N o v e m b e r 2 0 11
Carolina Vein Center Treating Tired, Achy, Heavy and Swollen Legs
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
Chronic Venous Disease
Introducing Protecta™ XT
CRT-D, DR and VR ICDs with SmartShockTM Technology
Fewer Shocks. Greater Living. The only ICD with SmartShock technology that dramatically reduces the incidence of inappropriate shocks while maintaining sensitivity.1,2
With Protecta XT, 98% of ICD patients are free of inappropriate shocks at 1 year and 92% at 5 years.*2 Changes in a patient’s disease and/or medications may alter the efficacy of a device’s programmed parameters or related features. * Primary prevention patient programmed for detection rate cut off at 188 bpm.
References
Protecta Clinical Study, Medtronic data on file. 2 Volosin KJ, Exner DV, Wathen MS, et al. Combining shock reduction strategies to enhance ICD therapy: A role for computer modeling. J Cardiovasc Electrophysiol. Published online October 11, 2010. 1
Brief Statement Indications: The Protecta™ XT CRT-D system is indicated for ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias and for the reduction of the symptoms of moderate to severe heart failure (NYHA Functional Class III or IV) in those patients who remain symptomatic despite stable, optimal medical therapy and have a left ventricular ejection fraction less than or equal to 35% and a prolonged QRS duration. Atrial rhythm management features such as Atrial Rate Stabilization (ARS), Atrial Preference Pacing (APP), and Post Mode Switch Overdrive Pacing (PMOP) are indicated for the suppression of atrial tachyarrhythmias in ICD-indicated patients with atrial septal lead placement and an ICD indication. The Protecta DR and VR system is indicated to provide ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias in patients with NYHA Functional Class II/III heart failure. The Protecta DR is also is indicated for use in the above patients with atrial tachyarrhythmias, or those patients who are at significant risk of developing atrial tachyarrhythmias. Atrial rhythm management features such as Atrial Rate Stabilization (ARS), Atrial Preference Pacing (APP), and Post Mode Switch Overdrive Pacing (PMOP) are indicated for the suppression of atrial tachyarrhythmias in ICD-indicated patients with atrial septal lead placement and an ICD indication. Additional Protecta XT DR System Notes: • The ICD features of the device function the same as other approved Medtronic market-released ICDs. • Due to the addition of the OptiVol® diagnostic feature, the device indications are limited to the NYHA Functional Class II/III heart failure patients who are indicated for an ICD. • The clinical value of the OptiVol fluid monitoring diagnostic feature has not been assessed in those patients who do not have fluid retention related symptoms due to heart failure. • The use of the device has not
been demonstrated to decrease the morbidity related to atrial tachyarrhythmias. • The effectiveness of high-frequency burst pacing (atrial 50 Hz Burst therapy) in terminating device classified atrial tachycardia (AT) was found to be 17%, and in terminating device classified atrial fibrillation (AF) was found to be 16.8%, in the VT/AT patient population studied. • The effectiveness of high-frequency burst pacing (atrial 50 Hz Burst therapy) in terminating device classified atrial tachycardia (AT) was found to be 11.7%, and in terminating device classified atrial fibrillation (AF) was found to 18.2% in the AF-only patient population studied. Additional Protecta XT VR System Notes: • The ICD features of the device function the same as other approved Medtronic market-released ICDs. • Due to the addition of the OptiVol diagnostic feature, the device indications are limited to the NYHA Functional Class II/ III heart failure patients who are indicated for an ICD. • The clinical value of the OptiVol fluid monitoring diagnostic feature has not been assessed in those patients who do not have fluid retention related symptoms due to heart failure. Contraindications: The Protecta XT CRT-D, DR and VR system is contraindicated for patients experiencing tachyarrhythmias with transient or reversible causes including, but not limited to, the following: acute myocardial infarction, drug intoxication, drowning, electric shock, electrolyte imbalance, hypoxia, or sepsis. The device is contraindicated for patients who have a unipolar pacemaker implanted. The device is contraindicated for patients with incessant VT or VF. Contraindications specific to Protecta XT CRT-D and DR: The device is contraindicated for patients whose primary disorder is chronic atrial tachyarrhythmia with no concomitant VT or VF. Contraindications specific to Protecta XT VR: The device is contraindicated for patients whose primary disorder is atrial tachyarrhythmia. Warnings and Precautions: Changes in a patient’s disease and/or medications may alter the efficacy of the device’s programmed parameters. Patients should avoid sources of magnetic and electromagnetic radiation to avoid possible underdetection, inappropriate sensing and/or therapy delivery, tissue damage, induction of an arrhythmia, device electrical reset, or device damage. Do not place transthoracic defibrillation paddles directly over the device. Additionally, for CRT-ICDs, certain programming and device operations may not provide cardiac resynchronization. Potential Complications: Potential complications include, but are not limited to, rejection phenomena,
erosion through the skin, muscle or nerve stimulation, oversensing, failure to detect and/or terminate tachyarrhythmia episodes, acceleration of ventricular tachycardia, and surgical complications such as hematoma, infection, inflammation, and thrombosis. 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 these devices to sale by or on the order of a physician.
www.medtronic.com World Headquarters Medtronic, Inc. 710 Medtronic Parkway Minneapolis, MN 55432-5604 USA Tel: (763) 514-4000 Fax: (763) 514-4879 Medtronic USA, Inc. Toll-free: 1 (800) 328-2518 (24-hour technical support for physicians and medical professionals)
UC201003400 EN © Medtronic, Inc. 2011. Minneapolis, MN. All Rights Reserved. Printed in USA. 05/2011
www.medtronic.com
JOHNSTON MEDIC AL CENTER Clayton A Healthier tomorrow begins today
JOHNSTON MEDIC AL CENTER Clayton
A H e a lt h i e r tom or r o w b e g i n s today
Contents
COVER STORY
6
Carolina Vein Center
Improved Leg Treatments Renew Quality of Life
n o v e m b e r 2 011
FEATURES
14
Orthopedics
Causes and Treatment of Anterior Knee Pain
V o l . 2 , I s s u e 11
16
DEPARTMENTS 13 Radiology
Your Financial Rx
Putting Paul in the Hot Seat, Part II
Dr. Derek Reinke points to the importance
Financial planner Paul Pittman offers more
of identifying the source of knee pain in
insight in the continued conversation with
successful non-surgical treatment.
The Triangle Physician.
Raleigh Radiology Opens New Cary Center, Expands Diagnostic Services in Brier Creek
21 UNC Research News AIDS Viruses Found in Cerebrospinal Fluid of Patients with HIV Dementia
22 UNC Research News Grant Targets Use of Services by Younger Breast Cancer Patients; International Study Discovers Common Genetic Contributions to Mental Illness
24 UNC Research News Missing Monocyte May Link to New Rheumatoid Arthritis Treatments
25 UNC Research News Researcher to Help Lead New Esophageal Cancer Network
26 Duke Research News Three Factors Could Point to a Patient’s Fate after Surgery
26 Regional News Hospitals Earn Cardiology Achievement Award
27 Practice News Medical day spa opens; medical director named; Burlington practices moves
28 News Welcome to the Area, Clinical Trials, editorial calendar
2
The Triangle Physician
Do Heavy Periods
Uterine Fibroids
associated with
Affect You?
Consider Volunteering for a Clinical Research Study Uterine fibroids symptoms can affect any woman, anytime, anywhere. If you’re at least 20 years old and have heavy periods associated with uterine fibroids, you may qualify for this oral investigational medication study. As a participant, you will receive all study-related care and investigational medication at no cost. If uterine fibroids affect your life, consider volunteering.
919-251-9223 • www.fibroidstrial.com Volunteer Today • 1-000-000-0000 Women's Dr. First and LastWellness NameClinic • Site Name www.cwrwc.com
From the Editor
Gratitude
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
When you talk with the patients of Dr. Lindy McHutchison, you can’t help but be touched by how greatly the medical treatment of this phlebotomist impacted their lives. They are so, very thankful. It is often the case that divine intervention – the phone book, referrals by other patients – gets the credit for leading patients suffering from venous disease to Carolina Vein Center, this month’s cover story in The Triangle Physician. Hopefully, greater awareness among physicians about the realities of varicose veins, of phlebotomy as an emerging
Editor Heidi Ketler, APR
heidi@trianglephysician.com
Contributing Editors Paul Pittman, C.F.P. Derek Reinke, M.D. Photography Jim Shaw Photography jimshawphoto@earthlink.net
specialization and of the availability of insurance coverage will make specialized treatment more accessible to those in need.
