N ov e m b e r / d e c e m b e r 2 015
Advanced Cardiovascular Care Introducing WakeMed Heart & Vascular Physicians – Focused on Access, Collaboration and Exceptional Patient Care
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
Also in This Issue Polycystic Ovary Syndrome Vaginal Plastic Surgery
EXPANDING MRI ACCESS Introducing Evera MRI™ ICD System Together, we can now provide safe MRI access for your ICD patients,1 with Medtronic MRI SureScan™ Systems. Backed by six years of market experience and five prospective clinical studies.2-6
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“Sometimes We Doctors Become Patients, And We Are Just As Glad As You Are To Find The Help We Need Close To Home.” - Johnston Health Cardiac Catheterization Patient Dennis Koffer, M.D.
“When Sandra and I were considering retiring from Greensboro to the family farm near Smithfield, our major concern was having the health care we needed nearby. Seeing the new services and facilities at Johnston Health helped us make our decision. Three years later, following some chest discomfort, I had a diagnostic cath, followed by two cardiac stent procedures, all done in their new interventional cath lab. I could not have asked for better care from the staff and physicians. From diagnostic process
through pre-op, stent procedures and recovery, everyone I came in contact with was kind, friendly, attentive and very professional. I am now in cardiac rehab at Johnston Health’s Cardiopulmonary Rehabilitation center. They are very helpful, not just physically, but also with encouragement to get the mindset I need to make some lifestyle changes. It’s wonderful to have this level of care here in our neighborhood, and I am thankful to feel like doing the things I enjoy again!”
Diagnostic & Interventional Cardiac Catheterization For Your Patients - Here In Smithfield! For Dr. Koffer’s full story visit:
509 N. Bright Leaf Blvd. www.johnstonhealth.org Smithfield, NC
Healing Neighbors... It’s What We Do. It’s Who We Are! 919-934-8171 www.johnstonhealth.org
Table of Contents
6
COVER STORY
Advanced Cardiovascular Care Introducing WakeMed Heart & Vascular Physicians – Focused on Access, Collaboration and Exceptional Patient Care n ov e m b e r / d e c e m b e r 2 0 15
FEATURES
10
V o l . 6 , I ss u e 1 0
DEPARTMENTS 9 Practice Marketing
Endocrinology
Loyalty and Memorability Included in 20 Reasons to Brand: Part 2 of 4
12 Practice Management
Polycystic Ovary Syndrome
Dr. Carly Kelley discusses diagnosis and treatment
16 Physician Advocacy
strategies, most of which begin with weight loss.
Developing and Implementing an Effective Recruitment Process
New AID-SAVE Program Helps Independent Practices Cut Expenses
17 Duke Research News
14
Women’s Health
Vaginal Plastic Surgery May Help Women with “Problem” Areas
Cellular Stress Process Identified in Cardiovascular Disease Risk
18 Duke Research News
Toxic Nail Polish Chemical Found
19 UNC Research News
Pancreatic Cancer Subtypes Discovered in Large Gene Expression Analysis
Dr. Andrea Lukes describes a growing interest and
21 UNC News
the value of compassionate medical guidance.
2
The Triangle Physician
Bravery Goes Pink for Breast Cancer Research
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From the Editor
Big 3-0, Big Thanks In this month’s cover story WakeMed formally introduces WakeMed Heart & Vascular Physicians. The group of 30 providers is at the leading edge of medical treatment to improve patients’ quality of life. Its goal is to improve the health of the region by preventing cardiovascular events and disease progression using evidence-based therapies.
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
Breadth of experience and depth of expertise allow the heart and vascular specialists to handle everything from the routine to the complex. Readers also will learn about the qualities that empower the group to help patients who may have exhausted all traditional treatment options.
Contributing Editors Wendy Coulter Marni Jameson Carly Kelley, M.D. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Margie Satinsky, M.B.A.
The complex arrhythmia program, for example, has outcomes that rank among the top centers in the country. The group even offers a program for patients with chronically occluded coronary arteries, which boasts the most success in North Carolina.
Creative Director Joseph Dally jdally@newdallydesign.com
Also in this issue of The Triangle Physician, endocrinologist Carly Kelley discusses polycystic ovary syndrome and the broad manifestations, including Type 2 diabetes, that need to be considered for comprehensive treatment. Gynecologist Andrea Lukes enlightens on the sensitive subject of vaginal plastic surgery and the need to weigh patient benefit along with risk. Branding consultant Wendy Coulter returns with five more reasons to distinguish one’s practice from the competition. Practice management consultant Margie Satinsky gives a comprehensive overview of an effective recruitment process. Physician advocate Marni Jameson highlights the AIDSAVE medical supply-savings program, which is designed to help level the playing field for independent physicians. Tis the season of gratitude, and all of us on The Triangle Physician team wish you and yours a wonderful Thanksgiving. A big thank you to our advertisers and contributors, whose generous support and valuable information enables us to produce a vibrant reflection of our amazing medical community each month. With sincere gratitude for all you do,
Heidi Ketler Editor 4
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Cover Story
Advanced Cardiovascular Care
Introducing WakeMed Heart & Vascular Physicians – Focused on Access, Collaboration and Exceptional Patient Care This fall, WakeMed is pleased to introduce
Unique Collaboration and
A History of Innovation –
WakeMed Heart & Vascular Physicians,
Team Approach
New Subspecialties and Procedures
which formally brings together the dozens
Our physicians value collaboration and
With a long history of innovation, we con-
of exceptional cardiologists, cardiovascu-
communication, because we know it re-
tinue to add new subspecialists and sur-
lar specialty physicians and surgeons who
sults in better patient care.
geons with advanced training in numerous areas, including structural heart, complex
have spent decades providing the highest
arrhythmia and complex coronary inter-
level of cardiovascular care in the region
“By
here at WakeMed. The group represents
the skills, exper-
more than 30 expert providers in numer-
tise and specialty
ous cardiovascular subspecialty areas,
training of more
Valve Disease Treatment
including: cardiology, cardiovascular and
than 30 providers,
and Structural Heart
thoracic surgery, vascular surgery, struc-
we can learn from
In 2013, WakeMed launched a compre-
tural heart, electrophysiology and complex
one another, share
hensive structural heart program to help
arrhythmia.
ideas and partner
patients managing valve disease enjoy a
across specialties
better quality of life.
The WakeMed Heart & Vascular
John R. Sinden, M.D., F.A.C.C.
to
leveraging
develop
ventions.
the
Physicians Difference
most effective cardiovascular plan. Our
Since its introduction, Surgical Director
Quality Time Equals Quality Care
patients truly benefit from our combined
Bryon Boulton, M.D., F.A.C.S., has pio-
Our physicians take pride in spending time
expertise and willingness to work together
neered our surgical program, performing
getting to know a patient’s medical history
as an integrated team,” explains John R.
numerous procedural firsts, including the
and how their symptoms are affecting their
Sinden, M.D., F.A.C.C., director, WakeMed
nation’s first transaxillary bicuspid TAVR
life. This approach helps us deliver the
Heart & Vascular Physicians.
