JUNE 2010
Reid Heart Center The FirstHealth Cardiac & Vascular Institute The Atrial Fibrillation Convergent Procedure
Also in this Issue
Men’s Health Initiatives Mechanics of BPH Leads to Greater Understanding
Add a pinch of spice,
a hint of laughter,
and a correct diagnosis,
and you’ll get Robert.
Robert suffered from unexplained fainting spells. His physicians couldn’t figure out why. To find answers, they implanted a Reveal® Insertable Cardiac Monitor (ICM) to see if his spells were heart rhythm related.
(Actual size)
The Reveal ICM is a long-term heart monitor that may help you rule in or rule out an abnormal heart rhythm as the cause of unexplained fainting spells. In Robert’s case, they were, and now he has a pacemaker. Possible risks associated with the implant of a Reveal Insertable Cardiac Monitor include, but are not limited to, infection at the surgical site, device migration, erosion of the device through the skin and/or sensitivity to the device material. Results may not be typical for every patient.
For more information, visit www.fainting.com.
Indications 9529 Reveal® XT and 9528 Reveal® DX Insertable Cardiac Monitors – The Reveal XT and Reveal DX Insertable Cardiac Monitors are implantable patient-activated and automatically activated monitoring systems that record subcutaneous ECG and are indicated in the following cases: • patients with clinical syndromes or situations at increased risk of cardiac arrhythmias; • patients who experience transient symptoms such as dizziness, palpitation, syncope, and chest pain, that may suggest a cardiac arrhythmia. 9539 Reveal® XT and 9538 Reveal® Patient Assistants – The Reveal XT and Reveal Patient Assistants are intended for unsupervised patient use away from a hospital or clinic. The Patient Assistant activates one or more of the data management features in the Reveal Insertable Cardiac Monitor: • To verify whether the implanted device has detected a suspected arrhythmia or device related event. (Model 9539 only); • To initiate recording of cardiac event data in the implanted device memory. Contraindications: There are no known contraindications for the implant of the Reveal XT or Reveal DX Insertable Cardiac Monitors. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated. Warnings/Precautions: 9529 Reveal XT and 9528 Reveal DX Insertable Cardiac Monitors – Patients with the Reveal XT or Reveal DX Insertable Cardiac Monitor should avoid sources of diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, therapeutic ultrasound and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing. MRI scans should be performed only in a specified MR environment under specified conditions as described in the device manual. 9539 Reveal XT and 9538 Reveal Patient Assistants – Operation of the Model 9539 or 9538 Patient Assistant near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device. Potential Complications: Potential complications include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin. See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.
UC201003796 EN © Medtronic, Inc. 2009. Minneapolis, MN. All Rights Reserved.Printed in USA. 12/2009
Brief Statement
Bringing more quality to the golden years Geriatrician William Plonk, MD, helps older adults face the health challenges that aging brings. How are geriatricians different from other physicians? Geriatricians focus specifically on the health care needs of older adults. We deal with memory loss, falls, multiple medications, and end-of-life issues on a daily basis, so we focus more on those problems than a generalist might. What are some ways an older person’s needs are different? As patients grow older, they can have important issues related to memory, mobility, medication management, and self-care. They often need more help at home, so we make sure to include the family and other caregivers in our treatment plans. When might a person switch to a geriatrician? The traditional age is 65, when Medicare starts, but a lot depends on the individual. We see everyone from frail 65-yearolds to robust 90-year-olds. Why did you choose this field? I originally trained in family medicine but learned I have a strong affinity for geriatrics while treating nursing home patients in my practice in upstate New York. Geriatrics isn’t the most popular or lucrative specialty. Those of us in it love what we do, and we see a strong need for our services in the community. Dr. Plonk and colleagues work closely with clinicians and programs throughout Duke to comprehensively and sensitively evaluate and treat older people with a broad range of health and wellness concerns. Duke University Medical Center is ranked #5 in the nation for geriatrics by U.S.News & World Report.
dukehealth.org
888-ASK-DUKE
Contents
COVER STORY Reid Heart Center The FirstHealth Cardiac & Vascular Institute
6
The Atrial Fibrillation Convergent Procedure
FEATURES
16
MEN’S HEALTH INITIATIVES
JUNE
2010
VOLUME 1
26
ISSUE 5
MECHANICS OF BENIGN PROSTATE
HYPERPLASIA
Help Raise Awareness
Leads to Better Understanding
The relatively new concept of focusing on
The long-term result of a complex physiological
men’s health is growing out of the recognition
response of the bladder to the enlarging
that men have unique health needs and they
prostate are irritative symptoms, such as an
are, in general, less likely than women to take
urgent need to urinate, voiding frequently and
a proactive stance with their health.
getting up to urinate several times a night.
DEPARTMENTS 13 RADIOLOGY Patient Management for Thyroid Modules 14 SCOLIOSIS Whatever Happened to Scoliosis Screening? 18 SPINAL SURGERY Minimally Invasive Spine Surgery Is
the Approach to the Future
21 PHLEBOLOGY
Treatment of a Venous Reflux often Quiets Restless Leg Syndrome
22 LIFESTYLE
Destructive Lifestyles Cause Chronic Illness
24 WOMEN’S HEALTH Integrative Medicine at Women’s
Wellness Clinic Has Holistic Focus to Promote Health and Healing
28 CARDIOLOGY Pregnancy Increases Heart Disease Risk 29 UROLOGY
Urology’s Medical Role Is Expanding with Great Strides
30 MEN’S HEALTH
Men Have Range of Treatments for Overactive Bladder
32 NEWS
Welcome to the Area Events & Opportunities New & Relocated Practices
34 PRACTICE MANAGEMENT Governance Structures Help
Medium-to-Large Practices
36 INSURANCE COVER PHOTO: Andy Kiser, M.D., Mark Landers, M.D. and Ker Boyce, M.D.
2
The Triangle Physician | JUNE 2010
PHOTO BY JIM SHAW
Employment Practices Liability Insurance Protects against Rising Workplace Lawsuits
JOHNSTON HE ALTH
w w w. j oh n s t o n h e a lt h . o r g
FEBRUARY 2010 | The Triangle Physician
15
From the Editor
T
he development of the Convergent Procedure is a story of brilliant minds coming together to create a more effective, less-invasive treatment for atrial fibrillation. Its genesis began with cardiac surgeon Andy Kiser, who was joined by electrophysiologist Mark Landers.
Together, these Pinehurst pioneers refined a treatment for persistent AF—a serious condition known to increase the risk of stroke and congestive heart failure. The Convergent Procedure involves the creation of a pattern of lesions on the inside and outside of the heart to create non-conducting segments. When performed together, it effectively controls chaotic electrical impulses. Patients who have experienced AF’s debilitating effects and then the profound sense of renewal that follows the Convergent Procedure sing their praises. Read on and you’ll learn that today its 90 percent success rate is nothing short of electrifying. This month, Triangle Physician takes a special look at scoliosis, once top of mind when spine-tickling grade-school screenings were routine in the 1970s and ’80s. Today, these checkups may be history, but scoliosis is not. Orthopedic surgeon Lloyd Hey discusses the role of physicians as the first line of defense in early detection and the screening tools available. Men’s health is also front and center, and not just in this issue of Triangle Physician. There is a growing awareness of the unique health needs of men and our general resistance toward dealing with them. Recognizing the health risks, advocates like urologist Judd Moul are promoting ways that make it easier to have a dialogue with a trusted physician about sensitive topics, such as prostate cancer. Area urologists continue the conversation about men’s health. Dr. Carmen Kalorin reviews the physiological responses to benign prostate enlargement. Dr. Joseph. Khoury addresses treatment for overactive bladder. Urologist Mark McClure reveals that United States men rank only 15th in the world when it comes to longevity, and lifestyle has a lot to do with it. Every issue of Triangle Physician offers the region’s leading medical practitioners and delivery partners a respected forum in which to come together and share news and information that empowers patients to live longer and better, personally and professionally. If this issue sparks your interest, we believe the return in increased awareness for you and your practice will have equally energizing results. As always, our deepest respect and gratitude for all you do.
Editor Mark Westphal
mark@trianglephysician.com
Contributing Editors Heidi Ketler heidi@trianglephysician.com Mateen Akhtar, MD; Dennis E. Bullard, MD, FACS; Lloyd A. Hey, MD, MS; Carmin M. Kalorin, MD; Joseph M. Khoury, MD, FACS; Michael D. Kwong, MD; Mark W. McClure, MD; Lindy McHutchinson, MD; Judd W. Moul, MD, FACS; Kevin Perry, MD; John Reidelbach; Mike Riddick; Amy Stanfield, MD, FACOG Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Dan Early Van Early
dan@trianglephysician.com van@trianglephysician.com
Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com The Triangle Physician is published by Early Design Group 982 Trinity Road | Raleigh, NC 27607-4940 Subscription rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Tucson, AZ 85726 Every precaution is taken to insure the accuracy of the articles published, The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography.
Mark Westphal Editor 4
The Triangle Physician | JUNE 2010
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.
From the Cover
Convergence of
General view of the Convergent Procedure set-up when performed in the operating room. Like any cardiac procedure, a well-trained, experienced team is required. Optimal viewing of the data presented is essential.
The Merriam-Webster Dictionary defines “converge” as coming together and uniting in a common interest or focus. The term describes the development in 2009 of the Convergent Procedure, a single minimally invasive procedure that fully integrates the best of the surgical and catheter approaches for the treatment of longstanding, persistent (also called “chronic”) or difficult-to-treat, atrial fibrillation.
T
he groundbreaking procedure was pioneered by cardiothoracic surgeon Andy C. Kiser of FirstHealth Cardiovascular & Thoracic Center and electrophysiologist Mark D. Landers of Pinehurst Cardiology Consultants. It was performed for the first time in the United States at FirstHealth Moore Regional Hospital, in Pinehurst, N.C., in 2009.
requires only three small incisions in the abdomen, rather than full-chest incisions, and access through the veins in the groin. A less invasive procedure, it allows for much faster recovery time, minimal scarring and a shorter hospital stay. Overall, the procedure combines the positive aspects of both catheter ablation and open-heart surgery done separately, with improved long-term outcomes.
Working side by side, the cardiac surgeon and Locations of the Epicardial and the Endocardial lesions placed during Until now, catheter ablation and surgery the Convergent Procedure. The epicardial lesions are large and robust, the electrophysiologist identify the source therapy were different aspects of the many but they are unable to reach all of the areas of the heart that must be ablated for a complete lesion set. The endocardial lesions, while of atrial fibrillation and create a pattern of treatment possibilities for AF. “By integrating much smaller, are able to target those areas of the heart inaccessible lesions inside and outside of the heart to treat from the epicardial approach. electrophysiology and cardiac surgery in a the problems. The resulting scar tissue controls the heart’s electrical ‘hybrid’ AF treatment, new procedural and perioperative standards impulses more effectively. have been established at our institution. The initial outcomes utilizing this multidisciplinary approach are excellent and patient The entire procedure is performed using miniature cardioscopic satisfaction is overwhelmingly positive,” says Dr. Kiser, who serves as cameras and instruments, and with small catheters with electrodes. It medical director of FirstHealth Arrhythmia Center. 6
The Triangle Physician | JUNE 2010
Boosts Outcomes in
&
Treating Atrial Fibrillation
Advantages of Convergent Procedure: • Performed on the inside and the outside of a beating heart, without bypass; • Treatment metrics can be established, since the heart continues beating and the electrical activity is uninterrupted; • Intra-operative metrics may suggest improved long-term outcomes; • Potential for shorter hospital stays and faster recovery; and • Decreased number of repeat ablation procedures.
