February 2011 by TTPLLC

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Duke Cardiology Extends Excellence in Cardiovascular Care

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

Also in This Issue

A Heart Pain Diagnosis Hope for a Better Sex Life

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.

JOHNSTON HE ALTH

Contents

COVER STORY

PHOTO BY JIM SHAW

Duke Cardiology

Extends Excellence in Cardiovascular Care to Wake County

FEATURES

Cardiology

Diagnosis and Treatment of Acute Pericarditis Diagnosis Dr. Mateen Akhtar explores the case of a patient with persistent chest pain, the acute pericarditis diagnosis and treatment using colchicine.

f e b r ua r y 2 011 V o l . 2 , I s s u e 2

DEPARTMENTS Charity

Walking for MS in Memory of a Wife and a Mother The legacy of Carol Ann Deâ&#x20AC;&#x2122;Courcy lives on in her family and friends who plan to participate in the Walk MS Saturday, April 9.

16 Financial Planning A Roadmap and Fine Tuning Will Get You to Your Destination

21 Endocrinology Treating Thyroiditis

22 Physician News Family Physician of the Year, Raleigh Orthopaedic Clinic, Wake Radiology and WakeMed and Boylan Healthcare

24 News Welcome to the Area, Upcoming Events and UNC OB/GYN

Cover Image: James Mills, M.D., F.A.C.C., and Mark Leithe, M.D., F.A.C.C., of Duke Cardiology of Raleigh.

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From the Editor

Much to Celebrate! 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

There is such a sense of wellbeing living in and near the “Medical Triangle.” If ever there were a place to have a medical emergency, it would be here. This proximity to world-class medicine is extending further into the region, thanks to physician practices that are associated with one of the Triangle’s major medical centers. Duke Cardiology of Raleigh, our cover story this issue, is among them. Duke Cardiology specialists are bringing to Duke Raleigh Hospital the same nextgeneration advances in interventional cardiology that lead patients around the world to Duke Medical Center. As part of Duke Raleigh’s cardiology expansion, comprehensive electrophysiology services will mirror those at the Duke Center for Atrial Fibrillation (DCAF), a leader in the treatment of atrial fibrillation. And, as you will read, Duke Cardiology physicians are actively engaged in advancing treatment

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Mateen Akhtar, M.D., F.A.C.C. Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G Paul J. Pittman, C.F.P. Michael J. Thomas, M.D., F.A.C.E., Ph.D. Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Joseph Dally

jdally@newdallydesign.com

through a number of promising clinical trails.

Advertising Sales Carolyn Walters carolyn@trianglephysician.com

Also in this issue of Triangle Physician cardiologist Mateen Akhtar presents a case

News and Columns Please send to info@trianglephysician.com

discussion on the diagnosis of acute pericarditis, a common cause of acute chest pain in up to 5 percent of hospitalized patients. Endocrinologist Michael Thomas discusses the treatment of thyroiditis, which affects some 20 million Americans; and

The Triangle Physician is published by New Dally Design 9611 Ravenscroft Ln NW, Concord, NC 28027

gynecologist Andrea Lucas enlightens on the hope of vaginal hormones to improve the sexual experience of woman in and post menopause. It’s said the heart beats an average of 100,000 times a day. In recognition of February as Heart Month, advances in cardiac and vascular medicine that keep hearts beating and healthy give us much to celebrate. There also is much to reflect, on given heart disease and stroke continue to be the No. 1 and No. 3 killers of Americans, respectively. For Triangle Physician, we celebrate the continued support of our readers, contributors and advertisers. You keep the heart of this publication, one dedicated

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.

to an amazing medical community, pumping. It’s a pleasure and an honor to serve. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography.

Heidi Ketler Editor

The Triangle Physician

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

Duke Cardiology

Extends Excellence in Cardiovascular Care to Wake County By Heidi Ketler

eople all over the world come to Duke University Health System for top-ranked cardiovascular care. Those living in Wake County need take only the short trip to Duke Cardiology of Raleigh for access to the same excellence in treating the world’s No. 1 killer – heart disease. The focus of the seven-physician Duke Cardiology of Raleigh is to improve Wake County’s access to the best care possible. Association with the multidisciplinary Duke University Heart Center increases patient access to the latest health care resources and best-care practices. “In our office, we have the expertise to take care of everything from standard cardiology problems to very complex peripheral vascular, valvular and congenital heart disease. We provide PHOTOs BY JIM shaw

“Our focus is to bring the cutting-edge expertise in patient treatment of Duke University Hospital to Wake County, and to work in concert with the aspiration of expanding the envelope of patient treatment and continuing the excellence in cardiovascular care that is the mission of the overall Duke system.” – Mark E. Leithe, M.D.

Members of the catheterization lab team at Duke Raleigh Hospital stand with George Adams, M.D., F.A.C.C., of Duke Cardiology of Raleigh. They are (from left): Christine Stoneman, R.N., R.T.R.; Anne Martin, R.N.; Monique Fjeldhiem, R.T.R.; Denise Cornell, R.N.; Daneille Regan, R.N.; Dr. Adams; Rhonda Hopkins, R.N.; Nancy Steves, R.N., R.C.I.S.; and Christopher Clark, R.N., R.C.I.S.

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Radha Kachhy, M.D., F.A.C.C., of Duke Cardiology of Raleigh evaluates the images of a nuclear stress test.

expertise in exercise stress testing, nuclear cardiology, echocardiography, noninvasive peripheral vascular imaging, and follow up of pacemakers and defibrillators,” says cardiologist Mark E. Leithe, M.D., who is Duke Cardiology medical director. Dr. Leithe also is medical director of Duke Raleigh Hospital cardiovascular services and charged with maintaining the standard of excellence set by Duke University Heart Center. “Our focus is to bring the cuttingedge expertise in patient treatment of Duke University Hospital to Wake County, and to work in concert with the aspiration of expanding the envelope of patient treatment and continuing the excellence in cardiovascular care that is the mission of the overall Duke system,” he says. Duke Heart Center is consistently ranked by U.S. News & World Report among the top 10 in the nation. Its heart failure center leads the country in patient volumes and outcomes, funded research and the impact of faculty

publications. Data show that its approach results in increased use of evidence-based treatments while reducing the number of hospital admissions, length of stay and cost. With some 3,800 procedures performed annually, Duke’s interventional cardiology program and heart disease program are among the country’s largest and most experienced. LETHAL EFFECTS OF ATHERSCLEROSIS The World Health Organization reports that cardiovascular disease claims 17.1 million lives each year. In the United States, it is the leading cause of death in both men and women. Deaths are primarily due to heart attacks and stroke. Tobacco and alcohol use, unhealthy diet, lack of physical activity, obesity and diabetes are risk factors. Coronary artery disease is the result of atherosclerosis, the accumulation of atheromatous plaque within arterial walls. Atherosclerosis progresses slowly over decades and usually remains asymptomatic

until an atheroma ulcerates. This leads to the formation of blood clots (thrombosis) at the site and obstruction of the blood flow (ischemia). The reduced oxygen causes tissue damage, increasing the risk for angina, heart attack, stroke or limb loss. Complete blockage of the coronary artery leads to ischemia of the heart muscle and damage, a process called myocardial infarction (heart attack). Complete blockage of the carotid artery or other central vessel leads to stroke. Since atherosclerosis is a body-wide process, similar events occur also in the arteries to the brain, intestines, kidneys, legs, etc. Those with blocked arteries of the lower extremities have a risk that is six to seven times greater for coronary artery disease, heart attack, stroke and transient ischemic attack. Atherosclerosis in the extremities and the resultant lack of circulation causes pain (claudication), skin discoloration, sores or ulcers and in the most extreme cases leads to amputation of limbs.

