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Rex Neurosurgery & Spine Specialists Rex Healthcare Expands Neurosurgical Services with a New Practice and Three of the Triangle’s Top Neurosurgeons

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

Also in This Issue

Autism Fecal Incontinence


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COVER STORY

6

Rex Neurosurgery & Spine Specialists Rex Healthcare Expands Neurosurgical Services with a New Practice and Three of the Triangle’s Top Neurosurgeons

AP r i l 2 0 1 3

Vol. 4, Issue 3

FEATURES

12

Urogynecology

New Treatment Is More Reason to Ask Women About Bowel Control Problems Dr. Catherine Matthews urges awareness of a condition that impacts quality of life and requires improved treatment.

15

Neuropsychiatry

Autism Awareness Is Needed to Help Remedy Public Misconceptions Dr. Sandeep Vaishnavi discusses social cognition dysfunction, promising research and possible treatments. COVER PHOTO: Grant Buttram, M.D., Robert Lacin, M.D. and Robin Koeleveld, M.D. bring over 50 years of combined experience to Rex Neurosurgery & Spine Specialists, now open on Lake Boone Trail in Raleigh.

DEPARTMENTS 9 Community Service

18 Duke Research News

Stomp the Monster: Local NonProfit Takes Financial Burdens Off of Cancer Patients

Obesity in Dads May Be Associated with Offspring’s Risk of Disease

10 Endocrinology

19 UNC Research News

Incidence and Advances in Diagnosis and Treatment of Thyroid Nodules

Research Needed on Interventions for Children Exposed to Traumatic Events

11 Practice Marketing

20 UNC Research News

Patient Communications: An Integral Part of Your Marketing Strategy

Steroids Help Reverse Process Involved in Rapid Bone Loss

16 Duke Research News

Promising Stem Cell Blood Test May Be a Sight-Saving Breakthrough

Bullied Children Can Suffer Lasting Psychological Harm as Adults

17 Duke Research News Growth Factor Aids Stem Cell Regeneration After Radiation Damage

22 UNC Research News

24 News

- Carolina Endocrine Open House - Welcome to the Area and Upcoming Events April 2013

3


From the Editor

Brains with Heart This month’s cover story in The Triangle Physician on Rex Neurosurgery & Spine Specialists does an excellent job of introducing the new practice and conveying the world-class, comprehensive care now

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

available. Its leading men, however, hardly need an introduction. Grant Buttram, M.D.; Robin Koeleveld, M.D.; and Robert Lacin, M.D., have been performing back, neck, cranial and peripheral nerve procedures for many years as partners with Raleigh Neurosurgical Clinic. Perhaps most compelling within the article is the genuine compassion and professional enjoyment that shines through in quotes and the powerful effect that has on boosting the patient confidence. “We are all great surgeons, but we are also great doctors; we don’t just operate with our hands, but with our hearts and brains, as well,” says Dr. Lacin. This month’s columnists personify brains with heart. Urogynecologist Catherine Matthews enlightens readers on the prevalence of fecal incontinence – the causes, the urgent need to develop better treatment options and the hope offered by a clinical trial now under way. Sandeep Vaishnavi explores the growing spectrum of autism disorders and

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Amanda Kanaan Catherine A. Matthews, M.D. Michael J. Thomas, M.D., Ph.D. Sandeep Vaishnavi, M.D., Ph.D. Photography Mark Jacoby Creative Director Joseph Dally

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promising cognitive neuroscience research. Readers of The Triangle Physician will remember the January cover story on Carolina Endocrine P.A., the practice of Michael Thomas. This month, Dr. Thomas returns with a comprehensive overview of the diagnosis and treatment of malignant and benign thyroid

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existing patients, who are an important referral source. Indeed, heart and soul are alive and well in the Triangle. So consider sharing instances where yours has shined through, either in a column or news release, which The Triangle Physician publishes at no charge to the contributor. Advertising also makes a lot of sense, with our highly competitive rates and exclusive coverage area. So if your marketing brains want to turn your practice message into referrals and clients, put The Triangle Physician’s brawn to work for you. Contact me at heidi@trianglephysician.com. With gratitude and respect for all you do,

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Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.


Cover

Rex Neurosurgery & Spine Specialists Rex Healthcare Expands Neurosurgical Services with a New Practice and Three of the Triangle’s Top Neurosurgeons Rex Healthcare has expanded its neu-

Grant Buttram Jr., M.D.; Robin Koeleveld,

patients with brain and spine cancers. “I

rological services with the addition of a

M.D.; and Robert Lacin, M.D., have been

really enjoy all aspects of general neuro-

new practice consisting of three of the

performing back, neck, cranial and pe-

surgery, but particularly like the challenge

Triangle’s top neurosurgeons. The newly

ripheral nerve procedures at Rex Hospital

of spine and brain tumor surgeries. In

established Rex Neurosurgery and Spine

for many years as partners with Raleigh

fact, one of my motivations in starting this

Specialists opened its doors this January,

Neurosurgical Clinic. Now as partners of

practice was the opportunity to perform

enhancing care for patients with routine

Rex Neurosurgery and Spine Specialists,

more brain tumor surgeries, in conjunc-

and complex spine problems, brain tu-

these leading neurosurgeons will have the

tion with both Rex Cancer Center and the

mors and other neurological ailments. Al-

unique ability to collaborate with the on-

UNC Department of Neurosurgery,” says

though the practice itself is new, the phy-

cologists at Rex Cancer Center, as well as

Dr. Koeleveld.

sicians share almost 50 years of combined

specialists at the University of North Caro-

experience and are well renowned in the

lina Department of Neurosurgery.

Dr. Buttram says working with cancer patients offers some of the most gratifying

region for offering the latest neurosurgical techniques combined with compassion-

The collaboration with Rex Cancer Cen-

experiences of his career. “I perform mis-

ate patient care.

ter will enhance treatments available for

sion work in Nicaragua and these patients, just like cancer patients, are so pleasant to work with, because they expect nothing yet appreciate everything.” By collaborating with Rex Cancer Center and the UNC Department of Neurosurgery, Rex Neurosurgery and Spine Specialists is able to provide more patients in Wake County and across Eastern North Carolina with greater access to comprehensive neuro-oncology treatments, novel therapies and clinical trials, including personalized, genetic medicine. “This partnership allows Rex Healthcare to expand the neuro-oncology services

Grant Buttram Jr., M.D., earned undergraduate degrees in animal science and chemistry, as well as a master’s degree in physiology from North Carolina State University. He graduated from East Carolina University School of Medicine and completed his internship, residency and fellowship at University of Tennessee at Memphis/Semmes-Murphey Neurologic & Spine Institute. Dr. Buttram completed a fellowship in complex and minimally invasive spine surgery, and his specialties include: general neurosurgery; brain, spine and spinal cord tumors; complex spine instrumentation; cervical and lumbar spine disease; minimally invasive spine techniques; peripheral nerve disorders; and scoliosis.

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The Triangle Physician

we provide by offering patients three disciplines – medical oncology, radiation oncology and neurosurgery – all in one location and without leaving Wake County,” says Linda Butler, M.D., chief medical officer of Rex Healthcare. The new practice


ed morbidity, i.e. a muscle-sparing technique versus muscle dissecting. Dr. Buttram, who completed a fellowship in complex and minimally invasive spine surgery at the renowned SemmesMurphey Neurologic and Spine Institute at University of Tennessee at Memphis, says there are many benefits to this technique. “Less muscle trauma means less blood loss, a lower risk of infection, less cost and a faster return to work for patients,” says Dr. Buttram, who trained under Dr. Kevin Foley – considered the pioneer of minimally invasive spine surgery. Robin Koeleveld, M.D., earned his undergraduate degree in chemistry from Harvard University. He graduated from the Columbia University College of Physicians and Surgeons and completed his internship and residency at Tufts-New England Medical Center. Dr. Koeleveld completed post graduate training in cervical, lumbar and thoracolumbar spine stabilization, and his specialties include: general neurosurgery, aneurysms, brain tumors and spine surgery.

