Page 1

j u ly 2 0 1 4

The Cancer Center at Maria Parham Medical Center

Delivers Community-Based World-Class Care

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

Communication Tips Administrative Leadership


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COVER STORY

6

The Cancer Center at Maria Parham Medical Center

Delivers Community-Based World-Class Care

j u ly 2 0 14

Vol. 5, Issue 4

FEATURES

9

Patient Relations

10 Tips for Improved Patient Communication â&#x20AC;&#x201C; Part II Dr. Douglas Drossman offers strategies for greater patient involvement in the management of their chronic disease.

10

DEPARTMENTS 12 Womenâ&#x20AC;&#x2122;s Health Genetic Testing for Breast and Ovarian Cancers Offers Benefits

14 Dermatology

Psoriasis: A Systemic Disease

15 Duke Research News

Heart Imaging Complexity in Children May Raise Lifetime Cancer Risk

16 Duke Research News

New Gamma and Neutron Imaging Techniques Deemed Safe in Simulations

17 WAKEMED NEWS

Practice Management

Could Your Practice Benefit from a Change in Administrative Leadership?

Donald Gintzig Assumes Helm

18 UNC Research News

Increased Mucins Pinned to Worsening Cystic Fibrosis Symptoms

19 UNC Research News

Discovery of Enzyme Role May Lead to Better Therapies for Various Cancers

20 UNC Research News

Margie Satinsky encourages careful and honest prac-

tice evaluation and taking the necessary steps

21 News

to achieve great leadership.

Clinical Tool Is First to Evaluate Violence Risk in Military Veterans

Welcome to the Area

COVER PHOTO: Standing in front of the linear accelerator at The Cancer Center at Maria Parham Medical Center (radiation oncology) are, from left: Dianne B. Dookhan, M.D., pathologist with Raleigh Pathology Laboratory Associates; Kulbir K. Sidhu, M.D., radiation oncologist with the Duke Oncology Network and The Cancer Center at Maria Parham Medical Center; Adrian M. Ogle, M.D., urologist; David Mack, M.D., medical oncologist with the Duke Oncology Network and The Cancer Center at Maria Parham Medical Center; John Faulkner, M.D., primary care physician with Four County Primary Care; and Bob F. Noel Jr., M.D., generalsSurgeon with Northern Carolina Surgical Associates.

2

The Triangle Physician


From the Editor

No Place Like Home This month, our cover story features The Cancer Center at Maria Parham Medical Center, a Duke Medicine affiliate that brought to Henderson in 1990 the most advanced technologies and specialized practitioners. Just this past March, the leadership and medical

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

staff achieved the voluntary Commission on Cancer (CoC) accreditation, underscoring their commitment to delivering world-class care to north-central North Carolina and Southside Virginia. Read on about a cancer care center that elevates quality of life for patients and their families living in this rural place.

Also in this issue, Dr. Douglas Drossman offers strategies for effective patient communications in the last of his two-part series. Dr. Andre Lukes discusses genetic testing for breast and ovarian cancers and the benefits to the patient of being informed. On the practice management front, Margie Satinsky outlines the questions whose answers may suggest the need to elevate administrative leadership and the strategies for doing so.

Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Laura Briley, M.D. Douglas A. Drossman, M.D. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Margie Satinsky, M.B.A. Creative Director Joseph Dally jdally@newdallydesign.com

Advertising Sales info@trianglephysiciancom

Summer is a time for vacations, when we can get away and, hopefully, recharge. If your time away is restorative, your relaxed alpha brainwaves just might lead to inspired thinking about your practice and your referral base.

If so, it may lead you to consider the many opportunities to increase awareness via The Triangle Physician, a cost-effective vehicle for delivering key messages straight to a very key audience â&#x20AC;&#x201C; the medical community throughout the eastern half of North Carolina. Your medical news and expert perspective runs at no cost, space permitting. Other opportunities for high-profile visibility include a practice profile on the cover and advertising at competitive rates.

There really is no better way to communicate with the medical community here at home. For more information, contact me at heidi@trianglephysican.com.

Hereâ&#x20AC;&#x2122;s wishing you a summer with opportunities to unwind and reflect.

With great appreciation,

Heidi Ketler Editor

4

The Triangle Physician

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.


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Cover Story

The Cancer Center

at Maria Parham Medical Center Delivers Community-Based World-Class Care The Cancer Center at Maria Parham Medi-

oped a consistent and effective communi-

nurses, radiation technologists, social

cal Center, a Duke Medicine affiliate, has

cation model that benefits each and every

workers, clerical personnel and even pa-

long provided a level of cancer care be-

cancer patient.

tient navigators, who are there to escort the cancer patient through the entire pro-

yond that typically seen at a rural hospital. Of course, it does help when the institute

At The Cancer Center at Maria Parham

cess. This multidisciplinary partnership

it’s affiliated with, the Duke Cancer Insti-

Medical Center, patients needing both dis-

results in improved patient care.

tute, has been ranked among the top cen-

ciplines of cancer therapy are seamlessly

ters in the nation for cancer services, ac-

seen by radiation and medical oncologists.

Hospital physicians involved in any aspect

cording to U.S. News & World Report, and

As needed, surgeons, pathologists, urolo-

of cancer care at Maria Parham routinely

a leader in the southeast since 1993. But

gists, radiologists and other physicians on

attend tumor board meetings and planning

it goes much deeper – the medical staff

the hospital staff join the patient’s health

sessions. Along with determining optimal

at Maria Parham Medical Center and the

care team. This multidisciplinary approach

medical care, other patient needs are rec-

Duke oncologists at the center have devel-

continues with a support staff of registered

ognized and best solutions are discussed.

From left, David Mack, M.D., medical oncologist with the Duke Oncology Network and The Cancer Center at Maria Parham Medical Center, reviews a chart with Catherine Blankenship, R.N., B.S.N., C.H.C.A., director  of The Cancer Center at Maria Parham Medical Center.

6

The Triangle Physician


This type of collaboration, along with an expansion of cancer-related diagnostic services offered at the hospital, allows most patients to receive the care they need here at home. Bob Noel Jr., M.D., a surgeon with Northern Carolina Surgical Associates, is one of the specialists who works closely with The Cancer Center at Maria Parham team. “We had a grass root effort by staff physicians and specialists to create the cancer committee and work toward accreditation as an ACS (American Cancer Society) cancer center. That includes ongoing participation in educational activities, such as tumor board and cancer program improvement activities, such as program and patient care quality analysis,” Dr. Noel says. The Cancer Center at Maria Parham Medical Center Earns

Physicist Qing Chen, R.S.O., D.A.B.R., (left) collaborates with chief therapist Anthony Kidd, C.M.D., R.T., (sitting) and radiation oncologist Kulbir K. Sidhu, M.D. All are members of the Duke Oncology Network and The Cancer Center at Maria Parham Medical Center medical staffs.

