Trianglephy june13 final

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Wake Forest Dermatology Offering a Thoughtful Approach to Skin 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

Pregnancy and Thyroid Disease HER and Meaningful Use

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COVER STORY

6

Wake Forest Dermatology Offering a Thoughtful Approach to Skin Care

june 2 0 1 3

Vol. 4, Issue 5

FEATURES

9

Endocrinology

Thyroid Disease in Pregnancy Requires Special Considerations Dr. Khushbu Chandarana explores the implications and treatment options.

10

Practice Management

Strategies for Meaningfully Using Your EHR

DEPARTMENTS 11 Men’s Health

19 UNC Research News

Statistics Mean Nothing to Patient on the Wrong End of Them

Fetuses Emit Hormone that Protects Mother from Preeclampsia

12 Women’s Health

20 UNC Research News

Uterine Fibroids: What Can a Woman Do?

14 Endocrinology

Congenital Hypothyroidism

15 WakeMed News

21 Duke Research News

Trauma Center Designation Is Renewed

Persistent Pain Following Stressful Events May Have Neurobiological Basis

16 Duke Research News

22 Recognition

Duke Researchers Identify Mutations Associated With Nearsightedness

Joe Reddy offers sound advice for

17 Duke News

those sweating the details.

Kernodle Clinic Physicians Join Faculty Practice Group

COVER PHOTO: Patricia Matheis, M.D., takes a thoughtful approach to the skin care at Wake Forest Dermatology.

2

The Triangle Physician

- I npatients Who Have STEMI More Likely to Die Than Outpatients -M argaret Gourlay Wins Top 10 Clinical Research Achievement Award

-P aulson Returns to Chair Duke’s Department of Radiology -B reast Cancer Expert Named One of TIME’s 100 Most Influential People

23 Recognition

18 Duke Research News

Certified Physician Assistant Joins Wake Internal Medicine & Pediatrics

Family History May Mean Higher Levels of Alzheimer’s Pathology

24 News

Welcome to the Area

Category

june 2013

3

From the Editor

Thoughtful Examination Experienced practitioners don’t typically base a diagnosis on one test. They consider multiple variables, including family history and lifestyle factors; even their professional instincts come into play.

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

One’s skin is a fascinating health indicator, offering clues of what might be going on within, the focus of dermatologist Patricia Matheis’ medical practice. In this month’s cover story “Wake Forest Dermatology Offers a Thoughtful Approach to Skin Care,” you will learn what distinguishes Dr. Matheis in her mission to help patients achieve the healthiest skin possible, including those who seek cosmetic treatment.

In this issue of The Triangle Physician introduces urologic oncologist Edward Rampersaud Jr., takes exception to the American Urological Association’s reassignment of PSA screening guidelines. In his column, he argues for the necessity of varied diagnostic tools to make the best, most-informed diagnoses.

Endocrinologists Khushbu Chandarana and Julie Warren-Ulanch discuss the importance of early and accurate diagnosis and treatment of thyroid disease in pregnant women and newborns, respectively. Gynecologist Andrea Lukes returns to discuss uterine fibroids and

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Khushbu Chandarana, M.D. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Edward N. Rampersaud Jr., M.D. Joe Reddy Julia Warren-Ulanch, M.D. Photography Mark Jacoby Creative Director Joseph Dally

mark@jacobyphoto.com

jdally@newdallydesign.com

the promise of treatment advances, including one available through a study conducted at

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her practice.

info@trianglephysiciancom

Joe Reddy’s practice management expertise and understanding of meaningful use show

News and Columns Please send to info@trianglephysician.com

in his article, which addresses some of the complexity of complying with new reporting requirements.

Also in this issue, be sure to read about the North Carolina Medical Board licensee contest and other incentives for keeping profiles polished on the board’s website. You might be surprised to learn what a popular fact-checking resource it is, with some 3,000 inquiring minds accessing its licensee information pages online each day.

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

Many thanks to all of our contributors, whose expert medical perspectives bring breadth and depth to the pages of The Triangle Physician – an information and referral resource for the Triangle medical community. Each issue is distributed to the more than 9,000 physicians, physician assistants, nurse practitioners and practice and hospital administrators, among others. And “shelf life” very often is extended in office waiting rooms.

For the thoughtful practitioner, referral decisions are not made lightly. Usually, they are based on a multitude of inputs, including patient feedback, collegial recommendation, personal observation and, perhaps, an article read or advertisement seen in The Triangle Physician.

With deep respect and gratitude,

Heidi Ketler Editor

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Cover Story

Wake Forest Dermatology

Offering a Thoughtful Approach to Skin Care Wake Forest Dermatology is a full-service dermatology practice

General and Surgical Dermatology

centered on thoughtful, compassionate care that helps patients of

Dr. Matheis’ thoughtful patient-care manner is reminiscent of a

all ages – including children – achieve the healthiest skin possible.

bygone era and complemented by her breadth of expertise in advanced medical and surgical dermatology and special interests

Treatment takes into account not only the condition of a patient’s

in pediatric skin care, skin cancer and immunology of the skin.

skin, but also contributing factors within his or her lifestyle, including nutrition and environment, as well as family history. Dis-

Her depth of knowledge in immunology fortifies her diagnos-

ease prevention and health promotion are always a part of the

tic and treatment expertise in numerous diseases and illnesses.

treatment and health plan.

Some of the most common are melanoma, moles and warts, blisters and lesions, acne and skin rash.

“My patient-centered approach to care emphasizes direct, oneon-one interaction, so I have no physician extenders, with whom

Wake Forest Dermatology diagnoses and treats patients of all ages

I share responsibilities,” says Patricia Matheis, M.D., the practice

with common and complicated skin conditions. Services include:

owner. “I give patients the time and attention needed to under-

• Mole and skin cancer evaluation and treatment;

stand the various internal and external influences on their skin’s

• Women’s personalized skin care and evaluation;

health.”

• Acne treatments, including isotretinoin (Accutane); • Psoriasis treatment, including the use of systemic biologic

As a measure of her patient’s gratitude, Dr. Matheis was recog-

agents;

nized last Sept. 10 as a Patient’s Choice physician, an independent

• Eczema treatment, including new therapies and emollients:

designation that is based on achieving patient ratings with near

• Hair-loss treatment;

perfect scores. Only 5 percent of active physicians in the United

• Vitiligo treatment;

States were accorded this honor by their patients in 2012.

• Wart treatment, including occlusion, salicylic acid, cryotherapy, electrosurgery, laser surgery and prescription medications; • Minor surgical procedures, including treatment of moles, cysts and skin tags; • Removal by excision, cryosurgery, electrosurgery or other methods of benign and malignant growth removal, including basal cell carcinoma, squamous cell carcinoma and melanoma; and • Preventive skin care for aging and sun damage.

Wake Forest Dermatology services also extend to the elimination of spider veins using sclerotherapy.

Screening and Dermoscopy Medical treatment begins with a thorough evaluation of a patient’s family and medical history and a detailed full-skin examination.

Dr. Matheis is experienced in the use of the dermascope to more The dermascope is a specialized tool that has gained enthusiasm in dermatology for its ability to increase detection of mutated moles by their appearance.

6

The Triangle Physician

accurately diagnose malignant skin lesions.

Psoriasis Psoriasis is a condition that goes through cycles of improving and worsening, and at times, can be uncomfortable and painful. The scaling and unpleasant appearance of psoriasis lesions (especially if left untreated) can cause embarrassment and be a significant source of anxiety or depression. Psoriasis can interfere with sleep and make everyday tasks difficult.

The condition can also be complicated by joint pain and swelling and other chronic medical conditions.

Laser technology has improved during recent years so it is more effective and better tolerated than previously, mostly requiring only topical anesthesia. There are numerous cosmetic applications and differing devices used. The pulsed-dye laser is effective at reducing pigmented lesions.

“Ongoing evaluation and treatment are important lifestyle choices for those suf-

“The accuracy of dermoscopy increases

a patient’s control, new treatments help

up to 20 percent in the case of sensitiv-

minimize adverse symptoms. To follow

ity and up to 10 percent in the case of

are descriptions of the most common

Hair Loss

specificity, compared with naked-eye ex-

conditions and represent the broad range

Androgenic alopecia, or male and female

amination,” says Dr. Matheis. “This helps

of services available at Wake Forest Der-

pattern baldness, is an inherited tendency

to reduce the frequency of unnecessary

matology.

for follicles to stop producing new hairs.

surgical excisions of benign lesions.”

fering from psoriasis,” says Dr. Matheis.

The hair-growing tissue’s sensitivity to horAging

mones is thought to be the cause. A num-

Digital dermoscopy images can be stored

Natural aging normally begins in one’s

ber of treatments are available to reduce

and compared to images obtained in

mid-20s and is continuous. Extrinsic fac-

the hair loss and restore the hair-growing

follow-up visits. “Suspicious changes in

tors that prematurely age skin are sun

follicles.

lesions are an indication for excision,”

exposure, repetitive facial expressions,

says Dr. Matheis. “Skin lesions that appear

gravity, sleeping positions and smoking.