Minimally invasive spine surgery differs from traditional, open spine surgery in that it only requires a small incision, muscle dilation and the use of microsurgi-

also now allows the hospital to provide

Dr. Koeleveld adds that each of the three

cal techniques to access, view and repair

the community with 24/7 neurosurgical

surgeons enjoys his specialty so much

spinal deterioration or damage. Muscle

coverage for emergency situations.

that patients take notice, and it actually

dilation involves the use of small tubular

becomes a source of comfort for them as

retractors that are inserted sequentially –

they recognize the passion each doctor

smaller to larger – through the muscle to

has for his craft.

gently and gradually separate, rather than

Skilled Surgeons, Compassionate Doctors Although it’s important to provide the pa-

cut or strip the muscles that surround the

tients of Wake County greater access to

Dr. Buttram says his practice philoso-

spine. The system’s retractor tubes main-

the latest in neurosurgical care, what re-

phy revolves around taking conservative

tain the opening while the surgeon uses

ally makes Rex Neurosurgery and Spine

measures to ensure patients only pursue

specially designed surgical tools to reach

Specialists unique are the surgeons them-

surgery if absolutely necessary – an ap-

and remove spinal elements that are caus-

selves. Each boasts an impressive resume

proach most surgeons aren’t known for.

ing pain.

with training from some of the top aca-

“I like to see people get better without

demic centers in the world. But ask any of

surgery if possible,” says Dr. Buttram, who

Minimally invasive spine surgery can be

them why they love what they do, and it

usually puts his patients through a series

utilized to treat chronic back and neck

all comes back to the patients. “We are all

of conservative therapies first before even

pain, and pain in the arms and legs as-

great surgeons, but we are also great doc-

considering surgery.

sociated with degenerative disc disease

tors; we don’t just operate with our hands,

and structural pathology. Unless it’s an

but with our hearts and brains, as well,”

From physical therapy, epidural steroid in-

extensively complex procedure, most

says Dr. Lacin, who believes that having

jections and traction to chiropractic treat-

spine conditions can be treated with

a close relationship with the patient and

ment and even acupuncture, Dr. Buttram

minimally invasive approaches, accord-

being able to counsel the family is part of

would rather see his patients try and fail

ing to Dr. Buttram.

what makes a great surgeon.

these initial therapies than head straight to surgery without being given another

Dr. Koeleveld seconds this notion: “These

option.

patients are among the most grateful and

Common Spine and Neurological Conditions The physicians at Rex Neurosurgery and

rewarding patients you can imagine. They

Minimally Invasive Spine Surgery

Spine Specialists treat more than 600

come to us very apprehensive and scared.

When most think of the phrase “minimally

forms of neurologic conditions that im-

We have the opportunity to counsel the

invasive,” they relate it to smaller surgical

pact patients in such ways as decreased

family and help them deal with the ill-

incisions. In this case, minimally invasive

mobility, difficulty speaking or learning or

ness.”

spine surgery refers to the approach-relat-

challenges with memory or mood.

April 2013

7


Neurological Conditions • Aneurysms • Carpal tunnel syndrome • Brain and pituitary tumors • Nerve disorders and injuries • Cerebral hemorrhage • Hydrocephalus • Radiculopathies • Trigeminal neuralgia • Vascular abnormalities of the brain

Spine Conditions • Disc disease • Neck and low back pain • Spinal cord tumors • Scoliosis • Vascular abnormalities of the spine Robert Lacin, M.D., graduated from the University of Lausanne Medical School in Switzerland. He completed his internship at St. Vincent’s Hospital in New York and residencies at Northwestern Memorial Hospital and Duke University Medical Center. Dr. Lacin completed fellowships at Lausanne Medical School and New York University Medical Center. His special interests include: general intracranial surgery; decompressive and reconstructive spine surgery; and decompressive and reparative peripheral nerve surgery.

The physicians at Rex Neurosurgery and Spine Specialists value their relationships with referring doctors and therefore are happy to accommodate patients that need to be worked into their schedules.

Some of these conditions can be difficult

• Reduced bladder control, or sexual dis-

“Anytime a physician needs a patient seen

to diagnose because they may present

turbance, associated with the above.

right away, they can just call us, and we’ll

as normal signs of aging. One condition

get them in either the same or next day,”

in particular that is sometimes misdiag-

Early diagnosis and treatment is important

nosed early on is cervical spondylotic my-

for CSM in order to help slow symptom

elopathy, or CSM.

progression. Cervical spine X-rays may

If the referral is of an urgent nature, Dr.

not provide enough information to con-

Lacin says he likes to involve the referring

CSM is the most common spinal cord dis-

firm CSM, but it may rule out other condi-

doctor. “I will personally call the referring

order in persons more than 55 years of

tions.

doctor if the patient has an urgent condi-

age in North America and perhaps in the

says Dr. Koeleveld.

tion to have them participate in the pa-

world. The aging process results in degen-

The best diagnostic test for CSM is mag-

erative changes in the cervical spine that,

netic resonance imaging, since they will

in advanced stages, can cause compres-

show the tight spinal canal and pinching

From minor procedures to more complex

sion of the spinal cord.

of the spinal cord. Surgery can be per-

spine surgeries and brain tumor resec-

formed to remove the pressure from the

tion, the physicians at Rex Neurosurgery

Signs of CSM:

spinal cord and prevent progression of

and Spine Specialists care for the full

• Deterioration of fine motor skills (such

symptoms.

range of patients’ needs by offering world-

as handwriting or buttoning a shirt). • Gait disturbance (bilateral uncertainty

tient’s care,” says Dr. Lacin.

class care close to home. “Because the symptoms of CSM can present so slowly or just seem like typical

Rex Neurosurgery and Spine Specialists

• Heavy feeling in the legs.

signs of aging, it’s important for patients to

is located at 4207 Lake Boone Trail, Suite

• Unable to walk at a brisk pace.

have an MRI early on, so the diagnosis is

220, across the street from the Rex Well-

• Feelings of numbness, tingling, pins

made as soon as possible and the symp-

ness Center on Lake Boone Trail in the

toms don’t progress,” says Dr. Koeleveld.

Rexwoods II building. To learn more, visit

when walking blindfolded).

and needles or shooting pain in the arms and/or legs when bending

www.rexneurosurgery.com. For referrals,

the head backward or far forward

To follow are other common conditions

(known as Lermitte’s phenomenon).

for which physicians refer to Rex Neurosurgery and Spine Specialists.

8

The Triangle Physician

call (919) 784-1410.


Community Service

STOMP the Monster

Local Non-Profit Takes Financial Burdens Off of Cancer Patients STOMP The Monster is a charitable organization providing financial and personal support for cancer patients, their families and caregivers when they need it most: during their battle with the disease. Recently, the motivated and dedicated group extended its great works to North Carolina. In October 2012, STOMP The Monster North Carolina was formed after chapter co-founder Susan Blumenthal, a physician’s assistant in a Cary oncology office, saw firsthand how easy it was for cancer patients to slip into financial distress. “I felt my patients had enough to deal with,” said Ms. Blumenthal. “To see them struggle with paying for medications – or worse, their family’s groceries – was just heartbreaking. Some didn’t have jobs or care for their children. They shouldn’t have those extra stresses while fighting the battle of their lives.” Working with her friend Andi Sawin, a founding board member of STOMP The Monster based out of New Jersey, Ms. Blumenthal brought the successful organization to the Triangle. STOMP The Monster was founded in 2010 by Seth Grumet of Marlboro, N.J., after he underwent his own treatment for Hodgkin’s Lymphoma. According to a press advisory, “when Mr. Grumet endured extensive testing, surgeries and chemo therapy, he saw

how quickly this monstrous disease could turn one’s world upside down. He was fortunate to have family and friends supporting him through this most difficult time, but he realized not every cancer patient is so fortunate. He saw so many struggling with financial and household hardship on top of their health issues.” Motivated by his 10-year-old daughter’s mantra to “stomp his cancer monster,” Mr. Grumet came up with a plan to raise money for these fellow cancer patients in need. Since then, STOMP The Monster of New Jersey and North Carolina has assisted 400-plus patients in five states with medical bills, prescriptions, utility bills, rent, gas, food, childcare, to name a few, anything that will help make their life easier. STOMP The Monster NC is a volunteeroperated organization that hosts events around the Triangle and seeks charitable contributions to fulfill local patient requests for assistance. All donations received stay in North Carolina and approximately 95 percent of the money raised goes directly to the patients. The advisory listed a few examples of how STOMP The Monster NC has helped North Carolinians: • K.F. is a 33 year old from Cary, N.C., with metastatic gastric cancer. She has been undergoing treatment for the past year

and is unable to work. She lives alone with support of her family but cannot pay all her bills. STOMP The Monster NC is paying her car and homeowners’ insurance for the next year to take away the stress of making those monthly payments. • R.B. from Garner, N.C., is 38 years old with colon cancer. He is a husband and father of three young children – one who was born during his second month of chemotherapy. Early in his treatment he was out of work, but he returned to work the night shift to help pay for his treatment and care for his family. STOMP The Monster NC paid off Mr. Brown’s medical bills and provided a holiday gift card to help make the season a little nicer for his family. • S.B. is a 54 year old from Raleigh, N.C., undergoing aggressive chemotherapy and radiation protocol for colon cancer. Both she and her husband are unemployed. She is fortunate to have COBRA insurance, but struggles with the premiums and additional medical expense from three hospitalizations and two surgeries. STOMP The Monster NC provided financial assistance to pay for her pathology bills, co-pays for radiological studies, and co-pays for her chemotherapy.