National Accreditation The Cancer Center at Maria Parham took

Hospital administration and our strong

that care as convenient as possible to the

another large step in distinguishing itself

clinical team have made the commitment

patient. One of the goals of the center

as a premier place to receive cancer care

to achieve and continue to challenge our-

when it was established in 1990 was to

when the Commission on Cancer of the

selves in how we provide multidisciplinary

eventually provide comprehensive care

American College of Surgeons granted it a

cancer care and awareness in our area.”

within one location. With the addition of

three-year accreditation with commendation in March.

on-board imaging, respiratory gating, comWhen patients receive care at The Cancer

puted tomography simulation and positron

Center at Maria Parham Medical Center,

emission tomography scanning, that goal

To earn voluntary Commission on Cancer

they also have access to information on

has been achieved for a majority of the

(CoC) accreditation, a cancer program

clinical trials and new treatments, genetic

cancer patients.

must meet or exceed 34 CoC quality care

counseling and patient-centered services,

standards, be evaluated every three years

including psycho-social support, a patient

“Most of our cancer patients can now re-

through a survey process and maintain lev-

navigation process and a survivorship care

ceive full-service cancer care right here at

els of excellence in the delivery of compre-

plan that documents the care each patient

Maria Parham,” says Ms. Blankenship.

hensive patient-centered care. Three-year

receives and seeks to improve cancer sur-

accreditation with commendation is only

vivors’ quality of life.

The center has undergone multiple face-

awarded to a facility that exceeds standard

lifts, including a major expansion of the

requirements at the time of its triennial sur-

“The CoC accreditation program brings

medical oncology department in 2010 that

vey.

new and evolving national standards for

nearly quadrupled the size of the unit.

cancer care to our attention quickly, al-

Each of the 12 patient spaces has a view

lowing for prompt incorporation into our

of an outdoor garden that allows natural

patient care plans,” says Dr. Noel.

light into the treatment room. The radiation

Catherine

Blankenship,

R.N.,

B.S.N.,

C.H.C.A., director of The Cancer Center at Maria Parham, says, “This achievement

oncology side of the center is currently

reflects the highest quality of cancer care

Excellent Technologies and

undergoing its own expansion with new

available anywhere. Our program not only

Facilities Improve Patient

treatment rooms, office space and wait-

met the standards to become accredited,

Convenience

ing areas being built to handle the ever-

but also exceeded the requirements to

An important aspect of providing high-

increasing patient volumes the center has

receive commendation in several areas.

quality cancer care is to make receiving

seen during the years.

JULY 2014

7


In the Hands of Well-trained Experts

“Maria Parham is fortunate to have not only

About Maria Parham Medical

As important as all of these new technolo-

a team of talented Duke oncologists but

Center, a Duke LifePoint Hospital

gies are, it is their use in the hands of

also a team of surgeons and specialists on

Maria Parham Medical Center, located in

well-trained, experienced physicians and

staff locally who work side by side with the

Henderson, is a regional hospital serving

staff that makes all the difference. Under

cancer team to provide excellent care here

the people of north-central North Carolina

the leadership of Duke medical oncolo-

in Henderson,” says Bob Singletary, chief

and Southside Virginia. As a Duke LifePoint

gist David Mack, M.D., and Duke radiation

executive officer of Maria Parham Medi-

Hospital, Maria Parham offers a combina-

oncologist Kulbir Sidhu, M.D., The Cancer

cal Center. “Our surgeons, specialists and

tion of Duke University Health System’s

Center at Maria Parham Medical Center

even our primary care physicians actively

world-renowned leadership in clinical

has seen consistent growth in the volume

participate in planning sessions and attend

excellence and quality care and LifePoint

of patients seeking medical and radiation

the tumor board sessions. This type of col-

Hospitals’ extensive resources, knowledge

cancer care. Working along with Drs. Mack

laboration makes for a continuity of care

and experience in operating community

and Sidhu are Duke oncologists Ivy Alto-

not seen in most facilities.”

hospitals.

The Cancer Center at Maria Parham Medi-

Maria Parham offers a wide range of ser-

cal Center is a testament to the way team-

vices and the latest technology to meet the

“Our goal has always been to provide

work between a world-renowned health

health care needs of the community. It is

world class, Duke-level cancer care at Ma-

care institution, like Duke Medicine, and

fully accredited by The Joint Commission

ria Parham, and we feel that we have done

a community-based hospital, like Maria

and Core Measure Sets. For more informa-

just that,” Dr. Mack says.

Parham, can create a special place where

tion about Maria Parham Medical Center,

patients can receive the quality, expertise

call (252) 438-4143 or visit the website at

and commitment they deserve.

www.mariaparham.com.

mare, M.D., (medical) and Nicole a. Larrier, M.D., M.S., (radiation).

Medical Oncology Treatment Room

8

The Triangle Physician


Gastroenterology

Part 2

10 Tips for Improved Patient Communication By Douglas A. Drossman, M.D.

It’s well recognized that good communi-

patient’s personal experience, understand-

cation skills are the cornerstone of an ef-

ing and interests in various treatments and

fective patient-provider relationship. The

then provide choices (rather than direc-

following outlines the final five elements

tives) that are consistent with the patient’s

toward reaching this goal. The first five ele-

beliefs. The patient needs to make the final

ments are outlined in last month’s issue of

decision in these options.

The Triangle Physician. 9) Help the patient take responsibility. 6) Set realistic goals. Patients may come to

Many patients may respond to their illness

the doctor with expectations for a rapid diag-

by feeling helpless and dependent on the

nosis and cure. However, the clinician may

clinician thus abrogating their responsibil-

see this as a chronic disorder requiring ongo-

ity. However, patients with chronic illness

ing management. Therefore it helps to clarify

do better when they take responsibility for

and reconcile the patient’s goals.

their care. As an example, rather than asking the patient: “How is your pain doing?”

For example, the clinician might say: “I

one might say “How are you managing with

can understand how much you want these

your pain?” The former question suggests

longstanding symptoms to go away, but

the responsibility for pain management is

realistically we need to find better ways to

the physician’s, while the latter acknowl-

manage them, just like arthritis or migraine

edges the patient’s role.

headaches. If you could reduce your symptoms by 30 percent or 40 percent would

Another method includes offering any of

that help?”

the several treatment approaches with a discussion of their risks and benefits, so the

7) Reassure. Patients often fear serious

patient can make the choice.

consequences of their disease and may feel helpless, vulnerable to their condition and

10) Establish boundaries. For some pa-

out of control. Reassurance occurs by:

tients, it is important to establish and main-

• Identifying the patient’s worries and

tain “boundaries” related to frequent phone

concerns

calls, unexpected visits, a tendency toward

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 patientprovider relationship. 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.

