f e b r ua ry 2 017
Women’s Wellness Clinic and Carolina Women’s Research and Wellness Center “A Passion for Women’s Health” and Care That Is Personalized and Evidence-Based
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
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From the Editor
A Priviledge to Serve As Women’s Wellness Clinic founder and medical director and contributor to The Triangle Physician, obstetric-gynecologist Andrea Lukes frequently reminds patients and colleagues of
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her patient-focused practice philosophy. True to form, the cover story on Women’s Wellness Clinic this month leads with a statement of commitment of service to patients and concludes by affirming a practice-wide passion for women’s health. Readers also will learn about the obstetric-gynecology practice’s family and primary care focus and interest in treating patients throughout the course of their lives. The specialized expertise of its staff and clinical research program bring the latest treatments to patients. Specialized services address common patient
Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Marni Jameson Carey Ivonne Draughon, D.N.P., N.P.-C. Margie Satinsky, M.B.A. Gregory J. Wilmoth, M.D.
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management consultant Margie Satinsky begins the first in a three-part series of articles on antidiscrimination that was written with the guidance of attorneys. The Triangle Physician staff is honored to serve the region’s medical community by providing a forum for news and insight. We invite you to participate. Consider promoting your practice on the cover or taking advantage of competitive advertising rates. For more information on rates or to submit your medical news and information at no charge, send an email to info@trianglephysician.com. With gratitude and respect for all you do,
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Table of Contents
6
COVER STORY
Women’s Wellness Clinic and Carolina Women’s Research and Wellness Center “A Passion for Women’s Health” and Care That Is Personalized and Evidence-Based f e b r u a r y 2 0 17
Vol. 8, Issue 2
FEATURES
14
Dermatolgy
Dispelling the Fear Associated with the Dreaded “C” Word Gregory Wilmoth argues that fear of cancer is more dangerous than the disease and share virtues of Mohs Surgery.
15
Patient Care
Wonderful World of Integrative, Patient-Centered Care Ivonne Draughon explores the ideal interdisciplinary health care system, one that is patient focused, holistic and collaborative.
DEPARTMENTS 11 Practice Management
Antidiscrimination Within Your Medical Practice, Part I
12 Physician Advocacy
Coalition of Doctors Weigh in on Making Health Care Affordable
16 Research News
Iron-Supplement Bars Effectively Reduce Anemia in Indian Women
17 News Joint Venture to Provide Patients on Medicaid with PhysicianManaged Care
18 Research News Sound Waves and Whirl Pools Are Used to Round Up Tiny Signs of Disease
19 Research News Tumor-Seeking Salmonella Improves Survival Rate of Brain Tumor Patients
On the Cover: The health care providers at Women’s Wellness Clinic and Carolina Women’s Research and Wellness Center are: (standing, from left) Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G.; and Janet Davis, clinic office manager and center director; and Makayla Downs, F.N.P.; and (sitting, from left) Scarlet Dial, F.N.P.; and Marcelle Provencial, F.N.P. Absent from the photo is Amy Stanfield, M.D.
february 2017
5
Cover Story
Women’s Wellness Clinic and Carolina Women’s Research and Wellness Center “A Passion for Women’s Health” and Care That Is Personalized and Evidence-Based The Women’s Wellness Clinic offers a
Research and Wellness Center (CWRWC)
as a world leader in the diagnosis and man-
unique combination of personalized care
and office manager of the Women’s Well-
agement of this common problem.
with the latest technology and research.
ness Clinic. All of the providers are board
“Part of our success is our wonderful staff,
certified.
In late 2016, Dr. Lukes joined HELP, an international medical group, as the United States
and women understand that we enjoy what we do. We all feel it is a privilege to
The clinic is conveniently located near
expert on HMB. HELP stands for “Heavy
be someone’s doctor or nurse practioner,”
the Streets at Southpoint, in Durham, N.C.
Menstrual Bleeding: Evidence-based Learn-
says Andrea S. Lukes, M.D., M.H.Sc.,
While it has grown during the past 10
ing for best Practice.” Experts from around
F.A.C.O.G., who leads the practice.
years, personalized care continues to be
the world convened at a meeting in Barce-
emphasized. The providers have experi-
lona, Spain, Jan. 25-26, to develop speaker
Dr. Lukes is joined at Women’s Wellness
ence and expertise in a range of special-
training programs on the effective diagnosis
Clinic by obstetric-gynecologist Amy Stan-
ized areas of women’s health.
and management of HMB.
Provencial, F.N.P.; and Makayla Downs,
Heavy Menstrual Bleeding
HMB is often associated with uterine fi-
F.N.P. Janet Davis is the director of clini-
Heavy menstrual bleeding (HMB) impacts
broids. Fibroids are the most frequent
cal research of the Carolina Women’s
one in four women. Dr. Lukes is recognized
noncancerous uterine tumors in premeno-
field, M.D.; Scarlet Dial, F.N.P.; Marcelle
Makayla Downs (right), a board-certified family nurse practitioner with genetic testing expertise, reviews test results and prescribes cancer prevention plans.
6
The Triangle Physician
Obstetric-gynecologist Andrea Lukes, a recognized leader in the diagnosis and management of heavy menstrual bleeding, performs an ultrasound.
pausal women with a lifetime incidence in
vestigator of one of the first clinical trials
Women’s Wellness Clinic providers of-
white and black women of 70 percent and
on adenomyosis. At the conclusion, she
fer patients with HMB a comprehensive
80 percent, respectively. Interestingly, the
presented data on how to more effectively
overview of treatment options. “There are
cause of fibroids is not completely under-
diagnose adenomyosis using pelvic ultra-
many options for a woman who has heavy
stood, but the growth and symptoms of fi-
sound.
periods. Often these depend on her de-
1
sire to have children and her age. We are
broids are clearly related to both estrogen and progesterone.
2
Ultrasound findings of adenomyosis can
also able to provide the newest treatments
include an enlarged uterus, with often
through various clinical trials.”
One common, overlooked cause of HMB
asymmetrical enlargement of one area.
is adenomyosis, a benign condition in
As well, changes in the junctional zone,
Clinical Research
which the endometrium, made of glands
including hypoechoic striations, hetero-
The Carolina Women’s Research and
and stroma, is found within the muscle or
geneousy myometrium and myometrial
Wellness Center is the research arm of
myometrium of the uterus. It is likely relat-
cysts, can be seen.
