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o c to b e r 2 014

WakeMed Health & Hospitals Maternal-Fetal Medicine High-Risk Maternal-Fetal Care From Preconception Through Delivery

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

Medical Sleuthing Low-FODMAP Diet


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COVER STORY

6

WakeMed: High-Risk Maternal-Fetal Medicine Care From Preconception Through Delivery

o c t o b e r 2 0 14

Vol. 5, Issue 7

FEATURES

12

Dermatology

DEPARTMENTS 9 Marketing

18 UNC News

10 Practice Management

Medical Sleuthing: Differential Diagnosis Dr. Eric Challgren explains the diagnostic process of elimination based on analysis of the presenting facts.

Gastroenterology

Understanding the LowFODMAP Diet

Tips for Marketing Your Practice

14 Women’s Health Infertility: It’s Causes, Treatments and Screening for Abnormalities

16 Duke Research News

13

Cultivating Your Brand

- Insight on Ancient Plague Could Lead to New Treatments for Infections - Gene Interacts With Stress and Leads to Heart Disease in Some People

-F  irst-in-Kind Study Hopes to Fill Knowledge Gaps about Sexual Assault -A  ward Is Nation’s Highest Honor for Supporting Guard, Reserve Employees

20 WakeMed News Three Leading Health Systems to Form Company that will Share and Economize

20 News

Nurses Named to the “Great 100”

21 News

- Welcome to the Area

Kellie Bunn reports on recent evidence that supports dietary management for irritable bowel syndrome.

2

The Triangle Physician

COVER PHOTO: The WakeMed Physician Practices-Maternal-Fetal Medicine team is led by (first row, from left) Carmen Beamon, M.D., F.A.C.O.G.; Avick G. Mitra, M.D., F.A.C.O.G.; and Jacqueline Muhammad, M.D., F.A.C.O.G.


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From the Editor

A Healthy Start The United States has one of the highest preterm birth rates in the world: one in

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

nine babies born (11.5 percent) is delivered before 37 completed weeks of gestation, according to the Society for Maternal-Fetal Medicine. Pre-term births are a major cause of infant mortality, and reducing both starts with preventing pregnancy complications, such as preterm labor, preeclampsia and placental dysfunction.

In this region, WakeMed Health & Hospitals Maternal-Fetal Medicine’s recent expansion of services for high-risk patients will give many newborns a healthier start. This month’s cover story gives an overview of the advances within WakeMed Physician PracticesMaternal-Fetal Medicine that include the addition of new physicians and a genetic counselor. It also is opening a new office in north Raleigh this month.

Editor Heidi Ketler, APR heidi@trianglephysician.com Contributing Editors Kellie Bunn P.A.-C. Eric Challgren, M.D. Wendy Coulter Margie Satinsky, M.B.A. Lindsay Wojciechowski, N.P. Creative Director Joseph Dally jdally@newdallydesign.com

Advertising Sales

In this issue of The Triangle Physician, several contributors return. Nurse practitioner Lindsay Wojciechowski discusses the challenges of infertility and the optimal testing and

info@trianglephysiciancom News and Columns Please send to info@trianglephysician.com

treatment paths. Physician assistant Kellie Bunn explores the use of the low-FODMAP diet in reducing functional gastrointestinal symptoms.

The Triangle Physician is published by: New Dally Design

Dermatologist Eric Challgren shares insights into the art and science of differential

Subscription Rates: $48.00 per year $6.95 per issue

diagnosis. Practice marketing consultants Margie Satinsky and Wendy Coulter, a new contributor, have columns on tips and tricks that you can put into practice today.

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

You can bolster your marketing efforts with a presence in The Triangle Physician. Each

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.

issue reaches more than 6,000 within the Triangle medical community, and that means your ads, news articles and cover stories will too.

Now’s the time to plan your marketing mix for a strong and healthy start for 2015. For more information on opportunities ahead, please send an e-mail to: heidi@ trianglephysician.com.