Cosmetic Dermatology

unchanged over time are considered be-

For those who are bothered by visible

Wake Forest Dermatology offers complete

nign.”

signs of aging, a number of treatments are

cosmetic dermatology services and the

available.

latest treatment options. “Our philosophy

Comprehensive treatment plans also are

is to customize the treatment so patients

designed for prevention and early detec-

Acne

can achieve a more natural look that mini-

tion and typically include annual skin ex-

While the exact cause is unknown, acne

mizes their wrinkles and folds,” says Dr.

ams. “Many of my patients find it helpful

may be the result of a variety of factors,

Matheis.

to schedule their annual skin examina-

including heredity, hormones, stress, diet

tion at the beginning of the year or in the

and/or vitamin deficiencies, especially

The best results, she says, are obtained

month of their birthday.”

vitamin D. It is often the source of emo-

by combining cosmetic procedures with

tional distress, so the good news is there

healthy skin. “Success in improving the

are many new treatment options.

overall health of a patient’s skin relies on

Dr. Matheis also encourages patients to incorporate sun-protection measures into

careful examination, treatment expertise

their daily lives. That includes the regular

Keloid Scars

and a comprehensive understanding of

use of hats, sunglasses and ultraviolet-pro-

Keloid scars are excessively large and

available therapies.”

tective creams and even clothing.

form at the site of wounds or trauma, including ear piercings, vaccinations or

The following is an overview of some

Commonly Treated Skin Conditions

surgical sites. They are most common on

available

Wake Forest Dermatology offers hope for

the upper chest and shoulders. A variety

from Dr. Matheis are usually best made

patients suffering from skin conditions

of treatments are available to reduce the

once she develops a relationship with pa-

of all types. While contributing intrinsic

size of the scar and minimize associated

tients and better understands their goals

factors, such as heredity, may be out of

discomfort.

and budget.

options.

Recommendations

june 2013

7

into the offending muscles, allowing the skin

Latisse

to relax and the folds to soften or disappear.

Eyelash hypotrichosis is another name for having inadequate or not enough eye-

Fillers

lashes. Lattisse is the only prescription ap-

Juvéderm is a dermal filler designed to

proved by the United States Food and Drug

smooth out wrinkles and add volume to

Administration for growing eyelashes and

facial folds. It is a natural complex sugar

making them longer, thicker and darker.

that retains water and is found in all living organisms. It has been formulated to be

Latisse is believed to affect the growth

more comfortable to inject and to provide

(anagen) phase of the eyelash hair cycle

long-lasting correction.

by increasing the length of this phase and increasing the number of hairs in this

Examination of suspicious skin lesions is aided by use of high-intensity luminescence tools.

Restylane provides immediate and long-

growth phase. “Many people experience

lasting wrinkle correction. It is a safe, natural

significant benefit with the use of Lat-

cosmetic dermal filler. It can be used to re-

tisse,” says Dr. Matheis.

duce laugh lines, reduce forehead wrinkles and improve the appearance of the lips.

Career Highlights Dr. Matheis earned her bachelor’s degree

Chemical Peels

Radiesse is a dermal filler used for restor-

in nursing from Creighton University in

Chemical peels use a chemical solution

ing a natural, more youthful appearance

1988. She later pursued her interest in skin

to improve and smooth the texture of the

to folds and lines in the nasolabial folds

disease and skin surgery at the renowned

skin by removing outer layers of the skin

around the nose and mouth. It is made of

North Carolina Jaycee Burn Center in Cha-

that are damaged by age, sun and environ-

unique calcium-based microspheres in a

pel Hill; additionally she continued clini-

mental factors. The process is helpful in

natural gel that is injected into the skin.

cal research at the Shriners Burns Institute

treating individuals with facial blemishes,

The calcium helps to stimulate the growth

in Texas. While earning her medical doc-

wrinkles and uneven skin pigmentation.

of your own collagen, which over time re-

tor degree at the University of Colorado

In many cases chemical peels may be

builds the skin’s foundation and restores

Health Sciences Center, she conducted

used to control acne, treat pre-cancerous

its youth.

investigations into the genetics of skin

lesions and soften facial scarring.

cancer and the immunology of the skin.

“Radiesse is typically longer lasting than

Microdermabrasion Microdermabrasion involves a gentle, gradual exfoliation of the skin’s surface cells, thereby reducing damage caused by age, heredity, sun and other environmental factors. It can minimize fine lines and wrinkles, improve acne scarring, lighten age spots and be performed on any part of the body.

Microdermabrasion is performed in a series of treatments, and patients are able to immediately return to work and normal activity after each.

Botox and Dysport Botox or Dysport may be the best solution for patients seeking an easy solution for smile lines, crow’s feet or frown lines on the face, forehead and glabella. Both are highly purified muscle relaxants that are injected

8

The Triangle Physician

other fillers on the market, lasting a year

After finishing her training at the Univer-

or longer,” says Dr. Matheis

sity of North Carolina in Chapel Hill, Dr. Matheis completed her internship in medi-

Beyond Skin

cine and residency in dermatology in 2006.

Sclerotherapy

A native of Omaha, Neb., Dr. Matheis is

Sclerotherapy is commonly considered

married with two children. In her spare

the best available treatment for spider

time she enjoys cycling, baking and par-

veins and has been in use for many years.

ticipating in church activities.

A small amount of chemical solution is in-

Physician Referrals Are Welcome

jected through a tiny needle directly into

Dr. Matheis serves as a consultant with

the faulty vein. The chemical irritates the

primary physicians to diagnose and man-

vein wall, causing it to close and eliminate

age skin disorders and recommends and

trapped blood.

administers treatment to counteract a defective response of the immune system.

Depending on the extent of the veins being treated, multiple sclerotherapy ses-

To refer a patient, call (919) 4880-0355.

sions may be needed to achieve full clear-

More information is available online at

ance, and some varicose veins issues may

wakeforestderm.com. Patients also have

require referral to a vein clinic due to their

access to a knowledge library and can

size and/or location.

schedule a consultation online.

Endocrinology

Thyroid Disease

in Pregnancy Requires Special Considerations

By Khushbu Chandarana, M.D.

In general, thyroid disease is five times

or thyroid-stimulating immunoglobin (TSI)

more common in women than men. The

are very high. In low doses, anti-thyroid

coincident occurrence of thyroid disease

drugs are generally safe during breastfeed-

before, during and after pregnancy involves

ing, and mothers should take it in divided

special considerations for the health of the

doses immediately following each feeding.

infant and the mother.

Hypothyroidism Hyperthyroidism

The most common cause of hypothyroid-

Early pregnancy is associated with several

ism in women of childbearing age is auto-

hormonal changes that alter thyroid

immune (Hashimoto’s) thyroiditis. Recent

function and structure. Approximately

studies have shown that the presence of

10 percent of women may have a mildly

thyroid peroxidase (TPO) antibodies in

suppressed thyroid-stimulating hormone

euthyroid women is associated with an in-

(TSH) during the first trimester, especially

creased risk of miscarriage, particularly in

with hyperemesis gravidarum (“morning

the first trimester; and treatment with low-

sickness”). This cause of suppressed TSH

doses of levothyroxine may lower the mis-

needs to be distinguished from Graves’

carriage rate to that of unaffected women.

disease, which is the most common cause

Dr. Khushbu Chandarana performed her medical training at New York University School of Medicine. Her residency training was done at Robert Wood Johnson University Hospital in New Brunswick, N.J., and it was followed by a fellowship in diabetes, endocrinology and metabolism at New Jersey Medical School. Prior to joining Carolina Endocrine in May 2011, Dr. Chandarana worked in private practice in Hamilton, N.J. She is board certified in internal medicine and endocrinology and has also completed endocrine certification in neck ultrasound (ECNU). For more information and patient referrals and appointments call (919) 571-3661 or visit the practice website at carolinaendocrine.com.

of clinically significant hyperthyroidism in

During the first 10-12 weeks of gestation, the

be safely performed during pregnancy;

pregnancy.

developing fetus is completely dependent

however, nuclear medicine studies are

upon maternal thyroid hormone levels for

contraindicated. If a thyroid FNA biopsy

Women who require therapeutic interven-

normal brain development. Untreated overt

reveals the presence of cancer or if a

tion during pregnancy are usually placed

maternal hypothyroidism is associated

nodule is found to be suspicious for

on anti-thyroid drugs (ATD). Propylthio-

with

fetal

malignancy, then the patient may elect

detrimental

effects

upon

uracil (PTU) is recommended to be used

neurocognitive development in addition to

to undergo surgical resection (usually

in the first trimester secondary to the tera-

an increased rate of miscarriage, low birth

during the second trimester) or may defer

togenic effect of methimazole (MMI). After

weight and pre-term delivery.

thyroidectomy until after delivery (in most cases). Women with thyroid cancer

the first trimester, consideration is given to switching to MMI in order to decrease the

These adverse outcomes may also be as-

who are on thyroid hormone suppressive

incidence of liver disease.

sociated with subclinical hypothyroidism,

therapy may require dose adjustment.

but the data is not as conclusive. Pregnant Both MMI and PTU can cross the placenta.

women with preexisting hypothyroidism

Post-Partum Thyroiditis

The goal is to maintain free thyroid levels

or newly diagnosed hypothyroidism re-

This is usually a painless, transient

at or just about the upper limit of normal,

quire careful monitoring and frequent ad-

disturbance in thyroid function that

while utilizing the smallest possible dose.

justment of thyroid hormone dose.

develops two to six months after delivery.

Incidence is estimated to be anywhere

Graves’ disease may become quiescent during the latter part of the pregnancy, but may

Thyroid Nodules and Cancer

intensify two-to-three months post-partum.

Newly discovered thyroid nodule presents

from 3-15 percent.

a unique challenge during pregnancy.

