n ov e m b e r 2 014
A Personal Choice With Dr. Monteith Where Permanent Is Not Forever
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
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A Personal Choice with Dr. Monteith
Where Permanent is Not Forever
n o v e m b e r 2 0 14
Vol. 5, Issue 8
DEPARTMENTS 10 Practice Management Social Media – Understand Opportunities and Pitfalls
15 Duke Research News
Lung Cancer Screening Will Offer More Hope with More Insurers in 2015 Dr. Carmelo Gullotto describes an early screening strategy for those with a history of heavy smoking.
16 Duke Research News
-K lotman Joins Institute of Medicine -P rostate Cancer’s Penchant for Copper May Be a Fatal Flaw
17 North Carolina Medical Society News
Stress Is Harder on Women’s Hearts
Radiologist Is Named 161st President
18 UNC Research News Gastroenterology
-F irst Mouse Model Aims to Accelerate Ebola Vaccine, Treatment Development -T rio Teams Up to Fight Cancer’s Resistance to Certain Drugs
19 UNC Research News $3.75 Million to Help Identify Ways to Prevent Heart Attacks and Strokes
The Use of Antidepressants in the Treatment of Irritable Bowel Syndrome
20 North Carolina Autism Society News
Dr. Douglas Drossman outlines the benefits that
come with proper use, including neurogenesis.
Toolkit Defends Against Bullies
Welcome to the Area
COVER PHOTO: Charles W. Monteith, M.D., medical director of A Personal Choice, formerly the Chapel Hill Tubal Reversal Center, performs sterilization reversal surgery.
The Triangle Physician
“ I Told Mother I Would Take Her Wherever She Wanted To Go For Radiation Treatment. She Chose Johnston Health In Smithfield For The Road Less Traveled.” David Brown Lillington, NC
Cancer Survivor Elsie Brown and friend, Bentley
Fighting Cancer Is Enough... Your Patients Shouldn’t Have To Fight Traffic!
Elsie Brown was prescribed radiation oncology following breast cancer surgery in 2011. “This meant repeated weekly trips to a treatment center from her home near Lillington,” said her son, David. “Mother was dealing with enough stress just to that point - the news, the surgery and recovery, and then, travel on top of that. I told her I would drive her anywhere she wanted to go for treatment. But she said she didn’t want to deal with the stress of traveling through triangle traffic, even as a passenger.
When she learned Johnston Health offered radiation oncology services in partnership with Rex/UNC, her decision was made.” “It was as positive an experience as I could imagine,” said Elsie. “The trips to Smithfield were easy and staff was very friendly and supportive. I had family and several friends volunteer to go with me. Three years later, I am doing well! To anyone requiring oncology treatment, I would recommend my path on the road less traveled - with Johnston Health.”
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From the Editor
Giving Thanks One of my first articles for The Triangle Physician was on Chapel Hill Tubal Reversal Center (“Database and Berger Babies Are Proof Tubes Can Be Untied,” May 2010). Fertility surgeon Charles Monteith had
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
joined the specialty practice of Gary Berger two years earlier, and the two were performing tubal ligation reversal surgery, helping women worldwide conceive again.
Now as I complete my fifth year as The Triangle Physician editor, it was a recent thrill to have revisited the practice. After Dr. Berger retired, Dr. Monteith continues the practice’s progressive, compassionate mission – to provide a more affordable and safer corrective surgery for tubal ligations.
Today the practice is called A Personal Choice and is this month’s cover story. Read on and you will learn how Dr. Monteith is building on Dr. Berger’s legacy – which includes raising awareness that lives change and tubal ligation doesn’t have to be permanent. For the thousands of patients in this country whose children have been referred to as “Berger Babies”
Editor Heidi Ketler, APR email@example.com Contributing Editors Douglas Drossman, M.D. Carmelo Gullotto, M.D. Margie Satinsky, M.B.A. Creative Director Joseph Dally firstname.lastname@example.org
Advertising Sales info@trianglephysiciancom
or “Monteith Miracles,” Thanksgiving has special meaning.
News and Columns Please send to email@example.com
Also in this issue, radiologist Carmelo Gullotto gives an overview of a new lung cancer
The Triangle Physician is published by: New Dally Design
screening strategy that improves early detection and is associated with reduced death rates from lung cancer. Gastroenterologist Douglas Drossman discusses the use of antidepressants to recover normal brain-gut function.
Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401
Marketing specialist Margie Satinsky offers tips for avoiding social media pitfalls and resources. North Carolina Autism Society reports on a bullying toolkit for parents and professionals designed to help prevent and stop bullying.
’Tis the season for expressing gratitude. So from all of us at The Triangle Physician, thank you for your interest in and support for our publication! Since this publication’s inception, it has been personally gratifying to share the news of world-class health care delivered in our region.
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.
Keep up the good work and your articles, columns and advertising coming.
Heidi Ketler Editor
The Triangle Physician
All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.
www.kendallmurphyphotography.com firstname.lastname@example.org Maternity
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A Personal Choice with Dr. Monteith
Where Permanent is Not Forever Women and men travel across the United
Many within the medical community re-
The new practice name is a reflection of
States and around the world to A Personal
call the practice when it was Chapel Hill
the broader vision, says Dr. Monteith. “Our
Choice of Raleigh, a unique practice dedi-
Tubal Reversal Center, founded by Gary S.
new name may not be understandable to
cated to outpatient, minimally invasive
Berger, M.D. Dr. Monteith joined Dr. Berger
the general public but for those who seek
sterilization and sterilization reversal ser-
there in 2008, and together they provided
our services the immense meaning of our
vices in a state-of-the-art facility.
a unique form of tubal ligation reversal
name is readily apparent,” he says.
that allows faster patient recovery, avoids The surgical specialty practice exclusively
prolonged hospitalization and decreases
A Personal Choice is conveniently located
offers tubal ligation reversal, and vasec-
patient recovery time.
