The Triangle Physician December 2010 by TTPLLC

DEcember 2010

Wake Radiology Pediatric Imaging Childrenâ&#x20AC;&#x2122;s Imaging for 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

PRSRT. STD U.S. POSTAGE

PAID

COLUMBIA, SC PERMIT NO. 939

Also in This Issue

Sleeping Well

May Take Teamwork

Treating Painful Spine Fractures

Add a pinch of spice,

a hint of laughter,

and a correct diagnosis,

and you’ll get Robert.

Robert suffered from unexplained fainting spells. His physicians couldn’t figure out why. To find answers, they implanted a Reveal® Insertable Cardiac Monitor (ICM) to see if his spells were heart rhythm related.

(Actual size)

The Reveal ICM is a long-term heart monitor that may help you rule in or rule out an abnormal heart rhythm as the cause of unexplained fainting spells. In Robert’s case, they were, and now he has a pacemaker. Possible risks associated with the implant of a Reveal Insertable Cardiac Monitor include, but are not limited to, infection at the surgical site, device migration, erosion of the device through the skin and/or sensitivity to the device material. Results may not be typical for every patient.

Brief Statement Indications 9529 Reveal® XT and 9528 Reveal® DX Insertable Cardiac Monitors – The Reveal XT and Reveal DX Insertable Cardiac Monitors are implantable patient-activated and automatically activated monitoring systems that record subcutaneous ECG and are indicated in the following cases: • patients with clinical syndromes or situations at increased risk of cardiac arrhythmias; • patients who experience transient symptoms such as dizziness, palpitation, syncope, and chest pain, that may suggest a cardiac arrhythmia. 9539 Reveal® XT and 9538 Reveal® Patient Assistants – The Reveal XT and Reveal Patient Assistants are intended for unsupervised patient use away from a hospital or clinic. The Patient Assistant activates one or more of the data management features in the Reveal Insertable Cardiac Monitor: • To verify whether the implanted device has detected a suspected arrhythmia or device related event. (Model 9539 only); • To initiate recording of cardiac event data in the implanted device memory. Contraindications: There are no known contraindications for the implant of the Reveal XT or Reveal DX Insertable Cardiac Monitors. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated. Warnings/Precautions: 9529 Reveal XT and 9528 Reveal DX Insertable Cardiac Monitors – Patients with the Reveal XT or Reveal DX Insertable Cardiac Monitor should avoid sources of diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, therapeutic ultrasound and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing. MRI scans should be performed only in a specified MR environment under specified conditions as described in the device manual. 9539 Reveal XT and 9538 Reveal Patient Assistants – Operation of the Model 9539 or 9538 Patient Assistant near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device. Potential Complications: Potential complications include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin. See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please 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.

For more information, visit www.fainting.com.

For women with fibroids, he’s an angel in white Angel Nieves, MD, PhD, is giving women one more weapon in their fight against uterine fibroids I’ve read some stats on uterine fibroids. They sound pretty common. Should I worry? That’s a great question. As many as three in four women have uterine fibroids and one in four women may suffer significant symptoms. Only when you have symptoms, do you need to seek treatment. Symptoms may include heavy bleeding, pelvic pressure or pain, painful periods, frequent urination, constipation, pain during sex, lower back pain, or infertility. I know there are medical and surgical ways to treat fibroids. But tell me about the MRI-guided focused ultrasound procedure. It’s the first completely non-invasive, scarless treatment for uterine fibroids. We use the MRI to capture a three-dimensional image of the fibroid and precisely target the ultrasound waves at the tissue. It’s the same concept as using a magnifying glass to catch the sunlight and have it converge at one point. The ultrasound waves raise the temperature of the fibroid, eventually destroying it.

The Federal Drug Administration approved it in 2004. It is a non-surgical alternative to hysterectomy or myomectomy (surgical removal of fibroids). That’s why most women want to try it first. It sounds like guerrilla warfare. Get in, hit the bad stuff, and get out. Exactly. You just target what needs to be treated. You sound proud to offer this option to patients. Duke is the only place in North Carolina that treats fibroids with the MRIguided focused ultrasound procedure. This new modality really has changed the way I care for women. To tell a woman, “You do have one more option,” is incredible. That is my goal before I die: give every woman with fibroids the chance to avoid major surgery.

Duke OB-GYN offers complete special services including leading programs in urogynecology, fertility, gynecologic oncology, menopausal medicine, and more. Learn more at dukehealth.org. Duke is ranked #7 in the nation in gynecology by U.S.News & World Report

Duke OB-GYN To schedule an appointment, call 888-ASK-DUKE or email us at fibroidcenter@mc.duke.edu 8042

8042_Nieves_OurState_F.indd 1

11/16/10 10:18 AM

Contents

COVER STORY

PHOTO BY JIM SHAW

Wake Radiology Pediatric Imaging Children’s Imaging for the Triangle

FEATURES

Cardiology

Ventricular Tachycardia Ablation – A New Hope for Patients Dr. Brett D. Atwater describes how tachycardia ablation can reduce ventricular tachycardia in patients with implantable cardioverter-defibrillators.

de c e m b e r

2 0 1 0 V O L U M E 1 I S S U E 11

DEPARTMENTS 14 Perspective

Neurology

Sleeping Well Leads to Better Health Dr. S. Thomas Kirk explains the connection between sleep disorders and health, and the multidisciplinary approach needed for effective treatment.

Professional Courtesy Is Near Extinction

16 Women’s Health WiSH – Let the Discussion About Sexual Dysfunction Begin

18 Practice Management Time to Call a Medical Practice Consultant

20 Neurology Non-Medication Pain Options for Chronic Back and Neck Pain

22 Ob/Gyn News Honors and Awards, Board Appointment, News and More

25 Hospital News Rex Breaks Ground on Holly Springs Medical Campus

24 Hospital News WakeMed First in North Carolina to Earn Heart Failure Accreditation

28 Hospital News Statewide Program Speeds Up Heart Attack Care In North Carolina

The Triangle Physician

JOHNSTON HE ALTH

From the Editor

On the Forefront of Pediatric Imaging

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

Wake Radiology is on the frontline, with centers of excellence that include specialized pediatric imaging, the focus of this month’s cover story. You should be aware of the statistic that children are estimated to be “2 to 10 times more sensitive than adults to radiation in terms of carcinogenesis, and they will have longer lifetimes of medical exposure.” Wake Radiology Pediatric Imaging Center’s practice approach is to determine the patient treatment plan that results in the least possible risks and the best results. Ultrasound is

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Brett D. Atwater, M.D., S. Thomas Kirk, M.D.; Andrea S. Lukes, M.D., M.H.Sc ., F.A.C.O.G.; Lindy McHutchinson, M.D.; Sonia N. Pasi, M.D.; and John J. Reidelbach

radiation-free and insensitive to motion, making it especially well suited for children. When a CT (computed tomography) scan, fluoroscopy or radiograph is advised, the pediatric radiologists strive for the lowest dose of radiation. Also this month, Dr. Brett D. Atwater describes how ventricular tachycardia ablation is the new hope for patients with implantable cardioverter-defibrillators. Dr. Sonia N. Pasi writes about non-invasive treatments without medication for patients suffering chronic neck and back pain. Dr. Andrea Lukes, a founding member of Women Involved with Sexual Health (WiSH), offers a frank overview of the realities of sexual dysfunction. Dr. Thomas Kirk writes an excellent review on the treatment of sleep apnea, which has been linked to serious cardiovascular problems, stroke and heart attack, among them. Dr. Lindy McHutchison shares a first-hand experience in the emergency department and laments the loss of professional courtesy. John Reidelbach provides insight on the value of a practice management consultant and when to call one. 2010 offered the new Triangle Physician magazine a great start, with tremendous interest and support from within the region’s medical community. We are now looking to the new year, with gratitude and hope. In 2011, we plan to build on our foundation and boost the marketing-communications benefits we can offer you and your practice. So keep sending your news and give us a call to discuss the business opportunities. ‘Tis the season for family and friends. Here’s wishing you and yours happy holidays, and a promising New Year, marked by good health.

Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Joseph Dally

jdally@newdallydesign.com

Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com

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.

Enjoy!

Heidi Ketler Editor

The Triangle Physician

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

Small Patients Deserve Big Differences in Imaging Studies Wake Radiology excels at low dose diagnostic-quality imaging When it comes to the importance of imaging children, being small is huge for the pediatric radiologists of Wake Radiology. Every day, they focus their resources on delivering the best answers to medical questions with the least amount of radiation exposure possible.

Fortunately, the concern shown by clinicians,

Medical radiation exposure is an important issue in the United States, where an estimated

“We may consider, for example, if there are

65 million CT (computed tomography) scans are performed each year—up to 7 million on children.1 Fast, definitive, and widely used, CT is an invaluable and essential tool for imaging children. But it also is the imaging modality that delivers the highest dose of radiation. This is vitally important in children because they are an estimated two to ten times more sensitive than adults to radiation in terms of carcinogenesis,2 and they will have longer lifetimes of medical exposure.

parents,

and

radiologists

has

inspired

concerted efforts to reduce exposure. At Wake Radiology, measures to reduce exposure begin with close communication between clinician and radiologist, made easier because of the practice’s resources. With four fellowshiptrained pediatric radiologists headquartered at a specially equipped Pediatric Imaging Center, there is always a pediatric radiologist on site. This is the area’s largest pediatric imaging practice outside of academic centers. Together, the clinician and pediatric radiologist confer on the best plan for imaging the child— with the goal of minimizing radiation always at the forefront.

times we could offer an ultrasound instead of a CT,” says Margaret R. Douglas, MD, director of pediatric imaging at Wake Radiology. Dr. Douglas, who joined the practice’s pediatric subspecialty group a decade ago, has seen concerns about dose magnify

PHOTO BY BRYAN REGAN PHOTOGRAPHY

over time. Long an advocate of minimizing exposure, she notes that her “three partners, who joined the group in 2009, had the importance of reducing pediatric radiation exposure instilled in them from the beginning of their residencies.” She points out that Catherine Lerner, MD, and Laura Meyer, MD, trained under one of the nation’s leaders in the dose-reduction movement, Donald P. Frush, MD, at Duke University Medical Center. Brent Townsend, MD, trained at one of the nation’s top-rated pediatric centers, Harvard’s Children’s Hospital in Boston, where dose reduction was also emphasized. “Once people began concentrating on bringing CT down into a lower dose range, Terry Allison at Wake Radiology’s Pediatric Center in West Raleigh welcomes our youngest patients and their families.

