october 2016
North Carolina Dermatology Associates Timely and Comprehensive Dermatology Care
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
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T
From the Editor
Great Day! 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
It says a lot when a dermatology practice offers same-day appointments. That’s what North Carolina Dermatolgy Associates can do. Its patient-focused approach doesn’t stop there. While this practice offers a complete array of services, its core focus is medical and surgical dermatology. It’s board-certified physicians pride themselves in direct supervision of patient care that is evidence based, holistic and cutting edge. They extend the same level of professionalism when providing cosmetic dermatology care. Featured medical columns in this issue of The Triangle Physician also are timely. Physician assistant Morrow Dowdle suggests consideration of a patient’s use of digital technology and electronic devices as part of your examination and evaluation. Practice consultant Margie Satinsky reviews the changes initiated by legislation authorizing a value-based payment system for clinicians. Physician advocate Marni Jameson Carey brings us up to date on Association of Indedpendent Doctors, whose membership has soared to more than 1,000 coast to coast. The Triangle Physician is here for you! Each issue reaches more than 9,000 within the Raleigh-Durham medical community. And any day is a great day to submit your news or take advantage of our competitive advertising. Coverage of your medical news and insights is provided at no cost. Email us at: info@trianglephysician.com. With gratitude,
Heidi Ketler Editor
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Marni Jameson Carey Morrow Dowdle, P.A.-C. Margie Satinsky, M.B.A. Creative Director Joseph Dally jdally13@gmail.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.
2
The Triangle Physician
Table of Contents
4
COVER STORY
North Carolina Dermatology Associates Timely and Comprehensive Dermatology Care october 2016
FEATURES
7
DEPARTMENTS 10 Physician Advocacy
Patient Care
Independent Doctors’ Group Growing With 1,000 Members Coast to Coast
Screening for Screen Time: Increasingly An Unmet Patient Need Morrow Dowdle urges evaluation of electronic device use aong patients and its potential impact on child and adult health.
8
V o l . 7 , I ss u e 9
11 Dermatology Medical Dermatology Matters
News 12 Study Shows how “Hair-of-the-Dog” Approach Works to Treat Allergies
Practice Management
Medicare Changes: What Lies Ahead? The counting of quality measures starts on Jan. 1, 2017, but
13 Mobile App Enhances Communication for Providers and Care for Patients
14 Grant Funds Key Infrastructure Role in ECHO Study on Childhood Health
Medicare participating physicians don’t see the result in the
14
Oxytocin Is Linked to Spirituality
payment until 2019.
17
Welcome to the Area
october 2016
3
Cover Story
North Carolina Dermatology Associates Timely and Comprehensive Dermatology Care In March 2009, Vikas Patel, M.D., returned
other practices were over two-to-three
Park and all of the surrounding towns. In
to North Carolina to open a dermatology
months and even longer at some of the
addition, the practice attracts patients from
practice in the Brier Creek area of Raleigh.
academic dermatology departments.”
as far as Rocky Mount, Greenville, Fayetteville, Henderson and southern Virginia.
He had spent the prior five years practicing in the Washington, D.C., area, but he
North Carolina Dermatology Associates
was drawn back to the Triangle to raise his
(NCDA) is a full-service dermatology prac-
NCDA prides itself on providing outstand-
family and saw a need for greater derma-
tice providing medical, surgical and cos-
ing accessibility to patients. With the ad-
tology accessibility.
metic dermatology treatment for adults
dition of Elizabeth Ju, M.D., in September,
and children across the entire Triangle
the practice can now accommodate same-
“I chose to return to the Triangle for many
community. Dr. Patel chose the Brier Creek
day appointments for most patients.
reasons, which included the opportunity
location near I-540 and US-70 for its central
to open a new practice in Raleigh. The
location in the Triangle with easy access for
need for additional dermatology services
people living and working in Raleigh, Dur-
tion of clinics offering “dermatologic ser-
was readily apparent. The wait times at
ham, Cary, Morrisville, Research Triangle
vices or skin care” that are not under the
In recent years, there has been a prolifera-
direct supervision of board-certified dermatologists. Both Dr. Patel and Dr. Ju are board certified by the American Board of Dermatology and both completed dermatology training locally at Duke University. “I would encourage all patients to inquire that any clinic providing specialized dermatologic service or skin care is rendered by a board certified dermatologist or a physician extender directly supervised by one onsite,” says Dr. Patel. NCDA leverages the latest EMR (electronic medical records) technology, allowing for easy appointment scheduling, tracking of medical records through a secure patient portal and digital appointment follow-up notices. NCDA’s core focus is on medical and surgical dermatology. Common issues include the diagnosis and treatment of: • Acne • Eczema • Hair disorders
4
The Triangle Physician
• Mole screenings • Nail conditions • Psoriasis • Rashes • Rosacea • Warts • Skin cancers • Removal of other skin growths “We pride ourselves on being at the forefront of dermatologic advances in therapy,” says Dr. Patel. In recent years there have been tremendous advances in the diagnosis and treatment of common skin conditions, such as psoriasis and atopic dermatitis. Several medications in the biologic class have been approved by the FDA (United States Food and Drug Administration), which has dramatically changed the approach to successfully treating psoriasis compared to a decade ago. There are several new immunomodulatory therapies, delivered topically and systemically, that will improve treatment of recalcitrant atopic dermatitis and eczema. “Our passion for providing evidence-based care, as well as using the most up-to-date treatments, allows us to consistently deliver top-notch care to our patients,” says Dr. Ju. In addition, North Carolina Dermatology Associates offers cosmetic dermatology services, including fillers, Botox, chemical peels, IPL (intense pulsed light), microdermabrasion and photodynamic therapy, as well as age spot and facial vein removal. “NCDA offers a range of cosmetic services to patients to promote healthy, rejuvenated skin. Our latest addition is microneedling, or collagen induction therapy, which has provided our patients with exceptional results. Microneedling stimulates new collagen and elastin to develop in the skin, allowing for a more long-lasting result than alternatives,” says Dr. Patel. Microneedling can help improve fine lines, wrinkles, skin texture, pore size, acne scars, stretch marks and other conditions.
