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november 2016

Carolina Spine Center

Creating a Positive Experience for Those with Spine Pain

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 Merger Shakeup Psoriasis Strides


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T

From the Editor

Game Changer Carolina Spine Center, this issue’s cover story, thrives on positivity and good humor, a game-changing attitude. If it doesn’t attract

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

clients or personnel, it certainly is part of the formula for keeping them. The positive, can-do spirit of practice founder, interventional spine physiatrist Paul Singh, has enabled him to provide life-enhancing spine care to patients in underserved and larger metropolitan areas at the same time! This attitude runs throughout the practice, strengthening teamwork and enhancing patient care. Louis Torres, who also is an interventional spine physiatrist, recently joined Dr. Singh and his medical team. Skill areas for both physicians include minimally invasive, X-ray-guided pain-relief procedures. Dr. Singh has special expertise in cervical transforaminal epidural steroid injections. Dr. Torres brings expertise in musculoskeletal ultrasounds, which will be provided in the near future.

Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Laura D. Briley, M.D. Marni Jameson Carey Margie Satinsky, M.B.A. Creative Director Joseph Dally jdally13@gmail.com

Advertising Sales info@trianglephysiciancom

Currently, the Carolina Spine Center staff is seeing Cary patients at Total Joint Care, while its new location is under construction. The new Cary office will

News and Columns Please send to info@trianglephysician.com

open this coming January. The Carolina Spine Center staff also sees patients in its Rockingham, N.C., office.

The Triangle Physician is published by: New Dally Design

Also in this issue of The Triangle Physician dermatologist Laura Briley explores

Subscription Rates: $48.00 per year $6.95 per issue

advances in treating psoriasis. Physician advocate Marni Jameson Carey discusses the hospital merger arguments that helped reverse a court decision and may have far-reaching implications. Practice consultant Margie Satinsky

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

reviews two aspects of patient portals, functionality and Health Insurance Portability and Accountability Act privacy and security issues. Consider submitting your medical insight or practice news to complement the editorial content of upcoming issues of The Triangle Physician. We will run it as space allows, at no cost. Or considering featuring your practice on the cover of an upcoming issue, a game-changing marketing strategy, if you consider that this magazine reaches more than 9,000 professionals in the Raleigh-Durham medical community. Articles that enlighten readers about a practice’s strengths typically lead to increased referrals. Contact info@trianglephysician.com for more information.

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.

With gratitude for all you do,

Heidi Ketler Editor

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The Triangle Physician

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.


Table of Contents

4

COVER STORY

Carolina Spine Center

Creating a Positive Experience for Those with Spine Pain n ovember 2016

V o l . 7 , I ss u e 1 0

FEATURES

7

Physician Advocacy

8 Practice Management Patient Portals and

Independent Doctors Help FTC Win Appeal to Stop Hospital Merger Marni Carey discusses arguments in a trade association amicus brief that resonated with the court.

10

DEPARTMENTS HIPAA Compliance

11 News Antibody Shown to Soothe Raging, Nerve-Driven Poison Ivy Itch

Dermatology

Expanded Treatment Improves Overall Health of Patients with Psoriasis

11

12 News Botox May Beat Neural Stimulation for Urge Incontinence, But Has Risks

Laura Briley explores the benefits of advanced medications and

13 News

their broader quality-of-life significance.

Welcome to the Area

november 2016

3


Cover Story

Carolina Spine Center Creating a Positive Experience for Those with Spine Pain Having an optimistic attitude, creating a

miles from his home in Cary and a place

my upbeat demeanor reminded a patient

positive culture and connecting with oth-

he had never been to. At the same time,

of Aziz Ansari, an actor and comedian

ers have been core values of interventional

Richmond County hospital administra-

who was raised in Bennettsville.”

spine physiatrist Paul G. Singh, M.D., since

tors tasked him with starting an additional

establishing Carolina Spine Center in 2009.

practice in Bennettsville, S.C.