With great appreciation for all you do,

Heidi Ketler Editor

4

The Triangle Physician

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


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Cover Story

High-Risk Maternal-Fetal Care

From Preconception Through Delivery WakeMed Expands Its Fully Comprehensive, High-Risk Prenatal Care Program in Wake County to Keep Patients Close to Home The WakeMed Health & Hospitals Mater-

Avenue. In October, they will expand their

F.A.C.O.G., director of WakeMed’s Mater-

nal-Fetal Medicine division is expanding

presence with an additional office on

nal-Fetal Medicine program. “WakeMed’s

threefold, with new specialists, an addi-

the WakeMed North Campus – the site of

expanded division and practice mean

tional practice location and more specialty

WakeMed’s future women’s hospital. This

more women who need highly specialized

services for high-risk expectant mothers.

expansion and addition of services truly

maternal-fetal medicine services, such as

WakeMed’s practice, known as WakeMed

solidifies WakeMed’s ability to provide full-

genetic counseling, chorionic villus sam-

Physician Practices – Maternal-Fetal Medi-

service, comprehensive care for the high-

pling (CVS), intrauterine transfusion and

cine (WPP-MFM), now consists of three

risk mother from preconception through

advanced treatments for cervical insuffi-

maternal-fetal medicine physician special-

delivery in Wake County.

ciency, can stay close to home.”

“Raleigh is the capital city of North Caro-

The Maternal-Fetal Medicine team at

lina, yet for decades, we have had to

WakeMed collaborates with both private-

Their current practice location is on the

send many high-risk mothers outside of

practice obstetricians to care for patients

WakeMed Raleigh Campus on New Bern

Wake County,” said Avick G. Mitra, M.D.,

who need maternal-fetal consultation during

ists, an experienced genetic counselor and several sonographers.

their pregnancy, as well as WakeMed’s inpatient obstetrics and gynecology physicians for patients who may need hospitalization prior to delivery for high-risk conditions. “Our focus is always to work with the patient and her physician to optimize results and ensure a healthy delivery of the baby,” added Dr. Mitra. “With the addition of our new physicians and genetic counselor, we can now truly offer a comprehensive prenatal diagnosis and treatment program for high-risk patients. And with the opening of our new office in north Raleigh this October, we hope to be even more accessible Utilizing 3-D sonography, Dr. Avick Mitra and sonographer Lisa Damiano demonstrate the normal facial anatomy of a baby in the early second trimester of pregnancy.

6

The Triangle Physician

to the patients and families who need our care.”


A Highly Skilled, Collaborative Team Dr. Mitra has recently been joined by Carmen Beamon, M.D., M.P.H.; Jacqueline Muhammad, M.D., and genetic counselor Cheryl Dickerson, M.S., C.G.C. Each brings a unique skill set and specific clinical interests that help enrich the range of offerings the practice is now able to provide. The team also includes a group of experienced registered diagnostic medical sonographer (RDMS)-certified sonographers who are specially trained in high-risk obstetric ultrasound, including fetal echocardiography. Avick Mitra, M.D., F.A.C.O.G. With clinical interests in cervical insufficiency and prenatal diag-

Now offering genetic counseling, WakeMed Physician Practices – Maternal Fetal Medicine can address women’s genetic or hereditary concerns either before conception or during pregnancy and assist patients in determining which, if any screening/testing options fit their particular situation.

nosis, Dr. Mitra brings more than 20 years of

cal degree and master’s degree in public

who have genetic risk

experience in caring

health from UNC-CH.

factors or who have had an abnormal fetal

for women with highrisk pregnancy con-

Jacqueline Muhammad, M.D., F.A.C.O.G.

ultrasound. She works

ditions and their unborn children. Board

Dr. Muhammad’s clinical interests include

closely with patients

certified in obstetrics and gynecology as

infant prematurity, infant

who are experiencing a

well as maternal-fetal medicine, Dr. Mitra

mortality, fetal therapy

high-risk pregnancy, as well as individuals

earned his medical degree from Emory Uni-

and disparities in health

who desire pre- or post-pregnancy consul-

versity School of Medicine in Atlanta and

care. She is dedicated to

tation for genetic concerns or other issues

completed a residency in obstetrics and

improving perinatal out-

that may place a future pregnancy at higher

gynecology and a fellowship in maternal-

comes for underserved

risk for complications. She earned her mas-

fetal medicine at The University of North

women. Board certified in obstetrics and

ter’s degree in human genetics from the

Carolina at Chapel Hill (UNC-CH). Prior to

gynecology and in maternal-fetal medicine,

Medical College of Virginia in Richmond,

joining WakeMed, he spent 20 years with

Dr. Muhammad has an extensive background

Va., and is certified by the American Board

Carolinas Medical Center in Charlotte, N.C.,

in managing high-risk pregnancies. She com-

of Genetic Counseling. Ms. Dickerson’s ca-

where he served as the director of maternal-

pleted her maternal-fetal medicine fellowship

reer is distinguished by several past leader-

fetal medicine for 13 years and director for

at Thomas Jefferson University Hospital in

ship positions with the National Society of

the Center for Cervical Insufficiency.

