The Triangle Physician October 2010 by TTPLLC

october 2010

Wake Radiology Womenâ&#x20AC;&#x2122;s Imaging Breast imaging specialists lead the way T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

Also in This Issue

Heath Care Reform Now What?

Right-Sizing

Practice Management

Add a pinch of spice,

a hint of laughter,

and a correct diagnosis,

and you’ll get Robert.

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

(Actual size)

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

Brief Statement Indications 9529 Reveal® XT and 9528 Reveal® DX Insertable Cardiac Monitors – The Reveal XT and Reveal DX Insertable Cardiac Monitors are implantable patient-activated and automatically activated monitoring systems that record subcutaneous ECG and are indicated in the following cases: • patients with clinical syndromes or situations at increased risk of cardiac arrhythmias; • patients who experience transient symptoms such as dizziness, palpitation, syncope, and chest pain, that may suggest a cardiac arrhythmia. 9539 Reveal® XT and 9538 Reveal® Patient Assistants – The Reveal XT and Reveal Patient Assistants are intended for unsupervised patient use away from a hospital or clinic. The Patient Assistant activates one or more of the data management features in the Reveal Insertable Cardiac Monitor: • To verify whether the implanted device has detected a suspected arrhythmia or device related event. (Model 9539 only); • To initiate recording of cardiac event data in the implanted device memory. Contraindications: There are no known contraindications for the implant of the Reveal XT or Reveal DX Insertable Cardiac Monitors. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated. Warnings/Precautions: 9529 Reveal XT and 9528 Reveal DX Insertable Cardiac Monitors – Patients with the Reveal XT or Reveal DX Insertable Cardiac Monitor should avoid sources of diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, therapeutic ultrasound and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing. MRI scans should be performed only in a specified MR environment under specified conditions as described in the device manual. 9539 Reveal XT and 9538 Reveal Patient Assistants – Operation of the Model 9539 or 9538 Patient Assistant near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device. Potential Complications: Potential complications include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin. See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.

For more information, visit www.fainting.com.

He’ll give you hope for a family David K. Walmer, MD, PhD, of the Duke Fertility Center, helps women and couples realize their dream of becoming parents. How is the Duke Fertility Center different? Duke’s program was one of the first to achieve success in in vitro fertilization (IVF), embryo freezing, and blastocyst culturing. Our IVF rates are some of the highest in the country. And Duke continues to develop new programs to offer egg freezing, fertility preservation for cancer survivors, pre-implantation genetics, and non-surgical management of uterine fibroids. What if my insurance doesn’t cover fertility treatment? Many of our patients do face financial considerations, and we are pleased to be the only North Carolina member of Advanced Reproductive Care (ARC), a network of premier fertility programs through which we can extend affordable and predictable care costs and a refund guarantee. What are my chances of becoming pregnant? The best way to get this answer is by scheduling a 30-minute consultation with a reproductive endocrinologist. Advances in assisted reproductive technologies have increased our chances of success greatly, but there are many variables to consider. When should I seek fertility treatments? If you know for sure that you have a problem there is no reason to wait. Clues that may signal potential fertility problems include abnormal menstrual cycles, history of pelvic inflammatory disease, or history of testicular trauma. If you have no reason to suspect a problem and you are younger than 35, it is okay to try for a year before seeking help. However, it is never wrong to seek preconception counseling. If you have concerns, make an appointment—we’re here to help.

Duke is ranked #7 in the nation in gynecology by U.S.News & World Report.

Duke Fertility Center dukefertilitycenter.org 888-ASK-DUKE

7929

Contents

COVER STORY

PHOTO BY JIM SHAW

Wake Radiology Women’s Imaging Leading-edge women’s imaging in the Triangle

FEATURES

Insurance

Health Reform: Now What? Most of the provisions and rules are still being written, but there are some things employers should be aware of and prepare for.

OCTOBER

2010

VOLUME 1

ISSUE 9

DEPARTMENTS 14 Radiology

Radiology

arly Diagnosis of Harlequin Eye and E Other Craniosynostoses Is Key

15 Phlebology

Importance of Screening in Breast Cancer Reduction

Early diagnosis is still key to life expectancy. The concerns is that if decreased screening rates continue, mortality rates may again increase.

18 Women’s Health

enus Reflux Is Commonly Overlooked, V Common Cause of Peripheral Edema

reating Increased Pigmentation and T Vascular Lesions

20 Radiology

he Power and Promise of Breast T Thermography

22 Business Management

Right-Sizing Your Medical Office Staff

25 Radiology

Referring a Patient for a Breast MRI

28 Hospital News

irsts, Awards, Designations, Openings F and More

31 News

COVER PHOTO: The Wake Radiology medical staff: Richard Bird, M.D.; Danielle Wellman, M.D.; Duncan Rougier-Chapman, M.D.; Kerry Chandler, M.D.; and David Ling, M.D.

The Triangle Physician

elcome to the Area, Upcoming Events, W Clinical Trials and More

From the Editor Breast Cancer Awareness Month needs help There is more uncertainty than ever this Breast Cancer Awareness Month. It’s fallout from the United States Preventive Services Task Force’s (USPSTF) 2009 recommendations on mammograms. Most leading organizations associated with breast cancer believe the recommendations are ill advised, and the Wake Radiology medical staff stands among them. Equipped with specialized expertise and the full complement of radiologic technologies, Wake Radiology is able to provide the best possible opportunity for minimizing false-positive readings and diagnosing breast cancer at its earliest, most treatable stages USPSTF recommends against all commonly accepted, routine breast cancer screening methods, except for women aged 50 to 74. The concern is with false-positive screening results. The harms, which USPSTF has assessed as unacceptable include: radiation exposure, false-positive and false-negative results, over diagnosis, pain during procedures, and anxiety, distress and other psychologic responses. The American College of Obstetricians and Gynecologists and the American College of Radiologists (ACR) are among those cautioning against the USPSTF recommendations. ACR states among other things, “Mammography screening for women ages 40 and above is one of the major health care advances of the past 40 years. With the onset of mammography screening, the death rate from advanced breast cancer, that had been unchanged for the preceding 50 years, has decreased by 30 percent since 1990.” In ACR’s view, the revised USPSTF recommendations “could reverse this decline in breast cancer morbidity and mortality, causing undue suffering to women facing breast cancer and their families.” Wake Radiology patient Marian Sichel lends a human element to the debate, telling how a breast self exam saved her life at age 43. Also weighing in on the issue is Dr. Kathleen Havlin, who cites studies that support the role of screening in breast cancer reduction. Dr. Ashley Hawkins reviews the guidelines for referring patients for breast MRI. Dr. John Pittman shares insights into the promise of breast thermography. This month, Dr. Joseph Khoury reviews treatments for incontinence that can follow prostate surgery. Dr. Andrea Lukes introduces pulsed-light treatments for pigmented and vascular lesions. Dr. Lindy McHutchison discusses peripheral edema, as a physical finding of venous reflux. We also hear from Teresa Gutierre on health care reform, and John Reidelbach begins a new series on staffing. Finally, just a reminder about the value of advertising in The Triangle Physician. Every month, the magazine is delivered to more than 8,000 medical professionals in private practices, health care systems and hospitals in Alamance, Chatham, Durham, Granville, Harnett, Johnston, Lee, Moore, Nash, Orange, Person, Sampson, Vance, Wake, Warren, Wayne and Wilson Counties. That’s quite a reach! Is it time to increase awareness about your medical services? As always, our gratitude for all you do!

Heidi Ketler Editor

The Triangle Physician

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

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Teresa Gutierrez; Kathleen A. Havlin, M.D.; Ashley Hawkins, M.D.; Joseph M. Khoury, M.D., F.A.C.S.; Catherine B. Lerner, M.D.; Lindy McHutchinson, M.D.; Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G.; John C. Pittman, M.D.; and John J. Reidelbach

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

jdally@newdallydesign.com

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

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

Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401 Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information. 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

October is National Breast Cancer Awareness Month

Wake Radiology Breast Services Leading-edge Women’s Imaging in the Triangle are not negative and require additional workup. “In all medical screening tests, whether for prostate-specific antigens or occult blood in the stool, unfortunately, there are a number of false-positives or indeterminant results for individuals who do not have any disease. For a screening mammogram, this means there is a finding on the mammogram that requires me to get additional imaging to be able to be more specific about the diagnosis. This does not mean that the woman has a malignancy. It just means the woman cannot be diagnosed as

PHOTO BY BRYAN REGAN PHOTOGRAPHY

Screening mammograms form the first line of defense In her 23 years of experience, Kerry Chandler, director of women’s imaging services at Wake Radiology, says that she has lost track of exactly how many mammograms she has read. She does know that she has read close to 24,000 mammograms in the last three years alone. Last year, tens of thousands of screening mammograms were performed at Wake Radiology’s six breast imaging locations throughout the Triangle, including Wake Radiology Comprehensive Breast Imaging

consolidating all reading at one location and establishing a reading team of radiologists with special expertise in mammography. Specially trained clerical staff dedicated to screening mammogram readings ensure that all relevant history and images are at their fingertips. She strongly believes this is a better process than promising women their results before they leave the office. Reading a screening mammogram is too vital a task to be done hurriedly or when distracted; it is challenging to find relatively small and sometimes very subtle signs of cancer. Having a team of radiologists consistently reading the mammograms promotes an additional level of quality control. For technologists, there are both formal feedback processes and a training program, beyond continuing medical education, that is led by breast imaging specialist Richard E. Bird, MD, FACR, one of the breast mammography icons in the US, who has been with Wake Radiology since 2004.

Dr. Danielle Wellman discusses her findings with a patient at Wake Radiology Comprehensive Breast Center in Cary.

Services in Cary, the area’s first center dedicated exclusively to breast imaging. Almost all mammograms are digital—an advantage over analog films for patients with dense breasts, patients who are younger, and patients who are pre-menopausal. “Some patients don’t realize the difference between screening mammograms and diagnostic mammograms, and this difference becomes important in reducing patient anxiety,” Chandler notes. Screening mammograms, by definition, are for patients who have no symptoms, and they allow the radiologist to separate out patients who are definitely negative or benign from those who

The Triangle Physician

negative based on our typical image screening protocol. Many patients do not understand this and react with a significant amount of alarm when told they need a diagnostic exam after a screening mammogram. “Wake Radiology has a screening recall rate of around 5 percent; optimal range is between 4 and 6 percent. This recall rate has been shown to be one indicator that the least number of disease-free women are being called back for additional imaging while still maintaining optimal sensitivity in finding small cancers.” Chandler has lifted to an advanced art the process of reading screening mammograms,

“We are trying to find cancers when they are less than 15 mm. That seems to be a cutoff of frequency of metastasizing to the local lymph nodes,” Dr. Chandler says. And she adds, “that process requires consistent highquality standards in screening mammogram interpretations.” Diagnostic mammograms and breast ultrasound aid diagnosis and evaluation Diagnostic mammography and/or breast ultrasound are complementary in the diagnosis and evaluation of a breast problem, and they are strongest when the same physician evaluates the patient, takes the history, reads the mammogram, and then performs or supervises the ultrasound, Chandler believes. The choice of modality is customized to each clinical situation. For a woman in her 20s with a palpable mass, an ultrasound in skilled

Almost all patients who come to Wake Radiology for diagnostic evaluation receive their results before leaving. “Women who have been called back for a diagnostic evaluation are very anxious. I spend time with them; that is critically important. It makes for a much better experience for the patients. They know where they stand in terms of what happens next,” Dr. Chandler says. “I directly supervise every ultrasound, so I usually use that opportunity to explain her exams to the patient. I often review findings on the diagnostic mammogram with the patient as well. The patients then know my thought process when I’m looking at their studies. “It is important to reassure a patient—to explain, for example, that breast calcifications are very common and very likely to be benign. I also want to make sure that I discuss what next steps need to be taken to fully work up any finding so each patient understands the rationale for what we do and has the opportunity to ask questions.

The process of going through a diagnostic evaluation and possible biopsy is very anxiety producing for the patient, and that impacts the ordering physician. This is why we try to complete the process as quickly as possible. We know that the majority of people, even if they go to biopsy, are not going to have cancer. For biopsies, our positive predictive value is around 40 percent; 40 percent of people we ask for biopsies have a positive biopsy. That is an optimal value we strive for. So you see, even for those women who get a full workup and then go on to biopsy, results are still negative 60 percent of the time. “If a patient has breast cancer, some referring doctors prefer to be the one to communicate that diagnosis to their patient while others prefer that we tell the patient her positive breast biopsy results. If the physicians at Wake Radiology discuss positive results with a patient, we do so in person rather than on the telephone. We believe that we are best able to communicate this extremely upsetting news face to face.” Close communication and a high degree of expertise – hallmarks of Wake Radiology’s practice – are much appreciated by referring physicians. “Wake Radiology has excellent physicians with a world of experience. We know we are getting quality films and quality readings,” says Sheppard McKenzie III, MD, of Kamm, McKenzie Ob-Gyn of Raleigh.

