s e p t e m b e r 2 015
Southern Dermatology Skin Cancer Center & Skin Renewal Center
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
Offering Complete Dermatologic Skin Care with a Gentle Touch
Also in This Issue Patient Engagement Pituitary Adenomas
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COVER STORY
6
Southern Dermatology Skin Cancer Center & Skin Renewal Center Offering Holistic Skin Care with a Gentle Touch
septe m b e r 2 0 15
FEATURES
10
V o l . 6 , I ss u e 8
DEPARTMENTS 9 Gastroenterology
Practice Management
Functional Vomiting Syndromes
12 Physician Advocacy
10 Best Practices for Independence
16 Physician Spotlight
George Stamataros, D.O., F.A.C.E., of Carolina
Endocrine
Use a Patient Portal to Enhance Patient Engagement
17 Physician Spotlight
Margie Satinsky offers insight into strategies for
19 Duke Research News
self care that features easy, secure, two-way engagement.
Carly E. Kelley, M.D., M.P.H., of Carolina Endocrine Study Links Success in Adulthood to Childhood
Psychiatric Health
20 Duke Research News
Even Moderate Picky Eating Can Have Negative
Effects on Childrenâ&#x20AC;&#x2122;s Health
14
21 UNC Research News Endocrinology
Understanding the Hyperprolactinemia Dr. Michael Thomas describes prolactin-producing tumors, the most common hormoneproducing pituitary adenomas.
2
Innovative Gene Transfer-based Treatment
Approach Brings Hope
The Triangle Physician
22 UNC Research News
Smart Insulin Patch Could Replace Painful
Injections for Diabetes
24 News
Innovative Mobile Program Helps Women Reduce Stress, Achieve Balance
25 Rex News
Partnership with Wake to Expand Care for Senior Patients in New Facility
On the Cover: Meet the Southern Dermatology medical staff . They are (from left): Gregory J. Wilmoth, M.D.; Margaret B. Boyse, M.D.; Laura D. Briley, M.D.; physician assistant Tracey S. Cloninger, P.A.-C.; and Eric D. Challgren, M.D.
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From the Editor
Mirror, Mirror This month’s cover story is a complimentary reflection of Southern Dermatology-Skin Cancer Center & Skin Renewal Center. Here, four board-certified dermatologists serve the Raleigh-Durham region with their advanced, compassionate care – pediatric, general, surgical and rejuvenative – for skin, hair and nail conditions. A comprehensive range of services – diagnosis, treatment, including Mohs micrographic surgery, and follow up – is provided within one state-of-the-art practice. Mohs micrographic surgery is the treatment of choice for primary skin malignancies that are recurrent and aggressive. At Southern Dermatology, specialized expertise has the benefit of boosting the confidence of patients whose condition is located on sensitive areas of the body, the face and hands being among the most visible. This month’s contributing editors also give readers a look at their specialized expertise. Endocrinologist Michael Thomas outlines the characteristics and treatment of hyperprolactinemia, which can alleviate cosmetic concerns, preserve premenopausal status and limit the growth, or decrease the size, of a pituitary mass. Gastroenterologist Douglas Drossman delves into the characteristics of vomiting syndromes with the start of a two-part series, the first part on functional vomiting. Two articles – one by physician advocate Marni Jameson, the other by practice management consultant Margie Satinsky – offer advice for serious consideration. Ms. Jameson shares tips for succeeding as an independent practice. Ms. Satinsky discusses the use of the patient portal for increasing involvement in one’s health care. The Triangle Physician is distributed to more than 9,000 professionals within the Raleigh-Durham medical community, making it a cost-effective vehicle for first impressions and renewing or adjusting existing reputations. There is no cost to run your medical news and insight, space permitting. The cost to be featured on the cover and to advertise is competitive. For more information and to reserve space please contact us at info@ trianglephysician.com. Here’s to seeing you, your partners or your practice in issues ahead! With gratitude and respect,
Heidi Ketler Editor 4
The Triangle Physician
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 Douglas A. Drossman, M.D. Marni Jameson Margie Satinsky, M.B.A. Michael J. Thomas, M.D., Ph.D. 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.
Cover Story
Southern Dermatology Skin Cancer Center & Skin Renewal Center
Offering Holistic Skin Care with a Gentle Touch When it comes to a patient’s skin, Southern
and reconstruction and cosmetic services
Innovation in Skin Cancer Care
Dermatology offers a turnkey, modern ap-
are all available in one facility!
Southern Dermatology offers comprehensive skin cancer screenings and, for those
proach to care, from general dermatology and skin cancer treatment to pediatric der-
“We are able to diagnose, treat and follow
who have a confirmed skin cancer diagno-
matology and skin rejuvenation services.
up on any disease of the skin, hair and
sis, a range of treatment options including
nails,” says Gregory J. Wilmoth, M.D. “For
Mohs micrographic surgery.
Referred patients can be seen in a matter
patients who have psoriasis, we offer mul-
of days, and sometimes hours if needed,
tiple therapies, including light, laser, bio-
Mohs micrographic surgery is the treat-
and communication with referring physi-
logic and systemic. For patients with skin
ment of choice for primary skin malignan-
cians through detailed consultation re-
allergies, we can perform patch tests and
cies that are recurrent and have aggres-
ports is a priority. Southern Dermatology’s
full treatments in-house. No matter what
sive features or ill-defined margins. These
board-certified and experienced providers
the problem, from a newborn’s birth defect
include basal cell carcinoma (BCC) and
offer a holistic approach to skin care. In
or a child’s acne, to a mom’s aging skin or
squamous cell carcinoma (SCC). Skin tu-
addition to general adult and pediatric der-
a cancerous skin tumor, we can handle
mors in areas that are at high risk for re-
matology, evaluation and biopsy, surgery
treatment from start to finish.”
currence and deep excision, often the ear and hand, should be treated with Mohs Surgery. “We offer complete patient care for dermatology and cutaneous oncology. Patients don’t have to go to four different offices to get through the entire process, from screening and treatment planning to surgery, reconstruction and follow-up care,” says Dr. Wilmoth. “For more advanced cancers, we coordinate care with colleagues in surgical oncology and radiation oncology.” The cure rate for Mohs micrographic surgery is the highest of all skin cancer treatments. It minimizes the chance of re-growth and lessens the potential for scarring. Both Dr. Wilmoth and Southern Dermatology partner Eric D. Challgren, M.D., have been
Dr. Briley discussing the importance of regular skin exams.
6
The Triangle Physician
trained in this highly specialized cancer
treatment, and both are fellows with the American Society for Mohs Surgery. They perform the surgery on an outpatient basis under local anesthesia, making it safe and cost-effective. “In many studies, Mohs micrographic surgery is superior to standard excision and any other treatment modality for skin cancer. Five-year recurrence rates can be as low as 1 percent for basal cell carcinomas and 3-5 percent for squamous cell carcinomas,” says Dr. Challgren. Drs. Wilmoth and Challgren are joined by board-certified dermatologists Margaret B. Boyse, M.D., and Laura D. Briley, M.D., and physician assistant Tracey S. Cloninger, P.A.-C., to deliver a complete range of dermatologic services, including general dermatology, pediatric dermatology, dermatologic surgery and skin rejuvenation services. General Dermatology
Dr. Boyse delivering cosmetic laser treatment to aging skin.
