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The Raleigh Center for Weight Loss Surgery Experts in Laparoscopic Bariatrics 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

Sleep Apnea and Cancer Easing the Stroke Burden


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Contents

COVER STORY

6

The Raleigh Center for Weight Loss Surgery

Experts in Laparoscopic Bariatrics june

2012

Vol. 3, Issue 6

FEATURES

12

Neurology

Obstructive Sleep Apnea Is Associated with a Higher Mortality from Cancer Dr. Paul Peterson reports on a recent human study that links sleep apnea to an elevated risk of cancer mortality.

14

Bariatric Surgery

DEPARTMENTS 14 Your Financial RX Market Gurus and 15 Minutes of Fame

15 Practice Management Rethinking the EHR Revolution

16 Women’s Health Vigilance Helps Protect Women from Advance of Ovarian Cancer

20 Neurology Stroke Threat Grows Despite Declining Mortality and Changing Care Patterns

22 Duke Research News - Statin Drugs Slow Benign Prostate Growth; Lifestyle Could Help Too - Cardio Fitness Levels May Affect Survival of Breast Cancer Patients

23 Duke News New Health Education Center Honors Philanthropist’s Lifelong Commitment

Obstructive Sleep Apnea: Effective Treatment Leads to Rapid Improvement

24 UNC News

Dr. Alfonso Torquati explores obesity, obstructive

Quest to Understand Hepatitis C and Liver Cancer Link Gets $2.35 Million

sleep apnea and the effectiveness of bariatric surgery as treatment. COVER PHOTO: Joseph C. Moran, M.D., F.A.S.M.B.S., stands with two of his bariatric surgery patients, Dylan McIntyre and Alison Stair. Photo by Jacoby Photography.

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Dr. Ned Sharpless Recognized as a Welcome Distinguished Professor

25 UNC Research News 26 UNC Research News - $900,000 Grant to Fund Use of Kinase Test in HER2-positive Breast Cancer - DNA Replication Protein also Has a Role in Mitosis and Cancer

28 News Welcome


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From the Editor

From the Editor

Eyes Wide Open 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

When faced with the likelihood of dying from a comorbidity of obesity or being overweight, such as heart disease, folks often turn to The Raleigh Center for Weight Loss Surgery, the focus of our cover story this month. Editor Heidi Ketler, APR

heidi@trianglephysician.com

Here, patients must accept that the medical procedures – gastric bypass or insertion of an adjustable gastric band, performed either laparoscopically or as an open surgery – are only 10 percent of the battle. The other 90 percent is dependent on proper nutrition and behavior modification. So in addition to a bariatric surgeon, the patient care team includes a psychiatrist and nutritionist, who specialize in weight loss. In this article, two patients share how weight-loss surgery freed them from the shackles of obesity, allowing them to see great results and experience improved health and quality of life. Also this month, we bring special attention to sleep and the growing awareness of its importance to overall health. Lack of quality sleep has been linked to serious disease. Addressing this subject are Dr. Alfonso Torquati, who reviews the risks of obstructive sleep apnea, diagnosis and treatment; and Dr. Paul Peterson, who discusses a recent study that links obstructive sleep apnea to an increased risk of cancer mortality.

Contributing Editors Larry B. Goldstein, M.D., F.A.A.N., F.A.H.A. Andrea S. Lukes, M.D., M.H.Sc Paul C. Peterson, M.D., F.A.C.E.P. Paul J. Pittman, C.F.P. Alfonso Torquati, M.D., M.S.C.I., F.A.C.S. Maryan Binkley Photography Mark Jacoby Creative Director Joseph Dally

mark@jacobyphoto.com

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Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com

Also contributing this month, neurologist Larry Goldstein explores the high incidence of stroke in North Carolina and efforts under way to minimize it. Gynecologist Andrea Lukes

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urges greater awareness of ovarian cancer and a pro-active approach to early detection. Finally, our resident financial planning expert, Paul Pittman, opens our eyes to the realities of investing and why a fickle global market makes fame for wealth managers so fleeting. And for those whose market is the Raleigh-Durham medical community, you need look no further than The Triangle Physician for a cost-effective medium to connect you with practice and health system leaders and administrations. Your news, commentary and, of course, advertising is always welcome. Respectfully,

Heidi Ketler Editor

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Cover

The Raleigh Center for Weight Loss Surgery Experts in Laparoscopic Bariatrics By Rory Cullen

Dylan McIntyre was at the end of his rope.

ended after I picked up the chicken wings,”

By the time he’d worked up the courage,

he says.

he’d developed a suite of comorbidities: sleep apnea, type 2 diabetes and danger-

For the first 20 years of his life, he’d been active and healthy. He ran, swam and

By his mid-30s, Mr. McIntyre had become

ously high blood pressure and cholesterol.

biked. He played sports and went to the

extremely obese. At 5 feet, 8 inches and

Medication was prescribed, but there was

gym. He was fit by any measure and had

more than 300 pounds, he knew he

little doubt that his habits were unsustain-

never struggled with his weight. But the

needed help but was reluctant to seek it. “I

able. “The doctor told me, ‘if you keep go-

pressures of adult life took their toll on

was afraid of going to the doctor, afraid of

ing this way, you’re going to die early.’”

his time – and his eating habits. “That all

what I might have,” he says. Motivated to change his life, Mr. McIntyre started exercising and eating right in 2008. Assiduous effort earned him an encouraging 60-pound drop in weight. “And then I gained 90 of it back,” he says. As with so many others, his initial enthusiasm was shattered when he couldn’t maintain his gains. Devastated, he let himself go. “A lot of this was mental, a lot. At that point I had basically given up.” It took a plaintive question from his daughter to snap him out of his despair. “We were watching a TV show,” he says. “It was something about obese people, and one of them had died. And my daughter turned to me and asked, ‘Daddy, if you keep getting bigger, are you going to die like that?’” Galvanized, Mr. McIntyre resumed his search for a solution. He’d investigated The Raleigh Center for Weight Loss Surgery once before, in 2007 – but his longtime reluctance to see a physician had precluded the five years of documented medical history required by his insurance provider. This time he was equipped with a different plan, and was able to take a fresh

Joseph C. Moran, M.D., F.A.S.M.B.S., poses in a day surgery suite at Rex Hospital in Raleigh, N.C.

6

The Triangle Physician

look at bariatric surgery.


Sandra Kelly, R.N., C.B.N., holds a Lap-Band model used as a patient educational tool.

The Raleigh Center for Weight Loss Surgery

Dr. Moran emphasizes the importance of the big picture: “In

Joseph Moran, M.D., F.A.S.M.B.S., is a godsend for Mr. McIntyre

helping our patients, 10 percent is surgery, and 90 percent is

and many like him. Dr. Moran completed his undergraduate work

proper nutrition and behavioral modifications, changes in routine

at SUNY-Stony Brook and medical school at the Ross University

and mindset.” The 90 percent number is often echoed by his

School of Medicine. He followed this with a five-year general sur-

patients and staff. Ashley House, P.A.-C., an assistant to Dr. Moran,

gery residency at St. Agnes in Baltimore and a two-year fellowship

underscores the importance of the post-surgical commitment:

in minimally invasive surgery.

“Surgery is just a small part – it’s about the amount of dedication that people put into it.”

Dr. Moran’s focus in bariatrics began in 2002, when he trained under the past president of the American Society for Metabolic

Significant weight loss is not something everyone can do, and Dr.

and Bariatric Surgery, Robert Brolin, M.D. “Working with him and

Moran has procedures in place to ensure that his patients have

looking forward, and seeing on the horizon this wave of obesity

realistic expectations and don’t presume the surgery alone to be

coming upon us … I saw an opportunity to do something for these

the cure. Before being scheduled for surgery, patients must pass a

people.”

rigorous screening process and get appropriate nutritional advice.

Arriving in North Carolina in 2004, Dr. Moran oversaw the

This is done through Tammie D. Moore, a psychiatrist and owner of

development of the bariatric surgery program at Rex Hospital,

Western Wake Counseling and Psychological Services, and Jennifer

among the very first bariatric programs in the Triangle area. In

Hunt, R.D., L.D.N., with Healthy Diets Inc., a private nutritional

2006, He opened his own practice, The Raleigh Center for Weight

practice. Both come to The Raleigh Center for Weight Loss Surgery

Loss Surgery (www.alasurgery.com) just across the street from Rex

twice weekly to treat Dr. Moran’s patients. Their onsite availability

and has since focused exclusively on minimally invasive bariatric

lends to patient convenience and fosters collaboration among all

surgery.

specialists involved in the patient’s care.

Immeasurably important to his and his patient’s success has been

The clinic encourages patients to begin making lifestyle changes

Dr. Moran’s profound understanding of the weight-loss process. “We

immediately. In addition to dietary concerns and exercise

have to take care of people who have these ingrained behaviors

recommendations, the clinic hosts regular support group meetings

and attitudes,” he says. “They deal with food addictions and other

to ameliorate the psychological and social issues that come with

problems emotionally, psychologically and socially.”

obesity and weight loss. “The support group is one of the ways we

June 2012

7


Front desk coordinator Rushmi Gross greets and assists all patients from their first visit to their five-year anniversary appointment.

try to get more personal with our patients,”

the weight.” But at 361 pounds, he still

GI tract serves to reduce the absorption of

says Mrs. House. Dr. Moran continues:

had a long way to go, and after careful

calories and nutrients from food, known

“We know our patients by name. We know

consideration he decided to proceed with

as malabsorption.

their families, we know their spouses. A

the surgery. The surgery also precipitates substantial

lot of times we’ve taken care of multiples within a family. Our patients recognize and

The Roux-en-Y procedure divides the

physiologic and neuroendocrinal changes.

appreciate that attention to detail.”

upper portion of the stomach from the

While not yet fully understood, they are

lower, creating a small, 1- to 2-ounce

known to offer considerable benefit

Roux-en-Y

“pouch” at the top and stapling both

to the patient by shifting the internal

Determined to succeed, Mr. McIntyre

portions of the stomach shut. The first

gastrointestinal

passed the screenings with flying colors

third of the small intestine is bypassed,

balance. Secretion of peptides promoting

and fully invested himself in his weight-

and the second third is connected to the

energy storage, such as ghrelin, is reduced,

loss journey, electing the Roux-en-Y

gastric pouch. The bypassed portions are

while peptides promoting oxidation of

laparoscopic gastric bypass surgery, one

left in place but are effectively removed

glucose, such as peptide YY 3-36, increase.

of two specialties offered by Dr. Moran.

from the gastrointestinal tract; all food

This results in increased metabolism and

In preparation for surgery, Mr. McIntyre

intake travels down the “Roux limb” to the

more energy, as well as neurological

went on a liquid diet to shrink his liver.

now Y-shaped configuration of the small

changes like different food preferences.

