Triangle Physician Oct 2015

s e p t e m b e r 2 015

Tolnitch Surgical Associates Nipple-Preserving Expertise Leads to Better Outcomes, Greater Satisfaction

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 Weight-loss Options Thyroid Disease

Sporting Clay Course

• Open Tuesday–Saturday 8a.m. till 6p.m.

• Sunday 1p.m. till 6p.m.

•Monday by appointment only • Over a mile course • 14 Stations • Covered 5 Stand • Wing Shooting- Quail/ Pheasant/ Chukar Hunts • Driven Pheasant Hunts • European Tower Hunts • Shooting Instructions • Gun Rental • Ammo Available • Dog Training

• Fishing • Corporate Events/ Retreats/Team Building • Birthday Parties, Bachelor/ Bachelorette Parties • Church Groups , Individual Outings • Complete Packages Available

Our Cancer Treatment Services Are Accredited By The American College Of Surgeons Commission On Cancer...

And Applied By Caring Neighbors!

Hematology/Medical Oncology Services in affiliation with Duke Medicine

Radiation Oncology Services in partnership with Rex/UNC

Smithfield: 919-989-2192 Clayton: 919-585-8835

Smithfield: 919-209-3555 Clayton: 919-585-8550

Fighting Cancer Is Enough... Without Having To Fight Traffic!

Johnston Professional Plaza 2076 NC Hwy 42 W Clayton

www.johnstonhealth.org

Johnston Medical Mall 514 N. Bright Leaf Blvd.

Smithfield

Table of Contents

6

COVER STORY

Tolnitch Surgical Associates Nipple-Preserving Expertise Leads to Better Outcomes, Greater Satisfaction o c to b e r 2 0 15

Vol. 6, Issue 9

FEATURES

10

DEPARTMENTS 9 Practice Marketing

Endocrinology

20 Powerful Reasons to Brand Your Practice: Part 1

12 Women’s Health

Thyroid Disease and Pregnancy

George Stamataros reviews critical thyroid distur-

14 Practice Management

bances that can lead to pregnancy complications, their diagnosis and treatments.

17

Physician Advocacy

AID Takes Aim at Physician Burnout Marni Jameson shares physician frustrations and that joining a unified, nationwide voice is a solution.

2

The Triangle Physician

New Options for Losing Weight

Physician Role in Practice Management

18 Duke Research News

Model Shows Meningitis’s Creep into the Brain of Transparent Zebrafish

19 UNC Research News

Study Shows Affect of Diabetes Drug on Bone Health and Benefit of Exercise

20 UNC News

Web-based Calculator Helps Providers Better Counsel on Prenatal Screening On the Cover: Meet the breast surgeons at Tolnitch Surgical Associates (from left): Gayle Ackerman DiLalla, M.D., F.A.C.S.; Laura Lazarus M.D., F.A.C.S.; and Lisa Tolnitch M.D., F.A.C.S.

The Magazine for Health Care Professionals

The Triangle Physician

Did You Know?

We mail to over 9,000 MDs, PAs, administrators, and Hospital staff in 17 counties in the Trinagle – Not to each practice but to each MD or PA personally

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

We are a LOCALLY dedicated magazine designed primary for MD referrals.

Macon Clay

Henderson

Jackson

ia lvan

Davie

Alexander

Burke

Rutherford Polk

Lincoln Gaston

sy Tran

Alamance Davidson

Randolph

Rowan

Catawba

Cleveland

Orange

Guilford

Cabarrus Mecklenburg

Montgomery

Anson

The Triad Physician Magazine The Triangle Physician Magazine The Eastern Physician Magazine

Edgecombe

Johnston

n

Greene

Dare

Hyde

Wayne

Cumberland Sampson

Scotland Robeson

de

Washington Tyrrell Beaufort

Pitt

Craven

Lenoir Hoke

Martin

m

Wilson

Harnett

Moore

Richmond Union

Wake

Chatham

Bertie Nash

Ca

Gates Hertford

Halifax

Franklin Durham

Lee Stanly

Northampton

Warren Vance

ck

Cherokee

Mcdowell

Haywood

Forsyth

Granville

u rit ur

Swain

Caldwell

Iredell

Buncombe

Graham

Yadkin

Person

n wa

Yancey

ell ch

Mit

Madison

Wilkes

Caswell

o Ch

Watauga Avery

Rockingham

Stokes

nk ta s uo an sq uim Pa rq Pe

Surry

C

Alleghany Ashe

Bladen

Duplin

Onslow

Pamlico

Carteret

Pender

New Hanover

Columbus

The Eastern and The Triangle Physician Magazines

Jones

Brunswick

Counties: Alamance, Chatham, Durham, Franklin, Granville, Harnett, Johnston, Lee, Moore, Nash, Orange, Person, Vance, Wake, Warren, Wayne, and Wilson Counties Cities: Raleigh, Durham, Chapel Hill, Smithfield, Roxboro, Henderson, Louisburg, Pine Hurst, Siler City

The Triad and The Triangle Physician Magazines

Local physician specialists and other professionals, affiliated with local businesses and organizations, contribute all editorials or columns about their respective specialty or profession.

Every issue includes the latest listing of: MDs and PAs who are newly licensed by the NC Medical Board and New MDs and PAs to the area.

We also publish free of charge: • Practice, hospital and other medical facility news, including: • New MDs and PAs; • New facilities, expansions and relocations;

• New or updated websites; and • Upcoming events, including CMEs. • Local charity events, ads and articles.

• Images for all of the above.

All FREE to the greater Triangle medical community- a vital REFERRAL SOURCE! We also profile the greater Triangle medical community, practices or companies that want to get “in front” of MDs • 1 page with 1 image and text • 2 page with 2 images and text • 4 page with 4 images and text • 8 pages with 8 images and text Long term Advertising is always the most effective way to keep your practice or company in the readers.

If you would like to be involved with The Triangle Physician, please contact us

info@TrianglePhysician.com

From the Editor

Knowns and Unknowns Breast conservation advances have led to a surge in nipple-sparing mastectomies because of improved cosmesis. But why aren’t all breast cancer patients candidates?

Tolnitch Surgical Associates shares its breast surgery expertise in this month’s cover story, by bringing to the forefront the complex considerations to be weighed in appropriate patient selection.

Endocrinologist George Stamataros of Carolina Endocrine is a new contributing editor. This month, he discusses thyroid conditions that occur during and after pregnancy.

Practice management consultant Margie Satinsky provides invaluable guidance on effective physician leadership. Physician advocate Marni Jameson explains that the Association of Independent Doctors is working on eliminating unfair pressures that can break the spirit.

One variable in the practice-success formula is clear, consistent marketing. The Triangle Physician removes guesswork by offering options that range in price from free to competitive.

You can make your practice news and specialized expertise known – space permitting, at no cost. Really make an impression by getting on the cover of the magazine and regularly advertising – both available at competitive rates.

One decision today seems clear: Decide to keep the medical community in the know. Submit your medical news and inquire about advertising opportunities via email to: info@trianglephysician.com.

