March 2011 by TTPLLC

M a r c h 2 0 11

UNC Healthway Direct Route to UNC Outpatient Services

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

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Contents

COVER STORY

PHOTO BY JIM SHAW

UNC Healthway

Is Direct Route to UNC Outpatient Services

FEATURES

Radiology

Varicocele Embolization Is Safe Alternative to Surgical Treatment Dr. Michael D. Kwong explores the advantages of this minimally invasive procedure.

M a r c h 2 011 V o l . 2 , I s s u e 3

DEPARTMENTS Cardiology

Atrial Fibrillation: What’s New in 2011? Dr. Andy Kiser and Dr. Paul Mounsey review the exciting advances for restoring sinus rhythm.

15 Radiology MR Enterography for the Evaluation of Crohn Disease

16 Urology Strong Cases for Prostate Cancer Screening

18 Women’s Health IUD Use in U.S. is Growing Slowly Amid Persistent Misperceptions

24 Urology Welcome to North Carolina: The Stone Belt

26 Orthopedics The Aging Spine: New Treatment Options

28 Financial Planning Help! My 401(k) Is Terrible

29 Radiology Update on MRI of Prostate Cancer

30 Gastroenterology Colon Cancer Screening: Update Sheds Light on Growing Concern

32 News Welcome and Clinical Trials

The Triangle Physician

JOHNSTON HE ALTH

From the Editor

UNC is Chapel Hill Driving Force The value of the University of North Carolina to the education of thousands and the surrounding Chapel Hill community can not be underestimated. Over the centuries, it has consistently served as one of the top-

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

ranked public universities in the nation. Along the way, it added a medical school, which delivers nationally ranked training and health care. The integration of health care delivery on the main campus of a medical school is unique and will continue to serve UNC students and patients, alike. Increasingly, as the university has grown, outpatient services have been moved off campus to improve access for patients. Most of those outpatient facilities are located off of Highway 54, so UNC recently named that stretch of road “UNC Healthway”– a landmark, of sorts, guiding patients, especially new ones, to the care they need more quickly. Read more about the UNC Healthway to outpatient services, in this month’s cover story. Also in this issue, cardiologist Andy C. Kiser, professor of surgery within the Division of Cardiothoracic Surgery and the University of North Carolina Center for Heart and Vascular Care, joins forces with J. Paul Mounsey, director of the UNC Cardiac Electrophysiology Laboratory, in an overview of the latest developments in atrial fibrillation. Drs. Glenn Preminger, Michael Ferrandino and Michael Lipkin also share a byline in an article on kidney stones.

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Greg Bortoff, M.D.; Michael N. Ferrandino, M.D.; Andy C. Kiser, M.D., F.A.C.S., F.A.C.C., F.C.C.P.; Michael D. Kwong, M.D.; Michael E. Lipkin, M.D.; Amy Stanford, M.D., F.A.C.O.G.; Sameer Mathur, M.D.; Mark W. McClure, M.D.; J. Paul Mounsey, B.M., B. Ch., Ph.D.; Rig Patel, M.D.; Paul J. Pittman, C.F.P.; Glenn M. Preminger, M.D.; and Todd Roth, M.D. 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

We have some new contributors this issue. Orthopedic surgeon Sameer Mathur writes about emerging spine treatments that offer particular benefits to elderly patients. Radiologist Michael D. Kwong explains how varicocele embolization is a safe alternative to surgical treatment. Radiologist Todd Roth offers insights on MR enterography for evaluation of Crohn disease and fellow radiologist at Raleigh Radiology Greg Bortoff gives an update on the treatment of prostate cancer using magnetic resonance imaging. Urologist Mark McClure provides the latest in support of prostate cancer screening in the

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earliest stages.

Advertising rates on request Bulk rate postage paid Greensboro, NC 27401

Returning to provide women’s health expertise is Dr. Amy Stanford, who discusses the

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.

increasing acceptance of intrauterine devices, aka IUDs, as misconceptions are erased. Our resident financial expert, Paul Pittman, offers expert advice on maximizing one’s 401(k). Thanks to all contributors for another information-packed issue, and to our returning and new advertisers, who recognize the value of the 8,000-plus readers Triangle Physician reaches each month. And as always, our gratitude for all you do to advance health care delivery in our region.

Heidi Ketler Editor

The Triangle Physician

Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.

On the Cover

UNC

Healthway

Is Direct Route to UNC Outpatient Services By Heidi Ketler

“It’s a well-traveled route that makes locating and getting to appointments easy,” says UNC Health Care Marketing Director Dan Stevens. “This is important

UNC Health Care has designated Highway 54 as the “UNC Healthway” to many of its outpatient services that are located on or directly off of this major Chapel Hill thoroughfare.

particularly from a customer service standpoint, and in line with UNC Health Care’s mission,” which is summarized in the slogan ‘Leading. Teaching. Caring.’” “We have very lofty goals for providing excellent care for our patients,” says Stevens. “UNC differentiates itself by not only being a nationally ranked public institution for education and research, but for also providing accessible quality health care for everyone.”

UNC Health Care is a public, academic medical center operated by and for the people of North Carolina, as directed by the North Carolina General Assembly. Its mission is to provide high quality patient care, to educate health

The Triangle Physician

found that UNC exceeds state and national customer service averages and is one of the top-ranked medical schools in the country. In 2010, U.S. News and World Report ranked it second in primary care and 20th in research. The challenge of a busy campus, however, is managing traffic and parking. To resolve these issues, UNC Health Care has been gradually moving outpatient services off of the main campus to locations along Highway 54 that offer free onsite parking. In the process, UNC Health Care has been investing in facility upgrades and in some cases all new construction. “This also supports the UNC vision to serve patients in really accessible, state-of-the-art facilities, with high quality physicians, nursing and staffing,” says Stevens. Outpatient stops along UNC Healthway UNC has a strong presence along the UNC Healthway corridor, particularly from Highway 86 to Interstate 40. The first UNC Healthway location closest to Highway 86 is the UNC Ambulatory Care Center (ACC) located on Mason Farm Road where, on March 1st, the Ambulatory Surgery Center (ASC) opened on the newly renovated first floor. This facility has eight operating rooms and a 10-bed 23-hour overnight recovery unit for patients who need additional nursing care.

care professionals, to advance research and

Enhancing outpatient access

to provide community service. Each year

UNC has the distinction of having a hospital

UNC Health Care serves residents from all

situated in the middle of the university

A variety of outpatient clinics are also

100 counties in North Carolina and several

campus. “It’s not always the case for an

available at the ACC including the Kittner

surrounding states.

academic medical center to have health care

Eye Center, UNC Orthopaedics, Internal

completely integrated within the campus,”

Medicine, Trauma Surgery, Plastic Surgery,

“The UNC Healthway serves as an easy

says Lafrenaye. “It’s a big positive for us,

Pulmonary, Nephrology & Hypertension,

reference for new outpatients on their way to

enhancing the learning environment while

Diabetes, Anticoagulation, and the Hand

one of the facilities,” says Ray Lafrenaye, UNC

maintaining the highest standards for patient

Rehabilitation Center. For more information,

Health Care vice president, facility planning

care.”

call (919) 966-7330.

direction of doing anything we can to make

Based on the latest U.S. News & World

UNC Family Medicine is just down the road

our services more accessible for all of our

Report analysis of nearly 5,000 United States

from the ACC and located off of Highway

patients.”

hospitals, UNC Health Care is on the right

15/501 at Manning Drive. It is an extension

track. The 2010-2011 Best Hospitals rankings

of the UNC Family Medicine Department,

and development. “We are working in the

MARCH 2011

which is ranked No. 3 in the nation by U.S. News & World Report and has 13 physicians recognized by Best Doctors, a ranking of the top 5 percent of physicians nationwide. A wide array of services are offered at UNC Family Medicine including prenatal care, family-centered maternity care, innovative child health care, chronic illness care, older adult care, and many others. Prevention and screening include birthing classes, state-ofthe-art

diabetic

retinal

screening

and nutrition counseling. For more information, call (919) 966-0210. The next stop on UNC Healthway is the state-of-the-art UNC Imaging & Spine Center on the corner of NC Highway 54 and Finley Golf Course Road. It offers comprehensive imaging services and spine care in one convenient location, eliminating the need for multiple physician referrals and allowing for the streamlining of services.