Between this and the new habits he was

intestine.

of

energy

Gastric bypass has been performed for

learning from the support groups, he lost 15 pounds right before surgery.

regulators

The procedure allows for a multifaceted

more than 30 years in the United States and

approach to weight loss: the stomach

is highly effective – when combined with

For a moment, he almost had second

pouch is restrictive, acting as a control

appropriate lifestyle changes, patients can

thoughts. “I was thinking, ‘do I really

on the patient’s portion sizes, limiting the

expect to lose between 50 percent and 75

need this?’ Lots of my friends were telling

amount of food he can consume in one

percent of their total excess body weight

me just to eat right and exercise to lose

sitting and increasing satiety. The shorter

within 18 months, with a further period of

8

The Triangle Physician


complications during and after surgery. This minimally invasive approach, wherein the surgery is performed through incisions less than a centimeter in length, is safer for the patient and takes around 75 minutes to complete. Most patients remain in the hospital for 24 to 48 hours, and return to normal activities within two weeks. However, Dr. Moran notes that certain patients are poor candidates for the laparoscopic approach. For patients with excessive scar tissue or when complications during the operation result in an inability to clearly see the internal organs or excessive bleeding, Dr. Moran will convert the surgery to a conventional open gastric bypass. Mr. McIntyre’s hospital stay was a little longer than the average, lasting three days, but the results were as impressive as they were fluctuation lasting between 18 months and two years. For many,

rapid. Within a week, he was able to go off his diabetes and blood

this quickly removes the physical barriers to exercise and activity,

pressure medications. His high cholesterol medication and sleep

putting the active lifestyle they need within reach. The National

apnea was, likewise, eliminated within the month.

Institutes of Health recommends this procedure for patients with a body mass index (BMI) of 40 or more or 35-40 with comorbidities.

“My wife could finally sleep at night,” he laughs. He went from averaging 3,500 calories per day to 1,200. “I’m eating to live now,

Dr. Moran prefers to perform the procedure laparoscopically

not living to eat,” he says.

to shorten the period of convalescence and reduce the risk of

Jennifer Hunt, R.D., L.D.N., of Healthy Diets Inc. examines the nutritional values of supplements recommended for bariatric surgery patients.

june 2012

9


Practice administrator Meredith Ledford updates the “Patient Manual” used as a guide and resource to patients before, during and after surgery.

Today, Mr. McIntyre is down to 211 pounds.

her efforts, she couldn’t seem to get any

Like the Roux-en-Y, the procedure is

He goes on long bike rides with his family

farther. Seeing a commercial for the LAP-

recommended for patients with a BMI of

and has regained all the mobility and

BAND® System, Mrs. Stair’s search for

40 or more or 35-40 with comorbidities.

activity he had once thought unattainable.

more information eventually led her to The

With accompanying lifestyle changes, the

The secondary benefits from his education

Raleigh Center for Weight Loss Surgery.

LAP-BAND® System can result in loss of 50 percent to 60 percent of excess body

at The Raleigh Center for Weight Loss Surgery are evidenced in his healthier

She was immediately impressed with Dr.

weight within two years, with a three-to-

family. “I haven’t cooked fried food in three

Moran. “He’s serious, but I like that. I didn’t

four-year period of fluctuation following.

years … my children are healthy, and my

want the warm-and-fuzzies,” she says. “I’d

wife is losing weight too.”

rather have a doctor who takes it seriously.

The minimally invasive surgery takes about

Dr. Moran was very knowledgeable. He

half an hour and is typically performed as

Lap-Band®

wanted me to be informed and to know

an outpatient procedure. Recovery is swift,

In contrast to Mr. McIntyre, Alison Stair had

what it would take to get to a healthy weight

with most patients returning to normal

always struggled with her weight.

and a healthy lifestyle.” With Dr. Moran’s

activities within a week.

expert counsel, she elected to have the “I’ve yo-yo’d my entire life,” she says. At just

LAP-BAND® surgery.

Compared to the Roux-en-Y and other conventional bariatric procedures, the

5 feet, 3 inches, she weighed 308 pounds at age 25. She suffered from sleep apnea

The LAP-BAND® device comprises an

LAP-BAND® is less invasive, much easier

and high blood pressure. “I had trouble

inflatable silicone band, 2 centimeters

to reverse and doesn’t modify the GI tract.

putting on pants,” she laughs. But she was

to 3 centimeters in diameter, connected

The device can be adjusted as required,

determined to live the active life she’d

by a thin tube to a subdermal port. The

providing easy flexibility unmatched by

always dreamed of.

band is placed around the upper part

other procedures.

of the stomach, creating a gastric pouch She changed her habits. She stopped

and restricting food intake. The port is

However, weight loss from the LAP-BAND®

smoking,

and

sutured to the abdomen, and allows for the

is considerably more gradual compared to

dramatically reformed her diet. In just six

restriction of the band to be adjusted with

other bariatric procedures and requires

months she’d lost 70 pounds. But for all

saline injections.

regular follow-up visits for adjustment –

10

started

The Triangle Physician

exercising


initially, every few weeks, and as needed

Changing Attitudes

out, she’s a new woman. Two, that the

once the patient’s weight stabilizes.

Dr. Moran’s endeavors to develop an

heart can’t tolerate the procedure. Before

accurate understanding of the risks

patients go into surgery, I make sure they

The LAP-BAND® System is a relatively

and

surgery

can tolerate it. Three, the idea that people

recent innovation, gaining United States

extend beyond his patients; despite its

who get bariatric surgery want an easy way

Food and Drug Administration approval

effectiveness, there remains an air of

out.”

in 2001, but there are few surgeons more

diffidence surrounding these procedures.

experienced in its use than Dr. Moran. As

“I used to feel that bariatric surgery was

Dr. Moran elaborates: “People hear horror

a proctor for Allergan, the manufacturer

a last resort, something done when

stories or bad outcomes. They’re very

of the LAP-BAND® System, Dr. Moran has

everything else had failed,” says Dr. Joseph

small in number but they tend to grab the

provided instruction to other surgeons on

Falsone, M.D., F.A.C.C., a cardiologist at

headlines, the attention of the media, a lot

performing the procedure laparoscopically.

Wake Heart and Vascular who provides

more easily than the success stories.”

benefits

of

weight-loss

pre-surgical cardiac clearance to Dr. Mrs. Stair’s story is testament to the

Moran’s patients. “Initially, I would say 98

The national mortality rate for the Roux-

effectiveness of the system – when

percent of physicians were against these

en-Y is 0.05 percent; for the LAP-BAND®,

combined with dedication. After receiving

procedures.”

0.005 percent. Dr. Moran’s personal mortality/morbidity rates are far below

the LAP-BAND® in March 2008, she’s down to 135 pounds and no longer suffers

Dr. Falsone believes that opposition

the national averages. “The risk is very

from sleep apnea or high blood pressure.

to bariatric surgery stems from poor

low. They’re very safe and well-tolerated

“I went from barely able to put on pants

knowledge regarding its safety and efficacy.

procedures,” he says.

to running a 10k,” she says. “It was so

“There are several misconceptions. One,

rewarding to be able to set goals and meet

that it’s horribly dangerous. That’s just not

In several cases, failing to consider bariat-

them. Realistically, I would not be able to

true. I sent Dr. Moran a patient who had

ric surgery may be the more dangerous ap-

be where I am without the band.”

suffered multiple heart attacks. Six months

proach. Dr. Falsone highlights the enormity

Ashley House, P.A.-C., meets with a patient three weeks after Roux-en-Y gastric bypass surgery to discuss her progress.

June 2012

11


of the situation facing some of his patients.