To date, the Convergent Procedure has been performed more than 200 times internationally. Since the first at Moore Regional Hospital, more than 40 AF patients have entrusted their hearts to Dr. Kiser, Dr. Landers and Ker Boyce, M.D., and outcomes have been 90 percent effective. That’s a big leap over outcomes when the procedures are done separately in this patient population. This is good news for the more than 40 percent of AF patients who have exhausted all existing treatment alternatives. More than 75 percent of patients are refractory to drugs within five years. Among the recent Convergent Procedure patients was Christian Broadcast Networking Inc. founder and 700 Club host Pat Robertson from Virginia Beach, Va. Drs. Kiser and Landers, who monitor patient progress after treatment, report, “He’s doing great and is in sinus rhythm (normal heart rhythm).” From 2005 to 2050, it is estimated that patients suffering from atrial fibrillation in the United States will grow from 5 million to 16 million. This increase is largely due to an aging population. Once considered a harmless annoyance, atrial fibrillation is now recognized as a dangerous condition that can increase the risk of death. Patients with atrial fibrillation are five to seven times more likely to have a stroke, and have an increased risk of congestive heart failure. The heart is a muscle that relaxes and contracts, pumping the blood that carries oxygen and nutrients throughout the body. The heart rhythm is controlled by electrical impulses that travel through the
heart, first through the upper chambers, called the atria; and then through the lower chambers, called the ventricles. Normally, the heart’s electrical system sends regularly spaced, predictable signals, telling the heart muscle to contract or beat. Atrial fibrillation is a type of rapid, irregular heartbeat. It occurs when a storm of electrical impulses spread through the atria in a chaotic and disorganized pattern, causing the atria to begin rapidly contracting, upwards of 400 times a minute. As a result, the electrical signals are transmitted to the ventricles, which also contract in a rapid irregular manner. When the heart is in atrial fibrillation, the efficiency of the heart’s ability to pump blood out to the body is reduced. As a result, the body lacks the oxygen and nutrients it needs. Symptoms related to rapid and irregular heart rate include palpitations – the sensation of an irregular pulse, fatigue or weakness, shortness of breath and limitations in a person’s ability to exercise. Stroke is the most devastating risk of atrial fibrillation. The atrium beats so rapidly that it is unable to move the blood into the ventricle. This causes stagnation of the blood in the upper chambers, where it can spontaneously form a clot. These blood clots sometimes break away, frequently traveling to the brain and causing a stroke. The clots can also travel to other organs and limbs of the body, which can be life threatening. Medications, such as aspirin or warfarin, can reduce this risk. “The common misconception of these medications is that they ‘thin’ the JUNE 2010 | The Triangle Physician
7
PHOTOS BY JIM SHAW
The cannula is placed midline well below the Xiphoid process along with two 5-mm ports for instrument use.
blood and can make a person cold. These medications only reduce the chance of blood clots forming and do not change the consistency of blood,” says Dr. Landers. “Like any muscle, the heart can become fatigued and weaken if it has to work too hard,” says Dr. Landers. “This is due to the AF causing the lower chambers to beat too rapidly for a longer period of time. Congestive heart failure, which manifests as fluid buildup in the lungs and legs, can be a possible results of not controlling the heart rate. This can potentially lead to life-threatening lower-chamber heart rhythms.” Atrial fibrillation is caused by changes in the electrical properties of the cells in the atrium. These changes occur in every person as they get older and explains the increasing risk for developing AF as a person ages. Contributing factors to the development of AF include high blood pressure, valve problems, congestive heart failure and damage from a heart attack or heart surgery. Sometimes episodes can be triggered by harmful substances like alcohol, tobacco and caffeine. “Other patients are younger and have no risk factors to explain their AF,” says Dr. Landers. “The development of AF in these patients is usually due to abnormalities in a single or small group of cells, socalled ‘Lone AF.’” Atrial fibrillation usually starts out with infrequent and self-terminating episodes. This is called paroxysmal AF. It commonly 8
The Triangle Physician | JUNE 2010
A depiction of the placement of the Pericardioscopic cannula that demonstrates the direct access to the posterior aspect of the Left Atrium gained through the trans-diaphragmatic approach used during the Convergent procedure.
progresses to more frequent and longer episodes, and over time can become permanent, a condition called chronic, or longstanding, persistent atrial fibrillation. Although some people can have AF and feel fine, most have symptoms. Regardless of how one feels, atrial fibrillation needs to be treated right away, or serious complications can develop. RATES FOR SURGICAL TREATMENTS VARY The goals of treatment for atrial fibrillation include regaining a normal heart rhythm, controlling the heart rate, reducing symptoms, and reducing the risk of blood clots and stroke. Many treatment options are available, including lifestyle changes, medications, and catheterand surgical-based procedures. Following the American College of Cardiology/American Heart Association/European Society of Cardiology 2006 Guidelines for the Management of Patients with Atrial Fibrillation, the type of treatment recommended depends on the severity of symptoms, prior treatments and other medical conditions that may affect the risk of treatment. Atrial fibrillation treatment begins with services provided by a cardiologist or electrophysiologist, but can ultimately require a surgical procedure. Initially, medications are used. Treatment options beyond medication include electric shock therapy or cardioversion, pacemaker therapy, catheter ablation and now the Convergent Procedure.
SURGICAL THERAPY The surgical treatment of atrial fibrillation is based on the creation of an anatomical pattern of myocardial lesions on the surface of the heart designed to disrupt the reentry circuits of AF by dividing the atria into non-conducting segments. The “Cox-Maze” procedure has been recognized as the “gold-standard” for treatment of AF using open-heart surgery. It involves cutting both atria in a specific pattern and sewing it back together. This creates a “maze” of scar tissue, which inhibits abnormal electrical charges that initiate and maintain atrial fibrillation. Its overall reported efficacy rate is approximately 75 percent at two years. Only 15 percent to 20 percent of the patients need a pacemaker after surgery, and there is only a 30 percent chance of requiring long-term medications to maintain a normal rhythm. However, this surgical procedure is technically challenging, requiring cardiopulmonary bypass and cardioplegia to stop the heart entirely. The complications are potentially significant and include stroke, bleeding, infection and death. Therefore, doctors usually do not recommend a surgical maze for the treatment of AF, unless the patient is undergoing open-heart surgery for another condition, such as coronary artery bypass, or replacement or repair of a diseased heart valve.
The heart is accessed through sheaths (like large IVs) placed in the groin or neck. Flexible catheters equipped with electrodes to record the electrical activity are directed to the various positions in the heart. One of the catheters usually used is equipped with an ultrasound transducer that allows the doctor to view the structures inside the heart. Once the areas of abnormal electrical impulses are identified, ablation is performed through a special catheter using radiofrequency energy or other energy sources to “cauterize” the tissue, creating a scar that is unable to conduct, and therefore blocks, the electrical impulses. When performed by experienced doctors, PVI alone can be expected to prevent AF in 70 percent to 80 percent of patients during the first year. Upwards of 20 percent of patients need additional PVI procedures to prevent further AF episodes or to treat other abnormal heart rhythms that develop. PVI has higher success rates in patients with smaller left atrial size and those who have paroxysmal AF. The size of the left atrium and the duration of AF are factors that can decrease the chance of success with catheter ablation alone. “The high rate of repeat procedures and less than desirable long-term outcomes in patients with longstanding, persistent AF have been disappointing,” says Dr. Landers. There also are some significant, though infrequent, risks to structures outside of the heart intrinsic to catheter ablation alone that arise from the endovascular nature of the technique, such as an atrio-esophageal fistula. Dr. Landers states, PHOTOS BY JIM SHAW
Surgery or a catheter-based endocardial ablation may be appropriate for patients whose AF symptoms continue despite treatment with medications or for those who cannot tolerate prescribed medications.
Variations through the years have led to a host of surgical AF alternatives, such as the Wolf mini-maze, which is practiced by many surgeons. Most surgical options today use alternative methods to create the scar pattern mimicking the Cox-Maze procedure. All of these, however, require access to the heart through either a full sternotomy or less-invasive approaches, such as the use of incisions on the left and/or right side of the chest (thoractomy). Some techniques still require cardiopulmonary bypass and sometimes cardioplegia. CATHETER-BASED ABLATION Pulmonary vein isolation (PVI) using endocardial ablation has been performed for approximately the past 15 years in the United States. PVI is a technique used during catheter ablation to target the narrow band of muscle cells surrounding the junction of the pulmonary veins with the left atrium. The electrical discharges crossing over from the veins to the left atrium are thought to initiate and maintain AF. During PVI, the cells in the transition zone between the atrium and the pulmonary veins are destroyed to block the abnormal impulses in the pulmonary from vein firing, thereby electrically “disconnecting,” or “isolating,” them from the heart. Frequently, other ablation sites are targeted during the ablation. Not unlike the surgical procedures, this minimally invasive procedure is lengthy and technically difficult, and performed by relatively few electrophysiologists in this country.
Andy Kiser, M.D., Kelly Garner, R.N., and Neal Murty, S.T., performing the Convergent Procedure at FirstHealth Moore. Regional Hospital
“These risks are likely reduced in the Convergent Procedure given the lack of need for extensive ablation on the posterior left atrium, where the problem can occur.” Despite the drawbacks, catheter ablation has the only catheter device approved by the Food and Drug Administration in the United States specifically for the treatment of atrial fibrillation. Additionally, “catheter ablation and the associated mapping technologies offer the means to positively identify sites of origin for atrial fibrillation. Most surgical approaches for AF do not map the electrical activity of the heart during the procedure,” says Dr. Landers. JUNE 2010 | The Triangle Physician
9
Best of Both Worlds PHOTOS BY JIM SHAW
Convergent Blends
The evolution of the Convergent Procedure began in 2006, when Dr. Kiser performed the first Ex-Maze procedure in the United States during open, concomitant cardiac surgery. With the ability to access the heart through an open sternotomy, the Ex-Maze lesion pattern could be created on the epicardial surface that closely mimicked the original open-chest Cox-maze III procedure. Dr. Kiser joined European colleagues in 2007 to develop the paracardioscopic Ex-maze (PEX) procedure that could be performed on a beating heart through several small incisions, instead of the open chest. In June 2007, he performed the world’s first minimally invasive PEX, in collaboration with Polish and German heart surgeons, on a patient in Krakow, Poland. During the PEX procedure, cardioscopy allows the physician to directly access the posterior aspect of the heart, particularly the left atrium, through a novel transdiaphragmatic approach, using a cannula. Right-chest thoracoscopy provides access to the right epicardium to complete a bi-atrial ablation pattern. Unlike a subxyphoid approach, cardioscopy provides access to the heart via the central tendon of the diaphragm. “This allows direct vision of the posterior cardiac structures, with minimal hemodynamic compromise. Such access and visualization of the epicardial cardiac surface has enabled epicardial ablation techniques as a treatment for atrial fibrillation,” says Dr. Kiser. Epicardial lesions are created using a unipolar, irrigated radiofrequency device. Because the lesions are created on the epicardium, lesion contiguity can be verified by visual observation. Also as the heart is beating, conversion to sinus rhythm can be directly observed and pulmonary vein isolation/exit block can be verified after lesion creation. Soon after the success of the first PEX procedure, Dr. Kiser began offering it at FirstHealth Moore Regional Hospital, and surgeons from such metropolitan locations as Chicago, St. Louis and Sacramento began adopting the surgery. Continued improvements came when Dr. Kiser and Dr. Landers joined forces and formed another international, multidisciplinary team in Krakow. This led to the convergence of the skills and expertise of the cardiac surgeon and the electrophysiologist. In January 2009, a 55-year-old Idaho man traveled to Moore Regional Hospital to become the first patient in the United States to have the Convergent Ex-Maze, or Convergent Procedure. The comprehensive treatment approach addresses the erratic electrical impulses on the inside, as well as on the surface of the heart. It involves the creation of a surgeon’s PEX epicardial ablation pattern followed by an electrophysiologist’s endocardial ablation pattern. 10
The Triangle Physician | JUNE 2010
The room specifically equipped for the Convergent Procedure at FirstHealth Moore Regional Hospital. The new Reid Heart Center on the campus of Moore Regional Hospital will house two hybrid operating rooms for the performance of the Convergent and other procedures
Bill Cockfield, P.A
“(The Convergent Procedure) totally corrected my atrial fibrillation. I just feel so blessed. I was so sick by the time I had the surgery,” she says. Only a month after her granddaughter’s first birthday, she describes the Convergent Procedure as “a piece of cake.” The biggest improvement, according to Dr. Kiser, has been the integration of these systems. “We look for areas that are problems, we test for problems, and then we go back and do more. We’ve started to see a merger of the technology and technique,” he says. The Convergent Procedure has established new criteria for lesion integrity by the verification of procedural completion using endocardial electrophysiologic metrics. The procedure is not complete until isolation of the pulmonary veins and the posterior left atrial is confirmed. The coronary sinus and Ligament of Marshall is ablated. A mitral annular and a cavo-tricuspid isthmus line is performed to reduce the chance of associated arrhythmias. “These metrics provide confidence of procedural success and set new standards for the hybrid treatment of longstanding, persistent AF,” says Dr. Kiser. (continued on page 12)
Convergent Procedure is Mount Gilead resident Carolyn Thompson made history as the second patient in the United States to undergo the Convergent Procedure, a revolutionary treatment for atrial fibrillation, in February 2009. She recalls being at wits’ end, but hopeful upon meeting the innovators of the procedure, cardiothoracic surgeon Andy C. Kiser of FirstHealth Cardiovascular & Thoracic Center and electrophysiologist Mark D. Landers of Pinehurst Cardiology Consultants.
“Piece of Cake” Twice Ms. Thompson went to her local hospital emergency department for relief. Both times she was admitted, so her medications could be changed, and each time her symptoms worsened. At her cardiologist’s appointment in early January 2009, she told him she couldn’t continue with the medication and intended to seek help elsewhere.
Gift of renewed life
“I was so sick, I could barely walk without being short of breath and I couldn’t drive,” says the 59-year-old wife, mother and grandmother. It was all she could do to get out of the car and walk to Dr. Kiser’s office at FirstHealth Moore Regional Hospital.
That same day, her daughter Melissa followed up on a recent newspaper article about the first groundbreaking Convergent Procedure in the United States performed in Pinehurst. The surgery combines two surgical AF treatments that are traditionally performed separately: epicardial ablation and endocardial ablation. The surgery is less invasive, with fewer risks and better outcomes.
“Dr. Kiser told me he would get me straightened out,” Ms. Thompson recalls. “By that time, I didn’t care what they did, I just wanted them to do something.” After all, she had a lot to live for. Her daughter was expecting her second child in April and her other daughter was planning an August wedding. Her son was just beginning college.
Dr. Kiser replied to the e-mail the same day, asking that her mother call his office for an appointment. Three days later, he examined her and referred her to Dr. Landers for further evaluation from an electrophysiologic perspective. Three weeks later, after pre-procedural testing, Ms. Thompson was ready for her Convergent Procedure.
From flip flops to frail
Ms. Thompson first grew concerned about her erratic heartbeat, shortness of breath and weakness in August 2008, while at the beach with her husband. She attributed it to high blood pressure, which she had been trying to control with medication. Her vacation was followed by months of “crazy spells” that made daily activity and performing her clerical duties at a medical practice increasingly difficult. “It was like a little war going on in my chest,” she says. “There was a lot of shortness of breath. I was not feeling good and I knew something was going on with my blood pressure and my heart.” One September day on her way to work, Ms. Thompson’s symptoms were so severe, she drove directly to her physician’s office. An electrocardiogram indicated she had atrial fibrillation, a dangerous condition that makes patients five to seven times more likely to have a stroke and increases their risk of congestive heart failure.