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The complete spectrum of imaging and

related conditions and injuries on the

meet the needs of a hectic schedule. In a

screening services on the first floor features

second floor. A team of orthopedic surgeons,

single day, patients receive a full physical,

the latest technology in mammography,

neurosurgeons,

and

nutritional counseling, fitness counseling,

ultrasound,

rehabilitation

bone

density,

fluoroscopy,

physical physicians,

medicine

physical

and an optional peak performance session

diagnostic X-ray and computed-tomography

therapists collaborate with pain management

and

to help assure optimal performance for busy

scan. First-of-its-kind magnetic resonance

specialists, making this a high-level stop

professionals. For more information, call

imaging equipment is being installed into

for spine care. Services include surgical

(919) 962-2862.

this brand new facility this month. Images

evaluation, rehabilitation, physical therapy

are viewed immediately by a network of

and pain injections. For more information,

UNC Hospitals Heart & Vascular Center

UNC physicians, helping to facilitate early

call (919) 957-6789.

provides the full breadth of cardiology and

diagnosis. For more information, call (919) 957-6800.

vascular care. The latest in stress testing, Just across the street from the Imaging &

echocardiography, nuclear imaging, and

Spine Center in the Meadowmont community,

vascular services, and vascular access are

The Imaging & Spine Center also offers

numerous UNC Heathway facilities reside.

available. The facility also is equipped with

comprehensive

and

At the UNC Carolina Clinic, a streamlined

on-site laboratory services. For scheduling,

personalized care for all types of spine-

â&#x20AC;&#x153;executive healthâ&#x20AC;? program is offered to

call (919) 966-7245.

treatment

services

MARCH 2011

Upstairs from Heart & Vascular is the UNC

Just across the plaza in Meadowmont on

on nutrition, stress management and risk

Hospitals Endoscopy Center where specialized

Sprunt Street, the UNC Hospitals Cardiac

factors, as well as medically supervised

outpatient gastrointestinal (GI) services are offered.

Rehabilitation is located within the UNC

exercise in a group setting. For more

Colonoscopy,

information, call (919) 843-2158.

esophagogastroduodenoscopy

Wellness Center. Patients taking advantage

(EGD), flexible sigmoidoscopy, esophagoscopy,

of the various heart healthy programs

enteroscopy are among the many procedures

offered here gain access to a program that

Leaving Meadowmont and near the Highway

available. Patients of this clinic can also participate

is certified by the American Association

54-Interstate

in a number of research opportunities. For more

Pulmonary

Pointe I is north on Farrington Road. Here,

information, call (919) 843-7200.

Rehabilitation. Services include education

the complete spectrum of ear, nose and

The Triangle Physician

Cardiovascular

and

interchange,

Carolina

Route 54 corridor in July 2004. In addition to

comprehensive

evaluations,

services

diagnostic include

hearing industrial

hearing testing, screening for middle ear abnormalities, and tinnitus evaluations and management. To make an appointment, call (919) 493-7980. Carolina Pointe II is also the location for the UNC Comprehensive Cancer Support Program, where cancer patients and their families can receive holistic support services from a compassionate team of health care professionals. For more information, call (919) 843-0680. For appointments, call (919) 966-3494. The last stop on the eastern-most point along UNC Healthway are the clinics at Highgate which include the Highgate Specialty Center (Diabetes & Endocrinology), University Pediatrics at Highgate and Highgate Family Medical Center. A comprehensive medical team at the Highgate Specialty Center (Diabetes & Endocrinology) tailors programs to suit each patientâ&#x20AC;&#x2122;s individual needs. Comprehensive diabetes

care

includes

blood

glucose

management and monitoring, foot care, stress management, smoking cessation, insulin pump therapy, cardiovascular risk reduction, weight management, exercise training and therapy to prevent or treat diabetes-related complications. A number of endocrinology services are also available onsite. For more information, call (919) 484-1015. The medical staff at University Pediatrics at Highgate provides compassionate, childcentered medical care to a diverse population throat (ENT) services are offered, including

Pointe II. Here you will find the UNC

of children and young adults, from birth to

voice, speech and language pathology, and

Allergy, UNC Orthopaedics, UNC Urgent

college age, including children with chronic

audiology at UNC Hospitals Hearing &

Care, UNC Hospitals Rheumatology, UNC

medical conditions and special needs. For

Voice Center, and UNC Ear, Nose & Throat.

Geriatrics, UNC Hospitals Hematology,

more information, call (919) 806-3335.

UNC Hospitals Radiology & Laboratory, Complementary to the ENT services offered

and UNC Hospitals Surgical Oncology.

Highgate Family Medical Center offers the full spectrum of family-centered medical

in Carolina Pointe I, an array of services reside across Highway 54 and continuing

The UNC Hearing & Communication

care, including pediatric, adult, geriatric, and

south on Farrington Road in Carolina

Center was the first clinic to move to the

procedural obstetric and gynecologic care.

MARCH 2011

In addition to preventive services, a wide

Health Care is preparing for the future,” says

Physician information

range of acute care services and in-office

Stevens.

UNC Health Care is committed to delivering

procedures are offered at convenient times

quality care and providing access to those

for families and the working professional. An

“With health care reform and an aging population,

onsite laboratory is also available. For more

health care delivery is evolving toward more

information, call (919) 361-2644.

outpatient care and a greater emphasis on the

Physicians can speak to a UNC physician

quality of the health care experience.”

regarding patient care via the toll-free

Paving the way for the future

UNC

“Our initiative to improve outpatient access

UNC Health Care’s Healthway is a step in that

along the UNC Healthway is one way UNC

direction.

The Triangle Physician

who deliver that care for all of North Carolina.

Carolina

(800) 862-6264.

Consultation

Center

Experience makes good medicine accurate

rapid results

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Raleigh Radiology is the oldest, and one of the most respected radiology practices in the Triangle area. We offer exceptional imaging services that include MRI (Magnetic Resonance Imaging) at 5 convenient outpatient imaging facilities throughout Wake & Johnston counties. All musculoskeletal, abdominal, and neurological MRI exams are interpreted by a subspecialty, fellowship trained radiologist in that field. We are committed to providing the best care for your patients and being there when you need us. When a practice has been around as long as we have, it’s evident that our motto rings true. At Raleigh Radiology, experience “truly does” make good medicine.

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Radiology Article

MR Enterography for the Evaluation of Crohn Disease By Todd Roth, MD

CT and fluoroscopic imaging studies, along with endoscopy, have traditionally played an important role in the evaluation of patients with known or suspected Crohn disease. Up until recently, MRI has not been used for the evaluation of the alimentary tract, mainly due to its susceptibility to motion artifacts and its suboptimal spatial resolution compared with other modalities. However, as the technology has matured, MRI, specifically MR enterography, has emerged as an alternative to CT and fluoroscopic studies for the evaluation of Crohn disease and other diseases of the small bowel. Standard endoscopy and video capsule endoscopy remain the first line choices for the diagnosis of Crohn disease due to their superior ability to detect early mucosal inflammation (e.g aphthoid ulceration). Fluoroscopic and CT imaging studies are commonly utilized to detect the presence of transmural disease, assess the extent of disease, and evaluate for complications such as abscess, fistula and bowel obstruction. MR enterography is a relatively new diagnostic tool capable of answering these same clinical questions and is comparable to CT for detecting the various stages of Crohn disease (i.e. acute inflammation, penetrating, and fibrostenosing). MR enterography has been shown to have greater overall accuracy than small bowel series and enteroclysis for detecting disease, with the exception of isolated mucosal inflammation. MR enterography also has several advantages over these radiologic modalities. MRI, with its excellent soft tissue contrast and multiplanar capabilities is superior to CT and fluoroscopic studies at evaluating the pelvic anatomy, an important consideration when assessing patients with suspected rectal or perianal inflammation, fistula or abscess. The cine capabilities of MRI allow for the detection of abnormal bowel motility, a secondary finding typically associated with

Todd Roth · Vice Chief of Radiology at Rex Hospital · BS, University of Texas, Austin · MD, University of Texas Health Sciences Center, San Antonio · Residency, Baptist Medical Center, Wake Forest University, Winston-Salem · Fellowship in abdominal imaging, Baptist Medical Center, Wake Forest University · Expertise in abdominal and pelvic MRI, CT, and ultrasound · Joined Raleigh Radiology in 2004

adhesions and bowel strictures. The most important advantage MRI has over other radiologic modalities is its lack of ionizing radiation. This is particularly beneficial to patients with Crohn disease, as they typically present in adolescence or early adulthood and will often require multiple imaging studies over their lifetime. MR enterography can be performed on most modern MRI scanners. Imaging is performed both with and without

enhanced imaging in order to relax the bowel. Bowel relaxation is necessary to minimize artifacts associated with bowel motility. In summary, MR enterography is a valuable technique for the evaluation of patients

intravenous Gadolinium and images are typically acquired in both the axial and coronal planes. Patients are asked to fast for four to six hours prior to the study and are given 1-1.5 L of an oral contrast agent (typically a low density barium solution) 45 minutes prior to the exam in order to fully distend the small bowel. Complete bowel distention is important in order to accurately depict bowel wall thickening and early inflammatory change. A bowel relaxing agent (typically Glucagon 1 mg IV or IM) is given immediately prior to contrast-

with known or suspected Crohn disease. It is capable of detecting early inflammation, differentiating acute from chronic disease, and assessing complications. Most importantly, MR enterography is able to answer these clinical questions without the use of ionizing radiation. Raleigh Radiology is pleased to offer MR enterography at its Cary, Cedarhurst and Blue Ridge locations. All studies are interpreted by fellowship-trained abdominal radiologists.

