The Triangle Physician April 2011 by TTPLLC

a p r i l 2 0 11

Wake Radiology Interventional Radiology Minimally invasive experts of the Triangle

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

Diabetes Myths

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Brief Statement The Revo MRI™ SureScan® pacing system is MR Conditional and as such is designed to allow patients to undergo MRI under the specified conditions for use. Indications The Revo MRI SureScan Model RVDR01 IPG is indicated for use as a system consisting of a Medtronic Revo MRI SureScan IPG implanted with two CapSureFix MRI® SureScan 5086MRI leads. A complete system is required for use in the MRI environment. The Revo MRI SureScan Model RVDR01 IPG is indicated for the following: • Rate adaptive pacing in patients who may benefit from increased pacing rates concurrent with increases in activity • Accepted patient conditions warranting chronic cardiac pacing include: – Symptomatic paroxysmal or permanent second- or third-degree AV block – Symptomatic bilateral bundle branch block – Symptomatic paroxysmal or transient sinus node dysfunctions with or without associated AV conduction disorders – Bradycardia-tachycardia syndrome to prevent symptomatic bradycardia or some forms of symptomatic tachyarrhythmias The device is also indicated for dual chamber and atrial tracking modes in patients who may benefit from maintenance of AV synchrony. Dual chamber modes are specifically indicated for treatment of conduction disorders that require restoration of both rate and AV synchrony, which include: • Various degrees of AV block to maintain the atrial contribution to cardiac output • VVI intolerance (for example, pacemaker syndrome) in the presence of persistent sinus rhythm

Antitachycardia pacing (ATP) is indicated for termination of atrial tachyarrhythmias in bradycardia patients with one or more of the above pacing indications. Atrial rhythm management features such as Atrial Rate Stabilization (ARS), Atrial Preference Pacing (APP), and Post Mode Switch Overdrive Pacing (PMOP) are indicated for the suppression of atrial tachyarrhythmias in bradycardia patients with atrial septal lead placement and one or more of the above pacing indications. The device has been designed for the MRI environment when used with the specified MR Conditions of Use. Contraindications The device is contraindicated for: • Implantation with unipolar pacing leads • Concomitant implantation with another bradycardia device • Concomitant implantation with an implantable cardioverter defibrillator There are no known contraindications for the use of pacing as a therapeutic modality to control heart rate. The patient’s age and medical condition, however, may dictate the particular pacing system, mode of operation, and implantation procedure used by the physician. • Rate responsive modes may be contraindicated in those patients who cannot tolerate pacing rates above the programmed Lower Rate • Dual chamber sequential pacing is contraindicated in patients with chronic or persistent supraventricular tachycardias, including atrial fibrillation or flutter • Single chamber atrial pacing is contraindicated in patients with an AV conduction disturbance • ATP therapy is contraindicated in patients with an accessory antegrade pathway

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Warnings and Precautions Changes in a patient’s disease and/or medications may alter the efficacy of the device’s programmed parameters. Patients should avoid sources of magnetic and electromagnetic radiation to avoid possible underdetection, inappropriate sensing and/or therapy delivery, tissue damage, induction of an arrhythmia, device electrical reset, or device damage. Do not place transthoracic defibrillation paddles directly over the device. Use of the device should not change the application of established anticoagulation protocols. Do not scan the following patients: • Patients who do not have a complete Revo MRI SureScan pacing system, consisting of a SureScan device and two SureScan leads • Patients who have previously implanted devices, or broken or intermittent leads • Patients who have a lead impedance value of < 200 Ω or > 1,500 Ω • Patients with a Revo MRI SureScan pacing system implanted in sites other than the left and right pectoral region • Patients positioned such that the isocenter (center of MRI bore) is inferior to C1 vertebra and superior to the T12 vertebra See the device manuals before performing an MRI Scan for detailed information regarding the implant procedure, indications, MRI conditions of use, contraindications, warnings, precautions, and potential complications/ adverse events. For further information, call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.

The Revo MRI SureScan pacing system is MR Conditional designed to allow patients to undergo MRI under the specified conditions for use. A complete system, consisting of a Medtronic Revo MRI SureScan IPG implanted with two CapSureFix MRI® SureScan leads is required for use in the MRI environment.

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Contents

COVER STORY

Wake Radiology

Excels with Minimally Invasive Procedures

A p r i l 2 011

Vol. 2, Issue 4

FEATURES

Endocrinology

Diabetes of Epic Proportion: The Role of Insulin Pump Therapy Dr. Prashant Patel describes the benefits of insulin pump therapy in managing diabetes and improving quality of life.

DEPARTMENTS 14 Womenâ&#x20AC;&#x2122;s Health Orthopedics

Conditions of the Female Athletes Shoulder Dr. Edouard Armour explains arthroscopic capsulorrhaphy and capsular release as treatment for multidirectional instability and frozen shoulder.

PMS and Periods No More

16 Endocrinology Dispelling the Diabetes Nutrition Myths

20 Health Care Reform Saving Lives or Making Money?

22 Financial Planning Do You Wear a Rolex, Or Are You Just Paying for One?

25 Radiology Uterine Fibroid Embolization Is Safe Minimally Invasive Therapy

26 Charity WakeMed Foundation Just for Kids Kampaign Tops $10 million at Midpoint

27 Hospital News New Physicians at Duke Medical

28 News Welcome, Health System News, Clinical Trials, Lectures and More

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JOHNSTON HE ALTH

From the Editor

The Wonder of It All This month’s cover story on Wake Radiology Interventional Services explores the

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

wonders of imaging-guided procedures to diagnose and treat a variety of medical conditions. Interventional radiology’s proven advantages over many surgeries include less risk, pain, recovery time and expense, prolonged life expectancy and improved quality of life. The precise, minimally invasive technique is available across all specialty areas, and new applications are discovered every year. Yet, for all of its advantages, interventional radiology is often overlooked as an alternative to open surgery. This likely could be improved with greater awareness among physicians, who are relied upon to be knowledgeable about the treatment options in order to help patients make informed choices. The cover story serves to enlighten. We also appreciate those who contributed to this issue in support of our focus on women’s health and diabetes. Dr. Satish Mathan reinforces the value of interventional radiology in the treatment of uterine fibroid embolization. Dr. Gary Berger raises concern about the exorbitant increase in the cost of a drug to reduce premature births after Food and Drug Administration approval. Dr. Edouard Armour discusses the mechanics and treatment of two conditions of the female athlete’s shoulder. Candy bars and ice cream should not be used to treat hypoglycemia. Endocrinologist Susan Spratt sets the record straight on this and other diabetes nutrition myths. Dr. Prashant Patel discusses the emerging role of insulin pump therapy, whose continuous delivery of rapid-acting insulin improves quality of life. Returning contributor Dr. Andrea Lukes offers more evidence of the role of physicians to help rid their patients of heavy menstrual bleeding and premenstrual syndrome. And certified financial planner Paul Pittman tells it like it is when it comes to paying unnecessary retirement plan fees. Once again, every page in this issue of The Triangle Physician is worth turning. It’s important for physicians, medical practices, hospitals, clinics and businesses supporting the Triangle medical community to remember that The Triangle Physician serves the region like no other publication. As always we appreciate all you do and thank you for your ongoing support.

Heidi Ketler Editor

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Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Edouard F. Armour, M.D. Gary S. Berger, M.D. Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G Satish Mathan, M.D. Prashant K. Patel, M.D., F.A.C.P. Paul Pittman, C.F.P. Susan E. Spratt, M.D. Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Joseph Dally

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The Triangle Physician is published by New Dally Design 9611 Ravenscroft Ln NW, Concord, NC 28027 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. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, 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.

On the Cover

Wake Radiology Excels with Minimally Invasive Procedures Interventional radiologists lead the Triangle Wake Radiology Interventional Services offers patients a number of benefits, including combined experience that spans nearly a century and close continuity of care, since the physician who sees the patient typically also performs the procedure. Patients benefit from the convenience and individual attention afforded by an outpatient setting at Wake Radiology’s Cary IR office.

Healthy looking legs may hide valvular dysfunction It is estimated that by age 60, approximately 50 percent of women and 25 to 30 percent of men will have chronic venous insufficiency (CVI). Wake Radiology’s Susan Weeks, M.D., a vascular and interventional radiologist, has for over 5 years been treating vein patients with CVI who suffer from a variety of symptoms that include aching, pain, heaviness, throbbing, tingling, itching, or burning. CVI usually affects two main superficial veins including the great saphenous vein (GSV) and the small saphenous vein (SSV). When associated tributaries become af-

Carroll Overton, M.D., director of interventional radiology services, leads a group of eight

fected, varicosities may develop.

In ad-

fellowship-trained interventional radiologists. “Whether it is by transvenous, transarterial, or other

dition to varicosities, other visible signs

minimally invasive means, we offer patients alternatives to many surgical procedures,” Dr. Over-

include edema and lipodermatosclerosis

ton says. Advances in image quality and speed of acquisition provide remarkable anatomic detail,

(skin color changes). It is important to note,

and innovative equipment allows high precision while sparing healthy tissue. “We work with

however, that some patients may have no

microcatheters —they are no bigger than what you’d see coming off a fishing reel,” he says.

visible signs of CVI and still have valvular

PHOTO BY BRYAN REGAN PHOTOGRAPHY

dysfunction. “It is important to have CVI in your differential, even if the person’s legs look perfectly healthy,” Dr. Weeks advises referring physicians. In addition to the more common superficial CVI, valvular dysfunction can also affect the lower extremity deep venous system, oftentimes secondary to prior deep vein thrombosis (DVT). Doppler ultrasound is frequently used to identify the exact problem. This painless examination uses a cuff (similar to a blood pressure cuff) applied to the calf just above the ankle. “We evaluate the deep and the superficial venous systems, including associated perforator and communicating veins. We look not only for appropriate valve closure, but also for the presence of venous thrombosis, both Dr. Carroll Overton and Teresa Ball, IR technologist, prepare a patient for a sclerotherapy treatment.

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chronic and acute.”