“If there is a mass or a lump in addition to an abnormal mammogram, we will refer a patient on to a general surgeon. But if it is a subtle finding, and Wake Radiology could do a directed biopsy with the mammogram, we utilize that. They are very good at getting in touch with us. Sometimes with the patient there, they will call to say there is a suspicious area, so we can order the other study right then, if it is convenient for the patient,” McKenzie says. “They are just very good at communicating with our physicians. It makes a huge difference. If the news is good, I like the fact that they will tell the patient. They’ll say ‘Findings discussed with the patient.’ I know patients want to know yesterday that everything’s okay.” Ultrasound plays important role in examining abnormalities The primary use of ultrasound is for the further examination of a mammographic or a palpable abnormality in the breast, according to Dr. Bird, MD, FACR. “It is a very good tool, and we use it frequently.” Improvements in technology have increased the sophistication of this modality, and it plays an integral role in breast imaging at Wake Radiology. Indications for breast ultrasound include: matrix characterization of palpable or clinically occult masses detected on mammogram; characterization of solid masses; evaluation PHOTO BY BRYAN REGAN PHOTOGRAPHY

hands may identify a simple benign breast cyst with no need to proceed to any further imaging. Because an older patient in her 30s is more likely to have occult cancer, a diagnostic mammogram is the first imaging choice. For the radiologist to see extremely small breast calcifications, a diagnostic mammogram would include magnification views, and for a palpable mass, special mammogram views are used to show the margin of any corresponding mass that could be present.

“My goal is to help solve the problem of what the patient has, and also to mitigate the anxiety that the patient has about the evaluation. I communicate to the patient at any level the referring physician wishes. “If we believe a finding needs to be biopsied, some referring doctors want us to go ahead and do that. Others prefer we send their patients to another practitioner. I show every patient who needs a biopsy all the imaging findings and explain why I think she needs a biopsy. I also try to give each patient an idea of what the possible final diagnostic possibilities are including how suspicious I am that the finding could be breast cancer.”

Dr. Duncan Rougier-Chapman, one of four breast MRI specialists who read and render 3D images of the breasts when cancer is detected. OCTOBER 2010

ACR guidelines for annual breast MRI Published guidelines by the American Cancer Society recommend breast MRI and mammograms once a year starting at age 30 for certain women who are defined as high risk if they have: • a greater than 20 percent calculated lifetime risk of developing breast cancer • the breast cancer gene BRCA1 or BRCA2 • a first-degree relative with a breast cancer gene • the TP53 or PTEN gene mutation • a rare genetic syndrome including Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba, or if a first-degree relative has such syndromes Help your patients assess their breast cancer risk To calculate a patient’s risk for breast cancer, you need answer only seven simple questions. Simplicity and accessibility are at the heart of the National Cancer Institute’s online Breast Cancer Risk Assessment Tool, known as the Gail Model. It estimates a woman’s risk of developing invasive breast cancer over specific periods of time, using data from more than 280,000 women aged 35 to 74 years and National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program.

Access the Breast Cancer Risk Assessment Tool at wakerad.com

of tissue potentially excluded on routine mammographic views, and characterization of masses that are incompletely demonstrated in mammography; evaluation of women with inflammatory symptoms to distinguish a mastitis from an abscess; and guidance for interventional procedures. Typically, ultrasound follows a screening or a diagnostic mammogram and is complementary to it. In general, it is not a screening tool for cancer, Bird observes. While studies confirm that ultrasound can find cancers not found by mammography, ultrasound is not specific enough, with the resulting cost a large number of false-positives. It is notable that ultrasound is operator dependent. The quality of the examination greatly depends upon the experience and expertise of the person performing the exam. At Wake Radiology, a women’s imaging radiologist experienced in ultrasound directly supervises each breast ultrasound.

dilemmas and often can uncover occult disease. “We see the benefits of breast MRI all the time,” says Duncan Rougier-Chapman, MD, co-director of breast MRI imaging for Wake Radiology. “On a daily basis, we are seeing cancers that are not known—cancers of the opposite breast and cancers thought to be one centimeter in size that are found to be five centimeters in size. Breast MRI detects metastases in the spine, chest, or liver that were not known beforehand—or never would have been known. The patient could fail therapy, as appropriate therapy cannot be administered unless the extent of disease is recognized.” Rougier-Chapman is one of the practice’s four breast MRI specialists. Since introducing breast MRI in 2005, they have performed more than 5,500 exams and approximately 150 MRIguided breast biopsies.

Risk Calculator (Click a question number for a brief explanation or read all explanations.) 1. Does the woman have a medical history of any breast cancer or of ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)?

Select

2. What is the woman’s age? This tool only calculates risk for women 35 years of age or older.

Select

3. What was the woman’s age at the time of her first menstrual period?

Select

4. What was the woman’s age at the time of her first live birth of a child?

Select

5. How many of the woman’s first-degree relatives – mother, sisters, daughters – have had breast cancer?

Select

6. Has the woman ever had a breast biopsy?

Select

6a. How many breast biopsies (positive or negative) has the woman had?

Select

6b. Has the woman had at least one breast biopsy with atypical hyperplasia?

Select

7. What is the woman’s race/ethnicity?

Select Calculate Risk >

The Breast Cancer Risk Assessment Tool, also known as the Gail Model, is an online interactive tool designed by scientists at the National Cancer Institute (NCI) and the National Surgical Adjuvant Breast and Bowel Project (NSABP) to estimate a woman’s risk of developing invasive breast cancer.

For certain women at high risk for breast cancer, the American Cancer Society recommends annual breast MRI screenings as an adjunct to mammography. Among them are women who have a greater than 20 percent calculated lifetime risk for developing breast cancer, as defined by a risk calculator such as the Gail Model. Also included are those who have the breast cancer genes BRCA1 and BRCA2 and those with a first-degree relative who carries the gene. “We probably are seeing only the tip of the iceberg of those who would qualify for breast MRI screening,” Rougier-Chapman says. They include both men and women whose families have a very high predominance of breast malignancy. “If a patient is genetically positive for the breast cancer gene, he or she should be screened with a breast MRI.”

Highly accurate breast MRI is the best study for screening and staging of high-risk patients Magnetic resonance imaging (MRI) of the breast is the most accurate imaging method to detect and stage breast cancer, and for women and men at high risk, it is the most effective screening modality. Research shows this three-dimensional imaging study has 91 to 100 percent sensitivity. Used in conjunction with mammography and ultrasound, breast MRI can solve diagnostic

The Triangle Physician

BSGI images (left) of a woman with a very difficult mammogram (due to extreme density, multiple calcifications, and numerous previous benign surgical biopsies) and the completely normal BSGI exam of the same woman.

It is important to understand that breast MRI does not preclude the need for mammography or ultrasound, he continues. “Mammograms and ultrasound can answer the question in the majority of cases. A mammogram can show precancerous conditions such as abnormal calcifications and often can obviate a need for additional imaging such as MRI. MRI can show a broad spectrum of disease, but we try to use the most cost-effective and simplest tools first.” For women with breast cancer, the extraordinary detail of breast MRI makes it the most accurate means available today for staging. “Current research suggests that in approximately 30 percent of cases staged with breast MRI, the information will in some way change management of that patient. And in 75 percent of those cases, it does so in a manner that benefits the patient,” RougierChapman says. The national standard for staging includes a bilateral breast MRI to evaluate the extent of the disease within a breast with a known cancer, and it also has been proven to detect occult disease in the contralateral breast that has been missed by mammography and clinical evaluation. Moreover, the detail of a breast MRI can reveal accurate tumor volume, which is vital to assessing patients pre- and post-therapy, specifically useful in neo-adjuvant therapies. And for women who have undergone surgery, breast MRI is able to distinguish scar tissue from disease recurrence. This can help patients avoid unnecessary biopsies. The negative predictive value of breast MRI is 99 percent. New advances in breast-specific gamma imaging (BSGI) With the addition of breast-specific gamma imaging (BSGI), Wake Radiology now has the most comprehensive approach to the diagnosis of breast cancer in the area. “BSGI has essentially the same indications as breast magnetic resonance imaging (BMRI). It is almost as sensitive and somewhat more specific and can be used in place of BMRI for women who cannot have BMRI for a variety of reasons. It is considerably less expensive, and pre-certification has not been a problem,” explains Dr. Bird, MD, FACR, who introduced the BSGI program to the area in 2007.

PAT I E N T P R O F I L E Marian Sichel Breast Cancer Survivor from age 43 At 43, a breast self-exam saved Miriam Sichel’s life, and when she hears suggestions that women discontinue breast self-exams or delay screening via mammogram until age 50, she becomes nearly speechless. At 41, the Raleigh clinical social worker, wife, and mother of three boys already had begun annual screening mammograms on her doctor’s recommendation. She felt that was wise; although she was negative for the breast cancer genes BRCA1 or BRCA2, her paternal grandmother and paternal great aunt both had died of breast cancer. Then one day in late 2008, about eight months after her latest mammogram, she learned that a childhood friend had breast cancer. She did her own breast self-exam, just in case, and felt a lump. That was Friday; Monday, she contacted her obstetriciangynecologist and soon was at Wake Radiology for a diagnostic mammogram and ultrasound. “The lump did not show up clearly on the mammogram, but it showed up on the ultrasound,” she recalls. “The way they put it was that this doesn’t have typical cancer characteristics, but we can’t take a chance. To be safe, I was referred to Richard Bird, a women’s imaging radiologist at Wake Radiology Comprehensive Breast Services, for a needle biopsy. Dr. Bird and Wake Radiology were absolutely wonderful. I had the biopsy on Tuesday, and by Thursday, we had the results.” To stage Sichel’s disease, Bird performed breast-specific gamma imaging (BSGI), a nuclear medicine study. This modality was chosen because Sichel had a metal prosthesis in her ear and could not have magnetic resonance imaging (MRI). The results suggested that the known carcinoma was unifocal and without microscopic disease in the lymph nodes, and the other breast was negative. “I remember Dr. Bird telling me how thorough the BSGI was. He was so reassuring,” Sichel says. After successful treatment with chemotherapy and surgeries that included double mastectomy and reconstruction, Sichel is back to her active life. She lauds two persons in particular who positively impacted her recovery. Her physical therapist, Todd Erbst from Avante Physical Therapy, was able to explain which tissues and muscles were going to be affected and stressed, helping her understand what was happening physically and feel more assured. The second person is friend and breast cancer survivor Debbie Horwitz, who developed the photographic portrait of her own breast reconstruction in the booklet, Myself: Together Again. “She was diagnosed with breast cancer at 32,” Sichel notes. “There were no photographs of the step by step reconstruction process out there before this. She put this out there so women wouldn’t be left in the dark as well as to be an educational tool for doctors to pass along to their patients. I felt much more in control, knowing what was going on and what to expect.” As for forgoing regular breast self-exams and not having screening mammograms until age 50, she takes a moment. “I’m getting choked up. Obviously, it saved my life. How do you answer that, with all the people I know under 50 who have been diagnosed with breast cancer?” Such a recommendation, she says, “is life threatening. I’m not a physician, and I don’t know the specific risks, but I know what I see around me.”

