october
2 013
Rex Comprehensive Breast Care Program A Team Approach to Treating Breast Cancer
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 Circumcision Dyspepsia
CURVED as nature intended.
Nature’s architecture is never accidental. The Viva™ CRT-D and Evera™ ICD feature a new PhysioCurve™ design to fit bodies more naturally – reducing skin pressure by up to 30%*1. Learn more at vivaevera.com/PhysioCurve. * Compared to noncontoured devices.
COVER STORY
6
Rex Comprehensive Breast Care Program
A Team Approach to Treating Breast Cancer
october 2 0 1 3
Vol. 4, Issue 9
FEATURES
9
Practice Marketing
Competing for Patients Online: Three of the Latest Web Design Trends Amanda Kanaan provides the latest techniques for an online presence that serves as a top-of-
DEPARTMENTS 12 Urology
18 UNC Research News
14 Raleigh Orthopaedic News
mind health care resource for patients.
10
Circumcision Update
- New Headquarters Is Joint Venture Between Rex and Raleigh Orthopaedic - Cadet Brings Specializations in Sports Medicine and Care of the Shoulder
15 Practice Management Endocrinology
What’s New with Radioactive Iodine?
- It’s Your Money - The Triangle Physician 2013-2014 Editorial Calendar
16 Community Support
-N ew Angle for Drugs May Prevent Stroke and Heart Attack -E nzyme Discovery Could Explain Many Biological Mechanisms Behind Autism
20 Duke Research News Newly Identified Genetic Factors Drive Severe Childhood Epilepsies
21 Duke Research News Three Subtypes of Gastric Cancer Suggest Varied Treatment Approaches
23 News
-O ’Keefe Achieves Highest Designation for Medical Practice Executives -N ew Facility Treats Average of 52 Patients per Day in One Month
Dance Dash for Duke Children’s Finishes with Flash Mob Dance Party
byproduct of nuclear fission in the treatment
17 Gastroenterology
of hyperthyroidism and thyroid cancer.
24 News
Dr. Michael Thomas describes the use of this
Dyspepsia: A Common Condition
- Welcome to the Area & Events
COVER PHOTO: Members of the Rex Comprehensive Breast Care Program team are: (first row, from left) medical oncologist Lola Olajide, M.D., breast surgeon David Eddleman, M.D., and medical oncologist JoEllen Speca, M.D.; and (second row, from left) nurse navigator Kristin Knott, B.S.N., breast surgeon Rachel Goble, D.O., radiation oncologist Courtney Bui, M.D., nurse navigators Leanne LeClair, R.N., B.S.N., and Joan Freeborn, B.S.N., and medical oncologist Susan Moore, M.D.
2
The Triangle Physician
Johnston Health’s Urology And Gynecology Surgical Procedures Are Now Quicker, More Precise And Less Invasive!
daVinci Robotic Surgery Johnston Health’s daVinci Surgical System, at Johnston Medical Center Smithfield, offers many advantages over traditional urology and gynecology surgical procedures. The less invasive option means, among other things, shorter recovery times. If you have patients who you think would benefit from this revolutionary technology, call Johnston Medical Center in Smithfield for a list of physicians who are trained and experienced on the da Vinci system.
509 N. Bright Leaf Blvd., Smithfield, NC
919-934-8171
www.johnstonhealth.org
From the Editor
Less Stress! Treatment is truly caring when it is designed to minimize stress on patients. That means facilitating access to quality care and coordinating services so they are delivered efficiently and conveniently.
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
The month’s cover story relates how Rex Comprehensive Breast Care Program does all that. Rex Comprehensive Breast Care Program embraces a team approach to streamlined and customized comprehensive care, with an eye on early diagnosis. Nurse navigators are assigned to patients early on to minimize uncertainty and help overcome possible barriers to needed health care, such as transportation and ability to pay. The cover story also is an opportunity to welcome fellowship-trained breast surgeon Rachel Goble, M.D., who recently joined Rex Surgical Specialists. This issue of The Triangle Physician features new contributing editor urologist John Wiener. He reviews the changing medical opinion of circumcision, which is currently
Editor Heidi Ketler, APR
heidi@trianglephysician.com
Contributing Editors Kellie Bunn, P.A.-C. Amanda Kanaan Joe Reddy Michael J. Thomas, M.D., Ph.D. John S. Wiener, M.D., F.A.A.P., F.A.C.S. Photography Three Oaks Photography jack@threeoaksphotography.com
not recommended as a routine procedure for male newborns by any medical
Creative Director Joseph Dally
organization. Although in its latest 2012 revision, the American Academy of Pediatrics
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stated, “the preventative health benefits… outweigh risks of the procedure.”
info@trianglephysiciancom
Physician assistant Kellie Bunn also is new to our pages, and she provides an
News and Columns Please send to info@trianglephysician.com
jdally@newdallydesign.com
overview of dyspepsia, including the treatment of this common abdominal condition. Endocrinologist Michael Thomas returns to discuss the clinical use of radioactive iodine. Practice management consultant Joe Reddy continues his discussion on 2013 tax strategies for building owners that can boost cash flow. And practice marketing specialist Amanda Kanaan shares what’s trending in web design.
The Triangle Physician is published by: New Dally Design Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
If physician referral is an ongoing concern, keep in mind that The Triangle Physician is a direct conduit to the Raleigh-Durham medical Triangle. Every month, your marketing message on our pages can easily reach the more than 9,000 physician, physician assistants, nurse practitioners and practice and hospital administrators within the region you serve. For more information, feel free to contact me at heidi@trianglephysician.com. With gratitude and appreciation,
Heidi Ketler Editor
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The Triangle Physician
Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.
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Cover Story
Rex Comprehensive Breast Care Program A Team Approach to Treating Breast Cancer For many breast cancer patients, the jour-
women who would otherwise not be able
Navigating the System
ney from detection to diagnosis is a com-
to afford it. Rex’s mobile mammography
A diagnosis of breast cancer comes with a
plicated one. It can begin with a suspicious
unit travels to events and organizations – a
flood of emotions and questions from pa-
lump usually found by a primary care
service that spans 13 counties.
tients. Therefore, when it comes to patient
physician. From there, a mammogram is
resources, Rex doesn’t just give patients
scheduled. Once the results come back,
When it comes to diagnosis, one of the
an educational handout or point them to a
a biopsy may be performed, followed by
worst parts for patients can be waiting. As
website. They take a larger step by provid-
a wait for the pathology report; and that’s
physicians, having no answers for patients
ing a real-life support system through their
just to receive a definitive diagnosis.
until the diagnostic testing results are
breast cancer navigators.
available can be frustrating as well. That’s All in all, it can be a disjointed roller
where the new Rex Breast Care Center
Joan Freeborn, a registered nurse and one
coaster ride full of anxiety-ridden waiting
can help. Performing mammograms, ultra-
of Rex’s breast cancer navigators, explains
periods. In a vulnerable time for patients,
sounds and biopsies all in one office, the
that the role of the navigator is to provide
this process can be not only inefficient but
fellowship-trained radiologists can identify
hands-on support and education to all
also torturous.
the mass and then proceed immediately
breast cancer patients who come through
with a biopsy onsite. This real-time care
the door. That begins as soon as the di-
Rex Healthcare’s solution is the compre-
helps cut back on the anxiety of delays
agnosis is made; the navigators often see
hensive breast care program. With the pa-
and allows for quicker results for both pa-
patients on the day of their diagnosis by
tient and referring physician in mind, Rex
tients and physicians.
receiving notification ahead of time of a
has revolutionized this process with a col-
positive result.
laborative approach that streamlines breast
New technology, such as Rex Breast Care
care from early detection to survivorship.
Center’s three-dimensional mammogra-
“We literally walk side-by-side with pa-
phy services, also contributes to reduced
tients throughout treatment,” says Ms.
Expediting Diagnosis
or even unnecessary waiting periods.