Women’s Wellness Clinic. In addition to providing personalized health care,
ed to endometriosis, in which the glands and stroma of the endometrium are found
The clinical and research team at Wom-
CWRWC has participated in more than
outside the uterus. However the associa-
en’s Wellness Cinic is adept in the use of
70 U.S. Food and Drug Administration
tion between adenomyosis and endome-
the newest Philips Affiniti ultrasound sys-
clinical trials (Phase 1 through Phase 4).
triosis is not well understood.
tem. The state-of-the-art technology helps
Many of these trials relate to heavy men-
the providers evaluate HMB and several
strual bleeding, in addition to uterine fi-
Adenomyosis is difficult to diagnose with
other gynecologic issues, including ovar-
broids, endometriosis, migraines, meno-
pelvic ultrasound. In an effort to improve
ian cysts, pelvic cancers, endometriosis,
pause, hormone replacement therapy,
understanding of the condition and its di-
the position of intrauterine devices (IUD),
contraception, among others.
agnosis, Dr. Lukes served as the lead in-
among others.
february 2017
7
Dr. Stanfield’s longstanding interest in nutrition and the mind-body connection led her to complete the 1,000-hour fellowship through the Program in Integrative Medicine at the University of Arizona in 2009. Tenets of integrative medicine that are vital to her practice are: an equal partnership and mutual respect between doctor and patient and an openness to, and expertise in, evidence-based treatments that may be found outside of standard western medicine. Anxiety is a common problem that impacts approximately 18 percent of American adults (https://nccih.nih.gov). There is growing evidence that mindfulness and other forms of meditation, music, relaxation techniques and melatonin may be helpful for anxiety. “We work with some of the best individuals and health care partners (e.g., life coaches, meditation experts, acupuncturists) to help women learn new ways to handle anxiety. We also review natural products (dietary supplements) and prescribe medications for anxiety,” says Dr. Stanfield. Primary Care Scarlet Dial leads Women’s Wellness Clinic’s primary care services. She has 20 years of experience in managing acute and chronic medical issues, including hypertension, diabetes, depression/anxiety, Marcelle Provencial, a board-certified family nurse practitioner with advanced skill in contraception counseling and aesthetic services, performs a laser hair removal procedure.
Dr. Lukes serves as the principal investi-
career with equal time at home to raise
gator, alongside sub-investigators Scarlet
her four children.
Dial and Marcelle Provencial and lead coordinator Janet Davis. Davis’ strong or-
According to Dr. Stanfield, she chose to
ganizational skills and six years of clinical
specialize in obstetric-gynecology, be-
research experience maintains the prac-
cause she cares about issues that are
tice as one of the top-performing clinical
unique to women and enjoys treating
research centers in the southeast.
the variety of health concerns that arise throughout a woman’s life. Her focus is
Integrative Medicine
on supporting women to optimize their
Dr. Amy Stanfield, who has been with the
health and the quality of their lives. She
Women’s Wellness Clinic since May 2008,
particularly values the relationships she
says she is fortunate to work at a family-fo-
forms with patients throughout the course
cused practice that allows her a part-time
of many years of care.
8
The Triangle Physician
thyroid abnormalities, hyperlipidemia and more. Dr. Lukes explains that as the clinic has grown, “we have added more providers who can focus on primary care for our patients. Scarlet offers not only experience and knowledge but has the ability to educate each woman she sees.” Makayla Downs and Marcelle Provencial focus on primary care, as well. Dial explains that “Women often neglect their own health care due to their career and juggling family responsibilities. So, the more we can offer within our clinic, the better for each woman. I have enjoyed the
opportunity to help our team provide com-
Each person fits into one of three risk
Marcelle Provencial has become an ex-
prehensive, evidence-based care.”
categories for cancer – sporadic (general
pert in presenting contraceptive options
population risk), familial (elevated be-
to women, especially on the various intra-
that
yond sporadic due to personal or family
uterine devices. She says that within the
women be seen every year for an annual
history) and hereditary (includes a pres-
U.S. “there are four IUDs available – these
wellness examination or more frequently
ence of a genetic mutation in a family
include the three devices that contain hor-
for followup of acute or chronic medical
that increases their risk of cancer and is
mones, Mirena, Kyleena and Skyla, as well
problems. Even though the medical guide-
the highest risk threshold), according to
as ParaGard, which is a non-hormonal,
lines require less frequent PAP screening
Downs. The hereditary cancer risk makes
copper-based device.” In addition to IUDs,
for women with normal test results, it is
up about 10 percent of the population.
Women’s Wellness Clinic providers are
Medical
guidelines
recommend
certified in Nexplanon, a long-acting im-
important that women realize they need to see a health care provider each year, Dr.
After the test, Downs meets with the indi-
Lukes says.
vidual to review results. If the patient has
Genetic Testing for Hereditary Cancer
plantable contraceptive.
a hereditary cancer risk, she prescribes a
Unintended pregnancy and abortion rates
cancer prevention plan for her.
are higher in the U.S. than in most other developed countries, and low-income
In addition to gynecology and primary care, Makayla Downs, has specialized
Contraception
women have disproportionately high rates3.
expertise in identifying women at risk for
Meeting patients’ contraceptive needs is
Women’s Wellness Clinic providers take the
genetic cancers, using the Myriad myRisk
one of the most frequently provided ser-
time to educate women of all ages on their
Hereditary Cancer test. The test consists
vice at Women’s Wellness Clinic, where
contraceptive choices. Lack of knowledge,
of a 28-gene panel that identifies elevated
women have access to a comprehensive
misperceptions and often exaggerated
risk for eight cancers: breast, ovarian, en-
range of choices and are counseled on
concerns about the safety of birth control
dometrial, gastric, colorectal, pancreatic,
those that may best address their issues
methods serve as barriers to using contra-
melanoma and prostate.
and align with their goals.
ception, according to Dr. Lukes.