(transcatheter aortic valve replacement) using the Edwards platform. The program
most individualized care possible based on their unique medical history and con-
Quality and Value
continues to grow with new providers and
dition. We recognize that spending more
Our focus is on providing the right level of
procedural offerings, including TAVR, Mi-
time with patients results in better patient
care at the right time based on evidence-
traClip® and Convergent, as well as vari-
care and improved outcomes.
based medicine. By avoiding unnecessary
ous left atrial appendage ligation treatment
testing, procedures and duplication of ser-
options, including Watchman®, Lariat®
Access and Convenience
vices, we ensure our patients receive only
and AtriClip® procedures.
With 11 offices throughout the region, our
the care they truly need. Our physicians
physicians are available in convenient lo-
are recognized as high-value specialists by
“These new options allow us to improve
cations. Most offices can accommodate
most managed care organizations for our
our patients’ quality of life and also to re-
a new cardiology patient visit within two
focus on value and quality.
duce their risk for future cardiovascular
days and a subspecialist appointment in
problems, such as stroke, heart failure or
two to four weeks.
sudden cardiac death,” explains Dr. Boul-
6
The Triangle Physician
ton. “Many patients who’ve failed other
WakeMed Heart & Vascular Physicians of-
ment of complex arrhythmia disorders,”
therapies for years come to us, and we’re
fers a comprehensive team of experienced
explains Dr. Hranitzky. “We are committed
often thrilled to discover that there are
electrophysiologists who can handle ev-
to helping patients who may have exhaust-
new options since their last evaluation. We
erything from routine diagnostics and
ed all traditional treatment options by offer-
appreciate the opportunity to collaborate
medication therapy to the most advanced
ing the latest emerging treatments.”
with primary care physicians and cardiolo-
device implantation/removal procedures
gists from throughout the region.”
to complex ablations performed by some
Patrick Hranitzky, M.D.,
of the nation’s leading specialists. By stay-
F.A.C.C., F.H.R.S.
Bryon Boulton, M.D., F.A.C.S.
ing on the forefront of research, our spe-
Electrophysiologist and Director,
Cardiothoracic Surgeon and Surgical
cialists were among the first to perform
Complex Arrhythmia Program
Director, Structural Heart Program
many emerging treatment options here
WakeMed Heart & Vascular Physicians
WakeMed Heart & Vascular Physicians
in Wake County, including the placement of the first subcutaneous implantable car-
Dr. Hranitzky is a
Dr. Boulton is a
dioverter-defibrillator (S-ICD) and the first
board-certified
board-certified
magnetic resonance imaging-compatible
diac electrophysiolo-
ICD defibrillator.
gist who specializes
car-
diothoracic surgeon
in cardiac arrhyth-
with advanced surgi-
Bryon Boulton, M.D., F.A.C.S.
car-
cal expertise in trans-
In 2013, WakeMed introduced a complex ar-
mias, catheter ab-
catheter aortic valve
rhythmia program to complement our broad
lations
replacement (TAVR)
range of electrophysiology services. Led by
rhythm
and off-pump coro-
Patrick Hranitzky, M.D., F.A.C.C. F.H.R.S.,
nary artery bypass
who joins WakeMed Heart & Vascular Phy-
Patrick Hranitzky, M.D., F.A.C.C., F.H.R.S.
and
heart
disorders.
He has interests in the evaluation and
surgery. He special-
sicians from Texas Cardiac Arrhythmia, our
management of cardiac dyssynchrony in
izes in minimally invasive cardiac surgery,
program performs hundreds of ablations for
heart failure patients, extraction of ICD/
robotic cardiac surgery and hybrid revas-
atrial and ventricular fibrillation per year –
pacemaker hardware and genomics/pro-
cularization, mitral valve repair, TEVAR
and is one of the highest volume centers for
teomics of electrophysiologic phenotypes.
(thoracic endovascular aortic repair) and
ablations in the Carolinas.
An accomplished researcher, Dr. Hranitzky has written and co-authored many articles
aortic aneurysm repair; as well as the full
in the area of electrophysiology.
complement of general thoracic services,
Our multidisciplinary team manages a
including thorascopic surgery of the lung,
wide variety of rhythm problems, includ-
mediastinum and pleura, including video-
ing atrial fibrillation, atrial flutter, ventricu-
assisted thorascopic (VATS) lobectomies.
lar fibrillation, ventricular tachycardia, si-
Complex Percutaneous Coronary
Dr. Boulton also performs minimally in-
nus tachycardia and much more. Patients
Intervention/Chronic Total
vasive atrial fibrillation surgery, and co-
have access to the latest advancements in
Occlusion Program
leads the team with the percutaneous mi-
complex arrhythmia treatment, including
Helping patients with chronic, complex or
tral valve repair device, the MitraClip. An
medications, devices and procedures –
unresolved cardiovascular symptoms is a
award-winning researcher, Dr. Boulton is
and even research trials that can provide
top priority for WakeMed Heart & Vascu-
the co-author of several articles and book
patients with emerging treatments that
lar Physicians. That’s why we developed
chapters that have been published in pres-
aren’t available yet to the general popula-
a program in 2014 to help patients with
tigious medical publications.
tion.
chronically occluded coronary arteries (complete blockage of a coronary artery).
With two electrophysiology labs dedicated
Led by Islam M. Othman, M.D., F.A.C.C.,
Electrophysiology and
to complex arrhythmia, and patient out-
program director and interventional cardi-
Complex Arrhythmia Program
comes that rank among the top centers in
ologist, our Chronic Total Occlusion (CTO)
Diagnosing and treating arrhythmia prob-
the country, WakeMed will soon become
Program boasts an incredibly high success
lems can be challenging – many patients
a training site for complex arrhythmia pro-
rate and is the most experienced program
who have undergone multiple traditional
cedures for cardiologists and electrophysi-
in North Carolina.
therapies continue to experience symp-
ologists from across the country. Ideal candidates include patients whose
toms that have a significant impact on their quality of life.
“WakeMed is on the leading edge of ad-
chest pain cannot be managed with medi-
vanced electrophysiology and the treat-
cation, patients who are not surgical can-
november/december 2015
7
didates and/or patients who need to have their blocked arteries resolved prior to heart valve replacement surgery. Successful CTO intervention helps patients with chronic chest pain (angina), shortness of breath or fatigue regain quality of life and also can help prevent loss of heart function and/or congestive heart failure. Because CTO intervention is complex, success rates are heavily determined by the physician’s ability to carefully navigate a wire and micro-devices in and around a dense blockage to open the artery and restore blood flow. Dr. Othman is among a small but growing number of United States physicians specially trained to successfully resolve CTOs. “Restoring quality of life for patients is the primary goal for our CTO program,” says Dr.
All Backed By the
ment and the reduction of risk factors is
Othman. “Many of these patients have been
WakeMed Heart Center
still the future of cardiovascular care. Our
told they have no further options for treat-
Long known for experience in, and a
exceptional team of general and non-in-
ment, and their ability to enjoy life really suf-
strong commitment to, cardiovascular
vasive cardiologists works closely with
fers. Seeing our patients feel better after the
care, the WakeMed Heart Center features
referring physicians to help prevent car-
procedure is incredibly rewarding.”
nine invasive cardiology and two electro-
diovascular events and the progression
physiology procedure rooms with state-
of heart disease through evidence-based
Islam M. Othman, M.D., F.A.C.C.
of-the-art
therapies.