october 2016
5
Meet the Physicians
Traditionally, cosmetic services have
cosmetic options. For example, acne can
Vikas Patel, M.D.
been sought out primarily by female
be treated with topical and oral medica-
patients, however NCDA recently has
tions, including antibiotics, retinoids and
seen an increase in demand from male
isotretinoin. Alternate approaches in-
patients, as well. In response to this de-
clude photodynamic therapy or chemi-
mand, NCDA offers services specifically
cal peels. From a cosmetic perspective,
designed for men.
acne scars can be treated with a variety
Dr. Vikas Patel was born in Canada, where he spent the first six years of his life. The remainder of his childhood was spent in the south, including North Carolina, Georgia and Arkansas. Dr. Patel graduated from Duke University with honors (magna cum laude) with a degree in biology and religion and a minor in chemistry. He also attended medical school at Duke University. Dr. Patel completed his internship in internal medicine in San Francisco and returned to Durham for his residency in dermatology at Duke University. After completing residency, Dr. Patel practiced in Washington, D.C., and its suburbs of Sterling, Va.
of techniques depending on the subtype There are differences in both intrinsic
of scarring, including chemical peels,
and extrinsic aging factors in men. “For
fractional resurfacing, microneedling or
example, the male skin has reduced an-
subcision.
tioxidant capacity and increased ultraviolet-inducted immunosuppression. We
“Our comprehensive approach allows
take these factors into consideration to
us to provide complete care to many
help tailor cosmetic treatments for men
conditions that have serious and nega-
and to minimize the process of aging,”
tive impacts on quality of life, such as
says Dr. Ju.
acne,” says Dr. Ju. “We understand that cosmetic conditions that are neither
A variety of skin issues that men look
health threatening nor associated with
to improve are acne scars, frown lines,
significant morbidity can still affect an
hollowness of the eyes, deep facial lines,
individual’s well being.”
hair rejuvenation, pore sizes and redDr. Patel is board certified by the American Board of Dermatology. Other society memberships include the American Academy of Dermatology, the American Society for Dermatologic Surgery and the North Carolina Medical Society. Elizabeth Ju M.D. Dr. Elizabeth Ju was born and raised in North Carolina. She attended Emory University as a Mellon Mays fellow, where she earned degrees in biology and music. She then attended the University of North Carolina School of Medicine. Dr. Ju completed an internship in pediatrics in Philadelphia, after which she returned to North Carolina to complete her residency in dermatology at Duke University. She is board certified by the American Board of Dermatology. Dr. Ju currently resides in Durham with her husband, David, who she met in high school in Raleigh. Outside of work, she enjoys playing piano and cello, exploring new countries, hiking, cycling and scuba diving.
6
The Triangle Physician
ness. All of these conditions can be ad-
For more information or to make a refer-
dressed by an evaluation to determine
ral to North Carolina Dermatology As-
an individual, customized plan.
sociates call (919) 596-9600. Additional information regarding the services and
Some skin conditions have to be ap-
treatment offered can be obtained by vis-
proached from a comprehensive per-
iting www.ncdaskin.com.
spective, utilizing medical, surgical and
Patient Care
Screening for Screen Time:
Increasingly An Unmet Patient Need By Morrow Dowdle, P.A.-C.
Screening questionnaires have become
veys that investigate the quantity and qual-
a routine part of health care across
ity of patients’ screen time.
medical specialties. An individual seeking to become a new patient of a practice is
The
last
thing
that
most
medical
more often than not asked to complete
practitioners want to hear is that they
screening forms prior to their initial visit.
are now expected to address one more
Some practices may administer such forms
aspect of their patients’ lives. There seems
routinely or at periodic intervals at follow-
to be more than enough to manage with
up visits. These surveys give medical
inquiring about diet, exercise, substance
providers information about a patient’s
use, sleep, pain level, personal safety and
lifestyle and general life circumstances
social and financial stability – in addition
that help providers in making proper
to taking care of the actual health problems
assessments and treatment plans.