Creative Director Joseph Dally
There is no denying the symptoms of venous disease, which are regularly cited by
Advertising Sales Carolyn Walters carolyn@trianglephysician.com Natalie Snapp natalie@trianglephysician.com
Dr. McHutchison and bear repeating: tired, achy, heavy, tender, crampy, itchy, painful,
jdally@newdallydesign.com
restless, burning and tingling. There is no need for a patient to negotiate life’s challenges with this added physical burden, knowing how easily it can be resolved under the specialized care of Dr. McHutchison, a phlebotomist who wields her expertise with compassion. Also in this issue of The Triangle Physician, we continue an interview with certified financial planner Paul Pittman, whose clients have expressed gratitude for his adept understanding. Likewise, one can imagine the gratitude of patients treated by orthopedic surgeon Derek Reinke, who shares with us the causes and treatment of anterior knee pain. As we prepare for a new year, only two months away, we remind you of the marketing power of advertising in The Triangle Physician. We offer a targeted, elite market, the medical community of the great Raleigh-Durham medical triangle. Every month, we reach more than 9,000 physicians, physician assistants, nurse practitioners, administrators and hospitals. As always, we are grateful for all you do. You will be in the minds of many this Thanksgiving. May you experience the joy of the season, as well. As always, our gratitude for all you do!
News and Columns Please send to info@trianglephysician.com
The Triangle Physician is published by: New Dally Design 9611 Ravenscroft Ln NW, Concord, NC 28027 Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401 Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. 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.
Heidi Ketler Editor
4
The Triangle Physician
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
Carolina Vein Center
Improved Leg Treatments Renew Quality of Life L
eg symptoms that affect a person’s
Affordable Quality Healthcare and American
disease (CVD) is a medical problem, most
quality of life can be caused by disease,
Osteopathic Association. Phlebology is
insurance companies, including Medicare,
varicose veins under the skin. Treatment is
dedicated to the diagnosis, treatment and
will cover the evaluation and treatments.
more effective and less invasive than ever,
study of venous disease, which afflicts 80
yet most don’t realize it’s a medical problem
million Americans or approximately 20
Phlebologist Lindy McHutchison, M.D., of
and covered by most insurance companies,
percent of the adult population. Since most
Carolina Vein Center spends considerable
which leaves thousands to suffer needlessly.
venous disease occurs in leg veins, most
time educating the public and medical
phlebology practices primarily take care of
community about CVD and advances in
Phlebology is one of the newest fields of
legs. Phlebologists treat both the medical and
treatment. Her patients, like Toney Chavis,
medicine recognized by the American
cosmetic (spider veins) aspects of venous
a 66-year-old retired electrician, become
Medication Association, North Carolina
disease. What’s important for physicians
enthusiastic ambassadors.
Medical
and patients to realize is – if chronic venous
national
Council
for
PHOTO BY JIM SHAW PHOTOGRAPHY
Board,
Dr. McHutchison and Tatiana review ultrasound findings of a leg vein
6
The Triangle Physician
He was reluctant to pursue treatment, worried that it would be similar to the experience his sister had, vein stripping the “old-fashioned” way. She had the big visible scars to prove it. “I didn’t want to have it done like my sister had it done. I didn’t want to get cut with a knife,” he says. Then, he reached a point where he’d “do anything to get rid of this pain. They really were hurting.” His physician suggested he go to a “vein doctor.” It was good fortune that Carolina Vein Center was near the top of the list, Mr. Chavis says. Locating feeder veins under the skin with a vein light.
From the start, Dr. McHutchison helps ease the patient’s fears through education. During the initial consultation, patients watch a video to learn the basics on the causes and treatments of medical varicose veins and cosmetic spider veins – and the remarkably quick improvement that results. “I found out treatment could be done without pain and large incisions,” says Mr. Chavis.
Pathophysiology of Chronic Venous Disease Varicose veins are a progressive problem that develops when damaged or abnormal valves in the leg veins allow blood to flow retrograde (backwards) down the leg instead of toward the heart. This retrograde flow is called venous reflux. By the end of the day
Closed feeder vein with sclerotherapy injection.
or with long standing, blood pools in the leg Mr. Chavis’ case sets the record straight on a
Mr. Chavis struggled for two years with tired,
number of varicose vein myths.
achy legs that would swell at the end of the
Fact: Varicose veins affect men, as well as women. Fact: Classic varicose veins typically manifest as bulging leg veins, but most problematic, diseased veins are under the surface of the
day. His primary care physician recommended running cold water on them and elevating them, but that didn’t help, he says. Despite taking over-the-counter pain medicine at bedtime, leg pain would wake him up.
veins, causing vein walls to distend, further valvular damage and the typical symptoms: legs that are tired, achy, heavy, tender, crampy, itchy, painful, restless, burning and tingling, and night cramps. Genetics is the No. 1 factor causing varicose veins. The greater this genetic tendency
skin undetectable to the naked eye. Fact: Varicose veins can cause discomfort and greatly impact one’s quality of life. Fact: Modern treatment is minimally invasive and effective at eliminating diseased veins
Symptoms of Chronic Venous Disease Tired, achy, heavy, tender, crampy, itchy, painful, restless, burning, tingling and night cramps.
and associated symptoms.
november 2011
7
Late Physical Signs of Chronic Venous Disease Hyperpigmentation, venous stasis, bulging varicose veins, venous ulcers, swelling, inner ankle and spider veins.
The two main roots or trunks of the superficial venous system are the great and small saphenous veins. “If venous disease is present, you must treat the abnormal, diseased saphenous veins first,” explains Dr. McHutchison, “Otherwise it’s like cutting the
the sooner it will happen. Pregnancy and
is responsible for the late phase physical
female hormones are large contributors
findings in CVD
grass without treating the roots.”
explains why women are three times more
Superficial Saphenous Vein System
Duplex Ultrasound Is Gold Standard in Leg Vein Reflux Evaluation
likely than men to have varicose veins. Jobs
There are two venous systems in the leg.
Duplex ultrasound, the gold standard for
that require prolonged standing and/or
The deep vein system is critical. It is a paired
diagnosis of venous disease, typically
sitting add increased risk, as well.
system with veins and arteries together and
is performed in the office during initial
drains the blood in the leg back to the pelvis.
consultation
The superficial venous system is outside the
ultrasound technician.
(progesterone
causes
smooth-muscle
relaxation, dilating vein walls), which
Fact: Varicose veins affect men, as well as women.
by
a
qualified
venous
muscle and lies under the skin. It is not a paired system and has no named arteries
The duplex ultrasound performs two
associated with it. It is essentially a reservoir,
functions. First, it determines if there is
so if the veins in the superficial system are
healthy flow or reflux in the saphenous veins.
venous
not functioning properly, these veins can be
Secondly, it “maps” the location and size of
hypertension. This increased pressure in the
eliminated and won’t affect critical blood
the saphenous veins, other contributing
leg veins leads to tissue inflammation and
flow in the leg.
veins and/or associated abnormal branches.
Venous
reflux
also
Toney Chavez Before
8
The Triangle Physician
causes
Toney Chavez After
The scan is vital in establishing an accurate
“Phlebology
diagnosis, which is the only way to assure
advanced
the most effective treatment of varicose
knowledge of venous disease,” says Dr.
veins. These veins, when abnormal and
McHutchison “Now we use ultrasound to
Treatments Options
refluxing, are usually the root of most venous
evaluate veins. Treatments are performed in
Treatments for CVD are individually tailored
disease medical problems.
the clinic setting and many patients return to
to the extent and severity of the specific
“Although Toney did have some visible bulging varicose veins, his main problem
has
evolved
technology
and
because
of
increased
work directly after their treatment with little or no down time.”
Maria Vartanian Before
was caused by diseased saphenous veins that were under the surface of the skin, but not obviously visible,” says Dr. McHutchison.
Fact: Classic varicose veins typically manifest as bulging leg veins, but most problematic, diseased veins are under the surface of the skin undetectable to the naked eye. Medical insurance carriers are increasingly recognizing the need for phlebologic treatments and most insurance policies offer benefits for vein procedures. Topics related to venous disease are appearing in record numbers in medical journals and medical
textbooks.