Freeborn. “Whether it’s telling them what
For Rex Healthcare, breast cancer care be-
“With 3-D mammography, we get a more
to expect next or actually attending doctor
gins well before the diagnosis. Rex offers
detailed view of the breast, which results
appointments with them, we want to pro-
mammography services at five locations
in a reduced number of false call-backs
vide a continuity of care that puts patients
throughout Wake County and extended
for abnormalities that ultimately turn out
at ease when they see a familiar face in
hours to make regular screening as easy as
to be negative,” says JoEllen Speca, M.D.,
the room.”
possible. In addition, the mammography
a medical oncologist at Rex Hematology
outreach program provides free testing for
Oncology Associates.
As you would imagine, the role of breast cancer navigator is a demanding one that
Dr. Goble is a fellowship-trained breast surgeon who has joined Rex Surgical Specialists. She earned her undergraduate degree with honors from the University of Kentucky and her medical degree from Kentucky College of Osteopathic Medicine. Dr. Goble completed her general surgery internship and residency at Kettering Health Network, Grandview Medical Center in Dayton, Ohio, and her breast surgical oncology fellowship at Moffitt Cancer Center in Tampa, Fla.
6
The Triangle Physician
truly requires a passion for the specialty. “I’ve worked my entire career at Rex, all 36 years of it, and this is by far the most rewarding position I’ve ever had. I’m exhausted when I get home at night, but it’s a good exhausted,” says Ms. Freeborn, who walks an average of five to seven miles a day while supporting patients.
A Team Approach Each of the providers involved in a patient’s breast cancer treatment aim for a tailored approach, but what’s unique at Rex is that they all do it together. Each Tuesday the breast care team collaborates on patient cases to approach treatment from every angle. In attendance with the breast cancer navigators are the surgeons, radiation and medical oncologists, pathologists, radiologists, an oncology-certified dietitian, social workers and clinical researchers. It’s much like a collaborative second opinion where all facets of care weigh in on the best options for the patient. “When caring for breast cancer patients, there are many treatment options available,” says Dr. Speca. “Being able to explore those options with a group of colleagues is very helpful. Putting more minds together often results in better and more well-rounded treatment plans. That even includes making sure patients have transportation to and from appointments, as well as providing financial counseling. We’re proactive about identifying any issues upfront, so we don’t wait until patients miss an appointment to discover there’s a problem.” One of the newest members of Rex’s collaborative breast care team is breast surgeon Rachel Goble, D.O. She joined Rex Surgical Specialists and breast surgeons David Eddleman, M.D., and Thomas Maddox, M.D., who are also part of the mul-
Radiation oncologist Courtney Bui, M.D., and medical oncologist JoEllen Speca, M.D., work together with a multidisciplinary team of physicians and other clinicians to develop a treatment plan tailored to each individual breast cancer patient’s needs.
tidisciplinary breast care team. A fellowship-trained breast surgeon, Dr. Goble
diagnosed and treated with breast cancer
breast radiation in order to reduce expo-
treats breast disorders, including cancer.
at Rex Healthcare each year, and no two
sure and maintain the same outcome.
cases are treated alike. “We are now iden“What I love about Rex is that it’s a team
tifying subsets of patients who respond to
Breast surgery is following a similar trend
approach all under one roof,” says Dr.
different therapies and are also using tar-
with a “less is more” approach. According
Goble. “I’ve also found that everyone here
geted therapies to more precisely attack
to Dr. Goble, the goal is to pursue less-
genuinely cares for these patients, and
the cancer cells while doing minimal dam-
invasive treatments that cater more toward
when you combine that with a collab-
age to normal cells,” says Dr. Speca. They
breast preservation. However, the deci-
orative environment, you achieve the best
also customize treatments around patients’
sion of how much breast tissue to remove
outcomes possible.”
lifestyle needs in order to maintain a good
is very much patient driven.
quality of life. A similar approach is used
Tailoring Treatment
for radiation treatments where physicians
“I’ve had patients with a 1 centimeter tu-
Hundreds of patients with breast cancer are
can choose to perform partial versus whole
mor request bilateral mastectomy,” says
october 2013
7
Dr. Goble. In these cases, she works di-
link, but if a woman tests positive for the
ily with ovarian cancer at any age, then
rectly with the plastic surgeon to devise a
BRCA1 or BRCA2 gene mutation, then she
she should consider getting tested. Cer-
plan for performing the mastectomy and
has an 80 percent chance of developing
tain ethnicities should also be considered.
breast reconstruction in the same surgery.
breast cancer. Dr. Goble says it’s also im-
BRCA testing is usually covered by insur-
As high-profile women speak out about
portant to note that these patients have a
ance if certain criteria are met (such as a
their decision to choose this type of sur-
40 percent chance of developing ovarian
strong family history). Without insurance,
gery and the heightened awareness of
cancer – a much more difficult cancer to
BRCA testing ranges from $475 to $5,000
BRCA testing, it may not be surprising that
catch early and treat effectively.
depending on the type of testing.
According to Dr. Goble, if a woman has a
Survivorship: Life after Cancer
first-degree relative who had breast cancer
Rex Healthcare is in its 25th year of cel-
before the age of 50 or anyone in her fam-
ebrating National Cancer Survivors Day
more women are requesting the bilateral mastectomy. Only 10 percent of cancers have a genetic
to honor survivors in the Triangle. Rex Cancer Center serves hundreds of patients each day, and care doesn’t end once treatment is complete. Even after remission, patients are offered support through a wellness, exercise and nutrition program, as well as a survivor support group to help adjust to life after cancer. “Treating cancer patients is complicated but very rewarding,” says Dr. Speca. “In the field of breast cancer, there are many effective treatment options available. So many of our patients are cured, and that’s extremely satisfying.” From early detection to diagnosis, through treatment and then survivorship, Rex’s Comprehensive Breast Care Program truly cares for patients at every stage of breast cancer. For referring physicians, knowing one referral gets patients the care they need offers peace of mind. “We want referring practices in the community to essentially feel like they can just make one phone call, and their patients will be taken care of,” says Ms. Freeborn. The new Rex Breast Care Center is located at 3100 Duraleigh Road, Suite 204 in Raleigh (corner of Edwards Mill Road and Duraleigh Road near Rex Healthcare’s main campus). Rex Cancer Care has locations in Raleigh, Wakefield, Smithfield and Clayton. For more information about the Rex Comprehensive Breast Care Program, Fellowship-trained breast surgical oncologist Rachel Goble, D.O., is the newest member of the breast cancer care team at Rex Healthcare.
8
The Triangle Physician
visit rexhealth.com/breast-care.
Practice Marketing
Competing for Patients Online
Three of the Latest Web Design Trends By Amanda Kanaan
If you’ve ever had a patient present in your
ing this thought process one step further
office with a self-diagnosis from WebMD,
by creating “responsive” websites. This
then you know firsthand the impact of
allows your website to adapt to any de-
the internet on health care. Patients are
vice – from smartphones to tablets (ipads,
not only searching for conditions online,
etc.) to computers. A responsive website
they’re also comparing doctors.
automatically responds and adapts to any size device, resulting in a better user experience. This also makes your website much more likely to convert visitors into patients.