MARCH 2011

Urology

Strong Cases for

Prostate Cancer Screening By Mark W. McClure, M.D.

and cure is possible, followed by a stage in which prostate cancer is disseminated and cure is no longer possible. The tipping point between these two stages is unknown. Current imaging studies are unable to accurately detect early metastatic disease. Computed tomography scans have the accuracy of a coin toss and bone scans are positive in less than 1 percent of men with a PSA less than 20 ng/dL. Nevertheless, prostate cancer cells have often disseminated prior to definitive intervention: as many as 40 percent of men with normal surgical margins following radical prostatectomy will experience a biochemical recurrence (rising PSA) at some point following their surgery. The goal of prostate cancer screening (PCS) is to detect prostate cancer at an early stage, when it is potentially curable. PCS consists of a digital rectal examination (DRE), serum PSA and a validated questionnaire about voiding symptoms. From a public policy standpoint, Prostate

cancer

presents

clinical

estimated that 192,000 men will be newly

PCS is controversial because of concerns

conundrum: Only a small percentage of

diagnosed with prostate cancer and 27,360

about over diagnosis, over treatment and

men with untreated prostate cancer will

men will die as a result of prostate cancer in

the chance of diminished quality of life, as a

die as a result of their disease, yet due to its

2010.

consequence of treatment-related side effects.

the second leading cause of cancer-related

The natural history of prostate cancer includes

Two large randomized controlled trials were

death in men. The American Cancer Society

a stage in which the disease is localized

conducted to determine whether there was

high prevalence, prostate cancer represents

The Triangle Physician

evidence-based data to support PCS. The

(or 1,068 men who actually participated in

The ERSCP trial studied 162,000 men from

trials reached difference conclusions. At

PCS) would have to be screened (NNS, or

seven European countries, whereas the

seven years or 10 years, the Prostate, Lung,

number needed to screen) and an additional

PLCO trial studied 76,693 men from a single

Colorectal and Ovarian Cancer Trial (PLCO)

48 men would have to be treated (NNT, or

country. The majority of men (85 percent)

failed to show a reduction in prostate cancer-

number needed to treat). A further decrease

with indications for biopsy in the ERSCP trial

related mortality in men that underwent PCS

in prostate cancer-specific mortality was seen

accepted a prostate biopsy. In contrast, only

compared to the control arm (N Engl J Med

for men that had been in the trial for 12 years

30 percent of men in the screening arm in

2009: 360: 1310-1319).

(36 percent lower mortality, NNS = 500). In

the PLCO study with an abnormal PSA had a

addition, the incidence of T3 and T4 tumors

prostate biopsy. Moreover, in the PLCO trial,

Conversely, the European Randomized Study

was 22 percent lower and the incidence of M1

52 percent of the men in the control arm had

for Prostate Cancer (ERSPC) showed 20

lesions was 41 percent lower in the screening

PSA screening during the study, which may

percent fewer deaths in the screening arm than

arm of the ERSPC trial than in the control

explain why the incidence and death rate

in the control arm after a mean of 8.8 years (N

arm. Fundamental differences between the

from prostate cancer was not significantly

Engl J Med 2009: 360: 1320-1328 ). To prevent

two studies may account for the divergent

different between the screening and control

one prostate cancer death, though, 1,410 men

conclusions.

arm. Other data from the United States are

Stages of Prostate Cancer

consistent with the findings of the ERSCP trial. Age-adjusted data from the prostate cancer Surveillance, Epidemiology and End Results (SEER data) show that the incidence of metastatic disease has dropped more than three-fold since the advent of PCS in 1990. Furthermore, data from the American Cancer Society show that the death rate from prostate cancer has dropped by almost 50 percent during the past two decades. Modified PCS for men between the ages of 40 to 50 may lead to earlier diagnosis and treatment of prostate cancer, which may further improve these statistics. Researchers at John Hopkins Medical Center advocate beginning PCS at age 40 in all men. According to data from the Baltimore Male Aging study, men aged 40 with a PSA of 0.6 ng/mL or less have a four-fold reduction in prostate cancer risk compared to men with a PSA higher than this benchmark. If the initial PSA is less than 0.6 ng/mL, repeat PCS is performed at age 45. If the PSA remains stable, further PCS is deferred until age 50. On the other hand, if an initial or subsequent PSA is greater than 0.6 ng/mL for men between the ages of 40 to 50, closer scrutiny is recommended. A prostate biopsy is recommended if a PSA value is greater than 2 ng/mL, if there is a palpable abnormality in the prostate or if the PSA increases by greater than 0.35 ng/mL/year.

MARCH 2011

Women’s Category Health

IUD Use in U.S. Is Growing Slowly Amid Persistent Misperceptions By Amy Stanfield, MD, FACOG

Intrauterine devices (IUDs) are one of the oldest methods of contraception and are appealing to many women because they are highly effective, safe, private, long acting and rapidly reversible. More and more young women are presenting to our office for intrauterine devices for contraception, and I think this is a positive trend. Intrauterine devices (IUDs) are one of the oldest methods of contraception and are appealing to many women because they are highly effective, safe, private, long acting and rapidly reversible. In the United States, there are two Food and Drug Administration-approved IUDs: the copper T380A (ParaGard) and the levonorgestrel intrauterine system (Mirena). For this article I will refer to them as the “copper IUD” and “levonorgestrel IUD” for clarity and simplicity. In a 2002 study examining American women’s contraceptive choices, only 2 percent chose IUDs. In other parts of the world, however, IUDs are much more commonly used. For example, in some parts of Asia, IUD use among contraceptive users approaches 50 percent, while 6-27 percent of European contraceptive users opt for IUDs. Misconceptions clarified Based on my clinical practice, I believe the number of IUD users is increasing steadily. However, misinformation and misperceptions about IUDs persist. The biggest misperception I encounter is that IUDs cause pelvic infections that, in turn, cause infertility. The origin of this fear can be directly linked to the problems that arose

The Triangle Physician

a patient acquires a sexually transmitted disease (STD), such as gonorrhea or chlamydia; this is not true. If a patient is asymptomatic, they can typically be treated for the STD without removal of their IUD and with close follow up. Furthermore, adolescents and women with a history of ectopic pregnancy, pelvic inflammatory disease or STDs are candidates for IUDs, with adequate counseling.

from the Dalkon Shield, an IUD pulled from the market in 1975 due to a design flaw that led to pelvic infections. (The Dalkon Shield’s strings were made of braided multifilament material and, thus, acted as a wick for bacteria to ascend into the upper genital tract. Today’s IUD strings are monofilament.) As a result, the 11 percent IUD use in our country pre-Dalkon Shield dropped to less than 1 percent post-Dalkon Shield.

When an IUD is an ideal choice A candidate for an intrauterine device does need to be at low risk for STDs. I tend to exclude patients who have more than one partner or whose partner has more than one partner. Other contraindications to IUDs include pregnancy, acute pelvic infection, a current STD, severe uterine cavity distortion, genital tract cancer and undiagnosed vaginal bleeding.

Today, the risk of pelvic infections attributed to IUD use is very low. If an infection is going to occur, it typically happens within the first month after insertion. A meta analysis of 22,908 patients revealed 9.7 cases out of 1,000 women with pelvic inflammatory disease (PID) in the first 20 days post insertion. After the first month, the rate dropped to 1.4 cases out of 1,000 women, which is equivalent to a non-IUD user’s risk for PID.

Many of my patients who choose IUDs are those who want or need to avoid estrogenbased contraception. This would include patients with diabetes, breast cancer, liver disease, smokers older than 35 years, those with a history of blood clots or those who are breast feeding. Certainly, patients who do not tolerate oral contraceptive pills or those who desire non-hormonal contraception are also excellent candidates for IUDs.