Greater
awareness
Maria Vartanian After
among physicians is enabling them to make knowledgeable phlebology referrals and to educate patients on the ranges of treatment available. In the past (prior to 2002), only those with the most severe varicose veins underwent vein stripping by vascular surgeons. Stripping was painful, required hospitalization, general or regional anesthetic, had a prolonged recovery and usually resulted in permanent scarring. A major leap came in 2002 with FDA approval of laser technology to treat the saphenous veins in an outpatient setting. It opened the door to treating less severe cases with simple, office procedure.
november 2011
9
Peter Wintz Before
leg elevation, nonsteroidal anti-inflammatory
or close. Occasionally, ultrasound is used to
drugs and avoiding hot baths, which dilate
help guide the needle into deeper veins. The
leg veins. Most insurance companies require
solution used is safe, says Dr. McHutchison,
at least a three-month trial of documented
and the procedure is relatively painless, so
conservative therapy before approving any
no anesthesia or sedation is needed
definitive treatments. “To me it was the most simple thing I ever
Definitive Treatments
saw in my life,” says Mr. Chavis. “I felt no pain
Definitive treatments permanently close and/
when she did it, just a little needle prick to
or eliminate the diseased veins by rerouting
numb the area. After she finished, she gave
the blood to other healthier existing veins.
me ibuprofen, but I never took it.”
These treatments include endovenous laser ablation, phlebectomy and sclerotherapy.
Contrary to the old-fashioned regimen of bed rest after vein treatment, patients today
Peter Wintz After
Fact: Varicose veins can cause discomfort and greatly impact one’s quality of life. Endovenous laser ablation is a simple, minimally invasive office treatment. Instead
Carolyn Rushing Before
of removing the saphenous vein, it is sealed closed and left in place. A small laser fiber is inserted into the damaged vein. Heat energy via the laser is delivered inside the vein, essentially “melting” the vein walls closed. This procedure is done in-office under local anesthesia. Following the procedure a bandage or compression stocking is placed on the treated leg. Patients are able to walk immediately after the procedure, and most individuals are able to return to work and usual activities the same or following next day. Ambulatory phlebectomy is a method of condition. Often, a combination of options
removing bulging varicose veins in the skin.
is used. Usually treatment(s) begin with
It is also usually performed in the office
“conservative” therapy. If symptoms persist
under local anesthesia. A small 2-3mm
after three months of conservative therapy,
puncture is made next to the varicose vein
definitive treatments are then considered
and a tiny hook is used to hook the varicose vein and extract it. The punctures typically
Conservative Therapy
leave nearly imperceptible scars. After the
Conservative treatments are usually simple
vein has been removed by phlebectomy, a
that a patient can do at home. This involves
bandage and/or compression stocking is
any activity that helps drain the blood from
worn for a short period.
the veins and relieves the pressure from venous congestion and pooling.
Sclerotherapy is a treatment to close a vein via injections. Sclerosants are liquids or foam
Conservative therapy includes the use of
injected into the diseased vein that irritate
therapeutic compression stockings, exercise,
the vein wall and cause the vein to shrink
10
The Triangle Physician
Carolyn Rushing After
are instructed to walk as much as possible after treatment, and they usually return to their usual daily activities. A compression bandage or stockings are worn for short periods after all treatments to assist in healing and reduce any mild discomfort or swelling that may occur. According to Dr. McHutchison, patients typically return for one or two postprocedure visits to assess the efficacy of treatment and evaluate the patient’s healing response to the therapy. Often, additional sclerotherapy, with or without ultrasound guidance, is performed to ensure the best long-term results.
Maria Vartanian and Dr. Lindy McHutchison “Dr. McHutchison is the most beautiful
“I feel very good. I sleep well. I’m walking.
doctor, personality-wise. She’s real good. I
I introduce everybody I can to Lindy
was really shocked how well my treatment
McHutchison. I enjoyed her service.”
was done.”
Fact: Modern treatment is minimally invasive and effective at eliminating diseased veins and associated symptoms.
Peter Wintz Maria Vartanian
Peter presented with severe bilateral leg
“When Maria Vartanian came to my clinic,”
edema, hyperpigmentation and venous
recalls Dr. McHutchison, “She was afraid she
stasis. He had been treated numerous times
was going to loose her legs because of the
for “cellulitis” and complained the “cellulitis
way they looked and felt.”
episodes were getting worse and closer together,” says Dr. McHutchison.
“My legs were awful,” says Maria Vartanian, 82, a retired seamstress from Brazil. Her
After treatment of his CVD, his swelling
varicose veins surfaced 10 years ago.
is significantly improved, his “cellulitis”
Expressions of Gratitude
episodes
Patients are more than eager to share
After her treatment at Carolina Vein Center
their stories of how Dr. McHutchison used
January through May 2011, she is thrilled.
have
resolved
and
the
hyperpigmentation has faded considerably.
her expertise and kind manner to end their suffering from the pain of varicose veins. They leave her Carolina Vein Clinic with a deep sense of gratitude, and they recommend her whenever possible. Toney Chavez Today, the pain that kept Mr. Chavis from the golf course and diminished the quality of his once-active life is a distant memory. “When I finish cutting the grass at my house, I don’t have to put my feet up in the air. I don’t have any pain. None! My legs feel great; they look great. I played 18 holes of golf yesterday.” “According to Toney, I messed up his golf game,” adds Dr. McHutchison. “He told me because his legs don’t hurt anymore, he now hits every golf ball 20 yards farther with each club and hits over the green.”
Toney Chavez
Peter Wintz
november 2011
11
Carolyn Rushing
located Carolina Vein Center in the phone
“Carolyn came to us in tears from her leg
directory. “From the minute I walked in
pain,” says Dr. McHutchison. “She had a
there, I was so glad. Lindy’s whole medical
large, painful, venous ulcer on her leg which
staff just makes you feel so good. They are
was made worse from standing in one spot
very caring.” Treatment resulted in a “night-
as a cashier.”
and-day improvement,” says Ms. Rushing.
“It is only because of Dr. McHutchison
She also found Dr. McHutchison’s father,
that I am able to work today,” says Carolyn
Don Burt, M.D., a retired orthopedic surgeon,
Rushing, 68. Prior to her treatments six
endearing. He now works at Carolina Vein
months ago, she was about to quit her job
Center, greeting patients and making them
as a full-time Walmart cashier because of the
feel comfortable. “He is such a dear, dear
pain. “I was having terrific problems with my
person and really an asset to the practice.”
legs, with severe varicose veins. After (Dr. McHutchison) completed my procedures, I
“Dr. McHutchison is a model doctor. I wish
am able to stand eight hours a day.”
all doctors were like her,” says Ms. Rushing, adding, “I’d like to express my deepest
She considers herself fortunate to have
heartfelt gratitude to her and her team.”
Carolyn Rushing
Dr. Lindy McHutchison (center) is surrounded by her staff. Together, they make a closely knit, compassionate, professional patient care team.
12
The Triangle Physician
Radiology
Raleigh Radiology Announces the opening of two new imaging centers in Cary and Brier Creek Expanded Services in Brier Creek In addition, Raleigh Radiology will expand services at our Brier Creek facility, located at 8851 Ellstree Lane, just off I-540, and minutes from RTP, Durham and Morrisville. The center will offer digital mammography, CT, bone density testing, ultrasound (including vascular studies) and walk-in X-ray services. MRI services will be added at a later date. A private women’s imaging suite will be offered, enhancing privacy and comfort for patients. Procedures performed will include mammograms, DEXA screenings and ultrasound services.
New Diagnostic Center in Cary Raleigh Radiology will open its newest full-service, state-of-the-art digital diagnostic facility in Cary on November 15 in the heart of Cary at 150 Parkway Office Court near the intersection of Tryon Rd and Cary Parkway. The 14,000-square-foot diagnostic center will combine the care you’ve learned to trust from our Women’s Imaging Center, located at 550 New Waverly Place, and our Raleigh Radiology Cary facility, located at 251 Keisler Drive, into one premium, convenient, and patient-friendly facility. The fully digital diagnostic center will offer the first in-house fixed 1.5 T Open Bore MRI in the Cary area, which along with available IV sedation, will better serve the needs of the community, including those with claustrophobia. Our private women’s imaging suite, which has been especially designed for privacy and comfort, will offer screening and diagnostic mammograms, breast ultrasounds and bone density screenings. Our 16-slice CT scanner allows us to perform a variety of procedures, such as CTA’s for pulmonary embolism and CT lung screenings, in addition to routine exams.
All Brier Creek technologists are certified by the American Registry of Radiologic Technologists. Additionally, our ultrasound technologists are vascular certified, enabling us to provide additional circulatory system services at this location. As an added convenience, our Brier Creek facility offers ample, welllit, ground-level parking located directly in front of the building. Raleigh Radiology is an active community member of Brier Creek and surrounding areas, and we are a proud sponsor of Relay for Life, Brier Creek Play For Pink and Susan G. Komen Race For the Cure. We are proud of our extensive expertise and enhanced access to outpatient imaging care at our Cary and Brier Creek facilities. They are a perfect option for our patients and referring physicians in the surrounding communities.