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they began to consider what reductions could be made with fluoroscopy and plain films,”

Dr. Douglas says. This overall approach to

boy referred for a CT of the abdomen for a

using the lowest dose possible is at the heart of

palpable mass. “We contacted the referring

Wake Radiology’s pediatric imaging services.

clinician prior to the patient’s arrival to gather more information about the palpable mass.

Collaboration is key to minimizing exposure

As we talked to the pediatrician, it became

New long-length x-ray benefits scoliosis patients Young scoliosis patients now can take advantage

pediatric

clear that this was a very superficial palpable

of new technology at Wake Radiology: a

radiologists and referring clinicians results in

mass, likely within the subcutaneous tissues

long-length imaging system that images the

the best care for patients. “In this community,”

or abdominal wall. I thought ultrasound

entire spine in one view. This advance makes it

Dr. Lerner observes, “the pediatricians feel

might be able to characterize the abnormality

unnecessary to obtain separate exposures of the

comfortable calling us before doing a study if

without requiring any radiation.

upper and lower spine. “We’re always looking

collaboration

between

they have a question about whether the test is appropriate. We love that, because it gives us a chance to learn more about the patient and the clinical question at hand, in order to make

“It turned out the patient had already had an ultrasound at a different institution, which had been read as negative. But when we

for ways to improve the quality of exams,” says Margaret R. Douglas, MD, director of pediatric imaging at Wake Radiology. Scoliosis is best

got the images and the report from the prior

evaluated with a standing view of the spine that

ultrasound, they had been focused on the

includes the entire spine and the iliac crests.

Pediatrician Jerry C. Bernstein, MD, of

solid organs of the abdomen, not the soft

“Because we could not reliably fit a teenager’s

Raleigh Pediatric Associates, is among area

tissues of the abdominal wall. We scheduled

spine onto one standard film, we invested in a

clinicians who appreciate the practice’s

the patient for an ultrasound of the soft tissues

long-length imaging system.”

attention to lowering radiation dose. “They

of the abdomen. When the family arrived, I was able to examine the patient myself and

The long-length equipment also will improve the

are on top of that type of concern and have been through the years. Do we do a CT scan

perform the ultrasound directed to the area

that requires this much radiation or would

of abnormality. Sure enough, there was a

ultrasound be sufficient? That’s how they

lipoma in the subcutaneous tissues of the

help us learn which is the best way to get the

abdominal wall. The family was very relieved,

information we need for the least risk to the

and we had been able to avoid a CT scan and

patient. They are very much tuned in to that.

its associated radiation and cost.”

a considered recommendation.”

They are getting equipment that minimizes exposure, and they use the proper shielding. So they are very much forward-thinking.”

be obtained, the patient may move and change position between films, making it hard to get accurate measurements of the spinal curvature,” Dr. Douglas says. She emphasizes that breast and gonadal shielding are used for these exams. The long-length system also is well suited for

Choosing the right study

evaluating the lower extremities for leg-length

One of the strengths of Wake Radiology’s

discrepancy since both legs and the pelvis can

pediatric subspecialists is their expertise at

At times, good communications between

suggesting the appropriate study for each

clinician and radiologist can lead to an

individual case while always weighing the

accurate diagnosis without the need for

risks and benefits of radiation exposure. In

radiation at all. Dr. Lerner provides an

many things pediatric, ultrasound often makes

example. “An 11-year-old boy came to our

the best first choice in imaging modalities

office recently complaining of several

because it is radiation free. Ultrasound’s

days of persistent abdominal pain. He had

weaknesses as a modality for adults are its

been febrile initially, and while the fever

strengths for children. “Ultrasound has the

had resolved, he continued to experience

advantages of not having any radiation, and

pain. His pediatrician called us to discuss the

of being insensitive to motion, which make

most appropriate study. She was considering

it the perfect modality for pediatric imaging,

CT scan and ultrasound of the abdomen. We

especially for young children or infants who

agreed it would be best to start with an

can’t stay still for CT scans or even for plain

ultrasound. The patient was able to show us

films. Ultrasound can penetrate only a certain

exactly where his pain was, and we saw a

number of centimeters through soft tissue,

fluid collection that led to the diagnosis of

which can be limiting in adults. In children we

an abscess from perforated appendicitis. In

don’t have that problem, as Dr. Meyer explains.

this case, a CT was not required.”

quality of the study. “When two exposures must

She adds another observation. “One of the

In one of Dr. Meyer’s cases, close collabo-

limitations of ultrasound is that it is operator

ration was crucial in diagnosing a 7-year-old

dependent. There is just no substitute for being

be seen on one image.

Scoliosis study obtained using the long length imaging system with auto fusion technology. Breast and gonadal shielding was used.

DECEMBER 2010

MRI offers non-radiation alternative In an increasing number of cases, MRI (magnetic resonance imaging) is the right choice for imaging a young patient, and the modality uses no radiation. Age is not a restriction; for a child younger than 8 years, the MRI is done in a hospital setting with sedation. “MRI is particularly useful as an alternative to CT in following chronic conditions for which the frequency of imaging would otherwise quickly lead to a large cumulative radiation dose,” Dr. Townsend says. “Examples of this include inflammatory bowel disease, such as Crohn disease or some childhood cancers, in Dr. Laura Meyer and staff technologist Jillian Cowan position a child for fluoroscopic imaging.

particular of the kidney or the liver.”

in the room, performing the scan yourself. That’s

who often need such pediatric imaging

why it’s so valuable that we always have a

procedures as voiding cystourethrograms

pediatric radiologist available to scan.”

(VCUG) and upper GI (UGI) examinations.

Naturally, in many cases, a child unquestion-

How is so great a reduction possible? For the

40 or 50 CT scans in their lifetimes. In recent

ably needs a study involving radiation, such

real-time moving images of dynamic processes

research, Dr. Townsend notes, MRI proves

as CT, fluoroscopy, or radiographs. “In

within the body, traditional fluoroscopy units

as effective as CT in determining bowel

these situations, it is our duty to make sure

take thirty images per second. “We selected

disease. “You can do an MRI instead of a CT

the dose is as low as possible. We take that

new fluoroscopic equipment with upgrades to

and get a highly accurate answer—and you

responsibility very seriously,” Dr. Meyer says.

allow the physician to control the number of

haven’t exposed the child to any radiation.

images taken per second,” Dr. Meyer explains.

Our practice has recently perfected our MR

“By taking three frames per second instead

enterography protocols for both adults and

of the standard thirty, this machine allows us

children.

When plain film studies are needed, young patients at Wake Radiology benefit from the recent, practice-wide upgrade in software aimed at reducing patient exposure on all plain film imaging. And in another technological advancement, a new long-length imaging system, particularly suited to scoliosis patients, can image the entire spine in a single view. This new technology makes it

to dramatically reduce the dose for all our standard pediatric fluoroscopic procedures without any loss of diagnostic information. It is a tremendous benefit to our young patients.”

In Crohn disease, since symptoms typically begin in children around ages 8 to 10, these young patients stand to receive as many as

“There are other indications for which MRI is a better initial test,” he says, including the workup of chronic headaches, seizures, and some pediatric cardiovascular abnormalities.

Relative Radiation Dose for Fluoroscopy

unnecessary to obtain separate exposures of the upper and lower spine. Another leadingedge innovation—this one in fluoroscopy— accomplishes a reduction in radiation exposure by a truly amazing magnitude.

120% 100% 80% 60%

Advanced fluoroscopic system reduces dosage

40%

Fluoroscopic studies are widely used for

20%

pediatric patients, and to minimize children’s

exposure, Wake Radiology’s new Siemens advanced fluoroscopic system in its West Raleigh office is able to reduce the dose for fluoroscopic studies by up to 80%. This is good news for adults and particularly for children,

The Triangle Physician

Continuous Fluoro

Pulsed Fluoro 3/sec Relative Dose Data provided by Siemens USA

Wake Radiology’s new fluoroscopy equipment allows for pulsed imaging that can reduce your patient’s radiation exposure up to 80% compared to continuous fluoroscopic imaging.

Reasons to perform AN MRI in the pediatric setting Wake Radiology’s Brent A. Townsend, MD, provides a partial list of reasons an MRI may be ordered. Brain

• Headache/seizure evaluation • Congenital abnormalities • Pituitary evaluation • Tumor evaluation • Not first step for acute trauma or shunt malfunction

Spine

• Follow-up study for abnormal spinal ultrasound, evaluation of cord compression • Tumor evaluation • Atypical scoliosis/kyphosis

Dr. Brent Townsend discusses a case with a mother and her sons at our pediatric imaging center in West Raleigh.

“MRI is great for soft tissues, and it provides

images right the first time, and avoiding

even better detail than ultrasound or CT,”

unnecessary exposures.