A Lifelong Journey

move rapidly through the small intestine,

“I take care of some very sick people. A lot

The stories of Mr. McIntyre and Mrs.

leading to abdominal cramps, nausea and

of them have high cholesterol and diabetes

Stair are uplifting, but Dr. Moran and his

diarrhea.

and some have had heart attacks. It gets to

staff are emphatic about articulating the

the point where this person is either going

realities of long-term weight loss. “They’re

With less of the small intestine to absorb

to lose weight or die.”

patients for life,” says Mrs. House. The

essential nutrients, patients of the Roux-

psychological and dietary counseling

en-Y procedure need to take supplementary

Many of Dr. Falsone’s patients have

continue for months and require studious

vitamins. Regular exercise is a must, and

benefitted greatly from bariatric surgery.

effort.

many patients continue attending support group meetings even after meeting their

After witnessing Dr. Moran’s expertise

goals.

firsthand, Dr. Falsone now regularly

Patients must change not only what they

refers patients to The Raleigh Center for

eat, but how they eat – how many times

Weight Loss Surgery. “Dr. Moran does

they chew, how much fluid they imbibe,

It’s truly challenging, and not every patient

fantastic with my high-risk patients. I’ve

how rapidly they finish their meals.

has the willpower. But dedication, not

seen the success of these surgeries, seen

Missing the mark often leads to vomiting

perfection, is the requirement. “Everyone

my patients come back so much better …

or “dumping syndrome,” wherein the

can fall off,” says Mrs. House. “What’s

They’re living longer, healthier lives.”

undigested contents of the stomach

important is to get them back on track.” The clinic offers services specifically for those who have “fallen off.” “Do the research, understand that your lifestyle is going to change and that you have to put in the effort,” advises Mrs. Stair. “Some people lose only 20 pounds because they don’t change their eating habits.” Mr. McIntyre adds, “It’s a lifetime journey, especially in the first year. You have to remember that this is a tool to help you lose weight – if you look at it that way, you will be successful.” Like his patients, Dr. Moran is optimistic about the future. In addition to the Rouxen-Y and the LAP-BAND® procedures, he’s considering offering another, the sleeve gastrectomy, in which up to three-fourths of the stomach is removed outright. Adding this procedure would enable him to more effectively meet the needs of extremely obese patients who may not be able to safely undergo gastric bypass. But for his hundreds of patients struggling with weight gain or diabetes, he’s already proven to be pivotal in changing their lives. “My only regret is in not telling my friends about this sooner,” notes Mr. McIntyre. “It’s such a great tool for someone who has

The Raleigh Center for Weight Loss Surgery staff work closely with patients and providers alike to ensure a seamless experience.

12

The Triangle Physician

struggled with their weight for their whole life,” says Mrs. Stair. “I love my lifestyle now.”


Neurology

Obstructive Sleep Apnea Is Associated with a Higher Mortality from Cancer By Paul C. Peterson, M.D., F.A.C.E.P.

Obstructive sleep apnea is a very prevalent

proangiogenic mediators, such as vascular

condition that induces or aggravates car-

endothelial growth factor, in tumor cells.

diovascular, metabolic and neurocognitive disorders. According to a new study, sleep

Moreover, tumor progression could be

apnea is associated with an increased risk

enhanced by external growth factors

of cancer mortality.

reaching the cancer cells, in particular those systemically induced by hypoxia

Obstructive sleep apnea (OSA) is well

and hence circulating in the blood. This

known to be associated with increased

pathway could be of particular relevance

risks of hypertension, cardiovascular

in OSA since patients with this sleep

disease,

breathing

cerebrovascular

disease,

depression and early death. Additionally,

disorder

exhibit

increased

proangiogenic factors in blood.

obstructive sleep apnea is common among patients with Alzheimer’s disease,

The Wisconsin Sleep Cohort is a longitudi-

with prevalence rates reported to be

nal, community-based epidemiology study

greater than 40 percent in those patients

of sleep apnea and other sleep problems

who are institutionalized.

that began in 1989 as a random sample of Wisconsin state employees. The partici-

Animal studies that have previously

pants underwent overnight sleep studies

been performed provide support for a

among other tests at four-year intervals.

hypothesis of causal link between OSA and

Dr. Paul Peterson is the medical director of the Sleep Laboratory and Stroke Center Program at Duke Raleigh Hospital and a physician with Duke Neurology of Raleigh. After earning his medical degree from the University of Texas Medical Branch at Galveston in 1995, he completed an initial residency in emergency medicine at San Antonio Uniformed Services Health Education Consortium in 1999 and a second residency in neurology at Duke University Medical Center in 2006. He completed a fellowship in sleep medicine and electroencephalography at Duke in 2007. Dr. Peterson is a member of several professional societies, including the American Academy of Sleep Medicine, the American Headache Society and the American Academy of Neurology, and he is a member and fellow of the American College of Emergency Physicians.

cancer. The recent study examining 22-

After adjustment for age, sex, body mass

year mortality data on 1,522 subjects from

index and smoking, the researchers in

the Wisconsin Sleep Cohort Wisconsin

the newly published study found that

supported the hypothesis. It showed a

both all-cause and cancer mortality were

nearly five times higher incidence of solid

associated with the presence and severity

Thus, in the first large, published,

organ cancer deaths in patients with severe

of obstructive sleep apnea in a dose-

population-based

obstructive sleep apnea compared to those

dependent fashion. Those participants

sleep apnea was found to be associated

without the disorder.

with severe obstructive sleep apnea died

with an elevated risk of cancer mortality.

of cancer at a rate of 4.8 times higher than

Additional studies will be needed to

people with no sleep apnea problems.

replicate and expound upon the results.

intermittent hypoxemia, which occurs in

The

after

If the association between obstructive

obstructive sleep apnea and promotes

excluding 126 subjects in the study who

sleep apnea and cancer mortality is

angiogenesis (increased vascular growth)

had used continuous positive airway

validated in further studies, the diagnosis

and, thereby, tumor growth. It has

pressure (CPAP), which is a treatment for

and treatment of obstructive sleep apnea in

been suggested that over-expression of

obstructive sleep apnea. The association

patients with solid organ cancer might be

hypoxia-inducible factor-1-alpha caused

was also stronger among non-obese

indicated to prolong survival.

by tissue hypoxia triggers upregulation of

subjects than obese subjects.

The putative mechanism suggested by

sample,

obstructive

prior animal studies is believed to be associations

were

similar

June 2012

13


Your Financial Rx

Market Gurus and 15 Minutes of Fame By Paul J. Pittman, C.F.P.

Every decade spawns market gurus who

present events and discounted future

make a few correct calls, get massive media

events) that it is impossible to develop

attention, then fizzle out. In the 1960s,

a mathematical model to predict stock

we had Gerry Tsai, Fred Carr and other

prices.

mutual fund gunslingers. In the 1970s, we

2. There are so many diverging opinions

had Joe Granville and Henry Kaufmann.

on stocks that at any given point in

In the 1980s, it was Robert Prechter and

time, there are buyers who believe in a

Elaine Garzarelli. The 1990s brought us the

price increase and sellers who believe

high-flying internet stock managers. Today,

in a price decrease. Since there’s no

Nouriel Roubini and Meredith Whitney are

reason to believe that the buyers are

all the rage. But, eventually, they all return

smarter than the sellers, or vice-versa,

to earth.

then at any given instant, the expected

“Instead of trying to hit home runs, we look for singles and doubles. This strategy may not put us on the cover of Money Magazine, but it may help us methodically meet our clients’ objectives.”

Paul Pittman is a Certified Financial Planner™ with The Preferred Client Group, a financial consulting firm for physicians in Cary, N.C. He has more than 25 years of experience in the financial industry and is passionate about investor education. He is also a nationally sought-after speaker, humorist and writer. Mr. Pittman can be reached at (919) 459-4171 and paul.pittman@ pcgnc.com. Send an e-mail to receive Mr. Pittman’s Weekly Market Commentary. born. But, the odds will eventually catch up with them, hence the fizzle. You can’t consistently and accurately interpret market-moving information. Even if you knew one day in advance what the

Why do all the gurus eventually stumble?

change in a stock’s price is zero. There

non-farm payroll numbers were going to be

They stumble because it is very difficult

are just as many buyers as sellers, and

or whether the Fed was going to change

to consistently pick winners, and it is very

neither one have better information.

interest rates, it would still be difficult to

difficult to accurately interpret market-

3. If you agree with No. 2 above, then

profitably trade with that information. The

moving information. Let’s look at these two

the mathematical expected return to a

problem is we would have to know what

issues in a little more detail.

speculator is zero – a “fair game.”

“the market” was expecting, how “the

4. If you agree with Nos. 2 and 3, then the

market” interpreted the information and

You can’t consistently pick winners. We all

market believes that the current stock

how quickly “the market” assimilated it.

try, and billions of dollars a year are spent

price is the true price. If the market

That’s impossible to do without surveying

on market research, trying to uncover the

didn’t believe that, then it would quote

every market participant. Even if you did

next big winner. Is that rational?

another price that is either higher or

that survey, their minds could change

lower.

before you could react.

In his book entitled Capital Ideas, Peter Bernstein reflects on The Theory of

According the Bachelier, a stock’s price

In the end, we’re back to the basics. Instead

Speculation, the doctoral dissertation of

will change only when there’s a good

of trying to hit home runs, we look for

French mathematician Louis Bachelier

reason for it to change, such as new

singles and doubles. This strategy may not

in the 1900s. Bachelier used complicated

information. Unfortunately, nobody knows

put us on the cover of Money Magazine,

mathematical formulas in an attempt to

whether this new information will cause

but it may help us methodically meet our

explain why the stock market behaves as it

the price to go up or down; hence, we have

clients’ objectives.

does. His conclusions, can be summarized

a 50/50 chance of an up or down move.

as follows:

And, probability theory says under those

Remember the mantra: “It’s Not What You

1. There are so many factors that influ-

conditions, one out of 1,000 will make 10

Make, It’s What You Keep.” Have a great

ence stock prices (e.g., past events,

accurate calls in a row; hence, a guru is

summer.

14

The Triangle Physician


Practice Management

Rethinking the

EHR Revolution By Maryan Binkley

For years, experts have pointed to electron-

ly dictate their exam notes into a phone sys-

ware automatically parses the document

ic health records as a cure for many of the

tem or digital recorder now have to log into

for discrete data, which is automatically

problems hindering our health care sys-

a computer and scroll through extensive

uploaded to the appropriate field of the

tem, including the inability of physicians to

lists of checkboxes for each patient they

EHR. The provider receives all of the struc-

quickly access a patient’s history.

see. The required computer interaction

tured data needed to meet Meaningful Use

limits their mobility, and if the computer

requirements, but also retains access to the

In terms of making information more read-

is in the exam room, their interaction with

note in narrative form. Further enhancing

ily available, new federal incentives to sub-

the patient, causing dissatisfaction from

the documentation process, mobile appli-

sidize the upfront costs of electronic health

both parties. Physicians who use front-end

cations are becoming increasingly robust

records (EHRs) are a welcome develop-

voice recognition fare only marginally bet-

and look to be a viable means to simplify-

ment. A recent report projects a robust

ter, as they’re required to immediately cor-

ing a clinician’s workflow.