This condition is characterized by a

Infrequently, the transplacental passage of

History, physical exam and ultrasound

thyrotoxic phase, followed by a hypothyroid

maternal antibodies can lead to transient

characteristics of a nodule can help with

phase, each of which may last for several

neonatal hyperthyroidism (about 2-5 per-

risk stratification.

weeks or months. About 10 percent of women with post-partum thyroiditis will

cent), particularly if titers of thyroid-stimulating hormone receptor antibody (TRAb)

Fine-needle aspiration (FNA) biopsy may

remain permanently hypothyroid. june 2013

9

Practice Management

Strategies for Meaningfully Using Your EHR

By Joe Reddy

Is your electronic health record helping

tion (GPRO) for PQRS requirements. If you

you obtain the available cash incentives by

missed the Jan. 31 requirement to register,

qualifying for meaningful use?

you will have another opportunity sometime this summer through Oct. 15.

Electronic health record (EHR) dissatisfaction is on the rise even with incentive

The PQRS incentive/penalty for GPRO is

payouts exceeding $12 billion. As many as

based on submission of data via registry or

39% of clinicians have buyer’s remorse and

completion of the GPRO web interface. EPs

would not recommend their EHR to a col-

reporting individually will enjoy the benefit

league.

of having PQRS “baked in” the Stage 2 MU

Joe Reddy is the owner of RevMedRx, a North Carolina-based revenuecycle management company. RevMedRx offers sophisticated, yet affordable, solutions to today’s complex practice management needs with a focus on efficiency and cash-flow optimization. Joe Reddy can be reached at joe.reddy@revmedrx. com. To learn more, visit www.revmedrx.com.

requirements that a qualified EHR should So do you accept the pain until you go

be leading you through. Therefore, you

numb or start over a little more educated?

should be able to get credit for both, with-

Moreover, the Centers for Medicare &

out two separate tracking records. There are

Medicaid Services (CMS) audits reveal

approximately 300 ambulatory MU program

that many providers struggle to document

EHR vendors. Only a few dozen of them are

meaningful use (MU)?

CMS-approved direct submitters for MU and PQRS, making it even easier to attest.

It’s hard to imagine how simple some of the challenges appear. For instance, some

Planning for Stage 2 and Beyond

EHRs don’t provide a functional audit log

We don’t know yet which EHR vendors

that allows necessary documentation for

will be certified for Stage 2. We can expect

designating attestation periods.

it to be less than those currently certified for Stage 1, largely due to the investment

On the positive side, there’s also some incentive to get engaged sooner rather than later. In fact, it’s not too late to begin and attest Stage 1 this year and still claim a total of up to $39,000 over the next several years and avoid the first-year PQRS penalty. This is not difficult if you are with the right vendor.

For 2014 Only The Centers for Medicare & Medicaid Services recently announced that all providers, regardless of their meaningful use stage

required.

are only required to demonstrate MU for

what you have and the functionality that’s

We also can expect some vendors to pass

reporting period. For Medicare providers,

currently available. Often this discovery is

along some of those costs to you in “fees.”

achieved only by comparison in today’s

You know what I’m talking about, if you’re

market.

working with one of them now, as you get

Given the technology advances even in the past year, it’s important to understand

your checkbook ready for your ICD-10 up-

a three-month electronic health record this three-month reporting period is fixed to the calendar quarter for eligible professionals in order to align with the PQRS. This one-time, three-month reporting period is

grade

being permitted so all providers who must

core and menu objectives as they were in

In 2014, a Stage 2-certified vendor will be

have adequate time to implement their new

Stage 1. For ambulatory-eligible profession-

required, even if you are still attempting to

als (EPs), Stage 2 requires reporting on 17

successfully attest for Stage 1. It would be

core objectives and three of the six menu

prudent to review vendors by comparison

objectives. In addition, EPs also must report

shopping before you progress much further

on one measures group or three individual

along this timeline.

Understanding MU Reporting Stage 2 MU measures are comprised of

measures as part of the Physician Quality Reporting System (PQRS).

By 2016, the PQRS penalties peak at 2%. The EHR penalties begin in 2015 and increase by

Beginning in 2013, two or more EPs in a

1 percent per year until 2019, maxing out at

group practice could register or self-nomi-

5%. That’s a 7% exposure in Medicare revenue

nate for the Group Practice Reporting Op-

penalties in 2019.

10

The Triangle Physician

upgrade to 2014-certified EHR technology system.

Finding efficiency equals survival for clinicians as they navigate these re quirements.

Stay Tuned There is some congressional discussion on Stage 2 qualification extensions. Just don’t get your hopes up for the early-adopter incentives to be extended as well.

Men’s Health

Statistics Mean Nothing to the Patient On the Wrong End of Them

By Edward N. Rampersaud Jr., M.D.

My father, a family physician, called me

instead, to whom treatment is offered.

Dr. Edward Rampersaud is a urologic oncologist and assistant professor of surgery for the Section of Urologic Oncology at the Duke Cancer Institute. He earned his medical degree from Duke University, where he also completed his urology residency and research fellowship.

He then completed a Society of Urologic Oncology fellowship at the Institute of Urologic Oncology at University of California, Los Angles. His clinical and research interests focus on kidney cancer and other malignancies of the upper retroperitoneum.

For more information on Dr. Rampersaud visit www.dukehealth.org/physicians/edward-nrampersaud-jr. He can be reached at (919) 681-8760 or edward.rampersaud@duke.edu.

To schedule a patient appointment, call (919) 668-8108.

from New York one year ago to ask, “So we shouldn’t get PSAs anymore?” The

Kidney cancer has been the focal point of

news was breaking in May 2012 that the

my clinical and research efforts for several

United States Preventative Task Force

years now. I perform complex partial and

(USPTF) had chosen the week of the

radical nephrectomies; and the topic of

American Urological Association (AUA)

competing risks and over-treatment has

national meeting to announce that they

begun to touch even kidney cancer, the

would be assigning Grade D recommen-

most lethal of genitourinary malignancies.

dations to population-based PSA screening. This occurred on the backs of two

As the number of partial and radical ne-

randomized trials, of debatable design,

phrectomies has risen during the last 20

attempting to measure the impact of PSA

years, the annual death rate for kidney

screening.

cancer has not appreciably diminished.

While this is certainly a multifactorial

Still, as the AUA Guidelines Panel mud-

event well beyond the scope of this edi-

dled through the data to construct its own

torial, it leads us to question the natural

set of guidelines , I cannot help but won-

history of small renal masses (SRMs), as

der why so much of the focus has been

we do not fully understand their biology.

1

on detection rather than treatment. Why would we not want to know more clinical

With the increasing prevalence of cross-

information upon which to base an even

sectional imaging obtained for any num-

more-informed decision?

ber of reasons comes the diagnosis of the incidentally discovered SRM. In the

While it is becoming clearer to me that we

last couple of years, centers have begun

have likely been over-treating men with

publishing their experiences of patients

low-risk prostate cancer, it is not at all evi-

with SRMs (usually less than 4 centime-

dent that men with intermediate or high-

ters in diameter) that have been placed

risk prostate cancer are not better served

on active-surveillance regimens. I, also,

by its detection and aggressive treatment.

believe that not every SRM needs to be

We cannot ignore the fact that remains

treated and have instituted a formal active-

– prostate cancer is still the second lead-

surveillance program for the appropriate

ing cause of cancer-related death in men

patients.

The phrase “art and science of medicine” describes the integration of two folds of a profession that at its skin appear to be distinct and separate, but actually meld together into one. Fallibility applies to both evidence and anecdotal experience.

However, we must use the available information – our experiences and abilities and the uniqueness of each individual patient – all combined to make the best and most-informed decision possible.

Guidelines and best-practice statements are well-intended and important; but we should never forget about common sense,

each year.

Nothing is worse than objectifying a paThe rate of death from prostate cancer has

tient by quoting a statistic – only to find

decreased by 20-30 percent in the PSA era,

out later that very patient is part of the mi-

and there are many possible explanations

nority contingent you originally described

for this phenomenon. As we continue to

to them. Even if the chance of the “bad”

observe, most men die with prostate can-

thing were 1 percent, for the patient to

cer, not of it. Perhaps the focus should not

whom it occurred, the chances were 100

be about narrowing the band of patients

percent after-the-fact.

intuition and the wisdom gained through actual experience that truly make us doctors and advocates of individual people.

Reference

www.auanet.org/education/guidelines/

1

prostate-cancer-detection.cfm

on whom prostate cancer is detected, but

june 2013

11

Women’s Health

Uterine Fibroids

What can Women Do?

By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.

Uterine fibroids are remarkably common.

The options for treatment of fibroids are

One study by radiologists found that by age

growing. Certainly a hysterectomy is the

50 years, 80 percent of African-American

classic “cure.” Importantly, a woman does

women have fibroids and 70 percent of

not have to remove her ovaries (source

Caucasian women have fibroids.

of estrogen and progesterone, or female hormones) when she has a hysterectomy.

As a clinician, I divide the problems of

If a woman is motivated to avoid a

fibroids into two broad categories: bulk

hysterectomy, then what can she do?

symptoms and bleeding symptoms. The bulk symptoms are due to fibroids that

The

minimally

grow to be large. Symptoms may include

for

pressure, a feeling “fullness,” back pain,

myomectomy with MyoSure, laparoscopic

fibroids

invasive

include:

treatments

hysteroscopic

urinary urgency, constipation, etc. The

myomectomy (removal of the fibroid, not

bleeding symptoms range from heavy

the uterus), uterine fibroid embolization

periods to abnormal bleeding.

(performed by radiologists), the new

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.

Drug Administration for cyclic heavy

HALT procedure (radiofrequency energy

menstrual bleeding (HMB). A large

Despite enormous efforts to understand

administered to fibroids) and ExAblate

proportion of women with HMB treated

why

our

(magnetic resonance imaging-focused

with Lysteda had uterine fibroids. An

understanding is still lacking. Even so,

energy to fibroids), as well as medications.

advantage to this medication is that it is

women

develop

fibroids,

nonhormonal, taken only during the days

women seem to find it reassuring that they are so common, so as a clinician, I

Medications for heavy periods related to

a woman has bleeding (up to five days),

start there.

fibroids include Lysteda, a medication

and it does not impact fertility.

approved by the United States Food and The Institution Review Board-approved advertisement on the Elagolix study at the Women’s Wellness Clinic.

