December/January 2 013 / 2 014
Associated Urologists of North Carolina Providing Advanced, Comprehensive and Specialized Care
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
Also in This Issue
Recurrent Vomiting Thyroid Testing
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COVER STORY
6
Associated Urologists of North Carolina
Providing Advanced, Comprehensive and Specialized Care
d e c e m b e r 2 0 13 / j a n u a r y 2 0 14
FEATURES
9
Vol. 4, Issue 11
DEPARTMENTS 12 Duke Research News
Gastroenterology
Rural and Southern Regions Lack Annual Training in CPR
13 Duke Research News
Functional Vomiting Syndromes II
Findings Explain the Link Between High Cholesterol and Breast Cancer
Dr. Douglas Drossman details causes,
14 Duke Research News
diagnoses and treatments of gastroparesis
New Artificial Protein Mimics a Part of the HIV Outer Coat
and cyclic vomiting syndrome.
15 UNC Research News Neuroscientists Discover Brain’s “Mini-Neural Computer”
10
16 UNC Research News Prison Study Questions the Need for HIV Screening in New Inmates
Endocrinology
New Diagnostic Options in Thyroid Biopsies Kellie Bunn, P.A.-C., discusses new tests to stratify the risk of malignancy in indeterminate nodules.
18 UNC Research News Poor Nutrition Is Risk Factor for Patients Who Have Cystectomy
20 News WakeMed Recruits Urogynecologist Raleigh Neurology Associates Celebrates 30 Years
21 News
Welcome to the Area
COVER PHOTO: Cover photo: From left, Brian C. Bennett, M.D.; Mark W. McClure, M.D., F.A.C.S.; Daniel Khera-McRacken, M.D.; Stephen F. Shaban, M.D.; and Scott D. Baker, M.D., of Associated Urologists of North Carolina. Photo above: From left, Kevin P. Khoudary, M.D., F.A.C.S.; William Steel Kizer, M.D., F.A.C.S.; Frank L. Tortora, M.D., F.A.C.S.; and Kevin P. Perry, M.D., F.A.C.S., also of AUNC. Not photographed are: Mark D. Benevides, M.D.; Timothy Bukowski, M.D., F.A.C.S., F.A.A.P.; Norman J. Goldbach, M.D., F.A.C.S.; Mark. W. Jalkut, M.D.; John Kaspar, M.D.; Douglas C. Leet, M.D.; and Joseph D. Neighbors, Jr., M.D..
2
The Triangle Physician
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From the Editor
State of Art and Down to Earth This month’s cover story on Associated Urologists of North Carolina conveys exceptional clinical expertise and intense passion to advance diagnosis and treatment. What also impressed me during this project was the approachable, easy-going manner of the
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
urologists, one that surely helps patients feel more at ease. For instance, AUNC pediatric urologist Timothy Bukowski told me he is a coach at heart. He said he coaches soccer and enjoys coaching his patients on their medical conditions. He noted the honesty of his young patients and how refreshing it is. Urologist Frank Tortora specializes in the treatment of urologic cancers and laparoscopic and robotic procedures. “I often joke with my patients, saying that (urologists) are like a hairdresser for men – with conversations about their love life, sexuality and fears,” he explained to me. Urologist John Kaspar subspecializes in female pelvic conditions and reconstruction. He noted the impact of the compassion of AUNC staff on patients. “There is a great amount of enthusiasm to help our patients and an emphasis on listening and
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Kellie Bunn, P.A.-C. Michael J. Thomas, M.D., Ph.D. Creative Director Joseph Dally jdally@newdallydesign.com
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understanding and really relating to our patients,” Dr. Kaspar told me. This issue of The Triangle Physician also features gastroenterologist Douglas Drossman, who completes his two-part series on functional vomiting with a review of gastroparesis and cyclic vomiting syndrome. Kellie Bunn, a physician assistant at Drossman Gastroenterology P.L.L.C., gives an overview on new pre-operative tests that further stratify the risk of malignancy in indeterminate thyroid nodules. Now in our fourth year, The Triangle Physician is increasingly recognized as a forum for practice news and clinical insight. Our expectation is that 2014 will be another year of growth. Articles relating to the region’s medical community run at no cost. Advertising and cover story rates are competitive. Consider also that The Triangle Physician is delivered to more than 9,000 readers – physicians, physician assistants, nurse practitioners, office administrators and other medical professionals within this region. Contact me at heidi@trianglephysician.com to learn about opportunities to showcase all that distinguishes you and your practice. Here’s wishing you all the best in the new year! Respectfully,
Heidi Ketler Editor
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Cover Story
Associated Urologists of North Carolina
Providing Advanced, Comprehensive and Specialized Care By Heidi Ketler
Five well-established practices in Raleigh and Cary embraced a medi-
incontinence, urinary tract infections, kidney stones, urological
cal mission to deliver high-quality care in a changing health care arena.
cancers, hematuria, cystitis, pelvic organ prolapse and congenital
United for more than two years now as Associated Urologists of North
urological abnormalities.
Carolina, theirs is one of the region’s largest urology practices – with 16 urologists – and it is singular in its breadth and depth of expertise.
John Kaspar, M.D., is one of only 125 urologists nationwide with certification in female pelvic medicine and reconstructive surgery
“By working together, we can concentrate more on our subspe-
(FPM-RS), and he has participated in the development of advances
cialty and approach most urologic problems with more depth,”
in the treatment of male sexual dysfunction. The highly subspe-
says Frank L. Tortora, M.D., F.A.C.S., a practice co-founder who is a
cialized FPM-RS field of medicine was recently recognized by the
nationally and internationally known specialist in urologic cancer
American Board of Urology and the American Board of Obstetrics
and minimally invasive laparoscopic and robotic procedures.
and Gynecology. FPM-RS focuses on the surgical and nonsurgical treatment of pelvic floor disorders, which include pelvic organ prolapse, incontinence and pelvic pain. The new 23,000-square-foot AUNC facility is a statement of the practice’s commitment to excellence in the delivery of comprehensive urological care. Here, patients have access to the most effective diagnostic and treatment approaches and to the brightest minds. Onsite lab services and an imaging center with X-ray, ultrasound and computed-tomography expedite diagnosis. Same-day appointments are often possible. Completing the continuum of care for many patients is individual, couple and group counseling provided by Sara Rosenquist, Ph.D., A.B.P.P., a widely known and respected board-certified clinical health psychologist with a specialty in sexual and reproductive medicine. “Dr. Sara” is now seeing patients at the new AUNC office
Male and female patients of all ages are diagnosed and treated at
in Raleigh on a weekly basis.
AUNC for urologic conditions, from simple to the most complex. Specialized care is routinely offered for incontinence, kidney stones
A practice culture that is kind, caring and approachable – from
and urologic cancers, as well as female pelvic floor disorders, male
the front desk to exam room, surgical suite to counseling setting –
sexual health and infertility, pediatric urology and beyond.
helps patients be more at ease in sharing their concerns.
Timothy Bukowski, M.D., F.A.C.S., F.A.A.P., is the region’s only
Advances in Cancer Treatment
fellowship-trained pediatric urologist. His expertise encompasses
“AUNC urologists are in constant pursuit of better diagnostic and
diagnosis and treatment, including surgery, of urologic problems
treatment approaches to cancer,” says AUNC President Brian C.
in the very young to teenagers and into adulthood for those with
Bennett, M.D. “As a result, we utilize all forms of radiation, and our
conditions that require long-term surveillance, such as those with
physicians perform the latest in laparoscopic and robotic surgical
significant spina bifida and urinary incontinence.
techniques, along with traditional surgery, in the treatment of urologic cancers.”
