Page 1

d e c e m b e r 2 014 / Ja n ua ry 2 015

Johnston Health Clayton

New Full-Service Hospital Brings Quality Health Care Closer to Home

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

Stress Marks Heart Health


now 87% Smaller

The Reveal LINQ Insertable Cardiac Monitor is a revolutionary system that transforms your ability to diagnose and treat even the most difficult-to-detect cardiac arrhythmias.

SMALL: 87% smaller than Reveal速 XT ICM, with 20% more data memory. SIMPLE: Simplified insertion procedure with <1 cm incision provides the most discreet cardiac monitoring option, with minimal scarring for greater patient acceptance.

CONNECTED: Only wireless insertable cardiac monitoring system that continuously

collects and trends data for up to 3 years, with automatic Medtronic CareAlert速 Notifications.

PRECISE: Clinically actionable, easy-to-read Medtronic CareLink速 reports reduce the

data management burden.

Shift into small at RevealLINQ.com

Innovating for life.


Triangle Homes Guaranteed to Sell! Wilson Realty Group will sell your home in 99 Days or we will sell it for free... Guaranteed!

For a FREE Home Value, visit: Raleigh.GuaranteedSale.com

Contact us Today!

919.675.4283

Jenn@WilsonRealtyGroupNC.com | www.RaleighRealEstate411.com


COVER STORY

6

Johnston Health Clayton

New Full-Service Hospital Brings Quality Health Care Closer to Home

d e c e m b e r 2 0 14 / J a n u a r y 2 0 15

FEATURES

9

Vol. 6, Issue 1

DEPARTMENTS 10 Practice Management

Dermatology

Dr. Margaret Boyse explains how stress can aggravate such skin conditions as eczema and psoriasis, among others.

12

13 Gastroenterology

Skin Mirrors Stress

Patient Satisfaction Survey Is a Tool for Gauging Effectiveness Doctor-Patient Communication, Part 1: Observations on Ineffective Approach

14 Duke Research News

- Half of STEMI Heart Attack Patients May Have Additional Clogged Arteries - Older Breast Cancer Patients Still Get Radiation Despite Limited Benefit

16 Duke Research News

“Financial Toxicity” Can Lower Cancer Patients’ Quality of Life

17 UNC Research News

Cardiovascular Health

Updated Guidelines Reflect Greater Understanding About Prevention Nurse practitioner Lindsay Wojciechowski discusses the change away from treatment to achieve specific cholesterol levels.

Silencing Molecule Shown to Impair Cancer Growth and Stop Its Spread

18 UNC Research News

Chemo’s Effect on Brain Cells and Potential Link to Autism Pinpointed

19 UNC Research News

Large Study Confirms High Mortality for Inpatient STEMI Heart Attacks

20 Autism Society of North Carolina

Toolkit Shares Residential Options for Adult Children with Autism

20 News

Welcome to the Area

COVER PHOTO: Johnston Health Clayton expands on its mission to provide world-class health care to a growing community.

2

The Triangle Physician


Great News!

New Hospital! New Services! New Levels Of Care!

As The New Year Arrives, Johnston Health Will Open The First Full-Service Hospital In The Clayton Area.

On January 14, 2015, Johnston Health proudly opened the first full-service hospital in Clayton, one of North Carolina’s fastest growing regions. In our beautiful three-story wing, you will find fifty inpatient rooms, as well as a women’s center with labor and delivery rooms, a nursery and a C-section room.

In addition, there is a 24-hour emergency department, which has been accredited as a chest pain center, and a fully equipped imaging center. To top it all off, this new hospital, with its new services and new levels of care, is brought to you with the strength and depth of our recent partnership with UNC Health Care.

Healing Neighbors.

It’s What We Do. It’s Who We Are!

www.johnstonhealth.org

CLAYTON 2138 NC Hwy. 42 W.

919-585-8000

SMITHFIELD 509 N. Bright Leaf Blvd.

919-934-8171


From the Editor

Happy New Year! When you or a loved one becomes seriously ill or injured, proximity to state-of-the-art health

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

care becomes “the most important thing in the world,” says Jim Lee, a former emergency medical technician, in this month’s cover story on Johnston Health Clayton. For residents in outlying areas, that level of care can be a lengthy road trip – often complicated by traffic. For residents of Clayton and the surrounding northern and western Johnston County, it just got closer to home. This month, a $50 million expansion brought emergency care, inpatient acute care and labor and delivery services to Johnston Health Clayton. Read on to learn how this new hospital is contributing to a growing community with some world-class partners.. Starting off 2015 in this issue of The Triangle Physician, returning contributors provide interesting medical perspectives. Practice management consultant Margie Satinsky discusses the use of patient satisfaction surveys to ensure a practice is achieving its health care delivery objectives. Gastroenterologist Douglas Drossman starts a two-part series on physician-patient communication with an example of an uneasy dialogue. Dermatologist Margaret Boyse reminds us about the health cues one’s skin provides. Nurse practitioner Lindsay Wojciechowski offers insight into the changing medical views behind the 2013 updated guidelines for cardiovascular health and stroke prevention. Findings on “financial toxicity” and information about an Ebola treatment trial is included in this issue’s news. So is the Autism Society of North Carolina, which announced its new toolkit for parents and caretakers with resources to ease the transition to independent or group living for adults with autism. Here at The Triangle Physician, we begin the New Year excited about the medical advances ahead. To submit your news and perspectives for publication, send by e-mail to: heidi@trianglephysician.com. I welcome questions and suggestions. All the best in the New Year! With gratitude for all you do,

Heidi Ketler Editor

4

The Triangle Physician

Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Margaret Boyse, M.D. Douglas Drossman, M.D. Margie Satinsky, M.B.A. Lindsay A. Wojciechowski, F.N.P.-C. Creative Director Joseph Dally jdally@newdallydesign.com

Advertising Sales info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com

The Triangle Physician is published by: New Dally Design Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401

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.


www.kendallmurphyphotography.com kendall@kendallmurphyphotography.com Maternity

Children

Newborns

Families

KendallPhotography_FP_AD_June14.indd 1

â&#x20AC;&#x153;Grow With Meâ&#x20AC;? packages

Boudoir

Business Professionals

6/10/14 9:24 PM


Cover Story

Johnston Health Clayton

New Full-Service Hospital Brings Quality Health Care Closer to Home By Suzette Rodriguez – Public relations specialist for Johnston Health

When prospective home buyers come to

“People don’t realize they need emergency

services. It has a management agreement

Clayton, developer Jim Lee of the Walthom

services until they do, and then it’s the most

with Duke for hematology and medical

Group takes them on a tour. And one of his

important thing in the world,” he says. “Not

oncology. For the patient’s convenience,

stops is right at the front door to the emer-

only does Johnston Health Clayton look

the two cancer services are across the hall

gency department at Johnston Health Clay-

nice and new, but it’s got the latest technolo-

from each other at the three-story Johnston

ton.

gy, high-caliber physicians, and the service

Professional Plaza, which is a stone’s throw

is extraordinary.”

from the hospital.

the value of an ED to a small town. He was

Bringing Together

Also important, N.C. Heart & Vascular,

once a volunteer emergency medical tech-

World-Class Partners

which has offices on the Clayton campus

nician in nearby Garner and remembers

Mr. Lee likes to point out that Johnston

and in Smithfield, has added angioplasty

long ambulance trips through heavy traffic

Health Clayton contracts with Wake Emer-

and stenting to its cardiovascular services

to big hospitals. “Those were stressful min-

gency Physicians for its emergency cover-

at the flagship hospital in Smithfield. These

utes,” he says.

age, which is the same group providing care

interventional procedures are in addition to

at WakeMed’s trauma center in Raleigh.

electrophysiology studies and defibrillator

More than most folks, Mr. Lee recognizes

implants available for some time in the cath-

But there’s comparatively less traffic on N.C. 42 West, where Johnston Health Clayton

There are other heavy hitters on the Clayton

sits, within sight of the bypass of U.S. 70.

campus, too.

eterization lab. “We’ve brought together world-class care for

The campus is a five-to-10-minute drive from most Clayton neighborhoods, and the wait

Johnston Health partners with Rex/UNC

our communities,” says Chuck Elliott, presi-

to be seen in the ED is always short, he says.