Nuclear imaging of the breast has been around since the 1990s, initially using a standard gamma camera that imaged the breast in anterior and lateral projections. This technique, however, produced poor resolution because of the large size of the detector, which limited the proximity of the breast tissue, and the nonstandard views, which did not correlate with mammographic views. Today, new equipment and technology allow close proximity of the detector to the breast and positioning that correlates precisely with mammographic positioning and allows mild compression of the breast. The result is a significant increase in sensitivity for small malignancies. “Previously, only lesions greater than 1.0 cm could be identified,” Bird explains. “Now, lesions as small as 2 mm to 3 mm can be detected. According to recent literature, the sensitivity is approximately 85

percent to 95 percent (depending on tumor size), and the specificity is approximately 75 percent to 85 percent.” BSGI is functional imaging of the breast dependent on hypermetabolic tissue with a high concentration of mitochondria in the cells. Following the intravenous injection of the isotope, each breast is imaged in the CC and MLO projections. Axillary views also may be obtained, if indicated. The examination is done with the woman comfortably seated and takes 30–45 minutes to complete. The radiation dose is approximately the same as that for an upper GI series. This exam is done only at Wake Radiology Comprehensive Breast Services in Cary. Like MRI, BSGI is unaffected by scar tissue and implants. It can be used for staging of newly discovered breast cancer and for evaluation OCTOBER 2010

of questionable recurrence after breast conserving therapy, although MRI generally is used in those situations. “BSGI provides an important alternative to MRI for women who otherwise would qualify for MRI reimbursement, but cannot have MRI because of claustrophobia or incompatible metal implants or devices,” Bird explains. “Because of the high negative predictive value, the primary use of BSGI in our practice is for screening women with mildly increased risk (less than 20%) and dense breast tissue, and for screening of women with normal risk, but very difficult mammograms. It is used in place of whole-breast ultrasound for screening because of slightly better sensitivity and much better specificity. It is adversely affected by high estrogen levels and should be done between days three and ten of the menstrual cycle, when practical.” Practice offers mammogram-, ultrasound-, and MRI-guided breast biopsy By providing breast biopsy guided by ultrasound, by mammogram (stereotactic), and by MRI, Wake Radiology helps make the diagnostic process more comprehensive and efficient. In stereotactic breast biopsy, ionizing radiation is utilized to help guide instruments. With ultrasoundguided core needle biopsies, images are viewed in real time while the patient lies comfortably. MRI-guided biopsies are an important capability when a breast MRI reveals areas of concern or abnormalities, especially those that cannot be seen on ultrasound or mammogram. These biopsies require specialized instrumentation. “I urge physicians to ensure they send a patient for a breast MRI to a facility that is able to perform an MRI-guided biopsy. Otherwise, if they do find something, they have no means to access it,” says Rougier-Chapman. For the patient, the process of going through any type of breast biopsy can produce anxiety, and Wake Radiology strives to make the procedure less so by going over images with the patient and PET-CT staging and restaging March 2010

August 2010

explaining why a biopsy is needed. For breast biopsy, the practice’s positive predictive value is 40 to 45 percent, Chandler notes. This means that patients who receive a biopsy are negative for cancer 55 to 60 percent of the time. PET increasingly utilized in evaluation of breast cancer Positron emission tomography (PET) is the most recent addition to the imaging studies available for the evaluation of patients with breast carcinoma. Unlike anatomic imaging modalities, which depend on a change in the morphology of normal structures to detect pathology, PET produces functional images based on differences in metabolic activity. This nuclear medicine study utilizes a short-lived radioactive tracer, F-18, which is attached to fluorodeoxyglucose (FDG), an analog of glucose. In general, malignant cells demonstrate greater metabolic activity and increased utilization of glucose compared to normal structures. The F-18 labeled FDG is actively taken up by malignant tissue and is displayed as hypermetabolic foci of increased activity on the PET images. One significant advantage of FDG PET imaging, explains Wake Radiology’s David Ling, MD, a body imaging radiologist and PET-CT specialist, is that PET can demonstrate increased metabolic activity in a malignant lesion before there are any apparent morphologic changes. PET images are co-registered with low-dose computed tomography (CT) images acquired during the same scanning session on the same hybrid PET-CT scanner. The CT images allow for more precise anatomic localization of the foci of increased metabolic activity detected by PET.

PET·CT images of 57-year-old female with metastatic breast cancer. First PET-CT in March 2010 (left images, top and bottom) show the conglomerate of adjacent nodes. After cancer therapies, on the follow-up PET-CT in August 2010, the conglomerate of adjacent nodes clearly decreased in both size and number.

The Triangle Physician

PET currently does not have a role in the detection of primary breast cancer, Ling notes. This is because the limited spatial resolution of the current PET scanners does not allow for the detection of small breast cancers. In the initial staging of patients with suspected early stage disease, while PET has not replaced CT, MRI, and bone scintigraphy, PET can help clarify findings that are equivocal on the initial staging studies. Compared to sentinel node biopsy, PET has a high specificity for axillary nodal metastases, but a lower sensitivity, and thus does not replace histologic evaluation of the sentinel nodes.

PET has proven to be of great utility in the staging of patients with suspected locally aggressive neoplasm at the time of initial diagnosis, in the assessment of response to therapy, and in the restaging of patients following treatment. This is because PET is able to assess for locoregional spread more precisely than CT, and it can detect metastatic lesions in areas that may not be optimally evaluated by other imaging modalities, such as the hilar nodes and the internal mammary chain nodes. Not infrequently, PET demonstrates more widespread disease than expected in patients with suspected recurrence. This is especially important in the clinical management of patients for whom aggressive local therapy is being considered. One study, Ling observes, showed that PET imaging altered therapeutic options in up to 44 percent of patients with suspected locoregional recurrence by demonstrating more widespread disease than CT. In another study of patients with elevated levels of tumor markers, PET-CT affected clinical management in 51 percent of patients. In the evaluation of osseous metastatic disease, bone scintigraphy remains the initial imaging study for surveying the entire skeleton. PET appears to be superior, however, in the detection of lytic and intramedullary metastases. An important application of PET is in treatment monitoring. PET images can assess the metabolic response to treatment, and they have been able to discriminate between responders and nonresponders more accurately and earlier than other imaging modalities. PET has been used to evaluate the efficacy of neo-adjuvant chemotherapy, sometimes after a single cycle of treatment. Studies have shown that a decline in a primary tumor FDG uptake by approximately 50 percent or more is predictive of a good response to neo-adjuvant systemic therapy. After completion of chemotherapy, residual activity on PET images is predictive of residual disease, but absence of activity is not a reliable indicator of complete pathologic response since residual microscopic disease is not excluded. “The introduction of FDG PET has changed patient management in breast cancer,” Ling says. “PET imaging represents early clinical application of molecular imaging. Research into other positron emitting isotopes and dedicated positron emission mammography scanners is ongoing.” USPSTF recommendations Last winter, the United States Preventive Services Task Force published new guidelines for screening mammography that surprised and perplexed Dr. Chandler. For years, various researchers and groups have considered at what age, and how often, women should have screening mammograms. The mammographers of Wake Radiology support yearly mammograms for women ages 40 to 80. These are the recommendations of the American Cancer Society and the American College of Radiology, and breast self-examination also is included. But the USPSTF, in contrast, recommended that women wait until age 50 to begin regular mammograms, that they need not continue after age 74, and that they could wait twice as long— two years—between mammograms. Breast self-examination was out altogether. The issue is critical,

Positive breast cancer findings from screening mammogram exams

Number of Patients

12 10 8 6 4 2 0

Female Patient Ages Wake Radiology data from Jan 2008 to December 2009

The Future of Breast Imaging What does the future hold in the fight against breast cancer? Here are just three examples. An association between inflammatory breast cancer and viral sequences Could breast cancer, like cervical cancer, be associated with a virus? Is a breast cancer vaccine on the distant horizon? In an intriguing yet very small study of 67 patients with inflammatory breast cancer, 44 were positive for viral sequences resembling mouse mammary tumor virus (MMTV). The 72 percent of cases that were positive was significantly more than the 40 percent positive in non-inflammatory breast cancer patients. See Levine, Paul H. et al. Increased Detection of Breast Cancer Virus Sequences in Inflammatory Breast Cancer. Advances in Tumor Virology 2009, Vol 1 pp 3–7. 3D tomosynthesis This promising new digital technology produces unmatched image quality and could help find tumors that otherwise could be missed. Moving in an arc around the breast, tomosynthesis acquires a series of images and creates a high-resolution image from the raw data—without increases in radiation exposure over standard mammography. Already available in Europe and Canada, tomosynthesis is in clinical trials in the US in preparation for US Food and Drug Administration pre-market approval. Elastography A new procedure related to ultrasound, shows promise in helping distinguish benign from malignant solid tumors. The technique estimates tissue stiffness, adding another dimension of specificity in characterizing lesions, and Wake Radiology’s expertise includes participation in a clinical trial of elastography. “Elastography has been helpful and has been quite accurate,” says radiologist Richard E. Bird, MD. While one day, elastography may help reduce the need for biopsies, Bird indicates that currently it is not used in making decisions regarding biopsy because there have not yet been enough clinical studies.

Chandler feels, because of the numbers. The National Institutes of Health estimates that breast cancer affects one in eight women over the course of their lives, and the disease kills more women in the United States than any cancer except lung cancer. “If the USPSTF recommendations are adopted by the government and insurance carriers, the reality is that more women will die each year from breast cancer,” Chandler wrote in letters to patients and a posting on Wake Radiology’s website, wakerad.com. The early detection of breast cancer through routine screenings, she believes, has driven the mortality rate down at least 20 percent, and perhaps 30 percent. To her, it’s a success story of modern medicine. “Our patients are asking us about these recommendations, so I’m sure primary care providers are also getting many questions OCTOBER 2010

from their patients,” Chandler says. “I would tell every provider that it is his or her duty to look critically at these recommendations and the data that the task force used to make these recommendations. By my own evaluation, it seems that the task force did not look at all the data.” Chandler points to landmark studies in Sweden conducted by radiologist and researcher Lázló Tabár, MD, a randomized trial of breast cancer screening of more than 130,000 women aged 40–74 years with a 13-year followup of more than 2,450 cancers.1 “The data was very clear that mammography performed even in 40- to 50-year-old women brought about a statistically significant decrease in mortality,” she says. “Screening mammograms allow us to identify small breast cancers of 15mm or less,

and for those patients, the prognosis is very favorable.” “I am confused about the reasons the USPSTF is making recommendations that essentially say no screening mammography for women between ages 40 and 50, because it is not unusual for me to find small cancers on screening mammograms on completely asymptomatic women in this age group. The USPSTF recommendations fly in the face of what I see and in the face of the data that I know. (See graph on previous page.) “I understand the USPSTF’s frustration with false-positive mammograms that lead to subsequent benign biopsies, but as of yet, we do not have a good alternative screening test.”

The interval between mammograms also is of concern. “The optimal interval between screening mammograms has not been proven to be two years (as the USPSTF recommends). In the best studies that have looked at this parameter, the optimal interval between screening mammograms has been shown to be about 16 months. The current yearly screening protocol was developed since this interval is the closest to the optimal interval that can easily be remembered by the patients and the referring providers.” 1 The Swedish Two-County Study found a reduction in mortality of 34 percent of women ages 50 to 74, and a reduction of 13 percent for women 40 to 49. The lower mortality reduction among the younger women, the researchers concluded, was due to faster progression of tumors and rapid increase in incidence during that decade of life. The researchers concluded the interval between screenings should be shortened and that annual screenings would increase the reduction to 19 percent. Tabár L, Fagerberg G, et al. Efficacy of breast cancer screening by age. New results from the Swedish Two-County Trial. Cancer. 1995 May 15. PubMed PMID: 7736395. http://www.ncbi.nlm.nih. gov/pubmed/7736395.

Wake Radiology Physician Decision Support

More info at wakerad.com

Each subspecialty section offers referring providers access to our physicians to discuss the most expedient workup for your patient or to discuss a challenging case.

Our newly designed website has over 300 pages of everything radiology including 6 videos on breast and women’s imaging for your education.

Breast Imaging Radiologist Physician Hotline 919-233-5338 x2123 Breast MRI Radiologist Physician Hotline 919-788-7978 PET·CT Radiologist Physician Hotline 919-233-7280 WR Express Scheduling: 919-233-4700

Watch the online video: Breast MRI: Beyond the Mammogram wakerad.com: Breast MRI Services: Videos

Wake Radiology Breast Imaging Physicians Kerry E. Chandler, MD Women’s Imaging Radiologist Director of Breast Imaging Services

Richard J. Max, MD Women’s Imaging Radiologist

Paul A. Haugan, MD Body Imaging Radiologist PET·CT Imaging Specialist

Elizabeth A. Rush, MD Women’s Imaging Radiologist

Richard E. Bird, MD, FACR Women’s Imaging Radiologist

Holly J. Burge, MD Body Imaging Radiologist Director of PET·CT Services

Carmelo Gullotto, MD Body Imaging Radiologist Breast MRI Specialist

David Ling, MD Body Imaging Radiologist PET·CT Imaging Specialist

Duncan P. Rougier-Chapman, MD

William G. Way Jr, MD Body Imaging Radiologist Director of Diagnostic Imaging PET·CT Imaging Specialist

Claire M. Poyet, MD Women’s Imaging Radiologist

Bryan M. Peters, MD Neuroradiologist Women’s Imaging Specialist

Eithne T. Burke, MD Women’s Imaging Radiologist

Danielle L. Wellman, MD Women’s Imaging Radiologist Breast MRI Specialist

Body Imaging Radiologist Co-director of Breast MRI Services

G. Glenn Coates, MS, MD Body Imaging Radiologist Co-director of Breast MRI Services

David I. Schulz, MD Body Imaging Radiologist PET·CT Imaging Specialist

Susan L. Kennedy, MD Women’s Imaging Radiologist

wakerad.com 12

The Triangle Physician

Urinary

Incontinence Following Treatment for Prostate Cancer By Joseph M. Khoury, M.D., F.A.C.S.