near North Hills Mall and Midtown Raleigh, so patients can stay in one of the nearby
tomy and vasectomy reversal. Tubal reversal and vasectomy reversal have proven to
After Dr. Berger retired in 2013, Dr. Monte-
luxury hotels and walk to many restaurants
be more effective and are more affordable
ith expanded on his health care vision by
and entertainment venues. The area also
than alternative treatments, and vasectomy
giving male patients greater reproductive
provides closer access to Raleigh Durham
is safer than tubal ligation.
choice. In late 2013, he relocated the prac-
tice to Raleigh, which includes a state-of“I provide male and female patients un-
the-art, in-office operating room equipped
biased care after they have made very
with laminar airflow HVAC, central vacu-
Affordable Surgical Services
personal choices about how best to con-
um and oxygen, modern anesthesia and
The cornerstone of Dr. Monteith’s prac-
trol their fertility,” says Charles W. Monte-
patient-monitoring equipment. He also
tice is offering female patients who desire
ith, M.D., medical director of A Personal
incorporated single-incision vasectomy re-
more children after tubal sterilization an
versal and vasectomy.
affordable treatment alternative to in-vitro fertilization. “Most of our patients have divorced, remarried and would like to have a child with their new partner. Unfortunately some have lost children to tragic events, while others simply have had a change of heart and want to reverse a decision they have grown to regret, because none of us can predict the future,” he says. Since inception of Chapel Hill Tubal Reversal Center, more than 12,000 corrective tubal surgeries have been performed. Since his first such procedure, Dr. Monteith has done 2,000 outpatient female sterilization reversal surgeries. His experience
This in-office operating room is where sterilization reversal surgeries are performed.
The Triangle Physician
is critically important to those seeking a reversal surgeon. It explains why more than
Since 2008, Dr. Monteith, along with Dr. Berger, has performed more than 160 procedures to remove these devices. In comparison, “Most gynecologists have never removed one of these newer sterilization devices,” he says. Dr. Monteith recently had a paper accepted for publication in Obstetrics and Gynecology, in which he describes the pregnancy rates within a larger cohort of his patients who have undergone Essure reversal. He expects the results of his research to become available before the end of 2014. Patients also seek Dr. Monteith’s experience in removing Essure coil devices, after
Dr. Monteith (second from left) and his medical team perform a sterilization reversal.
experiencing adverse symptoms. “In initial 95 percent of patients have traveled great
tion of the fallopian tube has historically
studies submitted to the FDA, less than 3
distances to the practice.
been the most difficult tubal blockage to
percent of women experienced pain of
surgically correct. Pregnancy rates after
varying degrees after Essure sterilization…
Additionally, the outpatient tubal ligation
Essure sterilization are age dependent but
. With more women undergoing the proce-
reversal services at A Personal Choice are
are approximately 35-40 percent.
dure, we are now seeing more Essure-relat-
approximately half the cost and twice as
ed complications and those seeking expe-
successful as a single in vitro fertilization
“I have been particularly proud of our
rienced surgical removal for treatment of
(IVF) treatment. Despite support for tubal
efforts in reversing this newer form of fe-
these complications,” he says.
reversal by leading infertility professional
male sterilization, because it provides our
organizations, in vitro fertilization is widely
patients with an alternative to IVF and
Dr. Monteith removes Essure devices dur-
viewed by many medical professionals as
because most of the medical community
ing an hour-long outpatient surgery with
the only option for women with a tubal li-
believes these newer procedures cannot
minimal risk to the patient, including low
gation. This misconception exists, because
be reversed. We simply used an older, his-
risk of device fracture, and without the
hospital-based female sterilization reversal
torical surgical procedure to correct the
need for a hysterectomy.
is unaffordable to most patients and, as a
newest form of female sterilization,” Dr.
result, younger doctors have not been ex-
posed to female sterilization reversal, according to Dr. Monteith. Experienced Essure Removal Specialists Dr. Monteith is the first surgeon in the world to report within peer-reviewed medical literature successful pregnancy and birth after reversal of two of the newest forms of female sterilization, Essure and Adiana. Essure and Adiana sterilization were both approved by the United States Food and Drug Administration in 2001.These newer forms of female sterilization cause blockage of the fallopian tubes in the narrowest portion of the tube. Blockage in this por-
Dr. Monteith (first row, center) is on a vasectomy mission in Kisumu, Kenya at Marie Stopes Health Clinic.
“Over the years, I heard constant requests from my female patients to provide vasectomy reversal. During a vasectomy surgical mission, we discussed the concept of how the possibility of vasectomy reversal makes vasectomy more acceptable for some men. Soon after my return from this mission trip, one of my own vasectomy patients inquired about having his vasectomy reversed. It was then that I decided in order to be a complete physician that I need to learn and offer vasectomy reversal.”
Above: Dr. Monteith (center, on floor) is with a vasectomy mission team in Cebu, Philippines. Right: Dr. Monteith comforts child while father has vasectomy.
Gentle Touch Vasectomy:
Gentle Touch Vasec-
The Science of No Scalpel, the Art of
tomy, an open-ended
Minimally Invasive Vasectomy
Although Dr. Monteith is board certified in
requiring neither a nee-
obstetrics and gynecology, he also offers
dle for anesthesia nor
male patients Gentle Touch Vasectomy,
a scalpel to complete
widely known as the most minimally inva-
the procedure. He is
sive form of vasectomy that requires nei-
the only vasectomy
ther a needle for anesthesia nor a scalpel
provider offering men
for a skin opening. He has performed more
the choice of having
than 500 of these procedures in the U.S.
a single-visit vasectomy procedure and, if
Today, after receiving one-on-one training
patients live long distances away, the op-
with vasectomy-reversal colleagues, Dr.
tion of returning semen samples by mail
Monteith reverses vasectomies as an out-
for after-vasectomy testing.
patient procedure in his office operating
“My background in women’s health is what
suite, while the patient is under general
motivated me to provide vasectomy. It was my personal experience that my female
An active supporter of No Scalpel Vasecto-
anesthesia, He keeps the procedure af-
patients were exposed to all of the risks of
my International, Dr. Monteith has partici-
fordable, which gives his female patients
pregnancy and most of the burden of hav-
pated in vasectomy mission trips to Kenya
another successful alternative to in vitro
ing sterilization. Women often get tubal li-
and the Philippines and is an active par-
gations because of convenience of proxim-
ticipant in online discussions with vasect-
ity to childbirth and barriers faced by men
omists world-wide regarding all aspects of
Learning More About This
who are not as integrated into the health
vasectomy. He also joins other vasectomy
care system,” he says.