Healthcare to provide radiation oncology

dent and chief executive officer of Johnston Health. “It’s been our board of directors’ strategic goal to provide more local options for health care. We want our neighbors, our friends, our family members to have quality, affordable health care close to home.” Speaking of quality, The Joint Commission in November recognized Johnston Health as a 2013 Top Performer on Key Quality Measures. Specifically, the health care system was recognized for achieving excellence in the measures relating to heart attack, heart failure, pneumonia and surgical care. From an Outpatient Center to a Full-Service Hospital This month, Johnston Health Clayton com-

Spacious work areas like this second-floor nursing station reflect the bright, contemporary interiors of Johnston Health Clayton’s new facility.

6

The Triangle Physician

pleted a $50 million expansion and welcomed its first inpatients. The construction


Johnston Health Clayton’s new three-story hospital wing features 50 private inpatient rooms, a cafeteria, a chapel and more.

included a three-story wing with 50 beds, as

A private driveway and back entrance to the

Convenient Services

well as alterations to the single-story build-

department make it easy for mothers in la-

for Doctors and Patients

ing, which opened as an outpatient center

bor to enter more quickly, instead of having

Through the past 14 years, Ghulam Shaikh,

five years ago.

to walk through the hospital corridors.

M.D., has seen businesses and rooftops

Back in 2009, the intent had been to estab-

A Hospital that

practice at the commercial area clustered

lish the core services and then add, soon

Doesn’t Feel Institutional

around I-40 and N.C. 42, which is a few miles

afterward, 27 inpatient beds. With the reces-

Visitors are welcome to dine in the café,

west of the hospital.

sion looming, however, Johnston Health put

which features a pizza oven, a fresh soup

the expansion on hold. But even with the

and salad bar, a grill and deli station. There’s

Until a few years ago, Dr. Shaikh was round-

down economy, the outpatient center per-

also a gift shop, a chapel for meditation and

ing daily at the Smithfield hospital and at

formed well, exceeding expectations. Bol-

an outdoor garden for quiet reflection.

WakeMed in Raleigh, a loop of about 110

spring up around his internal medicine

miles. To save time and travel expense, he

stered by its success in Clayton, the health system moved forward a plan to double the

“Architects have designed the building to

began using the hospitalist service in Smith-

number of inpatient beds.

feel less like an institution and more like

field, which provides 24/7 coverage to his

a resort,” Mr. Elliott says. “In the atrium,

patients.

The new wing is in keeping with the overall

visitors can look up three flights. Twinkling

design of the hospital, which has a stone

LED lights on the ceiling make you feel as if

The hospitalists, who are part of the Rex/

facade and large plate glass windows – all

you’re looking up at the stars.”

UNC Health Care specialists group, are available to take immediate action for pa-

of which make for an inviting atmosphere. Original works by local artists and public

The expansion includes nine additional

tient care and to answer family questions.

school students are a feature, too, and add

exam rooms in the emergency department,

Most importantly, they coordinate care with

color to patient rooms, reception areas and

bringing the total to 24, and an additional

the patient’s local primary care and special-

other public spaces.

operating suite, bringing the total to three.

ist providers.

The main entrance has moved from the The ground floor of the new wing is dedi-

front to the east side of the building.

“We believe in efficient and quality care of our patients,” said Dr. Saqib Aziz, who is the

cated to women’s services. The spacious labor and delivery rooms are designed for

Also notable, a rear parking lot is made of a

medical director of the hospitalist group.

comfort. All have flat-screen TVs, en suite

porous material so that rainwater can seep

“We’re very excited about taking care of pa-

bathrooms with safety features and pull-

into the ground, a feature that’s environ-

tients at Johnston Health Clayton.”

down beds to accommodate family mem-

mentally friendly.

bers who want to spend the night.

december 2014/January 2015

7


Dr. Shaikh thinks the addition of inpatient services in Clayton is a plus for his patients, many of whom are retirees. “The campus is easy to get in and out of,” he says. “They don’t have to travel as far, nor sit for hours in an emergency department.” Maternity services are a great addition, too, for the many young people in the Clayton area, he says. In fact, 26 percent of residents living in the zip code have children. The internist also likes the option of having the hospital’s ancillary services close by. And the hospital is ideal for patients with chest pain who need observation, he says. The hospital has four acuity-adaptable beds and six progressive care beds that will eventually transition into an intensive care unit. A Draw for Other Businesses In the five years since opening, Johnston Health Clayton has attracted other businesses to the strip along N.C. 42 West, including a nursing home, an assisted-living center and offices for physicians and other health care-related services.

The three-story atrium of Johnston Health Clayton’s new hospital features plenty of natural light and unique lighting features.

While commercial development of late has been off, Mr. Lee says, residential development has been on fire. “If you could snap your fingers today and suddenly finish all of the projects in the pipeline, I think the population here could grow 50 percent.” The 2013/2014 census puts Clayton’s population at 16,116 residents, which is a 131 percent increase from 10 years ago. The population of the larger trade area six miles around Clayton is 52,840. Also notable, 68 percent of Clayton residents are employed, and the median family income is $62,951. As for the house hunters, Mr. Lee says many are retirees who are following their children. They are mostly from Michigan, Pennsylvania, New Jersey, New York and Ohio. “And they’re all very interested in medical care,” he adds. “I tell them we have the best right here in Clayton, and they’re impressed.”

8

The Triangle Physician

Comprehensive Health Care Services The following is a list of services available at Johnston Health Clayton. Cardiovascular Services • Adult and pediatric electrocardiology (EKG or ECG) • Holter monitoring • Event monitoring • Ambulatory cardiac telemetry • Adult and pediatric echocardiography • Transesophageal echocardiography • Cardiac stress testing • Vascular ultrasound • Non-invasive vascular studies • Electroencephalography (EEG) • Home-sleep testing Radiology • Diagnostic imaging • Computed tomography (CT) scan • Magnetic resonance imaging (MRI) • Ultrasound • Mammography • Bone density • Interventional radiology • Nuclear medicine Respiratory Care 24/7 • Inpatient bronchoscopy • Pulmonary function testing

Pharmacy and Lab 24/7 Surgical Services • General • Orthopedic • Ear nose and throat • Gynecology • Vascular • Ophthalmology • Podiatry • Thoracic • Neurology • Elective endoscopy Behavioral Health •P  atients presenting to the emergency department are triaged for medical issues and physiological problems. •O  nce medical issues are stabilized or treatment is under way, behavioral health screening is done by the ED provider in collaboration with the behavioral health screener. • If admission is needed, the on-call psychiatrist will be contacted for admission acceptance, and transport orders will be given to the ED nurse in charge. Labor and Delivery


Dermatology

Skin Mirrors Stress

By Margaret Boyse, M.D.