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Interventional centers of excellence are an extension of Duke University Increasingly, interventional therapies and technologies offer the best options for treating cardiovascular diseases, and Duke Cardiology of Raleigh is leading the way through research, education and the introduction of the latest advances in diagnosis and treatment. Dr. Leithe notes the great advances in interventional cardiology, a subspecialty that is increasingly involved in the nonsurgical repair of damaged heart structures and vessels. Percutaneous interventional procedures gain access to the blood vessels through the puncture of a needle and refer to PTCA (percutaneous transluminal coronary angioplasty), stent delivery, filter delivery, cardiac ablation, and peripheral or neurovascular catheter procedures. The benefits are improved outcomes, faster recovery and less pain. “There’s a movement afoot that is changing things from invasive surgical treatment to less

invasive, more percutaneous procedures,” says Dr. Leithe. Duke Cardiology has kept pace, with advances in technologies and approaches for atrial fibrillation and heart failure, as well as coronary, peripheral, neurovascular and other cardiovascular interventions. “We use the newest medications and non-surgical procedures, such as the latest generations of stents and angioplasty, that have proven to be most effective in helping patients,” he says. Angioplasty uses a small, inflated balloon at the tip of a catheter to push open narrowed arteries caused by atherosclerosis-related disease. In most cases, a small metal mesh cylinder, or stent, is then placed in the vessel to help keep the artery open. Peripheral angioplasty refers to the use of angioplasty outside of the coronary arteries. It is commonly done to treat atherosclerotic narrowing of the arteries of the abdomen, leg, kidney and brain. It also can treat narrowing in coronary artery vein grafts. At Duke Raleigh Hospital, advanced catheterbased diagnostic capabilities at the ready

include intravascular ultrasound and direct coronary-flow measurements, using a pressure wire. Intravascular ultrasound is a specially designed, computerized catheter with a miniature ultrasound probe. It is commonly used to visualize and measure the volume of plaque and extent of stenosis of the arteries of the heart from inside the vessel, which is more accurate and reliable than standard angiography. The coronary pressure-wire assessment is a tiny diagnostic device (0.35 mm in diameter) with a pressure sensor at the tip. It identifies the location and extent of blockages in coronary arteries by measuring change in pressure across an area of narrowing. Peripheral vascular interventions of the carotid, aortic, renal and peripheral arteries also are a priority. In the United States, peripheral vascular disease (PAD) affects 12 percent to 20 percent of Americans age 65 and older. Approximately 10 million Americans have PAD.

James Peterson, M.D., F.A.C.C., of Duke Cardiology of Raleigh reviews patient records in advance of his examination.

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George L. Adams, M.D., H.M.S., F.A.C.C., and James Mills, M.D., F.A.C.C., interventional cardiologists with Duke Cardiology of Raleigh, specialize in the treatment of PAD. They usually see patients with claudication. The worst cases are in patients with a leg wound that won’t heal due to critical limb ischemia. This condition can lead to gangrene, where amputation is often a last resort to stop infected, dying tissue from causing septicemia. “George’s work is in conjunction with the wound center at Duke Raleigh Hospital. His interventions have helped heal long-standing ischemic ulcers of the legs in an effort to prevent amputation,” Dr. Leithe states.

SAVING A LIMB AND RENEWING QUALITY OF LIFE Rhonda Hall lost her left leg in 2002, after enduring years of intense pain and multiple surgeries to treat chronic peripheral artery disease in both legs. Throughout the next five years, she underwent many more revascularizations to reroute and rebuild damaged blood vessels, and restore circulation in her right leg. All they

Peripheral vascular interventions increasingly include revascularization of the legs, the brain and the kidneys. Revascularization involves creation of a new channel through blocked vessels to reestablish healthy blood flow.

seemed to do was add to the scars up and down her arms,

“Now, instead of using aortobifemoral bypasses to the legs, we’re doing a lot of that work by peripheral ballooning and stenting procedures,” says Dr. Adams. Aortobifemoral bypass surgery reroutes blood from the abdominal aorta to the two femoral arteries in the groin in a very invasive and potentially high-risk procedure.

spring of 2009, Rhonda was determined to end the pain

Dr. Adams explains that peripheral vascular interventions below the knee are more challenging, because the vessels are much smaller. “There is a big difference between working with an 8 mm vessel in the upper leg and a 2 mm vessel in the lower leg.” Cutting-edge atherectomy devices, such as the orbital and laser atherectomy at Duke Raleigh Hospital, are designed to improve on the limitations associated with standard balloon angioplasty. Atherectomy is the catheterbased procedure to modify plaque in vessels, so the vessel can be reopened. Low-pressure balloon angioplasty can then safely finish the procedure. Advantages over existing treatment alternatives include the capability to treat a broad range of plaque types in peripheral arteries above and below the knee, “without dissecting or tearing the vessel,” says Dr. Adams.

where veins for bypass grafting were removed. Yet, the intense leg pain due to ischemia persisted. In the by having her other leg amputated. “I was so ready to get rid of this leg. It hurt all the time and I was just so tired of hurting,” she says, knowing full well the challenges she would face with mobility, even in her own home. While she had a wheelchair ramp, the bathroom and other parts of her house would require modification. That’s when her son, Jerry, an X-ray technician at Duke Raleigh Hospital, started checking his sources. One name was mentioned more often than not. Dr. George L. Adams, M.D., M.H.S., was the cardiologist to see. “When Rhonda Hall presented to me, she had been through the mill,” says Dr. Adams. “She wanted her leg removed, because she was in so much pain.” He urged her to give him the chance to rebuild her leg using a catheter-based approach. With skepticism, she agreed and a diagnostic lower-extremity angiogram was

Carotid artery disease is another focal point. Often caused by atherosclerosis in the arteries that supply blood to the brain, it contributes to more than half of the strokes in the United States.

performed in May 2009. The angiogram showed the right lower-extremity bypass graft had occluded. Considering these findings, a difficult four-hour catheter-

The challenge has been diagnosing which patients with asymptomatic stenosis will develop stroke and which will remain asymptomatic. Many patients who have asymptomatic carotid stenosis will not go on to have a stroke. However, more than 50 percent of patients who go on to have a stroke will have proceeded from being asymptomatic one day to having a stroke the next.

based procedure from the artery behind the knee was used to successfully open the right bypass graft. That evening in her hospital bed, as the anesthesia wore off, Rhonda realized her pain was gone. What’s more, her leg remained and the procedure left no noticeable scar. “Dr. Adams literally saved my leg. If he had been around in

Adept diagnostic expertise is helping to improve the statistics. Treatment may involve medical therapy, percutaneous stenting, surgery or combination, and will depend on whether or not the patient has symptoms and how much narrowing is present. Dr. Adams has participated in a robust carotid stenting program that has been used to open carotid arteries and lessen the risk of stroke. The biplane catheterization laboratory, due to be completed within the next year, will aid physicians in performing diagnostic and therapeutic cerebrovascular procedures at Duke Raleigh Hospital.

2000, when I was having all that trouble, I’d have two legs today,” says the 53-year-old former secretary. Still, Rhonda is grateful that her days of rocking in pain and taking pain medicine are over. Life has been renewed and she stays busy with her granddaughters, 10 and 8. “They are a big part of my life,” says Rhonda, who is able to drive her van with ease and takes them on frequent outings.

FEBRUARY 2011

“As a peripheral vascular center of excellence, we are committed to education and research in addition to clinical expertise,” says Dr. Adams.

5) SonOx, a trial to evaluate the use of hyperoxygenated saline delivery by portable ultrasound to distal wound beds for patients with critical limb ischemia.