Philadelphia after earning her medical de-

Genetic Counselors and the Accreditation

gree and completing her residency in ob-

Council for Genetic Counseling.

Carmen Beamon, M.D., F.A.C.O.G.

stetrics and gynecology at the University of

Also board certified in obstetrics and gyne-

Medicine and Dentistry of New Jersey (now

All of WakeMed’s Maternal-Fetal Medicine

cology, with diplomate

Rutgers) Robert Wood Johnson Medical

providers value the ability to work as a part-

status, Dr. Beamon has

School in New Brunswick, N.J.

ner in care, collaborating with the patient and her already-established obstetrician

specific clinical interests in prenatal diag-

Dr. Muhammad, Dr. Mitra and Dr. Beamon

and/or specialist through the provision of

nosis and intervention,

are all members of The American College

genetic counseling, comprehensive prena-

preterm birth preven-

of Obstetricians and Gynecologists and the

tal diagnosis and testing, advanced thera-

Society for Maternal-Fetal Medicine.

pies and consultative recommendations.

medicine fellowship and a residency in ob-

Cheryl Dickerson, M.S., C.G.C.

“In the vast majority of cases, we provide

stetrics and gynecology at UNC-CH, where

Ms. Dickerson, the practice’s certified ge-

diagnostic and consultative services to a

she also served as the administrative chief

netic counselor, has more than 20 years of

patient’s doctor in order to determine the

resident. Dr. Beamon also earned her medi-

experience counseling pregnant women

best treatment options. We also provide

tion and management of high-risk maternal conditions. She completed a maternal-fetal

october 2014

7


additional specialist care on an as-needed basis and, if necessary, we help determine the optimal time for a patient to deliver her baby,” said Dr. Mitra. “Our intention is not to assume responsibility for the entire antenatal care of the patient. Instead, we collaborate and consult with the patient’s physician to help achieve the best possible outcome for both mother and baby.” Advanced Maternal-Fetal Medicine Care WakeMed’s Maternal-Fetal Medicine team provides the highest level of prenatal care by offering comprehensive prenatal diagnosis, surveillance and treatment. For patients with an indication that may increase the risk for a medical condition, birth defect, chromosomal abnormality or inherited condition, genetic counseling is

WakeMed North Women’s Hospital to Open May 2015 10000 Falls of Neuse Road, Raleigh In May 2015, the WakeMed North campus will add a 61-bed women’s hospital, providing state-of-the art, world-class care for patients. WakeMed North Hospital will be the first and only full-service women’s hospital in the area, providing a wide variety of health services for women of every age. A full range of obstetrics and gynecological services will range from general obstetrics to the most sophisticated specialty care. In addition to the physicians, patient care will be supported around the clock by a team of specialty trained obstetricians and gynecologists – known as hospitalists – who are experts in caring for women in a hospital environment.

WakeMed North Women’s Hospital will feature a tranquil environment and amenities tailored to women, such as: • Childbirth facilities – comfortable labor and delivery and C-section rooms • Spacious, family-centered post-partum unit, featuring a dedicated family lounge area and “coaches lounge” • Six-bed Level III Special Care Nursery • Family-friendly emergency services • Dedicated obstetrics triage unit • Diagnostic services and surgery suites • Environmentally friendly (LEED-certified) design

available for tailored risk assessment, review of testing options and supportive care

vical insufficiency. The team is highly-expe-

WakeMed Physician Practices-

throughout the pregnancy. Available pro-

rienced in performing all forms of cervical

Maternal-Fetal Medicine

cedures include comprehensive, targeted

cerclage procedures, including emergent

WakeMed Raleigh Campus

ultrasound CVS, amniocentesis, cordocen-

and transabdominal.

3000 New Bern Avenue Third Floor, Medical Office Building

tesis (PUBS), intrauterine fetal transfusions, and evaluation and surveillance of multiple

Seamless Transition to

gestations.