There is often a clear, strong connection

wide range of effective medications are

between the beauty of our skin and our

available to treat acne, regardless of the

internal and external existence, our health

severity of the condition, and laser therapy

and well-being.

is another choice that is proving beneficial in some instances. Laser therapy also has

Stress can unquestionably be a killer and

been used successfully for some time

do untold damage to our physical and

to diminish or remove scarring that may

emotional selves, which are intimately

result from severe acne.

intertwined. To varying degrees, we all experience stress in our lives, and the

There are two sides of the same coin: if

condition of our skin – the body’s largest

someone is feeling burdensome levels of

organ – often mirrors the results.

stress in their lives, there will be evidence of that fact in the appearance and health

We consider stress to be a trigger or irritant

of their skin. In the same manner, an

for a range of skin problems, including

inflammatory skin disease, such as acne,

acne, hives, eczema, psoriasis, rosacea

for example, is by itself a highly stress-

and other conditions.

inducing event.

Dr. Margaret Boyse practices at Southern Dermatology & Skin Cancer & Skin Renewal Center. After earning her medical degree from the University of Texas, she completed her internship at Walter Reed Army Medical Center and residency at the University of Michigan. Special interests include: general adult and pediatric dermatology, dermatologic surgery, cosmetic dermatology and skin cancer. She is a member of the American Academy of Dermatology and North Carolina Medical Society. For more information, visit www. southernderm.com.

Many of my patients get equally good results in reducing and managing stress

best for the individual.

Drossman Gastroenterology

Along with exercise to manage stress, I

55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514

Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.

919.929.7990

www.drossmangastroenterology.com

simply by walking, by doing yoga or Pilates, meditating or getting massages or some combination of therapies and activities. The important ingredient is the commitment to take charge of the issue of stress management in whatever ways work

often encourage patients to eat healthy foods, such as eggs, fish, nuts and fruits and vegetables. The combination of a good exercise-stress management program and a good diet is very powerful. I offer the same message for my teenage patients with acne, for patients with psoriasis, for obese patients and for those who simply want to improve the appearance of their skin. Acne, as we have observed many times, is too often a stressful blight on the lives of teenagers and even of some adults. A

december 2014/January 2015

9


Practice Management

Patient Satisfaction Survey

Is a Tool for Gauging Effectiveness By Margie Satinsky, M.B.A.

Patients judge your medical practice by

As each patient leaves the office, he/she

more than the quality of the clinical care

takes a few minutes to use the in-office

they receive. Regardless of whether they

computer to respond to an online patient

seek care for prevention, the onset of an

satisfaction survey. The results help the

acute condition and/or the management of

practice stay on target.

a chronic disease, your patients are your “customers.” Their satisfaction/dissatisfac-

Your strategy with patient satisfaction might

tion with their experience in your office

be different if you were a new practice in

depends on many more factors than a brief

town. Assuming you have differentiated

interaction with a clinician.

yourself from competitors in your specialty, you might want to ask questions related to

Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She’s the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www.satinskyconsulting.com.

Some of the factors are the ease of making

that goal. Since your staff is new, you might

appointments, wait times, the courtesy and

want to ask more questions about work-

Here’s an example. If a patient has waited

respect shown to them by administrative

force than you will after your practice has

for more than an hour to be seen by a cli-

and clinical staff, the convenience of park-

been up and running for a while.

nician, one would expect dissatisfaction. If the practice manager follows up with an

ing, the physical appearance of the office, the clarity of patient education material, the

What about patient satisfaction if your prac-

apology and an explanation for what the

ease of referrals to other physicians and ser-

tice is owned by a larger health care system?

practice is doing to minimize wait times,

vices and post-visit communications.

We think the surveys are particularly impor-

the patient might very well forget about the

tant in these situations, given that both your

wait and focus on the courteous manner of

Here are practical tips for using a patient

practice and the larger system of which you

the interaction.

satisfaction survey to obtain patient feed-

are a part need to understand the way in

back that can help you meet patient expec-

which patients perceive the experience.

Pick Your Moment

Timing is important. The best time to ask for

tations on an ongoing basis. Here’s an example. Often the larger system

patient feedback is as each patient leaves

Plan Your Strategy: Start with Why

dictates the way in which the phone system

your office or shortly thereafter, when the

Start by asking yourself an important ques-

at individual physician practices will work.

office experience is fresh in mind.

tion: “Why does our practice want to sur-

When patients have difficulties telephon-

vey patient satisfaction?” Let your response

ing the practice, the practice itself may not

Consider placing a computer in your office

guide your strategy.

have the option of improving the situation

so patients can take a short survey before

because the decision belongs to the system.

they leave. or, if you prefer to have patients take the survey after they leave your prac-

For example, one of our Triangle clients is a primary care practice that currently

Seek a Variety of Opinions

tice, facilitation participation by providing

has three locations and plans to expand. It

Also consider: From whom are you seek-

specific instructions both electronically

cares about patient satisfaction because it’s

ing feedback on your practice?

and on paper. Be sure to provide a phone number to call if questions arise.

mission driven. It’s gratifying to hear from patients who Unlike practices with an outdated or vague

have had a positive experience, but you

Decide What Questions to Ask

purpose for being, this practice knows

also need feedback from patients whose

You have two options in determining what

where it’s headed. It strives to: provide the

expectations have not been met. Some-

questions to ask on your survey. You can

convenience of urgent care, the customer

times the very act of asking for feedback

develop the questions yourself, or you can

focus of the hospitality industry and opera-

and immediately following up diffuses a

use questions that have already been de-

tional efficiency.

negative experience.

veloped by a reliable external source.

10

The Triangle Physician


For example, The Centers for Medicare &

derstand and respond to every question.

Although not dedicated to the health care

Medicaid (CMS) has developed a CAHPS

Make changes before administering the

sector,

(Consumer Assessment of Healthcare

survey to patients.

com) offers similar services. Still another

SurveyMonkey

(surveymonkey.

option is Avatar International L.L.C. (avatar-

Providers and Systems) Visit Survey and a

solutions.com), which has partnered with

report on their experiences with a clinician

Consider Outsourcing to a Company that Specializes in Patient Surveys

and office staff during a 12-month period.

The most effective way to use patient sat-

(AAFP). The office staff gives each patient

isfaction surveys is to integrate them into

an access code for the online survey. Sur-

One advantage of using questions devel-

practice operations and administer them

vey results are available in real-time, and

oped by an external source is that you may

on an ongoing basis. The task takes time,

there is a comparison with other practices

be able to “kill two birds with one stone.”

and you may want to minimize staff time

throughout the country.

CAHPS 12-Month Survey that asks patients to

the American Academy of Family Practice

spent on this task by outsourcing the surFor example, if you are a Patient Centered

vey function to an external company.

Review the Results Regularly

It’s one thing to conduct a patient satisfac-

Medical Home (PCMH) practice, you can meet NCQA (National Committee for Qual-

For example, Dr. Score, (drscore.com),

tion survey. It’s another to regularly review

ity Assurance) reporting requirements by

founded in 2003, is a leading provider of

the results about your practice and make

using the online CAHPS survey. Some spe-

online surveys for medical practices and

appropriate improvements.

cialty societies endorse the use of particu-

outpatient clinics throughout the United

lar patient satisfaction surveys as a way to

States. The company serves practices of all

If you have opted to work with an external

satisfy maintenance of board certification

sizes, ranging from solo practice providers

survey company, you’ll have access not

requirements.

to one of the largest health care groups in

only to results about your own practice,

the country. You have a choice of the type

but also to benchmark information from

Keep Survey Questions Simple

of package you purchase, and if you’re not

other medical practices throughout the

If you develop your own survey questions,

sure what you want, you can start with the

country. Use both kinds of information to

keep the language plain and simple.

free basic option.

identify problems and make changes.