12-percent growth rate for such systems

rect anything the software misinterpreted. Efforts to improve interoperability within

over the next few years. After a notoriously slow start for the technology, four of every

The quality of the document can also suf-

the industry continue to advance, sug-

10 physicians now utilize EHRs at their hos-

fer. The physician becomes the only set of

gesting a bright future for such interfacing.

pital or office.

eyes looking at information going into the

What’s becoming more apparent is that

record, making it harder to detect crucial

EHRs are not the solution to inefficiencies

Of course, adopting electronic records is

mistakes. When it comes to reviewing pa-

in health care, but rather part of the solu-

only step one. The real key to improving

tient information, because the information

tion. The sooner providers realize this, the

patient outcomes and gaining efficiencies

was entered into a one-size-fits-all template,

quicker we’ll see the real information revo-

lies in how EHRs are implemented. Clearly,

practitioners no longer have a narrative

lution we’ve been waiting for.

the industry is still finding its way in this

note they can look to for a clear under-

regard. Last year, a study of more than

standing of what previous medical person-

2,700 family physicians found that only 49

nel observed.

percent were satisfied in whole with their system.

EHR users do well by playing to the technology’s strengths. For a number of for-

While there’s no silver bullet to improving

ward-thinking facilities around the country,

the EHR experience, providers often ben-

this has meant integrating their EHR with

efit from taking a clear-eyed look at what

other software programs and building syn-

these systems can deliver. Many facilities

ergies between them. One promising trend

discover, only after an expensive rollout,

involves hospitals and clinics linking tran-

that electronic charts aren’t actually a pan-

scription management software with their

acea for their record-keeping challenges.

EHR system, creating a “hybrid” solution.

For instance, while physicians appreciate the ability to call up patient data instanta-

With the help of a software technology

neously, many are unenthused about not

known as “discrete reportable transcrip-

only how that information is initially cap-

tion,” doctors can realize the benefits of

tured, but also how it’s presented.

EHRs without giving up their ability to dictate patient notes. When the transcription-

Doctors who were previously able to quick-

ist types the note into the system, the soft

The Triangle Physician 2012 Editorial Calendar July

New Imaging Technologies Electronic Medical Records

August

Digestive Disease Computer Technologies

September

Sports Medicine – Physical Therapy

October

Breast Cancer – Reconstructive Surgery

November

Urology – Robotic Surgery

December

Pain Management June 2012

15


Women’s Health

Vigilance Helps Protect Women from Advance of

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

Women considering their cancer risks

Once diagnosed, the five-year relative sur-

disease is within advanced stages (Stage

often first think of breast cancer. Organi-

vival rate for ovarian cancer patients is only

III or IV), largely because the presenting

zations like Susan G. Komen for the Cure

46 percent – meaning that more than half

symptoms are ignored, overlooked or mis-

have done much to further education, and

of ovarian cancer diagnoses result in the

taken for a more common illness.

research of breast cancer and awareness is

death of the patient within five years. (As

at an all-time high.

a point of reference, the five-year relative

So what are the most common symptoms

survival rate for breast cancer patients is

of ovarian cancer?

Certainly these efforts deserve praise, but

about 89 percent.)

•A  bdominal bloating or swelling; •P  ressure or pain within the abdomi-

women should take care not to be blinded

nal, pelvic or back;

by the spotlight on the pink ribbon! Aware-

•E  arly satiety (or feeling full sooner

ness is just as necessary in combating

than usual);

many other forms of cancer, including less

•N  ausea, vomiting, gas, constipation

well-known threats, such as ovarian can-

or diarrhea;

cer, which frequently go overlooked.

•F  requent urination; According to estimates from the National

•W  eight gain;

Cancer Institute (www.cancer.gov/cancer-

•C  hange in menopausal or postmenopausal bleeding.

topics/types/ovarian), in 2012 health care providers will diagnose 22,280 new cases of ovarian cancer, and the disease will

As with many cancers, early detection

Unfortunately, no routine screening test

be responsible for 15,500 deaths. Ovarian

improves treatment options and efficacy.

exists that reliably detects ovarian cancer

cancer accounts for only three percent of

Survival rates of women who discover

(Pap smears are useful in diagnosing cer-

annual new cancer cases in women and

and treat the cancer early, when it is still

vical cancer, but not ovarian cancer.), and

ranks ninth in overall frequency; however,

localized, are more than 90 percent, and

few women adequately understand their

it is the fourth-leading cause of cancer-re-

treatment is likely to be less invasive and

risk factors. Higher rates of the cancer are

lated deaths in women.

painful.

associated with nulliparity (not having chil-

The median age at diagnosis of ovarian

The challenge for women with ovarian can-

cancer (also known as Lynch syndrome

cancer is 60-64 years, although younger

cer and their health care providers comes

II), and a personal or family history of

women are also at risk. Despite advances

in recognizing and responding to the often-

breast, colon or ovarian cancer. A long his-

in cancer treatment and research during

subtle symptoms of the disease before it

tory of uninterrupted ovulatory cycles may

the last 40 years, the prognosis for ovarian

advances too far. More than half of ovarian

also increase a woman’s risk.

cancer remains grim.

cancer patients are diagnosed when the

dren), hereditary non-polyposis colorectal

e p o H 16

The Triangle Physician

Strength

Faith


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 co-founded and served as the director of gynecology for the Women’s Hemostasis and Thombosis Clinic. She left her academic position in 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.

Fortunately, there’s a flip side to the coin – several protective factors for ovarian cancer have been identified. Multiparity (having many children), breast feeding and taking oral contraceptives are all associated with lower incidence of ovarian cancer. Women

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Like breast cancer, ovarian cancer is associated with mutations in the BRCA1 and BRCA2 genes, and women with a family history of either are at increased risk for both. We encourage active screening for hereditary breast and ovarian cancer now at annual examinations. Currently, the testing for BRCA1 and BRCA2 are done by Myriad Laboratories (www.myriad.com). We encourage providers to become familiar with this screening, and we are happy to see women for screening and education regarding hereditary breast and ovarian cancer.

Treatment Center

Doctors can confirm the presence or absence of ovarian cancer by starting with a good history and physical, including a pelvic exam, then proceeding to a pelvic ultrasound and blood tests, specifically CA-125. The CA-125 is a substance that is found on the surface of ovarian cancer cells. Because elevated CA-125 levels may result from a variety of conditions, the test alone can-

HD Treatment Center of Raleigh is seeking part-time physicians to come join its team and share in the success of this new practice. HD Treatment Center of Raleigh is a specialty practice dedicated solely to the treatment of Hemorrhoidal Disease (HD). Only FDA cleared treatment regimens are used and our treatment procedures are performed in-office.

not confirm a diagnosis of ovarian cancer and is not an effective

We offer:

screening tool. However, the test’s results often prove helpful in

• Outstanding rate of pay • • Part-time and hours • • Flexible scheduling • • No on-call or inpatient/hospital work • • No administrative responsibilities • • All training done on site •

the evaluation of an ovarian cyst, and in monitoring the cancer after a diagnosis. If a provider is suspicious of ovarian cancer, we recommend referral to a gynecologic oncologist. While ovarian cancer is often stealthy, it is rarely silent. It is vitally important for every woman to be aware of her health risks and to address them proactively. Both women and health care providers need to have a high index of suspicion in the diagnosis of ovarian cancer. Educating yourself and your patients may prompt early evaluation and prove to be the difference between statistic and survivor.

This is an ideal part time position for any primary care or family physician or surgeon. If interested, please call (919) 861-9777 or send your CV to Dr. Lawrence Fusco at HD Treatment Center of Raleigh, 4601 Lake Boone Trail, Suite 1D, Raleigh, NC 27607 or by email to information@hdtreatmentcenter.com. Please visit our website at www.hdtreatmentcenter.com for additional information.

June 2012

17


Bariatric Surgery

Obstructive Sleep Apnea: Effective Treatment Leads to Rapid Improvement By Alfonso Torquati, M.D., M.S.C.I., F.A.C.S.

In the United States, obstructive sleep

of the pharyngeal airway during sleep.

apnea is most common in the fourth, fifth

Some patients with OSA end up awaken-

and sixth decade of life, affecting up to

ing from sleep to restore normal breath-

one in four men and one in nine women,

ing, which compromises nocturnal sleep

for an estimated total of 23 million affected

quality. The main clinical presentation of

individuals. Despite a recent increase

OSA is snoring, which is frequently asso-

in public and health care workers’

ciated with symptoms of daytime fatigue

awareness, this condition is still largely

and sleepiness.

underdiagnosed, leaving perhaps one in four people with obstructive sleep apnea

The most profound effects of OSA are

without a diagnosis.

on the cardiovascular system. Repeated nocturnal

hypoxemic activation

events and

elicit

Obstructive sleep apnea (OSA) is a medi-

sympathetic

cal condition that causes disruptions to

inflammatory mediator release that carry

systemic

breathing during sleep. Apnea is defined

over into the daytime. Complications of

as a temporary absence or cessation of

untreated OSA include increased risk of

breathing for more than 10 seconds. Usu-

premature death, myocardial infarction,

ally a person affected by obstructive sleep

arrhythmias, stroke and motor vehicle

apnea experiences repeated episodes of

accidents.

apnea because of a narrowing or closure

Dr. Alfonso Torquati is an associate professor of surgery at Duke University and co-director of the Duke University Center for Metabolic and Weight Loss Surgery, one of the top academic bariatric centers in the country. Dr. Torquati is a nationally recognized leader in bariatric surgery, with more than 14 years’ experience in performing bariatric procedures. He has given more than 100 presentations worldwide about bariatric surgery and published more than 60 peer-reviewed studies. His current research effort, funded by the National Institutes of Health, focuses on the role of bariatric surgery as treatment for obesity and related diseases. Dr. Torquati may be reached by calling (919) 470-7000 or (919) 470-7041.