Whether patients need an annual skin check or have a very rare skin condition,
ment of various types of acute and chronic
the physicians and staff at Southern Der-
skin disorders and cutaneous manifesta-
matology offer diagnosis and treatment
tions of internal disease.
the proper use of skincare products. Overseen by the Southern Dermatology physicians, the licensed aesthetic profes-
for all adult skin, hair and nail problems, The goal is to be sure parents understand
sionals at The Skin Renewal Center at
• Adult acne
their child’s skin condition and how to
Southern Dermatology can help keep skin
• Psoriasis
manage it.
looking fresh and vibrant with such tech-
including:
niques as Fraxel®, Clear + Brilliant®, Ther-
• Eczema Services include:
mage® and chemical peels, all of which
• Rashes
• Cradle cap
smooth out the skin and release healthier
• Moles
• Eczema
skin layers. Each patient is assured the
• Skin tags
• Warts
most advanced techniques and medical
• Warts
• Head lice
equipment for skin rejuvenation, laser hair
• Hair loss
• Hives
removal and body aesthetics, like Cool-
• Skin discoloration
• Poison ivy
Sculpting®.
• Nail and hair disorders
• Impetigo
• Sunburns/sun damage
• Newborn rashes
To ensure the utmost care, the Southern
• Fatty tumor removal
• Sunburns
Dermatology providers perform all Botox®
• Benign cyst removal
• Adolescent acne
cosmetic and filler treatments – such as Ju-
• Diaper rashes
vederm® Voluma® XC and Juvederm®
• Rosacea
Pediatric Dermatology
Ultra XC, Restylane® Silk and Radiesse®
Southern Dermatology’s providers are
Skin Renewal and Rejuvenation
– and the physicians take an active role
dedicated to improving the care of infants,
Youthful, healthy looking skin free of
in the development and supervision of all
children and adolescents with comprehen-
wrinkles and blemishes can be achieved
cosmetic services.
sive, state-of-the-art evaluation and treat-
through skin rejuvenation procedures and
september 2015
7
thoughtful and respectful approach. I want their experience with me to be personal, not a cold ‘doctor’s appointment.’ I address concerns in an efficient and ethical way using modern techniques, and I treat each patient as if they are part of my family.” Dr. Margaret B. Boyse Specialties: Cosmetic Dermatology, General Adult and Pediatric Dermatology, Dermatologic Surgery and Skin Cancer “I take a conservative, affordable, holistic approach to determine if the simple solution is best or if we need to apply more advanced technologies to treatment. I enjoy educating patients about prevention, building long-term relationships through excellent customer care and being a part of their lives through my medical practice.” Dr. Laura D. Briley Specialties: General Adult and
Tracey Cloninger, PA-C examines patient for irregular moles.
Pediatric
Dermatol-
ogy, Dermatologic Surgery, Cosmetic Dermatology and
Meet the Providers
Skin Cancer Dr. Gregory J. Wilmoth Specialties: Dermatologic
“I am committed to help-
Surgery,
Surgery,
ing my patients make good
Skin Cancer Reconstruc-
choices everyday through-
tion, Laser Surgery and
out their lives to preserve, protect and enhance the health and ap-
General Dermatology
pearance of their skin. I enjoy helping my patients achieve their
Mohs
goals in terms of their skin’s health.” “When treating skin cancer, important decisions need to be made regarding surgery or other therapy. I am committed to giving patients all the facts, so together we can choose the right care that makes the most sense for them.”
Physician Assistant Tracey S. Cloninger “My passion is to help young patients make good lifestyle choices, so their healthy skin lasts a lifetime.
Dr. Eric D. Challgren
As the Physician Assistant,
Specialties: Mohs Surgery,
I collaborate with the phy-
Pediatric
Dermatology,
sicians who are always
Dermatologic Surgery, Cos-
available to discuss the dif-
metic Dermatology and
ficult cases.”
Skin Cancer “Skin issues affect each person differently, so I customize treatment with a
8
The Triangle Physician
www.southernderm.com Southern Dermatology & Skin Cancer Center - 919-782-2152 The Skin Renewal Center at Southern Dermatology - 919-863-0073
Gastroenterology
Functional Vomiting Syndromes By Douglas Drossman, M.D.
This begins a two-part series on vomiting
•C omplete metabolic panel
syndromes.
• L ipase • I maging: flat plate of the abdomen, abdom-
Vomiting as an occasional symptom is an
inal ultrasound, computed tomography,
adaptive physiological process by which
magnetic resonance imaging or endos-
the body seeks to rid itself of offending
copy, depending on the clinical situation.
substances that have been ingested. It also may occur in the setting of an acute illness,
When the vomiting occurs recurrently and
such as a gastroenterentitis, or as part of a
seemingly without clear recognition of
more chronic condition, such as a bowel
cause, a variety of functional gastrointesti-
obstruction. Because of neurological links
nal (GI) syndromes are to be considered,
to emotional centers, vomiting can occur
including functional vomiting, gastroparesis
during intense emotional distress.
and cyclic vomiting syndrome.
The differential diagnosis of recurrent vom-
Today we will discuss functional vomiting.
iting can include endocrine or metabolic
Functional vomiting, as defined by the
disorders (pregnancy, diabetes and hyper-
Rome III criteria, is described below.
thyroidism); infections (both gastrointestinal and systemic, nongastrointestinal); bowel
The following criteria must be fulfilled for
obstruction, including Crohn’s disease and
the last three months with symptom onset
other sources; central nervous system dis-
at least six months prior to diagnosis:
orders (migraine and increased intracranial
1) On average one or more episodes of
pressure); seizure disorders; psychiatric dis-
vomiting per week.
orders; or medication reactions.
2) Absence of criteria for an eating disorder, rumination or major psychiatric dis-
Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation. org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www.drossmancenter. com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patient-provider relationship. Drossman Gastroenterology P.L.L.C. (www.drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.
The diagnostic evaluation includes taking a
ease, according to Diagnostic and Statisti-
careful medical history seeking to identify
cal Manual of Mental Disorders, 4th Edition,
the potential structural or metabolic causes
Text Revision.
walking into the hospital where he or she
as noted above. One should identify the
3) Absence of self-induced vomiting and
received chemotherapy).
circumstances of the vomiting, i.e., after
chronic cannabinoid use and absence of
a meal (and how long after a meal) and
abnormalities of the central nervous system
Often these are associated with anxiety-
during emotional distress; whether there
or metabolic diseases to explain the recur-
inducing conditions though the circum-
are other symptoms, including abdominal
rent vomiting
stances may not be apparent to the patient
pain, fever and nausea; and if so which symptoms occurred first.
or health care provider. Generally patients Functional vomiting is often considered a
with functional vomiting do not lose weight,
behavioral, stress-induced conditioning re-
unless the vomiting occurs so frequently as
A physical examination should evaluate for
sponse, though the stressor may be unrec-
to impair nutritional intake. In these rare sit-
signs of dehydration, weight loss or muscle
ognized and possibly encoded from earlier
uations, dehydration and metabolic imbal-
wasting and abnormal physical features,
experiences. Examples include being in sit-
ance may occur. Routine diagnostic studies
such as an abdominal mass. Routine stud-
uations (by visual or emotional cues) that
are negative except for any metabolic con-
ies would include:
remind the individual of an earlier noxious
sequences of the vomiting.