Patients and referrers, alike, will be pleased with our great appointment availability and ease of scheduling. As an added benefit, results are guaranteed in 24 hours or less. We file most insurance and have self-pay plans available, as well. To schedule an appointment today call 919-877-5400 for our Brier Creek facility and 919-781-1437 for our Cary facility.
A board-certified musculoskeletal (MSK) radiologist will be onsite to perform orthopedic procedures with increased availability and convenience. Free Wi-Fi, spacious private men’s and women’s waiting rooms and a friendly staff are some of the amenities designed to enhance our patients’ experience, while obtaining the imaging critical to their health care.
november 2011
13
Orthopedics
Causes and Treatment of
Anterior Knee Pain By Derek Reinke, M.D.
It is a common situation in our practice
that is worse when going up and down stairs
number
to have a young athlete complain of pain
(more often down stairs). Running up and
chondromalacia patella or patellofemoral
in the anterior aspect of his or her knee.
down hills will have the same painful effect.
syndrome. The most common cause of
The patient will often tell us that this pain
Often getting out of a car or up from a movie
this condition is excessive pressure on the
came on slowly over time, and they do not
seat after sitting for a long period of time
articular surface of the lateral facet of the
remember any specific injury to the knee
will cause pain in the front of the knee. A
patella. The patella may experience up to
in question. This type of complaint often is
sensation of catching, locking or grinding in
three times more body weight going up or
categorized under the heading of “anterior
the front of the knee often accompanies this
down stairs so that this is a frequent cause
knee pain.�
pain.
of pain. In patients with malalignment
of
different
names
including
issues in the lower extremity this pressure may be even higher. It is not always clear
Recognizing if the source of the pain is related to the patellofemoral joint or external to the joint is important in treatment.
anatomically however why some athletes are affected by this disorder while others are not. Patellofemoral
Classically, the patient will tell us that they
Anterior
have significant pain in the front of the knee
patellofemoral joint is referred to by a
14
The Triangle Physician
knee
pain
related
to
the
treatable
symptoms
without
surgery.
are
usually
Contributing
factors may be relative weakness of the
Dr. Derek Reinke is a board-certified orthopedic surgeon. He completed medical school at the Medical College of Ohio, Toledo, Ohio, and finished a fellowship program in sports medicine at the Cincinnati Sports Medicine & Orthopaedic Center, Cincinnati, Ohio. Dr. Reinke is the team orthopedist for the Apex High School football program and practices at Cary Orthopaedic & Sports Medicine Specialists. He can be reached at (919) 467-4992 or by visiting www.caryortho.com.
and landing. Rather than acute inflammation,
Anterior knee pain is common in both the
the pathology involves degeneration of the
athlete and the non-athlete. Recognizing
tendon from microtears within the tendon
if the source of the pain is related to the
and attempted healing of the injury.
patellofemoral joint or external to the joint is important in treatment. Initial treatment is
Treatment
activity
usually non-operative in either situation and
modification or a period of rest, and the use
usually
involves
in the majority of cases this is successful.
of anti-inflammatories and patellar straps.
Therapy emphasizing strengthening and
Surgery is rarely needed in chronic cases to
flexibility, as well as a period of rest, is
remove part of the diseased tendon.
usually beneficial.
quadriceps muscles as well as tightness of the hamstrings. More recently the importance of strong hip musculature also has been recognized. Knowing the contributing factors to this problem allows us to develop a treatment plan.
Non-operative
treatment
involves
strengthening the muscles while avoiding exacerbation of the symptoms. Formal physical therapy is helpful to achieve this except in the mildest of cases. Closed-chain exercises, such as squats and those using the leg press machine, are employed. Open-chain exercise, such as those using the leg extension machine, should be performed carefully as these may exacerbate symptoms by placing higher shear stress on the articular surface. Physical therapy can also help to increase the flexibility of the quadriceps, hamstrings and iliotibial band, as well as strengthen the hip muscles. Surgery may at times be necessary. This may be done to treat the damaged articular surface or to address alignment problems involving the lower extremity and patellofemoral joint. Patella tendinitis is another frequent cause of anterior knee pain. It is called “jumper’s knee� because it is often seen in basketball and volleyball players. It may be caused by repetitive stress to the tendon from frequent acceleration and deceleration or jumping Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
november 2011
15
Your Financial RX
Putting Paul in the Hot Seat, Part II By The Triangle Physician
I want to know what they value most in life. What drives them. What principles guide their decisions. What they ultimately want to achieve in life. What their mission is in life and their vision for the future.
Any broker can look at a current portfolio and put together one that would have beat it. That is the row boat mentality; always looking where you have been. If a prospective client goes over our in-depth recommendations and it mirrors what they are already doing, then they don’t need us. I do run across financial advisors who do a great job. TTP: Do they get your recommendations in a nice leather-bound jacket with their name on it?
This month, The Triangle Physician continues
Paul: No, to the review; yes, to an analysis of
Paul: All of the planning and management
its interview with Paul Pittman, a certified
their financial picture.
that we do is tracked and reflected in real-
financial planner and regular contributor to
time, live and updated every day. They have TTP: No? What do you mean?
their own encrypted website to view all of
Paul: I don’t need to see all of the individual
their assets and planning in one place. Go
TTP: Readers have said, on numerous
holdings and investments that they currently
to our website (www.pcgnc.com) and click
occasions, that they knew they wanted to
own. Contrary to some popular beliefs, what
on “Physicians” on the left side of the page
work with you within minutes of talking
you currently own really has no bearing
to see what I am talking about. Many years
with you. Why do you think that is?
on my recommendations as to where you
ago we used those leather-bound folders,
Paul: Wow! That’s very nice to hear. I guess
need to be going forward. I’m going to put
but I noticed that it then sat on the client’s
I attribute it to a few different things. One,
together a complete analysis of where they
bookcase and six months later all of the
when they walk into my office, they see a
stand now and what they need to do to get
information was outdated and irrelevant.
team of people in a relaxed atmosphere,
where they want to be. If they have disability
This way, all parties are constantly in touch,
all working together for our clients. The key
or life insurance, we are going to review
current and can see the entire financial
word is “together,” because each person
it to make sure it accomplishes what it is
picture in a few minutes, in one place. Let
here has their own unique specialty. It’s not
intended, but I don’t need to see that they
me say this, all of their assets do not need
closed door after closed door of brokers
own 14 mutual funds and 12 stocks. I only
to be with me to see this. They can be and
hammering out daily phone-call quotas to
need to know the overall values, what they
usually are in many different places.
sell the mutual fund of the day. Secondly,
are putting away regularly and if it is qualified
once we sit down in my office, most of the
or non-qualified.
this column.
conversation is me listening to them talk. We
TTP: You have a very different approach and philosophy when it comes to money,
have usually had a conversation, or two, on
TTP: That sounds pretty simple.
don’t you?
the phone before now, and they are pleased
Paul: It only sounds simple. A tremendous
Paul: That’s an understatement! I don’t
to hear that I sound like I know what I am
amount of work behind the scenes goes into
want to just know that a person has “x” and
talking about.
putting together recommendations and a
wants to retire with “y” in so many years. I
plan of action. And this takes time. This can
want to know what they value most in life.
TTP: Do you put together some sort of
only be accomplished properly if I have full
What drives them. What principles guide
review and analysis for them?
knowledge and access to their information.
their decisions. What they ultimately want to
16
The Triangle Physician
NEWSOURCE-JUN10:Heidi
Paul 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.
8/5/10
12:57 PM
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achieve in life. What their mission is in life and their vision for the future. Only then can I guide them to their “true wealth.”
newsource & Associates
TTP: Sounds unique! Paul: It keeps me energized. How often do you hear that someone actually loves what they do?
Page 1
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november 2011
17
North Carolina Tradition Thrives at Beaver Pond Sporting Club B
eaver Pond Sporting Club L.L.C., less
open fields offer a diverse range of habitats,
than an hour from the Raleigh-Durham
from sorghum fields to native grass areas to
Triangle, in the historic community of Snow
thick brush. The European-style shooting
Camp., is more than a place to visit; it’s a
tower and clay range are state of the art.
place to belong. With three menus, the five-stand clay range Sporting
the
is perfect for a casual round of shooting
distractions of modern life and reconnect
game
enthusiasts
forget
or a spirited shooting match among
with their instincts. Many members are drawn
friends, practice for an upcoming hunt or a
to the thrills that made them outdoorsmen in
challenging course for the serious shooter.
the first place. Others experienced them for
A unique open/covered porch design gives
the first time here.
shooters the option of shooting in or out of the elements.