providers every November on World Va-
For those who are interested in more in-
sectomy Day to increase vasectomy aware-
formation about Dr. Monteith, his practice
“My goal in learning vasectomy was to
ness by offering free vasectomies to those
or the services he provides, he maintains
provide the best vasectomy procedure
who do not have adequate health care cov-
two active websites with extensive infor-
and experience possible while at the same
erage for the procedure.
mation for patients and doctors about his unique practice. Information about A
time decreasing barriers most men are exposed to when considering vasectomy. Va-
Mini-incision Vasectomy Reversal
Personal Choice and its tubal ligation and
sectomy is a safer and better for men and
Dr. Monteith performed vasectomy for
vasectomy reversal procedures is online at
years before he began offering microsurgi-
www.tubal-reversal.net. Information about
cal skills to male patients seeking reversal
A Personal Choice and vasectomy is at
Dr. Monteith is now one of the few providers in the Carolinas offering affordable
The Triangle Physician
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Understanding Opportunities and Pitfalls By Margie Satinsky
Social media is here in a big way, and it’s
tunities that you have with different social
here to stay. Facebook reports that it has
more than 1 billion users. The fastest-growing age bracket for both Facebook and
We think “manage” is a key word here. Put
Google Plus is 45-54. Twitter’s growth is pri-
yourself in the driver’s seat and strap your-
marily with an older group – 55-64.
self in tightly. For more suggestions, go to http://www.whitecoat-designs.com/blog/
According to surveys done by the DC In-
and click on “Social Media for Doctors:
teractive Group, 41 percent say that social
How to Control the Conversation Online.”
media would impact their choice of health
Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She’s the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www.satinskyconsulting.com.
care provider. That same group estimates
Understand the Nuts and Bolts of
that 42 percent of all consumers use social
Social Media and Take It Slowly
media to check reviews for providers, treat-
Using social media effectively involves far
them manage chronic conditions like Type
ment options and products. We offer four
more than hastily posting a message and
II diabetes, a blog can help clinicians pro-
recommendations for using social media
firing off a quick response to those who
vide important educational information to
to share information on your medical prac-
send messages to you. Know your options
patients that they might not otherwise have
and start slowly with LinkedIn and/or blog-
provided because of busy schedules.”
• Use it purposefully to support your
ging, two methods of online communica-
practice’s goals. A presence on social
tion that can be very effective. LinkedIn
Learn how to strengthen your social me-
media that is unrelated to your overall
was designed from the outset for profes-
dia presence with the top five sites that
intent is a waste of time and money.
sional networking rather than personal
Google uses in its ranking algorithm (i.e.
Facebook, Twitter, LinkedIn, Google Plus
• Understand the nuts and bolts of social
and YouTube). Monitor your profiles on
media so you can take advantage of Learn how to use one platform effectively
the top sites and respond quickly to any
• Use social media safely to avoid inap-
and safely before moving to the next. Blog-
negative comments. Social media man-
propriate disclosures of protected
ging (short for web logging), too, is a rela-
agement tools like Hootsuite and Google
health information (PHI) that are
tively simple way to have an online conver-
Alerts make the monitoring process more
sation, provided you have a clear focus and
the opportunities that it offers.
• Select the appropriate option for main-
intent. Here’s how the free Google Alerts tool
taining your social media presence. Alice Saunders of Trisecta in Raleigh offers
works. You set alerts for specific search cri-
Use Social Media Purposefully to
her insight on increasing your return on in-
teria (e.g. your practice name in quotation
Support Your Practice’s Goals
vestment (ROI): “A blog can help first-time
marks), and Google sends daily or weekly
Social media can be a powerful method
visitors to your website better understand
emails telling you what people are saying
of communicating with patients, potential
your credentials and expertise, resulting in
online. If comments are negative, you can
patients and medical colleagues. Amanda
more new-patient conversions. For exam-
respond quickly and appropriately, show-
Kanaan of WhiteCoat Designs in Raleigh
ple, patients might choose an oncologist
ing both concern and timeliness of your
explains the importance of controlling the
whose blog is focused on a specific type
response and perhaps counteracting the
online conversation about your practice.
of cancer or whose blog demonstrates an
complaint. Content is everything. Make it
Focus on the messages that you post, your
awareness of the latest advances and clini-
meaningful and reliable so patients and
response to what others post regarding
cal trials. As practices look for innovative
colleagues know they can trust your ad-
you, and/or your practice and the oppor-
ways to interact with patients and help
The Triangle Physician
Use Social Media Safely to Avoid Inappropriate Disclosures of
instances, the individual physician or prac-
tion of State Medical Boards’ Model Policy
tice has a knee-jerk reaction and counters
Guidelines for the Appropriate Use of Me-
Protected Health Information (PHI)
the comment as quickly as possible. Often
dia and Social Networking in Medical Prac-
The theory behind social media is that par-
the provider discloses PHI without even
ticipants voluntarily consent to contribute
thinking about the potential HIPAA viola-
P D F / F S M B / Ad vo c a c y / p u b - s o c i a l -
social and personal data to a social me-
on the type of social media, there may be
Social media and HIPAA are not incompat-
Select the Appropriate Option for
ways to restrict access to some of that infor-
ible. Still, it’s important to know that provid-
Maintaining Your Social Media
mation so not all users can see it.
ers, not patients, are responsible for main-
taining HIPAA compliance.