2. Patient Interaction Websites should be more than a pretty online brochure. There are plenty of interactive tools you can integrate to keep pa-
Amanda Kanaan is the founder and president of WhiteCoat Designs – a medical marketing agency providing doctors with medical website design, search engine optimization (SEO), mobile and responsive websites, social media management, graphic design, physician liaison services, and more. To contact Ms. Kanaan or to learn more about WhiteCoat Designs, visit www.whitecoat-designs.com.
tients on your website longer. This is good not only for search engine optimization
vous about collecting protected health
Your website has just seven seconds to
(SEO) purposes but also to bring value to
information (PHI) online and rightfully
make an impression on patients or they’re
your relationship with the patient.
so. However, there are now companies that specialize in meeting Health Insur-
on to the next link in Google. Patients will also use your website to compare
One example is the symptom checker.
ance Portability and Accountability Act
you to your competitors, and will actually
Another is a dosage calculator for parents
compliance regulations for online interac-
choose a provider based on the design,
to calculate their children’s medications
tions. This makes it possible for patients
functionality and messaging of a website.
online – a great tool for pediatric websites.
to reveal the reason for their appointment when making a request through your web-
With that in mind, here are three of the latest website design trends to help you
There are plenty of companies that offer
site. It also allows patient registration pa-
stand out online.
affordable online tools that allow patients
perwork to be filled out online.
to use your website as a resource for re-
1. Responsive Design
searching a condition. After all, wouldn’t
These benefits not only make your prac-
More than half of all smartphone owners
you rather a patient come to your website
tice more efficient, but they are also
have used their phone to look up health
to look up a symptom rather than relying
something patients appreciate. Sixty-five
or medical information. Mobile websites
on WebMD?
percent of patients are willing to switch to a physician who engages them using
make browsing the desktop version of your site much easier and faster for pa-
The benefit is that it drives more traffic to
digital communications. Research shows
tients. Since users’ search behaviors are
your website. It also positions you as the
that patients want to interact online. So by
different on mobile devices versus desk-
expert in your specialty, meaning anytime
giving patients what they want, you can
top computers, having a mobile website
a patient has a concern, you are top of
help your website standout among the
is a necessity, if you want to improve the
mind.
competition.
3. HIPAA Forms
Source: Pew Research Center, Pew Inter-
Medical providers are extremely ner-
net & American Life Project (2011)
online experience for patients. However, website designers are now tak-
october 2013
9
Endocrinology
What’s New with
Radioactive Iodine? By Michael J. Thomas, M.D., Ph.D.
Radioiodine (I-131), first discovered in
10-30 percent at 24 hours. Patients with
1938, is a nuclear fission byproduct of
Graves’ disease often have a markedly
uranium. In the early 1940s, radioiodine
elevated RAIU, whereas patients with thy-
was used to study thyroid physiology,
roiditis typically have extremely low RAIU
and by the late 1940s it was used to treat
measurements (due to lack of iodine up-
hyperthyroidism and thyroid cancer. So,
take in injured thyroid tissue).
remarkably, I-131 has been used clinically for the past 70 years.
RAIU can be influenced by dietary iodine intake (e.g. vitamins and fish oil cap-
Iodine is actively transported and incor-
sules), iodinated computed tomography
porated into thyroglobulin, a precursor to
contrast dye and anti-thyroid medica-
thyroid hormone, thus trapping the iodine
tions, so it is necessary to perform RAIU
in the gland. With the exception of the sal-
measurements several days (sometimes
ivary glands, very little iodine is absorbed
weeks) after these factors are discontin-
elsewhere in the body, and unincorporat-
ued or avoided. RAIU measurements are
ed iodine is quickly excreted in the urine,
inexpensive and can be performed in the
with much smaller amounts excreted in
office setting.
stool, saliva and perspiration. Two radioisotopes of iodine are used clinically: I-131
A radioiodine thyroid scan generates an
(half-life 8.02 days), which is used mostly
image of the iodine that is actively trapped
for therapy; and I-123 (half-life 13 hours),
in the thyroid, revealing areas of increased
which is a very low-energy gamma-emitter
or decreased absorption. In the past, thy-
useful for diagnostic and imaging studies.
roid scans were sometimes performed to determine whether a thyroid nodule
Dr. Michael Thomas of Carolina Endocrine P.A. graduated from the School of Medicine at West Virginia University in Morgantown, with a doctor of medicine and doctor of philosophy in pharmacology and toxicology. He completed his post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency and fellowship in endocrinology. Dr. Thomas was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. He established Carolina Endocrine in the summer of 2005. Board certified in internal medicine and endocrinology, Dr. Thomas is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology (FACE) and has completed endocrine certification in neck ultrasound (ECNU). For more information and patient referrals and appointments call (919) 571-3661 or visit the practice website at carolinaendocrine.com.
A radioiodine uptake (RAIU) measurement
was “hot,” a nodule that absorbed a lot of
determines how much iodine the thyroid
radioiodine; or “cold,” a nodule that did
(e.g. MIBG; iodine-131-meta-iodobenzyl-
gland absorbs during a several-hour peri-
not absorb any radioiodine. Nearly all hot
guanidine, an agent that is concentrated
od. It is useful to determine the underlying
nodules are benign, but “cold” nodules
into adrenal medullary [chromaffin] tis-
cause of thyroid dysfunction, and it can be
carry about a 20 percent risk of malignan-
sue, to identify pheochromocytomas).
used to guide therapeutic management de-
cy and should be further evaluated.
cisions based on the result.
Radioiodine has been extensively studied The advent of ultrasound and fine needle
under a variety of different thyroid disease
The procedure is straightforward: the
aspiration (FNA) biopsy have obviated
situations, doses and ages. Studies extend
patient ingests a known amount of radio-
the need for some thyroid scans, except
back to the 1950s.
iodine and then returns 24 hours later to
in the diagnosis of toxic multinodular goi-
have the amount of radiation in his thyroid
ter or toxic adenoma.
measured. A device similar to a Geiger
For “low” doses of radioiodine used to treat hyperthyroidism (e.g. 10-30 mCi), the
counter measures the levels in the neck
Another type of imaging study is a “whole
risk of malignancies appears negligible in
area. The amount of radiation is divided
body scan,” which is obtained before or
most studies and meta-analyses. However,
by the known starting amount of radioio-
after I-131 therapy in patients who have
there is heightened concern about the
dine, giving the percent uptake.
undergone total thyroidectomy for thyroid
routine use of radioiodine in pre-adoles-
cancer. Other nuclear medicine scans
cents, so caution is advised with radioio-
also employ I-131 in imaging other tissues
dine use in the pediatric population, and
A normal adult thyroid RAIU is between
10
The Triangle Physician
fewer side effects, but no apparent outcome
References
differences. There are more side effects
Sisson, J.C., et al Radiation Safety in the
with higher doses of radioiodine therapy,
Treatment of Patients with Thyroid Dis-
including nausea, vomiting and sialoadeni-
eases by Radioiodine 131I: Practice Rec-
tis (swelling of the salivary glands), which
ommendations of the American Thyroid
can lead to pain and dry mouth (xerosto-
Association. Thyroid 21(4):335-346, 2011
mia), as well as alterations in test sensation
never used in pregnancy.
and excessive tearing (epiphora). At high
For more information and patient referrals
doses of radioiodine, there is an increased
and appointments call (919) 571-3661 or
risk of secondary malignancies, including
visit carolinaendocrine.com.
salivary gland, stomach, bladder and hematologic malignancies, though these are
I-131 therapy is usually outpatient, and
very uncommon.
recipients are instructed to follow some basic hygiene and safety precautions for varying lengths of time following therapy. The side effects of low-dose radioiodine are minimal: some patients experience minor thyroid pain that usually responds to analgesics. Rates of post-procedural hypothyroidism vary in terms of their onset, depending on the dose of radioiodine given and the underlying cause of hyperthyroidism: the majority of patients with Graves’ disease develop hypothyroidism within several months, whereas a smaller percentage of patients with toxic multinodular or toxic adenomas develop hypothyroidism (1025 percent) over a longer period of time. Once the hypothyroidism develops, it usually requires lifelong thyroid hormone replacement therapy. Higher doses of radioiodine (30-200 mCi) are often used to treat high-risk papillary or follicular thyroid cancer. There is no evidence that radioiodine treatment will decrease the risk of recurrence or improve longevity in low-risk patients. Radioiodine therapy is administered to outpatients when TSH (thyroid stimulating hormone) levels are elevated (either using recombinant human TSH or thyroid hormone withdrawal). In the past decade, there has been a remarkable reduction in the doses of radioiodine used to treat thyroid cancer, with Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
october 2013
11
Urology
Circumcision Update By John S. Wiener, M.D., F.A.A.P., F.A.C.S.
Circumcision has been practiced for
Changing Recommendations
more than 10,000 years in cultures around
A close look at the limited evidence for
the globe; however, the circumcision of
or against circumcision led the American
newborn boys was limited to the Jewish
Academy of Pediatrics (AAP) to issue its
culture until recent times. In the late 19th
first statement on the practice in 1975:
century, medical experts in America and
“There is no absolute medical indication
Britain began to extol the virtues of the in-
for routine circumcision of the newborn.”
fant circumcision.