Ablative therapy is designed to control AF’s erratic electrical impulses, which cause the atria to begin contracting, upwards of 400 times a minute. It involves the creation of a pattern of myocardial lesions on the heart’s surface that divides the atria into non-conducting segments. The resulting scar tissue disrupts the reentry circuits of AF. Working together during the same procedure, Dr. Kiser first creates the epicardial ablation pattern on the outer surface. Dr. Landers follows, creating the endocardial ablation pattern on the inner surface. Today, over a year later, Ms. Thompson doesn’t recall pain, just intense weakness, all of which came to pass about two months after surgery. She has had no recurrence and requires only medications to control her blood pressure.
Ms. Thompson was referred to a cardiologist in her hometown, who prescribed antiarrhythmic medication, which is a typical, initial treatment option. Some patients, however, cannot tolerate the drugs and she was among them.
© ISTOCKPHOTO.ALEAIMAGE
Throughout November and December of 2008, she was “totally home bound and bed bound.” Her illness kept her from attending holiday festivities. She couldn’t eat and lost about 30 pounds. The medication made it nearly impossible for her to sleep. “It sort of wrecked my whole nervous system. I was in really bad shape.”
JUNE 2010 | The Triangle Physician
11
(continued from page 10)
PHOTOS BY JIM SHAW
“Electrophysiologic evaluation and intra-cardiac mapping at the time of the procedure demonstrate the effectiveness of the Convergent Procedure,” says Dr. Landers. “This allows for less procedural time and less fluoroscopy (radiation) exposure during the catheter ablation portion of the procedure. The Convergent Procedure reduces the overall operative time, avoids chest incisions and lung deflation, and uses only three miniature abdominal incisions, in addition to the access for the catheter ablation. For the patient, it means less pain, shorter hospital stays and greater overall chance for success.”
Surgical Team (bottom row, left to right) - Kelly Garner, R.N., Kathy Coon, R.N. and Tammy Horne, R.N. (top row, left to right) - Bill Cockfield, P.A. and Neal Murty, S.T.
one or more attempts at catheter ablation or are not candidates for catheter ablation.” Left atrial size and AF duration are important factors in this decision process. When the left atrium is larger than 6.0 centimeters or the duration of AF is greater than five years, the long-term success for the “cut-and-sew” maze procedure is under 80 percent. It is difficult for the electrophysiologist to consistently and effectively complete PVI when the left atrium is greater than 5.0 centimeters. Therefore, when a patient has paroxysmal AF and the left atrium is under 5.0 centimeters, percutaneous catheter ablation is considered. In this population, simple PVI—with or without additional ablation lesions—may be effective in more than 80 percent of patients. Patients with paroxysmal AF and a left atrium greater than 5.0 centimeters, and/or those with persistent, longstanding AF demonstrate the best outcomes when a bi-atrial lesion pattern is created. Surgeons who have experience with minimally invasive approaches choose the ablation technology best suited for their technique. Whichever approach and device is used, a comprehensive lesion pattern of contiguous and transmural lesions are essential. Persistence and intra-operative verification of lesion and pattern integrity is crucial. CONVERGENT TEAM Dr. Andy C. Kiser, M.D., FACS, FACC, FCCP, is board certified in cardiac and thoracic surgery. He earned his medical degree from the University of North Carolina at Chapel Hill, where he also completed his internship, residency and fellowship. Dr. Mark D. Landers, M.D., FACC, is a board-certified cardiologist and electrophysiologist with Pinehurst Cardiology Consultants L.L.P. He earned his medical degree from Eastern Virginia Medical School, and completed his internship and residency at the University of Connecticut. His cardiology and electrophysiology fellowship was completed at the University of Colorado.
EP Team (bottom row, left to right) - Lisa Tully, R.N., Christy Marley, R.N. and Joan Burge, R.N. (top row, left to right) - Nancy Carter, R.N., Randy Williams, CVT and Todd Laws, CVT
Outcomes “are fantastic,” the doctors say. The most recent 12-month data show a success rate of about 90 percent freedom from AF. An abstract of the Convergent Procedure summarizing the first 15 months of performing the Convergent Procedure was presented at the Heart Rhythm Society meeting in May.
Dr. Ker Boyce, M.D., FACC, is a board-certified cardiologist and electrophysiologist with Pinehurst Medical Clinic Inc. He earned his medical degree from Emory University School of Medicine in Georgia. He performed his internship and residency at Emory University Affiliated Hospitals. His cardiology and electrophysiology fellowship was completed at the Naval Medical Center in San Diego, Calif., and the University of California San Diego Medical Center.
CONVERGENT CANDIDATES Today, the FirstHealth Arrhythmia Center offers comprehensive treatment for patients with atrial fibrillation, and is recognized nationally and internationally for the Convergent Procedure for treatment.
For more information about the Convergent Procedure, call (910) 715-1713 or toll-free (800) 213-3284, or visit www.convergentprocedure.com.
The consensus opinion by the Heart Rhythm Society Task Force states that “standalone AF surgery should be considered for symptomatic AF patients who prefer a surgical approach and have failed 12
The Triangle Physician | JUNE 2010
Drs. Andy Kiser and Mark Landers regularly present “Treatment Options for Atrial Fibrillation” to help unravel the complexities of this troublesome condition. The information sessions are free and open to the public. The next one is set for July 20, from 5:30 to 7 p.m., at the Moore Regional Hospital conference center. To register, call (910) 715-1478 or toll-free at (800) 213-3284.
Radiology
by
Patient Management for
Thyroid Nodules
Michael D. Kwong, MD Dr. Kwong joined Wake Radiology in 2003 as a vascular and interventional radiologist. He is certified in diagnostic radiology by The American Board of Radiology.
Thyroid nodules are very common and are often incidental findings on chest CT, cervical spine MRI, or carotid ultrasounds. These are usually asymptomatic, not palpable on exam,
the patient to assist in the management of
and the chronicity or stability is unknown.
whereas a hot nodule is more likely a
These can be cystic or solid, and often multiple
hyperfunctioning benign lesion. The ultra-
nodules are present scattered throughout
sound and nuclear medicine thyroid scan are
the gland. Most thyroid nodules are benign;
complementary tests—one assesses the
however, approximately 10% of nodules are
physical nature and the other assesses the
cancerous. This means an estimated 37,000
physiological nature of a lesion.
important that the interventional radiologist
year. In fact, the rate seems to be increasing.
The Society of Radiologists in Ultrasound
in detail with you to ensure the highest
This may be due to the improved imaging
convened a special panel of medical experts
that allows for earlier detection at a smaller
to address this topic and published a consensus
size, increased awareness, vigilance of care
conference statement in 2005 with these
providers, and possibly from increased
recommendations:
cases of thyroid cancer are diagnosed each
exposure to ionizing radiation including CT scans. When symptoms develop, they can include a new or enlarging palpable mass, dysphagia, odynophagia, hoarseness or changes to voice, or adjacent adenopathy. Managing Thyroid Nodules The imaging evaluation of thyroid nodules following physical exam and laboratory studies should start with a thyroid ultrasound. This high-resolution evaluation will allow characterization of the nodule size, morphology, echogenicity, internal vascularity and whether there is a “halo” sign, assess for microcalcifications, and characterize the borders. Sometimes the ultrasound can show characteristically benign findings such as a comet tail artifact arising from echogenic foci, which is indicative of the colloid crystals of benign nodules. A cystic lesion and multiplicity of nodules are
care. In addition, all biopsy results should be reviewed and correlated back to the imaging findings to ensure that the pathologic results are concordant with the imaging. It is you select for the biopsy discusses the findings standard of care for your patient. Citations: Radiology 2005; 237:794–800 Management of Thyroid Nodules Detected at U/S: Society of Radiologists in Ultrasound Consensus Conference Statement. Mayo Clinic. com Health/thyroid cancer, Endocrineweb.com
Ultrasound Feature & Recommendation
Type of Thyroid Malignancy and Characteristics
Solitary nodule—microcalcifications Strongly consider U/S guided FNA if > 1 cm
Papillary thyroid cancer The papillary type of thyroid cancer is the most common, making up about 80 percent of all thyroid cancer diagnoses. Papillary thyroid cancer can occur at any age, but is most commonly diagnosed in people ages 30 to 50.
Solid (or almost entirely solid) or coarse calcifications Strongly consider U/S guided FNA if 1.5 cm Mixed solid and cystic or almost entirely cystic with solid mural component Consider U/S-guided FNA if >2 cm None of the above, but substantial growth since prior U/S examination Consider U/S-guided FNA Almost entirely cystic and none of the above and no substantial growth (or no prior U/S) U/S-guided FNA probably unnecessary Multiple nodules Consider U/S-guided FNA of one or more nodules, with selection prioritized on basis of criteria (in order listed) for solitary nodule
more favorable signs, but thyroid cancers can
When more than one nodule meets the
occur in all nodules. When a nodule is
criteria for biopsy, typically the most con-
confirmed to be solid and has indeterminant
cerning nodule is chosen for biopsy. Often
characteristics, a nuclear medicine thyroid
in a multinodular gland, one from each
scan can be performed to assess whether the
side is biopsied. Prior to biopsy, each case
nodule is “hot,” “warm,” or “cold.” A cold
should be carefully reviewed and additional
nodule would be more concerning for cancer
targeted history should be obtained from
Follicular thyroid cancer Follicular thyroid cancer also includes Hurthle cell cancer. Follicular thyroid cancer typically occurs in people older than 50. Medullary thyroid cancer Medullary thyroid cancer may be associated with inherited genetic syndromes that include tumors in other glands. Most medullary thyroid cancers are sporadic, meaning they aren’t associated with inherited genetic syndromes. Anaplastic thyroid cancer The anaplastic type of thyroid cancer is very rare, aggressive, and very difficult to treat. Anaplastic thyroid cancer typically occurs in people age 60 or older. Thyroid lymphoma Thyroid lymphoma begins in the immune system cells in the thyroid. Thyroid lymphoma is very rare. It occurs most often in adults age 70 or older.
JUNE 2010 | The Triangle Physician
13
SkinScoliosis Cancer
Scoliosis Screening? Whatever Happened to
by Lloyd A. Hey, MD, MS
It’s late on a Friday afternoon and an anxious call comes into the Hey Clinic for Scoliosis and Spine Surgery in Raleigh from a pediatrician requesting an urgent spine consult for a young man with a rapidly growing spinal tumor on his lower back. My staff made arrangements to get this young man and his mother in to see me right away. The adolescent, indeed, had a fairly large hump on his left lower back. X-rays revealed a very large thoracolumbar scoliosis as the cause of the hump. 14
The Triangle Physician | JUNE 2010
Š ISTOCKPHOTO.MCININCH
The loss of school-based screenings has led to some cost savings for schools, but it has also resulted in decreased awareness of scoliosis in the general population. Physicians and physician assistants in all subspecialties are encouraged to look for signs and symptoms.
After graduating from Harvard Medical School, Dr. Lloyd Hey completed a pediatric orthopedic fellowship at Children’s Hospital Boston and became chief resident of orthopedic surgery there. He moved to North Carolina in 1994 and completed a combined orthopedic/neurosurgical adult spine fellowship at Duke University Medical Center. He opened his private practice, Hey Clinic, in January 2005. For more information about scoliosis, contact the Hey Clinic at www.heyclinic.com or (919) 790-1717.
The mother was quite upset to the point of tears:
“Why wasn’t this picked up earlier? Don’t they screen for this?” she asked me. Many of us adults remember being screened as a middle schooler in gym class or by our school nurse. Gym teachers or school nurses often would have large groups of children bend forward, examining the upper and lower back for asymmetries (humps). Those who had suspicious findings were sent home with a letter to the parents, recommending they seek further evaluation and an X-ray. It seemed like a good idea from a public health standpoint: early diagnosis could lead to earlier treatment with molded scoliosis braces and the possible avoidance of surgery. While scoliosis screening was done consistently during the 1970s and 1980s, many school districts moved away from scoliosis screening during the 1990s, in part because the United States Preventive Services Task Force began to raise questions regarding the effectiveness of such screening. In a 1996 report, the task force expressed its belief that there was insufficient evidence to warrant the costs associated with widespread scoliosis screening in schools. Many states used this document to eliminate the requirement for scoliosis screenings in their schools and, as a result, school scoliosis screenings have become quite variable nationwide. And with this dramatic drop in school screenings, so too has overall awareness of scoliosis dropped among families and even some physicians. Doctor’s office screenings
Now that school scoliosis screenings have been largely eliminated, what role, if any, does the pediatrician, family physician, obstetrician/gynecologist and orthopedic surgeon play in the detection of scoliosis? Many are choosing to include scoliosis screening as a part of their usual physical examination for children, adolescents and adults. Many are also using the scoliometer, which is a tilt-gauge tool to help define paraspinal asymmetries that are large enough to warrant an X-ray evaluation. In my discussions with many Wake County pediatricians, I have found that the scoliometer
has been very useful as an objective “high-tech” measurement to show they checked for scoliosis. It gives our well-educated Wake County population (which likes objective measures) some visual proof that we checked their child/teenager thoroughly and that nothing is being overlooked or missed. (Parents will remember that you put a device on their child’s back; whereas, they may not remember that you “eye-balled” the child for potential rib hump.) Screening adults for scoliosis
It is also important to remember that scoliosis is something that can be checked in adulthood as well. Scoliosis often has its greatest progression during the adolescent growth spurt, but it can progress as an adult, especially because misalignment of the spine can lead to premature disc degeneration and collapse with subsequent progressive deformity, and possible pain and disability. Adults with a history of scoliosis earlier in life should be checked every year through age 25, and roughly every five years thereafter. Even adults who have had previous scoliosis surgery should be checked every few years, since they can have trouble with collapse and/or adjacent-level failure above or below where their fusion is. This is especially true in the adults who had Harrington Rod fusions years ago, many of whom suffer with flat-back syndrome and adjacent-level failure. Adult scoliosis is often accompanied by progressive spinal stenosis, spondylolisthesis and possibly visible deformity that can result in significant decreases in quality of life. Fortunately, advances in spinal surgery in the last 20 years have resulted in the ability to help many of these patients. However, just as in the adolescent population, early detection and conservative intervention is often very helpful. Having serial X-rays taken over several years also can help to see whether the spinal “core” is remaining stable or whether it is collapsing over time. Serial height measurement in the adult population is another great way to pick up on potential progressive scoliosis or kyphosis, with height losses more than an inch or two suggesting potential collapse. In conclusion, the loss of school-based screenings has led to some cost savings for schools, but it has also resulted in decreased awareness of scoliosis in the general population. Physicians and physician assistants in all subspecialties are encouraged to look for signs and symptoms. Physical examination findings might suggest a spinal deformity that would benefit from further evaluation and result in earlier intervention with less risk, better final clinical outcome, and better patient and family satisfaction. JUNE 2010 | The Triangle Physician
15
Men’s Skin Cancer Health
Men’s Health Initiatives Help Raise Awareness
by Judd W. Moul, MD, FACS
...as a urologist, I should not only focus on the prostate or PSA test, but should try to engage the patient related to smoking and alcohol counseling, and assessments related to body mass index, blood pressure, lipid testing, cardiac risk, erectile dysfunction, other cancer screenings and depression. The relatively new concept of focusing on
Think Globally
men’s health is growing out of the recognition
From a clinician’s standpoint, we need to
that men have unique health needs and they
think more globally when we encounter a
are, in general, less likely than women to take a
man in practice.