AUNC providers excel in the diagnosis and treatment of female urological problems. Among the more common conditions are urinary
6
The Triangle Physician
Prostate cancer is the most common non-cutaneous cancer of men
in the United States, with almost 200,000
Robotic surgery has led to great strides in
physician or family members of their prob-
new cases diagnosed each year and an
the treatment of kidney cancer, which ac-
lem. The common misconception is that
approximate one-in-eight lifetime risk of
counts for 5 percent of all male cancers
nothing can be done for it or it’s a normal
developing prostate cancer.
and approximately 3 percent of female
part of aging.
cancers. The challenge in treating kidney cancer is
“Most of the time, incontinence can be
early diagnosis. “Kidney cancer grows si-
improved. Nearly everyone with a blad-
lently, deep within and out of the kidney,
der control problem can be helped,” says
so it doesn’t stop any type of function,”
Dr. Tortora. And like urinary incontinence,
says Dr. Tortora. Today, it is possible to find
fecal incontinence is not a hopeless situa-
a kidney tumor as small as 2 centimeters
tion. Proper treatment at AUNC can help
with computed tomography, though the
most people, often eliminating the prob-
finding is likely made by chance during a
lem altogether, even in patients with dou-
test for another medical problem.
ble (urinary and fecal combined) incontinence.
Once the kidney cancer is diagnosed, robotic surgery can be used to remove just
Incontinence can be caused by everyday
the cancerous tissue, leaving 90 percent of
habits, underlying medical conditions or
the kidney behind. “Robotic surgery allows
physical and neurological problems. Effec-
us to focus in on the tumor, so once it’s
tive treatment requires a correct diagnosis
gone, it’s gone,” says Dr. Tortora.
of the type of urinary incontinence – stress incontinence, urge incontinence, mixed
“Prostate cancer has been revolutionized
Bladder cancer accounts for approximate-
incontinence, overflow incontinence and
over time with the advent of robotic sur-
ly 90 percent of cancers of the urinary tract.
functional incontinence.
gery,” says Dr. Tortora. “It’s a less-invasive
Usually it is diagnosed at an early stage,
way of removing prostate cancer, so there
when it is highly treatable. However, even
Treatment at AUNC typically starts con-
are fewer side effects,” such as impotence
early-stage bladder cancer is likely to recur.
servatively, with guidance on behavioral
and urinary incontinence.
For this reason, survivors often undergo
changes, such as drinking less fluid and
follow-up tests for years after treatment.
urinating more often, and pelvic floor muscle training, called Kegel exercises, to
According to Dr. Tortora, United States Food and Drug Administration approval of
The majority of bladder cancers are super-
strengthen the urethral sphincter. Biofeed-
HIFU (high-intensity focused ultrasound)
ficial and in most cases can be spared us-
back and electrical stimulation therapy
in the treatment of prostate cancer is ex-
ing routine cystoscopic techniques, along
may be helpful. Medications can help pa-
pected soon. The highly precise medical
with adjuvant intravesical chemotherapy.
tients with mild to moderate stress incon-
procedure applies high-intensity, focused
Transurethral resection of a bladder tu-
tinence.
ultrasound energy to locally heat and
mor (TURBT) is a cystoscopic procedure
destroy tissue through ablation. Results
to resect the bladder tumor and assess
While these measures usually improve
approaching those of surgery have been
the pathologic depth of invasion. During
symptoms, they don’t cure incontinence.
reported in large series of prostate cancer
TURBT, the surgeon inserts a cystoscope
Surgery can cure incontinence in certain
patients.
through the urethra into the bladder and
patients, but it is recommended only after
removes the cancer using a tool with a
first-line therapies fail.
Prostate cancer treatment using HIFU
small wire loop, a laser or fulguration
is performed under ultrasound-imaging
(high-energy electricity). The amount of
At AUNC, sacral neuromodulation (SNM)
guidance, which permits treatment plan-
anesthesia necessary depends on the size
and Botox injection are promising options
ning and some minimal indication of the
of the tumor.
for refractory urge incontinence, frequency and retention.
energy deposition. HIFU also may be used to ablate the entire prostate gland using a
Incontinence:
transrectal probe. The outpatient proce-
Treatment Is Available
SNM, also called sacral nerve stimulation,
dure usually lasts one to three hours. The
Approximately 10-35 percent of the popula-
addresses the underlying neurologic con-
procedure is currently available outside of
tion in the United States suffers from incon-
dition that causes overactive bladder and
the U.S.
tinence, and about half do not alert their
other pelvic floor conditions, including fe-
December 2013/January 2014
7
cal incontinence. The SNM system delivers
lifestyle changes that also are responsible
inguinal hernia and cryptorchidism, or un-
mild electrical pulses to the sacral nerves
for increasing rates of obesity, metabolic
descended testes.
through a thin wire lead and a neurostimu-
syndrome, diabetes and gout. Other pos-
lator implanted under the skin in the low-
sible factors include an aging population
He also treats urinary frequency in chil-
er back. The therapy is reversible, as the
and lack of awareness about how to pre-
dren, which unlike adult incontinence is
system can be turned off or surgically re-
vent kidney stones.
usually caused by stress. A physical exam is encouraged to rule out physical causes,
moved at any time. Dr. Bukowski says he has seen an increase
which are rare.
Dr. Kaspar was among the first 50 physi-
in the incidence of kidney stones in his
cians in 2000 to offer Medtronic’s InterStim,
young patients. He attributes it to increased
Without treatment, symptoms usually im-
the only SNM system approved by the FDA.
consumption by children of processed,
prove in two to three months. If the stress is
To date, more than 125,000 people world-
high-sodium foods and high-fructose bev-
resolved, the condition can improve in one
wide have received the InterStim system.
erages. Increasing childhood obesity is a
to four weeks. Overreaction to the child’s
factor.
urinary mishaps may make the condition worse.
“I began using InterStim, because at the time there were only two overactive blad-
Conservative
management
of
kidney
der medications, which did not work for
stones that are 3-5 millimeters is the ap-
Dr. Bukowski has a special research interest
all patients. Those who received no benefit
proach taken by AUNC specialists. This in-
in a randomized intervention for children
faced continued misery,” says Dr. Kaspar.
cludes an increase in fluids and a prescrip-
with vesicoureteral reflux to learn whether
“Sacral neuromodulation is a therapy that
tion for nonsteroidal anti-inflammatory
medical intervention is necessary. VUR is
can really improve quality of life.”
drugs or opioids for pain.
the abnormal flow of urine from the bladder back into one or both ureters and, in some
Botox injections also have proved effec-
Extracorporeal shock wave lithotripsy may
cases, to one or both kidneys. The study will
tive in treating overactive bladder. Botox
be used to shatter larger kidney stones.
help determine if prophylactic antibiotic
injected into the bladder muscle during a
Some cases require more invasive forms
treatment prevents urinary tract infections
cystoscope procedure causes the bladder
of surgery – cystoscopic procedures, such
and renal scarring in these children.
to relax, increasing the bladder’s storage
as laser lithotripsy; or percutaneous tech-
capacity and reducing episodes of urinary
niques, such as percutaneous nephroli-
“It’s become more apparent that we need
incontinence. One of the newest clinical tri-
thotomy. A ureteral stent may be placed
to fix the problem less and less with sur-
als available at AUNC is designed to evalu-
to bypass the obstruction and alleviate the
gery. An alternative may be to give the
ate the efficacy of Botox therapy in certain
symptoms, as well as prevent ureteral stric-
child a prophylaxis antibiotic to prevent
patients with overactive bladder whose
ture after ureteroscopic stone removal.
recurrent infection and observe and wait
treatment with medication was ineffective.
for them to outgrow the condition,” says After the first kidney stone, a person’s likeli-
Dr. Bukowski.