Do Heavy Periods associated with

Uterine Fibroids

Affect You?

Uterine fibroids symptoms can affect any woman, anytime, anywhere. If you’re at least 20 years old and have heavy periods associated with uterine fibroids, you may qualify for this oral investigational medication research study.

As a participant, you will receive all study-related care and investigational medication at no cost. If uterine fibroids affect your life, consider volunteering.

Call 919-251-9223

www.fibroidstrial.com Women's Wellness Clinic

12

The Triangle Physician

Elagolix is a medication under evaluation

which is taken daily, essentially stops

treatments for uterine fibroids and about

and available through a new study being

bleeding by suppressing ovarian function.

the Women’s Wellness Clinic can be found online at www.cwrw.com.

conducted at Carolina Women’s Research and Wellness Center. The oral medication,

More

information

about

the

latest

Statewide

Medical Board Contest Challenges Licensees to Polish Their Profiles The North Carolina Medical Board has

LI categories that must be reported include:

Information reported in optional licensee

launched its first-ever contest to promote

• Basics, such as the licensee’s current

information categories must be accurate

broader licensee participation in the op-

practice address and telephone number.

and relevant to each individual category

tional content listings offered through the

• Where applicable, such information as ac-

for which information is provided. Winning

board’s popular licensee information pages.

tions by out-of-state medical boards and

entries will be determined at the sole discre-

other regulatory agencies, certain crimi-

tion of the NCMB Public Affairs Department.

All licensed physicians and physician assis-

nal convictions and information about

tants have licensee information (LI) pages,

certain malpractice payments.

How to Enter

which include required and optional infor-

Visit www.ncmedboard.org, and click on

mation. The NCMB reports that not all li-

The NCMB also offers licensees the op-

“Update Licensee Info Page” in the green

censees are taking advantage of the opportu-

portunity to provide information in many

Quick Links box on the right. Log in and

nity to market themselves and their practice

optional categories, including “practice phi-

provide content for applicable optional cate-

through optional information categories.

losophy,” memberships in professional soci-

gories (practice philosophy, memberships,

eties, non-English languages spoken by the

languages spoken, etc.) Verify all informa-

Consider that, according to NCMB, the pub-

licensee and/or in the office, public service,

tion is accurate.

lic accesses these pages up to 3,000 times

participation in Medicare and Medicaid and

each day, most often by clicking on the

more! This information is of great interest to

When finished, let the board know in an e-

“Look Up a Licensee” tool, the most popu-

current and prospective patients. – in fact,

mail to: forum@ncmedboard.org. Include

lar feature on the board’s website.

according to NCMB, patients contact the

full name. Entrants must complete updates

board to ask why there is no information in

by end of business July 1.

To further incent licensees to maintain their

these categories.

Prizes

NCMB website profiles, the board is challenging licensees to polish their optional content,

Contest Details

Depending on the number and quality of

and the winner will be featured in an upcom-

The North Carolina Medical Board will ac-

entries, the NCMB’s Public Affairs Depart-

ing medical board promotional campaign!

cept entries to its Licensee Information

ment will select up to 10 licensees, who will

Challenge through July 1. Its goal is to en-

be offered the opportunity to be featured in

LI pages date back to the 1990s, when NCMB

courage more licensed physicians and phy-

an upcoming NCMB public awareness cam-

began posting basic licensee information

sician assistants to provide optional content

paign. Examples of upcoming campaigns

online as part of its ongoing commitment to

for their licensee information pages.

include print media/display advertisements,

public protection and transparency. In 2000,

radio spots and/or video public service an-

the board became one of the first medical

Rules

nouncements. Winners also will be featured

regulators in the country to begin posting

Licensed physicians and physician assis-

in The Forum.

public board actions on the web. The most

tants must:

recent enhancements to online licensee

• Have an active license,

Questions?

information came in 2009, when the board

• Practice medicine at least part time,

Contact Jean Fisher Brinkley, Director, Pub-

implemented changes to North Carolina law

• Have no history of public discipline for at

lic Affairs at jean.fisher@ncmedboard.org or

that significantly expanded the types of in-

least 10 years.

(919) 326-1109, ext. 230.

formation it is required to collect and report regarding its licensees.

june 2013

13

Endocrinology

Congenital Hypothyroidism Hypothyroidism is a common condition

thyroid), or only partially formed. These

to develop over the course of a lifetime,

cases are most often sporadic, and com-

but it is also a condition babies can be

prise the majority of cases of congenital

born with. As it is common (1 in 3000-4000

hypothyroidism, at 80-90%. Future babies

newborns), cost-effective to diagnose and

born to the same parents are not at any

treat, and a preventable cause of mental

higher risk to have the same problem. The

retardation, it is of the utmost importance

other way a baby can be hypothyroid is to

to address it early. Here, we’ll review

have a defect or deficient enzyme along

the causes, diagnosis, treatment, and

the pathway that takes precursors and cre-

management of this disease.

ates thyroxine. Another way to say this is there is a slow or broken machine along

Signs and symptoms of hypothyroidism

the factory that takes building blocks and

in a baby can be quite hard to detect,

creates the final product. This form of hy-

and devastating to miss. For this reason,

pothyroidism comprises the other 10-20%

in 1974, the United States began pilot

of congenital hypothyroidism, and is au-

programs for newborn screening. This

tosomal recessive. Future babies born to

is a special test for infants at twenty-four

the same parents have a 25% chance of be-

hours of life. A heel stick is performed,

ing normal, 50% chance of being a carrier,

and blood is collected onto a piece of

and 25% chance of being affected.

filter paper to be screened for diseases for

By Julia Warren-Ulanch, M.D.

Julia Warren-Ulanch is a board-certified adult and pediatric endocrinologist. She is a graduate of Texas A&M University, who travelled to the University of Michigan for residency in internal medicine and pediatrics. She went on to the University of Pittsburgh, where she completed her training as a fellow in adult and pediatric endocrinology. Dr. Warren-Ulanch is board certified and has Endocrine Certification in Neck Ultrasound (ECNU). Now an associate at Carolina Endocrine, P.A., she enjoys serving pediatric and adult patients with general endocrinology issues. For more information and patient referrals and appointments, call (919) 571 3661 or visit the practice website at carolinaendocrine.com.

which early intervention is available and

Once confirmed with repeat blood

life-changing. Amongst those conditions

testing, determining the cause of the

of water, levels can be normalized quickly.

tested is congenital hypothyroidism. The

hypothyroidism is important to provide

Infants on a soy formula may require

outcome for babies is best if treatment

implications for the patient (more severe

more, as absorption is impaired.

is started within 14-21 days of life. In

cases are at higher risk for developmental

the State of North Carolina, the test for

delay) future pregnancies. A nuclear

While no parent wants their newborn

hypothyroidism includes both thyroid

medicine test to image the thyroid with

afflicted with any problems, congenital

stimulating hormone (TSH) and thyroxine

technetium can be done quickly to

hypothyroidism is treatable with daily

(T4). Using the values of these tests,

assess the presence and location of the

hormone

infants are classified as normal, borderline

thyroid. As soon as the test is complete,

close

(TSH<20 and T4<5, TSH 20-29.9 and T4

replacement can begin. If levothyroxine

Endocrinologist, we can assist these

<12.9, or TSH 30-39.9) or hypothyroid (any

is started quickly at a dose of 10-15ug/kg/

babies to develop to their full intellectual

TSH>40uIU/mL). Those with borderline

day, and dosed in water or a small amount

potential.

replacement.

monitoring

with

Along a

with

Pediatric

or hypothyroid results are sent a letter within a week notifying the pediatrician that further testing is in order.

The common causes of congenital hypothyroidism fall into two major categories: athyreosis and dyshormonogenesis.

Infants can be born without a thyroid altogether, a gland in the wrong location (usually the base of the tongue, or lingual

14

The Triangle Physician

The Triangle Physician 2013 Editorial Calendar July Imaging Technologies Psoriasis, Medical Insurance

October Cancer in Women, COPD - Lung Health Medical Software - EMR

August Orthopedics, Gastroenterology Medical Real Estate

November Alzheimerâ&#x20AC;&#x2122;s Disease Diabetes, Financial Planning

September Atrial Fibrillation Urology, Web Design

December Pain Management, Spine Disorders Practice Management

Wake News

Trauma Center Designation Is Renewed The North Carolina Office of Emergency

in the state. In this capacity, it provides

a leader in this field,” said William “Bill” K.

Medical

has

sophisticated and multidisciplinary care

Atkinson, Ph.D., M.P.H., M.P.A., F.A.C.H.E.,

renewed the WakeMed Trauma Program’s

and serves as a regional referral site for the

president and chief executive officer of

designation as a Level 1 trauma center.

most critically injured.

WakeMed Health & Hospitals.

Level I is the highest designation awarded

“This re-designation exemplifies WakeMed’s

Osi Udekwu, M.D., serves as WakeMed’s

to trauma centers, and the renewal is for a

commitment to trauma care and validates

trauma director.

four-year period.

our expertise, experience and teamwork as

Services

(NCOEMS)

Following a comprehensive site visit and indepth examination of all processes related to WakeMed trauma services, the state cites zero deficiencies. In addition to strong leadership, vision and commitment to trauma, the report cited WakeMed’s robust trauma program staff, including clinical team members, physicians, researchers and support staff. It also cited: • Collaboration among area EMS providers, trauma service, emergency department and all the subspecialty team members who care for trauma patients; • Disaster preparedness program; • State-of-the-art

equipment,

training

techniques and facilities, including the Center for Innovative Learning and simulation trainings; • Staff involvement in trauma system endeavors

and

regional

system

development; • WakeMed’s physician assistant residency program; and • Commitment

to

injury

prevention,

education and outreach.