proactive stance with their health. It is widely known that men do not go to the doctor often
While we are all busy and most of us are
or in a timely manner, resulting in medical
overburdened with the need to see too many
conditions that often are diagnosed later.
patients in too little time, we should try to do a global men’s health assessment. For example,
As a urologist specializing in prostate cancer
as a urologist, I should not only focus on the
and prostate disease, my first foray into men’s
prostate or PSA test, but should try to engage
health and advocacy came in about 1991,
the patient related to smoking and alcohol
when the Us TOO prostate cancer support
counseling, and assessments related to body
group was founded and I had the opportunity
mass index, blood pressure, lipid testing,
to be a national advisor. This early era was
cardiac risk, erectile dysfunction, other cancer
focused on prostate cancer screening, the
screenings and depression.
prostate-specific antigen (PSA) test, and treatment for localized and advanced prostate
Tip offs of dysfunction in these areas should
cancer. Other organizations, such as Man to
prompt a discussion about the value of having
Man and the National Prostate Cancer
a primary care provider (PCP) and a referral,
Coalition, have also carried this torch well.
if necessary. I am constantly amazed that many of my urology/prostate patients do not have a PCP.
broadened and such organizations as the Men’s
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The Triangle Physician | JUNE 2010
Health Coalition have tried to increase awareness
As a urology specialist, I may be the only
and advocacy for a multitude of men’s health
physician contact many men have had in quite
issues. There is now even a scientific, peer-
some time, and making a positive impression
reviewed medical journal called The American
so the man will not avoid the health care system
Journal of Men’s Health, which focuses clinicians
is critical. I believe this is particularly important
and researchers on this emerging area of study.
for African-American men.
© ISTOCKPHOTO.PHOTOVIDEOSTOCK
During the last 20 years, the movement has
Dr. Judd W. Moul is Chief of the Division of Urologic Surgery and Director of the Duke Prostate Center at Duke University Medical Center. His clinical interests include the treatment of PSA-only or biochemical recurrence of prostate cancer and multidisciplinary management of prostate disease.
declines. If the T falls below physiologic levels
Multidisciplinary Care
and the man is symptomatic, then andro-
for Prostate Cancer
pause is diagnosed and treatment with T
Finally, for men who have prostate cancer,
replacement is considered. T replacement is now most commonly done using daily trans-dermal gels.
now available to help physicians assess
The new American Urological Association (AUA) best-practice policy on PSA testing has led to new guidelines, which have been endorsed by the Prostate Cancer Coalition of North Carolina. Educational efforts are under way in the state to make sure PCPs understand them. The AUA recommends that all men have a baseline PSA test at age 40. This initial test value can be used to assess the man’s future risk for prostate cancer. If the starting value is less than 1.0 ng/ml, the
symptoms. The ADAM (Androgen Deficiency in Aging Males) questionnaire screens for low T symptoms. The International Index of Erectile Function (IIEF) questionnaire is helpful in identifying symptoms of ED. It is now recognized that men exhibiting ED, particularly younger men, should have a work up for cardiac disease, as well. The same risk factors that cause blood vessel disease, such as smoking, diabetes, poor diet, hyperlipidemia, etc., are at play with both ED and coronary artery disease.
disciplinary team approach is becoming recognized as an optimizer of good care. I
Patient self-administered questionnaires are
New PSA Guidelines
which is a key men’s health issue, a multi-
am proud to be part of the Duke Prostate Center, the first true multidisciplinary program for prostate cancer in the state. Since 2004, more than 700 newly diagnosed men have been evaluated at Duke’s weekly Multi-D clinic. Here, they are seen and evaluated by a urologic surgeon, a medical oncologist, a radiation oncologist and a clinical trial team. This is in addition to more than 5,000 other men evaluated and treated with the condition at Duke University Medical Center. Our current research involves studying these two cohorts to increase clinical-trial participation, develop a personalized medicine approach and optimize outcomes.
man faces a low risk for prostate cancer and no further testing is needed until age 45, when the exercise is repeated. It is further deferred to age 50, if the number is still below one. Men with a starting PSA above 1.0 ng/ml are at higher future risk and should be tested annually to an age when their life expectancy is below 10 years. For men who have a PSA of 2.5 ng/ml or greater and who are between 40 and 60 years old, a referral to a urologist is prudent. Also, the rate of change of PSA over time is now more defined and clinically useful. Called PSA Velocity (PSAV), it may be just as much of a red flag for the possibility of prostate cancer as the PSA number alone. For men who have a PSAV greater than 0.35-0.50 ng/ ml/year, a referral to a urologist is prudent. Testosterone Replacement Other current men’s health topics include “andropause,” and the association between erectile dysfunction (ED) and coronary artery disease. Andropause is the result of low testosterone (T) in aging men. As men age, their serum T
Useful Web Sites Us TOO www.ustoo.com Men’s Health Network www.menshealthnetwork.org Prostate Cancer Coalition of North Carolina www.pccnc.org American Urological Association Foundation www.urologyhealth.org National Association for Continence www.nafc.org The Duke Prostate Center www.dukehealth.org/locations/prostate_center The American Journal of Men’s Health http://ajmh.sagepub.com JUNE 2010 | The Triangle Physician
17
Spinal Surgery
Minimally Invasive the Spine IsApproach Surgery to the
Dr. Dennis Bullard of Triangle Neurosurgery P.A. is board-certified in neurology. He graduated cum laude from the University of Southern California with a bachelor’s degree in psychology in 1971. He earned his medical degree cum laude from St. Louis University Medical School in 1975. He completed an internship in general and thoracic surgery in 1976; and as assistant resident and chief resident in neurological surgery Duke University Medical Center. A National Institutes of Health postdoctoral fellowship in immunology at Duke in 1979 was followed by a residency in medical neurology at the Institute of Neurology, National Hospitals for Nervous Disease in London, England; and a postdoctoral fellowship in neuro-oncology at the Gough-Cooper Department of Neurological Surgery, University of London, National Hospitals for Nervous Disease in 1980. Dr. Bullard went on to serve as assistant professor of neurosurgery and of pathology, and co-director of the Brain Tumor Clinic at Duke from 1982-1987.
by Dennis E. Bullard, MD, FACS
The chronic use of narcotics or other conservative measures to support a poor quality of life is not a substitute for the surgical correction of the problem, especially when surgery can be done as an outpatient procedure or with a minimal hospital stay.
T
Future
We consider the least invasive way to solve a problem to be the best. However, this is not always quite as simple as it seems. The chronic use of narcotics or other conservative measures to support a poor quality of life is not a substitute for the surgical correction of the problem, especially when surgery can be done as an outpatient procedure or with
riangle Neurosurgery provides a
should be based upon sound clinical data.
unique surgical specialty by
For 10 years, we exhibited our belief in
focusing entirely on cervical and
data-driven medicine by keeping records of
lumbar spine problems. In the
our results, collecting virtually all of the case
increasingly complex field of neurosurgery,
histories, demographic information, intra-
specialization is crucial.
operative X-rays, and extensive, long-term
a minimal hospital stay. What Is Minimally Invasive Spine Surgery? A surgical procedure is only minimally invasive if it offers the best solution to correct
follow-up data during that period.
the problem. This involves more than just
the treatment of spinal problems. Since then
In 2007, I received a research grant that
keeping the incision small results in limited
I have also kept abreast of state-of-the-art
allowed us to consolidate all of the data into
advances in that area and have contributed
a menu-driven database. It has proved
to the field by conducting clinical research
extremely useful to conduct prospective
and publishing scientific papers on the
studies based upon our past experiences and
comprehensive and surgical treatment of
our database.
Seven years ago I decided to focus only on
disorders of the spine. The more time I spent dealing with spinal problems, the more
At the 2010 meeting of the American
convinced I became that the minimally
Association of Neurological Surgeons, the
invasive treatment of complex cervical and
largest neurosurgical society in the world, we
lumbar spine is the future of spinal surgery.
used our extensive database to report on our efforts to minimize complications in
Throughout my intensive medical career,
complex cervical surgeries. We won the
I became convinced that clinical decisions
first-place award for scientific achievement.
18
The Triangle Physician | JUNE 2010
making the smallest possible incision. If access, incomplete repair of the problem or risk of re-operation to more fully correct the defect, then it cannot truly be called minimally invasive. In conventional spine surgery, the spine is often accessed by stripping away and retracting the muscles and soft tissue around the spine. Work performed thereafter is often done without sufficient visual magnification or the assistance of newer technologies. This can result in lengthier healing times, significantly greater pain, compromised blood (continued on page 22)
Triangle Neurosurgery, PA
A Complete Spine Care Center Dr. Dennis E. Bullard MD, FACS is a Board Certified Neurological Surgeon and a Fellow in the American College of Surgeons. He was trained at Duke and was on their staff as a tenured Associate Professor of Neurosurgery. He is a neurosurgeon who has been practicing for 28 years and is always striving for the most current and effective care for his patients. He is the recipient of the 2010 first place award given by the American Association of Neurological Surgeons for his research in cervical spine surgery. He has been honored with the Patients’ Choice Award and has been elected continuously to the lists of America’s Top Rate Physicians and Best Doctors in America. He is a member of the North Carolina Spine Society and elected to the International Who’s Who in Medicine. His major interests are spinal problems with a special emphasis on the cervical spine and minimally invasive procedures for the lumbar spine. Triangle Neurosurgery provides a unique blend of personalized attention to each patient with the latest advancements in state of the art technology. This results in compassionate and comprehensive care delivered through conservative management or surgery. Our emphasis is patient centered and we recognize the importance of helping patients return to an active and healthy lifestyle. Triangle Neurosurgery, PA 1540 Sunday Drive, Suite 214, Raleigh, NC 27612 Phone: 919-235-0227 Fax: 919-235-0227 triangleneurosurgery.org
(continued from page 20)
and nerve supply to the muscles because
3. C-arm fluoroscopy units provide
Summary
of prolonged retraction, and more extensive
accurate anterior, posterior and lateral views
We believe we can provide the best care
scarring and muscle atrophy.
of the spine for proper placement of cages,
possible to our patients because of our will-
screws and rods. Because of the tubular
ingness to learn and use the newest tech-
To utilize a minimally invasive surgical
dilators used, there is often little or no visu-
niques and because we use the information
approach, which we prefer in most cases over
alization of the spine. Fluoroscopy is a type of
we have to educate our patients about their
the older open surgical approach, we use an
X-ray imaging that enables the neurosurgeon
options. We have achieved better clinical
array of highly sophisticated tools and tech-
to precisely visualize the placement of
outcomes, by combining the use of newer
niques, including the following:
implants as opposed to a blind approach.
biologic products, innovative instrumenta-
1. Microscopes are imperative in order
4. Due to the limited viability, nerve
imaging and data-driven methods. We also
to receive high-quality neurological visual-
conduction studies are done through-
publish our clinical results so they can be
ization of the anatomy in great detail. This
out every minimally invasive spine surgery
reviewed.
helps to differentiate between normal and
to ensure precise placement of implants.
abnormal tissue.
This procedure verifies placement and also
tion and state-of-the-art intra-operative
eliminates breaching the pedicle walls, 2. The tubular dilator allows
nerve root infringement and other neuro-
maximum access through a minimal incision.
logical issues.
This instrument spreads the tissue and muscle apart as opposed to cutting. This helps
5. The newest biological systems, including
to eliminate tissue and muscle destruction,
stem cell technology can be used to
and bone removal. It also leaves the least
supplement, and often replace the need for,
amount of scarring; produces the best cos-
harvesting the patient’s own bone—often the
metic results; and supports minimal blood
most painful factor in their postoperative
loss, shorter hospitalizations, lower doses
recovery. There have been tremendous strides
of narcotic analgesics, less loss of work
in the development of biologic material. We
time and a shorter return to an indepen-
do not utilize any products that have not
dent lifestyle.
endured extensive testing in multi-center trials.