Another misperception I encounter is that nulliparous women (women who have never completed a pregnancy beyond 20 weeks) are not candidates for IUDs. In fact, both the Centers for Disease Control and Prevention, and the World Health Organization state that the advantages of IUDs for nulliparous patients outweigh the risks. While the rates of expulsion are higher in nulliparous women using the copper IUD, this is not true of the levonorgestrel IUD.

When compared with oral contraceptive pills, IUDs have both lower pregnancy rates and better continuation rates. Both of these facts are important information for patients, in light of the fact that unplanned pregnancies account for half of all pregnancies. Continuation rates with the levonorgestrel IUD are particularly impressive. In one study, continued IUD use was 93 percent, 87 percent, 81 percent, 75 percent and 65 percent at years 1 through 5, respectively. IUDs are also a good alternative for patients who are considering surgical sterilization, since efficacy is comparable.

The last misperception I will mention is the belief that an IUD must be removed if

Dr. Amy Stanfield, MD, FACOG, completed her undergraduate and medical degrees at UNC, followed by residency at Carolinas Medical Center. As a member of AOA, Dr. Stanfield truly provides excellence in gynecology. In addition to her private practice, Dr. Stanfield will complete the Fellowship in Integrative Medicine through the University of Arizona this December. She is now the Director of Integrative Medicine for CWRWC and is directly involved is the clinical trials conducted by our team. Dr. Stanfield provides a unique approach to caring for women of all ages, which distinguishes her from many of her colleagues. Integrative Medicine is an approach to health that will bring immense benefit to many women. As recently as December 2008, she was featured as an expert in Integrative Medicine for the Ob/Gyn Alliance, which has approximately 8,000 members of Ob/Gyn physicians across the U.S. For more information, call (919) 251-9223.

Copper IUD is only hormone-free option The copper IUD is a T-shaped device made of polyethylene wrapped with fine copper wire. It is a popular choice for women who want or need to avoid hormonal birth control. In fact, other than barrier methods, natural family planning and breast feeding, this is the only reversible “hormone free” option. Initially this IUD may cause increased menstrual flow and cramping. For women who already have menorrhagia or significant dysmenorrhea this may not be the best choice. However, the side effects of increased cramping and bleeding do tend to lessen over time. This IUD is effective for 10 years and, thus, is very cost effective. It also has the added benefit of lower rates of endometrial cancer. Studies have shown that copper levels are higher in patients using this IUD, but that this doesn’t have any known clinical significance. Benefits over the levonorgestrel IUD is that the copper IUD is effective twice as long and that one’s menstrual cycle remains intact.

This IUD can also be used as emergency contraception if placed within five days of intercourse. There is an increased risk of PID with this IUD when compared to the levonorgestrel IUD that is likely due to the protective effect of increased cervical mucus with the later. The most common adverse effects that drive patients to have this IUD removed are increased dysmenorrhea and menorrhagia. Levonorgestrel IUD is most cost effective The levonorgestrel IUD is effective for five years. It is also a T-shaped device made of polyethylene that releases the progestin levonorgestrel at a dose of 20 micrograms daily. Systemic affects, such as mood changes, acne and breast tenderness, can occur, though this is rare since the dose of levonorgestrel is quite low. The effect of levonorgestrel on the endometrium causes menses to lighten, and for approximately 50 percent of patients their cycles stop altogether by the third year of use. Patients choosing this IUD are instructed that their cycles may be erratic and stop altogether, or that they may have persistent spotting, which continues in 11 percent of patients after 24 months with this IUD. Many of my patients choose this IUD for the added benefit of improved menorrhagia and dysmenorrhea. In fact, the levonorgestrel IUD is being studied for patients with menorrhagia, endometriosis, endometrial hyperplasia and stage I, grade I endometrial cancer, as well as those who would like an alternative to postmenopausal estrogen and tamoxifen. Due to the progestin effects on the cervical mucus, protection from PID may, in fact, be a side effect. In my practice the most common adverse effects with this IUD are changes in bleeding pattern and the rare systemic hormonal affects discussed above. After five years of use, this is considered the most cost-effective reversible method available.

IUD mechanism may be twofold It is hard to believe that the exact mechanism of action of IUDs is unknown. It is thought that the effects are twofold. The first is the foreign-body effect. Just as a foreign body creates a sterile inflammatory reaction, so does the IUD. Second, the copper and levonorgestrel “medications” in the IUDs have additional effects. The copper is thought to inhibit sperm migration and sperm viability, as well as change the transport speed of the ovum. In addition the copper may damage the ovum. Levonorgestrel prevents pregnancy through endometrial suppression and increased cervical mucus, which serves as a barrier to sperm. The evidence suggests that while post-fertilization IUD effects may occur, all of the effects of the IUD occur preimplantation. Alleviating insertion pain The fear of pain with insertion can be an initial barrier to IUDs for many patients. I try to reassure my patients that the insertion of either IUD takes about five minutes, and that the procedure is well tolerated by the majority of patients. Intracervical 2% lidocaine gel is being studied to help with the pain of insertion, and this is an option for our patients. IUDs also can be placed under ultrasound guidance if needed. In the very rare instance that placement is unsuccessful, a dose of 400 micrograms of vaginal misoprostol can be used the night prior to repeat attempted placement. I advise patients to expect cramping during and after placement, and advise the use of a non-steroidal anti-inflammatory drug postprocedure. Patients are educated about signs of pelvic infections, since this rare complication is most common within the first month after insertion. Patients also are instructed on how to check the IUD strings monthly, since expulsion can occur, though only rarely. A follow-up appointment is scheduled one month after insertion.

MARCH 2011

Radiology

Varicocele Embolization

Is Safe Alternative to Surgical Treatment By Michael D. Kwong, M.D.

As innovations in menâ&#x20AC;&#x2122;s health have advanced, so have the many interventional radiology procedures that offer effective, minimally invasive alternatives to open surgery. This is the case for the treatment of varicoceles, which are varicosities in veins (pampiniform plexus) of the scrotum. It is estimated that perhaps 10 percent of men have varicoceles,1,2 and while most are asymptomatic, others may cause pain, testicular atrophy and infertility. The traditional treatment has been open surgery,2 and each year it is estimated that as many as 70,000 to 80,000 men in the United States may undergo surgical correction of varicocele.1 An alternative to surgery is varicocele embolization performed by an interventional radiologist. This treatment, which studies show is equally effective, has a number of advantages. It is minimally invasive (no surgical incision) and less painful, and recovery time can be much shorter. The procedure itself takes only about 30 minutes to an hour, patients are ready to go home in about two hours and they typically return to normal activity the next day. Safe and effective,2 varicocele

Digital subtraction venogram of the left testicular (gonadal) vein confirms reflux and dilatation, which leads to varicoceles.

The Triangle Physician

embolization is an underutilized choice2 for many men, perhaps because it is not so well known or widely publicized. Because the procedure is nonsurgical and is performed under local anesthesia with conscious sedation, men with other medical problems that preclude surgery are candidates for varicocele embolization. Varicocele embolization can help restore fertility There is substantial evidence that varicoceles adversely affect male fertility, a condition that has been called the most common correctable cause.2 In fact, studies show that in infertile couples, males have an incidence of varicoceles of 20-40 percent.2,3 Fertility is a very difficult problem, of course, and even if it is determined that the male is the cause, there are still many different reasons for it. Varicoceles may be just one reason. However, research indicates that when the cause is known to be male infertility, and varicoceles are treated, couples are able to conceive in around 40 percent of those cases.4

Post embolization image of a different patient shows the appearance of the coils along the length of the right testicular vein. The sclerosant or embolizing agent is in between the coils, however, that is radiolucent. The image confirms elimination of reflux post treatment.

Dr. Kwong is a vascular and interventional radiologist, with Wake Radiology since 2003. He earned his medical training at the University of Texas Health Science Center in San Antonio. He completed a diagnostic radiology residency at Boston University, and a fellowship in vascular and interventional radiology at the University of California San Diego. Dr. Kwong is a diplomate of the American Board of Radiology and a member of the Society of Interventional Radiology, the American College of Radiology, the Radiological Society of North America and the North Carolina Medical Society.