• Acknowledging and validating them

lengthy visits or unrealistic expectations

• Responding to their specific concerns

for care. The clinician needs to present

The

expectations in a way that is not perceived

information: 2012 David Sun Lecture:

It’s important to avoid premature or “false”

as rejecting or belittling to the patient yet

Helping Your Patient by Helping Yourself

reassurances (e.g., “Don’t worry, every-

is also consistent with personal needs. For

– How to Improve the Patient – Physician

thing’s fine.”) particularly before the medi-

example, if a patient calls by phone during

Relationship by Optimizing Communication

cal evaluation is completed.

off hours when not on call, the clinician can

Skills; Douglas A. Drossman, MD; Am

gently remind the patient that it would be

J Gastroenterol 2013; 108:521–528; doi:

8) Negotiate. The basis for patient-centered

better to have the discussion at their next

10.1038/ajg.2013.56; published online 19

care is that patient and physician must mu-

visit. Here it is important not to try to ad-

March 2013.

tually agree on diagnostic and treatment

dress the issue on the phone as that might

options. The doctor should ask about the

encourage further phone calls.

following

article

offers

more

JULY 2014

9


Practice Management

Could Your Practice Benefit from a Change in

Administrative Leadership? By Margie Satinsky

Managing a medical practice requires

Planning and Marketing

both strategic vision and operational

• Is there a strategic business plan that

skills. Ongoing changes in reimbursement,

guides the practice’s thinking and is

technology and the legislative landscape

regularly updated?

make the job challenging, regardless

• Is the practice well informed about

of the training and experience of the

demographic trends, community

individual responsible for the job.

dynamics, new laws and regulations and the competitive environment?

What’s the right administrative approach for your practice? There are big differences in the education and experience of an

• Is there a marketing plan that supports the strategic business plan?

Margie Satinsky is president of Satinsky Consulting, L.L.C., a Durham consulting firm that specializes in medical practice management. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century.

• Has the practice identified external

office manager, practice manager and

professionals who can help it

practice administrator.

accomplish its goals?

• Does the practice have and use a formal performance evaluation system? • Is there a formal orientation program

We recommend starting with the needs

Financial Management

of the practice, not with the availability

• Does the practice have both operating

• Is there a formal system for physician

of someone you know who might be

and capital budgets that support the

recruitment, hiring, orientation and

interested in making a job change or with

strategic plan?

performance?

a well-meaning but inexperienced relative who is willing to work for a low salary.

for all administrative and clinical staff?

• Is there a comprehensive revenue cycle management system that enables

Facilities

the practice to meet its financial goals?

• Does the current facility meet current

Ask the following questions about the

• Does the practice have a managed care

current management of the practice. If

strategy that helps it maximize revenue

the responses suggest a need for help,

and monitor actual vs. expected

Information Technology

develop a job description and recruit.

payments?

• Does the practice use information

Don’t put the cart before the horse!

• Is there a clear understanding of Accountable Care Organizations

What Does Your Practice Need?

(ACOs) and other value-based

Daily Practice Operations

methods of payment that encompasses

• Do the current methods for overseeing

how they work and how the savings/

daily practice operations meet

losses will be distributed?

the needs of patients, physicians, managers and staff? • Do staff members work as a team to identify and resolve operational problems on a timely basis? • Does the practice clearly communicate practice plans, policies and

administration and the direct provision of patient care? • Is every staff member trained to use the information technology solutions that are currently in place?

Human Resources

major changes in information

• Does the practice have a history of

technology, and if so, have decisions

high staff turnover?

already been made?

• Are responsibilities and accountabilities clear? • Does every employee have a clear job description and understand job

the information on a timely basis?

expectations?

The Triangle Physician

technology to support both

• Does the practice expect to make

procedures to all who need to know

10

and projected needs?

Quality Measurement and Improvement • Does the practice respond on a timely basis to patient complaints and


Establish a starting salary range with room

lowed by a written offer to your candidate

for growth. Advertise online and select the

of choice. A written employment contract

surveys for both patients and physician

health care management organizations

is optional. If you prefer to use this ap-

colleagues?

that can assist with recruitment. Two

proach, seek legal guidance.

questions about claims? • Does the practice use satisfaction

• Does the practice understand the

reliable resources are North Carolina

requirements of different systems

Medical Group Managers (www.ncmgm.

Conclusion

for measuring quality (e.g. Patient

org) and Medical Group Management

The best way to ensure outstanding

Centered Medical Home, Meaningful

Association’s

administrative leadership for your practice

Use)?

partner, HealtheCareers.com.

(MGMA)

administrative

is to start with your needs, develop a clear job description and then recruit. The best

• Does the practice use its software and reporting capabilities to profile

Conduct telephone interviews using a set

results come from taking the right steps in

the care provided to individuals and

list of questions and identify candidates

the right order.

groups of patien ts?

whom you would like to meet in person.

• Does the practice benchmark itself against acceptable standards and take

Following personal interviews, check ref-

For more information, visit

erences carefully. Make a verbal offer fol-

www.satinskyconsulting.com.

measures to improve the care that it provides? Legal and Regulatory Compliance • Does the practice have and use a compliance plan? • Is the practice compliant with the Health Insurance Portability and Accountability Act (HIPAA), Occupational Safety and Health Administration (OSHA) laws and regulations and other requirements? • Are annual coding audits included in the compliance program? Obtaining Outside Help When Needed • Does the practice know what it knows and where there are gaps in knowledge? • Does the practice engage external consultants to help with tasks that cannot be performed internally? • Does the practice manage the external consultants that it has identified as appropriate resources for the practice? Recruiting the Right Individual If the responses to the questions above suggest that your practice might benefit from a change in administrative leadership, develop a job description. Specify priorities, day-to-day responsibilities, reporting relationship, supervisory responsibility and required education and experience.

JULY 2014

11


Women’s Wellness

Genetic Testing for Breast and Ovarian Cancers Offers Benefits By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.