• Complete blood count (CBC)
experience (e.g., childhood abuse, smell-
• Sedimentation rate or C-reactive protein
ing a noxious substance previously experi-
In Part 2 of this series, I will discuss gastro-
enced and conditioned, such as a patient
paresis and cyclic vomiting syndrome.
(CRP)
september 2015
9
Practice Management
Use a Patient Portal to Enhance Patient Engagement By Margie Satinsky, M.B.A.
Patient engagement is a hot topic in
from her medical records, including test
following up with patients who have had a
the health care industry. In this article,
results, into a single place – her patient re-
procedure performed in the office.
we’ll explore its meaning and share our
cord. When Patient A visits her physician,
thoughts on the patient portal, an impor-
she’s armed with knowledge and eager to
Other practices take a hands-off attitude.
tant, although not the only, solution for
receive information. She’s engaged!
They don’t embrace the concept of patient engagement at all, nor do they care about
involving patients in their health and the care they receive.
Patient B takes a different approach. Right
the financial incentive (or penalty) that
now she’s overwhelmed with family re-
might apply to them under the Meaningful
Patient Engagement:
sponsibilities. She can barely manage her
Use program if they provide care to Medi-
What It Is and Why It’s Important
growing family of four young children and
care or Medicaid patients.
A growing body of evidence demonstrates
ailing parents, let alone concentrate on
that patients who are actively involved
her own health and health information.
Patient Portals: One Way to
in their own health and in the care they
She doesn’t remember much about her
Enhance Patient Engagement
receive have better outcomes and lower
health history and health care. When she
One of the most effective tools for enhanc-
costs than those who are uninvolved. In
takes time for a visit to her physician, she
ing patient engagement is a patient portal
response to this evidence, both public
wants a quick and inexpensive fix. She’s
– i.e. a secure online doorway into your
and private health care organizations are
focused on a fast exit so she can pick up
practice that enables both your practice
developing strategies to better engage pa-
her children at school. She doesn’t have
and your patients to communicate with
tients. Examples of patient engagement
the time or the interest in an extensive dis-
each other in a secure manner.
are educating patients about their condi-
cussion about stress reduction or generic
tions and fully involving them in decisions
drugs. She’s not engaged nor is she likely
Think of the airlines. Most people routinely
about their care.
to be without a concerted effort on her
use their portals in order to book and pay
provider’s part.
for airline tickets, to check in and to obtain information on upcoming travel. The con-
If patient engagement makes such good sense and can bring desired results,
Just as patients vary, so do medical prac-
cept is similar to that of a patient portal;
what’s the challenge? We’ve observed two
tices and their clinical and administrative
we sign in securely with a user name and
obstacles, one on the patient side and the
staff. Patient engagement doesn’t just hap-
password.
second on the provider side.
pen; it requires a planned strategy and positive intervention on the provider side.
Let’s examine how a patient portal can benefit your practice and your patients,
On the patient side, patients vary in their
how it works and where you can get it.
knowledge, skills, cognitive ability and
Some practices, providers and staff are
willingness to manage their own care.
strongly committed to communicating
Here’s an example:
with patients and families, before, during
A patient portal can enhance patient en-
and after a visit or procedure. These types
gagement by creating an easy and secure
Patient A takes great pride in her lifestyle,
of practices might set up a user-friendly
two-way communication. A portal also
making sure to exercise moderately and
website with a patient portal that not only
can enhance administrative efficiency in a
eat healthfully. She maintains a list of her
allows, but encourages, patients to com-
medical practice by reducing the number
medical conditions and current medica-
municate with the practice. They might de-
of incoming and outgoing telephone calls
tion in her wallet, so she can make it avail-
velop specific strategies for enhancing pa-
and faxes. Although not all portals have
able to her providers when asked for infor-
tient education and for encouraging patient
exactly the same features, here are the
mation. Just recently, she downloaded an
compliance with recommended treatment
most common ones:
app for her phone that pulls information
plans. They might implement a system for
• Exchange secure email with the health
10
The Triangle Physician
Practice Management Margie Satinsky, MBA, is President of Satinsky Consulting, LLC, a Durham, NC consulting firm that specializes in medical practice management. She’s provided HIPAA compliance consultation to more than 100 Covered Entities and Business Associates. 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. care team • Receive appointment reminders • Request prescription refills • Request (and sometimes schedule) non-urgent appointments • Check benefits and coverage • Update contact information • Download intake forms for patient demographic information and medical
an interface. In most cases, the vendor that
other software that you have or are
provides the PMS and EHR software builds
considering purchasing?
the interface.
• If you are purchasing a freestanding portal, does it already have an interface
If you’re interested in exploring options for
with the software solutions that you have
patient portals, here are the questions to
in your practice or must the interface
ask of both your own practice and the ven-
be built? If an interface must be built, is
dors that offer them:
your software vendor willing to pay for
• What are your goals with respect to patient engagement and do the features
the connection? • Is the contract acceptable to you?
of the patient portal software meet your
(Review language, term, price and exit
needs?
clause.)
• How will you promote your patient portal both within your practice and
Just setting up a patient portal doesn’t mean
with patients/families?
it will help your practice enhance patient
• Are you able to customize different fea-
engagement. Your entire practice must em-
tures of the portal to suit your practice?
brace and promote it, both internally and
• What are the vendor’s plans for future enhancements to the portal?
with patients. Regardless of what you do to promote the portal, there will always be pa-
• What training will you receive and at what cost?
tients who don’t use it. Respect their decision and encourage patient engagement in
• Following implementation, what type of
a positive but non-electronic way.
technical assistance is available? • Will you have a “go-to” person to whom you can direct questions? • How will the patient portal relate to
history • View test results • View patient balance and pay bills online • Obtain visit summary information • Obtain patient education materials recommended by the practice There are multiple ways to create a portal and link it to a practice website. Many, but not all, software vendors that offer practice management system (PMS) and electronic health record (EHR) solutions now offer a patient portal feature at minimal or no cost. You can also purchase a patient portal directly from a company that specializes in portals. For example, Medfusion in Raleigh offers a patient portal that is highly rated by the national rating service KLAS, and it’s been described as “agnostic.” The Medfusion portal can stand on its own or connect with other software applications through
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september 2015
11
Physician Advocacy
10 Best Practices for Independence By Marni Jameson
The pressure on independent doctors to
tiative to get out into the community to
join a hospital can be great, especially if
create a strong positive presence. Give
they’re not well insulated against acquisi-
health talks on your area of expertise.
tion. The more vulnerable providers feel,
Support a local sports team. Make your-
the more likely they are to succumb to
self available to the media.
that pressure. 3. Shore up your referral base. Yet, if you ask most doctors, most will say
Know where your patients come from
they would rather work for themselves
and reach out to your referral sources, in-
not for the hospital. As one practice man-
cluding other physicians, therapists and
ager put it, when I asked why the doctor
employers. Don’t just send a fruit basket.
she worked with was so staunchly inde-
Go out and talk to them. Business, includ-
pendent: “Because he gets to run the
ing the business of medicine, is still about
practice the way he wants want to run it,
relationships.
and he doesn’t have to ask anyone’s per-
Marni Jameson is the executive director of the Association of Independent Doctors. She will speak at the MGMA (Medical Group Management Association) 2015 Annual Conference in Nashville, Tenn., on “Fighting For Independence: How to Help Independent Doctors Stay That Way and Seven Reasons They Should” on Tuesday, Oct. 13, from 1:15-2:15 p.m. She can be reached at marni@aid-us.org.