In-Hospital Care

Raleigh, NC 27610

If the maternal or fetal condition necessi-

WakeMed North Healthplex

tates inpatient management and/or deliv-

Physicians Office Pavilion

ery, WakeMed’s Maternal-Fetal Medicine

10010 Falls of Neuse Road

physicians lead a coordinated care team fo-

Raleigh, NC 27617

cused on keeping both the mother and the baby safe and healthy. They partner with the

For more information, visit www.wakemed-

inpatient WakeMed Obstetrics & Gynecol-

physicians.com or call (919) 350-6002.

ogy team, WakeMed’s nationally recognized Level IV Neonatal Intensive Care Unit, as

Care For the Entire Family –

well as the pediatric surgical subspecialists

Outpatient Services

on staff at WakeMed.

WakeMed’s commitment to caring for families is demonstrated daily through outpa-

Dr. Carmen Beamon provides prenatal counseling for patients managing high-risk pregnancies or who are diagnosed prenatally with fetal abnormalities.

North Raleigh

tient services at WakeMed North Health-

Physicians Office Opens

plex. They include:

For the convenience of patients who live

• 24/7 emergency department

in north Raleigh, a second WakeMed Phy-

• Day surgery

sicians Practices opened at the WakeMed

• Imaging services

North Healthplex Physicians Office Pavil-

• Outpatient lab services

ion early this month. This office is immedi-

• Physical rehabilitation

ately adjacent to WakeMed North Women’s The WakeMed practice also provides com-

Hospital, which is scheduled to open in

prehensive care for patients managing cer-

May 2015.

8

The Triangle Physician

For more information visit www.wakemed.org.


Marketing

Cultivating Your Brand Online By Wendy Coulter

In an increasingly digital world, your

number of calls or patients you get for

website often creates the first impression

every 100 visits to your website).

your patients will have of your business.

• Focus on the unique elements of your

A vital part of your reputation, your online

practice. Health care consumers today

site is ultimately an extension of your

have endless choices, so when building

brick-and-mortar practice, playing a major

your online presence, it’s important

role in whether or not customers want to

to differentiate yourself from your

do business with you. Every aspect of your

competitors.

site – from the words and images to site

• Provide strong content that is useful

functionality – contributes to the overall

and educational to your patients. Every

impression of your medical practice.

medical practice website should have a frequently updated blog with seasonal

Here are a few tips for standing out from

health reminders, healthy lifestyle tips,

the competition:

preventive care information and other resources.

• Website designs should be clean, crisp

• Tell your company story with video.

and well organized. Information should

Consumers

are

looking

for

your

be categorized into distinct topics,

services, and YouTube is the second-

and forms should be easy to find and

largest search engine in the world after

download. Slow sites with confusing

Google. Physician spotlights, health tips

navigation are big turnoffs, and most

or procedure videos are a great way to

people will waste no time moving on to

give potential patients a real-life glimpse into your practice.

another site. • Take the time to cultivate your brand

• Don’t

forget

about

social

media.

image and make sure all collateral

Facebook, LinkedIn, Google+, Twitter

– text, logos, images, photos, linked

and stylized e-newsletters are a vital

brochures, press release boilerplates,

part of your online presence as well as

etc. – have a clear and consistent

an effective way to communicate with

message.

and share your content with current

Wendy Coulter graduated from the School of Design at North Carolina State University with degrees in architecture and industrial design and a minor in communications. She founded Hummingbird Creative Group in 1995, with a desire to put her ideas to work, creatively solving problems for small businesses. Hummingbird Creative Group is an award-winning, full-service branding agency that helps companies define brand strategy, develop sustainable brand messaging and implement marketing tactics through advertising, graphic design, sales enablement, public relations and online marketing services. Awards include “Pinnacle Business Award” from the Raleigh Chamber of Commerce, as well as “Business of the Year,” “Employer of the Year” and “Successful Achievement” awards from the Cary Chamber of Commerce. Ms. Coulter was named a “Top 50 Entrepreneur,” “Woman Extraordinaire,” “Mover and Shaker” and “40 Under 40,” to name a few. She is active in a variety of community and civic endeavors and frequently presents on such topics as branding, marketing, advertising and design.