Seven percent of breast cancer and 11-

population, up to 50 percent versus 2 per-

15 percent of ovarian cancer cases are

cent. Similarly the risk of breast cancer by

caused by BRCA1 or BRCA2 genes.

age 70 for those with the BRCA mutation compared to the general population is up

Fortunately, genetic testing is available

to 87 percent versus 8 percent.

for hereditary breast and ovarian cancer (HBOC) syndrome. Myriad offers a test

This highlights that age is a risk, but a wom-

called BRACAnalysis. The Centers for Dis-

an with the BRCA mutation has a markedly

ease Control and Prevention (CDC) offers

higher risk than a woman in the general

the Know:BRCA tool, which can help a

population. Further, second breast can-

woman understand her risk of having this

cers (after a primary cancer) and ovarian

gene mutation. Further, reliable informa-

cancer are more common in women with

tion for providers is available at both orga-

BRCA mutation compared to the general

nizations’ websites: www.myriad.com and

population.

www.cdc.gov/cancer/breast. Who Should Be Tested? Health care providers can and should

There are clear risk factors that support

screen women for risks and identify who

testing. Specifically, if a woman has:

should receive genetic testing. One of the

• Breast cancer at age 50 or younger.

best graphs highlighting the difference be-

• Ovarian cancer at any age.

tween the general population and those

• Ashkenazi Jewish descent and a person-

with BRCA mutations is below from the

al or family history of breast, ovarian or

Myriad website at www.myriad.com.

pancreatic cancer.

The graph shows that a woman with the

In terms of family history, the following

BRCA mutation has a higher risk of breast

supports testing:

cancer by age 50 compared to the general

• Two breast cancers in the same person

After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position (2007) to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.

or on the same side of the family. • Triple negative breast cancer at any age in the family. • Pancreatic cancer and an HBOCassociated cancer (breast, ovarian and pancreatic) in the same person or on the same side of the family. • Breast cancer in three or more on the same side of family. • BRCA1 or BRCA2 mutation in the family. The Hereditary Cancer Quiz can be found at www.hereditarycancerquiz.com. Also, the CDC and the National Cancer Institute have tools. Our clinic uses the one from Myriad.

12

The Triangle Physician


Women’s Wellness Why Should Those at Risk Be Tested?

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6/23/14 10:20 AM

as many other private practice facilities.

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

Breast Cancer Facts •O  ne in eight women will be diagnosed with breast cancer in her lifetime. In the United States, more than 220,000 women are diagnosed each year with breast cancer and over 40,000 will die from breast cancer. •B  reast cancer is more common in white women compared to other races. • S even percent of breast cancer cases

Drossman Gastroenterology

are hereditary. •E  arly menstruation (before age 12) and late menopause (after 55) are associated with breast cancer. • L ifestyle choices do matter; a sedentary lifestyle increases one’s risk of breast cancer. •O  ther risk factors include: being overweight or obese, frequent consumption of alcohol and taking combined hormone replacement therapy (HRT).

JULY 2014

13


Dermatology

Psoriasis A Systemic Disease By Laura Briley, M.D.

Our skin is our largest organ. It covers ap-

ing in severe pain, stiffness and inflamma-

proximately 18 square feet of the human

tion in and around the joints.

body and serves both as a protective layer that keeps invaders out and an expansive

“We’ve moved from rub-on medications

sensor packed with nerves that keep the

to highly effective photo light therapy to a

brain in touch with the outside world.

half-dozen very effective biologic medica-

The health of our skin is often a barometer

tions,” says Laura Briley, M.D., of Southern

for overall health, providing practitioners

Dermatology Skin Cancer & Skin Renewal

with vital diagnostic data.

Center in Raleigh.

Just a few decades ago, both doctors

Some biologics target T cells, the “gener-

and patients thought of psoriasis, the red

als” of the immune system that recognize

scaly patches that affect nearly 7.5 Ameri-

bacteria and viruses and coordinate an

cans, as a problem on the skin and not

immune response. In psoriasis, however,

as a systemic issue. We now know that

certain T cells are mistakenly activated

psoriasis is a systemic disease that can go

and migrate to the skin. Once in the skin,

deep into the body and the joints, with co-

they begin to act as if they are fighting an

morbidities linked to greater risks of heart

infection or healing a wound, which sets

disease, depression, obesity and diabetes.

off a chain of events that leads to the rapid

Some 10-30 percent of people with psoria-

growth of skin cells, causing lesions to

sis also develop psoriatic arthritis, result-

form. Certain biologic medications treat

Dr. Laura Briley, a board-certified dermatologist at Southern Dermatology Skin Cancer Center & Skin Renewal Center in Raleigh, specializes in dermatologic surgery and cosmetic dermatology, among other specialties. She earned her bachelor of science degree from Wake Forest University and her medical degree from The Brody School of Medicine at East Carolina University. She completed her internship at Roger Williams Medical Center in Providence, R.I., and residency at The Brody School of Medicine at East Carolina University. Dr. Briley is a member of the American Academy of Dermatology, American Medical Association and Alpha Omega Honor Society.

psoriasis by preventing the activation or migration of T cells or by reducing the number of psoriasis-involved T cells in the body. “We most often prescribe biologics for people with moderate to severe psoriasis and psoriatic arthritis. Often they work well for people who have not responded to other conventional treatments or cannot tolerate the side effects of some medications,” notes Dr. Briley. Not all patients will be able to tolerate biologics, however. Patients with liver problems can’t take the medication methotrexate, and those with a history of skin cancer are at risk with photo light therapy. Additionally, patients with active infections may not be eligible for some biologics.

14

The Triangle Physician


Duke Research News

Heart Imaging Complexity in Children May Raise Lifetime Cancer Risk percent for complex imaging.

Children with heart disease

patients who get frequent

are exposed to low levels

studies as part of their care,

of radiation during X-rays,

we wanted to better under-

“Clinicians need to weigh the risks and

which do not significantly

stand the risk associated

benefits of different imaging studies, in-

raise their lifetime cancer

with repeated exposure.”

cluding those with higher radiation exposure,” Dr. Hill said. “We’re not proposing

risk.

However,

children

who

undergo

repeated

Dr. Hill and his colleagues

eliminating complex imaging – in fact,

complex imaging tests that

studied a group of 337 chil-

they’re critically important to patients

deliver higher doses of ra-

dren ages six and younger

– but we can make significant improve-

diation may have a slightly

who had one or more sur-

ments by prioritizing tests and simply

increased lifetime risk of

geries for heart disease

recognizing the importance of reducing

from 2005 to 2010. During

radiation exposure in children.”

cancer, according to re-

Kevin D. Hill, M.D., M.S.

searchers at Duke Medicine.

the five-year study period, the children received an average of 17 im-

The findings, published June 9 in the

aging tests, each as part of their medical

American Heart Association journal Cir-

care before and after their surgeries.

culation, represent the largest study of cumulative radiation doses in children with

In order to estimate the amount of radia-

heart disease and associated predictions

tion delivered in the tests, the researchers

of lifetime cancer risk.

used a combination of existing data on radiation levels, as well as simulations that

Children with heart disease frequently

calculated radiation doses using child-

undergo imaging tests, including X-rays,

sized “phantoms,” or models, to estimate

computed tomography scans and cardiac

radiation exposure.

catheterization procedures. The number of imaging studies patients are exposed

The researchers found that most children

to depends on the complexity of their dis-

had low exposure to radiation, amounting

ease, with more serious heart conditions

to less than the annual background expo-

typically requiring more testing.

sure in the United States. However, certain groups of children, particularly those with

Although children benefit from advanced

more complex heart disease, were ex-

imaging procedures for more accurate

posed to higher cumulative doses from re-

The researchers also noted that lifetime

diagnosis and less-invasive treatment, the

peated tests and high-exposure imaging.

cancer risk was increased among girls and children who had imaging tests done

increase in radiation has potential health risks.

