on the se-
rates of autism in the United States,” said
medical conditions, such as diabetes and
verity of autism, nor were records avail-
Marie Lynn Miranda, Ph.D., senior author
high blood pressure, has remarkably de-
able for children diagnosed with autism
and dean of the University of Michigan
creased the chance of stillbirth.”
who did not attend a public school. The researchers also did not have access to
School of Natural Resources and Environment. “This study provides preliminary
The authors stress that these findings do not
the full maternal or child medical records,
evidence of an association between autism
support any deviation from the current stan-
which would provide more detailed infor-
and labor induction/augmentation, espe-
dard of care for using induction and/or aug-
mation on the pregnancy and events of
cially among male children.”
mentation until further research is performed.
labor and delivery.
At the same time, Dr. Miranda cautioned
“Over the last decade or so, it has be-
In addition to Drs. Gregory, Miranda and
that further investigation is warranted to
come clear that a combination of genetic
Grotegut, study authors include Rebecca
understand these preliminary results. “Ad-
and environmental risk factors contribute
Anthopolos of the Children’s Environ-
ditional studies are needed to differentiate
to risk for autism,” said Alycia Halladay,
mental Health Initiative at the University
among potential explanations of the as-
Ph.D., senior director of environmental
of Michigan and Claire Osgood of the
sociation, such as: underlying pregnancy
and clinical sciences at Autism Speaks,
Children’s Environmental Health Initia-
conditions requiring the eventual need
who was not involved in the study. “It is
tive at Duke University. The research was
to induce/augment, the events of labor
important for research to identify these
supported by funding from the USEPA
and delivery associated with induction/
risk factors so that the impact of these fac-
(RD83329301).
augmentation and the specific treatments
tors can be prevented.”
and dosing used to induce/augment labor
Duke News
Vice Dean Sally Kornbluth Is Elected to Prestigious Institute of Medicine Sally Kornbluth, Ph.D.,
University School of Medicine, has been
Andrews, M.D., Ph.D., dean of Duke Uni-
the James B. Duke Pro-
elected as one of 70 new members to the
versity School of Medicine. “She is inter-
fessor of Pharmacol-
prestigious Institute of Medicine.
nationally recognized for her contributions to the fields of cell signaling and cell
ogy and Cancer Biol-
18
ogy and vice dean for
“This is a tremendous and well-deserved
death, and she has had tremendous im-
basic science at Duke
honor for Dr. Kornbluth,” said Nancy C.
pact on the biomedical research commu-
The Triangle Physician
Duke News department chairs and faculty. Her duties
1989 and went on to postdoctoral training
include management of the biomedical
at the University of California, San Diego.
Dr. Kornbluth’s research interests in cell
graduate programs in the Duke University
She joined the Duke faculty in 1994.
proliferation and programmed cell death
School of Medicine, implementation of
are centrally important for understanding
programs to support the research mission
New members to the IOM are elected by
both cancer and degenerative disorders.
of the basic science faculty and oversight
current active members through a selec-
Her current work is exploring the precise
of new and existing core laboratories.
tive process that recognizes people who
nity as a scientist, a mentor and a leader.”
have made major contributions to the
signaling mechanisms used by cancer cells to accelerate proliferation and evade
Dr. Kornbluth earned a bachelor of arts
advancement of the medical sciences,
cell death mechanisms, with the aim of
degree in political science from Williams
health care and public health.
subverting these processes as potential
College in 1982 and a bachelor of science
therapies.
in genetics degree from Cambridge Uni-
Established in 1970 by the National Acad-
versity, England, where she was a Herchel
emy of Sciences, the IOM is a national
As vice dean for basic science, Dr.
Smith Scholar at Emmanuel College. She
resource for independent, scientifically
Kornbluth serves as a liaison between
received her doctorate in molecular on-
informed analysis and recommendations
the dean’s office and the basic science
cology from The Rockefeller University in
on health issues.