Many practices make the mistake of dele-
dia electronic storage system. Depending
Medical practices that use social media are
gating the responsibility for developing and
not exempt from HIPAA. As covered enti-
The safest way to communicate with pa-
maintaining social media to an enthusiastic
ties, they are obligated to protect the use
tients is through a secure patient portal.
workforce member. If that individual un-
and disclosure of PHI and to honor the
However, if you expect to enter into so-
derstands the big picture, i.e. all that we’ve
specific patient rights that are identified
cial media “friendships,” require patients
mentioned above, the decision to select an
in the privacy rule as amended by the HI-
to sign a written authorization regarding
internal person may be appropriate. But if
TECH Act of 2009 and the 2013 Omnibus
online disclosure before entering into the
the individual assuming the responsibility
online relationship. Even with the patient’s
for social media doesn’t understand the
written authorization, review what you
context into which social media must be
What if a health care provider or practice
post, making sure not to use or disclose
put or have the time to learn new skills, you
has a social media profile and a patient
PHI without proper prior authorization.
may be better served by outsourcing the re-
“friend” connects with the physician or practice? There’s a strong risk of inferring
sponsibility to a qualified professional. For additional guidance, read the Federa-
a patient-provider relationship – not information that should be publically shared. If the communication mentions treatment for
55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514
Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.
a particular condition, there’s another potential HIPAA violation. Voluntary posting by the patient and/or provider or practice does not exempt covered entities from obtaining written patient authorization prior to disclosing PHI. Here’s another situation that occurs frequently and may be a HIPAA violation. Patients often like the convenience of websites such as www.caringbridge.com or www.carepages.com, to communicate
with family and friends when they are ill or in the hospital. People sign up to be part of a group that receives blog posts on the patient’s condition. All too often, health care providers comment on the condition and treatment, mistakenly assuming that the blog post is equivalent to patient authorization to reveal PHI. Still another common situation arises when someone posts a negative comment about a provider and/or practice. In many
Lung Cancer Screening Will Offer More Hope with More Insurers in 2015 By Carmelo Gullotto, M.D.
Lung cancer kills more people in the United States than any other type of cancer. One reason it accounts for 27 percent of all cancer deaths – more than breast, colon and prostate cancer combined – is that lung cancer often is diagnosed at a late stage when treatments are less likely to result in a cure. Currently, more than 95 percent of lung cancer patients die from the disease within five years of being diagnosed.
This CT scan shows a small nodule, or abnormality, that can be difficult to identify on a standard X-ray.
of at least 30 pack-years – were screened annually using either a low-dose helical computed tomography (CT) or a standard chest X-ray. The study demonstrated a
Dr. Carmelo Gullotto is a body imaging radiologist and a breast magnetic resonance imaging specialist at Wake Radiology, the region’s largest outpatient imaging practice with 20 locations in the Triangle. He has a special clinical interest in abdominal imaging and MRI. Dr. Gullotto is board certified in diagnostic radiology by the American Board of Radiology. He is a member of the Radiological Society of North America, American Roentgen Ray Society, North Carolina Medical Society and the Wake County Medical Society. He performs lung cancer screenings at Wake Radiology, the first health care provider in North Carolina designated as a Lung Cancer Screening Center by the American College of Radiology.
20 percent reduction in death from lung cancer in the group screened with lowdose CT.
When interpreting the CT, the radiologist looks for nodules or abnormal-appearing
A CT scan captures detailed images of the chest.
The NLST study gives us hope that lung
tissue in the lungs. When nodules are
Heavy smokers in the Triangle now have
cancer screening strategies may be
identified, characteristics such as size,
greater access to a screening strategy that
effective in reducing lung cancer deaths
shape and appearance are evaluated to
has been shown to improve early detection
in the same way that mammograms and
determine the likelihood of malignancy
colon cancer screening help us improve
survival from other forms of cancer.
screenings have been available for a
How Lung Cancer Screenings Work
Who Should Undergo Lung
few years, but more private insurers are
The new lung cancer screening strategy
covering them under the Affordable Care
employs a low-dose, non-contrasted CT
The United States Preventive Services Task
Act beginning January 2015. Medicare and
that scans the entire chest and captures
Force recommends lung cancer screening
Medicaid have not yet determined if they
detailed images. The CT itself lasts less
for current and former smokers (ages 55
will cover the screenings.
than 15 seconds, and the entire exam only
to 80) who have a 30 pack-year history
takes about 15 minutes. During screening
of smoking – for example, people who
The National Lung Screening Trial (NLST)
examinations conducted at American
smoked one pack per day for 30 years or
is a 2011 study published in the New
College of Radiology-accredited Lung
two packs per day for 15 years.
England Journal of Medicine. More than
Cancer Screening Centers, patients are
50,000 current and former heavy smokers
provided with information and resources
Physicians should discuss lung cancer
– defined as those with a smoking history
to help them stop smoking.
screenings with patients who have a history
reduced death rates from lung cancer.
The evidence-based low-dose lung cancer
The Triangle Physician
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Standard X-rays are less likely to identify evidence of lung cancer.
of heavy smoking. In North Carolina, the nation’s leading tobacco-growing state, more than 20 percent of adults currently smoke.
newsource & Associates
Where Are Lung Cancer Screenings Available? Lung cancer screenings are available at outpatient imaging centers and hospitals
Call (540) 650-3686 or send inquiries to firstname.lastname@example.org.
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across the Triangle. Physicians may wish to refer patients to facilities that have been designated as
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cessation programs. Reference National Lung Screening Trial Research:
DERMATOLOGY & SKIN CANCER CENTER 919-782-2152
“Reduced Lung-Cancer Mortality with Low-Dose
SKIN RENEWAL CENTER 919-863-0073
Screening,” published in New England Journal of Medicine, August 4, 2011. More
information is available at: www.cancer. gov/clinicaltrials/noteworthy-trials/nlst.
ACNE • MOHS SURGERY • SKIN CANCER • PSORIASIS • ECZEMA • DERMATITIS • ALOPECIA DER131_AD_Triangle Physican 1_Magic.indd 1
9/19/14 9:30 AM
The Use of Antidepressants in the Treatment of Irritable
By Douglas Drossman, M.D.