Many men are given the news that they have newly diagnosed prostate cancer. If it is localized to the prostate gland, the options may include radical prostatectomy, some form of radiation therapy and cryotherapy, in addition to other treatments that are not approved by the United States Food and Drug Administration for use in this country. Patients may seek out “the best” surgeon or radiation oncologist in the country. But the fact is, even in the best of hands, urinary incontinence (UI) following treatment for localized disease may still occur. The social implications resulting from UI can be devastating. Many men are embarrassed and retreat from activities that provided them with much satisfaction in their lives. In addition, their relationship with family members may change, particularly if the family members are not fully aware of the situation. Sexual intimacy may be compromised with a spouse if the patient is incontinent, even if he has normal sexual function. UI may occur in 5 percent to 15 percent of men following prostate cancer surgery. The range depends on how UI is defined. Many investigators define their outcomes as “socially continent,” wearing one to two pads per day that are damp. Newer studies define the outcome as totally dry. The prostate gland is sandwiched between the bladder neck (the internal sphincter) and the external sphincter. It provides stability to the urethra, which travels through it. The bladder neck is under the control of the autonomic nervous system. Alpha-agonists,

such as phenylephrine, can help contract the smooth muscle of the bladder neck, while alpha-blockers, such as tamulosin, relax it. The external sphincter is comprised of fast- and slow-twitch somatic muscle fibers. The slow-twitch fibers allow passive involuntary control of the external continence mechanism. The fast-twitch fibers of the pelvic floor, commonly called the pubococcygeus muscles, provide voluntary control when contracted. Doing Kegel exercises may help men regain continence after surgery. During prostate surgery one or both of the sphincters may be compromised or the nerves going to them may be denervated, resulting in sphincteric dysfunction. This is called intrinsic sphincter deficiency (ISD), commonly called male stress incontinence. In the majority of cases, the external sphincter is impaired and UI occurs with laughing, coughing, sneezing and other activities that increase intra-abdominal pressure, such as golfing or weightlifting. Overactive bladder symptoms may occur immediately after prostate surgery and result in urinary frequency, urgency, urge incontinence and nocturia. These symptoms usually improve or resolve spontaneously, but may continue for several months following surgery. Overactive bladder symptoms can coexist with intrinsic sphincter deficiency, as well. Treatment for intrinsic sphincter deficiency varies depending on the severity of the symptom. Preoperatively men should be instructed in the proper technique to strengthen the pelvic floor. A physical

Urology Dr. Joseph Khoury is medical director of The Raleigh Continence Center. He is one of six urologists fellowship trained in urodynamics and reconstructive urology in North Carolina, and the only urologist in Wake County with this advanced training. He graduated from Georgetown University Medical School and finished his urology residency at Walter Reed Army Medical Center in Washington, D.C. Dr. Khoury completed his fellowship training in urodynamics and reconstructive urology at Duke University Medical Center, and was a professor of urology at Georgetown University and the University of North Carolina at Chapel Hill before going into private practice. He is board certified by the American Board of Urology and a member of the American Urologic Association, Society for Urodynamics and Female Urology, Society of Genito-Urinary Reconstructive Surgeons, American College of Physician Executives and a fellow of the American College of Surgeons. He has published several articles and textbook chapters on the topics of urinary incontinence, neurogenic bladder, pelvic floor dysfunction in women, urethral stricture disease and the artificial urinary sphincter.

therapist is invaluable in providing such instruction, as most patients are either taught how to perform the exercise incorrectly or involve antagonistic muscles of the pelvic floor, such as the abdominals or gluteals. In addition to pelvic floor training behavioral techniques such as scheduled voiding every two hours while awake, limiting fluids to two liters a day, and avoiding caffeinated and carbonated beverages will help decrease incontinent episodes by 50 percent. Using these strategies, the majority of men are able to gain continence within six months following prostate surgery. For men who continue to have significant UI, a frank discussion with the patient should help direct further treatment. This discussion should address the patient’s present quality of life and how UI is impacting his activities of daily living. The options presented should include the potential risks and complications of procedures or operations, and the risk level the patient is willing to take. Such knowledge OCTOBER 2010

will allow the patient to make an informed decision before embarking on further surgery. The initial workup usually entails a three-day voiding diary, well-tailored urodynamic study looking for detrusor overactivity and intrinsic sphincter deficiency. Cystoscopy will look for urethral or anastomotic strictures, and assess the external sphincter for sector defects and the patientâ&#x20AC;&#x2122;s ability to contract the pelvic floor under direct vision. Treatment options There are three options to treat ISD. The least-invasive, and probably least-effective, procedure is transurethral injection of bulking agents into the external sphincter. Fat, Teflon and collagen have been used. Unfortunately, the durability of these agents is limited and many patients need several reinjections to remain dry or improved. The procedure is performed under monitored anesthesia as an outpatient and safe. Urinary retention occurs rarely. The second option is a urethral sling. This is a relatively new operation that is performed

The Triangle Physician

as an outpatient or overnight hospital stay. Using a perineal incision the proximal bulbar urethra is exposed. Two small groin incisions are made lateral to the scrotum and a purposebuilt needle is passed through the obturator canal and into the perineal wound. The sling is attached to the needle and transferred to the skin. This is performed bilaterally. Appropriate tension is placed on the sling moving the hypermobile urethra back into its normal anatomic position. The success rate with this operation varies between 50 percent to 70 percent, depending on certain tissue factors, for example if the patient has had radiation therapy and the extent of urethral weakness. The gold standard to treat men with ISD is the artificial urinary sphincter (AUS). This device can be implanted as an outpatient or overnight hospital stay. The AUS has three components: a urethral cuff, pump and reservoir. The cuff is implanted circumferentially around the proximal urethra and then connected to the reservoir that is placed adjacent to the bladder and the pump, which is placed in the scrotum.

The fluid-filled cuff around the urethra maintains continence. When the patient needs to void he squeezes the pump in the scrotum, which hydraulically transfers fluid from the cuff to the reservoir, allowing the patient to void. After three to five minutes the cuff will refill restoring continence. The five-year mechanical reliability rate is 90 percent and patient satisfaction is high. Complications can occur and may result in infection, requiring explanation of the device; mechanical issues necessitating revision; urethral erosion; and urinary retention. Medical therapy may be helpful for men who have both ISD and overactive bladder. Imipramine, a drug used for depression, has both anticholinergic and alpha-agonist properties, and is useful for men with mixed urinary incontinence. Likewise for men with just overactive bladder symptoms, an anticholinergic medication in conjunction with behavioral therapy may help restore continence.

Venous Reflux Is Frequently Overlooked, Common Cause of Peripheral Edema

Phlebology Dr. McHutchison is the medical director at Carolina Vein Center, a well- established, solo, private Phlebology practice dedicated solely to the practice of Phlebology, the diagnosis, treatment and management of venous disease. Although Dr. McHutchison exclusively practices Phlebology, she is board certified in both Phlebology and Ob/Gyn. To learn more about venous disease, visit www.carolinaveincenter. com. Dr. McHutchison can be reached at lindymch@earthlink.net or (919) 405-4200.

By Lindy McHutchison, M.D.

Peripheral edema is a prevalent physical finding in patients. One of the most common causes of peripheral edema is venous reflux, a frequently overlooked, yet common occurrence in the American adult population. Approximately 20 percent of adult Americans have venous reflux, and because the conditions related to venous

vein wall permeability, and hence, leakage of intravascular proteins, chemicals and fluid into extravascular spaces, resulting in peripheral edema. What is venous reflux? Normal leg veins work against gravity, taking blood via antegrade flow back to the heart via one-way

Approximately 20 percent of adult Americans have venous reflux, and because the conditions related to venous reflux are progressive, approximately 30 percent of those 65 years and older are affected. reflux are progressive, approximately 30 percent of those 65 years and older are affected. Venous reflux is a principle contributor to venous pooling and congestion, thus causing venous distension and subsequent venous hypertension. This venous hypertension causes inflammation which mediates not only a macrophage response, but other elements as well, further damaging vein valves and walls. The cascade of venous reflux, venous hypertension and venous inflammation are collectively called chronic venous insufficiency (CVI). CVI is responsible for vein wall damage, increased

flow valves in leg veins. If there is venous dilation, valvular damage or malfunction, and/or abnormal or absent vein valves, blood flows retrograde toward the feet. This unhealthy, retrograde flow is called venous reflux. Diagnosing venous reflux – Venous reflux is diagnosed by performing a duplex ultrasound, usually by a specially trained venous ultrasonographer in the vein clinic setting. Duplex means “two,” so first, the flow in the veins is evaluated using the Doppler flow techniques, and second, the veins in the legs are “mapped.” The problem with venous reflux – When venous reflux is present, venous pooling and congestion occur, first distally,

eventually progressing proximally. Venous reflux is one of the primary sources leading to CVI. Thus, venous reflux is ultimately responsible for many of the physical findings of CVI: peripheral edema, bulging varicose veins, hyperpigmentation, other skin changes and eventually venous ulcers. Common symptoms of CVI include: tired, achy, heavy, swollen, tender, itchy, crampy, restless legs. Treatments – Treatments of venous reflux fall into two categories: conservative management and definitive treatments. Both are aimed at decreasing venous congestion, distention and hypertension. Conservative management includes prescription compressions stockings, leg elevation, avoiding hot tubs and baths (to decrease venous dilation) and exercise (calf and foot muscles help “pump” blood out of the leg). Definitive treatments involve closing or removing the abnormal veins and rerouting the blood flow into healthier remaining veins. The now obsolete vein stripping of yore has been replaced with endovenous laser ablation of the saphenous veins. Usually multiple treatment modalities are used with laser ablation, including sclerotherapy (injecting irritants into the veins to close them) and/or phlebectomy (micro-extraction techniques), all of which are short, simple procedures performed in the office setting. Patients usually return to normal activities the same or following day. Because CVI is considered a medical problem, the treatments are usually covered by most insurance plans, including Medicare.

OCTOBER 2010

Insurance

Health Reform Now What? By Teresa Gutierrez

After months of debate, the much anticipated Patient Protection and Affordable Care Act, commonly referred to as “health reform,” has become law. Even with widespread news coverage of the passage, employer groups are still wondering, “What does this mean to me?” As a company currently, or anticipating, offering employee health benefits, there is a lot to know and understand. Most of the provisions and rules are still being written, but there are a few pieces we do currently know and for which employers should prepare.

OTCs Are Out Effective Jan. 1, 2011, the purchase of overthe-counter medicines will be prohibited under Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs) and Flexible Spending Accounts (FSAs), unless prescribed by a physician. The only exception is insulin. What this means to you: If you currently offer one of these benefit plans to your staff, you will need to communicate the changes. Even if you do not offer these benefits, it is recommended you prepare your staff for fielding questions about this change. Primary care offices will feel the biggest

The employee benefits market is in its biggest period of change to date. Employers will face many rewards and challenges in navigating the new laws. A qualified and knowledgeable benefits broker is your best resource for understanding the new laws and remaining compliant. impact and will likely see a spike in the number of patients that come looking for over-the-counter prescriptions. Additional 1099s Within the health reform law is a requirement that the corporate exception for the collection and distribution of 1099s will end Dec. 31. This change means any corporate transaction in excess of $600 will need to be reported on Form

The Triangle Physician

Teresa Gutierrez is a managing partner at Integrated Benefit Solutions/White Bear Group. She has more than 25 years of experience in group health, self funding, disability, life and voluntary benefits. Ms. Gutierrez is vice president of the NC Association of Health Underwriters and a member of the Health Benefit Exchange and Insurance Oversight Workgroup for the state of North Carolina. She can be reached at (919) 439-7115 or teri@ibs4me.com.

1099-Misc. This rule includes both goods and services. For example, if your practice bought a desk or printer at OfficeMax for more than $600, you would have to send a 1099 to OfficeMax. Congress is working to revise some aspects of the law to relieve some of the burden on employers. One revision up for consideration is exempting expenses of less than $5,000 and employers with less than 25 employees. If no change is made, then this piece will go into effect Jan. 1, 2011. Know Your Renewal There are several incremental changes effective Sept. 23 that will impact your group health plan upon renewal. Depending upon your plan design and carrier, some requirements may have already been met while others take effect on your renewal and may affect renewal premium. You also may have the opportunity to maintain your current plan without changes. With “grandfathered” status, you are not subject to many of the long-term changes ahead. It is strongly recommended you discuss with your benefits broker what new provisions will impact you upon renewal, as well as the benefits and challenges of maintaining a grandfathered status. The employee benefits market is in its biggest period of change to date. Employers will face many rewards and challenges in navigating the new laws. A qualified and knowledgeable benefits broker is your best resource for understanding the new laws and remaining compliant.