Interventional Cardiologist and Director,
cardiovascular testing services, inpatient
Complex Percutaneous Coronary Interven-
and outpatient nursing care and a hotel
“As cardiologists, we recognize that tak-
tion/Chronic Total Occlusion Program
for the convenience of out-of-town pa-
ing the time to educate and communi-
WakeMed Heart & Vascular Physicians
tients and their family members.
cate with our patients and their families
technology,
comprehensive
– as well as partnering with our referring
Islam M. Othman, M.D., F.A.C.C.
As a board-certified
The WakeMed Heart Center serves as
physicians – can truly help us reduce
interventional cardi-
the hub for WakeMed Heart & Vascular
the incidence and severity of cardiovas-
ologist, Dr. Othman
Physicians’ patient care and procedures
cular disease throughout the region,”
specializes in adult
and is regionally recognized for its spe-
explains Dr. Sinden. “As we continue to
cardiovascular
dis-
cially trained staff of nurses, cardiovascu-
grow, WakeMed looks forward to helping
eases, cardiovascu-
lar specialists, technologists, respiratory
improve the health and well-being of our
lar disease preven-
therapists, dietitians and pharmacists. All
patients and the communities we serve.”
tion,
share our focus of putting patients and
heart
failure
management, inter-
their families first in everything we do.
ventional cardiology,
Contact hearts.wakemed.org
general cardiology and nuclear medicine.
The Future of Cardiovascular Care
WakeMed Heart & Vascular Physicians
His areas of expertise include coronary an-
While WakeMed Heart & Vascular Phy-
- Cardiology: 919-350-WMHV (9648)
giography and complex coronary interven-
sicians remains on the forefront of ad-
- Structural Heart: 919-232-5202
tions, echocardiography, transesophageal
vanced
- Cardiovascular & Thoracic Surgery:
echocardiography, nuclear imaging, and
state-of-the-art technology and emerging
stress imaging.
treatments, we recognize that improving
procedures,
subspecialties,
the health of the community through a committed focus on disease manage-
8
The Triangle Physician
919-231-6333 - Complex Arrhythmia: 919-397-4511
Practice Marketing
Loyalty and Memorability
Included in 20 Reasons to Brand: Part 2 of 4 By Wendy Coulter
In this series, we will cover 20 reasons to
positively has to be there overnight.”
brand your practice. As we explored in Part 1, patients who believe in your prac-
Stand Out from Competitors
tice’s brand will spread the word about its
In today’s economy competition is every-
benefits and thereby increase the value of
where, and it’s imperative to differentiate
the brand as an asset of the practice.
your practice from others. When you embark on branding your practice, one of
Last issue I shared five reasons to brand;
the most important things you should de-
here are five more.
termine is your unique sales proposition (USP) – this is the ultimate competitive
Build Brand Loyalty
advantage that makes you better by being
Strong brands live true to a consumer
different. Perhaps the hardest brand mes-
promise that supports how a person wants
sage to develop, it may well be the most
to feel about themselves or how they want
powerful!
to see themself when they use that product or service. This builds brand loyalty.
Reflect a Sense of Pride
A patient essentially buys into your brand
A significant message you develop when
because of the promise that they are a cer-
you brand your practice is the core values
tain type of person, which promotes loy-
it holds. Your brand should represent the
alty. Harley Davidson is a great example
values you are proud to stand for, no mat-
of how building loyalty through a strong
ter what. Zappos developed a unique set
consumer promise impacts the success of
of core values that are reflected in all its
the brand.
packaging, marketing materials and customer service activities. Zappos’ custom-
Be Memorable
ers can relate to these core values, which
A benefit of developing a strong brand sto-
influence their decision to buy from the
ry is to be top of mind. Examples of brands
company.
that stay top of mind include Apple, Levi’s,
Wendy Coulter is president of Hummingbird Creative Group Inc. She is a graduate of the School of Design at North Carolina State University with degrees in architecture and industrial design and a minor in communications. She founded Hummingbird Creative Group in 1995, with a desire to put her ideas to work, creatively solving problems for small businesses. Hummingbird Creative Group is an award-winning, full-service branding agency that helps companies define brand strategy, develop sustainable brand messaging and implement marketing tactics through advertising, graphic design, sales enablement, public relations and online marketing services. Awards include “Pinnacle Business Award” from the Raleigh Chamber of Commerce, as well as “Business of the Year,” “Employer of the Year” and “Successful Achievement” awards from the Cary Chamber of Commerce. Ms. Coulter was named a “Top 50 Entrepreneur,” “Woman Extraordinaire,” “Mover and Shaker” and “40 Under 40,” to name a few. She is active in a variety of community and civic endeavors and frequently presents on such topics as branding, marketing, advertising and design.
Victoria’s Secret, Rolex, Nike and FedEx.
Generate Referrals
These brands are memorable because of a
People love to share things they like. Yes,
to tell others about the brands they like.
brand promise incorporated into a strong
people love to talk and share products
People wear brands, eat brands, listen to
brand identity and message. Victoria’s Se-
through word of mouth, but they also will
brands, and they’re constantly telling oth-
cret represents “powerful, sexy and glam-
share your brand without even knowing it
ers about the brands they love. On the flip
orous women who love their bodies,” and
by talking about your experience, whether
side, you can’t tell someone about a brand
you can trust FedEx, “when it absolutely,
one on one or online posts. People love
you can’t remember.
november/december 2015
9
Endocrinology
Polycystic Ovary Syndrome By Carly Kelley, M.D., M.P.H.
Polycystic ovary syndrome is a chronic
In 2003, an international consensus
condition with reproductive, metabolic
group meeting in Rotterdam broadened
and psychological manifestations, all of
the definition to include polycystic ovar-
which need to be considered in the com-
ian morphology. A diagnosis of PCOS by
prehensive care of affected women.
Rotterdam criteria requires two of these three elements and exclusion of other
Potential complications include sub-fertil-
disorders, such as thyroid disease, hyper-
ity, menstrual irregularity, hyperandrogen-
prolactinemia and nonclassic congenital
ism, impaired glucose tolerance (IGT),
adrenal hyperplasia.