When venous insufficiency affects either

raising the possibility of significant nerve

the GSV or SSV, catheter directed thermal

injury, Dr. Weeks cautions. Instead, cath-

heat ablation, including laser or radiofre-

eter directed sclerotherapy has proven more

quency, offers a highly effective nonsurgi-

useful for ablating this segment of the GSV.

cal treatment. “Endovenous laser ablation

This is accomplished via the straightforward

(EVLA) is a one-hour procedure performed

placement of a small-bore, end-hole catheter

in our office with local anesthesia and an

into the below-knee GSV under ultrasound

oral relaxant such as Xanax,” Dr. Weeks

guidance. A sclerosant is then gently in-

explains. Using ultrasound for guidance,

jected through the catheter as it is slowly

Wake Radiology Cary interventional office and

a laser fiber is advanced up the vein to be

withdrawn, resulting in irritation, inflamma-

WR Northwest Raleigh. Patients may request

treated, the surrounding soft tissues are

tion, fibrosis, and resorption of the vein.

an appointment online at wakerad.com or

Treatment timeframe is another consid-

Interventional Services scheduler will contact

eration. Patients with more acute medical

the patient within one business day to set up

anesthetized with dilute local anesthetic, and the dysfunctional vein is ablated with a gentle pullback of the catheter, allowing a constant deposition of energy along the length of the vein. This results in inflammation and fibrosis of the treated vein, with eventual resorption by the body.

problems such as ulceration, hemorrhage, or recurrent thrombophlebitis can be treated immediately. But for patients whose painful legs are interfering with activities of

Available 24/7 at wakerad.com

Free Vein Therapy Consultations Wake Radiology Interventional Services offers an initial vein consultation free of charge at the

by calling 919-854-2180. A Wake Radiology

the appointment.

unfortunately, we still do not understand all of the variables involved!”

daily living, most insurers require a trial of

An important point to remember is that

“The EVLA procedure is 95-98 percent ef-

conservative therapy: the use of 20mm to

CVI is a lifelong diagnosis. With the current

fective and does not carry with it the asso-

30mm compression stockings, elevation,

technologies, CVI is not cured, and valves

ciated morbidity seen in conjunction with

over-the-counter pain medications, and at-

that were once functioning normally can

surgical stripping procedures,” Dr. Weeks

tempted avoidance of activities that exacer-

become incompetent, which may or may

says. “Patients walk out of the room when

bate symptoms. For some, the compression

not result in significant symptomatology.

they are done, and the next day they are

stockings work well, Dr. Weeks says. For

Dr. Weeks emphasizes to her patients that

back to normal activities as tolerated, ex-

others, symptoms recur when they take off

once they have chronic venous insufficien-

cept no heavy exercise and no long travel

the stockings, and with insurance company

cy, they will always have it. “We tell our pa-

for two weeks. The most onerous part for

approval, they proceed to treatment.

tients to keep an eye on their legs for any

many patients is that we have them wear their compression stockings for two weeks following the procedure.” While EVLA effectively ablates long, nontortuous superficial veins, protruding varicosities can be treated percutaneously as well. After dilute anesthetic is administered, tortuous varicose veins are sequentially removed via tiny (two millimeter) incisions created along the length of the vein. A hook instrument is used to gently extract the vein, segment by segment. This is known as an ambulatory phlebectomy, and is often performed in conjunction with EVLA. While symptoms resolve for most patients following EVLA with or without phlebectomy, some patients may have persistent symptoms that can be due to untreated venous insufficiency involving the GSV below the knee. Currently, heat ablation is not commonly used in conjunction with belowknee GSV reflux because the saphenous nerve runs in close proximity to the vein,

While many patients with CVI are significantly symptomatic, others may be more concerned solely with the appearance of their legs. In the latter patient population, sclerotherapy and microphlebectomy are also useful. Both procedures have their advantages and disadvantages. Dr. Weeks notes, “Phlebectomy is an excellent minimally invasive procedure, well tolerated by patients, and it results in the absolute removal of the vein 99+ percent of the time. However, when compared with sclerotherapy, it is a bit more invasive, requires tiny incisions, and the procedure is a bit longer than sclerotherapy. Sclerotherapy involves straightforward injections with a tiny 30-gauge needle into the vein. No prepping is required, there are no incisions, and it is usually a 30-minute procedure. The disadvantage of sclerotherapy is that it may require more than one treatment to make the vein completely resolve, whether it is a spider vein or a 5-millimeter varicosity. It is multi-factorial whether or not a single sclerotherapy session will be successful, and

changes in appearance as well as changes in symptomatology, and we recommend they continue to wear at least mild compression stockings as frequently as they can in order to maintain good leg health.” Venous obstruction in the pelvis may cause leg symptoms Besides

valvular

dysfunction,

another

cause of leg symptoms is venous outflow obstruction in the pelvis. “This can be seen especially in patients who have had a history of deep vein thrombosis,” Dr. Weeks notes. CT or MRI is used for diagnosis, with a preference for MRI because it does not use radiation. One of the more common findings is May-Thurner Syndrome, in which the right common iliac artery is compressing the left common iliac vein. Extrinsic venous compression can result in scarring of the vein, with or without associated thrombosis. If thrombosis is present, catheter-directed thrombolysis may be indicated. Once the vein is recanalized, a stent is usually required to maintain patency. APRIL 2011

These two images demonstrate a solid complex nodule with shadowing macrocalcifications. Although this lesion is smaller than the dominant nodule, the irregular appearance of the macrocalcifications raised our concern. This was proven to be a papillary carcinoma on the biopsy.

Stent placement is performed under fluoroscopic guidance, using catheter venography as a roadmap. “You always have to keep in the corner of your mind that venous obstruction in the pelvis is another possible cause of leg symptoms,” she says. Minimally invasive UFE offers alternative to hysterectomy Of the 600,000 hysterectomies performed each year, perhaps half are due to leiomyomatous disease. As the nation strives to reduce this number, Wake Radiology’s interventional radiologists team with gynecologists to offer patients a nonsurgical option: uterine fibroid embolization (UFE). The procedure is performed in a hospital and includes an overnight stay for pain management. Approximately 90 percent of women receive relief from symptoms, and the complication rate is a low 0.2 percent. Candidates are women with uterine leiomyomata who no longer desire fertility. For their diagnostic imaging, Dr. Overton explains, “If they have a high-quality ultrasound that gives us the answer, that is good enough. If they do not have prior imaging, or if the ultrasound shows something that is unclear, we will proceed to MRI for diagnostic imaging prior to treatment.” “This is a transarterial procedure, very much like heart catherization, with the same access in the top of a leg as a heart catheter, but we stop in the pelvis,” he explains. “This can be challenging, but the success rate of completing the procedure is about 98 percent in the United States.”

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Follow-up does not involve additional imaging unless there is a concern, he adds, and the recurrence rate is less than 10 percent.

dure performed under mild IV sedation and local anesthetic, and it takes approximately

Nonsurgical embolization relieves women’s pelvic pain Another minimally invasive procedure that benefits women is embolization to treat pelvic congestion syndrome, also referred to as pelvic venous insufficiency. This painful condition, which can last for years and affect every element of a woman’s life, is caused by reflux of blood in the ovarian vein. The malady primarily affects women during their childbearing years. “This is a source of discomfort that is very much under-diagnosed,” explains vascular and interventional radiologist Michael Kwong, M.D. “But it is a very well-known, well-documented entity, and we have a nonsurgical treatment for it.” For this image-guided outpatient procedure, a tiny nick is made at the groin, a small catheter is inserted, and the ovarian vein is permanently occluded using coils and either a sclerosant or an embolic agent. This forces venous blood return to seek normal collateral veins that have competent valves, thereby resolving the problem.

Thyroid nodule biopsies help diagnose cancer

Variococele embolization can improve infertility in men Similar to pelvic congestion syndrome, reflux in the testicular veins can produce varicoceles in men. Nonsurgical embolization can also be used to treat men suffering from varicoceles, abnormally enlarged veins in the scrotum that can cause pain, testicular atrophy, or infertility. Varicocele embolization is also an outpatient proce-

sound provides size criteria and scientific,

two hours.

In the diagnostic arena, image-guided biopsies increasingly provide definitive answers without the pain, long recovery, and expense of surgery. This is the case for thyroid nodules that frequently are incidental findings on chest CT, cervical spine MR, or carotid ultrasounds. One in ten thyroid nodules is cancerous, and physicians need to know how concerned they should be. “The imaging evaluation begins with a highresolution ultrasound to assess the physical nature of the nodule,” Dr. Kwong explains. “If a nodule is confirmed to be solid and has indeterminate characteristics, then a nuclear medicine scan may be performed to assess the physiological nature of the lesion.” How large should a nodule be before it is appropriate to biopsy it? That’s a frequent and important question, Dr. Kwong acknowledges. “The consensus statement from the Society of Radiologists in Ultradata-driven recommendations on that.” (See chart.) The

biopsy

performed

Wake

Radiology’s Cary IR office, where the interventional suite provides a sterile operative setting. A repeat high-resolution ultrasound is performed to confirm the diagnostic findings prior to the procedure. “If I see there

are tiny calcifications or an area that is more vascular, I specifically target the most suspicious area—even if the nodule is only a centimeter in size,” Dr. Kwong notes. He adds, “We are meticulous about our technique. We take a minimum of three to four passes each time, although only one may be needed. 85 to 90 percent of the time, we get diagnostic results.” In addition to thyroid nodules, the interventional radiologists also perform biopsies of lymph nodes and the parotid gland. We call or fax all reports to the referring physician to make sure all pathology reports are received. If the diagnosis is cancer, we are sure to make a doc-to-doc phone call as well. Dr. Kwong phones the referring physician to discuss the findings, and a faxed copy of the pathology report is forwarded to the referring office. Even if the biopsy is nondiagnostic, he adds, “We often call the referring doctor to discuss what we think, in terms of imaging. Sometimes the imaging strongly favors a benign process. Even though it technically falls into the category of nondiagnostic, the imaging along with a biopsy that shows no malignant cells may provide enough information to help make a decision.”

Less invasive techniques aid oncology patients Wake Radiology Interventional Services has a well-established record of helping cancer patients. “Our skills in doing image-guided procedures match up well with oncology,” says Philip Pretter, M.D., a vascular and interventional radiologist. “Referring physicians realize there is a lot of value in less-invasive techniques, and the ability to do some procedures as an outpatient is quite beneficial to the patient.” One strength is image guidance for non-surgical biopsies. “If the tumor is very small, you may only see it with a CT scan, an ultrasound, or an MRI. Being able to direct a needle under the guidance of that machine taking pictures allows you to precisely target that lesion. “This is something we can do with an 18- or a 20-gauge needle that requires no stitches, just a tiny nick in the skin, local anesthesia, and a little bit of conscious sedation,” he says. Interventional techniques play a role in treatment as well. Radiofrequency ablation treats liver or kidney tumors and has even been used on lung tumors, Dr. Pretter notes. For palliative care, interventional radiologists can treat metastatic liver disease with radioactive microspheres or with chemoembolization,

which directly deposits a high concentration of chemotherapy to the target location. Outpatient port placement at Wake Radiology saves time, reduces stress To help ease the pain and stress of cancer treatment, Interventional Services offers outpatient placement of ports and catheters. Some allow access to veins for lab work, medications, or chemotherapy, and the newer power-injectable ports can accommodate the injection of contrast for follow- up CT scans. Port placement, which takes about an hour or slightly less, is performed in the Cary IR office. “We use ultrasound and fluoroscopic guidance to place ports accurately, so that they function well for long periods of time,” says Dr. Pretter. “Many outpatients come in, have the port placed, and oftentimes start chemotherapy the same day.” Techniques help relieve complications of cancer A number of interventional procedures help oncology patients with complications such as ascites or pleural effusions. “We are often asked to do a paracentesis to remove the fluid from the abdomen or a thoracentesis to remove excess pleural fluid from around the lungs. These procedures can be both

Society of Radiologists in Ultrasound Recommendations for Thyroid Nodules 1cm or Larger in Maximum Diameter Ultrasound feature

Recommendation

Solitary nodule – microcalcifications

Strongly consider ultrasound-guided FNA if > 1 cm

Solid (or almost entirely solid) or coarse calcifications

Strongly consider ultrasound-guided FNA if 1.5 cm

Mixed solid and cystic or almost entirely cystic with solid mural component

Consider ultrasound-guided FNA if > 2 cm

None of the above, but substantial growth since prior ultrasound examination

Consider ultrasound-guided FNA

Almost entirely cystic and none of the above and no substantial growth (or no prior ultrasound)

Ultrasound-guided FNA probably unnecessary

Multiple nodules

Consider ultrasound-guided FNA of one or more nodules, with selection prioritized on basis of the criteria (in order listed) for a solitary nodule*

*The panel had two opinions regarding selection of nodules for FNA. The majority opinion is stated here.