Triangle Neurosurgery, PA A Complete Spine Care Center Triangle Neurosurgery provides a unique blend of personalized attention to each patient with the latest advancements in state of the art technology. This results in compassionate and comprehensive care delivered through conservative management or surgery. Our emphasis is patient centered and we recognize the importance of helping patients return to an active and healthy lifestyle.

Dr. Dennis E. Bullard MD, FACS is a Board

in cervical spine surgery. He has been

Certiﬁ ed Neurological Surgeon and a Fellow

honored with the Patients’ Choice Award

in the American College of Surgeons. He is a

and has been elected continuously to the

neurosurgeon who has been practicing for

lists of America’s Top Rate Physicians and

28 years and is always striving for the most

Best Doctors in America. He is a member

current and effective care for his patients.

of the North Carolina Spine Society and elected to the International Who’s Who in

He is the recipient of the 2010 ﬁrst place

Medicine.

award given by the American Association of Neurological Surgeons for his research

1540 Sunday Drive, Suite 214, Raleigh, NC | P: 919-235-0222 | F: 919-235-0227

triangleneurosurgery.org

Women’s Health

Treating Increased Pigmentation and Vascular Lesions: Basic Skin Care By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G

There may be many reasons why a woman may have a cosmetic flaw: heredity, medication, pregnancy or environmental factors. Most of these pigmented and vascular lesions are ideal candidates for noninvasive AFT pulsed light treatments. What is AFT pulsed light treatments? AFT stands for advanced fluorescent technology, and through this laser technology at the Women’s Wellness clinic the AFT’s selective pulsed light energy is precisely absorbed by the target areas (age spots, rosacea, erythema, melasma, benign vascular lesions) without damaging healthy skin. By selectively heating and closing off blood vessels, AFT pulsed light reduces the lesions.

lesions may fade, but others become more pronounced over time and through years of sun exposure. What can patients expect? Patients (men and women) must consult with Dr. Andrea Lukes or Dr. Amy Stanfield to determine their course of treatment. Physicians set treatment plans according to the characteristics of each lesion (the size and location). Most lesions can be treated within five to 20 minutes, but repeated treatments are recommended for optimal results. Dr. Lukes explains, “We prefer to treat conservatively by treating gradually as opposed to being more aggressive.” The

We prefer to treat conservatively by treating gradually as opposed to being more aggressive. Pigmented lesions respond because the light energy heats the melanin in the lesion and causes it to fragment. The melanin fragments are then absorbed by the body and eliminated. By providing smooth, consistent light pulses, the energy delivered to the skin is gentle and effective. What are benign vascular and pigmented lesions? The benign vascular lesions are usually red in color and are caused by an abnormal clustering of blood vessels. The pigmented lesions (nevi) are clusters of melanin in the skin and are brown in color. Some

The Triangle Physician

Alma Laser offers a cooled tip that is applied to the skin. Combining this with a cooled gel offers little or no pain with AFT treatment and “individuals return to their normal activities immediately,” Dr. Lukes says. Is it safe and does it hurt? The AFT’s high levels of light and gentle energy parameters assure safe and effective treatment. There is little or no skin damage or discomfort. The majority of patients require no anesthesia, although Dr. Stanfield describes that “a topical anesthetic is an option we discuss with patients.”

What minimal efforts should I do for my skin? This is an important question for women (and men), and at the Women’s Wellness Clinic, we emphasize practical and easy steps for skin care. We have focused on two main steps that every individual must do. After washing your face in the morning and before you put on any makeup use: 1) A serum that is applied just after cleaning your face in the morning, and then after waiting one to two minutes… 2) A hydrating sun screen is used prior to applying make-up. Women’s Wellness Clinic selected the exclusive SkinCeutical® brands after reviewing many on the market. The two top serums include Phloretin CF and CE Ferulic. Below are summaries of each of these antioxidant leaders: Phloretin CF is derived from apples and the root bark of fruit trees. Phloretin is a broadspectrum molecule that has antioxidant properties and is now recognized as a pigment-regulating and penetrationenhancing agent. It also has anticancer, antifungal, antibacterial, antiviral and antiinflammatory bioactivities. This serum also contains vitamin C and ferulic acid, a plantbased antioxidant that helps to prevent and treat photodamage at every level of the skin. This serum is recommended for: hyperpigmentation, erythema, uneven skin tone, loss of elasticity, mottled appearance and photodamaged skin. It is best suited for women with normal or oily skin.

After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/ gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thombosis Clinic. She left her academic position in 2007 to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head the Women’s Wellness Clinic, the private practice associated with CWRWC. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.

C E Ferulic is a revolutionary topical antioxidant that provides eight times the natural skin’s photoaging protection. It has vitamin C and E, as well as ferulic acid.

In addition, it contains the original potent formulation of 15 percent pure L-ascorbic acid and 1 percent alpha tocopherol. This serum is recommended for: rosacea, reducing fine lines and wrinkles, erythema, hyperpigmentation, photoaged or photodamaged skin. It is better suited for women with normal or dry skin. This serum actually is a three-time winner for best serum and received the 2009 Allure women’s magazine Best of Beauty Editors’ Choice Awards. Hydrating sun screen is the second step that we recommend as a must for daily skin care. Not many realize that sunscreen bought at Target is not the best standard. It is worth paying a little more for effective sunscreen. The SkinCeutical® sun defense creams are excellent. These are optimal for daily use. We recommend the following: • Daily Sun Defense SPF 20 • Ultimate UV Defense SPF 30 • Sport UV Defense SPF 45 • Sheer Physical UV Defense SPF 50 These sunscreens are superior because they offer both a chemical block against UVA and

UVB rays and provide a physical block with a transparent zinc oxide. These are ideal for all skin types because they are PABA-free and oil-free. “Our entire staff uses these products – we love them and offer them to all of our patients,” says Dr. Lukes. Summary It is important for women and men to learn basic skin care. Sun and the environment exposes us to many damaging effects that accelerate aging. Women’s Wellness Clinic emphasizes the most fundamental steps for healthier skin.

• Financial strength – $2.6 billion in net admitted assets and $677 million in policyholder surplus; a Best’s Rating of A- (Excellent) • Unparalleled experience – more than three decades of service to the healthcare community • Aggressive claim defense – nearly 73% of cases closed without an indemnity payment; win rate of more than 93% for those that went to a verdict at trial • Innovative risk management – extensive risk management services and customized, practice-specific programs

THE TIME IS RIGHT TO EVALUATE PROMUTUAL GROUP To learn more about ProMutual Group, please visit www.promutualgroup.com/NC.html or call us at (888) 776-6888.

OCTOBER 2010

Radiology

The Power and Promise of Breast Thermography

A pain-free, radiation-free tool for improving early breast cancer detection By John C. Pittman, M.D.

Breast thermography works on the principle that factors involved in tumorigenesis, notably neovascularization (the formation of new blood vessels), generate a tiny amount of heat or inflammation. These infrared emissions can be accurately measured to tiny fractions of a degree using a specialized infrared camera and then displayed as a spectrum of colors representing temperature – the so-called “thermogram.” Why do we screen for breast cancer? The theoretical rationale is that early detection and early treatment should improve the prognosis. This seems so commonsensical that mammography has long been embraced without question. However, the recently revised federal guidelines published last November in the Archives of Internal Medicine – waiting until age 50 to get the first mammogram and then only getting one every

The Triangle Physician

two years – have caused many physicians to reexamine their beliefs about this technology. It can be argued, of course, that at least some women screened via mammography will avoid dying from breast cancer or receive less aggressive treatments. But many more women will be over-diagnosed due to a false positive reading and receive needless treatment. In October 2009, the esteemed Cochrane

Database of Systematic Reviews, concluded that, based on all randomized trial evidence, only 1 out of every 2,000 women getting an annual mammogram over a 10-year period will have her life prolonged. In addition, 10 healthy women will be over-diagnosed with breast cancer and will be treated unnecessarily, while more than 200 women will experience serious emotional distress for months due to false-positive findings.

Dr. John Pittman, M.D., became interested in thermography in the early 1990s, which led him to team up with Carolina Thermascan founder Lewis Stocks, M.D., Ph.D. (Dr. Stocks currently reads all scans. He is available to provide follow-up ultrasounds and any other evaluation should an abnormality be found, though the patient’s primary care physician is encouraged to review all scan results.) In addition to directing Carolina Thermascan, Dr. Pittman directs the Raleigh-based Carolina Center for Integrative Medicine (www.carolinacenter. com). He regards breast thermography as a superb opportunity for early detection and ultimately for the successful prevention and treatment of breast cancer. For more information, call (919) 781-6999 or visit www.carolinathermascan.com.

In response to the Cochrane review, the U.S. Preventive Services Task Force performed a systematic review that found a 16 percent relative risk reduction, in agreement with the Cochrane review. However, the absolute risk reduction was a mere 0.05 percent. Because about 10 percent of women will die of other causes, this finding means that, if women choose not to get a mammogram, 90.20 percent will be alive after 10 years versus 90.25 percent who choose mammography.

representing temperature – the so-called “thermogram.”

of the breasts probably increases a woman’s risk of getting breast cancer at least ten-fold.”

The sensitivity of thermography appears to exceed that of mammography, meaning that a normal thermogram has a smaller chance of missing cancer when compared to a normal mammogram. According to recently published clinical studies, the sensitivity of thermography for detecting breast cancer ranges from 97% to 99%. In contrast, estimates of mammography’s sensitivity range from 75% to 90%. On the other hand, although an abnormal thermogram could indicate cancer, it lacks the specificity to show whether cancer actually exists. This would require further testing, such as the use of ultrasound and perhaps ultimately a tissue biopsy.

As noted in a 2009 review published in Integrative Cancer Therapies, “No single tool provides excellent predictability; however, a combination that incorporates thermography may boost both sensitivity and specificity.” The combination of mammography and thermography appears to be the best strategy for women over 50, with each provided on alternating years biannually. For these older women, breast thermography cannot replace mammography, as there are some tumors that do not generate much heat and may be missed.

In 2002, researchers offered the following conclusion in IEEE Engineering in Medicine and Biology: “Several studies have shown that infrared imaging [thermography] is a good, and perhaps the best, method for risk assessment in breast cancer…the presence of an abnormal asymmetric infrared heat pattern

Based on the new screening guidelines, we believe a good overall strategy for monitoring breast health would be as follows: • At age 25, start Thermascan screening every two years. • At age 35, increase to every year until age 50. • After age 50, go back to every other year, alternating with mammograms so that one or the other procedure is done yearly.

Moreover, several recent studies indicate that mammography could be doing more harm than good for women under age 50, women with dense breasts, and women with the BRCA1 and BRCA2 mutations. As stated in a 2004 Radiation Research report, “[T]he risks associated with mammography screening may be approximately five times higher than previously assumed.” Such risks are avoided entirely with the radiation-free, contact-free technology called breast thermography, or digital infrared thermal imaging. Breast thermography works on the principle that factors involved in tumorigenesis, notably neovascularization (the formation of new blood vessels), generate a tiny amount of heat or inflammation. These infrared emissions can be accurately measured to tiny fractions of a degree using a specialized infrared camera and then displayed as a spectrum of colors OCTOBER 2010

Business Management This is the first in a two-part series.