Yet, only 14 years later, the AAP amended its guidelines, noting some health benefits
Dr. John Wiener is an associate professor of surgery (urology) and pediatrics at Duke University Medical Center. He is head of the section of pediatric urology and vice chief and associate resident director in the division of urologic surgery. He can be reached at (919) 684-6994 or john. wiener@duke.edu.
In 1914, Abraham Wolburst wrote in the
without recommending routine circumci-
Journal of the American Medical Associa-
sion. Circumcision was found to confer
tion that circumcision was “a great aid to
a nearly 10-fold decrease in urinary tract
could be significantly reduced with ap-
cleanliness,” and a “prophylaxis against a
infections (UTIs) in infant boys, but UTIs
propriate measures.
variety of venereal diseases,” and it led to
are rare and occur in only 1 percent of un-
a “diminished tendency to masturbation,”
circumcised boys.
Circumcision, as with any surgical procedure, is not without risks. Death was a very
which supposedly led to physical and
rare but noted risk, but this has essentially been eliminated with antimicrobials (when rarely needed) and treatment for bleeding disorders (which could be tragically discovered after circumcision in hemophiliacs.) In addition to bleeding and infection, other complications include injury to the penis and urethra, as well as poor cosmetic appearance which may require later surgical revision. There remains controversy over the hypothesis that circumcision impairs penile sensation and sexual satisfaction without a clear answer. Based on these data, no medical organization in the world currently recommends newborn circumcision. North Carolina, along with at least 16 other states, denied moral decline. “It is the moral duty of ev-
Penile cancer essentially does not occur
Medicaid coverage for routine newborn cir-
ery physician to encourage circumcision
in males circumcised at birth, but this is
cumcision beginning in 2001. As a result of
in the young.”
an exceedingly rare cancer in the U.S.,
this and additional factors, the prevalence
even among uncircumcised men. In 1999,
of newborn male circumcision in the U.S.
With increasing medical support, new-
the AAP again revised its guidelines to
today has declined to 31-79 percent, de-
born circumcision grew from an uncom-
promote discussion of the risks and ben-
pending upon regional variations. Another
mon practice to 33 percent of male births
efits of circumcision with expecting/new
factor behind this decline is increased im-
in the United States by 1930. As hospital
parents but still did not recommend the
migration of individuals from areas and cul-
births became the norm, newborn male
practice routinely. They did recommend
tures where circumcision is not the norm.
circumcision became nearly universal by
procedural analgesia, as several studies
the 1970s.
confirmed that the pain of the procedure
12
The Triangle Physician
In the last decade, three randomized con-
trolled trials from sub-Saharan Africa demonstrated a statistically significant reduc-
Services
tion in HIV sero-conversion of 53 percent,
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in aggregate, in circumcised young men engaging in heterosexual sex. These and other studies also noted a more modest
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reduction in transmission of other sexually transmitted infections, most notably, human papillomavirus. With these findings, the AAP again revised its recommendation in 2012, stating that “the preventative health benefits… outweigh risks of the procedure.” They did not recommend routine circumcision of all newborn males but did state that the data are sufficient “to justify access to this procedure for families choosing it and to warrant thirdparty payment for circumcision.” This policy statement was endorsed by the American College of Obstetricians and Gynecologists.
What to Tell Parents Parents of newborn boys should be counseled to the potential benefits of circum-
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cision, as well as its risks. This conversation should begin long before delivery.
tional risks and significantly greater costs.
Drossman Gastroenterology
For families opting to keep the foreskin
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
The newborn penis undergoes a growth spurt and may quickly become too large to safely remove the foreskin; hence, most practitioners limit the procedure to the first month of life. After that age, circumcision is typically performed in the operating room under general anesthesia, incurring addi-
intact, proper penile hygiene should be taught. “Physiologic phimosis” is present in nearly all infants but typically resolves in most boys by age three and will likely continue to resolve spontaneously by puberty in the remainder. Lack of resolution or occurrence of UTIs, balanitis or ballooning with urination may prompt therapy with steroid creams, which have shown high success rates. The ideal age to begin regular retraction and cleaning is not clear, but, if possible, it is best done at an early age so that the boy learns this as a regular part of bathing.
october 2013
13
Raleigh Orthopaedic News
New Headquarters Is Joint Venture Between Rex and Raleigh Orthopaedic Raleigh Orthopaedic Clinic has opened its new practice headquarters at 3001 Edwards Mill Road in Raleigh. The four-story, 98,000-square-foot, state-of-the-art facility replaces the previous Glenwood Avenue location, which served as the practice’s home since 1977.
As the official sports medicine provider of the Carolina Hurricanes, North Carolina State University, the Carolina Ballet and several high school sports programs in Wake County, ROC’s proximity to the PNC
According to a press advisory, the construction lasted 18 months. Initially 28 full-time jobs were created at Raleigh Orthopaedic Surgery Center, a joint venture between Raleigh Orthopaedic and Rex Healthcare.
Arena and North Carolina State university may make care more convenient for these athletes. Raleigh Orthopaedic dates back to 1919. Today, it offers comprehensive orthopedic care, including an in-office pharmacy, magnetic resonance imaging, digital X-ray, sports medicine, physical therapy, hand therapy, orthotics, prosthetics and pedorthics, durable medical equipment and orthopedic urgent care. ROC has offices in Raleigh, North Raleigh, Cary and Garner.
Cadet Brings Specializations in Sports Medicine and Care of the Shoulder Edwin R. Cadet, M.D., a fellowshiptrained orthopedic surgeon specializing in shoulder and sports medicine has joined Raleigh Orthopaedic Clinic. Dr. Cadet previously served as an assistant professor of clinical orthopedic surgery at Columbia University College of Physicians and Surgeons and an assistant attending orthopedic surgeon at New York-Presbyterian/Columbia University Medical Center. While at Columbia University, Dr. Cadet was an attending surgeon on the shoulder, elbow and sports medicine service. He also was director of hip arthroscopy. Additionally, Dr. Cadet was head team physician for the 17 varsity team sports
14
The Triangle Physician
at the City College of New York and two regional high schools. He also was an integral part of training medical students, orthopedic residents and fellows.
ies as the American Orthopaedic Society for Sports Medicine, the American Academy of Orthopaedic Surgeons and the Arthroscopy Association of North America.
Dr. Cadet completed his orthopedic surgery residency training at The New York Orthopaedic Hospital at Columbia Presbyterian Medical Center and a fellowship in shoulder and sports medicine at the Hospital for Special Surgery. During his fellowship, Dr. Cadet spent dedicated time learning hip arthroscopy, as well as assisted with the medical care for NCAA Division I collegiate and professional teams, including the Red Storm of St. John’s University and the New York Knicks.
Dr. Cadet has spoken nationally and internationally, and he has presented his research at regional and national meetings. He is a reviewer for the Journal of Shoulder and Elbow Surgery. He has co-edited a book on shoulder and elbow trauma and has authored several publications in many of the leading journals in orthopedic surgery, including The Journal of Bone and Joint Surgery, Journal of the American Academy of Orthopaedic Surgeons, The American Journal of Sports Medicine, Arthroscopy and Journal of Orthopaedic Research.
He was selected as a member of the prestigious American Shoulder and Elbow Surgeons Society last fall. He also is an active member of such professional societ-
For more information call (919) 781-5600 or visit www.raleighortho.com.
