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Southern Dermatology & Skin Cancer Center Specialists in Mohs Surgery and Diagnosis Deliver Cost-effective, Streamlined 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

Alternative Constipation Diagnosis Permanent Birth Control

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Add a pinch of spice,

a hint of laughter,

and a correct diagnosis,

and you’ll get Robert.

Robert suffered from unexplained fainting spells. His physicians couldn’t figure out why. To find answers, they implanted a Reveal® Insertable Cardiac Monitor (ICM) to see if his spells were heart rhythm related.

(Actual size)

The Reveal ICM is a long-term heart monitor that may help you rule in or rule out an abnormal heart rhythm as the cause of unexplained fainting spells. In Robert’s case, they were, and now he has a pacemaker. Possible risks associated with the implant of a Reveal Insertable Cardiac Monitor include, but are not limited to, infection at the surgical site, device migration, erosion of the device through the skin and/or sensitivity to the device material. Results may not be typical for every patient.

Brief Statement Indications 9529 Reveal® XT and 9528 Reveal® DX Insertable Cardiac Monitors – The Reveal XT and Reveal DX Insertable Cardiac Monitors are implantable patient-activated and automatically activated monitoring systems that record subcutaneous ECG and are indicated in the following cases: • patients with clinical syndromes or situations at increased risk of cardiac arrhythmias; • patients who experience transient symptoms such as dizziness, palpitation, syncope, and chest pain, that may suggest a cardiac arrhythmia. 9539 Reveal® XT and 9538 Reveal® Patient Assistants – The Reveal XT and Reveal Patient Assistants are intended for unsupervised patient use away from a hospital or clinic. The Patient Assistant activates one or more of the data management features in the Reveal Insertable Cardiac Monitor: • To verify whether the implanted device has detected a suspected arrhythmia or device related event. (Model 9539 only); • To initiate recording of cardiac event data in the implanted device memory. Contraindications: There are no known contraindications for the implant of the Reveal XT or Reveal DX Insertable Cardiac Monitors. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated. Warnings/Precautions: 9529 Reveal XT and 9528 Reveal DX Insertable Cardiac Monitors – Patients with the Reveal XT or Reveal DX Insertable Cardiac Monitor should avoid sources of diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, therapeutic ultrasound and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing. MRI scans should be performed only in a specified MR environment under specified conditions as described in the device manual. 9539 Reveal XT and 9538 Reveal Patient Assistants – Operation of the Model 9539 or 9538 Patient Assistant near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device. Potential Complications: Potential complications include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin. See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.

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UC201003796 EN © Medtronic, Inc. 2009. Minneapolis, MN. All Rights Reserved. Printed in USA. 11/2009

For more information, visit www.fainting.com.

3/17/14 7:08 PM


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UC201003796 EN Š Medtronic, Inc. 2009. Minneapolis, MN. All Rights Reserved. Printed in USA. 11/2009


COVER STORY

6

Southern Dermatology & Skin Cancer Center

Specialists in Mohs Surgery and Diagnosis Deliver Cost-effective, Streamlined Care

m a r c h / a p r i l 2 0 14

FEATURES

10

Vol. 5, Issue 2

DEPARTMENTS 11 Duke Research News

Gastroenterology

A Discussion of Pelvic Floor Dyssynergia Kellie Bunn explains the importance of considering this diagnosis when evaluating patients with constipation symptoms.

12

In

Blasts May Cause Brain Injury Even Without There Being Clear Symptoms

12 Duke News

Dzau Named Institute of Medicine President

13 ECU News Free App Makes It Easy for Doctors to Teach Patients About Heart Risks

14 UNC Research News

Women’s Health

Finished Having Children?

More than $40 Million from NIH Goes to Global HIV Clinical Trials

15 UNC Research News Ear Tubes vs. Watchful Waiting: Tubes Do Not Improve Long-Term Development

Dr. Andrea Lukes reviews the Essure system, a permanent

16 WakeMed News

form of birth control that is often preferred to tubal ligation.

New Defibrillator Helps Those at Risk of Sudden Cardiac Arrest

COVER PHOTO: Dr. Wilmoth (left) and Dr. Challgren (right) stand with the rest of the Southern Dermatology medical staff. They are (from left) Laura D. Briley, M.D.; Tracey S. Cloninger, PA-C; and Margaret E. Boyse, M.D.

2

The Triangle Physician

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In in pr to a A ap


In-Home Care

In cases of acute or chronic illness, injury, or disability, our home care provides medically necessary services to treat, rehabilitate, sustain or restore a patient to their optimal health status. All with a warm, supportive, hands-on approach to healing.

In-Home Hospice

Our team of doctors, nurses, medical social workers, certified nursing assistants, and clergy work together to provide support, privacy, dignity and choices for patient with life-limiting illnesses - with the comfort of home and family.

The SECU Hospice House

There are times in hospice care when in-home care is no longer the best option for the patient or family. When this arises, our SECU Hospice House takes care to a level few can offer. This beautiful facility on the Johnston Health Campus offers our excellent hospice care in a very home-like setting designed specifically with accommodations to improve quality of life – for patients as well as family.

919-938-7560 www.johnstonhealth.org TrianglePhy_Mar14.indd 3

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From the Editor

Exacting and Expedient For certain skin cancers, Mohs micrographic surgery is the way to go. It saves the greatest amount of healthy tissue, appears to reduce the rate of local recurrence and has the highest overall cure rate, greater than 99 percent, and recurrent cure rate of 95

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

percent.

In this month’s cover story on Southern Dermatology & Skin Cancer Center, the reader is introduced to dermatologists who specialize in the range of skin cancer treatments, including Mohs micrographic surgery. A benefit of their experience is skilled evaluation of tumors and biopsies. So, patients get expedient care – from accurate diagnosis to appropriate treatment – resulting in improved chances for a skin cancer cure.

Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Kellie Bunn, PA-C Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Creative Director Joseph Dally jdally@newdallydesign.com

Advertising Sales

The beauty of Mohs surgery is that it is so precise, removing the least amount

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of tissue possible. Analysis of tissue samples occurs during surgery, so all of

News and Columns Please send to info@trianglephysician.com

the cancer is removed during one in-office procedure. Mohs is often ideal for removing skin cancer in the most visible and the most delicate places, leaving a scar that usually is barely negligible.