Kidney Disease: Kidney Stones
hood of forming another is 50 percent with-
The range of congenital and acquired kid-
in five years and 80 percent during a life-
Another study of interest to Dr. Bukowski
ney diseases treated at AUNC is diverse.
time. Preventive measures, which depend
is being conducted by the National Insti-
Nephrolithiasis, or kidney stones, is one of
on the type of stone produced – calcium,
tute of Diabetes and Digestive and Kidney
the more common and painful.
struvite, uric acid or cysteine – can help
Diseases’ Division of Kidney, Urologic
lower risk to 10 percent or less.
and Hematologic Diseases. It is exploring
Numerous studies point to an increase in
the effects on children of environmental
the rate of kidney stones among all eth-
The AUNC specialists follow up treatment
exposure to estrogen-like chemicals and
nicities and particularly in women and chil-
for a kidney stone with a metabolic evalua-
the possible connection to an increasing
dren. Today, one out of every 11 people, or
tion to guide prevention strategies.
incidence of central precocious puberty,
nearly 10 percent of the population, experi-
the premature start of puberty before age
ences a kidney stone. In 1994, the rate was
Treating Congenital Urological
one out of 20 people, or 5 percent of the
Disorders in Children
population.
Dr. Bukowski treats congenital anomalies
For more information about AUNC’s spe-
eight.
of the genital-urinary tract, including the
cialized medical care, visit the practice
The increased prevalence may be due to
kidneys, bladder and genitalia. Among
website at www.auncurology.com or call
a number of factors, primarily dietary and
those are hydronephrosis, hypospadias,
(919) 758-8677. Referrals are welcome.
8
The Triangle Physician
Gastroenterology
Functional Vomiting Syndromes II By Kellie Bunn PA-C
This is the second in a two- part series on functional vomiting syndromes. In this review on functional vomiting I will
Initially, there is a well phase, in which
discuss two functional GI syndromes: gas-
patients are without significant symptoms.
troparesis and cyclic vomiting syndrome
This then progresses to a pre-emetic phase
(CVS).
with increased sweating and severe nausea. A phase of intense vomiting follows
Gastroparesis is a type of obstructive
and can last multiple days. In the final re-
vomiting, where the normal coordination
covery phase the vomiting decreases, and
of gastric emptying of ingested food is de-
the nausea improves. These episodes may
layed. This most commonly occurs with
be accompanied by abdominal pain in
diabetic neuropathy and as an idiopathic
some patients.
gastroparesis syndrome. CVS has been defined by the Rome III Other secondary causes include extreme
criteria, in which it must include all of the
weight loss, as with anorexia nervosa; Par-
following:
kinson’s disease; or medications, includ-
1) Stereotypical episodes of vomiting
ing opioids, anticholinergics or any others
regarding onset (acute) and duration
that slow gastric motility. Clinically this
(less than one week),
syndrome is identified by vomiting poorly digested foods, rather than on an empty stomach, and often the vomitus can contain food ingested many hours prior.
2) Three or more discrete episodes in the prior year, 3) Absence of nausea and vomiting between episodes.
The diagnosis of gastroparesis is made by
History or family history of migraine head-
physiological testing showing delay on
aches are supportive criterion.
a four-hour gastric-emptying scintiscan.
Kellie Bunn PA-C graduated from the University of North Carolina at Chapel Hill with a degree in Biology before training at the Duke University Physician Assistant Program. She earned a degree of Master of Health Sciences and was inducted in Pi Alpha, the national honor society for physician assistants. She is currently a member of the American Academy of Physician Assistants, North Carolina Academy of Physician Assistants, and the North Carolina Medical Society. Kellie has worked with Dr. Douglas Drossman at Drossman Gastroenterology PLLC for over a year and is well trained in the care of patients with functional GI disorders. Drossman Gastroenteroogy PLLC (www. drossmangastroenterology.com) specializes in patients having difficult to diagnose gastrointestinal disorders and the management in particular of severe functional GI disorders. The office is located at Chapel Hill Doctors 55 Vilcom Center Drive, Suite 110, Chapel Hill, NC. Appointments can be made by calling 919-929-7990.
Treatment of gastroparesis may begin with
Though the cause of CVS is not fully un-
identification and treatment of an under-
derstood, some associations with this syn-
lying condition if identified. Patients also
drome have been identified with abdomi-
Treatment during the acute emetic phase
may work to adjust their diet with smaller,
nal epilepsy and abdominal migraine. The
of CVS may include supportive care with
more frequent meals and also by drinking
syndrome also may be associated with a
rest, hydration, anti-emetics (ondanse-
water during meals. Medication options in-
metabolic disorder called mitochondrial
tron or promethazine), anxiolytics (ben-
clude metoclopramide, erythromycin and
disease (dysfunction).
zodiazepines), analgesics, antimigraine
domperidone. New research is exploring
medications (5-HT agonists) and gastric Infections, psychological stress, lack of
acid suppressants (PPIs or H2 blockers).
sleep, physical exhaustion, certain foods
Prophylactic treatment options to prevent
Cyclic vomiting syndrome is character-
and menses may trigger episodes. In ad-
subsequent episodes include lifestyle
ized by paroxysmal episodes of vomiting
dition, symptoms can be associated with
changes in order to avoid potential trig-
occurring in cycles with intermittent symp-
panic attacks and frequent use of hot
gers and medications, including TCAs, SN-
tom-free periods.
showers or baths to lessen symptoms.
RIs, anti-anxiety agents, beta blockers and
Frequent marijuana use (i.e., cannabinoid
most recently anti-epileptic agents, includ-
Adults with CVS often experience four
hyperemesis syndrome) also had been as-
ing zonisamide and levetiracetam.
distinct phases to the vomiting episodes.
sociated with CVS.
the use of botulinum toxin.
December 2013/January 2014
9
Endocrinology
New Diagnostic Options in
Thyroid Biopsies By Michael J. Thomas, M.D., Ph.D.
Thyroid fine needle aspiration biopsy of thy-
(which encode certain proteins expressed
roid nodules is the recommended proce-
in benign or malignant thyroid nodules) or
dure for assessing whether a thyroid mass
detect mutations in mRNA associated with
is likely to benign or malignant.
differentiated thyroid cancers (Table 2).
The Bethesda Category classification system
Some genetic mutations, such as BRAF, dis-
was developed in 2009 to assist endocrinol-
play nearly 100 percent specificity, but this
ogists in ascertaining the risk that a thyroid
mutation is only present in 40-50 percent of
nodule is malignant (Table 1). Nodules that
papillary thyroid carcinomas. But these two
are read as Bethesda Category 3 (atypia of
very different types of tests can add useful
undetermined significance, follicular lesion
information to the patient’s clinical history,
of undetermined significance; AUS/FLUS),
physical exam, ultrasound findings and cy-
Bethesda Category 4 (follicular neoplasm
topathology results, depending on the clini-
or suspicious for follicular neoplasm; FN/
cal scenario.
SFN) or Bethesda Category 5 (suspicious for malignancy) are “indeterminate” and
Gene expression classifier (Veracyte
have increasing risks of malignancy.