“Our Clay Range Is as Fine as They Come.”
“Our clay range is as fine as they come,” says
shot can be set up with the push of a button.
Beaver Pond Sporting Club offers year-round
owner Johnny Miller. “It is a great asset to
It offers right and left crossers, incoming
opportunities to hunt and target practice. The
our shooting instruction because almost any
targets, a tower shot, a rabbit and a wobble trap.” Typically, a five-stand sporting range is configured for each shooter to have five shots from each of the five shooting stations, creating the standard 25 shot round. Five stand simulates hunting because, in the course of firing 25 shots, you never shoot the same shot twice.
“Wingshooting …Is Challenging and Exciting for Any Sportsman.” “Wingshooting, classic southern hunting that involves shooting at pointed birds over dogs, is challenging and exciting for any
18
The Triangle Physician
sportsman,” says Johnny. “Quail and chukar are the favorites.” This hunt style for upland game bird is best for one to three people. It is offered full service, with guides and bird dogs provided, or can be self guided. Driving pheasants, involving groups of people flushing ring necks from field cover with retrievers, is a guided-only hunt. “It is a great option for families and small corporate teams,” says Johnny. “The large amount of acreage available makes it comparable to
firewood mingles with roasting
any plains hunt.”
chickens, game birds, pork shoulders or oysters on the grill.
European-style tower shooting is a semi-
Outside the lodge is a large covered
stationary hunt that is fun for all ages and
The main sitting area with a huge stone
patio area with a stone fireplace, another
abilities. It involves 10 or more shooters
fireplace, and leather chairs and couches is
great place where stories … some true …are
rotating around a 40-foot tower. Birds are
comfortable for large groups. There’s a big-
told and retold. So is “Frank’s Shed,” which
released from the tower and reach maximum
screen TV for ball games and a convenient
also is the bird-cleaning area, tool shop
wing speed by the time they are overhead. A
bar. The kitchen, with tables and a wood
and refreshment center at Beaver Pond,
regularly scheduled pheasant tower shoot is
stove, is large enough to service a big party.
according to Johnny.
The Pro Shop offers everything one
Join the Fun and Excitement
might need but forgot, including clothing,
Beaver Pond Sporting Club is open year
Accommodations Are Great for Sleepovers and Storytelling
accessories, rental guns and shells. Down
round. Hours of operation are Tuesday
the hall are the bedrooms and baths. “With
through Saturday 9 a.m. to 6 p.m.
Beaver Pond’s Whippoorwill Lodge is an
trips, members can enjoy it for a half day, a
During hunting season – from Oct. 1 to
inviting retreat, where the aroma of burning
day or a week,” says Johnny.
March 31 – hunting opens a half hour before
offered the first Saturday of each month from November through March.
bedrooms and a bunkhouse for overnight
sunrise and closes at sunset. This year, dove season is split into three segments. The first segment was from Sept. 3 to Oct 8. The second segment is from Nov. 21-26 and the final segment is from Dec. 17 to Jan. 13. Possession limit is set at 30 doves per hunter. See what makes Beaver Pond Sporting Club a premier destination. Spend time in the fields behind the dogs. Try your luck on a big largemouth in the pond. Sit by the stove and savor true contentment. Give us a call at (336) 376-1200 or visit beaverpondnc.com online.
november 2011
19
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UNC Research News
AIDS Viruses Found in Cerebrospinal Fluid of Patients with HIV Dementia When the virus that causes AIDS infects the
demonstrated active replication of HIV virus
Dr. Swanstrom said. “But no one has ever
central nervous system, it can lead to the
in a cell type other than T cells,” said study
brought the two together in a way that makes
development of a severe neurological disease
senior author Ronald Swanstrom, Ph.D.,
sense and could give you a tool to evaluate
called HIV-associated dementia.
professor of biochemistry and biophysics and
what’s going on in the brain by looking at
director of the UNC Center for AIDS Research.
cerebrospinal fluid.”
therapy, or HAART, has helped reduce HIV-
During their own clinical investigations,
The
associated dementia (HAD). But some studies
Dr.
collaborators,
macrophages present in a CSF sample two
show that HAART may not offer complete
neurologists Richard R. Price, M.D., and
years before the patient was diagnosed with
protection from less severe HIV-associated
Serena Spudich, M.D., at the University of
dementia. Dr. Swanstrom said this tells us
neurological problems, nor might it always
California, San Francisco, had been collecting
there’s information in the CSF that potentially
help to reverse it. As people live longer with
blood and CSF samples from patients who
could predict disease progression. “Is it bad
AIDS, their risk of developing neurological
had either HIV-associated dementia or other
to have these viruses around even if you don’t
problems may increase.
severe neurological defects. Samples were
get a diagnosis of dementia? And are they
The advent of highly active antiretroviral Swanstrom’s
current
study
also
found
HIV-infected
collected with written informed consent from
potentially causing cognitive damage that can
New research for the first time may have
the patients’ families. These were the samples
be reversed with HAART?”
pinpointed a possible explanation for the
used for the current study. To explore these and other questions,
problem, one that also might help predict “After the start of therapy, we looked at the
Dr. Swanstrom and Dr. Price of UCSF will
rate at which the virus disappeared,” Dr.
collaborate again under a five-year, $3
Scientists led by researchers from the
Swanstrom said. “We know that HIV in the
million grant from the National Institute of
University of North Carolina at Chapel Hill
blood disappears quickly when you go
Mental Health to expand the research in
School of Medicine have discovered that
on therapy, and that’s because the virus is
HIV patients who don’t have dementia and
some people diagnosed with HAD have
growing in T cells, which have a very short
are starting therapy. The new study will look
two genetically distinct HIV types in their
half-life.” Infected T-cells decay by half every
for biomarkers in the CSF in the form of HIV
cerebrospinal fluid (CSF). What’s more, these
one to two days
variants or other immune protein information
who is at greatest risk for HAD.
that may predict improvement, stability or
variants are not detected in HIV circulating
decrease in cognitive capacity during therapy.
in the blood, and one of them could be
But for half of the patients in the new study,
present years before the onset of dementia.
HIV growing in the cerebrospinal fluid
The detection of these viruses in the CSF
decayed very slowly, several weeks to one
People infected with HIV sometimes delay
is evidence that they are growing in the
month. “This is evidence the virus is actually
going on HAART, Dr. Swanstrom said. “Our
central nervous system, according to a UNC
being produced by a cell with a longer half-
research will help further understand what’s
announcement.
life, and not a T-cell,” Dr. Swanstrom said.
going on in the central nervous system of patients who are still alive and in tissue that’s
In a study published Oct. 6 in the journal
The researchers also found that the slow-
accessible in the clinical setting, i.e. CSF. If
PloS Pathogens one of the two HIV variants
decaying HIV had a particular tropism to
these individuals knew there was an AIDS
found in CSF reproduces in immune system T
macrophages and were able to infect them.
virus replicating independently in their CNS, it might affect their decision when to start
cells, as does the virus growing in the blood.
treatment with HAART.”
But the other type does not. It infects and
“Those viruses are known to exist in autopsy
replicates in macrophages, another white
brain studies. It has been known for 10 years
immune cell that engulfs and digests foreign
that a subset of HIV-infected patients have
In the new project, Dr. Swanstrom’s UNC team
material, including bacteria.
slow decay of the virus in the CSF, and it’s
will include Joseph J. Eron, M.D., professor of
also been known for a long time that you can
medicine and director of the UNC Center for
find macrophage-tropic virus in the brain,”
AIDS Research Clinical Core; Kevin Robertson,
“This is the first time that anyone has
november 2011
21
UNC Research News Ph.D., clinical psychologist in the department
Coauthors with Drs. Swanstrom, Price and
fellow at the UNC Lineberger Comprehensive
of neurology; and Angela Kashuba, Pharm.D.,
Spudich (who is now at Yale University)
Cancer Center.
associate professor of the Eshelman School
include first author Greta Schnell, PhD,
of Pharmacy and director of the UNC Center
former UNC graduate student, and now at the
The research was supported by the National
for AIDS Research Clinical Pharmacology and
University of Washington School of Medicine
Institute of Mental Health and the National
Analytical Chemistry Core.
in Seattle, and Sarah Joseph, postdoctoral
Institute of Allergy and Infectious Diseases.