With respect and appreciation of all you do,

Heidi Ketler Editor

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

Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Wendy Coulter Marni Jameson Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Margie Satinsky, M.B.A. George Stamataros, D.O., F.A.C.E. Creative Director Joseph Dally jdally@newdallydesign.com

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

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

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.

4

The Triangle Physician

Cover Story

Tolnitch Surgical Associates

Nipple-Preserving Expertise Leads to Better Outcomes, Greater Satisfaction During the past decade there has been a

misleading, as nipple-sparing mastectomies

Both SSM and NSM have advantages over

trend towards patients who are eligible to

were performed as early as the 1960s and

traditional mastectomy in that more breast

undergo breast conservation (BCS) sur-

called “subcutaneous mastectomies.” The

skin is preserved, improving the ability

gery to choose mastectomy as treatment

change in terminology is deliberate, as sub-

of the plastic surgeon to reconstruct the

for their early-stage breast cancer. The

cutaneous mastectomies were performed

breast at the time of mastectomy with less

number of women who are BCS-eligible

by plastic surgeons for fibrocystic disease

visible scarring. However, preservation of

and choose to undergo mastectomy in-

and risk reduction, with a bias toward cos-

the nipple areolar complex allows for a

creased from 34.3 percent in 1998 to 37.8

metic outcomes and little concern for com-

more natural-looking breast contour with

percent in 2011, with the greatest increase

plete removal of the breast tissue.

improved central projection of the breast that is difficult to achieve when recon-

occurring after 2006.

1

In fact, B.S. Freeman, the plastic surgeon

structing the nipple areolar complex.

In part, this trend is due to improved cos-

who first described the technique in 1962,

metic outcomes from mastectomy and re-

proscribed that a small amount of breast

Multiple studies have shown that patients

construction – surgical options that have

parenchyma be left attached to the der-

have improved self-esteem and self-image

been fueled by the media and celebrities.

mis.2 John E. Woods, M.D., Ph.D., of the

due to the improved cosmesis with NSM.

Most notably Angelina Jolie and Christina

Mayo Clinic in describing the procedure

A recent study demonstrated improved lev-

Applegate have come forward with their de-

stated, “This procedure leaves approxi-

els of satisfaction with the reconstructed

cisions to undergo bilateral mastectomies.

mately 1 centimeter of breast tissue under

breasts, outcome and sexual well being

the nipple areola, which is essential for the

compared to women undergoing SSM

preservation of blood supply.”

with no differences noted in cancer-related

Improved screening has increased the

3

anxiety.4

percentage of breast cancers that are identified early. In addition, advances in

By the 1980s reports of cancer developing

treatment have improved outcomes. These

in the residual breast tissue led to aban-

A surgical oncologist, breast surgeon or

advancements have contributed to more

donment of subcutaneous mastectomy un-

general surgeon now performs NSM with a

attention being focused on the technical

til the late 1990s, when new literature was

focus on maximizing breast tissue removal,

aspects of the surgical treatments offered

published supporting its safety. Since that

while attempting to optimize the cosmetic

to patients.

time, after careful “re-branding,” NSM has

result. Just as in a traditional mastectomy,

again slowly gained footing as a surgical

during a NSM the surgeon removes nearly

option for carefully selected patients.

all of the contents of the breast except for a

Nipple-sparing mastectomy (NSM) is one of the most recent advances in surgical

thin layer of fat and blood vessels needed

techniques to improve the cosmetic out-

Like NSM, skin-sparing mastectomy (SSM)

to preserve the skin with all visible breast

comes of mastectomy. NSM is defined as

is an option that preserves most of the

tissue being excised.

the removal of the breast tissue while pre-

breast skin and is equally as effective at

serving the entire skin envelope, including

removing breast cancer as the more tradi-

NSM is more difficult to perform than tra-

the nipple areolar complex (NAC).

tional mastectomy. It is different from NSM,

ditional or skin-sparing mastectomies, be-

as the nipple areola is commonly removed

cause the incisions are smaller and in direct

along with the breast tissue during SSM.

contrast to the technique used for subcu-

To state that NSM is “new “ is somewhat

6

The Triangle Physician

taneous mastectomies. The surgeon must remove the ductal tissue directly behind the nipple yet preserve sufficient blood supply to the skin and nipple to prevent tissue necrosis.

To assure oncologic and cosmetic success, it is important that women considering nipple-sparing mastectomy choose a surgeon with experience in this procedure. Lisa Tolnitch M.D., F.A.C.S., of Tolnitch Surgical Associates was the first breast surgeon in the Triangle Region to perform NSM. She and her partners – breast surgeons Gayle Ackerman DiLalla, M.D., F.A.C.S., and Laura Lazarus M.D., F.A.C.S. – have the combined experience of performing more than 400 NSM. In 1999, Lynn C. Hartman, M.D., et al from the Mayo Clinic performed a retrospective review evaluating the efficacy of prophylactic mastectomy in high-risk patients and identified no significant difference in the incidence of subsequent breast cancers between the women who underwent subcutaneous mastectomy and those who underwent total mastectomy.5 That same year Christine Laronga, M.D., F.A.C.S, from MD Anderson first published data suggesting that NSM using appropriate selection criteria could be performed safely with occult tumor being missed in less than 2 percent of cases.6 In 2003, Bernd Gerber, M.D., Ph.D., et al from Ludwig Maximilian University of Munich, Germany, compared recurrence and survival data from patients undergoing simple mastectomy, SSM and subcutaneous mastectomy showing no difference and concluding that NSM could be performed safely with appropriate selection criteria.7 Since that time many retrospective analyses and larger, single institution experiences have been published with varying inclusion

This set of before (top photo)-and-after photos demonstrates the improved outcome after advanced nipple-sparing mastectomy.

criteria, technical considerations and outcomes results. Despite the inconsistencies between studies, they have shown favorable

suits her individual needs. Though the cosmetic benefits of keep-

outcome data in carefully selected women undergoing NSM, both

ing one’s own nipple and areola are readily apparent, women who

in the prophylactic and therapeutic settings, and NSM has contin-

are considering NSM must be aware of the potential risks of the

ued to gather support.

procedure.

At the American Society of Breast Surgeons annual meeting in Or-

Additionally, not all patients are good NSM candidates. It is impor-

lando in May, Lucy De La Cruz, M.D., from the University of Miami

tant to note that the patients chosen for this procedure and includ-

reported in an interview with Sanjay Gupta, M.D., editor of Med-

ed in the studies have all been carefully evaluated prior to surgery

Page Today, that the Surveillance, Epidemiology and End Results

and again once surgical pathology is completed to ensure that the

(SEER) registry demonstrates that the rate of nipple-sparing mas-

primary goal of removing the cancer was achieved.

tectomy has increased 202 percent since 2005.6 In a systematic review of the literature Dr. De La Cruz, et al identified eight studies

In situations where NSM is either not recommended or desired,

comparing NSM to SSM and modified radical mastectomy (MRM)

SSM is frequently an option that can provide excellent cosmetic

demonstrating a consistent rate of local recurrence between treat-

results with delayed reconstruction of the nipple and areolar tattoo-

ment groups.

ing to complete the result.