Wake Med News
Gintzig Named Interim President/CEO Rear Adm. Donald Gintzig has been
increasing responsibility, including depu-
The list of community and trade organiza-
named interim president and chief ex-
ty commander and chief operating officer
tions Mr. Gintzig has been involved with
ecutive officer for the 884-bed WakeMed
of Navy Medicine East, vice commander
during his career is extensive and includes
Health & Hospitals, effective Oct. 25.
for U.S. Navy Reserve Forces Command,
the American Hospital Association, Ten-
deputy commander and COO for Navy
nessee Hospital Association, American
Mr. Gintzig has had a long career in health
Medicine West. Most recently, he served
College of Healthcare Executives, Military
care, serving as CEO for not-for-profit,
as acting deputy surgeon general of the
Officers Association of America, Naval Re-
faith-based and for-profit health systems.
Navy for the Bureau of Medicine and Sur-
serve Association and the Association of
He was a commanding officer and reserv-
gery, assistant deputy surgeon general for
Military Surgeons of the United States.
ist in the United States Navy and retired
Reserve Affairs and deputy chief of medi-
Oct. 1 from his active-duty position as rear
cal operations and future plans. During
Mr. Gintzig earned his bachelor’s degree
admiral, senior health care executive and
his military career, Mr. Gintzig oversaw
in business administration and finance
acting deputy surgeon general.
more than 150,000 individuals, 40 military
and a master of business administration
treatment facilities and 200-plus clinics,
in accounting from George Washington
and budgets of more than $7 billion.
University in Washington, D.C. He com-
“We received a significant amount of in-
pleted his post-masters hospital adminis-
terest in the interim CEO position from very well-qualified professionals,” said
Mr. Gintzig also has served as CEO for
tration fellowship at South Miami Hospital
William H. McBride, chair, WakeMed
hospitals across the country, including
in Miami, Fla. He is married and has three
Board of Directors. “We were looking for
St. Thomas Health Service in Nashville,
grown daughters.
a strong leader with relevant experience
Tenn.; The Pottsville Hospital and Warne
who could lead WakeMed as we search
Clinic and Schuylkill Health Care Services
The transition and search for a permanent
for a permanent CEO. Donald’s vast expe-
in Pottsville, Pa.; Lutheran General Hospi-
CEO will not impact WakeMed’s commit-
rience and strengths in strategic planning,
tal in San Antonio, Texas; and Brazosport
ment to acute and critical care, children’s
quality improvement, financial perfor-
Memorial Hospital in Lake Jackson, Tex-
care, cardiovascular care, rehabilitation,
mance and physician relationships make
as. He has also served as CEO and senior
trauma or any initiatives currently under
him the right individual for the job.”
vice president of military and veterans
way. WakeMed intends to name a perma-
services for United Health Group in Min-
nent president and CEO within the next
neapolis, Minn.
12 months.
With the Navy, Mr. Gintzig had positions of
november 2013
19
Community Support
Myself: Together Again
Advances Awareness of Breast Reconstruction The Myself: Together Again Project has an updated website at www.myselftogetheragain.org. The Myself: Together Again Project (M:TA) started as a Susan G. Komen North Carolina Triangle affiliate grant in 2006 and grew to become a 501c-3 public charity in 2007 after its appearance on the Today Show. Its mission was simple: “We wanted women to feel empowered and educated going into tissue expander breast reconstruction following mastectomy surgery. We felt strongly that if women could see real ‘process’ pictures when they first meet with their plastic surgeon after diagnosis then they could be better prepared to be
an advocate for themselves throughout the breast reconstruction process.” From 2006-2010 Debbie Horwitz, breast cancer survivor and M:TA project founder and leader, and the M:TA team worked to get their first book, Myself: Together Again Project: A Project to Empower Young Women Through the Breast Reconstruction Process, into hospitals and doctors’ offices all over the world. Today, a second book shares a more current experience of a breast reconstruction. Sherri’s Story: Innovations in Mastectomy & Breast Reconstruction was produced in 2011.
Ms. Horwitz is now an inspiring speaker for many, even outside the breast cancer community. She hopes to further build her speaking platform to reach a broader audience. For more information, send an e-mail to info@myselftogetheragain.org.