The brain monitors and processes bodily
Their symptoms may be controlled by
activity. Antidepressants work not only in
other treatments. Patients with moderate
the brain and spinal cord but also in the
or severe IBS may benefit from taking an
enteric nervous system. Through this
antidepressant medication either alone or
system they can facilitate or block pain
in combination with other treatments.
messages between the gastrointestinal (GI) tract and the brain.
typically take four to six weeks to occur. Since functional GI pain involves impair-
Usually, dosages lower than treating major
ment of this system, antidepressants can
depression are used at the onset and
recover more normal brain-gut function
gradually increased as needed. In some
in these conditions via neuromodulation
cases the low dose is sufficient to improve
of incoming pain impulses. Certain antide-
pressants also can help regulate abnormal bowel functions, like diarrhea and con-
Which antidepressants are used for
stipation, as well as other irritable bowel
IBS? Traditionally, the most frequently
syndrome (IBS) symptoms. The anticho-
prescribed antidepressants fell into one
linergic effect of tricyclic antidepressants
of two large groups â€“ tricyclics (TCAs)
(TCAs) with noradrenergic, which inhibits
and SSRIs. More recently, a newer group,
motility, reduces diarrhea, and the sero-
tonin reuptake inhibitors (SSRIs) also can
inhibitors (SNRIs), also has been shown to
help treat constipation by increasing colon
be effective in treating these disorders.
transit. They also help with anxiety and depression, which are often associated with
TCAs have been on the market for many
chronic painful disorders and can contrib-
years, are relatively inexpensive and have
ute to dysmotility.
been used more frequently in treating functional GI disorders. TCAs include
Finally, a recent observation relates to
amitriptyline, imipramine, desipramine
growing knowledge that antidepressants
also may stimulate nerve cell growth
Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation. org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www.drossmancenter.com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patientprovider relationship. Drossman Gastroenterology P.L.L.C. (www.drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.
and possibly restore more normal nerve
The SSRIs also can be useful in treating
functioning in the brain and intestines
IBS particularly when associated with
pain like the TCAs but without the same
over time. This is called neurogenesis and
other symptoms such as depression or
side effects of TCAs. SNRIs include
helps explain why we may recommend
anxiety though may not be as helpful as
venlafaxine, duloxetine, desvenlafaxine
treatment for a year or two before tapering
the other classes of medications for pain.
off the medication.
SSRIs include citalopram, escitalopram, paroxetine, sertraline and fluoxetine.
When are antidepressants used for
If single medication treatments are not successful,
IBS? Patients with mild IBS symptoms
The SNRIs are a relatively new class of
the treatment using combinations of
do not usually need antidepressants.
medications that are effective in treating
treatments. In our referral population,
The Triangle Physician
Gastroenterology sequencing one medication after another
one medication, hence possibly reducing
sometimes fails, due to lack of response
side effects. The concept of augmentation
Drossman, Douglas A; Beyond Tricyclics:
or side effects, so when this occurs what
relates to the use of two or more treatments
New Ideas for Treating Patients With
is needed is an approach that employs
that act upon different receptor sites
multiple treatment modalities to achieve
or areas of the brain to enhance the
synergistic or additive effects often in
Journal of Gastroenterology 2009;104:2897–
lower dosages than when treating with
Duke Research News
Stress Is Harder on Women’s Hearts Researchers have known for decades that
flow to the heart, or ischemia, as compared
The data also found sex distinctions in blood
stress contributes to heart disease. But a new
to 41 percent of men. Ischemia is a prevalent
platelet behavior. The aggregation of platelets
analysis by researchers at Duke Medicine
component of cardiovascular disease and
can lead to a blockage that could cause a
shows mental stress may tax women’s hearts
often the factor that leads to death.
heart attack. Despite the use of medications designed to keep blood platelets from
more than men’s. Differences between the sexes could provide
clustering together, the platelets of female
The research appears online Oct. 13 in the
clues on how to tailor heart disease education,
participants under mental stress were still
Journal of the American College of Cardiology.
prevention and treatment for women and
clumping to a greater extent than those of
men. Heart disease kills about 600,000 people
“Normally when under
each year and remains the leading cause of
stress, we fight back or
death in the United States for both men and
Dr. Samad said that with further research,
run away. In order to do
women, according to the Centers for Disease
this detail could help tailor blood-thinning
that, we need to pump
medications for more effective use in women.
said Wei Jiang, M.D., the
But studies have shown disparities in the
“The impact of negative physiologic responses
study’s senior author
outcomes of ischemic heart disease, with
to mental stress needs to be recognized in
and professor of medicine, psychiatry and
women faring worse than men. CDC surveys
cardiovascular risk assessment in both sexes,”
behavioral sciences at the Duke University
have found disparities in women’s awareness
Dr. Samad said. “These differences may be
School of Medicine. “According to the data,
of heart disease risks, and how quickly
potential reasons for differences in outcomes
women were not reacting that way as well as
women seek treatment for their symptoms.
and may also serve as avenues for further
more blood to the body,”
research. This could be a si gnal that we have
men were.” In the Duke study, women under mental
been looking for to treat heart disease better,
In their analysis, Duke researchers reviewed
stress expressed a greater increase in negative
especially in women.”
data on 254 men and 56 women who had
emotions and a greater decrease in positive
a history of ischemic heart disease or
feelings. By contrast, men had greater rise in
In addition to Drs. Jiang and Samad, study au-
decreased blood flow to the heart. The group
blood pressure in response to mental stress,
thors included Stephen Boyle, Mads Ersboll,
was part of a Duke study published in 2012
the data showed.
Amit N. Vora, Ye Zhang, Richard C. Becker, Redford Williams, Cynthia Kuhn, Thomas
called REMIT, which evaluated the impact of an antidepressant medicine to reduce stress-
“Men may have been ex-
L. Ortel, Joseph G. Rogers, Christopher
induced heart trouble.
pressing (fewer) chang-
O’Connor and Eric J. Velazquez.
es in emotions, but they Participants performed stressful tasks, such
had an obvious negative
The National Heart, Lung, and Blood Institute
as describing an event that made them angry,
physiologic response to
provided grant support (RO1HL085704).
while researchers monitored their heart
stress,” said Zainab Sa-
function and other vital signs.
mad, M.D., M.H.S., the study’s lead author and assistant professor of
During times of stress, 57 percent of female
medicine at Duke.
participants experienced reduced blood
Duke Research News
Klotman Joins Institute of Medicine HIV researcher Robert C. Gallo, M.D.