Patients prefer multiple choice or rating questions that allow them to rank an aspect of your service from 1 (Not acceptable) to 5 (Exceeded expectations). Although you can offer patients the opportunity to write specific comments, avoid questions that require long, written explanations. Remember to Translate

BOTOX® COSMETIC • COOLSCULPTING® • FACIAL FILLERS • MICRODERMABRASION • AND MORE

Your Skin needs some

GLAMOUR Your skin will be a local celebrity with great medical grade skin care products and skin rejuvenation procedures from The Skin Renewal Center at Southern Dermatology including:

If your practice provides care to non-Eng-

• BOTOX COSMETIC® • LASER HAIR REMOVAL • COOLSCULPTING® • MICRODERMABRASION • LATISSE

lish-speaking patients, make sure that the patient satisfaction survey is available in languages that patients understand.

We can have you camera ready everyday, with the most advanced therapies for prevention and early detection of skin cancer!

The CAHPS surveys mentioned above are available in English and Spanish, and you can get help in translating the surveys into other languages. If you develop your own survey questions, collaborate with inter-

DERMATOLOGY & SKIN CANCER CENTER 919-782-2152

preters in your community.

SKIN RENEWAL CENTER 919-863-0073

Test Your Patient Satisfaction Survey

If you develop your own patient satisfaction

southernderm.com

survey, test your instrument with friends and colleagues to make sure they can un-

ACNE • MOHS SURGERY • SKIN CANCER • PSORIASIS • ECZEMA • DERMATITIS • ALOPECIA DER131_AD_Triangle Physican 1_Glamour.indd 1

11/13/142015 10:04 AM december 2014/January 11


Cardiovascular Health

2013 Updated Guidelines

Reflect Greater Understanding About Prevention By Lindsay A. Wojciechowski, F.N.P.-C.

When the American Heart Association and

Patients advised to implement statin ther-

the American College of Cardiology an-

apy include:

nounced the long-awaited, updated guide-

1. Patients with a personal history of

lines for cardiovascular health and stroke prevention in November 2013, the differences were striking and highlighted what we have learned about preventing cardiovascular disease.

Lindsay Wojciechowski is a nurse practitioner and consultant to the Women’s Wellness Clinic and the Carolina Women’s Research and Wellness Center (CWRWC). She has worked as a clinical nurse practitioner for Triangle Family Practice at Duke University Medical Center since 2006. She also has lectured and taught courses at the Duke University School of Nursing. Ms. Wojciechowski’s focus is on women’s health and family medicine, and she also is the lead medical writer for the Women’s Wellness Clinic.

cardiovascular event. 2. Patients aged 21 and older who have LDL levels > 190 mg/dL. 3. Patients aged 40-75 with Type 1 or Type 2 diabetes. 4. Patients aged 40-75 without cardiovas-

The most obvious difference is that the

cular disease who have a 7.5 percent or

new guidelines no longer recommend

higher risk of having a heart attack or

treating toward specific cholesterol levels.

stroke within 10 years.

The guidelines highlight the importance of evaluating a patient’s overall risk and

For patients in the first two categories, high-

appreciate the ability of statins to reduce

intensity statin therapy is recommended

risk in ways other than just lowering cho-

for optimal risk reduction. For those in the

a statin is no longer recommended. This

lesterol values.

latter two categories, high-intensity or mod-

addition has not been shown to significant-

erate-intensity therapy can be used depend-

ly reduce risk.

Heart healthy lifestyle habits are certainly

ing on the judgment of patient and provider. The elimination of specific LDL value

the foundation of atherosclerotic cardiovascular disease (ASCVD) prevention. The

For a more detailed guide: http://circ.

goals in the new guidelines requires a dif-

guidelines encourage providers to help

ahajournals.org/content/129/25_suppl_2/

ferent way of thinking about cholesterol

patients consume heart healthy diets, get

S1/F2.expansion.html.

treatment. While research has shown that lowering LDL decreases ones risk of heart

adequate physical activity and avoid smoking and obesity. They highlight the assess-

The choice of appropriate medication and

attack and stroke, there is no evidence that

ment of risk and take into account multiple

starting dose depends on the suggested

one particular target number is best.

determining factors.

dose intensity (see chart below). Note that most statins are not indicated for both low-

High LDL levels are well-known markers

Under the 2002 federal guidelines, a pa-

and high-intensity treatment. In contrast to

for increased risk of cardiovascular dis-

tient’s 10-year risk had to be 20 percent or

old guidelines, the need for regular liver

ease. However if the risk is high, the treat-

higher to warrant statin therapy. The 2013

function monitoring is eliminated. Risk of

ment should be aimed at reducing the risk

CV Risk Calculator determines 10-year risk

liver toxicity is rare and only advised prior

itself, rather than just reducing the choles-

and lifetime risk for younger patients and

to prescribing.

terol level. And statins are a proven therapy for significantly reducing just that.

encourages statin therapy for some patients with 10-year risk as low as 7.5 percent. While some criticize this lower percentage

Another change highlighting the value of statins is that adding non-statin drugs (like

The chart below shows the relative LDL-

niacin and fibrates) to patients already on

lowering efficacy of statin therapies.

as potentially overestimating risk, scientists involved in its development argue that

Relative LDL-lowering Efficacy of Statin Therapies

overestimating risk can create necessary

Atorva

Fluva

Pitava

Lova

Prava

Rosuva

Vytorin†

Simva

-----

40 mg

1 mg

20 mg

20 mg

-----

-----

10 mg

30%

10 mg

80 mg

2 mg

40 or 80 mg

40 mg

-----

-----

20 mg

38%

20 mg

-----

4 mg

80 mg

80 mg

5 mg

10/10 mg

40 mg

41%

40 mg

-----

-----

-----

10 mg

10/20 mg

80 mg

47%

dialogue about prevention between providers and those at early risk.

80 mg

12

The Triangle Physician

Source: www.fda.gov % LDL-C

-----

-----

-----

20 mg

10/40 mg

-----

55%

-----

-----

-----

40 mg

10/80 mg

-----

63%


Gastroenterology

Doctor-Patient Communication, Part 1:

Observations on Ineffective Approach By Douglas Drossman, M.D.

In this two-part series, we evaluate two ap-

Doctor: (Frustrated) “OK, OK, I want to do

proaches to physician-patient communication.

a physical examination and then maybe we can talk about the plans, OK?” (Patient

Situation

looks dissatisfied.)

Ms. Simpson is a 38-year-old woman with several years of abdominal pain and bowel

After the physical exam

difficulties. Blood studies, barium enema

Doctor: “Well everything seems OK. I’d

and computed tomography have been neg-

like to do a blood test for celiac disease

ative. She has been on numerous medica-

and then a colonoscopy. (Patient looks

tions, including antispasmodics, fiber, pro-

surprised) No, it’ll probably be OK, this

biotics and antibiotics without benefit. She

way we’ll be sure there is really nothing to

is depressed and frustrated and asks her

worry about. So don’t worry.”

doctor for a second opinion.

Patient: “Doctor, what is it that I have? I’ve been reading online about patients that

Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation.org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www. drossmancenter.com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patient-provider relationship.

New physician interview

have the same symptoms that I do and they

Doctor: “How can I help you?”

call it IBS (irritable bowel syndrome). Is

Patient: “Well, when I came back from

that what I have?”

vacation, I got a flare up of whatever it is I

Doctor: “Perhaps, but we first need to rule

have… nausea, diarrhea, fatigue and stom-

out anything organic.”

ach pain. (Pause) So Dr. Jones thought I

Patient: “What’s ‘organic’?”

should see you and… .”