Grant Targets Use of Services by Younger Breast Cancer Patients A project to improve use of supportive care
According to UNC Health Care, many women
The study is designed to provide information
services for younger women who have breast
do not take full advantage of the broad
needed to modify existing systems or create
cancer has received a grant of more than
spectrum of support services through its
alternative systems that facilitate assessment
$780,000 from the Centers for Disease Control
Comprehensive Cancer Support Program,
of patients’ needs and utilization of needed
and Prevention.
such as genetic counseling, psychological
support services, according to Dr. Marks,
counseling, survivorship services, nutrition
who also studies process improvement in the
counseling and smoking cessation services.
health care setting. “The goal is to be both
“Younger women – those under 45 – who have breast cancer have a set of concerns that
more effective and efficient.”
may differ in certain ways from those of other
Dr. Marks, who is also a member of UNC
cancer patients,” said Lawrence Marks, M.D.,
Lineberger Comprehensive Cancer Center,
Other members of the research team include
chair of the department of radiation oncology
will be working with a team of colleagues to
Deborah
Mayer,
and the project’s principal investigator.
define the gap between the needs of patients
F.A.A.N.;
Thomas
in this group and their actual use of beneficial
Rosenstein, M.D.; Jean Sellers, R.N., M.S.N.,
“They may also have concerns about genetic
support services. They will perform a
O.C.N.; and Marianne Jackson, M.D. Dr.
factors, the long-term effects of anti-cancer
survey and a formal assessment of existing
Jackson, who is relatively new to UNC, has
therapies, or worries about how to change
procedures (using the “Lean Methodology”
specialized training in operations efficiency
their lifestyle to positively influence their future
central to the Toyota production system)
and the application of “Lean” methods to the
health. They are also at a stage of life where they
to identify barriers that keep health care
health care setting.
may be building their careers, raising children
providers from working with these patients.
Ph.D., Shea,
R.N., M.D.;
A.O.C.N., Donald
or facing other challenges,” said Dr. Marks.
International Study Discovers Common Genetic Contributions to Mental Illness A team of more than 250 researchers from
The findings, reported by the Psychiatric
“This is the largest study of its kind by
over 20 countries have discovered that
Genome-Wide Association Study Consortium
far,” said Patrick F. Sullivan, M.D., Ray M.
common genetic variations contribute to a
and published online Sept. 18 in two papers
Hayworth & Family distinguished professor
person’s risk of schizophrenia and bipolar
in the journal Nature Genetics, represent
of psychiatry and professor of genetics at
disorder.
significant advances inbunderstanding the
the University of North Carolina at Chapel
causes
Hill. Dr. Sullivan, a Psychiatric Genomics
The study of more than 50,000 adults ages 18
of
these
chronic,
severe
and
debilitating disorders.
Consortium (PGC) coordinator and principal investigator in the study, is also a member of
and older provides new molecular evidence that 11 DNA regions in the human genome
Also known as a whole genome association
the UNC Lineberger Comprehensive Cancer
have strong association with these diseases,
study, a genome-wide association study
Center and the Carolina Center for Genome
including six regions not previously observed.
examines all or most of the genes of different
Sciences.
The researchers also found that many of these
individuals to see how much the genes vary
DNA variants contribute to both diseases.
from individual to individual.
The study that focused on schizophrenia identified “strong evidence for seven different
22
The Triangle Physician
UNC Research News places in the human genome, five of which were new and two previously implicated, that contain DNA changes that are significantly associated with schizophrenia,” Dr. Sullivan said. And in a joint analysis of a schizophrenia and bipolar disorder sample, the consortium found three different DNA regions, or loci, in which both disorders reached genome-wide statistical significance. “This tells us that these disorders, which many of us have considered to be separate things, actually share fundamental similarity,” Dr. Sullivan said.
Managing your patients’ health is your life’s work. Managing physicians’ wealth is mine. Financial Rx for Physicians: • • • • •
Aiding Wealth Creation, Preservation and Protection Business Management Tax-strategies Liability Protection Asset Preservation
Trust your wealthcare to a specialist. Schizophrenia and bipolar disorder are common
and
often
devastating
brain
disorders. Some of the most prominent symptoms in schizophrenia are persistent delusions,
hallucinations
and
cognitive
problems. Bipolar disorder (or manicdepressive illness) is characterized by episodes of severe mood problems, including mania and depression. Both affect about 1 percent of the world’s population and usually strike in late adolescence or early adulthood.
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Despite the availability of treatments, these illnesses are usually chronic, and response to treatment is often incomplete, leading to prolonged disability and personal suffering. Family
history,
which
reflects
genetic
inheritance, is a strong risk factor for both schizophrenia and bipolar disorder, and it has generally been assumed that dozens of genes, along with environmental factors, contribute to disease risk. “The consortium is the largest research consortium ever in psychiatry and is certainly the largest biological experiment we’ve ever done in the field,” Dr. Sullivan said. “We are studying on the order of 90,000 individuals across multiple disorders, while trying to do something for the greater good, which is effectively to go as far and as deep as we can in understanding the genomics of mental illness.” The research was supported by numerous European, United States and Australian funding bodies. Funds for coordination of the consortium were provided by the National Institute of Mental Health in Bethesda, Md.
november 2011
23
UNC Research News
Missing Monocyte May Link to New Rheumatoid Arthritis Treatments An estimated 1.3 million people in the United States suffer from rheumatoid arthritis. The causes behind this chronic disease have eluded scientists for centuries.
response is responsible, at least in part, for the increased disease severity,” said Dr. Liu. Inhibiting the activities of Th17 cell, therefore, may be a promising new direction for drug treatments for rheumatoid arthritis.
A new study by University of North Carolina researchers offers tantalizing glimmers about the roles of a gene called CCR2, an immune system cell called Th17 cell and a missing monocyte. The study contributes to a better understanding of the disease mechanism and has implications to guide the clinical trial strategy, said lead researcher Peng Liu, M.D., Ph.D., research assistant professor at the UNC Thurston Arthritis Research Center. Her team’s findings were reported online in PLoS One on Oct. 4. The mystery began several years ago when arthritis researchers zeroed in the CCR2 gene. CCR2 is highly expressed in the joints of patients with rheumatoid arthritis, which led researchers to believe it might contribute to the disease. “Scientists thought that if you inhibited CCR2 you would have a beneficial effect,” said Dr. Liu. “But actually, the result was the opposite.” Studies revealed that suppressing CCR2 in fact cannot ameliorate joint inflammation. In some cases, it leads to disease exacerbation.” Intrigued, Dr. Liu and her team used mice to investigate how CCR2 affects immune system cells. The immune system is critical because rheumatoid arthritis is an autoimmune disease, in which the immune system attacks the body’s own tissues, causing inflammation. They found the smoking gun when they looked at a type of immune cell known as Th17 cell. Arthritic mice without the CCR2 gene produced three times the amount of Th17 cells, increasing the inflammation in their joints. “We found that an enhanced Th17 cell
24
The Triangle Physician
The team also found that a particular type of monocyte (a type of white blood cell) disappeared from certain tissues in the mice without CCR2. They hypothesize that the CCR2-expressing monocyte plays an important regulatory role, so without the monocyte, Th17 cells proliferate. “The potential link between CCR2 and the Th17 cells is the monocyte subset,” said Dr. Liu. “This subset of monocytes may have a suppressive function in autoimmune disease.”
However much you value wildlife conservation in North Carolina,
The finding opens the door to new treatment possibilities, such as injecting this monocyte subset into patients with rheumatoid arthritis. “Finding this monocyte may be important for later development of cell-based therapy,” said Dr. Liu. Other collaborators from the UNC Thurston Arthritis Research Center include Teresa Tarrant, M.D.; Alan Fong, Ph.D.; Rishi Rampersad; Christopher Vallanat; Tatiana Quintero-Matthews; and Michael Weeks. Additional collaborators include Denise Esserman, Ph.D., from the UNC Department of Medicine and UNC Department of Biostatistics; Jennifer Clark of the UNC Department of Biostatistics; and Franco Di Padova, M.D., and Dhavalkumar Patel, M.D., Ph.D., of the Novartis Institutes for Biomedical Research, Switzerland. Support for the research comes from the North Carolina Translational and Clinical Science (NC TraCS) Institute, home of the UNCChapel Hill Clinical and Translational Science Award (CTSA); the Arthritis Foundation; and the National Heart Lung and Blood Institute.