The Triangle Physician is published by: New Dally Design

Also in this issue of The Triangle Physician, obstetric gynecologist Andrea Lukes

Subscription Rates: $48.00 per year $6.95 per issue

gives an overview of a permanent means of birth control. Gastroenterologist Doug Drossman explores narcotic bowel syndrome and its treatment. Certified physician assistant Kellie Dunn discusses when a complaint of chronic constipation is pelvic floor dyssynergia and strategies for treatment.

Your medical news and insight also is welcome. So consider contributing an article to The Triangle Physician at no cost to you and advertising at competitive rates. The Triangle Physician reaches more than 9,000 medical professionals throughout the Raleigh-Durham Triangle. So if this is your market, this is an exacting and expedient delivery system.

With great respect and appreciation,

Heidi Ketler Editor

4

Advertising rates on request Bulk rate postage paid Greensboro, NC 27401

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

The Triangle Physician

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Cover Story

Southern Dermatology & Skin Cancer Center

Specialists in Mohs Surgery and Diagnosis Deliver Cost-effective, Streamlined Care By Heidi Ketler

Southern Dermatology & Skin Cancer Cen-

leagues in surgical oncology and radiation

sample to ensure that all the cancer cells

ter streamlines care for patients with skin

oncology. We offer complete care all within

have been removed.

cancer, offering specialized surgical treat-

the same practice at a convenient location,

ment and reconstruction at one location

while providing superior continuity of care

“Other procedures either do not evaluate

and often on the same day.

at decreased costs.”

the adequacy of cancer tissue removal, or

Gregory J. Wilmoth, M.D., and partner Eric

Mohs micrographic surgery is the treatment

tal margin of skin removed or they examine

D. Challgren, M.D., are dermatologists and

of choice for primary skin malignancies, such

the excised tissue days after the wound has

fellows of the American Society for Mohs

as basal cell carcinoma (BCC) and squamous

been stitched,” says Dr. Wilmoth. For recur-

Surgery, with specialized expertise in Mohs

cell carcinoma (SCC) that are recurrent, have

ring tumors, scar tissue makes identifying

micrographic surgery, a precise, tissue-

aggressive features or ill-defined margins.

the cancer margins even more challenging,

sparing technique for removing cutane-

Skin tumors in areas that are at high risk for

without Mohs micrographic surgery.

ous tumors. Their extensive knowledge of

recurrence and deep extension, often the

skin cancer and unique pathological skills

H-zone of the face, should be treated with

Dr. Wilmoth likens usual pathology speci-

enable them to achieve complete tumor

Mohs surgery. The ear and hand also have

mens to a slice of bread, in which only

removal with maximum preservation of

a high rate of recurrence and are suitable for

about 3 percent of the total surface area of

healthy tissue.

treatment with Mohs surgery.

the margins of the cancer is evaluated. By

they evaluate only a small fraction of the to-

contrast, the Mohs technique allows evaluTypical cure rates in these cases are greater

ation of the complete surface area. This is

than 99 percent for primary lesions, accord-

important because many basal cell cancers

ing to Dr. Wilmoth. “Multiple studies have

grow with fingerlike projections or roots,

confirmed the superiority of Mohs micro-

and the random sampling of the specimens

surgery over standard excision and any

used by conventional pathology may not

other treatment modality for these indica-

permit a thorough assessment of residual

tions and five-year recurrence rates as low

cancer.

as 1 percent for basal cell carcinomas and 3-5 percent for squamous cell carcinomas,”

Frequently, patients are referred for Mohs

he says.

surgery after excision of a BCC on the head or the neck, because the pathology comes

Dermatologist Eric D. Challgren, M.D., performs Mohs micrographic surgery to remove a basal cell carcinoma from a patient’s nose.

The Mohs micrographic surgery cure rate

back showing the excision marks are still

drops slightly to 95 percent for recurrences

positive. “Referral to us by physicians who

of BCC and SCC that were unsuccessfully

don’t regularly treat skin cancers for the ini-

“Our practice philosophy is complete pa-

treated by other methods. But it is better

tial skin cancer treatment saves the patient

tient care for dermatology and cutaneous

than the cure rates of reoccurrences using

some steps,” says Dr. Challgren.

oncology. We provide screening and evalu-

other means, which can be as low as 50-60

ation for all forms of skin cancer, plan ap-

percent, according to Dr. Wilmoth.

Dr. Wilmoth established Raleigh’s first private Mohs micrographicsurgery practice in

propriate treatment, implement the treatment in-house, reconstruct the defect and

During the Mohs procedure, the derma-

2000. The surgery is performed on an outpa-

provide proper follow-up care,” says Dr.

tologist serves as both the surgeon and the

tient basis and under local anesthesia, mak-

Wilmoth.

pathologist. The Mohs specialist performs

ing it safe and cost-effective.

both the surgical excision of the skin can“For more advanced cancers we provide

cer and the microscopic examination of

In addition to skin cancer care, Southern

coordination of care with appropriate col-

the complete surgical margin of each tissue

Dermatology medical professionals also

6

The Triangle Physician

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deliver the complete range of dermatologic services, including general dermatology, adult and pediatric dermatology, dermato-

patients time and money and reducing the

margin after surgical resection). • Tumors occurring in sites of previous radiation therapy or in chronic scars.

possibility of unnecessary discomfort and more scarring,” Dr. Challgren says. “My general MO is to look at each patient’s case

logic surgery and cosmetic dermatology.

• Tumors with aggressive patterns (includ-

Drs. Wilmoth and Challgren are joined by

ing micronodular, infiltrative and mor-

board-certified dermatologists Margaret E.

pheaform basal cell carcinoma, basal

Boyse, M.D., and Laura D. Briley, M.D., and

squamous carcinoma and poorly differ-

“Say you have a basal cell on your fore-

Tracey S. Cloninger, P.A.-C., as well as certi-

entiated or deeply invasive squamous

head. It’s tiny, and you’re adamant that you

fied aesthetic consultant Angie Lalewicz.

cell carcinomas.

don’t want surgery. You may have many

• Tumors in immunosuppressed patients.

individually.

choices. Often when I give the patient all the facts, the patient and I will select the

Mohs surgery also can be used to treat

option that makes the most sense. Some-

other skin cancers, including dermatofibro-

times the patient prefers to wait and see,

sarcoma, extramammary Paget’s disease,

and then after six months we go over the

Merkel cell carcinoma, sebaceous carcino-

best options again. Many times the patient

mas and microcystic adnexal carcinomas.

will prefer Mohs as an option in the medical office setting.”