Dr. Townsend explains. For instance, a child with hip pain who refuses to bear weight might first have plain film studies and/or ultrasound, a good test of hip effusion. If those do not offer definitive answers, MRI would come next. “You would go to MRI to look for septic arthritis. MRI would be more sensitive than ultrasound for detecting infection in, say, the sacroiliac joint or infections in the muscles. Basically, MRI is better at picking up fluid, edema, and swelling in muscles or within small joints. “MRI is generally our best test for detecting osteomyelitis. CT would not give you that information at the early, critical stage. If the infection has been there for a long time, you

Chest

• Mediastinal abnormalities, especially posterior masses such as neuroblastoma or NF that may involve the spinal canal • Cardiac evaluation for structural abnormalities

Abdomen

“When a CT scan is determined to be the best test for a child, steps can be taken to minimize radiation risk,” Dr. Lerner says. Wake Radiology participates in the Image Gently campaign sponsored by the Society SM

for Pediatric Radiology and other national organizations. Among the steps the group advocates to minimize risk associated with CT scans are: decreasing the amount of radiation used in the scan; decreasing the field of view, or amount of the child included in the scan; avoiding multiple phases of the scan; and using appropriate shielding. Skill in handling children is pivotal. “If a child is afraid or apprehensive, it can

• MRCP, for pancreas/biliary tree • Enterography for inflammatory bowel disease • Tumor evaluation • MR Urography

Pelvis

• Congenital abnormalities • Tumor evaluation • Imperforate anus follow up

Musculoskeletal

• Osteomyelitis/soft tissue infection • Tumor evaluation • Lymphangioma/vascular malformation • Radiographically occult sports medicine injuries

Additional reading:

Alexopoulou E, Roma E, Loggitsi D, et al. Magnetic resonance imaging of the small bowel in children with idiopathic inflammatory bowel disease: evaluation of disease activity. Pediatr Radiol. 2009;39:791-797. Epub 2009 May 19. Leyendecker JR, Bloomfeld RS, DiSantis DJ, et al. MR enterography in the management of patients with Crohn disease. Radiographics. 2009;29:1827-1846.

can see bone-end destruction with X-ray and CT. MRI, however, can pick up the edema in the bone before it becomes very bad,” Dr. Townsend says. Additionally, MRI’s ability to visualize the soft tissues makes it the test of choice for sports-medicine or traumatic injuries that are more subtle than fractures.” Skill and expertise are at the heart of quality care Beyond selecting the best imaging study for a young patient, achieving minimal radiation exposure rests in the skills of the radiologists and technologists. Their experience and expertise make the difference in adequately safeguarding the child’s body, getting the

A mother comforts her child in one of our private ‘quiet rooms’ designed for feeding, changing, and calming sick or anxious children.

DECEMBER 2010

It’s a Great Time To Be a Child in the Raleigh Area Margaret Douglas, MD, who joined Wake Radiology’s pediatric imaging practice in 2000, remembers when there were far fewer medical resources for children and their parents. Today she works with three colleagues to lend and pediatric specialists. They also serve brand-new WakeMed Children’s, the first children’s hospital in Wake County. “This is a great time to be a child in Raleigh,” Dr. Douglas says. “I’m very proud that our group has gotten bigger just as the community needed us to get bigger.” Raleigh pediatrician Jerry Bernstein

Dr. Brent Townsend Dr. Catherine Lerner understands the special challenges of working with children and is skilled at calming their fears, as are all of our pediatric radiologists.

be very difficult to get a good imaging study,” Dr. Douglas says. “Frightened children have

couldn’t agree more. “With Dr.

trouble holding still, and the images can be blurred. If there is too much motion artifact, the

Douglas’s lead, they have been able

test can take longer or, in the case of a CT, the study may need to be repeated entirely. All of

to afford us a real resource,” he says.

these problems can lead to increased radiation doses, which we strive to avoid.

“They are right there with us to guide us, helping us make the diagnosis. They bring a lot of value to us in taking care of kids. “Having them available full time makes our lives so much easier—and the care of our patients so much better,” Dr. Bernstein says. “We have opened the WakeMed Children’s Hospital, which we think is the first step in

“Our pediatric team has put a lot of thought into helping our young patients feel more secure. We want their experience to be positive from the moment they come through the door. Our waiting rooms are decorated with murals of playful outdoor scenes in tranquil blues and greens with the goal of creating a calm, soothing atmosphere for our patients and their families. “Our pediatric imaging office is equipped with three private “quiet rooms”, which families use to calm their sick or anxious children. Parents also use these rooms for feeding and changing their children and for private consultations with the pediatric radiologists. “Our technologists have a wealth of pediatric experience and understand how to

really increasing the availability of

guide children through a test so that they are less apprehensive and more cooperative. They

sub-specialists in the care of children in

know that a child may be able to hold still for only a minute or two, so they are experts at

Wake County and surrounding areas.

getting high-quality studies quickly and efficiently. Often, this makes the difference in whether

Having a pediatric radiology team here

or not a patient needs to be sedated.

makes it so much more attractive, say, for another pediatric surgeon who comes in, or a pediatric neurosurgeon. They help us with recruiting physicians coming into the community. And that’s very important, because people want resources. ‘If I’m going to take care of this, I need to know that I can get well-timed, efficient, and authoritative studies done.’ And that’s what the pediatric radiologists afford us. To have four pediatric radiologists in Raleigh puts us on the level of any university teaching hospital.”

The Triangle Physician

“They also know that while a one-year-old who is afraid of the big fluoroscopy camera may need to be distracted with stickers or songs, an older child may require a careful explanation of each step of the exam in order to feel comfortable. “Every child is unique, with his or her own set of concerns or fears,” Dr. Douglas says. “To me, one of the most rewarding challenges is to figure out what is worrying each child, and then to find an effective way to relieve those fears.” ARTICLE CITATIONS 1 Frush, Donald P., Michael Callahan, Marilyn Goske, Sue Kaste, and Marta Hernanz-Schulman, CT and Radiation Safety: Content for Community Radiologists. Accessible online at http://spr.affiniscape.com/associations/5364/files/Community%20Radiologistsforweb.pdf 2 Hall EJ. Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol. 2002;32:700-706. Epub Jul 19. Preston DL, et al. Solid cancer incidence in atomic bomb survivors: 1958-1998. Radiat Res. 2007;168:1-64. Preston DL, Shimizu Y, Pierce DA, Suyama A, Mabuchi K. Studies of mortality of atomic bomb survivors. Report 13: Solid cancer and noncancer disease mortality: 1950-1997. Radiat Res. 2003;160(4):381-407.

PHOTO BY BRYAN REGAN PHOTOGRAPHY

their expertise to a host of pediatricians

DECEMBER 2010

MRI

Need assistance with a case? Call our Pediatric Radiologist Physician Hotline 919-782-4830

4301 Lake Boone Trail, Suite 100 Raleigh, NC 27607 WR Express Scheduling 919-232-4700

• No radiation

Laura T. Meyer, MD

Pediatric Radiologist

Brent A. Townsend, MD

Pediatric Radiologist

Catherine B. Lerner, MD

Pediatric Radiologist

children at hospital.

Very loud. Music and earplugs available. Sedation available for

Child will be in an enclosed cylinder

Child goes through a donut-shaped structure

Child needs to stay relatively still

prenatal ultrasound (with which the mother might be familiar).

First line choice for assessment of a child with a UTI. Just like a

reflux

First line choice for screening asymptomatic siblings of child with

First line choice for follow-up of reflux

First line choice for girls

Pediatric Radiologist Director of Pediatric Imaging

• Child will need IV

younger children

• Sedation may be required for

• Child will need IV

Notes

First line choice for suspected anatomic abnormality

First line choice for boys

Margaret R. Douglas, MD

acute pyelonephritis

• Identifies 90–95% of

alternative diagnoses

• Can assess for

x-rays

• RADIATION equals 250 chest

acute pyelonephritis

• Identifies 90-95% of

x-rays • Child will need IV

pyelonephritis

• Identifies 90% of acute • RADIATION equals 9 chest

nuclear medicine)

(cortical scintigraphy with

DMSA

anatomic abnormalities

• Very sensitive for

acute pyelonephritis

• Identifies only about 25% of

• No radiation

• Fast

Ultrasound

anatomic abnormalities

• Less detail for identifying

• Child will need catheter

x-rays

• RADIATION equals 16 chest

Cons

• Child will need catheter

Equals 9 chest x-rays

• (LOWER) RADIATION

bladder, and urethra

evaluation of ureters,

• Better resolution for

Pros

medicine)

(Cystogram with nuclear

RNC

VCUG

EXAM

Wake Radiology Pediatric Imaging

Are there anatomic abnormalities or complications from pyelonephritis?

This child had a UTI—does he/she have reflux?

Clinical Condition

Diagnosed by a catheterized or clean-catch specimen.

IMAGING OPTIONS FOR A CHILD WITH A URINARY TRACT INFECTION

Special Pull-out Reference Material

Meet the Pediatric Radiologists Margaret R. Douglas, MD

Laura T. Meyer, MD

Pediatric Radiologist Director of Pediatric Imaging

Pediatric Radiologist • Medical School | Duke University School of Medicine, Durham

• Medical School | University of Virginia School of Medicine, Charlottesville • Residencies | Pediatrics, University of Alabama Children’s Hospital, Birmingham; Diagnostic Radiology, University of Virginia Hospital, Charlottesville • Fellowship | Pediatric Radiology, University of Colorado Health Sciences Center, Denver • Certifications | American Board of Radiology – Diagnostic Radiology, American Board of Radiology – Pediatric Radiology, American Board of Pediatrics • Memberships | Radiological Society of North America, Society of Pediatric Radiology, Southern Society for Pediatric Radiology • Joined practice in 2000 Catherine B. Lerner, MD

• Residency | Diagnostic Radiology, Duke University Medical Center • Fellowship | Pediatric Radiology with special emphasis in cardiovascular imaging, Duke University Medical Center • Certification | American Board of Radiology – Diagnostic Radiology • Memberships | Radiological Society of North America, Society for Pediatric Radiology, North Carolina Medical Society, Wake County Medical Society

Brent A. Townsend, MD

Pediatric Radiologist

• Medical School | Columbia University College of Physicians and Surgeons, New York • Residency | Diagnostic Radiology – Chief Resident, Duke University Medical Center, Durham • Fellowship | Pediatric Radiology, Duke University Medical Center • Certification | American Board of Radiology – Diagnostic Radiology

• Medical School | Duke University School of Medicine, Durham • Residency | Diagnostic Radiology, Brigham and Women’s Hospital Boston • Fellowship | Pediatric Radiology, Children’s Hospital Boston • Certification | American Board of Radiology – Diagnostic Radiology • Memberships | Radiological Society of North America, Society for Pediatric Radiology, North Carolina Medical Society, Wake County Medical Society

• Memberships | Radiological Society of North America, Society for Pediatric Radiology, North Carolina Medical Society, Wake County Medical Society

Image Gently Providers All Wake Radiology physicians are concerned about radiation exposure and especially to children. We are registered as an Image Gently Provider by the American College of Radiology’s Alliance for Radiation Safety in Pediatric Imaging. The Alliance’s goal is to raise awareness of the opportunities to lower radiation dose in the imaging of children. All Wake Radiology’s imaging centers uphold strict protocols to ensure the lowest levels of radiation for diagnostic-quality images for both children and adults.