APRIL 2011

Patient Case: Gastric Hemorrhage Patient is a 40-year-old male with acute hemorrhage into the stomach from a gastric ulcer that could not be stopped by endoscopy. A catheter was threaded into the left gastric artery, and the artery was temporarily blocked with gelfoam embolization. This case stands as an example of how interventional radiologists can address problematic bleeding in various locations. Often patients have significant hemorrhage in locations that surgeons have great difficulty accessing, the patients are in poor health, or are anti-coagulated. Embolization may be a viable treatment for these cases.

This image shows the circulation to the stomach before treatment.

diagnostic and therapeutic as the fluid can be sent for laboratory analysis. Higher volume thoracenteses also help patients breathe more easily and more comfortably, while higher volume paracentesis typically decreases the pain and discomfort from excess peritoneal fluid. “Using ultrasound, we can, in a few minutes, direct a small tube into the fluid and drain it out over a period of 20 minutes to an hour. The patient goes home shortly after that, and usually feels much better immediately. Occasionally, we put in a PleurX® catheter so the patient can drain the fluid at home.” Vertebroplasty/Kyphoplasty show 75% to 90% success rate in relieving pain The skilled hands of experienced interventional radiologists provide vital help in relieving the severe pain of vertebral compression fractures. These fractures are most frequently caused by osteoporosis, a widespread and costly disease. “There are 10 million Americans with osteoporosis and another 34 million at risk of developing the disease,” notes Pete Leuchtmann, M.D., a joint and spine interventional specialist who is fellowship trained in both interventional and musculoskeletal radiology. “The annual cost for fractures due to osteoporosis is on the order of $20 billion. In the United States, there are an estimated 700,000 vertebral compression fractures each year.” For the appropriate patient population, Dr. Leuchtmann says, minimally invasive vertebral augmentation procedures—vertebroplasty or kyphoplasty—are the most effective therapy. “Some 75 to 90 percent of patients show significant relief, typically within the first days after the procedure.” Vertebroplasty involves a fluoroscopically guided injection of bone cement into the fractured vertebra. Kyphoplasty utilizes a balloon to create a void and correct the deformity, restoring some height to the fractured vertebra. A similar procedure, sacroplasty, is used to treat sacral fractures.

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This image shows the blood vessel after embolization.

“The patients for whom this treatment is most appropriate are usually in their fifties or older, have osteoporosis, and have developed a fracture from weakened bones,” Dr. Leuchtmann explains. Indications for treatment include acute or subacute onset of back pain, most often with point tenderness, and pain that interferes with normal daily activities without medication. Wake Radiology interventionalists also treat vertebral fractures in cancer patients, typically those with advanced-stage cancer or cancer with bone metastases. “Imaging studies to demonstrate compression fracture should always begin with radiographs,” Dr. Leuchtmann says. Most patients undergo an MRI during their workup to determine the acuity of the compression fracture. For patients who cannot undergo an MRI, a bone scan and CT scan combination can be performed. These findings are crucial in determining which patients will most likely benefit. “Optimal results are obtained in patients with active bone edema on MRI, usually within two to six weeks of their fracture,” he says. Numerous factors affect the interventional radiologist’s choice of vertebroplasty or kyphoplasty, among them the fracture location. “We are not able to treat fractures in the highest portion of the thoracic spine because of the smaller size of the vertebra at those levels. Typically, the highest level we treat with Balloon Kyphoplasty is T7. We may go up to the T5 level with vertebroplasty.” Vertebroplasty is performed as an outpatient procedure at WakeMed in Raleigh. It requires only conscious sedation and local anesthesia, and it takes about 40 minutes. Using c-arm fluoroscopy as a guide, the interventional radiologist inserts a needle/cannula into the fractured vertebral body and infuses it with surgical bone cement, polymethyl methacrylate. The cement hardens within 15 minutes, stabilizing the fracture and preventing further collapse.

The overwhelming majority of patients report no pain from the procedure itself. If necessary, more than one vertebral level can be performed in a single setting. Post-procedural fluoroscopic images are obtained for documentation. After a vertebroplasty, patients remain in bed for two hours. Patients often report improvement immediately, and most report pain relief or significant improvement over the next 48 hours. Vertebroplasty has a typical success rate of greater than 80 percent for patients with osteoporosis and greater than 50 to 60 percent for treatment of neoplastic fractures. Vertebroplasty has been shown to be safe when performed in the appropriate setting by a well-trained physician. The incidence of complications is less than 1 percent in osteoporotic patients and less than 5 percent in the neoplastic population. Balloon Kyphoplasty, a slightly more invasive procedure, is also performed at WakeMed in Raleigh. This procedure, like vertebroplasty, is usually performed on an outpatient basis, although there are times when inpatients need the procedure as well. With kyphoplasty, a balloon introduced into the center of the vertebral body is used to create a cavity in the bone and to increase the height of the fractured vertebra. The space is then filled with bone cement. Pain relief can be dramatic and nearly complete in more than 80 percent of patients.

“Overall, vertebral augmentation procedures have provided dramatic relief for countless patients with debilitating pain,” Dr. Leuchtmann says. “No longer suffering from the fractures, these individuals can avoid the side effects (deconditioning, pulmonary complications, etc.) of being bedridden or on narcotic pain medications, and they can return to their normal activities and enjoy their lives.” Saving the lives of trauma patients Quite often a Wake Radiology interventional radiologist gets a call and heads for WakeMed’s emergency department, one of the busiest in the state. Thomas Presson, M.D., a vascular

“Those are particularly gratifying because the injuries are life-threatening. A surgical approach is felt to be dangerous by the surgeons, and that’s why they’ve asked us to look at them. In some cases, it’s one of the few alternatives a patient may have,” Dr. Presson says.

Wake Radiology interventional Services VENOUS ACCESS • Chest Ports • PICCs • Hickmans • Catheter Removals • Dialysis Access • Shuntgrams/Fistulagrams with revascularization

and interventional radiologist, describes the

VARICOSE VEIN THERAPIES

typical situation. “Acute hemorrhage in a trau-

• Laser Ablation of Superficial Venous system • Microphlebectomy • Sclerotherapy • Topical Laser for Spider Varicosities

ma patient is a typical emergency case. Bleeding may be caused by penetrating trauma or blunt trauma, such as a car accident. Bleeding from small vessels, or vessels within organs such as the liver or spleen, may be particularly hard to approach surgically due to the risk of further disturbing the damaged organ. In that case, we do an embolization where you run a little catheter right up into the bleeding vessel and block it off.”

THYROID BIOPSIES PARACENTESIS / THORACENTESIS BONE THERAPIES • Balloon Kyphoplasty • Vertebroplasty • Facet Injection • SI Joint Injection

CONSULTATIONS FOR

“If a trauma patient is particularly unstable, our objective is to immediately find the bleeding vessel and stop the bleeding. Sometimes you embolize the bleed site without even seeing exactly which vessel is disrupted, because you have to do something before it’s too late.

• Vein Therapies • Vertebral Compression Fractures (Kyphoplasty/Vertebroplasty) • Uterine Fibroid Embolization (UFE/UAE) • Tumor Therapy (Radiofrequency Ablation) • Peripheral Arterial Disease

Long-term ascites/pleural effusion drainage catheter placement (PleurX®)

Patient Case: Liver Brachytherapy treatments Patient is a 74-year-old woman with metastatic carcinoma of the pancreas, progression despite conventional therapy, and prior Whipple procedure. The patient was referred for liver brachytherapy with radioactive microspheres. This case shows an end-stage malignancy that has failed to respond to first-line therapy. The malignancy is widespread in the liver, which precludes surgical removal of a portion of the liver. Brachytherapy can treat the whole liver while preserving liver function, often significantly slowing the progression of disease, and it is sometimes curative. Our physicians support local radiation oncologists with arterial procedures for their liver brachytherapy patients.

This image shows one of the hepatic lesions on the CT scan.

Numerous hepatic metastases on an angiogram.

Hepatic arteries following microsphere infusion.

Distribution of the test dose of radiation concentrated in the liver.

APRIL 2011

Meet Our Interventional Radiologists Carroll C. Overton, MD Vascular & Interventional Radiologist Director of Interventional Services • Medical School | University of North Carolina School of Medicine, Chapel Hill • Residencies | Diagnostic Radiology, Mercy Hospital of Pittsburgh; Diagnostic Radiology, University of Pittsburgh Medical Center; Surgical Residency, Mercy Hospital of Pittsburgh • Fellowship | Interventional Radiology, Alexandria Hospital, Alexandria, VA • Certification | American Board of Radiology – Diagnostic Radiology • Appointments | Director of Interventional Services, Wake Radiology; Chairman, Credentials Committee, WakeMed (2010) • Membership | Society of Interventional Radiology, North Carolina Medical Society, Wake County Medical Society • Joined practice in 1998 Alan B. Fein, MD Vascular & Interventional Radiologist • Medical School | Columbia University College of Physicians and Surgeons, New York • Residencies | Internal Medicine, Emory University Affiliated Hospitals, Atlanta; Diagnostic Radiology, Duke University Medical Center, Durham • Fellowships | Mini-fellowship Vascular Interventional Radiology, Duke University Medical Center; Vascular IR and Abdominal Imaging, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO • Certifications | American Board of Radiology – Diagnostic Radiology, American Board of Internal Medicine, National Board of Medical Examiners • Memberships | ACR, Society of Interventional Radiology, North Carolina Medical Society • Joined practice in 1986 Andrew Wu, MD Vascular & Interventional Radiologist • Medical School | Washington University School of Medicine, St. Louis • Residency | Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis • Fellowship | Interventional Radiology, University of Michigan Medical School, Ann Arbor • Certification | American Board of Radiology – Diagnostic Radiology • Appointments | President, NC state chapter of ACR (2010), Fellow of American College of Radiology (5/2011) • Memberships | American College of Radiology, Society of Interventional Radiology, North Carolina Medical Society, Wake County Medical Society • Joined practice in 1991 Philip C. Pretter, MD Vascular & Interventional Radiologist • Medical School | University of Pittsburgh School of Medicine, Pittsburgh • Residency | Diagnostic Radiology – Chief Resident, University of Pittsburgh Medical Center • Fellowship | Interventional Radiology – Fellow of the Year, Department of Radiology, University of Pittsburgh School of Medicine • Certifications | American Board of Radiology – Diagnostic Radiology • Appointments | Vice Chairman, Department of Radiology, WakeMed Raleigh Hospital