When small skin cancers are removed, the

Dermatologist Gregory J. Wilmoth, M.D., prepares a patient for micrographic surgery to remove a squamous cell carcinoma from her shoulder.

scars are usually cosmetically acceptable. If

Treatment options for BCC and SCC and as-

the tumors are very large, a skin graft or flap

sociated cure rates are as follows:

may be used to repair the wound in order to

• Mohs micrographic surgery – Mohs

achieve the best cosmetic result and facili-

saves the greatest amount of healthy tis-

tate healing. This is usually done the same

sue, appears to reduce the rate of local

day and in same procedure event as the

recurrence and has the highest overall

Mohs excision. Drs. Wilmoth and Challgren

cure rate, greater than 99 percent, and

have extensive experience in reconstruc-

recurrent cure rate of 95 percent.

tion of Mohs defects. In rare cases where

• Excisional surgery – Cure rate for pri-

large amounts of tissue need to be removed,

mary tumors is about 90-92 percent; for

the Mohs surgeon sometimes works with a

recurrent SCC, 77 percent.

facial plastic surgeon on an ear, nose and

• Curettage and electrodesiccation –

Indications for

throat specialist to achieve the best possible

Cure rates approach those of surgical

Mohs Micrographic Surgery

post-surgical appearance.

excision for certain BCC and superficially invasive SCC without high-risk character-

The choice of non-melanoma skin cancer treatment is based on type, size, location

Specialized Experience and Skill

istics. It is not considered as effective for

and depth of penetration of the tumor, as

“Standard excision may be preferable to

more invasive, aggressive SCC or those

well as the patient’s age, general health

Mohs surgery for some small or less ag-

in high-risk or difficult sites, such as the

and the likely cosmetic outcome of specific

gressive cancers and for cancers on larger

treatments.

open areas of the body,” says Dr. Challgren.

• Radiation – Cure rates range widely,

eyelids, genitalia, lips and ears.

“There are times when I might not recom-

from about 85-95 percent, and the tech-

According to the Skin Cancer Foundation,

mend Mohs and do something a bit more

nique can involve long-term cosmetic

non-melanoma skin cancer indications for

simplistic, such as wide-margin excision,

problems and radiation risks, as well as

Mohs micrographic surgery are:

topical therapy or ED&C (electrodesicca-

multiple visits. For these reasons, this

• Recurrent tumors.

tion and curettage). In some instances ra-

therapy is mainly used for tumors that are

• Tumors greater than .6 centimeters on

diation may be the best option.”

hard to treat surgically, as well as patients for whom surgery is not advised, such as

the face, neck, hands and genitals or greater than 2.0 centimeters on the body

“In these cases,” he says, “a standard surgical

and extremities.

removal can achieve a reasonable cure rate.”

the elderly or those in poor health. • Cryosurgery – A lower overall cure rate than surgical methods is approximately

• High-risk anatomic locations (eyelids, “There are a number of options for treating

85-90 percent. Depending on the physi-

• Tumors with indistinct clinical margins

non-melanoma skin cancers, and experi-

cian’s expertise, the five-year cure rate can

or incompletely excised margin (positive

ence will dictate proper treatment, saving

be 95 percent or higher with selected, gen-

nose, ears, lips, genitalia, fingers).

TrianglePhy_Mar14.indd 7

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erally superficial SCC. But cryosurgery is not often used today for invasive SCC, because deeper portions of the tumor may be missed and scar tissue at the cryotherapy site might obscure a recurrence. • Photodynamic therapy (PDT) – Treatment selectively destroys tumors while causing minimal damage to surrounding normal tissue. While it may be effective with early, noninvasive tumors, overall SCC recurrence rates vary considerably (from 0-52 percent), so the technique is not currently recommended for invasive SCC. PDT is FDA approved for treatment of superficial and nodular BCCs. Cure rates can vary considerably, from 70-90 percent. • Laser surgery – The risks of scarring and pigment loss are slightly greater than with other techniques, and recurrence rates are similar to those of PTD. The technique is not yet FDA-approved for BCC or SCC. • Topical medications – 5-fluorouracil and imiquimod are both FDA-approved for treatment of actinic keratoses and superficial BCCs. They are being tested for the treatment of more invasive BCCs and some superficial SCCs. Rare cases, metastatic BCC or locally advanced BCC can become dangerous, sometimes even life threatening. Erivedge (vismodegib), the first medicine ever for advanced BCC, is an oral drug approved by the FDA in early 2012 only for very limited circumstances in which the nature of the cancer precludes other treatment options, such

Drs. Wilmoth (left) and Challgren analyze tissue samples, as part the tissuesaving Mohs surgery.

as surgery or radiation. Due to a risk of birth defects, vismodegib should not be used by women who are pregnant or attempting to

– metastasizes to distant tissues and organs and become life threat-

conceive.

ening. About 2,500 deaths result each year in the U.S.

Skin Cancer Overview

Metastases most often arise on sites of chronic inflammatory skin

Basal cell carcinoma is the most common form of skin cancer in the

conditions and on the ear, nose, lip and mucosal regions, includ-

United States, with an estimated 2.8 million cases diagnosed each

ing the mouth, nostrils, genitals, anus and the lining of the internal

year. More than one out of every three new cancers are skin cancers,

organs.

and the vast majority is BCC. Referrals for Streamlined, Specialized Care The abnormal, uncontrolled growths or lesions arise in the skin’s

“Dermatologists are experts in diagnosis and treatment of skin can-

basal cells, which line the deepest layer of the epidermis and are

cer. In our facility, we have the ability to treat most cancers with the

usually caused by a combination of cumulative ultraviolet exposure

latest techniques, including Mohs surgery. What distinguishes our

and intense, occasional UV exposure. BCC almost never metasta-

practice is the philosophy of caring for patients and their dermato-

sizes beyond the original tumor site. Only in exceedingly rare cases

logic ailments from A to Z – we can diagnose, treat and repair in the

does BCC spread to other parts of the body and become life threat-

same practice and often on the same day for previously biopsied

ening.

sites,” says Dr. Wilmoth.