Wake radiology EXPRESS SCHEDULING STREAMLINE YOUR SCHEDULING 1 number, 17 locations to serve you. 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

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Wake Radiology Pediatric Imaging 4301 Lake Boone Trail, Suite 100 Raleigh, NC 27607 Pediatric Radiologist Physician Hotline 919-782-4830

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Ventricular Tachycardia Ablation A New Hope for Patients with Implantable Cardioverter-Defibrillators By By Dr. Brett D. Atwater, M.D.

Cardiology Dr. Brett Atwater of Duke Cardiology of Lumberton earned his medical degree at the University of Chicago Pritzker School of Medicine. He completed fellowships in cardiovascular medicine at the University of Wisconsin Hospital and clinical cardiac electrophysiology at Duke University Medical Center. Clinical Interests include clinical and procedural management of complex heart arrhythmias including atrial fibrillation, supraventricular tachycardia and ventricular tachycardia. Dr. Atwater performed his residency in internal medicine at Duke University Medical Center.

Ventricular tachycardia ablation reduces the risk of implantable cardioverterdefibrillator shocks in patients with prior myocardial infarction by approximately 65 percent compared to treatment with medical therapy. The implantable cardioverter-defibrillator (ICD) is a very important component of comprehensive heart failure management. Patients with prior myocardial infarction (MI) or heart failure and an ejection fraction â&#x2030;¤ 35% who are treated with prophylactic ICD implantation have a 15-25 percent lower risk of all-cause death, compared to patients without ICD implantation. ICDs save lives primarily by preventing sudden cardiac arrest, a condition that occurs when the heart suddenly converts from a stable rhythm to ventricular tachycardia (VT) or ventricular fibrillation. The ICD automatically detects that the patient has converted to VT and can then treat the rhythm with a combination of pacing maneuvers and high-voltage shocks. While ICDs dramatically reduce the risk of sudden cardiac arrest in patients with prior MI or heart failure, they do not cure patients of the underlying problem, VT. ICD shocks are painful and they decrease quality of life. Patients who receive shocks are at a higher risk of anxiety, depression, heart failure exacerbation and death than patients who do not receive shocks. For the past 15 years, patients who received ICD shocks for VT have been treated with a combination of beta-blockers and amiodarone to suppress future events. Unfortunately, long-term use

of amiodarone has been associated with a 12 percent chance of developing restrictive lung disease, liver disease, thyroid disease or problems with the eyes and skin. Recently catheter ablation of VT has shown great promise for prevention of ICD shocks. VT ablation is typically performed in an electrophysiology lab under general anesthesia to minimize patient discomfort. During the procedure the patient is usually put into VT intentionally to allow the electrophysiologist to localize the areas of abnormal electrical conduction that are triggering and sustaining the VT. VT can originate on the inside of the heart or on the surface of the heart. When VT originates on the surface of the heart, the area is studied by placing the mapping catheters directly on the heartâ&#x20AC;&#x2122;s surface through a small sheath placed through the chest wall into the pericardial sac. Areas of the heart that are responsible for triggering or sustaining VT are ablated, terminating VT. VT ablation reduces the risk of ICD shocks in patients with prior

MI by approximately 65 percent compared to treatment with medical therapy. At Duke University Medical Center, we are currently designing a large-scale, multi-center trial to determine if VT ablation, in addition to prophylactic ICD implantation, reduces the risk of death compared to treatment with prophylactic ICD implantation and medical therapy in patients with prior MI. Our hope is that preventing VT by catheter ablation may help patients with ICDs live longer, more enjoyable lives.

A 3-Dimensional map created during ablation of a VT originating from the inferior wall of the left ventricle. Areas of ablation are marked with red points.

DECEMBER 2010

Perspective

Professional Courtesy Is Near Extinction By Lindy McHutchison, M.D.

Despite the changing times, with insurance companies and politicians essentially attempting to practice medicine, and the seeming omission of professional courtesy from medical education, I will always value, practice and mourn the loss of this unspoken benefit of medicine. It seems as though a crucial course has

51 years. Back then, professional courtesy

done one or been taught one. Extinction is

been eliminated from the current medical

was not only local and regional, it was global

a well-known scientific evolutionary trend,

education – Professional Courtesy 101. What

and universal. Everywhere in the world,

why should medicine be immune?

a shame. As the advantages of medicine

doctors took special care of each other and

dwindle with each passing day, professional

their families. The special favor was never

I have noticed this change gradually over

courtesy was one priceless aspect of

requested, it automatically occurred with, “I

the years. However, no experience was

medicine even the insurance companies

am in medicine, too.”

more confirming than a recent trip to a local

and politicians could not effect. Ironically,

emergency room with my mother this past

we seemed to have stripped this invaluable

How sad to see this priceless aspect of

Halloween morning. My dear friend, also a

benefit from each other.

medicine

nearly

physician, offered to call ahead to alert the

absent, in what seems to be the youngest

emergency department that I was bringing

I have the right to talk (write). I grew up in the

generation of physicians. It’s not their fault.

my mother for evaluation. Peer-to-peer

golden days of medicine. My father, now retired,

One cannot be accountable to see one, do

communication is mainstay, right? Of course,

practiced committed, caring orthopedics for

one, teach one, if they have not yet seen one,

she mentioned I was a physician, as well.

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progressively

fading,

Dr. Lindy McHutchinson began training with notable physicians in the field of phlebology, first at Duke University as an observational fellow with Dr. Cynthia Shortell, chief of vascular surgery at Duke. Subsequently, she completed an extended clinical preceptorship with Dr. John Mauriello, fellow of the American College of Phlebology and nationally known educator in the field. She also trained with Dr. John Kinglsey in Birmingham, Ala., another nationally known phlebologist. Today, Dr. McHutchinson is medical director of Carolina Vein Center, a practice dedicated to the treatment of chronic venous insufficiency and other conditions associated with venous disease. To learn more about venous disease, visit www.carolinaveincenter.com. Dr. McHutchinson can be reached at lindy@carolinaveincenter.com or (919) 405-4200.

in an ER than the cumulative time of the four young physicians I encountered that day. I, too, was a resident; we all were. However, as a resident, I rarely evaluated/treated a physician or their family. I respectfully moved aside, learned from watching and allowed the attending to assume the care. As an attending for 13 years in a teaching hospital in San Diego, I watched the young residents do the same, respectfully. It was an unspoken protocol. But the point of all this is not about the comedy of errors from urgent care-recommended follow-up, the shift change comments or ER protocol. It’s about the dying art, consideration and unspoken value of professional courtesy benefit. Is it nearing extinction? Perhaps,

Upon our 7 a.m. arrival, I was first told by the check-in personnel,

it never existed. Such a shame these young physicians may not

“It will be awhile before we get to you, it’s shift change.” – words

experience that special gift with their own families. At least, we older

previously as taboo in a hospital as “Uh-Oh” in the operating room.

physicians can still “remember when… .” Perhaps, it’s because we sometimes feel undervalued by insurance companies and politicians

Despite an empty waiting room, we waited. Eventually, we were seen

that we may start undervaluing each other.

by the usual cast, first vitals, then a triage nurse, then our ER nurse and eventually, a kind, courteous and young second-year medicine resident.

To anyone who reads thus far, please know, I was reared on

I assumed he was staff; he wasn’t. After he returned a few times, to

professional courtesy and old-fashioned medicine. It’s all I know.

complete parts of the workup he’d forgotten, I knew he was a resident

Despite the changing times, with insurance companies and

and reminded myself, it is a teaching hospital. I didn’t want to be rude.

politicians essentially attempting to practice medicine, and the seeming omission of professional courtesy from medical education,

Finally, the kind, courteous, young ER attending came in. This second

I will always value, practice and mourn the loss of this unspoken

physician evaluation was complete and correct. Now he would call

benefit of medicine.

the ophthalmologist on call. Wait, wasn’t the on-call ophthalmologist already mobilized by my friend’s requests during her peer-to-peer call? No, he or she wasn’t. We waited. A first-year ophthalmology resident came from home. Such a smart, courteous, thorough, young physician he was. So competent after, presumably, just finishing his fourth month of ophthalmology training. His evaluation was complete. Then, four hours after our initial presentation, we saw the confident, courteous, young attending ophthalmologist. Her evaluation, diagnosis and management were quick and easy. Five hours later, after telling the “story” six times, we were discharged home with a few eye drops. If only the ophthalmology department had seen my mother the next day, as the urgent care physician allegedly recommended five days earlier. If only the urgent care department had scheduled the appointment they recommended for her. If only my mother wasn’t allegedly told by the ophthalmology department, “we don’t see sameday appointments,” none of this would have happened. Instead, we endured a five-hour emergency room charade only to be comforted with the phrase “that’s ER protocol.” Yes, I am familiar with ER protocols, I practiced Ob/Gyn for 17 years before retraining in phlebology. I am sure I have spent more time

DECEMBER 2010

Women’s Health

WiSH

Let the Discussion About Sexual Dysfunction Begin

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

Approximately 43 percent of American women report a “sexual problem.1” This is an important issue for women’s health and one that health care providers often neglect. We formed a group called Women Involved with Sexual Health (WiSH) to formalize an approach designed to help with sexual dysfunction. (See members below.) This allows our team at the Women’s Wellness Clinic to know the latest information on sexual dysfunction and to coordinate care for women and their partners. Given the impact sexual problems can have for women and their partners, Amy Stanfield, M.D., F.A.C.O.G, and I emphasize some of the more “typical” statistics about sex. For instance, the average amount of sex for couples is approximately two times

per week. The prevalence of same-sex relationships is approximately 12 percent, and sexual dysfunction is just as common in this group as heterosexual couples. The National Health and Social Life Survey (NHSLS) has shown that sexual problems/ complaints were associated with low physical and emotional satisfaction with sexual partners and low general happiness.2 Managing expectations is an important component of sexuality. So within our practice, we review the frequency of orgasm with women, as well as pervasive myths. Couples counseling has the benefits of: building communications between partners, sharing and learning one another’s expectations, understanding a relationship’s impact on sex (and vice versa), and learning

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what your partner likes and dislikes. Further, individual consultations help with addressing an individual’s concerns and problems with sexuality. A good history and physical is important in addressing sexual function. Further, a careful review of medications may yield insight into why someone may have dysfunction. Standard blood work includes testing of thyroid function, SHBG (sexual hormone binding globulin), testosterone, estrogen, progesterone and albumin levels. One useful, but often overlooked, aspect of sexual function includes a healthy lifestyle approach. We emphasize several aspects: optimizing medical illnesses; making time for leisure and relaxation, exercising; stopping smoking; and avoiding excessive alcohol. Often there are contributing aspects to sexual dysfunction that are overlooked by providers. The specific types of sexual dysfunction include several categories, each of which can cause personal distress: • Sexual desire disorders. • Hypoactive sexual desire disorder – deficiency (or absence) of sexual fantasies/thoughts; and/or desire for, or receptivity to, sexual activity. • Sexual aversion disorder – phobic aversion to, and avoidance of, sexual contact with a partner. • Sexual arousal disorder – inability to attain or maintain sufficient sexual excitement, causing personal distress that may be expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other somatic responses. • Orgasmic disorder – difficulty, delay in, or absence of, attaining orgasm following

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 Thombosis 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.

sufficient sexual stimulation and arousal. • Sexual pain disorders: dyspareunia – defined as genital pain associated with sexual intercourse; and vaginismus – noncoital sexual pain disorder, defined as genital pain induced by noncoital sexual stimulation.