Thomas L. Presson Jr., MD Vascular & Interventional Radiologist • Medical School | Bowman Gray School of Medicine, Wake Forest University, Winston-Salem • Residency | Diagnostic Radiology, Duke University Medical Center, Durham • Fellowship | Vascular and Interventional Radiology, Duke University Medical Center • Certification | American Board of Radiology – Diagnostic Radiology • Appointments | Radiation Safety Officer – Wake Radiology, WakeMed Raleigh, WakeMed Cary Hospital • Memberships | American College of Radiology, Society of Interventional Radiology, North Carolina Medical Society, Wake County Medical Society • Joined practice in 2001 Michael D. Kwong, MD Vascular & Interventional Radiologist • Medical School | University of Texas School of Medicine, San Antonio • Residency | Diagnostic Radiology, Boston Medical Center • Fellowship | Vascular and Interventional Radiology, University of California San Diego Medical Center • Certification | American Board of Radiology – Diagnostic Radiology • Memberships | Society of Interventional Radiology, Radiological Society of North America, American College of Radiology, North Carolina Medical Society, Wake County Medical Society • Joined practice in 2003 Peter L. Leuchtmann, MD Vascular & Interventional Radiologist Musculoskeletal Radiologist • Medical School | Indiana University School of Medicine, Indianapolis • Residency | Diagnostic Radiology, University of Maryland School of Medicine, Baltimore • Fellowships | Cardiovascular/Interventional Radiology, The Johns Hopkins Hospital, Baltimore; Musculoskeletal Radiology, University of North Carolina Hospitals, Chapel Hill, NC • Certifications | American Board of Radiology – Diagnostic Radiology, International Society for Clinical Densitometry • Memberships | American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, Society of Interventional Radiology, International Spine Intervention Society, North Carolina Medical Society, Wake County Medical Society • Joined practice in 2006 Susan M. Weeks, MD Vascular & Interventional Radiologist • Medical School | University of North Carolina School of Medicine, Chapel Hill • Residency | Diagnostic Radiology, University of North Carolina Hospitals, Chapel Hill • Fellowship | Vascular and Interventional Radiology, University of North Carolina Hospitals, Chapel Hill • Certification | American Board of Radiology – Diagnostic Radiology • Memberships | American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, Society of Interventional Radiology, North Carolina Medical Society, Wake County Medical Society • Joined practice in 2006

• Memberships | American Roentgen Ray Society, Radiological Society of North America, Society of Interventional Radiology, NC Medical Society, Wake County Medical Society • Joined practice in 2000

Wake radiology EXPRESS SCHEDULING STREAMLINE YOUR SCHEDULING With Wake Radiology’s Express Scheduling, scheduling patients throughout the region takes only one call or fax to order any service. As an additional feature, Wake Radiology Express Schedulers will contact referring physicians’ patients to coordinate the best date, time, and location for their procedures. WR Express Scheduling

919-232-4700

Wake Radiology Interventional Radiology & Vein Therapy Center 300 Ashville Avenue Ste 160 Cary, NC 27518 Interventional Radiologist Physician Hotline 919-854-2180

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wakerad.com

Endocrinology

Diabetes of Epic Proportion: The Role of Insulin Pump Therapy By Prashant K. Patel, M.D., F.A.C.P.

Now commonplace, insulin pumps improve a patients ability to take control of their diabetes and lead more productive lives. With

the

ever-growing

population

Dr. Prashant Patel is director of The Diabetes Center at Cary Internal Medicine & The Diabetes Center in Cary. The internist/ diabetologist is board certified with the American Board of Internal Medicine and a fellow of the American College of Physicians. He has been recognized for excellence in diabetes and heart/stroke care by the National Committee for Quality Assurance. Dr. Patel is also a member of North Carolina Medical Society Legislative Cabinet and the State Health Coordinating Council, and serves as president of the Triangle Indian-American Physicians Society. For questions or comments, he can be reached at ppatel1110@hotmail.com or (919) 467-6125. The practice website is www. caryinternalmedicine.com.

basal insulin, such as Lantus or Levemir, and

(the difference between the highest and

overweight and obese individuals (over

separate mealtime insulin for better diabetes

lowest glucose levels).

two-thirds of adults in the United States)

control and a minimization of hypoglycemia.

increasing at alarming rates, the rest of the

• Reduction

severe

hypoglycemic

episodes.

world, with America taking the helm, faces

Despite such options, the inconvenience of

• Diabetes management made easier when

an epidemic of diabetes.

four insulin injections a day, labile diabetes

one wants to eat or if glucose is elevated.

control has lead to the emergence of the

The

While the United States houses 4.5 percent

need for better options. Hence, the emerging

of insulin to take based on “preset”

of the world’s general population (310

role of insulin pump therapy, providing

parameters and then presses a button on

million out of 6.9 billion), it is home to

continuous and seamless delivery of short

the pump.

a vastly disproportionate portion of the

or rapid-acting insulin.

patient

calculates

the

amount

• Greater flexibility about when and what

diabetic population. Worldwide, as per the

one eats.

World Health Organization (WHO), diabetes

• Ability to exercise without having to

prevalence exceeds 220 million, and in the

consume large amounts of carbohydrate.

U.S. we have a vast 25.8 million diabetics. Hence, we have a disproportionate 11.7

However, just as there are pros to the use

percent of the world’s diabetic population

of insulin pumps, consideration should

within our borders.

be given to the cons. The disadvantages include:

In 1921, Drs. Frederick Banting and Charles

• Possible weight gain.

Best at the University of Toronto made the

• DKA if the catheter comes out and insulin

greatest discovery in the field of diabetes,

is not being pumped for hours.

insulin. Previously, diabetes was a death

• Expense.

sentence, as the lives of type 1 diabetics

Insulin

were cut short due to diabetic ketoacidosis

an attractive solution for many insulin-

(DKA) and type 2 diabetics, by nonketotic

dependent diabetics. Advantages include:

hyperosmolar coma.

• Eliminating individual insulin injections.

Despite concerns about the disadvantages,

• Greater accuracy in insulin delivery.

most patients have preferred the pump to

• Often improved A1c, also known as HbA1c

multiple daily injections. Hence, insulin

or glycated hemoglobin (a good general

pumps have become more commonplace,

measure of diabetes care).

and permitted many patients to take control

To this day, while numerous oral and injectable

medications

have

been

developed, often patients, ultimately, require

pump

therapy

has

provided

insulin. Over one-fourth of all diabetic

• Fewer large swings in blood glucose or

patients are on insulin. Many, however, use

improvement in the glycemic excursion

• Bothersome attachment to the pump most of the time.

of their diabetes and lead more productive lives. APRIL 2011

Womenâ&#x20AC;&#x2122;s Category Health

PMS and Periods No More By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G

Study underscores the need to emphasize to patients with heavy menstrual bleeding and premenstrual syndrome that there are effective treatments. Recent research has shown the benefits of NovaSure endometrial ablation in the treatment of heavy menstrual bleeding and symptoms of premenstrual syndrome, two common problems for reproductive-aged women. A recent review of NovaSure endometrial ablations showed that this technology has one of the higher amenorrhea (no periods) rates compared to competing devices with one-year rates of amenorrhea at 44 percent

The Triangle Physician

to 56 percent and with prospective cohort studies showing higher rates at five years between 58 percent to 75 percent1. So for women with heavy periods, this is an effective treatment. The important aspect for these patients is that prior to having a NovaSure endometrial ablation they should: 1) have completed childbearing, and 2) have an endometrial sampling or biopsy showing normal endometrium (lining of the uterus).

The Carolina Womenâ&#x20AC;&#x2122;s Research and Wellness Clinic (CWRWC) coordinated a study using obstetricians and gynecologists within North Carolina to evaluate the impact of NovaSure endometrial ablation on symptoms of premenstrual syndrome (PMS). The study showed that in women with heavy menstrual bleeding, PMS significantly improves after having a NovaSure endometrial ablation. Measurement of PMS was done using validated instruments, called the DSR (Daily Symptoms Report) and DRSP (Daily Record of Severity of Symptoms). This is encouraging news for women with both heavy bleeding and PMS. Our findings were presented at the 2010 American Association of Gynecological Laparoscopists congress in Nevada. Updated data was submitted to the Journal of Minimally Invasive Gynecology in March.

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 co-founded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position in 2007 to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.

In an important survey of 906 women with heavy periods, associated symptoms included pain, mood changes and feeling tired2. All are also part of PMS.

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The key elements of the diagnosis of PMS include prospective recording of symptoms that are restricted to the luteal phase of the menstrual cycle, impairment of some facet of a woman’s life and exclusion of other diagnoses3. The symptoms of PMS are divided into affective (mood) or somatic (physical). Notably, up to 85 percent of women have one or more symptoms of PMS3. We are excited to present this information to our patients and colleagues, because it underscores the need to emphasize to patients with HMB and PMS that there are effective treatments. For more information, call Women’s Wellness Clinic at (919) 251-9223. References 1. Bongers M, Second-generation endometrial ablation treatment: NovaSure, Best Pract Res Clin Obstet Gynaecol, 21(6):989-94, 2007 Dec. 2. Santer M, Wyke S, Warner P, What aspects of periods are most bothersome for women reporting heavy menstrual bleeding? Community survey and qualitative study, BMC Women’s Health, 7:8, 2007. 3. ACOG practice bulletin, Number 15, April 2000.

APRIL 2011

Endocrinology

Dispelling the Diabetes Nutrition Myths

What All Doctors, Nurses and Patients Need to Know About Diabetes Nutrition By Susan E. Spratt, M.D.

Diabetes has reached epidemic proportions in the southeastern United States. Recently, the Centers for Disease Control and Prevention released county-by-county maps of the level of inactivity in the U.S. (Figures 1a and 1b). Not surprisingly, counties where physical inactivity levels are the highest also have the highest rates of diabetes. Although there are more than seven classes of medications to treat type 2 diabetes (Table 1), lifestyle changes, in addition to medical therapy, remain a mainstay of therapy for achieving better glucose control. Despite the importance of nutrition, exercise and weight loss in controlling and preventing diabetes, there are multiple barriers to adopting healthier habits, not the least of which are the many myths that abound about diabetes nutrition. This misinformation is propagated by the media, family members and even health care providers. So it’s understandable that patients with diabetes are confused about which measures to adopt to achieve good glucose control. Because what we eat is so important to diabetes control and prevention, a group of diabetes physicians and nutritionists from Duke University Medical Center and Durham Public Health Department have been visiting primary care practices to discuss five big myths of diabetes nutrition.

Figure 1a. Percent of County with No Leisure-Time Physical Activity

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Control portions Probably the most popular myth is that patients with diabetes should eat a lowcarbohydrate diet. Obviously, the type and quantity of carbohydrates impacts glucose control. However, rather than advising patients to remove carbohydrates from their diets completely, we recommend normal portions of starch or carbohydrate at each meal. Because the average portion of food served in restaurants and sold in containers has increased substantially, many patients need education on what a normal portion is. Just by reducing portion, many patients with type 2 diabetes can see dramatic changes in their glucose levels. Another myth is that brown food, considered whole grains or foods in their natural state, are good, and white food, which is often refined, is bad. However, non-white foods can also contain large amounts of carbohydrates and sugar. The other confusion about white and brown foods comes from the concept of the glycemic index. The list of foods and where they lie on the glycemic index was developed by David Jenkins, M.D., at the University of Toronto. He compared the rise in glucose after two hours of each food compared to a standard 50g glucose challenge.

Dr. Susan Spratt is with the Duke Medicine endocrinology, metabolism and nutrition department. A graduate of Harvard Medical School, Dr. Spratt completed her residency in internal medicine at Beth Israel Deaconess Medical Center and a fellowship in endocrinology at Duke University Medical Center. Clinical interests include primary hyperparathyroidism, osteoporosis, diabetes types 1 and 2, diabetes in pregnancy, insulin pumps, Graves’ disease, papillary and follicular thyroid cancer. To reach Dr. Spratt, call (919) 668-5314. To make an appointment with her, call (919) 668-7630.