Doctor: “I mean something specific that

Doctor: (Interrupting) “Was this like some-

we can treat. If the studies are negative, I’ll

thing you’ve had before?”

put you on an antidepressant to feel more

Patient: “Well, yes, but it’s never been this bad.”

comfortable with your symptoms.”

Doctor: “Is it made worse by food?”

Patient: (Looking confused) “Doctor, I’m

Patient: “No. Do you think it’s something I ate?”

not depressed… . I just can’t deal with the

Doctor: “I don’t know yet. Did you have

pain. I… .”

diarrhea or fever?”

Doctor: (Interrupting, turns back to patient)

After the physical exam, the education and

Patient: “I think so… but I didn’t take my

“No, I’ m sorry; I didn’t say you were

treatment plan was ineffective. He recom-

temperature.”

depressed. These medications can help

mended tests without summarizing his ob-

Doctor: “So you have diarrhea and fever?”

your symptoms. Look, let’s just see what

servations, making a diagnosis or offering

Patient: “Uh no, I get constipation too,

the tests show and then we can take it from

education. His reassurance was ineffective;

but that’s normally when I’m not eating

there, OK?” (Patient looks disappointed.)

this ended the discussion and left the pa-

Drossman Gastroenterology P.L.L.C. (www. drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.

tient disappointed.

well. I know some diets can help, and it’s important to eat regular meals, right? I do

Observations

know that if I eat fatty foods I get pain and

There are several observations about this dia-

The physician delegitimized IBS by seeking to

I feel queasy right here. (Patient starts to

logue that demonstrate ineffective communi-

identify “organic” conditions, which he pre-

look concerned). Doctor, I’m really worried

cation skills. The interview was non-facilita-

sumed to be treatable. The recommendation

about this. ”

tive and did not disclose helpful information.

to take an antidepressant was rejected by the patient, who assumed it was given for depres-

Doctor: (Ignores affect) “I’m sorry I’m not

sion, which she did not believe she had.

quite following. What type of bowel prob-

The doctor did not actively listen and spoke

lems did you say you are having? ”

from his agenda rather than the patient’s. He

Patient: (Folds arms) “Normally I get

asked closed-ended questions and frequent-

In part two of this series, we will discuss a

constipation, but when it’s really bad I have

ly interrupted. He seemed frustrated when

more effective approach to this physician-

diarrhea too.”

not understanding.

patient encounter.

december 2014/January 2015

13


Duke Research News

Half of STEMI Heart Attack Patients May Have Additional Clogged Arteries A blocked artery causes a deadly kind

Patel, M.D., director of Interventional

compared to a 1.9 percent death rate

of heart attack known as ST elevation

Cardiology and Cardiac Catheterization

among those who had a single blockage.

myocardial infarction (STEMI), and a rapid

Labs at Duke University Health System.

response to clear the blockage saves lives.

“We found that more than half of the

“The current thinking among cardiologist

28,000 patient scans we analyzed showed

is that it is dangerous to treat these other

But in more than half of cases studied

at least one additional blocked artery, and

blockages at the same time as treating the

recently by Duke Medicine researchers,

about 19 percent had blockages in all three

artery that created the heart attack,” Dr.

one or both of the patient’s other arteries

arteries.”

Patel said. “There has been a sense that the patient is healing and it may damage

were also obstructed, raising questions about whether and when additional

In their retrospective study, Dr. Patel and

the heart. But we haven’t had a good idea

procedures might be undertaken.

colleagues analyzed eight large, interna-

of the risks or the potential benefits.

tional clinical trials of patients who sufIn a study published in

fered a STEMI heart attack. These serious

“Our study has established that these

the Nov. 19 issue of the

heart attacks strike nearly 250,000 people

additional blockages appear to be very

Journal of the Ameri-

in the United States a year, according to

common, and these patients seem to do

can Medical Associa-

the American Heart Association.

worse, so we need additional studies to confirm these findings and then determine

tion, Duke researchers and their colleagues

The researchers analyzed angiograms for

when and how best to open up the

report the first large

the patients to quantify how many had

additional arteries to restore blood flow,”

analysis of how often

additional blockages in one of the other

Dr. Patel said.

these secondary block-

three arteries of the heart. While it has long

ages occur, along with evidence that they

been assumed that many patients would

In addition to Dr. Patel, study authors

lead to worse outcomes.

have additional blockages, the research

include Duk-Woo Park, Robert M. Clare,

team’s finding that 52.8 percent of patients

Phillip J. Schulte, Karen S. Pieper, Linda

The findings provide fodder for additional

had more than one blockage indicates the

K. Shaw, Robert M. Califf, E. Magnus

studies to determine whether opening all

prevalence.

Ohman, Frans Van de Werf, Sameer Hirji,

Manesh Patel, M.D.

Robert A. Harrington, Paul W. Armstrong,

the blocked arteries – either at the same time or within a few days or weeks –

Further, the research team found that

Christopher B. Granger and Myung-Ho

should become a standard procedure.

additional clogged arteries were associated

Jeong.

with a small but significant increase in “We assumed this was a common problem,

death rates. Patients with more than one

The John Bush Simson Fund provided

but it has not been well understood or

blocked artery had a 3.3 percent mortality

support for the study.

quantified,” said senior author Manesh

rate within 30 days of the heart attack,

Older Breast Cancer Patients Still Get Radiation Despite Limited Benefit Women over the age of 70 who have cer-

The study suggests that doctors and

“The onus is on physicians to critically

tain early-stage breast cancers overwhelm-

patients may find it difficult to withhold

analyze data to shape our treatment rec-

ingly receive radiation therapy despite

treatment previously considered standard

ommendations for patients, weighing the

published evidence that the treatment has

of care, even in the setting of high-quality

potential toxicities of treatment against

limited benefit, researchers at Duke Medi-

data demonstrating that the advantages are

clinical benefit,” said Rachel Blitzblau,

cine report.

small.

M.D., Ph.D., the Butler Harris Assistant Professor of Radiation Oncology at Duke

14

The Triangle Physician


Duke Research News University Medical Center. Dr. Blitzblau

percent of older women who would have

She said physicians might have delayed

was the senior author of a study published

been eligible for enrollment in the CALGB

making practice changes until longer-term

online Dec. 8, in the journal Cancer.

trial received radiation therapy. In the five

data was available; the research team’s

years after the study was first reported, the

analysis did not include results after the

Dr. Blitzblau and col-

rate dropped, but only slightly, to 61.7 per-

10-year data from CALGB was published in

leagues launched their

cent.