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The Triangle Physician | JUNE 2010
We look forward to the informative evaluation that an analysis of the Triangle’s surgical cases will provide. We continue to base decisions about new products on results and offer our patients straightforward, unbiased information about their options rather than just using randomized protocols. We think the fact that the majority of our referrals come from previous patients speaks for itself. We consider ourselves our patients’ partner in determining their best path of care.
Phlebology
Treatment of Venous Reflux often Quiets Restless Leg Syndrome
It is postulated that when venous congestion is present, there may be an accumulation of metabolites, as well as, other contributing factors which may precipitate RLS.
by Lindy McHutchinson, MD
Restless leg syndrome affects 5 percent to 15 percent of American adults, with women twice as likely affected. It also afflicts 1 in 3 seniors. This poorly understood disorder is characterized by an urge to move the legs to relieve discomfort. Most patients describe the leg sensations as “heebie-jeebies,� or antsy, and frequently can not describe the nature of the feeling. Thirty percent of the sensations are considered painful. Symptoms of RLS are typically worse in the evening, while relaxing, lying or reclining and frequently infer with sleep, causing chronic sleep deprivation and its associated psychological or cognitive impairments. The etiology of RLS is still a mystery and may be a heterogeneous group of disorders. There are no known biomarkers and the diagnosis is made on clinical history. RLS is divided into primary (idiopathic) and secondary causes. Primary is most common and felt to have a sensory-motor origin, involving central nervous system dysfunction. Secondary RLS has been associated with many conditions, from iron deficiency to renal failure. One recognized association with secondary RLS is venous insufficiency.
Correlation to Venous Reflux Venous insufficiency, usually from venous reflux, results from non-functioning one-way flow valves in the leg veins, allowing blood to flow retrograde down the leg, instead of antegrade toward the heart. This venous reflux creates venous pooling and resultant venous congestion. It is postulated that when venous congestion is present, there may be an accumulation of metabolites, as well as other contributing factors which may precipitate RLS. Prior publications describe relieve of RLS symptoms when treated for venous insufficiency. In Hayes, et al, 2008, the venous insufficiency was treated in 33 patients with RLS. The patients had venous reflux documented on duplex ultrasound. They found an average 89 percent improvement in symptoms. Of these patients, 53 percent indicated their symptoms were largely alleviated and 31 percent had complete relief of their RLS symptoms. While further research is needed to better understand RLS, Dr. Hayes concluded that RLS patients with venous reflux should be referred to a vein specialist for evaluation and treatment. Treating underlying venous reflux with endovenous laser ablation and/or sclerotherapy to close affected veins is a simple, office-based procedures, covered by most insurance plans, including Medicare. Most patients return to usual activities the same or following day. JUNE 2010 | The Triangle Physician
21
Lifestyle
Destructive Lifestyles Cause Chronic Illness by
Mark W. McClure, MD
The message is clear. We don’t need legislation to dramatically improve our nation’s health care. We need to find a way to convince our patients to change their unhealthy behaviors.
Research is writing on the wall Three decades ago, Stanford University researcher James Fries challenged the prevailing notion that, regardless of lifestyle, advancing age is equated with increasing risk of disability (New England Journal of Medicine, 1980; 303, 130-5). He proclaimed that Americans with lower health risks will have less disability at any given age, less disability later in life and will live longer than those with higher health risks. Health risks were defined as smoking, lack of exercise and obesity. Many scholars dismissed his “compression of morbidity” hypothesis
The silent onslaught of chronic illness robs years from life for millions of Americans. Although individuals often equate aging with declining health, fortunately this equation isn’t necessarily so. With proper health habits, individuals can enjoy vitality into the golden years. Destructive lifestyle choices, though, lead to the emergence of disease and premature aging. Even though the United States has one of the highest standards of living in the world, American males rank only 15th in the world in longevity. Research has shown that men can dramatically improve these statistics by reducing their health risks.
as simplistic and impractical. Undaunted, Dr. Fries set out to prove his theory. He studied a group of University of Pennsylvania graduates whose lifestyles had been tracked since 1939. He assigned risk factors to each participant based on three factors: body weight, smoking and exercise habits. Each risk factor was rated from 0 to 3 based on predetermined criteria. The scores for the three risk factors were then totaled and participants were assigned to one of three separate risk categories based on their scores: low risk 0-2, moderate risk 3-4 and high risk 5-9. These individuals were carefully monitored on an annual basis. When the study was completed, as predicted, the data confirmed that Americans with lower health risks live longer and suffer less morbidity (Journal of Gerontology: Medical Sciences 2002; Vol. 57A, No. 6, M347 – M351). Indeed, he found overall that the low-risk group had 100 percent less disability and 50 percent less mortality when compared
© ISTOCKPHOTO.YSAL
to the high-risk group.
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The Triangle Physician | JUNE 2010
Dr. McClure graduated from Indiana University School of Medicine. He received his urology training at the University Of Pennsylvania. He is medical editor for Health and Healing, a Research Triangle-based health newspaper. He is board certified in urology and currently practices in Raleigh, NC.
Furthermore, when disability occurred, it was postponed by approximately seven years in the low-risk vs. the high-risk group. In addition, for those in the study who died, the low-risk group had less cumulative disability and less disability one and two years prior to death than those in the high-risk group. The moderate-risk group also benefited. Although the results were not as impressive as those from the low-risk group, the moderate-risk group still experienced significantly less morbidity and mortality when compared to the high-risk group. Tobacco, exercise and obesity Based on current understanding, these results should not come as a surprise. According to
the National Institute on Drug Addiction, tobacco use is the leading preventable cause of disease, disability and death in the United States. Between 1964 and 2004, cigarette smoking caused an estimated 12 million deaths, including 4.1 million deaths from cancer and 5.5 million deaths from cardiovascular diseases.
of life expectancy, respectively, compared with normal-weight smokers. Obese female and male smokers lost 13.3 years, and 13.7 years respectively, compared with normalweight nonsmokers (Annals of Internal Medicine: Jan. 7, 2003; 138, 1-44).
Furthermore, all-cause mortality is inversely related to total exercise. Physical inactivity is associated with an eight-fold increase in the incidence of strokes and heart attacks. Unfortunately, one-quarter of the American population never exercises.
Among other things, overweight and obesity are known risk factors for diabetes, high blood pressure, heart disease, gallbladder disease, stroke and cancer. Researchers have discovered that fat may induce these chronic diseases by releasing special chemicals called cytokines that increase inflammation in the body.
There is an epidemic of obesity in the United States: three-quarters of Americans are overweight and one-third are obese. Large decreases in life expectancy are associated with overweight and obesity. According to data from the Framingham Heart Study, 40-year-old male and female nonsmokers lost approximately three years of life expectancy because of overweight. Forty-year-old female and male nonsmokers lost 7.1 years and 5.8 years, respectively, because of obesity. Obese female and male smokers lost 7.2 years and 6.7 years
Obesity has also reached epidemic proportions in children. The incidence of obesity in children ages 12 to 19 years of age has tripled since 1976. Roughly 12 percent of Caucasian, 20 percent of African American and 27 percent of Hispanic children are obese, and the same disturbing trend applies to children between 6 to 11 years of age. As a consequence, the incidence of non-insulin-dependent diabetes in children is skyrocketing and so is the incidence of lipid abnormalities and hypertension.
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JUNE 2010 | The Triangle Physician
23
Women’s Health
Integrative Medicine at Women’s Wellness Clinic Has The myth we tell ourselves is that (the United States) has the best health care and that is why it is so costly. However, when examining longevity, infant mortality, physical fitness and chronic disease rates, Americans are at the bottom or near the bottom, compared to other developed countries. Integrative medicine is a healing-oriented
umbrella of complementary and alternative
near the bottom, compared to other developed
medicine that takes account of the whole person,
medicine. IM practitioners, such as myself,
countries.
body, mind and spirit. It focuses on the patient’s
make it a priority to guide patients away from
lifestyle and on the doctor-patient relationship.
treatments that, in the best case, are harmless
There is no doubt America is one of the best,
It is a medicine where the best of conventional
but a waste of money, and in the worst case,
if not the best, places to be if you are sick. But
Western medicine is integrated (hence the
are dangerous.
what about the tools and knowledge to keep
name) with the best of evidence-based non-
us healthy and well in the first place? This is
traditional medicine. Nutritional counseling,
A cure for health care
one of the primary focuses of integrative
herbal medicine, dietary supplements, massage
Many experts agree that our current health
medicine—to promote wellness and disease
therapy, mind-body medicine and acupuncture
care system is broken, and that this is due in
prevention. Integrative medicine is appealing
are examples of therapies an integrative
part to the fact we have created a “sick care”
to many Americans right now because many
practitioner may utilize.
or “disease management” system in America,
are dissatisfied with the current heath care
rather than a health care system. In the past,
system and want to see a doctor who prac-
Today the term integrative medicine (IM) is
western medical schools have focused
tices healing-oriented medicine that
recognized by many, thanks to Dr. Andrew Weil,
primarily on how to diagnose and treat illness,
empowers patients towards heath and healing.
one of the pioneers of the field. He started the
with very little emphasis on teaching lifestyle
world’s first fellowship in integrative medicine
recommendations to keep patients healthy.
A healing patient-physician partnership
in the 1990s at the University of Arizona. Today, the program now called the Arizona
We cannot deny the amazing advances that
IM values the partnership between the doctor
Center for Integrative Medicine is the leading
western medicine has made and continues to
and the patient. The relationship is one of
provider of integrative medicine education
make. It is hard to imagine a time before
equals, and both doctor and patient work
worldwide and the most comprehensive
antibiotics or bypass surgery or chemotherapy.
together to come up with solutions to optimize
fellowship of its kind.
health and treat illness. A sobering note, however, is that despite all
More than 400 fellows from throughout the
the medical progress and the billions spent
An integrative practitioner spends quite a bit
world have trained at the Arizona Center for
in health care in our country, America ranks
more time with the patient, usually an hour
Integrative Medicine and many are now
37th in overall health outcomes, according
or more for a new-patient visit. A typical
recognized leaders in the field. I completed
to the World Health Organization. This is on
visit includes a broader history with questions
the fellowship in 2009.
par with Serbia and behind such countries as
relating to lifestyle, relationships, goals and
Costa Rica and Columbia.
stressors, for example. The history focuses on
During the fellowship, doctors, physicians
the whole patient, not just the medical
assistants and nurse practitioners spend two
The United States spends more per capita on
problem or disease. Not only are a patient’s
years and 1,000 hours of training in integrative
health care than any other country in the
physical complaints addressed, but emotional,
medicine. A vital part of the integrative
world. The myth we tell ourselves is that we
social and spiritual aspects of heath and
medicine fellowship is gaining knowledge on
have the best health care and that is why it is so
illness are addressed as well. The time and
therapies that have high-quality evidence to
costly. However, when examining longevity,
attention given to patients, in and of itself, is
support their use. There is a lot of quackery
infant mortality, physical fitness and chronic
valuable and is part of the therapeutic part-
that unfortunately falls under the broad
disease rates, Americans are at the bottom or
nership between patient and practitioner.
24
The Triangle Physician | JUNE 2010
Holistic Focus to Promote Health and Healing
by
Amy Stanfield, MD, FACOG Dr. Amy Stanfield is board certified in obstetrics/gynecology. She completed the Arizona Center for Integrative Medicine Fellowship at the University of Arizona in 2009. She now leads a comprehensive integrative medicine program at the Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Center (www.cwrwc.com). For more information about this life-enhancing service, contact the Women’s Wellness Clinic at (919) 251-9223.
The philosophy of integrative medicine empha-
supplements, herbal medicines, stress reduction,
Individualized, in-depth integrative health
sizes the fact that our bodies have innate healing
breath control, acupuncture and mind-body
services, such as those available at the
mechanisms. In this age when prescriptions
medicine are considered and discussed.
Women’s Wellness Clinic, help patients living with a chronic disease, or those coming to
are handed out so readily, this is a fact that many of us seemed to have forgotten. IM
A nice analogy is that an integrative medicine
terms with a new diagnosis or preparing for
practitioners strive to uncover the root cause
doctor has more tools in his or her toolbox
surgery.
of illness, rather than just treating symptoms.
and, therefore, has more treatment options
Much of integrative medicine is common sense.
available beyond pharmaceutical approaches.
Many patients seek out integrative medicine
Time is also spent educating patients about
consults to discuss optimal health and the
the influence of lifestyle choices on their risk
prevention of future diseases, such as cancer
Effective interventions that are natural and less invasive are tried first. When a treatment
for
disease.riddick insurance group ad.pdf 12/28/2009 7:13:50 PM
and heart disease.
is recommended that carries a high risk of side effects or complications and/or is very expensive, then this treatment needs to have strong, randomized, controlled study data supporting its use. The flip side of this is with low risk, low-cost treatments, observational data is deemed sufficient. Integrative medicine practitioners value low-tech methods, such as dietary changes, exercise, stress reduction and breath control, just as much as they value C
the high-tech procedures and technologies
M
they, likewise, have at their disposal.