for which patients present. Unfortunately, the potential impact of electronic device
One aspect of patients’ wellbeing that
use on patients’ physical and mental health
seems to be overlooked is their use of elec-
can no longer be ignored or minimized.
tronic devices. The United States Preven-
Morrow Dowdle is a certified physician assistant at Carolina Partners. She earned her master of science in physician assistant studies degree from the Medical University of South Carolina in Charleston and is a member of the American Academy of Physician Assistants, the North Carolina Academy of Physician Assistants and the Neuroscience Education Institute. Before joining Carolina Partners in 2016, Ms. Dowdle practiced at Triangle Neuropsychiatry. She treats all ages and specializes in anxiety, mood disorders, psychotic disorders, post traumatic stress disorder and developmental disorders.
tive Task Force currently makes no recom-
There is currently very little information
mendation for any screening of patients’
regarding appropriate parameters for
technology consumption. Anecdotally, a
digital technology use. The American
number of practices have begun screening
Academy of Pediatrics recommends no
the negative effects of electronics overuse,
their patients’ technology use, particularly
screen time for children under two and a
which can cause a deterioration of cogni-
in the pediatric population. However, there
maximum of two hours daily for children
tive abilities akin to that seen in patients
are very few standardized primary care sur-
over two. Research has demonstrated that
with a head injury or chronic mental ill-
excessive use of electronic devices
ness. Effects include short-term memory
(including TV, computers, tablets,
dysfunction, difficulty concentrating, short-
video games and cell phones) has
ening of attention span and emotional dis-
resulted in weight gain, poor dietary
turbances.
habits, inadequate sleep, anxiety, depression and attention problems
Many patients have an intuition that
in children. Furthermore, there is
the amount of time they spend on their
good evidence that it may hinder
electronic devices versus engaged in real-
development of visual-motor, self-
time activities might be out of balance, but
regulation, empathy, social and
they don’t know how or why they should
problem-solving skills.
change their habits. A primary care, mental health or specialist provider or one
While there are no spe-
of their support staff can be the person to
cific standards for adults,
begin that conversation and turn it into an
they are not immune to
ongoing discussion.
october 2016
7
Practice Management
Medicare Changes: What Lies Ahead? By Margie Satinsky, M.B.A.
Changes in Medicare are imminent! On
more than $30,000 per year or provide care
Oct. 14, 2016, the Department of Health
for more than 100 Medicare patients per
and Human Services issued the final rule
year are eligible to participate beginning
regarding implementation of key provi-
in 2017. So are physician assistants, nurse
sions of the Medicare Access and CHIP
practitioners, clinical nurse specialists
Reauthorization Act of 2015 (MACRA).
and certified registered nurse anesthetists. Other health care professionals such as
MACRA is the legislation that replaced the
physical and occupational therapists,
flawed sustainable Growth Rate formula,
speech-language pathologists, audiolo-
and that accelerates the conversion of
gists, nurse midwives, clinical social work-
Part B clinician payments from a fee-for-
ers, psychologists and dietitians/nutrition-
service to a value-based payment system.
al professionals become eligible in 2019.
In this article we explain the new
There’s one exception. If 2017 is your first
approach to paying clinicians for the
year of participation in Medicare, you are
value and quality of care they provide.
not eligible for the MIPS track.
By law, Merit-based Incentive Payment System (MIPS) will be budget neutral.
Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She has helped many physicians start new practices, assess the wisdom of affiliating with a larger health care system and improve their current practices. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www.satinskyconsulting.com. appropriate to the type of care they provide. Eligible clinicians also have options regarding the speed with which they jump in to participate.
The Quality Payment Program (QPP)
MIPS
MIPS has four performance categories,
described in the final rule offers two
Under the current program, Medicare
each of which contributes to the total
paths. Option 1, the Merit-based Incentive
recognizes and measures the value and
amount of Medicare reimbursement. The
Payment System (MIPS) is the one in
quality of care by physician and other
percentages below apply to 2017, the first
which most eligible Medicare providers
providers through multiple programs.
year of the program. In subsequent years,
will initially participate. It offers a small
Examples are the Physician Quality
the relative weighting will change. In most
annual inflationary adjustment to the
Reporting System (PQRS), the Value
cases, eligible clinicians can choose to
Part B fee schedule. Option 2, Advanced
Modifier Program, and the Medical
participate as individuals or as a group
Alternative
(APMs)
Health Record (HER) Incentive Program
with a single tax ID number. Eventually,
offers payment adjustments or bonuses
(i.e. Meaningful Use). Recognizing that
but not in 2017, a group of 10 eligible
that reward both demonstration of quality
the current quality programs are both
clinicians can combine to report as a
and participation in the APM.
confusing
single group.
