j u ly
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Triangle Vein Clinic
Serving the Greater Raleigh Area for More Than 20 Years 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
Congenital Hypothyroidism Liver Disease
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COVER STORY
6
Triangle Vein Clinic
Serving the Greater Raleigh Area for More Than 20 Years
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Vol. 4, Issue 6
FEATURES
9
DEPARTMENTS 10 Women’s Health
Endocrinology
Urinary Tract Infections: Is There a Prevention for Women?
15 Practice Marketing
Diagnosing and Treating Congenital Hypothyroidism
Mobile Websites: A Waste of Time or a Necessary Investment?
Dr. Julia Warren-Ulanch addresses the importance
Preparing for ICD-10
16 Practice Management
of early detection of this treatable condition and preventable cause of mental retardation.
12
19 Duke Research News Parenting, Home Environment Influence Children’s Exercise, Eating Habits
Gastroenterology
20 Duke Research News Antidepressant Is Shown to Reduce Stress-Induced Heart Condition
Clinical Conundrums in Non-alcoholic Fatty Liver Disease
21 WakeMed News
Dr. Kerry Whitt explores discusses the varied
22 UNC Research News
challenges that face physicians in treatment and strategies for improved outcomes. COVER PHOTO: From left, Lemuel G. Yerby, M.D.; Victor A. Medina, M.D., F.A.C.S.; and David Z. Zeiler, M.D., of the Triangle Vein Center/Triangle Surgical Associates.
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The Triangle Physician
New ACO Endeavors to Improve the Coordination of Care Across Continuum - I nterventions Aimed at Reducing Colon Cancer Screening Disparities - Recruitment Begins for Long-Term Diabetes Drug Efficacy Study
24 News - Welcome to the Area - Events
Category
july 2013
3
From the Editor
Long Lived This month’s cover story explores the longevity of Triangle Vein Clinic. Part of the Triangle Surgical Associates, it was founded in 1991 as the first clinic of its kind, offering an alternative to vein stripping. Today, the clinic is a 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
leader in vein care and the founder, vascular surgeon Victor Medina, is one of the most experienced vein specialists in the country. The article provides an overview of venous disease, the skill required to properly diagnose it and the latest minimally invasive treatment options available. In it, Triangle Vein Clinic leaders, Lemuel G. Yerby III and David Zeiler, discuss their general surgical practice and specialized expertise in breast disease through their Comprehensive Breast Clinic of the Triangle, hernias and hemorrhoids. Also in this issue, new contributor gastroenterologist Kerry Whitt summarizes the importance of understanding nonalcoholic fatty liver disease, which affects nearly half of the adults in our country. Endocrinologist Julia Warren-Ulanch reviews congenital hypothyroidism, a preventable cause of mental retardation if not detected soon after birth. Obstetric-gynecologist Andrea Lukes provides information on urinary tract infections, including ways women may be able to avoid recurrence.
Editor Heidi Ketler, APR
heidi@trianglephysician.com
Contributing Editors Amanda Kanaan Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Joe Reddy Julia Warren-Ulanch, M.D. Kerry N. Whitt, M.D. Photography Mark Jacoby Creative Director Joseph Dally
mark@jacobyphoto.com
jdally@newdallydesign.com
Advertising Sales info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com
Practice management consultant Joe Reddy returns to offer valuable insight into ways practices can prepare for the replacement of the outdated ICD-9 with ICD-10 on Oct. 1, 2014. Marketing specialist Amanda Kanaan advises on creating mobile-friendly practice websites. The face of the Raleigh-Durham medical Triangle is rapidly changing as it stretches the bounds to make health care better and to stay competitive. Those who are wellestablished are keeping pace with the advances and, aside from their core values, many
The Triangle Physician is published by: New Dally Design Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
look very little like they did at inception. The Triangle Physician is designed as a resource to help medical professionals keep up with our ever-changing medical community. Contributors are welcome to share their news and insight with us at no charge. Our advertisers also take advantage of extremely competitive rates. So consider The Triangle Physician as a partner in your pursuit to be long-lived and prosperous. With deep appreciation and respect,
Heidi Ketler Editor
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The Triangle Physician
Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.
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Cover Story
Triangle Vein Clinic
Serving the Greater Raleigh Area for More Than 20 Years In 1991, vascular surgeon Victor A. Medi-
ognized as a leader in the comprehensive
na, M.D., F.A.C.S., brought to life his vision
treatment of venous disease.
angle area for more than 20 years.
voted to the treatment of venous disease.
Triangle Vein Clinic is also a part of Trian-
Venous Disease: It’s Not Just a Cosmetic Problem
It was the first of its kind in the Triangle,
gle Surgical Associates – a general surgery
When asked how he’s been able to sustain
and more than 20 years later Triangle Vein
practice that’s been offering a comprehen-
such a busy practice for the last 22 years,
Clinic and Dr. Medina are nationally rec-
sive range of surgical services to the Tri-
Dr. Medina explains that venous disease
for a unique medical practice solely de-
is twice as common as coronary heart disease and five times more common than peripheral arterial disease. Although a large portion of the population will suffer from some sort of vein disorder in their lifetime, the challenge comes in properly identifying those with the condition. “It’s easy to diagnose a patient who has protruding varicose veins, but oftentimes the disease is manifested by a greater number of smaller veins that can’t be diagnosed at first glance,” says Dr. Medina. Patients with venous disease who do not display protruding veins are sometimes misdiagnosed or their symptoms are ignored and remain untreated. In fact, more than 30 million people are undiagnosed with varicose veins, or chronic venous insufficiency (CVI)1. Chronically untreated varicose veins associated with recurrent bouts of phlebitis may lead to irreversible leg discoloration (browning), swelling and skin ulcers that are painful and difficult to heal. Varicose veins are therefore more than just a cosDr. Medina positions the Venefit radio frequency catheter in the right greater saphenous vein.
6
The Triangle Physician
metic problem. They are symptomatic
manifestations of venous disease. Keeping in mind that not all cases can be diagnosed by the naked eye, some symptoms to look out for include the sensation of fullness, tiredness and tenderness in the legs. According to Dr. Medina, patients need an ultrasound diagnosis to accurately identify venous insufficiency.
New Minimally Invasive Treatment Options After Dr. Medina diagnoses the patient through ultrasound performed in office, he starts with conservative measures by having patients wear medical compression stockings for three months. If patients benefit from the compression stockings, then they most likely will benefit from a minimally invasive procedure. According to Dr. Medina, “Eighty percent of patients benefit from compression stockings and are therefore good candidates for a vein procedure that will give them permanent relief.” Varicose veins are known to be unsightly, but they can also be debilitating for patients if left untreated. Triangle Vein Clinic offers a state-of-the-art minimally invasive procedure called Venefit (formerly known as VNUS Closure) that is effective and also allows for a quick and easy recovery – patients can return to normal activities within 24 hours. Covered by most insurance, the Venefit procedure is the only minimally invasive ablation treatment that uses radiofrequency energy to contract the collagen in the diseased vein walls, caus-
Dr. Medina displays the heating element of the Venefit radio frequency catheter.
ing them to collapse and seal. Once a leg vein is closed, blood flow is redirected to healthy veins.
Smaller veins that are cosmetic in nature are treated with sclerotherapy, which involves injecting a solution directly into the vein.
When asked if Venefit is suitable for larger veins, Dr. Medina re-
The solution causes the veins to collapse and fade from view in
ports that “there has not been anyone I haven’t been able to treat
about two to 12 weeks. According to Dr. Medina, the vein struc-
with a minimally invasive procedure. Even the few patients who
ture can be described as a tree, whereby the trunk is best treated
presented with large veins up to 33 millimeters in diameter were
with minimally invasive procedures while the smaller branches
treated successfully with minimally invasive ablation.”
can simply be treated with injections.
Dr. Medina has performed more than 5,000 Venefit procedures,
A National Leader in Vein Care
which makes him more experienced than any vascular special-
Dr. Medina is a fellowship-trained vascular surgeon who received
ist in the Triangle. His practice is also a training center to teach
a specialized education in venous diseases after working at a vein
vascular procedures to other providers. As the first in the area to
clinic throughout his training. He completed his general surgery
offer an alternative to painful vein stripping, Dr. Medina constantly
residency at Yale-New Haven Hospital and St. Mary’s Hospital in
seeks the most advanced and effective treatments for patients.
Connecticut and his fellowship in vascular surgery at St. Vincent Medical Center in Ohio.