Scarlet Dial, a board-certified family nurse practitioner who oversees primary care services, performs a wellness exam.
february 2017
9
“Taking the time to understand each indi-
sidered to be overweight (body mass in-
notably positive ways. This is yet another
vidual woman’s concerns is so important
dex, or BMI, equal to 25 to 29.9); one-third
way the medical staff at the Women’s Well-
in helping her make educated choices
of adults are obese (BMI greater than 30).
ness Clinic provides comprehensive care,”
about birth control,” says Provencial.
One in 20 adults are extremely obese (BMI
says Dr. Lukes.
greater than 40). “Overall, we hope women will find a warm
Aesthetics Marcelle Provencial also leads the Wom-
Being overweight or obese impacts a
and welcoming environment. Our goal
en’s Wellness Clinic aesthestic division,
woman’s family as well. One-third of chil-
is to provide personalized and patient-
which offers painless laser hair removal
dren and adolescents ages six to 19 are
centered care that is evidence-based. We
with the Alma Laser.
considered to be overweight or obese.
function as a team at the Women’s Well-
Many women suffer from unwanted hair
Many women come to the practice only
growth related to polycystic ovarian syn-
for weightloss, according to Dr. Lukes.
drome (PCOS), hyperandrogenism and
“There are several options for medically
Sources
hormone imbalances. Offering painless
guided weight loss, making this an excit-
1
hair removal for these women in combina-
ing time for providers and patients.”
ness Clinic and share a passion for women’s health.”
Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative inci-
tion with medication therapy provides the
dence of uterine leiomyoma in black and
best results and improves overall satisfac-
In addition to the standard dietary chang-
tion, according to Dr. Lukes.
es, exercise and behavior changes, the medical options include phentermine,
Women’s Wellness Clinic also uses the
phentermine and topiramate (Qsymia),
Dysport neuromodulator, which targets
buproprion and naltrexone (Contrave)
unwanted wrinkles on the face.
and the latest liraglutide (Saxenda).
white women: ultrasound evidence. Am J Obstet Gynecol 2003;188(1)100-7. 2
Bulun SE. Uterine Fibroids. N Engl J Med 2013;369(14):1344-55.
3
Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception
Weightloss
“We provide close medical monitoring for
Weightloss is an area that all Women’s
women and prescribe all available options
Wellness Clinic providers address with
for weightloss. Often losing a small amount
their patients. Two-thirds of adults are con-
of weight can impact a woman’s health in
2011;84:478-85.
Janet Davis (left), director of Carolina Women’s Research and Wellness Center, discusses clinical trial opportunities.
10
The Triangle Physician
Practice Management
Antidiscrimination Within Your Medical Practice, Part I By Margie Satinsky, M.B.A.
(This is the first of a three-part series.)
To what entities do the new protections apply? The new nondiscrimina-
Antidiscrimination laws and regulations
tion regulations apply to entities that both
protecting the workforce have been in
operate a health program or activity and
existence since the 1960s. New regulations
that receive federal financial assistance
that protect patients, as well, went into
administered by HHS. The definition of
effect in July 2016. Now is a perfect time to
federal financial assistance means HHS
review the situation in your practice!
grants, loans, subsidies, contracts or other arrangements by which the federal
Guided by several attorneys with whom
government provides assistance through
we frequently work, we have developed
funds, services of federal personnel or
a three-part series on the most frequently
property. Medicare (other than Medi-
asked questions and answers (FAQs).
care Part B payments), Medicaid and the
This month we’ll focus on protection
Children’s Health Insurance Program fall
for patients. Next month we’ll focus on
under the definition of federal financial
protection for employees. Finally, we’ll focus
assistance.
partial list of steps that can be taken to comply with the law includes:
on suggestions for future direction in your practice. Keep in mind that all three articles
Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She has helped many physicians start new practices, assess the wisdom of affiliating with a larger health care system and improve their current practices. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www.satinskyconsulting.com.
What steps can we take regarding the new protections for patients? Take a hard look at the programs you have
(1) revision of forms that request gender identity; (2) development and dissemination
in place regarding language assistance
of information about processes for
and respect for gender identity. If you
designating or changing gender
have 15 or more employees, you must
identity;
designate one individual as responsible
(3) training coding staff to use modifiers
for compliance, and you must put a
to avoid erroneous claims denials;
grievance procedure in place. Notices
(4) revision of procedures to ensure that
about the grievance procedure must be
all staff and communications use the
posted along with taglines in the top 15
names preferred by patients;
Let’s work backwards starting with
languages spoken by individuals with
(5) revision of staff training materials;
the newest regulations. Earlier this year
limited English proficiency in the state.
(6) ensuring that electronic health
are just the tip of a very large iceberg.
records allow data correction and
the Department of Health and Human Services (HHS) finalized regulations under
With respect to gender identity, you
linking of accounts (e.g., electronic
Section 1557 of the Patient Protection and
are required to respect the gender with
linking of Jane Doe’s medical record
Affordable Care Act (ACA). The section
which the patient identifies. Gender is
with those of John Doe;
prohibits certain covered entities from
no longer a binary concept. Rather, it is
(7) reviewing/revising check-in
discriminating on the basis of race, color,
defined as an individual’s internal sense
national origin, sex (including gender
of gender – i.e. male, female, neither
identity), age or disability with respect to
or a combination of male and female.
any health program or activity. The regula-
That identity may be different from an
tions went into effect on July 18, 2016.
individual’s sex assigned at birth. A
procedures (8) reviewing/revising disciplinary policies; and (9) applying grievance policies to gender identity issues. february 2017
11
Physician Advocacy
Coalition of Doctors Weigh in on Making Health Care
Affordable By Marni Jameson Carey
A new coalition of doctors’ organizations is
“What these groups have in common
geared up to have its say in Washington –
is that their members are all fed up with
and the timing couldn’t be better.
the liberties government, hospitals and insurance companies have taken at
As the new White House administration
doctors’ and patients’ expense,” said Marni
gears up to repeal, replace or revamp
Jameson Carey, executive director of AID,
the Affordable Care Act, Practicing
a national nonprofit trade association with
Physicians of America (PPA), the new
1,000 members in 31 states.