Practice Management
It’s Your Money By Joe Reddy
I thought I would extend the theme of cash
and HVAC. Through tax year 2013, you are
flow for building owners one more month
allowed to catch up on the remaining de-
given the time-sensitive opportunity to take
preciation on the disposed roof and HVAC.
unclaimed depreciation. Because the value of the components While we are still waiting for final guidance
need to be determined, you need an asset
on tangible property regulations and inter-
valuation study done by a qualified engi-
pretation for tax year 2014 and beyond, we
neering firm to support the write down on
are under a temporary regulation in tax
your taxes and meet all the compliance
year 2013 that allows you to reach back and
rules. We are talking big dollars.
write down disposed building components
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.
from renovated office buildings. Some
You could find additional deductions of
previously capitalized items may now be
$60,000 to $80,000. That could go a long
considered “repairs” and thus currently
way towards helping offset the purchase of
deductible. And items that had previously
much needed new equipment.
study needs to be done.
temporary rules for a current write off of
The application of the temporary tangible
Because few CPAs have much experience
the un-depreciated balance of the original
property regulations is in addition to the
with these applications, don’t assume
cost.
cost segregation discussed in last month’s
yours has reviewed your case for potential
issue. These studies should be done to-
benefit of a study. Their job is to evaluate
Keep in mind that this application is only
gether to reduce costs and maximize the
an analysis and apply favorable results if a
economical for disposition of high-dollar
cash flow they might generate. Certain
study follows. So it’s really up to you to ask
building system components. The Internal
engineering firms provide a no-cost pre-
for the analysis.
Revenue Service rules on tangible proper-
dictive analysis that can be done on either
ty regulations could help you recover lost
or both methods to determine a potential
By the time this article is published, we
depreciation.
economic benefit before you engage a
could have an interpretation on a final IRS
study.
ruling on tangible property regulations for
been capitalized may be eligible under the
Here’s What It Looks Like
tax years 2014 and beyond.
Let’s say you or you and your partners
These two tax applications could be just
purchased a $1 million building for your
the booster shot your practice needs. For
Feel free to email me for additional infor-
practice in year 2000, and in 2012 you
adequate documentation to support these
mation at joe.reddy@revmedrx.com or call
spent $200,000 on replacement of the roof
applications, an IRS-defined engineering
me at (919) 457-0390.
The Triangle Physician 2013-2014 Editorial Calendar November Alzheimer’s Disease Diabetes, Financial Planning
December Pain Management, Spine Disorders Practice Management
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
october 2013
15
Community Support
Dance Dash for Duke Children’s Finishes with Flash Mob Dance Party More than 300 participants in the Dance
Throughout the 5K course, participants
Two Duke Children’s patients, Josh and
Dash 5K boogied, twirled and dashed
learned a new dance move or routine
Eve, and their families joined the dancing
their way into Research Triangle Park to
at each kilometer. Dance routines were
and encouraged dashers along the course.
raise funds for Duke Children’s Hospital &
taught by members of community dance
At the end of dash, participants combined
Health Center on Sept. 7.
organizations, including Duke University’s
all of the dances for a large flash-mob
Dancing Devils, ELONTHON Dance Mara-
dance party.
All ages and dancing abilities joined in this
thon, North Carolina State University Dance
inaugural event hosted by Children’s Mira-
Marathon and Nina’s School of Dance.
For more pictures, visit dancedashrdu2013. shutterfly.com.
cle Network Hospitals.
Duke Children’s patients Eve and Josh stand ready to cheer on the Dance Dash participants.
Dashers strike a pose as they learn the ELONTHON dance routine.
Cary Endocrine & Diabetes Center, P.A.
CEDC provides diagnosis and treatment for patients with hormonal and metabolic disorders including: diabetes, lipid disorders, PCOS, thyroid disorders, osteoporosis and other bone disorders, pituitary disorders, adrenal disorders, and sex hormone disorders.
Celebrating our first year in Cary!
Sung-Eun Yoo, MD
Endocrinologist Diplomat, American Board of Endocrinology, Diabetes and Metabolism Diplomat, American Board of Internal Medicine Endocrine Certification in Neck Ultrasound (ECNU) Certification in the International Society for Clinical Densitometry (ISCD)
On-Site Services: • Thyroid, parathyroid and neck ultrasound • Ultrasound guided FNA • DEXA bone density scans and interpretation • Osteoporosis therapy • Comprehensive diabetes management including diabetes education, insulin pump therapy, and continuous glucose monitoring • LabCorp in-house Introducing Jeanne Hutson, NP-C Board Certified in Advanced Diabetes Management
Cary Endocrine & Diabetes Center, P.A. • 103 Parkway Office Court, Suite 202 • Cary, NC 27518 • 919-378-2332 • www.caryendocrine.com
16
The Triangle Physician
Gastroenterology
Dyspepsia:
A Common Condition By Kellie Bunn, P.A.-C.
Dyspepsia is a common clinical condition
•A decrease in distal stomach motility
associated with a complex array of upper
(antral hypomotility) and delay in gas-
abdominal symptoms including: discom-
tric emptying;
fort or pain centered in the upper abdo-
• I mpaired reduction in gastric tone (im-
men, feeling of abdominal fullness, early
paired gastric accommodation) in re-
satiety, abdominal distention and bloating,
sponse to meals, which may lead to a
belching and nausea. The exact preva-
decrease in the ability of the stomach
lence of dyspepsia in the general popula-
to expand and allow the consumption
tion is not known, but it is estimated that as
of large meals; and
many as 25 percent to 40 percent of adults
•D isordered gastric electrical activity as
experience symptoms of dyspepsia in a
recorded by electrodes placed over the
given year.
upper abdomen (electrogastrography or EGG).
The differential diagnosis of dyspepsia in-
These findings suggest that some patients
cludes: acid-related disorders, such as gas-
with FD may have gastric motor or electri-
troesophageal reflux disease (GERD) and
cal abnormalities.
peptic ulcer disease (PUD); gastric inflammatory conditions, such as helicobacter
Several studies have also shown that
pylori gastritis or nonsteroidal anti-inflam-
patients with FD are significantly more
matory drug (NSAID)-related erosions or
sensitive to stomach distention (by an in-
gastropathy; functional dyspepsia; and,
tragastric balloon) compared to healthy in-
less common but still possible, upper ab-
dividuals. Moreover, patients with FD have
dominal cancer (e.g., gastric, esophageal,
reduced duodenal motor response and
pancreatic tumors).
are more sensitive to intraduodenal acid
Kellie Bunn, P.A.C., graduated from the University of North Carolina at Chapel Hill with a degree in biology before training in the Duke University Physician Assistant Program. She earned a master of health sciences degree and was inducted into Pi Alpha, the national honor society for physician assistants. Ms. Bunn is currently a member of the American Academy of Physician Assistants, North Carolina Academy of Physician Assistants and the North Carolina Medical Society. She has worked with Douglas A. Drossman, M.D., at Drossman Gastroenterology P.L.L.C. for more than a year and is well trained in the care of patients with functional GI disorders.
- It does not fulfill criteria for gallbladder or sphincter of Oddi disorders.
infusion. Interestingly, hypersensitivity to Consistent with the Rome III classifica-
mechanical distention was found to be cor-
Newer understanding in functional dyspep-
tion system, functional dyspepsia (FD) is
related with symptoms of pain, belching
sia shows that these two subgroups may
diagnosed by one or more of the follow-
and weight loss, while intraduodenal acid
have different physiological features and
ing symptoms occurring for at least three
correlated more with nausea.
thus be amenable to more specific medication treatments. Postprandial distress
months: • Bothersome postprandial fullness
Functional dyspepsia may also be subclas-
syndrome reflects impaired relaxation of
• Early satiation
sified by Rome III criteria into one or both
the gastric fundus and could respond to
• Epigastric pain
of two symptomatic groups:
buspirone (a fundic muscle relaxant), and
•P ostprandial Distress Syndrome (PDS)
more recent evidence shows a response to
In addition, there is no evidence of struc-
– Bothersome postprandial fullness
mirtazapine. On the other hand, epigastric
tural disease identified by upper endos-
and/or early satiety.
pain syndrome reflects nerve sensitization
• Epigastric burning
copy or other diagnostic studies.
•E pigastric Pain Syndrome – Epigastric
and treatments, such as proton pump in-
pain and/or burning and
hibitors initially, and then tricyclic antide-
The cause of functional dyspepsia has
- The pain is not intermittent,
pressants (TCAs) or serotonin-norepineph-
been difficult to define. Several specific
- It is not generalized or localized to
rine reuptake inhibitors (SNRIs) may be
motility abnormalities have been described in subgroups of patients with FD. These abnormalities include:
other abdominal or chest regions,
helpful for this, as well.