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UNC Research News
Researcher to Help Lead New Esophageal Cancer Network A University of North Carolina at Chapel Hill researcher is one of five co-principal investigators in a new collaborative network created to study genetic determinants of Barrett’s esophagus and esophageal adenocarcinoma. Nicholas J. Shaheen, M.D., M.P.H., professor in the UNC School of Medicine, adjunct professor in the UNC Gillings School of Global Public Health and director of the UNC Center for Esophageal Diseases and Swallowing, will co-direct these Barrett’s Esophagus Translational Research Network (BETRNet) projects. The BETRNet is funded by a $5.4 million grant from the National Institutes of Health. The other co-principal investigators of this BETRNet consortium are Amitabh Chak, M.D., professor of medicine at the Case Western Reserve University School of Medicine (CWRU); Sanford Markowitz, M.D., Ph.D., Ingalls professor of cancer genetics at the CWRU School of Medicine; Nathan A. Berger, M.D., Hanna-Payne professor of experimental medicine at CWRU; Robert C. Elston, Ph.D., professor of epidemiology and
biostatistics at CWRU; and Dr. William Grady, professor of medicine at the University of Washington and Fred Hutchinson Cancer Research Center. “Collaborations such as these between basic and translational scientists and clinical researchers will be essential to unravel the complex interplay between environmental and genetic influences on cancer development,” said Dr. Shaheen. Roy C. Orlando, M.D., Mary Kay & Eugene Bozymski and Linda & William Heizer distinguished professor of gastroenterology and adjunct professor of cell and molecular physiology at UNC, is also a member of the BETRNet faculty. Although the rate of many common cancers has declined in recent years, the rate of esophageal cancer has increased greater than six-fold over the past three decades. The prognosis for this cancer remains poor, accounting for over one in 50 adult male cancer-related deaths. Though Barrett’s esophagus, a precursor
of esophageal cancer, can be easily recognized at endoscopy, current medical strategies of performing endoscopy based on the close association of Barrett’s with chronic heartburn in adults are inadequate, according to a UNC announcement. It reports that nearly 40 percent of patients who develop esophageal cancer have no preceding symptoms of heartburn, and most people with heartburn never have endoscopy. Less than 5 percent of cancers are diagnosed at an early stage in patients whose Barrett’s was recognized prior to cancer diagnosis. The BETRNet projects include discovery of genes that cause Barrett’s esophagus to run in certain families, genes that become targets of DNA methylation in Barrett’s and in esophageal cancers, and genes that are either turned on or turned off in Barrett’s esophagus and in esophageal cancers. The overall aims of the network are to develop new methods of identifying individuals at risk for Barrett’s esophagus, early detection of Barrett’s and esophageal cancers, and monitoring Barrett’s esophagus to recognize when it is likely to progress to cancer.
CARY ORTHOPAEDIC Spine Specialists • Epidural Steroid Injections • Acupuncture • Discograms • Spinal Cord Stimulator Trials • Microdiskectomy • Lumbar fusion • X-Stop (spine stenosis) • Kyphoplasty (compression fractures) Our Spine Specialists center employs highly experienced and skilled physiatrists as well as an accomplished Spine Surgeon. This combination of services allows a “total approach” to the health and well being of our patient population.
1110 SE Cary Pkwy, Cary, NC 27518
919-297-0000 Fax 919-232-5328
1005 Vandora Springs Rd., Garner, NC 27529
919-779-3861
www.caryortho.com
Fax 919-779-3234
november 2011
25
Duke Research News
Three Factors Could Point to a Patient’s Fate after Surgery Duke University Medical Center researchers
“The take-home message is that physicians
Risk was even high in one of the “double
have verified data that suggest three medical
who learn about this triple-low set of factors
low” groups: if a patient had low MAC and
factors correlate with mortality for a patient
should be alert to the needs of such a
low BIS values, the risk of death in the first
who has been under anesthesia for an
patient after surgery and watch for potential
year after an operation remained significant.
operation.
problems or avoid the triple-low combination
Anesthesiologists are the first-line doctors
in the first place,” said Dr. Tong J. Gan,
who monitor patients closely and would see
The risk of death was 2.5 times higher during
M.D., Duke professor of anesthesiology
these values in patients during surgery.
the first year after surgery if a patient has low
and lead author of the study presented at
values in all three measures, called a “triple
the American Society of Anesthesiologists
“This new information is likely to spur
low,” compared to patients whose values are
meeting in Chicago on Oct. 19.
interest in conducting research into avoiding
all normal.
the combination of factors to potentially The researchers conducted this study
The three factors are the median arterial
because they had seen small studies that
pressure
(MAP),
median
improve patient outcome,” Dr. Gan said.
anesthetic
indicated these values had predictive power,
Other researchers on the study include Mark
concentration (MAC) and the bispectral
and wanted to look at data from a much
Newman, M.D., chair of the Duke Department
index (BIS). The BIS is a complex
larger sample. They studied data from nearly
of Anesthesiology, and William White, Ph.D.,
mathematical algorithm that measures the
20,000 patients who underwent procedures
Betsy Hale, B.S., Eugene Moretti, M.D., all of
effects of anesthetic drugs on the brain and
that weren’t related to heart disease. Even
the Duke University Medical Center.
tracks a patient’s level of sedation.
after adjusting for patient age and patient risk profile, the findings held up.
Regional News
Hospitals Earn Cardiology Achievement Award Several Triangle hospitals were among the 167
To receive the ACTION Registry–GWTG Gold
hospitals nationwide to earn the American
Performance Achievement Award, recipients
College of Cardiology Foundation’s NCDR
consistently
ACTION Registry–GWTG Gold Performance
guidelines
Achievement Award for 2011.
for eight consecutive quarters and met a
Foundation
followed in
ACTION
the
outcomes for our patients.”
treatment
ACTION Registry–GWTG is a partnership
Registry–GWTG
between the American College of Cardiology and
the
American
Heart
performance standard of 85 percent for
Association with partnering support from the
The are Duke University Hospital, Duke
specific performance measures. Guidelines
American College of Emergency Physicians,
Raleigh Hospital, Durham Hospital, Rex
monitor drug safety and the overall quality
Society of Chest Pain Centers and the Society
Hospital, WakeMed Cary Hospital and
of care provided to ST-elevation myocardial
of Hospital Medicine. ACTION Registry-
WakeMed Raleigh Campus.
infarction (STEMI) and non-ST-elevation
GWTG empowers health care provider
myocardial infarction patients (NSTEMI).
teams to consistently treat heart attack
The award recognizes a hospital’s commitment
patients according to the most current,
and success in implementing a higher
“These awards reflect our commitment to
science-based guidelines and establishes
standard of care for heart attack patients, and
excellent cardiac care throughout a patient’s
a national standard for understanding and
signifies that it has reached an aggressive goal
entire experience,” says Michael Komada,
improving the quality, safety and outcomes
of treating these patients to standard levels
M.D., F.A.C.C., interventional cardiologist
of care provided for patients with coronary
of care as outlined by the American College
at Durham Regional. “Heart attack patients
artery disease, specifically high-risk STEMI
of Cardiology/American Heart Association
receive seamless, streamlined care, from
and NSTEMI patients.
clinical guidelines and recommendations.
first contact to discharge, resulting in better
26
The Triangle Physician
Regional News
Medical Day Spa Opens The Medical Day Spa of Chapel Hill has opened at 109 Conner Drive, suite 2202,
nail technicians. Contact Medical Day Spa of
he was awarded the Terry Kane Award for
Chapel Hill at (919) 904-7111 or visit online at
Excellence in Clinical Family Medicine.
www.chapelhilldayspa.com. Ms. Wiest is a certified adult nurse
Street and the 15-501 Bypass. It was formed
Medical Director Appointed
from the idea that corrective, therapeutic
David B. Tsai, M.D., has joined Rex Primary
and highly effective treatments need not be
Care of Holly Springs as the new medical
performed in a cold, medical environment.
director and began seeing patients Oct. 10.
Chapel Hill, NC 27514 – between Franklin
practitioner. She earned her nursing degree at Virginia Commonwealth University and
Nurse practitioner Melanie Lyn Wiest, A.N.P.Medical Day Spa of Chapel Hill combines
B.C., joined the practice Nov. 1.
her master’s in nursing science from the University of North Carolina. Previously, she was a clinical nursing instructor at UNC Health Care for 10 years. Rex Primary Care of Holly Springs is located
a serious approach to skin and body care with a welcoming environment focused on
Dr. Tsai is a board-certified family physician
customer service. It is designed to appeal
with experience practicing family medicine
to men and women seeking goal-oriented
with Duke Primary Care, Austin Regional
procedures, while enjoying the powerful
Clinic and Kaiser Permanente of Hawaii.
benefits of relaxation and stress reduction.