Marni Jameson Carey is the executive director of the Association of Independent Doctors. You may reach her at (407) 571-9316 or marni@aid-us.org. Visit www.aid-us.org for more information.
coalition, wants a say, if not a seat at the table, said PPA meeting organizer Marion
“These entities have all taken more money
Mass, M.D., a Philadelphia pediatrician.
from the system while making it worse,” she
The bipartisan group invited lawmakers
said. “We are facing a unique opportunity
“If Congress incorporates the key tenets
from both sides of the aisle to a town hall
to change America’s health care system, so
that AID was founded on – stop the
meeting Feb. 2.
it truly is affordable and accessible.”
consolidation of hospitals and medical
PPA is a grassroots consortium of national
Ms. Carey was among the panel of speakers
enforcement of anti-trust laws and stopping
medical organizations that include the As-
who advised and informed lawmakers
the abuse of the tax-exempt status by
sociation of Independent Doctors, Let My
about the concerns those on the frontlines
nonprofit hospitals – we would save
Doctor Practice, the National Board of
of health care believe need to be resolved
hundreds of billions of health care dollars
Physicians and Surgeons, the Pennsylva-
as part of the new health care plan.
and improve access.”
America, Physicians Working Together and
“AID is working to help lawmakers –
At the Washington meeting, titled “Healing
United Physicians and Surgeons of Ameri-
regardless of their party affiliations –
Our Doctors and Our Healthcare System,”
ca, among others.
understand why helping doctors stay
six presenters addressed issues of reporting
independent is good for America’s health
mandates, the importance of preserving
care system,” said Carey.
groups,
transparency,
pay
parity,
nia Medical Society, Physician Women for
12
The Triangle Physician
Physician Advocacy independent doctors, new models of mental and public health care, harnessing social media for better health and doctors’ disconnect with the American Medical Association (AMA). “We want to provide a voice for doctors separate and apart from the AMA,” said Westby G. Fisher, M.D., F.A.C.C. a Chicago cardiologist, who presented. “The members of the coalition and most practicing physicians in this country agree that the AMA has not represented America’s doctors for some time,” Dr. Fisher said of the nation’s oldest politically active medical association. “The AMA gets most of its funding – $72 million a year – from selling the codes that insurance companies require doctors to use to get paid,” said Dr. Mass. “Any doctor paying attention can see the conflict of interest. By serving insurance
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AC N E
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•
ECZEMA
• Ads may be used in newspapers, fliers, posters, mailings, public transportation, or outdoor advertising. “Never in the nation’s • Ad mayhistory appearhave white on black or black on white or color. doctors been so disenchanted with their • Compensation in ad will match compensation listed in IRB approved consent form. profession, and never hasmay therebe been such • Ad used in its entirety for website posting or e-mail communication. an opportunity to effect change,” said Brian –When possible, all internet website postings will fall under the “Research Opportunities” heading sho Jamal Dixon, M.D., a child be psychiatrist one, butinmay also fall under the “Employment Opportunities” heading should there not be a relevan Texas who presented on a option new model on aofgiven website. If there is not a relevant “Research” heading, the following disclaimer will be psychiatric care. the study related text: “Please note that the following is not an employment opportunity but an opportunity to participate in research In short, the coalition hopes to get trial.” Notice: Radiant Research Inc. and Clinical Research Advantage retains all exclusive rights. All content, form an lawmakers to understand why helping protected under doctors is good forare America’s health care U.S. and Foreign copyright laws. No portions of this document may be reproduced or use without the express written consent of Radiant Research, Inc. system, said Dr. Mass.
SHE WANTED HER DAUGHTER TO HAVE THE BEST CARE AVAILABLE
The 3.5-hour town hall meeting was conducted in the Library of Congress. Lawmakers, media and health care administra-
I R E F E R R E D H E R T O S O U T H E R N D E R M AT O L O G Y
tors were invited.
FOR THE MOST ADVANCED SKIN CANCER TREATMENTS, REFER YOUR PATIENTS TODAY!
For more information about Practicing Physicians of America’s efforts contact Dr. Mass at marion@practicingphysicians.org.
919-782-2152
southernderm.com ROSACEA • HIVES
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VITILIGO
DER131_AD_Triangle Physican BEST CARE 1/3.indd 1
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february 2017
13
Dermatology
Dispelling the Fear Associated with the
Dreaded “C” Word By Gregory J. Wilmoth, M.D.
Cancer… A word that elicits the most un-
gery. The procedure is performed in the
wanted, sinister cousins: Fear and Dread.
office and under local anesthesia.
Fortunately the most common form of
Here are 10 of the most important facts
cancer, skin cancer, is treatable. Still, the
you should know about skin cancer and
phobia of cancer persists and is often
Mohs micrographic surgery:
more detrimental than the disease. The
1. M elanoma can be readily identified
challenge is, the anxiety that most feel
with screening, with the most com-
delays the opportunity for adequate care.
mon areas being the torso on men
Delays can allow the illness to become more severe.
and the legs on women. 2. M elanoma is typically not a large raised lesion, but instead a flat mark
Contrary to widely held beliefs, a diag-
about six millimeters or the size of a
nosis of skin cancer is not a death sen-
pencil eraser, with color variation and
tence. Most skin cancer is preventable
asymmetry
and, when diagnosed, is treatable. One
3. T he superficial appearance of skin
treatment that eradicates most, if not all,
cancer may be larger than it appears
of the skin cancer is Mohs micrographic
for the area may have roots, so good
surgery.
margin control during surgery is essential. 4. M ohs surgery offers the highest
Dr. Gregory Wilmoth, a board-certified dermatologist at Southern Dermatology & Skin Cancer Center in Raleigh, specializes in Mohs surgery and skin cancer reconstruction, among other specialties. He earned his bachelor of science degree in chemistry from the University of North Carolina at Chapel Hill and his medical degree from Bowman Gray School of Medicine, Wake Forest University. He completed his internship at North Carolina Baptist Hospital and residency at Mayo Clinic, Rochester, Minn. Dr. Wilmoth is a fellow of the American Society for Mohs Surgery. He is a member of the American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Academy of Dermatology, American Medical Association and the North Carolina Medical Society.
cure rate of any skin cancer removal technique. 5. B asal and squamous cell skin cancers have up to a 98 percent, five-year cure rate. 6. S unscreen creates a false sense of
of misinformation in self-treating skin cancer. 10. An estimated 40-50 percent of melanomas are not totally sun-induced but
protection from the sun, as it blocks
genetic mutations possibly triggered
only ultraviolet B light, which causes
by UVA light exposure.
sunburns, but not the equally damagAn outpatient procedure, Mohs provides
ing ultraviolet A light. This also allows
When referring patients for skin screen-
the highest reported cure rate by enabling
extensive exposure, since people
ings or skin cancer treatment, look for der-
doctors to check 100 percent of the mar-
don’t burn while getting hours of UVA
matologists who are fellows of the Ameri-
gin, unlike other procedures that provide
exposure.
can Society of Mohs Surgery, specially
only a cross-sectional look at the cancer.