According to Dr. Singh, these same quali-

“Starting one office was a challenge, but

in which the board “was incredibly kind

ties that define his practice today were de-

another at the same time in a different

to assist me with a financial grant for pro-

veloped early on in his medical practice.

state, was an even tougher task,” said Dr.

viding medical care in their underserved

He had accepted the opportunity to build

Singh. “I was fortunate in that after work-

region.”

a practice in Richmond County, N.C., 100

ing in Bennettsville for a period of time,

The patient, a member of the hospital board, was inspired to initiate a meeting

Dr. Paul Singh performs a lumbar transforaminal epidural to ease nerve inflammation and associated pain.

4

The Triangle Physician


The years went by. “Patients in the area ap-

Positive Practice Culture

One-on-one review of imaging and edu-

preciated my care and commitment, and

In order to provide a positive patient ex-

cation during patient visits also are key

I found that my time there deepened my

perience, Dr. Singh believes that it starts

to patient satisfaction. “I have found that

fulfillment in medicine.” In 2011 Dr. Singh

with the staff and how they feel about the

people appreciate seeing the imaging of

returned to Cary, where he developed

practice they work at.

their spine and understanding it as I see it relate to their spine health and issues,”

a working relationship with Cary Orthopedics, while also continuing to operate

“I have been fortunate that the staff mem-

Carolina Spine Center in Rockingham, N.C.

bers I work with are people I genuinely re-

says Dr. Singh.

spect, care about and enjoy working with.

The Medical Team of

In June 2016, Dr. Singh decided to ex-

They are my friends, and I fully accept that

Carolina Spine Center

pand Carolina Spine Center to Cary and

the practice functions because of their

Dr. Singh works with a capable, compas-

forged a partnership with Total Joint

dedication. What we do for people, we do

sionate team.

Care, the office of orthopedic surgeon

together, but in large part because they

Stephen G. Struble, M.D. Dr. Singh and

make it happen,” says Dr. Singh.

Louis Torres, M.D., joined the practice in July as a fellowship-trained, interven-

his team are currently serving patients at Total Joint Care, while the new office for

“I have been fortunate in not losing any

tional spine physiatrist after recently

Carolina Spine Center is under construc-

staff member for a better employment

completing fellowship training. “Having

tion in Parkway Professional Park in Cary.

opportunity in the seven years I’ve prac-

Dr. Torres join the team has been incred-

He expects to be treating patients at the

ticed. Their well-being and happiness

ible – he’s great with patients and skilled

new location in January 2017.

mean a lot to me, and I am committed to

in procedures. He’s truly been a great

them as they are committed in creating a

friend and fun to share a laugh with. We

Interventional Spine Care Services

positive culture. The staff thrives on the

share thoughts about how to help pa-

Dr. Singh is board-certified in physical

autonomy to provide excellent care to all

tients and often see them together. He’s

medicine and rehabilitation and is fel-

those we serve, which contributes to our

made his time with the practice enjoy-

lowship trained in interventional spine

progress,” says Dr. Singh.

able for all of us.”

diagnosis and rehabilitation of musculo-

When working with patients, it’s important

Dr. Torres is competent in all interven-

skeletal injuries.

to Dr. Singh to understand each patient as

tional procedures and has extensive

care. As a physiatrist, he is trained in the

a person and not as a symptom or diagno-

training and ability in musculoskeletal

Rigorous fellowship training and nine

sis. “Having empathy and connecting to

ultrasound, a service Carolina Spine Cen-

years of experience in interventional

people’s lives is the best aspect of my job

ter intends to provide in the near future.

spine care have given Dr. Singh skill in

and what keeps the day fun.”

the use of minimally invasive, X-ray-guided procedures that provide pain relief for those with painful spinal disorders. “One particular area of procedural expertise that I have developed is cervical transforaminal epidural steroid injections that deliver corticosteroid directly around an inflamed nerve in the cervical spine.” These elective procedures often decrease, and even resolve, longstanding pain in the neck and back and can at times prevent or delay the need for surgical intervention. “Because of our ease and efficiency with fluoroscopic injections, we are able to accommodate people’s need for sameday service,” says Dr. Singh.

november 2016

5


Meet the Physicians Paul G. Singh, M.D.

Paul G. Singh is

Neema Patel, N.P.,

but our plan is to be more accessible for

works

with

patients by the new year,” says Dr. Singh.

Singh

in

Dr. Cary

and Rockingham.