8

Like all surgical procedures, NSM has benefits and risks. A woman

In deciding if a patient is a candidate for NSM, we evaluate both

considering this procedure must discuss it carefully with the mem-

oncologic factors and patient factors. From an oncologic perspec-

bers of her breast management team and make a choice that best

tive inclusion criteria have varied somewhat between series, but

October 2015

7

factors include breast size and ptosis, body habitus and body mass index. Additionally, some surgeons will not consider women who have had prior radiation therapy or collagen vascular diseases due to higher risks of complications.

Similar to other types of mastectomy there is a potential risk of skin flap ischemia or necrosis. The risk increases as the length of the skin flap increases, so inherently women undergoing NSM will have higher risks than women undergoing SSM, which is higher than that of a simple, or modified radical mastectomy. Additionally, immediate reconstruction of the breast increases this risk. In NSM there is the additional risk of nipple necrosis, with the overall incidence of nipple complications in the literature varying widely.

However, Laura Esserman, M.D., M.B.A., and her group at the University of California, San Francisco has published data showing increased experience decreases the incidence of complications.10 While individual patients may be eligible for NSM, it may not always yield the best cosmetic outcome for a patient. Therefore, a good oncologic and reconstructive surgical team will be able to provide this critical information to patients prior to the surgical procedure, so the results meet patient expectations.

Resources

This set of before (top photo)-and-after photos shows the outcome following traditional mastectomy.

fundamentally they comprise factors that influence the risk of occult nipple involvement that varies between 0-53 percent in the reported literature with an overall incidence of 11.5 percent.9 Primary tumor characteristics influencing occult nipple malignancy include: • Tumor-nipple distance that is less than 2 centimeters, • Grade, • Lymph node metastasis (with studies showing it is likely safe to retain the nipple if fewer than three lymph nodes are involved on final pathology, • Lympho-vascular invasion (focal LVI is likely ok), • Tumor size that is greater than 5 centimeters, • Retroareolar/central location, • Multicentric tumors (defined as two or more separate invasive tumors occupying more than one quadrant of the same breast).

Variability between individual surgeon’s determinations of their patient’s eligibility for NSM is based on patient factors. The patient

8

The Triangle Physician

1 Kummerow KL, Du L, Penson DF, et al. “Nationwide trends in mastectomy for early-stage breast cancer.” JAMA Surgery. 2015; 150(1):9-16.

2 Freeman BS. “Subcutaneous mastectomy for benign breast lesions with immediate or delayed prosthetic replacement.” Plastic and Reconstructive Surgery. 1962; 30:676-82.

3 Woods JE. “Detailed technique of subcutaneous mastectomy with and without mastopexy.” Annals of Plastic Surgery.1987; 18(1)51-61.

4 Bloomberg LS. “Long-term psychosocial functioning in women with bilateral prophylactic mastectomy: Does preservation of the nipple areolar complex make a difference?” Annals of Surgical Oncology. 2015 Oct; 22(10): 3324-30.

5 Hartman LC, Schaid DJ, Woods JE, et al. “Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer.” New England Journal of Medicine. 1999; 340:77-84.

6 Laronga C, Kemp B, Johnston D, Robb GL, Singletary SE. “The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy.” Annals of Surgical Oncology. 1999; 6(6), 609-13.

7 Gerber B, Krause A, Reimer T, et al. “Skin-sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction is an oncologically safe procedure.” Annals of Surgery. 2003; 238:120–127.

8 The Gupta Guide, May 1, 2015. Source Reference: DeLaCruz L., et al “Nipple-sparing mastectomies as safe as more radical procedures for appropriate patients.” American Society of Breast Surgeons.

9 De La Cruz L, Moody AM, Tappy EE, et al. “Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: A meta-analysis and systematic review.” Annals of Surgical Oncology. 2015; 22:3241–3249.

10 Garwood ER, Moore D, Ewing C, et al. “Total skin-sparing mastectomy – complications and local recurrence rates in two cohorts of patients.”

Annals of Surgery. 2009; 249:26–32.

Practice Marketing

20 Powerful Reasons to

Brand Your Practice: Part 1

By Wendy Coulter

In order to create a strong brand, your

what your practice stands for. This helps set

practice must differentiate its product or

patients’ expectations and tell a story that

service from others. This differentiation

will resonate through all your media outlets

helps build a collection of perceptions in

and patient contact points.

the mind of the patient.

Increase Credibility Patients who believe in your practice’s

Establishing and keeping a brand promise

brand will spread the word about its ben-

will help build credibility for your practice

efits, increasing the value of the brand as

with patients, prospective patients and

an asset of the practice. If your practice

vendors, as well as in your industry and

does not live up to its brand promises to

community. Keep in mind that even a very

patients, it will suffer.

creative marketing strategy will not render as high of an ROI (return on investment),

This is the first of a four-part series. Below

if you are not believable. Believable prac-

are the first five of 20 powerful reasons to

tices gain trust with patients with less ef-

brand your practice.

fort, and people prefer to use businesses they trust.

Create an Experience Patients by nature are looking for an

Create an Emotional Tie

experience when they interact with your

with Your Target Market

brand. All their experiences with your

By gaining insight into what your patients

brand make an impression and help set an

want and need, you can learn how to con-

expectation of what your brand is about. An

nect with your target market on an emo-

example of a brand focused on creating an

tional level, so they feel good when they

experience is Disney. Whether you are at

buy from you. Purchasing is an emotional

one of their amusement parks, watching a

experience, so make sure to tell your

Disney movie, or visiting a Disney store, you

brand story in a unique way that resonates

have an expectation that your experience

emotionally with patients!

will be filled with wonder and the highest level of service with a smile.

Motivate Patients to Come Back Next Time

Wendy Coulter is president of Hummingbird Creative Group Inc. She is a graduate of the School of Design at North Carolina State University with degrees in architecture and industrial design and a minor in communications. She founded Hummingbird Creative Group in 1995, with a desire to put her ideas to work, creatively solving problems for small businesses. Hummingbird Creative Group is an award-winning, full-service branding agency that helps companies define brand strategy, develop sustainable brand messaging and implement marketing tactics through advertising, graphic design, sales enablement, public relations and online marketing services.

Awards include “Pinnacle Business Award” from the Raleigh Chamber of Commerce, as well as “Business of the Year,” “Employer of the Year” and “Successful Achievement” awards from the Cary Chamber of Commerce. Ms. Coulter was named a “Top 50 Entrepreneur,” “Woman Extraordinaire,” “Mover and Shaker” and “40 Under 40,” to name a few.

She is active in a variety of community and civic endeavors and frequently presents on such topics as branding, marketing, advertising and design.

Develop Clear Messaging

Once patients trust your brand, they will

Going through the process of branding your

be more loyal and visit more often. A

practice will help you develop clear market-

strong brand helps foster business growth.

ing messages. From your mission and vi-

According to a study by Gartner Group, on

a well-known soap brand, which made it

sion, to your core values, value proposition

average 8 percent of a company’s future

easy to increase sales when the brad intro-

and competitive advantages, it’s important

profits come from 20 percent of its exist-

duced body washes, lotions and deodor-

to have very clear messages that represent

ing customers. For example, Dove became

ants to their existing happy customer base.