7. The Mohs technique spares skin,
trained to perform the Mohs Micrographic
The immediate and thorough microscop-
which is of great importance for the
surgical removal of skin cancer and other
ic exam of the diseased tissue ensures
face, neck, hands and lower legs.
malignancies. Also look for an office that
all cancerous cells have been removed.
8. R econstruction is an integral part of
offers complete care for skin cancer, from
In addition to minimizing the chances of regrowth, Mohs preserves healthy tissue and minimizes the cosmetic impact of sur-
14
The Triangle Physician
care for skin cancer patients. 9. “ Dr. Google,” or Internet-based research, is the most dangerous source
initial screenings and treatment planning to reconstruction and follow-up care.
Patient Care
Integrative, Patient-Centered Care
Wonderful World of By Ivonne Draughon, D.N.P., N.P.-C.
Wouldn’t it be wonderful if health care
tend to operate independently of one
professionals could provide patients with
another, increasing the likelihood that a
choices about how they live their lives
patient might only be treated for certain
while also protecting them from chronic
aspects of their condition but not all of
diseases? That certainly would be a dream
them. For example, a victim of a car acci-
scenario for many humanistic doctors.
dent might have a great physical therapist but never even realize they need a psy-
Fortunately, we may be closer to real-
chologist to deal with the trauma-related
izing this goal than we think. During the
post-traumatic stress disorder.
last 50 years, the health care industry has evolved, so individual providers are much
Furthermore, the inconvenience of seek-
better equipped to work with a range of
ing out specialists from completely sepa-
collaborative resources and tools de-
rate health care organizations can be
signed to help patients achieve their de-
mentally and financially taxing.
Dr. Ivonne Draughon earned her doctor of nursing practice degree from East Carolina University and has been practicing for more than 10 years. She currently treats all ages at Carolina Partners of Wake Forest and specializes in psychiatric medication management and general primary care services. For more information visit www.carolinapartners.com.
system should be to connect all patients to their own personal-care teams. This
sired health outcomes without having to Right here in North Carolina, there are
means that each patient would work with
several high-end, state-of-the-art facilities
a central provider, who would act as the
The biggest development in this evolution
that subscribe to the “integrative” meth-
leader of a group of specialists - across all
was the birth of integrated health care – a
od. In these locations, medical profession-
disciplines - dedicated to the individual’s
system that places the patient front and
als create strategies, personalized to each
various health care needs.
center in the medical process and allows for
patient, based on the individual’s unique
comprehensive, holistic, effective treatment.
conditions, needs and circumstances.
sacrifice their normal ways of life.
Achieving such a lofty goal won’t be easy. Each new idea needs to pass through a
What Is Integrated Health Care?
The benefits of this approach are mani-
process called the “diffusion of innova-
Integrated (or interdisciplinary) health
fold: Not only are patients, caregivers and
tion.” The convoluted process begins with
care refers to a system in which medical
providers put in a better position to suc-
the original, innovative idea, which then
professionals from the two main health
ceed, but the larger health care system
must trickle through a series of commu-
care arenas - behavioral (mental) health
is buoyed as well. For example, studies
nication channels over a long period of
care and primary (physical) care – col-
show that the integrated health care ap-
time, receiving pushback from the more
laborate and communicate extensively.
proach can improve a society’s access to
rigid denizens of the older, outdated sys-
services, improve the general quality of
tem, gradually taking hold and hopefully,
care and lower health care costs overall.
eventually, reshaping the broader social
This system is unique, because informa-
system.
tion is shared across multiple disciplines among health care professionals, so a pa-
How Can Providers Optimize
tient’s needs are met comprehensively. A
Patient Care?
However, this is an endeavor worth striv-
given integrated health care team might
Given the availability of these resources
ing toward, as it will ensure strong rela-
include physicians, nurse practitioners,
and methods, it remains to be seen how
tionships between the patient, the provid-
psychologists, dietitians, personal trainers
they will be adapted and cultivated by ex-
er and the patient care team, improving
and physical therapists, depending on the
isting health care professionals.
everyone’s lives. And what a wonderful world this would be.
individual case. I believe the first priority for achieving Conventionally, these health care spheres
the goal of a fully integrated health care
february 2017
15
Research News
Iron-Supplement Bars Effectively Reduce Anemia in Indian Women An iron supplement bar given to anemic
Duke medical student and lead author
“We are encouraged by the results of this
women in and around Mumbai, India, led
Rajvi Mehta developed the supplement
study which show a positive connection
to increased hemoglobin and hematocrit
bar made with iron-rich natural, local
between consuming an iron-fortified
levels, reducing anemia with no reported
and culturally accepted ingredients. The
nutrition bar and a reduction in anemia
side effects, according to a study by Duke
GudNesS bars contain the World Health
prevalence,”
University researchers and collaborators
Organization’s daily-recommended dose
study author and assistant professor of
in India.
of iron. In 2011, Ms. Mehta worked with
biostatistics and global health at Duke.
nutritionists and physicians in India to
“It appears to be a practical and well-
The study appears in the Jan. 18 edition of
establish a social venture there called
tolerated solution to a significant health
the American Journal of Clinical Nutrition.