- It is not relieved by defecation or flatus, and
october 2013
17
UNC Research News
New Angle for Drugs May Prevent Stroke and Heart Attack A new study — the first
& Biology and funded by grants from the
and allows researchers to track the actual
to apply a new screen-
American Heart Association and the Na-
activities of proteins operating within a
ing technique to human
tional Institutes of Health.
cell. The team first pre-screened human platelets to narrow the field of drug-like
platelets — netted a potential drug target for
In the human circulatory system, platelets
compounds, then generated an activity-
preventing dangerous
are something of a double-edged sword.
based protein profile using one of these
Without their clotting abilities, even a mi-
compounds to single out proteins that play
nor injury could result in potentially fatal
a role in platelet activation.
blood clots in high-risk people. Platelets, which allow blood to clot, are at
bleeding. But during a heart attack or
the heart of numerous cardiovascular prob-
stroke, platelets form a clot that can poten-
The hunt was successful. “Using this tech-
lems, including heart attacks and stroke.
tially block blood flow through our veins
nique, we discovered both novel inhibitors
New research has uncovered a key plate-
and arteries, a dangerous condition called
of platelet activation and a novel enzyme
let protein that could offer a new angle for
thrombosis, which can deprive tissues of
involved in platelet signaling,” said Dr. Holly.
developing drugs to prevent thrombosis, or
oxygen and lead to death. This new knowledge of platelets’ natural
dangerous blood clots, in patients who are at high risk, such as those with atheroscle-
Several antithrombotic drugs are avail-
“on-off” switches could be exploited to
rosis or a history of heart problems.
able, but some have been found to cause
develop drugs that keep platelets from
bleeding – a side effect that is particularly
forming pathological blood clots. As a
“I think we’re at the start of an exciting jour-
troublesome when these drugs are used
next step, the researchers hope to investi-
ney of drug discovery for a new class of
to prevent thrombosis in people undergo-
gate the proteins’ roles in animal models
antithrombotic therapies,” said lead study
ing heart surgery. “There’s still room for
before potentially pursuing clinical trials in
author Stephen Holly, Ph.D., assistant pro-
improvement, in terms of making an ideal
humans.
fessor of biochemistry and biophysics at
drug that can block platelet function with-
the University of North Carolina School
out initiating bleeding,” said Dr. Holly.
Study co-authors from UNC-CH included Ryan Phillips, Raymond Piatt, Justin Black,
of Medicine. This work was performed in collaboration with senior authors Leslie
Dr. Holly and his colleagues uncovered
Yacine Boulaftali and Wolfgang Bergmeier.
Parise, Ph.D., at UNC and Benjamin Cravatt,
several potential drug targets using a
Additional co-authors included Jae Won
Ph.D., at The Scripps Research Institute.
screening technique that has never before
Chang, Weiwei Li and Sherry Niessen from
been applied to the cardiovascular system.
The Scripps Research Institute and Mat-
The study was published online Aug. 29
The technique called activity-based protein
thew Smith and Andrew Weyrich from the
ahead of print in the journal Chemistry
profiling has been used in cancer research
University of Utah, Salt Lake City.
Enzyme Discovery Could Explain Many Biological Mechanisms Behind Autism Problems with a key group of enzymes
vance in the hunt for environmental factors
hibiting these enzymes has the potential
called topoisomerases can have profound ef-
behind autism and lends new insights into
to profoundly affect neurodevelopment –
fects on the genetic machinery behind brain
the disorder’s genetic causes.
perhaps even more so than having a mutation in any one of the genes that have been
development and potentially lead to autism spectrum disorder, according to research an-
“Our study shows the magnitude of what
nounced Aug. 28 in the journal Nature.
can happen if topoisomerases are im-
linked to autism.”
paired,” said senior study author Mark
The study could have important implica-
Scientists at the University of North Caro-
Zylka, Ph.D., associate professor in the
tions for autism spectrum disorder (ASD)
lina School of Medicine have described
Neuroscience Center and the Department
detection and prevention.
a finding that represents a significant ad-
of Cell Biology and Physiology at UNC. “In-
18
The Triangle Physician
UNC Research News “This could point to an environmental
Of the more than 300 genes that are linked to
cause it shows that having problems tran-
component to autism,” said Dr. Zylka. “A
autism, nearly 50 were suppressed by topo-
scribing long synapse genes could impair
temporary exposure to a topoisomerase
tecan. Suppressing that many genes across
a person’s ability to construct synapses.
inhibitor in utero has the potential to have
the board – even to a small extent – means a
a long-lasting effect on the brain, by affect-
person who is exposed to a topoisomerase
“Our discovery has the potential to unite
ing critical periods of brain development.”
inhibitor during brain development could
these two classes of genes – synaptic
experience neurological effects equivalent
genes and transcriptional regulators,” said
This study also could explain why some
to those seen in a person who gets ASD be-
Dr. Zylka. “It could ultimately explain the
people with mutations in topoisomerases
cause of a single faulty gene.
biological mechanisms behind a large number of autism cases.”
develop autism and other neurodevelopmental disorders.
The study’s findings could also help lead to a unified theory of how autism-linked
The study’s coauthors include Benjamin
Topiosomerases are enzymes found in all
genes work. About 20 percent of such
Philpot (co-senior author), Terry Magnu-
human cells. Their main function is to un-
genes are connected to synapses, the con-
son, Ian King, Chandri Yandava, Angela
tangle DNA when it becomes overwound,
nections between brain cells. Another 20
Mabb, Hsien-Sung Huang, Brandon Pear-
a common occurrence that can interfere
percent are related to gene transcription,
son, J. Mauro Calabrese, Joshua Starmer
with key biological processes.
the process of translating genetic informa-
and Joel Parker from UNC; and Jack S.
tion into biological functions. Dr. Zylka said
Hsiao and Stormy Chamberlain of the Uni-
this study bridges those two groups, be-
versity of Connecticut Health Center.
Most of the known topoisomerase-inhibiting chemicals are used as chemotherapy drugs. Dr. Zylka said his team is searching for other compounds that have similar effects in nerve cells. “If there are additional compounds like this in the environment, then it becomes important to identify them,” said Dr. Zylka. “That’s really motivating us to move quickly to identify other drugs or environmental compounds that have similar effects – so that pregnant women can avoid being ex-
Increase your
chance of breast cancer survival
posed to these compounds.” Dr. Zylka and his colleagues stumbled upon the discovery by accident while studying topotecan, a topoisomerase-inhibiting drug that is used in chemotherapy. Investigating
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functioning of genes that were exceptionally long – composed of many DNA base pairs. The group then made the serendipi-
| Semimonthly in office multdisciplinary conferencing with radiology and pathology
tous connection that many autism-linked
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genes are extremely long. “That’s when we had the ‘Eureka moment,’” said Dr. Zylka. “We realized that a
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lot of the genes that were suppressed were incredibly long autism genes.”