Abdominal and chest X-rays accounted

at very young ages. Girls had double the

for 92 percent of the imaging tests, but

cancer risk of boys because of their in-

“In general, the benefits of imaging far

only 19 percent of the radiation exposure.

creased chances of developing breast and

outweigh the risks of radiation exposure,

Advanced imaging (CT and catheteriza-

thyroid cancers.

which on a per-study basis are low,” said

tion) made up only 8 percent of imaging

senior author Kevin D. Hill, M.D., M.S., an

tests performed, but accounted for 81 per-

In addition to Dr. Hill, authors include Ja-

interventional cardiologist and assistant

cent of radiation exposure.

son Johnson, Christoph Hornik, Jennifer Li, Daniel Benjamin Jr., Terry Yoshizumi,

professor of pediatrics at Duke University School of Medicine.

The researchers estimated the average

Robert Reiman and Donald Frush. The

increase in lifetime cancer risk to be 0.07

study was supported by the National In-

“We know that each of these individual

percent, with the risk increase ranging

stitutes of Health (UL1TR001117) and the

tests carries a small amount of risk, but for

from 0.002 percent for chest X-rays to 0.4

Mend a Heart Foundation.

JULY 2014

15


Duke Research News

New Gamma and Neutron Imaging Techniques Deemed Safe in Simulations Gamma and neutron imaging offer possible improvements over existing techniques such as X-ray or computed tomography, but their safety is not yet fully understood. Using computer simulations, imaging the liver and breast with gamma or neutron radiation was found to be safe, delivering levels of radiation on par with conventional medical imaging, according to researchers at Duke Medicine. The findings, published in the June issue of the journal Medical Physics, will help researchers move testing of gamma and neutron imaging into animals and later humans. Conventional medical imaging tools – including X-ray, ultrasound, CT and magnetic resonance imaging – detect disease by finding the anatomy, or shape and size, of the abnormality. When using these tools to screen for cancer, a tumor must be large enough to be detected, and if found, a surgical biopsy is generally required to determine if it is benign or malignant. Duke researchers are working to develop imaging technologies to detect disease in its earliest stages, much before the tumors grow large enough to be detected using conventional methods. Two imaging techniques they are researching are neutron stimulated emission computed tomography and gamma stimulated emission computed tomography. Research has shown that many tumors have an out-of-balance concentration of trace-level elements naturally found in the body, such as aluminum and rubidium. These elements stray from their normal concentration levels at the earliest stages of tumor growth, potentially providing an early signal of disease. The neutron and gamma imaging methods measure the concentrations of elements in the body, determining molecular properties without the need for a biopsy or injection of contrast media. The goal is for these tests to be able to distinguish between benign and malignant lesions, as well as healthy tissue. “Gamma and neutron imaging may eventually be able to help us to detect cancer earlier without having to perform an invasive biopsy,” said Anuj Kapadia, Ph.D., assistant professor of radiology at Duke University School of Medicine and the study’s senior author. Gamma and neutron imaging may also have applications for patients undergoing cancer treatment. Patients currently wait weeks or months to see if their cancer is responding to a particular treatment and shrinking in size, but gamma and neutron imaging may

16

The Triangle Physician

Simulated three-dimensional dose measurements of the breast (top) and abdomen/liver (bottom) show the dose imparted by gamma and neutron imaging to the whole body. The dose is shown on a red and yellow color map, where yellow shows maximum dose. (Credit: Duke Medicine)


Duke Research News be able to tell if a treatment is working

breast using neutron and gamma imaging.

est amount of radiation given its location in

earlier by detecting molecular changes di-

They found that the majority of radiation

the direct path of the beam. Further work

rectly within the tumor.

was delivered to organs directly within the

is needed to reduce and better target gam-

radiation beam, and a much lower dose

ma radiation doses in liver scans.

While improved diagnostic tests would

was absorbed by tissue outside of the ra-

provide clinicians with useful tools, one

diation beam.

“The results show that despite the use of a highly scattering particle, such as a neu-

ongoing question is the safety of gamma and particularly neutron radiation. Upon

In simulated breast scans, the radiation

tron, the dose from neutron imaging is on

entering the body, neutrons scatter con-

was almost entirely limited to the area of

par with other clinical imaging techniques

siderably, with the possibility of reaching

the breast being scanned. The dose to the

such as X-ray CT,” Dr. Kapadia said. “Neu-

several vital organs. Thus, researchers

breast accounted for 96 percent of the ra-

tron and gamma radiation may become vi-

have been concerned about how much

diation in neutron scans and 99 percent

able imaging alternatives, if further testing

radiation is absorbed in the targeted organ

in gamma scans. The heart and lungs re-

proves them to be safe and effective.”

versus surrounding tissue. For instance, in

ceived less than 1 percent of the radiation

a breast scan, how much radiation is deliv-

dose.

In addition to Dr. Kapadia, authors include Matthew D. Belley and William Paul Segars

ered unnecessarily to the heart or lungs? When imaging the liver in simulation, the

of Duke Medicine. The study was support-

Using detailed computer simulations, Dr.

neutron scan imparted the highest radia-

ed by the National Institutes of Health (R01-

Kapadia and his colleagues estimated the

tion dose to the liver, while in the gamma

EB001838, T32-EB007185).

radiation dose delivered to the liver and

scan, the stomach wall absorbed the great-

WakeMed News

Donald Gintzig Assumes Helm Donald R. Gintzig

physician engagement, fiscal stewardship

assumed the role

and the health of our community,” said

Mr. Gintzig, a retired rear admiral in the

of

William H. McBride, chair, WakeMed

United States Navy, held positions of

and

Board of Directors. “We believe Donald

increasing responsibility throughout his

executive

is the right leader to ensure WakeMed

military career, during which he oversaw

officer May 27,

remains the preferred provider of health

more than 150,000 navy personnel (active

after serving in

care in Wake County and is able to deliver

and reserve), 40 military treatment

the interim role

upon its vitally important mission for

facilities and 200-plus clinics and budgets

since

years to come.”

of more than $7 billion.

from multiple well-qualified candidates

“I am humbled and honored to be chosen

Mr. Gintzig began his career in private

following

WakeMed

president chief

Donald R. Gintzig

October.