Duke Cardiology offers the opportunity for patients to be involved in a variety of clinical trials. Some of theses trials are: 1) ZEN, a first-in-man trial testing the use of a zotarolimus-eluting stent for the treatment of erectile dysfunction; 2) Choice, a carotid registry to determine the outcomes of carotid stenting versus carotid surgery in high-risk patients; 3) Xience and Cypress drug-eluting stent registries to determine optimal Plavix treatment duration; 4) Spinal-stimulator study to evaluate improvement in pain for people with critical limb ischemia without further medical or invasive options; and

DUKE CARDIOLOGY OF RALEIGH IS OFFERING NEW SERVICES As an extension of the Duke University Heart Center, Duke Cardiology of Raleigh plans to develop areas of excellence to augment services not readily available in Wake County. The Duke Raleigh heart failure clinic will offer the specialized physicians and technologies to evaluate and treat some of the most challenging heart problems. Cardiomyopathy is among them, explains Dr. Leithe. Cardiomyopathy refers to diseases that weaken the heart muscle or make it thicker and more rigid than normal, reducing its

Stephen Robinson, M.D., F.A.C.C., of Duke Cardiology of Raleigh reviews the chart of a pacemaker patient.

The Triangle Physician

ability to pump blood through the body. This can cause complications, such as heart failure, which can then lead to fluid accumulation, shortness of breath, weakness and abnormal heart rhythms. Treatment of the weakened heart muscle requires careful adjustment of multiple medications, dietary and lifestyle interventions, and close follow up. End-stage cardiomyopathy may require implantation of a left ventricular assist device or even cardiac transplantation. Duke University Heart Center’s Hypertrophic Obstructive Cardiomyopathy Clinic is one of only a few dedicated programs of its kind in the southeast. Clinicians evaluate and treat hundreds of patients each year with therapies that include medication, surgery and catheterbased alcohol septal ablation.

Lawrence Liao, M.D., F.A.C.C., of Duke Cardiology of Raleigh analyzes the results of an echocardiography.

Expansion of electrophysiology services at Duke Cardiology of Raleigh will share new treatment strategies within the Duke Center for Atrial Fibrillation (DCAF) that have been proven effective in correcting rapid, irregular atrial impulses and ineffective atrial contractions. One of the most common arrhythmias, chronic AFib also is one of the most challenging to treat. Treatments have focused on drug therapy, with limited effect and considerable complications. “We are moving away from just using medications... to actually changing the milieu of the heart to restore normal rhythm,” says Dr. Leithe. Impressive strides in unraveling the complexities of AFib at DCAF have resulted in successful control of symptoms in more than 90 percent of people seeking treatment. According to Dr. Leithe, multidisciplinary treatment teams that include electrophysi-

ologists, cardiologists and cardiovascular surgeons are better able to pinpoint the mysterious origins of AFib and deliver fine-tuned drug strategies in combination with catheter ablation and surgery. Treatment is more precise and individualized. AFib ablation is a catheter-based procedure that delivers energy to tiny areas of the heart muscle where the electrical abnormality is occurring and “disconnects” the current’s pathway. It is often guided by advanced computer-based catheter mapping and robotic navigation systems. Currently, DCAF performs the highest volume of AFib catheter ablations in North Carolina and that rate is expected to grow exponentially. Plans for Duke Raleigh’s AFib program include the acquisition of a dedicated 3-D biplane catheterization lab. “This is a very specialized type of cath lab, very expensive and not commonly available,” says Dr. Leithe.

Biplane laboratories achieve two separate planes of view with the same injection, and thus save time and limit radiation exposure and contrast dye-induced kidney damage. The advanced technology will be a useful tool in guiding the electrophysiologist during atrial ablation, among other procedures. The comprehensive range of rhythm services offered by Duke Radiology of Raleigh also includes: • Permanent pacemaker placement as an adjunct to medical therapy; • Cardioversion to restore normal rhythm when required; and • Ongoing evaluation to ensure effectiveness and safety of therapy. To learn more about interventional cardiology options available through Duke Cardiology of Raleigh, visit www.dukehealth.org/heart_ center/programs/interventional_cardiology. To schedule an appointment, call (919) 862-5500.

FEBRUARY 2011

Meet the Cardiologists with Duke Cardiology of Raleigh

from Duke University School of Medicine in 1996. He completed his

George L. Adams M.D., M.H.S., F.A.C.C., earned his medical

in Tennessee in 1999 and a fellowship in cardiology at Duke University

degree from the Brody School of Medicine at East Carolina University

Medical Center in 2003. Dr. Liao is a fellow of the American College of

School of Medicine in 2000. He completed his residency in internal

Cardiology.

medicine at the University of Texas Southwestern, Parkland Hospital

Clinical Interests

in 2003. His fellowships in general cardiology and interventional

General cardiology; echocardiography, including transesophageal

cardiology were completed at Duke University Medical Center in 2007

echocardiography; nuclear cardiology; pre-operative risk evaluation;

and 2008, respectively. He also earned his master’s degree in health

and valvular heart disease.

Lawrence Liao, M.D., F.A.C.C., earned his medical degree residency in internal medicine at Vanderbilt University Medical Center

science in cardiology from Duke in 2007. Dr. Adams is a fellow of the American College of Cardiology.

Dr. James Mills, M.D., F.A.C.C., earned his medical degree from

Clinical Interests

the University of Florida College of Medicine in 2000. He completed

Interventional cardiology, with interests in coronary, cerebral, aortic,

his residency in internal medicine at Brigham and Women’s Hospital in

renal and peripheral vascular disease; in coronary interventions,

Massachusetts in 2003. Fellowships in cardiology and interventional

peripheral interventions and carotid interventions; and in non-

cardiology were completed at Duke University Medical Center in 2007

invasive procedures, such as nuclear stress tests, trans-thoracic

and 2008, respectively. Dr. Mills is a fellow of the American College of

echocardiography, coronary computed tomography, carotid ultrasound,

Cardiology.

venous duplex, ankle/brachial indices and pulse-volume recordings of the lower extremities. Dr. Adams’ research interests include the development of ST elevation myocardial infarction systems of care and novel device therapies for coronary, carotid and peripheral vascular disease.

Radha Goel Kachhy, M.D., F.A.C.C., earned her medical degree from Baylor College of Medicine in Texas in 1999. She completed her residency in internal medicine at Duke University Medical Center in 2002 and a fellowship in cardiology at the University of Maryland Medical Center in 2005. Dr. Kachhy is a fellow of the American College of Cardiology. Clinical Interests Clinical consultative cardiology; cardiac imaging, including nuclear cardiology, echocardiography, stress echo and transesophageal echocardiography; women’s heart disease; preoperative risk assessment; and valvular heart disease.

Mark E. Leithe, M.D., F.A.C.C., earned his bachelor’s degree in zoology and chemistry from Miami University in Ohio. He went on to earn his medical degree from Ohio State University College of Medicine, where he also completed his residency and served as chief medical resident. His fellowship in cardiology was completed at Duke University Medical Center in 1989. His interventional cardiology fellowship was completed at the University of Maryland in 1991. Dr. Leithe is a fellow of the American College of Cardiology. Clinical Interests Complex interventional cardiology, including high-risk patients, rotational atherectomy and intravascular ultrasound; and general cardiology, including echocardiography, stress testing and risk-factor modification. Dr. Leithe also has been active in many professional and scientific societies, including the American Heart Association and the Triangle Update in Cardiology series.

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Clinical Interests Diagnostic and interventional coronary angiography; peripheral arterial disease; diagnostic and interventional peripheral angiography; and noninvasive vascular imaging.