Another minimally invasive procedure Dr. Medina offers is the VeinGogh System, which targets spider veins on the face, hands
During the last 20-plus years in practice, Dr. Medina has performed
and legs. VeinGogh uses ohmic thermolysis – a state-of-the-art
thousands of vein treatments and is one of the most experienced
technology comprised of insulated micro probes that deliver
vein specialists in the country. His leadership in vein treatment
high-frequency bursts of electrical energy directly into the ves-
has attracted the attention of several national magazines as well
sels.This coagulates the blood and collapses the vessel wall while
as the local CBS, ABC and NBC affiliates.
leaving the outer layers of the skin unaffected.
july 2013
7
Another area of expertise for Triangle Surgical Associates is hernias. “It used to be that if a patient had a hernia then you’d take them to the operating room and just pull the tissue back together. However, often the hernia would just return,” says Dr. Zeiler. Hernias then become “complex” when repeated surgical attempts to close the hole in the abdominal wall fail. The likelihood of hernia repairs being successful diminish with each successive surgery. To virtually eliminate the chance of reoccurrence for complex hernias, the surgeons use the component separation technique (CST). This entails cutting some of the fascial planes to get the tissue needed to pull the abdominal wall back together. It is then reinforced with a synthetic mesh material. “This is a huge advance that has significantly reduced the reoccurrence of hernias. In fact, not one of my patients has come back to me with a recurrent hernia after this procedure,” says Dr. Zeiler. The group also performs surgery for hemorrhoids – a condition that affects about half of the general population. For stage II to IV hemorrhoids, they use a technique called transanal hemorrhoidal dearterialization (THD). THD is a minimally invasive surgical approach to treating the source of hemorrhoids. It is less painful for David Z. Zeiler, M.D., (left) and Lemuel G. Yerby, M.D., discuss an upcoming surgery.
patients because it doesn’t actually cut any tissue. “If you think of hemorrhoids like a water balloon, then what THD does is turn the faucet off on the water balloon by getting rid of the artery that
Triangle Surgical Associates: Comprehensive Surgical Care
feeds it,” says Dr. Zeiler.
Triangle Vein Clinic is a part of Triangle Surgical Associates – a general surgery practice led by Lemuel G. Yerby III, M.D. and Da-
Accessibility for Referring Doctors and Patients
vid Zeiler, M.D. Combined, the two surgeons share more than 50
Dr. Medina, Dr. Yerby and Dr. Zeiler all feel strongly that one of the
years of experience treating a wide range of common surgical
main characteristics that sets their practices apart is that they are
ailments. “We are a rarity. Most surgeons these days limit their
extremely accessible to both referring doctors and patients. “We
practices to a particular specialty, but we really do it all,” says Dr.
don’t have an answering service,” says Dr. Yerby. “Patients and
Zeiler.
referring doctors are often taken aback by the fact that when they contact us after hours we answer their call directly. We think hav-
Dr. Yerby adds, “We take care of 95 percent of common surgical
ing an instantaneous connection to your surgeon is important.”
diseases.” Depending on the need, the physicians are also willing to see Besides managing general surgical procedures, both traditionally
referred patients on the same day.
and through minimally invasive techniques, the physicians at Triangle Surgical Associates also have a special interest in treating
To refer a patient to Triangle Vein Clinic or Triangle Surgical As-
such conditions as breast disease, hernias and hemorrhoids.
sociates, call (919) 851-5055. Triangle Vein Clinic and Triangle Surgical Associates are located at 115 Crescent Commons Drive
Known as the Comprehensive Breast Clinic of the Triangle, the
in Cary. To learn more, visit www.trianglesurgical.com or www.
breast disease division of Triangle Surgical Associates was started
triangleveinclinic.com.
by Dr. Yerby and provides advanced techniques in the treatment of all breast diseases (benign or malignant), as well as recon-
Reference
struction and cosmesis. Complimentary clinical services include
1
physical therapy, social services and support groups.
sociated chronic diseases: clinical practice guidelines of the Society
Gloviczki P, et al. The care of patients with varicose veins and as-
for Vascular Surgery and the American Venous Forum. JVS; May 2011.
8
The Triangle Physician
Endocrinology
Diagnosing and Treating
Congenital Hypothyroidism By Julia Warren-Ulanch, M.D.
Hypothyroidism is a common condition to
cases are most often sporadic, and com-
develop over the course of a lifetime, but
prise the majority of cases of congenital
it is also a condition babies can be born
hypothyroidism, at 80-90 percent. Future
with. As it is common (one in 3000-4000
babies born to the same parents are not at
newborns), cost-effective to diagnose and
any higher risk to have the same problem.
treat, and a preventable cause of mental
The other way a baby can be hypothyroid
retardation, it is of the utmost importance
is to have a defect or deficient enzyme
to address it early. Here, we’ll review
along the pathway that takes precursors
the causes, diagnosis, treatment and
and creates thyroxine. Another way to
management of this disease.
say this is there is a slow or broken machine along the factory that takes building
Signs and symptoms of hypothyroidism
blocks and creates the final product. This
in a baby can be quite hard to detect
form of hypothyroidism comprises the
and devastating to miss. For this reason,
other 10-20 percent of congenital hypothy-
in 1974, the United States began pilot
roidism, and is autosomal recessive. Fu-
programs for newborn screening. This
ture babies born to the same parents have
is a special test for infants at 24 hours of
a 25 percent chance of being normal, 50
life. A heel stick is performed, and blood
percent chance of being a carrier, and 25
is collected onto a piece of filter paper to
percent chance of being affected.
be screened for diseases for which early
Julia Warren-Ulanch is a board-certified adult and pediatric endocrinologist. She is a graduate of Texas A&M University, who travelled to the University of Michigan for residency in internal medicine and pediatrics. She went on to the University of Pittsburgh, where she completed her training as a fellow in adult and pediatric endocrinology. Dr. Warren-Ulanch is board certified and has Endocrine Certification in Neck Ultrasound (ECNU). Now an associate at Carolina Endocrine, P.A., she enjoys serving pediatric and adult patients with general endocrinology issues. For more information and patient referrals and appointments, call (919) 571 3661 or visit the practice website at carolinaendocrine.com.
intervention is available and life-changing.
Once confirmed with repeat blood
close
Among conditions tested is congenital
testing, determining the cause of the
endocrinologist, we can assist these
hypothyroidism. The outcome for babies
hypothyroidism is important to provide
babies to develop to their full intellectual
is best if treatment is started within 14 to 21
implications for the patient (more severe
potential.
days of life. In the state of North Carolina,
cases are at higher risk for developmental
the test for hypothyroidism includes both
delay) and for future pregnancies.
thyroid stimulating hormone (TSH) and thyroxine (T4). Using the values of these
A nuclear medicine test to image the
tests, infants are classified as normal,
thyroid with technetium can be done
borderline (TSH<20 and T4<5, TSH 20-
quickly to assess the presence and
29.9 and T4 <12.9, or TSH 30-39.9) or
location of the thyroid. As soon as the
hypothyroid (any TSH>40uIU/mL). Those
test is complete, replacement can begin. If
with borderline or hypothyroid results are
levothyroxine is started quickly at a dose
sent a letter within a week notifying the
of 10-15ug/kg/day and dosed in water
pediatrician that further testing is in order.
or a small amount of water, levels can be normalized quickly. Infants on a soy
The common causes of congenital hy-
formula may require more, as absorption
pothyroidism fall into two major catego-
is impaired.
ries: athyreosis and dyshormonogenesis. Infants can be born without a thyroid
While no parent wants their newborn
altogether, a gland in the wrong location
afflicted with any problems, congenital
(usually the base of the tongue, or lingual
hypothyroidism is treatable with daily
thyroid), or only partially formed. These
hormone
replacement.
Along
monitoring
with
a
pediatric
The Triangle Physician 2013 Editorial Calendar August Orthopedics, Gastroenterology Medical Real Estate September Atrial Fibrillation Urology, Web Design October Cancer in Women, COPD - Lung Health Medical Software - EMR November Alzheimerâ&#x20AC;&#x2122;s Disease Diabetes, Financial Planning December Pain Management, Spine Disorders Practice Management
with july 2013
9
Women’s Health
Urinary Tract Infections
Is There a Prevention for Women? By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
Many women will experience at least one
species causing UTI is E. coli (between
urinary tract infection in their lifetime.
75-95 percent). Others include Enterobac-
While a urinary tract infection can occur
teriaceae, Proteus mirabilis and Klebsiella.
in the kidneys, ureter, bladder or urethra, most impact the bladder and urethra. Just being a woman is a risk factor.