White bread, rice and potatoes are higher on the glycemic index list than whole wheat bread, wild rice and sweet potatoes. If a patient with diabetes chooses to eat carbohydrates that are lower in glycemic index, these foods won’t be digested as quickly into glucose, blunting a glucose spike. However, if a patient chooses to eat twice as much brown rice and sweet potatoes because these foods aren’t white, glucose control will be impacted adversely. Portion size is still key. Don’t’ confuse calories and carbs Many people confuse calories with carbohydrates. Patients often don’t know

Figure 1b. Bottom and Top Quartiles for Diabetes, Obesity and Leisure-Time Physical Activity

As health care providers, we can provide a clinical environment where the benefits of good nutrition and exercise are promoted and taught. which foods contain carbohydrate and which foods contain mostly protein or fat. Because public health is benefited by eating fewer fried or salty foods, patients can be confused about which diet advice affects which medical problem. It’s important to explain to patients the categories of foods that contain

carbohydrates, and that eggs and bacon, while caloric, don’t contain carbohydrates. Avoid fatty foods to treat hypoglycemia The last big nutrition myth for patients with diabetes is in regard to treating hypoglycemia. It should be treated with rapid-acting glucose, such as 4 ounces of

Table 1. Classes of Medication for Type 2 Diabetes Mellitus Class

Generic (Brand) Name

Route of Administration

Sulfonylureas

Glimeperide (Amaryl) Glipizide (Glucotrol) Glyburide (Diabeta, Micronase)

Oral

Non Sulfonylurea Insulin Secretagogues

Nateglinide (Starlix) Repaglinide (Prandin)

Oral

Biguanides

Metformin (Glucophage)

Oral

Thiazolindenediones

Pioglitazone (Actos)

Oral

Alpha Glucosidase Inhibitors

Acarbose

Oral

Insulin

Multiple options

SQ Injection

GLP-1 Agonists

Exenatide (Byetta) Liraglutide (Victoza)

SQ Injection

Amylin Agonists

Pramlintide (Symlin)

SQ Injection

DPP-IV Inhibitors

Sitigliptin (Januvia) Saxigliptin (Onglyza)

Oral

Miscellaneous

Welchol Bromocriptine (Cycloset)

Oral

Insulin Secretagogues

juice or sweetened soda, or glucose tablets that have 15 grams of carbohydrate. Glucose should be rechecked in 15 to 20 minutes, and the patient should retreat himself if glucose is still low. Sweet desserts like chocolate candy bars, ice cream and cake should not be used to treat hypoglycemia. Fat delays the absorption of glucose and can, thus, delay the treatment of hypoglycemia. Exercise 30 minutes per day The benefits of exercise in reducing insulin resistance, improving glucose control and prevention of diabetes is well established, but many people do not know that just 30 minutes per day of walking five days a week is as little as it takes to make a difference. As health care providers, we may not be able to directly affect other barriers to care, such as financial difficulties in buying healthy food, diabetes testing supplies and medication, lack of access to safe places to exercise, lack of time and lack of family support. But we can provide a clinical environment where the benefits of good nutrition and exercise are promoted and taught.

Incretin Hormone Based

Modified from a presentation given by Allison Chalecki, R.D., L.D.N.; Jennifer Bellizzi, M.S., R.D., L.D.N.; Susan Totten, R.D., L.D.N.; Susan Rohn, R.D., L.D.N.; Jessica Simo, M.H.A.; and Susan E. Spratt, M.D.

CARY ORTHOPAEDIC Sports Medicine Specialists Pain and injury can sideline your activities. Whether you’re training for a marathon, getting back to work or coaching little league, you can benefit from our 28 years of hands-on experience in diagnosis, treatment, and rehabilitation.

• Minimally Invasive Surgery • Gortex Casting • Intra-articular joint injections • On-Site Physical Therapy • Custom Orthotics

Our practice is unique. When you need care you will be seen by a board certified orthopedic surgeon.

1120 SE Cary Pkwy, Cary, NC 27518

919-467-4992 Fax 919-481-9607

1005 Vandora Springs Rd., Garner, NC 27529

919-779-3861 Fax 919-779-3234

www.caryortho.com

APRIL 2011

Orthopedics

Conditions of the

Female Athleteâ&#x20AC;&#x2122;s Shoulder By Edouard F. Armour, M.D.

Multidirectional instability and frozen shoulder are debilitating conditions affecting shoulder mechanics and function, and occur more commonly in women than men. The relationship between gender and disease has recently become a major focus in health care. Orthopedic surgeons continue to study gender-specific differences in musculoskeletal injury in an effort to better understand and treat women and men effectively. As increasing numbers of women engage in strenuous exercise and sport, understanding the uniqueness of their musculoskeletal pathology is of greater importance. The gender differences in knee mechanics and the associated greater risk of knee ligamentous injury in females have been well studied. Also identified are a female predominance in osteoporosis, stress fractures, patellofemoral disorders and bunions.

called multidirectional instability (MDI), is characterized by excessive glenohumeral translation. Most females who present with MDI are adolescents or young adults who seek care after minor trauma or repetitive injury, such as seen in overhead-throwing athletes, swimmers, tennis players and volleyball players. Patients present with vague symptoms of shoulder fatigue, discomfort, apprehension and pain, rather than full-scale instability. Over time, these symptoms can progress, greatly affecting strength, range of motion and ability to perform activities of daily living.

Frozen shoulder and multidirectional instability (MDI) are two conditions affecting the shoulder that appear to be more prevalent in females than males.

Excessive or pathologic shoulder laxity may occur after significant trauma or can be atraumatic. Atraumatic laxity, often

The Triangle Physician

The study of choice for evaluation is the magnetic resonance (MR) arthrogram. Intracapsular volume is increased. The pathoanatomy involves a thin attenuated capsule and large auxiliary pouch with thinning of the glenohumeral ligaments. Treatment of choice of MDI is primarily conservative, with the aim of improving coordination and enhancing muscle tone surrounding the scapulothoracic and glenohumeral joints. Aggressive physical therapy accompanied by a focused home exercise program over four to six months has been found successful in upwards of 80 percent of patients.

But, what of the shoulder?

Multidirectional Instability Women generally have more ligamentous laxity than men. The reason is not completely clear, but the role of estrogen, as well as possible slight differences in neuromuscular composition, is suggested.

Dr. Edouard Armour is a board-certified orthopedic surgeon specializing in sports medicine. He has been affiliated with Cary & Garner Orthopaedic and Sports Medicine Specialists P.A. since September 2009, after having practiced in Burlington, N.C., for eight years. He earned his medical degree from Vanderbilt University School of Medicine in Nashville, Tenn., completed his residency at Albert Einstein College of Medicine, Bronx, N.Y., and has a fellowship in sports medicine from the University of Connecticut. Dr. Armour can be reached at (919) 467-4992 or by visiting www.caryortho.com.

Assessment and Treatment of Multidirectional Instability Assessment of MDI is primarily based on history and exam. These women are often slender, with signs of generalized laxity. X-rays are normal.

For persistent symptoms at greater than six months with failed conservative management, surgical intervention is recommended. While the gold standard has been the open anterior/ inferior capsular shift, arthroscopic capsular plication or capsulorrhaphy has gained popularity. With arthroscopy, minimally invasive techniques are used to create pleats

the shoulder through the arthroscope in search of any other lesions.

in the capsule and decrease intracapsular volume. Frozen Shoulder Frozen shoulder, or adhesive capsulitis occurs in 2 percent to 5 percent of the general population, and two to four times more often in females. It occurs primarily in those 40 to 60 years of age. The condition describes a painful restriction of shoulder motion in the face of normal X-rays. These patients often present with pain during the day, and particularly at night, with disrupted sleep. The cause of this disorder is unknown. Occasionally, there is a history of minor injury. Frozen shoulder can be associated with hyperthyroidism, diabetes, ischemic heart disease, breast surgery and autoimmune disorders. Often, however, there are no associated disorders or precipitating events. On physical exam, there is typically marked restriction in range of motion passively and actively. Differential diagnosis includes rotator cuff disease with secondary restricted motion, metastatic disease, primary diseases of the apical area of the lung or referred pain from the cervical spine.

Arthroscopic capsular release has been found effective when manipulation under anesthesia is not enough. In fact, in recent studies, orthopedists recommend arthroscopic capsular release over manipulation. Arthroscopic capsular release is a minimally invasive surgical technique usually performed through two or three 6mm puncture incisions, called portals. The procedure involves dividing or cutting the abnormally thickened capsule and inflamed ligaments using radiofrequency ablation energy. At the same sitting, the surgeon is able to explore

Financial Rx for Physicians:

Treatment of Frozen Shoulder The mainstay of treatment is conservative management. The protocol includes rest, oral nonsteroidal anti-inflammatory drugs followed by use of injectable steroids, formal physical therapy and a closely monitored home therapy program.

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Many choose to pursue manipulation under anesthesia and/or surgical options.

Together, multidirectional instability and frozen shoulder are debilitating conditions affecting shoulder mechanics and function, and occurring more commonly in women than men. The reason for the gender difference is not completely understood. Arthroscopic capsulorrhaphy and arthroscopic capsular release are minimally invasive techniques providing an excellent option in the treatment of these disorders.

Managing your patients’ health is your life’s work. Managing physicians’ wealth is mine.

As with MDI, the study of choice is MR arthrogram. This will show restricted capsular volume, and thickening of the capsule.

Conservative management is successful in a large percentage of patients, but may take upwards of 14 months. Many patients cannot tolerate debilitating pain and decreased function for such a long period. In these cases, more aggressive measures are often welcome.

The results are successful in more than 80 percent of patients, and relief from pain is quicker than traditional manipulation under anesthesia and safer for people who have developed a resistant frozen shoulder. Arthroscopic capsular release aims to reduce the recovery time by freeing the joint to gain full range of motion and reduce pain.

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APRIL 2011

Health Care Reform

Saving Lives or Making Money? By By Gary S. Berger, M.D.

Women will receive the same drug, in the same formulation and dosage, as before to prevent premature births. Now that the FDA has approved 17-hydroxyprogesterone caproate, marketed as Makena by KV Pharmaceuticals, it will cost 15,000 percent more..

Premature births are on the rise. Currently, one in every eight babies in the United States is born before 37 weeks. Babies born prematurely are seven times more likely to die or have long-term neurologic problems than babies delivered at term. About one in four premature births is due to early induction of labor or C-section. In some cases, pregnancy complications require early delivery. In others, induction of labor or C-section leads to premature delivery without medical justification. Another one in four cases follows premature rupture of membranes weakened by the process of apoptosis. Recent studies show that progesterone prevents apoptosis of the fetal membranes. On Feb 4, the U.S. Food and Drug Administration approved a progesteronerelated drug to reduce the risk of premature delivery. The drug’s brand name is Makena, supplied by KV Pharmaceuticals. Makena is indicated for women with singleton pregnancies and a history of spontaneous preterm birth. It is given in weekly injections starting between 16 to 21 weeks and continued through 36 weeks of pregnancy. The drug became available for use during the week of March 14. The FDA gave Makena “orphan drug” status. That designation ensures that KV Pharmaceutical and its sister company, Ther-Rx, will be the sole source of the drug for seven years. Makena is 17α-hydroxyprogesterone caproate (17HP). This medication was marketed decades ago as Delalutin, which was withdrawn from the market in 1980. 17HP has been available since then from compounding pharmacies for approximately $10 per dose. Now that KV has exclusive rights to market 17HP, the cost of a medication that has been available for decades has jumped from $10 to $1,500 per dose, or at least $30,000 per pregnancy.