James W. Peterson, M.D., F.A.C.C., earned his bachelor of arts degree in economics from The College of Wooster in 1981 and his master of arts degree in theological studies from McCormick University of Rochester School of Medicine and Dentistry in New York in 1988. He completed his residency in internal medicine at the University of Iowa Hospital and Clinics in 1991, and a fellowship in cardiology at The Ohio State University Medical Center in 1994. Dr. Peterson is a fellow of the American College of Cardiology. Clinical Interests Clinical and consultative cardiology; echocardiography, including stress echo and transesophageal echocardiography; nuclear cardiology; and cardiac computed tomography angiography.

Stephen Robinson, M.D., F.A.C.C., earned his bachelor of science degree in biomedical and electrical engineering from Duke University in 1989. He served in the United States Navy and went on to earn his medical degree from Wake Forest University School of Medicine in 1999. He completed his residency in internal medicine from Wake Forest University, Baptist Medical Center in 2002; and a fellowship in cardiovascular diseases at Saint Louis University Health Sciences Center in Missouri in 2005. Dr. Robinson also is a fellow with the American College of Cardiology. Clinical Interests Clinical and consultative cardiology; echocardiography, including stress echo and transesophageal; nuclear cardiology; diagnostic cardiac and peripheral angiography; pacemaker and defibrillator implantation; integrative medicine; cardiac rehabilitation; and wellness.

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FEBRUARY 2011

Women’s Health

Menopause:

Vaginal Hormones Can Improve Sexual Health By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G

We encourage providers to address sexual health and vaginal atrophy in women who are in menopause. The use of vaginal estrogen and vaginal DHEA can improve vaginal atrophy effectively and safely. Menopause is a normal and natural transition in a woman’s life. The average age is 51.4 years (1). Many changes occur during this time, including a decrease in estrogen, progestin, and dehydroepiandrosterone (DHEA). A great deal of research has been done on replacing these hormones. In terms of replacing estrogen and progestin, one of the most influential large-scale studies includes the Women’s Health Initiative (WHI), established by the National Institutes of Health (NIH), National Heart, Lung and Blood Institute (NHLBI) in 1991. Details of this study can be found online at www.nhlbi. nih.gov/whi. WHI encompassed a set of clinical trials and an observational study, and results led to dramatic changes in prescribed hormone replacement therapy (HRT) For instance, there was a gradual increase in the number of HRT prescriptions within the United States, from 58.3 million in 1995 to 91 million in 2001(2). However, this trend reversed after results of the WHI emerged. Between 2001 and 2003, the annual number of prescriptions for HRT fell to 56.9 million. Thus, many providers who used systemic hormones questioned their best use for patients in menopause. The established relationship between estrogen and breast cancer continues to impact prescribing habits of most health care providers.

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Treatment of vaginal atrophy For this article, we are highlighting hormones used vaginally for sexual function – specifically vaginal atrophy. The use of systemic hormones has far more negative impact than does vaginal preparations. As highlighted by Dr. Clayton in her 2007 review of Epidemiology and Neurobiology of Female Sexual Dysfunction(3), good sexual health is associated with good physical and mental health. She also observes that low sexual desire occurs in 24 percent of pre-menopausal women and remains at 29 percent in women who go through natural menopause. How can health care providers help maintain sexual health for their female patients in menopause? Amy Stanfield, M.D., and I support the use of vaginal estrogen or vaginal DHEA. Both have shown to treat vaginal atrophy and improve sexual function. There are many Food and Drug Administration-approved products for vaginal estrogen. One of the most comprehensive lists is found on the FDA website www.fda.gov/drugs. It includes, but is not limited to, Estrace cream, which became available in 1984; Estring ring in 1996; and Vagifem tablets in 1998.

The trend in vaginal estrogen has been to provide the lowest effective dose. For instance, Vagifem dosing was recently reduced from 25 mcg to 10 mcg tablets. There are not as many choices for vaginal DHEA compared to estrogen. DHEA is the precursor for androstenedione, which is a precursor to both testosterone and estrodiol. Currently, there is no FDAapproved DHEA vaginal compound. We have used the Central Compounding Center (www.centralcompounding.com) in Durham, N.C., to compound DHEA for use to treat vaginal atrophy. Our patients have noticed significant improvement in vaginal atrophy with the use of DHEA. Clinical trials for vaginal DHEA In January, Women’s Wellness Clinic began two FDA clinical trials using vaginal DHEA. The Institutional Review Board-approved advertisement is below: You are a menopausal woman and you suffer from vaginal atrophy? You are bothered by one of the following symptoms: vaginal dryness, vaginal or vulvar irritation or itching, or pain associated with sexual activity? Then, you could participate in clinical trials sponsored by EndoCeutics, which last three or 12 months and involve the daily application of a vaginal ovule containing DHEA or a placebo. At each visit, you will have to undergo different tests. If you are interested, you must: 1) Be between ages 40 and 75 2) Answer the other trial criteria A financial compensation up to $450 will be provided. If you want more information, please call the Women’s Wellness Clinic at (919) 251-9223.

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.

In addition to offering the FDA clinical trials on vaginal atrophy, Dr. Stanfield and I work with a network of providers (clinicians, psychologist, pharmacist) within the WiSH (Women Interested in Sexual Health) group for managing female sexual function. We encourage providers to address sexual health and vaginal atrophy in women who are in menopause. The use of vaginal estrogen and vaginal DHEA can improve vaginal atrophy effectively and safely. This can then improve and/or maintain a woman’s sexual health. References: (1) Gold EB, Bromberger J, Crawford S, et al. Factors associated with age at natural menopause in a multiethnic sample of midlife women. Am J Epidemiol 2001; 153:865. (2) Hersh AL, Stefanick ML, Stafford RS. National use of postmenopausal hormone therapy: annual trends and response to recent evidence. JAMA. 2004;291:47-53. (3) Clayton, AH. Epidemiology and Neurobiology of Female Sexual Dysfunction. J Sex Med 2007;4(suppl 4): 260-268.

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FEBRUARY 2011

Financial Planning

A Roadmap and Fine Tuning Will Get You to Your Destination By Paul J. Pittman, C.F.P.

Think of the “plan” as the roadmap to your desired destination, what you want to see and do, and how long it will take to get there. The “management” is the vehicle you choose to take on that journey. I got an e-mail recently in response to one of my articles. The reader asked me to explain the terms “financial planning” and “wealth planning,” and the differences between the two. This is a very good question and gave me the topic for this month’s column. In my mind, the two are one and the same. Wealth planning is just a polished-up word created by the marketing departments of financial services firms to instill a sense of importance in the marketplace. You would be amazed at the time, effort and money spent by firms to create just the proper terms and titles to try to differentiate themselves from their competition. Money would be better spent in education of their employees to be advisors, as opposed to just being salespeople hustling the firm’s latest and most profitable (for the firm) products. (I have said many times before that I am not a fan of retail-packaged financial products.) For the purpose of this article, I am going to refer to “wealth” and “financial” planning as plain ol’ “financial planning.” I feel the better distinction should be made between the terms “financial planning” and “financial management.” Financial planning Let’s start with “financial planning.” According to the College for Financial

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Planning, the financial planning process consists of six very specific steps that certified financial planners follow: 1) Establishing and defining the clientplanner relationship. 2) Gathering client data, including goals. 3) Analyzing and evaluating client financial status. 4) Developing and presenting financial planning recommendations and/or alternatives. 5) Implementing the financial planning recommendations. 6) Monitoring the financial planning recommendations. These six steps are paramount in the ongoing relationship between the client and the planner. Not only does this process keep everyone on the same page, but clearly outlines and defines the needs and goals of the client, and the course of action to be taken. Without proper planning, you really have no direction in your financial lives. Just owning a few stocks and mutual funds doesn’t get it. You can’t make chicken salad out of chicken manure, no matter how much mayonnaise you use. Everyone needs and uses financial planning, but everyone’s definition is different. Proper planning can make you feel empowered.