WakeMed’s trauma program has reportedly seen a 93 percent increase in trauma patients in the past decade. Last year, more than 3,200 patients were treated there, making it one of the busiest trauma centers in North Carolina.

WakeMed first earned designation as Wake County’s only Level I trauma center in 2006.

Today, it is one of six Level I trauma centers Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

june 2013

15

Duke Research News

Duke Researchers Identify Mutations Associated With Nearsightedness Mutations in a gene that helps regulate

international research team.”

Pharmacology and Cancer Biology at Duke, said the finding suggests that different

copper and oxygen levels in eye tissue are associated with a severe form of

In this study, Dr. Young and her colleagues

kinds of mutations in the SCO2 gene result

nearsightedness, according to a study

sought to identify these genetic factors by

in different diseases. Dr. Thiele, an expert in

published in the American Journal of

studying families with high-grade myopia.

copper metabolism who was not involved

Human Genetics May 2.

They performed next-generation deep

in the research, noted that another SCO2

sequencing on four relatives from an

gene mutation is responsible for a lethal

Nearsightedness – also known as myopia –

11-member American family of European

form of cardiomyopathy.

is the most common human eye disease in

descent.

“This is a fascinating finding, and it points

the world. It occurs if the eye is too long or the cornea has too much curvature, which

Analyzing DNA extracted from blood and

to the relevance of copper metabolism to a

keeps light entering the eye from focusing

saliva, the researchers identified mutations

spectrum of different human diseases,” Dr.

correctly.

in the SCO2 gene in common among family

Thiele said.

members with high-grade myopia, but High-grade myopia, a more severe form

absent in those family members with no

Since normal copper metabolism is

of nearsightedness, affects up to 2 percent

myopia. They confirmed four mutations in

important for eye health, future research

of Americans and is especially common

the SCO2 gene in an additional 140 people

may focus on whether copper deficiency

in Asian populations. Individuals with

with high-grade myopia.

could place someone at higher risk for nearsightedness.

high-grade myopia are at an increased risk for other serious eye problems,

Once the researchers identified the

including retinal detachment, cataracts and

mutations in DNA samples, they turned

“Our findings, plus information from the

glaucoma.

to human eye tissue and verified that the

literature, suggest that copper deficiency

SCO2 gene was expressed in areas of the

could predispose people to develop

eye connected to nearsightedness.

myopia,” Dr. Young said. “While this wasn’t

Studies suggest that myopia is caused by a

directly tested in this study, it’s possible that

combination of environmental factors, such as large amounts of reading and genetics.

To further support their findings, they

our diets – which are deficient in a number

Nearsightedness runs in families, but little

performed an experiment in which mice

of minerals and vitamins – play a role, and

is understood about genetic factors that

were made nearsighted in one eye by

it may be something as easy as taking a

cause it.

wearing a strong lens. Collaborators at Duke-

supplement with copper that helps thwart

NUS, the Singapore Eye Research Institute

the development of myopia.”

In recent years, researchers have reported

and Yong Loo Lin School of Medicine at

several genes or locations of genes

the National University of Singapore found

Dr. Young noted that multiple factors

associated with myopia and have continued

that SCO2 gene expression decreased in

are likely responsible for developing

to search for additional clues.

the nearsighted eye, suggesting that SCO2

nearsightedness,

may play a role in the development of

additional research. She hopes to continue

nearsightedness.

by studying animal models with SCO2

“This is the first time a gene mutation

and

this

warrants

mutations to better understand the gene’s

for autosomal dominant nonsyndromic

connection with nearsightedness.

high-grade myopia in Caucasians has

In the body, the SCO2 gene helps

been discovered,” said senior author

metabolize copper, an element important

Terri Young, M.D., M.B.A., professor of

for regulating oxygen levels in eye tissue.

In addition to Dr. Young, co-authors include

ophthalmology, pediatrics and medicine

Increased stress brought on by too much

Khanh-Nhat Tran-Viet, Caldwell Powell and

at the Duke Eye Center, Duke Center for

oxygen may alter the eye’s development

Erica Nading of Duke; Yi-Ju Li of Duke, Duke-

Human Genetics and the Duke-National

and function.

NUS and Yong Loo Lin School of Medicine at the National University of Singapore

University of Singapore Graduate Medical School (Duke-NUS). “Our findings reflect

Dennis J. Thiele, Ph.D., George Barth

(NUS); Steve Rozen and Thomas Klemm of

the hard work and collaboration of our

Geller professor in the Department of

Duke-NUS; Veluchamy A. Barathi of Duke-

16

The Triangle Physician

Duke News NUS, Singapore Eye Research Institute

Oklahoma/Dean McGee Eye Institute;

The research was supported by the National

and Yong Loo Lin School of Medicine at

Georg Schneider of the Agency for Science

Institutes of Health, the Lew Wasserman

NUS; Candace Ho of the Singapore Eye

Technology and Research in Singapore and

Award from Research to Prevent Blindness

Research Institute; Sebastian Maurer-Stroh

Institute of Science and Technology Austria;

Inc., a Duke-NUS core grant, the Toulouse

of the Agency for Science Technology

Ravikanth Metlapally of the University of

Hospital Young Researcher Fellowship, the

and Research and Nanyang Technological

California, Berkeley; Seang-Mei Saw of the

Fondation pour la Recherche Médicale,

University in Singapore; Vincent Soler of

Yong Loo Lin School of Medicine at NUS;

Fondation de France and the National

the Université Paul Sabatier in France;

and Liang Goh of Duke-NUS and the Yong

Medical Research Council of Singapore.

Tammy Yanovitch of the University of

Loo Lin School of Medicine at NUS.

Kernodle Clinic Physicians Join Faculty Practice Group The physicians of Kernodle Clinic Inc., a

same time, access and coordination of care

Carolina, with more than 40 physicians at

multispecialty medical practice serving the

will be streamlined, where needed, with

four locations in Alamance County. Kernodle

Triad region, have joined Private Diagnostic

Duke specialty and subspecialty programs

Clinic provides services in many specialties

Clinic, Duke Medicine’s physician practice

and faculty.

including internal medicine, family medicine, pediatrics,

organization.

obstetrics

and

neurology,

gynecology,

Kernodle providers and patients also will gain

cardiology,

This affiliation, effective Aug. 1, ensures that

access to Duke Medicine’s new state-of-the-

podiatry, rheumatology, gastroenterology,

orthopedics,

current and future Kernodle Clinic patients

art electronic health record technology.

endocrinology,

pulmonology,

sports

medicine, physiatry, physical therapy and

will continue to receive their medical care locally from their existing Kernodle

Founded in 1949, Kernodle Clinic is one of

physicians and other local providers. At the

the largest multispecialty practices in North

general surgery.

Expert, cost effective and timely care is what Carolina Endocrine has to offer your patients.

• Neck Ultrasounds (ECNU certified) • Fine needle aspiration biopsies • Nuclear medicine studies • Pediatric Endocrinology

All in one convenient location at 3840 Ed Drive, behind Rex Hospital.

919-571-3661

www.CarolinaEndocrine.com Dr. Michael Thomas, Ph.D. Dr. Julia Warren-Ulanch Dr. Khushbu Chandarana Courtney Kovalick, PA-C Eileen Andres, PA-C

june 2013

17

Duke Research News

Family History May Mean Higher Levels of Alzheimer’s Pathology Close family members of people with

Duke

trainee

people with a positive family history may

Alzheimer’s disease are more than twice

Erika J. Lampert, Mr. Doraiswamy and

also have higher levels of Alzheimer’s

as likely as those without a family history

colleagues analyzed data from 257 adults,

pathology earlier, which could be a reason

to develop silent buildup of brain plaques

ages 55 to 89, both cognitively healthy and

why they experience a faster cognitive

associated

with varying levels of impairment. The

decline than those without a family history,”

participants were part of the Alzheimer’s

Ms. Lampert said.

with

Alzheimer’s

disease,

according to researchers at Duke Medicine.

neuroscience

research

Disease Neuroimaging Initiative, a national The study, published online in the journal

study working to define the progression of

The findings may influence the design of

PLOS ONE April 17, confirms earlier findings

Alzheimer’s through biomarkers.

future studies developing new diagnostic tests for Alzheimer’s, as researchers may

on a known genetic variation that increases one’s risk for Alzheimer’s and raises new

The researchers looked at participants’ age,

choose to exclude those with a positive

questions about other genetic factors

gender and family history of the disease,

family history – a group that has historically

involved in the disease that have yet to be

with a positive family history defined as

volunteered to participate in studies to

identified.

having a parent or sibling with Alzheimer’s.

better understand the disease – as healthy

This information was compared with

controls, given that they are more likely to

An estimated 25 million people worldwide

cognitive assessments and other biological

develop Alzheimer’s pathology.

have Alzheimer’s disease, and the number

tests, including APOE genotyping, magnetic

is expected to triple by 2050. More than 95

resonance

measuring

“Our study shows the power of a simple

percent of these individuals have late-onset

hippocampal volume and studies of three

one-minute questionnaire about family

Alzheimer’s, which usually occurs after

different pathologic markers (Aβ42, t-tau,

history to predict silent brain changes,” Mr.

the age of 65. Research has shown that

and t-tau/Aβ42 ratio) found in cerebrospinal

Doraiswamy said. “In the absence of full

Alzheimer’s begins years to decades before

fluid.

understanding of all genetic risks for late-

imaging

scans

onset Alzheimer’s, family history information

it is diagnosed.