Afirma [www.veracyte.com/afirma/]). This test determines what mRNAs are being
In the past, most indeterminate nodules
expressed in thyroid nodules based on ge-
were referred for surgical excision for defini-
netic message present in the aspirated ma-
tive diagnosis, but a substantial number of
terial. The expression of 142 specific genes
those nodules would turn out to be benign
are then quantitated and analyzed using a
on surgical pathology. Are there any new pre-
gene expression classifier (GEC), which is
operative tests that can further stratify the risk
a proprietary DNA chip that uses a complex
of malignancy in indeterminate nodules?
algorithm to determine whether an indeter-
In the past three years, two broad types
Dr. Michael Thomas of Carolina Endocrine P.A. graduated from the School of Medicine at West Virginia University in Morgantown, with a doctor of medicine and doctor of philosophy in pharmacology and toxicology. He completed his post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency and fellowship in endocrinology. Dr. Thomas was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. He established Carolina Endocrine in the summer of 2005. Board certified in internal medicine and endocrinology, Dr. Thomas is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology (FACE) and has completed endocrine certification in neck ultrasound (ECNU). For more information and patient referrals and appointments call (919) 571-3661 or visit the practice website at carolinaendocrine.com.
minate thyroid nodule (Bethesda Category
of malignancy is ≥40 percent. The results
3 or 4) is most likely benign or “suspicious.”
of the Veracyte Afirma GEC should not be
of molecular testing have been developed
used on nodules with benign cytopathol-
to address the problem of indeterminate
If an indeterminate nodule GEC is found to
ogy, and its negative predictive value for
thyroid nodules. Both types of tests utilize
be benign, the risk of malignancy is ≤5 per-
Bethesda Category 5 nodules is lower than
thyroid biopsy aspirates to measure mRNAs
cent; and if the GEC is “suspicious,” the risk
Category 3 or 4 nodules (Alexander EK, et al. N Engl J Med. 367:705-715, 2012).
Table 1 - The Bethesda System for Reporting Thyroid Cytopathology Risk of Malignancy (%)
Usual Management (prior to 2011)
Veracyte Afirma requires a set of dedicated
I. Nondiagnostic or Unsatisfactory
1-4%
Repeat FNA with ultrasound guidance
cytopathology slides (or Cyto-Lyt) be co-
II. Benign
0-3%
Clinical follow-up
Diagnostic Category
III. Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance
~5-15%
IV. Follicular Neoplasm or Suspicious for a Follicular Neoplasm
15-30%
Surgical lobectomy
V. S uspicious for Malignancy
60-75%
Near-total thyroidectomy or surgical lobectomy
VI. Malignant
97-99%
Near-total thyroidectomy
10
The Triangle Physician
Repeat FNA
submitted with the aspirates, and these cytopathology slides must be read at a designated cytopathology group. The Afirma test cannot diagnose what type of thyroid cancer is present, only the likelihood that a nodule is malignant. DNA mutations (Asuragen miRInformR
[asuragen.com], QuestR [www.questdiagnostics.com], University of Pittsburgh [path.upmc.
Table 2 - Cancer probability in thyroid nodules with indeterminate cytology based on specific cytological diagnosis and results of molecular testing performed in FNA samples (BC = Bethesda Category)
edu], others). These tests evaluate a panel of
BC 3 AUS/FLUS (n = 247)
known genetic mutations (RAS, BRAF, RET/
BC 4 FN/SFN (n = 214)
BC 5 SMC (n = 52)
BC 3, 4, 5 Total (n = 513)
PTC and PAX8/PPARg) that have been found
Cytology Only
14%
27%
54%
24%
in differentiated thyroid cancer (Table 2). The
Any Mutation
88%
87%
95%
89%
RAS
84%
85%
88%
85%
BRAF
100%
100%
100%
100%
100%
100%
100%
100
na
na
100%
100%
5.9%
14%
25%
11%
negative predictive value is not quite as good as the results of the GEC (above), but some mutations, particularly BRAF V600E, are extremely specific, if positive.
PAX8/PPARγ RET/PTC No mutation
Again, the main value is assessing malig-
value), and the DNA mutation tests tell how
roidectomy (coupled with lifelong thyroid
nancy potential in indeterminate (Bethesda
“malignant” a thyroid nodule is (based on its
hormone supplementation and any other
Category 3 or 4) nodules, and it may permit
high positive predictive value). Though these
post-procedural consequences, e.g. hypo-
pre-op planning of a hemi thyroidectomy
molecular diagnostic tests are still relatively
parathyroidism) are huge.
vs. total thyroidectomy, depending on the
new, they are already making an impact in
mutational analysis. This test can theoreti-
potentially avoiding surgery in nodules that
Patients with non-suspicious molecular re-
cally be performed on aspirates, or in some
display benign molecular characteristics.
sults should still be followed closely by serial thyroid ultrasound and either re-biopsied
instances, fixed slides (depending on the stain used). Cytopathology can be assessed
Cytopathology will always remain the gold
or referred to surgery if continued growth of
separately by any pathology group.
standard for determining if a nodule is be-
the nodule occurs. In the future, additional
nign or malignant, and in these situations
molecular markers, including micro-RNAs
Basically, it has been said that the Veracyte
the molecular markers are not useful. From
and noninvasive imaging techniques may
Afirma test tells how “benign” a thyroid nod-
an economic standpoint, the potential cost
improve our capability to assess malignant
ule is (based on its high negative predictive
savings in avoidance of a partial or total thy-
potential in indeterminate nodules.
Expert, cost effective and timely care is what Carolina Endocrine has to offer your patients. • Neck Ultrasounds (ECNU certified) • Fine needle aspiration biopsies • Nuclear medicine studies
All in one convenient location at 3840 Ed Drive, behind Rex Hospital.
919-571-3661
www.CarolinaEndocrine.com Dr. Michael Thomas, Ph.D. Dr. Khushbu Chandarana Courtney Kovalick, PA-C Eileen Andres, PA-C
December 2013/January 2014
11
Duke Research News
Rural and Southern Regions Lack Annual Training in CPR Annual rates of CPR training in the United
gathered data on the number of people
son said. “These areas are often far away
States are low and vary widely across the
trained in CPR by the American Heart As-
from hospitals, and ambulances can take
country, but the communities most in
sociation, the American Red Cross and
longer to arrive. To bring about a change
need of training are the least likely to be
the Health & Safety Institute, the three ma-
in these areas, we need community, gov-
trained, according to a new study from the
jor organizations providing training across
ernment, health care institutions and
Duke Clinical Research Institute.
the U.S.
training organizations to come together (and) figure out how to improve the entire ‘chain of survival’ for cardiac arrest.”
The findings, published Nov. 18 in JAMA
During the one-year study, 13.1 million
Internal Medicine, add to known geo-
people in the United States received CPR
graphic disparities in cardiac arrest surviv-
training, with a median county training
Some factors associated with variabil-
al and offer a rationale to increase access
rate of 2.39 percent.
ity in training rates overlap with factors
to training for the lifesaving intervention. Each year, more than 350,000 Americans experience cardiac arrest outside of a hospital. On average, 7 percent to 9 percent of them survive, but these figures vary by geographic location. Bystander CPR is the second step in the “chain of survival” for cardiac arrest and should be started quickly after 911 has been called. It is a critical step before emergency personnel arrive, defibrillate, initiate advanced cardiac life support and get the patient to a hospital. Research has shown that when bystanders perform CPR, it doubles the likelihood of an individual surviving cardiac arrest outside of the hospital. However, rates of bystanders performing CPR vary widely, from 10 percent to 65 percent, depending
Duke researchers analyzed CPR training rates across United States. They found that counties in the south were the most likely to have lower rates of CPR training compared with the northeast. Credit: Duke Clinical Research Institute
on the community. While low overall, CPR training rates also
previously found to be associated with
“This variability in bystander CPR use may
varied by county. Counties with the low-
variation in bystander CPR use, including
be accounted for by the proportion of
est rates of CPR training were more likely
household income and African-American
CPR training in a particular community,”
to be rural, have a higher proportion of
and Hispanic populations. The findings
said Monique Anderson, M.D., the study’s
African-American and Hispanic residents
suggest that lower county-level rates of
lead investigator and a cardiologist at
and a lower median household income.
CPR training may, in part, contribute to
Duke Clinical Research Institute.
In addition, counties in the south were
the lower use of bystander CPR.
the most likely to have lower rates of CPR The researchers studied whether varia-
training compared with the northeast.