Type 2 diabetes (T2DM), hypertension, dyslipidemia, nonalcoholic fatty liver dis-
Although the exact etiology is unknown,
ease (NAFLD), obstructive sleep apnea
insulin resistance is present in approxi-
(OSA), anxiety, depression and disor-
mately 50-80 percent of women with PCOS
dered eating.
and plays a key role in its development. Insulin resistance leads to hyperinsu-
Polycystic ovary syndrome (PCOS) af-
linemia, which contributes to the hyper-
fects up to 20 percent of reproductive-
androgenism seen in PCOS by directly
aged women, accounting for more than
stimulating ovarian androgen production
30 percent of cases of amenorrhea and
and reducing hepatic sex hormone-bind-
up to 75 percent of cases of anovulation.
ing globulin (SHBG), which increases
The health care economic burden in the
bioavailable testosterone. Obesity is not
United States exceeds $4 billion annually.
a cause of PCOS, but exacerbates many
Carly Kelley graduated magna cum laude from the College of William & Mary. She earned her medical degree and masters in public health from the University of Medicine and Dentistry in New Jersey, at which point she was inducted into the Alpha Omega Alpha Honor Medical Society. She then completed all her postgraduate medical training at Duke University, including internship, residency and an endocrinology fellowship. During her fellowship training, she presented or published in the areas of thyroid, parathyroid, pituitary, lipids and polycystic ovary syndrome. She is board certified in internal medicine and endocrinology and is working on her endocrine certification in neck ultrasound (ECNU). She is a member of the American Association of Clinical Endocrinology and the Endocrine Society.
aspects of the phenotype; about 80 per-
pre-term delivery. Although research on
American gynecologists Irving F. Stein Sr.
cent of women diagnosed with PCOS in
the psychosocial impact of PCOS is very
and Michael L. Leventhal first described
the United States are obese.
limited, small studies have shown that
PCOS in 1935, when they reported on a
women with PCOS are more prone to de-
group of seven women with amenorrhea,
The clinical presentation of PCOS var-
pression, anxiety, low self-esteem, nega-
hirsutism, obesity and the characteristic
ies across a woman’s lifespan, with both
tive body image and eating disorders.
polycystic appearance to their ovaries.
short and long-term complications. Ovarian dysfunction often manifests in ado-
A diagnosis of PCOS confers a five-to-10-
A precise and uniform definition for PCOS
lescence or early adulthood as oligo- or
fold increased risk for developing T2DM.
was subsequently lacking until a 1990
amenorrhea. Women have unopposed
Additional risk factors for cardiovascu-
National Institutes of Health conference
estrogen, which may lead to menorrha-
lar disease include: abdominal obesity,
attempted to standardize the diagnosis.
gia, endometrial hyperplasia and an in-
dyslipidemia, NAFLD and OSA. Greater
They proposed the following diagnostic
creased risk for endometrial cancer. The
endothelial dysfunction, arterial stiffness,
criteria: oligo- or anovulation and bio-
presence of anovulatory cycles results
presence of carotid and aortic plaque,
chemical or clinical signs of hyperan-
in reduced fertility, and once pregnant,
carotid intima media wall thickness and
drogenism, such as hirsutism, acne or
women with PCOS are at an increased risk
coronary artery calcification were all re-
male-pattern hair loss.
of gestational diabetes, preeclampsia and
ported in PCOS women compared to con-
10
The Triangle Physician
Endocrinology trols. Despite the increased prevalence of cardiovascular risk factors in women with PCOS, there are no large-scale longitudinal studies confirming a higher rate of cardiovascular disease morbidity and mortality. Lifestyle modification (diet and exercise) is the first-line treatment for women with PCOS; as little as 5 percent to 10 percent weight loss may improve ovulatory rates, hyperandrogenism and the metabolic features of this syndrome. Medical therapy is targeted to symptoms and should not be used as an alternative to lifestyle therapy in PCOS. Hormonal contraceptives (HC) regulate menstrual cycles, protect the endometrium and treat hyperandrogenism by decreasing ovarian androgen production and increasing SHBG. Metformin may be used as a second-line treatment in women who cannot take
Do you have lower abdominal pain due to
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or do not tolerate HCs; it is also recommended for the prevention of T2DM in women with PCOS and IGT when lifestyle modifications are unsuccessful.
Gastroenterology PLLC • Ads may be used in newspapers, fliers, posters, mailings, Drossman public transportation, or outdoor advertising. a patient-centered gastroenterology • Ad may appear white on black or black on white or color. practice focusing on patients with trogen modulators, such as letrozole) is • Compensation in ad will match compensation listed in IRB approved consentand form. difficult to diagnose manage recommended as first-line therapy for functional GI and motility disorders. • Ad may be used in its entirety for website posting or e-mail communication. anovulatory infertility in women with The officethe is located within the –When possible, all internet website postings will fall under “Research Opportunities” heading shou PCOS, though metformin is an option to multidisciplinary health care center, be one, but may also fall under the “Employment Opportunities” heading should there not be a relevan restore ovulation in women not desiring Chapel Hill Doctors. Dr. Douglas option on a given website. If there is not a relevant “Research” following disclaimer will be Drossman Drossman isheading, joined bythe physician’s pregnancy in the immediate future. the study related text: assistant, Kellie Bunn, PA-C. Gastroenterology Appointments arebut scheduled on Tuesday “Please note that55theVilcom following is not an employment opportunity an opportunity to participate in Center Drive Additional therapies targeting hirsutism and Wednesday and most laboratory research trial.” Boyd Hall, Suite 110 include the following: spironolactone, studies are available. Chapel NC Research 27514 Notice: Radiant Research Inc. and Hill, Clinical Advantage retains all exclusive rights. All content, form an enflornithine hydrochloride cream, laser 919.929.7990 www.drossmangastroenterology.com are protected under U.S. and Foreign copyright laws. No portions of this document may be reproduced or used therapy and electrolysis. Androgenic alowithout the express written consent of Radiant Research, Inc. Clomiphene citrate (or comparable es-
pecia may be treated with topical minoxidil. Women should be screened for OSA and referred for a sleep study if indicated. Finally, stress management is a key com-
ponent to taking care of women with PCOS; increasing their psychological wellbeing will improve their motivation and ability to successfully implement and sustain the lifestyle changes essential to treating this condition.
november/december 2015
11
Practice Management
Developing and Implementing an
Effective Recruitment Process By Margie Satinsky, M.B.A.
The people who work with you and for
to honoring the individuality of each and
you are your practice’s most important as-
every patient.
sets. Regardless of how well you are organized and financed, success depends on
What’s the practice’s future direction?
your practice’s ability to recruit and retain
Clearly articulate goals for the next three
good employees.
to five years.
This article suggests a multi-step recruit-
What personal characteristics are important
ment process that includes understand-
in your work environment? Smart and mo-
ing federal and state laws, articulating
tivated individuals who focus on tasks with
the practice’s mission, goals, priorities
little regard for interpersonal relationships
and values, setting employee goals, de-
and teamwork may not be the best choice.
termining job requirements, developing
Margie Satinsky, MBA, is President of Satinsky Consulting, LLC, a Durham, NC consulting firm that specializes in medical practice management. She’s provided strategic planning and operational guidance to more than 100 practices in North Carolina. Margie is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For additional information, go to www.satinskyconsulting.com.
a formal job description, publicizing the
State the Position Goals
position, reviewing applications, conduct-
Make sure that the goals for the vacant
ing telephone and face-to-face interviews,
or new position are consistent with the
checking references, making a job offer,
practice’s goals. For example, if you plan
providing orientation and seeking external
to simultaneously open a satellite office
formal job description. We recommend
guidance as needed.