As expected, the researchers found that a

can serve as a risk-stratification tool for

Family history is a known risk factor and

variation in the APOE gene associated with a

prevention research and personalizing

predictor of late-onset Alzheimer’s disease,

greater risk and earlier onset of Alzheimer’s

care.” He encouraged those with a known

and studies suggest a two- to four-fold greater

was overrepresented in participants with a

positive family history to seek out clinical

risk for Alzheimer’s in individuals with a

family history of the disease. However, other

trials specific to preventing the disease.

mother, father, brother or sister who develop

biological differences also were seen in

the disease. These first-degree relatives share

those with a family history, suggesting that

In addition to Ms. Lampert and Mr.

roughly 50 percent of their genes with another

unidentified genetic factors may influence

Doraiswamy,

member of their family. Common genetic

the disease’s development before the onset

Kingshuk Roy Choudhury, Christopher A.

variations, including changes to the APOE

of dementia.

Hostage and Jeffrey R. Petrella.

heritability of Alzheimer’s, but the disease’s

Nearly half of all healthy people with a

Funding for the study was provided in part

other genetic roots are still unexplained.

positive family history would have met

by the Alzheimer’s Disease Neuroimaging

study

authors

include

gene, account for around 50 percent of the

the criteria for preclinical Alzheimer’s

Initiative, a public-private partnership created

“In this study, we sought to understand

disease based on measurements of their

with $60 million in grants from the National

whether simply having a positive family

cerebrospinal fluid, but only about 20

Institute on Aging, the National Institute of

history, in otherwise normal or mildly

percent of those without a family history

Biomedical Imaging and Bioengineering,

forgetful people, was enough to trigger silent

would have met such criteria.

the Food and Drug Administration, private pharmaceutical companies and non-profit

buildup of Alzheimer’s plaques and shrinkage of memory centers,” said senior author P.

“We already knew that family history

organizations. Trainees in Mr. Doraiswamy’s

Murali Doraiswamy, M.B.B.S., professor of

increases

lab are supported by the Wrenn Clinical

psychiatry and medicine at Duke.

Alzheimer’s, but we now are showing that

18

The Triangle Physician

one’s

risk

for

developing

Research Scholars Fund.

UNC Research News

Fetuses Emit Hormone that Protects Mother from Preeclampsia In a study using mice, researchers from

“We really don’t know that a pregnant

By

the University of North Carolina School

woman is going to get preeclampsia until

adrenomedullin, the research could pave

of Medicine found that the hormone

she has it,” said Dr. Caron. Because the

the way to new methods for detecting and

adrenomedullin plays a crucial role in

condition has numerous risk factors

preventing preeclampsia. For example,

preventing the pregnancy complication

and causes, it’s difficult for doctors to

adrenomedullin levels could potentially

preeclampsia. They also found that

know which patients are at highest risk.

be used as a biomarker, or early indicator,

this hormone protects women from

“Identifying molecules that could predict

to identify which patients might be

preeclampsia when emitted by the

preeclampsia would be really important.”

predisposed to the condition. “Having

the

key

role

of

a biomarker would be wonderful – it

fetus, during the most critical times in pregnancy.

identifying

The researchers studied mice that were

could allow the physician to manage a

genetically

woman differently in the early part of her

programmed

to

produce

pregnancy,” said Dr. Caron.

“We’ve identified the fact that the baby

either reduced or increased levels of

is important in protecting the mom from

adrenomedullin. The study revealed that

preeclampsia,” said the study’s senior

in a normal pregnancy, the fetus secretes

As a next step, the researchers plan to

author, Kathleen M. Caron, Ph.D., assistant

adrenomedullin into the placenta during

build upon their mouse studies to examine

dean for research at the UNC School of

the second trimester, signaling special

patterns of adrenomedullin levels and

Medicine and an associate professor

cells called “natural killer cells” to help

preeclampsia in pregnant women.

in the Department of Cell Biology and

dilate the mother’s blood vessels and

Physiology. “If the baby’s cells are not

allow more blood to flow to the growing

This paper was published online on May 1

secreting this hormone, the mother’s

fetus.

in the Journal of Clinical Investigation and appears in the June print edition.

blood vessels don’t undergo the dilation The study is one of the first to identify an

that they should.”

important chemical message sent from

The study’s co-authors include: Manyu

Preeclampsia affects roughly one in 15

fetus to mother in the womb. Scientists

Li, Nicole M.J. Schwerbrock, Patricia M.

pregnancies. An important characteristic

understand more about the mom’s side

Lenhart, Kimberly L. Fritz-Six, Mahita

of the condition is that blood vessels in

of the “chemical conversation” that goes

Kadmiel, Kathleen S. Christine, Scott T.

the placenta fail to enlarge, or dilate, to

on between mother and baby, but much

Espenschied, Helen H. Willcockson and

accommodate increased blood flow to

of the hormonal signaling in the placenta

Christopher P. Mack of UNC; and Daniel

the fetus. Untreated, it can threaten the

remains a mystery.

M. Kraus of Duke University Medical Center.

life of both mother and baby.

Cary Endocrine & Diabetes Center, P.A.

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june 2013

19

UNC Research News

Inpatients Who Have STEMI More Likely to Die Than Outpatients between Jan. 1, 2007 and July 31, 2011, com-

Researchers have found that the chances

er than people who suffer a STEMI outside

of surviving an ST elevation myocardial in-

the hospital. But even after adjusting the

pared to 227 patients with outpatient STEMI

farction while being treated in the hospital

statistical analysis to account for this, there

treated at UNC Hospitals during the same

for something else is greater than for those

were important differences in survival, Dr.

time period. UNC Hospitals earned the

who have this kind of a heart attack outside

Stouffer said.

American Heart Association’s Gold Level Performance Achievement Award in 2012

the hospital and are quickly brought to the According to a UNC press advisory, another

for its care of STEMI patients and has a very

possible explanation: Hospital emergency

active STEMI program. Further research is

The study is the first to systematically ex-

departments are trained to react very quick-

needed to determine the inpatient STEMI

amine outcomes among hospital inpatients

ly when a patient with a suspected STEMI is

survival rates at hospitals that have not

who have an ST elevation myocardial in-

brought in. For that reason, the time from a

achieved such AHA recognition.

farction (STEMI). It was published April 4

STEMI outpatient’s arrival to treatment with

in the Journal of the American Heart Asso-

angioplasty, referred to as “door-to-balloon

Nationwide, there are approximately 11,000

ciation.

time,” averages about 45 minutes at UNC

cases of STEMI a year among hospital inpa-

Hospitals.

tients, which would translate into approxi-

emergency department for treatment.

mately 4,300 deaths based on extrapolating

“We found that the survival rate for outpa-

data from this study.

tients brought to UNC Hospitals for STEMI

“In contrast, when patients who are in the

treatment was slightly more than 96 per-

hospital for a non-cardiac condition have a

cent,” said George A. Stouffer, M.D., distin-

STEMI, the onset is not usually heralded by

First author of the study is Xuming Dai,

guished professor in the University of North

chest pain and thus health care providers

M.D., a fellow in interventional cardiol-

Carolina School of Medicine and senior au-

may not suspect that a coronary artery has

ogy at UNC. The other authors are Joseph

thor of the study. “But the survival rate for

occluded. As a result, the time it takes for

Bumgarner, M.D.; Andrew Spangler, M.D.;

inpatients who suffered a STEMI was much

restoration of coronary blood flow for inpa-

Dane Meredith, M.P.H.; and Sidney C. Smith

lower, only 60 percent.”

tients is much slower and more variable,”

Jr., M.D., professor of cardiology at UNC

Dr. Stouffer said.

and a past president of the American Heart Association.

Part of the difference is explained by the fact that people who suffer a STEMI while

These results are based on 48 cases of

hospitalized are, as a group, older and sick-

STEMI among inpatients at UNC Hospitals

Margaret Gourlay Wins Top 10 Clinical Research Achievement Award For leading a study that

England Journal of Medicine in January 2012,

“Dr. Gourlay’s study has proven to be very

was the first to define ap-

calculated time estimates that doctors can

influential in the field of bone and mineral

propriate bone density-

use for bone density screening in primary

research, and it has the potential to change

screening intervals for

care practice, based on a woman’s first bone

the way doctors order bone density tests,”

older women, Margaret

density T-score at age 65 or older. The study

said Eugene P. Orringer, M.D., a professor

Gourlay, M.D., M.P.H., of the University of

found that when women had good T-scores

of medicine at UNC who nominated her for

North Carolina School of Medicine has

on their first test, it took about 15 years for

this award.

been honored with a Top 10 Clinical Re-

10 percent of them to develop osteoporo-

search Achievement Award from the Clini-

sis. But women with lower T-scores on their

“The results should help doctors target the

cal Research Forum.

first test developed osteoporosis sooner – it

bone density screening, so that they test

took about one to five years for 10 percent of

patients with lower T-scores and thinner

them to develop osteoporosis.

bones more frequently. The results also

Dr. Gourlay’s study, published in the New

20

The Triangle Physician

Category UNC Research News mean that older women with very good

light up more of these beacons for the mil-

tigious and acclaimed academic medical

bone density on their first test don’t need

lions who look to us for help.”

centers and health care systems. Its goal is to sustain and expand a cadre of talented,

tests to be performed nearly as often as was originally thought,” Dr. Orringer said.