October 2015

9

Endocrinology

Thyroid Disease and Pregnancy

By George Stamataros, D.O., F.A.C.E.

In general, thyroid disease is five times more

Anti-thyroid drugs – propylthiouracil (PTU)

common in women than men. The coinci-

and methimazole – may be used in preg-

dent occurrence of thyroid disease before,

nancy, but they can both cross the placenta

during and after pregnancy involves special

and may harm the fetus by causing fetal hy-

considerations for the health of the infant

pothyroidism and goiter. PTU is usually the

and the mother. This article will discuss four

drug of choice, due to a lower transplacental

common thyroid disturbances during preg-

passage into the fetal circulation. PTU also

nancy and post-partum.

appears to a lesser extent in breast milk and is advantageous during breast-feeding. Infre-

Hyperthyroidism

quently, the transplacental passage of mater-

Early pregnancy is associated with several

nal antibodies can lead to transient neonatal

hormonal changes that alter thyroid func-

hyperthyroidism (about 2-5 percent), par-

tion. Estrogen alters production of thyroxine-

ticularly if titers of TRAb or TSI are very high.

binding globulin (TBG), a carrier protein

Graves’ disease may become quiescent dur-

for thyroid hormone. Human chorionic

ing pregnancy, but may intensify two to three

gonadotropin (hCG) bears structural resem-

months post-partum.

blance to thyroid stimulating hormone (TSH, thyrotrophin) and may weakly stimulate the

Hypothyroidism

thyroid and suppress TSH production during

The most common cause of hypothyroidism

the first trimester.

in women of childbearing age is autoimmune (Hashimoto’s) thyroiditis.

About 10 percent of women may have a mild-

George Stamataros was born in Queens, N.Y., and grew up near Princeton, N.J. He completed his undergraduate studies at Rutgers University with a focus in biological Sciences.

He earned his medical degree from the University of Medicine and Dentistry of New Jersey and completed his graduate medical training in internal medicine and subspecialty training in endocrinology at UMDNJ-Robert Wood Johnson Medical School in New Brunswick, N.J. Dr. Stamataros is board certified in internal medicine and endocrinology. He has worked in private practice in New Brunswick for three years before relocating to North Carolina. He was active in teaching medical students and served as a director at Somerset Medical Center. Dr. Stamataros is also a member of the American Association of Clinical Endocrinology and Endocrine Society. Dr. Stamataros now practices at Carolina Endocrine P.A., 3840 Ed Drive, Suite 111 Raleigh, NC 27612. He can be reached by calling (919) 571-3661 or sending an email to gstamataros@ carolinaendocrine.com.

ly suppressed TSH during the first trimester,

Most women with Hashimoto’s thyroiditis

especially with hyperemesis gravidarum

have thyroid peroxidase (TPO) antibodies,

(“morning sickness”). This cause of sup-

which often precede the onset of primary

pressed TSH needs to be distinguished from

hypothyroidism. Recent studies have shown

Graves’ disease, which is the most common

that the presence of TPO antibodies in euthy-

cause of clinically significant hyperthyroid-

roid women is associated with an increased

or to pregnancy and should have thyroid func-

ism in pregnancy.

risk of miscarriage, particularly in the first

tion tests reevaluated six to eight weeks later.

trimester, and treatment with low doses of leSince nuclear medicine studies are contrain-

vothyroxine may lower the miscarriage rate

Nearly half of women on thyroid hormone

dicated during pregnancy (e.g., radioiodine

to that of unaffected women.

replacement therapy will see an increase in

uptake/thyroid scan), diagnosis of Graves’

their dosage requirement. Following deliv-

disease must either be made on clinical

During the first 10 to 12 weeks of gestation,

ery, most women will return to their original

grounds (goiter, bruit, exophthalmus) or

the developing fetus is completely depen-

thyroid hormone dosage requirement.

the measurement of thyrotrophin receptor

dent upon maternal thyroid hormone levels

antibody (TRAb) or thyroid stimulating im-

for normal brain development. Untreated

Women should be reminded to separate

munoglobulin (TSI), which are present in

maternal hypothyroidism is associated with

their thyroid hormone supplement from

the serum of about 70-80 percent of patients

a decrease in neonatal IQ, in addition to an

their prenatal vitamin by at least a couple

with Graves’ disease. Women who require

increased rate of miscarriage and pre-term

hours, since the iron contained in prenatal

therapeutic intervention during pregnancy

delivery.

vitamins can bind and inhibit absorption of

are usually placed on anti-thyroid drugs, or

thyroid hormone.

uncommonly they may undergo thyroidec-

Women who are hypothyroid and are taking

tomy (usually during the second trimester).

thyroid hormone supplementation should

Thyroid Nodules and Cancer

have their TSH in the low range of normal pri-

There is an increased incidence of thyroid

10

The Triangle Physician

Endocrinology nodule discovery during pregnancy, thought

ACNE • MOHS SURGERY • SKIN CANCER • PSORIASIS • ECZEMA • DERMATITIS

to mostly be due to increased clinical surveil-

Thyroid ultrasound can confirm additional

“He wanted his confidence back.”

characteristics of thyroid nodules, and fine-

I REFERRED HIM TO SOUTHERN DERMATOLOGY

lance during the prenatal period.

needle aspiration (FNA) biopsy may be safely performed during pregnancy. However, nuclear medicine studies (e.g., thyroid scans) are contraindicated.

If a thyroid FNA biopsy reveals the presence of cancer or if a nodule is found to be suspicious for malignancy, then the patient may elect to undergo surgical resection (usually during the second trimester) or may defer thyroidectomy until after delivery (in most cases). Women with thyroid cancer who are on thyroid hormone suppressive therapy FOR THE MOST ADVANCED DERMATOLOGY TREATMENTS, REFER YOUR PATIENTS TODAY!

should usually permit their thyroid function tests to normalize, either by lowering the dose or auto-correcting from a suppressed TSH to normal.

southernderm.com

919-782-2152

ROSACEA • HIVES • VITILIGO • KERATOSIS • WART REMOVAL • ALOPECIA

Post-Partum Thyroiditis This is usually a painless, transient disturbance in thyroid function that develops two

DER131_AD_Triangle Physican I Want 4.indd 2

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

919.929.7990

www.drossmangastroenterology.com

to six months after delivery. Incidence is estimated to be anywhere from 3-15 percent, depending on the population being studied.

This condition is characterized by a thyrotoxic phase, followed by a hypothyroid phase, each of which may last for several weeks or months. Anti-thyroid drugs are rarely of benefit during the thyrotoxic phase, although thyroid hormone supplementation can be used for the hypothyroid phase.

3/18/15 3:56 PM

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.

Drossman Gastroenterology

A low radioiodine uptake (RAIU) will distinguish this condition from Graves’ disease (which has a high RAIU), although women who are breastfeeding should not undergo this procedure unless they temporarily suspend breastfeeding.