Y
The real measure of success for integrative
CM
medicine will be when integrative medicine
MY
becomes the medicine we all practice. My
CY
hope is not for integrative medicine to stay a
CMY
separate field of medicine, but for it to replace K
the current system. IM offers more treatment options A visit to an integrative doctor includes all the typical things that occur in a regular doctor’s office, such as measuring blood pressure, checking cholesterol and recommending screening tests for cancer. In addition, recommendations about nutrition, dietary JUNE 2010 | The Triangle Physician
25
Men’s Health
Mechanics of
BPH Leads to Greater Understanding
by Carmin M. Kalorin, MD
The long-term result of a complex physiological response of the bladder to the enlarging prostate are irritative symptoms, such as an urgent need to urinate, voiding frequently and getting up to urinate several times a night. Benign prostatic hyperplasia (BPH) affects millions of men worldwide. Studies have shown that benign enlargement of the prostate occurs in 70 percent of men between the ages of 40 and 60; and in more than 90 percent of men over age 80. As the prostate enlarges, it can result in many of the bothersome symptoms that bring men to the doctor. The prostate is a male gland that sits between the bladder and penile urethra. In order for urine to pass, it must exit the bladder and flow through a “tunnel” created by prostate tissue surrounding the urethra. Urine then exits through the penile urethra. Normally, the prostatic urethra provides a small amount of resistance to the flow of urine. The contractile action of the bladder easily provides enough force to overcome this resistance and the result is a strong, smooth urinary stream.
Some patients begin to help the bladder generate more force by bearing down and straining to initiate the flow of urine. Other symptoms soon follow, such as weak force of stream, post void dribbling, a sensation of incomplete emptying, double voiding (having to void again soon after a previous void), inconsistent or “stop and start” stream, and urinary retention. 26
The Triangle Physician | JUNE 2010
© ISTOCKPHOTO.RAPIDEYE
Early Symptoms As the prostate enlarges the growing tissue surrounding the urethra compresses the walls of the tunnel. As this tunnel narrows, the resistance to flow greatly increases. The bladder has to contract more forcefully to overcome the increased resistance.
Dr. Carmin Kalorin of Capital Urological Associates P.A. in Raleigh completed his undergraduate degree at Emory University in Atlanta and earned his medical degree at Albany Medical College. He completed his internship at the United States Naval Hospital (Balboa), San Diego. He served as a flight surgeon for the Navy, while based in Jacksonville, N.C. He worked as a general surgeon at Albany Medical Center, where he performed his residency in urology. He is a member of the American Urological Association; the Northeast Section, American Urological Association; and the Endourological Society. For more information contact Capital Urological Associates at (919) 526-1717 or visit www.capitalurological.com
Unfortunately, this simple mechanical obstruction model of BPH explains only half of most men’s complaints. Symptoms such as the urgent need to urinate, voiding very frequently and getting up to urinate several times a night can be the most bothersome to patients. In fact, getting up to void three or four times per night results in significant daytime fatigue, and is one of the most common reasons men seek treatment. Urologists refer to these as “irritative” symptoms. Long-term Implications Irritative symptoms are the long-term result of a complex physiological response of the bladder to the enlarging prostate. BPH causes increased resistance to urine flow within the prostatic urethra. In order to overcome this resistance, the detrusor (bladder) muscle must contract harder to generate enough force to overcome the higher resistance.
This is very similar to a weightlifter doing bicep curls. The dumbbell provides the resistance and the bicep contracts creating the force needed to overcome it. If this occurs repeatedly over time, the bicep muscle will
grow and hypertrophy to be able to provide more contractile force. This is why the amount the weightlifter can curl increases over time. Now imagine the prostate as the dumbbell and the bladder as the bicep. The enlarged prostate has created more resistance and the bladder must respond by increasing its contractile force. The bladder muscle, too, will undergo growth and hypertrophy just like the bicep. This is seen clinically as a patient with a very thick-walled bladder muscle—evidence that it has been working hard to force urine past the prostate. Unfortunately, the bladder muscle is not exactly like the bicep, and the key differences can result in long-term voiding symptoms, bladder dysfunction and even serious systemic problems. First, the bladder is hollow and spherical. It must stretch in order to hold urine. As the muscle hypertrophies and becomes thickened, it looses its vesico-elastic properties
and cannot stretch enough to hold a normal amount of urine. This results in having to void more frequently. Secondly, the detrusor is composed of smooth muscle that is richly innervated. As a normal bladder fills the nerves fire, resulting in relaxation of the bladder so it can hold more urine. In a hypertrophied bladder, however, the nerves become altered and do not respond properly, resulting in loss of bladder relaxation and decreased functional capacity. This results in even more frequent urination and also creates a sense of urgency to void. Thirdly, the thickened muscle is very strong, and when the bladder reaches its limit, it creates a very forceful contraction. The patient senses this as a severe urgent need to void and often cannot make it to the bathroom in time.
Finally, if this process goes on too long, the bladder muscle will decompensate and fail. This is the result of the hypertrophied muscle becoming replaced by collagen, which has little to no contractile properties. If this is unrecognized, it can result in chronic urinary retention, serious urinary system infections, bladder stone formation and even renal failure. Theories While doctors aren’t completely sure of the cause of BPH, it’s probably linked to hormonal changes. One theory suggests that as men age, active testosterone levels decrease and the higher amount of estrogen within the gland increases the activity of substances that promote cell growth. Another focuses on dihydrotestosterone (DHT), a substance derived from testosterone in the prostate. Some research has indicated that with a drop in the blood’s testosterone level, older men continue to produce and accumulate high levels of DHT within the prostate, and this may encourage cell growth. Treatments Regular checkups to watch for early problems are recommended. Treatment is considered when symptoms cause a major inconvenience or health risks. Today, there are a variety of treatments. The Food and Drug Administration has approved several drugs to relieve common symptoms. Because drug treatment is not effective in all cases, a number of procedures that are less invasive than conventional surgery have been developed to relieve BPH symptoms. Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with irritative BPH. Nearly all of the treatments for BPH, both medical and surgical, have one primary goal: to decrease the amount of resistance supplied by prostatic obstruction. If this can be accomplished, over time both the patient’s symptoms and the potentially dangerous effects on the bladder can be alleviated. JUNE 2010 | The Triangle Physician
27
Cardiology
Management of Heart Disease in Pregnancy
Dr. Mateen Akhtar is a clinical and invasive cardiologist with Wake Heart & Vascular Associates. He has offices in Clayton, Smithfield, and Goldsboro. He welcomes new patient referrals and offers same-day appointments. He can be reached at (919) 989-7909 or mateenakhtarmd@gmail.com.
by Dr. Mateen Akhtar
Approximately 2 percent to 3 percent of all
stenosis, mitral stenosis, hypertrophic
Aspirin is generally regarded as safe to continue
pregnancies occur in women with significant
cardiomyopathy);
during pregnancy. However, warfarin is a
cardiovascular disease. Since marked hemodynamic changes occur during pregnancy, underlying cardiovascular disease increases risk to both mother and fetus. This month, I will review some common cardiovascular questions that arise during pregnancy: 1. What hemodynamic changes
• Advanced congestive heart failure (New York Heart Association Functional Class III-IV); • Significant aortic aneurysm; • Cyanotic heart disease; and, • Prior history of peri-partum cardiomyopathy
known teratogen and increases bleeding risk. In the first trimester, there is a high risk of warfarin embryopathy, so alternate anticoagulation therapy should be used, such as low-molecular-weight heparin. Typically, warfarin may cautiously be resumed in the second trimester and continued until approximately 36 weeks of pregnancy, at
and cardiac physical exam findings
3. What medications should be used
which time the patient is begun on unfrac-
are normal during pregnancy?
to manage hypertension during
tionated heparin, until the peri-partum
Total blood volume normally increases by
pregnancy?
period. Warfarin is associated with increased
40 percent to 50 percent during pregnancy.
It is important to remember that ACE
risk of fetal hemorrhage, so risks vs. benefits
Cardiac output increases by 30 percent to 50
(angiotensin-converting enzyme) inhibitors,
percent. Heart rate increases by approximately
ARBs (angiotensin II receptor blockers), and
10 beats per minute. Meanwhile, systemic
direct rennin inhibitors are contraindicated
vascular resistance decreases.
during pregnancy. Commonly used first-line
must be evaluated. Warfarin may be resumed post-partum, since it does not enter breast milk. 6. What is peri-partum
anti-hypertensive agents during pregnancy
cardiomyopathy (PPCM)?
On exam, a pulmonary outflow murmur (early
include methyldopa or labetalol. A long-acting
PPCM is a rare disorder of acquired left-
peaking systolic ejection murmur) is common
calcium channel blocker, such as nifedipine,
ventricular (LV) dysfunction and congestive
in up to 90 percent of women. A third heart
may be added as second-line therapy.
heart failure in the last month of pregnancy
sound may frequently be auscultated.
Thiazide diuretics may be used, but care must
or the first five months post-partum. Incidence
Peripheral edema and venous varicosities are
be taken to avoid volume depletion. All
is approximately 1 in 2,000 deliveries. PPCM
also common. The physiologic changes in
anti-hypertensive drugs cross the placenta
is a diagnosis of exclusion and no clear
pregnancy are typically well-tolerated.
and have possible side effects, including fetal-
etiology is known, although it shares features
growth retardation, so risks vs. benefits of
of viral myocarditis. Treatment is supportive
therapy need to always be evaluated.
with diuretics, afterload reduction, digoxin
Signs of underlying heart disease may
and inotropes, if needed. There is a 10 per-
include dyspnea, orthopnea or edema out of proportion to normal pregnancy, a loud
4. Is endocarditis prophylaxis needed
cent mortality rate and 4 percent of patients
systolic murmur (>2/6 intensity), presence of
during delivery?
go on to require cardiac transplant.
a fourth heart sound or a diastolic murmur.
According to the American Heart Association,
Fortunately, half of the women may normalize
2. Is pregnancy contraindicated in certain cardiac conditions? The following cardiac conditions represent
endocarditis prophylaxis is not needed for routine vaginal or caesarean delivery in the absence of infection, prosthetic heart valve, prior endocarditis or congenital heart disease.
such a high risk of mortality to mother and
LV function after six months. Future pregnancy is contraindicated due to risk of developing recurrent PPCM. Cardiology consultation is recom-
fetus that pregnancy should be avoided:
5. How should I manage the need
mended for all patients with known
• Severe pulmonary hypertension;
for anti-coagulation therapy during pregnancy?
or suspected heart disease during
• Severe obstructive cardiac lesions (aortic 28
The Triangle Physician | JUNE 2010
pregnancy.
Urology
Urology’s Medical Role Is Expanding with Great Strides
Dr. Kevin P. Perry is a board certified urologist and fellow of the American College of Surgeons. He practices with Cary Urology, P.A. and has been in private practice for thirteen years. He has interests in all aspects of general and pediatric urology. (www.caryurology.com)
by Kevin Perry, MD
Urologic diagnostics, therapies and surgical
radiotherapy. The urology specialty continues
tion of the risk factors that may preclude
to expand routine urinary cancer care in a
to these difficult problems. From simple
less-invasive and traumatic manner. It also
changes to complex reconstructions, eradi-
stands on the cusp of genetic medicine, now
cation of the causes for recurrent infections
with more frequent application of molecular
is the goal, and a high level of function and
testing and therapies.
patient satisfaction is often the endpoint.
thought of as the care of the older male with
Common, Yet Troublesome
Infertility
little thought given to the broad spectrum
Another specific aspect of urology that has
Male factor infertility also can be dealt with
changed greatly (in men, women and children)
using increasingly sophisticated assisted-
is therapy for lower urinary tract symptoms
reproductive technologies, medical treatments
and incontinence. From bladder outlet
and the surgical repair of varicoceles or the
obstruction, to incontinence, to painful
reconstruction of the obstructed reproductive
bladder syndromes, advances in thediagnosis
tract. Paternity can often be achieved even in
and treatment of these diseases have been many.
situations once thought impossible to overcome.
treatments today bear little resemblance to the training and practice of the recent past, because our specialty is pushing the envelope in all aspects of our every day work. The role of the urologist has traditionally been
of therapies that is offered to all age groups and genders. Urologists not only play an instrumental medical and surgical role in the care of genito-urinary disease, but also act as a point of entry into the health care system for a spectrum of disorders. Consider, for example, the index patient with erectile dysfunction. He often presents with a multitude of risk factors for both coronary and peripheral artery disease, metabolic syndrome, endocrine disorders, depression or even infectious diseases, and often has not seen the appropriate primary care or subspecialty physician to definitively deal with these issues. Urologists are in a unique position not only to treat the primary complaint, but to also guide these patients on toward appropriate care so that larger, underlying issues will not be missed. Carcinomas Of course, the urologist also plays a central role in treating urinary carcinomas. Therapy
They include urodynamics, biofeedback, novel medicines, implantable pacing devices
Pediatric Applications
and minimally invasive surgical procedures
Finally, pediatric patients also have enjoyed the
both in the office and the operating suite.
fruits of the evolution of our specialty. With the
These changes have relieved many previously
application of less-invasive surgery, improved
difficult and troublesome urinary bothers.
imaging and better medical management of pediatric issues, diseases like vesico-ureteral
The surgical management of urinary stone
reflux, undescended testicle and obstructive
disease is long and creative. Today it includes
uropathy can be dealt with much earlier and
percutaneous removal, ureteroscopy and
more effectively.
shockwave lithotripsy, all of which substantially decrease the morbidity of these everyday
Urologic diagnostics, therapies and surgical
operations. Great strides also have been made
treatments today bear little resemblance of
in the evaluation and medical management
the training and practice in the recent past,
of metabolic disorders to prevent worsening
because our specialty is pushing the envelope
of stone-disease risk factors, helping to lessen
in all aspects of our every day work. Urolo-
the burden of this very common problem.
gists are continually challenged to evaluate and apply new technology and modalities to
is both surgical, with an ever-evolving arsenal
Infectious Diseases
of less-invasive tools, such as laparoscopic,
deliver the best possible care to our patients.