BCC should not be taken lightly, as it can be disfiguring if not treated

Both Dr. Wilmoth and Dr. Challgren have 4- and 5-star patient-satis-

promptly, during its early stages. The larger the BCC, the more dam-

faction ratings on HealthGrades.com and on UCompareHealthCare.

age to surrounding tissue and the more disfigurement. Some BCCs

com. Dr. Wilmoth also was identified as one of the country’s “Top

are more aggressive than others.

Doctors,” according to U.S. News and World Report.

SCCs usually are confined to the epidermis for some time. However,

For more information and to make a referral to Southern Dermatol-

these tumors eventually penetrate the underlying tissues, which can

ogy & Skin Cancer Center call (919) 782-2152 or The Skin Renewal

lead to major disfigurement, sometimes even the loss of a nose, eye-

Center at Southern Dermatology call (919) 863-0073. Visit Southern

lid or ear. A small percentage – from 2 percent to almost 10 percent

Dermatology online at www.southernderm.com.

8

The Triangle Physician

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Gastroenterology

A Discussion of

Pelvic Floor Dyssynergia By Kellie Bunn PA-C

About 30 percent of patients who com-

The digital rectal exam (DRE) is an impor-

plain of chronic constipation symptoms

tant component of an evaluation for PFD.

demonstrate dysfunction of their pelvic-

Unfortunately, DREs may be underutilized

floor musculature, known as pelvic floor

at this time and inadequately taught to

dyssynergia. These complaints are similar

those with recent training. To test specifi-

to that of normal and slow-transit con-

cally for PFD during the DRE, insert the

stipation, including excessive straining,

finger deep into the rectum and feel the

pressing around the anal opening to help

puborectalis muscle. Ask the patient to

a bowel movement pass or feeling of not

push down, at which time the puborectalis

fully evacuating after a bowel movement.

should relax to increase the angle allowing for defecation and your finger will be pushed down. In patients with PFD, you will feel the puborectalis paradoxically tighten instead and the angle needed for proper defecation will close. Anorectal manometry testing is also an important tool for the diagnosis of PFD. A manometry study measures the pressure in the anal canal when the patient attempts to defecate. It is usually done with pelvic floor electromyography (EMG) and balloon defecography. Pelvic floor EMG is a test whereby small electrical sensors are placed in the anal

Kellie Bunn PA-C graduated from the University of North Carolina at Chapel Hill with a degree in Biology before training at the Duke University Physician Assistant Program.  She earned a degree of Master of Health Sciences and was inducted in Pi Alpha, the national honor society for physician assistants.  She is currently a member of the American Academy of Physician Assistants, North Carolina Academy of Physician Assistants, and the North Carolina Medical Society. Kellie has worked with Dr. Douglas Drossman at Drossman Gastroenterology PLLC for over a year and is well trained in the care of patients with functional GI disorders. Drossman Gastroenteroogy PLLC (www. drossmangastroenterology.com) specializes in patients having difficult to diagnose gastrointestinal disorders and the management in particular of severe functional GI disorders. The office is located at Chapel Hill Doctors 55 Vilcom Center Drive, Suite 110, Chapel Hill, NC.  Appointments can be made by calling 919-929-7990.

canal to record the electrical activity of the sphincter muscles when the patients

using a water-filled balloon introduced in

squeezes, relaxes and bears down. This

the rectum. The balloon is slowly with-

Though the patient-reported symptoms

test will demonstrate whether the sphinc-

drawn while the patient is asked to con-

may be the same, pelvic floor dyssynergia

ter muscles relax normally when the pa-

centrate on the sensations evoked by the

(PFD) can occur separately or in combi-

tient strains to have a bowel movement

balloon and to try to ease its passage.

nation with both normal and slow-transit

or whether they involuntarily contract

constipation. It is important to consider

instead. During balloon defecography,

During their biofeedback session, the

this diagnosis when evaluating patients

a small tube with a balloon at the tip is

EMG activity information from the anal ca-

with constipation symptoms, as PFD war-

inserted into the rectum and inflated to

nal is used to teach patients to relax the

rants a unique treatment plan that can be

about 50 cc. The patient is then asked to

sphincter muscles and avoid straining for

utilized in combination or separately from

evacuate the balloon like a stool. Inability

an easier passage of stool. Biofeedback

the treatments of other chronic constipa-

to do this suggests pelvic floor dysfunc-

usually requires several treatments to ob-

tion causes.

tion.

tain maximal benefit.

PFD is characterized by an inappropriate

Biofeedback is used to treat pelvic floor

contraction of the pelvic floor or puborec-

dyssynergia. This may involve sensory

talis muscle during attempted defecation.

training, in which defecation is simulated

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Women’s Wellness

Finished Having Children? By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.

Birth control can be divided into tem-

stainless steel and solder. The coils are

porary, or reversible, versus permanent

placed using a special catheter through

options. Once a woman knows she is fin-

the vagina and cervix into the fallopian

ished having children, then a permanent

tube. Over time, scar tissue grows around

option is appropriate. This article focuses

the coils and blocks the fallopian tubes.

on the permanent option for women using the Essure system.

For the first three months following placement of Essure, a woman cannot

Essure has become the premier option,

rely on it and must use a back-up method

essentially replacing the old-fashion bilat-

of birth control. After three months, a

eral tubal ligation, or BTL. A tubal ligation

confirmation test, involving an X-ray and

may be preferable when done during a

introduction of a dye, is performed. This

concomitant surgery, such as a cesarean

will either confirm blockage or show

section, or when an Essure procedure

failure to block the fallopian tube. This

cannot be performed, due to anatomy or

is an important confirmation and helps

other reasons.

maintain the high efficacy rate of the Essure system, which is more than 99.83

The Essure procedure is a surgery-free op-

percent (www.essure.com).

tion that can be performed between 5-10 minutes in an office setting. Still, many

Our clinic has worked with a number of

health care providers and women do not

different sites to order the confirmation

know of this safe and effective option for

test. Most recently, we added Atlantic

permanent birth control.

Reproductive Medicine Specialists in Raleigh, where a tranquil, spa-like environ-

Approved by the United States Food and

ment is combined with an experienced

Drug Administration in November 2002,

team of providers (atlanticfertility.com).