6. Make the patient experience 4. Look for alternatives to
over the top.
the hospital.
Patients are still your best referral source.
Not every doctor is so fortunate. To have
One Central Florida practice took advan-
If your patient has a good (or bad) experi-
the luxury of being your own boss and
tage of office space becoming available
ence, he or she will likely tell five people.
practicing medicine the way you – not a
next door. They took over the space and
Train your team to make patients feel like
group of hospital administrators – want to
turned it into a procedure room, where
they’re first and not just the next patient
takes savvy practice management.
they now perform services they used to
in line. Also strive to make the patient’s
do in the hospital. The practice now re-
visit as efficient as possible from check in
Recently, I invited several administrators
ceives the technical fee that would have
to check out. If the doctor is running be-
of thriving independent practices to meet
gone to the hospital. The technical fee
hind, tell the patient how much longer it
with me and share their inside tips on
helps boost practice revenue, and also
will be. Don’t keep the patient in the dark.
how they helped their doctors stay suc-
helps patients, since the fee to the inde-
cessfully independent. Here are some of
pendent practice is less than the fee to
And lose the phone tree. One practice ad-
their best practices:
the hospital for the same procedure.
ministrator said, her patients appreciate
1. Stay positive.
5. Don’t say “yes” to the
a recording. A live human being answers
They practice managers agreed, attitude is
first contract.
the phone during business hours.
everything. It’s easy to get discouraged, but
When working with insurance compa-
believing you will survive is half the battle.
nies, don’t take the first offer they give
7. Educate your patients.
you. Sell them on your practice. Let them
Unfortunately, most consumers don’t un-
2. Keep your community
know what differentiates you, your qual-
derstand the differences between an in-
presence strong.
ity measures and patient satisfaction
dependent doctor and a hospital-based
Hospitals promote their employed doc-
scores and what your practice is worth to
practice. They don’t know that seeing an
tors into the community often through
them. Then negotiate for more, because
independent doctor will save them hun-
media outreach and community educa-
ultimately your practice’s success rides
dreds, if not thousands, of dollars. Those
tion. Non-employee physicians rarely get
on reimbursements.
who do understand have trouble know-
mission to take a day off.”
never calling into a phone tree or getting
that support, so they need to take the ini-
12
The Triangle Physician
ing which practices are independent.
Physician Advocacy To help educate them, many members
sources with a fax form. They fax you a re-
could make up for it and then follow up.
of the Association of Independent Doc-
ferral before the patient leaves their office
Nip dissatisfaction before patients let out
tors display signs in their lobby stating
and within a few hours, your office has
their frustrations online. Some practices
that their practice is “A proud member
called that patient, scheduled an appoint-
hire a reputation management consultant
of the Association of Independent Doc-
ment and reported back to the referring
to manage their social media. When a
tors.” Some providers go further and give
provider, assuring that his or her patient
doctor goes down a star, the consultant
patients a letter in new patient packets
is getting prompt attention.
finds out why and works to get his or her reputation back up.
explaining why that matters. 9. Be sure your stars align. Here’s an excerpt from one:
Love them or hate them, star ratings on
10. Connect with other
“We would like to reassure our patients
sights, such as Health Grades, and on
independent doctors.
that we have not been acquired, nor do
various insurance company websites
Camaraderie among independent prac-
we have any intention of being acquired,
hold enormous sway with patients, many
tice managers and providers is critical to
by a hospital system. When a physician’s
of whom get their information from the
insulating practices from being acquired.
practice is bought by a hospital system
Internet. Even if these scores are based
So is joining an organization like the As-
the costs to patients increase signifi-
on a small, random sampling, where one
sociation of Independent Doctors (www.
cantly…. This results in higher expenses
disgruntled patient can have an outsized
aid-us.org), a national nonprofit with
to Medicare, private insurers and, most
impact, they count.
members coast to coast that gives independent doctors a voice. When indepen-
importantly, individual patients…. As an independent practice…the only partner-
To keep your star rating high, survey pa-
dent doctors don’t feel isolated and feel
ship we seek is with our patients.”
tients as they check out. Ask how their
they’re part of a greater whole, they can
visit was and whether you can do any-
practice better medicine with greater
8. Make it easy to refer.
thing to improve. If they express a con-
confidence.
To streamline referrals, provide referral
cern, ask what went wrong and how you
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
september 2015
13
Endocrinology
Understanding the Hyperprolactinemia By Michael J. Thomas, M.D., Ph.D.
Prolactin is a polypeptide hormone from
Diagnosis
the anterior pituitary gland that is under
Prolactin-producing tumors are the most
inhibitory control by dopamine. Like
common hormone-producing tumors of
most pituitary hormones, prolactin is
the pituitary gland, accounting for 30-40
secreted in a pulsatile manner. The sole
percent of all functional pituitary adeno-
function of prolactin appears to be the
mas.
promotion of lactation during the postpartum period.
The upper range of normal for prolactin in most laboratories is 20 ng/mL. If a patient
Premenopausal women with hyperprolac-
has a mildly elevated prolactin level, a re-
tinemia may present with infertility or oli-
peat measurement should be considered,
gomenorrhea/amenorrhea; approximate-
as the level may have been elevated due to
ly two-thirds of women have galactorrhea.
the pulsatile nature of the hormone.
Hyperprolactinemia in post-menopausal women may go unrecognized, due to the
Pregnancy should be ruled out prior to
absence of a menstrual cycle. Men with
any additional workup. The rise in prolac-
hyperprolactinemia present with testos-
tin associated with pregnancy is likely due
terone deficiency, low libido or gyneco-
to elevations in serum estradiol concentra-
mastia, but galactorrhea is uncommon,
tions. The nipple stimulation that occurs
due to the paucity of glandular breast
with breastfeeding also causes hyperpro-
tissue.
lactinemia via a neural pathway.
There are many possible etiologies of hy-
A diagnosis of hypothyroidism should be
perprolactinemia (see Table 1).
considered and ruled out via a thyroid-
Dr. Michael Thomas graduated from the School of Medicine at West Virginia University in Morgantown, with medical and doctorate degrees in pharmacology and toxicology. He completed post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency and fellowship in endocrinology. Dr. Thomas established Carolina Endocrine, P.A., in the summer of 2005. He was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. Dr. Thomas is board certified in internal medicine and endocrinology and is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology and has completed Endocrine Certification in Neck Ultrasound.
stimulating hormone (TSH) measurement. Table 1
Although the mechanism is unknown,
The patient should be questioned about
Causes of Hyperprolactinemia
hypothalamic synthesis of thyrotropin-
a history of chest wall injury or surgery,
releasing hormone (TRH) and pituitary re-
as hyperprolactinemia can result via the
sponsiveness to TRH has been described.
same neural pathway stimulated during
•P ituitary Adenoma
breastfeeding.