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

In addition to Dr. Stanfield and I, WiSH members include: Sara Rosequist, Ph.D., Jennifer Burch, Ph.D., and Dr. Tiffany Marum of Southwest Durham Family Medicine P.L.L.C. We look forward to working with providers in North Carolina and improving communications about sexual function between providers and patients. Beginning in 2011, we will offer seminars to women on sexual function. Reviewing the information above is a good beginning – but beginning the conversation/discussion with women is a vital first step in helping someone have a healthy sexual relationship with their partner. 1. Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual Problems and Distress in United States Women. Obstet Gynecol. 2008;112(5):970-978. 2. Laumann E, Paik A, Rosen RC. Sexual Dysfunction in the United States: Prevalence and Predictors. JAMA. 1999;28(6):537-544.

DECEMBER 2010

Practice Management

Medical Practice Consultant Time to Call a By John J. Reidelbach

Not all medical practices have a need for consultants. However, if your practice is experiencing operational, strategic-growth and analytical issues, a consulting firm may be the answer. There are thousands of consulting firms in the United States. However, there are few that specialize in health care and medical practices.

law that is becoming a reality over the next few years. Everyone has heard of the term â&#x20AC;&#x153;meaningful use,â&#x20AC;? which by the way, continues to change.

Not all practices feel they have a need to retain a consulting firm. Their reasons include having an administrator in place, a physician leadership that does not want to incur additional practice expense, fear of the unknown or what can be uncovered, etc.

Most practices believe if they have a certified electronic health record (EHR), the practice will receive $44,000 per doctor. This is not totally true. There are other requirements, such as utilizing e-scribe, the percentage of Medicare/Medicaid patients in the practice, as well as other factors. This is just one facet of information that good consultants should know and that would have a large dollar impact to the practice from a cost perspective, but you would need to know how to apply for the CMS (Centers of Medicare and Medicaid Services) $44,000 rebate.

With the ever-changing landscape of health care, it is very difficult for some practices to stay tuned to all these changes due to resource requirements and the day-to-day running of a busy medical practice. One example of this is the current health care

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If a practice is considering a consultant, whether it be for a specific project or to assist the practice with operations and/or analysis, the practice should research the following attributes, as these are critical for a successful outcome: 1. Does the firm have expertise in the project, operation or analysis you need assistance with, and, if so, how long has the firm been in business and what types of practices have they worked with on these specific requests? 2. Does the initial consult with the firm cost the practice? Most reputable firms will provide the initial consult free of charge. This largely depends on the location of the firm in regard to the practice requesting an initial consult. However, there are some firms that will travel, provide a web-based meeting or a phone conference with no charge to the practice. 3. Will the consultant you meet with be your main point of contact or will there be another person performing the tasks? It is important that the person you meet with be involved with the tasks requested. Many times there will be other resources involved with the project. The practice should, however, have a main point of contact from the inception of the first meeting. 4. The practice should request background information on the firm and the consultants. As in hiring other personnel for the office, certain due diligence should be performed by the practice prior to retaining a firm. Request CVs

John Reidelbachâ&#x20AC;&#x2122;s career in health care spans more than 20 years and all facets of administration within physician practices, hospitals and large health care insurers. He founded Physician Advocates Inc. in 1996. Today, he assists health care entities in all aspects of practice management, operation, strategic development and implementation, education, contract negotiations, data analysis and capital funding. His credentials include degrees in engineering and education, and a masterâ&#x20AC;&#x2122;s in business administration. Mr. Reidelbach has designed several health care management entities, including independent physician associations, physician practice management companies, management service organizations and group practices. His experience includes developing equity ownership structures, financial incentives, network administration, and information systems selection and implementation. He also has developed detailed analysis tools for health care providers and product vendors. Mr. Reidelbach can be reached in North Carolina at (919) 321-1656 or in Atlanta at (404) 664-9060; and by e-mail to info@mdpracticeadvice.com.

would not be applicable, as typically commissions are paid on a practice sale. 8. W hat is the fee structure of the consulting firm? It is advantageous for the practice to determine whether it is an hourly, project based or retainer. Another question to ask is whether or not the rates are fixed for the project or timeframe of the engagement. 9. P rior to engagement, have the consulting firm provide a list of measurable deliverables for the tasks. These should be specified in an addendum to the

agreement, as well as the frequency of the deliverables. Not all medical practices have a need for consultants. However, if your practice is experiencing operational, strategic-growth and analytical issues, a consulting firm may be the answer. The benefit of a consulting firm is experience. Those who have it are the ones that work with many different practices, are exposed to an array of issues and resolve similar problems every day.

and references to verify the abilities, experience, and certainty of the firm and the consultants. 5. During the initial meeting, the practice must be honest and specific in identifying the issues surrounding the project. This helps the consultant identify the approach and method to be used to correct the issues/challenges, as well as understand the amount of time and effort it will take to accomplish the task. 6. After the initial meeting, the practice must ask if this is a person or firm is one they can work with over a period of time. 7. Prior to retaining a consultant, the practice should ask if the firm receives any compensation, via commissions or finderâ&#x20AC;&#x2122;s fees, from outside vendors the practice works with or may work with. This can sometimes cause a conflict of interest when selecting vendors for various issues within the practice. For practices that are retaining a firm for the purpose of selling the practice, this Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

DECEMBER 2010

Neurology

Non-Medication Pain Management Options for

Chronic Back and Neck Pain By By Dr. Sonia N. Pasi, M.D.

It is not necessary that every spine pain be treated with pain medications. There are non-pharmacological options for treatment of back and neck pain, as well. Back and neck pain are among the most common reasons for doctor visits and are major causes of disability, lost work days and high health care costs. Back pain affects about 80 percent of adults at some time in their life, and about 50 percent of people experience neck pain.

There are many different causes of back and neck pain. The clinical examination along with supportive diagnostic testing can help the clinician evaluate the precise pain generator. It is not necessary that every spine pain be treated with pain medications. There are non-pharmacological options for treatment of back and neck pain, as well. As some of the patientâ&#x20AC;&#x2122;s medical options disappear, it may be time to re-evaluate what is working and what we can do differently to help the patient. Facet joints are key pain source Facet joints are often the primary source of pain. Located at each segment in the back of the spine, these small joints provide stability to the spine and allow the spine to move and be flexible. The joints can become painful due to arthritis of the spine, back injury, whiplash injury, or mechanical stress of the back or neck. Depending on where the problematic facet joints are located, they can cause pain in the mid-back, ribs, chest (thoracic facet joint); lower back, abdomen, buttock, groin, legs (lumbar

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facet joint); and neck, shoulders and head (cervical facet joint). Joint block is diagnostic, treatment tool Patients who have chronic back or neck pain who have not responded to the conservative care should undergo diagnostic evaluation to find the primary source of spine pain. Pain associated with facet joints can be easily diagnosed and treated using diagnostic and therapeutic joint blocks, which can confirm or reject the facet joint as the source of pain and pinpoint the exact location. If the blocks are successful, then proceeding with radiofrequency lesioning is worthwhile. This is considered to be a non-surgical option and may avoid extensive surgery, such as lumbar fusion. For these patients, facet joint rhizotomy/radiofrequency ablation may be the answer. In some patients with multifactorial pain, reducing the total pain burden by percutaneous facet joint denervation enables the patient to better tolerate his or her remaining pain. Radiofrequency ablation can zap facet joint pain Facet rhizotomy, or radiofrequency ablation, is proven to be a safe and effective way to treat spine pain originating from the degeneration of facet joints. It works by shutting off the pain signals the joints send to the brain.

Dr. Sonia Pasi of Advanced Pain Consultants P.A. is board certified in pain management and neurology. She earned her medical degree from the Government Medical College and Hospital of India. She completed her fellowship at Duke University Medical Center and the Medical College of Georgia. Clinical interests include management of various pain disorders, such as back and neck pain; reflex sympathetic nerve blocks, peripheral neuropathy and headaches; conservative pain management; and treatments that include diagnostic and therapeutic nerve blocks and various injection therapy.

Using a local anesthetic and X-ray guidance, a needle with an electrode at the tip is placed alongside the small nerves of the facet joint and delivers pulsed radiofrequency waves to ablate, or stun, them. This technique is very safe, requiring only an outpatient procedure that takes about 30 to 60 minutes. The patient is monitored for a short time, then released. Pain relief from radiofrequency ablation can last from six months to a year or more without the need for medication. Spinal cord stimulator offers relief for neuropathic pain A spinal, or dorsal, cord stimulator has been very successful for relief of chronic neuropathic neck and back pain. In layman’s terms, the spinal cord stimulator (SCS) is called a “pain pacemaker.”

pulses replace the feeling of pain with a pleasant tingling and massaging sensation, thus reducing and eliminating the patient’s pain. SCS is recommended for chronic neuropathic pain when conservative treatments have not been successful, surgery failed or surgery is an unlikely option. The spinal cord stimulator has portable angiogenic properties and at present is used mostly in the treatment of failed back surgery syndrome, complex region pain syndrome and the refractory pain of ischemia. Trial period precedes implantation SCS is an excellent option, however, the device is not for everyone. The key for success is patient selection. A major benefit is that patients can participate in a trial run, before the decision is made to implant. The trial period is important to determine if therapy provides significant pain relief and if the patient is comfortable with the sensation of the spinal stimulation.