Right-Sizing Your Medical Office Staff By John J. Reidelbach

Your goal must be to fine-tune your daily operations and retain good employees, as turnover is costly to a practice. Staffing appropriately presents one of the greatest challenges in a medical practice. Much has been written about this very subject over the years, but there are still no hard and fast rules cited in the literature. With careful management and attention to detail, every practice has the ability to come close to its ideal. Along the way, your goal must be to fine-tune your daily operations and retain good employees, as turnover is costly to a practice. Benchmarking Benchmarking is a comparative measure that will provide a starting point for you as you critically evaluate your staffing model. The Medical Group Management Association (MGMA) provides benchmarks by specialty for the number of full-time employees (FTEs) in an average practice as a total and by separating out clinical staff from

administrative personnel. Staff costs as a percentage of revenue is another benchmark you should carefully evaluate. To apply benchmarks to your practice, it would behoove you to examine the inner workings of your office. If you donâ&#x20AC;&#x2122;t have an organizational chart, you will need to develop one. If you already have one, does it still make sense? If it doesnâ&#x20AC;&#x2122;t truly reflect the functioning of the practice and the specific staffing requirements, as well as to whom each employee reports, it is time to update it. The organizational chart is mission critical for establishing a foundation for your human resources structure. It is the heart and soul of practice communications, staffing models, and more importantly, accountability. Job Descriptions If you do not have a job description for

every employee in the company, you will likewise need to develop them. The job description should define what is required of that employee in terms of education and experience, as well as what is expected of each position. A job description typically includes the position title, educational requirements and the skills needed to be considered for employment. It must also define the job responsibilities so each employee knows what is expected of him/ her. To follow is a listing of the essential components of a well-written job description: 1. Job Title 2. General Summary of Duties 3. Supervision Received 4. Supervision Exercised 5. Essential Functions 6. Education 7. Experience 8. Requirements 9. Knowledge 10. Skills 11. Abilities 12. Environmental/Working Conditions 13. Physical/Mental Demands This disclaimer is also recommended at the conclusion of the job description: This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve. You must remember that a job description is a living document and should be reviewed on a regular basis and updated from time to time, as you make changes and

The Triangle Physician

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

reflect those changes so that you optimize staff productivity.

that it pays to invest in a well-educated, welltrained staff.

Staff cost as a percentage of revenue is another benchmark to evaluate as you compare your group with better performing practices. It is important to remember that as you increase productivity, the cost of doing business goes down. Staffing costs in a typical primary care practice in the United States are at or slightly above 30 percent and even higher in specialty practices. It is, therefore, completely reasonable to focus continually on your staffing costs. Remember however,

Also integral to a discussion of wages is the high cost of providing benefits to your staff, particularly healthcare insurance. Medical practice employees are rated in a higherthan-average risk category when it comes to premiums and with it comes an inherently higher cost. Despite this, you must remember that benefits are an important consideration in attracting and retaining skilled staff, and they can provide a competitive advantage in a tight labor market.

processes in your office evolve. For example, if you automate insurance verification and eligibility prior to patient registration, it will take less time to schedule new patient appointments and open up time for your front desk support staff members to assume additional responsibilities that should be added to their job description. Staff Evaluations Conducting yearly reviews of your staff will allow you to establish performance measures specific to the job description and help you better understand your staffing needs. More importantly, this review lets staff members know what is expected of them and provides an objective tool when itâ&#x20AC;&#x2122;s time to give pay increases. For example, does the front desk receptionist make numerous errors when entering the patient demographics in your practice management system and/ or are you even tracking the errors? What is the rejection rate of your electronic claims filings? How many phone calls does your appointment scheduler book in one day? When the needs of the practice change, you will need to modify the job description to Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

OCTOBER 2010

Radiology

Studies Support Importance of

Screening in

Breast Cancer Reduction By Kathleen A. Havlin, M.D.

Mortality rates from breast cancer were stable for many years until 1990, when rates were noted to decline on an average of 2.1 percent per year, but mostly in white women. Investigators using several statistical models estimated the proportional reduction in breast cancer mortality from mammographic screening ranged from 28 percent to 65 percent with adjuvant treatment accounting for the remainder of benefit. These results correlate with a 10 percent decrease in mortality from breast cancer due to screening. October is dedicated to breast cancer awareness, with an appropriate focus on screening. Breast cancer is a common disease, in which 1 in 8 women are diagnosed with breast cancer over their lifetimes. Most individuals can name a relative, friend or co-worker who has been diagnosed with the disease. When diagnosed early, most individuals will continue to enjoy a normal life expectancy. The majority of breast cancers in the United States are diagnosed as a result of an abnormal screening exam or found by the patient or clinician exam. The incidence of breast cancer peaked in 1998 and then declined by 3.5 percent per year from 2001 to 2004. This decline in part followed the Women’s Health Initiative report. It noted the association of hormone replacement therapy with an increased incidence of breast cancer, and reflected decreased use of hormone therapy but also may reflect lower screening rates. Documented screening rates for U.S. women aged 40 and older fell from 70 percent to 66 percent from 2000-2005.

The Triangle Physician

Mortality rates from breast cancer were stable for many years until 1990, when rates were noted to decline on an average of 2.1 percent per year, but mostly in white women. Investigators using several statistical models estimated the proportional reduction in breast cancer mortality from mammographic screening ranged from 28 percent to 65 percent with adjuvant treatment accounting for the remainder of benefit. These results correlate with a 10 percent decrease in mortality from breast cancer due to screening. The obvious concern is that if decreased screening rates continue, mortality rates may again increase. Mortality rates in African-American women declined less than in white women. A large study conducted between 1996-2002 noted that AfricanAmerican women were more likely to have inadequate screening than white women. However, differences in characteristics of breast cancers – size, stage and lymph node positivity (grade not included) – were not significant between white and black women when screening histories were similar. Breast self-exam and regular mammograms are encouraged to find early disease. Only

mammograms, however, have shown in welldesigned clinical trials to decrease mortality from breast cancer. Like any other modality in medicine, radiologic techniques and machines are constantly evolving and improving. There are two basic types of mammograms – film-screen and digital – which represent the mainstay of screening in breast cancer. Film screen mammography results in an image captured on a film, which is then developed and read. With full field digital mammography, the image is captured on a computer, which is then processed and displayed in multiple formats. Two large studies, Oslo II and Digital Mammographic Imaging Screening Trial (DMIST) compared the two types of mammograms. The Oslo II study randomized 25,263 women to digital or film screen mammography. The DMIST study involved 49,528 women who underwent both film screen and digital mammograms. The overall diagnostic accuracy was similar with the two modalities. However, digital mammograms were more accurate in preand peri-menopausal women and in women with dense breasts. Film mammography

Dr. Kathleen A. Havlin is a breast cancer specialist, who recently joined the medical staff at Johnston Hematology and Oncology, an outpatient service of Johnston Health. She also is an associate professor of clinical medicine at Duke University School of Medicine. Prior to moving to North Carolina, Dr. Havlin was director of the hematology oncology fellowship program at the University of Cincinnati College of Medicine. She has 23 years of experience in academic medicine, including a previous appointment in the Duke University Breast Program from 1992 through 1996. After earning her medical degree in 1982 from Northwestern University in Chicago, Dr. Havlin completed an internship and residency at Northwestern Memorial Hospital. She did a fellowship at the University of Wisconsin in Madison and another at the University of Texas Health Science Center at San Antonio, where she worked on testing and development for cancer drugs, several of which are now standard chemotherapy treatments.

Increase your

chance of breast cancer survival

| First breast dedicated surgical practice in Raleigh | Among the first in the country to receive Masters of Breast Surgery Certification

remains an acceptable screening modality for all women. If available, digital mammography may offer an advantage in women younger than 50 or in those with dense breasts. No studies have been published evaluating breast MRI as a screening tool and its effect on breast cancer mortality. It is more sensitive, but less specific than mammograms. Breast MRI is currently approved as an adjunct to mammograms in individuals at high risk of developing breast cancer (> 20-25% lifetime risk), such as those women with BRCA1 or BRCA2 mutations.

| Studies show that patients being cared for by surgeons specializing only in breast cancer have a higher survival rate | Semimonthly in office multdisciplinary conferencing with radiology and pathology | Six years of collaborative relationship with radiology with in office diagnostic imaging

2301 Rexwoods Drive Suite 116 | Raleigh

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

919.782.8200 | www.carolinabreastcare.com

The American Cancer Society, American College of Radiology, American Medical Association, the National Cancer Institute, the American College of Obstetrics and Gynecology and the National Comprehensive Cancer Network recommend screening starting at age 40. Some groups recommend screening every one to two years for the 40-49 age group or shared decision-making regarding interval screening in this age group. There is insufficient evidence for screening beyond the age of 74. In general, if life expectancy approaches 10 years, continued mammographic screening is reasonable.

OCTOBER 2010

Radiology

Guidelines for

Referring a Patient for Breast MRI By Ashley Hawkins, M.D.

Currently, breast magnetic resonance imaging (MRI) is a staple in the armamentarium of todayâ&#x20AC;&#x2122;s breast radiologist. Despite the increased broad clinical use of breast MRI, there is still some confusion among clinicians as to when to refer a patient for a breast MRI. This article intends to outline the current indications for breast MRI. They can be

The Triangle Physician

divided into three broad categories: implant integrity, breast cancer screening and new diagnosis of breast cancer.

used when evaluating implants. In addition, special sequences are performed that make water and fat dark and silicone bright.

Implant Integrity In the first category, it is important to be aware that the imaging techniques for evaluating silicone implant integrity are vastly different than those for the evaluation of breast cancer. For one, no contrast is

These techniques are not done with traditional breast cancer screening protocols. Therefore, if a clinician is concerned about silicone implant rupture and the answer cannot be ascertained with clinical exam, mammogram or ultrasound, then an

Ashley Hawkins, M.D. has joined the staff at Raleigh Radiology. • BA, University of North Carolina at Chapel Hill • MD, Wake Forest University School of Medicine • Internship in Internal Medicine, Carolinas Medical Center • Residency, Duke University Medical Center • Fellowship in Breast Imaging, Duke University Medical Center

implant protocol breast MRI could be done. Evaluation for implant rupture should be indicated when the MRI is ordered so the appropriate protocol is performed.

Cowden syndrome or Bannayan-RileyRuvalcaba syndrome, or those who may have one of these syndromes based on the history of a first-degree relative. If you are uncertain of your patient’s lifetime risk, you can use the National Cancer Institute’s Breast Cancer Risk Assessment Tool at www.cancer.gov/bcrisktool. Some highrisk breast clinics screen high-risk patients using mammogram one month and then MRI six months later. This allows the patient to have both their mammogram and MRI on an annual basis, yet the patient is undergoing imaging surveillance every six months. New Diagnosis or Prior History The third broad category applies to those women with a new diagnosis of breast cancer

The National Cancer Institute offers a Breast Cancer Risk Assessment Tool at www.cancer.gov/bcrisktool. For the rare case, where silicone implant integrity and breast cancer surveillance are both of concern, rather than have a patient undergo two separate MRIs, evaluation of the implant could be done with mammogram and ultrasound, and then an MRI using the breast cancer protocol could be obtained for breast cancer screening.

or a prior history of breast cancer. Breast MRI is currently the most accurate imaging we have for establishing disease extent (in both the ipsilateral and contralateral breast) in patients with newly diagnosed or recurrent breast cancer. Pre-operative MRI can help establish extent of disease, which better enables the surgeon to get clear margins with only one surgical intervention.

Breast MRI is also used to evaluate for residual disease in the setting of close or positive margins in the post-lumpectomy patient. In addition, in patients undergoing neoadjuvant chemotherapy, MRI can be used to monitor early response to therapy, as well as determine if there is residual cancer at the completion of therapy. Finally, in a small percentage of women, the initial presentation of breast cancer is with metastatic disease to the axillary lymph nodes. In these scenarios, where the primary breast cancer is mammographically occult, an MRI is indicated to locate the site of primary breast cancer. Ideally breast MRI exams are not interpreted by a radiologist in a vacuum. Correlation with recent mammography enhances the strength of the interpretation, and a current mammogram is suggested within a month of the MRI, unless the patient is undergoing high-risk screening. Therefore, if a patient has not had a recent mammogram and she is over age 40, she should get a mammogram at the time she gets her MRI. Finally, the last important point to make is that diagnostic mammogram and ultrasound are still the initial imaging tests for palpable lumps, not MRI.

Breast Cancer Screening The second broad category for the use of breast MRI is breast cancer screening. The American Cancer Society has come out with guidelines for the use of screening MRI. According to these new guidelines, those who are eligible for annual screening breast MRI have one or more of these characteristics: • A known BRCA1 or BRCA2 mutation, • A first-degree relative with the BRCA1 or BRCA2 mutation, • A lifetime risk of breast cancer greater than 20-25 percent, • A history of radiation to the chest between the ages of 10 and 30, • Either Li-Fraumeni syndrome, OCTOBER 2010

Hospital News

Duke Weight-loss Surgery Center Is Redesignated a Center of Excellence The Duke Center for Metabolic and Weight Loss Surgery at Durham Regional Hospital has been redesignated as an American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence (BSCOE).

To earn BSCOE recertification, the Duke Center for Metabolic and Weight Loss Surgery underwent a series of site inspections, during which all aspects of the program’s surgical processes and outcomes were closely examined.

The ASMBS BSCOE designation recognizes surgical programs with a demonstrated track record of favorable outcomes in bariatric surgery. The program has been continuously credentialed since 2006. The recertification process occurs every three years.