In addition, counties with lower rates of CPR training correlated with counties
tions in CPR training by county existed and what factors were associated with
“Rural counties were strongly associated
with higher rates of mortality due to heart
low CPR training among counties. They
with low rates of CPR training,” Dr. Ander-
disease. Although these factors are not di-
12
The Triangle Physician
Duke Research News rectly linked, they suggest that CPR train-
The researchers noted that the study cap-
Fosbol of the Duke Clinical Research In-
ing may be lacking in populations with
tured county-level factors in CPR training,
stitute; Graham Nichol of the University
residents at the highest risk of cardiac
not individual factors, so the study does
of Washington-Harborview Center for Pre-
arrest.
not demonstrate who is actually being
hospital Emergency Care in Seattle; Paul
trained. In addition, the study looked at
S. Chan of Saint Luke’s Mid America Heart
“Our study points to a large unmet need
data from the three leading organizations
Institute in Kansas City, Mo.; Brian Eigel of
for moving CPR training to target at-risk
offering CPR training, but there are likely
the American Heart Association in Dallas;
populations in rural and poor communi-
other training efforts not reflected in the
and Bill Clendenen of the Health & Safety
ties,” said senior author Eric Peterson,
study.
Institute in Eugene, Ore.
director of the Duke Clinical Research In-
In addition to Drs. Anderson and Peter-
The study was funded by the American
stitute. “Such an effort could substantially
son, study authors include Margueritte
Heart Association Pharmaceutical Round-
reduce the known racial gap in survival
Cox, Sana M. Al-Khatib, Kevin L. Thomas,
table and by David and Stevie Spina.
following cardiac arrest.”
Paramita Saha-Chaudhuri and Emil L.
M.D., M.H.S., professor of medicine and
Findings Explain the Link Between High Cholesterol and Breast Cancer A byproduct of cholesterol functions like
terol itself, but an abundant metabolite of
man breast cancer tissue. An additional
the hormone estrogen to fuel the growth
cholesterol - called 27HC - that mimics the
finding in the human tissue showed a di-
and spread of the most common types of
hormone estrogen and can independently
rect correlation between the aggressive-
breast cancers, researchers at the Duke
drive the growth of breast cancer.”
ness of the tumor and an abundance of the enzyme that makes the 27HC molecule. Dr.
Cancer Institute report. The hormone estrogen feeds an estimated
McDonnell’s team also noted that 27HC
The researchers also found that anti-
75 percent of all breast cancers. In a key
could be made in other places in the body
cholesterol drugs, such as statins, appear
earlier finding from Dr. McDonnell’s lab,
and transported to the tumor.
to diminish the effect of this estrogen-like
researchers determined that 27-hydroxy-
molecule.
cholesterol (27HC) behaved similarly to
“The worse the tumors, the more they
estrogen in animals.
have of the enzyme,” said lead author Erik Nelson, Ph.D., a post-doctoral associate
Published in the Nov. 29 edition of the journal Science, the findings are early, us-
For their current work, the researchers set
at Duke. Dr. Nelson said gene expression
ing mouse models and tumor cells. But the
out to determine whether this estrogen ac-
studies revealed a potential association
research for the first time explains the link
tivity was sufficient on its own to promote
between 27HC exposure and the devel-
between high cholesterol and breast can-
breast cancer growth and metastasis and
opment of resistance to the antiestrogen
cer, especially in post-menopausal women
whether controlling it would have a con-
tamoxifen. Their data also highlights how
and suggests that dietary changes or thera-
verse effect.
increased 27HC may reduce the effectiveness of aromatase inhibitors, which are
pies to reduce cholesterol may also offer a simple, accessible way to reduce breast
Using mouse models that are highly pre-
among the most commonly used breast
cancer risk.
dictive of what occurs in humans, Dr. Mc-
cancer therapeutics.
Donnell and colleagues demonstrated the “A lot of studies have shown a connec-
direct involvement of 27HC in breast tumor
“This is a very significant finding,” Dr.
tion between obesity and breast cancer
growth, as well as the aggressiveness of the
McDonnell said. “Human breast tumors,
and specifically that elevated cholesterol
cancer to spread to other organs. They also
because they express this enzyme to
is associated with breast cancer risk, but
noted that the activity of this cholesterol
make 27HC, are making an estrogen-like
no mechanism has been identified,” said
metabolite was inhibited when the animals
molecule that can promote the growth of
senior author Donald McDonnell, Ph.D.,
were treated with antiestrogens or when
the tumor. In essence, the tumors have
chair of the Department of Pharmacology
supplementation of 27HC was stopped.
developed a mechanism to use a different source of fuel.”
and Cancer Biology at Duke. “What we have now found is a molecule – not choles-
The studies were substantiated using hu
December 2013/January 2014
13
Duke Research News Dr. McDonnell said the findings suggest
research include clinical studies to verify
Ruchita V. Pillai, Patrick M. Sullivan, Varun
there may be a simple way to reduce the
those potential outcomes, as well as stud-
Sondhi, Michihisa Umetani and Joseph
risk of breast cancer by keeping cholester-
ies to determine if 27HC plays a role in
Geradts.
ol in check, either with statins or a healthy
other cancers, Dr. McDonnell said. The National Institutes of Health
diet. Additionally for women who have breast cancer and high cholesterol, taking
In addition to Drs. McDonnell and Nelson,
(K99CA172357) (R37DK048807) and the
statins may delay or prevent resistance to
study authors include Suzanne E. Wardell,
Department of Defense funded the study.
endocrine therapies, such as tamoxifen
Jeff S. Jasper, Sunghee Park, Sunil Suchin-
or aromatase inhibitors. The next steps for
dran, Matthew K. Howe, Nicole J. Carver,
New Artificial Protein Mimics a Part of the HIV Outer Coat A team of scientists at Duke Medicine and
neutralizing antibodies are so difficult to
Recent research, however, has demon-
Memorial Sloan-Kettering Cancer Center
produce – that of competition between de-
strated that the human immune system
has created an artificial protein coupled
sired and undesired antibody responses,”
prefers not to target these vulnerable sites,
with a sugar molecule that mimics a key
said senior author Barton F. Haynes, M.D.,
but instead aims at the outer-coat sites that
site on the outer coat of HIV where anti-
director of the Duke Human Vaccine Insti-
do not result in the production of protec-
bodies can bind to neutralize a wide vari-
tute. “By immunizing with a vaccine that
tive antibodies.
ety of HIV strains.
primarily has the desired target for the immune system, we will be able to see if the
Fostering the preferred broadly neutral-
Reported the week of Oct. 21 in the journal
immune system is now free to make this
izing antibodies has not been a simple
Proceedings of the National Academy of
type of response.”
matter, because they tend to have unusual features that make them targets for
Sciences, the finding provides a potential new strategy in vaccine development to
Dr. Haynes and colleagues built upon a
elimination by the body’s own immune
elicit the broadly neutralizing antibodies
growing body of recent research that has
system. Instead, other less-effective anti-
considered essential for long-lasting pro-
illuminated how the HIV virus manages to
bodies against HIV dominate and in some
tection from the ever-changing HIV virus.
thwart potential vaccine candidates and
instances crowd out the desired broad-
how the immune system mounts what is
neutralizing antibodies.
The new protein was designed by scien-
ultimately a futile fight. In the most recent study, the researchers
tists at Duke University and Harvard University and made by Samuel Danishefsky,
The targets of protective antibodies are
found a way to approach those challeng-
Ph.D., and his team at Memorial Sloan Ket-
vulnerable regions of the outer coat of
es, according to a Duke press advisory.
tering Cancer Center in New York.
the virus, also called the viral envelope.