Ideally, the blueprint of how you manage and deal with finances was formed very early in life, but you need to always be flexible. I can’t tell you how many people I have met that paid thousands of dollars to have a financial plan done for them, only to relegate it to a shelf or in a file. Any plan done and printed is usually obsolete in nine months. A financial plan should be ever-changing. I refer to this as “fluid financial planning.” This process gives you a daily view of your financial picture: • how you are doing with regard to your goals and needs, • how your investments are performing and exactly what you own, and • how much risk you are taking. You should be able to bring up this picture 24 hours a day, if you would like, and in an instant see everything that you own and how they are all working together without respect to where the assets are being held. This should encompass current retirement plan holdings, your IRAs, savings accounts, 529 plans, mortgages, real estate, loans, debts and investment accounts, etc., even if they are all in different places. Have you ever tried to get allocation and performance detail for the current month, year, trailing year, five or 10 years from a brokerage statement? This is next to impossible. You should not have to wait for a yearly review to check your progress. I call this a Groundhog Day review of your financial situation. Once a year, you see your broker, pop your head up, look around and then

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

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duck back down again until next year. Does this sound familiar? Ask your advisor for a daily vision of your financial plan. Your planner should ask you, “what is going on in your life?” and then demonstrate how s/he is going to help with the financial aspects of it.

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Financial management Now that you have the “plan,” let’s discuss “financial management.” This is the actual day-to-day management of the holdings that make up your complete financial picture. The management of your assets should follow and reflect your plan. Think of the “plan” as the roadmap to your desired destination, what you want to see and do, and how long it will take to get there. The “management” is the vehicle you choose to take on that journey. I don’t have to tell you that mortality is 100 percent assured, but arrival at our final destination may not be in the manner we would prefer. I compare long-term financial management to holding a long fishing pole; the slightest hand adjustments can make a big difference at the tip, or the end. Consistent fine-tuning and proper management of your finances can get you to your destination in style. I have seen plans that would allow someone to retire today… if they died by next Friday. I hope you have the life of your time. Plan and manage.

FEBRUARY 2011

Cardiology

Progressive in a Middle Chest Pain Aged Woman

By Mateen Akhtar, M.D., F.A.C.C.

Case History I recently had the pleasure of caring for Mrs. M., who is a 46-year-old African-American woman, with no significant cardiac risk factors, who presented to the hospital with three days of progressively worsening chest pain. Her chest pain was constant, sharp, radiated across her precordium, 8/10 intensity, worsened with inspiration and improved with leaning forward. She denied recent travel, fevers, chills, hemoptysis or recent infection. She had no significant past medical history and took no outpatient medications. Her vitals were: BP 128/60, heart rate 102 bpm, respiratory rate 20 breaths/minute, temperature 98.7째 F, oxygen saturation 98 percent on 2 liters. She was in no acute distress. Cardiac exam demonstrated presence of a triphasic friction rub and grade 1/6 systolic ejection murmur. Her

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lungs were clear to auscultation bilaterally. Extremities were warm, without edema. Her EKG (shown in Figure 1) demonstrates diffuse ST segment elevation with PR depression, consistent with acute pericarditis. A computed-tomography scan performed in the emergency room was negative for pulmonary embolism. She had leukocytosis (white blood count = 16k) and markedly elevated C-reactive protein of 165. Her thyroidstimulating hormone (TSH) and chemistries were within normal limits. She had normal antinuclear antibody (ANA), and serial cardiac markers were negative. Her echocardiogram demonstrated normal left ventricular (LV) systolic function without segmental wall motion abnormalities and a small-to-moderatesized circumferential pericardial effusion. Mrs. M was treated for acute pericarditis with intravenous Toradol and transitioned

to Ibuprofen 800 mg tid (three times per daily). However, over the next three days, she became progressively more tachycardic and her chest pain continued to worsen in severity. She was given intravenous saline and a repeat echocardiogram was performed. Her pericardial effusion had increased in size, measuring 3.2 cm in greatest diameter, without tamponade physiology but evidence of right atrial diastolic collapse. She underwent pericardial window for diagnostic and therapeutic purposes. Her pericardial fluid was negative for cytology and pericardium was thin, but with signs of acute and chronic inflammation. She was started on colchicine and she completed a course of nonsteroidal anti-inflammatory drugs (NSAIDs). She was seen in follow-up two weeks later with complete resolution of chest pain and return to baseline functional status.

Dr. Mateen Akhtar is a board-certified cardiologist with Wake Heart & Vascular Associates. He sees patients daily in Clayton, Smithfield and Goldsboro. He welcomes new patient referrals and offers same-day appointments. He can be reached at (919) 989-7909 or by e-mail to mateenakhtarmd@gmail.com.

Obtaining viral titers for suspected viral pericarditis has low diagnostic yield and does not tend to alter management. Development of pericardial tamponade in the setting of acute pericarditis is rare. However, close clinical monitoring is important. Highrisk patients for development of tamponade include those on anticoagulant therapy, or with fever, immunosuppressed state, recent trauma, elevated troponin (myopericarditis) and failure to respond to NSAIDs.

The mainstay of treatment for acute pericarditis is with NSAIDS, either ibuprofen (800 mg tid) or aspirin (2-5 grams/day). Studies have shown that colchicine can be effective in reducing incidence of recurrent viral or idiopathic pericarditis. Corticosteroids are usually reserved for those with severe connective tissue or autoimmune disease, who are refractory to NSAIDs. Administration of corticosteroids for acute pericarditis increases the risk of developing recurrent pericarditis. Corticosteroids should be avoided post myocardial infarction.

Discussion Acute pericarditis is a common cause of acute chest pain in up to 5 percent of hospitalized patients. This patient demonstrated several classic signs and symptoms of acute pericarditis by history and exam. Chest pain from acute pericarditis may have pleuritic features and tends to improve with leaning forward or worsen with lying down. A pericardial friction rub, a scratchy tri-phasic sound heard best along the left sternal border

Acute pericarditis is a common cause of chest pain in up to 5% of hospitalized patients with the patient leaning forward, is highly sensitive for pericarditis. It is also common to see elevation of inflammatory biomarkers, such as ESR (erythrocyte sedimentation rate or sedrate) or CRP (C-reactive protein). The presence of pericardial effusion by echocardiography can support the diagnosis of pericarditis. However, absence of effusion does not exclude the diagnosis. Common causes of pericarditis include viral etiology, neoplastic, idiopathic, autoimmune disease, or post-pericardiotomy (Dresslerâ&#x20AC;&#x2122;s syndrome). It is also important to consider tuberculosis, uremia or human immunodeficiency virus in appropriate clinical settings. Pericarditis may also accompany an acute myocardial infarction. Womens Wellness half vertical.indd 1

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FEBRUARY 2011

Charity

Walking for MS in Memory of a Wife and a Mother If you ask Pat DeCourcy how he felt last year amidst the 3,433 participants at the Walk MS event held at the RBC Center on April 24, 2010, he will say that he was proud. For many years Pat’s late wife, Carol Ann, lived with Multiple Sclerosis, a disease that interrupts the flow of information from the brain to the body and stops people from moving. In her memory, Pat and his four-person team, Team Carol Ann DeCourcy, did something he says they should have done a long time ago; they walked.

and how close we are coming to achieving a world free of this disease. MS research is progressing at a remarkable rate, with more potential therapies in the pipeline than at any other time in history. Walk MS is a wonderful opportunity for people to come together, create awareness about MS, celebrate hopes for a cure, support those who live with the daily challenges of the disease, or in Pat’s case, honor the memory of someone who did.