“We are pleased to be honored for our contributions to weight loss surgery and for providing the highest quality in patient care,” said Aurora Pryor, M.D., surgeon and co-medical director of the Duke Center for Metabolic and Weight Loss Surgery.

ASMBS is a professional organization that works to elevate the quality of bariatric surgery nationwide by providing its members support to improve care, advance science, foster communication, advocate for health care policy and educate the next generation of providers.

Obesity has become a significant national health issue, with the Centers for Disease Control and Prevention (CDC) reporting that 66 percent of all adults in the United States are overweight or obese. Morbid obesity is closely correlated with a number of serious conditions that severely undermine the

health of overweight patients, including heart disease, high blood pressure and diabetes. Bariatric surgery, when performed correctly, can help obese patients manage these conditions. “At the Duke Center for Metabolic and Weight Loss Surgery, our focus is on improving the lives of our patients,” said Pryor. “We take a multidisciplinary approach for each patient, offering extensive education and counseling and a high commitment to patient follow up and outcomes.” In fiscal year 2010, surgeons with the Duke Center for Metabolic and Weight Loss Surgery performed more than 700 bariatric surgery procedures. The program offers Roux-en-Y gastric bypass, adjustable gastric banding (Lap Band and Realize), duodenal switch, sleeve gastrectomy and revisional procedures at Durham Regional Hospital.

Rex Earns Bariatric Distinctions Rex Healthcare now has two national designations for bariatric surgery. The Blue Cross and Blue Shield of North Carolina (BCBSNC) Blue Distinction Center for Bariatric Surgery designation is in addition to the American Society for Metabolic Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence designation. Obesity is widely recognized as a contributor to serious health risks. According to the Agency for Healthcare Research and Quality, the total number of bariatric surgeries increased 400 percent from 1998 to 2004. Bariatric surgery may help some individuals reduce extreme obesity and its associated health risks, and Blue Distinction provides objective information to help them make informed decisions when choosing a provider. Rex Healthcare provides a full range of bariatric services, including surgery inpatient care, postoperative care and outpatient follow-up, and patient education and wellness services.

The Triangle Physician

To be designated as a Blue Distinction Center for Bariatric Surgery, Rex Healthcare met the selection criteria posted at www.bcbs.com, which includes: • An established bariatric surgery program, actively performing these procedures for the most recent 12-month period and performing a required minimum volume of 125 such surgeries annually. • Appropriate experience of its bariatric surgery team. • An acute care inpatient facility, including intensive care and emergency services. • Full accreditation by The Joint Commission, Healthcare Facilities Accreditation Program or national equivalent. • A comprehensive quality management program. “Rex is pleased to be recognized for our efforts to help patients overcome obesity and get healthy,” said Linda Butler, M.D., chief medical officer at Rex Healthcare. “BCBSNC’s continued efforts to advance the practice of bariatric care have helped patients make more

informed decisions and have raised the bar for all quality bariatric care.” “Blue Distinction puts a high value on research and evidence-based health and medical information,” said Allan Korn, M.D., Blue Cross and Blue Shield Association chief medical officer. “Blue Distinction Centers show our commitment to working with doctors and hospitals in communities across the country to identify leading institutions that meet clinically validated quality standards and deliver better overall outcomes in patient care.” The BCBSNC designation is based on rigorous, evidence-based selection criteria established in collaboration with expert physicians’ and medical organization’s recommendations. Today, more than 800 Blue Distinction Center designations have been awarded to facilities nationwide, providing consumers with a framework for making informed decisions on where to go for specialty care in the areas of bariatric surgery, cardiac care, complex and rare cancers, and transplants.

Hospital News

Total Joint Program Is First To Earn Gold Seal of Approval The Joint Commission awarded Duke Raleigh Hospital Disease-Specific Care Certification for its Total Joint Replacement Program in recognition of its commitment to excellence.

excellence and the caliber of teamwork and collaboration across the entire hospital that enables us to provide the very best care to our patients.”

Duke Raleigh’s Total Joint Replacement Program is a comprehensive, multidisciplinary program that includes pre-operative patient education, surgical and medical care, acute rehabilitation, assistance with discharge planning and post-operative wellness instruction. Duke Raleigh performed more than 700 joint replacement surgeries last year.

Duke Raleigh is the first in the Triangle to earn this distinction and one of only five other programs in the state with the certification. To earn this distinction, the program underwent an extensive, announced, on-site evaluation by The Joint Commission. The program was evaluated against Joint Commission standards through an assessment of the program’s processes and ability to evaluate and improve care within its own organization and through interviews with patients and staff. “Duke Raleigh Hospital voluntarily pursued this comprehensive, independent evaluation to enhance the safety and quality of care we provide,” said Doug Vinsel, president. “We are honored to demonstrate our standard of

Disease-Specific care programs that successfully demonstrate compliance in all three areas are awarded certification for a two-year period.

Disease-Specific Care Certifications are based on three core areas: compliance with national standards; effective use of established clinical practice guidelines; and an organized approach to performance measurement and improvement activities.

“We applied for certification because we are proud of our program,” said Liz Jackson, director of orthopedic services at Duke Raleigh. “In the process, we have examined our program and identified opportunities to improve and now have even more to be proud of. Thanks to this distinguished recognition, now others will know why we’re so proud too.”

Smithfield Radiation Oncology Opens Smithfield Radiation Oncology brings comprehensive cancer care to Smithfield and the surrounding Johnston County. The new state-of-the-art facility, which opened Sept. 13, is a partnership between Johnston Health and Rex/UNC Radiation Oncology. It offers expert physicians and dedicated staff using the latest technologies and treatment options to provide a broad scope of services and quality care for patients.

“Now, the same expertise and quality care found at the Rex Cancer Center and the nationally recognized NC Cancer Hospital at UNC Health Care is more accessible for patients and families in Smithfield and surrounding areas,” said medical director Dr. Scarantino. “We look forward to working with our new patients and the Smithfield community.”

radiation oncology services and cutting-edge, comprehensive cancer care in Clayton with the opening of Clayton Radiation Oncology.

Johnston Health and Rex/UNC Radiation Oncology also recently partnered to offer

For more information, visit www.rexhealth. com or www.johnstonhealth.org.

Smithfield Radiation Oncology is located across the street from Johnston Medical Center–Smithfield in Johnston Medical Mall in Smithfield.

The practice’s clinical team is led by medical director Charles W. Scarantino, M.D., Ph.D., and physicians Catherine Lee, M.D., and Justin Wu, M.D. OCTOBER 2010

Hospital News

Scanners Are Region’s First For Larger Patients Durham Regional Hospital has become the first hospital in the region to install computed-tomography (CT) scanners that can accommodate oversized patients. The two new 64-slice CT scanners are bariatric rated, with larger bores and highcapacity tables to accommodate patients up to 660 pounds. “With obesity reaching epidemic levels, there are more people in need of medical equipment that can cater to a higher weight,” said Greg Thon, M.B.A., director of radiology at Durham Regional Hospital. Computerized tomography, also known as a CAT scan, combines a series of X-ray views taken from many different angles to produce

a cross-sectional image of the tissues and bones in the body. The 64-slice scanner allows radiologists to image the heart, brain or lungs in only a few seconds. Capabilities also include CT angiography, which enables physicians to view arteries in the brain, heart and peripheral vascular system in greater detail than before, and CT brain perfusion studies to evaluate blood flow to the brain in potential stroke patients.

Hemang Pathak, M.D., chair of the Radiology Department at Durham Regional Hospital. “The scanners also deliver low-dose X-ray radiation, while providing this excellent image quality, making it safer for patients and staff.”

“The new technology allows radiologists higher quality images than ever before,” said

Durham Regional Wins Cardiovascular Award Durham Regional Hospital is one of only 135 hospitals nationwide to have won the American College of Cardiology Foundation’s National Cardiovascular Data Registry (NCDR) ACTION Registry-GWTG (Get With the Guidelines) Gold Performance Achievement Award for 2010. The award recognizes Durham Regional’s commitment to, and success in implementing, a higher standard of care for heart attack patients. It also signifies that the hospital has reached an aggressive goal of treating coronary artery disease patients, with 85 percent compliance to core standard levels of care outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations. “We’re honored to be recognized by the American College of Cardiology for the work our physicians and staff have done to maintain high quality cardiovascular care for our patients,” said Kerry Watson, president of Durham Regional Hospital.

The Triangle Physician

To receive the award, Durham Regional consistently followed the treatment guidelines for 24 consecutive months. These include aggressive use of medications like cholesterol-lowering drugs, beta-blockers, ACE (angiotensin-converting enzyme) inhibitors, aspirin and anticoagulants in the hospital.

experienced and coordinated staff,” said Elizabeth Henke, M.D., division chief of cardiology at Durham Regional Hospital. “It requires skill and dedication by every member of the cardiac team. We are honored that our cardiac team’s excellence in patient care has been recognized with the prestigious gold performance award.”

“The American College of Cardiology Foundation and the American Heart Association commend Durham Regional Hospital for its success in implementing standards of care and protocols,” said Gregg C. Fonarow, M.D., ACTION Registry-GWTG Steering Committee chairman and director of Ahmanson-UCLA Cardiomyopathy Center. “The full implementation of acute and secondary prevention guidelinerecommended therapy is a critical step in saving the lives and improving outcomes of heart attack patients.”

Created by the merger of the American College of Cardiology Foundation’s NCDR ACTION Registry and the American Heart Association’s Get With The GuidelinesCAD program, ACTION Registry–GWTG combines both programs into a single, unified national registry. The new registry joins data collection and quality reporting with collaborative models, tools and quality improvement techniques. It establishes a national standard for understanding and improving the quality, safety and outcomes of care provided for patients with coronary artery disease.

“Providing life-saving care for the patient with heart disease is only possible with an

News Welcome to the Area

Physicians P.A.ula Clark Adkins, M.D. Emergency Medicine Pinehurst

Jason Michael Arru, M.D. General Surgery Kernodle Clinic, Burlington

Janine Serebro Beeson, M.D. Radiology Duke University Hospitals, Durham

Jennifer Lynn Brown, M.D. Chapel Hill

Kathryn Pierce Celauro, M.D.

Upcoming Events Lynn Bunch O’Neill, M.D.

Molly Elizabeth Speight, P.A.

Hospital Medicine Program Duke University Hospitals, Durham

Raleigh

Vamsee Prasad P.A.ruchuri, M.D.

Hillsborough

Cary

Sonal Shirish P.A.tole, M.D. Psychiatry UNC De P.A.rtment of Psychiatry, Chapel Hill

Anesthesiology University of North Carolina Hospitals, Chapel Hill

David Arthur Pillinger Jr., M.D.

Chitrabharathi Chandrasekaran, M.D.

Carol Marie Schobert, M.D.

North State Medical Center, Roxboro

Shelby Lynette ClayRogers, M.D.

Flat Rock

Trisha Miller Shattuck, M.D. Pathology Duke University Hospitals, Durham

Johnston Medical Center, Smithfield

Monica Nora Slubicki, M.D.

Tarek Dakakni, M.D.

Psychiatry Duke University Hospitals, Durham

Neurology Duke University Hospitals, Durham

Sa P.A.n Sharankishor Desai, M.D. General Surgery Duke University Hospitals, Durham

Neda Esmaili, M.D. Ophthalmology 7 Preakness Drive, Durham

Ezmin George, M.D. Internal Medicine Duke University Hospitals, Durham

Ashley Hawkins, M.D.

• BA, University of North Carolina at Chapel Hill • MD, Wake Forest University School of Medicine • Internship in Internal Medicine, Carolinas Medical Center •R esidency, Duke University Medical Center • F ellowship in Breast Imaging, Duke University Medical Center

Michael Benjamin Hopkins, M.D. Duke Raleigh Hospital, Raleigh

Olga James, M.D.

Stela Susac- P.A.vic, M.D. Family Practice University of North Carolina Hospitals, Chapel Hill

Ana Carolina Vega, M.D. Burlington

Emanuela Fernandes Tavora Veras, M.D. Durham

North State Medical Center, Roxboro

Physician Assistants Georie Melissa F. Briggs, P.A. Durham

Justin Michael Call, P.A. Cary

Danielle Elizabeth Cardona, P.A.

Matthew Gary Kanaan, DO

Kristin Ilene Flood, P.A.

Michelle McCrain Kiser, M.D. General Surgery University of North Carolina Hospitals, Chapel Hill

Kevin York Marra, M.D. Psychiatry University of North Carolina Hospitals, Chapel Hill

Justin Thomas Mhoon, M.D.

Raleigh Raleigh

Nicole Marie Graf, P.A. Duke University, Durham

Jami Lee Hagler, P.A. Kernodle Clinic Mebane, Mebane

Erica Dawn Hill, P.A. Angier

Julia Michelle Koch, P.A. Loren Thomas-Chew Macias, P.A.