April 2013

9


Endocrinology

Incidence and Advances in Diagnosis and Treatment of

Thyroid Nodules The advent of numerous imaging techniques, including neck ultrasound, carotid Doppler and neck computed tomography or magnetic resonance imaging, has led to an increase in the incidental discovery of subclinical thyroid nodules that were not previously noted on physical examination. Thyroid nodules are quite common, and the incidence increases with increasing age. The risk of a thyroid nodule-containing cancer is approximately 5-15 percent, depending on age, gender, family history or a history of neck irradiation. Size and number of nodules do not seem to influence the risk of thyroid cancer in any single nodule, although other sonographic features, such as irregular borders or microcalcifications, can increase the risk of a nodule being malignant. Initial evaluation of thyroid nodule(s) should include measurement of serum TSH (thyrotropin/thyroid stimulating hormone) to determine whether a patient is hyperthyroid. A suppressed TSH usually indicates hyperthyroidism, which may be associated with an elevated free T4 (thyroxine) and/ or Free T3 (triiodothyronine). Hyperthyroid nodular thyroid disease occurs with toxic multinodular goiter or hyperfunctioning (toxic) adenoma, whereas non-hyperthyroid nodular disease may occur in nontoxic multinodular or uninodular goiter, or autoimmune (Hashimoto’s) thyroiditis. If a patient has hyperthyroidism, a nuclear medicine thyroid scan may be performed to confirm the presence of hyperfunctioning, or “hot,” nodules or photopenic, or “cold,” nodules. “Hot” nodules are rarely malignant, whereas a “cold” nodule on hyperthyroid nuclear medicine scan carries an approximate 20 percent chance of malignancy and should be evaluated by

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The Triangle Physician

fine needle aspiration (FNA) biopsy. Therapeutic options for toxic multinodular goiter and hyperfunctioning nodules include radioiodine (I-131) therapy, thyroidectomy or lifelong anti-thyroid drug therapy (e.g. methimazole). If a patient has a thyroid nodule and a normal or elevated TSH, then a FNA biopsy should be considered to see whether there is any evidence of malignancy. Thyroid nodules that are greater than 1 centimeter in size should be considered for FNA biopsy, whereas smaller nodules may be watched or biopsied, if they harbor any sonographic features worrisome for malignancy. FNA biopsy can be done under ultrasound guidance, particularly if the nodule is small. Three to four passes are often done, using a 25-27-gauge needle, and cellular aspirates are prepared on microscope slides or into saline solution for cytopathological analysis. The procedure usually takes less than 15 minutes, and complications are rare. FNA thyroid biopsy results usually fall into one of four broad categories: cancer; suspicious, e.g. follicular neoplasm; benign; or non-diagnostic. Patients with malignant thyroid nodules should undergo a total thyroidectomy, often with lymph node dissection, particularly if lymphadenopathy is noted on a pre-op ultrasound. Benign nodules may be followed sonographically to note whether there is any evolution or progression in size and may warrant re-biopsy, if a “false-negative” cytopathology result is suspected. Non-diagnostic FNA biopsies may be re-attempted. Suspicious nodules may need to be surgically removed for pathologic examination and definitive diagnosis, or some new molecular diagnostic tests (e.g. Veracyte Afirma, Asuragen mIRinformm) can further risk-stratify the

By Michael J. Thomas, M.D., Ph.D.

Dr. Michael Thomas of Carolina Endocrine P.A. graduated from the School of Medicine at West Virginia University in Morgantown, with a Doctor of Medicine and Doctor of Philosophy in pharmacology and toxicology. He completed his post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency, and fellowship in endocrinology. He was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. Dr. Thomas established Carolina Endocrine in the summer of 2005. He is board certified in internal medicine and endocrinology, and is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology (FACE) and has completed endocrine certification in neck ultrasound (ECNU). For more information and patient referrals and appointments call (919) 571-3661 or visit the practice website at carolinaendocrine.com

likelihood of malignancy vs. benign follicular lesions. Thyroid hormone suppressive therapy with levothyroxine may be considered, if the patient has any compressive symptoms (dysphagia, fullness, pressure) or cosmetic concerns, as long as the patient does not have a suppressed TSH. Levothyroxine dose is titrated upward to bring the TSH into the lower range of normal. Approximately, 50 percent of nodules may have some modest reduction in size (about 10-30 percent) over a period of several months, but therapy needs to be continued indefinitely or until the patient desires surgery. If the patient is asymptomatic, benign nodules may be monitored without therapeutic intervention.


Practice Marketing

Patient Communications

An Integral Part of Your Marketing Strategy By Amanda Kanaan

You may not traditionally think of patient communication tools such as blogs and e-newsletters as a marketing tactic, but staying top of mind with current patients is an integral part of attracting new business – not to mention it can also result in increased patient satisfaction. Doctors often tell me that one of their most fruitful sources of new patients is referrals from current patients. That means it’s important not to neglect your current patients when deciding where to spend your marketing dollars. The good news is that marketing to current patients is often the most costeffective form of marketing, because it can be achieved through strategies as simple as improved communications. Some examples of ways you can utilize these communications include: • Enhancing patient satisfaction by sending timely updates about early closings due to inclement weather, • Increasing repeat business by informing patients of other services your practice offers, or • Positioning yourself as the medical expert by sharing or commenting on recent health news and articles. To follow is a three-step process for communicating one message or article across three different channels to save time and costs when marketing to current patients. Step 1 – Write a Blog Post: I recommend that every practice incorporate a blog into their website. Most practices title their blog something along the lines of “News and Updates”

and will have their most recent posts listed on the homepage. It’s a quick and easy way to get a message to your patients, add fresh content to your site, feature services and even share educational articles. It’s also really good for your search engine optimization (SEO) efforts to enhance your Google rankings. The average blog should be about 400 words in order to get the full benefit from SEO. Read articles online to learn how to optimize your blog with proper keywords. Or you can always hire an SEO agency to do it for you. Step 2 - Social Media: Once you’ve written your blog news/ article, you can then post a link to the blog on your social media pages to act as a megaphone for announcing the message. Use social media to engage patients in the content and most importantly, get them talking about it. According to a Pew Internet Survey, 50 percent of all adults use social media; the fastest growing age segment of which is 50 to 64 years of age. This is one of your most affordable and effective tools to spread the word to your target audience. You can even ask your peers to post it as well. For instance, if you are an infertility clinic, ask the obstetrics clinics you’ve befriended on Facebook to post your blog link. Just be sure you’re willing to return the favor. Step 3 - E-Newsletter: So once you’ve written your blog and posted it on your social media channels, then the third step is to include it in an

Amanda Kanaan is the president of WhiteCoat Designs – a Raleigh-based medical marketing agency providing doctors with online marketing services as medical website design, search engine optimization (SEO), social media management, blog writing, graphic design, referring physician outreach and more. To contact Ms. Kanaan or to learn more about WhiteCoat Designs, visit www. whitecoat-designs.com.

e-newsletter to your patients. If you currently aren’t collecting e-mail addresses for patients, you should start. Email addresses are invaluable when it comes to using digital communications to stay top of mind with your patients. Not to mention, it’s something patients want. In fact, 65 percent of patients who use the Internet say they are willing to switch to a doctor using digital communications to engage them (Pew Internet Research Group, 2011). Using this three-step process, you can take just one piece of content and deliver it across various mediums to get the most impact for your efforts. While each of these methods is extremely inexpensive, I always caution practices against thinking they are free. There is definitely time involved to carry out this strategy, and we all know time is not free. However, as compared to relying on traditional snail mail, a digital approach is much more budget-friendly, time-sensitive and preferred by most patients.

April 2013

11


Urogynecology

New Treatment Is More Reason to Ask Women About

Bowel Control Problems By Catherine A. Matthews, M.D.