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october 2013
19
Duke Research News
Newly Identified Genetic Factors Drive Severe Childhood Epilepsies Researchers have identified two new genes and implicated 25 distinct mutations in serious forms of epilepsy, suggesting a new direction for developing tailored treatments of the neurological disorders. The findings by an international research collaboration, which includes investigators from Duke Medicine, appear Aug. 11 in the journal Nature. Epileptic encephalopathies are a devastating group of severe brain disorders characterized by the onset of seizures at an early age. The seizures are often ac-
companied by cognitive and behavioral issues, which can hinder the quality of life of affected children and their families. The cause of epileptic encephalopathies is largely unknown. While genes are believed to play an important role, specific genes have only been identified in a small number of cases. “One important aspect of the study is that we identified an unusually large number of distinct disease-causing mutations – 25 in total, all of which were de novo mutations. These mutations will be an invaluable resource to scientists working to elucidate the underlying causes of the epilepsies,” said study author David Gold-
20
The Triangle Physician
stein, Ph.D., director of the Duke Center for Human Genome Variation. A de novo mutation is a new alteration in a gene that appears for the first time in a family and results from a genetic mutation in a parent’s germ cell (egg or sperm). Learning more about the disorders’ origin will guide development of effective therapies, which is the goal of Epi4K, an international research consortium funded by the National Institute of Neurological Diseases and Stroke (NINDS).
leptic encephalopathies and their parents. The Epi4K researchers then focused on identifying all new mutations in the children using next-generation sequenced data, which looks at the part of genome that encodes protein. The Center for Human Genome Variation at Duke conducted this analysis and confirmed 329 de novo mutations. Most of these mutations had no connection to the risk of disease, but the researchers showed that a fraction of them strongly influence risk. The researchers saw that the genes already known to cause epileptic encephalopathies carried multiple de novo mutations. However, they found multiple de novo mutations in two additional genes– GABRB3 and ALG13 – not previously connected to epileptic encephalopathies. Developing and applying new statistical approaches to determine risk factors, the researchers identified a statistical excess of mutations of those genes and concluded that the two new genes were influencing epileptic encephalopathies.
“This research focusing on epileptic encephalopathies is the first large-scale project of Epi4K,” said study author Erin Heinzen, Ph.D., assistant professor of medicine in the Division of Medical Genetics at Duke. “The study was designed to identify de novo mutations and search for ones that contribute to risk.” The Epi4K researchers partnered with the Epilepsy Phenome/Genome Project, another NINDS-funded group working to unlock the mysteries of epilepsy. Led by Daniel Lowenstein, M.D., professor of neurology at the University of California, San Francisco, the researchers in the Epilepsy Phenome/Genome Project gathered genetic information on 264 children with epi-
Combining the known genetic mutations with the newly identified genetic mutations, the researchers have now pinpointed the genetic cause of more than 10 percent of epileptic encephalopathies. “It won’t be long before a reasonable fraction of epileptic encephalopathy patients come into the clinic genetically explained,” said Dr. Goldstein. “Right now, the vast majority of patients are genetically unexplained, and in consequence, genetics plays little role in patient care. What we see here is a clear direction for the systematic identification of the genes responsible for severe epilepsies and the beginnings of a program to use that information to improve the care of patients with epilepsy. It’s about as encouraging as we could have hoped for when we started this work.”
Duke Research News Genetics can be applied to clinical care in a variety of ways. Most fundamentally, genetics can provide new information about the underlying biology of the disease, suggesting new directions for treatment. Genetics also can help stratify patients in ways that are meaningful both for prognosis and for optimizing treatment. In the case of epileptic encephalopathies, tailoring treatment to each mutation would be challenging, given the rarity of the mutations. However, the researchers observed
that the mutations identified organize into a small number of biologic pathways. Focusing drug development efforts on the pathways involved would allow physicians to treat patients based on the affected pathways.
director of the NINDS.
“These promising results highlight the strength of supporting large international research teams devoted to studying the genetics behind highly complex neurological disorders,” said Story Landis, Ph.D.,
The research was supported by the NINDS (NS053998, NS077364, NS077274, NS077303 and NS077276), Finding a Cure for Epilepsy and Seizures and the Richard Thalheimer Philanthropic Fund.
The study resulted from a collaboration of researchers at more than 40 institutions across three continents. A full list of authors can be found in the manuscript.
Three Subtypes of Gastric Cancer Suggest Varied Treatment Approaches Stomach cancer, one of the leading causes of cancer death worldwide, actually falls into three broad subtypes that respond differently to currently available therapies, according to researchers at Duke-NUS Graduate Medical School Singapore.
The finding could greatly improve patient care with the development of a genetic test to classify tumors and match them to the therapies that offer the best outcomes. “One of the features that makes gastric cancer so lethal is that it arises from many genetic alterations, creating differences
in how the tumors respond to therapies,” said Steve Rozen, Ph.D., director of the Centre for Computational Biology at DukeNUS. Dr. Rozen is senior author of the study published in the September issue of the journal Gastroenterology. “What our study has shown is that there are actually three distinct molecular classifications
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october 2013
21
Duke Research News that appear to be biologically and therapeutically meaningful.” Worldwide, only lung cancer is more lethal than stomach cancer. Rates in all countries have been dropping for decades and are much lower in the United States than in Asia. But the malignancy still afflicts more than 21,000 people in the U.S. a year, according to the National Cancer Institute. Despite differences in the way their tumors respond to treatments, patients often receive a “one-size-fits-all” treatment approach, resulting in a five-year survival rate of about 27 percent in the United States.
“There has been an urgent need for improved classification of gastric cancer that provides insight into the biology of the tumors that might help predict treatment response,” said co-senior author Patrick Tan, M.D., Ph.D., professor in the Cancer and Stem Cell Biology Program at DukeNUS. Using a technology called microarraybased gene expression profiling, Dr. Rozen and colleagues analyzed 248 gastric tumors, and then further grouped them according to the genes that were expressed in the tumors. The gene expression analysis broadly sorts the tumors into three subtypes: proliferative, metabolic and mesenchymal.
These subtypes also differ in their genomic and epigenomic properties. Tumors of the proliferative subtype have high levels of genomic instability and a mutation in the TP53 tumor suppressor gene that occurs in many types of cancers. Cancer cells of the metabolic subtype are more sensitive to the chemotherapy agent 5-FU. Cancer cells of the mesenchymal subtype have some features of cancer stem cells and are particularly sensitive to a class of therapies called PI3K−AKT− mTOR inhibitors. “In terms of clinical treatment, there are two promising findings from our research,” Dr. Rozen said. “One is that 5-FU has been particularly effective against metabolic-subtype tumors, and the second is that drugs targeting the PI3K−AKT−mTOR pathway may be particularly effective against mesenchymal-subtype cancers.” “If confirmed in future studies, the classification of gastric cancers reported here could guide development of therapies tailored to the molecular subtypes,” said lead author Zhengdeng Lei, PhD. In addition to Drs. Rozen, Tan and Lei, study authors include Iain Beehuat Tan, Kakoli Das, Niantao Deng, Hermioni Zouridis, Sharon Pattison, Clarinda Chua, Zhu Feng, Yeoh Khay Guan, Chia Huey Ooi, Tatiana Ivanova, Shenli Zhang, Minghui Lee, Jeanie Wu, Anna Ngo, Sravanthy Manesh, Elisabeth Tan, Bin Tean Teh, Jimmy Bok Yan So, Liang Kee Goh, Alex Boussiouta, Tony Kiat Hon Lim and Horst Flotow. The study was supported by the DukeNUS Signature Research Programs, with funding from the Singapore Agency for Science, Technology, and Research and the Singapore Ministry of Health; the Singapore National Medical Research Council; the Singapore National Research Foundation and Ministry of Education; and the Singapore Biomedical Research Council.
22
The Triangle Physician
News
O’Keefe Achieves Highest Designation for Medical Practice Executives Colleen M. O’Keefe,
for Medical Practice Management. This
Today, 6,600 MGMA-ACMPE members are
F.A.C.M.P.E., practice
includes business operations, financial
participating in the ACMPE board certifi-
administrator, Caro-
management, human resources manage-
cation and fellowship; 600 have achieved
lina Endocrine, has
ment, information management, organiza-
fellow credential; 2,200 have achieved the
been named a fellow
tional governance, patient care systems,
CMPE credential; and 3,800 are pursuing
in the American Col-
quality management and risk manage-
board certification.
lege of Medical Practice Executives.
ment. Since 1926, the MGMA-ACMPE asso-
Fellowship in the ACMPE (FACMPE) is the
To earn fellowship, Ms. O’Keefe submitted
ciation has been delivering networking,
highest distinction in the medical group
three case studies (“Bringing in Ancillary
professional education and resources,
practice management profession. The fel-
Services the Right Way,” “Renting, Buying
political advocacy and certification for
lowship is conveyed by Medical Group
or Building-the Expansion of a Practice’s
medical practice professionals. Today,
Management Association (MGMA)-Amer-
Physical Facility” and “Creating Appro-
22,500 members administer 13,200 health
ican College of Medical Practice Execu-
priate Staff Incentive Programs”). Each
care organizations nationwide.
tives (ACMPE).
documented the objectives and results of
To achieve fellowship, Ms. O’Keefe first
investigations into these health care man-
MGMA-ACMPE’s mission is to continu-
agement topics.
ally improve the performance of medical group practice professionals and the orga-
earned the certified medical practice executive (CMPE) designation by passing
Ms. O’Keefe’s accomplishment will be for-
nizations they represent, helping medical
rigorous essay and objective examina-
mally recognized at the October ACMPE
practices provide efficient, safe, patient-
tions that assess knowledge of the broad
Luncheon and Fellows Convocation, in
focused and affordable care. For more
scope of medical practice management,
conjunction with the MGMA 2013 Annual
information, visit mgma.com.
as outlined in the Body of Knowledge
Conference in San Diego.