Urology also touches on the specialty of
The future holds many more changes, as
infectious disease with the evaluation and
we strive to offer our patients the most
treatment of complex urinary tract infections,
cutting-edge treatment in an appropriate,
including the correction of congenital
cost-effective and compassionate manner.
abnormalities, stone removal and reduction,
The only thing certain is that nothing will
relief of urinary obstruction and modifica-
remain the same for long.
robotic and percutaneous surgery, as well as noninvasive techniques. Additionally, oncologic care is offered with office-based immunotherapy, hormonal manipulation, intravesical chemotherapies and the application of
JUNE 2010 | The Triangle Physician
29
Men’s Health
Men Have
Range of Treatments for Overactive Bladder by Joseph M. Khoury, MD, FACS
Bladder storage symptoms occur when bladder capacity is functionally diminished, resulting in frequent toileting, urgency and urge incontinence and frequent nighttime voiding, called “nocturia.” Lower urinary tract symptoms (LUTS)
First-line Treatment
commonly occur in men over the age of 45
Treatment for overactive bladder is based on
years. Classified as bladder storage and/or
the underlying cause. Unfortunately, many
bladder emptying symptoms, LUTS interferes
patients will have an unremarkable evaluation
with a patient’s quality of life and activities
and are thus treated empirically.
of daily living. As a first-line treatment, the physician will Symptoms can be caused by a urinary tract
recommend avoiding certain beverages and
infection; bladder cancer; bladder stones;
foods implicated in triggering overactive
neurological disease, such as multiple
bladder. They include caffeinated and
sclerosis, Parkinson’s disease and stroke; an
carbonated beverages and beverages with
enlarged obstructing prostate; and consump-
artificial sweeteners; as well as chocolate, nuts,
tion of alcoholic and caffeinated beverages,
tomatoes and citrus. Over-the-counter
and certain foods, many of which have a high
supplements that help neutralize acidity, such
acidic content.
as Prelief, bicarbonate of sodium and AlkaSeltzer, have been helpful in alleviating these
Bladder emptying symptoms include a weak
bothersome symptoms.
urinary stream, stuttering of the urinary stream, straining to urinate and hesitancy,
Pelvic floor rehabilitation that includes
which is difficulty initiating the stream. They
strength and relaxation techniques of the
are often caused by benign prostate hyperplasia
pubococcygeus muscles, in conjunction
(BPH), a condition covered in “Mechanics
with bladder retraining, often helps increase
of BPH Leads to Greater Understanding” on
The International Prostate Symptom Score
the functional capacity of the bladder and
page 26 in this issue of Triangle Physician.
(IPSS), a validated patient questionnaire, will
allows better bladder emptying. Scheduled
help determine the intensity of the symptoms Evaluation
voiding every two hours, while awake
and how those symptoms interfere with the
can decrease urgency and urge incontinence
Evaluation of overactive bladder begins with
patient’s quality of life. A three-day voiding
by 50 percent and is a useful strategy in
a thorough history and physical examination,
diary is invaluable in helping to determine
elderly patients, particularly those with
to include a digital-rectal examination,
if the patient is consuming large volumes of
dementia.
assessing prostate size, rectal tone and fecal
fluid and if nighttime output is a result of
impaction. A well-tailored neurologic
nocturnal polyuria or overactive bladder.
Medication
examination, to include gait assessment, deep-
Urine analysis will look for infection and/or
In some men, bladder outlet obstruction may
tendon reflexes, particularly of the lower
hematuria, and urine cytology will rule out
cause overactive bladder symptoms. Many men
extremities, and sensation within dermatomes
bladder cancer, particularly carcinoma in situ.
can be initially treated with an alpha-blocker,
S2 through S4, is an essential part of the
Postvoiding residual urine testing is important
such as Tamulosin, and then reevaluated in
evaluation.
to ensure appropriate bladder emptying.
two to four weeks.
30
The Triangle Physician | JUNE 2010
Joseph M Khoury, MD, FACS, is Medical Director of Raleigh Continence Center. He is one of six urologists fellowship trained in Urodynamics and Reconstructive Urology in the State of North Carolina and the only urologist in Wake County with this advanced training. He graduated from Georgetown University Medical School, finished Urology Residency at Walter Reed Army Medical Center and completed Fellowship at Duke University Medical Center. He was a Professor of Urology at The University of North Carolina-Chapel Hill and Georgetown University. His clinical interests are in urinary incontinence, prolapsed surgery and neurogenic bladder.
approved by the Food and Drug Administra-
in which the bladder is bivalved, like a clam,
tion to treat overactive bladder. Several studies
and a detubularized piece of intestine, usually
of intravesical Botox show improvement in
small bowel, on a vascular pedicle is interposed
symptoms lasting six to nine months. The
as a patch on the bladder increasing the
potential side effects include incomplete bladder
bladder’s functional capacity.
emptying or urinary retention requiring intermittent catheterization, urinary infection
Many patients will need to perform
and the need for repeat injections.
intermittent catheterization after cystoplasy. Other potential problems include bladder
Surgery
stones, mucus production, metabolic
Augmentation cystoplasty is reserved for those
acidosis, electrolyte abnormalities and
patients who fail all conservative and minimally
gastrointestinal problems, such as diarrhea
invasive treatments. It is a surgical procedure,
and bowel obstruction.
If there is no improvement in the symptoms, then one may consider an anticholinergic drug. Contemporary studies document that anticholinergic drugs are safe to use in men, and urinary retention occurs infrequently. The side effects of these drugs are commonly dry mouth, constipation, cognitive impairment and rare arrhythmias. Unfortunately, the potential side effects limit long-term use, and treatment is often discontinued after six months. If symptoms are refractory to initial treatment, then the patient should be evaluated by a urologist and undergo further diagnostic studies, with urodynamic evaluation and cystoscopy. Further management is then based on the findings of such studies. Minimally Invasive Approach Patients who have overactive bladder symptoms that are refractory to behavioral and medical therapy may be candidates for either sacral neuromodulation or intravesical injection of Botox. Sacral neuromodulation involves placing an electrode percutaneously into the S3 nerve foramen. The electrical stimulation to the S3 nerve root is thought to modulate the neurologic pathways involving micturition, thereby decreasing frequency, urgency and urge incontinence. Intravesical Botox is a novel approach to manage refractory overactive bladder symptoms. It remains in the investigational stage and is not Womens Wellness half vertical.indd 1
2/18/2010 3:35:23 PM
JUNE 2010 | The Triangle Physician
31
News Welcome to the Area
Joseph Onyiah, MD
Kristen Grace Shirey, MD
Duke University Hospitals Durham
Duke University Hospitals Durham
Michelle Rogers Pleasant, MD
Spencer Crawford Smith, MD
Duke Raleigh Hospital Raleigh
Marc Kenichiro Akashi, MD Duke University Hospitals Durham
Matthew Elliot Atkins, MD Duke University Hospitals Durham
Benjamin Nairn Rattray, DO Duke University Hospitals Durham
Silvia Yunghee Rho, MD Duke University Hospitals Durham
Rachel Catherine Blitzblau, MD
Matthew Blair Sellers, MD
Duke University Medical Center Durham
Duke University Hospitals Durham
Jason Keith Boyd, MD Southeastern Medical Oncology Center Goldsboro
Alfred Carroll Burris II, MD Duke University Hospitals Durham
Luke Francis Chen, MD Duke University Hospitals Durham
Jessica Heng Chow, MD Duke University Eye Center Durham
Mary Knox Cross, MD University of North Carolina Hospitals Chapel Hill
Lauren Elizabeth Galpin, MD University of North Carolina Hospitals Chapel Hill
Jorge Antonio Gutierrez, MD Duke University Hospitals Durham
Sara Louise Hebbeler-Pittenger, MD UNC Anesthesiology Dept Chapel Hill
Jerrell Waika Herod, MD Duke University Hospitals Durham
Jay Kher, MD Duke University Medical Center Durham
Scott David Lawrence, MD UNC School of Medicine Chapel Hill
David Andrew Margolis, MD Chapel Hill
Joseph Scott McMonagle, MD Duke University Durham
Amit Ramesh Mehta, MD Regional Cancer Care Durham
Robert John Mentz, MD Duke University Hospitals Durham
Jennifer Maria Nunez, MD Mebane
Nwora Lance Okeke, MD Duke University Hospitals Durham
Thomas Joseph O’Neill IV, MD University of North Carolina Hospitals Chapel Hill
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The Triangle Physician | JUNE 2010
Duke University Hospitals Durham
Kurtis Todd Sobush, MD Durham
Thomas James Veldhouse, MD Durham
Melanie Rebecca Walter, MD Duke University Hospitals Durham
Agnes J. Wang, MD Duke University Medical Center Durham
June 25 – 26, 2010
THE 8TH ANNUAL LANDES SYMPOSIUM: ADVANCES IN UROLOGY
Events & Opportunities June 3, 2010
PRE-OPERATIVE ORTHOPAEDIC SURGERY CLASS Registration open 12:00 p.m. - 2:00 p.m. Duke Raleigh Hospital offers a Pre-Operative Orthopaedic Replacement Surgery Class for all patients and family members. The class covers what you can expect before, during and after surgery. June 3, 2010
CANCER SUPPORT GROUP 6:00 p.m. - 7:30 p.m. Duke Raleigh Hospital Join us for a general cancer support group: Living with Cancer. June 5, 2010
2010 GEORGE HAM SYMPOSIUM FOR PSYCHIATRY The William and Ida Friday Center for Continuing Education Chapel Hill, NC james_hayes@med.unc.edu http://www.med.unc.edu/cme/events/george-ham-symposium/ ?searchterm=None Mental illness is the leading cause of disability in the U.S. and Canada among people aged 15-44. Nearly half (45%) of those with any mental illness meet diagnostic criteria for two or more disorders. NAMI (National Alliance on Mental Illness) estimates that 334,855 North Carolina adults were diagnosed with a serious mental illness. The goal of this meeting is to provide mental health providers with the latest research and clinical findings that will allow them to formulate treatment algorithms for schizophrenic and subspecialty patients. June 7, 2010
FREE WELLNESS DEMOS! 1025 Blue Ridge Road, Raleigh, NC Fairgrounds in Raleigh Health and Fitness June 7, 2010
PRE-OPERATIVE SPINE CLASS 12:00 p.m. - 2:00 p.m. Learn what to expect before, during, and after a spinal procedure at Duke Raleigh Hospital. June 8, 2010
TOTAL JOINT WELLNESS CLASS Registration open 3:30 p.m. - 4:30 p.m. Duke Raleigh Hospital Come and learn how to maintain the health of your new knee or hip joint following surgery. June 8, 2010
BREAST CANCER SUPPORT GROUP 6:30 p.m. - 8:00 p.m. Duke Raleigh Cancer Center is offering a breast cancer support group designed for any breast cancer patient. The group provides a place where patients can meet others going through similar experiences and can gain support and friendship. This is an informal group that meets the 2nd Tuesday night each month from 6:30 p.m. until 8:00 p.m. June 10, 2010
PRE-OPERATIVE ORTHOPAEDIC SURGERY CLASS Registration open 12:00 p.m. - 2:00 p.m. Duke Raleigh Hospital offers a Pre-Operative Orthopaedic Replacement Surgery Class for all patients and family members. The class covers what you can expect before, during and after surgery.
June 12, 2010
THE KOMEN NC TRIANGLE RACE FOR THE CURE® Komen NC Triangle Race for the Cure; 5k; 7:00am Meredith College, Raleigh, NC http://www.komennctriangle.org/komen-race-for-the-cure/ June 14, 2010
PRE-OPERATIVE SPINE CLASS 12:00 p.m. - 2:00 p.m. Learn what to expect before, during, and after a spinal procedure at Duke Raleigh Hospital. June 15, 2010
LOOK GOOD, FEEL BETTER Registration open 7:00 p.m. - 9:00 p.m. Duke Raleigh Hospital This support group works with cancer patients to improve their outward appearance and therefore, improve their self-confidence and personal perception. Many patients comment on the marked improvement in their mental and physical health once they felt like they looked “normal.” This program teaches patients how to work with their appearance to improve their self-esteem. June 17, 2010
PRE-OPERATIVE ORTHOPAEDIC SURGERY CLASS Registration open 12:00 p.m. - 2:00 p.m. Duke Raleigh Hospital offers a Pre-Operative Orthopaedic Replacement Surgery Class for all patients and family members. The class covers what you can expect before, during and after surgery. June 17 – 20, 2010
CAROLINA REFRESHER LECTURES Kiawah Island, SC http://www.med.unc.edu/cme/events/carolina-refresher-lectures/ Care of the surgical patient now requires a team approach in the perioperative period to ensure good outcomes. The goals of this meeting are to highlight several key areas in caring for surgical patients including preoperative assessment, high-risk obstetrics, patients with cardiac disease, pediatric care, and perioperative complications. A dynamic and expert faculty has been assembled to present this educational program, which has been designed for physicians, anesthetists, physician assistants, and others who care for the surgical patient. June 21, 2010
GOLF CLASSIC benefiting Hospice of Wake County will be held at MacGregor Downs Country Club, 430 St. Andrews Lane, Cary on June 21 starting at 9 am. Contact 919-522-6131 or visit http://www.hospiceofwake.org/pages/5/Calendar-of-Events/. June 21, 2010
PRE-OPERATIVE SPINE CLASS 12:00 p.m. - 2:00 p.m. Learn what to expect before, during, and after a spinal procedure at Duke Raleigh Hospital. June 24, 2010
PRE-OPERATIVE ORTHOPAEDIC SURGERY CLASS Registration open 12:00 p.m. - 2:00 p.m. Duke Raleigh Hospital offers a Pre-Operative Orthopaedic Replacement Surgery Class for all patients and family members. The class covers what you can expect before, during and after surgery. June 24, 2010
HEALTHY FOCUS SEMINAR: FOOD ALLERGIES IN CHILDREN Registration open 6:30 p.m. Duke Raleigh Hospital Join Dr. Michael Land as he discusses food allergies in children.