Dr. Singh and Dr. Torres plan to introduce

“Neema is wonder-

to the practice proven, emerging thera-

diana, where he

ful with people,

peutic options for those with spine and

completed his un-

she

musculoskeletal pain.

dergraduate stud-

at summarizing a

ies at the University of Notre Dame.

person’s medical history and pertinent

All the while, patients can count on the

details, which allows me to focus on the

same uplifting practice spirit. “I believe

person and their spine. She is very detail

that as long as we continue to make the at-

oriented and meticulous and conscien-

mosphere positive and one where people

cine and Science/Chicago Medical

tious in her care. I am fortunate to have

want to work and receive care, it’s going

School and completed his residency

her as a friend and colleague.”

to be a fun journey to help patients who

originally from In-

He earned his medical degree at Rosalind Franklin University of Medi-

is

amazing

need our services,” says Dr. Singh.

at Rush University Medical Center in Chicago. He completed a fellowship in Interventional Spine at the University of Pennsylvania. Dr. Singh has been in practice for nine years and

Ava White, N.P., also works with Dr. Singh in Rockingham. Ava has over 30 years of

Contact Information

experience as a medical provider, and

Patients are being accepted at both con-

“her greatest strength is her ability to re-

venient Carolina Spine Center locations:

late to patients as people,” Dr. Singh says.

• 115 Parkway Office Court, Suite 101,

enjoys spending time with his family and playing tennis.

Cary, N.C., 27518 (currently the office The Future of Carolina Spine Center It is an exciting time for Carolina Spine

Louis A. Torres, M.D. Originally

from

Chicago, Louis A. Torres

attended

of Total Joint Care) • 809 S. Long Drive, Suite G, Rockingham, N.C. 28379.

Center. With a new office under construction, the hope is to increase access to

For more information and to schedule

care in Cary and continue to deliver care

an appointment, call (910) 997-3733.

in Rockingham.

The fax number is (910) 997-3707. Visit

Northwestern Uni-

the Carolina Spine Center website at

versity, where he

“We are currently available Mondays and

competed on the collegiate swim

Wednesdays in Cary at Total Joint Care,

www.carolinaspinecenter.com.

team while completing his undergraduate studies. He earned his medical degree at Ross University School of Medicine in Dominica and completed his residency in physical medicine and rehabilitation at MedStar Georgetown University Hospital/National Rehabilitation Hospital in Washington, D.C. He completed a fellowship in Interventional Spine and Sports at OSS (Orthopedic and Spine Specialists) Health in York, Pa. Dr. Torres says he has enjoyed the transition to the Triangle area, and he and his wife are looking forward to raising their young children here. The Carolina Spine Center medical team treats patients with personalized, leading-edge care in an upbeat, positive way.

6

The Triangle Physician


Physician Advocacy

Independent Doctors Help FTC Win Appeal to Stop Hospital Merger By Marni Jameson Carey

In a legal victory announced in late Sep-

they can negotiate higher reimbursements,

tember that many believe will help slow

which drives up health care costs.

the unhealthy wave of hospital mergers in

Marni Jameson Carey is the executive director of the Association of Independent Doctors. You may reach her at (407) 571-9316 or marni@aid-us.org. Visit www.aid-us.org for more information.

America, the Federal Trade Commission

Meanwhile, AID and other health care

successfully put the brakes on a merger

insiders are awaiting the outcome of an-

under way in Central Pennsylvania between

other merger decision in northern Illinois.

Penn State Hershey Medical Center and Pin-

AID filed a second amicus brief on behalf

nacleHealth System. The decision came

of the FTC to prevent the merger of Advo-

from the U.S. Court of Appeals for the Third

cate Health Care and NorthShore Univer-

Circuit.

sity HealthSystems, a proposed $7 billion

Leaders in the health care industry are

merger. That case, which is pending, is with

watching these decisions closely, as they

The Association of Independent Doctors, a

the U.S. Court of Appeals for the Seventh

will set the tone for future hospital mergers,

national trade association based in Winter

Circuit.

he said. AID is a three-year-old nonprofit with members in 30 states coast to coast.

Park, Fla., helped the FTC achieve the victory, which has nationwide ramifications.