Payment
Models
and
time-consuming
for
providers, Congress created a single program,
Incentive
year one and a replacement of the
health care industry, CMS changed the
Payment System. MIPS consolidates a
Value Modifier Program (i.e. Resource
eligibility criteria to make the transition
variety of programs and offers eligible
Use). The score is based on Medicare
to MACRA easier, particularly for small
providers the flexibility to choose quality
claims submission and does not
practices. Physicians who bill Medicare
measures and activities that are most
require special reporting. The category
8
The Triangle Physician
the
Merit-based
1. Cost: 10 percent of the total score in
In response to suggestions made by the
Practice Management will use more than 40 episode-specific
APMs
end-stage renal disease care models,
measures to account for differences
Although most eligible clinicians will start
comprehensive primary care plus (CPC+),
among specialties.
with the MIPS option, those who take a
Medicare shared savings program (tracks
2. Quality: 60 percent of the total score
further step toward care transformation
two and three), and next generation
in year one and a replacement for
by participating to a sufficient extent in
ACO model and oncology care model
PQRS and the quality component of
Advanced Alternative Payment Models
two-sided risk arrangement (available
the Value Modifier Program. Clinicians
are exempt from the MIPS payment
in 2016). Primary care physicians can
choose and report on six measures
adjustment and will qualify for a 5 percent
also participate through medical home
that are appropriate for the specialty
Medicare Part B incentive payment.
models. CMS will update the list on an ongoing basis.
and type of practice. In 2017, there is an option to reduce and simplify the
In order to qualify for APM incentive
reporting to one quality measure or
payments, an eligible clinician must
WHAT’S NEXT?
one improvement activity.
meet participation requirements that
Here’s the timeline. Clinicians who are
3. Clinical Practice Improvement Ac-
are spelled out in the statute and that
eligible for MACRA can begin measuring
tivities: 15 percent of the total score
increase over time. At the outset, the
quality in January 2017. They must submit
in year one. Eligible clinicians are re-
participation criteria will include only
performance data by March 31, 2018.
warded for clinical practice improve-
Medicare programs. By 2019, clinicians
Changes in reimbursement based on
ment activities that focus on care co-
can qualify for incentive payments based
performance data will begin in January
ordination, engagement of Medicare
in part on participation in Advanced
2019.
beneficiaries and patient safety. They
APMs developed by private and public
can choose from more than 90 options
non-Medicare providers.
Stay tuned. CMS has already published a great deal of information on its website
and also receive credit in this category from participation in Alternative Pay-
The types of programs that currently
(www.cms.gov), and there will be more
ment Models and in Patient-Centered
qualify as APMs are: comprehensive
to come.
Medical Homes. Eligible clinicians may attest to having completed up to four medium-weighted or two high-weighted clinical practice improvement activities. Special provisions apply to 2017, the transition year. 4. Advancing Care Information: 25 percent of the total score in year one and a replacement for the Medicare EHR
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Incentive Program. Eligible clinicians will choose to report customizable measures that show how they use EHR technology in their daily operations, with a particular emphasis on interoperability and information exchange. By law, MIPS will be budget neutral. Therefore, each clinician’s MIPS score would be used to compute a positive, negative, or neutral adjustment to Medicare payments. In year one, depending on the variation in MIPS scores, both positive and negative adjustments will be calculated so that each is no more than 4 percent. The highest performers will receive additional bonuses.
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october 2016 3/15/16 2:49 PM9
Physician Advocacy
Independent Doctors’ Group Growing With 1,000 Members Coast to Coast
By Marni Jameson Carey
Three and a half years ago, 100 frustrated in-
are telling others about the association,
dependent doctors and two certified public
which is devoted to helping doctors stay in-
accountants got together in the lobby of a
dependent, and they are joining the cause.
cardiology practice in Winter Park, Fla., and formed an association to help doctors na-
In the past 10 years, hospitals have been ag-
tionwide fend off the advances of hospitals
gressively buying independent doctors and
looking to acquire them.
turning them into employed physicians. In 2000, 57 percent of the nation’s doctors
Marni Jameson Carey is the executive director of the Association of Independent Doctors. You may reach her at (407) 571-9316 or marni@aid-us.org. Visit www.aid-us.org for more information.
Since that night in April 2013, the Asso-
were independent; today only one in three
ciation of Independent Doctors has grown
are, or 33 percent, according to Accenture,
AID representatives have spoken on Capitol
rapidly and on August 25th added its 26th
a global professional services company.
Hill in Washington, D.C., four times, addressed national health care associations
member state with the addition of Ohio. In August, the association saw its biggest surge
That trend is not good for patients, doctors
and partnered with the Federal Trade Com-
of members in new states since AID began,
or communities. The founders of Asso-
mission to fight hospital consolidations and
with the addition of seven states: Michigan,
ciation of Independent Doctors recognized
has been a resource to many media outlets.