How Does a Woman Know She Has a UTI? Symptoms of dysuria (pain with urination),
Most commonly, urinary tract infections
frequency, urgency, suprapubic pain and/
(UTIs) occur when bacteria enter the uri-
or hematuria are commonly seen with a
nary tract through the urethra and then
UTI. Physical examination of a woman with
multiply. The lower urinary tract is most of-
potential UTI should include evaluation of
ten impacted: the bladder (cystitis) and the
fever, costovertebral angle tenderness and
urethra (urethritis). When treated, these
abdominal and pelvic examination. The
UTIs are usually cured, but complications
differential diagnosis (see www.uptodate.
can occur.
com) includes vaginitis, urethritis (chlamydia, gonorrhea, trichomoniasis etc.),
Recurrent infections, kidney damage and
urethral diverticula or strictures, pelvic
increased risk of premature birth and low
inflammatory disease and nephrolithiasis.
birth weight are among the complications of UTIs. Thus, it is important for health care
Treating a UTI
providers to effectively treat UTIs when
Providers at the Women’s Wellness Clinic
they occur.
usually prescribe nitrofurantoin (100 milli-
After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position (2007) to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 2519223 or visit www.cwrwc.com.
gram orally twice daily for five days) for an An analysis of urine with a dipstick can
uncomplicated UTI. Other potential antibi-
show that a woman likely has a UTI with
otics include trimethoprim-sulfamethoxa-
Additionally, a bladder analgesic is impor-
a positive test for leukocyte esterase or ni-
zole, fosfomycin and pivmecillinam. What
tant to consider. Phenazopyridine (Pyr-
trites; however, performing a urine culture
is helpful with the urinary culture is that a
idium) is a medication that can be taken
is important. The definition of a UTI (un-
sensitivity can be done with specific an-
three times a day and relieve the discom-
complicated cystitis) is a positive urine cul-
tibiotics, and treatment can be targeted if
fort due to dysuria. This does not treat the
ture showing more than 100,000 colonies
necessary.
bacteria causing the UTI but is helpful in
of bacteria. The most common bacterial
treating the dysuria. We usually prescribe both an antibiotic and phenazopyridine.
Recurrent UTIs The definition of a recurrent UTI is two or more infections in six months or three or more infections in one year, either due to reinfection or relapse. In one study of 113 college age women, 30 (27 percent) women had a recurrent within six months following an initial infection1. In this study, the presCranberry juice and cranberry juice supplements may be of benefit in prevention of UTIs.
10
The Triangle Physician
ence of hematuria and urgency were the strongest predictors of a second infection.
Can a Woman Prevent a UTI?
many providers and often refers to Triangle
It is important to educate women to stay hy-
Urology Associates of Durham (online at
drated and drink plenty of water, but avoid
www.triangleurologync.com).
drinks that can irritate the bladder (coffee, alcohol, soft drinks with caffeine). The simple
References
reminder of a woman wiping from front to
1
back is important (to prevent bacteria near
tion: incidence and risk factors,” Am J Pub-
the anus from spreading to the urethra and
lic Health. 1990;80(3):331
Foxman B, “Recurring urinary tract infec-
This fall, the Women’s Wellness Clinic will begin a research study on recurrent UTIs. Call (919) 251-9223 or visit www.cwrwc.com for more information.
bladder). Also, emptying your bladder before and after sexual intercourse is important. We know you’re committed to taking excellent care of your patients, but when was the last time you took a close look at your business? We’re part of a nationwide network of over 1,500 offices, and we specialize in practice management, revenue cycle optimization, and private practice business support.
There are some risk factors for recurrent UTIs (see www.uptodate.com and search: recurrent urinary tract infection in women), including biologic or genetic factors. For instance, women may have vaginal colonization with certain bacteria. Other important risk factors include frequent sexual intercourse and diaphragm use (with spermicide). Cranberry juice and cranberry juice supplements may be of benefit in the preven-
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tion of UTIs. There are studies showing benefit and some showing no benefit, but in our experience this can be helpful. Prevention of a UTI with antibiotics should be considered. This can be done after intercourse or on a daily basis. Providers are encouraged to consult with urologists when recurrent UTIs are noted or when there are complications with a UTI. Women’s Wellness Clinic works closely with
4441 Six Forks Rd. Suite 106-293 • Raleigh, NC 27609 • Phone: (800) 845-6090
Cary Endocrine & Diabetes Center, P.A.
CEDC provides diagnosis and treatment for patients with hormonal and metabolic disorders including: diabetes, lipid disorders, PCOS, thyroid disorders, osteoporosis and other bone disorders, pituitary disorders, adrenal disorders, and sex hormone disorders.
Celebrating our first year in Cary!
Sung-Eun Yoo, MD
Endocrinologist Diplomat, American Board of Endocrinology, Diabetes and Metabolism Diplomat, American Board of Internal Medicine Endocrine Certification in Neck Ultrasound (ECNU) Certification in the International Society for Clinical Densitometry (ISCD)
On-Site Services: • Thyroid, parathyroid and neck ultrasound • Ultrasound guided FNA • DEXA bone density scans and interpretation • Osteoporosis therapy • Comprehensive diabetes management including diabetes education, insulin pump therapy, and continuous glucose monitoring • LabCorp in-house Introducing Jeanne Hutson, NP-C Board Certified in Advanced Diabetes Management
Cary Endocrine & Diabetes Center, P.A. • 103 Parkway Office Court, Suite 202 • Cary, NC 27518 • 919-378-2332 • www.caryendocrine.com
july 2013
11
Gastroenterology
Clinical Conundrums in
Non-alcoholic Fatty Liver Disease By Kerry N. Whitt, M.D.
Nonalcoholic fatty liver disease (NAFLD)
Clinical Presentation
occurs in nearly half of United States
NAFLD most often presents as an asymp-
adults1. Recognition and understanding
tomatic condition with abnormal liver
of NAFLD are requisite of any provider
chemistries. It is associated with the meta-
involved in primary care, medicine/pediat-
bolic syndrome, and clinicians intuitively
ric subspecialties and surgery.
can make a diagnosis by history alone. It is standard of care to image with a transab-
Common quandaries facing practitioners
dominal ultrasound while ruling out other
include:
causes of liver disease. Biopsy is rarely re-
• How much investigation is required in at-risk patients? • How to risk stratify patients with sus-
quired to establish a diagnosis of NAFLD but is currently invaluable in predicting prognosis.
pected NAFLD? • When is it safe to utilize potentially hepatotoxic medications? • How to educate an asymptomatic patient about the significance of NAFLD?
Risk Stratification NAFLD exists along a continuum of severity, and the transition to its most virulent form, termed nonalcoholic steatohepatitis (NASH), is a turning point in the natural history of the disease. Biopsy is currently
Dr. Kerry Whitt is a gastroenterologist with RMG Gastroenterology and Wake Endoscopy Center. He earned his medical degree from the University of Virginia. He completed fellowship training at the University of Tennessee and Mount Sinai School of Medicine. He is board certified in gastroenterology and hepatology. His clinical interests include therapeutic endoscopy, management of liver disease and colorectal cancer screening. He has a clinic and performs procedures in Raleigh and at Johnston Medical Center-Clayton. He can be reached at (919) 783-4888. For more information visit rmggastroenterology. com or wakeendoscopy.com.
the only definitive modality to document the presence of NASH. Noninvasive mark-
• Age
ers that portend a more severe disease
• ALT level
progression include :
• Non-African-American race
2
• High body mass index (BMI)
Medication use Clinicians have a limited pharmacologic armamentarium to make NASH regress. Vitamin E has received optimism in this regard, but enthusiasm is tempered by concerns regarding potential cardiovascular toxicity.
Practical measures like avoiding elevators and parking at the rear of parking lots are a good starting point to get patients to begin an exercise routine.
Some have cautioned against using vitamin E in diabetics for this reason3. Despite concerns about cirrhosis and its complications, individuals with NASH are still most likely to succumb to cardiovascular disease.
12
The Triangle Physician
Clinicians are commonly fearful of using
•N o fast food. Eating poorly is inexpen-
statins due to liver toxicity, but it is clear
sive and this represents a significant
fatty liver on ultrasound. Clinical Gastro-
that NASH patients benefit from these
practical barrier in educating at-risk pa-
enterology and Hepatology 2008; 6: 26-29.
drugs when indicated. With appropriate
tients on behavioral modification to treat
monitoring, statins are beneficial to those
NAFLD.
Resources
mented benefit in the treatment of portal
1
hypertension.