and replace your electronic health record
a standard format that includes the job
(EHR) system, recruit a practice manager
title, reporting relationship, span of con-
Understand the Federal and State
who can handle both special projects
trol/supervisory responsibilities, required
Laws that Govern the Employer-
while continuing to manage ongoing daily
initiative/leadership, general summary
Employee Relationship
operations. If the goal is business as usual
of duties and responsibilities, priority
Make sure you understand the legal envi-
with no special projects, think less about
and secondary functions, working condi-
ronment in which you manage your prac-
initiative and recruit a person who is
tions, physical and mental effort required,
tice. Your attorney can provide guidance.
skilled at keeping things on an even keel.
time commitment and performance requirements
Design your recruitment process so it
(knowledge/skills/abilities,
shows your commitment to equal employ-
Identify the Job Requirements
education, experience, certification, li-
ment and the Americans with Disabilities
What knowledge, skills and education are
censes and alternatives to minimum quali-
Act (ADA) by producing an adequate pool
required to successfully perform the job?
fications).
of women, minorities, mature and dis-
Is an advanced degree necessary? Does
abled workers.
the position require someone who thrives
Publicize the Position
on taking the initiative and in helping you
Publicize the new or vacant position in
Articulate your Practice’s Mission,
move in new directions? What’s the scope
appropriate places. If you are an existing
Goals, Priorities and Values
of supervision?
practice and encourage current employees to apply for vacant positions, start by
Start with your practice’s unique characteristics. What makes the practice spe-
Develop a Formal Job Description
cial? It may be a combination of services
Use the position goals and job require-
offered and demonstrated commitment
ments as a foundation for developing a
12
The Triangle Physician
posting the job internally. For recruitment outside the practice, use
Practice Management both free recruitment methods (e.g. men-
information and a sense of the applicants’
an outside service to do the criminal and
tioning the position to medical colleagues
telephone skills. Pare down the list and in-
background checks. Second, ask those em-
and employees) and select appropriate
vite only the best four or five candidates to
ployees who require professional certifica-
paid advertising. For example, in North
come in for personal interviews.
tion or licensure to sign a statement indicating they will maintain these credentials.
Carolina, the North Carolina Medical Group Managers maintains an active job
Prepare carefully for the personal inter-
recruitment service. National organiza-
views. Develop a standard list of interview
Make the Job Offer
tions like the Medical Group Management
questions that you ask every applicant,
When ready to make a job offer to the
Association of America (MGMA) offer job
keeping in mind the questions that you
top candidate, call the individual on the
search assistance to both practices that
can ask/cannot ask to comply with federal
phone, make a verbal offer and follow up
are hiring and to individuals who are look-
and state laws. For example, ask about
with a written letter. The offer letter is dif-
ing for new opportunities. The national
each applicant’s ability to perform the job,
ferent from an employment contract, and
organizations for both primary care and
not about a disability or handicap. Don’t
for some employees you need both.
specialty physicians may also offer recruit-
ask about marital status; it’s not relevant
ment services.
to the job.
Be sure to post vacant positions on your
Consider starting with one-on-one inter-
tion, benefits and eligibility date and de-
website. Some of your patients or their
views. When you invite the most promis-
scription of the probationary period (if
family members and friends may be well
ing candidates back for second interviews,
you have one). If the offer is contingent on
qualified for a position.
involve other members of your team.
the results of drug and alcohol screening,
Include in the letter the job title, starting date, reporting relationship, job descrip-
make that requirement clear. Attach a copy
When ready to make a job offer to the top candidate, call the individual on the phone, make a verbal offer and follow up with a written letter.
of the employee benefits so the individual to whom the offer is being extended can take this information into consideration in making his/her decision. Provide Orientation Regardless of the position level of the new employee, schedule one or more formal orientation sessions. Taking time to introduce new employees to the practice’s
Review the Resumes
Contact References
unique environment yields better results
that You Receive
Following the completion of several
than asking new people to hit the ground
Designate one individual in your practice
rounds of interviews, narrow the selection
running.
(or an external consultant, if you have
to two or three people. At this point, with
chosen to use one) to review the resumes
applicant permission, contact references
Seek External Help As Needed
that you receive. As a courtesy and as a
and check credentials. Ask each reference
Two external professionals can assist in
method of reducing phone calls to your
the same set of questions.
the recruitment process. Seek guidance from legal counsel regarding employment
practice, notify all applicants that you have received the applications. When you elim-
Perform Criminal and
contracts. If you’d like guidance on the
inate candidates, let them know and thank
Background Checks
overall process, telephone and personal
them for their interest. Tell the candidates
As an employer in the medical field, be
interviews and reference checks, seek
that interest you of the timetable for inter-
particularly diligent about performing
help from a qualified practice manage-
viewing and making a decision.
criminal and background checks. The fi-
ment consultant.
nancial penalties and/or repercussions for Conduct Telephone and
billing fraud and clinical incompetence
Regardless of whether or not you do ev-
Face-to-Face Interviews
are severe.
erything internally or outsource some or part of the recruitment responsibility,
Reduce the group of qualified applicants down to six to eight people. Schedule brief
Two practical steps can help you ac-
move slowly and carefully. Make a good
telephone interviews to obtain additional
complish this step easily. First, engage
choice!
november/december 2015
13
Women’s Health
Vaginal Plastic Surgery May Help Women with “Problem” Areas By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
Plastic surgery is hugely popular in the Unit-
ness of a procedure must be measured care-
ed States and worldwide. Usually, it is done
fully before deciding to move forward with a
to improve a “problem” area.
procedure or surgery.
An increasing number of women and young
Although I rarely perform elective proce-
girls are seeking medical and surgical con-
dures that relate to changing the appear-
sultation for the appearance of their external
ance of the external genitalia and vagina, I
genitalia and vagina. How health care pro-
am supportive of women who have carefully
viders handle such consultation can impact
considered all of the issues involved in hav-
an individual.
ing such a procedure. Any “problem” area,
Plastic surgery, whether it is cosmetic or reconstructive, empowers the patient by giving them control over their appearance, their image and ultimately their self-esteem. The American College of Obstetricians and
if changed, can have a positive impact. This
Gynecologists issued a committee opinion,
is true for the vulva and vagina and for other
which states (September, 2007):
areas, most notably the breasts (augmenta-
So-called “vaginal rejuvenation,” “de-
tion and reduction).