The Triangle Physician

Dr. Gary Berger is founder and medical director of Chapel Hill Tubal Reversal Center. The reproductive surgeon graduated with honors from Harvard University and the University of Rochester Medical School. Following a medical internship at Duke University Medical Center, he began his residency in obstetrics and gynecology at the Johns Hopkins Hospital. He went on to serve in the U.S. Public Health Service at the Centers for Disease Control as an Epidemic Intelligence Service officer in the Family Planning Evaluation Program. Dr. Berger completed his residency in obstetrics and gynecology, and simultaneously earned master’s degree in maternal and child health at the University of North Carolina School of Public Health at Chapel Hill. During his appointment as assistant professor of obstetrics and gynecology at the UNC School of Medicine, Dr. Berger trained abroad in tubal microsurgery techniques and initiated the tubal microsurgery program at the UNC Medical Center. He then entered private practice specializing in tubal reconstructive surgery. Dr. Berger is board certified in obstetrics and gynecology, preventive medicine and epidemiology. He is a charter member of the Society of Reproductive Surgeons.

for Makena will fall primarily to Medicaid

not answer the question of how much

since low-income women are at high risk for

regulatory approval is worth?

premature birth. Medicaid is facing massive budget cuts across the US and will almost

Women will be receiving the same drug, in the

certainly not be able to cover these costs. With

same formulation and dosage, as before. But

compounding pharmacies being threatened

now it’s FDA-approved. The FDA places a high

by KV with legal action if they provide 17HP,

value on it – seven years of market exclusivity.

fewer women may get the drug than in the

As long as the FDA’s stamp of approval for

past, resulting in even higher numbers of

old drugs is valued this highly, there will be

premature births.

companies like KV that will take advantage of it to make as much money as possible. This

KV has announced a patient assistance

is one of the reasons that health care is so

program for Makena based on income

expensive in the United States.

eligibility requirements. However, this does

How can KV justify the 15,000 percent increase in price for this potentially lifesaving drug? The company cites medical costs, estimated at approximately $50,000 in the first year of life and lifelong disabilities that may result from prematurity. However, KV has incurred no costs in research and development of a new drug. Its approval was based on studies that had already been published. Admittedly, there were legal costs involved in the FDA application, and as a condition of orphan status, KV will need to continue to study the safety and effectiveness of the drug. Since winning approval from the FDA, KV has sent a “cease and desist” letter to compounding pharmacies to stop producing 17HP, warning they face FDA action if they continue to sell cheaper “unbranded” versions of the drug. The burden of paying the exorbitant cost Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

APRIL 2011

Financial Planning

Do You Wear a Rolex,

Or Are You Just Paying for One? By Paul J. Pittman, C.F.P.

It is my belief (and practice) that your investments should cost you no more than 1.25 percent a year. This is an “all-in” cost, which includes management and the cost of the investments. If you have been reading my articles over the years, then you are well aware of my mantra. “It’s not what you make, it’s what you keep.” I have written many times about the importance of knowing what you own and how much it is costing you, and I have talked about fees and expenses being the silent killer in a portfolio. Still it amazes me how many people I meet who give such little regard to how fees impact their returns and overall success. On that note, I am going to remove the gloves! Blunt, in-your-face writing is normally not my style, but this time I am going to run with it. Retail investment products are loaded with fees. Some you can see, and some you can’t. The prospectus will spell them out, but only if you perform deep forensic analysis. Retail mutual funds, permanent life insurance, annuities (fixed or variable) and even bundled retirement plans (401(k)s, 403(b)s, etc.) are products of salesmen and sales firms.

The Triangle Physician

Salesmen are interested in one thing, making the sale. Their existence and livelihood is based on you buying their product. An insurance salesman can fix all of your ills through the use of permanent life insurance. (You already know that I am not a fan of permanent life insurance.) Life insurance and annuities are the biggest commission-generating products on the market. What kinds of companies generally have the largest buildings in the city? Life insurance companies! A life insurance salesperson will sell you a Rolls Royce, when you may only need a walking stick. The largest companies on Wall Street also have the largest sales forces! The average fee you pay to own the average mutual fund is around 3 percent. And they don’t even outperform the indexes! There are front-end loads, back-end loads and even no-loads, but this certainly doesn’t mean nofee! Some firms even charge you a fee to manage a mutual fund portfolio. This is what I call double-dipping. The firm and broker is being paid twice.

Most mutual funds have a management fee already built inside of them. This is supposed to compensate someone for helping you invest your money, but most importantly, it keeps you in the funds. Is someone earning this fee from you? The term “broker” is a polished-up word for salesman. They are “brokering” the deal between you and the firm that is offering the product, and for that they are paid handsomely. Are you paying for your broker’s Rolex? BMW? Beach house? Let me demonstrate how much this is costing you. You are not only paying dearly in terms of money, but also in terms of lost opportunity. For discussion, let’s say you have built an investment portfolio of $1,000,000. If you are using a broker, and have one of their “personalized” asset allocation mutual fund management accounts, you are probably paying a management fee of 1 percent to 1 ½ percent per year. Now, add

Paul J. Pittman is a Certified Financial Planner™ with The Preferred Client Group, a financial consulting firm for physicians in Cary, N.C. He has more than 25 years of experience in the financial industry and is passionate about investor education. He is also a nationally sought-after speaker, humorist and writer. Mr. Pittman can be reached at (919) 459-4171 and paul.pittman@pcgnc.com. He personally answers all of his own e-mail.

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in the cost of the funds themselves, which is probably 2 percent, and you are paying somewhere in the neighborhood of 3 ½ percent per year for your investments. This is $35,000 a year in true costs and that is probably on the conservative side. It is my belief (and practice) that your investments should cost you no more than 1.25 percent a year. This is an “all-in” cost, which includes management and the cost of the investments. That means you would be paying $12,500 a year in fees and expenses. That leaves a difference of $22,500 a year. Is there something more important you could be doing with an extra $22,500 of your own money each and every year? Fund a college education plan? Add money to your own retirement plan and retire a few years earlier? Help out with the kid’s or grandkid’s first home purchase? The ideas are unlimited, but the point is that it’s your money.

Janet Clayton, CCIM 919.420.1581 janet.clayton@tlgcre.com Independently Owned & Operated

NEWSOURCE-JUN10:Heidi

8/5/10

12:57 PM

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How many extra patients do you have to see to make an additional $22,500 a year net? How many more rounds do you have to do to make up that amount of net money? I hope I have painted a vivid picture for you that brings it all clearly into focus. Don’t take my word for it; ask your accountant or your attorney. Just don’t ask your salesperson.

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I feel like I just went 10 rounds with Apollo Creed; cut me, Mick. Remember the mantra, “It’s not what you make, it’s what you keep.” Have a great spring!

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APRIL 2011

News

GHS Named Blue Distinction Center for Knee and Hip Replacement Granville Health System has the distinctions

present clinical-based evidence to establish

as a Blue Distinction Center for Knee and

that they meet the selection criteria.

Hip Replacement. Examples of some of the criteria GHS met include:

Shield Association (BCBSA) program that

• An established acute care inpatient facility,

recognizes facilities that meet objective,

including intensive care, emergency

evidence-based

care, and a full range of patient support

thresholds

for

clinical

quality. These facilities have demonstrated in

teams

and

clinical

pathways to coordinate and streamline care; • Use of an internal registry or database to

Blue Distinction is a Blue Cross and Blue

experience

• Multidisciplinary

offering

track patient outcomes over time; and • Clinical outcomes for specific procedures

services;

that meet objective thresholds, such as complication rates and length of stay. “When it comes to spine surgery, and hip

comprehensive

• An established knee and hip replacement

and knee replacement, there is compelling

inpatient knee and hip replacement services,

program, performing required annual

evidence that institutions with experience

volumes for certain procedures;

that also adheres to their care protocols

including total knee replacement and total hip replacement.

• An experienced knee and hip replacement surgery

team,

including

deliver better outcomes,” says Don Bradley,

surgeons

M.D., chief medical officer of Blue Cross

BCBSA collaborated with expert physicians

with board certification, subspecialty

and Blue Shield of North Carolina. “We’re

and medical organizations to determine

fellowship training, and case volumes that

providing that information to our members

the selection criteria for all Blue Distinction

meet selection criteria;

to help them make informed choices about

programs. Candidates for Blue Distinction

• Preoperative patient education;

where to receive care that’s proven to meet

Centers for Knee and Hip Replacement must

• Processes to support transitions of care;

national quality standards.”

Granville Health System in Top 10 of Most Customer-Friendly Hospitals The American Alliance of Healthcare

400 hospitals for consideration of this

of Granville County and the surrounding

Providers named Granville Health System

award. Approximately 100 hospitals are

areas. As we move forward, Granville Health

one of the top 10 hospitals in the country in

recognized

application

System will continue to invest further in the

its 2011 Hospital of Choice Awards.

process requires a review of six principal

hospital, supporting our commitment to

areas of consideration including standards

deliver new medical programs, technologies

The award recognizes America’s “most

of conduct, performance management and

and expanded services to the community.”

customer-friendly hospitals,” according to

improvement, staff development and training,

Ric Vincent Parr, president of American

systems of communication, good citizenship,

Granville Health System ranked third after

Alliance of Healthcare Providers (AAHP). It is

and educational and promotional consumer

first-place University of Kansas Hospital and

“designed to find America’s most customer-

material.

second-place UCLA Medical Center. The

annually.

The

friendly hospitals based either on an

Top 10 winners will have an opportunity to

extensive application process, or by a review

“We are pleased to be chosen as one of the

compete for the Hospital of the Year Award,

of a facility’s public communication and staff

top hospitals in the nation,” says L. Lee Isley,

to be announced this month.

interaction with customers,” according to a

Granville Health System chief executive

press release from the alliance.

officer. “This award recognizes the high level

Past Hospital of Choice Award recipients

of quality care provided by our dedicated

include The Johns Hopkins Hospital, the

doctors, nurses and staff to the patients

Mayo Clinic and the Cleveland Clinic.

Each year, AAHCP evaluates approximately

The Triangle Physician

Uterine Fibroid Embolization Is Safe Minimally Invasive Therapy By Satish Mathan, M.D.

Treatment of symptomatic fibroids by UFE appears to be safe, technically feasible with standard equipment and easily tolerated. Most patients experience significant symptomatic improvement within a few weeks. Fibroids are a very common and oftendiagnosed womenâ&#x20AC;&#x2122;s health condition. Uterine fibroids are the most common pelvic mass in women in the United States with prevalence as high as 40 percent in some areas. Only one-quarter seek medical attention, most commonly for irregular bleeding, extremely heavy menses, with or without anemia, pelvic pain, and pressure on the bladder and other organs. Traditionally, treatment of symptomatic fibroids has been hysterectomy or myomectomy, and more recently endometrial ablation. Oral contraceptive pills, hormonal-impregnated intrauterine devices and GnRH, or gonadotrophinreleasing hormone, antagonists have also been used for nonsurgical management. The first U.S. experience with uterine fibroid embolization (UFE) was reported in 1997 from the University of California, Los Angeles, with seven of nine patients having significant clinical improvement. Since that time, numerous well-constructed clinical studies in the radiology and obstetric/ gynecology literature have validated the use of UFE as a viable option for treatment of symptomatic uterine fibroids. The UFE procedure typically takes between one and two hours. Pelvic angiogram is performed with both uterine arteries selectively catheterized and embolized via one arterial access. Typically, embolization is performed with submillimeter Tris acrylic gelatin microspheres (TAGM) particles. These occlude the arterioles and preferentially devitalize the fibroids, while sparing the uterus.