Recent evidence suggests that OSA has strong association with obesity,

Diagnosis and Treatment

diabetes,

hypertension

Polysomnography plays a prominent role

and cardiovascular disease. Therefore,

in the evaluation of sleep disorders and

the prevalence of OSA has the potential

diagnosing OSA, since the disorder cannot

to increase substantially in the coming

be correctly suspected on the basis of

years, secondary to the obesity epidemic

interview and physical examination alone.

dyslipidemia,

facing our society. Continuous positive airway pressure Primary prevention interventions are

(CPAP) is used as first-line treatment if

aimed at the known risk factors for OSA

symptoms and disease are severe. The

and include:

effectiveness of CPAP in eliminating

• Losing weight, reducing alcohol or

obstructive sleep apnea has been proven

sedative use, stopping smoking;

by a number of randomized clinical trials.

• Optimizing treatments for conditions that may exacerbate OSA (e.g. asthma,

of life and to decrease fatigue during

allergic rhinitis);

daytime in patients with intermediate and

• Assessing one’s risk for cardiovascular disease and diabetes.

18

The Triangle Physician

CPAP therapy is likely to increase quality

severe OSA.


NEWSOURCE-JUN10:Heidi

8/5/10

12:57 PM

Page 1

Weight loss should be recommended for all overweight and obese patients with OSA, as it results in improvement of the condition. A study from Paul E. Peppard,

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Ph.D., and collaborators reported that a 10 percent weight loss predicted a 26 percent decrease in the severity of sleep apnea.

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Considering that medical weight loss usually fails to provide long-term results, bariatric

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should

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and with body mass index greater than 35 (Class 2 obesity). The 2004 Buchwald meta-analysis of the impact of bariatric surgery on weight loss in patients with four comorbidities (diabetes, hyperlipidemia, hypertension

newsource & Associates

and OSA) reviewed 136 studies involving 22,094 patients. The mean percentage of excess weight loss was 61.2 percent in all patients, and OSA was completely

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resolved in 85.7 percent of patients. In one of the largest series measured by polysomnography before and after bariatric

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K.L.

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collaborators confirmed that bariatric surgery results in significant improvement

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of OSA and parameters of sleep quality in obese patients. The above mentioned studies and many others clearly support the role of bariatric surgery in treating OSA in obese adults. Bariatric surgery is effective because weight loss has been shown to be rapid, significant and durable. Other methods of weight loss are less effective in resolving OSA, because weight loss is not as significant and rapid as with bariatric

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surgery at Duke, visit the website at www.dukehealth.org. To schedule an appointment for a patient at the Durham clinic, call (866) 637-0711 and select option one; or at the Raleigh Clinic, call (919) 862-2715.

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June 2012

19


Neurology

Stroke Threat Grows Despite Declining Mortality and Changing Care Patterns By Larry B. Goldstein, M.D., F.A.A.N., F.A.H.A.

In January 2000, the United States Depart-

stroke death rate in the state has declined

North

Carolina

ment of Health and Human Services, in

over recent years, in 2008 it remained

implementation funding from the CDC

conjunction with voluntary health organi-

above the national average and above

National

zations including the American Heart As-

the Healthy People 2010 target. Stroke-

Prevention Program since 1998. The

sociation, launched Healthy People 2010,

related direct costs in North Carolina are

program aims to facilitate and implement

a program aimed at improving Americans’

estimated at $1.05 billion annually.

cardiovascular

health and decreasing disease-related

With more than 75 percent of strokes

Hypertension, the single most important

Heart

has

received

Disease

preventive

and

basic Stroke

programs.

treatable stroke risk factor, is one target.

It is a leading cause of adult disability and a major cause of cognitive impairment, and was responsible for $73.7 billion in direct and indirect medical costs in 2010.

Reflecting the program’s success, a recent report indicates that more than 94 percent of North Carolina adults had their blood pressure checked by a health care professional within the prior two years, with the state having the fourth-

morbidity through a variety of popula-

being first events, much of the reduction

highest rate of blood pressure screening

tion-based initiatives. A target 25 percent

in stroke mortality in the country has

nationally.

reduction in stroke mortality was set, a

been attributed to improved prevention.

goal that was actually achieved in 2006.

Following a healthy lifestyle is arguably

Recognizing the burden of heart disease

By 2008, stroke deaths had declined by

the most important stroke preventive

and stroke in the state, the North Carolina

34 percent. Due to a combination of lower

measure. Those who have an 80 percent

legislature established the Justus-Warren

mortality and a reclassification of respira-

lower risk of stroke as compared to those

Heart Disease and Stroke Prevention Task

tory diseases in national statistics, in 2010

who do not.

Force in 1995. Comprised of members of the legislature, medical and public health

the Centers for Disease Control reported that stroke had fallen from the country’s

Healthy lifestyle recommendations in-

professionals, heart attack and stroke

third- to its fourth-leading cause of death.

clude not smoking; following a healthy

survivors,

diet, such as the DASH (Dietary Ap-

leaders and other stakeholders, the task

Despite these encouraging statistics, stroke

proaches to Stop Hypertension) eating

force helps to coordinate multiple private,

remains a major public health problem. It

plan; engaging in at least 30 min per day

is a leading cause of adult disability and

of at least moderate physical activity, such

a major cause of cognitive impairment,

as brisk walking; maintaining an optimal

and was responsible for $73.7 billion in

body weight (body mass index less than

direct and indirect medical costs in 2010.

25 kg/m2); and not consuming alcohol

The impact of stroke is particularly high in

to excess. Health care providers need to

North Carolina. Situated in the country’s

reinforce these lifestyle recommendations

“Stroke Belt,” North Carolina has the sixth-

with their patients. The American Heart

highest stroke death rate in the country,

Association (mylifecheck.heart.org) has

with rates disproportionately high in the

tools to help people optimize their cardio-

eastern part of the state. Although the

vascular health.

20

The Triangle Physician

business

and

community


Dr. Larry Goldstein is professor of medicine (neurology) at Duke University and the Durham Veterans Affairs Medical Center and director of the Duke Stroke Center. He has published nearly 600 journal articles and other professional papers and chaired or been a member of several national guideline committees. He served as chairs of the ASA Advisory Committee and the Leadership Committee of the AHA Stroke Council, and was a member of the AHA National Board of Directors. He is a member of the editorial boards of several medical journals and was a member or chaired review panels for granting agencies, the Food and Drug Administration and CMS-Centers for Medicare & Medicaid Services. Locally, he served as a member of the Board of Directors and president of the AHA Mid-Atlantic Affiliate and is a member of the North Carolina Stroke Advisory Council.

federal and state-funded activities in heart disease and stroke prevention. In 2007, the legislature also established a Stroke Advisory Council to report to the task force. This was based on national data showing that stroke care was poorly coordinated and research data showing geographic disparities in stroke treatment capabilities across the state. In parallel with these activities, the American Heart Association

improvement registries and programs. Both North Carolina’s Collaborative Stroke Registry (part of the CDC’s Paul Coverdell Stroke Registry) and the AHA Get with the Guidelines program provide hospitals with comparative quality metrics (many of which are also required for Primary Stroke Center certification). Participation in Get with the Guidelines is associated with improvements in a variety of quality indicators. Despite these advances in prevention and the organization of stroke care in North Carolina, considerable hurdles remain. A survey found that less that 18 percent of adults in the state know all the symptoms of stroke and indicate they would call 911 if they thought someone was having a stroke. Another study found that those at highest risk (the elderly and African Americans) were the least knowledgeable. The risk of stroke doubles with every decade of age over 55 years. As the average age of the population of the country continues to rise, the burden of stroke is expected to dramatically increase in coming years. The impact may be blunted by more effective prevention combined with better public education and enhanced organization of care. The 2010 goals have now been replaced by 2020 goals – to improve cardiovascular health and further reduce cardiovascular and stroke-related death. The health care community will all need to work together to achieve these goals.