New Facility Treats Average of 52 Patients per Day in One Month WakeMed Garner Healthplex celebrated
on initial numbers, the WakeMed Garner
phy scans and magnetic resonance imag-
a month of service to residents of south-
Healthplex is on track to surpass original
ing, as well as physician offices.
eastern Wake and Johnston counties. Dur-
year-end expectations by 2,500 to 4,000
ing that time, its emergency department
patients.
Wake Specialty Physicians-Garner Primary Care, WakeMed Faculty Physicians-
had cared for 1,465 patients since opening The new Garner facility features the sys-
Carolina
tem’s seventh emergency department. All
Physicians-ENT Head & Neck Surgery and
In addition, WakeMed reported that the
are staffed by the same emergency physi-
Wake Specialty Physicians-Urology plan
WakeMed Garner Healthplex medical staff
cian group and are backed by our Level I
to open at the site in late September and
had treated an average of 52 patients per
Trauma Center and WakeMed Children’s
early October. The 50,000-square-foot facil-
day during the month of September.
in Raleigh.
ity also serves as the base for WakeMed’s
According to a WakeMed press advisory,
In addition to the 10-bed, 24/7 ED,
an estimated 12,000 to 15,000 patients
WakeMed Garner Healthplex offers lab
WakeMed Garner Healthplex is located at
were anticipated to receive treatment in
and imaging services including diagnostic
400 U.S. Highway 70 East Garner (27529).
the new ED during the first year. Based
X-rays, ultrasounds, computed tomogra-
Aug. 19.
Cardiology,
Wake
Specialty
Air Mobile medical helicopter operations.
october 2013
23
News Welcome to the Area
Physicians Teah Martin Bayless, DO Family Practice Duke University Hospitals Durham
Michael Joseph Fedewa Jr., DO Family Practice Oxford
Justin Rorie Glodowski, DO Hospitalist Generations Family Practice Cary
Scott Harmon McQuilkin, DO Anesthesiology Duke University Hospitals Durham
Brent Cameron Mellis, DO Orthopedic Surgery, Adult Reconstructive Triangle Orthopaedics Durham
Raphael Tito Penela Balbino, MD Family Medicine Duke University Hospitals Durham
Manijeh Berenji, MD Student Health Duke University Health System Durham
Leigh Ebony Boulware, MD Internal Medicine Division of General Internal Medicine Durham
Ziga Cizman, MD Vascular and Interventional Radiology University of North Carolina Hospitals Chapel Hill
Wendy Gladys Concas Achata, MD Internal Medicine Moore Regional Hospital Pinehurst
Elizabeth Quattlebaum Cox, MD Psychiatry University of North Carolina Hospitals Chapel Hill
Chad David Crim, MD Urgent Care Hillsborough
Thomas Edward DiCarlo, MD Anesthesiology Doctors Making Housecalls Durham
Laura Virginia Duggan, MD Anesthesiology Duke University Hospitals Durham
Michael Joseph Durkin, MD Infectious Diseases, Internal Medicine Duke University Hospitals Durham
Cory Ryan Forbach, MD Emergency Medicine University of North Carolina Hospitals Chapel Hill
Carly Susan Gardner, MD Diagnostic Radiology Duke University Hospitals Durham
Samyka Yanicke Harris-Edwin, MD Hospitalist 811 Handsworth Lane Raleigh
24
The Triangle Physician
Jeffrey Clarence Hope, MD Emergency Medicine Duke University Hospitals Durham
Lindsey Elizabeth Hughes, MD Neurological Surgery Nash Neurosurgery Rocky Mount
Samuel Joseph Kuzminski, MD Radiology Duke University Hospitals Durham
Physician Assistants
Kevin Edward Sullivan, PA Cary
Jessica Billheimer Wagoner, PA
Emily Carson Amoni, PA
Dermatology Carolina Dermatology & Endocrinology Clayton
Family Medicine Durham
Mary Sheldon Boney, PA Dermatology - Pediatric - Dermatology Duke Pediatric Dermatology Durham
Events
Carolyn Soyun Chyu, PA
Durham Regional
Richard Dayrit Lopez, MD
Medical Oncology Duke University Hospital Durham
DUMC Div of Cellular Therapy/BMT Durham
Cameran Anne Collins, PA
Look Good Feel Better Oct. 7, 5:30-7:30 p.m. Look Good Feel Better is a free American Cancer Society program that teaches women beauty techniques while they undergo chemotherapy and radiation treatments. Participants receive a free cosmetics kit and instruction by beauty professionals. Location: North Conference Room, Durham Regional Hospital Registration: Call (919) 470-7168
Benjamin William McClintock, MD Radiology University of North Carolina Hospitals Chapel Hill
Brett Pariseau, MD Ophthalmology University of North Carolina Hospitals Chapel Hill
Joseph West Paul Jr., MD Internal Medicine WakeMed Raleigh
Deepa Reddy, MD Internal Medicine WakeMed Raleigh Campus Raleigh
Rupali Navin Shah, MD Otorhinolaryngology University of North Carolina Hospitals Chapel Hill
Tiffany Matoska Sills, MD Radiology UNC Chapel Hill
Deeb Sudd, MD Internal Medicine Johnston Medical Center Smithfield
Katherine Winstead Suttle, MD Anesthesiology University of North Carolina Hospitals Chapel Hill
Christopher Henry Swan, MD
Hospitalist Duke Hospital Medicine Programs Durham
Damon James DiLorenzo, PA Anesthesiology - Critical Care Medicine American Anesthesiology Raleigh
Victoria Rae Gomarko, PA Critical Care-Internal Medicine Durham
Lisa Marie Langmesser, PA Urology Duke Cancer Center Durham
Katherine Elizabeth Lindsay, PA Gastroenterology, Internal Medicine Southern Gastroenterology Associates Roxboro Clinic Roxboro
Weight Loss Surgery Support Group Oct. 22, 6-7 p.m. This weight-loss surgery support group encourages discussion on topics related to adjustment before and after weight-loss surgery. February’s topic will be “Healthy Tips for Dining Out.” Location: Duke Center for Metabolic and Weight Loss Surgery Durham Clinic, 407 Crutchfield St., Durham 24404
Kimberiey Anne Milliam, PA Internal Medicine Knightdale
Allison Davis Ross, PA Psychiatry Adolescent Child & Adult Psychiatry of Raleigh Raleigh
Emily Lynn Schwartz, PA Gastroenterology, Internal Medicine Raleigh
Register for these events online at www. durhamregional.org/events or by calling (919) 403-4374, unless otherwise noted.
Michelle Nicole Stiles, PA Zebulon NEWSOURCE-JUN10:Heidi
Stroke Support Group Oct. 14, 1-2:30 p.m. The mission of this support group is to help educate the stroke survivor, caregiver and community about stroke prevention and stroke disabilities. This group meets the second Monday of each month. Location: Durham Regional Hospital, private dining room C
8/5/10
12:57 PM
Page 1
Cardiology Duke University Hospitals Durham
Steven Taylor Szabo, MD Psychiatry Duke University Hospitals Durham
Brian Christopher Talbott, MD
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