Let’s Be Well Red (LBWR) to begin large-
challenge in India.”
said
Elizabeth
Turner,
scale production of the bars. Ms. Mehta reportedly imagined her simple and accessible solution to the iron-deficiency as an undergraduate. She brought it to fruition by winning a $50,000 grand prize from a Duke start-up challenge as a medical student. Colleagues interpret the supplement bar’s steady path to clinical results as further proof of its efficacy and potential. Let’s Be Well Red is currently operating in three locations in India and produces 100,000 bars each year that it distributes throughout the country. “Anemia is a debilitating condition that Iron-deficiency anemia is the most
The study, conducted from March 2014
can have severe health consequences,”
common and widespread nutritional
through August 2014 in Mumba, India, and
said Ms. Mehta. “I am thrilled that my
disorder in the world, and in India it affects
Navi Mumbai, India, involved 179 anemic
colleagues and I were able to develop a
more than 600 million people, according
non-pregnant participants of reproductive
solution that has proven to be effective
to a Duke press advisory. India’s high
age in 10 demographically diverse sites.
among a high-risk population. Making an
prevalence of iron-deficiency anemia is
The sites were then randomly placed in
impact in global health has long been a
largely due to the local vegetarian diet.
either a control group or an intervention
goal of mine.”
group with the latter receiving one iron Iron-deficiency anemia can cause fatigue, pregnancy
complications
and
This study was supported by the Duke
supplement bar daily for 90 days.
Global Health Institute through the
heart
problems. Iron supplement pills often
Each group underwent three blood
DukeMed
have gastrointestinal side effects, so are
tests during the 90-day follow-up period
guidance was provided by Mulliben
Engage
Award.
Technical
an undesirable remedy for many people.
to
and
Dulabhai Trust (Mumbai, India). The
hematocrit. It was a rare study to examine
funder of the study had no role in study
According to study authors, iron-fortified
changes in hematocrit as an outcome in
design, data collection, analysis or
foods offer a more attractive alternative,
an Indian population.
interpretation, or in the writing of the
but large-scale production and distribution have proven unsustainable.
16
The Triangle Physician
measure
their
hemoglobin
report.
News Citation
A
Controlled
Elizabeth L Turner. The American Journal
“Efficacy of Iron Supplement Bars to
Trial,” Rajvi Mehta, Alyssa C Platt, Xizi
of Clinical Nutrition, January 2017. DOI:
Reduce Anemia in Urban Indian Women:
Sun, Mukesh Desai, Dennis Clements,
10.3945/ajcn.115.127555
Cluster
Randomized
Joint Venture to Provide Patients on Medicaid with Physician-Managed Care The North Carolina Medical Society, work-
form process and to put patients’ needs
patient-centered medical home model
ing in conjunction with the North Carolina
first.”
at FQHCs and their focus on providing a broad spectrum of services to low-income
Community Health Center Association, and Centene Corp. have signed a defini-
When the General Assembly in Septem-
and underserved populations, make them
tive agreement to collaborate on a patient-
ber 2015 passed Medicaid reform leg-
uniquely prepared to meet the state’s Med-
focused approach to Medicaid under the
islation privatizing the state’s Medicaid
icaid reform goals. NCCHCA believes part-
reform plan enacted in North Carolina.
program, NCMS began to proactively
nering with the North Carolina Medical
pursue opportunities to keep patients at
Society and Centene will enable FQHCs
Under the agreement, the organization
the forefront, according to an NCMS press
to work more closely with physician spe-
will create a joint venture, Carolina Com-
advisory. The society established key cri-
cialists and health systems in their local
plete Health, to establish, organize and
teria for a partnership, including finan-
communities to improve patient continu-
operate a physician-led health plan to
cial strength, experience with statewide
ity of care, quality and cost,” said E. Ben-
provide Medicaid-managed care services
Medicaid networks and an openness to a
jamin Money Jr., NCCHCA chief executive
in North Carolina, according to a North
patient-focused approach.
officer.
“Centene is pleased to enter into this
NCMS is the oldest professional member
Carolina Medical Society (NCMS) press advisory.
partnership with the NCMS and NCCHCA
organization in North Carolina, represent-
A key feature of the joint venture will be
(North Carolina Community Health Cen-
ing physicians and physician assistants
the active participation of physicians in
ter Association) to serve Medicaid recipi-
who practice in the state. Founded in
the ownership and governance of the
ents in North Carolina,” said Michael F.
1849, the society seeks to promote access
health plan. While Centene will manage
Neidorff, chairman, president and chief
to quality health care for all citizens in
the financial and daily operations, Caroli-
executive officer for Centene. “We believe
North Carolina and champions initiatives
na Complete Health Network – which will
this physician-directed health plan can be
that seek to improve quality of care and
be owned jointly by NCMS, physicians,
an ideal model when properly executed
promote patient safety.
physician assistants, nurse practitioners
to ensure providers are leading health
and Federally Qualified Health Centers
care decisions and contributing toward a
NCCHCA is a private, non-profit member-
– will provide medical management ser-
value-based reimbursement system that
ship association that represents federally
vices, hold a majority on the board of di-
results in better health outcomes for mem-
qualified health centers, as well as health
rectors and oversee the medical policies
bers at a lower cost to the state. We have
centers that aspire to be federally quali-
for the health plan.
seen this type of health plan model work,
fied. The NCCHCA’s mission is to promote
and we look forward to bringing this ap-
and support these patient-governed com-
proach to North Carolina.”
munity health care organizations and the
“With the changes taking place in our
populations they serve.
health care system at the state level, with Medicaid reform and new programs at the
Moving forward, the NCCHCA will serve
national level, the NCMS remains com-
as an integral part in making the joint ven-
A Fortune 500 company, Centene Corp.
mitted to ensuring that physicians are the
ture a success.
is a diversified, multinational health care enterprise that provides a portfolio of
ones making the clinical decisions in the best interest of their patients,” said Robert
“North
Qualified
services to government-sponsored health
W. Seligson, NCMS chief executive officer.
Health Centers (FQHCs) are key provid-
care programs, focusing on under-insured
“Our leadership views this partnership as
ers of primary care services to Medicaid
and uninsured individuals.
a unique opportunity to help lead the re-
recipients across North Carolina. The
Carolina
Federally
february 2017
17
Research News
Sound Waves and Whirl Pools Are Used to Round Up Tiny Signs of Disease engineers
experts. Duke engineers are moving to
The new technology relies on calculating
at Duke University have
develop a new device that addresses
and manipulating the effects of the two
demonstrated a tiny whirl-
these obstacles.