Outpatient embolization Patients typically are diagnosed using ultrasound and then are referred by their primary physicians or urologists to an interventional radiologist for treatment. The patient is seen in the interventional radiologistâ&#x20AC;&#x2122;s office for a patient history and physical, and arrangements are made for the outpatient procedure to be performed in the hospital. There, patients are given local anesthesia with conscious sedation. (If a patient in the past has experienced an allergic reaction to iodine contrast, he receives premedication the night before and the morning of the procedure to prevent this.)

which the vein goes into the renal vein on the left side or the inferior vena cava on the right side. Occluding the entire vein is helpful in preventing recurrence. Patients stay for a two-hour observation period prior to discharge. They are followed up the next day via phone. Some patients may

easily available. It represents one of several options that can be presented to a patient so that he can weigh his choices. Many men may not be aware that a nonsurgical option is available at all. Both surgery and varicocele embolization are good options. The important point for patients is that they know treatment is available.

Varicocele embolization can be less invasive, less painful and as effective as surgery, yet many are not familiar with this interventional procedure. experience some mild achiness. Typically, patients return to work the next day. Success rate is equal to surgery The recurrence rate of this condition has traditionally been measured at around 15 percent. Success rates for varicocele embolization are 90 percent, which are the same results as those achieved with more invasive surgical procedures, according to the Radiological Society of North America.5,6 Varicocele embolization is safe, effective, and

1. Nonsurgical Treatment for Male Infertility Caused by Varicoceles: Highly Effective, Widely Available Treatment Is Underutilized. Society of Interventional Radiology. 2011. 2. Nonsurgical Treatment of Varicocele: A Monograph. Smith, SJ and Robert White Jr. 3. Varicocele. White, Wesley, Edward Kim and Joe Mobley. Medscape. eMedicine Specialties. 4. Varicocele. Cornell Institute for Reproductive Medicine. Cornell University Weill Medical College. 5. Varicocele Embolization. RadiologyInfo.org. Radiological Society of North America. 6. Beecroft, J Robert. Percutaneous Varicocele Embolization. CUAJ. Sept 2007. 1:3.

For the procedure, the femoral vein is accessed. A tiny catheter is fed through the inferior vena cava and down the testicular vein, and contrast is injected. A venogram is performed to show the extent of the problem and to confirm that reflux is present in the testicular vein. The venogram provides the map for performing the procedure. Rather than simply blocking one level of the vein, the embolization technique creates a kind of sandwich with coils and a sclerosant or embolizing agent. A coil is placed to block the flow at the bottom part of the vein, and then the sclerosant or embolizing agent is injected throughout the long length of the vein. In the middle, another coil is placed, then another long length of sclerosant or embolizing agent. At the very top, another coil is inserted. In that way, the entire vein is blocked to the point at

MARCH 2011

Cardiology

Atrial Fibrillation

Whatâ&#x20AC;&#x2122;s New in 2011?

By Andy C. Kiser, M.D., F.A.C.S., F.A.C.C., F.C.C.P.; and J. Paul Mounsey, B.M., B.Ch., Ph.D.

The development of combined epicardial and endocardial approaches to ablation of atrial fibrillation offers promise both to reduce the recurrence rate of atrial fibrillation and reduce the need for redo surgery. These are exciting times in the AFib world! Over the past 15 years, we have moved from the idea that definitive, catheter-based therapy to restore sinus rhythm was a distant goal to catheter ablation as a routine therapy offered in many centers on a daily basis. To be sure, success rates are not 100 percent, but in the majority of patients with atrial fibrillation (AF), catheter ablation, sometimes with adjuvant anti-arrhythmic drug therapy, results in sinus rhythm most of the time. Among the highly symptomatic patients who undergo invasive therapy, the symptomatic benefits of restoration of sinus rhythm can be life transforming. Encouraging clinical results, such as these, are pushing those of us in the field to embrace new technologies to enhance the success rate of surgery and make it available to a wider range of patients.

The Triangle Physician

The development of combined epicardial and endocardial approaches to ablation of atrial fibrillation offers promise both to reduce the recurrence rate of atrial fibrillation and reduce the need for redo surgery. This is because the instruments used to make epicardial lesions can make much longer burns on the surface of the heart than is possible with a catheter from inside the heart (figure 3), minimizing the number of burns necessary. Fewer burns means less overlap, reducing the chances for gaps to develop between the lesions.

Fig. 1. Endocardial isolation of the pulmonary veins

When the AF is persistent or if paroxysmal AF coexists with severe structural heart disease, most would advocate a more extensive ablation, with additional linear lesions and multiple isolated radiofrequency burns to sites where very rapid electrical activity is driving the arrhythmia (figure 2). Many of these patients will also require an antiarrhythmic drug to maintain sinus rhythm, at least in the medium term.

In modern cardiac electrophysiology practice, the ideal patient for catheter ablation is symptomatic from his or her arrhythmia and will have failed an anti-arrhythmic drug. The arrhythmia can be paroxysmal or persistent and, although arrhythmias of shorter duration have a higher success rate from ablation, length of time the patient has been out of rhythm is not critical in the decision process. The majority of patients with paroxysmal AF are well treated with a pulmonary vein isolation procedure (figure 1), where lines of radiofrequency burns are made encircling the pulmonary veins to isolate arrhythmogenic electrical activity within the veins. This isolation of potential AF triggers is usually sufficient to abolish the arrhythmia.

treated successfully with repeat catheterbased procedures, it would be far better if they could be avoided in the first place.

Fig. 3. Transabdominal laporoscopic epicardial ablation

Fig. 2. Endocardial catheter maze procedure

Epicardial AF surgery can now be done endoscopically using a minimally invasive transabdominal approach. Access to the pericardium is straightforward and many of the lesions required to ablate AF can be made. After completion of the epicardial lesion set, the operation can then be completed using a traditional endocardial catheter-based approach where areas inaccessible from within the pericardial space can be accessed and ablated.

These more extensive surgeries can be prolonged (up to several hours). Recurrences of arrhythmia are reasonably common (around 25 percent), principally because linear lesions develop gaps as the heart heals after surgery. Although recurrences can be

These hybrid procedures, where a cardiac surgeon and a cardiac electrophysiologist cooperate to treat the patient together, offer the prospect that the whole range of AF patients â&#x20AC;&#x201C; from those with simple paroxysmal AF to our most highly symptomatic patients

with the most severe structural heart disease – can be offered curative surgical therapy for their atrial fibrillation. Exciting times in the AF world indeed!

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Dr. Andy Kiser is a professor of surgery within the Division of Cardiothoracic Surgery and the University of North Carolina Center for Heart and Vascular Care. Dr. J. Paul Mounsey is a professor of medicine and director of the UNC Cardiac Electrophysiology Laboratory. Dr. Kiser, a native of Moore County, N.C., earned his bachelor of science and medical degrees at the University of North Carolina at Chapel Hill, and completed his training in both general surgery and cardiothoracic surgery at UNC. He practiced cardiac and thoracic surgery at Pinehurst until he joined the UNC Division of Cardiothoracic Surgery in November 2010. Dr. Kiser is recognized as an international leader in arrhythmia surgery, having pioneered paracardioscopic procedures to treat atrial fibrillation. He has expertise in minimally invasive valve and coronary artery surgery, performing valve procedures using only a threeinch incision. He also has extensive experience in the treatment of cancers and other disease processes that involve the lungs, esophagus and chest wall.

After undergraduate studies and research leading to a doctorate in cardiac electrophysiology at the University of London, United Kingdom, Dr. Mounsey attended the University of Oxford Medical School, UK. He completed an internship and residency at Oxford, and went on to complete a cardiology fellowship at the University of Newcastle, UK, and then a fellowship in cardiac electrophysiology at the University of Virginia. Dr. Mounsey served on the faculty of the University of Virginia from 1996 to 2007, before joining the University of North Carolina, where he directs the cardiac electrophysiology and pacing service. Although Dr Mounsey sees all kinds of patients with cardiac rhythm disorders and cardiac rhythm management devices, his main interest is catheter ablation of complex arrhythmias, including atrial fibrillation and ventricular tachycardia. He can be reached at (919) 966-4743 or pmounsey@med.unc.edu.

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MARCH 2011

Urology

Welcome to North Carolina:

The Stone Belt By Glenn M. Preminger, M.D.; Michael N. Ferrandino, M.D.; and Michael E. Lipkin, M.D.