Dr. Gourlay, an assistant professor in the

well-trained clinical investigators at all stage

Department of Family Medicine in the UNC

of career development and support nurtur-

“These achievements are beacons of hope

School of Medicine and an adjunct assis-

ing environments and comprehensive re-

that show what can be accomplished when

tant professor in the UNC Gillings School

search capabilities within academic institu-

our nation’s researchers are given the free-

of Global Public Health, and the other win-

tions. Its mission is to provide leadership

dom and resources to tackle tough clinical

ners were honored April 18 during the Clin-

to the national clinical and translational re-

problems,” said National Institutes of Health

ical Research Forum annual meeting and

search enterprise and promote understand-

Director Francis S. Collins, M.D., Ph.D. “The

awards dinner in Washington, D.C.

ing and support for clinical research and its impact on health.

opportunities for advancing clinical research have never been better. So, we at NIH

The Clinical Research Forum is an organi-

look forward to doing everything we can to

zation comprised of the nation’s most pres-

Persistent Pain Following Stressful Events May Have Neurobiological Basis A new study led by University of North

to the body’s response to stressful events.

have no idea what the biologic mecha-

Carolina School of Medicine researchers

The study evaluated whether the HPA axis

nisms are that cause chronic pain. Chron-

is the first to identify a genetic risk factor

influences musculoskeletal pain severity

ic pain after these events is common and

for persistent pain after traumatic events,

six weeks after motor vehicle collision

can cause great suffering, and there is an

such as motor vehicle collision and sex-

and sexual assault.

urgent need to understand what causes chronic pain, so that we can start to de-

ual assault.

Its findings revealed that variation in the

velop interventions.”

In addition, the study contributes further

gene encoding for the protein FKBP5,

evidence that persistent pain after stress-

which plays an important role in regulat-

This study is an important first step in de-

ful events has a specific biological basis.

ing the HPA axis response to stress, was

veloping this understanding, he said.

A manuscript of the study was published

associated with a 20 percent higher risk of

online in the journal Pain April 29.

moderate to severe neck pain six weeks

“In addition, because we don’t under-

after a motor vehicle collision, as well as

stand what causes these outcomes, indi-

“Our study findings indicate that mecha-

a greater extent of body pain. The same

viduals with chronic pain after traumatic

nisms influencing chronic pain devel-

variant also predicted increased pain six

events are often viewed with suspicion, as

opment may be related to the stress

weeks after sexual assault.

if they are making up their symptoms for financial gain or having a psychological

response, rather than any specific injury caused by the traumatic event,” said

“Right now, if someone comes to the

reaction,” Dr. McLean said. “An improved

Samuel McLean, M.D., M.P.H., senior au-

emergency department after a car acci-

understanding of the biology helps with

thor of the study and assistant professor

dent, we don’t have any interventions to

this stigma.”

of anesthesiology. “In other words, our

prevent chronic pain from developing,”

results suggest that in some individuals

Dr. McLean said. “Similarly, if a woman

The study was conducted by a multidisci-

something goes wrong with the body’s

comes to the emergency department af-

plinary team of investigators from 13 insti-

‘fight or flight’ response or the body’s re-

ter sexual assault, we have medications to

tutions. Co-lead authors on the study were

covery from this response, and persistent

prevent pregnancy or sexually transmit-

Andrey Bortsov, M.D., Ph.D., assistant re-

pain results.”

ted disease, but no treatments to prevent

search professor in the UNC Department

chronic pain.

of Anesthesiology; and Jennifer Smith, B.S., a UNC medical student and former

The study assessed the role of the hypothalamic-pituitary adrenal (HPA) axis, a

“This is because we understand what

physiologic system of central importance

causes pregnancy or infection, but we

Doris Duke fellow.

june 2013

21

Recognition

Paulson Returns to Chair Duke’s Department of Radiology Erik Paulson, M.D., is returning to the Duke University School of Medicine as chairman of the Department of Radiology, after serving as professor and chairman of the Department of Diagnostic Radiology at MD Anderson Cancer Center.

and his collaborative spirit make him an exceptional leader for the department of radiology,” said Nancy C. Andrews, M.D., Ph.D., dean of Duke University School of Medicine. “I am thrilled that Erik is returning to Duke to take on this important role.”

Dr. Paulson was educated and trained at Duke, and spent 20 years as a faculty member with increasing responsibilities and leadership roles. Before joining MD Anderson in 2012, he was named Duke’s division chief of abdominal imaging in 2001 and vice chairman of the Department of Radiology in 2009.

A highly regarded expert in cross-sectional imaging of the abdomen, Dr. Paulson has built an academic career around clinically driven research. His academic interests include cross-sectional imaging of the liver, assessments of computed tomography (CT) technology and new image-guided interventions. Recent work focuses on advanced CT methods and reducing the radiation patients receive during CT scans.

“Dr. Paulson’s knowledge of Duke and of the national and international radiology landscape, his commitment to excellence

Dr. Paulson’s work reflects his collaborative approach to clinical care and research.

His contributions to peer-reviewed publications, his clinical practice and his leadership in professional societies have earned him respect within and beyond radiology circles.

“I am committed to listening, learning and navigating progress within Duke radiology,” Dr. Paulson said. “My goals are to maintain areas of excellence, introduce new initiatives to meet evolving demands, address the impacts of a changing health care environment and nurture collaboration that is essential for clinical and research excellence in a major medical center.”

An author on more than 176 publications,

Breast Cancer Expert Named One of TIME’s 100 Most Influential People Kimberly Blackwell, M.D., a clinical oncolo-

targeted therapy, and chemotherapy to im-

contributions to improving breast cancer

gist at Duke Cancer Institute and one of the

prove survival rates with fewer unpleasant

care.

country’s leading breast cancer research-

side effects. The treatment for advanced

ers, is included in this year’s roster of TIME

HER-2 positive breast cancer was approved

“Being recognized by TIME not only reflects

magazine’s 100 most influential people.

by the United States Food and Drug Admin-

my work, but the thousands of patients who

istration earlier this year.

have bravely participated in the clinical trials that allow us to move the field of breast

Dr. Blackwell was the only cancer specialist named to the TIME list, which recognizes

Dr. Blackwell served as the principal inves-

cancer therapy forward,” Dr. Blackwell

activism, innovation and achievement,

tigator on the pivotal TDM-1 study. Previous-

said. “Although TIME is recognizing me as

along with political leaders, such as Presi-

ly, she was a leader in the development of

an individual involved in some of the excit-

dent Barack Obama, first lady Michelle

the breast cancer drug treatment lapatinib.

ing breast cancer therapies that have been developed in the last five years, it is really

Obama and New Jersey Gov. Chris Christie; activist Aung San Suu Kyi; and celebrities

A professor of medicine and director of

an acknowledgment of the patients and the

Justin Timberlake, Beyoncé and Jay Z.

the breast cancer program at Duke Cancer

scientists who have been instrumental in

Institute, Dr. Blackwell treats patients at the

this important pursuit.”

In her commentary, Sherry Lansing, the

Duke Cancer Institute, focusing on com-

former chairman and chief executive offi-

plex breast cancer cases that include those

A full list of the TIME 100 most influential

cer of Paramount Pictures and co-founder

involving women under age 40. A national

people appeared in the April 29 issue of the

of Stand Up to Cancer, cited Dr. Blackwell’s

and community leader, she has served on

magazine, which is currently online at time.

work on TDM-1. Dubbed a “smart bomb,”

numerous cancer advisory panels, includ-

com/time100.

the treatment combines Herceptin, a gene-

ing as a Komen Scholar for distinguished

22

The Triangle Physician

Recognition

Certified Physician Assistant Joins Wake Internal Medicine & Pediatrics Jessica Hedrick, PA-C., has joined Wake Internal Medicine & Pediatrics in North Raleigh.

In practice since 2006, Ms. Hedrick has been with the Wake Internal Medicine Consultants

We know you’re committed to taking excellent care of your patients, but when was the last time you took a close look at your business? We’re part of a nationwide network of over 1,500 offices, and we specialize in practice management, revenue cycle optimization, and private practice business support.

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Please contact us today at info@revmedrx.com for a free practice analysis. Let us help you keep your business as healthy as you keep your patients.

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family of practices at Rx Urgent Care since 2009.

She graduated from the University of North Carolina at Wilmington cum laude with a bachelor of arts degree in chemistry. She completed her physician assistant master of science degree at South University in Savannah, Ga. She has earned certification from the National Commission on Certification of Physician Assistants (NCCPA) and is licensed by the North Carolina Medical Board.

4441 Six Forks Rd. Suite 106-293 • Raleigh, NC 27609 • Phone: (800) 845-6090 NEWSOURCE-JUN10:Heidi 8/5/10 12:57 PM Page 1

“Ms. Hedrick has been a great asset to our Rx Urgent Care division and we are very pleased to have her in the North Raleigh offices,” said

Do They Like What They See?

Arvind Jariwala, M.D., practice president.

“Her experience, compassion and relational skills are a great fit with our philosophy of providing convenient and exceptional medi-

Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.

cal care.”

In addition to Wake Internal Medicine & Pediatrics, Wake Internal Medicine Consultants is

Our services range from consultation, to design, to creation and implementation of strategic plans.

comprised of Wake Gastroenterology, Wake Women’s Health and Rx Urgent Care. Twenty-four physicians provide a comprehensive range of health care services, including primary care and specialty diagnosis and treatment in cardiology, gynecology, pulmonary medicine, sleep medicine, pediatrics and gastroenterology.

newsource & Associates

Same-day appointments are offered for most specialties. Call (919) 781-7500. Complete practice information is available at www.