Mary E. Klotman, M.D.,
cine, pathology, and molecular genetics
chairwoman of the De-
and microbiology. Her research team has
partment of Medicine
demonstrated the direct role of HIV genes
Dr. Klotman joined the faculty at the Mount
at the Duke University
in the pathogenesis of HIV-associated ne-
Sinai School of Medicine in New York in
School of Medicine,
phropathy, a devastating complication of
1994, serving as chief of the Division of
has been elected as
HIV infection. Her team also has sought
Infectious Diseases for 13 years and as
one of 70 new mem-
to identify antiviral host factors involved in
co-director of Mount Sinai’s Global Health
transmission and control of HIV.
and Emerging Pathogens Institute. In 2010,
bers to the prestigious Institute of Medi-
Dr. Klotman returned to Duke to chair the
cine. Dr. Klotman attended Duke University
Department of Medicine.
Dr. Klotman is an expert in infectious diseas-
for both her undergraduate degree in
es and the human immunodeficiency virus.
zoology (1976) and her medical degree
New members to the Institute of Medicine
(1980) and then completed her internal
(IOM) are elected by current active
“Election to the Institute of Medicine is
medicine residency and a fellowship in
members through a selective process that
considered one of the highest honors in
infectious diseases in the Department of
recognizes people who have made major
medicine,” said Nancy C. Andrews, M.D.,
Medicine at Duke.
contributions to the advancement of the medical sciences, health care and public
Ph.D., dean of Duke University School of
Medicine. “Dr. Klotman’s election is a no-
She started her career at Duke in 1985 as
table achievement and recognition of her
an associate faculty member in medicine,
important contributions as a leader and as
before moving to the National Institutes of
Established in 1970 by the National
a physician-scientist focused on the mo-
Health, where she was a member of the
Academy of Sciences, the IOM is a national
lecular pathogenesis of HIV-1 infection.”
Public Health Service. At NIH, she trained
resource for independent, scientifically
and worked in the Laboratory of Tumor Cell
informed analysis and recommendations
Biology under the direction of renowned
on health issues.
Dr. Klotman is also a professor of medi-
Prostate Cancer’s Penchant for Copper May Be a Fatal Flaw Like discriminating thieves, prostate can-
cal trials among patients with late-stage
enough in cancer cells to kill them, how
cer tumors scavenge and hoard copper
about we boost the copper and then use a drug that requires copper to be effective
that is an essential element in the body. But such avarice may be a fatal weakness.
“This proclivity for copper uptake is some-
to attack the tumors. It’s the old if-you-
thing we have known could be an Achilles’
Researchers at Duke
heel in prostate cancer tumors as well as
Medicine have found
other cancers,” said Donald McDonnell,
Dr. McDonnell and colleagues searched
a way to kill prostate
Ph.D., chairman of the Duke Department
libraries of thousands of approved thera-
cancer cells by deliver-
of Pharmacology and Cancer Biology and
pies to identify those that rely on copper
ing a trove of copper
senior author of a study published Oct.
to achieve their results. Among those
along with a drug that
15 in Cancer Research, a journal of the
they found was disulfiram, a drug ap-
American Association of Cancer Research.
proved by the United States Food and
Drug Administration to treat alcoholism.
the diseased cells brimming with the mineral, leaving non-cancer cells healthy.
“Our first efforts were to starve the tu-
Disulfiram had at one time been a can-
mors of copper, but that was unsuccess-
didate for treating prostate cancer – it
The combination approach, which uses
ful. We couldn’t deplete copper enough
homes in on the additional copper in
two drugs already commercially available
to be effective,” Dr. McDonnell said. “So
prostate cancer tumors – but it showed
for other uses, will soon be tested in clini-
we thought if we can’t get the level low
disappointing results in clinical trials
The Triangle Physician
Duke Research News among patients with advanced disease.
“Unfortunately, hormone therapies do not
recurrent prostate cancer in our recent
cure prostate cancer, and most patients
clinical trial, this new data suggests a po-
The Duke team found that the amount
experience relapse of their disease to a
tential way forward and a reason why this
of copper cancer cells naturally hoard is
hormone-refractory or castration-resistant
trial did not have more positive results,”
not enough to make the cells sensitive to
state,” Dr. McDonnell said. “Although
Dr. Armstrong said. “Further clinical stud-
the drug. But when the Duke researchers
tremendous progress has been made in
ies are now warranted to understand the
added a copper supplement along with
treating prostate cancer, there is clearly
optimal setting for combining copper with
the disulfiram, the combination resulted
a need for different approaches, and our
disulfiram or similar compounds in men
in dramatic reductions in prostate tumor
findings provide an exciting new avenue
with progressive prostate cancer, particu-
growth among animal models with ad-
larly in settings where the androgen receptor is active.”
vanced disease. Dr. McDonnell said clinical trials of the And there was another surprise: Andro-
combination therapy are planned in up-
In addition to Dr. McDonnell, study au-
gens, the male hormones that fuel pros-
thors include Rachid Safi, Erik R. Nelson, Satish K. Chitneni, Katharine J. Franz,
tate cancer, increase the copper accumu-
Daniel J. George and Michael R. Zalutsky.
lation in the cancer cells. Dr. McDonnell
Andrew Armstrong, M.D., associate pro-
said this finding could make the combina-
fessor of medicine, was involved with a
tion of disulfiram or similar compounds
recent study at Duke testing disulfiram in
The National Institutes of Health
and copper especially beneficial for men
men with advanced prostate cancer.
funded the study (CA139818, CA42324, RO1GM084176).
who have been on hormone therapies that have failed to slow tumor growth.