For the past 22 years the National Multiple Sclerosis Society has hosted Walk MS events nationwide. Last year North Carolina’s Walk MS events raised $771,650 and Pat’s team made up $2,605 of that. Money raised funds cutting-edge MS research, life-changing programs and services, and policy-sculpting advocacy efforts. Walk MS events help people gain a better understanding of what MS is

Pat first learned of Walk MS through reading about it in the media. When his daughter suggested they participate in memory of Carol Ann, he agreed that it would mean a lot to her because she was always worried about her daughters and other people. Team Carol Ann DeCourcy was formed, consisting of Pat, his present wife, Pat’s daughter, and her husband. The team’s initial goal was to raise

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a little money and support and get the word out about the devastation of the disease. He says participating in Walk MS was also a way to meet other people walking for the cause and make new friends. Pat DeCourcy feels proud that there are people out there that care and want to support people they know who are affected. He hopes that with the support of his family and friends, their accomplishments will snowball. They know it won’t help Carol Ann, but hope it can help others. Pat and his team hope to walk again this year on April 9 with an additional team member, a new grandchild to be born in February. To register to participate in any of the five Walk MS events hosted by the Eastern NC Chapter of the National Multiple Sclerosis Society, please visit http://www.nationalmssociety.org

Treating Thyroiditis By Michael J. Thomas, M.D., Ph.D., F.A.C.E.

Recent studies show that treating euthyroid women with autoimmune thyroiditis may lower the incidence of miscarriage, particularly in the first trimester. Thyroiditis, as the name implies, is an inflammation of the thyroid, which encompasses a broad range of conditions that can result in dysfunction, enlargement or discomfort. Some types are self-limiting (e.g. subacute), while others can be chronic and progressive. Autoimmune (Hashimoto’s) thyroiditis is the most common type, affecting approximately 20 million Americans. It is five to 10 times more common in women than men, and is the most common cause of primary hypothyroidism. Thyroid ultrasound reveals a hypoechoic gland with a heterogeneous echotexture and occasionally a nodular appearance. Fineneedle aspiration biopsy is indicated for nodular structures greater than 1 centimeter. Most patients will develop primary hypothyroidism. Thyroid autoantibodies (directed against thyroid peroxidase or thyroglobulin) are usually present, though it is unclear whether these antibodies play a destructive role in disrupting thyroid function or whether they arise as a consequence of the lymphocytic infiltration. Recent studies show that treating euthyroid women with autoimmune thyroiditis may lower the incidence of miscarriage, particularly in the first trimester. Hypothyroidism is usually treated with thyroid hormone supplementation (e.g. levothyroxine). Other causes of thyroiditis are transient and occur as a result of release of prestored thyroid hormone, which produces a thyrotoxic phase. This phase typically lasts for several days to weeks, and as thyroid hormone levels gradually fall, patients may either return to normal thyroid levels or enter a hypothyroid phase that may last several

more weeks to months, but usually, eventually recovers. Two main subtypes of transient thyroiditis exist: painful (DeQuervain’s) thyroiditis and painless (silent) thyroiditis. Painful thyroiditis may be viral in origin and runs its course over a several-week period. A short course of steroids may control pain for cases that are refractory to non-steroidal anti-inflammatory drugs (NSAIDs). Additional diagnostic tests may reveal an elevated sedimentation rate, C-reactive protein and leukocytosis. Painless thyroiditis can be more difficult to diagnose during the initial clinical presentation. In the absence of pain, the thyrotoxic phase of silent thyroiditis may be difficult to distinguish from Graves’ disease. The etiology of silent thyroiditis is unclear, but speculated to be autoimmune. The mechanisms of silent thyroiditis are probably the same or similar to “post-partum” thyroiditis (i.e., silent thyroiditis may simply be more common in the post-partum period). Radioiodine uptake (RAIU) measurement is usually low (less than 5 percent at 24 hours), and therefore, nuclear medicine imaging of the thyroid is not feasible. Thyroid ultrasound may reveal an enlarged heterogeneous, hypoechoic gland, sometimes with nodular structures that may resolve over the course of several weeks. During the thyrotoxic phase, anti-thyroid drugs are of no benefit, although beta blockers may be useful in controlling the symptoms of tachycardia, palpitations and tremor. If a patient develops hypothyroidism after the thyrotoxic phase of thyroiditis, patients may do well with observation until resolution of

Endocrinology Dr. Michael Thomas earned his undergraduate degree from Duke University and his medical degree and doctorate in pharmacology and toxicology from the School of Medicine at West Virginia University in Morgantown. He completed all of his post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency and fellowship in endocrinology. He was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. Dr. Thomas established Carolina Endocrine, P.A., in the summer of 2005. He is board-certified in internal medicine and endocrinology, and is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology and has completed endocrine certification in neck ultrasound.

the hypothyroid phase or may benefit from thyroid hormone supplementation if hypothyroid symptoms are present. The dose of thyroid hormone supplementation is slowly tapered, to see if thyroid function normalizes. About 10 percent of patients may remain permanently hypothyroid, requiring long-term thyroid hormone supplementation. Recurrent thyroiditis is uncommon. Occasionally, radiation thyroiditis can aggravate and worsen thyrotoxicosis in Graves’ disease or toxic multi-nodular goiter. Thyroid pain typically develops three to seven days after radioiodine therapy and usually responds to NSAIDs. The risk of radiationinduced thyroiditis can be diminished by pre-treatment of hyperthyroid goiters with anti-thyroid drugs for several weeks prior to radioiodine treatment. Bacterial (suppurative) thyroiditis is rare, but life-threatening and typically occurs in the setting of an open neck wound or surgical infection. Riedel’s thyroiditis is a rare hardening of the thyroid that usually causes constrictive/compressive symptoms and may pose a surgical challenge to alleviate discomfort. FEBRUARY 2011

Physician News

Pittard Wins Physician of the Year Award Jesse C. Pittard, M.D., a family physician in Smithfield, has won the 2010 North Carolina Family Physician of the Year Award, presented by the North Carolina Academy of Family Physicians. Dr. Pittard is a founding partner of Horizon Family Medicine. Since 1980, the practice has grown to include 12 physicians, 50 staff

members and clinic sites in Smithfield, Clayton, Four Oaks and Princeton. Throughout his medical career serving patients in Johnston County, Dr. Pittard has been a leading advocate for patient-focused, personalized care. He is actively involved in the medical leadership of Johnston Medical CenterSmithfield, where he has served three terms as medical chief of staff. “There’s nothing more gratifying than family medicine,” said Dr. Pittard. “You get

back more than you give, from patients and colleagues.” Dr. Pittard earned his undergraduate degree from Duke University in 1973, attended medical school at the University of North Carolina-Chapel Hill and completed his residency training at Wake Forest University in 1980. He is a fellow of the American Academy of Family Physicians. The North Carolina Academy of Family Physicians Inc. is a nonprofit professional association headquartered in Raleigh.

Pediatric Specialist Joins Raleigh Orthopaedic Clinic Neil C. Vining, M.D., a board-certified, fellowship-trained orthopedic surgeon specializing in pediatric orthopedics recently joined Raleigh Orthopaedic Clinic. Dr. Vining earned his undergraduate degree at Campbell University in Buies Creek, N.C., and his medical degree from the University of North Carolina at Chapel Hill, with highest honors. He completed his orthopedic residency at Madigan Army Medical Center in Tacoma, Wash., and at the University of Washington in Seattle.

Immediately following his residency, Dr. Vining spent three years as a military orthopedic surgeon at Landstuhl Regional Medical Center in Germany. While there, he was deployed for three months with the 212th Mobile Army Surgical Hospital in Muzafarabad, Pakistan, and for seven months with the 160th Forward Surgical Team in Asadabad, Afghanistan. After returning to the United States, Dr. Vining served as assistant chief of orthopedic surgery at Winn Army Community Hospital in Fort Stewart, Ga.