Radiology Article Dr. Satish Mathan is medical director for interventional services at Rex Hospital and Raleigh Radiology. The vascular and interventional radiologist earned his bachelor of science degree from the University of California at Santa Barbara and his medical degree from the Medical College of Wisconsin. He completed an internship at Santa Clara Valley Medical Center in San Jose, Calif., and was a chief resident at the University of North Carolina Hospitals, Chapel Hill. He completed a fellowship in vascular and interventional radiology at UNC Hospitals.

In the perioperative or early postoperative course, patients may develop pelvic pain and nausea/vomiting. Therefore, they are admitted under the care of the interventional radiology service for overnight observation and pain control with PCA (patientcontrolled anesthesia). As soon as patients are tolerating oral intake, oral narcotic and nonsteroidal anti-inflammatory drugs are started, and patients are home the next day and back to work the next week. Abdominal pain typically is the worst within the first few days, and tapers off by the third to fifth day. Risks are minimal, but include infection, hematoma, nontarget embolization and angiographic-related vascular injury. With regard to radiation, the overall dose to the pelvic organs is higher than most diagnostic tests, but well within acceptable range, with maximum dose reduction techniques used during the procedure. A small series show a 38 percent pregnancy rate after UFE for those patients trying to get pregnant. Women seeking future childbearing are generally screened and counseled to consider other treatment options. For them, myomectomy is the preferred treatment at this time. However, if the fibroids are too large or numerous that a myomectomy may result in a hysterectomy, UFE may still be advised. Most series report average technical success rates for myomectomy of about 98 percent. A 90 percent rate of clinical success means patients have a significant enough decrease in their bleeding or mass-effect symptoms

that they require no further treatment. Despite a high rate of symptomatic relief, most patients have only modest (50 percent to 75 percent) volume reductions. In summary, the treatment of symptomatic fibroids by UFE appears to be safe, technically feasible with standard equipment and easily tolerated. Most patients experience significant symptomatic improvement within a few weeks. Raleigh Radiology was the first to offer this procedure within the Triangle and has been providing this service for more than 10 years. Prior to a Raleigh Radiology consult, patients with known or suspected fibroids will need magnetic resonance imaging taken of their pelvis with and without contrast to better delineate the location of the fibroids and vascularity. UFE consults can be scheduled at Raleigh Radiologyâ&#x20AC;&#x2122;s Interventional Services Clinic at the Blue Ridge facility by calling (919) 781-1437 or at Rex Hospital by calling (919) 784-3419.

APRIL 2011

Charity

WakeMed Foundation

Just For Kids Kampaign Tops $10 Million at Midpoint

The WakeMed Foundation, the charitable resource for WakeMed Health & Hospitals, is grateful to the 400 businesses, 50 organizations and 2,700 individuals who helped raise $10 million toward the $20 million Just for Kids Kampaign (JFKK) goal. The funds received to date helped complete phase one of the Just for Kids Kampaign, which supported the June 2010 opening of the WakeMed Children’s Hospital - the first and only children’s hospital in Wake County. The children’s hospital comprises 34,000 square feet of the new patient tower on the WakeMed Raleigh Campus and features 45 beds – an eight-bed Pediatric Intensive Care Unit, a 12bed Pediatric Observation Unit and a 25-bed Pediatric Inpatient Unit – a Ronald McDonald family room, a teen room, a children’s play room, and additional treatment and support facilities. “Reaching the halfway mark in the campaign is a victory for the families in our community. We would like to offer our heartfelt appreciation to everyone who has given their time and resources to this important cause,” commented Jack Radford, executive director, WakeMed Foundation. An additional $10 million is being raised for phase two of the Just For Kids Kampaign to fund the expansion and renovation of WakeMed’s Level IV Neonatal Intensive Care Unit (NICU) and to also add other pediatric services. The WakeMed Raleigh Campus

The Triangle Physician

operates the only Level IV NICU in Wake County offering the highest level of neonatal intensive care to the region’s premature and critically ill newborns. The NICU will be expanded from 36 to 48 beds. In addition, it will offer enhanced facilities to provide more space for families and staff in the care of newborn babies. “We have been blessed with tremendous support from the WakeMed family, including administration, physicians, employees, and

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right here in the Old North State. Conservation education efforts are preparing future generations to sustain your concern for the lands we protect today. At www.ncwhf.org, download the license tag application and see the good works in process. pp Your new n tag shows your support and your contribution is put to work…times four. co

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Hospital News

New Physicians at Duke University Health System We are pleased to introduce the following new physicians: William S. Abernathy, MD Division: Cardiology Particular Clinical Interests and Skills: All types of cardiology patients including non-invasive cardiac testing MD Degree: Columbia University College of Physicians and Surgeons (New York), 1969 Residency: Internal Medicine, University of Kansas Medical Center, 1969-1970 Internal Medicine, Presbyterian Hospital (New York), 1970-’71 Fellowship: Cardiology, University of Michigan Hospital, 1972-1974 http://www.dukehealth.org/physicians/william-s-abernathy

Robert A. Buchanan, Jr., MD Division: Cardiology Particular Clinical Interests and Skills: Clinical cardiology, general interest in all cardiovascular disease and echocardiography, non-invasive testing, special interest in neurocardiogenic syncope MD Degree: Wake Forest University School of Medicine (North Carolina), 1969 Residency: Internal Medicine, Vanderbilt University Hospitals (Tennessee), 1969-1972 Fellowship: Cardiovascular Diseases, University of Alabama in Birmingham Hospitals, 1972-1974 http://www.dukehealth.org/physicians/robert-a-buchanan-jr

Benjamin J. Conway, MD Division: Cardiology Particular Clinical Interests and Skills: All non-invasive aspects of general cardiology MD Degree: University of Mass. Medical School, 2001 Residency: Internal Medicine, Rhode Island Hospital, 2004 Fellowship: Cardiology, Maine Medical Center, 2007 http://www.dukehealth.org/physicians/benjamin-j-conway

Timothy P. Donahue, MD Division: Cardiology Particular Clinical Interests and Skills: Treatment and ablation of supraventricular tachycardias, including atrial fibrillation; pacemaker and defibrillator implantation and management MD Degree: Louisiana State University School of Medicine in New Orleans, 1996 Residency: Internal Medicine, Emory University Medical Center (Georgia), 1999 Fellowship: Cardiology, University of FL Medical Center, 2002 Electrophysiology, University of Florida Medical Center, 2003 http://www.dukehealth.org/physicians/timothy-p-donahue Jeffrey T. Guptill, MD Division: Neurology Particular Clinical Interests and Skills: Electromyography; neuromuscular disease, particularly myasthenia gravis and inflammatory muscle disease MD Degree: Virginia Commonwealth University School of Medicine, 2005 Residency: Internal Medicine, Medical College of Virginia Hospitals, 2005-2006 Adult Neurology, Duke University Medical Center, 2006-2009 Fellowship: Neuromuscular Medicine and EMG, Duke University Medical Center, 2009-2010 Advanced Neuromuscular Medicine, Duke University Medical Center, 2010-2011 Other Degree: MA, Anatomy and Neurobiology, Boston

University School of Medicine (Massachusetts), 2001 http://www.dukehealth.org/physicians/jeffrey-t-guptill

M. Alycia Hassett, MD Division: Cardiology Particular Clinical Interests and Skills: Consultative cardiology to include acute and chronic coronary artery disease, valvular heart disease, heart failure, heart disease in women, prevention of heart disease, diagnostic catheterization MD Degree: Duke University School of Medicine, 1978 Residency: Internal Medicine, Emory University (GA), 1981 Fellowship: Cardiology, Duke University Medical Center, 1984 http://www.dukehealth.org/physicians/m-alycia-hassett

Elizabeth Henke, MD Division: Cardiology Particular Clinical Interests and Skills: Clinical cardiology, consultative cardiology, echocardiography, transesophageal echocardiography, diagnostic cardiac catheterization MD Degree: Welsh National School of Medicine (UK) Residency: Internal Medicine, University of North Carolina at Chapel Hill, 1981 Fellowship: Cardiology, Duke University Medical Center, 1986 http://www.dukehealth.org/physicians/elizabeth-henke

Janet L. Hortin, MD Division: General Internal Medicine/Student Health Particular Clinical Interests and Skills: Student health care, headaches, women’s health, health issues related to graduate school/professional school stresses, assisting students in coping with chronic illness during graduate and undergraduate school, non-traditional student and international student health care issues MD Degree: University of Michigan Medical School, 1977 Residency: Internal Medicine, University of Wisconsin Hospital, 1977-1980 Other Training: Board Certified, American Board of Internal Medicine, 1980 http://www.dukehealth.org/physicians/janet_l_hortin

Fellowship: Heart Failure/Heart Transplant, University of Pittsburgh (Pennsylvania), 1991-1992 Cardiology, University of Missouri at Kansas City/St. Lukes Mid-America Heart Institute, 1992-1995 Interventional and Peripheral Vascular Cardiology, Iowa Heart Center Mercy Hospital, 1995-1996 Other Degree: BS, Chemistry, Baylor University (Texas), 1983 http://www.dukehealth.org/physicians/j-stewart-jones

Michael R. Komada, MD Division: Cardiology Particular Clinical Interests and Skills: All aspects of general and interventional cardiology including valvular heart disease and coronary artery disease MD Degree: Wake Forest University School of Medicine (North Carolina), 1993 Residency: Internal Medicine, University of Virginia, 1993-’96 Fellowship: Cardiovascular Medicine, Wake Forest University Baptist Medical Center (North Carolina), 2003 Interventional Cardiology, Wake Forest University Baptist Medical Center (North Carolina), 2004 http://www.dukehealth.org/physicians/michael-r-komada

Eric S, Moore, MD, MBA, MPH Division: Cardiology Particular Clinical Interests and Skills: Non-invasive cardiovascular imaging, including transthoracic and transesophageal echocardiography, cardiac CT, nuclear cardiac imaging, and stress testing; diagnosis and management of coronary disease, congestive heart failure, and valvular disease MD Degree: University of Alabama School of Medicine, 2001 Residency: Internal Medicine, St. Louis University (Missouri), 2001-2004 Fellowship: Cardiovascular Disease, Virginia Commonwealth University, 2005-2008 Other Degrees: MBA, University of AL at Birmingham, 1997 Masters of Public Health, Health Care Organization and Policy, University of Alabama at Birmingham, 1997 http://www.dukehealth.org/physicians/eric-s-moore

Jerry B. Hung, MD Division: Pulmonary, Allergy, and Critical Care Medicine Particular Clinical Interests and Skills: Diagnosis and treatment of lung cancer, management of lung nodules, atypical lung infection, critical care medicine MD Degree: State University of New York at Stony Brook, School of Medicine Residency: Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 2000-2003 Fellowship: Pulmonary and Critical Care, NYU Medical Center, 2003-2007 http://www.dukehealth.org/physicians/jerry-b-hung