• Let your potential patients get to know

and potential patients. Tip: Compelling

In short, today’s consumers increasingly

you. People want to know who they’re

headlines and beautiful images or

expect to be able to manage their lives

doing business with. Post high-quality

videos are the best way to capture

online, so be sure your medical website

photos of your team and well-written

attention on social media outlets.

makes a good impression and answers

bios that not only talk about medical

• Offer incentives: Placing offers on online

all the questions your patients may have

specialties and awards, but about

directories, such as CitySearch or Yelp,

about you. Your online content should of-

hobbies and personal interests.

is a great way to attract new patients and

fer potential patients concrete value and

give them a taste of your unique care

showcase how you are uniquely qualified

approach. This doesn’t need to be a

for the solutions they are searching for on

happy

discount, but more of an incentive, like

the web.

patients. Reviews from a third-party site

a free kit or low-priced preventive care

are most effective and can significantly

visit for self-pay patents.

• Include awards, curriculum vitae and medical specialties. • Include

testimonials

from

increase your conversion ratio (i.e., the

october 2014

9


Practice Management

Tips for Marketing Your Practice By Margie Satinsky – Special thanks to colleague Alice Saunders at Trisecta in Raleigh for her contributions to this article.

The options for marketing your practice

Tips for Marketing Effectively

are numerous. This article suggests tips

Direct your efforts to all segments

for marketing effectively and traps to

of your target market. You have

avoid.

the opportunity to market to different groups, including existing patients and

Start at the Beginning

their influencers, potential new patients,

Let’s start with basics. Just what is

medical colleagues in other practices and

marketing? Marketing consultant Peter

your entire workforce.

Drucker calls marketing your “whole firm, taken from the customer’s point of view.”

Existing patients comprise your captive

Taken one step further, marketing means

audience. Ease of making appointments,

“coordinated efforts to communicate with

clarity of instructions prior to a visit or

and persuade customers to purchase,

procedure, provision of a clear treatment

use and repurchase the services that

plan and caring follow-up all impact their

you provide through multiple points

perception of your practice.

of influence.” The American Medical Association describes marketing as the

Pay close attention to marketing in your

process of planning and executing the

waiting area, thinking less about keeping

conception,

and

patients occupied than about educating

distribution of ideas, goods and services

them about the different services you

to create exchanges that satisfy individual

offer. For example, specialty practices

and organizational objectives.

that offer a mix of covered services

pricing,

promotion

and elective procedures have a good Why Bother?

opportunity to inform patients about the

We count at least three good reasons

full range of offerings.

why you should market your practice.

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. quire careful thought and time for feedback and revisions. Up-to-date, customized and easy-to-read information helps build patient trust and facilitates referrals. Track the ways in which patients find you. Ask new patients how they heard about you – e.g., recommendation of another patient, suggestion from an employee, physician recommendation, website. Track the data by age, sex and zip code and reassess your marketing strategy every six months. Make your hard-earned dollars work for you.

First, medicine is competitive, like it or

Potential new patients and medical

not. You’re competing with others in your

colleagues will look carefully at your

specialty, as well as with large health care

website; make sure your message to each

systems. Second, decision-making about

group is clear and that you distinguish

medical care involves patients and those

yourself from competitors. With respect

who influence them (e.g., family, friends,

to your own workforce, if your employees

other health care providers). All need to

respect you and like the work atmosphere,

know what’s special about you. Third,

they’ll give you free positive publicity. If

patients and influencers make decisions

they’re disgruntled, they’ll share those

based not only on the perceived quality

feelings too.

particularly if they are integrated into

such as location, ease of parking, customer

Make print and online information

burdensome.

service, technology and reputation.

look professional. A professional look

of medical care, but also on other factors,

doesn’t need to be costly, but it does re-

10

The Triangle Physician

Regularly assess the experiences of both patients and medical colleagues. Patient perceptions of your scheduling system,

office

comfort,

efficiency,

feedback of results and interaction with employees may surprise you and your workforce. You won’t know if you don’t ask. Patient satisfaction surveys are great, your practice operations and don’t feel

We like the approach of Avance Care,


a primary care practice with multiple

Broaden your goal from getting something

in recent years to curtail search engine

Triangle locations. It asks each patient

up fast to creating a website with sound

spamming techniques that historically al-

to stop briefly at a kiosk on the way out

information architecture, or in layperson’s

lowed vendors to manipulate rankings.