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.

the Essure system works by blocking the fallopian tubes so sperm cannot reach a

We have been performing the Essure pro-

of physicians on how to perform Essure

woman’s eggs. The coils are made from

cedure since we opened more than five

within an office setting. Of course, it

polyester fibers, nickel-titanium and

years ago. I have trained a large number

doesn’t have to be done within an office setting, but it is my preference given it is such a simple and straightforward proce-

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10

medium to use with hysteroscopy, is used

the patient (and physician) and allows for more flexibility in scheduling. right here in the Old North State. Conservation education efforts are preparing future generations to sustain your concern for the lands we protect today. At www.ncwhf.org, download the license tag application and see the good works in process. pp Your new tag shows your support and your n contribution is put to work…times four. co

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Individuals can watch the procedure on the website through Bayer at www. essuremd.com. We are happy to see women who may be interested in this procedure. Appointments may be made by calling (919) 251-9223.

The Triangle Physician

TrianglePhy_Mar14.indd 10

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Duke Research News

Blasts May Cause Brain Injury Even Without There Being Clear Symptoms Veterans exposed to explosions who do not

veterans without blast exposure. The study

research health scientist at the W.G. (Bill) He-

report symptoms of traumatic brain injury

focused on veterans with primary blast ex-

fner Veterans Affairs Medical Center and the

may still have comparable damage to the

posure, or blast exposure without external

study’s lead author. “We are not sure whether

brain’s white matter, according to research-

injuries, and did not include those with brain

this indicates differences among individuals

ers at Duke Medicine and the United States

injury from direct hits to the head.

in symptoms-reporting or subconcussive effects of primary blast. It is clear there is more

Department of Veterans Affairs. To measure injury to the brain, the research-

we need to know about the functional conse-

The findings, published in the Journal of

ers used a type of magnetic resonance imag-

quences of blast exposures.”

Head Trauma Rehabilitation on March 3

ing called diffusion tensor imaging (DTI). DTI

suggest that a lack of clear traumatic brain

can detect injury to the brain’s white matter

Given the study’s findings, the researchers

injury (TBI) symptoms following an explo-

by measuring the flow of fluid in the brain.

said clinicians treating veterans should take

sion may not accurately reflect the extent of

In healthy white matter, fluid moves in a di-

into consideration a person’s exposure to

brain injury.

rectional manner, suggesting that the white

explosive forces, even among those who did

matter fibers are intact. Injured fibers allow

not initially show symptoms of TBI. In the fu-

the fluid to diffuse.

ture, they may use brain imaging to support

Veterans of recent military conflicts in Iraq

clinical tests.

and Afghanistan often have a history of exposure to explosive forces from bombs,

White matter is the connective wiring that

grenades and other devices, although rela-

links different areas of the brain. Since most

“Imaging could potentially augment the exist-

tively little is known about whether this

cognitive processes involve multiple parts of

ing approaches that clinicians use to evaluate

injures the brain. However, evidence is

the brain working together, injury to white

brain injury by looking below the surface for

building – particularly among professional

matter can impair the brain’s communica-

TBI pathology,” Dr. Morey said.

athletes – that subconcussive events have

tion network and may result in cognitive

an effect on the brain.

problems.

The researchers noted that the results are preliminary and should be replicated in a larger study.

“Similar to sports injuries, people near an ex-

Both groups of veterans who were near an ex-

plosion assume that if they don’t have clear

plosion, regardless of whether they had TBI

symptoms – losing consciousness, blurred

symptoms, showed a significant amount of

In addition to Drs. Morey and Taber, study

vision, headaches – they haven’t had injury

injury compared to the veterans not exposed

authors include Courtney C. Haswell of the

to the brain,” said senior author Rajendra A.

to a blast. The injury was not isolated to one

Durham VA Medical Center; Susan D. Hurt

Morey, M.D., associate professor of psychia-

area of the brain, and each individual had a

and Cory D. Lamar of the W.G. (Bill) Hefner

try and behavioral sciences at Duke Univer-

different pattern of injury.

VA Medical Center; Jared A. Rowland of the W.G. (Bill) Hefner VA Medical Center and

sity School of Medicine and a psychiatrist at the Durham Veterans Affairs Medical Center.

Using neuropsychological testing to assess

Wake Forest School of Medicine; and Robin

“Our findings are important, because they’re

cognitive performance, the researchers

A. Hurley of the W.G. (Bill) Hefner VA Medi-

showing that even if you don’t have symp-

found a relationship between the amount of

cal Center, Wake Forest School of Medicine

toms, there may still be damage.”

white matter injury and changes in reaction

and Baylor College of Medicine.

time and the ability to switch between mental Researchers in the Mid-Atlantic Mental Illness

tasks. However, brain injury was not linked to

This research was supported by a grant from

Research, Education and Clinical Center at

performance on other cognitive tests, includ-

the Department of Defense, Joint Impro-

the W.G. (Bill) Hefner Veterans Affairs Medi-

ing decision-making and organization.

vised Explosive Device Defeat Organization (51467EGJDO), the Department of Veterans

cal Center in Salisbury, N.C., evaluated 45 U.S. veterans who volunteered to participate

“We expected the group that reported few

Health Affairs Rehabilitation Research and

in the study. The veterans, who served since

symptoms at the time of primary blast expo-

Development (RX000389-01) and with re-

September 2001, were split into three groups:

sure to be similar to the group without expo-

sources of the Mid-Atlantic Mental Illness

veterans with a history of blast exposure with

sure. It was a surprise to find relatively similar

Research, Education and Clinical Center and

symptoms of TBI; veterans with a history of

DTI changes in both groups exposed to pri-

W.G. Hefner VA Medical Center.

blast exposure without symptoms of TBI; and

mary blast,” said Katherine H. Taber, Ph.D., a

TrianglePhy_Mar14.indd 11

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Duke News

Dzau Named Institute of Medicine President explosion of new data resources, novel

strength, imagination and unflagging en-

technologies and breathtaking research ad-

ergy. He has been an outstanding citizen of

vances make this the most promising time

the university, the city and the region and a

in history for driving innovations that will

major voice for health care innovation glob-

improve health care delivery, outcomes and

ally through the World Economic Forum.

quality.”