2012. In addition, she said, there is likely lingering concern among both doctors

inquiry to determine

Rachel Blitzblau, M.D., Ph.D.

whether clinical prac-

“The publication of the trial had only a

and patients that reducing treatments may

tice changed as a result

very small impact on practice patterns,” Dr.

worsen outcomes for older women who

of a large randomized,

Blitzblau said. “Our findings demonstrate

have excellent overall health and therefore

prospective study first

the potential difficulty of incorporating

longer life expectancies.

published in 2004 that

clinical trial data that involves omitting a

compared

treatment that has been considered the

But Dr. Blitzblau said the findings of the

standard of care.”

current study highlight an important and

treatment

options for women ages 70 and older with early-stage

hormone-receptor

positive

breast cancers. The CALGB 9343 study reported limited benefit for adding radiation therapy plus the drug tamoxifen after lumpectomy among older women. Specifically, the 2004 study’s five-year data showed a small but statistically significant reduction in the rate of cancer recurrence; a similar finding was reported again in 2012 with a decade of data. However, the addition of radiation to tamoxifen after surgery did not improve overall survival among the study participants at either of the reporting periods. “The discussion at the time of the first CALGB report in 2004 was that we should consider omitting radiation for these women, because the small observed benefits might not be worth the side effects and costs,” Dr. Blitzblau said, adding that side effects include fatigue, discomfort and changes in the radiated breast tissue, among others. But little has changed following publication of the study, with about two-thirds of women still getting radiation therapy. Dr. Blitzblau and colleagues analyzed cancer treatment patterns from a national health database called the Surveillance, Epidemiology and End Results (SEER) registry. They found that before the CALGB study results were published in 2004, 68.6 Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

december 2014/January 2015

15


Duke Research News increasingly difficult challenge for physi-

“It’s important to improve patient and doctor

we will need to understand what processes

cians: Striking the right balance between

communication to ensure that the right

may be needed to spur change.”

offering effective treatments while also ac-

patients are getting the right treatment at the

knowledging the need for more financially

right time,” Dr. Blitzblau said. “As we work

In addition to Dr. Blitzblau, study authors

efficient medical care.

toward more efficient and evidence-based

include Manisha Palta, Priya Palta, Nrupen

medical practice in all medical specialties,

A. Bhavsar and Janet K. Horton.

“Financial Toxicity” Can Lower Cancer Patients’ Quality of Life Doctors who treat cancer are vigilant

and clothing, all to help pay for care.”

This and other research on financial tox-

when it comes to the physical side ef-

The findings are based on self-report-

icity should prompt discussion among

fects of the therapies they prescribe,

ed surveys and medical record data

providers on how to cut out-of-pocket

but financial stress from accumulating

for 1,000 patients who had been diag-

costs for treatments, Dr. Zafar said. One

medical bills can also weigh on patients’

nosed with colorectal or lung cancers

way is to ask a pharmacist to run expen-

health – even those who have finished

at five health care systems in the United

sive prescriptions through patients’ in-

their treatments and are cancer-free.

States; 889 of the patients were cancer-

surance plans before sending the patient

free, while 111 patients had advanced

to the pharmacy, he said.

The finding, published Dec. 16, in the

cancers. Nearly half reported difficulty

Journal of Oncology Practice, advances

making ends meet on their household

“Financial toxicity is potentially harming

ongoing research at Duke Medicine

income.

our patients,” Dr. Zafar said. “Without a doubt, we have our patients’ best in-

that has explored the issue of “financial toxicity” from cancer care and whether

Burdensome bills can lead to what re-

terests in mind, so if we become more

costs can affect a patient’s outlook and

searchers call “financial toxicity” and

cognizant of that, we’re more likely to act

outcomes.

can impact patients regardless of in-

on it.”

come, employment, the status of the

Yousuf Zafar, M.D., M.H.S.

“Our focus has been

cancer and other health problems. A

“We, as physicians, don’t bear the bur-

on how the cost of

high financial burden was linked with

den of finding the answer on our own,”

cancer care impacts

a poorer health-related quality of life. In

Dr. Zafar added. “We might not have all

a patient’s wellbeing,

turn, the data also showed a relationship

the answers on how to decrease our pa-

and we found that

between patients’ quality of life and their

tients’ costs, but we have people around

patients are at risk of

perceptions of the quality of the care

us – pharmacists, financial advisors, so-

experiencing

they received.

cial workers – who are just a phone call

finan-

away.”

cial harm as a result treatments

The study builds on previous findings

we prescribe,” said Yousuf Zafar, M.D.,

that cancer patients are unlikely to dis-

The research was supported with grants

M.H.S., associate professor at Duke and

cuss out-of-pocket costs with doctors,

from the National Cancer Institute (U01

lead author of the study.

and that patients often worry that simply

CA093344, U01 CA093332, U01 CA093329,

mentioning strained finances could re-

U01 CA093324, U01 CA093348, U01

sult in a lower quality of care.

CA093339, and U01 CA093326), and by

of

the

“Even for patients who have insurance,

the Department of Veterans Affairs, the

those out-of-pocket costs add up,” Dr. Zafar said. “Patients are at risk for not

Dr. Zafar plans to continue studying in-

American Cancer Society and Duke Uni-

adhering to their treatments due to cost.

terventions that might improve quality of

versity. A full listing of the grant support

They may have to borrow, spend their

life for financially strapped patients.

is included in the journal manuscript.

savings or cut back on basics like food

16

The Triangle Physician


UNC Research News

Silencing Molecule Shown to Impair Cancer Growth and Stop Its Spread Researchers from the

causing genes ever discovered, and it

nificantly impairing the growth of can-

UNC School of Medi-

was the obvious target to go after. People

cer cell lines. The technique also led to

cine and colleagues at

have been trying for decades to hit it, but

marked reduction of two signaling mol-

The University of Tex-

they haven’t had much luck.”

ecules called pERK and pMEK, which lie downstream of KRAS and have been im-

as MD Anderson Cancer Center have devel-

Inhibiting KRAS signaling has been

plicated in cancer cell proliferation and

oped a new approach

tricky, because it lacks good pockets or

tumor growth.

to block the KRAS

crevices for small molecules and drugs

oncogene, one of the most frequently

to bind to. Some researchers have tried

Next, Dr. Pecot and his colleagues test-

mutated genes in human cancer. The ap-

instead to target the proteins downstream

ed the siRNAs in mouse models of lung

proach, led by Chad Pecot, M.D., an as-

in the KRAS signaling cascade, but those

and colon cancer. They wrapped the se-

sistant professor of medicine at UNC, of-

attempts have also had limited success.

quences in protective lipid nanoparticles

Chad Pecot, M.D.

and delivered the siRNA solution into

fers another route to attack KRAS, which has proven to be an elusive and frustrat-

Rather than try another conventional ap-

the mice. The researchers found that this

ing target for drug developers.

proach, Dr. Pecot decided to use a new

treatment significantly slowed the growth

genetic tool known as RNA interference

of primary tumors. For example, tumors

The new method relies on a specifically se-

– or RNAi – to destroy the KRAS protein

from colon cancer models that had been

quenced type of small interfering RNA – or

before it fully forms. RNAi uses bits of

treated with the KRAS siRNAs were 69

siRNA. The findings, published in the jour-

synthetically engineered RNA – the sin-

percent smaller than tumors treated with

nal Molecular Cancer Therapeutics, show

gle-stranded molecule transcribed from

control RNA sequences.

that using a form of siRNA to halt KRAS

DNA – to silence specific genes. These

not only dramatically stunted the growth

bits of RNA bind to specific genetic mes-

In addition, the researchers discovered

of lung and colon cancers in cultured cells

sages called mRNA in the cell and direct

that silencing KRAS stemmed the spread

and mice but also stopped metastasis – the

enzymes to recognize the messages as

of cancer cells to other organs. The

main cause of cancer deaths.

enemies. In this context, the enzymes

siRNA treatment reduced the number

destroyed the genetic messages of KRAS

of these secondary malignant growths

“KRAS has been widely regarded as an

mRNA so that KRAS can’t be made. As a

by about 80 percent in mice with lung

undruggable protein, but we show that

result, the cells don’t grow, replicate or

cancer and to a similar degree in colon

that’s simply not the case,” said Dr. Pecot,

move nearly as well.

cancer models.

UNC Lineberger Comprehensive Cancer

RNAi has shown great promise in the

Dr. Pecot’s findings come on the heels of

Center.

treatment of liver diseases, viral infec-

two other papers using siRNAs to target

the study lead author and member of the

tions and cancers. To see if this approach

KRAS, one from the laboratory of Frank

KRAS is a signaling molecule – a protein

could thwart the KRAS oncogene, Dr.