of the practice and answer a short list of

terms, “good bones.” Over time, you want

Clicks on a high-ranking link in Google

questions while the experience of the

to be able to deliver better functionality

may not translate to a conversion to a pa-

office visit is fresh. Ask medical colleagues

and expand content without redoing your

tient who enters your practice door. Use

as well as patients about their perceptions

initial efforts.

a search engine marketing professional who has a good recent track record with

of dealing with you and your staff. Looking and sounding like everyone

other practices, and ask those practices

Take a practical approach to social

else in your specialty. Forget about

how they know that their Google ranking

media. Use social media only in ways

trying to be all things to all people and

is driving new patient acquisition.

that directly, safely and cost-effectively

focus on your uniqueness. For example,

support your marketing objectives and

mention special fellowship training, the

Re-inventing the wheel in the develop-

communications needs. Just because a

frequency with which you perform a

ment of marketing materials and pa-

neighboring practice uses Twitter and

particular procedure, a new procedure in

tient communications. Take time at the

Facebook doesn’t make it right for you.

your community, the depth and warmth

beginning to create comprehensive and

Understand and manage the potential

of patient interaction and ease of making

understandable content about the subjects

risks before you begin, particularly with

an appointment. Ask patients and medical

that are important to you. Over time, refine,

respect to HIPAA privacy and security

colleagues for written permission to use

but don’t necessarily rewrite all that you

rule requirements.

their comments as testimonials.

have. Retain your primary source documents, so you can easily go back for more

Blogging can be useful for both marketing

Misunderstanding your Google rank-

and patient communication. For example,

ing. Google has made many changes

as you enhance what you do.

a primary care physician might start a blog with brief tips for managing a chronic condition. The effort has the potential to

what we call the potshot approach. A well-

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.

planned and carefully executed marketing

919.929.7990

www.drossmangastroenterology.com

better inform existing patients, attract new patients and help improve patient outcomes. Effective blogging takes time, effort, talent and clearly defined goals. Traps to Avoid Taking

potshots

with

marketing

strategy and budget. Many practices allocate marketing dollars according to the medium (e.g., website, print, outreach) –

Drossman Gastroenterology

strategy may deliver better results. Who do you want to reach and what message do you want to deliver? Can you track the effectiveness of what you are doing? Saving a buck by hiring a relative to do your website unless… that individual is

experienced

in

developing

and

maintaining professional websites using industry-standard

development

tools

and is committed to providing the timely ongoing support that requires.

october 2014

11


Dermatology

Medical Sleuthing:

Differential Diagnoses By Eric Challgren, M.D.

Even the simplest rash has the potential

ably analytical. When a patient comes to

for signaling a serious health issue. This is

me with something as common as acne,

why dermatologists are trained, day after

for example, I of course want to offer help-

day, case after case, in the art and science

ful treatment. But I am also intrigued by

of differential diagnosis. Ever alert, a der-

the cause of these skin conditions I see ev-

matologist inspecting potential skin can-

ery day. Is this simply teenage acne, or is

cer or something as common as atopic

there something else going on? Are heavy

dermatitis will have a half-dozen or more

cosmetics causing occlusive acne or is

diagnosis possibilities come to mind in

an athlete using anabolic steroids? These

rapid succession. You can almost hear a

causes and triggers will run through our

clicking noise in their heads as they check

heads as possibilities if the situation fits.

off the possibilities.

Eric Challgren graduated from North Carolina State University with a bachelor of science degree in chemical engineering. He earned his medical degree from the Medical College of Ohio and completed his dermatology internship at Medical College of Ohio and residency at the Medical College of Wisconsin.

Another example of a skin problem with The thought process behind differential

multiple causes is eczema, which often

diagnosis works much like that of a detec-

improves as a child ages. Often, by late

tive. Using clues drawn from symptoms,

adolescence or early adulthood, it clears

medical tests, medical and family history

up entirely, although there’s a tendency

and a physical exam, a list is made of all

for the skin of these patients to continue

the possible diagnoses. Then, one by one,

to be sensitive and easily irritated. This

the list will be narrowed down by the clues

skin condition is typically red, blistering,

that don’t fit. This process of elimination is

itchy or oozing, and you can be sure that

called “differential diagnosis.” Ultimately,

high on the differential diagnosis list will

the outcome is an accurate diagnosis.

be the term “atopic dermatitis.”