After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position (2007) to begin Carolina Women’s Research and Wellness Center. She and partner Amy Stanfield, M.D., F.A.C.O.G., head the Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals. Call (919) 251-9223 or visit www.cwrwc.com.
tressing. There are certain trends (shaving,
signer vaginoplasty,” “revirgination” and “G-spot amplification” are vaginal surgi-
One expert in Raleigh is Cynthia Diehl, M.D.,
waxing, tight yoga pants) that have made pa-
cal procedures being offered by some
F.A.C.S., of Diehl Plastic Surgery. She is a
tients more aware of this anatomy.”
practitioners. These procedures are not
board-certified plastic surgeon who has de-
medically indicated, and the safety and
veloped an expertise with vaginal and vulvar
Given the increased availability of information
effectiveness of these procedures have
plastic surgery. As she purports through her
on the internet, many women research this
not been documented. Clinicians who re-
website (www.diehlplastics.com), “plastic
area of plastic surgery. This can have positive
ceive requests from patients for such pro-
surgery, whether it is cosmetic or reconstruc-
and negative impacts. The positive can be
cedures should discuss with the patient
tive, empowers the patient by giving them
that women feel more comfortable discussing
the reason for her request and perform
control over their appearance, their image
something that is bothersome to them.
an evaluation for any physical signs or
and ultimately their self-esteem.” Dr. Diehl notes that excessively large labia
symptoms that may indicate the need for surgical intervention. Women should be
I recently asked Dr. Diehl to explain her
minora (and the definition of what is exces-
informed about the lack of data support-
approach to women who present with con-
sively large varies significantly from woman
ing the efficacy of these procedures and
cerns about their external genitalia. She
to woman) can be inhibiting and/or frustrat-
their potential complications, including
emphasized the following: “The focus of my
ing. Some women may complain of irritation
infection, altered sensation, dyspareunia,
vaginal rejuvenation practice is reduction
and “pinching” when exercising or sitting,
adhesions and scarring.
of the labia minora. When the labia minora
discomfort with intercourse, moisture re-
(hairless inner labia) protrude beyond the
tention, visibility in tight clothing and social
Explaining the risks of any procedures is
labia majora (outer, hair bearing labia), it
anxiety about an area that they feel is dispro-
standard of care. The safety and effective-
can be physically irritating and socially dis-
portionately large.
14
The Triangle Physician
Women’s Health I have seen many women who request labiaplasty – and I refer them to Dr. Diehl.
BOTOX® COSMETIC • COOLSCULPTING® • FACIAL FILLERS • MICRODERMABRASION
approximately one hour. If a woman pre-
“She wanted a doctor who is also an artist.”
fers general anesthesia, Dr. Diehl is able
I REFERRED HER TO SOUTHERN DERMATOLOGY
She is able to perform this within an office setting and under local anesthesia. It takes
to provide this within her office. Diehl Plastic Surgery has a fully certified operating room when a woman needs more anesthesia. Finally, Dr. Diehl explains that the vulva (including the labia minora) heals well, and there is minimal downtime from having labiaplasty. She recommends some change in exercise routines for the first month. As I discussed this with Dr. Diehl, what impressed me is the high patient satisfaction that she has found. Given the limited number of experts in this area of North Carolina, I recommend my own patients to Dr. Diehl for consultation.
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november/december 2015
15
Physician Advocacy
New AID-SAVE Program
Helps Independent Practices Cut Expenses
By Marni Jameson
As independent doctors weather increasing
Save on Everyday Medical Supplies
cuts in their reimbursements, one way to
Part one of the AID-SAVE program lets mem-
help them survive is to help them cut their
bers purchase more than two dozen com-
expenses.
mon medical supplies at a discounted rate through McKesson, the nation’s leading sup-
Members of Association of Independent
plier of medical supplies, pharmaceuticals,
Doctors (AID), a national nonprofit devoted
equipment, technology and services.
Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at (407) 865-4110 or marni@aid-us.org.
to helping doctors stay independent, can now take advantage of a new, money-saving
To start saving, members simply contact
Group Purchasing
program called AID-SAVE.
their local McKesson account manager, who
Offers More Savings
will confirm the AID member is in good
Part two of the AID-SAVE program was cre-
AID-SAVE incorporates two supply-savings
standing. The account manager will then
ated thanks to a collaboration with a group
programs and is available to AID members in
load pricing so the member can access sav-
purchasing program that will yield even
all 50 states. Through the program, doctors
ings. (Contact Kent Olsen for information
more savings on more than 1.2 million items,
can save – sometimes significantly – on al-
about representatives in your local market
including medical supplies, office supplies
most everything they buy for their practices,
by e-mail to kent.olsen@mckesson.com or
and equipment. The group purchasing pro-
including medical supplies, office supplies,
by phone at 904-624-9414).
gram complements – and does not replace
equipment and more.
– the McKesson-brand program outlined above. Though savings will vary among medical
Family Physician Needed
groups, most practices can expect to save between 15 percent and 35 percent on medical supplies. A test we ran for one large specialty group (and AID member) on one
Family Physician Needed at Avance Primary Care, Raleigh, NC Avance Care, P.A. is seeking a Board Certified Family Physician at our new Oberlin Rd practice opening in late 2015. Avance Care’s model was created to benefit our patients AND our physicians. • Work/life balance – our providers work 40 hours per week or less • Average patient load of less than 3 patients per hour • Proprietary operating and provider support systems – paperless facilities • Highly trained support staff • State of the art facility with onsite Pharmacy, X-Ray, Nutritionist, Behavioral Health Services, Allergy Testing and Immunotherapy • Operation that has consistently met or exceeded NCQA PCMH level 3, BQPP level 3, United Bridges to Excellence, Meaningful Use, NCQA DRP • Market leading private practice compensation package
Learn more about us at avancecare.com/about/about-us Apply online at avancecare.com/about/careers-providers 16
The Triangle Physician
month’s worth of medical supplies found the group would save 19.2 percent under the new program. In addition to saving on medical supplies, AID members may benefit from costsaving programs available in the following categories: • Office supplies • Reference laboratory (program varies by state) • FedEx • AT&T, Verizon and Sprint Cellular Plans – for both the practice and the employees • US Pay – merchant processing • Imaging Capital Equipment and Contrast Media
Physician Advocacy • More than 1,000 additional contracts available to AID members “Most medical groups will recoup what they
Don McGahee, who runs the group purchas-
To benefit from these savings programs, you
ing side of the program. “We believe in inde-
must be an AID member. For more informa-
pendent doctors and want to do all we can to
tion or to join, visit www.aid-us.org or call
support them,” he said.
(407) 865-4110.
spend on their AID dues in one month,” said
Duke Research News
Cellular Stress Process Identified in Cardiovascular Disease Risk Combining the investigative tools of genet-
“ER stress has long been linked to Type 1
cardiovascular disease, the mechanisms
ics, transcriptomics, epigenetics and me-
diabetes and Parkinson’s disease, among
underlying the inherited susceptibility to
tabolomics, a Duke Medicine research team
others, but this is the first indication that it is
this disease have not been fully understood.
has identified a new molecular pathway in-
also playing a role in common heart attacks
Dr. Shah said the Duke team’s research ap-
volved in heart attacks and death from heart
and death from heart disease,” said senior
proach – using a variety of analytical meth-
disease.
author Svati H. Shah, M.D., associate profes-
ods measuring more than a million data
sor of medicine and faculty at the Molecu-
points in 3,700 patients – enabled them to
The researchers, publishing online in the
lar Physiology Institute at Duke. “It’s also
fill in some of the missing steps leading to
journal PLOS Genetics, found that stress on
exciting that we are able to measure this ER
cardiovascular disease, which is often in-
a component of cells called the endoplas-
stress in a small drop of blood, providing
herited.
mic reticulum (ER) is associated with risk
a potential way to intercede and lower the
of future heart events, and it can be detect-
risk of a major cardiovascular event.”
er, if they share a trait,” Dr. Shah said. “But
ed in bits of molecular detritus circulating in the blood.