Accidental bowel leakage, or fecal incontinence, is a common but largely silent problem in women’s health. Embarrassment surrounding the condition and a lack of successful treatment options has limited public awareness and prevented patients and doctors from discussing the condition.

Forceps-assisted vaginal delivery is consistently identified as a major risk factor for anal sphincter injury, the muscle involved in voluntary bowel control. Many women who sustain a severe perineal laceration during vaginal childbirth may suffer from fecal urgency and accidental bowel leakage at a young age.

Recent general population surveys indicate the prevalence of fecal incontinence (FI) at 9 percent to 12 percent and in older women, as high as 24 percent.1,2,3 This translates into as many as 17 million women in the United States who are suffering from FI.

Women with irritable bowel syndrome (IBS) may also experience FI as one of the symptoms of their condition.

While traditionally thought of as a condition that only afflicts the elderly, perhaps the most surprising finding in recent studies is the high prevalence in younger women. The onset of symptoms often occurs in the 40s, 50s and 60s, and sometimes younger, with the average age of onset being 51. At any age, the condition is both physically limiting and emotionally devastating. Those afflicted are often forced to withdraw from social and professional activities and often face problems in their private personal relationships.

The damage that may lead to FI and other bowel control issues can involve the internal and external anal sphincters, pelvic floor muscles and associated nerves. Symptoms from damage sustained during childbirth may not manifest until later in life, when their emergence is possibly due to age-related changes in rectal sensation, compliance and volume, as well as general weakening of the sphincters and pelvic floor muscles. As the cause to FI is often complex and poorly understood, it has been difficult to develop effective treatments. Existing treatment options have had limited success, and include dietary modification with increased fiber, physical therapy, surgery and surgical device implants.

Cause and Treatment The causes of FI are likely multifactorial but are not completely understood. Many women with FI have a history of damage to the pelvic region caused by pregnancy and childbirth and additionally may have changes to the muscles in this area associated with aging.

12

The Triangle Physician

Dr. Catherine Matthews is an associate professor at University of North Carolina Department of Obstetrics and Gynecology and director of UNC Pelvic Health. She earned her medical degree from the University of Virginia, where she served as president of the medical honor society, Alpha Omega Alpha, and graduated valedictorian of her class. Dr. Matthews completed her residency and specialty training in obstetrics and gynecology and urogynecology at Virginia Commonwealth University Medical Center, where she served on the faculty from 2001-2010. Voted into “Best Doctors in America,� Dr. Matthews has dedicated her career to improving the quality of life for women who suffer from the potentially embarrassing conditions of urinary and bowel incontinence and pelvic organ prolapse. Dr. Matthews is nationally and internationally recognized for her expertise in robotic surgery for pelvic floor reconstruction and the repair of complicated genito-urinary fistulae. She also has an interest in the management of sexual dysfunction in postpartum women, anal sphincter repair and defecation disorders. For more informa-

Without good treatment options, many women with bowel control problems are resigned to coping with the condition in silence using products, such as pads and adult diapers.

tion visit www.UNCpelvichealth.org or call 919-966-2131.

New Investigational Option Recognizing the limitations of available treatments, I am a member of a select


group of physicians across the United States who are studying LivSure, a new intra-vaginal bowel control device developed for treating FI in women. It originated at Stanford University as part of a joint development effort between Stanford engineers and physicians.

April is Autism Awareness Month.

1 of every 70 North Carolina children will be diagnosed with a form of autism.

The investigational device is non-surgical and therefore avoids many of the risks and complications of more invasive treatments. Placed intra-vaginally, it resides in a similar position as a diaphragm. It consists of a flexible ring with an inflatable balloon that compresses the rectum through the vaginal wall. The device can easily be removed at any point, so patients can try the treatment as a first option with little long-term risk. Initial results from clinical evaluations have been promising. As overcoming social stigma regarding this distressing disease state is still an issue, improved efforts at disease identification are ongoing. Practitioners treating women with other pelvic floor disorders, namely urinary incontinence and pelvic organ prolapse, should be aware that fecal incontinence is a common comorbid medical condition. Many women may be too embarrassed to bring this to their health care provider’s attention, therefore routinely inquiring about it as a specific entity is paramount.

The Autism Society of North Carolina is your partner in improving patient care by providing training workshops for medical professionals. For more information, please visit www.autismsociety-nc.org or call 919-743-0204, ext. 1501.

Partnering with patients and providers for a healthier community.

References  harucha et al. Prevalence and B burden of fecal incontinence: a population-based study in women. Gastroenterology 2005;129:42-49. 2 Varma et al. Fecal incontinence in females older than aged 40 years: who is at risk? Dis Colon Rectum. 2006 June; 49(6): 841-851. 3 Nygaard et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008; 300(11):13111316. 1

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The Triangle Physician


Neuropsychiatry

Autism Awareness Is Needed to Help Remedy Public Misconceptions By Sandeep Vaishnavi, M.D., Ph.D.

Autism is a neurodevelopmental disorder of increasing interest to the public, partly because of rising numbers. There has been a steady increase in the estimated prevalence of autism, now up to one out of every 88 live births in the United States. There is controversy as to whether this is truly an increase in the disease, or rather, if this is reflective of better surveillance or perhaps more liberal diagnostic criteria. Autism can be thought of as a spectrum of disorders, as opposed to a unitary disorder. There has been recent controversy with the upcoming publication of the updated Diagnostics and Statistics Manual (DSM-V), because Asperger’s Syndrome will be incorporated into the autism diagnosis. Currently, Asperger’s is listed separately. The updated DSM will reflect the current consensus in the field, which is that autism symptoms range from mild (like with Asperger’s) to severe, with intellectual disability and seizures. Autism spectrum disorders tend to have three core constellations of symptoms: dysfunction with social cognition, language abnormalities and repetitive thoughts and behaviors. Autism may be thought of at the most fundamental level as a disorder of social cognition. There is often poor eye contact, little interest in socializing with peers and more interest with things and machines than with people. Language difficulties are also part of autism spectrum disorders. People with severe autism may not develop language

at all. Those that do develop language may speak in a monotonous, robotic way. There is little inflection or prosody. Even mild autistic patients may have problems with the pragmatics of language, the social communication that language facilitates. For example, they may not evidence any interest in the thoughts or interests of others. They may tend to talk too much about particular interests of their own and not know when to stop talking. Finally, autism spectrum disorder patients may have repetitive thoughts and behaviors. They may have motor stereotyped behavior, such as toe walking, hand flapping or head banging. They may be preoccupied with narrow interests, such as train or plane schedules, or World Series statistics. Autistic patients may have an “obsessive need for sameness,” such that they cannot tolerate very well any deviation from their established routine. Mood and anxiety symptoms are quite commonly comorbid. Obsessive and compulsive symptoms are, as we have seen, often a key component of autism. These symptoms are amenable to treatment with medications. The core symptom of social cognitive dysfunction, though, is not treatable at this time. However, there are promising studies with oxytocin and arbaclofen for this core feature of autism. There is data that early intervention with intensive therapies can be helpful in modifying the severity or trajectory of the illness.

Dr. Sandeep Vaishnavi is the director of the Neuropsychiatric Clinic at Carolina Partners. He has been trained at Johns Hopkins and Duke Universities and is board certified in behavioral neurology and neuropsychiatry, as well as general psychiatry. His doctorate is in cognitive science, with specialization in cognitive neuroscience. For more information, visit www.carolinapartners.com or call (919) 929-9610 or (877) 876- 3783 toll free.

To diagnose autistic spectrum disorders properly, it may be helpful to refer to specialists, like neuropsychiatrists, who have training in aspects of both neurology and psychiatry. They can help in consulting for medication management as well. In some cases, agitation and aggression can be part of the clinical picture and so consultation for management can be helpful in those cases. General psychiatrists and neurologists also can help with diagnosis and management. There is much research on the neurodevelopmental basis of autism. Social cognition is a relatively new area of cognitive neuroscience research, and much needs to be learned about how our brains allow us to generally interact with others in a fluid, engaging way. Hopefully, this research will allow us soon to provide more help for the core symptoms of our autistic patients.