McCormick, Ph.D., F.R.S, D.S.C. (Hon.),

switch that triggers a cascade of molecu-

Pecot and his colleagues first had to test

at the University of California at San Fran-

lar events that tell cells to grow and sur-

different sequences of RNA to determine

cisco and the other from the laboratory of

vive. Mutations in the KRAS gene create

which one most effectively tagged KRAS

Tyler Jacks, Ph.D., at the Massachusetts

a switch that is perpetually “on,” causing

for destruction. Of five RNA sequences,

Institute of Technology. What sets the

cells to divide uncontrollably. KRAS mu-

the researchers identified two candidates

UNC study apart is that it demonstrates

tations are present in roughly 30 percent

worthy to take into cancer models.

that this approach can be used to control the development of metastatic disease.

of human cancers, particularly lung, colon, pancreatic and thyroid.

When they delivered these sequences into tissue culture cells, they found that

“Having all three papers come out at

“It is the elephant in the room,” Dr. Pecot

the siRNAs destroyed more than 90 per-

about the same time is encouraging be-

said. “KRAS was one of the first cancer-

cent of the KRAS gene messages, sig-

cause it means that KRAS is druggable,

december 2014/January 2015

17


UNC Research News if you use outside-the-box methods,” Dr.

to specifically target the mutant form of

a professor of cancer biology at the Uni-

Pecot said. “Now, we essentially have

KRAS without disrupting the normal form

versity of Texas MD Anderson Cancer

three platforms for targeting KRAS with

of the gene, which is necessary for main-

Center.

siRNAs that may get to the clinic.”

taining normal growth in healthy cells.

Dr. Pecot said the results, while promis-

Other UNC co-authors include UNC grad-

National Institutes of Health, a Ben F.

ing, are just a first step in combating this

uate student Salma Azam and research

Love Fellowship in Innovative Cancer

cancer-causing gene. Ultimately, the siR-

specialist Trent A. Waugh. The senior

Therapies, and the Jeffrey Lee Cousins

NA sequences will have to be designed

author of this study was Anil Sood, M.D.,

Fellowship in Lung Cancer Research.

This research was funded through the

Chemo’s Effect on Brain Cells and Potential Link to Autism Pinpointed UNC School of Medicine researchers have found for the first time a biochemical mechanism that could be a cause of “chemo brain” – the neurological side effects, such as memory loss, confusion, difficulty thinking and trouble concentrating – that many cancer patients experience while on chemotherapy to treat tumors in other parts of the body. The research, published in Proceedings of the National Academy of Sciences, shows how the common chemotherapy drug topotecan can drastically suppress the expression of Topoisomerase-1, a gene that triggers the creation of proteins essential for normal brain function. Specifically, the drug tamps down the proteins that are necessary for neurons to communicate through synapses. However, the researchers found that the protein levels and synaptic communication return to normal when the drug is removed. “There’s still a question in the cancer field about the degree to which some chemotherapies get into the brain,” said Mark Zylka, Mark Zylka, Ph.D. Ph.D., associate professor of cell biology and physiology and cosenior author of the PNAS paper. “But in our experiments, we show that if they do get in, they can have a dramatic effect on synaptic function. We think drug developers should be aware of this when testing

18

The Triangle Physician

their next generation of topoisomerase inhibitors.”

same synaptic genes linked to autism. This discovery led them to investigate how topotecan affects the specific topoisomerase enzymes in cancer cells and in neurons. In the PNAS paper, the researchers describe how topotecan hits its intended target – the topoisomerase proteins that are integral for cell division, a hallmark of cancer cells. But these proteins exist to varying degrees in many cell types.

Neurons expressing the Topoisomerase-1 gene (green). Image by Angela Mabb, Ph.D.

The researchers also suggest that if these synaptic enzymes are affected during brain development and throughout life, then the result could be long-term neurodevelopmental problems, such as those found in people with autism spectrum disorder. Essentially, the brain would be wired incorrectly. Topotecan is not the only “environmental factor” that can suppress the genes linked to autism. Research to quantify these biochemical effects in animals is ongoing at UNC. The PNAS study comes one year after Dr. Zylka and UNC colleague Ben Philpot, Ph.D., professor of cell biology and physiology and co-senior author, reported in Nature that topotecan halted the expression of unusually long genes in neurons – the

UNC postdoctoral fellow Angela Mabb, Ph.D., used several biochemical, electrophysiological and imaging techniques to study how cortical neurons of mice react to topotecan. She found that the drug depleted the synaptic proteins that extremely long genes encode – proteins including Neurexin-1, Neuroligin-1, Cntnap2, and GABAAβ3. This depletion drastically dampened the spontaneous synaptic activity and transmission of signals between neurons. But the main bodies of the neurons remained unaffected. “The cells seemed quiet, as if in a dormant state,” Dr. Mabb said. “But they remained healthy. And once the drug was washed out, Angela Mabb, Ph.D. the synaptic function returned to normal.” Dr. Philpot added, “Although we stress that our experiments are with cells in a dish,


UNC Research News our results are consistent with the kinds of side effects that cancer patients report during chemotherapy.” Ben Philpot, Ph.D.

These experiments used only topotecan, but there’s an entire class of topoisomerase inhibitors. Many other similar drugs are now in development, and scientists have already found that these drugs can effectively penetrate

the blood-brain barrier.

person.”

“Many in the cancer field are focused, as they should be, on whether a drug can kill a tumor, not what the cognitive side effects might be,” Dr. Zylka said. “But this study provides insights into potential serious side effects of drugs used to treat various forms of cancer. It is very good to know that at UNC we have a big effort to study patient-reported outcomes during therapy so that we can balance care for the whole

Drs. Zylka and Philpot are members of the UNC Lineberger Comprehensive Cancer Center, the UNC Neuroscience Center and the Carolina Institute for Developmental Disabilities. This research was funded by the National Institutes of Health, the Simons Foundation, and the Angelman Syndrome Foundation.

Large Study Confirms High Mortality for Inpatient STEMI Heart Attacks In 2013, University of North Carolina School of Medicine researchers published a study with a surprising finding: Patients who suffered an ST elevation George A. “Rick” myocardial infarction Stouffer, M.D. (STEMI) heart attack while in the hospital for something else are more likely to die than patients who had the same type of heart attack outside the hospital. A new study by the UNC researchers that evaluated data from more than 62,000 patients treated at hundreds of hospitals in California confirms their earlier finding. The study was published Nov. 16 in the Journal of the American Medical Association. “This study is the largest ever performed on patients who have a heart attack while they are in the hospital for a non-heartrelated condition,” said George A. “Rick” Stouffer, M.D., chief of cardiology at UNC and senior author of the study.

authors analyzed data from the California State Inpatient Database, which included 62,021 STEMI patients treated in 303 California hospitals from 2008 to 2011. Of these patients, 3,068 (4.9 percent) suffered a STEMI while hospitalized for conditions that were not heart related. A STEMI occurs when an artery in the heart is suddenly and completely blocked. This type of heart attack is considered to be more serious and lifethreatening than a non-STEMI heart attack, in which a coronary artery is severely narrowed but is not completely blocked. The new study found that patients who developed STEMI while hospitalized were more likely to be older and female and less likely to be treated with measures that are routinely used for patients who suffer a STEMI outside the hospital, such as cardiac catheterization or angioplasty. In addition, the hospitalized patients were three times more likely to die than those who were not in the hospital when their STEMI started.