It is estimated that nearly 1 in 8 men will suffer from kidney stone disease in their lifetime1 and the prevalence of kidney stone disease is on the rise. North Carolina, in particular, has one of the highest rates of stone disease in the country and this prevalence continues to increase. The economic impact of

The Triangle Physician

bowel disease or gout are at increased risk of forming kidney stones. Obesity is also a major risk factor for stone formation.3 Men with any of these risk factors should be considered for a metabolic work up to determine the cause of their kidney stones. Men in certain occupations, such as pilots or long haul truckers, should be considered for a metabolic work up, as well. The work up has evolved from a twoweek inpatient evaluation to a two-visit outpatient evaluation. At the first visit, blood chemistries are obtained, including a basic metabolic panel and uric acid levels. Patients then complete two 24-hour urine collections at home. The results of these tests are reviewed at the second visit. With these exams, an underlying cause for recurrent stones can be identified in approximately 95 percent of patients. Specific treatments are offered to reverse the causes of the patientsâ&#x20AC;&#x2122; stones. These treatments, which include dietary modification often in conjunction with medications, can reduce stone formation rates by up to 95 percent.4

kidney stone disease is enormous, costing an estimated $2.1 billion in health care expenditures in the United States in 2001.2

The surgical management of kidney stones continues to evolve, as well. Such minimally invasive treatments as shock wave lithotripsy (SWL) and ureteroscopy are performed as outpatient procedures. SWL can be used to treat stones less than 1.5 cm in the kidney. Ureteroscopy is used to treat stones in the ureter or smaller stones in the kidney.

Men with a history of kidney stones, a family history of stones and such medical conditions as diabetes, inflammatory

Advances in technology, such as digital flexible ureteroscopes and higher-powered lasers, have led to ureteroscopy surpassing

Dr. Preminger earned his medical degree from New York Medical College in 1977. After completing his urologic training at the University of North Carolina in 1983, he was an American Urological Association scholar for two years in the Division of Mineral Metabolism at the University of Texas (UT) Southwestern Medical Center, concentrating on the medical management of nephrolithiasis. He spent 10 years on the faculty in the Departments of Urology, Medicine and Radiology at UT Southwestern, Dallas. In 1993, Dr. Preminger returned to North Carolina as professor of urologic surgery, director of the Comprehensive Kidney Stone Center, and director of the Urology Residency Program at Duke University Medical Center.

treatment option. In the majority of patients, a nephrostomy tube is no longer left in place at the end of the surgery. Patients undergoing “tubeless” PNL have less pain and are able to leave the hospital sooner, usually the morning after their surgery. The evaluation and treatment of kidney stones is continually changing. For men who suffer from recurrent bouts of kidney stones, the cause can be determined and future stones can be prevented. When patients require surgical management for their stones, there are a number of highly effective and minimally invasive techniques.

References: 1. Curhan, GC. Epidemiology of stone disease. Urol Clin North Am, 2007. 34(3): p. 287-93. 2. Lotan, Y. and Pearle, MS. Economics of stone management. Urol Clin North Am, 2007. 34(3): p. 443-53. 3. Taylor, EN., Stampfer, MJ, and Curham GC. Obesity, weight gain, and the risk of kidney stones. JAMA, 2005. 293(4): p. 455-62. 4. Preminger, G.M., J.A. Harvey, and C.Y. Pak, Comparative efficacy of “specific” potassium citrate therapy versus conservative management in nephrolithiasis of mild to moderate severity. J Urol, 1985. 134(4): p. 658-61. 5. Preminger, G.M., et al., 2007 guideline for the management of ureteral calculi. J Urol, 2007. 178(6): p. 2418-34.

Dr. Ferrandino earned his medical degree from New York University School of Medicine in 2001. He completed his residency in urology at State University of New York Downstate Medical Center in 2007 and a fellowship in laparoscopy, robotics and endourology at Duke University Medical Center in 2009. Dr. Lipkin earned his medical degree from the University of Medicine and Dentistry of New Jersey, New Jersey Medical School in 2003. He completed an internship/ residency in urology at New York University Medical Center in 2009, and a fellowship in minimally invasive surgery and endourology at Duke University Medical Center.

SWL in efficacy for treating ureteral stones.5 The stone-free rates after ureteroscopic treatment of a ureteral stone is more than 90 percent. For larger stones or those that are refractory to shock wave lithotripsy, percutaneous nephrolithotomy (PNL) is the preferred Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

MARCH 2011

Orthopedics

The Aging Spine New Treatment Options

By Sameer Mathur, M.D.

Certain spinal pathology (spondylolisthesis and scoliosis) in the elderly population requires stabilization. New techniques have been developed to limit damage to the spinal muscles and minimize blood loss. As our aging population continues to grow at an exponential rate, health care professionals are obliged to anticipate and attend to their mounting medical needs. This is particularly important for the field of spinal surgery. It is estimated that during the next 25 years, the number of people older than 65 years of age will increase by 125 percent, to approximately 70 million people, with a doubling of those older than 85 years of age.

A new minimally invasive procedure called the X-STOP has revolutionized the treatment for spinal stenosis. The X-STOP device is placed in-between the spinous processes, preventing extension of the spine, which prevents compression of the nerves. This outpatient procedure is done under local anesthesia with minimal muscle disruption. Patients recover and return to normal activity much quicker.

The older patient must be differentiated from the typical younger patient in terms of atypical presentation, frailty from co-morbidities and inability to undergo extensive spinal surgery. This population trend has inspired the modern spinal surgeon to develop effective surgical options, with a focus on minimally invasive surgery, non-fusion treatments, motion preservation technologies, such as dynamic stabilization, and biologics. New minimally invasive surgical techniques have focused on lumbar spinal stenosis, compression fractures and lumbar fusions. Lumbar Spinal Stenosis Spinal stenosis occurs when there is narrowing of the spine resulting in compression of the spinal nerves. People present with back and leg pain that is worse with standing and walking, and relieved with sitting and bending forward. The traditional surgical approach involves wide lumbar decompression and possible fusion. Patients are in the hospital for several days and may suffer from chronic back pain. Furthermore, patients with multiple medical problems may not be candidates for general anesthesia.

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While the diagnosis can be suspected from history and physical examination, plain radiographs, as well as occasional computed tomography or magnetic resonance imaging, are often helpful in accurate diagnosis and prognosis. Traditional conservative treatment includes bed rest, pain control and physical therapy. When traditional therapy fails, kyphoplasty is a great treatment option. Kyphoplasty is accomplished via two small incisions at the level of the fracture. Cement is placed into the vertebral body utilizing a low pressure system that minimizes cement migration. This is done under local anesthesia, and the patient has immediate pain relief in the recovery room.

Spinal Compression Fractures Compression fracture of the vertebral body is common, especially in older adults. It is usually caused by osteoporosis and ranges from mild to severe. More severe fractures can cause significant pain, leading to inability to perform activities of daily living, and life-threatening decline in the elderly patient who already has decreased reserves.

Minimally Invasive Lumbar Spine Fusions Certain spinal pathology (spondylolisthesis and scoliosis) in the elderly population requires stabilization. New techniques have been developed to limit damage to the spinal muscles and minimize blood loss. Using a tubular retraction system with radiographic guidance we are able to fuse segments of the spine. The new retraction system does not violate the natural muscle

Dr. Sameer Mathur is a board-certified orthopedic spine surgeon. He completed medical school at the University of Pennsylvania. He finished his spinal reconstructive fellowship at Rush University Medical Center in Chicago, Ill. He, subsequently, conducted research at the National Institutes of Health and Dana-Farber Cancer Institute at Harvard Medical School. Dr. Mathur was assistant professor in the Department of Orthopaedic Surgery at the University of North Carolina-Chapel Hill. He was also the principal investigator on multiple research projects studying spinal cord injury and the genetics of scoliosis. He now practices at Cary Orthopaedic Sports and Spine Specialists.

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plains preserving anatomic muscle attachments. Fusion can be achieved from a posterior or lateral approach. These procedures allow for reduced operative time, reduced blood loss with minimal scarring, and reduced hospital stay and pain.

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

MARCH 2011

Financial Planning

Help! My 401(k) Is Terrible! By Paul J. Pittman, C.F.P.

Very few certified public accountants, and even fewer brokers, know about a little-known strategy to transfer funds from your 401(k) to an IRA while you are still working. In about 85 percent of meetings with new clients, I hear the same comment. “My 401(k) options are terrible; can I do anything about it?” The short answer is yes, but I will get to that in a moment.

called a non-hardship in-service distribution and allows you to accomplish just that. The Summary Plan Document (SPD) of your 401(k) outlines the guidelines for this to occur.

For 2011, if you are under age 50, you can defer $16,500 of your own income into a 401(k). If you are age 50 and above, you can defer an additional $5,500 “catch-up,” for a total of $22,000. This is your contribution. In addition, your company can also add up to a maximum total contribution of $49,000. For most people, this 401(k) is their major source of retirement savings.