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20
The Triangle Physician
UNC Research News
Findings Indicate Moderate Exercise Does Not Increase Knee Osteoarthritis Adults age 45 and older who engaged in moderate physical activity up to two and a half hours a week did not increase their risk of developing knee osteoarthritis over a six-year follow-up period, a new study finds. Study participants who engaged in the highest levels of physical activity – up to 5 hours a week – did have a slightly higher risk of knee osteoarthritis, but the difference was not statistically significant. Those findings taken together are good news, said Joanne Jordan, M.D., M.P.H., senior study author and director of the Thurston Arthritis Research Center in the University of North Carolina School of Medicine. “This study shows that engaging in physical activity at these levels is not going to put you at a greater risk of knee osteoarthritis,” she said. “Furthermore, we found this held true no matter what a person’s race, sex or body weight is. There was absolutely no association between these factors and a person’s risk.”
The corresponding author of the study, published online Aug. 27 by the journal Arthritis Care & Research, is Kamil Barbour, Ph.D., of the Centers for Disease Control and Prevention (CDC) in Atlanta. “Moderate physical activities are those that produce some increase in heart rate or breathing, like rapid walking,” Dr. Barbour said. “Meeting physical activity recommendations through these simple activities are a great way to reduce your risk of heart disease, stroke, high blood pressure, diabetes and other diseases.” The results are based on an analysis of data collected from 1999 to 2010 as part of UNC’s long-running Johnston County Osteoarthritis Project, a prospective, population-based study of knee, hip, hand and spine osteoarthritis and disability in African Americans and Caucasians, aged 45 years and older. This project is funded by the CDC and the National Institute of Arthritis, Musculoskeletal, and Skin Diseases (NIAMS). This new analysis included data from 1,522 study participants and tested wheth-
er or not there was an association between meeting Department of Health and Human Services (HHS) guidelines for 150 minutes of physical activity per week and the development of knee osteoarthritis, as confirmed both by X-rays and the presence of knee pain or other symptoms. The study’s findings support HHS recommendations and conclude that activities such as walking, conditioning exercises and household activities, such as gardening or yard work, that amount to moderate weekly levels of physical activity should continue to be encouraged. In addition to Dr. Jordan, study authors from UNC are Jordan Renner, M.D., from the School of Medicine; and Todd Schwartz, Dr.P.H., and Bill Kalsbeek, Ph.D., both from the UNC Gillings School of Global Public Health. In addition to Dr. Barbour, authors from the CDC are Jennifer Hootman, Ph.D., Charles Helmick, M.D., Louise Murphy, Ph.D., and Kristina Theis, M.P.H.
Findings Suggest New Route to Better Fragile X and Autism Treatments Neurons in the brain send chemical signals, called neurotransmitters, across synapses to receptors on other neurons. How well that process unfolds determines how well an experience is comprehended and what behaviors might follow. In people with fragile X syndrome, a third of whom are eventually diagnosed with autism spectrum disorder, that process is severely hindered, leading to intellectual impairments and abnormal behaviors. In a study published Oct. 18 in the online journal PLoS One, a team of UNC School
of Medicine researchers led by pharmacologist C.J. Malanga, M.D., Ph.D., describes a major reason why current medications only moderately alleviate fragile X symptoms. Using mouse models, Dr. Malanga discovered that three specific drugs affect three different kinds of neurotransmitter receptors that all seem to play roles in fragile X. As a result, current fragile X drugs have limited benefit because most of them only affect one receptor.