3
Harrison, SA. Abnormal liver tests and
Chalasani, N, Younossi, Z, Lavine, J et al. The diagnosis and management of
with NASH in terms of cardiovascular protection. Statins even have some docu-
2
non-alcoholic fatty liver disease: practice
Williams, CD, Stengel, J, Asike MI et al. Prevalence of non-alcoholic fatty liver disease and nonalcoholic steatohepatitis
Patient Education
among a largely middle-aged population
Empowering patients to take an active role
using ultrasound and liver biopsy: a pro-
in managing NAFLD remains a challenge.
spective study. Gastroenterology 2011; 140:
Mainstays of treating all stages of NAFLD
124-131.
guidelines by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 2012; 55: 2005-2023.
include increasing activity and decreasing caloric intake through behavioral modification strategies. Practical advice for patients includes: • Use the stairs. Regimented studies of 200 minutes of exercise weekly with calorie restriction result in sustained weight loss and regression of NASH. However, getting patients who do not exercise to “buy in” to such a program is ill fated. Practical measures like avoiding elevators and parking at the rear of parking lots are a good starting point. • Do not drink soda or juice. The dramatic rise in obesity and NAFLD prevalence have been paralleled by the food industry’s use of high-fructose corn syrup as a cheap sweetener in juice and soda. Animal models have correlated this sweetener with hepatic steatosis. Patients mistakenly feel that they are making a wise choice by drinking fruit juices that are high in calories and fructose. Coffee is thought to have a positive benefit in NAFLD. Although this is still under investigation, encouraging patients to drink coffee with whole milk instead of creamer is sensible. • Avoid a large midday meal. Intensive dietary intervention with calorie restriction to 1,000-1,500 kcal daily works to reverse NASH but again is unrealistic in most. However, focusing on cutting calories at lunch is less daunting to implement. Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
july 2013
13
14
The Triangle Physician
Practice Marketing
Mobile Websites
A Waste of Time or a Necessary Investment? By Amanda Kanaan
Walk into most waiting rooms these days
website and create a bad first impression
and you’ll notice that patients no longer
for potential patients. Instead, these mov-
have their heads down in a magazine;
ing images, or “sliders” as we call them,
instead their heads are down in their
need to be built in Javascript, which mo-
smartphone. It’s pretty obvious that smart-
bile devices support.
phones are not just a supped-up cell phone but an actual way of life for many
There are three ways to improve the mo-
people. I would literally have no idea
bile experience for your patients (in order
where I’m going tomorrow if my iphone
of cost- effectiveness).
didn’t tell me.
1. Mobile friendly. This just means that when you look at your site on a smart-
Amanda Kanaan is the president of WhiteCoat Designs – a Raleigh-based medical marketing agency providing doctors with online marketing services as medical website design, search engine optimization (SEO), social media management, blog writing, graphic design, referring physician outreach and more. To contact Ms. Kanaan or to learn more about WhiteCoat Designs, visit www. whitecoat-designs.com.
For those who want some substantiating
phone or tablet it should literally be a mini
data on the popularity of smartphones,
version of what you would see on a com-
the following is from the Pew Research
puter screen. You may have to zoom in to
Center, 2013:
read the text but for the most part the lay-
• More than half of cell phone users are
out is correct, and there are no blank gaps
using smartphones, and some market
where images should appear. If you are
able. There are even some do-it-yourself
watchers project that tablet purchases
thinking about designing a new website,
programs out there for the tech-savvy.
will surpass laptops in 2013.
at the very least make sure the site will be
• 61 percent of smartphone users and 64
mobile friendly. This should be a given and
3. Responsive Design. This is the most
percent of tablet owners search locally
is the most cost-effective option, because it
expensive option, because it involves cre-
once a week or more.
usually just requires minor tweaks.
ating a custom wireframe than can adapt to any device. That means that depending
• 52 percent of smartphone owners have looked up health information from their
2. Mobile website. Mobile websites look
on whether you are looking at the website
mobile devices.
completely different from the computer
on a computer, a smartphone or a tablet,
version and provide enhanced function-
the website will automatically adapt to
At this point you’re probably tempted to
ality for those on a mobile device. (You
that particular device. The site literally
check your website on your mobile device.
should always offer a link to show the full
changes its entire layout to be best suited
Go ahead. It’s important to know what your
version of the website though.) Mobile
for the screen it’s being viewed on. It may
patients are seeing. Is the layout different?
websites take into account the fact that
show the user a three-column layout on
Is it easy to navigate? Are some of the fea-
visitors behave differently when using
the computer, a two-column layout on a
tures not working properly?
mobile and as a result create a separate
tablet and maybe only a one-column lay-
layout to cater to these differences.
out on a smartphone. It is the latest trend in website design, and it significantly en-
You may have a beautiful website when viewed on a computer screen, but that
The thought process is that patients who
hances the user experience by conform-
doesn’t always translate well to a smart-
are looking you up on their smartphone
ing itself to any screen size.
phone or tablet. For instance, many web-
are probably seeking very specific infor-
sites have moving images on their home-
mation and do not plan to spend much
Whether you choose to make your site
page that are created in Flash.
time perusing your website.
mobile friendly, design a separate mobile
Smartphones and tablets don’t support
Therefore, mobile sites make it quick and
the point is that providing a better mobile
Flash, so they just show up as big blank
easy for them to get the information they
experience is something that can’t be ig-
spaces on the mobile version of your web-
need, such as your phone number or di-
nored. Patients not only want it, they now
site. This can totally ruin the look of your
rections. Mobile websites are very afford-
expect it.
website or integrate responsive design,
july 2013
15
Practice Management
Preparing for
ICD-10
By Joe Reddy
On Oct. 1, 2014, the International Classifi-
cient documentation to support the speci-
cation of Diseases, ninth edition (ICD-9)
ficity required. Even with fully prepared
code sets used to report medical diagnosis
technology, without proper clinical docu-
and inpatient procedures will be replaced
mentation and accurate coding, proper
by ICD 10th edition (ICD-10). This is a “go
payment will not be possible.
live” date with no grace period. In addition, many practices are already
Joe Reddy is the owner of RevMedRx, a North Carolinabased revenuecycle management company. RevMedRx offers sophisticated, yet affordable, solutions to today’s complex practice management needs with a focus on efficiency and cash-flow optimization. Joe Reddy can be reached at joe.reddy@ revmedrx.com. To learn more, visit www.revmedrx.com.
The transition to ICD-10 is required for ev-
lean and over-committed in their resourc-
eryone covered by the Health Insurance
es. Appointing someone in the office to be
Portability Accountability Act (HIPAA).
an ICD-10 coding expert from Day 1, even
This change does not affect current proce-
with some training, is likely unrealistic and
dural terminology (CPT) coding.
unprofitable.
The ICD-9 code set is more than 30 years
What Now?
old and outdated. It does not reflect ad-
If you are currently using a suberbill, it is
will cost and how it will be managed. This
vances in medical technology, and the
likely to be put to rest. A replacement su-
is especially true for server-based systems
format limits the ability to add new codes.
perbill could be 10 or more pages.
rather than cloud-based systems.
You will need intelligent electronic health
If you don’t like your answers, then go
record (EHR) and practice management
shopping, because there are good vendors
The ICD-10 code set has been the interna-
technology. This creates problems for a
that are ICD-10 ready and not charging ex-
tional standard for years. ICD-10 CM (clini-
practice currently using one vendor for
tra for it.
cal modification) will be used in all health
EHR and another for practice management
care settings. ICD-10 PCS (procedure cod-
and billing. Some of the outsourced billing
It would be wise to put together a training
ing system) is used only in the inpatient
arrangements involve superbills.
plan for all appropriate staff. One of the
The biggest difference will be granularity of the 140,000 new codes.
care hospital setting. ICD-9 is likely to con-
first things you might want to do is run a
tinue to be used for workers compensation
Outsourcing your billing is not the prob-
frequency report to determine your top 25
and disability claims.
lem (in fact it’s usually more cost effec-
to 30 diagnostic codes.
tive). The problem is using two different
Productivity Impact
systems. It’s much more efficient to have
You should use a mapping tool, like www.
Without the right software, more docu-
one vendor with both a good EHR and bill-
icd10codesearch.com, to crosswalk ICD-9
mentation time could be required, which
ing cloud-based software program.
to 10 and to practice. With this you should
may mean that a provider sees fewer pa-
also pull charts with these codes to reIntelligent EHRs include programing that
view current documentation practices and
drives proper documentation without hav-
needed changes. Even with these two very
It’s estimated that less than 40 percent of
ing to start almost from scratch in creating
important exercises, with your income at
today’s documentation is ready for the
templates. If you are accustomed to getting
risk, you may want to consider temporar-
transition. Thus, one of the biggest issues
fees at every turn, you need to start ask-
ily outsourcing your coding through the
for implementation of ICD-10 will be insuffi-
ing about how much your ICD-10 update
transition.
tients, especially early on.
16
The Triangle Physician
NEWSOURCE-JUN10:Heidi
8/5/10
12:57 PM
Page 1
Your coding outsource will come with two additional benefits: audit-protection reviews and identification of under-coding. In addition, you may find helpful cod-
Do They Like What They See?
ing and documentation training offered through American Association of Professional Coders (AAPC).
Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.
A final consideration is financial exposure immediately following Oct. 1, 2014. There’s obviously a lot of opportunity for things to go wrong. Even if you’ve prepared well,
Our services range from consultation, to design, to creation and implementation of strategic plans.
there could be glitches on the payer’s end that delay reimbursement. You should consider getting a line a credit, if you don’t have cash to cover your existing overhead. On a brighter side, this data should ultimately lead to a better health care future. If you currently see sicker patients and
newsource & Associates
under-code out of fear, then you could see higher reimbursements with ICD-10 or at least be able to substantiate that negotiation with your payers.