/American Stroke Association published a white paper outlining the components of stroke systems of care. Based on recommendations from this report, Brain Attack Coalition criteria and AHA/ASA guidelines, the Joint Commission began to certify primary stroke centers (PSCs), hospitals organized and capable of providing coordinated acute stroke care. There are currently 13 such hospitals in the state. Studies now show that care in PSCs is associated with higher rates of treatment with intravenous tissue plasminogen activator (tPA, the only FDA-approved treatment for selected patients with acute ischemic stroke), as well as improved patient outcomes. To maintain certification, hospitals must regularly report on a variety of stroke-related quality metrics and have biannual site visits. Non-PSC hospitals are now being linked via telemedicine to hospitals having stroke expertise, extending treatment to otherwise underserved areas of the state. This is particularly important as the provision of tPA is time sensitive; the longer the interval between symptom onset and treatment, the less likely the patient will benefit. In 2010, the North Carolina Office of Emergency Medical Services required that each EMS provider have a triage plan for patients with likely stroke to reduce treatment delays. The effectiveness of the program is currently under study. Many hospitals are now participating in stroke-related quality

June 2012

21


Duke Research News

Statin Drugs Slow Benign Prostate Growth; Lifestyle Could Help Too Statins drugs prescribed to treat high

Enlarged prostate, diagnosed as benign

“We don’t yet understand the mechanisms

cholesterol also may work to slow benign

prostate hyperplasia, causes urinary prob-

that might be causing this,” Dr. Muller

prostate growth in men who have elevated

lems that can escalate to bladder and kid-

said. “Some have suggested that statins

PSA levels, according to an analysis led

ney damage. Up to 90 percent of men over

may have anti-inflammatory properties,

by researchers at Duke University Medical

the age of 70 have some symptoms associ-

and inflammation has been linked to pros-

Center.

ated with enlarged prostate, according to

tate growth, but this needs further study.”

the National Institutes of Health. Dr. Muller said the findings in the current

The finding, presented at the annual meeting of the American Urological As-

Dr. Muller and colleagues used data gath-

research also suggest that lifestyle choic-

sociation, provides additional insight into

ered for an unrelated, large trial testing

es, such as diet and exercise, may not

the effects statins have on the prostate.

a drug called dutasteride, which can be

only affect cholesterol, but also prostate

Previous studies at Duke and elsewhere

used to treat prostate enlargement. From

health.

had found a link between the cholesterol

that trial, the researchers culled data for

drugs and lower levels of PSA, a protein

more than 6,000 men, including 1,032 who

“Prostate enlargement was once con-

produced by the prostate that is often ele-

also took statins.

sidered an inexorable consequence of aging and genetics, but there is growing

vated by cancer or by non-lethal prostatic Men on statins were older on average

awareness that prostate growth can be

than non-users, but had a similar prostate

influenced by modifiable risk factors,” Dr.

In the current finding, prostatic growth

volume. At two years, prostate growth

Muller said. “In this context, the role of

rate diminished among men with elevated

was less for the men in the study who

blood cholesterol levels and cholesterol-

PSA levels who took statins, although that

took a statin drug, regardless of whether

lowering drugs, such as statins, warrants

effect was relatively small and tapered off

they had been randomly assigned to take

further study.”

after about two years.

dutasteride or a dummy pill. In men who

diseases.

took both a statin and dutasteride pill,

In addition to Dr. Muller, study authors

“Given that benign prostate growth is an

prostate growth was 5 percent less than

included Leah Gerber; Daniel Moreira;

important health problem in the United

in untreated men. For those taking a statin

Gerald Andriole; J. Kellogg Parsons; Neil

States and elsewhere, and will be a larger

and a dummy pill, prostate growth was 3.9

Fleshner; and Stephen Freedland.

problem as the population ages, it’s impor-

percent less. The study was funded by GlaxoSmith-

tant to understand and treat its causes,” said Roberto Muller, M.D., a urology fellow

Those reductions, however, did not per-

at Duke and lead author of the study.

sist after two years.

Kline, which markets dutasteride.

Cardio Fitness Levels May Affect Survival of Breast Cancer Patients Women receiving care for breast cancer

tial evidence that poor cardiopulmonary

people who do not have cancer; however,

have significantly impaired cardiopulmo-

function may be a strong predictor of sur-

relatively little research has been done as-

nary function that can persist for years

vival among women with advanced breast

sessing the clinical importance of these

after they have completed treatment,

cancer.

tests in patients with cancer,” said Lee Jones, Ph.D., associate professor at Duke

according to a study led by scientists at “We know that exercise tolerance tests,

and lead author of the study. “Our work

which measure cardiopulmonary func-

provides initial insights into the effects a

The findings, reported online in the Jour-

tion, are among some of the most impor-

cancer diagnosis and subsequent therapy

nal of Clinical Oncology, also provide ini-

tant indicators of health and longevity in

may have on how the heart, lungs and rest

Duke University Medical Center.

22

The Triangle Physician


Duke Research News of the body work together during exer-

ment called VO2-peak, the gold standard

it with exercise training. Although we cur-

cise.”

assessment of cardiopulmonary function

rently do not know if improving fitness in

that athletes use to measure fitness levels

cancer patients is associated with longer

and design training programs.

survival, our data provides initial evi-

Treatment regimens for breast cancer

dence to pursue this question.”

have saved lives, contributing to a decline in death rates of about 2.2 percent a year

The researchers found that women with

since 1990, according to a Duke press re-

breast cancer, regardless of treatment

Dr. Jones said the findings of this study

search. But successful treatments often

status, had significantly worse cardiopul-

indicate exercise may be a good interven-

come at a heavy price to the cardiopulmo-

monary function than healthy women of

tion for cancer patients both during and

nary system, including the lungs, heart,

the same age who were sedentary. Even

after therapy. His team at Duke has several

blood and skeletal muscle.

among patients who had completed can-

studies under way examining the effects

cer therapy years previously, cardiopul-

of exercise training on women with breast

Certain types of chemotherapy can impair

monary function levels were markedly

cancer, plus patients with other cancers.

the heart’s pumping function, reduce the

impaired, suggesting that fitness levels

ability of red blood cells to carry oxygen

may not recover after therapy. More strik-

In addition to Dr. Jones, study authors

throughout the body and diminish the

ing, approximately a third of women in

from Duke include Whitney E. Hornsby,

ability of muscle cells to work efficiently.

the study had a cardiopulmonary function

April D. Coan, James E. Herndon II and

Patients also may experience secondary

score below the threshold that suggests

Pamela S. Douglas.

effects of therapy, becoming less active

people can function independently – do

and gaining weight, which can also impair

household tasks, walk up and down stairs

Authors from the University of Alberta, in

cardiopulmonary function.

or walk a half mile.

Edmonton, Alberta, Canada, include: Kerry S. Courneya, John R. Mackey, Edith N.

To begin to understand the direct and

Among the patients with advanced breast

Pituskin and Mark Haykowsky. Hyman B.

indirect effects of therapy on breast can-

cancer, median survival was significantly

Muss is from the University of North Caro-

cer patients, Dr. Jones and his colleagues

longer for women with higher cardiopul-

lina at Chapel Hill; Jessica M. Scott is from

examined cardiopulmonary function at

monary function. Median survival was

NASA Johnson Space Center in Houston,

rest and during exercise in 248 women in

36 months in high-fitness patients vs. 16

Texas.

various stages of treatment for breast can-

months in the low-fitness patients. Dr. Jones is supported by grants from the

cer. All completed a carefully controlled cardiopulmonary exercise test on a sta-

“Fitness level may be an important bio-

National Institutes of Health. The authors

tionary bike, which escalated until the pa-

marker of survival among cancer pa-

reported no conflicts of interest.

tients reached maximum exertion. At that

tients,” Dr. Jones said. “But the beautiful

point, the researchers took a measure-

thing about fitness is that we can improve

Duke News

New Health Education Center Honors Philanthropist’s Lifelong Commitment constant reminder, now and in the future.”

Duke University’s Board of Trustees has

school’s missions of research, education

approved naming the school of medicine’s

and patient care was always a source of

new Center for Health Education in

inspiration to our faculty and students,”

According to Victor J. Dzau, M.D., chan-

honor of the late Mary Duke Biddle Trent

says Nancy C. Andrews, M.D., Ph.D., dean

cellor for health affairs and chief executive

Semans, a philanthropist with a lifelong

of the Duke University School of Medicine.

officer of Duke University Health System,

commitment to the University.

“It is fitting that Duke Medicine’s new

Mary Semans “was a close friend who rep-

home for health education be named in

resented the very heart and soul of Duke

her honor so that her legacy will be a

Medicine. She will always have a presence

“Mary Semans’ unwavering support for the

June 2012

23


Duke News on the university campus, and naming the

one of the largest private foundations in

The new Center for Health Education,

Center for Health Education in her honor

the country. Mrs. Semans was a trustee

currently under construction, was initially

befits the legacy she has left the medical

of The Duke Endowment for 55 years and

funded with $35 million from The Duke

center.”

served as its first female chairman from

Endowment. When it is completed in late

1982-2001.

fall 2012, the five-story, limestone-andglass facility will be centered at the heart

Mrs. Semans, who died Jan. 25 at the age of 91, had deep roots with the university.

“Mother loved Duke Hospital and the Duke

of the medical campus. It will feature high-

Her grandfather, Benjamin Newton Duke;

Medical Center and we are so pleased

tech teaching and learning opportunities,

his brother, James B. Duke; and their

that her memory will be kept alive for the

including an entire floor of simulation

father Washington Duke, were the chief

future medical students and leaders who

laboratories, flexible classroom space,

benefactors of Trinity College, which later

will pass through these halls,” said Mary

teaching labs and event space. Classes

became Duke University. In 1924, James B.

Jones, Mrs. Semans’ daughter.

will begin in the new building in January 2013.