April 2013

15


Duke Research News

Bullied Children Can Suffer Lasting Psychological Harm as Adults Bullied children grow into adults who are

A previous longitudinal study of bullied chil-

ed being bullied at least once; 887 said

at increased risk of developing anxiety dis-

dren, conducted in Finland, found mixed

they suffered no such abuse. Boys and

orders, depression and suicidal thoughts,

results, concluding that boys had few lasting

girls reported incidents at about the same

according to a study led by researchers at

problems, while girls suffered more long-

rate. Nearly 200 youngsters, or 9.5 percent,

Duke Medicine.

term psychological harm. That study, how-

acknowledged bullying others; 112 were

ever, relied on registry data in the health

bullies only, while 86 were both bullies and

The findings, based on more than 20 years

system that didn’t fully capture psychiatric

victims.

of data from a large group of participants ini-

records. Of the original 1,420 children, more than

tially enrolled as adolescents, are the most definitive to date in establishing the long-

Dr. Copeland and colleagues had a much

1,270 were followed up into adulthood.

term psychological effects of bullying.

richer data set. Using the Great Smoky

The subsequent interviews included ques-

Mountain Study, the research team tapped

tions about the participants’ psychological

Published online Feb. 20 in JAMA Psychia-

a population-based sample of 1,420 chil-

health.

try, the study belies a common perception

dren ages 9, 11 and 13 from 11 counties in

that bullying, while hurtful, inflicts a fleeting

western North Carolina. Initially enrolled in

As adults, those who said they had been

injury that victims outgrow.

1993, the children and their parents or care-

bullied, plus those who were both victims

givers were interviewed annually until the

and aggressors, were at higher risk for psy-

“We were surprised at how profoundly bully-

youngsters turned 16, and then periodically

chiatric disorders compared with those

ing affects a person’s long-term functioning,”

thereafter.

with no history of being bullied. The young people who were only victims had higher

said William E. Copeland, Ph.D., assistant clinical professor in the Department of Psychiatry

At each assessment until age 16, the child

levels of depressive disorders, anxiety dis-

and Behavioral Sciences at Duke University

and caregiver were asked, among other

orders, generalized anxiety, panic disorder

and lead author of the study. “This psycho-

things, whether the child had been bullied

and agoraphobia.

logical damage doesn’t just go away because

or teased or had bullied others in the three

a person grew up and is no longer bullied.

months immediately prior to the interview.

Those who were both bullies and victims had higher levels of all anxiety and depres-

This is something that stays with them. If we can address this now, we can prevent a whole

A total of 421 child or adolescent partici-

sive disorders, plus the highest levels of

host of problems down the road.”

pants – 26 percent of the children - report-

suicidal thoughts, depressive disorders,

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16

The Triangle Physician


Duke Research News generalized anxiety and panic disorder.

Jane Costello, Ph.D., associate director of re-

In addition to Drs. Costello and Copeland,

Bullies were also at increased risk for anti-

search at Duke’s Center for Child and Family

study authors include Adrian Angold, M.D.,

social personality disorder.

Policy. “Bullying, which we tend to think of

of Duke and Dieter Wolke, Dipl.-Psych.,

as a normal and not terribly important part

Ph.D., of the University of Warwick, Coven-

The researchers were able to sort out con-

of childhood, turns out to have the potential

try, England.

founding factors that might have contrib-

for very serious consequences for children,

uted to psychiatric disorders, including pov-

adolescents and adults.”

The work received support from the National Institute of Mental Health (MH63970,

erty, abuse and an unstable or dysfunctional home life.

Drs. Costello and Copeland said they would

MH63671, and MH48085); the National In-

continue their analysis, with future studies

stitute on Drug Abuse (DA/MH11301); the

“Bullying is potentially a problem for bullies

exploring the role sexual orientation plays

Brain and Behavior Research Foundation;

as well as for victims,” said senior author E.

in bullying and victimization.

and the William T. Grant Foundation.

Growth Factor Aids Stem Cell Regeneration After Radiation Damage Epidermal growth factor has been found to

regeneration after injury could benefit pa-

plants. One group received regular bone

speed the recovery of blood-making stem

tients who are undergoing bone marrow

marrow cells; a second group got bone

cells after exposure to radiation, according

transplantation, plus others who suffer

marrow cells from donors that had been

to Duke Medicine researchers. The finding

radiation injury from accidental environ-

irradiated and treated with EGF; a third

could open new options for treating can-

mental exposures, such as the Japanese

group got bone marrow cells from irradi-

cer patients and victims of dirty bombs or

nuclear disaster in 2011.

ated donors treated with saline.

nuclear disasters. The Duke researchers launched their inves-

The regular bone marrow cells prolifer-

Reported in the Feb. 3 issue of the journal

tigation using mice specially bred with de-

ated well and had the highest rate of en-

Nature Medicine, the researchers explored

letions of two genes that regulate the death

graftment in the recipient mice. But mice

what had first appeared to be an anomaly

of endothelial cells, which line the inner

that were transplanted with the cells from

among certain genetically modified mice

surface of blood vessels and are thought

irradiated/EGF-treated donors had 20-fold

with an abundance of epidermal growth

to regulate the fate of hematopoietic stem

higher engraftment rate than the third

factor in their bone marrow. The mice were

cells. Blood vessels and the hematopoietic

group.

protected from radiation damage, and the

system in these mice were less damaged

researchers questioned how this occurred.

when exposed to high doses of radiation,

Additional studies showed that EGF im-

improving their survival.

proved survival from a lethal radiation exposure, with 93 percent of mice surviving

“Epidermal growth factor was not known to stimulate hematopoiesis, which is the

An analysis of secretions from bone mar-

the radiation dose if they subsequently

formation of blood components derived

row endothelial cells of the protected

received treatment with EGF, compared to

from hematopoietic stem cells,” said se-

mice showed that epidermal growth factor

53 percent surviving after treatment with a

nior author John Chute, M.D., a professor

(EGF) was significantly elevated - up to 18-

saline solution.

of medicine and professor of pharmacol-

fold higher than what was found in the se-

ogy and cancer biology at Duke University.

rum of control mice. The researchers then

Dr. Chute said it appears that EGF works

“However, our studies demonstrate that

tested whether EGF could directly spur

by repressing a protein called PUMA that

the epidermal growth promotes hemato-

the growth of stem cells in irradiated bone

normally triggers stem cell death following

poietic stem cell growth and regeneration

marrow cultured in the lab. It did, with sig-

radiation exposure.

after injury.”

nificant recovery of stem cells capable of “We are just beginning to understand the

repopulating transplanted mice.

mechanisms through which EGF promotes

Hematopoietic stem cells, which constantly churn out new blood and immune cells,

Next, the Duke team tried the approach in

stem cell regeneration after radiation in-

are highly sensitive to radiation damage.

mice using three different solutions of cells

jury,” Dr. Chute said. “This study suggests

Protecting these cells or improving their

in animals undergoing bone marrow trans-

that EGF might have potential to acceler-

April 2013

17


Duke Research News ate the recovery of the blood system in

burg, Katherine Helms, J. Lauren Russell,

Heart, Lung and Blood Institute (HL-

patients treated with chemotherapy or ra-

Emma Fixsen, Mamle Quarmyne, Jeffrey R.

086998-01); the National Institute of Allergy

diation.”

Harris, Divino Deoliviera, Julie M. Sullivan,

and Infectious Diseases (AI-067798-06, AI-

Nelson J. Chao and David G. Kirsch.

067798-01); the National Institutes of Health

The study was funded by the National

Award; and Duke University.

(T32 HL0070757-33); the Barton Haynes

In addition to Dr. Chute, study authors include Phuong L. Doan, Heather A. Him-

Obesity in Dads May Be Associated with Offspring’s Risk of Disease A father’s obesity is one factor that may in-

Decreased DNA methylation at the IGF2

The researchers noted that the changes in

fluence his children’s health and potentially

gene has been associated with an in-

DNA methylation could have been a result

raise their risk for diseases like cancer, ac-

creased risk of developing certain cancers,

of something related to obesity, such as

cording to new research from Duke Medicine.

including colorectal and ovarian cancers.

eating a certain diet or having diabetes that

The study, which appears Feb. 6 in the jour-

“Our genes are able to adapt to our envi-

nal BMC Medicine, is the first in humans

ronment. However, we adjust in a way that

Additional research is under way to see if

to show that paternal obesity may alter a

may be problematic later,” said Cathrine

these changes in DNA methylation at the

genetic mechanism in the next generation,

Hoyo, Ph.D., M.P.H., a cancer epidemiolo-

IGF2 gene remain as the children grow

suggesting that a father’s lifestyle factors

gist at Duke Medicine and the study’s se-

older. Future studies may also determine

may be transmitted to his children.

nior author. “It is not a change in the se-

if certain interventions – similar to women

quence of the DNA itself, but how genes

taking folic acid while pregnant to prevent

“Understanding the risks of the current

are expressed. Some genes may get ‘shut

birth defects – can be used prior to or after

Western lifestyle on future generations is

off’ as a result of environmental trauma.”