In 2015, the number of hospital transac-

AID filed a friend-of-the-court opinion, also

tions grew by 18 percent from the pri-

known as an amicus brief, on behalf of

or year and by 70 percent from 2010,

the FTC arguing that if the hospital were permitted to merge, competi-

according to Becker’s Hospital

tion would be reduced and costs

Review. The Affordable Care Act is driving much of this consoli-

would go up considerably.

dation by reinforcing the notion that there is safety in size.

In siding with the FTC, the appeals court reversed a lower

Like all hospitals seeking to

court’s order that would have allowed the merger to proceed while

merge, these entities promised

the government agency looked into

that together they would lower prices by creating greater efficien-

the potential negative impacts.

cies. However, studies prove other-

But the verdict did more than slow the

wise: Consolidation unilaterally raises

merger down pending the analysis: After

prices.

losing the appeal, the two hospital systems decided to abandon their merger plans altogether.

“The FTC wasted no time letting the Sev-

We are proud to be a part of a decision that

enth Circuit know about the Third Circuit

is not only healthy for the citizens of central

Studies repeatedly show that when hos-

win,” said attorney Charles Artz of Har-

Pennsylvania but also for all of America. We

pitals consolidate, they harm communi-

risburg, Pa., who filed the amicus brief on

hope the Seventh Circuit also views the Il-

ties by forming monopolies. Because they

behalf of AID.

linois hospitals merger with the same clear headedness.

have more bargaining power with insurers,

november 2016

7


Practice Management

Patient Portals and HIPAA Compliance By Margie Satinsky, M.B.A.

A patient portal that allows patients to

pliance. At the June 2016 NCHICA Confer-

communicate securely with your practice is

ence on Managing Security & Privacy in an

an effective way to actively involve patients in

Environment of Increased Risk & Threats,

their own health. A growing body of evidence

portal compliance issues were a significant

demonstrates that patients who are actively

concern. We’ll share the highlights with you.

involved in their own health and in the care they receive have better outcomes and less

Patient Requests for Information

costly care than patients who are uninvolved.

HIPAA grants patients the right to access their protected health information (PHI)

In this article we’ll review two important as-

in a “designated record set” or snapshot of

pects of patient portals, functionality and

the complete medical record. Here’s the

Health Insurance Portability and Accountabil-

reasoning behind the concept:

ity Act (HIPAA) privacy and security issues. Patients don’t always need the entire medical

Margie Satinsky is president of Satinsky Consulting L.L.C., a Durham consulting firm that specializes in medical practice management. She has helped many physicians start new practices, assess the wisdom of affiliating with a larger health care system and improve their current practices. Ms. Satinsky is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For more information, visit www.satinskyconsulting.com.

With respect to functionality, a patient portal

record. More often than not, they need infor-

can enhance patient engagement by creat-

mation related to a specific visit, condition,

to PHI – including but not limited to PHI that

ing an easy and secure way to communicate

test result or situation. Patients also have the

is available through the patient portal – to

electronically. Although not all portals offer

right to request that their information be sent

others. Covered entities are required to ask

the same options and not all providers use

in a particular electronic format, provided that

each patient to sign an authorization to use

all of the options available to them, here are

it is “readily producible.” An example might

and disclose PHI. That form might include a

the most common:

be a thumb drive. The covered entity retains

specific item about portal access.

• Exchange secure email with the health

the right to deny access to the requested infor-

care team • Request (and sometimes make) non-urgent appointments

mation for numerous reasons, among them

Covered

the potential to endanger the life of the patient

precautions to protect portal access. They

entities

can

take

additional

or another individual.

might require that portal registration be done in the office and/or under the supervision

• Receive appointment confirmation and Given these rules, the covered entity must

of staff. They also might require that every

• Request prescription refills

recognize that a patient may request more

portal user, including patients and others

• Check benefits and coverage

than he/she might automatically receive

authorized by patients, register separately

• Update contact information

through the portal. The patient also may

in order to track portal usage. And finally,

• Download (and sometimes fill out and

request information in a format other than

they can confirm portal signup by a method

return) forms for patient demographic

what appears in the portal. Finally, not all

called out-of-band communication, i.e. by

information and medical history

patients use the portal, so the covered entity

sending an email to verify that portal signup

must offer other options.

has occurred.