“There likely won’t be one magic bullet that really helps people with fragile X,” said Dr. Malanga, an associate professor in the UNC School of Medicine Department of Neurology. “It’s going to take therapies acting through different receptors to improve their behavioral symptoms and intellectual outcomes.” Nearly one million people in the United States have fragile X syndrome, which is the result of a single mutated gene called FMR1. In people without fragile X, the gene produces a protein that helps maintain the proper strength of synaptic comnovember 2013
21
UNC Research News munication between neurons. In people with fragile X, FMR1 doesn’t produce the protein, the synaptic connection weakens, and there’s a decrease in synaptic input, leading to mild to severe learning disabilities and behavioral issues, such as hyperactivity, anxiety and sensitivity to sensory stimulation, especially touch and noise. More than two decades ago, researchers discovered that in people with mental and behavior problems a receptor called mGluR5 could not properly regulate the effect of the neurotransmitter glutamate. Since then, pharmaceutical companies have been trying to develop drugs that target glutamate receptors. “It’s been a challenging goal,” Dr. Malanga said. “No one so far has made it work very well, and kids with fragile X have been illustrative of this.” But there are other receptors that regu-
late other neurotransmitters in similar ways to mGluR5. And there are drugs already available for human use that act on those receptors. So Dr. Malanga’s team checked how those drugs might affect mice in which the fragile X gene has been knocked out. By electrically stimulating specific brain circuits, Dr. Malanga’s team first learned how the mice perceived reward. The mice learned very quickly that if they press a lever, they get rewarded via a mild electrical stimulation. Then his team provided a drug molecule that acts on the same reward circuitry to see how the drugs affect the response patterns and other behaviors in the mice. His team studied one drug that blocked dopamine receptors, another drug that blocked mGluR5 receptors and another drug that blocked mAChR1, or M1, receptors. Three different types of neurotransmitters – dopamine, glutamate, and ace-
tylcholine – act on those receptors. And there were big differences in how sensitive the mice were to each drug. “Turns out – based on our study and a previous study we did with my UNC colleague Ben Philpot – that fragile X mice and Angelman syndrome mice are very different,” Dr. Malanga said. “And how the same pharmaceuticals act in these mouse models of autism spectrum disorder is very different.” Dr. Malanga’s finding suggests that not all people with fragile X share the same biological hurdles. The same is likely true, he said, for people with other autism-related disorders, such as Rett syndrome and Angelman syndrome. “Fragile X kids likely have very different sensitivities to prescribed drugs than do other kids with different biological causes of autism,” Dr. Malanga said.
Study Provides Strongest Clues for Causes of Schizophrenia A new genome-wide association study
on these two pathways in our quest to un-
dent samples. The total number of people
estimates there are 22 different places
derstand what causes this disabling men-
in the study was more than 59,000.
in the human genome that are involved
tal illness.” One of the two pathways identified by the
in schizophrenia. Of those, 13 are newly discovered and believed to play a role in
Dr. Sullivan is a professor in the depart-
study, Dr. Sullivan said, is a calcium chan-
causing schizophrenia.
ments of genetics and psychiatry and
nel pathway. This pathway includes the
director of the Center for Psychiatric Ge-
genes CACNA1C and CACNB2, whose pro-
“If finding the causes of schizophrenia is
nomics at the University of North Carolina
teins touch each other as part of an impor-
like solving a jigsaw puzzle, then these
School of Medicine. The new study was
tant process in nerve cells. The other is
new results give us the corners and
published online Aug. 25 by the journal
the “micro-RNA 137” pathway. This path-
some of the pieces on the edges,” said
Nature Genetics.
way includes its namesake gene, MIR137 – which is a known regulator of neuronal
study lead author Patrick F. Sullivan, M.D. “We’ve debated this for a century, and we
The results are based on a multi-stage anal-
development – and at least a dozen other
are now zeroing in on answers.”
ysis that began with a Swedish national
genes regulated by MIR137.
sample of 5,001 schizophrenia cases and “This study gives us the clearest picture to
6,243 controls. It was followed by a meta
“What’s really exciting about this is that
date of two different pathways that might
analysis of previous genome-wide associa-
now we can use standard, off-the-shelf ge-
be going wrong in people with schizo-
tion studies (GWAS) and finally by replica-
nomic technologies to help us fill in the
phrenia,” Dr. Sullivan said. “Now we need
tion of single nucleotide polymorphisms
missing pieces,” Dr. Sullivan said. “We now
to concentrate our research very urgently
(SNPs) in 168 genomic regions in indepen-
have a clear and obvious path to getting
22
The Triangle Physician
UNC Research News a fairly complete understanding of the ge-
Stockholm, Sweden, the Stanley Center
from the National Institutes of Mental
netic part of schizophrenia. That wouldn’t
for Psychiatric Research at the Broad Insti-
Health (R01 MH077139), the Stanley Cen-
have been possible five years ago.”
tute of MIT and Harvard, and the Mt. Sinai
ter for Psychiatric Research, the Sylvan
School of Medicine in New York.