“While we did not observe significant clinical activity with disulfiram in men with
North Carolina Medical Society News
Radiologist Is Named 161st President Robert E. Schaaf, M.D.,
“This year we will continue to be a vocal
professor of radiology at Duke University
and committed leader in discussions
Medical Center and the University of
and former president
about Medicaid reform in North Carolina,”
North Carolina-Chapel Hill for a combined
he said of his goals for 2015. “The society
is the 161st president
stands at the forefront, ensuring that
of the North Carolina
physicians and physician assistants have
In addition to his service with the NCMS,
a strong voice on behalf of our patients
since 2005 Dr. Schaaf has been a gover-
with policymakers and legislators. We
nor-appointed member of the North Caro-
Dr. Schaaf is board certified in diagnostic
have important work to do in 2015, and
lina Medical Care Commission, which
radiology and is a fellow of the American
together we can creatively chart a path to
oversees regulation in North Carolina’s
College of Radiology. He became a
reasonable and sustainable change.”
hospitals and health care facilities. He
also has served as vice chairman on the
member of the North Carolina Medical Society (NCMS) in 1981 and has been
Dr. Schaaf earned his medical degree
board of directors for the North Carolina
a member of the board of directors
from Tufts University Medical School in
Medical Mutual Insurance Company. Dr.
since 2004. Throughout the years, he
Boston, Mass., and went on to complete
Schaaf has been on the board of visitors
has participated on numerous NCMS
a combined internship/residency at Duke
for the Wake Forest University School of
committees including finance and the
University Medical Center in Durham,
Law since 2012.
where he served as chief resident in his final year. He also was a clinical assistant
UNC Research News
First Mouse Model Aims to Accelerate Ebola Vaccine, Treatment Development In the war against Ebola one important hurdle has just been cleared – by a mouse. Researchers at the University of North Carolina at Chapel Hill and colleagues have developed the first genetic strain of mice that can be infected with Ebola and display symptoms similar to those that humans experience. This work, published in the current issue of Science, will significantly improve basic research on Ebola treatments and vaccines, which are desperately needed to curb the worldwide public health and economic toll of the disease. “You can’t look for a cure for Ebola unless you have an animal model that mimics the Ebola virus disease spectra,” said study co-author Ralph Baric, professor of epidemiology at the UNC Gillings School of Global Public Health and UNC School of Medicine. “For the first time, we were able to produce a novel platform for rapidly developing new mouse models that replicate human disease for this virus, as well as other important emerging human pathogens.” Typical laboratory mice usually do not
develop human-like Ebola disease, including the severe symptoms that can prove fatal in humans. So the researchers asked whether all mice are immune to Ebola or whether some strains of mice are susceptible; and if some are susceptible, could they harness the power of mouse genetics to figure out what genes make someone susceptible to the disease. To find out, the team, including researchers from the University of Washington and the National Institutes of Health Rocky Mountain National Laboratory, where the research took place, were able to breed together eight genetic mouse variants and successfully test a strain of mice to permit active research on potential Ebola vaccines and treatments. This model system more accurately reflected the human experience when infected with the virus. The team was able to show that a combination of genes were involved in producing a range of disease symptoms, such that the genetic variation of the mice directly led to the variety of symptoms that the disease produced. What’s more, the researchers pinpointed a single gene that
accounted for much of that variation – a gene responsible for encoding a protein known as TEK. “Public perception of Ebola infection typically focuses on the high mortality rate following hemorrhagic fever, but Ebola actually produces a range of disease symptoms,” said co-author, Martin Ferris, a research assistant professor of genetics in the UNC School of Medicine. “During an outbreak, it is often difficult to assess the role that genetic variation plays in determining disease severity in people. And if we’re going to develop treatments, then we need to know about this genetic variation.” Co-author Mark Heise, professor of genetics at the UNC School of Medicine, added, “the mice were part of the Collaborative Cross initiative at UNC-Chapel Hill, which was designed to better model human genetic diversity, and it has proven to be a powerful system for studying how genetic variation affects susceptibility to a number of emerging pathogens, including Ebola virus. It has been a tremendous program with big dividends.”
Trio Teams Up to Fight Cancer’s Resistance to Certain Drugs A dynamic team of cancer researchers at UNC Lineberger Comprehensive Cancer Center has been funded by The V Foundation for Cancer Research to focus on finding new treatments for cancers of the head, neck, lung and esophagus while better understanding why these cancers can become resistant to new therapies.
M.P.H., associate professor of medicine; and Gary Johnson, Ph.D., Kenan Distinguished Professor and chair of the Department of Pharmacology. The V Foundation, one of the nation’s leading cancer research foundations, awarded $600,000 to the UNC Lineberger team to use during a period of three years.
The research team will be led by Ben Major, Ph.D., assistant professor of cell biology and physiology; Neil Hayes, M.D.,
“Most patients with the types of cancers being studied in this grant – head and neck, lung and esophageal – are initially di-
The Triangle Physician
agnosed with advanced disease, with over 80 percent of lung cancer patients and 90 percent of esophageal cancer patients dying of the disease,” said Dr. Hayes, a medical oncologist who, in addition to his cancer genetics research, also treats patients at the N.C. Cancer Hospital. While very few new treatments for these types of cancers are available to patients currently, exciting advances have been made in the development of targeted, ki-
UNC Research News track kinase activation in real-time. Together with Dr. Major, the two researchers have refined the kinome technology, since its initial discovery in 2012 for use in small-volume clinical samples. “With this new technology, we can measure both the presence and activity of 7080 percent of all kinases simultaneously, allowing us to see how cancers evade treatment,” said Dr. Major.
The research is being led by (from left) Neil Hayes, M.D., M.P.H.; Ben Major, Ph.D.; and Gary Johnson, Ph.D.
nase inhibitor therapies. Kinases are proteins expressed in human tissues that play a key role in cell growth, particularly in cancer. Of the 518 known human kinases, more than 400 are expressed in cancers. Efforts have been made to develop kinase inhibitors as targeted cancer treatments, but most metastatic cancers eventually become resistant to these treatments. The research team will track kinase activity in 50 tumor samples both prior to and following treatment with a combination of kinase inhibitor therapies. Matching both
the genomic profile of the tumor with the kinase activity will offer the researchers a glimpse into why cancer cells begin to resist these therapies, and further study how combination therapies might help block resistance. “By defining the tumor kinase activity before and after therapy along with the overall kinome-level response to therapy, we hope to identify certain kinase signatures that can be targeted to accelerate the development of new drugs,” said Dr. Johnson, who developed the technology to
The grant is funded through The V Foundation’s Translational Clinical Research grant program and meant to facilitate the transition of projects from the laboratory to the clinic. “We are excited to bring together translational scientists with patient-centered research to care for our patients with some of the harder-to-treat cancers,” said Jason Akulian, M.D., M.P.H., clinical assistant professor, Division of Pulmonology & Critical Care Medicine. “This is exactly the kind of team science we can all support.” Translational researchers seek to apply basic knowledge of cancer and bring the benefits of the new basic-level understandings to patients more quickly and efficiently.