We will miss him at Duke, but we appreciate the well-deserved honor of his new position

Under the congressional charter of the Na-

at the Institute of Medicine, which will give

tional Academy of Sciences, the Institute of

a national scope for his leadership skills.”

Medicine is recognized widely as a primary source for independent, scientifically in-

Dr. Dzau has also maintained an active re-

formed analysis and recommendations on

search laboratory focused on the molecular

health issues. IOM provides advice to gov-

and genetic mechanisms of cardiovascular

ernment policymakers, health professionals

disease and the development of new gene

and the public on such issues as health care

and stem cell-based therapies to regenerate

Victor J. Dzau, M.D., chancellor for health

delivery and quality, the obesity epidemic,

and repair tissue damage from heart attack

affairs at Duke University and president and

vaccine safety, nutrition, cancer prevention

and heart disease. His research work has

chief executive officer for the Duke Univer-

and management, and military and veter-

earned numerous awards and recognitions

sity Health System, has been named presi-

ans’ health.

over the years, including the Henry G. Fri-

dent of the Institute of Medicine.

esen International Prize in Health Research; In his nearly 10 years at Duke, Dr. Dzau has

the Gustav Nylin Medal from the Swedish

Dr. Dzau will be leaving Duke on June 30

been the driving force behind the creation

Royal College of Medicine; the Polzer Prize

and will succeed current Institute of Medi-

of the Duke-National University of Singapore

from the European Academy of Sciences &

cine President Harvey V. Fineberg, M.D.,

Graduate Medical School, as well as the

Arts; the Ellis Island Medal of Honor; and

Ph.D., effective July 1.

Duke Global Health Institute, Duke Institute

the Distinguished Scientist Award of the

for Health Innovation, Duke Cancer Institute

American Heart Association. He has earned

Dr. Dzau is recognized nationally and

and the Duke Translational Medicine Insti-

six honorary degrees.

internationally

and

tute. Most recently under his leadership,

transformational leadership across Duke

for

his

visionary

Duke University Health System has under-

Dr. Dzau is a past chairman of the Associa-

Medicine’s renowned academic, research

gone a historic system-wide transformation

tion of Academic Health Centers (AAHC)

and clinical care enterprises. He is also

of its clinical information systems to a sin-

and has published widely on the need to

an acclaimed voice in academic health

gle, state-of-the-art electronic health record.

transform America’s academic medical and

systems, national health policy, health care

Dr. Dzau also led a transformation of the

health centers. He has also served in leader-

innovation and global health. Dr. Dzau

Duke Medicine campus that has added the

ship roles on numerous voluntary commu-

has served as an advisor to universities,

new Duke Cancer Center facility, the Duke

nity and statewide boards in North Carolina,

corporations and foreign governments

Medicine Pavilion, the Trent Semans Center

and will continue to reside in Durham and

and is a member of the Board of Health

for Health Education, a new Duke Universi-

maintain an active role in the community.

Governors and chair of the Global Agenda

ty School of Nursing facility and a Duke Eye

Council on Personalized and Precision

Center building that is under construction.

Medicine for the World Economic Forum.

“It has been a distinct honor to serve such an outstanding university and health sys-

“Victor Dzau has been a visionary leader

tem, and Duke will always have a very spe-

“I’m deeply honored to become the next

and, in collaboration with outstanding fac-

cial place in my heart,” Dr. Dzau said. “I am

president of the IOM (Institute of Medicine)

ulty and staff, has made Duke one of the

proud of the achievements of the team at

and recognize the critically important role

country’s leading centers of biomedical

Duke – faculty, staff and management – over

that the IOM will have in improving the

research and patient care,” said Duke Uni-

the past nearly 10 years and believe Duke

health of the nation at a time of extraordi-

versity President Richard H. Brodhead. “He

is positioned for even greater successes in

nary evolution in biomedical research and

has guided Duke Medicine through a rap-

the future.”

health care delivery,” Dr. Dzau said. “The

idly changing health care landscape with

12

The Triangle Physician

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ECU News

Free App Makes It Easy for Doctors to Teach Patients About Heart Risks Last fall, the American Heart Association issued new guidelines

taught himself to program it over the weekend. By the following

to help doctors teach their patients about their risks of developing

Tuesday, he had finished the app and submitted it to Apple’s iTunes

cardiovascular disease. It was accompanied by a bulky computer

app store.

spreadsheet calculator. Dr. Nguyen said his moOne East Carolina University physician thought he had a better idea.

tivation for creating the

Tin Nguyen, M.D., a second-year internal medicine resident and for-

app was “Trying to get

mer computer engineer, decided to create a smartphone app that

something that’s going to

makes assessing patients’ risk as simple as tapping a screen.

help improve stroke and heart attack outcomes

The Cardiac Risk Assist app takes the newest risk assessments and

and get it to physicians

recommendations from the American Heart Association and puts

around the world.”

them in an easy-to-use mobile platform. Dr. Nguyen made the app The app is designed to help primary care physicians explain to pa-

free. “If we can improve

tients how changing behaviors, such as stopping smoking or reduc-

these things, it’s going to

ing cholesterol, can help them reduce their risk of developing car-

help patients’ lives,” he

diovascular disease. It also recommends whether starting a statin

said. “It’s not about the

drug will benefit patients and has information about various statins

money. It’s about getting

for reference.

it out and making it accessible.”

Dr. Tin Nguyen explains the Cardiac Risk Assist smartphone app he developed.

Deepa Kabirdas, M.D., an ECU cardiologist and assistant professor, said she and Dr. Nguyen were talking about the American Heart As-

Jennifer G. Robinson, M.D., M.P.H., a professor and heart disease

sociation guidelines and its spreadsheet after the guidelines were

specialist at the University of Iowa College of Public Health, was

released. They agreed the spreadsheet was hard to use.

a physician with which Dr. Nguyen consulted to create an app for simpler information access.