The trial can be done as an outpatient procedure using local anesthetic and mild sedation, and the patient goes home afterward. During the trial, leads are placed percutaneously under fluoroscopy guidance into the epidural space within the spine. The other ends of the leads are connected to a small battery-powered generator that the patient carries during the trial period. If the system works well for patients and significantly reduces the pain and functionality, then a permanent spinal cord stimulator system is recommended and usually implanted. Return to a happy, productive life The goal is to achieve significant or total relief from back or neck pain and to be able to return to a happy and productive lifestyle. While this therapy does not work for everyone, most patients with a spinal cord stimulator report 50 percent to 70 percent reduction in overall pain and the ability to completely taper off the narcotic painkillers.

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Approved by the Food and Drug Administration in 1989, SCS has become a standard treatment for patients with chronic neuropathic pain in the back, neck and/or limb caused by nerve injury and abnormal nerve function. It is a second line of therapy for patients who have failed the conservative methods of pain management. Spinal cord stimulation is a procedure that delivers a low level of electrical signals to the spinal cord or to a specific nerve to block pain signals from reaching the brain. When received by the spinal cord, the electrical

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

DECEMBER 2010

Neurology

Sleeping well Leads to Better Health By S. Thomas Kirk, M.D.

Some studies have found that depriving a rat of sleep can shorten its life by as much as 98 percent. Why wouldn’t we expect it to be so pervasively important in the quality and length of our waking lives? There are more than 85 sleep disorders, as last recognized by the American Academy of Sleep Medicine, involving almost one-fourth of Americans. What are the sleep disorders? There are eight broadly classified categories of sleep disorders: insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep disorders, parasomnias, sleep-related movement disorders, isolated symptoms and normal variants, and other sleep disorders. There is a heavy representation by number of the sleep-related breathing disorder classification in the form of apnea, which is ubiquitous, growing quickly in our elevated-body mass index and aging populace. Alone, it affects a likely underestimated 12 million to18 million Americans. At least six million are likely undiagnosed due to a variety of reasons: lack of time allocated to the primary care physician for such a consideration, an under appreciation of this as a contributing factor to the patient’s other more glaring morbidities, or as a misdiagnosis altogether as some other issue. Currently, no reliable estimate approximates well the number of sleep disorders remaining undiagnosed by us in the medical community within the remaining seven broad categories.

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Why assess for a possible sleep disorder? Quite a few reasons: • Positive feedback relationship between depression, as well as other psychopathologies and underlying sleep disorders; • Greater difficulty in controlling diabetes and obesity; • Increased risk of stroke (up to three times) and heart attack as a factor independent of hypertension (HTN) and hyperlipidemia (HLD);

• Increased work-related accidents and vehicular crashes; • Lost work productivity, costing $50 billion annually in the United States, or up to $16 billion in health care expenses annually. Sleep accounts for one-third of our lives, with processes as vital to us as what our waking bodies do. Some studies have found that depriving a rat of sleep can shorten its life as much as 98 percent. Why wouldn’t we expect it to be so pervasively important in the quality and length of our waking lives? How are sleep disorders diagnosed? Most of the recognized sleep disorders can be diagnosed and addressed adequately by a thorough history and physical alone. Only in some of the patients seen by a sleep specialist is further clarification by more objective means required.

• Greater recalcitrance in HTN treatment or up to 50 percent greater risk of just having HTN; • Left- and right-sided cardiac remodeling with an increased chance of developing heart failure; • Greater difficulty in treating atrial fibrillation (if not an independent cause); • Reduced infection resistance;

The most familiar of the sleep specialist’s diagnostic tools is the polysomnogram (PSG). A PSG simultaneously evaluates several physiologic variables during a full night of sleep. The various components consist of: • Electroencephalography (EEG), which can either be a montage of three or six channels for sleep staging, or even a full 12, if needed for epileptic concerns;

Dr. Thomas Kirk specializes in adult neurology and sleep medicine at Raleigh Neurology’s Durham office. He earned his doctorate degree from the University of Texas Medical Branch in 2005. He completed his neurology residency at Baylor College of Medicine in 2009 and, subsequently, his sleep medicine fellowship training at the Duke University Medical Center in 2010. He is a member of the American Academy of Neurology and American Academy of Sleep Medicine.

• Electro-oculography (EOG); • Electromyography (EMG) for limb activity; • Single-lead electrocardiography (EKG); • Nasal and oral airflow; • Respiratory effort (by thoracic and abdominal movement belts); • Pulse oximetry: • Microphone for quantifying snoring: • Body position; • Video monitoring, vital in evaluating many unusual nocturnal movements/behaviors; and even, • Capnography, in the case of children or adults with concerns for obesity hypoventilation syndrome. There are additional channels which can be added, as needed, although a patient may already feel like Pinocchio with these basic leads. In actuality, it is rare for a patient not to sleep adequately during a sleep study due to strategic placement of monitoring wires. In the case of sleep apnea, many individuals can have both their diagnostic evaluation and a titration of possible viable continuous positive airway pressure (CPAP) during the first night of PSG if the apnea reveals itself early enough in the night. Other individuals require a second night if the apnea reveals itself late in the study or if their apnea is complex and needs: • Higher static CPAP pressures than time allows; • Utilization of variable bi-level positive airway pressure (BiPAP); or possibly, • More dynamic adaptive servo-ventilation (ASV) pressures to address complex

apnea or etiologies, such as CheyneStokes respiration. Some individuals are candidates for a home PSG, with their more limited self-applied lead assessment, and there are other diagnostic tools available in the assessment of sleep disorders, such as: • Daytime multiple sleep latency testing (MSLT) for narcolepsy and excessive daytime sleepiness; • Maintenance of wakefulness testing (MWT) to test efficacy of treatment in some patients or as an indicator of how well one is able to function and remain alert in quiet times of inactivity; and, • Actigraphy, used to address circadian rhythm disorders. How are sleep disorders treated? Addressing success rates of treating all the individual sleep disorders would be daunting, to say the least. For obstructive sleep apnea alone, it is difficult to truly capture a reliable number regarding treatment efficacy. NEWSOURCE-JUN10:Heidi

8/5/10

The gross estimate for dental appliance success alone is around 50 percent, however, in the properly selected individual, the success rate is likely quite higher. Surgical intervention approaches 50 percent, as well; and not always durable in its effect, however, this is also likely much higher when interventions are closely tailored to the individual. CPAP efficacy is theoretically 100 percent, however, remains diluted by a multitude of factors which diminish compliance, all of which are addressable by a dogmatic specialist. A true assessment of sleep disorders requires a comprehensive, multidisciplinary approach, with a group of clinicians working together. It is important for a sleep specialist to have a strong referral base of psychologists, otolaryngologists and dentists, as well as a willingness for the more common subspecialties entering into sleep medicine, pulmonology, neurology and internal medicine to refer to each other when a specific sleep disorder dictates.

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DECEMBER 2010

Hospital News

Statewide Program Speeds Up Heart Attack Care in North Carolina A program designed to speed up heart attack care has led to significant improvement in the quality of care after it was extended across North Carolina last year, according to researchers at Duke University Medical Center. Study results show a notable decrease in hospital death rates, from 7.5 percent in the 2006 RACE study to below 6 percent now. “The odds of a person surviving a heart attack are directly related to the time it takes to open the artery, resuming blood flow,” says Michael Komada, M.D., cardiologist with Triangle Heart Associates. Speedy treatment leads to less heart damage and saved lives among heart attack patients. Guidelines by the American College of Cardiology and the American Heart Association state that patients suffering from heart attacks due to blocked arteries should receive clot-busting medical therapy within 30 minutes or artery-opening therapy within 90 minutes. The program, RACE-ER (which stands for Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments – Emergency Response), builds on the success of the initial RACE project. It involved emergency services personnel, physicians, nurses and administrators working collaboratively to reduce the time between occurrence of heart attack and initial treatment.

prompt, artery-opening care or angioplasty. Results also show a substantial change in urban areas, with more people calling 911 and more patients going directly to specialty centers. There also has been improvement in reducing patients door-in to door-out times among smaller hospitals that transfer them to specialty centers. The findings were presented in November at the American Heart Association’s Scientific Sessions 2010 in Chicago, Ill. Each extension of the RACE program has brought added success and a deeper, more collaborative look at providing the best quality of care, according to Komada. “We strive to make the entire treatment process seamless,” he says. “It really is a carefully orchestrated system.”

Increase your

chance survival

RACE-ER expands the program to all 119 hospitals and all emergency medical services systems throughout North Carolina. It focuses on early diagnosis, early treatment and optimizing performance at every point of care. The protocol begins when emergency medical responders enter the patient’s home. They evaluate blood pressure, breathing and EKG. If a heart attack is indicated, they call the DRH STEMI hotline, which is connected to the hospital emergency department (ED). The ED calls the cardiologist on call and the cardiac catheterization laboratory team is notified, so all staff members are prepared for the patient. As soon as the patient enters the hospital, he is evaluated by the cardiologist and, if appropriate, sent directly to the cath lab, where his artery will be opened. The RACE-ER study consisted of 6,841 patients with a specific type of heart attack called STEMI, which can be treated successfully with

The Triangle Physician

of breast cancer

| First breast dedicated surgical practice in Raleigh | Among the first in the country to receive Masters of Breast Surgery Certification | Studies show that patients being cared for by surgeons specializing only in breast cancer have a higher survival rate | Semimonthly in office multdisciplinary conferencing with radiology and pathology | Six years of collaborative relationship with radiology with in office diagnostic imaging

2301 Rexwoods Drive Suite 116 | Raleigh

| Most experienced surgical practice in Mammosite radiation (accelerated partial breast radiation), sentinel node mapping and image directed breast biopsy

919.782.8200 | www.carolinabreastcare.com

News Welcome to the Area

Physicians Sophiya Benjamin, MD Psychiatry Duke University Hospitals, Durham

Upcoming Events Nicole Maria Kuderer, MD

James Elbert Winslow, MD

Oncology, Internal Medicine Hematology, Internal Medicine Duke University Hospitals, Durham

Family Practice 609 Professional Drive, Roxboro

Christine Lin, MD

Feb 15-17

Step Lively: A Walk for Hospice MIX 101.5 Radiothon for Duke Children’s Contact: Robyn Soffera at 919-667-2565 or robyn.soffera@duke.edu

Diagnostic Radiology Duke University Hospitals, Durham

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Physician Assistants

Seamus Michael Bhatt-Mackin, MD

Gines Diego Miralles, MD

7324 Barham Hollow Drive, Wake Forest

Infectious Diseases, Internal Medicine Internal Medicine Duke South Orange Zone, Durham

Clinical Trials

Charles Stuart Forbes, PA

Do you have patients with any of these problems?