conception to prevent irregular methyla-

was not measured in this study.

tion profiles.

important,” said molecular biologist Adelheid Soubry, Ph.D., a postdoctoral associ-

To gather data on newborn health out-

ate at Duke Cancer Institute and the study’s

comes, the researchers followed families

“This study is an important start in looking

lead author. “The aim of this study was to

enrolled in the Newborn Epigenetics Study

at the effects of environmental exposure on

determine potential associations between

(NEST), a research program developed by

children, not only through the mother but

obesity in parents prior to conception and

Dr. Hoyo and funded by the National Insti-

also through the father,” said Dr. Soubry.

epigenetic profiles in offspring, particularly

tutes of Health to test the influence of en-

“Although we cannot define at this point

at certain gene regulatory regions.”

vironmental exposures on genetic profiles

which obesity-related factor may cause

in newborns.

an epigenetic effect, we measured in this study a significant association between

Researchers looking at health outcomes in newborns have historically focused on

Researchers gathered information about

paternal obesity and aberrant methylation

pregnant women. Studies have shown that

the mothers and fathers using question-

profiles in the offspring.”

nutrition and environmental factors during

naires and medical records. They then

pregnancy can affect children’s health and

examined DNA from the umbilical cords

In addition to Drs. Soubry and Hoyo, study

may raise their risk of chronic diseases.

of 79 newborns to determine potential as-

authors include Joellen M. Schildkraut,

However, little has been done to uncover

sociations between the offspring’s DNA

Amy Murtha, Frances Wang, Zhiqing

how paternal factors can affect children.

methylation patterns and parental obesity

Huang, Autumn Bernal, Joanne Kurtzberg,

before conception.

Randy L. Jirtle, and Susan K. Murphy.

mine associations between obesity in par-

DNA methylation at the IGF2 gene in the

The study was supported by National Insti-

ents and changes in DNA methylation at

offspring of obese fathers was significantly

tutes of Health (R21ES014947, R01ES016772,

the insulin-like growth factor 2 (IGF2) gene

lower than in the children of fathers who

R01DK085173, R25CA126938-01A2), the

among offspring. DNA methylation regu-

were not obese. This suggests that paternal

American Cancer Society (ACS-IRG 83-

lates the activity of certain genes, which

obesity may be associated with an increased

006), Fulbright and the Fred and Alice

can reflect a higher risk for some diseases.

risk of children developing certain cancers.

Stanback Foundation.

The Duke research team sought to deter-

18

The Triangle Physician


UNC Research News

Research Needed on Interventions for Children Exposed to Traumatic Events About two of every three children will

study that met the criteria for inclusion in

ply don’t have much of an evidence base

experience at least one traumatic event

the review. Only a few psychotherapeu-

to be able to recommend best treatment

before they turn 18. Despite this high rate

tic treatments showed possible benefits

practices.”

of exposure, little is known about the effec-

for children exposed to

tiveness of treatments aimed at preventing

trauma. The most prom-

“These findings serve as a call to action:

and relieving traumatic stress symptoms

ising interventions were

psychotherapeutic intervention can provide

that children may experience after such

school-based

psycho-

some benefit to children exposed to trau-

therapy interventions that

matic events, but far more research is need-

included cognitive behav-

ed to make definitive conclusions,” said

ior therapy. These inter-

Adam J. Zolotor, M.D., M.P.H., a family physi-

idence-based Practice Center and Boston

ventions were associated with changes in

cian at the University of North Carolina and

Medical Center.

symptoms of post-traumatic stress, anxiety,

a co-author of the review. “Because trauma

events, according to researchers at RTI International, the University of North Carolina School of Medicine, the RTI-UNC Ev-

Adam J. Zolotor, M.D., M.P.H.

depression and anger.

is a common and costly source of child-

The article, published today in the journal

The review did not find

hood psychological distress, it is critical to

Pediatrics, summarizes the results of a sys-

evidence of effectiveness

understand effective forms of treatment.”

tematic review of clinical interventions for

for any of the pharmacologic interventions.

children under age 18 exposed to at least one traumatic event, such as an accident,

Valerie FormanHoffman, Ph.D.

The authors recommend immediate attention from funding agencies, clinicians, re-

“The current body of

searchers, policymakers and other public

or political instability. Child abuse and ne-

evidence provides only a little insight into

health authorities to support further, well-

glect were not included in this research;

best practices in treating children exposed

designed research that can broaden the ev-

a separate review covers interventions for

to trauma, some of whom already have

idence base. They suggest that future stud-

these types of traumas. The United States

symptoms,” said Valerie Forman-Hoffman,

ies expand their examination of the impact

Agency for Healthcare Research and Qual-

Ph.D., a research epidemiologist at RTI

of trauma interventions to a wider range of

ity funded the review.

International and lead author of the study.

outcomes, such as risk-taking behaviors

“This is particularly discouraging given re-

and suicidality and focus on longer-term

After reviewing 6,647 abstracts, the inves-

cent shootings at schools and other places

indicators of development and functioning.

tigators found 21 trials and one cohort

where children have been victims. We sim-

natural disaster, community violence, war

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february/march 2013

19


UNC Research News

Steroids Help Reverse Process Involved in Rapid Bone Loss New research in animals triggered by a

process. A report of the new findings ap-

M.D., assistant professor in the departments

combination of serendipity and counterin-

pears online Feb. 5 in the journal PLOS ONE.

of Medicine and Cell Biology and Physiol-

tuitive thinking could point the way to treat-

ogy at UNC.

ing fractures caused by rapid bone loss in

Osteoporosis, or the loss of bone mass, is

people, including patients with metastatic

a major public health problem in the west-

“While little is known about the biology of

cancers.

ern world and commonly results in hip and

rib fractures, we have identified a molecu-

spine fractures. “But rib fractures are the

lar mechanism that could have important

A series of studies at the University of North

most common and yet most unreported os-

implications for the treatment of fractures

Carolina School of Medicine found that ste-

teoporotic fractures and also occur in many

in cancers and other conditions often asso-

roid drugs, known for inducing bone loss

cancers, such as breast cancer, malignant

ciated with rapid bone loss,” said Dr. Deb,

with prolonged use, actually help suppress

melanoma and myelomas that metastasize

who also is a member of UNC’s McAllister

a molecule that’s key to the rapid bone-loss

and spread to the ribs,” said Arjun Deb,

Heart Institute and Lineberger Comprehensive Cancer Center. The UNC researcher indicated that his lab arrived at the study “via serendipity.” From stromal cells of adult mice, they had deleted a gene called beta catenin. These cells, also known as fibroblasts, form the connective tissue of almost all organs in the body. The Deb lab was working on the molecular regulation of these cells. But something “amazing” occurred, Dr. Deb said. Following beta catenin deletion, the mice died within three weeks. The researchers looked at the functioning of every organ – heart, kidney, lung, spleen – wherever this gene could possibly be expressed. All appeared normal, except lung function. “With just a whiff of anesthesia, their blood oxygen saturation dropped precipitously. This was a first clue of a problem in the respiratory system of these animals.” But the lungs looked absolutely fine under the microscope. Dr. Deb then turned to UNC’s Department of Physics and Astronomy, which had developed a novel contactless fiber-optic displacement sensor for monitoring respiration during mouse computed tomography scans. In association with the department of radiology and the Biomedical Research Imaging Center at UNC, three-dimensional

20

The Triangle Physician


lung reconstruction revealed profound lung

vived,” Dr. Deb said. “And after 80 days,

“From that perspective, these studies are

collapse on one or both sides.

we saw that the ribs showed evidence of

interesting and challenge the existing para-

repair; they were able to form new bone.

digm that steroids are drugs that cause

This was a puzzle. “How can an animal

And when we looked at new CT lung scans,

bone loss. They do, but in rapid bone loss

with normal lung tissue under a micro-

the lungs were expanded and the ribs con-

from aggressive osteoclast overactivity, ste-

scope have lung collapse and respiratory

tained far less numbers of osteoclasts.”

roids may be helpful. That’s the principle

problems?” Dr. Deb wondered whether the chest wall could be the culprit.

message of this story.” As to mechanism, Dr. Deb said that a molecule in bone called rank ligand (RANKL)

Study co-authors were JinZhu Duan, Yueh

CT scans of the chest wall in these animals

is important for osteoclast formation. “We

Lee, Corey Jania, Jucheng Gong, Mauricio Ro-

revealed multiple spontaneous fractures af-

found that steroids were suppressing

jas, Laurel Burk, Monte Willis, Jonathon Ho-

fecting multiple ribs. The affected ribs had

RANKL to the extent that RANKL levels in

meister, Stephen Tilley and Janet Rubin. The

60-70 percent less bone compared to nor-

these animals were the same as healthy

study was funded by the National Institutes of

mal ribs. Essentially the bony rib cage had

animals.”