Authorization to Access Information through the Patient Portal

Patient Restrictions on Using and

What about authorization to access informa-

Patients have the right not only to authorize

tion through the patient portal? In some in-

access to their PHI, be it available or not on

In our experience, portal functionality re-

stances, only the patient accesses the portal.

the patient portal. That same authorization

ceives far more attention than portal com-

In other instances, the patient gives access

to use and disclose PHI gives patients the

reminders

• View patient balance and pay bills online • View normal test results • Obtain visit summary information • Obtain patient education materials recommended by the practice

8

The Triangle Physician

Disclosing PHI


Practice Management opportunity to restrict the sharing of their PHI by category of information (e.g., behavioral health, HIV status, pregnancy) and by the patient’s relationship to an individual (e.g., spouse, parent, child). Patients who pay out-of-pocket for a service also have the right to request that information on the care delivered not be sent to an insurer. Given these patient rights, covered entities must be able to segregate specific information, so it remains outside of the “designated record set.” It’s best to work with the software vendor(s) to determine the best method to segregate information upon patient request. Suggested Action Steps Here are four proactive steps that covered entities can take to ensure their patient portal meets HIPAA compliance requirements. • Include the patient portal in the security risk analysis that is performed each year in order to identify and correct any problems.

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• Finally, audit the use of the portal on a regular basis in order to identify suspicious patterns and correct problems. The print version of the October issue of The Triangle Physician included an article on changes in Medicare reimbursement that was written prior to CMS’ issuance of the Final Rule on Oct. 14, 2016. The Final Rule made important changes in clinician eligibility for participation, timing and weighting of quality measures. For an updated article, please contact margie@satinskyconsulting.com, and we’ll provide a PDF of the corrected information. We apologize for the inconvenience.

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november 2016 3/15/16 2:44 PM9


Physician Advocacy

Expanded Treatment Improves Overall Health of Patients with Psoriasis By Laura D. Briley, M.D.

During the past 15 years, targeted treatment

for psoriasis, such as Cosentyx, Otezla and

approaches and medications with fewer

Taltz, are now available.

side effects have expanded the options for patients with severe psoriasis.

When treating a psoriasis patient it is important to consider the presence of associated

The goal of treatment in most autoimmune

diseases, such as heart disease, obesity, dia-

diseases is to suppress the immune system

betes and depression. Many patients also

from attacking the body. In the past,

have arthritis, which limits their ability to

medications for psoriasis suppressed the

lead a healthy, active lifestyle.

entire immune system, but now treatments target the part of the immune system that is

Compounding

over active. This leads to fewer side effects

emotional toll of being shunned by those

the

challenges

is

the

and greater tolerability.

who wrongly believe that the scaling plaques of psoriasis are contagious. Patients

Dr. Laura Briley specializes in general adult and pediatric dermatology, dermatologic surgery, cosmetic dermatology and skin cancer. She graduated from Wake Forest University and earned her medical degree from the Brody School of Medicine at East Carolina University. She completed her internship at Roger Williams Medical Center in Providence, R.I., and her residency at the Brody School of Medicine. Dr. Briley is a member of the American Academy of Dermatology, American Medical Association and Alpha Omega Alpha Honor Society.

Methotrexate, Soriatane and Cyclosporine

frequently describe being brought to tears

used to be some of the only options for pa-

in situations where people don’t want to

tients with severe psoriasis who failed ultravi-

touch them and otherwise make them feel

olet light therapy and topical corticosteroids.

dirty or contaminated. All of these issues

Regular primary care visits are needed to

However, all of these medications have seri-

can lead to severe depression, alcoholism

coordinate care provided by cardiology,

ous side effects, such as deleterious effects

and substance abuse.

rheumatology, dermatology and nutritional providers. Stress reduction and assessment

on liver, kidneys and blood pressure. With treatment, clearing the skin and help-

of mental health is essential. As these pa-

Biologic medications, such as Enbrel,

ing the joints can enable individuals with

tients are on medications that suppress the

Humira and Stelara, have proven over time

psoriasis to lead healthier lives and greatly

immune system, it is important that they not

to have milder side effects that are well

reduce the emotional burden. Management

delay normal skin cancer screenings.

tolerated. Excitingly, even more medications

of the comorbidities requires a team of health care providers.