Call (540) 650-3686 or send inquiries to hketler@verizon.net.
Our network of smart, creative, award-winning specialists serves the health care industry throughout the Mid-Atlantic.
Maybe it’s happiness in a child’s eyes. Whatever the desired outcomes, count on us to ensure your key messages have the 20/20 clarity to deliver.
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 • Pediatric Endocrinology
All in one convenient location at 3840 Ed Drive, behind Rex Hospital.
919-571-3661
www.CarolinaEndocrine.com Dr. Michael Thomas, Ph.D. Dr. Julia Warren-Ulanch Dr. Khushbu Chandarana Courtney Kovalick, PA-C Eileen Andres, PA-C
july 2013
17
Duke Research News
Animal Study Shows Promising Path To Prevent Epilepsy Duke Medicine researchers have identified
and Stroke, who oversees the grants that
When
a receptor in the nervous system that may
funded this study.
epilepticus in the animals, both the normal
researchers
caused
status
and genetically modified mice developed
be key to preventing epilepsy following a prolonged period of seizures.
the
Retrospective studies of people with severe
epilepsy. However, treatment with 1NMPP1
temporal lobe epilepsy reveal that many of
after the prolonged period of seizures
Their findings from studies in mice, published
them initially have an episode of prolonged
prevented epilepsy in the genetically altered
online in the journal Neuron June 20, provide
seizures, known as status epilepticus. Status
but not the normal mice.
a molecular target for developing drugs to
epilepticus is often followed by a period of
prevent the onset of epilepsy, not just manage
seizure-free recovery before people start to
“This demonstrated that it is possible to
the disease’s symptoms.
experience recurring temporal lobe seizures.
intervene following status epilepticus and prevent the animal from becoming epileptic,” Dr. McNamara said.
“Unfortunately, there are no preventive
In animal studies, inducing status epilepticus
therapies for any common disorder of
in an otherwise healthy animal can cause
the human nervous system – Alzheimer’s,
them to become epileptic. The prolonged
Importantly,
Parkinson’s, schizophrenia, epilepsy – with
seizures in status epilepticus are therefore
administered treatment with 1NMPP1 for
the exception of blood pressure-lowering
thought to cause or importantly contribute to
two weeks, which was sufficient to prevent
drugs to reduce the likelihood of stroke,”
the development of epilepsy in humans.
epilepsy from developing in the mice when
researchers
only
tested many weeks later. The results suggest
said study author James O. McNamara, M.D., professor of neurobiology at Duke Medicine.
the
“An important goal of this field has been to
that a preventive therapy may only need to
identify the molecular mechanism by which
be given for a limited period of time following
Epilepsy is a serious neurological disorder
status epilepticus transforms a brain from
the initial bout of prolonged seizures, not an
marked by recurring seizures. Temporal
normal to epileptic,” said Dr. McNamara.
individual’s entire life, which could prevent
lobe epilepsy – the region of the brain
“Understanding that mechanism in molecular
unnecessary side effects that come with long-
where seizures occur and memories are
terms would provide a target with which one
term use of drugs.
stored and language, emotions and senses
could intervene pharmacologically, perhaps
are processed – is the most common form
to prevent an individual from becoming
In future studies, the researchers hope to
and can be devastating. Because afflicted
epileptic.”
determine the exact time window in which
individuals
have
seizures
that
TrkB signaling needs to be repressed to
impair
their awareness and may have associated
Earlier research in epilepsy flagged a
prevent the onset of epilepsy. Long term,
behavioral problems, they may have difficulty
receptor in the nervous system called TrkB
this research provides a molecular target for
with everyday activities, including holding a
as a key player in transforming the brain from
developing the first drugs to prevent epilepsy.
job or obtaining a driver’s license.
normal to epileptic. In the current study, Dr. McNamara and his colleagues sought
“This study provides a strong rationale for the
Conventional therapies to treat epilepsy
to confirm if TrkB was important for status
development of selective inhibitors of TrkB
address the disease’s symptoms by trying
epilepticus-induced epilepsy.
signaling,” said Dr. McNamara.
However, many people with temporal lobe
Using an approach combining chemistry and
In addition to Dr McNamara, study authors
epilepsy still have seizures despite taking
genetic analyses, the researchers studied
include Gumei Liu, Bin Gu, Xiao-Ping He,
these drugs.
normal and genetically altered mice. The
Rasesh B. Joshi, Harold D. Wackerle, Ramona
genetically altered mice were unique in that a
Marie Rodriguiz and William C. Wetsel. The
“This study opens a promising new avenue
drug, 1NMPP1, inhibited TrkB in their brains.
study was supported by funding from the
of research into treatments that may prevent
If the drug stopped the genetically altered
National Institute of Neurological Disorders
the development of epilepsy,” said Vicky
mice from becoming epileptic, this genetic
and Stroke (NS56217 and NS060728).
Whittemore, Ph.D., a program director at the
approach would prove that inhibiting TrkB
National Institute of Neurological Disorders
prevents the onset of epilepsy.
to reduce the likelihood of having a seizure.
18
The Triangle Physician
Duke Research News
Parenting, Home Environment Influence Children’s Exercise, Eating Habits Kids whose moms encourage them to
In this study, Dr. Østbye and his colleagues
for you and your own health; it is also
exercise and eat well and model those
examined the relationship between the
important for your children, because you
healthy behaviors themselves are more
home environment and behaviors related
are a role model for them,” said Marissa
likely to be active and healthy eaters,
to obesity – dietary and exercise habits –
Stroo, a co-investigator on the study. “This
according to researchers at Duke Medicine.
among preschoolers.
might be common sense, but now we have
Their findings, published online in the
The researchers studied data from 190
International Journal of Obesity June 18,
children, ages two to five whose mothers
The
remind parents that they are role models
were overweight or obese. They collected
socioeconomic factors of the mothers,
for their children and underscore the
information on the children’s food intake
including their education levels and whether
importance of parental policies promoting
over the past week, with foods rated as
they worked, to see if this had an effect on
physical activity and healthy eating.
junk food or healthy food. To gauge their
the children’s behaviors. The mother’s
levels of physical activity, the children wore
socioeconomic factors did not affect their
Exercise and healthy diets are critical in
accelerometers for a week, which measured
kids’ physical activity, but had mixed results
fighting childhood obesity, a considerable
moderate to vigorous physical activity, as
when it came to their dietary habits.
problem in the United States, where more
well as sedentary time.
some evidence to support this.” also
looked
at
Further research is needed to better
than a quarter of children ages two to five are already overweight or obese.
researchers
The mothers reported information about
understand how a mother’s socioeconomic
their children’s environments, including
factors influence her child’s health, but
“Obesity is a complex phenomenon, which
family policies around food and physical
it is possible that different strategies may
is influenced by individual biological factors
activity, accessibility of healthy versus
be needed to prevent obesity in children
and behaviors,” said study author Truls
junk foods, availability of physical activity
depending
Østbye, M.D., Ph.D., professor of community
equipment and whether they model healthy
and work status. More research is also
and family medicine at Duke. “But there
eating or exercise for their kids.
necessary to see if the influence of the
on
a
mother’s
education
home environment changes as children
are variations in obesity from one society to another and from one environment to
When they analyzed the data, the researchers
get older and if parenting strategies should
another, so there is clearly something in the
found significant associations between
adapt accordingly.
environment that strongly influences the
these environmental measures and the
obesity epidemic.”
preschoolers’ physical activity and healthy
In addition to Dr. Østbye and Ms. Stroo, study
versus junk food intake. They concluded that
authors at Duke include Bernard Fuemmeler
The home environment and parenting
to promote healthy behaviors in children, a
in the Department of Community and Family
can influence a child’s health by shaping
healthy home environment and parental role
Medicine, Rebecca Brouwer at Duke Global
dietary and physical behaviors, such as
modeling are important.
Health Institute and Nancy Zucker in the Department of Psychiatry and Behavioral
providing access to fruits and vegetables or encouraging kids to play outside.
For example, limiting access to junk foods
Sciences. Rahul Malhotra of the Duke-
at home and parental policies supporting
National University of Singapore Graduate
“The ‘obesiogenic’ environment is broad
family meals increased the amount of
Medical School and Cheryl Lovelady of the
and multi-faceted, including the physical
healthy foods kids ate. Overall, the home
University of North Carolina at Greensboro
neighborhood environment, media and
environment had more influence on the
also contributed to this research.
advertising and food tax policies, but we
children’s dietary habits than on their
feel that the home environment is critical,
physical activity levels.