“I told (Dr. Nguyen) ‘I wish there was an app for this,’” she said. “We discussed it in our clinic on Friday, and Monday morning he

“Tin’s app is a well-designed, handy, easy-to-use tool that will help

showed us the preliminary app.”

doctors better take care of patients,” Dr. Robinson said in an e-mail. “The app lets the doctor estimate the risk of heart attack/stroke/

To create his simpler way for doctors to help their patients, Dr. Nguy-

death in the next years. Using this information the doctor and the

en bought an Apple laptop computer on that November Friday and

patient can then discuss whether the patient should start a statin to reduce that risk of heart attack/stroke/death. The app is also a memory aid that includes the recommendations from the 2013 (American College of Cardiology/) AHA cholesterol guidelines.” Dr. Nguyen hopes to enter a cardiology fellowship once he completes his residency training. He might also keep making apps. Doing little things to make (patients) feel better, it’s very rewarding,” he said. Cardiac Risk Assist is available for iPhones on the iTunes App Store. A version for Android phones, published by the American College of Cardiology and called the ASCVD Risk Estimator, is available at

A close-up of the Cardiac Risk Assist app. (Photos by Cliff Hollis, ECU News Services

Google Play. Both are free.

TrianglePhy_Mar14.indd 13

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13

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UNC News

More than $40 Million from NIH Goes to Global HIV Clinical Trials The University of North Carolina at Chapel Hill has received a seven-year, more than $40 million award from the National Institutes of Health for a clinical trials unit that will implement the scientific agendas of five NIH networks devoted to HIV/AIDS treatment, prevention and cure research. UNC has had a continuously funded AIDS Clinical Trials Unit since 1987. The latest competitive funding renewal consolidates HIV clinical research operations in North Carolina, Malawi and Zambia into a Global HIV Prevention and Treatment Clinical Trials Unit (UNC Global CTU). The UNC Global CTU will get approximately $5.5 million in the first year to continue and develop studies addressing the prevention, treatment, and cure of HIV infection.

of the Year” in 2011) was spearheaded by UNC researchers. It showed that HIV treatment prevents transmission of the virus. UNC is also home to one of the largest HIV cure initiatives in the world. The new grant provides funding through 2021 for five clinical research sites that make up the UNC Global CTU: Chapel Hill, Raleigh, and Greensboro, N.C.; Lilongwe, Malawi; and Lusaka, Zambia. The southeastern United States and sub-Saharan Africa represent some of the most severely affected populations in the United States and worldwide.

“Researchers at Carolina have been at the forefront of the AIDS epidemic from day one,” said Marschall Runge, M.D., Ph.D., executive dean of the UNC School of Medicine. “This award recognizes the scientific leadership and global reach of the UNC HIV/AIDS enterprise.”

The UNC Global CTU will lead clinical research that addresses treatment of HIV and associated illness in adults and children, including tuberculosis and viral hepatitis co-infections. Prevention research will include studies of behavior change, treatment as prevention, preexposure prophylaxis, HIV vaccines and microbicides. Intensive clinical studies to advance a cure for HIV will be a critical focus of the unit.

UNC is home to a top 10-ranked HIV/AIDS program, involving dozens of researchers from laboratory scientists and clinicians to epidemiologists and policy experts. Between 2008 and 2012, the university got approximately $430 million in external research funding for HIV. The landmark study HPTN 052 (named “Breakthrough

The UNC Global CTU is led by three coprincipal investigators from the UNC School of Medicine: Joseph Eron, M.D., professor of medicine; Jeffrey Stringer, M.D., professor of obstetrics and gynecology; and Mina Hosseinipour, M.D., M.P.H., professor of medicine. The CTU is housed in the UNC Institute for Global Health &

Infectious Diseases. Although known for just 30 years, the human immunodeficiency virus has touched every corner of the globe, with 35 million people infected and 25 million lives lost, according to a UNC press advisory. “Not only is HIV a fierce biological opponent, but it is complicated by social factors related to stigma and the disproportionate burden on poor and marginalized populations,” according to the advisory. “This disease will not be conquered with single-pronged solutions,” said Dr. Eron, who also serves as CTU project director. “The complexity of HIV requires a multidisciplinary approach. Our CTU brings together a broad range of leading investigators whose expertise is focused on the greatest disease challenge of our time.” The CTU leadership team also includes site leaders Benjamin Chi, M.D., associate professor of obstetrics and gynecology (Zambia); Francis Martinson, M.D., Ph.D., research associate professor of medicine (Malawi); Cornelius van Dam, M.D., clinical assistant professor of medicine (Greensboro); David Wohl, M.D., M.P.H., associate professor of medicine (Chapel Hill); international operations director Irving Hoffman, P.A., M.P.H., professor of medicine; and Cheryl Marcus, B.S.N., C.T.U., coordinator and clinical research director.

The Triangle Physician 2014 Editorial Calendar

14

April Pediatrics Infectious disease

July Sports medicine Rheumatology

October Cancer in women Wound management

May Women’s health Neurology

August Gastroenterology Nephrology

November Urology ADHD

June Cancer in men Pulmonary

September Bariatrics Neonatology

December Otorhinolaryngology Pain management

The Triangle Physician

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UNC Research News

Ear Tubes vs. Watchful Waiting: Tubes Do Not Improve Long-term Development Study suggests tubes, adenoidectomy reduce fluid in the middle ear and improve hearing in the short term, but tubes did not improve speech or language for children with middle ear fluid. Watchful waiting or ear tube surgery? It is

eral pediatrics and adolescent medicine

to two years compared with no treatment

a decision faced by millions of families of

at the University of North Carolina School

or as an adjunct to myringotomy; rarely, it

children with recurrent or chronic otitis

of Medicine, who served as the review’s

increased the risk of postsurgical hemor-

media with effusion (non-infected fluid in

lead medical advisor and senior author.

rhage.

regarding long-term effects like hearing

OME is a collection of fluid in the middle

“With the large number of tube insertions

loss and potential developmental delays,

ear without signs or symptoms of acute

and adenoidectomies done on children

about a million such families choose ear

ear infection. The fluid decreases middle

each year, more research needs to be

tubes annually, opting for surgery that car-

ear function, leading to hearing loss and

done to assist clinicians and parents in un-

ries risks of its own.

occasional pain from the pressure chang-

derstanding the level of improvement in

the middle ear) each year. Out of concern

es. As many as 90 percent of children have

quality of life and other patient-centered

New research by the RTI-University of

at least one episode of OME by age 10,

outcomes that these common procedures

North Carolina Evidence-based Practice

and OME is a primary reason for children

offer, especially for periods longer than 24

Center, though, may have practitioners

to undergo surgery.