Patient education is a key component in care. The better a patient’s understanding of their skin condition and related health issues, the more empowered they can be to take charge of their own health. Only with proper understanding can one be convinced to adopt a healthier lifestyle. Proper treatment of the skin and joints often can result in the patient becoming more active and feeling less depressed. Awareness of the comorbidities of psoriasis can help elevate the priority one gives to stress reduction, a healthy diet and regular screenings.

10

The Triangle Physician


News

Antibody Shown to Soothe Raging, Nerve-Driven Poison Ivy Itch Scientists at Duke Health and Zhejiang Chinese developed

Medical a

University

strategy

to

stop

have the

uncontrollable itch caused by urushiol, the oily sap common to poison ivy, poison sumac, poison oak and even mango trees. The team found that by blocking an immune system protein in the skin with an antibody, they could halt the processes that tell the brain the skin is itchy. The hope is the model could lead to potential treatments for people who are allergic to poison ivy – an estimated 80 percent of the population. The research was done in mice and is

A fluorescence microscope image shows the skin of a healthy mouse (left) and skin from a mouse with a poison ivy rash (right). Interleukin-33, shown in green stain, is a protein that acts directly on the nerves, telling the brain the skin is extremely itchy. Credit: Sven-Eric Jordt/Duke Health

severe itching doesn’t go away with

found they could also alleviate itch by

antihistamines, because it arises from a

blocking a receptor for IL-33, called ST2.

different source, Dr. Jordt said. “There could be translational significance

described in the Nov. 7 Proceedings of the Dr. Jordt and collaborators determined

here,” Dr. Jordt said. “So our next step will

the itch is triggered by interleukin 33

be to look at human skin to see if we see

For most people, contact with poisonous

(IL-33), a protein in the skin involved in

the same activity and the same pathways.

plants is painful but not life threatening.

immune response.

We will also look at anti-inflammatory

National Academy of Sciences.

drugs that are already approved to see if

Still, there are significant health care costs associated with more than 10 million

All people have IL-33 in their skin, but

people in the United States affected

the protein is elevated in people who

each year, said senior author Sven-

have eczema and psoriasis, Dr. Jordt

In addition to Dr. Jordt, study authors

Eric Jordt, Ph.D., associate professor of

said. The protein is known for inducing

include Boyi Liu, Yan Tai, Satyanarayana

anesthesiology at Duke.

inflammation, but these new experiments

Achanta, Melanie M. Kaelberer, Ana I.

show the protein also acts directly on the

Caceres, Xiaomei Shao and Jianqiao Fang.

they have the potential to alleviate itch.”

“Poison ivy rash is the most common

nerve fibers in the skin, exciting them and

allergic reaction in the U.S., and studies

telling the brain that the skin is severely

The research was supported by the

have shown that higher levels of carbon

itchy.

Duke Anesthesiology DREAM Innovation Grant (2015-DIG LIU), Zhejiang Chinese

dioxide in the atmosphere are creating a proliferation of poison ivy throughout

The researchers used an antibody to

Medical

the U.S. – even in places where it wasn’t

block IL-33 and found that it not only

(722223A08301/ 001/004), the National

growing before,” Dr. Jordt said. “When

reduced inflammation, but also cut

Natural Science Foundation of China

you consider doctor visits, the costs of

down scratching in mice with poison

(81603676) and three National Institutes of

the drugs that are prescribed and the lost

ivy rashes. An antibody that counteracts

Health: the National Center for Advancing

time at work or at school, the societal

human IL-33 is currently being evaluated

Translational Sciences (UL1 TR001117),

costs are quite large.”

in humans through a Phase 1 clinical trial

the National Institute of Environmental

to determine its safety and potential side

Health Sciences (R01 ES015056, U01

effects.