Call (540) 650-3686 or send inquiries to hketler@verizon.net.

Our network of smart, creative, award-winning specialists serves the health care industry throughout the Mid-Atlantic.

Maybe it’s happiness in a child’s eyes. Whatever the desired outcomes, count on us to ensure your key messages have the 20/20 clarity to deliver.

wakeinternalmedicine.com.

june 2013

23

News Welcome to the Area

Physicians Eric Todd Lee, DO Neurology; Neuromuscular Medicine

University of North Carolina Hospitals Chapel Hill

Michael Thomas Durheim, MD

Mallory Jean McClester, MD

Alyssa Ann Williams, MD

Internal Medicine; Pulmonary Disease and Critical Care

Family Medicine

Psychiatry

University of North Carolina Hospitals Chapel Hill

University of North Carolina Hospitals Chapel Hill

Duke University Hospitals Durham

Amber Marie Huffman Gaught, MD

Benjamin Aaron Alman, MD

Physical Medicine & Rehab - Pain Medicine

Orthopedic Surgery, Pediatric

University of North Carolina Hospitals Chapel Hill

Duke Orthopaedics Durham

Ahmad Moustafa Aouthmany, MD Emergency Medicine; Internal Medicine; Pediatrics; Diagnostic Radiology; Nuclear Medicine; Nuclear Radiology

Duke University Hospitals Durham

Daniel Lee Gilstrap, MD Duke University Hospitals Durham

Maria Olivares, MD

Brad Patrick Barnes, MD

UNC Hospitals Chapel Hill

University of North Carolina Hospitals Chapel Hill

Brian Barrett, MD

Matthew Robert Kappus, MD Gastroenterology, Internal Medicine

Duke Gastroenterology Durham

Anne Christine Kelly, MD

Anesthesiology

University of North Carolina Hospitals Chapel Hill

Jessica Beierle Boyer, MD

Crysten Brinkley Kragel, MD

Emergency Medicine

Neurology

Wake Emergency Physicians Cary

Duke University Dept of Neurology Durham

Joseph McNeill Bumgarner, MD

Ginger Nichole Locklear, MD

Internal Medicine

University of North Carolina Hospitals Chapel Hill

Nathaniel James Coleman, MD Internal Medicine - Endocrinology, Diabetes & Metabolism

UNC-Chapel Hill Endocrinology Chapel Hill

Stephen James Dolgner, MD Internal Medicine; Pediatrics

Durham

Emergency Medicine

Duke University Medical Center Durham

Events

Pediatrics

University of North Carolina Hospitals Chapel Hill

Kevin Alan Paduchowski, MD Emergency Medicine

University of North Carolina Hospitals Chapel Hill

Neha Jadeja Pagidipati, MD

Pediatrics

University of North Carolina Hospitals Chapel Hill

Paul Bryan Maloof, MD

June 3, 5:30-7:30 p.m.

Look Good Feel Better is a free American Cancer Society program that teaches women beauty techniques while they undergo chemotherapy and radiation treatments. Participants receive a free cosmetics kit and instruction by beauty professionals.

Location: North Conference Room, Durham Regional Hospital Registration: Call (919) 470-7168

Kavita Dali Patel, MD

Stroke Support Group June 10, 1-2:30 p.m.

Duke University Hospitals Durham

Karl Martin Schweitzer Jr, MD Orthopedic Surgery; Orthopedic, Ankle Foot

Duke University Hospitals Durham Internal Medicine

University of North Carolina Hospitals Chapel Hill

Duke University Hospitals Durham

Duke Health Center Durham

Margaret Marie, MD

Gaurav Vij, MD

Psychiatry

Hospitalist; Internal Medicine; Radiology; Neuradiology

Weight Loss Surgery Support Group June 25, 6-7 p.m.

This weight-loss surgery support group encourages discussion on topics related to adjustment before and after weight-loss surgery. June’s session is entitled “Physical Activity 101.”

Andrew Robert Spector, MD

Orthopedic Surgery; Orthopedic, Ankle Foot

The mission of this support group is to help educate the stroke survivor, caregiver and community about stroke prevention and stroke disabilities. This group meets the second Monday of each month.

Location: Durham Regional Hospital, private dining room C

Lee Brinkley Sigmon, MD

Internal Medicine - Sleep Medicine; Neurology

Fairway Center Raleigh

Look Good Feel Better

Duke University Hospital Durham

Cardiovascular Disease, Internal Medicine

Family Medicine

Psychiatry

Duke University Hospitals Durham

Mark Salvatore Ritchie, PA

Matthew David Oettinger, MD UNC Hospitals Family Medicine Chapel Hill

University of North Carolina Hospitals Chapel Hill Adolescent & Young Adult Medicine; General Practice; Hospitalist; Adolescent Medicine; Internal Medicine; Pediatrics

Durham Regional Hospital Durham

Pulmonary Disease and Critical Care, Internal Medicine

Pediatric: Cardiology, Gastroenterology, Hematology-Oncology, Infectious Diseases, Pulmonology; Pediatrics - Developmental - Behavioral; Adolescent Medicine; Critical Care Pediatrics; Pediatric - Nephrology

Internal Medicine, Geriatric

Physician Assistants

Internal Medicine; Hospitalist

Family Medicine

Margaret Sandbank Hall, MD

Charles Adrian Austin III, MD

Dustin Lee Norton, MD

Location: Duke Center for Metabolic and Weight Loss Surgery Durham Clinic, 407 Crutchfield St., Durham 24404.

Register for these events online at www. durhamregional.org/events or by calling (919) 403-4374, unless otherwise noted.

Duke University Hospitals Durham

Orthopedic Specialists welcomes the following people:

Ashley Mason, PA-C

Justin Scruggs, MD

Albert Harris, MD

Jon Verceles, PA-C

Katie Truscello, PA-C

Michelle Fegeley, PA-C

Shannon Poplstein, PA-C

Triangle Ortho welcomes the following people:

Bryan Stanislaus PA-C

24

Courtney Jordan, PA-C

The Triangle Physician

Jennifer Chazan, PA-C

Kelly Egbert, PA-C

Kim Jones, PA-C

Rosie Polinsky, PA-C

Ruth Berger, PA-C

Sue Weeks MD

Woody Burns III MD

“More than a doctor.

Like a friend.”

Trust.

WHV provides comprehensive heart services to prevent, diagnose and treat a full range of cardiovascular-related conditions. As heart specialists we are committed to providing access to quality care throughout Central and Eastern North Carolina.

As part of UNC Health Care / Rex Healthcare, we can tap into the most up-to-date research and expertise, providing our patients with access to clinical trials and new therapies, resulting in the best cardiovascular care in the area.

Experienced Cardiologists J. Tift Mann, III, MD, FACC (retired) Michael Zellinger, MD, FACC William N. Newman, MD Gregory C. Rose, MD, FACC Joel E. Schneider, MD, FACC Eric M. Janis, MD, FACC R. Lee Jobe, MD, FACC Randy A.S. Cooper, MD, FACC Robert B. Wesley, II, MD, FACC Joseph M. Falsone, MD, FACC Kevin R. Campbell, MD, FACC Benjamin G. Atkeson, MD, FACC Ravish Sachar, MD, FACC

Locations in North Carolina

Benson Clayton Clinton

Goldsboro Knightdale Lillington

Arthur Y. Chow, MD, FACC Christian Gring, MD, FACC Matthew A. Hook, MD, FACC Andrew C. Kronenberg, MD, FACC Mateen Akhtar, MD, FACC Richard J. Pacca, MD, FACC Waheed Akhtar, MD, MRCP, FACC Malay Agrawal, MD, FACC Sunil P. Chand, MD, MRCP, FACC Paul A. Perez-Navarro, MD, FACC Sidharth A. Shah, MD Ashley M. Lewis, MD

Louisburg Raleigh Rocky Mount

Cardiovascular Services General Cardiology Echocardiography Nuclear Cardiology Interventional Cardiology Carotid Artery Interventions Cardiac Catheterization Cardiac CT Angiography and Calcium Scoring Electrophysiology and Cardiac Arrhythmia Peripheral Vascular Interventions Pacemakers / Defibrillators Stress Tests Holter Monitoring Lipid (Cholesterol) Clinics

Smithfield Wake Forest Wilson

When it comes to your cardiovascular care – We know it by heart.

1.800.WHV.2889 (800.948.2889) | www.WHVheart.com

The No-Excuse Mammogram.

Saturday and evening appointments where your patients live, work and play in the Triangle.

An annual screening mammogram only takes 20 minutes, from check-in to exam completion. That’s the convenience of Wake Radiology, where we specialize in state-of-the-art digital mammography as well as comprehensive women’s imaging.

It‘s easy for patients to schedule this important exam, because many of our nine breast imaging offices throughout the Triangle are open evenings and Saturdays, and walk-ins are welcome at all locations. Wake Radiology is in-network with most insurance plans and offers financial assistance or payment plans to those who need it.

If your patients have celebrated 40 birthdays or more, encourage them to safeguard their health by calling 919-232-4700 or going online to schedule their annual screening mammogram today.

Wake Radiology. Excellence in breast imaging.

Wake Radiology is a 2013 Year-Round Sponsor Wake Radiology is the only multi-site freestanding imaging provider in the Triangle to earn the prestigious American College of Radiology (ACR) designation of Breast Imaging Center of Excellence (BICOE).

Nine convenient Triangle locations Raleigh | West Raleigh | Morrisville | Chapel Hill | Cary North Raleigh | Garner | Wake Forest | Fuquay-Varina

wakerad.com

Scheduling 919-232-4700 Chapel Hill Scheduling 919-942-3196

Comprehensive Breast Imaging Centers