Herman Foundation, the Karolinska Institutet and the Swedish Research Council.
Collaborators in the study include coauthors from the Karolinska Institutet in
Funding for the study included grants
Molecular Findings Could Lead to New Therapies for Treating Septic Shock The body’s immune system is set up
M.D., Ph.D., assistant professor of microbi-
ies pinpointed the role of the toll-like re-
much like a home security system; it has
ology and immunology. “You can think of
ceptor 4 gene (TLR4) as a sensor on the
sensors on the outside of cells that act
the exterior sensors as a yellow alert; they
outside of cells; mice without that gene
like motion detectors – floodlights – that
tell us that bacteria are present. But these
resisted endotoxic shock.
click on when there’s an intruder rustling
bacteria could either be simple ones in
in the bushes, bacteria that seem suspect.
the wrong place or very dangerous ones
In a study published in January 2013, also
For more than a decade researchers have
that could cause a serious infection. The
in the journal Science, Dr. Miao and his
known about one group of external sen-
interior sensors act as a red alert; they
colleagues showed that a sensor called
sors called “toll-like receptors” that detect
warn us that there are bacteria with ill
caspase-11 sounds an alert when bacte-
when bacteria are nearby.
intent that have the genetic capacity to in-
ria enter a cell. However, it wasn’t clear
vade and manipulate our cells.”
which of the thousands of molecules that make up a bacterial cell triggers that new
Now, researchers at the University of
sensor.
North Carolina School of Medicine have
The body responds to a bacterial infection
identified a sensor pathway inside cells.
by increasing blood vessel permeability
These internal sensors are like motion
near the area under attack, which allows
In the current study, Dr. Miao and his col-
detectors inside a house; they trigger an
immune system cells to leave the blood-
leagues investigated which bits of foreign
alarm that signals for help – a response
stream and seek and destroy the bacteria.
material were being detected. They took
from the immune system. This research,
Fluid also leaks into the area surrounding
apart and delivered different chunks of
published in the Sept. 13 issue of the jour-
the infection, causing characteristic swell-
bacteria into the cytoplasmic compart-
nal Science, indicates that both exterior
ing.
ment inside the cell. To their surprise, they found that the caspase-11 sensor in-
and interior sensors work together to detect the same component of bacterial cell
This is beneficial in fighting infection, but
side the cell was detecting the same mol-
membranes, a molecule called lipopoly-
when the infection gets out of hand and
ecule, LPS, as the TLR4 sensor outside the
saccharide or LPS.
these immune responses occur through-
cell. The researchers wondered whether
out the body, blood pressure plummets,
there was a link between these two sen-
By showing how the immune system dis-
overtaxing the heart and leading to organ
sors.
tinguishes between suspicious activity
failure and often death. This increasingly
and real threats, the study could lead to
prevalent syndrome, known as septic
Through a number of experiments in
new therapies for septic shock – when the
shock, afflicts more than 750,000 people
animal models of sepsis, Dr. Miao’s team
immune system overreacts to a bacterial
each year in the United States at a cost of
showed that the exterior and interior
infection to such an extent that it causes
nearly $17 billion.
alarms work together through a two-step defense mechanism: LPS is first seen on
more harm than good. About half of the cases of septic shock are
the outside of the cell by TLR4, which sets
“During the defense against an infection
caused by bacteria that produce LPS, also
the interior caspase-11 alarm into a watch-
you want to be able to differentiate be-
known as endotoxin. In fact, much of what
ful state. At very high doses, the LPS cross-
tween the bacteria that stay on the outside
is known about endotoxic shock comes
es into the cell, tripping the caspase-11
of the cell and the ones that get inside,”
from studying animals injected with high
alarm. The end result is the generation
said senior study author Edward A. Miao,
doses of LPS. For example, previous stud-
of the red alert signal, which causes the
november 2013
23
UNC Research News cell to explode, a form of cell death called
two sensors get activated in response to
if so, is there a way to block them so we
pyroptosis.
a bacterial infection could help research-
can keep patients from dying.”
ers develop new ways of preventing or During an infection, the immune system
treating septic shock, a condition that kills
Study co-authors from UNC were Jon A.
essentially burns the house down around
about half its victims.