Vijay Rudrakumar Patil, MD

Tara Rae Herrmann, PA

Erica Young Berg, MD

Psychiatry Durham Va Medical Center, Durham

Nicholas Hagen Bird, MD Divers Alert Network, Durham

Elan Chanel Burton, MD Thoracic Cardiovascular Surgery 111 Cedar Elm Road, Durham

Khalilah Celecia Dann, MD

Lana Jean Cooper, PA

North Carolina Neuropsychiatry, Raleigh

10511 Rosegate Ct., Raleigh

Duke University Medical Center, Durham

Ron Howard Rawlings, MD

John Paul Kumhyr, PA

Anesthesiology Duke University Hospitals, Durham

3596 NC Hwy 231, Wendell

Samantha Kayin Kwan, PA

Family Medicine University of North Carolina Hospitals, Chapel Hill

Waqas Sohail, MD Neurology WFU Baptist Medical Center, Winston-Salem

Kari Elizabeth Loomis, PA

Suzanne Elizabeth Dvergsten, MD

Deneen Marie Spatz, MD

Orthopedic Specialists of North Carolina, Wake Forest

100 Eatondale Road, Durham

Tracy Lyn Eskra, MD 608 Walnut Creek Drive, Goldsboro

Edgar Allen Fike, MD Carolina Regional Orthopaedics, Rocky Mount

Hunter Alvert Hearn, MD Feeling Great Sleep Center, Durham

Julie Rachelle Holden, MD Diagnostic Radiology 2608 Erwin Road, Durham

Alison Beth Jazwinski, MD Internal Medicine Duke University Hospitals, Durham

North Carolina Neuropsychiatry, Raleigh

Duke University Medical Center, Durham

Debbie TestBrienzi, MD

Rachel Anne Robinson, PA 57 Lake Village Drive, Durham

Raleigh

Anantachote Vimuktanandana, MD Anesthesiology Duke University Hospitals, Durham

Jeffrey Michael Rosowski, PA Brier Creek Integrated Pain & Spine, Raleigh

Natasha Renee Wright, PA 1503 Poplar Ridge Rd, Fuquay Varina

Neil Carroll Vining, MD

Pathology Duke University Hospitals, Durham

Joseph Benjamin Williams, MD Psychiatry Central Prison Inpatient Mental Health, Raleigh

Wake Urological Associates, PA Currently screening Do you have a sudden and urgent need to urinate? Do you have accidental loss of urine? If you are a male/female, 18 years of age and older you might be eligible to participate in a clinical trial study for Over Active Bladder conducted by Wake Urological Associates. For additional information and qualification criteria please call 919.782.1255 and ask for Clinical Trials Department or visit our web site www.Wakeurological.com.

Gynecology Women’s Wellness Clinic

Raleigh Orthopaedic Clinic, Raleigh

Dava Susanne West, MD

Urology

Upcoming Events Saturday, Dec 4

Duke Children’s Teddy Bear Ball

is conducting a research study. If you are female and 12-18 years old, have regular periods, requesting birth control pills for any reason (OR you can be part of a control group that does not take any pills), You may be eligible to participate in this study. Participants

Rex Healthcare Breaks Ground on Holly Springs Medical Campus Rex Healthcare announced the second phase of its Holy Springs development with the groundbreaking for a state-of-the-art medical campus Nov. 10. It will feature a two-story, 30,000-squarefoot outpatient center, offering urgent care, imaging services, a clinical lab and physician offices. It is expected to be operational in late 2011. It will be complemented by a new 10,000-square-foot medical office building. This construction represents the second phase in Rex’s Holly Springs development. The opening of Rex Family Practice at Southpark Village in Holly Springs Oct. 4 marked completion of the first phase. “This is exciting because it means we’re

closer to providing quality health care services to the residents of southern Wake County,” says David Strong, president of Rex Healthcare. “We appreciate the community’s warm welcome and look forward to having Rex co-workers and physicians care for people at our new health campus.”

Sears, Holly Springs mayor; and Ed Woods, Duke Realty development executive. The facility will be located near the intersection of Avent Ferry Road and N.C. 55. For more information, visit www.rexhealth.com.

The groundbreaking ceremony featured speakers Lindy Brown, Wake County commissioner; Scoop Green, executive director of the Holly Springs Chamber of Commerce; Dale Jenkins, Rex Healthcare Board of Trustees chairman and Medical Mutual chief executive officer; Dick

DECEMBER 2010

Hospital News

WakeMed First in North Carolina to Earn Heart Failure Accreditation adjust medications, diet and activity levels to prevent hospital readmission and improve a patient’s quality of life. National statistics show that 1 in 5 heart failure patients who is discharged from the hospital is readmitted within 30 days.”

akeMed Raleigh Campus and WakeMed Cary Hospital are the first hospitals in North Carolina to earn full heart failure accreditation from the Society of Chest Pain Centers (SCPC). To achieve SCPC Heart Failure Accreditation, WakeMed met or exceeded 10 criteria, including quality measures that improve the process of care for heart failure patients, integration with emergency medical services, and personnel competencies and training, to name a few. “Being first in the state to earn heart failure accreditation demonstrates WakeMed’s continued commitment to ensuring cardiac patients receive gold-standard care based on demonstrated best practices,” says Betsy Gaskins-McClaine, vice president of Heart & Vascular Services. “Providing this quality care requires a commitment across the health care continuum, starting from emergency medical services through the emergency department, Heart Center, and continued care from a multi-disciplinary team during the patient’s hospital stay to follow-up care with cardiologists, primary care practitioners, home health and outpatient therapy programs. “For heart failure patients, this commitment from health providers is even more critical due to the need to continuously monitor and

The Triangle Physician

In Wake County, heart failure patients’ health and quality of life are positively impacted by a strong commitment from Wake County EMS and WakeMed. Examples of these commitments include: • Wake County Emergency Medical Services has an advanced paramedic program that targets heart failure patients, as well as other complicated disease processes. This program ensures heart failure patients receive appropriate treatment at first contact. • WakeMed Emergency Department staff and physicians are specially trained and work in collaboration with cardiologists and primary care providers to ensure heart failure patients are identified, treated appropriately, educated and have a means for follow up after discharge. • Raleigh Campus and Cary Hospital inpatient units have increased the number of resource nurses and referrals to the outpatient heart failure program. Inpatient programs are also consistently reevaluating and improving the patient education and discharge process to help ensure patients understand how to manage their disease. • Established in 1999, the WakeMed Heart Failure outpatient program works to reduce hospital readmissions for heart failure patients within one year of discharge by concentrating on contacting patients, educating them on disease management, and collaborating with patients’ cardiologists and primary care physicians. Since the heart failure program’s inception, it has enrolled 2,359 patients and is currently actively following 830 patients. The program

has reduced hospital readmissions to 8 percent of the national average for program participants. • WakeMed Home Health collaborates with the heart failure outpatient program to track the most medically fragile patients using telehealth and home visits. If a weight, blood pressure or other early heart failure complication is identified, patients are referred to cardiologists and primary care physicians, enabling better and more consistent treatment and earlier interventions, reducing the need for an emergency department visit or inpatient hospital stay. “Our heart failure program is unique in that it focuses on the relationship between the patient, program and the doctors…,” says Marian Uy, R.N., coordinator of the congestive heart failure program. “It is (helping patients manage) this chronic disease by monitoring their condition, empowering them through education and being available for emotional support. This heart failure accreditation reinforces that patients in Wake County who come to WakeMed are receiving quality care from first contact to well after discharge.” Heart failure is a leading cause of morbidity and mortality in the United States. The National Heart Lung and Blood Institute estimates that five million patients in the United States have heart failure and 300,000 people each year die from the disease. Heart failure patients are responsible for 12 to 15 million physician office visits per year and 6.5 million hospital days. Of Medicare patients hospitalized with heart failure, 29 percent are readmitted to a hospital within 30 days of discharge at a cost of $37.2 billion per year. Because of the added cost of hospital readmission for heart failure patients, this is an area of targeted cost savings under health care reform.

Hospital News

WakeMed Mobile Critical Care Celebrates 20th Anniversary with National Award WakeMed Health & Hospitals’ Mobile Critical Care service has won the 2010 Ground Critical Care Award of Excellence by the Association of Air Medical Services. The Association of Air Medical Services presents nine awards annually to individuals and organizations that exemplify the best of the air-medical and critical care ground transport community. The awards recognize an individual or team that has made an outstanding contribution in a dedicated critical care ground program in any of the following areas: enhancing safety, education, leadership or patient advocacy by developing or promoting the improvement of patient care in the medical transport community. “Receiving this award is a true honor and reflects the entire Mobile Critical Care Services team,” says Betsy Casanave, director and chief of Mobile Critical Care Services.

“Our team is made up of outstanding, talented professionals, and I cannot think of a more deserving group.” Founded in 1990 with one ambulance and seven providers, WakeMed Mobile Critical Care Services (MCCS) transported 229 patients during its first year of service. By 2000, MCCS was completing over more than 1,800 transports annually, with 22 providers and three ambulances. Now in its 20th year, WakeMed Mobile Critical Care Services has 20 ground ambulances and one air ambulance, 133 employees and 17,309 patient transports annually. The transports include, but are not limited to: cardiac, neonatal, pediatric, medical, respiratory, obstetric, convalescent and trauma patients. Patients are transported to or from all 100 counties in North Carolina, southeastern Virginia and northeastern South Carolina.