Missouri, Ohio, Pennsylvania, Tennessee,
that as the number of independent doctors
Virginia and Utah.
shrinks, unfavorable market dynamics, in-
Meanwhile, association goals have not wavered: • Fight the trend of hospitals buying up medical practices. • Educate consumers about how this consolidation increases costs and lowers quality and access. • Increase price transparency, so consumers can know what health care costs are before they get their bills. • Expose and stop nonprofit hospitals’ abuse of their tax-exempt status. • Inform lawmakers about why independent doctors are critical to America’s health. Marking another milestone, the association is hosting its first conference for indepen-
As a result, the national nonprofit now has
cluding higher health care costs and less
dent doctors, Independence in Action 2016,
1,000 members coast to coast and is in more
competition, grow.
on Nov. 5, in Orlando.
ters have been organized in four states: Flor-
In the past three years, the association has
A one-year membership in the association
ida, California, Maine and South Carolina.
landed a role on the national stage provid-
costs $500 and is tax deductible. For more
ing a collective voice for independent doc-
information about the conference or AID
tors, who before AID had little to no voice.
visit www.aid-us.org or call (407) 571-9316.
than half the country. In addition, AID chap-
Word is getting out. Independent doctors
10
The Triangle Physician
Dermatology
Medical Dermatology Matters By Dr. Eric D. Challgren
Too often primary care physicians under-
that sells potions rather than cures. It’s
utilize dermatology services. Of course,
the nine-to-five job envied by surgeons
this is partially the fault of dermatologists
approaching their 24th hour. Of course
themselves who make it nearly impossi-
there is some accuracy to these claims,
ble for someone to make a referral. Some
but there are also many inaccuracies and
dermatologists don’t accept new patients
misclassifications.
at all, or they make patients schedule their first appointment months in ad-
Medical dermatology goes a lot farther
vance. It’s a little too much to ask a pri-
than cosmetic treatment. Like any other
mary care physician to tell their patients
specialist,
to wait. At Southern Dermatology, we are
medical school, excelled in classes
committed to finding ways to see referrals
and spent countless hours studying
very quickly.
his specialty. A dermatologist sees rare
a
dermatologist
attended
skin conditions hundreds of times and
Dr. Eric Challgren graduated from North Carolina State University with a bachelor of science degree in chemical engineering. He earned his medical degree from the Medical College of Ohio and completed his dermatology internship at Medical College of Ohio and residency at the Medical College of Wisconsin. Dr. Challgren is a fellow of the American Society for Mohs Surgery and a member of the American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Academy of Dermatology, American Medical Association, North Carolina Medical Association. Areas of special interest include Mohs surgery, pediatric dermatology, dermatologic surgery, cosmetic dermatology and skin cancer.
Another explanation for why primary
as a result, has a much larger frame
care physicians underutilize dermatology
of reference. In contrast, the average
services has to do with misconceptions.
medical student gets about two hours of
To many physicians, dermatology is con-
lecture on the integumentary system, the
sidered rogue in
rest of her knowledge is supplemental.
the medical field.
She will likely only see certain rare skin
It’s a specialty
condition two or three times in her career
after I reviewed her biopsy tests, I decided
and probably fail to give a proper
to perform a chest X-ray to see if she had an enlarged mediastinum — which she
diagnosis each time.
did. It turned out she had undiagnosed There are significant overlaps
mantle cell lymphoma. We were able to
in symptoms and appearanc-
treat the lymphoma, and both the itch and
es for various skin issues,
the cancer were cured.
and with limited exposure, it can be nearly impossible
This is not to say that a general doctor
for a general practitioner to dis-
should refer every lump and bump
tinguish the one from the other. A
to a dermatologist. A well-informed
recent patient was having issues with
practitioner will be able to treat most of
a persistent itch all over her body.
the common skin issues. But the next time
Her primary care doctor had pre-
your patient is not improving, or when
scribed creams that did not help
you come across something you’re not
at all. By the time she arrived, her
sure about, rather than trying six different
skin was deeply excoriated and
lotions, refer her to a dermatologist.
october 2016
11
News
Study Shows How “Hair-of-the-Dog” Approach Works to Treat Allergies The hair-of-the-dog-that-bit-you is a time-
at Chapel Hill, pioneered a peanut allergy
honored allergy remedy for a good
approach for children that relied on rush
reason: It works. But how it works has not
desensitization principals.
exposure occurs. Once produced, these IgE antibodies collect in large numbers on the surface of
been well understood. Allergy symptoms arise from a process
mast cells. During subsequent exposures,
Now a research team led by Duke Health,
that starts in the immune system’s mast
the allergen is promptly recognized by
using mice as the models, has described
cells, which are white blood cells that
IgE, which binds to it and immobilizes
the cellular processes that occur during
harbor tiny containers called granules that
it on the mast cell. That process initiates
“rush desensitization.” The approach
are filled with chemicals involved in the
a signal that triggers expulsion of the
involves giving a small dose of the allergy
inflammatory process, such as histamines
granules from the mast cell, releasing the
trigger – peanuts or bee poison or even
and heparins.
inflammatory chemicals.
in small, yet increasing doses over a short
When a person is exposed to an allergen,
The result is allergy symptoms, such as
period.
such as pollen for the first time, the body
sneezing, wheezing, itching and swelling.