Duke established The Duke Endowment,

UNC News

Dr. Ned Sharpless Recognized as a Wellcome Distinguished Professor “Ned”

“In addition to his accomplishment in fun-

North Carolina, where he studied math-

Sharpless, M.D., profes-

damental research, Dr. Sharpless is an ex-

ematics as an undergraduate. He gradu-

sor

Norman

E.

and

emplar of a new breed of entrepreneurial

ated with honors and distinction from

genetics and associate

researcher. He has gathered intellectual

the UNC School of Medicine, followed

of

medicine

director for translational

property from his UNC work and created a

by internal medicine training at Massa-

research at UNC Lineberger Comprehen-

UNC start-up, G-Zero. The company is de-

chusetts General Hospital and Harvard

sive Cancer Center, has been appointed

veloping agents that can be used to mini-

Medical School in Boston. He completed

the Wellcome Distinguished Professor in

mize the toxicity of chemotherapy and be

his hematology and oncology training at

Cancer Research.

used as radioprotectants in the case of

the Dana-Farber Cancer Institute, also at

human exposure to accidental radiation,”

Harvard Medical School. After finishing

Mr. Roper added.

his clinical training, Dr. Sharpless com-

The professorship was established by the

pleted a research postdoctoral fellowship

University of North Carolina School of Medicine in 1988 with gifts from the Bur-

“Simply put, Ned is one of the outstanding

at the Dana-Farber Cancer Institute, prior

roughs Wellcome Fund and the William

clinician scientists in the nation. His ex-

to joining the faculty at Harvard Medical

A. Smith Trust of Wadesboro, N.C. The

traordinary mastery of clinical medicine,

School in 2000. Dr. Sharpless returned to

gifts were supplemented by the state Dis-

high-level knowledge of molecular genet-

UNC in 2002.

tinguished Professors Endowment Trust

ics and animal modeling and passion for

Fund to create the endowed professor-

improving the lot of cancer patients are a

In addition to his clinical work as a physi-

ship.

rare combination. He meets anyone’s defi-

cian, Dr. Sharpless runs a 17-person basic

nition of a rising star in medical oncology

science laboratory that studies cancer

“Dr. Sharpless is an outstanding clinician,

and meets all of the criteria for appoint-

and aging. He is co-leader of the Molecu-

teacher and scientist. He is among this

ment to a distinguished professorship.

lar Therapeutics Program, co-founder and

institution’s most sought-after teachers

Ned’s work will make a difference for

co-director of the UNC Mouse Phase I Unit

and mentors and his laboratory is one of

cancer patients worldwide,” said Shelley

and associate director of The UNC Center

the most innovative and productive in his

Earp, M.D., director of UNC Lineberger

for Aging and Health. He has authored

field,” said William L. Roper, M.D., M.P.H.,

Comprehensive Cancer Center.

more than 90 original reports, reviews and book chapters and is an inventor of

dean of the UNC School of Medicine and chief executive officer of UNC Health Care

Dr. Sharpless, a Greensboro native, was

System.

a Morehead Scholar at the University of

24

The Triangle Physician

10 patents.


UNC News Dr. Sharpless’ lab has received support

the 2007 recipient of the Jefferson Pilot

by supporting research and other scien-

from the Sidney Kimmel Foundation for

Award, the 2009 recipient of the Hettle-

tific and educational activities. Through

Cancer Research; the American Federa-

man Prize for Scholarly Achievement, a

its programs, BWF seeks to accomplish

tion of Aging Research; the William Guy

2010 recipient of a Glenn Award for Re-

two primary goals: to help outstanding

Forbeck Research Foundation; the Golf-

search in Biological Mechanisms of Ag-

scientists early in their careers develop as

ers Against Cancer Foundation; the Breast

ing and a 2012 Triangle Business Journal

independent investigators and to advance

Cancer Research Foundation; the Paul

Health Care Hero.

fields in the basic medical sciences that are undervalued or in need of particular

Glenn Foundation; and the Ellison Medical

encouragement.

Foundation. He is supported by a Clinical

He is a member of the American Society

Scientist in Translational Research Award

of Clinical Investigation (ASCI), the na-

from the Burroughs-Wellcome Fund.

tion’s oldest honor society for physician-

The William A. Smith Trust is a charitable

scientists, and has been elected to serve

foundation chartered in 1934 under the

on the ASCI council from 2011 to 2014.

will of William Smith, a resident of An-

He is on the scientific advisory board of

sonville. The foundation is primarily inter-

several scientific foundations and is an associate editor of Aging Cell and Impact

The Burroughs Wellcome Fund (BWF) is

ested in funding educational projects in

Aging and is deputy editor of the Journal

an independent private foundation estab-

Anson County but occasionally extends

of Clinical Investigation. Dr. Sharpless was

lished to advance the medical services

its interests beyond that area.

UNC Research News

Quest to Understand Hepatitis C and Liver Cancer Link Gets $2.35 Million Does hepatitis C cause liver cancer due

medicine and microbiology and immu-

recently developed mouse model that

to inflammation associated with the

nology and a member of UNC Lineberger

develops a human immune response to

disease, or does the virus interact with

Comprehensive Cancer Center, the Cen-

HCV (hepatitis C virus) and human liver

host cells in a different way to promote

ter for Translational Immunology and the

diseases when infected with HCV. The

the development of cancer?

UNC Center for Infectious Disease. His

project will combine the expertise of

laboratory’s recombinant DNA virus tech-

the Su group in human immunology and

Two University of North Carolina scien-

nology will help the team understand how

humanized mouse models with that of the

tists have received $2.35 million to com-

genetic changes in hepatitis C virus may

Lemon group in HCV viral genetics and

bine the power of technologies developed

affect disease progression, including liver

liver cancer to elucidate mechanisms of

in each of their laboratories to answer this

cancer.

HCV-induced liver cancer,” said Dr. Su.

The researchers are both principal

“A number of studies have documented

Lishan Su, Ph.D., is a professor of

investigators on the five-year grant from

that inflammation plays a role in liver

microbiology

immunology

the National Cancer Institute, a member

cancer. But there is evidence that there is

and a member of UNC Lineberger

institute of the National Institutes of

more to the story of virus-cell interaction

Comprehensive Cancer Center and the

Health.

in the development of cancer. We believe

question.

and

that the virus is interacting specifically

UNC Center for Infectious Disease. His team has developed a laboratory model of

“Chronic hepatitis C infection is now

with host cell tumor suppressor pathways

hepatitis C that more faithfully replicates

the leading cause of hepatocellular

to promote cancer, and we want to

the course of the disease in humans,

carcinoma (HCC) in the United States,

understand what drives this progression

both in terms of inflammation, immune

but how it causes liver cancer is not

from infection to cancer in order to figure

response and other factors, according to

well understood because of the lack of a

out how to stop it,” said Dr. Lemon.

a university press release.

small animal model for hepatitis C. This

Stanley M. Lemon, M.D., is a professor of

multi-PI (multiple-principal investigators)

According to the Centers for Disease

project will allow us to further refine a

Control and Prevention, hepatitis C is

June 2012

25


UNC Research News the most common chronic blood borne

individual research awards. Additionally,

thirds of these cases.

more than one PI on individual grants was

infection in the United States, affecting approximately 3.2 million people. The

Editor’s Note: The National Institutes of

a major recommendation of the 2003 NIH

disease accounts for the deaths of more

Health allows multiple program director/

Bioengineering Consortium Symposium

Americans each year than HIV/AIDS.

principal investigator (PD/PI) research

on Catalyzing Team Science. NIH says its

Liver cancer is the third leading cause

as part of its NIH Roadmap initiative.

multiple-PD/PI policy offers approaches

of death from cancer worldwide and the

According to the NIH website, the NIH

to maximize the potential of team science

ninth leading cause of cancer deaths in

multiple-PD/PI

efforts and does not replace the traditional

the United States. Chronic hepatitis virus

response to a federal-wide directive to

infections account for more than two-

formally allow more than one PD/PI on

initiative

also

is

in

single-PD/PI model.

$900,000 Grant to Fund Use of Kinase Test in HER2-positive Breast Cancer Susan G. Komen for the Cure has award-

cancers eventually become resistant.

cancers. Several HER2-targeted drugs are in clinical use and many more are in de-

ed a grant of almost $900,000 to Lisa A. Carey, M.D., and Gary Johnson, Ph.D., to

Dr. Johnson, who is the Kenan distin-

velopment. But we don’t know who needs

research clinical applications for the first

guished professor and chair of the de-

which targeted drug and why, who needs

broad-based test for protein kinase activa-

partment of pharmacology in the UNC

dual HER2-targeted therapy and what oth-

tion and response to inhibitory drugs in

School of Medicine and a member of

er strategies might be needed to best treat

HER2-positive breast cancer.

UNC Lineberger Comprehensive Cancer

HER2-positive breast cancer.”

Center, worked with his team to develop Kinases are proteins expressed in human

a test that can measure both the presence

The team will use the test developed in Dr.

tissues that play a key role in cell growth,

and activity of 60-70 percent of all kinases

Johnson’s lab as part of a clinical trial led

particularly in cancer. Of the 518 known

simultaneously, allowing investigators to

by Keith Amos, M.D., assistant professor

human kinases, about 400 are expressed

see how cancers evade treatment with

of surgical oncology, to understand the

in cancers, but which ones and how many

kinase inhibitors, so they can combine

kinome activation state before and after

are actually active in tumors has been diffi-

drugs to block resistance.

treatment with kinome-targeted drugs to determine how and why the tumors “re-

cult to measure. Tremendous efforts have been made to develop kinase inhibitors as

Dr. Carey, who is Preyer distinguished

program” in response to various HER2-

cancer treatments, which have resulted in

professor of breast cancer research and

targeted therapies. Their goal is to define

key drugs such as Herceptin, Tykerb and

medical director of the UNC Breast Cen-

the best combinations of therapies and to

Gleevec. However, in spite of the effective-

ter, says, “HER2-positive breast cancers

develop selection strategies for individual

ness of this class of cancer drugs, most

comprise about 20 percent of all breast

patients.