The study was supported by funding from the National Institutes of Health (R01-
particularly among children. However, we didn’t have a lot of evidence as to how
“It’s hard for parents to change their
DK-07549, 1-K23-MH-070-418-01 and 1-K07-
important this was,” Dr. Østbye said.
behaviors, but not only is this important
CA-124-905-01).
july 2013
19
Duke Research News
Antidepressant Is Shown to Reduce Stress-Induced Heart Condition A drug commonly used to treat depres-
While MSIMI can be serious, little is
placebo. A total of 112 participants com-
sion and anxiety may improve a stress-
known on how to treat it; previous studies
pleted the full study and final assessments.
related heart condition in people with
looking at interventions for MSIMI were
stable coronary heart disease, according
not conclusive based on small sample
At the end of the six-week study, the par-
to researchers at Duke Medicine.
sizes and conflicting results.
ticipants underwent the same stress tests and their cardiovascular function was
Compared with those receiving placebo,
“In order to advance our understanding
compared to what was measured before
people who took the antidepressant es-
of improving cardiovascular health, we
taking the medication or the placebo. The
citalopram (sold as Lexapro) were more
believe that continued research between
researchers observed that those who took
than two-and-a-half times less likely to
the intersection of mental health and car-
escitalopram were 2.62 times less likely to
have mental stress-induced myocardial
diovascular disease should be a priority,”
experience MSIMI during the three men-
ischemia (MSIMI), a heart condition
said senior author Christopher O’Connor,
tal stress tasks compared with those tak-
brought on by mental stress. The findings,
M.D., director of the Duke Heart Center
ing placebo.
published in the May 22/29, issue of The
and chief of the Division of Cardiology. During the final mental stress tasks, par-
Journal of the American Medical Association, add to the current understanding of
To better understand how to ease the
ticipants in the escitalopram group felt
how negative emotions affect cardiovas-
negative cardiovascular effects brought
significantly more in control and calmer
cular health.
on by mental stress, Duke researchers led
than those in the placebo group. Taking
the Responses of Mental Stress Induced
escitalopram was also associated with
In myocardial ischemia, the heart muscle
Myocardial Ischemia to Escitalopram
several positive changes in cardiovascular
does not receive enough blood flow or
Treatment (REMIT) study, a randomized,
markers, including reducing the number
supply or the supply does not meet the
double-blind, placebo-controlled clinical
of platelet serotonin receptor transporters.
needs of the heart muscle. Patients with
trial. They enrolled participants with exist-
myocardial ischemia often have no notice-
ing coronary heart disease who were in
“Our findings support the hypothesis that
able symptoms, but research has shown
stable condition.
short-term use of SSRIs improves levels of biomarkers associated with adverse car-
that emotional stress can trigger such heart conditions.
In order to find people experiencing MSI-
diovascular outcomes,” said Dr. Jiang.
MI, the researchers subjected participants “Mental stress-induced myocardial isch-
to a common exercise stress test using a
The study suggests that SSRIs or similar
emia is a serious condition, as patients
treadmill, as well as three mental stress
treatments could play an important role in
with the condition tend to have worse
tests: a tricky mental math task, tracing
managing coronary heart disease, a find-
heart problems compared to patients
a diagram of a star while looking at hand
ing relevant for physicians and patients at
without it,” said lead author Wei Jiang,
movement as a reflection in a mirror,
risk for or living with coronary heart dis-
M.D., associate professor of psychiatry
and telling a story about a situation that
ease.
and behavioral sciences and internal
evoked anger or sadness. Echocardiogra-
medicine at Duke. “This study showed
phy and electrocardiography testing and
“All physicians treating patients with coro-
for the first time that it is treatable with an
blood pressure and heart rate measure-
nary artery disease need to be aware of
emotion-modulating medication.”
ments were used to assess heart function
how emotional stressors may negatively
during the stress tests.
impact their disease management,” said study author Eric Velazquez, M.D., associ-
MSIMI is diagnosed based on certain changes in the heart: new wall motion ab-
Of the 310 participants who were tested,
ate professor of cardiology at Duke. “We
normality, a reduction in how much blood
127 developed MSIMI and were random-
should be having conversations with our
is pumped out of the heart’s left ventricle,
ized to either receive escitalopram – a se-
patients about their lifestyles to gauge
ischemic changes on electrocardiography
lective serotonin reuptake inhibitor (SSRI)
their levels of mental stress and whether
tests or a combination of these symptoms.
used to treat depression and anxiety – or
the coping mechanisms they use are ad-
20
The Triangle Physician
Category Duke Research News equate or if more mental health-focused
or angina, stroke, heart failure or death. A
Boyle, Cynthia Kuhn, Richard C. Becker,
help is needed.”
study is also necessary to determine how
Thomas L. Ortel, Redford B. Williams Jr.
long escitalopram should be taken and
and Joseph G. Rogers.
Additional research is warranted to fully
whether the participants already achieved
understand the mechanisms behind MSIMI
the maximum benefit at six weeks.
The research was supported by funding from the National Heart, Lung and Blood
and whether improvements in the condition from taking escitalopram may result in re-
In addition to Drs. Jiang, O’Connor and
Institute (R01 HL085704). A full list of
ducing occurrence or recurrence of serious
Velazquez, researchers include Maragatha
author disclosures can be found in the
health conditions, including heart attack
Kuchibhatla, Zainab Samad, Stephen H.
manuscript.
WakeMed News
New ACO Endeavors to Improve the Coordination of Care Across Continuum Key Physicians and WakeMed Health &
a coordinated health care team focused
executive officer of WakeMed Health &
Hospitals have signed a letter of intent
on delivering efficient, quality care at
Hospitals. “The formation of this ACO is
to form WakeMed Key Community Care,
a reasonable cost,” said John Rubino,
important in the overall effort to improve
a Medicare shared savings accountable
M.D., president of Key Physicians. “While
access, reduce costs and improve quality
care organization.
patients will retain access to all of the re-
in our area and across the state. In this era
gion’s hospitals, they will benefit from an
of health reform, care across the continu-
Key Physicians is an organization of more
overall strategy to provide a more seam-
um must be focused on delivering quality
than 220 independent physicians located
less experience regardless of where the
and value to the patient.
in Wake, Durham, Orange and Johnston
care is delivered.” “To accomplish this, it is extremely impor-
counties. Savings accountable care organizations (ACOs) are an organized
According to Dr. Rubino, successful ACOs
tant to develop comprehensive models
approach to managing a defined popu-
deliver positive results for patients, the
of patient care that rely on providers de-
lation’s health by focusing on reducing
community and health care providers.
veloping solutions to address acute care
health care costs and improving quality
“Population health improvement strate-
episodes as well as the overall health of a
in both the traditional Medicare program
gies enhance physicians’, hospitals’ and
population through wellness, disease pre-
and in private insurance programs.
managed-care organizations’ ability to
vention and well-coordinated care man-
share health information and resources
agement,” Dr. Atkinson said. “This col-
ACOs shift the reimbursement of care
for the benefit of the patient. Communica-
laboration will uniquely benefit patients
from a fee-for-service model to a value-
tion with the patient and between health
by bringing together the valuable health
based approach in which providers work
care providers helps reduce duplication
resources of the community in a more co-
together and are held accountable for the
of services, limits unnecessary tests, eas-
ordinated way to provide the right care, at
cost and quality of care delivered. ACOs
es transitions from hospital to home and
the right time, in the right setting and at
are unique because they give doctors and
helps patients maintain good health,” Dr.
the right price.”
hospitals a direct financial incentive for
Rubio said. All of the primary care practices affili-
reducing costs, improving quality and ensuring care is coordinated and resources
“WakeMed Key Community Care brings
ated with Key Physicians and WakeMed
are used wisely at every point along the
together a significant network of estab-
Physician Practices have achieved patient-
health care continuum.
lished community-based, independent
centered medical home designation from
primary care physicians with a large inde-
the National Committee for Quality As-
“By forming an ACO of Key Physicians’
pendent health system that serves as the
surance, according to a WakeMed press
extensive primary care network and
leading provider of inpatient, outpatient
advisory.
WakeMed’s inpatient and outpatient ser-
and physician services in Wake County,”
vices, clinical resources and physicians,
said William “Bill” K. Atkinson, Ph.D.,
Visit www.keymedicalhome.com or www.
we will help facilitate patient access to
M.P.H., M.P.A., who is president and chief
wakemed.org for more information.
july 2013
21
UNC Research News
Interventions Aimed at Reducing Colon Cancer Screening Disparities The American Cancer Society has awarded University of North Carolina School of Medicine researcher Dan Reuland, M.D., M.P.H., a $1.7 million research scholar grant to test interventions designed to reduce colon cancer screening disparities in vulnerable patient groups, particularly Latinos. Dr. Reuland, associate professor of medicine in the division of general medicine and clinical epidemiology, will lead a five-year, multi-site project titled “Improving Colon Cancer Screening for Diverse Populations.” Collaborators include Mike Pignone, M.D., M.P.H., professor and chief of the general medicine division and nationally recognized expert on colon cancer screening, as well as researchers from the Mecklenburg Area Partnership for Primary-Care Research (MAPPR) and the University of New Mexico. Colorectal cancer is the third-leading cause of cancer death in the United States. Although screening can reduce colorectal cancer mortality, screening rates are low in certain vulnerable patient populations. United States Latinos, the nation’s largest and fastest growing racial/ethnic minority population, have particularly low screening rates. The study will focus on assessing the impact of a clinic-based intervention that includes having patients view a
multimedia decision aid (in English or Spanish) before seeing their physician, as well as support from a bilingual patient “navigator” on completion of recommended colon cancer screening tests.
the UNC School of Medicine and senior investigator at the Sheps Center for Health Services Research, and others developed the original colon cancer screening decision aid.