Prior to joining Raleigh Orthopaedic Clinic, Dr. Vining completed a pediatric orthopedic fellowship at Seattle Children’s Hospital in Washington. In addition to participation in several research publications and presentations, Dr. Vining is a fellow of the American Academy of Orthopaedic Surgeons, and is a candidate member of the Pediatric Orthopaedic Society of North America. Appointments with Dr. Vining may be scheduled by calling Raleigh Orthopaedic Clinic at (919) 863-6808.

Wake Radiology Appoints Subspecialty Co-directors Nik P. Wasudev, M.D., and Joseph B. Cornett, M.D., have accepted appointments as co-directors within subspecialty services at Wake Radiology. Dr. Wasudev joins Russell “Rusty” C. Wilson, M.D., as co-director of musculoskeletal imaging and Dr. Cornett is serving with Philip R. Saba, M.D., as co-director of neuroradiology. Wake Radiology’s musculoskeletal services is staffed by seven subspecialty-trained and board-certified radiologists who provide imaging interpretation and interventional procedures for patients who present with sports injuries, joint, and musculoskeletal disorders and diseases. They also perform

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pain-relieving injections in joints in the back, sacroiliac, facet, shoulder, upper and lower extremities, spine, foot and ankle. Dr. Wasudev, who joined Wake Radiology in 2007, is certified in both diagnostic imaging by the American Board of Radiology and densitometry by the International Society for Clinical Densitometry. A graduate of the University of Pennsylvania School of Medicine in Philadelphia, he trained in orthopedic surgery at the University of Michigan Medical Center in Ann Arbor and subsequently completed a residency in diagnostic radiology at the University of California, San Francisco. He was a fellow in musculoskeletal magnetic resonance imaging (MRI) at National Orthopedic

Imaging Associates in San Francisco. Dr. Wasudev is a member of the American College of Radiology, the Radiological Society of North America and the American Roentgen Ray Society. Dr. Cornett, who has been on staff at Wake Radiology since 1999, is certified in diagnostic radiology and holds a Certificate of Additional Qualifications in neuroradiology from the American Board of Radiology. After receiving his medical degree from the University of Virginia School of Medicine in Charlottesville, he interned in general surgery at Roanoke Memorial Hospital in Roanoke, Va. Dr. Cornett then completed his residency in diagnostic radiology at the University of Virginia Health Sciences Center. He finished a two-year

Practice News fellowship in neuroradiology at the University of Michigan Medical Center in Ann Arbor. He is a senior member of the American Society of Neuroradiology and is a member of the

Radiological Society of North America. Wake Radiology’s neuroimaging specialists have more than 150 years of combined experience with state-of-the-art imaging techniques of the

brain and spine, using computed tomography, MRI and MR spectroscopy. For more information, visit the Wake Radiology website at www.wakeradiology.com.

Mankin Joins WakeMed Ethics Committee Keith P. Mankin, M.D., F.A.A.P., of Raleigh Orthopaedic Clinic was appointed to the WakeMed Ethics Committee. The WakeMed Ethics committee is a group of doctors, nurses, a hospital chaplain, and representatives from medical social work, administration and the community designed to help patients make difficult health care decisions about themselves or loved ones. The committee members are trained and prepared to listen to the patient cases

objectively in order to help individuals make the best decision possible. Dr. Mankin’s medical expertise is in treating scoliosis and other pediatric spinal conditions. He also is experienced in the evaluation and treatment of children with neuromuscular disorders, including cerebral palsy, spina bifida, spinal injuries, autism and other medical and neurologic diseases. He is board certified by the American Board of Orthopaedic Surgery and the National

Board of Medical Examiners. The co-developer of the Wake County Pediatric Spasticity Clinic, in conjunction with Wake Rehab and Raleigh Neurology, Dr. Mankin has a monthly Special Needs Clinic at the Cary office for new intake and established neuromuscular patients. He also serves as the team physician for North Carolina State University women’s sports and Southeast Raleigh High School.

Boylan Healthcare Joins Triangle Physician Network Boylan Healthcare P.L.L.C., comprised of 35 staff, including eight board-certified physicians, has joined Triangle Physician Network L.L.C. (TPN), effective Jan. 1. The physician practice brings to the network 46 years of experience caring for patients, as well as expertise in cardiac and diabetes care. Offices are located in North Raleigh and at North Hills. “Boylan has a long reputation for outstanding care. We are fortunate to have them join our network,” said TPN’s Executive Administrative Director Bob Ricker. “Mutually beneficial relationships between hospitals and private practices will continue to increase. We look forward to strengthening our network of care providers in 2011.” The regional physician network is a joint effort of Rex Healthcare and UNC Health Care to expand the system’s ability to support the evolving health care needs of the region. The not-for-profit, wholly-owned subsidiary of UNC Health Care based out of Morrisville, N.C., currently includes 16 regional physician practices and more than 68 physicians.

TPN provides affiliated primary care and specialty physician practices the ability to coordinate with the health care system’s electronic medical records and access to operational support, and specialty and subspecialty care providers. “This coordinated approach provides more opportunities for our team to engage in patient care,” said Todd Helton, M.D., Ph.D., of Boylan Healthcare. “We are excited to collaborate with care providers across the region to enhance the care we provide patients.” Boylan Healthcare physicians and staff joining TPN include: Browning Place location (North Hills) 3900 Browning Place, Suite 101, Raleigh, N.C., 27609 Gregory Appert, M.D. Joshua Garriga, M.D. Todd Helton, M.D. Robert Smithson, M.D. Teresa Terezis, M.D. Polly Watson, M.D. Kim Bastide, PA-C Suzanne Hage, PA-C Mandy Wilson, PA-C

Healthpark location (North Raleigh) 8300 Health Park, Suite 309, Raleigh, N.C., 27615 Howard Newell, M.D. Charles Wehbie, M.D. Blythe Ward, PA-C Mandy Wilson, PA-C Current, TPN practices include: Boylan Healthcare Chapel Hill North Medical Center Chatham Crossing Medical Center Chatham Primary Care Executive Health (The Carolina Clinic) Highgate Family Medical Center Pittsboro Family Medicine Rex Primary Care of Holly Springs Rex Family Practice of Knightdale Rex Family Practice of Wakefield Rex Senior Health Center Rex/UNC Family Practice of Panther Creek Sanford Hematology Oncology Sanford Specialty Clinics UNC Family Medicine at Hillsborough University Pediatrics at Highgate For more information about TPN, visit www.tpnmd.com. For more information about Boylan Healthcare, visit www. boylanhealthcare.com. FEBRUARY 2011

News Welcome to the Area

Upcoming Events

Jessica Dawn Benson, DO

Sean Paul Montgomery, MD

Durham

UNC Chapel Hill, Chapel Hill

Michael Wesley Cammarata, MD

John Robert Morsek, MD

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Cody Allan Chastain, MD

Lindsey Thomas Murphy, MD

Internal Medicine Duke University Hospitals, Durham

Pediatrics University of North Carolina Hospitals, Chapel Hill

Joseph Charles Crozier, MD

Meredith Cates Northam, MD

Psychiatry Duke University Hospitals, Durham

Radiology University of North Carolina Hospitals, Chapel Hill

Saturday, March 7

Guiding Lights Hosts First Fund Raiser North Raleigh Hilton

Guiding Lights Caregiver Support Center is hosting its first annual Share to Care Event Saturday, March 7, from 7-11 p.m. at North Raleigh Hilton. This inaugural event will feature a silent auction and notable entertainment leading up to live music by The Party Nuts, a popular Raleigh cover band. Guests also will enjoy heavy hors d’oeuvres and cash bars. Guiding Lights was founded to be “the comprehensive caregiver support center for family and professional caregiving in the Triangle.” Its vision is to help clients

Irina Ellen Gault, MD Anesthesiology University of North Carolina Hospitals, Chapel Hill

with “relevant, timely and comprehensive information” from a central location. Services include referral and education, and most are offered free. Proceeds will benefit Guiding Lights, a private, nonprofit community organization in Raleigh, which recently received its 501c3 status. The organization relies on fund raising through ticket sales and sponsorship. Tickets are $50 in advance and $60 at the door. For sponsorship information, contact Stacy Milburn, sponsorship chair, at (919) 371-2062 or by e-mail to stacy@guidinglightsnc.org. For event or volunteer information, contact Gina Myers of La Cosa Bella Events at (919) 435-7400 or gmyers@lacosabellaevents.com.