There are, in fact, many paths to the

A thorough medical history involving ques-

same destination. In terms

tions about allergic diseases in the family,

of diagnosing illness,

problems, such as hay fever or asthma, al-

my pathway is

lergic reactions to foods, sleep problems,

invari-

questions on medications, recent illnesses, immune status and much more will be un-

Dr. Challgren is a fellow of the American Society for Mohs Surgery and a member of the American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Academy of Dermatology, American Medical Association, and North Carolina Medical Association. Areas of special interest include Mohs surgery, pediatric dermatology, dermatologic surgery, cosmetic dermatology and skin cancer. Dr. Challgren works at Southern Dermatology & Skin Cancer Center 4201 Lake Boone Trail, Suite 200 Raleigh, NC 27607.

dertaken. But ultimately, it’s the process of elimination that will play the big-

The art of seeing clearly what others may

gest part in coming up with

miss is a crucial factor in the life of a der-

the correct diagnoses.

matologist. In the case of skin cancer, early detection can save a life. It takes a very well-trained eye to diagnose quickly and give the patient the greatest chance for effective treatment. Luckily, these days there are excellent treatment options, and many chronic skin conditions can be wellmanaged, if not cured.

12

The Triangle Physician


Gasatroenterology

Understanding the Low

FODMAP Diet By Kellie Bunn P.A.-C.

Patients with irritable bowel syndrome

leading to increased water content of

often describe food as a significant

the stool and associated complaints of

trigger for flares of their gastrointestinal

diarrhea.

symptoms. They often associate specific food choices and alterations in stool

FODMAPs can be found in a variety of

frequency, consistency or abdominal pain.

common foods. The FODMAP family includes:

These dietary changes are not typically

•F  ructose, which is found in many

completed in a systematic way that

fruits (apple, mango and pear) and

would allow for appropriate correlation

sweeteners.

of specific foods and symptoms. Thus patients often find themselves confused and frustrated as to what foods are “safe” for them, and many patients unduly restrict

•F  ructans, which are found in wheat and some vegetables (broccoli, asparagus, cabbage and onions). •L  actose, which is found in dairy

their diet excessively. They often look to

products, like milk and soft cheeses.

their providers for guidance in their quest

•G  alacto-oligosaccharides, which are

to determine their IBS “trigger” foods.

found in legumes. •P  olyols, which are found in sweeteners

There has been little evidence to support

ending in “-ol,” such as sorbitol and

the use of dietary management for irritable

mannitol.

Kellie Bunn PA-C graduated from the University of North Carolina at Chapel Hill with a degree in Biology before training at the Duke University Physician Assistant Program. She earned a degree of Master of Health Sciences and was inducted in Pi Alpha, the national honor society for physician assistants.  She is currently a member of the American Academy of Physician Assistants, North Carolina Academy of Physician Assistants, and the North Carolina Medical Society. Kellie has worked with Dr. Douglas Drossman at Drossman Gastroenterology PLLC for over a year and is well trained in the care of patients with functional GI disorders.

The goal is to first eliminate all FODMAPS

bowel syndrome (IBS) symptoms until a

and

2014 article in Gastroenterology. This article

FODMAP foods can be added back into

discusses a controlled, cross-over study of

a low-FODMAP diet without triggering

patients with IBS who were placed on

then

determine

which

high-

symptoms. Providers may want to

a diet low in fermentable oligosac-

consider a referral to a dietician

charides, disaccharides, mono-

who specializes in this specific

saccharides and polyols (FOD-

diet.

MAPs). The study was able to

recommend a full FODMAP

The

dietician

may

show a statistically significant

elimination diet for two to four

reduction in their functional gas-

weeks, followed by a series of

trointestinal symptoms, including

food challenges. During these

bloating, pain and loose stool con-

challenges, the patient carefully

sistency with implementation of a low-

observes symptoms, as they reintroduce

FODMAP diet.

specific high-FODMAP foods.