Talal Imad Mousallem, M.D.

Sarah Marie Meleen, P.A.

Iliana Angelica Neumann, M.D. Family Medicine University of North Carolina Hospitals, Chapel Hil

Anne-Caroline Norman, M.D. Emergency Medicine Durham

Saturday, Oct. 2, 9 a.m.

Over the Edge for Special Olympics NC Wachovia Capitol Center courtyard, Raleigh Raise at least $1,000 to rappel from the edge of the 30-story Wachovia Capitol Center Building. Limited to 80 people. Call (919) 821-6975.

Thursday, Oct. 7, 6:30-9 p.m.

LUNAFEST 2010-2011 Varsity Theatre, Chapel Hill An evening of short films by, for and about women will benefit Family Violence Prevention Center of Orange County and the Breast Cancer Awareness Fund. Filled with stories of reflection and whimsy, hope and humor, grace and perseverance, LUNAFEST films are renowned for celebrating the talents and stories of women. $10, general admission;$5, students. Call (919) 929-7122

Saturday, Oct. 9, 6 a.m. to noon

You Don’t Have To Run 5K Run/Walk Against Domestic Violence Research Triangle Park Headquarters, Durham Hosted by I’m Still Standing Inc., a new area nonprofit, to fight domestic violence and raise funds for a safe home for families in transition. $20, adults 18+; $10, adolescents 11-17; $5, children 5-10; free, under 5. Call (919) 724-8139

Saturday, Oct. 9, 9 a.m.

le Tour de Femme All Women’s Bike Ride Cycling Spoken Here, 1377 N.W. Maynard Road, Cary This charity ride supports Breast Cancer Awareness Month, and benefits Rex Hospital’s Angel Fund and the Lance Armstrong Foundation. It offers options of 15-, 31- or 62-mile distances. The ride is fully catered with breakfast, sag stops, lunch and entertainment. Call (919) 461-0066.

Raleigh

Neurology Duke University Hospitals, Durham Pediatrics Duke University Hospitals, Durham

Upcoming Events

Triangle Surgical Association, Cary

Nuclear Medicine Duke University Hospitals, Durham Family Medicine Duke University Hospitals, Durham

Kelly A Watson, P.A.

David Zachary Zeiler, M.D. Sha Zhu, M.D.

Durham PrimeCare Physicians, Goldsboro

Christopher Brown Newlin, P.A. Durham

Rachel Ann Shaarda, P.A. Apex

FAAN Walk for Food Allergies Bond Park, Cary Two-mile walk to raise awareness and support in the search for a cure for food allergies.

Durham Durham

Internal Medicine University of North Carolina Hospitals, Chapel Hill

Yong Chen, M.D.

Khoan Thanh Thai, P.A.

Sarah Ann P.A.tterson, M.D.

Obstetrics and Gynecology 4215 New Bern Place, Durham 406 Perrault Drive, Morrisville

Erica Booth Sudyk, P.A.

Saturday, Oct. 23, 9 a.m.

Saturday, Oct. 9, 5-9 p.m.

Friday, Nov. 12, 7 p.m.

Raleigh Roundup Kerr Scott Building at the NC State Fairgrounds, Raleigh To benefit the American Cancer Society. Hosted by the Red Sword Guild. Music by popular country band YARN, followed by dance band Party on the Moon. Other entertainment: bull riding, gambling, silent and live auctions, and raffles. Food and libations: fine food by top area chefs and a variety of beverages. Call (919) 782-5599.

Saturday, Nov. 20, 6 p.m.

Cat Angels Pet Adoptions Annual Silent Auction N.C. State University Club, Raleigh Third annual silent auction to benefit rescued cats and kittens. Attendees can bid on more than 300 assorted items, including: jewelry, art, holiday, spa and beauty, services, pet care, house wares and more! Call (919) 828-0308.

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

Urology

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

Gynecology Women’s Wellness Clinic

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

Sixth Annual Live Auction Raleigh Auction and Estate Sales, 4900-A Craftsman Drive, Raleigh To benefit SAFE Haven for Cat. Everyone who attends will be entered into a drawing for a $3,100 gold and diamond tennis bracelet. Cats will be available for adoption. Call (919) 790-2251.

Study participants will receive at no cost: Birth control pills for 1 year, study related exams, compensation for time and travel is available. For information, please call 919-251-9223.

Holly Marie Short, P.A. Duke University Medical Center, Durham

OCTOBER 2010

News

UNC Obstetrics and Gynecology Is in the News Honors and Awards UNC Reproductive Endocrinology & Infertility Clinic was named in the latest quarterly listing of the Top 5 clinics at UNC Health Care by the Ambulatory Patient Experience Team (APEX) as part of UNC’s Commitment to Caring initiative. Dr. Vickie Bae-Jump was awarded a K23 Mentored Patient-Oriented Research Career Development Award grant entitled “Metformin as a Novel Chemotherapeutic Strategy for the Treatment of Endometrial Cancer.” The grant award is $792,104 over five years. Dr. Barbara Robinson has been selected as one of two lead fellows for the American Urogynecologic Society Fellows Interest Group.

Sound Bites Dr. Dan Clarke-Pearson was featured in the popular Brazilian magazine Veja in the July 27 issue, when he talked about cancer care in the United States. Dr. Linda Van Le was featured on YOUR HEALTH, UNC Family Medicine’s weekly health radio show, to talk about the women and cancer. The News & Observer reported on UNC Maternal and Infant Health Center being praised by the March of Dimes for its role in North Carolina hospitals showing a 44 percent decrease in early elective deliveries. “Helping Babies Arrive at the Right Time” featured the Perinatal Quality Collaborative of North Carolina on North Carolina Public Radio WUNC. On www.kickstarter.com, check out the “Cancer Rock Documentary,” featuring N.E.D. (No Evidence of Disease), a musical journey of six gynecologic oncologists and the power of music in the fight against cancer. Band members include: Dr. John Boggess, guitar, vocals, is associate professor of obstetrics & gynecology and fellowship program director, Division of Gynecologic Oncology at the University of North Carolina School of Medicine. Dr. John Soper, guitar, is the Hendricks professor of obstetrics and gynecology at the University of North Carolina School of Medicine.

The Triangle Physician

Blogging Dr. Jennifer Howell talks about the top five breast cancer myths in an Aug. 20 post. Dr. Bill Goodnight explains recent American College of Obstetricians and Gynecologists guidelines for use of antibiotics before C-sections in an Aug. 25 post. Dr. John Soper sheds light on over treating and under treating dysplasias in a Sept. 8 post. Susan Nickel, C.N.M., M.S.N., shares advice about menopause in a Sept. 13 post.

Presentations Dr. Dan Clarke-Pearson and Dr. John Soper were local hosts of the 60th annual Meeting of the Society of Pelvic Surgeons in Durham, N.C., Sept. 15-18. UNC presenters included: John Boggess, M.D., “Robotic Surgery in Gynecology;” and Catherine Matthews, M.D., “Prospective Evaluation of Surgical Outcomes of Roboticassisted Colpo and Cervicosacropexy.”

Dr. AnnaMarie Connolly was the featured speaker at the Annual Surgeons as Educators Conference, UNC Department of Surgery, Sept. 11.

Dr. David Grimes had the following presentations: • The Perlmutter lecturer at Beth Israel Deaconess Medical Center, Boston, Mass., Sept. 8. • “Unsafe Abortion: The Preventable Pandemic” at Global Health in Obstetrics and Gynecology at Harvard, Boston, Mass., Sept. 10.

Poster presentations: • “Prospective Evaluation of Surgical Outcomes of Robotic-Assisted Colpo- and Cervicosacropexy for the Management of Apical Pelvic Support Defects.” Woodward A, Matthews C, Hill A, Ramakrishnan V, Gill E • “Surgical Management of Apical Pelvic Support Defects: Evaluation of the Introduction of Robotic Technology.” Woodward A, Matthews C, Lamb E, Gill E

S, Klein RL, Boggess K. Am J Obstet Gynecol. 2010 Sep;203(3):246.e1-4.

“Vitamin D Status and Periodontal Disease Among Pregnant Women.” Boggess KA, Espinola JA, Moss K, Beck J, Offenbacher S, Camargo CA. J Periodontol. 2010 Sep 1. [Epub ahead of print]

Oral presentation: “Robotic-assisted Sacrocolpopexy for the Management of Vaginal Vault Prolapse”

UNC Women’s Health Lecture Series Dr. Catherine Matthews, “Urinary Incontinence: NOT an Acceptable Consequence of Aging” Aug. 31

Dr. Wesley Fowler, “Overview of Gynecological Cancers” Sept. 8

Dr. Michael Evers, “Screening Tests and Women’s Health” Sept. 15

Publications “A Nested Case-Control Study of Midgestation Vitamin D Deficiency and Risk of Severe Preeclampsia.” Baker AM, Haeri S, Camargo CA Jr, Espinola JA, Stuebe AM. J Clin Endocrinol Metab. 2010 NEWSOURCE-JUN10:Heidi 8/5/10 12:57 Aug 18. [Epub ahead of print]

“B Cell Acute Lymphocytic Leukemia in Pregnancy.” BottsfordMiller J, Haeri S, Baker AM, Boles J, Brown M. Arch Gynecol Obstet. 2010 Aug 18. [Epub ahead of print]

“Deletion of Hepatocyte Nuclear Factor-1-Beta in an Infant with Prune Belly Syndrome.” Haeri S, Devers PL, Kaiser-Rogers KA, Moylan VJ Jr, Torchia BS, Horton AL, Wolfe HM, Aylsworth AS. Am J Perinatol. 2010 Aug;27(7):559-63.

“Obesity and Diabetes Genetic Variants Associated with Gestational Weight Gain.” Stuebe AM, Lyon H, Herring AH, Ghosh J, Wise A, North KE, Siega-Riz AM. Am J Obstet Gynecol. 2010 Sep;203(3):283. e1-17.

Page 1

Do They Like What They See? Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.

Dr. Catherine Matthews had the following presentations at the third annual World Robotic Symposium Latin America in Brazil, Aug. 19-20. • “Applications of Robotic Surgery in Urogynecology” • “Optimize the Placement of Trocars and the Connection of Robot” Dr. Matthews also had presentations at the Joint Annual Meeting of the International Continence Society and International Urogynecological Association in Toronto, Canada, Aug. 23-26.

“Association of Midgestation Paraoxonase 1 Activity and Pregnancies Complicated by Preterm Birth.” Baker AM, Haeri

Our services range from consultation, to design, to creation and implementation of strategic plans.

newsource & Associates Call (540) 650-3686 or send inquiries to hketler@verizon.net.

Our network of smart, creative, award-winning specialists serves the health care industry throughout the Mid-Atlantic.

Maybe it’s happiness in a child’s eyes. Whatever the desired outcomes, count on us to ensure your key messages have the 20/20 clarity to deliver.

YOUR LOCAL CARDIOLOGY PROFESSIONALS IN JOHNSTON COUNTY DEDICATED TO QUALITY, SERVICE, AND INTEGRITY Benjamin G. Atkeson, MD, FACC Cardiology, Echocardiography, Nuclear Cardiology

Mateen Akhtar, MD, FACC

Eric M. Janis, MD, FACC

Matthew S. Forcina, MD

Diane E. Morris, ACNP

Christian N. Gring, MD, FACC

Ravish Sachar, MD, FACC

2 LOCATIONS TO SERVE OUR PATIENTS Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7907 Fax: 919-989-3147

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

Matthew A. Hook, MD, FACC

Nyla Thompson, PA-C

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

THE HIGHEST QUALITY CARDIOVASCULAR CARE, CLOSE TO HOME.

Location courtesy of Rapid Fitness Boxing Center, Raleigh

Penni, survivor since 2006

Darlene, survivor since 2005

Nancy, survivor since 2004

Robin, survivor since 2006

Lee, survivor since 2003

For living proof that early detection can deck this disease, just ask us. We’re some of the breast cancer survivors of Wake Radiology — we know personally what this fight is like. So we’re a little different when it comes to our patients. Highly understanding. Confidently reassuring. Ready with a solid one-two combination of expert medicine

Read our stories online at wakerad.com

and championship care, starting with your annual screening mammogram.

Wake Radiology salutes the grit, the grace, and the undaunted courage of every breast cancer survivor. Wake Radiology. The team you want in your corner.

PROUDLY SUPPORTING THESE IMPORTANT ADVOCATES FOR WOMEN

Breast Imaging Services 1 number to call, 17 locations serving the Triangle area. 919-232-4700 | wakerad.com