forces associated with sound waves –
Mechanical
acoustic radiation and acoustic streaming.
pool that can concentrate nanoparticles using noth-
In a new study, researchers paired a small
An example of acoustic radiation is the
ing but sound. The inno-
acoustic transducer to a glass cylinder
tone created when blowing air across the
vation could gather proteins and other
to produce a whirlpool that can capture
top of a bottle. Acoustic streaming is the
biological structures from blood, urine
these
same phenomenon but in reverse, where
or saliva samples for future diagnostic de-
in its vortex. The system shows early
vices.
promise for new diagnostic devices
Tony Jun Huang, Ph.D.
disease-signaling
nanoparticles
a vibrating body induces a fluid to flow.
because it is compact, inexpensive, lowEarly diagnosis is key to successfully
energy and does not alter the properties
treating many diseases, but spotting
of the corralled particles. The results
early indicators of a problem is often
appear online on Jan. 25, in the journal
challenging.
American Chemical Society Nano.
To
pick
out
the
first
warning signs, physicians usually must concentrate scarce proteins, antibodies or
“Diagnosis impacts about 70 percent of
other biomarkers from small samples of a
health care decisions,” said Tony Jun
patient’s body fluid to provide enough of
Huang, Ph.D., professor of mechanical
a signal for detection.
engineering and materials science at
Nanoparticles tagged with fluorescent markers to make them easier to see are concentrated in a column by a new acoustic whirlpool device.
Duke. “If we can improve the quality of
Sound is a travelling pressure wave
While there are many ways to accomplish
diagnostics while reducing its costs, then
that pushes on whatever it encounters.
this today, most are expensive, time-
we can tremendously improve the entire
Devices have used this phenomenon to
consuming or too cumbersome to take to
health care system.”
concentrate particles before, but it does not provide enough force on its own once
the field, and they might require trained
particles drop to the nanoscale.
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In the new device, a small, 5-volt acoustic transducer creates a standing sound wave aimed toward a long, thin glass vial. Because the vial is perpendicular to the sound wave, and because Dr. Huang’s team has precisely tuned the two to each other, the vibrations in the glass create a standing vortex along the vial’s axis. The whirlpool sucks in any particles suspended in the test liquid – such as those extracted from blood or urine samples – while the acoustic radiation keeps them there. In the study, fluorescent markers help make suspended nanoparticles more visible. But in an actual diagnostic device, Dr. Huang says that wouldn’t be necessary.
18
The Triangle Physician
Research News 1455658).
“My goal is to create a small diagnostic
Dr. Huang now plans to work on other
device about the size of a cell phone that
components of such a device and to
can autonomously separate biomarkers
collaborate with scientists at Duke Health
Citation
from samples,” said Dr. Huang. “With this
to test the new vortex technology in
“Enriching Nanoparticles via Acoustoflu-
vortex technology, the biomarkers could
disease diagnosis.
idics.” Zhangming Mao, Peng Li, Mengxi Wu, Hunter Bachman, Nicolas Mesyngier,
then be concentrated enough to see with a simple camera like the ones found in
This work was supported by the National
Xiasheng Guo, Sheng Liu, Francesco
today’s cellular phones.”
Institutes of Health (R01 HD086325) and
Costanzo, and Tony Jun Huang. ACS
the National Science Foundation (IDBR-
Nano, 2017. DOI: 10.1021/acsnano.6b06784
Tumor-Seeking Salmonella Improves Survival Rate of Brain Tumor Patients Biomedical engineers at Duke University have recruited an
from Georgia Tech, where much of the work was completed.
unlikely ally in the fight against the deadliest form of brain cancer – a strain of salmonella that usually causes food poisoning.
Previous studies have shown, quite accidentally, that the presence of bacteria can cause the immune system to recognize
Clinicians sorely need new treatment approaches for glioblastoma,
and begin attacking tumors. However, follow-up clinical trials with
the most aggressive form of brain cancer. The blood-brain barrier
genetically detoxified strains of S. typhimurium have since proven
– a protective sheath separating brain tissue from its blood
ineffective by themselves.
vessels – makes it difficult to attack the disease with drugs. It’s also difficult to completely remove through surgery, as even tiny remnants inevitably spawn new tumors. Even with the best care currently available, median survival time is a dire 15 months, and only 10 percent of patients survive five years once diagnosed. The Duke team decided to pursue an aggressive treatment option to match its opponent, turning to the bacterium Salmonella typhimurium. With a few genetic tweaks, the engineers turned the bacterium into a cancer-seeking missile that produces selfdestruct orders deep within tumors. According to a Duke press advisory, tests in rat models with extreme cases of the disease showed a remarkable 20 percent survival rate over 100 days – roughly equivalent to 10 human years – with the tumors going into complete remission. The results appeared online on Dec. 21 in the journal Molecular Therapy – Oncolytics. “Since glioblastoma is so aggressive and difficult to treat, any
A fluorescent, stained image shows tumor-marking bacterial nanocarriers in pink, cancer cell nuclei in blue and human mitochondria (another indicator of tumor cells) in green.
change in the median survival rate is a big deal,” said Jonathan G. Lyon, a Ph.D. student working with Ravi V. Bellamkonda,
To use these common intestinal bacteria as tumor-seeking
Ph.D., Vinik Dean of Duke’s Pratt School of Engineering and
missiles, Mr. Lyon and Dr. Bellamkonda, working with lead co-
corresponding author of the paper. “And since few survive a
author Nalini Mehta, Ph.D., M.B.A., selected a detoxified strain of
glioblastoma diagnosis indefinitely, a 20 percent effective cure
S. typhimurium that was also deficient in a crucial enzyme called
rate is phenomenal and very encouraging.”
purine, forcing the bacteria to seek supplies elsewhere. Tumors are an excellent source of purine, causing the bacteria to flock to
Dr. Bellamkonda’s laboratory is currently transitioning to Duke
them in droves, according to the press advisory.
february 2017
19
Research News Then, the Duke engineers made a series
“And because their natural toxicity has
100 days, which translates to roughly 10
of genetic tweaks so the bacteria would
been deactivated, they don’t cause an
human years.
produce two compounds called Azurin
immunological response. At the doses
and p53 that instruct cells to commit
we used in the experiments, they were
In the 80 percent that did not survive,
suicide – but only in the presence of low
naturally cleared once they’d killed the
however, the treatment didn’t change
levels of oxygen. And since cancerous
tumors, effectively destroying their own
the length of time the rats survived.
cells are multiplying so energetically, the
food source.”