The researchers built a glyocopeptide – an
HIV protects these vulnerable envelope
artificial protein synthesized by organic
“This new protein will allow the testing
regions with multiple strategies that cam-
chemistry with sugars attached – that is
of a major hypothesis for why broadly
ouflage the sites.
structured so it readily binds to the broad-
The Triangle Physician 2014 Editorial Calendar
14
January Diabetes Endocrinology
April Pediatrics Infectious disease
July Sports medicine Rheumatology
October Cancer in women Wound management
February Cardiology Ophthalmology
May Women’s health Neurology
August Gastroenterology Nephrology
November Urology ADHD
March Orthopedics Hematology
June Cancer in men Pulmonary
September Bariatrics Neonatology
December Otorhinolaryngology Pain management
The Triangle Physician
ly-neutralizing antibodies rather than the
dominant undesired target, that a vaccine
In addition to Drs. Haynes and Alam,
more dominant antibodies. That quality is
can provide a fair chance for neutralizing
study authors from Duke include S. Moses
important for allowing the preferred anti-
antibodies to develop,” said lead author S.
Dennison, Shelley Stewart, Frederick H.
bodies to have a chance to develop.
Munir Alam, Ph.D., professor of medicine
Jaeger, Kara Anasti, Julie H. Blinn, Mattia
and pathology at Duke. “As in the case of
Bonsigniori, and Hua-Xin Liao. In addition
The newly synthesized glycopeptide also
our designed glycopeptide, if we start with
to Dr. Danishefsky, authors from Sloan-Ket-
attaches to the original ancestors of the
a vaccine, to which not only the broadly
tering include, Baptiste Aussedat, Yusuf
broadly neutralizing antibodies, with the
neutralizing antibodies bind well but also
Vohra, Peter K. Park and Alberto Fernán-
potential to trigger the receptors on naïve
the receptors on naïve B cells, we hope to
dez-Tejada. Authors from Boston Universi-
B cells of the neutralizing antibodies. B
optimize the chance that the induced anti-
ty and Harvard are Thomas B. Kepler and
cells are white blood cells that make an-
bodies will go down the right path.”
Joseph G. Sodroski, respectively.
ture may be critical for a vaccine to induce
Dr. Alam said additional studies are ongo-
The study was funded with grants from
antibodies that neutralize the HIV virus.
ing, including efforts to create a crystal
the National Institute of Allergy and
tibodies. The researchers believe this fea-
structure of the glycopeptide bound to the
Infectious Diseases (AI0678501) (UM1-
“It’s by presenting the correct target for
neutralizing antibody and to begin testing
AI100645) and the Bill & Melinda Gates
a neutralizing antibody, yet masking the
the glycopeptide in animal models.
Foundation.
UNC Research News
Neuroscientists Discover Brain’s “Mini-Neural Computer” Dendrites, the branch-like projections of neu-
“That’s what this finding is like. The implica-
normal brain activity involved those den-
rons, were once thought to be passive wiring
tions are exciting to think about.”
dritic spikes. For example, could dendritic spikes be involved in how we see?
in the brain. But now researchers at the University of North Carolina at Chapel Hill have shown that these dendrites do more than re-
The answer, Dr. Smith’s team found, is
lay information from one neuron to the next.
“yes.” Dendrites effectively act as mini-
They actively process information, multiply-
neural computers, actively processing neu-
ing the brain’s computing power.
ronal input signals themselves.
“Suddenly, it’s as if the processing power
Directly demonstrating this required a se-
of the brain is much greater than we had
ries of intricate experiments that took years
originally thought,” said Spencer Smith,
and spanned two continents, beginning in
Ph.D., an assistant professor in the UNC
the lab of senior author professor Michael Häusser at University College London and
School of Medicine. His team’s findings, published October 27 in the journal Nature, could change the way
This is a dendrite in a single neuron in the brain. The bright object from the top is a pipette attached to a dendrite in the brain of a mouse. The pipette allows researchers to measure electrical activity, such as a dendritic spike.
ending after Dr. Smith and Ikuko Smith, Ph.D., D.V.M., set up their own lab at the University of North Carolina. There they used patch-clamp electrophysiology to at-
scientists think about long-standing scientific models of how neural circuitry functions
Axons are where neurons conventionally
tach a microscopic glass pipette electrode,
in the brain, while also helping researchers
generate electrical spikes, but many of the
filled with a physiological solution, to a
better understand neurological disorders.
same molecules that support axonal spikes
neuronal dendrite in the brain of a mouse.
also are present in the dendrites. Previous
The idea was to directly “listen” in on the
“Imagine you’re reverse engineering a piece
research using dissected brain tissue had
electrical signaling process.
of alien technology and what you thought
demonstrated that dendrites can use those
was simple wiring turns out to be transistors
molecules to generate electrical spikes
“Attaching the pipette to a dendrite is tre-
that compute information,” Dr. Smith said.
themselves, but it was unclear whether
mendously technically challenging,” Dr.
December 2013/January 2014
15
UNC Research News Spencer Smith said. “You can’t approach
ing on the visual stimulus, indicating that
input; they seem to be a computational
the dendrite from any direction. And you
the dendrites processed information about
unit as well.”
can’t see the dendrite. So you have to do
what the animal was seeing.
this blind. It’s like fishing if all you can see is
According to a UNC press advisory, Dr.
the electrical trace of a fish.” And you can’t
To provide visual evidence of their finding,
Smith’s team plans to explore what this
use bait. “You just go for it and see if you
the researchers filled neurons with calcium
newly discovered dendritic role may play
can hit a dendrite,” he said. “Most of the
dye, which provided an optical readout of
in brain circuitry and particularly in con-
time you can’t.”
spiking. This revealed that dendrites fired
ditions like Timothy syndrome, in which
spikes while other parts of the neuron did
the integration of dendritic signals may go
But Dr. Smith built his own two-photon
not, meaning that the spikes were the result
awry.
microscope system to make things easier.
of local processing within the dendrites.
Once the pipette was attached to a den-
This work was supported by a Long-Term Fel-
drite, his team took electrical recordings
Study co-author Tiago Branco, Ph.D., cre-
lowship and a Career Development Award
from individual dendrites within the brains
ated a biophysical mathematical model
from the Human Frontier Science Program;
of anesthetized and awake mice. As the
of neurons and found that known mecha-
and a Klingenstein Fellowship to Dr. Spen-
mice viewed visual stimuli on a computer
nisms could support the dendritic spiking
cer Smith; a Helen Lyng White Fellowship to
screen, the researchers saw an unusual pat-
recorded electrically, further validating the
Dr. Ikuko Smith; a Wellcome Trust and Royal
tern of electrical signals – bursts of spikes
interpretation of the data.
Society Fellowship and Medical Research
– in the dendrite.
Council (UK) support to Dr. Branco; and “All the data pointed to the same conclu-
grants from the Wellcome Trust, the Europe-
Dr. Smith’s team then found that the den-
sion,” Dr. Smith said. “The dendrites are
an Research Council and Gatsby Charitable
dritic spikes occurred selectively, depend-
not passive integrators of sensory-driven
Foundation to Mr. Häusser.
Prison Study Questions the Need for HIV Screening in New Inmates A significant proportion of people with HIV in the United States enter the prison system each year, and many have believed that screening new inmates for HIV would yield many new diagnoses.
David A. Wohl, M.D.
“We found that was not the case and that few of the HIV-positive individuals coming into state prison in North Carolina had not previously been diagnosed with HIV,” said David A. Wohl, M.D., an associate professor of infectious diseases at the University of North Carolina School of Medicine and the lead author of the paper.
16
The Triangle Physician
The study, published in the November 27 issue of The Journal of the American Medical Association, found that more than 90 percent of HIV-infected inmates entering prison in North Carolina had previously tested positive for the virus.
ulations with higher levels of undiagnosed HIV infection may constitute a higher priority for screening for HIV than prisoners. Of all new HIV diagnoses in North Carolina in 2008-2009, less than 2 percent were prison entrants,” the authors concluded.