Hagar and Youssef Aachoui. The work was done in collaboration with Robert K.
the invading bacteria, depriving it of a place to replicate, and exposing it to more
“The septic shock we see in patients is
Ernst and Daniel A. Powell at the Univer-
potent immune defenses. During sepsis,
probably a lot more complicated than
sity of Maryland in Baltimore. This work
however, too much fire leads to the onset
what we see in this experimental system,”
was supported by NIH grants AI007273
of shock.
said Dr. Miao. “The next question we need
(J.A.H),
to ask is whether these same sensors are
(E.A.M), and AI101685 (R.K.E).
Dr. Miao says that figuring out how these
AI097518
(E.A.M),
AI057141
going off in people with septic shock, and
News Welcome to the Area
Physicians Mehreen Arshad, MD Pediatric Infectious Diseases
Duke University Hospitals Durham Gene Robert Botwright Jr., MD Family Medicine
Raleigh
Brian Adam Boyd, MD Therapeutic Radiology; Vascular and Interventional Radiology; Neuroradiology; Nuclear Radiology; Pediatric Radiology; Radiologic Physics; Roentgenology; Diagnostic Radiology; Musculoskeletal Radiology
Brooke Rambally, MD Pathology
University of NC Hospitals Chapel Hill Robert Charles Shepard, MD Hematology and Oncology, Internal Medicine
Raleigh
Nathaniel Adam Sowa, MD Psychiatry
University of NC Hospitals Chapel Hill Kavitha Subramanian, MD Hospice and Palliative Medicine; Geriatrics; Internal Medicine
University of North Carolina Hospitals Chapel Hill
Maria Parham Medical Center Henderson
Eliseu Yung Chuang, MD
Internal Medicine; Anesthesiology
Hospitalist; Internal Medicine
Duke Raleigh Hospital Raleigh
Gregory Eric Wells, MD Durham
Meredith Laine Whitacre, MD Surgery (general); Surgery
Jeanette Estelle Wedsworth, PA
Dr Artis Office Goldsboro
Neurology; Hospitalist
Pediatrics; Adolescent Medicine
Cary John Zakrzewski, PA
WISH Goldsboro
Urological Surgery; Urology
Durham
Roger Dale Page, PA Anesthesiology; Emergency Medicine
Duke Univ Med Center Durham Paul Stephen Toth, PA Dermatology; Plastic Surgery; Abdominal Surgery; Administrative Medicine; Dermatology - Clinical & Laboratory; Facial Plastic Surgery
Durham
James Glendon Trenner, PA
Candra Kameko Wooten, MD
Family Medicine; Surgery (general); Administrative Medicine
Lee Antoinette Darville, MD
Physician Assistants
Pediatric Infectious Diseases
UNC, Dept of Pediatrics, Div of Infectious Diseases Chapel Hill Caroline Joy Mariano, MD Internal Medicine
UNC Chapel Hill Chapel Hill Jill Marsh, MD Family Medicine; Geriatrics
Duke University Hospitals Durham Kunal Panda, MD Anesthesiology; Anesthesiology - Critical Care Medicine
Curtis Lee Bowe Jr., PA Internal Medicine; Family Medicine
Chapel Hill
Marian Elaine Cranford, PA
Burlington
Bradford Cole Powell, MD Medical Genetics
Chapel Hill
The Triangle Physician
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Rex News
Cancer Care Practice Opens in Garner The new Rex Hematology Oncology Associates of Garner offers comprehensive cancer care that is closer to residents of southern Wake County, Johnston County and surrounding areas. The practice is led by medical oncologist/ hematologist Brendan D. McNulty, M.D., and features private and semi-private chemotherapy infusion bays, lab services and more. Dr. McNulty most recently practiced at a satellite cancer center outside of Boston, Mass., for the Dana-Farber Cancer Institute. “I’m excited to join Rex’s renowned clinical team and help develop this sophisticated cancer clinic,” Dr. McNulty said. “Cancer diagnosis and treatment are difficult enough, and we can go a long way in easing the burden on patients by provid-
ing state-of-the-art care closer to home.” The practice now collaborates with the cancer care teams at Rex Cancer Center in Raleigh, as well as the N.C. Cancer Hospital and UNC Lineberger Comprehensive Cancer Center in Chapel Hill. The new practice adds to Rex’s continuum of care already present in nearby communities. Rex offers radiation cancer treatment at Clayton Radiation Oncology and Smithfield Radiation Oncology, a joint partnership between Johnston Health and Rex/ UNC Health Care. “We are pleased to provide patients with easier access to oncology and hematology services and to offer the expertise and experience of a compassionate physician like Dr. McNulty,” said Vickie Byler, director of Rex Cancer Center. Dr. McNulty earned his medical degree from the University of Massachusetts Med-