Health and the Ellison Medical Foundation.

disappeared within three weeks, said Dr. Deb, and he immediately realized that the animals were dying from respiratory failure because the frail chest wall was unable to support respiration. Bone mass is usually maintained by a close functional coupling of osteoblasts (cells that form bone) and osteoclasts (cells that resorb bone). The study team found a huge infiltration of osteoclasts into the animals’ ribs. Other bones, including the spine and femur, also showed some resorption but not as dramatic as in the ribs. And when drugs, such as bisphosphonates, commonly used to preserve bone mass in humans were given to the animals, their survival was prolonged only briefly. This led the study team to think that the osteoclast formation was so aggressive that the body was unable to form new bone to keep pace with the bone loss. In conditions such as rheumatoid arthritis and other problems involving inflammation, many types of inflammatory cells promote bone resorption, which led the researchers to see if treatment with corticosteroids might be helpful in these animals. And it was: a 30-40 percent increase in bone mass, compared to animals that did not get steroids. They also found 60-70 percent of the ribs were preserved. “Notably, 75 percent of the animals surWomens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

April 2013

21


UNC Research News

Promising Stem Cell Blood Test May Be a Sight-Saving Breakthrough A study led by researchers at the Univer-

ing of this event, we have no way of prevent-

ARCA, a new technology capable of mea-

sity of North Carolina is the foundation for

ing it,” Dr. Chavala said.

suring rare cell populations reliably, was better suited as a diagnostic blood test. This

a promising new blood test to detect the Currently, no test is available to predict the

technology is currently being used in clini-

more serious form, which can lead to blind-

conversion from dry to wet ARMD. How-

cal practice for cancer patients, so the tech-

ness.

ever, a paper by the study authors and

nology can be readily adopted for macular

published online Jan. 24 in the journal

degeneration patients.

progression of macular degeneration to its

Age-related macular degeneration (ARMD)

PLOS ONE describes how it could be ac-

is the most common cause of central vision

complished.

The study compared traditional FACS and ARCA in 23 subjects with age-related mac-

loss in the western world, according to a press advisory. Those affected by macular

The ability to predict the conversion from

ular degeneration, both dry and wet. The

degeneration find many daily activities,

dry to wet age-related macular degenera-

samples were “masked” so that no one

such as driving, reading and watching tele-

tion is one of the most coveted achieve-

involved in the sample assessments at the

vision, increasingly difficult.

ments in vision science, according to Dr.

two labs where the analyses were done

Chavala. “A clinical test that predicts im-

knew the type of macular degeneration the

In the United States as many as 11 million

pending conversion is the first step in de-

patients had.

Americans have some form of macular de-

veloping treatments to prevent the switch to

generation, including both early and later

wet macular degeneration.”

“We found a promising trend favoring the ARCA technology in detecting a higher

stages of the “dry” and wet” forms. The eye condition deteriorates the macula, the cen-

In the study, the researchers used the Cell

number of EPCs in the wet macular degen-

tral area of the retina, causing blind spots

Search system, an FDA-approved technolo-

eration group compared to the dry. And

and blurred or distorted vision.

gy for automated rare cell analysis (ARCA),

that trend was not observed with traditional

which Dr. Chavala and colleagues applied

FACS,” Dr. Chavala said. “We were sur-

“People with macular de-

to the identification and analysis of endo-

prised that we needed to analyze relatively

generation start out with

thelial progenitor cells (EPCs).

few patients to detect this trend.”

can detect with a simple

These cell types are rare compared to other

“Our ‘proof of concept study’ suggests that

dilated eye exam,” said

blood cells. EPCs are a stem cell subset that

the ARCA technology could be a powerful

Sai H. Chavala, M.D., di-

gives rise to the endothelium found in the

tool for monitoring progression in macular

the dry type, which we

Sai H. Chavala, M.D.

rector of the Laboratory

inner lining of blood vessels. EPCs are liber-

degeneration. Further study is required to

for Retinal Rehabilitation and assistant pro-

ated from the bone marrow and circulate

validate this test for detecting and prevent-

fessor of ophthalmology and cell biology

in the blood in response to signals for new

ing the conversion from dry to wet macular

and physiology at the UNC School of Medi-

blood vessel growth.

degeneration.

Previous studies using fluorescence activat-

“The next step is to do a prospective study

cine. Dr. Chavala practices at the Kittner Eye Center at UNC Health Care in Chapel

ed cell sorting (FACS), or flow cytometry,

in a greater number of subjects having the

have demonstrated that EPCs are elevated

known criteria that puts them at higher risk

“But about 20 percent of patients at some

in patients with wet macular degeneration

of progressing from dry to wet macular de-

time in their life will develop wet macular

compared to patients with the dry type.

generation,” Dr. Chavala said.”

degeneration, which is characterized by

However, FACS measurements are subject

blood vessels that grow under the surface

to substantial variability between observ-

Co-authors include lead author Emil An-

of the retina. These abnormal vessels can

ers, along with an element of subjectivity

thony T. Say, M.D., at UNC Kittner Eye

leak blood and fluid, which causes irre-

when measuring rare cell populations chal-

Center; Alex Melamud, M.D., Retina Group

versible damage to the cells of the retina

lenging its clinical use.

of Washington, Washington, D.C.; Denise

Hill and New Bern.

Ann Esserman, Ph.D., UNC Gillings School

leading to irreversible vision loss. Since we don’t have a way to predict the precise tim-

22

The Triangle Physician

Dr. Chavala and colleagues thought that

of Global Public Health; and Thomas J.


UNC Research News Povsic, M.D., Ph.D., Duke University Medi-

Foundation, Hope for Vision and Research

a patent surrounding this technology and is

cal Center in Durham.

to Prevent Blindness grants.

founder of Serrata L.L.C., a company that plans to market diagnostic testing for ocular

Support for the study came from the Adler

Disclosure Statement: Dr. Chavala has filed

disease.

New Chemical Probe Is Tool to Study Malignant Brain Tumor Domains development, especially in the case of cancer.

tary, Dr. Frye outlined the qualities that make

While many chemical probes work through

a good chemical probe. To Dr. Frye, a good

the inhibition of enzyme activity, L3MBTL3

chemical probe must be highly selective to

functions as a mediator of protein-to-protein

enable specific questions to be asked and it

interactions, which have been historically

must function as well in a cell as in the test

difficult to target with small, drug-like mol-

tube, providing clear quantitative data with a

ecules. The researchers found three to four

well-understood mechanism of action in ei-

further disease subtypes within TN tumors,

ther situation. It also must be available to all

with more than 75 percent of the tumors fall-

academic researchers without restrictions on

ing into the basal-like subtype.

its use. The Frye lab fulfills this criterion with its commitment to provide researchers with

The chemical probe UNC1215 will be used to investigate the function of malignant brain tumor (MBT) domain protein, L3MBTL3, and study its role in different signaling pathways and disease.

In an article published as the cover story

Further research is needed to identify the distinct biomarkers shared by the expanded

UNC1215 is already available through com-

subtypes of TN cancers. The ultimate goal will

mercial vendors, as well.

be to target the individual biomarkers of these subtypes and create therapies that target their individual biology, according to Dr. Perou.

This research was supported by National Institutes of Health grants (RC1GM090732 and R01GM100919) and the University Cancer Re-

of the March 2013 issue of Nature Chemical Biology, Lindsey James, Ph.D., research as-

“Many people believe that protein-protein

sistant professor in the lab of Stephen Frye,

interactions are difficult to target. Often they

Fred Eshelman distinguished professor in

have a large surface area, so it is hard for

the UNC School of Pharmacy and member of

small molecules to go in and intervene,” said

the UNC Lineberger Comprehensive Cancer

Dr. James.