Microprolactinoma (<1 cm)
Patient medications should be reviewed,
Macroprolactinoma (>1 cm)
as there are several that have the potential
If a prolactin level is persistently elevated
• I diopathic
to cause hyperprolactinemia. Dopamine
and other possible causes of hyperprolac-
•P regnancy
receptor antagonists raise serum prolac-
tinemia have been ruled out, a pituitary
tin by that mechanism. These medica-
magnetic resonance imaging scan should
tions include antipsychotics (i.e. risperi-
be obtained to assess for the presence of a
done, haloperidol) and antihypertensives
pituitary tumor.
•M edications • “ Stalk Effect” (impingement on pituitary stalk)
(i.e. methyldopa, reserpine). Verapamil
•H ypothyroidism
may also cause elevations in prolactin,
Pituitary tumors less than 1 centimeter
•C hest Wall Trauma
although the mechanism of action is un-
are considered microadenomas, and
known.
those greater than 1 centimeter are mac-
14
The Triangle Physician
Endocrinology roadenomas. Some microadenomas are
If the adenoma remains visualized on MRI
too small to be visualized on pituitary
or the prolactin remains elevated during
MRI. Those with large pituitary tumors
treatment, the dopamine agonist should
may experience headaches or visual
not be discontinued. Transphenoidal pitu-
impairment and should undergo formal
itary tumor resection may need to be con-
visual-field testing.
sidered, if dopamine agonists are unsuccessful in decreasing prolactin levels or
Patients with persistently elevated prolac-
the size of an adenoma and signs or symp-
tin levels and negative MRIs who do not
toms persist. In addition, women with an
have any other identifiable cause of hy-
adenoma greater than 3 centimeters who
perprolactinemia should still be treated
desire pregnancy should consider sur-
medically.
gery, as the tumor may enlarge.
2015 Editorial Calendar October Cancer in Women, Dermatology, Wound Management, November Urology, ADHD, Austism December Sports Medicine, Otorhinolaryngology Pain Management
Treatment It is important to treat patients with hyperprolactinemia to alleviate any cosmetic concerns (i.e. breast discharge), preserve premenopausal status and limit the growth or decrease the size of a pituitary mass. Patients with hyperprolactinemia are often treated with a dopamine agonist (i.e. cabergoline or dopamine). These medications not only decrease prolactin production but may stabilize and sometimes decrease the size of a prolactinoma. Cabergoline is typically administered once or twice weekly and tends to have fewer side effects (i.e. less nausea, orthostatic hypotension) than bromocriptine, which is typically administered daily. Prolactin levels tend to fall within the first few weeks of treatment, and prolactin level should be remeasured after approximately four to six weeks of therapy. In patients with a pituitary adenoma visualized on MRI, a repeat imaging study should be performed after six to 12 months. Dopamine agonists should be taken until a woman becomes pregnant. If prolactin levels are normal for one to two years and no adenoma is visualized on MRI, discontinuation of the medication can be considered. However, the patient should be monitored for return of the hyperprolactinemia and/or recurrence of the prolactinoma. Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
september 2015
15
physician spotlight
Women’s Wellness
George
Stamataros C urrent practice: Carolina Endocrine C redentials: D.O., F.A.C.E. U ndergraduate degree: B.A. Biological Sciences, Rutgers University
o you have a personal hero or mentor: D My father – he came to this country a poor man, and he made something of himself. our advice to aspiring physicians: Y Treat your patient like a person, not a disease. hat word describes you? W Patient hat’s your extracurricular passion? W Cooking with my beloved and soccer hat’s your favorite restaurant? W Bida Manda What’s your favorite getaway?
M edical degree: Doctor of Osteopathic Medicine, Robert Wood Johnson Medical School
ell us something surprising about yourself, your T practice or your medical specialty: People are usually surprised to find out that I’m not as serious as I look. I definitely have a side that loves to laugh.
R esidency: Internal medicine, Robert Wood Johnson Medical School
arried: M Yes
F ellowship: Endocrinology, Robert Wood Johnson Medical School
hildren: C None yet
physician spotlight
Women’s Wellness
Carly E.
Kelley C urrent practice: Carolina Endocrine
C redentials: Credentials: M.D., M.P.H. U ndergraduate degree: B.S., Biology, College of William & Mary M edical degrees and others: M.D., University of Medicine and Dentistry-New Jersey Medical School (Rutgers University) M.P.H., University of Medicine and Dentistry School of Public Health (Rutgers University) R esidency: Duke University-Internal Medicine
ellowship: F Duke University-Endocrinology pecial medical interests: S General Endocrinology, Polycystic Ovary Syndrome, Women’s Health, Thyroid Disease, Pituitary Disease, Lipids our advice to aspiring physicians: Y − Find mentors who will help guide you along the way. You will likely have more than one mentor for various aspects of your career and life. I have had many mentors (clinical, research, life, etc.) who have provided me with invaluable advice and support throughout my training. −D o not shy away from constructive criticism. Learn from your experiences and turn your weaknesses into strengths. This attitude has helped me improve my skills to become a better physician and a lifelong learner. −K eep your eyes on the goal while also enjoying the ride! o you have a personal hero or mentor? D As previously mentioned, I have had multiple influential mentors throughout my training and even prior to medical school. These mentors have all been physicians who
have role modeled the type of physician I strive to be. Some qualities that stand out are: a warm and kind bedside manner, collegiality with coworkers, outstanding knowledge of evidence-based medicine and a solid balance between work and home life. W hat word describes you? Attentive W hat’s your extracurricular passion? My greatest passion is spending quality time with my children and family. I love taking my children to the museum, pool, playground or dance on the weekends. We also frequently try to take trips to Virginia Beach or New Jersey to visit with grandparents and the rest of our family. My other interests include fitness and photography. I try to keep healthy and active by cycling and running, and I love taking pictures for photo albums or scrapbooks; my children are my favorite subjects. W hat’s your favorite restaurant? Parker and Otis or the Weaver Street Market for breakfast or lunch. Bocci or Nantucket Grill, because my daughter can run around outside and play during dinner.
California Pizza Kitchen for their salads. Menchies for frozen yogurt. What’s your favorite getaway? Hawaii. I went there on my honeymoon and can’t wait to go back one day!
physician spotlight
Physician Spotlight
Tell us something surprising about yourself, your practice or your medical specialty. While at UMDNJ, I worked on a research study with the School of Public Health and the New Jersey Department of Health and Senior Services to survey all the hospitals in New Jersey providing obstetric services on their policies and procedures regarding rapid HIV testing for pregnant women in labor and delivery. Our findings led to a change in the law regarding the consent policy for testing these women: An opt-in consent approach became opt-out. It was very exciting for me to take part in research that made a significant impact on public health. Married: Yes
Children: Yes. Daughter is three years old, and son is six months old.