ical School, completed his residency in internal medicine at Beth Israel Deaconess Medical Center in Boston and attended the Brown University Hematology/Oncology Fellowship Program. Following his training, Dr. McNulty joined Dana-Farber Cancer Institute and over the next four years developed a successful practice at its satellite cancer center in Milford, Mass. Rex Hematology Oncology Associates of Garner is located behind the White Oak Shopping Center at 300 Health Park Drive, Suite 220, in Garner. The area, at the intersection of I-40 and U.S. 70, has become a major medical hub with Rex Wellness Center of Garner nearby, as well as satellite offices of North Carolina Heart & Vascular, Rex Surgical Specialists, Raleigh Orthopaedic Clinic and others. To make an appointment or for more information, call (919) 250-5955.
National Hospital Reports Give Rex Top Marks for Quality and Safety Rex Healthcare has earned top marks in two highly regarded national reports that grade hospitals on quality, safety and reputation. Rex has been awarded the Consumer Choice Award by the National Research Corp. and earned an “A” safety grade by the Leapfrog Group’s annual Hospital Safety Score. “These accolades reinforce our commitment to providing quality healthcare and ensuring patient satisfaction,” said Rex Chief Operating Officer Steve Burriss. The National Research Corp. recognized Rex with its Consumer Choice Award for the 10th consecutive year. Rex is the only hospital in Wake County to earn the 2013 award and one of only 10 recipients in North Carolina.
The National Research Consumer Choice Award honors the nation’s hospitals rated by consumers as having the best overall quality and reputation and best doctors and nurses, based on a survey of more than 270,000 households across the country. The recipients of the 2013-2014 Consumer Choice Award were named in the October issue of Modern Healthcare magazine. For more information about the award, visit: nationalresearch.com/about/consumerchoice-awards. Rex Hospital, along with several other area hospitals, were honored with an “A” grade in the Leapfrog Group’s Fall 2013 update to its Hospital Safety Score, which rates how well hospitals protect patients
from accidents, errors, injuries and infections. The score is compiled under the guidance of the nation’s leading experts on patient safety and is administered by Leapfrog, an independent industry watchdog. The first and only hospital-safety rating to be analyzed in the peer-reviewed Journal of Patient Safety, the score is designed to give the public information that can help protect individuals and families. To see scores as they compare nationally and locally and to find safety tips for patients and their loved ones, visit the Hospital Safety Score website at hospitalsafetyscore.org. Local hospital scores are also available on a free mobile app. To learn about other awards Rex has won, visit rexhealth.com/awards. november 2013
25
3D MAMMOGRAPHY WE’RE TALKING WAY BETTER IMAGING, EARLIER DETECTION, FEWER FALSE POSITIVES AND LESS CHANCE OF A CALL BACK. END OF DISCUSSION.
3D MAMMOGRAPHY • GREATER ACCURACY • REDUCED ANXIETY • NOW AT WAKE RADIOLOGY Let’s have a frank discussion. You can’t treat what you can’t detect. And 3D mammography, along with your regular 2D exam, is revolutionizing breast cancer detection. How? By significantly improving clarity for earlier detection and fewer false positives. Which, of course, reduces recall rates and the anxiety that comes with additional tests. To learn more about 3D mammography or to schedule an appointment, visit wakerad.com. Like we said, you can’t treat what you can’t see. And now we’re seeing better than ever. Wake Radiology | North Hills Breast Center | 919-232-4700 | wakerad.com Daily, evening and Saturday appointments | 20 minutes from check-in to exam completion