Dr. Wohl and his team tested 22,134 inmates entering prison between 2008 and 2009 for HIV using excess blood collected for mandatory syphilis testing. Overall, 1.45 percent (320) of these inmates tested HIV-positive. Merging test results with records from the North Carolina Department of Health and Human Services revealed that all but 20, or 93.8 percent, of these inmates had a record of a positive HIV test prior to their incarceration.
At the time the study was conducted, HIV testing in the North Carolina state prison system was voluntary. In July 2013, the state passed a bill requiring all prisoners to be tested for HIV at entry, every four years during incarceration and at release.
The relatively low prevalence of undiagnosed HIV among those entering state prison suggests that an emphasis on screening incoming inmates to detect HIV may not be warranted. “Other at-risk pop-
Study co-authors are Carol Golin, M.D.; Jeanine May, Ph.D.; and Becky White, M.D., of the UNC Sheps Center for Health Services Research; and David Rosen, Ph.D., of the UNC School of Medicine. The National Institute of Drug Abuse at the National Institutes of Health funded this research.
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UNC Research News
Poor Nutrition Is Risk Factor for Patients Who Have Cystectomy Patients with bladder cancer are two times more likely to have complications
Researchers mined the American Col-
after a radical cystectomy procedure if
lege of Surgeons National Surgical Qual-
they have a biomarker for poor nutrition-
ity Improvement Program (ACS NSQIP)
al status before the operation, according
database to analyze postoperative com-
to study findings presented at the 2013
plications data from 1,085 patients who
Clinical Congress of the American Col-
underwent radical cystectomy at 315
lege of Surgeons in October.
medical centers across the United States from 2005 to 2011. ACS NSQIP is the lead-
Surgeons from the University of North
ing nationally validated, risk-adjusted,
Carolina at Chapel Hill School of Medi-
outcomes-based program to measure
cine and UNC Lineberger Comprehen-
and improve the quality of care in private
sive Cancer Center identified a poten-
sector hospitals.
tially modifiable risk factor for such postsurgical problems: a low preopera-
“Poor nutrition is a known risk factor
tive level of albumin, a marker of the pro-
for adverse results after radical cystec-
tein level in the blood.
tomy,” Dr. Johnson said. “The prevalence
Angela Smith, M.D.
of nutritional deficiency is very high in patients with bladder cancer, partly be-
“We are currently implementing a nutri-
cause of their disease and partly because
tional protocol in which all cystectomy
of their advanced age – 73 years on aver-
patients will receive a preoperative nutri-
age.”
tional assessment by a certified clinical nutritionist to address and optimize nu-
Bladder cancer will be newly diagnosed
tritional deficiencies. Furthermore, a nu-
in more than 72,500 people this year,
tritionist will be involved in postoperative
the American Cancer Society estimates,
care, both on an inpatient and outpatient
and about one third of all cases involve
basis. We hope that proactive emphasis
cancer that has spread into the muscu-
on nutrition will lead to improved out-
lar wall of the bladder, which permits
comes in this vulnerable population,” Dr.
spread to other organs. For these pa-
Smith said.
tients, radical cystectomy is the standard
David C. Johnson, M.D., M.P.H.
treatment, but the complication rate after
Among study patients who experienced
the operation remains high, particularly
complications within the first month af-
for infections and poor wound healing,
ter the surgical procedure, the authors
explained study authors.
looked for the presence of any of three known preoperative nutritional factors
David C. Johnson, M.D., M.P.H., lead au-
“Nutrition is clearly an important issue
that could affect surgical results. These
thor of the study and a senior urology
among post-cystectomy bladder cancer
factors were a low albumin level (less
resident at UNC School of Medicine, and
patients, and our study highlights this on
than 3 grams per deciliter), weight loss
colleagues evaluated the impact that pa-
a large scale…. As UNC is a Bladder Can-
greater than 10 percent of body weight
tients’ nutritional status before radical
cer Center of Excellence, we are making
six months before the operation and
cystectomy had on the rate of complica-
strides to use this information to benefit
obesity, defined as a body mass index of
tions within 30 days after the operation.
our patients,” said Angela Smith, M.D.,
30 kilograms per square meter or higher.
Radical cystectomy is a procedure that
assistant professor of urology, UNC Line-
involves surgical removal of the bladder
berger member, and senior author and
Study results showed that 575 patients
and lymph nodes.
lead investigator on the study.
(53 percent) experienced complications
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The Triangle Physician
NEWSOURCE-JUN10:Heidi
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12:57 PM
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within the first month after the surgical procedure. Of these patients, 32 (6 percent) had a low preoperative albumin level, 28 (5 percent)
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had major weight loss within the six months before the operation, and 182 (32 percent) were obese at cys-
Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.
tectomy. The investigators found that only low albumin level was a significant predictor of experiencing a postopera-
Our services range from consultation, to design, to creation and implementation of strategic plans.
tive complication, after controlling in the statistical analysis for patient age, involvement of a trainee surgeon in the operation, the year the operation took place and a history of a prior operation. Patients with low albumin levels before the surgical procedure
newsource & Associates
had 2.1 times the risk of having a complication within 30 days after the operation compared with those whose albumin level was in a normal
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range or above (3 g/dL and higher), the authors reported.
whether they need to make dietary
55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514
Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.
changes before their operations.
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It is unclear from this study whether preoperative correction of low albumin levels, such as from nutritional supplementation, will translate to fewer problems after radical cystectomy. However, based on their findings, Dr. Johnson still recommends that patients whose albumin levels are low before a scheduled radical cystectomy see a nutritionist to learn
Drossman Gastroenterology
Dr. Johnson’s other coauthors for the study were: E. Will Kirby, M.D.; Jed E. Ferguson, M.D., Ph.D.; Jonathan Matthews, M.P.H.; Michael E. Woods, M.D., F.A.C.S.; Matthew E. Nielsen, M.D., M.S., F.A.C.S.; Mathew C. Raynor, M.D.; Raj S. Pruthi, M.D., F.A.C.S.; and Eric M. Wallen, M.D., F.A.C.S.
December 2013/January 2014
19
News
WakeMed Recruits Urogynecologist Board-certified obstetric gynecologist Andrea Crane, M.D., has joined Wake Specialty Physicians – Women’s Center to become WakeMed Health & Hospitals’ first urogynecologist. This relatively new subspecialty helps women manage urogynecological conditions and pelvic floor disorders, such as overactive bladder, pelvic organ prolapse, incontinence and others. Pelvic floor disorders – or PFDs – are relatively common, as one in three women will suffer from at least one type of PFD in their lifetime. The pelvic floor can be damaged by childbirth, repeated heavy lifting, chronic disease or surgery. Dr. Crane specializes in pelvic reconstruction and robotic surgery. Her training in-
cludes evaluation and treatment of childbirth trauma, advanced pelvic organ prolapse, urinary and fecal incontinence, vesicovaginal and rectovaginal fistulae and mesh complications. In order to provide care in this specialized field, urogynecologists either complete a four-year ob/ gyn residency with a three-year fellowship or a five-year urology residency with a two-year fellowship after medical school. Dr. Crane earned her medical degree from Loma Linda University School of Medicine. She completed her residency at Summa Health System in Akron, Ohio, and her fellowship in female pelvic medicine and reconstructive surgery at
Raleigh Neurology Associates Celebrates 30 Years Raleigh Neurology Associates is celebrating its 30-year anniversary. “In 1983, we began as a small neurology practice with just Mitch and I in a small office on Computer Drive. We could only imagine growing as we have over the past 30 years,” said Keith J. Hull, M.D., who cofounded Raleigh Neurology with S. Mitchell Freedman, M.D. “The practice has expanded to meet the growing needs of those in the community,” said Dr. Freedman. Now Raleigh Neurology Associates, the practice has 26 physicians, 20 mid-level providers and more than 250 employees providing comprehensive services that encompass a range of subspecialties, including adult and pediatric neurology, developmental pediatrics and neuro-ophthalmology. Its scope of care includes a multiple sclerosis center, rapid-response neurologic clinic and nerve conduction studies, sleep medicine program, pain management clinic, infusion therapy, an on-site MRI and even an in-house pharmacy. For more information about Raleigh Neurology Associates, visit raleighneurology.com.