Spend Time c Your Patients, Not Battling IT. Get HIPAA Compliant Solutions
Let’s Talk Tech! Call (919) 296-1089 SAMIT-Medical.com 18
The Triangle Physician
Duke Research News
Study Links Success in Adulthood to Childhood Psychiatric Health Children with even mild or passing bouts
behavioral disorder in childhood; 31 percent
tors as kids, 41.9 percent had at least one of
of depression, anxiety and/or behavioral
had milder forms that were below the full
the problems in adulthood that complicates
issues were more inclined to have serious
threshold of a diagnosis; and 42.7 percent
success, and 23.2 percent had more than
problems that complicated their ability to
had no identified problems.
one such issue. For those who met the full psychiatric diagnosis criteria, 59.5 percent
lead successful lives as adults, according to research from Duke Medicine.
The researchers found that as these children
had a serious challenge as adults, and 34.2
grew into adults, even some of those who
percent had multiple problems.
Reporting in the July 15 issue of JAMA Psy-
had no psychiatric diagnosis as children –
chiatry, the Duke researchers found that chil-
nearly one in five – stumbled in adulthood,
Dr. Copeland said specific psychiatric dis-
dren who had either a diagnosed psychiatric
suggesting that difficulties were not limited
orders were associated with specific adult
condition or a milder form that didn’t meet
to those with psychiatric diagnoses.
problems, but the best predictor of having adult issues was having multiple psychiatric
the full diagnostic criteria were six times
problems as kids.
more likely than those who had no psychi-
But having a psychiatric diagnosis or a close
atric issues to have difficulties in adulthood,
call dramatically raised the odds that adult-
including criminal charges, addictions, early
hood would have rough patches. This was
“When we went into this, it was an open ques-
pregnancies, education failures, residential
the case, even if those in the study group did
tion: Are these psychiatric diagnoses in child-
instability and problems getting or keeping
not continue to have psychiatric problems in
hood impairing in the moment, but some-
a job.
adulthood.
thing people recover from and go on?” Dr. Copeland said. “We weren’t expecting to find
“When it comes to key
Of those with the milder psychiatric indica-
these protracted difficulties into adulthood.”
psychiatric problems – depression, anxiety, behavior
disorders
– there are successful interventions and William Copeland, Ph.D.
prevention programs,” said lead author Wil-
liam Copeland, Ph.D., assistant clinical pro-
MOHS MICROGRAPHIC SURGERY • EXCISIONAL SURGERY • CRYOSURGERY
“She wanted to move on with her life.” I REFERRED HER TO SOUTHERN DERMATOLOGY
fessor of psychiatry and behavioral sciences at Duke. “So we do have the tools to address these, but they aren’t implemented widely. The burden is then later seen in adulthood, when these problems become costly public health and social issues.” Dr. Copeland and colleagues analyzed data from the Great Smoky Mountains Study, which began nearly two decades ago and includes 1,420 participants from 11 North Carolina counties. The study is ongoing and has followed the participants from child-
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hood through adulthood – most are now in their 30s. Of those in the study group, 26.2 percent met the criteria for depression, anxiety or a
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PHOTODYNAMIC THERAPY • LASER SURGERY • TOPICAL MEDICATION
DER131_AD_Triangle Physican I Want 4.indd 1
september 20153:49 PM 19 8/27/15
Duke Research News Jane Costello.
Dr. Copeland said the findings reinforce the
treatment, and those who do don’t get what
need to attack problems early with effective
we would consider optimal care,” Dr. Cope-
therapies. He said only about 40 percent of
land said. “So the problems go on much lon-
The study received funding from the National In-
children get the treatment they need for psy-
ger than they need to and cost much more
stitute of Mental Health (MH080230, MH63970,
chiatric disorders, and even fewer who have
than they should in both money and dam-
MH63671, MH48085, MH075766, MH094605);
borderline problems are treated.
aged lives.”
the National Institute on Drug Abuse (DA/
“A big problem with mental health in the
In addition to Dr. Copeland, study authors
Brain and Behavior Research Foundation; and
United States is that most children don’t get
include Dieter Wolke, Lilly Shanahan and E.
the William T. Grant Foundation.
MH11301, DA011301, DA016977, DA036523); the
Even Moderate Picky Eating Can Have Negative Effects on Children’s Health Picky eating among children is a common
study also found that children with selective
“There’s no question that not all children go
but burdensome problem that can result in
eating behaviors were nearly twice as likely
on to have chronic selective eating in adult-
poor nutrition for kids, family conflict and
to have increased symptoms of generalized
hood,” Dr. Zucker said. “But because these
frustrated parents.
anxiety at follow-up intervals during the study,
children are seeing impairment in their health
which screened an initial 3,433 children.
and well-being now, we need to start developing ways to help these parents and doctors
Although many families see picky eating as a
know when and how to intervene.”
phase, a new study from Duke Medicine finds
“These are children whose eating has be-
moderate and severe picky eating often coin-
come so limited or selective that it’s starting
cides with serious childhood issues, such as
to cause problems,” Dr. Zucker said. “Impair-
Dr. Zucker said some children who refuse to
depression and anxiety that may need inter-
ment can take many different forms. It can
eat might have heightened senses, which can
vention.
affect the child’s health, growth, social func-
make the smell, texture and tastes of certain
tioning and the parent-child relationship. The
foods overwhelming, causing aversion and dis-
According to the study, published Aug. 3 in
child can feel like no one believes them, and
gust. Some children may have had a bad expe-
the journal Pediatrics, more than 20 percent
parents can feel blamed for the problem.”
rience with a certain food and develop anxiety
of children ages two to six are selective eat-
when trying another new food or being forced
ers. Of them, nearly 18 percent were classified
Although children with moderate picky eating
as moderately picky. The remaining children,
did not show an increased likelihood of for-
about 3 percent, were classified as severely
mal psychiatric diagnoses, children with se-
“What’s hard for physicians is that they don’t
selective – so restrictive in their food intake
vere selective eating were more than twice as
really have data to help predict which chil-
that it limited their ability to eat with others.
likely to also have a diagnosis of depression.
dren will age out of the problem and which
to try the offensive food again, she said.
children won’t, and so they’re trying to do the
Nancy L. Zucker, Ph.D.
“The question for many
Children with moderate and severe patterns
best they can with limited information and in-
parents and physicians
of selective eating would meet the criteria for
terventions,” Dr. Zucker said.
is: when is picky eating
an eating disorder called avoidant/restrictive
truly a problem?” said
food intake disorder (ARFID), a new diagno-
Some children may benefit from therapy,
lead author Nancy L.
sis included in the most recent Diagnostic and
which may include demystifying foods that
Zucker, Ph.D., director
Statistical Manual of Mental Disorders.
cause anxiety through exposure. But traditional methods may not address children with
of the Duke Center for Eating Disorders. “The
The findings also suggest that parents are in
sensory sensitivities, for whom some smells
children we’re talking about are not just misbe-
conflict with their children regularly over food
and flavors are too intense and may never
having kids who refuse to eat their broccoli.”