Here is the good news: Most of you are the business owner and administrator of your own plan. If your plan does not specifically allow this kind of non-taxable distribution, you can add language that will allow it.

The vast majority of 401(k)s that I see look exactly alike; five to seven investment options made up of some stock funds, some bond funds and a fixed bucket. They are setup this way for two main reasons: 1) To keep it simple and manageable for the employer and employee, and 2) To satisfy the Employee Retirement Income Security Act of 1974 ( ERISA) guidelines to help cover the employer’s fiduciary liability. These platforms are cookie-cutter retirement plans mostly sold by brokers and mutual fund companies. While they do serve their purpose, they can be expensive (to the account holder and the administrator), and mediocre investment vehicles. So, what can you do to change this? Very few certified public accountants, and even fewer brokers, know about a little-known strategy to transfer funds from your 401(k) to an IRA while you are still working. This is

The Triangle Physician

This can be a fantastic option for you. The main reason I like this type of distribution is that most people come to me because they desperately need a solution that offers better investment options, diversification (without redundancy) and continued market participation. Few people truly understand how these plans work and the options available to them. Many 401(k) holders also failed to properly rebalance their account over time, and as a result, took a huge hit to their retirement accounts in 2008.

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

practice management. This means that the accountant, the attorney and the financial advisor all have to be on the same page and have an intimate knowledge of what it takes to have a successful, growing practice. When assembling this team, remember that these people work for you and should be concerned with one thing – taking care of you. Anyone can sell you an investment product and send out statements, but it takes a specialist to lead and coach you. It is my experience that simple “I Love You” wills, with a hodge-podge of retail investment products, does not make a sound fiscal and financial plan. Planning is an ongoing and ever-changing process. It is not an inoculation. I use the analogy of a piano tuner. This is a constant, gradual process, not a one-time fix.

For many of you, this retirement strategy would be very helpful and appropriate. Have you experienced significant volatility in your 401(k) account balance over the past several years? If “yes,” take the time to learn more about this strategy. If your advisor has not told you about this, have your office manager contact my office. I’ll be glad to review your SPD and tell you if this can be done.

Finances are not usually the most important aspects of our lives. You should hyperconcentrate on this several times a year, take care of them and then get back to wherever your passion lies, be it healing, curing, teaching a child how to throw a mean curveball or whittling that pesky handicap into the single digits.

My advice is to work with trusted financial professionals that specialize in physician

Until next happiness.

month,

good

health

and

Radiology Article

Update on MRI of

Greg Bortoff

Prostate Cancer By Greg Bortoff, MD

Other than skin cancer, prostate cancer is the leading cause of malignancy in American men and the second leading cause of cancer death. With a progressively aging population, it is estimated that the rate of prostate cancer will continue to rise. Therefore, it is vitally important to have a keen awareness of the disease and suitable means to detect and treat the disease. Currently, screening involves the digital rectal exam and laboratory analysis, specifically serum prostate specific antigen (PSA) levels. If indicated by abnormalities in one or both of these tests, an ultrasoundguided biopsy is then typically performed on the prostate gland. If cancer is detected at biopsy, the tumor is characterized by the TMN (tumor, metastasis, nodes) stage, the Gleason score and the PSA level. Results of these studies help to establish the optimal treatment strategy, namely watchful waiting, surgery, radiation therapy (of which there are various types), androgen therapy, chemotherapy or ablative therapy. Role of MRI The prostate gland is comprised of three zones: the transitional zone, the central zone and the peripheral zone. While magnetic resonance imaging (MRI) is able to detect tumors outside the peripheral zone, it has its highest sensitivity for tumor detection when the tumor involves the peripheral zone, from which the majority of prostate cancers arise (70-80%). MRI has been shown to increase the accuracy of staging of prostate cancer, particularly in the setting of intermediate or high probability of spread of the cancer beyond the gland. The exam is able to determine with relatively high accuracy whether the tumor is confined to the prostate gland, whether there is extracapsular extension beyond the gland, whether the tumor involves adjacent structures such as the neurovascular bundles, seminal vesicles, and bladder, whether there is pelvic lymphadenopathy, and whether there is

evidence of osseous metastatic disease in the pelvis. In addition, MRI may be useful in detecting suspected prostate cancer given a rising PSA or a palpable mass with negative biopsy results, i.e., a suspected false negative biopsy. MRI also provides useful anatomic information for pre-radiation therapy planning which allows more accurate targeting for radiation oncologists. Finally, it may provide useful information in the evaluation of the post-prostatectomy pelvis, e.g., in the setting of a rising PSA and suspected tumor recurrence. MRI Technique Standard MRI protocol for imaging of the prostate gland includes T1 and T2 weighted imaging in multiple planes, including thin

section imaging and small field of view. At our institutions, the majority of exams are performed without intravenous contrast. In addition, we have found the image quality of exams performed with the pelvic surface coil to be excellent and comparable to that obtained with the endorectal coil. Therefore, most exams at Raleigh Radiology are performed with the surface coil, which is much more comfortable for the patient. We offer the option of imaging in a high

· BS, Cornell University · MD, PhD, State University of New York Health Science Center at Syracuse · Resident in radiology, Wake Forest University Baptist Medical Center · Fellowship in abdominal imaging, Wake Forest University Baptist Medical Center · Member, Radiological Society of North America · Expertise in abdominal imaging, including MRI, MRA, ultrasound, oncologic imaging, and PET/CT · Joined Raleigh Radiology in 1999

field 1.5 T open bore scanner for patients who may be claustrophobic or have relatively large body habitus. We also offer IV Valium sedation for those patients who are severely claustrophobic over the age of 18. It has been established that the accuracy of interpretation of prostate MRI is improved when the studies are read by experienced body imaging experts. At Raleigh Radiology, prostate MRI exams are read by boardcertified radiologists with additional expertise in body imaging.

Conclusion MRI has proven to be a powerful tool in the evaluation of prostate cancer. With continued improvements in technology which are on the horizon, e.g., computer-aided detection (CAD) imaging – similar to what is currently used in mammography – stronger gradients, nanoparticles, and MR spectroscopy, to name a few, the contribution of MRI in the detection and staging of prostate cancer will very likely continue to grow. MARCH 2011

Gastroenterology

Colon Cancer Screening Update Sheds Light on Growing Concerns By Rig S. Patel, M.D.

Colorectal cancer is the second leading cause of cancer-related death for both men and women in the United States. It is estimated that in 2010, approximately 142,000 patients were diagnosed with colorectal cancer (CRC), and the disease caused 51,000 deaths. Worldwide, the incidence is approximately 1 million new cases, with 500,000 deaths per year with an expected 3040 percent increase by 2020. The lifetime risk of developing colorectal cancer is approximately 5 percent (1 in 19 in women and 1 in 20 in men). The overall disease survival continues to improve, particularly when diagnosed at an early stage. The five-year survival for early stage disease is approximately 90 percent; conversely the corresponding five-year survival for patients with known metastatic disease is 10 percent. CRC is potentially preventable in most individuals who undergo screening (by detecting and then removing colon polyps at colonoscopy), and potentially curable if found early. Unfortunately, although the CRC screening rate is increasing in the United States, only 40 percent of the eligible population is getting screened. Additionally, less than 40 percent of CRCs are found at an early stage. In other words, most cancers are being detected at later stages. Risk factors and screening types Several risk factors have been associated with CRC and are listed in Table 1. Identification of risk factors helps in guiding screening (when to start and frequency) and providing intervention guidelines to the patients (e.g., diet). The goals of CRC screening are to detect and remove precancerous polyps, and detect and diagnose CRC. Various options for CRC screening are listed in Table 2. Colonoscopy is the only modality that can remove polyps and diagnose (biopsy) cancers, and is regarded