“With genetics, everyone is lumped togeth-
Even after mapping the human genome
everyone knows if you have two people
and finding genetic traits associated with
with the same trait, but one is overweight, smokes and has a bad lifestyle, that person has a different pathway that led to heart disease than someone who is normal weight, doesn’t smoke, eats right and exercises.” The Duke team focused on the intermediates between the genes and the disease pathway. This involved metabolomics – an analysis of the metabolites, or trace chemicals, left behind as the byproducts from cellular processes. Among a group of 3,700 patients referred for cardiac catheterization in the CATHGEN study, Dr. Shah and colleagues performed a genome-wide analysis of specific metabolite levels that had previously been identified as predictors of cardiovascular disease. In their earlier work, the researchers had flagged these metabolites as markers for car-
Using DNA and RNA markers, endoplasmic reticulum stress was uncovered as the biological process responsible for the increased risk of heart disease events. Credit: Mark Dubowski, Duke Medicine
diovascular disease, but had not known how november/december 2015
17
Duke Research News they were generated or what the underlying
metabolites. Once again, the ER stress path-
In addition to Dr. Shah, study authors in-
biological pathways were. The current study
way came up as a key component.
clude William E. Kraus; Deborah M. Muoio; Robert Stevens; Damian Craig; James R.
resolved that question, finding that these genes were directly linked to ER stress, which
“Using this multi-platform ‘omics’ approach,
Bain; Elizabeth Grass; Carol Haynes; Lydia
occurs when the endoplasmic reticulum or-
we identified these novel genetic variants as-
Kwee; Xuejun Qin; Dorothy H. Slentz; De-
ganelle becomes overworked in its job man-
sociated with metabolite levels and with car-
idre Krupp; Michael Muehlbauer; Elizabeth
aging excess and damaged cellular proteins.
diovascular disease itself,” Dr. Shah said. “We
R. Hauser; Simon G. Gregory; and Christo-
don’t believe that the metabolites themselves
pher B. Newgard.
Dr. Shah and colleagues then took an epi-
are causing heart attacks – they might just be
genetics and transcriptomics approach to
byproducts of a dysregulated process that
The study received funding from the Na-
determine what the differences were be-
people are genetically susceptible to – but
tional Heart, Lung and Blood Institute
tween patients with high or low levels of
that’s something we need to study further.”
(HL095987, HL101621).
Toxic Nail Polish Chemical Found
Sally Hansen, OPI, Wet N Wild Among Brands Selling Nail Polish with Endocrine Disruptor Researchers at Duke University and Environ-
cluding polishes made by Sally Hansen, OPI
associate professor at Duke University and
mental Working Group have found evidence
and Wet N Wild, contain TPHP.
principal investigator of the Duke-EWG study.
of a suspected endocrine-disrupting chemi-
“However, it’s not clear that TPHP is the bet-
cal widely used in popular nail polishes in
Visit www.ewg.org/research/nailed for a list
ter alternative. There is growing evidence
the bodies of more than two-dozen women
of brands that list TPHP as an ingredient.
suggesting that TPHP may affect hormone
who participated in a biomonitoring study.
regulation, metabolism, reproduction and More nail polishes may contain undisclosed
development.”
The study, published Oct. 14 in Environment
TPHP. The Duke-EWG study tested 10 polish-
International, found that all women had a me-
es for TPHP and found the chemical in eight
The new study raises the prospect that mil-
tabolite of triphenyl phosphate, or TPHP, in
of them. Two of the eight with TPHP did not
lions of American teens, tweens and even
their bodies just 10 to 14 hours after painting
list the ingredient on their labels.
younger girls are being exposed to a suspected hormone-disrupting chemical at a time
their nails. Their levels of diphenyl phosphate, or DPHP, which forms when the body metabo-
A number of laboratory studies have found
when their bodies are rapidly developing
lizes TPHP, had increased by nearly sevenfold.
that exposure to TPHP caused endocrine
and entering puberty. Nails Magazine, a nail
disruption. In animal studies, it has caused
salon industry trade publication, reported in
“It is very troubling that nail polish being
reproductive and developmental problems.
August 2014 that, according to market sur-
marketed to women and teenage girls con-
Recent scientific research suggests that TPHP
veys, an overwhelming 97 percent of Ameri-
tains a suspected endocrine disruptor,” said
may contribute to weight gain and obesity.
can girls ages 12 to 14 used nail products, including polish, and 14 percent of all teens
Johanna Congleton, Ph.D., M.S.P.H., a senior
and tweens used them daily.
scientist with the Environmental Working
The chemical probably functions as a plasti-
Group (EWG) and co-author of the Duke-
cizer in nail polish, rendering it more flexible
EWG study entitled Nailed: Endocrine Dis-
and durable. For years, it has been used in
Entrepreneur and eco expert Erin Schrode
ruptor In Nail Polishes Gets Into Women’s
plastics manufacturing and as a fire retardant
has dedicated her time to educating teens
Bodies. “It is even more troubling to learn
in foam furniture.
about healthier, safer lifestyle choices since co-founding the non-profit, Turning Green,
that their bodies absorb this chemical relatively quickly after they apply a coat of pol-
“It is possible that TPHP is now being used
in 2005. After learning about the dangers of
ish.”
in nail polish as a replacement for phthal-
toxic ingredients in cosmetics and personal
ates, which also have endocrine-disrupting
care products, she launched her organiza-
According to EWG’s Skin Deep cosmetics
properties and are toxic to the reproduc-
tion and went on to participate in a 2008
database, more than 1,500 nail products, in-
tive system,” said Heather Stapleton, Ph.D.,
EWG study that found a host of endocrine-
18
The Triangle Physician
Duke Research News disrupting chemicals used in everyday items
ful chemicals in our world today, but each
EWG launched a consumer petition in ear-
in her body.
of us can become informed and spread the
ly October to press companies that make
word, support legislation that protects our
popular nail polish brands to stop using
“It is alarming to think my ruby-red nail
health and make smarter choices whenever
TPHP. EWG has long called on Congress to
polish could come with a side of toxic in-
possible. By voting with our dollars we can
update federal chemical and cosmetics laws
gredients that could ultimately end up in
shift the marketplace towards safer, healthier
to better protect consumers from endocrine
my body,” said Ms. Schrode. “We cannot
products…beginning with my own bottle of
disruptors and other potentially toxic ingre-
control far too many exposures to harm-
bright, glossy nail polish.”
dients in personal care products.
UNC Research News
Pancreatic Cancer Subtypes Discovered in Large Gene Expression Analysis Dense surrounding tissue can block drugs
netics, researchers reveal findings of both
we personalize treatment
from reaching pancreatic cancer tumors,
new subtypes of stroma and two subtypes of
based on an individual
but it can also help prevent the cancer from
pancreatic cancer tumors. The findings could
patient’s tumor genetics
spreading. Now a new study by University of
help doctors tailor treatments to individual
or other characteristics,”
North Carolina Lineberger Comprehensive
patients. And the researchers say that could
Cancer Center researchers and collaborators
be particularly important for a disease that
helps explain the conflicting role of the sur-
has only a 7 percent five-year survival rate.
said the study’s senior author Jen Jen Yeh, M.D.,
a UNC Lineberger member and an associate professor and the vice chair for research in
rounding tissue known as stroma. In the study published Sept. 7 in Nature Ge-
Jen Jen Yeh, M.D.