DNA Replication Protein also Has a Role in Mitosis and Cancer The foundation of biological inheritance

hallmark of the genomic instability seen

cell cycle, mitosis. The finding presents

is DNA replication – a tightly coordinated

in most birth defects and cancers.

a possible explanation for why so many cancers

process in which DNA is simultaneously

possess

not

just

genomic

copied at hundreds of thousands of

University of North Carolina School of

instability, but also more or less than the

different sites across the genome. If

Medicine

usual 46 DNA-containing chromosomes.

that copying mechanism doesn’t work

that a protein known as Cdt1, which is

as it should, the result could be cells

required for DNA replication, also plays

The new research, which was published

with missing or extra genetic material, a

an important role in a later step of the

online ahead of print by the journal Nature

26

The Triangle Physician

scientists

have

discovered


UNC Research News Cell Biology, is the first to definitively show

Cdt1 function had been blocked did not

Dr. Cook says cells that make aberrant

such a dual role for a DNA replication

undergo mitosis properly.

amounts of Cdt1, like that seen in cancer, can therefore experience problems in

protein. Once the researchers knew that Cdt1

both replication and mitosis. One current

“It was such a surprise, because we thought

was involved in mitosis, they wanted to

clinical trial is actually trying to ramp up

we knew what this protein’s job was – to

pinpoint its role in that critical process.

the amount of Cdt1 in cancer cells, in the

load proteins onto the DNA in preparation

They further combined their genetic,

hopes of pushing them from an already

for replication,” said Jean Cook, Ph.D.,

microscopy and computational methods

precarious position into a fatal one.

associate professor of biochemistry and

to demonstrate that without Cdt1, Hec1

biophysics and pharmacology at the

fails to adopt the conformation inside

The research was funded by the National

UNC School of Medicine and senior study

the cells necessary to connect the

Institutes of Health. Study co-authors

author. “We had no idea it also had a night

chromosomes with the structure that pulls

from UNC were Dileep Varma; Srikripa

job in a completely separate part of the

them apart into their separate daughter

Chandrasekaran; Karen T. Reidy; and

cell cycle.”

cells.

Xiaohu Wan.

The cell cycle is the series of events that take place in a cell leading to its growth, replication and division into two daughter cells. It consists of four distinct phases: G1 (Gap 1), S (DNA synthesis), M (mitosis) and G2 (Gap 2). Dr. Cook’s research focuses on G1, when Cdt1 places proteins onto the genetic material to get it ready to be copied. In this study, Dr. Cook ran a molecular screen to identify other proteins that Cdt1 might be interacting with inside the cell. She expected to just find more entities that controlled replication and was surprised to discover one that was involved in mitosis. That protein, called Hec1 for “highly expressed in cancer,” helps to ensure that the duplicated chromosomes are equally divided into daughter cells during mitosis, or cell division. Dr. Cook hypothesized that either Hec1 had a job in DNA replication that nobody knew about, or that Cdt1 was the one with the side business. Dr. Cook partnered with Hec1 expert Edward “Ted” D. Salmon, Ph.D., professor of biology and co-senior author in this study, to explore these two possibilities. After letting Cdt1 do its replication job, the researchers interfered with the protein’s function to see if it adversely affected mitosis. Using a high-powered microscope that records images of live cells, they showed that cells where

Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

June 2012

27


News Welcome to the Area

Physicians Sarah Lucille Larson, DO

Anatomic and Clinical Pathology Duke University Hospitals, Durham

Mashael Saleh Al-Hegelan, MD

Pulmonary Disease and Critical Care, Internal Medicine; Critical Care-Internal Medicine; Critical Care Medicine; Internal Medicine; Pulmonary Disease Duke University Hospitals Durham

Amanda Marshburn Allen, MD

Internal Medicine University of North Carolina Hospitals Chapel Hill

Arghavan Almony, MD

Ophthalmology Carolina Eye Associates, P.A. Southern Pines

Kristen Beth Barrio, MD

Emergency Medicine University of North Carolina Hospitals Chapel Hill

Tania Beatriz Beltran Papsdorf, MD

Neurology University of North Carolina Hospitals Chapel Hill

Richard Alan Bloomfield, Jr., MD

Internal Medicine; Pediatrics University of North Carolina Hospitals Chapel Hill

Brittany Andriot Chapman, MD Neurology

University of North Carolina Hospitals Chapel Hill

Michael Rene Contarino, MD

Internal Medicine; Pediatrics University of North Carolina Hospitals Chapel Hill

Stephanie Ane Crapo, MD

Emergency Medicine University of North Carolina Hospitals Chapel Hill

Nell Brock Pollard Johnson, MD

Obstetrics and Gynecology University of North Carolina Hospitals Chapel Hill

Theresa Ann Kallman, MD

Lauren Alexandra McQueen, MD Critical Care Medicine; Anesthesiology Duke University Hospitals, Durham

Suhail Kamrudin Mithani, MD

Pediatrics 200 Towne Ridge Lane, Chapel Hill

Hand Surgery; Plastic and Reconstructive Surgery Duke South Clinics, Durham

David Edward Karol, MD

Priyesh Ashok Patel, MD

Internal Medicine; Psychiatry; Addiction Psychiatry; Administrative Medicine; Alcohol and Drug Abuse Duke University Hospitals Durham

Jacqueline Farber Kerkow, MD Pediatrics Duke University Hospitals Durham

Brendan John Kiel, MD Anesthesiology 3305 Magical Pl Raleigh

Internal Medicine Duke University Hospitals, Durham

Emily Marie Patel, MD Obstetrics and Gynecology Duke University, Durham

Diagnostic Radiology Duke University Hospitals Durham

Nicholas John Kuntz, MD Urology Duke University Hospitals Durham

Sean Michael Lee, MD

Abdominal Surgery; Colon and Rectal Surgery; Critical Care Surgery; General Surgery; Surgical Oncology; Vascular Surgery Duke University Hospitals, Durham

Ashley Moore Lewis, MD

Cardiology; Cardiovascular Disease, Internal Medicine Wake Heart and Vascular, Cary

Kara Alina May McElligott, MD Gynecologic Oncology; Obstetrics & Gynecologic Surgery; Obstetrics and Gynecology Duke University Hospitals, Durham

Anesthesiology University of North Carolina Hospitals Chapel Hill

Ramesh Srinivasan, MD

Hand Surgery; Orthopedic Surgery; Orthopedic, Hand Surgery Durham

Ashley Goodwin Sutton, MD

Pediatrics University of North Carolina Hospitals Chapel Hill

Michael John Sylvia, MD

Critical Care Pediatrics; Internal Medicine University of North Carolina Hospitals Chapel Hill

Fernanda Patricia Payan Schober, MD

Internal Medicine University of North Carolina Hospitals Chapel Hill

Elliot Jay Pearson, MD

Alison J Kim, MD

Justin Lee Rountree, MD

Testier Testiest, MD

University of North Carolina Hospitals Chapel Hill

Tung Thanh Tran, MD

Pediatrics Division Offices, Durham

Neurology Duke University Medical Center Durham

Zachary Eric Potter, MD Neurology UNC Chapel Hill Chapel Hill

Kiran Venkatesh, MD

Edward Nandlal Rampersaud, MD Urological Surgery Duke University Division of Surgery Durham

Kristoff Rewi Reid, MD

Hospitalist; Internal Medicine Durham Regional Hospital, Durham

Amy Hooks Wallace, MD

Gynecology/Oncology; Obstetrics and Gynecology Duke University Hospitals, Durham

Adult Reconstructive; Orthopedic Surgery, Pediatric; Orthopedic Surgery, Trauma; Orthopedic, Ankle Foot Duke Univ Dept of Orthopaedic Surgery, Durham

Michael Jan-Chi Wang, MD

Zachary Martin Robertson, MD Ophthalmology Kittner Eye Center Chapel Hill

Internal Medicine; Psychiatry; Psychosomatic Medicine Duke University Medical Center Durham

John James Rommel, MD

Yongqin Wu, MD

Cardiology; Internal Medicine University of North Carolina Hospitals Chapel Hill

Neurology; Vascular Neurology University of North Carolina Hospitals Chapel Hill

Jason Allen Webb, MD

Neurology University of North Carolina Hospitals Chapel Hill

Adam Cory Creech, MD Internal Medicine WakeMed Hospital Raleigh

Zubin John Eapen, MD

Cardiovascular Disease, Internal Medicine Duke University Div of Cardiology Durham

Paul Douglas Evans, MD

Diagnostic Radiology; Vascular and Interventional Radiology; Radiology Duke University Hospitals Durham

Kathryn Louise Everton, MD Radiology Duke University Hospitals Durham

Nicholas Gregory Heyne, MD

Psychiatry University of North Carolina Hospitals Chapel Hill

Arun Laxminarayan Jayaraman, MD

Anesthesiology Duke University Hospitals Durham

28

The Triangle Physician

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


DIAGNOSTIC IMAGING | PEDIATRIC IMAGING | SPORTS IMAGING | NEURORADIOLOGY ADVANCED BREAST IMAGING | INTERVENTIONAL RADIOLOGY | ONCOLOGIC IMAGING

Since 1953, Wake Radiology has been a leader in diagnostic imaging in the Triangle and beyond. We bring to you and your patients the most advanced imaging technologies available, delivered with the reassurance and compassion that are at the heart of health and healing. We have 18 outpatient imaging locations throughout the Triangle—many offering studies on evenings and Saturdays, including screening mammography, CT, Ultrasound, and MRI exams. Wake Radiology’s 55 subspecialty trained radiologists diagnose injury and illness quickly, while working with you and your staff to ensure the best possible outcome. So, the next time your patients require medical imaging think of Wake Radiology, where outstanding imaging is backed by expertise, convenience, and compassion. Wake Radiology. Here when you and your patients need us. Wake Radiology is the only multi-site outpatient imaging service provider in the Triangle to receive the American College of Radiology’s designation of Breast Imaging Centers of Excellence. Scan now to request a Screening mammogram with your smartphone.

Express Scheduling 919-232-4700 | Chapel Hill Area Express Scheduling 919-942-3196 | wakerad.com

©2012 Wake Radiology. All rights reserved.

©2011 Wake Radiology. All rights reserved. Radiology saves lives.

Advanced Imaging For The Entire Family.

Triangle Physician June 2012  

Triangle Physician June 2012