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as the â&#x20AC;&#x153;gold standard.â&#x20AC;? Advancements in endoscope technology (e.g., high-definition video and narrow band imaging) have aided in the recognition of flat right-sided colon polyps, previously difficult to identify with other imaging techniques, and make colonoscopy a more attractive primary modality for screening. Timely screening effects both prevention and early detection. In addition, treatment for colorectal cancer has improved during the last several years. As a result of these combined measures, there are now more than 1 million survivors of colorectal cancer in the United States. New trends in CRC patients Age remains an important risk factor for developing CRC, and without screening, individuals older than 50 years are still at highest risk. Though the overall incidence of CRC has decreased (by 2.6 percent per year in men and 2.2 percent per year in women), the decrease being most evident in men over age 50 (likely due to screening), it has increased among young adults. Incidence rates among young adults ages 20 to 49 increased 1.5 percent per year in men and 1.6 percent per year in women from 1992 to 2005. Table 1: CRC Risk Factors Age: Incidence increases markedly at age 50 years, though the rate is increasing for younger, 20-to-40-year-old adults. Personal history of adenomas or prior CRC Personal history of inflammatory bowel disease Family history of colonic neoplasia (polyps or cancer) Inherited syndromes: e.g., familial adenomatous polyposis, Lynch syndrome, Turcots syndrome, Peutz-Jeghers syndrome) Racial/ethnic background: African Americans, Ashkenazi Jews Poor diet: Red /processed meat, low fiber/ fruits/vegetable intake, low calcium intake Physical inactivity Obesity Smoking Heavy alcohol use Diabetes

Dr. Rig Patel has been in private practice with Digestive Healthcare in Raleigh since 2001. He is currently an Adjunct Associate Professor of Medicine at the University of North Carolina, and serves as secretary of the North Carolina Society of Gastroenterology. He has served on local and national committees and is currently president of the medical staff at Rex Hospital. He is the medical director of the Endoscopic Ultrasound Program at Rex Hospital. Dr. Patel obtained his medical degree from the University of London, England. He completed his internal medicine residency through the University of Virginia. In addition to a three-year gastroenterology fellowship, he also completed a dedicated advanced endoscopy fellowship training program after being awarded a training scholarship from the American Society of Gastrointestinal Endoscopy. Before going into private practice, Dr. Patel was on the faculty (assistant professor of medicine/gastroenterology) at the Digestive Diseases Center at the Medical University of South Carolina for five years. During this time he practiced and taught clinical gastroenterology/advanced endoscopy. Dr Patel has co-authored several clinical research studies (more than 50 of which have been accepted for presentation or publication) and which include two Governors Awards for excellence in clinical research awarded by the American College of Gastroenterology. His current research and clinical interests are related to the benefits of endoscopic ultrasound in the community hospital settings and the endoscopic management/detection of cancer. Dr. Patel and his partners at Digestive Healthcare can be contacted at (919)791-2040 and www.dhcraleigh.com

Even more concerning, the largest annual percent increase in colon cancer incidence was in the youngest age group (20 to 29 years), in whom incidence rates rose by 5.2 percent per year in men and 5.6 percent per year in women. Tumors in this group were notably in the left colon and rectum. Proposed explanations for CRC in these

Table 2: Modalities for CRC screening Tests that detect adenomatous polyps and CRC: Colonoscopy: Regarded as the “gold standard” for detecting and removing polyps, but not 100 percent accurate Flexible sigmoidoscopy: Only examines the left colon. Barium enema Computed-tomography colonography: Not widely accepted (not covered by Centers for Medicare & Medicaid Service, or CMS), concerns about radiation exposure and missing flat or small lesions.) Tests that primarily detect CRC: Fecal Immunohistochemical tests (FIT): Should replace guaiac-based testing – some problems with standardization. Guaiac fecal occult blood tests: High false positive rate. Stool DNA: Problems with specificity and cost- not ready.

young individuals include lifestyle habits, particularly diet. Between the late 1970s and the mid-1990s, fast-food consumption in the United States increased five-fold among children and three-fold among adults. A diet high in fast food is associated with both greater meat and less milk consumption, and obesity. Increased consumption of red and processed meat and obesity have been associated with an increased risk of cancers of the distal colon and rectum. Clearly, this unexpected increase in left sided CRC in young individuals will require further investigation to identify other potential environmental and behavioral risk factors. What We Should Be doing Clearly CRC screening rates and education regarding prevention need to improve. A careful review of patients’ potential risk

factors (in addition to being older than 50 years) for CRC is essential, as well as patient education, particularly regarding risks, benefits, indications and various alternatives for CRC screening. Lifestyle measures (exercise, stopping smoking), healthy diet (reduce red meat and fat intake, increase intake of fruits/vegetables to five portions per day, fiber, and assure adequate calcium intake), should also be discussed. This should be emphasized with patients who have children, so they realize the significance of a “healthy household diet” in reducing morbidity in the next generation of 20 to 40 year olds. Of note, based on recent data suggesting an increase in CRC in young adults, there should be a higher level of suspicion for colorectal pathology (and earlier investigation) when these young adults present with lower

gastrointestinal symptoms, including minor bleeding. We should also be educating patients on identifying and reporting suspicious symptoms (bleeding, change in bowel habit, pain, weight-loss anemia). Additionally, identifying asymptomatic patients who should be screened prior to the age of 50 years (e.g. African Americans at age 45 years, patients with a family history of colonic neoplasia or personal history of inflammatory bowel disease, family history suggestive of an inherited cancer syndrome and possibly some obese patients and heavy smokers) should not be overlooked. Prevention and early detection is the key to reducing both the incidence and mortality of CRC. References: 1. Chao et al. Meat Consumption and Risk of Colorectal Cancer. JAMA 2005;293:172-82. 2. Siegel et al. Increase in incidence of colorectal cancer among young men and women in the United States. Cancer Epidemiol Biomarkers Prev. 2009;18:1695-1698. 3. Levin B et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008;134:1570-1595. 4. Rex et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008 Am J Gastroenterol 2009;104:739-750.

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MARCH 2011

News Welcome to the Area

Physicians Nzingha Jaunita White, DO Family Practice University of North Carolina Hospitals Chapel Hill

Paula Clark Adkins, MD Emergency Medicine Pinehurst

Cary Frederick Bizzell, MD Carolina Radiology Consultants Wilson

Steven Robert Breault, MD Diagnostic Radiology Morrisville

Tara Chandrasekhar, MD Psychiatry University of North Carolina Hospitals Chapel Hill

Christine Marie Drower, MD Family Medicine Duke University Hospitals, Durham

Erikka Daniene Dzirasa, MD Psychiatry Duke University Hospitals Durham

Timothy Ryan Heacock, MD Internal Medicine Duke University Hospitals Durham

Tyler Scott Jorgensen, MD Internal Medicine University of North Carolina Hospitals-Emergency Medicine, Chapel Hill

Margaret Jackson Kihlstrom, MD

Clinical Trials Matthew Robert Paszek, MD Rocky Mount Urology Associates, PA Rocky Mount

Shawn Christopher Patterson, MD Emergency Medicine University of North Carolina Hospitals Chapel Hill

Elias Joseph Sayour, MD Pediatrics Duke University Hospitals, Durham

Rodney Kevin Sessoms, MD Internal Medicine Clinton

Christa Shea, MD Neurology Duke University Hospitals, Durham

Bryan Dorsey Smith, MD Psychiatry 106 Watertree Ln, Apex

Andrew Brian Smitherman, MD Internal Medicine University of North Carolina Hospitals Chapel Hill

UNC Hospitals Chapel Hill

Graham Warner Lyles, MD Ophthalmology University of North Carolina Hospitals Chapel Hill

Daniele Marin, MD Radiology Duke University Hospitals Durham

Timothy Paul Moran, MD Pediatrics University of North Carolina Hospitals Chapel Hill

Terel Newton, MD Anesthesiology University of North Carolina Hospitals Chapel Hill

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Gastroenterology Stomach Ulcers Wake Research Associates Charles F. Barish, MD Currently screening Have you suffered from a heart attack or stroke and take 325 mg of aspirin daily to prevent another from occurring? If so, Wake Research is conducting a research study of an investigational medication that combines aspirin with a second medication to see if It can help prevent stomach ulcers. You’ll receive investigational medication and study-related exams at no cost and compensation up to $500 for time and travel. 8/5/10

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

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Pain Medicine for Shingles

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Little Is Big To Us.

BRENT A. TOWNSEND, MD | Pediatric Radiologist

CATHERINE B. LERNER, MD | Pediatric Radiologist

LAURA T. MEYER, MD | Pediatric Radiologist

Wake Radiology is the first radiology practice in Raleigh to open a dedicated pediatric outpatient imaging center. Four fellowship-trained, pediatric radiologists have created a child-friendly environment for your young patients who range from a few days of age to eighteen years old. Our pediatric radiologists are all subspecialty trained and are keenly aware of the unique challenges that your pediatric patients present. Because children are more sensitive to radiation than adults, we strive to use the smallest doses of radiation possible that will still provide diagnostic images and offer experienced guidance in selecting the most appropriate imaging modalities for your patient. Wake Radiology Pediatric Imaging. Deliverying the finest care for your smallest patients.

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