After testing for common signs of resistance to the anti-tumor compounds
environment around and within tumors has unusually low oxygen.
The researchers tested the modified
and finding none, the researchers
bacteria by injecting them directly into
concluded the ineffectiveness was likely
“A major challenge in treating gliomas
the rats’ brains. The first course of action
due to inconsistencies in the bacteria’s
is that the tumor is dispersed with
usually performed with glioblastoma is
penetration
no clear edge, making them difficult
to surgically remove the primary tumor,
tumor growth outpacing the bacteria.
to completely surgically remove. So
if possible, leaving the opportunity to
According to the press advisory, every
designing bacteria to actively move and
directly deliver therapeutics.
rat showed initial signs of improvement
or
to
the
aggressive
after treatment.
seek out these distributed tumors and express their anti-tumor proteins only
The treatment worked in 20 percent
in hypoxic, purine-rich tumor regions
of the rats, causing complete tumor
“It might just be a case of needing to
is exciting,” said Dr. Bellamkonda.
regression and extending their lives by
monitor the treatment’s progression and provide more doses at crucial points in the cancer’s development,” said Mr. Lyon. “However, this was our first attempt at designing such a therapy, and there is some nuance to the specific model we used, thus more experiments are needed to know for sure.” The researchers now plan to program their bacteria to produce different drugs that cause stronger reactions in the tumors. These will be more difficult to
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implement, however, as other drugs are not as specific to tumor cells as those used in this study, making potential side effects more of a concern. This research was supported by the Ian’s Friends Foundation, Ann Rankin Cowan, Children’s Healthcare of Atlanta and Georgia Research Alliance.
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Citation “Bacterial Carriers for Glioblastoma Therapy.” Nalini Mehta, Johnathan G. Lyon, Ketki Patil, Nassir Mokarram, Christine Kim, Ravi V. Bellamkonda. Molecular Therapy – Oncolytics, 2016. DOI: 10.1016/j.omto.2016.12.003
Welcome to the Area Welcome to the Area
Physicians
Elijah Bryan Wilder, DO
Ali Kazemi, MD
Erin Ebaugh Sukhu, MD
Anesthesiology - Pain Medicine
Pediatrics
Duke University Hospitals Durham
University of North Carolina School of Medicine Chapel Hill
Akinniran Abisogun, MD
Adam Jordan Kimple, MD
Psychiatry
Cardiovascular Disease, Internal Medicine
University of North Carolina Hospitals Chapel Hill
Clayton Aldon Alfonso, MD
Angela Anne Kuntz, MD
Duke University Hospital Durham
Michael Kelly Altenburg, MD
Caitlin Barstow Low Magraw, MD
Diagnostic Radiology; Internal Medicine; Musculoskeletal Radiology; Neuroradiology; Nuclear Radiology; Pediatric Radiology; Vascular and Interventional Radiology
UNC Oral & Maxillofacial Surgery Chapel Hill
Anatomic and Clinical Pathology; Pathology
Duke University Hospitals Durham
David Ismael Arbona Calderon, MD Emergency Medicine
UNC School of Medicine Chapel Hill
Adam Gregory Back, MD Neurological Surgery
Duke University Hospitals Durham
Michael Habib Burchell, MD Anesthesiology
Wake Forest University Baptist Medical Center Winston-Salem
Don Clarence Chaplin, MD Burlington
Steven Henry Cook, MD Neurological Surgery, Critical Care
Duke University Hospitals Durham
Paul Arthur Dowsett, MD Anesthesiology
Chapel Hill
Kafui Dzirasa, MD Psychiatry
Duke University Hospitals Durham
Ruwan Lalinda Gamage Gamarallage, MD Hospitalist; Internal Medicine
Duke Raleigh Hospital Raleigh
Nikki Monique Henry, MD Family Medicine
Duke University Hospitals Durham
Karoline Regina Johnson, MD Hospitalist; Internal Medicine
Southern Pines
Duke University Hospitals Durham Hospitalist; Internal Medicine
Psychiatry
UNC Hospitals Chapel Hill
Rebeca Alvarez, MD
Pathology
Adam James Tosh, MD
Duke Women’s Health Associates Durham
University of North Carolina Hospitals Chapel Hill
Sherry Tang, MD
Otolaryngic Allergy; Otorhinolaryngology; Rhinology
UNC Hospitals Chapel Hill Obstetrics and Gynecology
UNC Hospitals Chapel Hill
Physician Assistants
Maxillofacial Surgery
Marisa Danielle Cunningham, PA Dermatology; Family Medicine; Family Practice; Psychiatry
Diana Leigh Marchese, MD
6026 Six Forks Rd Raleigh
Physical Medicine and Rehabilitation
UNC Hospitals Chapel Hill
Jillian Eve Darden, PA
Nitin Lee Mehdiratta, MD Anesthesiology, Critical Care-Internal Medicine
Duke Anesthesiology Durham
Critical Care Surgery; General Surgery; Internal Medicine - Critical Care Medicine; Neurological Surgery
Duke University Medical Center Durham
Kevin Charles Oeffinger, MD Family Medicine
Christina Marie Lynch, PA
Duke Cancer Center Durham
Oncology, Internal Medicine
Holly Springs
Sunil Ramesh Pandya, MD
Jennifer Elizabeth McCleary, PA Family Practice; General Practice; Urgent Care
Hospitalist; Internal Medicine; Pediatrics
Sanford Health & Rehabilitation Sanford
Health Zone Medical Center Smithfield
Michael J. Plakke, MD
Shannon Marcus Jude Quamina, PA Emergency Medicine; Family Medicine; Family Practice; Urgent Care
Anesthesiology
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