$3.75 Million to Help Identify Ways to Prevent Heart Attacks and Strokes The Center for Health Promotion and Disease Prevention (HPDP) at the University of North Carolina at Chapel Hill received a $3.75 million cooperative agreement to renew its status as a Prevention Research Center through 2019. The Centers for Disease Control and Prevention funding will help UNC researchers conduct innovative prevention research in North Carolina communities that can help combat chronic disease with long-term solutions. The Center for Health Promotion and Disease Prevention (HPDP) is one of 26 prevention research centers in 25 states
to receive the award and is eligible for additional funding in the next five years to study how people and their communities can avoid chronic illnesses, such as heart disease, obesity and cancer. HPDP, which partners with other prevention research centers to ensure effective health strategies are readily shared with other underserved communities, was one of the first three centers funded when the program began in 1986 and has maintained its status for the past 27 years. “HPDP is a research center at UNC that serves the people of North Carolina by
leveraging substantial federal funding to help prevent chronic disease, thus building a healthier population and workforce and improving quality of life,” said Alice Ammerman, professor of nutrition in the Gillings School of Global Public Health, who will continue as director of HPDP. The cooperative agreement includes Carolina Heart Alliance Networking for Greater Equity (CHANGE), an applied research project that will begin in Hertford County, an underserved community with high rates of heart disease. The project will test more effective ways to prevent november 2014
UNC Research News heart attacks and strokes through several approaches, including clinical care, behavior change counseling and policy and environmental change, such as accessible sidewalks and farmers markets.
tant professor in the UNC School of Nursing, and Sam Cykert, professor in the UNC School of Medicine, will lead the CHANGE project.
“By building on and connecting the strengths of local communities, we will help foster their capacity for long-term health, rather than creating something that will disappear at the end of the grant,” said Ms. Ammerman.
“We plan to develop and test a novel approach to train community health workers to help patients, families and friends better understand their personal heart disease risks and deliver a lifestyle change intervention to reduce this risk,” Ms. Leeman said.
Successful strategies will be scaled up and disseminated to other communities across the state. Jennifer Leeman, assis-
HPDP will partner with the Roanoke Chowan Community Health Center and Hertford County Public Health Author-
ity initially and then other clinical sites and health departments will join the work. Kim Schwartz, chief executive officer of the Roanoke Chowan Community Health Center, said the project provides a unique opportunity for her community. “It truly takes a village to assist in reducing the negative impact of chronic disease,” Ms. Schwartz said. “By working with the UNC Center for Health Promotion and Disease Prevention, our team is excited about the project and the potential for more tools to strengthen the community-clinical linkages in Hertford County.”
North Carolina Autism Society News
Toolkit Defends Against Bullies The Autism Society of North Carolina is offering parents, teachers and others a toolkit to help combat bullying in schools. The new bullying toolkit is an easy-touse, accessible guide to teach parents and professionals about the signs of bullying, ways to prevent bullying and how to stop it. It provides an overview of antibullying programs that have been proven effective for schools and a detailed list of resources. The toolkit can be read online, downloaded and printed here: http://bit. ly/ASNCSchoolIssues. The Autism Society of North Carolina (ASNC) works year-round to ensure students with autism have a safe learning environment in which they are treated as valued members of the school community. Children with disabilities are bullied at far greater rates than their nondisabled peers.
Students with Autism Spectrum Disorder (ASD) often have characteristics that make them especially susceptible, including age-inappropriate interests, clumsiness or inflexibility when it comes to rules. The Autism Society of North Carolina offers other resources for families who might be dealing with bullying: • Autism Resource Specialists provide support for families who are addressing challenges, such as bullying, and can also give presentations in schools about understanding those with autism. • The ASNC blog is a constant source of information; a recent post by D.J. Svoboda, an artist and motivational speaker who lives in Cary, addressed bullying. (http://autismsocietyofnc. wordpress.com/) • The Safe in the Community section of
the website addresses wandering as well as other safety concerns. Background: • ASD is a lifelong developmental disability that typically appears during the first three years of life. Recent studies estimate that up to one of every 58 children born in North Carolina will be affected by ASD. • For more than 44 years, the Autism Society of North Carolina has worked to address areas of need and expand services for the autism community in North Carolina. ASNC works to directly improve the lives of individuals affected by autism by providing advocacy, education and services. •F or more information, call (800) 4422762 or visit www.autismsociety-nc.org.
Correction: In last month’s issue of The Triangle Physician, a photo incorrectly identified Paul E. Mock, major general (ret.), national chair of Employer Support of the Guard and Reserve, who is standing beside Timothy M. Weiner, M.D.
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3D MAMMOGRAPHY WE’RE TALKING WAY BETTER IMAGING, EARLIER DETECTION, FEWER FALSE POSITIVES AND LESS CHANCE OF A CALL BACK. END OF DISCUSSION.
3D MAMMOGRAPHY • GREATER ACCURACY • REDUCED ANXIETY • NOW AT WAKE RADIOLOGY Let’s have a frank discussion. You can’t treat what you can’t detect. And 3D mammography, along with your regular 2D exam, is revolutionizing breast cancer detection. How? By significantly improving clarity for earlier detection and fewer false positives. Which, of course, reduces recall rates and the anxiety that comes with additional tests. To learn more about 3D mammography or to schedule an appointment, visit wakerad.com. Like we said, you can’t treat what you can’t see. And now we’re seeing better than ever. Wake Radiology | North Hills Breast Center | 919-232-4700 | wakerad.com Daily, evening and Saturday appointments | 20 minutes from check-in to exam completion