– which does not necessarily result in the
be palatable. New interventions are needed
child eating – and families and their doctors
to deal with children who have sensory sen-
Children with both moderate and severe se-
need new tools to address the problem, Dr.
sitivity and frequent experiences of palpable
lective eating habits showed symptoms of
Zucker said.
disgust, Dr. Zucker said. Treatments also need
anxiety and other mental conditions. The
20
The Triangle Physician
to be better tailored to a patient’s age range.
Research News One benefit to spotting picky eating in young
“It’s a good way to get high-risk children into
berly Carpenter, Lori Keeling, Adrian Angold
children is that it’s a condition parents can
interventions, especially if the parents are ask-
and Helen Egger.
easily recognize, and it could be a good tool
ing for help,” Dr. Zucker said. The study was sponsored by the National In-
for identifying who may be at risk for anxiety and depression.
In addition to Dr. Zucker, study authors in-
stitute of Mental Health (RC1-MH-088678, R01-
clude William Copeland, Lauren Franz, Kim-
MH-075766, R01-MH-081025).
Innovative Gene Transfer-based Treatment Approach Brings Hope University of North Carolina School of Medi-
jections is prepared at the UNC Vector Core
cine researchers have developed an inno-
Human Applications Laboratory.
vative, experimental gene transfer-based
eases studied in my lab.” Dr. Gray serves as an associate investigator
treatment for children with giant axonal neu-
A clinical trial of this approach is now under
on the trial as does R. Jude Samulski, Ph.D.,
ropathy.
way at the National Institute of Neurological
director of the UNC Gene Therapy Center.
Disorders and Stroke (NINDS) of the NationResearchers led by
al Institutes of Health (NIH) in Bethesda, Md.
“After 30 years of fo-
Steven J. Gray, Ph.D.,
The first patient was enrolled in May. This is
cusing on optimizing
assistant
professor
the first gene delivery approach directly into
successful gene deliv-
in the Department of
the spinal fluid in order to treat an inherited
ery, it is very reward-
Ophthalmology
and
neurological disorder and is expected to
ing to finally see these
a researcher in UNC’s
pave the way to developing treatments for
approaches
Gene Therapy Center
many other related diseases.
R. Jude Samulski, Ph.D.
tested for some of the
for Developmental Disabilities, developed
Dr. Gray chose to focus his career on this rare
caused by these terminal genetic disorders,”
the experimental treatment in studies con-
genetic condition after meeting Hannah, who
Dr. Samulski said. “This specific study repre-
ducted at UNC.
is the same age as his own daughter, Aubrey.
sents a culmination of years of basic research
Dr. Gray’s work in this area was funded
“This has been a coordinated and commit-
primarily of Steve Gray’s team, coupled with
almost entirely by Hannah’s Hope Fund,
ted effort between Hannah’s Hope and UNC
clinical expertise at the NIH. More important-
a charity founded by the parents of Han-
to drive a treatment forward for GAN. Han-
ly, this journey for me has personally been a
nah Sames, an 11-year-old girl with giant
nah’s Hope is a truly amazing community
truly rewarding one that started seven years
axonal neuropathy (GAN), to support the
that provides a constant source of inspira-
ago with a parent knocking on the office
development of a treatment and cure. This
tion. Our goal has always been to bring hope
door asking if we could ‘help save her child,’
extremely rare genetic disorder causes chil-
to the families affected by this devastating
to last week’s gene therapy administration; a
dren to gradually lose the ability to balance
disease, and we are proud to be taking the
remarkable and humbling journey that I’m
themselves, move their muscles and to feel
first step to making a GAN treatment a real-
privileged to be a part of.”
certain sensations. Most children born with
ity,” said Dr. Gray. “We are greatly apprecia-
GAN do not survive beyond their early 20s
tive of NIH/NINDS for partnering with us on
Carsten Bönnemann, M.D., who is lead-
because of progressive impairment of their
this lifesaving mission.
ing the trial at NIH said, “This first intrathe-
Steven J. Gray, Ph.D.
and Carolina Institute
being
unmet clinical needs
from the UNC Gene Therapy Center and that
ability to breathe.
cal (into the spinal fluid) delivery of a viral This trial is the first in history to deliver
gene therapy vector in a human patient is
The treatment approach developed at UNC
gene therapy through the spinal fluid to test
a fundamental step towards developing a
uses a genetically modified virus called AAV
the potential to achieve broad treatment of
causal treatment for giant axonal neuropa-
to deliver a missing gene, the gigaxonin gene
the spinal cord and brain (central nervous
thy (GAN), a devastating progressive neuro-
(scAAV9/JeT-GAN), into the cerebrospinal
system or CNS). It is a momentous step
genetic disorder of childhood. At the same
fluid of children with GAN. The therapeutic
forward, and we’re already seeing clear ap-
time it is also paving the way for similar gene
viral vector to be used in each of these in-
plication of this approach to treat other dis-
transfer-based treatments for many other
september 2015
21
UNC Research News neurological disorders in which nerve cells
That this first step is now being taken is testa-
up to 20 patients with GAN who are ages
of the spinal cord and brain need to be tar-
ment to Hannah’s Hope Fund and Dr. Steve
five and older (ClinicalTrials.gov; identifier:
geted, including spinal muscular atrophy.
Gray’s tenacity and enormous commitment,
NCT02362438). Each of the children and
but also to the courage of our first young pa-
their families will be required to live within
“Bringing such path-breaking treatments to
tient, who volunteered to receive this treat-
100 miles of the NIH for two months after
children affected by neurogenetic disorders
ment, and others who will follow.”
receiving the gene transfer treatment, which will be given by a single injection by spinal
is really the core mission of our team here at the NINDS, so we are very excited to be help-
The Phase I clinical trial, which officially
ing to move this approach to a clinical trial.
started in January, seeks to enroll a total of
tap into their cerebrospinal fluid.
Smart Insulin Patch Could Replace Painful Injections for Diabetes A joint effort between diabetes doctors and biomedical engineers
be required before the patch can be administered to patients, but the
could revolutionize how people with diabetes keep their blood sugar
approach shows great promise.
levels in check. “We have designed a patch for diabetes that Painful insulin injections could become a thing of the past for the mil-
works fast, is easy to use and is made from non-
lions of Americans who suffer from diabetes, thanks to a new inven-
toxic, biocompatible materials,” said co-senior
tion from researchers at the University of North Carolina and North
author Zhen Gu, Ph.D., a professor in the Joint
Carolina State, who have created a “smart insulin patch” that can de-
UNC/NC State Department of Biomedical Engi-
tect increases in blood sugar levels and secrete doses of insulin into
neering. Dr. Gu also holds appointments in the UNC School of Medicine, the UNC Eshelman
the bloodstream whenever needed.
Zhen Gu, Ph.D.
The patch – a thin square no bigger than a penny – is covered with
Center. “The whole system can be personalized to account for a dia-
more than 100 tiny needles, each about the size of an eyelash. These
betic’s weight and sensitivity to insulin,” he added, “so we could make
“microneedles” are packed with microscopic storage units for insulin
the smart patch even smarter.”
School of Pharmacy and the UNC Diabetes Care
and glucose-sensing enzymes that rapidly release their cargo when blood sugar levels get too high.