Recurrence of post-partum thyroiditis in subsequent deliveries is uncommon. About 10 percent of women with post-partum thyroiditis will remain permanently hypothyroid.

October 2015

11

Physician Spotlight

New Options for Losing Weight

By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.

We know that obesity is on the rise. In the

freezer makeover – get rid of the foods

United States, 34.9 percent of adults are

that tempt you

obese, which is defined as a BMI (body

• No late-night eating!

mass index) of 30 or greater.1 Commit to Weight-loss At Women’s Wellness Clinic women often

and Set Goals

ask for weight-loss assistance. Sometimes

The first step to meaningful and lasting

receiving recommendations is all the incen-

weight loss is committing to do it. However,

tive needed.

it is important to recognize that the triggers

• A deficit of 3,500 calories per week (500

that cause stress eating aren’t likely to go

calories per day for seven days) is need-

away. It requires understanding the reasons

ed to lose one pound per week. A deficit

for overeating and managing the triggers.

of 4,900 calories per week (700 per day) is needed to lose two pounds per week.

Next, weight loss requires setting realistic

• Do not consume less than 1,200 calories

goals. In general, losing 1-2 pounds per week

per day to avoid slowing down your me-

is achievable. Calorie counting can be an ed-

tabolism.

ucational process. Did you know that a glass

• Eat less but more often to boost metab-

of wine can range between 300-500 calories?

olism. Try to consume five to six small

So having a glass of red wine at night may

meals during the day beginning with

wipe out a day’s efforts.

breakfast within 45 minutes of walking.

• Keep a food journal – potentially an

Becoming more active is important to weight-

online version that will keep calorie

loss success. Exercise also comes with a

count for you: www.thedailyplate.com,

number of other health benefits, including

www.calorieking.com, www.sparkspeo-

improved mood, cardiovascular system and

ple.com, www.nutrihand.com, as well as

blood pressure.

www.mypyramid.com.

• Exercise! This is so important for weight

Any extra movement helps burn calories!

loss (and weight control), although what

The simple decision to use the steps instead

you eat is more important.

of the elevator can burn calories.

• Be mindful of the food you are eating both in terms of quality and quantity.

• Do not multitask when you are eating, and chew your foods well.

• Give yourself a pantry and refrigerator/

Medication Support For those who need extra support, medications can help change eating habits by easing cravings.

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. She and partner Amy Stanfield, M.D., F.A.C.O.G., head the Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals. Call (919) 251-9223 or visit www.cwrwc.com.

Most recently, the drugs Contrave (Takeda Pharmaceuticals) and the injection Saxenda (Novo Nordisk) were approved for chronic weight management in 2014. Three yeas ago (2012), Qsymia (Vivus) and Belviq (Arena Pharmaceuticals) were approved for chronic management. Probably the oldest available medication for weight loss is phentermine, which now is available in generic forms. This is indicated for short-term weight loss and works as an appetite suppressant.

Take Care of Yourself Women’s Wellness Clinic is offering these fall offers to encourage self care: • 50 percent off pain-free laser hair removal. Six underarm treatments for $300 or six bikini-line treatments for $475.

• 30 percent off laser treatment for facial age spots ($240, includes topical anesthetic).

• $75 visit with a provider to review weight-loss strategies. Subsequent visits for those who choose medical assistance for weight loss can then be billed under their medical insurance. Those without medical insurance can receive further medical assistance at a reduced cost this fall.

Call (919) 251-9223 to learn more about or take advantage of these offers.

12

The Triangle Physician

Duke Research News

Meridia (Knoll Pharmaceutical) was ap-

Family Physician Needed

proved in 1997 and withdrawn from the United States market in October 2010. This was to be used for treatment of obesity, but there was increased risk of serious heart events.

Family Physician Needed at Avance Primary Care, Raleigh, NC

The support of family members and friends, a

Avance Care, P.A. is seeking a Board Certified Family Physician at our new Oberlin Rd practice opening in late 2015. Avance Care’s model was created to benefit our patients AND our physicians.

support group or even a professional coach is helpful. Given the increase in the number of medications for weight loss, consultation with a health care provider who is knowledgeable about what works is recommended.

Whether the goal is to lose five pounds or 105, there are healthy options. At the Women’s Wellness Clinic, we are dedicated to helping each woman become healthy and familiar with weight-loss strategies. Appointments can be made by calling (919) 251-9223.

• Work/life balance – our providers work 40 hours per week or less • Average patient load of less than 3 patients per hour • Proprietary operating and provider support systems – paperless facilities • Highly trained support staff • State of the art facility with onsite Pharmacy, X-Ray, Nutritionist, Behavioral Health Services, Allergy Testing and Immunotherapy • Operation that has consistently met or exceeded NCQA PCMH level 3, BQPP level 3, United Bridges to Excellence, Meaningful Use, NCQA DRP • Market leading private practice compensation package

Learn more about us at avancecare.com/about/about-us Apply online at avancecare.com/about/careers-providers

Reference www.cdc.gov

1

Spend Time c Your Patients, Not Battling IT. Get HIPAA Compliant Solutions

Let’s Talk Tech! Call (919) 296-1089 SAMIT-Medical.com

October 2015

13

Practice Management

Physician Role in

Practice Management

By Margie Satinsky, M.B.A.

Just as patients schedule a visit to discuss

nobody is doing the job, and it shows.

one symptom when they really want to talk about a different one, we receive re-

Second, many physicians don’t know how

quests for help on a myriad of practice

to move from science to business. The

management issues when the real issue is

difference in disciplines appears may be

the role that physicians themselves play or

smaller than you think. The same diagnos-

don’t play in managing their practices.

tic and problem-solving skills that apply to clinical care also apply to practice man-

Last month we dealt with two situations

agement.

in which the practice managers were not meeting expectations regarding accounts

Dig In

receivable, escalating expenses and poor

The body of knowledge that practice man-

staff morale caused by delayed perfor-

agement encompasses includes many

mance reviews. The real issue in these sit-

topics that need to be mastered individu-

uations wasn’t money or staff competence.

ally and then related to each other. These

It was the role that physicians played in

topics include, but are not limited to, orga-

the management of their practices.

nization and management, financial man-

Margie Satinsky, MBA, is President of Satinsky Consulting, LLC, a Durham, NC consulting firm that specializes in medical practice management. She’s provided strategic planning and operational guidance to more than 100 practices in North Carolina. Margie is the author of numerous books and articles, including Medical Practice Management in the 21st Century.

For additional information, go to www.satinskyconsulting.com.

agement, human resources, compliance

administrator may designate and com-

Get Past the Obstacles

and operations, including information

pensate one physician as the managing

Medicine is a challenging field but no less

technology and quality management.

partner. Other practices divide managerial responsibilities among the physician

challenging than running a small business.