He also brings a rich knowledge of sports
at 208 Village Walk Drive, suite C140, Holly Springs, NC 27540. Call (919) 552-8911 or visit online at rexhealth.com.
medicine, having completed a sports
Burlington Practice Relocates
The management team consists of two
medicine fellowship at Duke University
The Burlington, N.C., practice of Lynde
physicians, a quality assurance coordinator
Medical Center.
Knowles-Jonas, M.D., has relocated. As of Sept. 1, Grace Women’s Clinic is now
and three registered nurses, one specializing in infection control. They are joined by two
Dr. Tsai earned his medical degree from
located at 2280 South Church St., suite 201,
licensed paramedical estheticians with more
Temple University School of Medicine
Burlington, NC 27215. Call (336) 538-2014 or
than 40 years of combined experience,
and his residency in family medicine at
visit online at www.gracewomensclinic.com.
certified massage therapists and licensed
Duke University Medical Center, where
The Medical Day Spa of Chapel Hill
november 2011
27
News Welcome to the Area
Physicians Sam Adams, MD Orthopaedics Duke, Durham
John Joseph Paat, MD Internal Medicine Duke University Medical Ctr., Durham
Alejandro Paya, DO
Brian Arthur Kessler, DO Fuquay-Varina
Duke Raleigh Hospital Raleigh
Terence Duane Rhodes, MD
Alejandro Paya, DO DUHS, Raleigh
Ramon Bataller Alberola, MD UNC Hospitals, Chapel Hill
William Tate Bradford, MD Anesthesiology University of NC Hospitals, Chapel Hill
Hematology and Oncology, Internal Medicine Duke University Hospitals, Durham
Marc Spencer Richards, MD Internal Medicine University of North Carolina Hospitals Chapel Hill
Rachel Reilly, MD Orthopaedics Duke, Durham
Daniel Robert Breazeale, MD Atrium Obstetrics & Gynecology Raleigh
Matthew Steven Chin, MD Diagnostic Radiology University of NC Hospitals, Chapel Hill
Kathryn Watson Cobb, MD Anesthesiology University of North Carolina Hospitals Chapel Hill
Lee Diehl, MD Orthopaedics Duke, Durham
Domenick Joseph Roma, MD Internal Medicine University of North Carolina Hospitals Chapel Hill
Lewis Arthur Rosenberg, MD Radiation Oncology University of North Carolina Hospitals Chapel Hill
Katherine Alison Scott, MD Emergency Medicine University of North Carolina Hospitals Chapel Hill
Eric Devon, MD Psychiatry University of North Carolina Hospitals Chapel Hill
Achilles John Fakiris, MD Rex/UNC Radiation Oncology, Raleigh
Grant Garrigues, MD Orthopaedics Duke, Durham
Rebecca Dana Semble, MD Psychiatry UNC Hospitals Dept. of Psychiatry Chapel Hill
Mohammad Shahsahebi, MD Family Medicine Duke University Hospitals, Durham
Thomas Payson Thompson, MD Rhett Hallows, MD NC Orthopaedicis Clinic Duke, Durham
Caroline Bennett Hobbs, MD
Accent Urgent Care Cary
Michal Pawel Zlowodzki, MD Duke University Hospital Durham
Physician Assistants
Pediatrics University of North Carolina Hospitals Chapel Hill
Samuel David Aloian, PA
Terence William Kolb, MD
Durham
Emergency Medicine Granville Medical Center, Oxford
Meagan Ann Jones, PA
Ashley Fitzgerald Logan, MD Durham
Chad Mather, MD
Morrisville
Valerie Lane Cumbea, PA
Vance Family Medicine, Henderson
Christopher Wayne Oliver, PA Butner
Orthopaedic Duke, Durham
Matthew Wallace Schwanke, PA
Dolphin Henry Overton, MD
Corrine Adelle Skislak, PA
Cardiology, Internal Medicine 2605 Forest Hills Rd, Wilson
28
The Triangle Physician
Universal Family Medicine, Raleigh
Raleigh
Clinical Trials Do you have patients with this problem?
Ovulation and Ovarian Activity Women’s Wellness Clinic Dr. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. If you are a healthy female age 18-40 years with regular periods, then you may qualify for a research study on the effects of an investigational medication on ovulation and ovarian function. The research study procedures include: • physical exam • PAP smear • ultrasounds • blood draws • EKG Reimbursement up to $225 per week (up to 20 weeks for those who qualify). This study is being conducted by Dr. Andrea Lukes at the Women’s Wellness Clinic. Women’s Wellness Clinic is located by the Streets of SouthPoint. For more information call (919) 251-9223 or visit www.cwrwc.com.
The Triangle Physician 2011/12 Editorial Calendar December
Pain Management – Sleep Disorder
January
Diabetes – Banking
February
Heart Disease in Women Accounting for Medical Practices
March
Men’s Health – Vision New Medical Devices
April
Women’s Health Marketing Your Services
May
Orthopedics – Medical Insurance
June
Neurology – Sleep Apnea
July
New Imaging Technologies Electronic Medical Records
August
Digestive Disease Computer Technologies
September
Sports Medicine – Physical Therapy
October
Breast Cancer Reconstructive Surgery
November
Urology – Robotic Surgery
December
Pain Management
“More than a doctor. Like a friend.”
Trust. WHV is an independent group of heart specialists with locations throughout Eastern North Carolina - ready to provide the care for your patient’s heart when and where they need it. We’ve been pioneering and delivering innovative cardiovascular care for over 25 years. Through our affiliation with UNC Health Care, our physicians can also tap into the latest research and expertise associated with a world-class academic institution. And this in turn allows all our patients to have more access to clinical trials and new therapies, resulting in the best cardiovascular care available in the area.
Cardiovascular Professionals in Johnston County Mateen Akhtar, MD, FACC Benjamin G. Atkeson, MD, FACC Kevin R. Campbell, MD, FACC Randy A.S. Cooper, MD, FACC Christian Gring, MD, FACC
Matthew A. Hook, MD, FACC Eric M. Janis, MD, FACC Diane E. Morris, ACNP Ravish Sachar, MD, FACC Nyla Thompson, PA-C
WHV Locations in Johnston County 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7909 Fax: 919-989-3147
2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326
When it comes to your cardiovascular care – We know it by heart. To learn more, visit our website www.WHVheart.com or call us at 1-800-WHV-2889 (800-948-2889).
We know it by heart. Cardiovascular Services Echocardiography Nuclear Cardiology Interventional Cardiology Carotid Artery Interventions Cardiac Catheterization Cardiac CT Angiography and Calcium Scoring Electrophysiology and Cardiac Arrhythmias Peripheral Vascular Interventions Pacemakers / Defibrillators Stress Tests Holter Monitoring Lipid and Anti-Coagulation Clinics Vascular Ultrasounds / AAA Screening
DIAGNOSTIC IMAGING | PEDIATRIC IMAGING | SPORTS IMAGING | NEURORADIOLOGY ADVANCED BREAST IMAGING | INTERVENTIONAL RADIOLOGY | ONCOLOGIC IMAGING
Since 1953, Wake Radiology has been a leader in diagnostic imaging in the Triangle and beyond. We bring to you and your patients the most advanced imaging technologies available, delivered with the reassurance and compassion that are at the heart of health and healing. We have 17 outpatient imaging locations throughout the Triangle—many offering studies on evenings and Saturdays, including screening mammography, CT, Ultrasound, and MRI exams. Wake Radiology’s 55 subspecialty trained radiologists diagnose injury and illness quickly, while working with you and your staff to ensure the best possible outcome. So, the next time your patients require medical imaging think of Wake Radiology, where outstanding imaging is backed by expertise, convenience, and compassion. Wake Radiology. Here when you and your patients need us. Wake Radiology is the only multi-site outpatient imaging service provider in the Triangle to receive the American College of Radiology’s designation of Breast Imaging Centers of Excellence. Scan now to request a Screening mammogram with your smartphone.
Express Scheduling 919-232-4700 | Chapel Hill Area Express Scheduling 919-942-3196 | wakerad.com
©2011 Wake Radiology. All rights reserved. Radiology saves lives.
©2011 Wake Radiology. All rights reserved. Radiology saves lives.
Advanced Imaging For The Entire Family.