“There is increasing recognition that improving preventive and chronic care will require an enhanced primary care model that employs proactive, team-based approaches. These approaches will need to move beyond the model of having physicians acting as individuals delivering care in brief visits with limited care coordination or support, particularly when it comes to caring for our most vulnerable patient groups,” said Dr. Reuland.
In 2009, Dr. Reuland was awarded the American Cancer Society Cancer Control Career Development Award for Primary Care Physicians, which he used to conduct the project’s preliminary studies, including adaptation and testing of the decision aid in Spanish-speaking populations. During that award, he was mentored by Dr. Pignone, who holds a National Cancer Institute K05 Established Investigator Award.
“The interventions tested in the study are pragmatic and have potential for integration into real-world practice under the patient centered medical home (PCMH) model, particularly if payment for this type of systematic, team-based care can be implemented under provisions of the Affordable Care Act. This work is meant to inform clinical and policy level decisions about how to reduce disparities and promote informed decision making in vulnerable patient groups,” Dr. Reuland said.
Preliminary studies were also supported by grant funding from the UNC Lineberger Comprehensive Cancer Center, including its Communication for Health Applications and Interventions Core; the Nation Institutes of Health Clinical and Translational Science Awards (CTSA) program at UNC-CH; and in-kind support from the Cecil G. Sheps Center for Health Services Research.
The grant builds on a line of research dating back to the late 1990s when Russell Harris, M.D., M.P.H., a professor in
Drs. Reuland, Pignone and Harris are all members of the UNC Lineberger Comprehensive Cancer Center.
Recruitment Begins for Long-Term Diabetes Drug Efficacy Study The UNC Diabetes Care Center is seek-
the Glycemia Reduction Approaches in
lower glucose (blood sugar). But while
ing volunteers to take part in a study to
Diabetes: A Comparative Effectiveness
short-term studies have shown the effi-
compare the long-term benefits and risks
(GRADE) study.
cacy of different drugs when used with metformin, there have been no long-term
of four widely used diabetes drugs in combination with metformin, the most
If metformin is not enough to help man-
studies of which combination works best
common first-line medication for treat-
age Type 2 diabetes, a person’s doctor
and has fewer side effects. The GRADE
ing Type 2 diabetes. The project is called
may add one of several other drugs to
study will compare drug effects on glu-
22
The Triangle Physician
UNC Research News cose levels, adverse effects, diabetes
health care through their own providers.
GRADE
(ClinicalTrials.gov
number:
NCT01794143) is supported under NIH
complications and quality of life during “What differentiates GRADE from previ-
grant U01DK098246. Additional sup-
ous studies is that it will perform a head-
port in the form of donation of supplies
“Type 2 diabetes is a progressive disease
to-head comprehensive comparison of
comes from the National Diabetes Edu-
that requires the addition of more medi-
the most commonly used drugs over a
cation Program, Sanofi-Aventis, Bristol-
cations over time,” said Sue Kirkman,
long period of time,” said David M. Na-
Myers Squibb, Novo Nordisk, Merck, BD
M.D., the principal investigator of the
than, M.D., of Massachusetts General
Medical and Roche Diagnostics.
study at UNC. “The GRADE study will pro-
Hospital, Boston. Dr. Nathan and John
vide important information to clinicians
Lachin, Sc.D., of The George Washington
Learn more about the GRADE study at
about the comparative effectiveness of
University, Washington, D.C., are co-prin-
grade.bsc.gwu.edu.
four commonly used drug classes. UNC
cipal investigators.
an average of nearly five years.
For information about enrolling in
is honored to be one of 37 sites participating in this multi-center NIH (National
“In addition to determining which medi-
the trial, contact Michelle Duclos at
Institutes of Health) trial.”
cations control blood glucose levels
(919) 484-0931 for the UNC Diabetes Care
most effectively over time, we hope to
Center in Durham or Dawn Culmer at
Participant enrollment and follow up will
examine individual factors that are as-
(919) 260-885 for the UNC Diabetes Re-
occur at the UNC Highgate clinical trials
sociated with better or worse response
search at Eagles in Greensboro. Visit the
office in Durham and at UNC Diabetes
to the different medications,” Dr. Nathan
UNC Diabetes Care Center website at
Research at Eagles, located in Greens-
said. “This should provide understand-
www.uncdiabetes.org.
boro.
ing of how to personalize the treatment of diabetes.”
GRADE aims to enroll about 5,000 patients. Investigators at UNC and 36 other study sites are seeking people diagnosed with Type 2 diabetes within the last five years. They may be on metformin, but not on any other diabetes medication. During the study, all participants will take metformin, along with a second medication randomly assigned from among four classes of medications, all approved for use with metformin by the United States Food and Drug Administration. Three of the classes of medications in-
Partnering with patients and providers for a healthier community.
crease insulin levels. They are: sulfonylurea, which increases insulin levels directly; DPP-4 inhibitor, which indirectly
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P: 919.781.0815 F: 919.781.0816
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july 2013
23
News Welcome to the Area
Physicians
Abigail Lynn Jacobs, MD
Krystle Perez, MD
Ellen Elizabeth Volker, MD
Demetri Manuel Economedes, DO
Nuclear Medicine
Pediatrics
72 Almay Rd Apex
University of North Carolina Hospitals Chapel Hill
Critical Care Medicine; Pulmonary Disease and Critical Care, Internal Medicine
Jennifer Ann Jarosz, MD
Michael Robert Polin, MD
Radiology
Obstetrics and Gynecology
Duke University Hospitals Durham
Duke University Durham
Sheila T. Johnson, MD
Conor Matthew Regan, MD
Vascular Surgery
NCMB Raleigh
Orthopedic Surgery, Pediatric; Trauma; Spinal Reconstructive Surgery; Orthopedic Surgery of the Spine
Neel Nikul Kapadia, MD
Wake Orthopaedics Raleigh
Orthopedic Surgery, Adult Reconstructive
Cary Orthopaedic & Sports Medicine Specialists, Cary
Peter Howard Adler, MD Emergency Medicine
Wake Emergency Physicians, PA Cary
Waitman Kurt Aumann, MD Pediatrics
Duke University Hospitals Durham
Mehul Kantilal Bhakta, MD Radiology; Nuclear, Vascular, Pediatric, Diagnostic, Neuroradiology
Emergency Medicine
Duke University Hospitals Durham
Larissa Marie Songalia Saldana, MD Pediatrics
Growing Child Pediatrics Raleigh
University of North Carolina Hospitals Chapel Hill
Daniel Matthew Lercher, MD
Corey Scofield Bolac, MD
Univ of North Carolina Hospitals Chapel Hill
Nicholas Paul Schaub, MD
Duke University Hospitals Durham
John David Lilley, MD
Ninita Helen Brown, MD
4901 Quail Hollow Dr Raleigh
UNC Chapel Hill 1150 Physicians Office Bldg Chapel Hill
Obstetrics and Gynecology
Ophthalmology
Duke Eye Center, Durham
Brian John Burrows, MD Emergency Medicine
Duke University Hospitals Durham
Michael Curtis Garofalo, MD Radiation Oncology
Radiation Medicine Group Raleigh
Margaret Elizabeth Goodwin, MD Pediatrics
Duke University Hospitals Durham
Christopher Campbell Gratian, MD Anesthesiology
Univ of North Carolina Hospitals Chapel Hill
Jason Ross Guercio, MD Anesthesiology - Pain Medicine
Duke University Hospital Durham
Mark Spencer Hansen, MD Ophthalmology
Duke Eye Center, Durham
Shane Jared Havens, MD Ophthalmology
Duke Eye Center, Durham
Russell Wesley Homan, MD Adolescent Medicine; Pediatrics
Chapel Hill Pediatrics Chapel Hill
Lucius Alexander Howell, MD Cardiovascular Disease, Internal Medicine
UNC Heart and Vascular Care; Cardiology Fellowship Chapel Hill
Huankai Hu, MD Clinical Pathology; Dermatopathology
Marlboro-Chesterfield Pathology Pinehurst
Nidhi Gupta Huff, MD Pulmonary Disease and Critical Care, Internal Medicine
Duke University Hospitals Durham
24
The Triangle Physician
Pediatrics
Emergency Medicine
Kenneth Todd Lindley, MD Orthopedic Surgery; Hand Surgery
Triangle Orthopaedic Associates, PA Durham
Micael Lopez, MD Gynecologic Oncology; Obstetrics & Gynecologic Surgery; Reproductive; Urogynecology
Duke University Hospitals Durham
Kelly Ann Mason, MD
Surgical Oncology; Abdominal Surgery; Colon and Rectal Surgery; General Surgery
Angel Lorrine Schuster, MD Pediatric - Emergency Medicine;
Univ of North Carolina Hospitals Chapel Hill
Amita Rashmikant Shah, MD
Krishn Chris Sharma, MD Hospitalist; Internal Medicine
Anatomic and Clinical Pathology
Anesthesiology, Critical Care
University of North Carolina Hospitals Chapel Hill
Duke University Hospitals Durham
Peter Richard Steenland III, MD
Eric Dean McLoney, MD
Neurological Surgery, Critical Care; Neurological Surgery, Pediatric
Diagnostic Radiology; Vascular and Interventional Radiology
University of North Carolina Hospitals Chapel Hill
Univ of North Carolina Chapel Hill
Elizabeth Nina Strachan, MD
Pediatrics; Pediatric Nephrology
Duke University Hospitals Durham
Matthew Louis Zerden, MD Obstetrics & Gynecology - Gynecologic Oncology; Hospice & Palliative Medicine; Reproductive; Critical Care
Univ of North Carolina Hospitals Chapel Hill
Physician Assistants Gene Arnold Bailey Jr., PA Pulmonary Disease and Critical Care
Pinehurst Medical, Pinehurst
Julie Sitnik Dunaway, PA Emergency Medicine; Family Medicine
302 Highlands Bluffs Dr., Cary Abdominal Surgery; Surgery
Ashley King, PA General Surgery; Surgical Oncology
Pinehurst Hip & Knee, Pinehurst
Events Look Good Feel Better July 1, 5:30-7:30 p.m.