Center, announced the discovery of a chemical probe that can be used to investigate

Almost 40 percent of the genes that drive

the L3MBTL3 methyl-lysine reader domain.

cancer can be mapped to dysfunction with-

The probe, named UNC1215, will provide re-

in signaling pathways. In the last five years,

searchers with a powerful tool to investigate

chemical probe development has allowed

the function of malignant brain tumor (MBT)

researchers to make fundamental observa-

domain proteins in biology and disease.

tions of the role of these pathways in cancer development, as well as pointing to potential

“Before this there were no known chemical

targets for new therapies. Each of the com-

probes for the more than 200 domains in the

plex interactions within the signaling path-

human genome that recognize methyl lysine.

ways represents a potential point where a

In that regard, it is a first-in-class compound.

therapy can be applied, and the probes allow

The goal is to use the chemical probe to un-

researchers to interact with these processes

derstand the biology of the proteins that it

at the molecular level and observe the over-

targets,” said Dr. James.

all effect of their perturbation on the disease state.

Chromatin regulatory pathways play a fundamental role in gene expression and disease

the L3MBTL3 probe free of charge on request.

In a 2008 Nature Chemical Biology commen

search Fund.

Vascular Access Center of Durham invites you to join us for our Open House Celebration! Date: Thursday, April 4, 2013 Time: 5:30pm – 7:30pm Location: 3624 Shannon Road, Suite 104

Please join us for wine & hors d’oeuvres as we welcome our new Medical Director, Dr. Harold Tate, MD. We look forward to seeing you there! Please RSVP by March 28th to:

Diane Beaudet dbeaudet@vascularcenters.com 919.943.1617 April 2013

23


News

Carolina Endocrine Open House

Welcome to the Area

Physicians

Michael Allen Evans, MD

Sarah Elisabeth Haley-Wien, DO

Johnston Memorial Hospital Smithfield

Emergency Medicine

FirstHealth Pinehurst

Michael Christopher Moore, DO Family Medicine; Urgent Care

Cary

Melanie Frances Barrett, MD Psychiatry

University of North Carolina Hospitals Chapel Hill

John Berry VII, MD Anesthesiology

University of North Carolina Hospitals Chapel Hill

Yijun Chen, MD Abdominal Surgery; Surgery

Duke Weigh Loss Surgery Center Durham

Emergency Medicine

Jonathon Porter Heath, MD Internal Medicine; Pediatrics

University of North Carolina Hospitals Chapel Hill

Pablo Fernando RecinosChavarria, MD Neurological Surgery, Pediatric

UNC Dept of Neurosurgery Chapel Hill

Mary Joyce Rico, MD Dermatology

Durham

Pinehurst

Raleigh Skin Surgery Center Raleigh

LaKesha Nicole Legree, MD

Lois Onkoba Wilkinson, MD

Scott David Long, PA

General Practice

Family Medicine; Geriatric Medicine; Internal Medicine; Occupational Medicine; Pediatrics; Preventive Medicine/Occupational; Emergency Medicine; Urgent Care

Anesthesiology

Durham

Charles Patrick McCormick, MD Internal Medicine; Psychiatry

Duke University Hospitals Durham

Knightdale

Jeanie Wang Yen, MD Physical Medicine and Rehabilitation

University of North Carolina Hospitals Chapel Hill

Dhipthi Mulligan, MD Psychiatry

Brittany Anne Davidson, MD

Duke University Hospitals Durham

Gynecology; Obstetrics

Atrium ObGyn Raleigh

24

The Triangle Physician

Kelly Elizabeth Jernigan, PA

University of North Carolina Hospitals Chapel Hill

Daniel Seoyjong Oh, MD

Philip Thiem Deibel, MD

Wilson Surgical Associates, P.A. Wilson

Child and Adolescent Psychiatry

Kelly Lynn Bombach, PA

Duke University Dept OB/GYN, Div GYN-Oncology Durham

Ruth Hinkle Huffman, PA

Internal Medicine; Nephrology

UNC Chapel Hill Gynecology/Oncology; Obstetrics and Gynecology - Critical Care Medicine

FastMed Urgent Care Clayton

Bryan Dorsey Smith, MD

Physician Assistants

Obstetrics & Gynecology - Endocrinology/ Infertility; Obstetrics and Gynecology

Family Practice; Urgent Care; Family Medicine

Lindsay Anne Kruska, MD

Duke University Hospitals Durham

Natalie Minns Crawford, MD

Crystal Marie Howell, PA

Radiation Oncology

Matthew David Pierson, MD Child Psychiatry; Psychosomatic Medicine

Margaret Faye Potter, PA Family Medicine; Hospitalist; Internal Medicine; Adolescent and Young Adult Medicine; Pediatrics; Obstetrics and Gynecology

Carolina Rehab Raleigh

Laura Elizabeth Smith, PA

Cary

Urgent Care of Smithfield Smithfield

Justin Wayne Bordeaux, PA Family Practice; Emergency Medicine

Nash General Hospital Rocky Mount

Melissa Guffey Potisek, MD

Elizabeth Aimee Crowgey, PA

University of North Carolina Hospitals Chapel Hill

NextCare Urgent Care Burlington

Family Medicine; Internal Medicine; Pediatrics; Family Practice

Duke University Hospitals Durham Anesthesiology

Dermatology

Urgent Care

Urgent Care of Smithfield, PA Smithfield

Urgent Care

Chad Ethan Tiller, PA Urgent Care; Emergency Medicine

Duke Urgent Care South Durham


“More than a doctor. Like a friend.”

We know it by heart.

Trust. WHV is an independent group of heart specialists with locations throughout Eastern North Carolina - ready to provide the care for your patient’s heart when and where they need it. We’ve been pioneering and delivering innovative cardiovascular care for over 25 years. Through our affiliation with UNC Health Care, our physicians can also tap into the latest research and expertise associated with a world-class academic institution. And this in turn allows all our patients to have more access to clinical trials and new therapies, resulting in the best cardiovascular care available in the area.

Cardiovascular Professionals in Johnston, Wayne and Wilson Counties Mateen Akhtar, MD, FACC Benjamin G. Atkeson, MD, FACC

Matthew A. Hook, MD, FACC Eric M. Janis, MD, FACC

Waheed Akhtar, MD, FACC Malay Agrawal, MD, FACC

Kevin R. Campbell, MD, FACC Randy A.S. Cooper, MD, FACC

Diane E. Morris, ACNP Ravish Sachar, MD, FACC

Sunil Chand, MD, FACC Paul Perez-Navarro, MD, FACC

Laura Davis, ANP-BC Christian Gring, MD, FACC

Nyla Thompson, PA-C

Joel Schneider, MD, FACC

Cardiovascular Services Echocardiography Nuclear Cardiology Interventional Cardiology Carotid Artery Interventions Cardiac Catheterization Cardiac CT Angiography and Calcium Scoring Electrophysiology and Cardiac Arrhythmias Peripheral Vascular Interventions Pacemakers / Defibrillators Stress Tests Holter Monitoring Lipid and Anti-Coagulation Clinics Vascular Ultrasounds / AAA Screening

WHV Locations in Johnston, Wayne and Wilson Counties 910 Berkshire Road

2076 NC Hwy 42 West, Suite 100

2605 Forest Hills Road South West

2400 Wayne Memorial Drive, Suite A

Smithfield, NC 27577 Phone: 919-989-7909 Fax: 919-989-3147

Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326

Wilson, NC 27893 Phone: 252-243-7049

Goldsboro, NC 27534 Phone: (919) 736-8655 Fax: (919) 734-6999

When it comes to your cardiovascular care – We know it by heart. To learn more, visit our website www.WHVheart.com or call us at 1-800-WHV-2889 (800-948-2889).


Advanced Medical Imaging for Your Patients 19 Convenient Triangle Area Locations

Established in 1953, Wake Radiology is the leading provider of outpatient medical imaging for families in the Triangle. Our 54 radiologists are recognized experts, subspecialty trained and certified by the American Board of Radiology. A longtime leader in low-dose imaging, we are committed to minimize patients’ radiation exposure while maintaining the highest quality. We are proud to be the only multi-site freestanding outpatient imaging provider in the Triangle to earn the American College of Radiology’s prestigious Breast Imaging Center of Excellence (BICOE) designation. Our group is also the only one to earn certification from the International Society for Clinical Densitometry (ISCD) for bone density screenings and the first in Wake County to offer dedicated pediatric imaging services. Our 19 outpatient offices provide easy access to a full range of imaging procedures including: • Screening and diagnostic mammography • PET-CT and nuclear medicine • Interventional radiology and vein care • Orthopedic and sports imaging • Low-dose CT and MRI • Pediatric imaging So the next time imaging is necessary for your patients, choose Wake Radiology. We are in-network with most insurance plans and offer financial assistance or payment plans to patients who need it.

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