UNC Obstetrics and Gynecology News Honors, Awards and Appointments Amy Bryant, M.D., has been appointed family planning expert for the Malawian Ministry of Health’s Guidelines for antiretroviral therapy and prevention of motherto-child transmission of human immunodeficiency virus (ART/PMTCT). Ursula Balthazar, M.D., was awarded The Society for Gynecologic Investigation (SGI) President’s Presenter Award for her research entitled “Periconceptional Changes in Thyroid Function.” She and Anne Steiner, M.D., were the project authors. David Grimes, M.D., was voted “Doctor of the Month” by the staff at the Ambulatory Care Center Day-Op. M. Kathryn Menard, M.D., (PI) and Sarah Verbiest were awarded a grant through National Institute of Child Health and Human Development (NICHD) entitled: AcademicCommunity Partnership to Reduce Health Disparities in Infant Mortality. The goal of this project will be to engage a diverse group of communitybased health care providers, practice organization leaders, infant mortality prevention coalitions, and community public health opinion leaders in dialogue about shared concerns, research goals and practice improvements. These meetings will create a forum to solidify discussions into a long-term community-based participatory research agenda with a supporting network. By improving the outreach to and information dissemination of evidence-based approaches among community-based health care providers and organizations across the state, we hope to make

The Triangle Physician

significant strides towards reducing maternal and infant morbidity and mortality.

On the Blog Wanda Nicholson, M.D., on the recently released United States Preventive Services Task Force on new screening recommendations for osteoporosis – http://bit.ly/e7ULUn Home fertility test may be inaccurate according to study by Anne Z. Steiner, M.D., M.P.H. – http://bit.ly/gbXe3d William Goodnight, III, M.D., helps to demystify prenatal testing, which can easily overwhelm parents – http://bit. ly/eICTJj Nancy C. Chescheir, M.D.’s, book Your Pregnancy and Childbirth: Month to Month is in the WebMD Health & Pregnancy blog discussing pregnancy myths – http://bit.ly/ewgdhE Daniel L. Clarke-Pearson, M.D., co-authored Stereotactic Body Radiotherapy (SBRT): Technological Innovation and Application in Gynecologic Oncology on research in innovative therapy for gynecological cancers – http://bit.ly/fUpUY9 Mary L Jannelli, M.D., shares options for treatment of pelvic floor prolapse – http://bit.ly/eBluIl One couple shares the highs and lows of in-vitro fertilization and the options available through UNC Fertility – http://bit.ly/gALEhd John Boggess, M.D., talks about the new Cancer Center at Rex – http://bit. ly/hKOyAq Research on Institute of Medicine May 2009 guidelines for pregnancy weight gain was co-authored by Alison

Stuebe, M.D. – http://bit.ly/eQhqDD Mary E. Schlegel, M.D., gives tips on making the most of an annual gynecological exam – http://bit.ly/fj5Gzc The Center for Maternal & Infant Health created the “Family Voice” video to commemorate its 10th anniversary in 2010 – http://bit.ly/h1TABL David Grimes, M.D.’s, recent research investigates the reality of birth control pill side effects –http://bit.ly/eccZsX UNC OB/GYN launches a YouTube site with videos for everyone from providers to patients. – http://bit.ly/ dIfXwT Watch as Catherine A. Matthews, M.D., performs a robotic sacrocolpopexy for vaginal prolapse – http://bit.ly/hmbCvx David Grimes, M.D., co-authored Electronic Fetal Monitoring as a Public Health Screening Program: The Arithmetic Failure – http://bit.ly/ gdQN6F

Publications Carey ET, El-Nashar SA, Hopkins MR, Creedon DJ, Cliby WA, Famuyide AO. Pathologic Characteristics of Hysterectomy Specimens in Women Undergoing Hysterectomy After Global Endometrial Ablation. J Minim Invasive Gynecol. 2011 JanFeb;18(1):96-9. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2010. Grimes DA, Schulz KF. Nonspecific Side Effects of Oral Contraceptives: Nocebo or Noise? Contraception. 2011 Jan;83(1):5-9. Epub 2010 Aug 5.

Harper M, Zheng SL, Thom E, Klebanoff MA, Thorp J Jr, Sorokin Y, Varner MW, Iams JD, Dinsmoor M, Mercer BM, Rouse DJ, Ramin SM, Anderson GD; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Cytokine Gene Polymorphisms and Length of Gestation. Obstet Gynecol. 2011 Jan;117(1):125-30. Higginson DS, Morris DE, Jones EL, Clarke-Pearson D, Varia MA. Stereotactic Body Radiotherapy (SBRT): Technological Innovation and Application in Gynecologic Oncology. Gynecol Oncol. 2010 Dec 29.

Presentations Alice Chuang, M.D., participated in the Association of Professors of Gynecology and Obstetrics (APGO) Faculty Development Seminar in Amelia Island, Fla., from Jan 8-11. • Chuang A, Zite N. Achieving the 40Hour Work Week: Practical Tools for Reclaiming Time and Energy. • Chuang A, Nuthulapaty F, McLean M. The Teacher Learner Contract: Negotiating an Optimal Relationship between Educator and Student. • Chuang A, Using the Role Analysis to Negotiate your Perfect Job. • Program Co-Chair, Association of Professors of Gynecology and Obstetrics, Clerkship Directors’ School, Parts 101 and 201. • Nuthalapaty F, Chuang A. Nuts and Bolts: Anatomy of a Clerkship. New Clerkship Director’s Workshop. • Fundamentals and Assessment and Grading. New Clerkship Director’s Workshop.

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

Mateen Akhtar, MD, FACC

Benjamin G. Atkeson, MD, FACC

Christian N. Gring, MD, FACC

Matthew A. Hook, MD, FACC

Kevin Ray Campbell, MD, FACC

Eric M. Janis, MD, FACC

Randy Cooper, MD, FACC

Diane E. Morris, ACNP

cardioLogY services

Ravish Sachar, MD, FACC

Nyla Thompson, PA-C

2 Locations to serve our Patients Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7907 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

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.

Make life easier for your schedulers today!

As a referring provider, you can now place your imaging orders online with our new CMS-compliant provider portal. You or your schedulers can login and view each of our sub-specialty order forms to make ordering a breeze. The WR Provider Portal includes: • Fast ordering with auto-fill cells • Online CPT code lists for MR and CT exams for quick reference • Order logs showing archived orders and orders pending authorization • Quick access to all WR patient forms and location maps • Complete training available for your staff Get started today by calling our referral services staff at 919-788-7909. Wake Radiology. Making your life easier. Scan now to learn all about Wake Radiology. Download any QR Reader App for your Smartphone!

1 number to call, 17 locations serving the Triangle area. | Scheduling: 919-232-4700 | wakerad.com