makes an antibody known as immuno-
In severe cases, when mast cells lining
“We have known for at least 100 years that
globulin E, or IgE, which is capable of
blood vessels release their inflammatory
the approach is effective,” said Soman
binding to the allergen whenever another
contents
chemotherapy – to the susceptible patient
Abraham, Ph.D., senior author of a study published online Sept. 26 in the Journal of Clinical Investigation. Dr. Abraham is professor in the departments of Pathology, Immunology,
and
Microbiology
and
Molecular Genetics at Duke University School of Medicine and professor in the Program of Emerging Infectious Diseases at Duke-National University Singapore Medical School. “People who have terrible, even life-threatening, reactions to certain antigens can then tolerate an exposure – if just for a short period of time.” Understanding how the process works could lead to new and better therapies for managing allergies to foods, dust, pollen, drugs and insect bites that cause serious and even fatal reactions for millions of people annually. Dr. Abraham and colleagues employed different experiments to track the cellular events during allergic reactions and after rush desensitization. The team included A. Wesley Burks, M.D., who, before he left Duke for the University of North Carolina
12
The Triangle Physician
throughout
the
body,
the
News When
reaction can be life threatening.
tiny
doses
of
allergen
are
Gladys Ang, a graduate student in the
administered during rush desensitization,
Department of Molecular Genetics &
It’s long been understood that rush
however, the actin are fooled into
Microbiology at Duke. “This will allow for
desensitization therapy somehow disrupts
disassembling and prematurely move to
recovery to be slower, enabling people
the mast cells through the repeated
the center of the cell. The misplacement
to be tolerant of allergens for longer
exposure of allergens over several hours
of the cellular actin, however, does not
periods.”
or days.
initiate expulsion of the granules and the inflammatory chemicals. Even with
In addition to Mr. Ang, Dr. Abraham and
Dr. Abraham and colleagues found that
repeated and escalating exposures, the
Dr. Burks, study authors include Alison M.
the disruption occurs inside the mast
cascade of events is avoided and there is
Church, Mike Kulis and Hae Woong Choi.
cells, among tiny filaments called actin
no allergic reaction. The study received funding from the
that line the inner envelop of the cell. When confronted with an allergen, the
“Having figured out the mechanism, we
National
actin break down and rush to the center of
should now be able to find new drugs
AI-068074, R01-AI-096305, R01-HL-112921).
Institutes
of
Health
(R01-
the cell, creating the conditions necessary
that can target the actin and prolong the
for the eruption of the granules.
desensitization,” said lead author W.X.
Mobile App Enhances Communication for Providers and Care for Patients “Better communication leads to better
results, communicate patient information,
implemented RapidConnect, a secure,
patient
Gintzig,
notify patient arrivals, process admissions
cloud-hosted,
desktop
WakeMed president and chief executive
and more from a smartphone. The app
faster
officer. “RapidConnect is an important
also integrates call schedules to make it
communication between hospital and
investment for us in support of our
easier for physicians to know who is on
community health care providers.
mission to improve the health and well-
call.
WakeMed
Health
application
&
mobile that
Hospitals and
allows
for
has
care,”
says
Donald
being of our community as well as our The app was implemented systemwide
commitment to innovation, our physician
For example, if a pediatrician has a
Oct. 1, after extensive testing that began
partners and our patients.”
patient with appendicitis (confirmed through imaging) that needs to come
earlier this year and generated positive feedback, according to a WakeMed Press
“RapidConnect removes the call centers
to WakeMed Children’s, the doctor can
advisory. Its broad functionality and ability
and guesswork by guiding physicians to
contact and notify the on-call WakeMed
to reduce call center volume and medical
the best person to communicate with in a
physician through RapidConnect. This
costs were well received by WakeMed
particular specialty or facility,” says Karen
direct communication with the WakeMed
physicians, community physician partners
Hohenstein, CEO and founder of MD
physician allows the patient to bypass
and pediatric subspecialists.
Interconnect, the Raleigh-based mobile
the emergency department and go
health company behind RapidConnect.
directly into the hospital for surgery,
by
“This technology helps bring together a
thus improving the patient and family
physicians for physicians and designed
patient’s care team quickly and securely,
experience and lowering medical costs.
to enhance communication in a HIPAA-
improving patient care while reducing
secure environment. Replacing outdated
costs.”
RapidConnect
was
developed
The move toward RapidConnect follows WakeMed’s 2015 implementation of the
paging systems and devices, the complete communication system features a secure,
Physicians, referring providers and health
Epic electronic health record system, a
HIPAA-compliant messaging platform for
professionals can use RapidConnect to
tool that also helps improve how patient
smartphones as well as a desktop version.
quickly reach the right provider at the
care is delivered while driving down
The result is better coordination and
right facility at the right time. Health
costs.
improved care for the patient’s benefit.
providers can coordinate consults, share
october 2016
13
News
Grant Funds Key Infrastructure Role in ECHO Study on Childhood Health The Duke Clinical Re-
procedures, monitor quality controls and
The awards will build the infrastructure and
search Institute has been
establish and maintain websites and other
capacity for the ECHO program to support
named part of a $157
communications tools.
multiple longitudinal studies that extend and expand existing studies of mothers and
million federal initiative Brian Smith, M.D., M.H.S., M.P.H.
involved in studying how
The ECHO coordinating center at DCRI
their children. ECHO research will focus on
environmental factors af-
also will include an Opportunities and
factors that may influence health outcomes
fect childhood health.