He was selected nationwide

to lead this extraordinary organization

sector health care in 1983 and has served

search. The search process was led by

which is devoted to improving the

as CEO for not-for-profit, faith-based

a nine-person committee and included

health and wellbeing of our community

and for-profit health systems, including

input from more than 400 internal and

while building upon the legacy of those

United Health Group, Minneapolis, Minn.;

community-based stakeholders.

preceding me,” said Mr. Gintzig. “Our

St. Thomas Health Services, Nashville,

patients and their families dignify us by

Tenn.; and The Pottsville Hospital and

“In addition to having the right credentials,

choosing us at times when they are most

Warne Clinic, Pottsville, Pa.; among

Donald’s leadership style has proven

vulnerable, and WakeMed is blessed to

others. He earned both his undergraduate

to be a good fit with the culture of our

have an exceptionally talented team of

and graduate degrees from George

organization. He has demonstrated an

physicians, volunteers, caregivers and

Washington University, Washington, D.C.

outstanding commitment to WakeMed’s

support associates who embody our

mission, patient and family-centered care,

mission every day.”

an

inclusive

JULY 2014

17


UNC Research News

Increased Mucins Pinned to Worsening Cystic Fibrosis Symptoms University of North Carolina School of Medicine researchers have provided the first quantitative evidence that mucins – the protein framework of mucus – are significantly increased in cystic fibrosis patients and play a major role in failing lung function. The research, published June 2 in the Journal of Clinical Investigation, shows that a three-fold increase of mucins dramatically increases the water-draining power of the mucus layer. This hinders mucus clearance in the CF lung, resulting in infection, inflammation and ultimately lung failure. “Our finding suggests that diluting the concentration of mucins in CF mucus is a key to better treatments,” said Mehmet Kesimer, Ph.D., associate Mehmet Kesimer, Ph.D. professor of pathology and laboratory medicine and co-senior author of the JCI paper. Ashley Henderson, M.D., assistant professor of medicine and co-first author of the JCI paper, added, “We think this study shows why nebulized hypertonic improves Ashley Henderson, M.D. saline the hydration of the CF airway, improves the patient’s mucus clearance and, in so doing, increases lung function.” The UNC study also casts further doubt on a controversial 2004 study that disputed the theory that mucins play a major role in CF.

18

The Triangle Physician

This work, a collaboration of 13 UNC scientists, is part of an extensive UNC lung research program based in the new Marsico Lung Institute, which is led by Richard Boucher, M.D., co-senior author of the JCI paper. “This paper points to a therapeutic strategy to rectify this problem of mucus clearance and provides signposts, or biomarkers, to guide development of novel therapies,” said Dr. Boucher, the James C. Moeser Eminent Distinguished Professor of Medicine. Also, by measuring mucin concentration in patient mucus, doctors could learn whether therapies are working and to what degree. Scientists and doctors have known for a long time that failing to clear mucus is the major reason why CF patients face chronic lung infection and inflammation. But the mechanisms of this failure have not been well understood. Normally, when humans breathe, the mucosal layer of our lungs trap the contaminants – dust, pollutants, bacteria – naturally found in air. Then, epithelial cells brush the mucus up and out of our lungs. In people with cystic fibrosis, though, this process doesn’t work as well because they lack a properly functioning CFTR gene. They continually battle infections and must work hard to clear mucus from their lungs. This is where mucins come into play. Mucins give mucus its gel-like thickness and elasticity. “Without mucins, mucus would have the viscosity of blood,” Dr. Kesimer said. “The vast majority of mucus is water, but 30 to 35 percent of the remaining solid material is made up of mucins. They form a network of bonds that serves as a framework.” This is why Dr. Kesimer and his UNC mentor, the late John Sheehan, Ph.D., Distin-

guished Professor of Biochemistry and Biophysics, suspected that something must happen to mucins in the CF lung. They and others knew that CF mucus is typically drier than normal mucus. Back in 2004, however, other researchers used a standard immunologic analysis to show that mucins were decreased in CF secretions. They suspected DNA was the main culprit that caused problems in CF mucus. Dr. Sheehan and Dr. Kesimer were skeptical, as was Dr. Henderson, a clinician who saw CF patients and had been a research fellow in Dr. Sheehan’s lab. They set out to conduct various novel experiments to physically measure the amount of mucins in CF secretions and normal mucus. In one experiment, they used a technique called size exclusion chromatography: In a column, they added custom-made beads that had small pores. Smaller proteins could enter the pores while mucins could not. Through this separation, Dr. Kesimer and Dr. Henderson’s team isolated the mucins and simultaneously measured their concentration using a refractometer. By using sputum samples from CF patients, the researchers found that CF mucus contained three times as many mucins than did normal samples. They also conducted experiments to show that mucin overabundance led to a six-fold increase of the pressure between the mucus layer and the ciliated layer. This finding affirms the CF disease model that UNC researchers published in the journal Science in 2012. In essence, in a CF patient, the increased osmotic pressure of the concentrated mucus layer crushes the ciliated cells so that mucus is not cleared. The lung becomes a breeding ground for bacteria. This leads to more mucins, more mucus, inflammation and subsequently lung failure.


UNC Research News Moreover, Dr. Kesimer’s team showed precisely why the 2004 research was flawed. Those researchers used a classic antibody-based immunologic technique called a western blot, which measures the expression of a given protein – in this case mucins – based on an antibody response to that protein. But, as Dr. Kesimer pointed out, antibodies must latch onto proteins at specific sites on the proteins’ surfaces. When Dr. Kesimer conducted the western blot, he got the same result as the 2004 researchers. But then he used a technique called mass spectrometry to find that CF secretions are full of proteases – enzymes that

break down molecules. The mass spectrometry showed that the proteases degraded the mucins, essentially “erasing” many of the sites where antibodies could bind without disrupting the structural integrity of mucins. “For that reason, we saw less antibody response using the western blot,” Dr. Kesimer said. And so it looked as if there were fewer mucins. “But by using more accurate methods, we clearly saw the increase of mucins. In fact, we’ve analyzed many samples of sputum from patients with other chronic pulmonary diseases and we saw the increase in mucins in them, as well.”

Camille Ehre, Ph.D., a research associate at the UNC CF Research Center/ Marsico Lung Institute, is co-first author of the paper. Other authors of the paper, all of whom conducted this research while at UNC, include Brian Button, Ph.D., Lubna Abdullah, Ph.D., Li-Heng Cai, Ph.D., Margaret Leigh, Ph.D., Genevieve DeMaria, Ph.D., Hiro Matsui, Ph.D., Scott Donaldson, Ph.D., C. William Davis, Ph.D., and John Sheehan, Ph.D. The National Institutes of Health and the Cystic Fibrosis Foundation funded this research.