As a small business owner, you need to

Let’s look at the role that physicians

owners. Either way, the physician(s) col-

know what must be managed and how to

should play in order to actively manage

laborate with a practice manager whose

provide guidance to staff. It is unlikely that

their practices.

experience and skill level are below those of a practice administrator.

you learned about business in medical school, so perhaps you are reluctant to get

Organization and Management: Physi-

involved. Where do you start? How do you

cians have three options for organizing

Finally, the practice can hire an office man-

learn what practice management means,

and managing the practice.

ager to execute the instructions issued by the owners. Notice that we haven’t listed

and once you understand the scope, how do you master the skills that will help you

If the practice is large enough to support

the option of rotating physicians as manag-

succeed?

a professional practice administrator, that

ing partners, so nobody gets “stuck” with

individual can take a leadership role in ini-

the job. We think rotating the managerial

In our experience, two concerns deter

tiating strategic and operational programs

responsibility is avoidance of a job that no-

many physicians from taking proactive

subject to physician approval on major

body wants to do.

roles in the management of their practices.

decisions.

Financial Management: Financial man-

One, believe it or not, is the presumption that someone else is doing the job. Often

14

The Triangle Physician

Practices that don’t have a professional

agement involves both revenue cycle man-

Practice Management agement (e.g., managed care negotiations,

tify problems and take corrective action.

sors, each other and the physicians and

billing, collections, management of deni-

Make sure that the appropriate policies

that communication on what is important

als) and activities that the practice per-

and procedures are in place in order to

in your practice come directly from the

forms regularly (e.g., budgeting, checks

prevent problems before they occur. Take

top.

and balances).

an active, not a passive role in the finan-

If the practice is part of an accountable

cial management and prevent problems

Here’s an example of a situation that

before they arise.

might have been avoided. A primary care practice in the eastern part of North Caro-

care organization (ACO), it also involves the relationship with that organization. In

We like the advice that hockey great

lina hired a new practice administrator to

any practice environment, there’s a great

Wayne Gretzky provided when asked what

take charge of the eight-person practice.

deal of available information. The certi-

made him such an outstanding player. He

Shortly after her arrival, the practice add-

fied public accountant provides monthly

replied: “I skate to where the puck is go-

ed a new provider by merging with an ex-

reports, and the practice management sys-

ing to be.”

isting practice. The marching orders for the practice administrator changed, and

tem (PMS) contains the details – provided one knows what he/she needs and what

Human Resources: The most valuable

the owners directed her to focus on the

to do with it.

assets of every medical practice are its

details of the merger. She did, only to find

employees. Practices that have the best

herself out of a job within nine months

Regardless of the way in which the prac-

staff retention and loyalty treat human re-

because she wasn’t devoting enough at-

tice is organized, physicians should play a

sources as a major investment.

tention to ongoing operations. In hindsight, the outcome might have been dif-

major role in financial management. Take responsibility for making sure that there

Practice owners should make sure that job

ferent had the owners been more clear

are realistic annual operating and capital

expectations and priorities are clear, that

on their priorities and the potential nega-

budgets. Use the budgets to guide both

employees are treated consistently and

tive consequences of neglecting day-to-

revenue generation and spending. Review

fairly, that training is available, that staff

day business.

reports regularly, using the data to iden-

have opportunities to meet with supervi-

October 2015

15

Practice Management Compliance: Compliance with require-

if physicians make disparaging remarks

put the practice, the practice administra-

ments by Medicare and Medicaid, Health

about compliance and are unwilling to

tor and the patients in a risky situation.

Insurance Portability and Accountabil-

support these activities, the staff will as-

ity Act (HIPAA), Occupational Safety and

sume a similar attitude. Don’t put the prac-

Operational Management: When is the

Health Administration (OSHA), Clinical

tice at unnecessary risk.

last time the physicians in your practice looked critically at the workflow process-

Laboratory Improvement Amendments

es?

(CLIA) and other governing bodies is an

We’ve helped more than 100 practices

essential component of running a medical

become HIPAA compliant. Our most chal-

practice.

lenging client was the practice where the

Does everybody know what happens to

physician owners chose to ignore the

patients from the time they make an ap-

If physicians convey the attitude that com-

major recommendations for privacy and

pointment to the time that they check out?

pliance is important to your practice, your

security rule compliance. Their hostility

Does the practice use patient satisfaction

staff will adopt your attitude. Conversely,

toward any type of government regulation

surveys and act on the results? How much do the owners know about the information technology applications that the practice has and about new enhancements that may become available? Is there an active quality management program?

Don’t leave these important issues up to staff discretion; get involved.

Conclusion Hopefully we’ve convinced you. As a physician owner you need to be knowledgeable about practice management.

How do you obtain the information and the managerial skills? Professional organizations, such as the American Association for Physician Leadership, Medical Group Management Association (MGMA) and your own specialty society, offer mini courses on practice management. You also can enroll in master in business administration courses that are offered on weekends and/or online.

Or you can ask one or more qualified consultants to teach you particular subjects that you want to learn. Finally, check the Internet. Many of those topics that may seem mysterious will become very clear once you begin your quest for knowledge.

As physician owners of a medical practice, practice management is ultimately your job. With a methodical approach to both substance and skills, you can make a big difference.

Womens Wellness half vertical.indd 1

16

The Triangle Physician

12/21/2009 4:29:23 PM

Physician Advocacy

AID Takes Aim at Physician Burnout

By Marni Jameson

As a non-physician who talks to a lot of doc-

We are painfully aware that doctor burnout

tors, I’m often struck and saddened by how

is on the rise. A January 2015 report by Med-

frustrated they are.

scape from WebMD found that is a problem for 46 percent of physicians – up 16 percent

Not long ago, after speaking at an Ameri-

in just two years. The study defined burnout

can College of Cardiology summit, I was

as a loss of enthusiasm for work, feelings of

besieged by doctors asking for ways they

cynicism and a low sense of personal ac-

could stay independent and not succumb to

complishment.

Marni Jameson is the executive director for the Association of Independent Doctors.

You may reach her at (407) 865-4110 or marni@aid-us.org.

hospital offers of employment.

Among the top reasons for burnout are too

Most doctors are by nature autonomous.

They wanted to know, privately, if we, the

much bureaucracy, too many hours, not

Most don’t go into practice to do unneces-

Association of Independent Doctors (AID),

enough income, computerization, impact

sary procedures, order unnecessary tests

could help them get fairer contracted rates

of the Affordable Care Act and not enough

and meet quotas to please their employers

with insurers; that is, reimbursement rates

time to provide quality care.

and keep their jobs.

hospital-employed physicians for the same

“How Being a Doctor Became the Most

The same week of the aforementioned Med-

procedure. It should be a fair playing field,

Miserable Profession,” an article written by

scape article, I got an email from a physician

and we’re working on it.

Daniele Drake for The Daily Beast in April

and AID member asking for help. The medi-

2014, opened with the news that nine of 10

cal staff had elected him to be chief of sur-

The physicians wanted help forming in-

doctors would discourage others from join-

gery at his hospital. However, the hospital

dependent physician associations (IPAs),

ing the profession, and that over the past few

board followed with a vote not to approve

giving them better leverage and clout with

years being a doctor has risen to become

his position. The board wanted an employed

payers. That’s a solution, and we’re working

the second-most suicidal occupation

physician in that seat.