Infrastructure
around the time of birth as well as into later
Fund
to
support
pilot
projects, encourage development of junior
childhood and adolescence, including:
The grant from the National Institutes of
investigators and introduce new tools and
• Airway diseases, such as allergies and
Health (NIH) will fund the organizational
technologies in the context of the ECHO
asthma
framework of the Environmental Influences
program.
• Obesity and nutrition • Pregnancy and childbirth
on Child Health Outcomes (ECHO)
• Brain and behavioral development
initiative. The Duke Clinical Research
“We are certainly honored to be selected as
Institute (DCRI) has been awarded $14.7
the coordinating center for this important
million in fiscal year 2016. This award is a
research initiative at the NIH,” said
“Every baby should have the best
seven-year grant with a total value of $119
principal investigator Brian Smith, M.D.,
opportunity to remain healthy and thrive
million.
M.H.S., M.P.H., a Duke neonatologist and
throughout
childhood,”
NIH
Director
faculty member of the DCRI. “This builds
Francis S. Collins, M.D., Ph.D., said in an
As the coordinating center for the research
on a number of our strengths in clinical
NIH statement announcing the grants.
initiative, DCRI will provide support to
research, notably in pediatric clinical
“ECHO will help us better understand the
the study’s steering committee, lead site
research, where we have developed
factors that contribute to optimal health in
training for participating research teams,
specific expertise.”
children.”
develop common rules and standard
Oxytocin Is Linked to Spirituality research,” Van Cappellen said. “We were
The results appear online in the journal
dubbed the “love hor-
interested
Social Cognitive and Affective Neuroscience.
mone” for its role pro-
factors that may enhance those spiritual
moting social bonding,
experiences.
Oxytocin
has
been
in
understanding
biological
Patty Van Cappellen, Ph.D.
Oxytocin occurs naturally in the body. Produced by the hypothalamus, it acts as a
altruism and more. Now new research from Duke
“Oxytocin appears to be part of the way our
hormone and as a neurotransmitter, affecting
University suggests the
bodies support spiritual beliefs.”
many regions of the brain. It is stimulated during sex, childbirth and breastfeeding.
hormone may also support spirituality. Study participants were all male, and
Recent research has highlighted oxytocin’s
In the study, men reported a greater sense of
the findings apply only to men, said Dr.
role in promoting empathy, trust, social
spirituality shortly after taking oxytocin and
Van Cappellen, associate director of the
bonding and altruism.
a week later. Participants who took oxytocin
Interdisciplinary and Behavioral Research
also experienced more positive emotions
Center at Duke’s Social Science Research
To test how oxytocin might influence
during meditation, said lead author Patty
Institute. In general, oxytocin operates
spirituality, researchers administered the
Van Cappellen, Ph.D., a social psychologist
somewhat differently in men and women,
hormone to one group and a placebo to
at Duke.
Dr. Van Cappellen added. Oxytocin’s effects
another, according to a Duke press advisory.
on women’s spirituality still needs to be
Those who received oxytocin were more
investigated.
likely to say afterwards that spirituality was
“Spirituality and meditation have each been linked to health and well-being in previous
14
The Triangle Physician
important in their lives and that life has
News meaning and purpose. This was true after taking into account whether the participant reported belonging to an organized religion or not. Participants who received oxytocin also were more inclined to view themselves as interconnected with other people and living
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things, giving higher ratings to statements such as “All life is interconnected” and “There is a higher plane of consciousness or spirituality that binds all people.” Study subjects also participated in a guided
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Oxytocin did not affect all participants equally, though. Its effect on spirituality was stronger among people with a particular variant of the CD38 gene, a gene that
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regulates the release of oxytocin from hypothalamic neurons in the brain. Dr. Van Cappellen cautioned that the findings should not be over generalized, noting the many definitions of spirituality. “Spirituality is complex and affected by many factors. However, oxytocin does seem to affect how we perceive the world and what we believe.” The research was supported by grants from The National Center of Complementary and Alternative Medicine (R01 AT007884) and the National Institute of Nursing Research (R01 NR012899). R01NR012899 is supported by the National Institutes of Health Common Fund, which is managed by the National Institutes of Health Office of the Director/ Office of Strategic Coordination. Citation: “Effects of oxytocin administration on spirituality and emotional responses to meditation,” Patty Van Cappellen, Baldwin M. Way, Suzannah F. Isgett and Barbara L. Fredrickson. Social Cognitive and Affective Neuroscience, 2016. DOI: 10.1093/scan/