Over the last several years, WakeMed Mobile Critical Care has appointed a dedicated medical director and added 800 MHz radio communications for state-wide coverage, computer-aided dispatch (CAD) for better accountability and monitoring of the ambulances while in transit; and implemented safety equipment and software that monitors and records ambulance activity while in motion. Additionally, many of the ambulance configurations were upgraded to a quad cab to provide better crew member safety en route to a call and to offer the ability to safely transport patients’ family members with the patient to the receiving facility. Mobile Critical Care Services also recently expanded its response area by adding remote bases in northern Wake County, Cary, Benson and Apex.

77kids Holiday Campaign to Benefit WakeMed Children’s WakeMed Children’s Center is one of eight children’s hospitals nationwide to benefit from 77kids by american eagle’s WISH4SNOW holiday program. As part of the program, customers of the 77kids Crabtree Valley Mall location will be invited to make a 77-cent donation to

WakeMed Children’s Hospital with each purchase. Additionally, customers can visit www.77kids.com to make “virtual snowflakes” stating their holiday wish, with the goal of creating 100,000 snowflakes by Dec. 14. The site also features a free virtual snowflake-catching game.

Each customer who makes a snowflake will be automatically entered into a sweepstakes in which a $77 gift card will be awarded daily, along with the grand prize of a winter block party. If customers reach the goal of 100,000 snowflakes, American Eagle Outfitters will donate $25,000, to be split evenly among the eight WakeMed hospitals.

DECEMBER 2010

Hospital News

UNC Obstetrics and Gynecology Is in the News Honors, Awards and Appointments At the annual American Association of Gynecologic Laparoscopists meeting Nov. 9, Drs. Paola Gehrig and John Boggess received the Best Minimally Invasive Oncology Paper award for “Surgical Staging for Type II Endometrial Cancer: Laparotomy or Minimally Invasive Surgery?” Jeanette Moore, R.N., was presented the 2010 School of Medicine Nursing Recognition Award for Outpatient Services. Dr. Emma Rossi was awarded $50,000 as recipient of the 2010 UNC Lineberger Cancer Research Award for Clinical/Translational Research for her research entitled “Pelvic and Para-Aortic Sentinel Lymph Node Mapping with Robotically Assisted Nearinfrared Imaging after Cervical and Uterine Indocyanine Green Injection.” Dr. Kevin Schuler was elected to the Administrative Board of the Organization of Resident Representatives for the Association of American Medical Colleges (AAMC) at the annual AAMC meeting in Washington, D.C. Dr. Marc Fritz was elected to a threeyear term on Board of Directors for the American Society for Reproductive Medicine.

From our Blog Meet Willie Mae Walker from Graham, N.C., who shares her cancer survivor story – http://bit.ly/cC6QvC. Meg Berreth, C.N.M., M.S.N., talks about protecting the perineum during delivery – http://bit.ly/cYZKqv.

In the News The Washington Post health reporter Rob Stein writes about Dr. Anne Steiner’s study on the reliability of home fertility tests – http://wapo.st/ bn2Gfv. Dr. Anne Steiner is quoted in a Time.com article by reporter Bonnie Rochman – http://bit.ly/9XEyrw.

The Triangle Physician

Sarah Avery of the Myrtle Beach Sun News writes about the study that casts doubt about fertility kits led by Dr. Anne Steiner – http://bit.ly/az92Ax. Gynecologic oncologist authors latest clinical updates for the American College of Obstetricians & Gynecologists – http://bit.ly/b2Kkrm.

Presentations Dr. Amy Bryant, “Contraception for Medically Complex Adolescents,” UNC Department of Pediatrics grand rounds in October. Dr. Nancy Chescheir: • Ellie Pryor Memorial Lectureship at East Tennessee State University (ETSU): “The Seven Habits of Highly Effective Medical Educators;” and ETSU OB/GYN grand rounds: “Women in Academic Medicine: As Yet an Unfinished Story,” Johnston City, Tenn., Oct. 19-20. • “Beyond the ‘Checky Box:’ Real OB Safety Initiatives” for the Perinatal Safety Meeting, Novant Hospital Systems at Presbyterian Hospital, Charlotte, N.C., Nov. 13. • “Cesarean Section: What Does the National Data Tell Us,” Rex Healthcare OB/GYN grand rounds Nov. 3. Dr. David Grimes, visiting professor for the Robert Wood Johnson Clinical Scholars, University of Pennsylvania, Philadelphia, Pa., Oct. 20. Dr. Catherine Matthews: • Course faculty at Female Pelvic Medicine for the Office Based Practitioner, Chicago, Ill., Oct. 23-24. • At the American Association of Gynecologic Laparoscopists meeting Las Vegas, Nev., Nov. 8-11: - “Implementing Robotics in Benign Minimally Invasive Gynecologic Surgery;” - “Evaluation of Surgical Time, Complications and Learning Curve for Robotic Sacropexy;” and - “Innovations in Robotic and Gynecologic Surgery: The Learning Curve First Year Experience.” • Grand rounds at Carolinas Medical Center, Nov. 3-4 in Charlotte, NC. Dr. Susan Nickel, “Safety in Pregnancy” at the UNC School of Nursing seminar entitled “What’s New in Perinatal Care” Oct. 29.

Dr. Gretchen Stuart, “A Novel Approach to Post-Partum Contraception” at the “The V and X: Tracking Transitions in Family Planning, Preconception and Women’s Health” Region IV Network for Data Management and Utilization workshop Sept. 29. Group Meeting Presentations American Society for Reproductive Medicine annual meeting, Orlando, Fla., Oct. 15-19: • U. Balthazar, M.A. Fritz, T. Bardsley, J. E. Mersereau, “Fertility Preservation Treatment Options: What Do Patients Actually Understand About Their Choices?” and “Decision Making Under Duress: What Predicts Decisional Conflict Among Fertility Preservation Patients?” • K.C. Calhoun, A.Z. Steiner, “Diminished Ovarian Reserve Is Not Associated with Increased Risk of Preterm Birth or Low Birth Weight.” • R.H. Fogle, O.R. Minkhorst, J.P. Toner, A.Z. Steiner, “Antimullerian Hormone (AMH) Efficiency Curves: Predicting a Threshold for Pregnancy in In Vitro Fertilization (IVF) Cycles.” • A.Z. Steiner, M.A. Fritz, C.K. Sites, C. Coutifaris, B.R. Carr, K. Barnhart, “Resident Experience on Reproductive Endocrinology and Infertility (REI) Rotations Affects Perceived Knowledge.” • A.Z. Steiner, A. Herring, J. Kesner, J.W. Meadows, S. Hoberman, D.D. Baird, “Urinary Markers of Ovarian Aging and Predicting Natural Fertility.” Association of Reproductive Health Professionals meeting, Denver, Colo., Nov. 6-13: • D. Bartz. J. Tang, R. Maurer, “Medical Student Intrauterine Contraception Knowledge and Attitudes: Evaluation of Obstetric and Gynecology Clerkship Training.” • A. Bryant, G.S. Stuart, D.A. Grimes, “Dilation and Evacuation Vs. Labor Induction for Fetal Indications: A Retrospective Cohort Study.” Mid-Atlantic Gynecologic Oncology Society meeting, Oct. 28-30: • K.M. Schuler, N. Banet, V. BaeJump, R. Lininger, P.A. Gehrig, “Predictors of Metastatic Spread in Uterine Papillary Serous Carincoma: A Pilot Study.”

• R.K. Hanna and J.F. Boggess, “Robotic Assisted UreteroNeocystotomy,” a surgical video presentation. • R.K. Hanna and J.F. Boggess, “Robotic Assisted Para-Aortic Lymph Node Dissection (PA-LND), Preparation and Technique,” a surgical video presentation. UNC Center for Functional GI Motility Disorders Annual Research Day Nov. 6: • Dr. Barbara Robinson, “Influence of Stool Consistency, Urgency, and Obstetric History on Fecal Incontinence.” • Dr. Catherine Matthews, “Surgical Innovations for the Management of Fecal Incontinence.”

Publications • Baker AM, Haeri S, Camargo CA Jr, Espinola JA, Stuebe AM. A Nested Case-Control Study of Midgestation Vitamin D Deficiency and Risk of Severe Preeclampsia, J Clin Endocrinol Metab. 2010 Nov;95(11):5105-9. • Cantrell LA, Westin SN, Van Le L. The Use of Recombinant Erythropoietin for the Treatment of Chemotherapy-Induced Anemia in Patients with Ovarian Cancer Does Not Effect Progression-free or Overall Survival. Cancer. 2010 Nov 8. • Grimes DA., Epidemiologic Research Using Administrative Databases: Garbage in, Garbage Out. Obstet Gynecol. 2010 Nov;116(5):1018-9. • Matthews CA, Reid N, Ramakrishnan V, Hull K, Cohen S. Evaluation of the Introduction of Robotic Technology on Route of Hysterectomy and Complications in the First Year of Use. Am J Obstet Gynecol. 2010 Nov;203(5):499.e1-5. • Parnell BA, Dunivan GC, Connolly A, Jannelli ML, Wells EC, Geller EJ. Validation of Web-based Administration of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Int Urogynecol J Pelvic Floor Dysfunct. 2010 Oct 23.

Benjamin G. Atkeson, MD, FACC Cardiology, Echocardiography, Nuclear Cardiology

Mateen Akhtar, MD, FACC

Eric M. Janis, MD, FACC

Matthew S. Forcina, MD

Diane E. Morris, ACNP

Christian N. Gring, MD, FACC

Ravish Sachar, MD, FACC

2 LOCATIONS TO SERVE OUR PATIENTS Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7907 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

Matthew A. Hook, MD, FACC

Nyla Thompson, PA-C

CARDIOLOGY SERVICES 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.

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1/16/2010 4:57:17 PM

GREAT NEWS FOR SCHEDULERS.

The Rules Have Changed.

Wake Radiology is now one option for handling the authorization process for your patients with CIGNA benefit plans that require pre-authorization for CT, MRI, and PET·CT. To schedule your next patient with CIGNA coverage, regardless of exam type, simply call or fax your order to WR Express Scheduling and let us manage the pre-authorizations for you. Our one-call scheduling for all 16 locations makes us even more convenient—919-232-4700.

If your office isn’t set up as WR Preferred Schedulers for this benefit and many others, please call us at 919-788-7909 to schedule your personal referral service manager visit.

Preferred Scheduling Services All Wake Radiology locations are accredited by the American College of Radiology.

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Wake Radiology. Where your time is golden.