“Right now, we still treat pancreatic cancers
the UNC School of Medicine Department of
as one entity, while for some other cancers,
Surgery. “We believe these results will set
november/december 2015
19
UNC News the groundwork for future clinical trials, al-
to separate the normal from the cancerous
spread,” Dr. Yeh said. “We are seeing two dis-
low treatments to be assigned based on the
tissue and the stroma. They were then able
tinct types of stroma in patients.”
subtypes and guide the development of new
to examine gene expression patterns for
therapies.”
each type in tissue samples from five differ-
Their analysis also revealed two subtypes
ent institutions. They analyzed 145 primary
of pancreatic cancer tumors. One subtype,
The study reveals the most rigorously vali-
and 61 metastatic tumors, 17 cell lines, as
called “basal-like,” is linked to worse out-
dated classification system for pancreatic
well as 46 normal pancreatic samples and
comes for patients. Forty-four percent of pa-
ductal adenocarcinoma to date. Previous
88 samples of normal, noncancerous tissue
tients with the basal-like subtype lived one
studies, such as a 2011 study led by Eric A.
outside of the pancreas.
year after surgery, compared to a 70 percent survival for patients with other subtype,
Collisson, M.D., an assistant professor at the University of California, San Francisco
“The issue is that pancreatic cancer is a par-
which they called “classical.” Basal-like tu-
School of Medicine, have identified subtypes
ticularly difficult cancer to analyze because
mors also trended toward a better response
of pancreatic cancer. But the researchers be-
of its confounding stroma, so we needed to
to adjuvant therapy.
lieve those attempts were confounded by the
marry the right data analysis technique to the
large amount of surrounding stroma that is
right problem,” Dr. Moffitt said.
then it may be important to treat your whole
intermixed with both normal and cancerous pancreatic tissue.
“If we know that your tumor is aggressive,
The researchers uncovered two subtypes of
body first with neoadjuvant therapy, which is
pancreatic stroma that they called “normal”
therapy given prior to surgery, as opposed to
To solve that problem, UNC Lineberger re-
and “activated.” Patients with the activated
just trying to remove the tumor with surgery
searchers used a mathematical approach
subtype had worse survival outcomes.
at the outset,” said Dr. Yeh, who, in addition to her role in the UNC Department of Surgery,
led by Richard Moffitt, Ph.D., a postdoctoral research associate at UNC Lineberger, to sep-
“This study helps make sense of research-
also has an appointment in the UNC School of
arate the tissue. That approach, called blind-
ers’ conflicting findings about stroma – that it
Medicine Pharmacology Department.
source separation, allowed the researchers
can either promote or be a barrier to tumor
Spend Time c Your Patients, Not Battling IT. Get HIPAA Compliant Solutions
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The Triangle Physician
UNC News In addition, the basal-like subtype is very
is given a therapy that is unsuccessful, that is
ics; Lindsay A. Williams of UNC Lineberger
similar to basal breast and bladder cancers,
time in which the patient’s disease has pro-
and the UNC School of Global Public Health
which respond to therapies differently than
gressed. So the goal is to start patients on the
Department of Epidemiology; Keith E. Vol-
other tumor subtypes, so we are very inter-
right therapy from the get-go.”
mar of Rex Healthcare; Samuel C. Eaton and Alexander H. Chung of the UNC School of
ested in seeing whether or not this is true for The study was supported in part by the Na-
Medicine Department of Pharmacology;
tional Cancer Institute, the University Cancer
Judy M. Anderson and Michael A. Holling-
Overall, the findings suggest that treatment
Research Fund, the Sidney Kimmel Founda-
sworth, Ph.D., of the Eppley Institute of the
decisions should be based on both a pa-
tion, the American College of Surgeons and
University of Nebraska Medical Center; Da-
tient’s stroma and tumor subtype. Dr. Yeh
a UNC Lineberger Comprehensive Cancer
vid J. Bentrem of the Robert H. Lurie Com-
said the researchers will be launching clini-
Center Postdoctoral Training Grant.
prehensive Cancer Center of Northwestern
pancreatic cancer as well.”
University and the Feinberg School of Medi-
cal trials to investigate how patients with the In addition to Dr. Moffitt and Dr. Yeh, other
cine; Mark S. Talamonti of the NorthShore
study authors include: Raoud Marayati,
University HealthSystem Department of Sur-
“For pancreatic cancer in particular, it’s a
Elizabeth L. Flate, S. Gabriela Herrera Loeza,
gery; and Christine S. Iacobuzio-Donahue of
race against the clock. Every therapy counts,
Naim U. Rashid and Jadwiga K. Smyla of
the Memorial Sloan-Kettering Cancer Center
so you want your first therapy to work,” she
UNC Lineberger; Katherine A. Hoadley of
Human Oncology & Pathogenesis Program
said. “With this cancer, you don’t have a lot
UNC Lineberger and the University of North
and of the David Rubenstein Center for Pan-
of time to try different therapies. If a patient
Carolina at Chapel Hill Department of Genet-
creatic Cancer Research.
different subtypes respond to treatment.
Bravery Goes Pink for Breast Cancer Research Innovative toy company IAmElemental is
UNC Lineberger developed from a conversa-
helping to fund breast cancer research at
tion between Ms. Kerwin and an early cus-
UNC Lineberger Comprehensive Cancer
tomer: E. Claire Dees, M.D., M.Sc., a profes-
Center at the University of North Carolina-
sor, researcher and oncologist at the cancer
Chapel Hill.
center.
IAmElemental created Pink Bravery, a 4-inch,
“I have spent the past 17 years taking care
metallic-pink action figure. All proceeds
of breast cancer patients and conducting
from its sale, along with the sale of bravery-
clinical trials to move new anti-cancer
inspired greeting cards, will be donated.
drugs to patient care. I am continually inspired by my patients, who show such
“IAmElemental’s female action figures ex-
remarkable inner power and strength, and
ist because of my mother, who inspired me
I get up every day hoping to make a differ-
not only with her own bravery in her battle
ence in this disease. We at UNC Lineberger
against breast cancer but also by teaching
are proud to be part of this unique fund-
me early critical lessons about personal
raiser, as we work to find a cure for breast
strength and empowerment. In her memo-
cancer,” said Dr. Dees.
ry, we are thrilled to align Pink Bravery with UNC Lineberger – home to some of the most
New York City-based IAmElemental is a pri-
exceptional physicians and scientists in the
vately held toy company creating the first-
country – to support their work towards
ever female action figures designed spe-
age via Kickstarter and was named by TIME
prevention, early detection and treatment of
cifically for girls (and boys!). IAmElemental
Magazine one of the “25 Best Inventions of
cancer,” said Julie Kerwin, IAmElemental’s
envisions kids as the creators of a play ex-
2014” and “Top 10 Toys of 2014.”
chief elemental officer.
perience in which they are the active agents
The partnership between IAmElemental and
in a story of their own design. Founded in
Visit www.iamelemental.com or call
2013, the company launched Series 1/Cour-
(800) 274-8282 for more information.
november/december 2015
21
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