Look Good Feel Better is a free American Cancer Society program that teaches women beauty techniques while they undergo chemotherapy and radiation treatments. Participants receive a free cosmetics kit and instruction by beauty professionals.
Pediatrics
Location: North Conference Room, Durham Regional Hospital Registration: Call (919) 470-7168
Duke University Hospitals Durham
Stroke Support Group
Joshua Benjamin Surowitz, MD
Plastic Surgery/Hand Surgery; General Surgery; Plastic & Reconstructive Surgery
Facial Plastic Surgery; Otolaryngic Allergy; Rhinology; Head and Neck Surgery; Otolaryngology - Plastic Surgery Within the Head & Neck; Otology; Otorhinolaryngology; Pediatric Otolaryngology
Duke University Hospitals Durham
Cynthia Gregg Cary
Susan Robin Parlow, MD
Tushar Natvarlal Suthar, MD
Pediatrics
Ophthalmology
Nash Healthcare systems Rocky Mount
Duke University Eye Center Durham
Krish Patel, MD
David Van Duin, MD
Hematology and Oncology, Internal Medicine
Infectious Diseases, Internal Medicine
Duke University Hospitals Durham
Univ of North Carolina Health Care Chapel Hill
Nilesh Vinod Patel, MD
Eric Michael Vikingstad, MD
Internal Medicine; Hospitalist
Diagnostic Radiology
Duke University Hospitals Durham
Duke University Medical Center Durham
Michael Patrick Ogilvie, MD
Katherine Davis Westreich, MD
Our Medical Center, Raleigh
Olga Speck, MD
200 Trent Drive Durham
Boice-Willis Clinic, P.A. Rocky Mount
Dan Jones Jr., PA
Duke University Hospitals Durham
Emergency Medicine - Undersea and Hyperbaric Medicine; Internal Medicine
Hematology and Oncology, Internal Medicine
UNC Chapel Hill Chapel Hill
Pediatrics
Marlon Andre Medford, MD
Andrew Campbell Weil, MD
Abdominal Surgery; Plastic & Reconstructive Surgery; Surgery - Surgery of the Hand
Duke University Hospitals Durham
Cory Daniel Maxwell, MD
Duke University Hospitals Durham
July 8, 1-2:30 p.m.
The mission of this support group is to help educate the stroke survivor, caregiver and community about stroke prevention and stroke disabilities. This group meets the second Monday of each month. Location: Durham Regional Hospital, private dining room C
Weight Loss Surgery Support Group July 23, 6-7 p.m.
This weight-loss surgery support group encourages discussion on topics related to adjustment before and after weight-loss surgery. June’s session is entitled “Physical Activity 101.” Location: Duke Center for Metabolic and Weight Loss Surgery Durham Clinic, 407 Crutchfield St., Durham 24404. Register for these events online at www. durhamregional.org/events or by calling (919) 403-4374, unless otherwise noted.
“More than a doctor. Like a friend.”
Trust. WHV provides comprehensive heart services to prevent, diagnose and treat a full range of cardiovascular-related conditions. As heart specialists we are committed to providing access to quality care throughout Central and Eastern North Carolina. As part of UNC Health Care / Rex Healthcare, we can tap into the most up-to-date research and expertise, providing our patients with access to clinical trials and new therapies, resulting in the best cardiovascular care in the area.
Experienced Cardiologists J. Tift Mann, III, MD, FACC (retired) Michael Zellinger, MD, FACC William N. Newman, MD Gregory C. Rose, MD, FACC Joel E. Schneider, MD, FACC Eric M. Janis, MD, FACC R. Lee Jobe, MD, FACC Randy A.S. Cooper, MD, FACC Robert B. Wesley, II, MD, FACC Joseph M. Falsone, MD, FACC Kevin R. Campbell, MD, FACC Benjamin G. Atkeson, MD, FACC Ravish Sachar, MD, FACC
Locations in North Carolina
Benson Clayton Clinton
Goldsboro Knightdale Lillington
Arthur Y. Chow, MD, FACC Christian Gring, MD, FACC Matthew A. Hook, MD, FACC Andrew C. Kronenberg, MD, FACC Mateen Akhtar, MD, FACC Richard J. Pacca, MD, FACC Waheed Akhtar, MD, MRCP, FACC Malay Agrawal, MD, FACC Sunil P. Chand, MD, MRCP, FACC Paul A. Perez-Navarro, MD, FACC Sidharth A. Shah, MD Ashley M. Lewis, MD
Louisburg Raleigh Rocky Mount
Cardiovascular Services General Cardiology Echocardiography Nuclear Cardiology Interventional Cardiology Carotid Artery Interventions Cardiac Catheterization Cardiac CT Angiography and Calcium Scoring Electrophysiology and Cardiac Arrhythmia Peripheral Vascular Interventions Pacemakers / Defibrillators Stress Tests Holter Monitoring Lipid (Cholesterol) Clinics
Smithfield Wake Forest Wilson
When it comes to your cardiovascular care – We know it by heart.
1.800.WHV.2889 (800.948.2889) | www.WHVheart.com
Advanced Medical Imaging for Your Patients 19 Convenient Triangle Area Locations
True subspecialized diagnostic and interventional radiology Established in 1953, Wake Radiology is the leading provider of outpatient medical imaging for families in the Triangle. Our more than 50 radiologists are recognized experts, subspecialty trained and certified by the American Board of Radiology. As a longtime leader in low-dose imaging of children and adults, our commitment to minimize radiation exposure while maintaining high quality imaging is at the corner of what we do. We are proud to be the first outpatient provider in the Triangle to earn the American College of Radiology’s prestigious Breast Imaging Center of Excellence (BICOE) designation. Our group is also the only one to earn certification from the International Society for Clinical Densitometry (ISCD) for bone density studies and the first in Wake County to offer dedicated pediatric imaging services. Plus, we operate the region’s only freestanding Positron Emission Tomography (PET-CT) facility. Our 19 outpatient offices provide easy access to a full range of imaging procedures including: • Screening and diagnostic mammography • PET-CT and Nuclear medicine • Interventional radiology and vein care • Orthopedic and sports imaging • MRI and Low-dose CT • Pediatric imaging So the next time imaging is necessary for your patients, choose Wake Radiology. We are in-network with most insurance plans and offer financial assistance or payment plans to patients who need it.
Wake Radiology. Excellence in medical imaging.
Express Scheduling: 919-232-4700 Mon-Fri 7:30am-6:30pm Chapel Hill Scheduling: 919-942-3196 Mon-Fri 8:00am-5:00pm wakerad.com Wake Radiology has 19 convenient outpatient imaging locations in Raleigh | Cary | Garner | Wake Forest | Morrisville Fuquay-Varina | Chapel Hill
Comprehensive Outpatient Imaging Services