Discovery of Enzyme Role May Lead to Better Therapies for Various Cancers Twelve years ago, University of North Carolina School of Medicine researcher Brian Strahl, Ph.D., found that a protein called Set2 plays a role in how yeast genes are expressed – specifically how DNA gets transcribed into messenger RNA. Now his lab has found that Set2 is also a major player in DNA repair, a complicated and crucial process that can lead to the development of cancer cells if the repair goes wrong. “We found that if Set2 is mutated, DNA repair does not properly occur” said Dr. Strahl, a professor of biochemistry and biophysics. “One consequence Brian Strahl, Ph.D. could be that if you have broken DNA, then loss of this enzyme could lead to downstream mutations from inefficient repair. We believe this finding helps explain why the human version of Set2 – which is called SETD2 – is frequently mutated in cancer.”

The finding, published online June 9 in the journal Nature Communications, is the first to show Set2’s role in DNA repair and paves the way for further inquiry and targeted approaches to treating cancer patients. In previous studies, including recent genome sequencing of cancer patients, human SETD2 has been implicated in several cancer types, especially in renal cell carcinoma – the most common kind of kidney cancer. SETD2 plays such a critical role in DNA transcription and repair that Dr. Strahl is now teaming up with fellow UNC Lineberger Comprehensive Cancer Center members Stephen Frye, Ph.D., director of the UNC Center for Integrative Chemical Biology and Drug Discovery (CICBDD); Jian Jin, Ph.D., also with the CICBDD; and Kim Rathmell, M.D., Ph.D., an associate professor in the department of genetics. Their hope is to find compounds that can selectively kill cells that lack SETD2. Such personalized medicine is a goal of cancer research at UNC and elsewhere.

In recent years, scientists have discovered the importance of how DNA is packaged inside nuclei. It is now thought that the “mis-regulation” of this packaging process can trigger carcinogenesis. This realm of research is called epigenetics and at the heart of it is chromatin – the nucleic acids and proteins that package DNA to fit inside cells. Proper packaging allows for proper DNA replication, prevents DNA damage and controls how genes are expressed. Typically, various proteins tightly regulate how these complex processes happen, including how specific enzyme modifications occur during these processes. Some proteins are involved in turning “on” or turning “off” these modifications. For instance, protein and DNA modifications involved in gene expression in kidneys must at some point be turned off. In 2002, Dr. Strahl found that Set2 in yeast played a role as an off switch in gene expression – particularly when DNA is copied to make RNA. Now, Dr. Strahl’s team found that Set2 also regulates how the broken strands of DNA – the most severe

JULY 2014

19


UNC Research News form of DNA damage in cells – are repaired. If DNA isn’t repaired correctly, then that can result in disastrous consequences for cells, one of them being increased mutation that can lead to cancer. Through a series of biochemDeepak Jha ical and genetic experiments, Deepak Jha, a graduate student in Dr. Strahl’s lab, was able to see what happens when cells experience a

break in the double-strand of DNA. “We found that Set2 is required when cells decide how to repair the break in DNA,” said Mr. Jha, the first author of the Nature Communications paper. He said that the loss of Set2 keeps the chromatin in a more open state – not as compact as normal. This, Dr. Strahl said, leaves the DNA at greater risk of mutation. “This sort of genetic instability is a hallmark of cancer biology,” Mr. Jha said. Dr. Strahl and Mr. Jha said they still don’t know the exact mechanism by which Set2 becomes mutated or why its mutation affects its function. That’s the subject of

their next inquiry. They are now collaborating with Dr. Rathmell and Ian Davis, also members of UNC Lineberger Comprehensive Cancer Center, to study how the human protein SETD2 is regulated and how its mutation contributes to cancer. “We think this work will lead to a greater understanding of cancer biology, and open the door to future therapeutic approaches for patients in need of better treatment options,” Dr. Strahl said. This research was funded through a grant from the National Institutes of Health.

Clinical Tool Is First to Evaluate Violence Risk in Military Veterans A new five-question screening tool can help clinicians identify which veterans may be at greater risk of violence, according to a new study led by a University of North Carolina researcher.

Eric Elbogen, Ph.D., research director of the Forensic Psychiatry Program in the UNC School of Medicine and psychologist in the United States Department of Veterans Affairs.

The study, published online by the American Journal of Psychiatry, is based on a national survey sample of veterans combined with a smaller, in-depth assessment sample. The screening tool, called the Violence Screening and Assessment of Needs (VIO-SCAN), asks veterans about financial stability, combat experience, alcohol misuse, history of violence or arrests and probable posttraumatic stress disorder (PTSD), plus anger. The screening tool can be viewed in the text of the article at http://ajp.psychiatryonline.org/data/Journals/AJP/0/appi.ajp.2014.13101316.pdf.

On the VIO-SCAN, veterans give yes-or-no answers to questions such as, “Did you personally witness someone being seriously wounded or killed?” and “Have you ever been violent towards others or arrested for a crime?” The answer to each question is scored as either O or 1. The score for each answer is combined to yield an overall score, ranging from 0 to 5, with O indicating generally lower risk and 5 indicating generally higher risk.

“When we hear about a veteran being violent, there is a knee-jerk reaction that it stems from PTSD. The VIO-SCAN shows that PTSD is relevant to screening risk but is only the tip of the iceberg. Non-PTSD factors need to be looked at, such as alcohol abuse or past criminal behavior, just like in civilians,” said study lead author

20

The Triangle Physician

“We believe this screening tool will provide clinicians with a rapid, systematic method for identifying veterans at higher risk of violence. It can help prioritize those in need of a full clinical workup, structure review of empirically supported risk factors and develop plans collaboratively with veterans to reduce risk and increase successful reintegration in the community,” Dr. Elbogen said.

However, Dr. Elbogen cautioned, the VIOSCAN is not intended to be a comprehensive assessment of whether a veteran will or will not be violent. Instead, it is a screen identifying whether a veteran may be at high risk and thereby require a full clinical workup to make a final risk judgment. Co-authors of the article are Michelle Cueva, Ph.D., at UNC; H. Ryan Wagner, Ph.D., Mira Brancu, Ph.D., and Jean C. Beckham at the Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center and Duke University; Shoba Sreenivasan, Ph.D., at the Greater Los Angeles Veterans Affairs Forensic Outreach Services, and Lynn Van Male, Ph.D., at the Veterans Health Administration Office of Public Health. The study was funded in part by the National Institute of Mental Health; the Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Office of Mental Health Services; and the Office of Research and Development Clinical Science and Health Services, Department of Veterans Affairs.