Diabetes affects more than 387 million people worldwide, and that number is expected to grow to 592 million by the year 2035. Patients
The study, which is published in the Proceedings of the National Acad-
with Type 1 and advanced Type 2 diabetes try to keep their blood
emy of Sciences, found that the new, painless patch could lower blood
sugar levels under control with regular finger pricks and repeated in-
glucose in a mouse model of Type 1 diabetes for up to nine hours.
sulin shots, a process that is painful and imprecise.
More pre-clinical tests and subsequent clinical trials in humans will “Injecting the wrong amount of medication can lead to significant complications like blindness and limb amputations, or even more disastrous consequences such as diabetic comas and death,” said John Buse, M.D., Ph.D., co-senior author of the PNAS paper and the director of the UNC Diabetes Care Center. Researchers have tried to remove the potential for human error by creating “closed-loop systems” that directly connect the devices that track blood sugar and administer insulin. However, these approaches involve mechanical sensors and pumps, with needle-tipped catheters that have to be stuck under the skin and replaced every few days. The smart insulin patch could be placed anywhere on the body to detect increases in blood sugar and then secrete doses of insulin when needed. (Photo courtesy of Zhen Gu, Ph.D.)
22
The Triangle Physician
Instead of inventing another completely manmade system, Gu and his colleagues chose to emulate the body’s natural insulin generators
UNC Research News known as beta cells. These versatile cells act both as factories and warehouses, making and storing insulin in tiny sacs called vesicles. They also behave like alarm call centers, sensing increases in blood sugar levels and signaling the release of insulin into the bloodstream. “We constructed artificial vesicles to perform these same functions by using two materials that could easily be found in nature,” said PNAS first author Jiching Yu, a doctor of philosphy student in Dr. Gu’s lab. The first material was hyaluronic acid, or HA, a natural substance that is an ingredient of many cosmetics. The second was 2-nitroimidazole, or NI, an organic compound com-
An up-close fluorescent image of the microneedle patch with insulin tagged in green. (Photo courtesy of Zhen Gu, Ph.D.)
monly used in diagnostics. dles or catheters that had beleaguered previ-
could tune the patch to alter blood glucose
The researchers connected the two to cre-
ous approaches, they decided to incorporate
levels only within a certain range by varying
ate a new molecule, with one end that was
these balls of sugar-sensing, insulin-releasing
the dose of enzyme contained within each
water-loving or hydrophilic and one that was
material into an array of tiny needles.
of the microneedles. They also found that the patch did not pose the hazards that insu-
water-fearing or hydrophobic. A mixture of these molecules self-assembled into a vesi-
Dr. Gu created these “microneedles” using
lin injections do. Injections can send blood
cle, much like the coalescing of oil droplets
the same hyaluronic acid that was a chief
sugar plummeting to dangerously low levels
in water, with the hydrophobic ends point-
ingredient of the nanoparticles, only in a
when administered too frequently.
ing inward and the hydrophilic ends pointing
more rigid form so the tiny needles were stiff
outward.
enough to pierce the skin. They arranged
“The hard part of diabetes care is not the
more than 100 of these microneedles on a
insulin shots or the blood sugar checks or
The result was millions of bubble-like struc-
thin silicon strip to create what looks like a
the diet but the fact that you have to do them
tures, each 100 times smaller than the width
tiny, painless version of a bed of nails. When
all several times a day every day for the rest
of a human hair. Into each of these vesicles,
this patch was placed onto the skin, the mi-
of your life, said Dr. Buse, the director of
the researchers inserted a core of solid insu-
croneedles penetrated the surface, tapping
the North Carolina Translational and Clini-
lin and enzymes specially designed to sense
into the blood flowing through the capillar-
cal Sciences (NC TraCS) Institute and past
glucose.
ies just below.
president of the American Diabetes Associa-
In lab experiments, when blood sugar lev-
The researchers tested the ability of this ap-
els increased, the excess glucose crowded
proach to control blood sugar levels in a
into the artificial vesicles. The enzymes then
mouse model of Type 1 diabetes. They gave
Because mice are less sensitive to insulin
converted the glucose into gluconic acid,
one set of mice a standard injection of insu-
than humans, the researchers think that the
consuming oxygen all the while. The result-
lin and measured the blood glucose levels,
blood sugar-stabilizing effects of the patch
ing lack of oxygen or “hypoxia” made the
which dropped down to normal but then they
could last even longer when given to actual
hydrophobic NI molecules turn hydrophilic,
quickly climbed back into the hyperglycemic
patients. Their eventual goal, Dr. Gu said, is
causing the vesicles to rapidly fall apart and
range. In contrast, when the researchers treat-
to develop a smart insulin patch that patients
send insulin into the bloodstream.
ed another set of mice with the microneedle
would only have to change every few days.
tion. “If we can get these patches to work in people, it will be a game changer.”
patch, they saw that blood glucose levels Once the researchers designed these “intelli-
were brought under control within 30 minutes
This research was funded by a pilot grant
gent insulin nanoparticles,” they had to figure
and stayed that way for several hours.
from the NC TraCS Institute and a “Pathway to Stop Diabetes” Research Award from the
out a way to administer them to patients with diabetes. Rather than rely on the large nee-
In addition, the researchers found that they
American Diabetes Association. september 2015
23
News
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encouragement
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them how to incorporate Developed by Thrive 4-7, a woman-owned
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startup,
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their food choices and staying active,
as diabetes, cardiovascular disease and
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24
The Triangle Physician
Rex News
Partnership with Wake to Expand Care for Senior Patients in New Facility Rex Healthcare and Wake Health Services
The new Senior Health Center will offer
to provide personalized, compassionate
have partnered to provide a new home
convenient, expanded services in one
medical, preventive and wellness care for
for the Rex Senior Health Center, with en-
location, including primary care, den-
many years to come.”
hanced care and expanded services for
tal care, behavioral health, lab services
senior patients in Southeast Raleigh and
and a new pharmacy. The center will be
“By combining resources, we can give se-
beyond.
supported by a full team of health care
niors in the community access to quality
professionals and clinical staff and offer
health care and improve their health and
The Senior Health Center will be a fea-
expanded access to care, including early
well-being,” said Penny Washington, chief
tured service at the new 35,000-square-
morning, evening and weekend hours.
executive officer of Advance Community Health. “We welcome Dr. Darkes and the
foot, $13 million health center Wake Health Services building at 1001 Rock
Leroy S. Darkes, M.D., who helped found
expertise he brings to help engage the
Quarry Road. In August, patients started
the Rex Senior Health Center 17 years
community in healthy living.”
receiving services at an existing Wake
ago, will continue to lead the new Senior
Health Services building and will move to
Health Center as community medical di-
For more information and to make an
the new building in October.
rector. “This new partnership is a tremen-
appointment, call (919) 833-3111 or visit
dous opportunity for us, but more impor-
www.advancedcommunityhealth.org.
As part of the transition, Wake Health
tantly, for our senior patients,” he said.
Services will change its name to Advance
“Our region’s population is growing and
Community Health.
aging, and we look forward to continuing
september 2015
25
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