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The Triangle Physician
the University of North Carolina at Chapel Hill. She is the recipient of several accolades and achievements, including the American Urogynecologic Society Resident Scholars Award; and the American Association of Gynecologic Laparoscopists Special Resident in Minimally Invasive Gynecology Award, the Best Overall Resident Award and seven teaching awards. She has been inducted into the Alpha Omega Alpha Medical Honor Society. Dr. Crane also is a member of the American Congress of Obstetricians and Gynecologists (ACOG), the American Urogynecologic Society (AUGS), the American Association for Gynecologic Laparoscopists (AAGL) and the International Urogynecological Association (IUGA).
News Welcome to the Area
Physicians Shazia Sabahat Shadani, DO Internal Medicine; Rheumatology
Orthopaedic Specialists of NC Raleigh Tammi Michele Waters, DO General Preventive Medicine; Pediatrics; Family Practice/ Geriatric Medicine; Adolescent & Young Adult Medicine
Fuquay-Varina Primary Care Fuquay-Varina
James Lewis Abbruzzese, MD Internal Medicine; Medical Oncology
Duke University Medical Center Durham John Homer Barton Jr., MD Medical Oncology; Hematology; Internal Medicine
Raleigh
Kyla Megan Bennett, MD Vascular Surgery; Pediatric Surgery; Colon and Rectal Surgery; Surgical Oncology; Thoracic Surgery; Abdominal Surgery
Duke University Hospitals Durham
John Nathan Copeland, MD Child and Adolescent Psychiatry; Geriatric Psychiatry
University of North Carolina Hospitals Chapel Hill Hassan Karim Dakik, MD Gastroenterology, Internal Medicine
Durham
James McDowell Davis Jr., MD Hospitalist
Duke Univ Medical Center Durham Kathleen Beach Jackson Dunlap, MD Psychiatry; Child Psychiatry
Duke University Hospitals Durham Laura Leigh Hans, MD Pediatrics - Neurodevelopmental Disabilities; Child Psychiatry
Durham
Amit Kalra, MD Infectious Diseases, Internal Medicine
Durham
Lawrence Thomas Kim, MD Abdominal Surgery; Colon and Rectal Surgery; General Surgery; Head and Neck Surgery; Surgical Oncology
University of North Carolina Hospitals Chapel Hill Robert William Lampman, MD
Nirali Mahendrakumar Patel, MD
Anna Sydney, MD
Pathology - Molecular Genetic Pathology; Anatomic and Clinical Pathology
Urology
Sunshine Medical Cary
University of North Carolina Hospitals Chapel Hill
William James Sydney Jr., MD
Samip Patel, MD
Pain Medicine
Otolaryngology; Head and Neck Surgery; Otorhinolaryngology
UNC Chapel Hill
NCMB Raleigh
Roderick O’Hara Thompson, MD
William Franklin Pendergraft III, MD
Internal Medicine
Durham
Immunology; Internal Medicine; Nephrology
UNC Kidney Center, Div of Nephrology Chapel Hill
Song-Yih Tu, MD Emergency Medicine
Sean David Pokorney, MD Cardiology; Cardiovascular Disease; Internal Medicine
Duke University Hospitals Durham
Sandhills Emergency Physicians, PA Pinehurst Henry Joseph VanPala, MD Internal Medicine
David Michael Rasmussen, MD
Garner Mary Katharine Weeks, MD
Maxillofacial Surgery
University of North Carolina Hospitals Chapel Hill
Emergency Medicine
Univ of North Carolina Hospitals Chapel Hill
Norberto Rafael Rosado, MD Family Medicine; Emergency Medicine
Central Harnett Hospital Lillington
Physician Assistants
Sean David Rotolo, MD
Lorraine Elizabeth Anglin, PA Durham
Neurology
University of North Carolina Hospitals Chapel Hill
Chetan Dilip Kapat, PA
Shaun Richard Rybak, MD
Orthopedic Surgery; Orthopedic Sports Medicine
Diagnostic Radiology; Pediatric Radiology; Neuradiology; Vascular and Interventional Radiology
University of North Carolina Hospitals Chapel Hill
University Orthopaedics & Sports Medicine Clayton Jean Carla Luansing, PA Cardiovascular Disease, Internal Medicine; Critical Care Surgery
Jiyoung Ryu, MD
Rex Healthcare Raleigh
Physical Medicine & Rehab - Pain Medicine
7621 Sumter Crest Drive Raleigh
Katherine Robinson Pocock, PA
Syed Asad Ali Shah, MD
Family Medicine; Hospitalist
Vance Family Medicine Henderson
Family Medicine; Pediatrics
West Burlington Medical Center Burlington
Pamela Mae Schafer, PA
John William Sleasman, MD
Orthopedic Surgery
Allergy/Immunology, Diagnostic Lab, Immunology; Pediatrics
Duke Division of Pediatrics Durham
Durham VAMC Durham
Mallory B Williams, PA
Kathryne Judith Stabile, MD
Orthopedic Sports Medicine
Raleigh
Orthopedic Sports Medicine; Orthopedic Surgery
Duke University Hospitals Durham
Hospitalist; Internal Medicine
Hospital Medicine Durham
Joel Stephen Marquess, MD Diagnostic Radiology; Radiology; Neuroradiology
University of North Carolina Hospitals Chapel Hill Subash Cheriyan Mathew, MD Pediatrics; General Practice
Raleigh
However much you value wildlife conservation in North Carolina,
DEC NC
11
1234
quadruple it.
Merrick Miles, MD Anesthesiology
University of North Carolina Hospitals Chapel Hill Eddy Jose Morales, MD Musculoskeletal Radiology; Diagnostic Radiology
Duke University Medical Center-Dept of Radiology Durham Marshall James Ney III, MD Physical Medicine and Rehabilitation
University of North Carolina Hospitals Chapel Hill
That’s right! Your conservation effort is increased by a 3-to-1 matching gift. So, when you are one of the first to display the new North Carolina Wildlife Habitat Foundation NCDMV license tag, your $10 tag contribution to the organization becomes $40 in lands preserved. The all-volunteer North Carolina Wildlife fe Habitat Foundation assists in acquisition, on, management, and protection of land in North Carolina for the conservation of habitats needed to preserve wildlife
right here in the Old North State. Conservation education efforts are preparing future generations to sustain your concern for the lands we protect today. At www.ncwhf.org, download the license tag application and see the good works in process. pp Your new tag shows your support and your n contribution is put to work…times four. co
www.ncwhf.org w
December 2013/January 2014
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3D MAMMOGRAPHY WE’RE TALKING WAY BETTER IMAGING, EARLIER DETECTION, FEWER FALSE POSITIVES AND LESS CHANCE OF A CALL BACK. END OF DISCUSSION.
3D MAMMOGRAPHY • GREATER ACCURACY • REDUCED ANXIETY • NOW AT WAKE RADIOLOGY Let’s have a frank discussion. You can’t treat what you can’t detect. And 3D mammography, along with your regular 2D exam, is revolutionizing breast cancer detection. How? By significantly improving clarity for earlier detection and fewer false positives. Which, of course, reduces recall rates and the anxiety that comes with additional tests. To learn more about 3D mammography or to schedule an appointment, visit wakerad.com. Like we said, you can’t treat what you can’t see. And now we’re seeing better than ever. Wake Radiology | North Hills Breast Center | 919-232-4700 | wakerad.com Daily, evening and Saturday appointments | 20 minutes from check-in to exam completion