News Welcome to the Area

Physicians

Jeremy Andrew Halbe, MD

Behrouz Namdari, MD

Aaron Thomas Trimble, MD

Hospitalist; Internal Medicine

Neurology

Duke Hospital Medicine Durham

Psychiatry

Internal Medicine - Critical Care Medicine; Pulmonary Disease, Internal Medicine

Nicole Marie Gill, DO Carolina Headache Institute Chapel Hill Leah Rebecca Goodson-Gerami, DO

John Carroll Haney, MD Cardiovascular Surgery; Thoracic Surgery

Obstetrics and Gynecology

Duke Medicine Durham

Womenâ&#x20AC;&#x2122;s Healthcare Associates Jacksonville

Andrew Zachary Heling, MD

Misha Oswald Harrell, DO Aerospace Medicine

Seymour Johnson AFB 4th Medical Group Goldsboro Scott Julius Noorda, DO Family Medicine - Geriatric Medicine, Sports Medicine

Doctors Making Housecalls Durham Christele Behalal-Bock, MD Rheumatology, Internal Medicine

Durham Stephanie Davis Cardella, MD Hospitalist; Internal Medicine

University of North Carolina Hospitals Chapel Hill

Neonatal-Perinatal Medicine; Pediatrics

University of North Carolina Hospitals Chapel Hill Heather Sue Hoff, MD Gynecology; Gynecology/Oncology; Obstetrics; Gynecologic Surgery; Gynecology - Endocrinology/Infertility; Gynecology - Gynecologic Oncology; Gynecology - Reproductive; Obstetrics

UNC Reproductive Endocrinology Chapel Hill Thomas Patrick JensenII, MD Addiction Psychiatry; Alcohol and Drug Abuse; Child Psychiatry; Neurology/ Psychiatry

Person County Family Medical Center Roxboro Allen Manuel Joseph, MD Diagnostic Radiology

Marcela Carolina Castillo, MD Obstetrics and Gynecology

UNC Dept of Obstetrics & Gynecology Chapel Hill

Pinehurst Matthew Douglas Kalp, MD

Ophthalmology Duke Eye Center Durham

Laura Caitlin Page, MD Pediatrics

Duke University Medical Center Durham Roma P Patel, MD Ophthalmology

Duke University Durham Carrie Monica Polin, MD Anesthesiology Durham Pinakpani Roy, MD Angiography; Interventional Radiology; Diagnostic Radiology; Diagnostic Roentgenology Radiology; Interventional and Vascular Radiology

Duke Neurology/DUMC Durham

UNC Medical Center Chapel Hill

University of North Carolina Hospitals Chapel Hill

Diabetes; Endocrinology, Internal Medicine; Internal Medicine; Internal Medicine Endocrinology, Diabetes &amp; Metabolism

Cary

Duke Eye Institute Durham

Division of Endocrinology Durham

Brett L MacLean, MD

Rebecca Kay Simpkin, MD

Pediatrics

Pediatrics

Pulmonary Disease and Critical Care, Internal Medicine

Duke University Hospitals Durham

Anna Langley, PA Duke University Hospital Durham Dermatology; Laboratory; Dermatology Pediatric - Dermatology

Wilson

Evan Silverstein, MD

Raleigh Deesha Dhaval Mago-Shah, MD Pediatrics

Duke University Hospitals Durham

Sandhills Pediatrics Inc Southern Pines Julia Anne Marsh Sung, MD Infectious Diseases, Internal Medicine; Internal Medicine

Kirk Joseph MatthewsJr, MD

Duke University Hospitals Durham

Gynecologic Surgery; Obstetrics and Gynecology

Sara Tarjan, MD

Wilkerson Obstetrics & Gynecology Raleigh Margaret Kathryn McGinn, MD Internal Medicine

Carrboro Marcus Muehlbauer, MD Gastroenterology, Internal Medicine

University of North Carolina Hospitals Chapel Hill

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

Family Medicine

Ophthalmology

Coral Xantia Giovacchini, MD

UNC Hospitals Chapel Hill

Obstetrics and Gynecology

General Practice; General Surgery

University of North Carolina Hospitals Chapel Hill

Emergency Medicine; Pediatric - Emergency Medicine

Jennifer Thomas Sandbulte, MD

Thersia Jeane Knapik, MD

Ophthalmology; Pediatric Ophthalmology

Aaron Edward Wiener, MD

Duke University Hospitals Durham

David Andrew Dâ&#x20AC;&#x2122;Alessio, MD

Kevin Ray Gertsch, MD

Duke University Hospital Durham

Internal Medicine

Duke University Hospitals Durham

Duke Neurosurgery Durham

Rheumatology, Internal Medicine

Jennifer Anne Rymer, MD

University of North Carolina Hospitals Chapel Hill

Critical Care; Neurological Surgery, Pediatric

Sara Dana Wasserman, MD

Philip George Reasbeck, PA

Radiology

Monica Ann Selak, MD

Neurological Surgery

Peter Edward Fecci, MD

Boone Dermatology Clinic Boone

Adam Thomas Ryan, MD

WakeMed Raleigh

Pediatrics

Department of Orthopaedics University of North Carolina at Chapel Hill

Dermatology

Critical Care Surgery

Emergency Medicine

Isaac Obiri Karikari, MD

Orthopedic Surgery; Orthopedic, Hand Surgery

Brittain Hammill Tulbert, MD

University of North Carolina Hospitals Chapel Hill

University of North Carolina Hospitals Chapel Hill

Shelby Ann Kaplan, MD

Mark Stephen Connelly, MD

Reid Wilson Draeger, MD

University of North Carolina Hospitals Chapel Hill

Neurology; Vascular Neurology

Garrick Chak, MD Ophthalmology; Pediatric

Duke University Hospitals Durham

Emergency Medicine

University of North Carolina Hospitals Chapel Hill Brian David Thorp, MD Head and Neck Surgery; Otolaryngic Allergy; Otolaryngology; Otolaryngology - Neurotology; Otolaryngology - Plastic Surgery Within the Head; Neck; Otolaryngology - Sleep Medicine; Otology; Otorhinolaryngology; Pediatric Otolaryngology; Rhinology

University of North Carolina Hospitals Chapel Hill

2014 Editorial Calendar August Gastroenterology Nephrology September Bariatrics Neonatology October Cancer in women Wound management November Urology ADHD December Otorhinolaryngology Pain management JULY 2014

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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

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Trianglephy july14 final  

The triangle Physician July 2014

Trianglephy july14 final  

The triangle Physician July 2014

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