months,” said Ina Wallace, Ph.D., senior research psychologist at RTI International

reconsidering their clinical recommenda-

and the study’s lead author.

tions to families. The systematic review of

Myringotomy and tube placement is a pro-

more than 40 studies found that implant-

cedure in which a tiny incision is created

ing tubes in the ears of children who have

in the eardrum, and then a small tube is

“Our research showed that tubes and ad-

persistent or recurrent episodes of otitis

placed to relieve pressure and fluid build-

enoidectomy seem to be effective in the

media with effusion (OME) improves

up. This can be done alone or sometimes

short term, although they carry some

hearing over a short period but is less

is also done with adenoidectomy, where

risks. We found evidence that tubes may

likely to improve long-term cognitive and

tissue is removed from the back of the

not make a difference in hearing and func-

functional development.

throat. In the United States these are two

tional outcomes over one or two years or

common surgical treatments for OME.

longer, but less is known about the long-

“Surgery

term outcomes for adenoidectomy,” she

can

certainly help

The systematic review, published online

ease pain as-

in Pediatrics, examined 41 studies and

sociated

said.

with

found that, compared with watchful wait-

The full report sought to clarify the ben-

pressure

ing or myringotomy alone, implanting

efits or harms of interventions for OME

changes in the

tubes decreased middle ear effusion and

among adults but found no suitable evi-

middle ear and

improved hearing up to nine months post

dence.

even improve

surgery. Limited evidence suggested that

hearing in the

tube placement increased the rate of pro-

RTI-UNC Evidence-based Practice Center

ear

short term, but

longed discharge from the ear or calcifica-

is a collaboration between RTI and the

we found no evidence that surgical inter-

tion of tissues in the ear compared with

five health professions schools and the

vention improves longer term hearing,

no ear surgery or just myringotomy.

Cecil G. Sheps Center for Health Services Research at UNC. It is funded by the Agen-

speech, language or other functional outcomes in normally developing children,”

Adenoidectomy also reduced time with

said Michael Steiner, M.D., chief of gen-

ear infections and improved hearing up

TrianglePhy_Mar14.indd 15

cy for Healthcare Research & Quality.

march/april 2014

15

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Wake Med News

New Defibrillator Helps Those at Risk of Sudden Cardiac Arrest Forty-six years after performing the first open heart surgery in Wake

To date, more than 2,000 devices have been implanted in patients

County, WakeMed Health & Hospitals physicians implanted the

around the world. And in September 2013, the S-ICD System was

first subcutaneous implantable defibrillator (S-ICD) that will never

named best medical technology product by the Galien Foundation,

touch the heart of the patient at WakeMed Heart Center in February.

which honors excellence in scientific innovation and humanitarian efforts.

This new technology provides a gentler form of defibrillation therapy and new class of protection for patients in the event of

The S-ICD System from Boston Scientific has two main components:

an abrupt loss of heart function, known as sudden cardiac arrest

(1) the pulse generator, which powers the system, monitors heart

(SCA), a press advisory said. Most episodes of SCA are caused by

activity and delivers a shock if needed; and (2) the electrode,

the rapid and/or chaotic activity of the heart known as ventricular

which enables the device to sense the cardiac rhythm and serves

fibrillation.

as a pathway for shock delivery when necessary.

The S-ICD System is implanted just subcutaneously to help restore

Both components are implanted just under the skin – the generator

the heart’s normal rhythm whenever it is needed, leaving the

at the side of the chest and the electrode beside the breastbone.

heart and blood vessels untouched. Unlike traditional transvenous

Implantation with the S-ICD System is straightforward and can be

implantable cardioverter defibrillators (ICDs), the S-ICD System

done using only anatomical landmarks, which removes the need

doesn’t implant hardware – thin, insulated wires known as leads

for fluoroscopy (an X-ray procedure) that is needed in order to

– into the heart.

place the standard leads in the heart.

“WakeMed has been an innovator in matters of the heart for nearly 50 years,” said Betsy Gaskins-McClaine, vice president, WakeMed Heart & Vascular Services. “Offering this new procedure is an extension of the WakeMed Heart Center’s commitment to leadership in ensuring our cardiac patients receive the right treatments at the right time with the highest quality of care.” George L. Hamrick, M.D., F.A.A.C., (WakeMed Physician PracticesCarolina Cardiology) and Pavlo Netrebko, M.D., F.A.A.C., (WakeMed Physician Practices-Cary Cardiology) are among only a handful of cardiologists in North Carolina trained to use and able to offer the S-ICD System option to patients. Dr. Hamrick performed the first WakeMed procedure. The S-ICD system has been widely studied and supported for its safety and efficacy, receiving its CE Mark in 2009 and regulatory approval from the United States Food and Drug Administration in September 2012. This less-invasive treatment is a new option for patients without venous access, those with high risk for infections and potentially younger patients who need long-term ICD therapy. Other potential patient benefits include a decreased risk for systemic infections and clinical complications, prevention of any vascular injury as well as the preservation of venous access. Recent estimates show that approximately 850,000 people in the United States are at risk of sudden cardiac arrest, but remain unprotected without an ICD.

16

The Triangle Physician

TrianglePhy_Mar14.indd 16

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Do Heavy Periods

Uterine Fibroids

associated with

Affect You?

Consider Volunteering for a Clinical Research Study Uterine fibroid symptoms can affect any woman, anytime, anywhere. If you’re premenopausal, up to 49 years old, and have heavy periods associated with uterine fibroids, you may qualify for this oral investigational medication study. As a participant, you will receive all study-related care and investigational medication at no cost. If uterine fibroids affect you, consider volunteering.

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THEY SAY THE SUN SHINES BRIGHTEST AFTER A STORM. WE’RE NO EXCEPTION.

Now that last summer’s floodwaters have receded from our Chapel Hill office, it’s not just business as usual – it’s business that’s better than ever. A completely remodeled first floor. New advanced imaging equipment. And our specialty-trained radiologists doing what the region’s premier provider of outpatient medical imaging has done best for more than sixty years: everything from X-ray and ultrasound to CT, MRI and mammography. Even Mother Nature can’t rain on that.

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Job # 1405.WRA.13 • Job Title: Chapel Hill Flood Ad


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