This much is clear: Employment is not the

As we told this doctor, and as we tell ev-

They wanted to know if we could help them

answer. We understand that for some going

eryone who is frustrated about the state of

combat the fact that hospitals direct patients

to work for a hospital seems like a good op-

health care, the only way independent doc-

only to employed physicians, cutting inde-

tion. But we know from those who have left

tors are going to gain ground, protect their

pendent doctors out of the referral network.

independent medicine, the grass is not nec-

interests and secure their professions is to

We’re working on that as well.

essarily greener.

develop a unified, nationwide voice that pa-

closer to what insurers and Medicare pay

on it.

tients, hospitals, insurers and governments listen to, take seriously and respect.

They want a life raft, or at least a life pre-

We know, because we have many physician

server, to help them keep cash flow up and

members who were employed by hospitals

disillusionment down.

and have returned to private practice. One

That is the purpose of Association of Inde-

internist was frustrated, because her hospi-

pendent Doctors. But we can’t do this with-

AID offers assurance to independent physi-

tal employer insisted she see 25 patients a

out your support. If you’re independent and

cians. We are working with media, lawmak-

day rather than her average of 17, a number

believe in our efforts, please support us by

ers, the judicial system, insurers, doctors

she felt she could see in one day and pro-

joining our cause. To become a member of

and consumers on all of these issues. They

vide quality care. When she didn’t pick up

AID go to www.aid-us.org. Let’s do this to-

are big, complicated and entrenched, but

her pace, her employment contract wasn’t

gether.

we are making a difference.

renewed.

October 2015

17

Duke Research News

Model Shows Meningitis’s Creep into the Brain of Transparent Zebrafish Scientists at Duke Medicine are using transparent fish to watch in real time as cryptococcal meningitis takes over the brain. The resulting images are worthy of a sci-fi movie teaser, but could be valuable in disrupting the real, crippling brain infection that kills more than 600,000 people worldwide each year.

Airborne cells of cryptococcus make their way into our lungs practically every day — unwelcome guests, but of little consequence for those with healthy immune systems. But for those with compromised immunities, whether by HIV infection or cancer treatment, a resulting cryptococcal meningitis infection can quickly become deadly.

To be able to target the infection with medications in the future, researchers need to know more about how the organism (technically a yeast) moves from the lungs into the blood stream and through the blood-brain barrier. So they injected the organism into microscopic

A zebrafish larva is infected with cryptococcal meningitis and photographed under a microscope. Scientists observe as the infection (visible red orbs) takes over the brain. Macrophages (shown in blue) attack the infection as it travels through green blood vessels and throughout surrounding tissue. The eyes of the fish are located at the top and bottom left corners of the image. Photo by Stefan Oehlers/Duke Medicine.

zebrafish larvae, which have clear bodies, and watched the infection take hold.

while it is living with an infection,” Dr. Tobin said. “It will allow us to screen libraries of drug compounds relatively quickly. We can also

The newly developed fish model is described in mBio, a journal of the

develop and test mutant strains of cryptococcus in these larvae. This

American Society of Microbiology.

can teach us which factors play a role in infection and those could be therapeutic targets in the future.”

“What’s impressive is that, unlike in a mouse or rabbit, you can actually see the organism producing disease in the live animal,” said John

Dr. Tobin also uses zebrafish to study bacteria closely related to those

R. Perfect, M.D., chief of the division of infectious diseases at Duke

that cause tuberculosis, and findings from this model have been ap-

University School of Medicine. “Day-by-day, it’s growing and moving

plied to understanding human disease.

throughout the body. You can’t see this anywhere else.”

There are some drawbacks to studying these infections in fish – their A YouTube video shows a transparent larva’s body as cryptococcus

body temperatures are cooler, and they lack lungs, which is where

fungi, made red by a fluorescent tracer, moves through tissue, blood

cryptococcus enters the human body, Dr. Perfect said. But the fish

vessels and into the brain. Blue macrophages chase and gobble up

offer a starting point to create leads that scientists can then investigate

some of the red infection as it spreads through and around green

further in more complex mammals.

blood vessels.

“Our hope is that by creating this system, we can continue our own Using a zebrafish to observe the process of infection offers a small ver-

investigations into other harmful organisms and that other scientists

tebrate animal with an immune system somewhat similar to a human’s,

worldwide can adapt our zebrafish model to investigate the diseases

Dr. Perfect said. Because the fish are tiny and easy to reproduce, they

that are priorities in their communities,” Dr. Perfect said.

cost less and are easier to study than a mouse or larger mammal.

In addition to Drs. Perfect and Tobin, study authors include Jennifer L. The larvae also are permeable to small molecules, which will allow

Tenor, Stefan H. Oehlers and Jialu L. Yang.

scientists to batch-test different drug compounds against the infection

The study was sponsored by the Duke University Center for AIDS

relatively quickly and easily, said co-author David Tobin, Ph.D., assis-

Research (CFAR), the National Institutes of Health (5P30 AI064518;

tant professor in molecular genetics and microbiology and immunol-

1DP2-OD008614; AI73896; AI93257), the Australian National Health

ogy at Duke.

and Medical Research Council, a Mallinckrodt Scholar Award, a Searle Scholar Award, the Vallee Foundation and a Medicine Research Col-

“This model will allow researchers to screen the whole organism

18

The Triangle Physician

laboration Award.

UNC Research News

Study Shows Affect of Diabetes Drug on Bone Health and Benefit of Exercise bones

“First, we were surprised by the massive

Yet, other drugs under development that

there is fat. Diabetes

amount of bone fat caused by rosigli-

could be close to Food and Drug Admin-

increases the amount

tazone,” Dr. Styner said. “The images were

istration-approval lower blood sugar by en-

of this marrow fat.

just stunning. Also, the drug is so power-

hancing the PPAR (peroxisome proliferator-

And now a study

ful, and we used such a high dose that we

activated receptors) pathway. These drugs

from the University of

didn’t think exercise would decrease the fat

are referred to as fibroblast growth factor-21

North Carolina School

depot much, if at all. But exercise did de-

agonists.

Inside

Maya Styner, Ph.D.

our

of Medicine shows

crease the volume of bone fat by about 10

how some diabetes drugs substantially in-

percent, which was similar to the decrease

“Early reports show that the same bone

crease bone fat and thus the risk of bone

we reported seeing in mice that were not

concerns are popping up with these new

fractures.

given the drug but were instead fed a high-

drugs,” Dr. Styner said. “Doctors and pa-

fat diet.”

tients need to be aware of this.”

The study, published in the journal Endocrinology, also shows that exercise can decrease the volume of bone fat caused by high doses of the diabetes drug rosiglitazone, which is sold under the brand name Avandia.

“These drugs aren’t first- or second-line choices of treatment for Type 2 diabetes, but some patients do take them,” said study first author Maya Styner, M.D., assistant professor of medicine. “And we know there are drugs in development that target the same cellular pathways as rosiglitazone does. We think doctors and patients need to better understand the relationship between diabetes, certain drugs and the often dramatic

Images of bones stained with osmium. Left: bone fat decreased due to exercise. Right: bones of mice on high dose of rosiglitazone. Far right image shows decrease in bone fat due to exercise.

effect on bone health.”