Chetan B. Patel, MD Division: Cardiology Particular Clinical Interests and Skills: General cardiology, heart failure, cardiac transplantation, mechanical circulatory support MD Degree: University of Texas Southwestern Medical School, 2002 Residency: Internal Medicine, University of Texas Southwestern Medical Center, 2006 Fellowship: Cardiology, Duke University Medical Center, 2010 Heart Failure and Cardiac Transplantation, Duke University Medical Center, 2010 http://www.dukehealth.org/physicians/chetan-b-patel

J. Stewart Jones, DO Division: Cardiology Particular Clinical Interests and Skills: All aspects of cardiovascular disease with special interests in interventional cardiology, peripheral vascular disease, nuclear cardiology, coronary computed tomography, cardiac rehabilitation, risk factor modification/preventative medicine DO Degree: Michigan State University College of Osteopathic Medicine, 1987 Residency: Osteopathic Internship, Oakland General Hospital (Michigan), 1987-1988 Internal Medicine, Michigan State University, 1988-1991

Jennifer V. Rowell, MD Division: Endocrinology, Metabolism, and Nutrition Particular Clinical Interests and Skills: General endocrinology including thyroid disorders, pituitary and adrenal disease, polycystic ovary syndrome, hypercalcemia, diabetes MD Degree: Medical University of South Carolina College of Medicine, 2004 Residency: Internal Medicine, University of Alabama at Birmingham, 2004-2007 Fellowship: Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, 2007-2010 http://www.dukehealth.org/physicians/jennifer_rowell

APRIL 2011

News Welcome to the Area

Physicians Mark Fredric Abbott, MD Radiology Duke University Hospitals, Durham

Khaleel Mohammed Ahmed, MD Parkway Sleep Centers, Cary

Brenda Lynn Bohnsack, MD

UNC Health Care Jennifer Lynn Kauffman Thompson, MD

New Locations

Obstetrics and Gynecology Duke University Medical Center, Durham

Four new clinics opened last month.They are:

Eddie Joe Turner, MD Family Medicine Chapel Hill

Andrew Alton Waas, MD

Duke Eye Center, Durham

Internal Medicine Duke University Hospitals, Durham

Warren Clifford Botnick, MD

Rodney Duane Welling, MD

PAREXEL International, Durham

Justin James Clark, MD

Radiology Duke University Hospitals, Durham

Durham

Julius Middleton Wilder, MD

Matthew James Conner, MD

Internal Medicine Duke University Hospitals, Durham

Psychiatry Duke University Hospitals, Durham

Eric Bryan England, MD Internal Medicine Duke University Medical Center, Durham

Bjorn Ingemar Engstrom, MD Diagnostic Radiology Duke University Hospitals, Durham

Timothy Joseph Erpelding, MD

James Houston Williams, MD UNC Hospitals, Chapel Hill

Physician Assistants Patricia Bauserman Blanchard, PA Wakelon Internal Medicine, Zebulon

Anesthesiology University of North Carolina Hospitals Chapel Hill

Brittani Rose Boehlke, PA

Sara Bigelow Faber, MD

Southern Pines

Internal Medicine University of North Carolina Hospitals Chapel Hill

Jason Bradley Newman, PA

Waverly Hematology Oncology, Cary

Lance Patrick Hoepner, PA

Harnett Health Lillington Medical Services Lillington

Nicole Gaskins Greyshock, MD Internal Medicine Duke University Hospitals, Durham

Granville Health System

Zubair Ali Hashmi, MD

New Locations

Duke University Medical Center, Durham

Granville Express Care has opened for walk-in patients at 1015 Lewis St. in Oxford. Hours of operation are Monday through Friday from 10 a.m. to 6 p.m.; Saturday from 9 a.m. to 1 p.m.; and Sunday from 11 a.m. to 3 p.m. No appointments are necessary. For more information, call (919) 603.0873.

Christopher Warren Jones, MD Emergency Medicine University of North Carolina Hospitals Chapel Hill

William Allen Kwan, MD Internal Medicine Durham

Brian Eric Munro, MD Radiology University of North Carolina Hospitals Chapel Hill

New Services The www.ghshospital.org website is a onestop resource for patients, physicians and the community.

New on Staff These physicians have joined the medical staff:

James Carey Pate, MD

Richard Pacca, M.D.

Taylor Vitreoretinal Center, Raleigh

Granville Heart and Vascular 103-C Professional Park Drive Oxford, N.C. 27565

Utpal K. Patel, MD Internal Medicine Anesthesia Services of Dunn, P.C., Dunn

Ben Eugene Paxton, MD Radiology Duke University Medical Center, Durham

Jay Ira Pomerantz, MD Chapel Hill

Jonathan Charles Routh, MD Duke University Medical Center, Durham

Tiffany Lynn Scott, MD Cary

Neha Priyavadan Serrano, MD Duke Eye Center, Durham

Hemang Kalpeshkumar Shah, MD Kernodle Clinic, Burlington

The Triangle Physician

Vikesh Patel, M.D. Granville Internal Medicine and Geriatrics 1032 College Street Oxford, N.C. 27565

UNC Health Care Recognitions Paula F. Miller, M.D., clinical associate professor of medicine, director of cardiac rehabilitation and director of the Womenâ&#x20AC;&#x2122;s Heart Program, was awarded the Heart of Change Award by the American Heart Association. The award honors community leaders who have significantly impacted change in the treatment or prevention of heart disease and stroke-elated death or disability.

UNC Imaging & Spine Center 1350 Raleigh Road Chapel Hill, NC 27514 Imaging: (919) 957-6800 Spine: (919) 957-6789 UNC Urgent Care at Carolina Pointe II 6013 Farrington Road, Suite 101 Chapel Hill, NC 27517 (919) 957-6610 UNC Orthopaedics at Carolina Pointe II 6011 Farrington Road, Suite 201 Chapel Hill, NC 27517 (919) 962-6637 UNC Eye at Chapel Hill North 1828 Martin Luther King Blvd. Chapel Hill, NC 27514 (919) 945-0393

Clinical Trials

General Medicine/ Infections

Wake Research Associates Charles F. Barish, MD Currently screening Do you have an upcoming hospitalization? You could be at risk of infection by Clostridium difficile (C.diff.), a bacteria that can cause severe gastrointestinal problems.You may qualify for this study if you are between 40 and 75 years old and have an upcoming hospitalization. Study-related medical exams and study medication are provided at no cost and compensation will be provided for time and travel. For additional information and qualification criteria please call 919-781-2514 or visit us online at www.wakeresearch.com.

Clinical Trials Do you have patients with any of these problems?

Pain Medicine for Shingles

Wake Research Associates Wayne Harper, MD Currently screening Pain after shingles? Has your shingles rash healed, yet you are still suffering from symptoms including burning, stabbing pain, sharpness or sensitivity? If so, you may have a condition called PostHerpetic Neuralgia, also known as PHN. We are conducting a clinical research study for people who have experienced these symptoms for at least 9 months after the onset of their shingles rash. This study will evaluate the effectiveness of an investigational medication for PHN. Study-related medical exams and study medication are provided at no cost and compensation will be provided for time and travel. For additional information and qualification criteria please call 919-781-2514 or visit us online at www.wakeresearch.com.

Gastroenterology Stomach Ulcers Wake Research Associates Charles F. Barish, MD Currently screening Have you suffered from a heart attack or stroke and take 325 mg of aspirin daily to prevent another from occurring? If so, Wake Research is conducting a research study of an investigational medication that combines aspirin with a second medication to see if It can help prevent stomach ulcers. Youâ&#x20AC;&#x2122;ll receive investigational medication and study-related exams at no cost and compensation up to $500 for time and travel.

For additional information and qualification criteria please call 919-781-2514 or visit us online at www.wakeresearch.com.

Lectures Carolina Refresher Lectures: Care of the Surgical Patient 2011 June 16-19, 2011 Grove Park Inn, Asheville, NC Care of the surgical patient now requires a team approach in the perioperative period to ensure good outcomes. The goals of this meeting are to highlight several key areas in caring for surgical patients including preoperative assessment, high-risk obstetrics, postoperative respiratory failure, pediatric care, and perioperative complications. A dynamic and expert faculty has been assembled to present this educational program, which has been designed for physicians, anesthetists, physician assistants, and others who care for the surgical patient. The School of Medicine of The University of North Carolina at Chapel Hill is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Physicians The School of Medicine of The University of North Carolina at Chapel Hill designates this educational activity for a maximum of 19.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. CRNAs The course has been approved by the American Association of Nurse Anesthetists for 19 CE credits (AANA Code #33512, Expiration Date 6/19/11). For more information visit the following link: http://www.med.unc.edu/cme/events/ carolina-refresher-lectures-care-of-thesurgical-patient

Moving Carolina Vascular Surgery & Diagnostics, PA 3713 Benson Drive, Ste 201, Raleigh, NC 27609 All contact information will remain the same.

Your LocaL cardioLogY ProfessionaLs in Johnston countY dedicated to QuaLitY, service, and integritY

Mateen Akhtar, MD, FACC

Benjamin G. Atkeson, MD, FACC

Christian N. Gring, MD, FACC

Matthew A. Hook, MD, FACC

Kevin Ray Campbell, MD, FACC

Eric M. Janis, MD, FACC

Randy Cooper, MD, FACC

Diane E. Morris, ACNP

cardioLogY services

Ravish Sachar, MD, FACC

Nyla Thompson, PA-C

2 Locations to serve our Patients Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7909 Fax: 919-989-3147

Wake Heart & Vascular Associates 2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326

Coronary and Peripheral Vascular Interventions Pacemakers/Defibrillators Atrial Fibrillation Ablations Echocardiography Nuclear Cardiology Vascular Ultrasound Clinical Cardiology CT Coronary Angiography Stress Tests Holter Monitoring Cardiovascular Medicine Echocardiography Nuclear Cardiology Cardiac Catheterization

the highest QuaLitY cardiovascuLar care, cLose to home.

Are Tired Legs Holding Your Patients Back?

Scan now to set up your vein therapy consultation with your smartphone. To access, you may use any QR Reader App for your smartphone or iPod Touch (use AT&T Reader).

FREE CONSULTATIONS FOR MEN AND WOMEN

Think of the decisions your patients make in life based on how fatigued their legs are. Many men and women are affected by the discomfort and unsightly appearance of varicose veins; fortunately, advances in vein therapies allow us to offer your patients new choices and relief. Most of our treatments, including spider vein therapies, are minimally invasive or laser-based, have little or no downtime and are performed in our convenient outpatient setting. Wake Radiology’s comprehensive approach to vein therapy is unlike others around. Our skilled interventional physicians have training and expertise in minimally invasive vein treatments, evaluating each patient personally and discussing the best treatment plan for their unique situation. There are beaches to be combed, trails to be explored, and greenways to be enjoyed—so help your patients stop thinking about their tired legs and start thinking about what they want to do. Call us or go online to request a free consultation where we’ll help your patients determine how they can step back into great-feeling legs. Wake Radiology. Making tired legs a thing of the past.

You or your patient can request a free consultation online today at wakerad.com Wake Radiology Cary | 300 Ashville Avenue, | Cary, NC 27518 | 919-854-2180 | wakerad.com