The William and Ida Friday Center for Continuing Education Chapel Hill, NC. james_hayes@med.unc.edu http://www.med.unc.edu/cme/events/the-8th-annual-landessymposium/?searchterm=None Urologic Surgery is the integration of surgical activities for the pelvis, primarily for the treatment of obstructions, dysfunction, malignancies, and inflammatory diseases. In recent years, Urologic Surgery has been revolutionized by advances in urodynamic diagnostic systems and minimally invasive surgical techniques, such as laparoscopy, endoscopic examination, implantation procedures, and advanced imaging techniques. The UNC Division of Urologic Surgery offers this educational activity to physicians and other health care providers in the Southeast as an opportunity for attendees to update their knowledge and skills to the newest standards and guidelines in the field. June 28, 2010
PRE-OPERATIVE SPINE CLASS 12:00 p.m. - 2:00 p.m. Learn what to expect before, during, and after a spinal procedure at Duke Raleigh Hospital. July 15-18, 2010
HEART FAILURE MANAGEMENT: ESTABLISHED THERAPY AND NEW FRONTIERS Amelia Conference Center, Amelia Island Plantation, FL Deirdre_Boyer@med.unc.edu http://www.med.unc.edu/cme/events/heart-failure-2010/view The contemporary management of heart failure is characterized by a combination of evolving strategies and newer approaches that are based on recent research advances. This educational activity is designed to provide a comprehensive overview of the current standards of practice in the treatment of heart failure. Course faculty will review cutting-edge approaches to diagnosis and classification and provide techniques and tips for the pharmacological and device management of heart failure. The material presented will have an interdisciplinary focus and will be of interest to physicians and other health care professionals who care for patients with heart failure. September 19, 2010
THE MAGNIFICENT MILE Finding a cure for motor neuron disease – one step at a time 300 Hillsborough St, Raleigh, North Carolina Please visit www.magmilerace.com for more information. Event Will Celebrate its Fifth Anniversary Planning is currently underway for The Fifth Annual Magnificent Mile. In honor of this special anniversary, the 2010 event will be bigger and better than ever. November 7, 2010
CITY OF OAKS MARATHON AND REX HEALTHCARE HALF MARATHON Raleigh, NC Start Time: 7 a.m. For registration and other information please visit: www.cityofoaksmarathon.com
New & Relocated Practices TOTS N TEENS PEDIATRICS Radhika S. Gopan, MD 3434 Kildaire Farm Road, Suite 124 Cary, NC 27518 919-362-7155 CAPITOL ENT is relocating their Blue Ridge Office to: 4600 Lake Boon Trail, Suite 100 Raleigh, NC 27607 919-787-1374 Mark S. Brown, MD, FACS David A. Clark, MD, FACS R. Glen Medders, MD, FACS Steven H. Dennis, MD H. Craig Price, MD Stanley A. Wilkins, Jr. MD JUNE 2010 | The Triangle Physician
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Practice Management
Governance Structures Help Medium-to-Large Practices
by
John Reidelbach
Governance within a group is very critical to the success of a practice. If your practice seems to be stagnant and not making enough progress, it might be time to implement a governance structure. One of the many pitfalls of medium-to-large practices today is the lack of communication between physician leaders and the management team. A well-planned and methodical governance structure alleviates this and many other problems within the practice, and it does not require a tremendous amount of time on the part of any one physician shareholder in the group. Furthermore, it provides downstream communication for all employees about current and future operations, and growth plans for the practice.
In larger practices, this committee should have a balance of junior partners and senior partners. In addition, the practice manager, chief executive officer or chief operating officer should participate in all executive committee meetings in a non-voting capacity. This will assure the understanding of communication from the top down. The purpose of this committee is to discuss the issues of the practice regarding operations, finance, human resources, risk and liabilities, growth, planning, etc. This committee should meet at least monthly at a time when all members are available.
Š ISTOCKPHOTO.LATTAPICTURES
Most practices enjoy growth and success over many years due to the diligence of physicians working long hours, as well as having a successful management team in place. However, when practices reach a size of greater than five physician partners, it is time to establish singular roles for the physician partners. This is for the benefit of the practice and to assure that one physician partner is not left carrying the burden alone. There should be a plan for a governance structure at the earliest stages of a practice, otherwise its implementation later on can be overwhelming.
Formation of an Executive Committee The first step is to establish an executive committee that includes the majority of the physician partners when the practice is small. However, there should be no more than five on the executive committee, no matter the size of the practice.
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The Triangle Physician | JUNE 2010
John Reidelbach’s career in health care spans more than 20 years and all facets of administration within physician practices, hospitals and large health care insurers. He founded Physician Advocates Inc. in 1996. Today, he is experienced in providing assistance to health care entities in all aspects of practice management, operation, strategic development and implementation, education, contract negotiations, data analysis and capital funding. His credentials include degrees in engineering and education, and a master’s in business administration. Mr. Reidelbach has designed several health care management entities, including independent physician associations, physician practice management companies, management service organizations and group practices. His experience includes developing equity ownership structures, financial incentives, network administration, and information systems selection and implementation. He also has developed detailed analysis tools to assist health care providers and product vendors. He can be reached in North Carolina at (919) 321-1656 or in Atlanta at (404) 664-9060; and by e-mail to info@mdpracticeadvice.com.
All physician partners should present matters for administration as agenda items, so they may be closely followed during the meeting. Administrative matters include strategic, financial, clinical, ancillary, hiring of a new provider, etc. Administration should also present items for committee review, discussion and understanding, with an eye toward resolution. The meeting should be documented and archived for future reference, as well as keeping track of outstanding issues that may not have been resolved at the last meeting. All items that are voted on should be documented for future reference. Additional Committees for Growing Practice As a practice matures and grows, the formation of additional committees can alleviate the executive committee from some responsibilities. The following committees are the most common:
recruiting committee could be organized to recruit senior management positions or additional physicians, midlevels and specialties. Shared Leadership The establishment of committees serves many purposes, the main one being to share physician leadership among the partners of the practice and to foster communication with the practice as a whole. This allows all physician partners to be involved with the operation and growth of the practice. Committees other than the executive committee can be smaller in size or represented by one physician partner working with an administrator. Nonetheless, all committees serve an important role in the success, management and long-term viability of the practice. Some practices may elect to compensate leaders who serve on these committees. The compensation covers the extra time physicians provide for the benefit of the practice. A minimum and maximum tenure for a physician in the position, usually one to three years, should be established. This assures that no single physician partner is giving more to the practice than his or her peers. This turnover also allows for new ideas. Governance within a group is very critical to the success of a practice. If your practice seems to be stagnant and not making enough progress, it might be time to implement a governance structure.
The finance committee can deal with pertinent financial matters, such as capital acquisitions, provider compensation models, as well as overseeing the budgeting process and reviewing the financials of the practice. This committee works closely with the controller and/or chief financial officer and the practice’s certified public accountant; reports to the executive committee; and is available to discuss the financial matters of the practice at physician partner meetings. A clinical committee handles issues relative to clinical staffing, clinical supplies, clinical vendor suggestions and negotiations for such matters as capital purchases, medical supplies, disciplinary actions related to physicians and other providers. A clinical committee assists in minimizing risk exposure and assuring compliance among peers within the practice. A strategic planning committee addresses matters of significant importance to the practice for periods of up to five to ten years. It plans and discusses strategies related to infrastructure, physical plant, information technology, capital acquisitions and expansion. It reviews existing and long-range strategies and models for bringing in new physicians, as well as exit strategies for outgoing partners. Other committees may be applicable to a practice, such as a real estate committee in the event there is need for a different or additional practice location. This committee would be responsible for bringing suggestions and proposals to the physician partners for approval and funding. A JUNE 2010 | The Triangle Physician
35
Insurance
Employment Practices Protects Against Rising Liability Workplace Insurance Lawsuits
Mike Riddick is president of Riddick Insurance Group Inc., an independent insurance agency in Raleigh. For 10 years, he has been helping professionals protect their assets through insurance and financial planning. Riddick Insurance Group specializes in property, casualty, liability and life insurance planning for small business owners. Mr. Riddick can be reached at (919) 870-1910 or mike@riddickinsurancegroup.com.
by Mike Riddick
The average wrongful-termination lawsuit (including legal expenses) costs between $22,000 and $41,000 to settle, yet only 10 percent of small business owners have Employment Practices Liability Insurance. Double-digit unemployment rates here in
termination lawsuit (including legal
North Carolina and throughout the United
expenses) costs between $22,000 and $41,000
States have caused an increase in wrongful
to settle, yet only 10 percent of small
Most insurance carriers can add basic EPLI
termination lawsuits. Add discrimination and
business owners have EPLI. Are you prepared
to an existing policy for a small cost. The
to pay more than $20,000 to settle a claim?
cost is generally based on the number of
sexual harassment to the list, and workplace lawsuits are at an all-time high. Employment-related suits can be fueled by many different types of workplace issues. Most involve discrimination based on age, sex, race, color, familial status, compensation, sexual orientation, obesity, medical leave… and the list goes on and on. Fifty percent of all employment practices liability claims are filed against small
employees. Adding $25,000 in coverage
EMPLOYMENT SUITS
generally runs $20 to $30 per employee per
Racial Discrimination 35 percent Gender Discrimination 31 percent Age Discrimination 23 percent Disability Discrimination 19 percent Sexual Harassment 17 percent
year. Having $50,000 in coverage generally runs $30 to $40 per employee per year. In 2005, the Equal Employment Opportunity Commission reported that racial discrimination was the leading employment allegation at 35 percent of all claims. Gender discrimination was alleged 31 percent of the time, followed by age discrimination at 23 percent, disability
S o u rc e : E m p l o y m e n t O p p o r t u n i t y C o m m i s s i o n
businesses, yes, 50 percent! Even a false
discrimination at 19 percent and sexual
claim requires thousands of dollars in legal
harassment at 17 percent.
defense costs. Have you ever had an employee who could have Most small businesses don’t have human
fallen into one of the categories above? Have
resource departments to create employee
you ever hired a female? Have you hired
handbooks and personnel policies to help
someone with disabilities? Does anyone over
keep small businesses out of trouble
age 40 work for you? Do you have male and
with these kinds of claims. Additionally,
female employees who work together on a
small business owners oftentimes don’t have
daily basis? Have you hired a minority? Of
deep pockets to pay attorney costs and
course you have; we all have.
payroll. So what can a small business do to protect itself? The answer is Employment Practices Liability Insurance (EPLI). The average wrongful36
The Triangle Physician | JUNE 2010
© ISTOCKPHOTO.ALUXUM
don’t have a team of attorneys on their My lesson for you this month — save
yourself thousands of dollars in potential losses with EPLI on your business policy.
YOUR LOCAL CARDIOLOGY PROFESSIONALS IN JOHNSTON COUNTY DEDICATED TO QUALITY, SERVICE, AND INTEGRITY Matthew A. Hook, MD, FACC Coronary and Peripheral Vascular Intervention
Mateen Akhtar, MD
Benjamin G. Atkeson, MD, FACC
Eric M. Janis, MD, FACC
Diane E. Morris, ACNP
Matthew S. Forcina, MD
Ravish Sachar, MD, FACC
2 LOCATIONS TO SERVE OUR PATIENTS Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7907 Fax: 919-989-3147
Wake Heart & Vascular Associates 2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326
Christian N. Gring, MD, FACC
Nyla Thompson, PA-C
CARDIOLOGY SERVICES Coronary and Peripheral Vascular Interventions, Pacemakers/Defibrillators, Atrial Fibrillation Ablations, Echocardiography, Nuclear Cardiology, Vascular Ultrasound, Clinical Cardiology, CT Coronary Angiography, Stress Tests, Holter Monitoring, Cardiovascular Medicine, Cardiac Catheterization
THE HIGHEST QUALITY CARDIOVASCULAR CARE, CLOSE TO HOME.
L]Zc >i 8dbZh Id 7gZVhi 8VcXZg! LZ¼gZ :kZc Idj\]Zg L]Zc I]Z <adkZh 8dbZ D[[# ©2010 Wake Radiology. All rights reserved. Radiology Saves Lives.
Location courtesy of Rapid Fitness Boxing Center, Raleigh
Penni, survivor since 2006
Darlene, survivor since 2005
Nancy, survivor since 2004
Robin, survivor since 2006
Lee, survivor since 2003
For living proof that early detection can deck this disease, just ask us. We’re some of the breast cancer survivors of Wake Radiology — we know personally what this fight is like. So we’re a little different when it comes to our patients. Highly understanding. Confidently reassuring. Ready with a solid one-two combination of expert medicine
Read our stories online at wakerad.com
and championship care, starting with your annual screening mammogram.
Wake Radiology salutes the grit, the grace, and the undaunted courage of every breast cancer survivor. Wake Radiology. The team you want in your corner.
7gZVhi >bV\^c\ HZgk^XZh 1 number to call, 16 locations serving the Triangle area. 919-232-4700 | wakerad.com
Proud Year-round Partner of the Susan G. Komen for the Cure, NC Triangle Affiliate.