ES015674) and the National Institute of

Some symptoms of the fiery, blistering

University

Start-Up

Funding

Arthritis and Musculoskeletal and Skin

rash can be alleviated with antihistamines and steroids. But in recent years,

In an additional approach tested in the

Disease (R21 AR070554). The authors

scientists have determined that the most

mouse experiments, the researchers

declare no conflicts of interest.

november 2016

11


News

Botox May Beat Neural Stimulation for Urge Incontinence, But Has Risks bladder

The findings were published Oct. 4 in

The study involved 381

incontinence, the urge to urinate can come

the Journal of the American Medical

women from nine United

on suddenly and sometimes uncontrollably,

Association.

States medical centers that

When

women

suffer

from

recorded at least six ur-

leading to leakage. Patients looking for relief

gency incontinent episodes

can initially opt for first- and second-line

An injection of botulinum toxin in the

therapies, such as drinking fewer liquids or

bladder muscle works to address urgency

caffeinated beverages, pelvic floor muscle

urinary incontinence by relaxing the over-

days and had not improved with other treat-

training and medication.

active bladder muscles that cause the con-

ments.

Cindy L. Amundsen, M.D.

during three consecutive

dition. A sacral neuromodulation implant If those treatments prove inadequate,

does the same thing by sending electrical

The participants were randomly assigned

however, patients may seek more invasive

pulses to nerves in the spine.

to either receive sacral neuromodulation or a 200-unit injection of botulinum

options, including a form of nerve stimulation called sacral neuromodulation

“Urgency urinary incontinence is common,

toxin. After a trial period to test their

(an implanted device sold as InterStim) or a

with 17 percent of women over age 45 and

responsiveness to the therapies, 364

bladder injection of botulinum toxin, which

25 percent of women over age 75 suffering

women were enrolled and followed for six

is sold as Botox.

from it,” said Cindy L. Amundsen, M.D., the

months after treatment.

study’s lead author and the Roy T. Parker A head-to-head comparison of sacral

Professor of Obstetrics and Gynecology at

The study team analyzed the number of

neuromodulation and botulinum toxin led

Duke University School of Medicine. “That’s

urgency incontinent episodes on monthly

by a Duke Health researcher shows that

why it’s important for both patients and

“bladder diaries.” Participants who received

Botox provides more daily relief for women

health care providers to have information

botulinum toxin saw their number of daily

but might also be associated with more

that can guide their choice between these

urgency incontinent episodes decrease by

adverse events.

two therapies.”

3.9 on average versus 3.3 on average in the sacral neuromodulation group. The difference was statistically

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significant. Botulinum toxin participants also reported a greater reduction in bothersome symptoms, higher satisfaction with treatment and a greater likelihood of endorsing the treatment. Additionally, among participants who completed at least four monthly

diaries,

a

higher

percentage of botulinum toxin participants saw at least a 75 percent reduction in or complete resolution of urgency incontinent symptoms. However, the Botox patients also had three times the rate of urinary

12

The Triangle Physician


News tract infections. Some botulinum toxin

Amundsen said. “The information should

Yuko M. Komesu, Lily A. Arya, W. Thomas

participants also required intermittent self-

help guide care.”

Gregory, Deborah L. Myers, Halina M. Zyczynski, Sandip Vasavada, Tracy L. Nolen,

catheterization, although at lower rates than reported in previous studies using this dose.

While the study did not compare the cost

Dennis Wallace and Susan F. Meikle.

of the two treatments, Dr. Amundsen noted For the sacral neuromodulation partici-

that patients who receive botulinum toxin

The study was funded by the Eunice

pants, the most common adverse event was

may require additional injections as part

Kennedy Shriver National Institute of Child

removal or revision of the implant during

of continued treatment. Additionally, the

Health and Human Development and

the six months. This occurred at a low rate,

study only takes Botox into account, and

the National Institutes of Health Office of

similar to previous studies.

no conclusions can be drawn for other

Research on Women’s Health 3316.

botulinum toxin preparations that may be “This study is valuable because it is the first

used to treat urgency incontinence.

One co-author reported financial relationships with the commercial makers of both

randomized trial comparing the efficacy of two FDA-approved, third-line therapies

In addition to Dr. Amundsen, co-authors

InterStim and Botox. Full disclosures are

in a severely affected population,” Dr.

include Holly E. Richter, Shawn A. Menefee,

available in the study’s manuscript.

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