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The Triangle Physician
News Welcome to the Area
Physicians
Andrea Ramirez Lightle, DO Anatomic and Clinical Pathology; Pediatric Pathology
UNC Div of Nephropathology Chapel Hill
James Edward Powers, DO Emergency Medicine
216 Flint Point Lane Holly Springs
Mazen Al Mushref, MD Endocrinology, Internal Medicine
UNC Hospitals Chapel Hill
Katayoon Baradaran Ebrahimi, MD Ophthalmology
Duke Eye Institute Durham
Jillian Marie Bores, MD Emergency Medicine
UNC Hospitals Chapel Hill
Meredith Edwards Clement, MD Infectious Diseases, Internal Medicine
Duke University Hospitals Durham
Quindelyn Seante’ Cook, MD Allergy and Immunology; Diagnostic Lab; Pediatrics
UNC Hospitals Chapel Hill
Chikanele Adanna Emekauwa, MD Diagnostic Radiology
UNC Hospitals Chapel Hill
Kristina Renee Ericsson, MD Obstetrics and Gynecology
Cary
Kirk Joachim Fleischer, MD Thoracic Cardiovascular Surgery
Belmont
Eugene Friedman, MD Internal Medicine; Pulmonary Disease and Critical Care
Billy Yu-Ang Lan, MD
Neal K Viradia, MD
Abdominal Surgery; Colon and Rectal Surgery; General Surgery
Diagnostic Roentgenology Radiology; Musculoskeletal Radiology; Neuroradiology; Nuclear Radiology; Pediatric Radiology; Radiologic Physics; Therapeutic Radiology; Vascular and Interventional Radiolo
Duke Colorectal Surgery Durham
Joshua Lancaster, MD Family Medicine; Family Practice; General Practice
Adolescent Medicine; Pediatric Pulmonology; Sleep Medicine
Duke Asthma, Allergy, and Airway Center Durham
Gabriele Nicholas Morosoff, MD UNC Hospitals Chapel Hill
UNC Hospitals Chapel Hill
Hector Jesus Hidalgo, MD Diagnostic Radiology; Nuclear Cardiology; Nuclear Radiology; Neuradiology
Jonda Ward Young, MD Pediatrics
Chapel Hill
Physician Assistants
Daiva Nevidomskyte, MD Vascular Surgery
Lucas Domingo Amuchastegui, PA
Duke Health Center Durham
Cardiovascular Disease, Internal Medicine; Family Medicine; Infectious Diseases, Endocrinology, Geriatric
Jonathan David O’Donnell, MD Durham
Durham Internal Medicine Durham
Christine Lee Pao, MD
Marilyn Engelhard Caldwell Snyder, PA
Internal Medicine
Student Health; Urgent Care
Psychiatry
UNC Hospitals Chapel Hill
NC State Student Health Center Raleigh
Kristen Michelle Paral, MD
Jesslyn Patrice Doody, PA Cardiology
Anatomic and Clinical Pathology
Duke University Medical Center Durham
Duke University Hospital Durham
Michael Brandon Parrott, MD
Amanda Aydelette Futrell, PA Cardiology; Family Medicine - Adolescent Medicine, Geriatric Medicine; Family Practice
Ophthalmology
Carolina Eye Associates PA Southern Pines
Rocky Mount
Kelly Ann Green, PA
Marco Giuseppe Patti, MD Abdominal Surgery; General Surgery; Thoracic Surgery
UNC Dept. of Surgery Chapel Hill
UNC Hospitals Chapel Hill
Psychiatry
University of North Carolina Department of Pediatrics Chapel Hill
Child Psychiatry; Psychiatry
Juan Manuel Garza Jr, MD
Brandon Christopher Harsch, MD
Pediatric Infectious Diseases; Pediatrics
Jason Edward Lang, MD
Daniel James Rosenkrans, MD
Duke Medical Center Durham
Zachary Inskeep Willis, MD
Duke University Hospitals Durham
Duke University Hospitals Durham Emergency Medicine
Duke University Hospitals Durham
Young Adult Medicine; Internal Medicine; Obstetrics and Gynecology
Wake Forest
Elizabeth Grace Hartig, PA
Anesthesiology - Critical Care Medicine, Hospice and Palliative Medicine, Pain Medicine
Surgery - Surgical Critical Care
UNC Dept of Surgery Chapel Hill
Jason Michael Kaylor, PA Neurological Surgery; Orthopaedic Sports Medicine; Pain Management; Vascular Surgery
Mona Walid Shaban, MD Hospitalist; Internal Medicine
University of North Carolina Hospitals Chapel Hill
Triangle Neurosurgery, P.A. Raleigh
Paul Leo Shea, MD
Justin Ryan Lynch, PA Emergency Medicine - Sports Medicine; Orthopedic Surgery of the Hand; Trauma; Orthopedic, Ankle Foot
Critical Care Pediatrics
UNC Children’s Hospital Chapel Hill
Duke Sports Science Institute Durham
Durham Radiology Associates Raleigh
Kevin William Southerland, MD
Megan Justine Huchko, MD
Duke University Hospitals Durham
Duke Orthopedics Durham
Andrew Joshua Vincent, MD
Kirk James Williams, PA
Obstetrics and Gynecology
Duke University Durham
Rachel Marie Hughes, MD Pediatrics
Duke University Hospitals Durham
Abdominal Surgery; Surgical Critical Care; Trauma Surgery; Vascular Surgery
Diagnostic Roentgenology Radiology; Musculoskeletal Radiology; Nuclear Radiology; Pediatric Radiology; Neuradiology
Duke University Medical Center Durham
Myriam Danielle Riboh, PA Emergency Medicine
Emergency Medicine; Hospitalist; Internal Medicine Critical Care Medicine
Duke Regional Hospital Durham
october 2016
17
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