In the new study, Dr. Stouffer and his co-

“There are several reasons why the mortality rate is so high in patients who have a STEMI while in the hospital,” Dr. Stouffer said. “The patients are older and have more co-morbidities, such as lung or kidney disease, than do patients who have a STEMI outside of the hospital. But our study shows that the use of percutaneous coronary intervention was associated with a lower mortality rate, even in the highest risk patients. This finding, along with our earlier observation that recognition of STEMI in hospitalized patients is often delayed, suggests two areas in which the care of these patients can be improved.” First author of the study is Prashant Kaul, M.D., assistant professor of cardiology in the UNC School of Medicine. Co-authors are Jerome J. Federspiel, Ph.D.; Xuming Dai, M.D.; Sally C. Stearns, Ph.D.; Sidney C. Smith Jr., M.D.; Michael Yeung, M.D.; Hadi Beyhagi, M.D.; and Lei Zhou, M.D. All of the authors are UNC faculty with appointments in the School of Medicine, the McAllister Heart Institute, the UNC Gillings School of Global Public Health and the Sheps Center for Health Services.

december 2014/January 2015

19


Autism Society of North Carolina

Toolkit Shares Residential Options for Adult Children with Autism Planning for a child’s move away from home can be emotional for any parent; for families affected by autism spectrum disorder, the task is made more difficult by their children’s needs. The Autism Society of North Carolina (ASNC) has created a toolkit to help parents and caregivers as they consider residential options for their loved ones with autism who are nearing adulthood. Almost 14,000 children in North Carolina public schools have a diagnosis of autism. As these students with autism become adults with autism, the state’s families face a growing shortage of supports. The Autism Society of North Carolina is committed to advocating for more resources for families affected by autism and helping them through transitions.

The new toolkit describes the options available on a continuum from independent living to group living settings. It can help parents begin planning for their child’s future by exploring financial options and teaching independent living skills. Finally, the toolkit describes all of the factors to consider when researching a group home for an individual with autism spectrum disorder (ASD). The toolkit was made possible by a grant from The Jack Fanning Memorial Foundation. The foundation, which honors the memory of fallen New York City firefighter Jack Fanning, is committed to aiding the autism community and providing the appropriate research, educational opportunities and support needed for individuals and families to reach their full potential.

The toolkit can be read online, downloaded, and printed at: http://bit.ly/ASNCtoolkits. ASNC offers other resources for families dealing with a loved one’s transition to adulthood: • Autism resource specialists, who are parents of children with autism themselves, connect families to resources and help them as they navigate the services system. • Workshops on topics such as guardianship, transitioning to adulthood and residential options are offered around the state. • The ASNC Bookstore is a one-stop shop for quality autism books and materials on the topic of residential placement. Call (800) 442-2762 for more information or visit www.autismsociety-nc.org.

News Welcome to the Area

Physicians Shifali Arora , MD Gastroenterology, Internal Medicine; Internal Medicine

UNC Gastroenterology Chapel Hill Lindsay Carol Boole , MD Internal Medicine

Duke University Hospitals Durham

Yuen-Jong Liu , MD

Adam Paul Roth , MD

Facial Plastic Surgery; General Surgery; Reconstructive Surgery; Plastic Surgery/Hand Surgery

Anesthesiology

UNC Division of Plastic Surgery Chapel Hill Morgan Rebecca Marino , MD Anesthesiology - Critical Care Medicine, Pain Medicine, and Pain Management

University of North Carolina Hospitals Chapel Hill

UNC Medical Center Dept of Anesthesiology Chapel Hill Kenneth Leland Stone , MD Diabetes; General Practice; General Preventive Medicine; Geriatrics; Internal Medicine

Cary Jeremy Hunter Sutton , MD General Practice

Taren Jarmce Burnette Coley , MD

Sandra Beth Morris , MD

Durham

Psychiatry

Addiction Psychiatry; Child Psychiatry; Forensic Psychiatry; Neurology; Geriatric; Psychosomatic Medicine

Francisco Augusto Sylvester , MD

University of North Carolina Hospitals Chapel Hill Christina Melissa Cruz , MD

University of North Carolina Hospitals Chapel Hill

Psychiatry

Nisarg Babulal Patel , MD

University of North Carolina Hospitals Chapel Hill

Emergency Medicine; Family Medicine; Urgent Care

Lisa Katharyn Lindquist , MD

John Alvin Pfeiffer , MD

Psychiatry

University of North Carolina Hospitals Chapel Hill

20

The Triangle Physician

Pediatric Gastroenterology

North Carolina Children’s Hospital Chapel Hill

Wilson Family Practice

Cary

Physician Assistants Diane Elaine Mayhugh Coles , PA Durham


Take good care of your money.

3.99 LOANS FOR YOUR HOME AWAY FROM PRACTICE. %* APR

Because we know your time and money are both valuable, First Tennessee has developed an exclusive home loan offer for medical professionals that simplifies the mortgage process and allows you to finance up to 100% of your home’s value. Take advantage of our low competitive rates, and move into your dream home or refinance your current one. Contact a Relationship Manager to learn more about our low rates. Ken Reece Senior Vice President ph: 919-789-2981 email: kgreece@ftb.com

Matt Robinson Senior Vice President ph: 919-789-2991 email: mprobinson@ftb.com

Helen Ballentine Senior Vice President ph: 919-789-2992 email: hballentine@ftb.com

1122 Oberlin Road, 3rd Floor, Raleigh, NC 27605 *All loans are subject to credit and collateral approval. Some restrictions apply. For a first lien, non-escrowed 30-year term conventional loan to be held in First Tennessee’s portfolio, the APR may be as low as 3.99%. When the maximum CLTV does not exceed 100%, you have a minimum FICO of 720, a new or existing First Tennessee deposit account with enrollment in payment auto-debit. Rate offer good for applications through 12/31/14. At 3.99% APR for 30 years, your payment for a $250,000 loan would be $1097.75 per month. The payment does not include amounts for taxes, property insurance or flood insurance, where required. Payment amounts will vary if you select a different term or qualify for a different rate. Rates and terms are based on repayment period, loan amount and borrower qualifications and are subject to change. Medical professional defined as an M.D., D.O., or O.M.S. To qualify for the loan, one of the following must be completed: Receive a financial plan prepared by one of First Tennessee Bank’s CERTIFIED FINANCIAL PLANNER™ professionals; have an appointment with an investment adviser from FTB Advisors, Inc.; or have a trust business development officer from First Tennessee Bank work with you and your attorney or accountant to prepare an estate plan for you. © 2014 First Tennessee Bank National Association. www.firsttennessee.com


3D MAMMOGRAPHY WE’RE TALKING WAY BETTER IMAGING, EARLIER DETECTION, FEWER FALSE POSITIVES AND LESS CHANCE OF A CALL BACK. END OF DISCUSSION.

3D MAMMOGRAPHY • GREATER ACCURACY • REDUCED ANXIETY • NOW AT WAKE RADIOLOGY Let’s have a frank discussion. You can’t treat what you can’t detect. And 3D mammography, along with your regular 2D exam, is revolutionizing breast cancer detection. How? By significantly improving clarity for earlier detection and fewer false positives. Which, of course, reduces recall rates and the anxiety that comes with additional tests. To learn more about 3D mammography or to schedule an appointment, visit wakerad.com. Like we said, you can’t treat what you can’t see. And now we’re seeing better than ever. Wake Radiology | North Hills Breast Center | 919-232-4700 | wakerad.com Daily, evening and Saturday appointments | 20 minutes from check-in to exam completion

Profile for TTPLLC

Trianglephy jan2015 final  

The Triangle Physician Dec2014/ January 2015

Trianglephy jan2015 final  

The Triangle Physician Dec2014/ January 2015

Advertisement