Dr. Styner said that many of her patients

Bone fat, in general, isn’t nearly as well un-

According to Dr. Styner’s study, rosiglitazone

have been surprised to learn that some

derstood as other fat depots.

affects bone fat by enhancing a critical tran-

diabetes drugs can adversely affect bone

scription factor called PPAR – peroxisome

health. She also said that diabetes itself can

“Our field is just beginning to investigate

proliferator-activated receptor – which regu-

harm bones.

bone fat and its implications for patients,” Dr. Styner said. But she said that more bone

lates the expression of specific genes in the nuclei of cells. Essentially, rosiglitazone

Avandia fell out of favor about a decade ago

fat means less actual bone, which increases

takes glucose out of blood to lower blood

because of heart-related side effects. Physi-

the risk of bone fractures.

sugar and treat diabetes. But that glucose is

cians can still prescribe the drug, but it isn’t

then packaged into lipid droplets – fat. Other

as popular as it once was. Its cousin pio-

All of us have fat in our bones. It’s just a

researchers showed that some of that fat is

glitazone is also still available and has been

matter of how much. Dr. Styner said that

stored in tissue, such as belly fat. Dr. Styner’s

shown to cause fewer heart-related side ef-

the same kind of stem cell in our marrow

latest research showed that the drug also

fects, Dr. Styner said, but it also isn’t used as

creates bone cells and fat cells. Previously,

causes fat to be stored inside bone.

a first- or second-line drug to treat diabetes.

Dr. Styner used a new osmium-staining technique to visualize that a high-fat diet in-

October 2015

19

UNC News creases the fat depots in the bones of mice,

Whatever the case, exercise aids bone

risk of declining bone health to find an ex-

just as a high-fat diet increases belly fat.

health. In her studies, Dr. Styner’s team add-

ercise that suits them; the default would be

ed a running wheel to mouse cages. Mice

taking very long walks.

There are still differing theories for how

are natural runners. At night, they’d run sev-

bone fat increases due to a high-fat diet and

eral miles on the wheel. Dr. Styner’s team

Also, Dr. Styner is hoping to work with exer-

how exercise lowers it. Dr. Styner said exer-

then measured the effects of running. (See

cise scientists at UNC-Chapel Hill to use ad-

cise might trigger marrow stem cells to cre-

images.) Even on a high dose of a powerful

vanced magnetic resonance imaging tech-

ate more bone cells instead of fat cells. Or

drug, such as rosiglitazone, the mice that

nologies to visualize the effects of exercise

perhaps exercise causes the body to access

exercised showed a significant decrease in

on human bone health.

bone fat as fuel.

bone fat.

The National Institutes of Health funded this

“It could be that bone fat is just another de-

Dr. Styner said her findings are not yet di-

research. Janet Rubin, M.D., professor of

pot, a good energy store that allows bone

rectly relatable to human activity. For hu-

medicine and pharmacology, is the senior

cells to do what they need to do, so bones

mans, running isn’t nearly as natural. But

author of the paper that appeared in the

become stronger,” Dr. Styner said.

she said she would still advise patients at

journal Endocrinology.

Web-based Calculator Helps Providers Better Counsel on Prenatal Screening of

women interested in genetic testing for

tests depends on how high a patient’s risk

North Carolina De-

their pregnancies increases, said Matt

of having a baby with Down syndrome is,

partment of Obstet-

Grace, M.D., a fellow in the Division of

which ultimately depends upon her age.

rics & Gynecology,

Maternal-Fetal Medicine and lead author

The calculator offers a way for physicians

Division of Maternal-

of a paper on the topic that appears in the

and genetic counselors to better explain

Fetal Medicine has

July 2015 issue of the American Journal of

how the tests perform and to enhance

unveiled a free, web-

Obstetrics and Gynecology.

their counseling of patients both before

The

Matt Grace, M.D.

University

the testing and after.

based calculator to

help providers better counsel patients

“When communicating the results of

on the benefits and risks of the four most

these tests, it’s important for providers to

“For instance, if our calculator shows that

common screening tools for fetal genetic

help their patients interpret them. These

the positive predictive value of a test is 46

abnormalities available commercially in

tests are screening tests, and when a pa-

percent for a woman of a specific age and

the United States.

tient receives a positive result, we recom-

at a specific gestational age, there is still

mend follow up with a diagnostic test,

a 54 percent chance that the fetus does

Using age- and gestational age-related risk

such as an amniocentesis, to confirm or

not have the abnormality,” said Dr. Grace.

tables for trisomies 21, 18 and 13 (com-

rule out a genetic abnormality,” said Dr.

“This is an opportunity for the provider to

monly known as Down syndrome, Ed-

Grace. “There are a number of reasons

offer additional information and another

ward syndrome and Patau syndrome) as

why a false positive might happen, and

level of care to the patient.”

well as the previously reported sensitivity

the evidence shows that some women are

and specificity of each cell-free fetal DNA

deciding to terminate their pregnancies

The calculator can be found at The UNC

testing platform, the calculator can esti-

without further confirmatory testing.”

Center for Maternal and Infant Health website at mombaby.org/NIPS.

mate the positive predictive value (PPV) of each test or the likelihood that a posi-

All four tests – known commercially as

tive result is a true positive. Most of the

Harmony, Materniti 21, Panorama and

Also listed as authors on the paper are:

laboratories do not currently report the

Verifi – appear to perform better than

Emily Hardisty; Noah S. Green; Emily Da-

PPV of their testing platforms.

previous genetic screening tests and have

vidson, M.D.; Alison Stuebe, M.D.; and

reduced the need for unnecessary and

Neeta Vora, M.D.

The ease and accessibility of such a tool

more invasive procedures for many wom-

is especially important as the number of

en. The positive predictive value of the

20

The Triangle Physician

State-of-the-art, expert, cost effective, timely endocrinology care is what Carolina Endocrine has to offer your patients.

• Neck Ultrasounds (ECNU certified) • Fine needle aspiration biopsies • Nuclear medicine studies

All in one convenient location behind Rex Hospital at 3840 Ed Drive, Suite 111.

919-571-3661

www.CarolinaEndocrine.com Michael Thomas, M.D., Ph.D. George Stamataros, D.O. Carly Kelley, M.D., M.P.H. Eileen Andres, PA-C Erin Wetherill, PA-C

October 2015

21

NO ONE SEES YOU LIKE WE DO. The way we see it, image is everything. So we specialize in everything imaging.

From prevention and detection to diagnosis and intervention. All provided in 20 Triangle locations by more than 150 certiďŹ ed technologists and subspecialty radiologists. Every one of them with the unique ability to see beyond the patient to the person inside.

G

BO I

G MA

IN

DY

RO

I

MA G

NEU

IN G

VA

VE

IN

T

TH

-C

ERA

PET

PY

MRI

P E D I AT

ST IMAGING

RIC I M AGIN G

BREA

SC

R

PH

Y

U

LA

IM

AG

IN

G

ORT

HO PEDIC I M AGING

M

M AM

OG

RA

Be seen by people who specialize in you at WakeRad.com.