FODMAP foods are poorly absorbed in

Getting started with a low-FODMAP diet

Resource

the small bowel and thus are fermented by

can be a difficult task for patients. Though

Emma P. Halmos, Victoria A. Power, Susan

bacteria. The fermentation produces gas,

the diet initially calls for avoidance of all

J. Shepherd, Peter R. Gibson, and Jane G.

which then provokes cramping and pain

high-FODMAP foods, some patients may

Muir; A Diet Low in FODMAPs Reduces

in IBS patients who are sensitive to luminal

tolerate some high-FODMAP foods without

Symptoms of Irritable Bowel Syndrome;

distension

experiencing associated symptoms.

Gastroenterology 2014;146:67–75

(visceral

hypersensitivity).

FODMAPs are also osmotically active,

october 2014

13


Women’s Health

Infertility:

Its Causes, Treatments and Screening for Abnormalities By Lindsay Wojciechowski

Bearing children is considered a rite of

Health-related issues can include hormon-

passage that is highly valued by cultures

al imbalances, sexually transmitted infec-

all over the world, and as a result, not be-

tions, chronic disease, etc.

ing able to bear children can cause significant stress both in individuals and on

Lifestyle factors like smoking, obesity,

relationships. Paradoxically, most couples

excessive weight loss, aging, stress, use

take their fertility for granted. Many are sur-

of anabolic steroids and other drugs may

prised when infertility is recognized, while

cause infertility.

in reality, one couple in six has a problem

Lindsay A. Wojciechowski is a nurse practitioner and consultant to the Women’s Wellness Clinic and the Carolina Women’s Research and Wellness Center (CWRWC). She has worked as a clinical nurse practitioner for Triangle Family Practice at Duke University Medical Center since 2006. She also has taught courses at the Duke University School of Nursing. Ms. Wojciechowski’s focus is on women’s health and family medicine, and she also is the lead medical writer for the Women’s Wellness Clinic.

that requires assistance. Navigating the op-

However, all attempts to categorize these

timal path of diagnostic testing and treat-

issues are somewhat artificial due to the

ments for a couple requires a highly per-

overlap and interrelationships that exist

sonal and individualized approach.

between them.

Causes of Infertility

Fertility Treatments

Infertility is defined as not being able to

The most comprehensive fertility treatment

conceive after one year of unprotected

is in vitro fertilization – also known as IVF.

sex. However, all humans are relatively

IVF essentially fixes every problem that we

sperm either by culturing sperm and

inefficient at reproduction and figuring

know how to fix by controlling the meeting

eggs together or by inserting one sperm

out if and where a problem exists can be

of the sperm and the eggs and early

into each mature egg through a process

challenging. It is relatively common for

embryo development, as well as ensuring

called intracytoplasmic sperm injection

both men and women to have issues that

that the embryos get into the uterine cavity

(ICSI). The fertilized eggs are then kept

lower the probability of becoming parents.

where they can implant.

in an incubator for three to six days before transfer. Culturing to the expanded

One way to categorize some of these issues

IVF is a five-step process, briefly outlined as:

blastocyst stage on Day 5 or Day 6 in-

is to think of them in terms of anatomy,

1. Ovulation induction: Prior to IVF, the

creases pregnancy rates, because many

woman takes a series of medications

human embryos arrest at an important

that are designed to stimulate the

stage of development, called gene acti-

environment, health and lifestyle.

vation that occurs on culture Day 4.

Examples of the physical issues associated

recruitment of several healthy eggs.

with fertility on the macroscopic level are

Because sperm, eggs and early embryos

4. Embryo transfer: After five to six days

blocked ducts (fallopian tubes in women

can make mistakes in cell division,

in culture, the fertilized eggs are placed

and vas deferens in men), ovarian cysts,

starting with more than one egg and

into the womb or vitrified (frozen) for

uterine fibroids, etc. On the microscopic

embryo increases the probability of

later transfer.

level, there can be problems with sperm,

success.

eggs, genetics, etc.

2. E  gg retrieval: Once a cohort of mature

Screening for Genetic

eggs develops, the woman is sedated

Abnormalities in Embryos

Environmental causes of infertility may

with intravenous medications and her

Not all embryos that develop to the

include rare exposures to environmental

eggs are harvested through a brief

expanded blastocyst stage of development

hazards, such as heavy metals or more

outpatient procedure.

will result in a positive pregnancy test.

commonly known exposures to medical

3. I nsemination and culture: An em-

One of the primary reasons for this is that

treatments that have known adverse

bryologist finds the mature eggs in the

eggs and early embryos frequently make

reproductive consequences.

harvested fluid and introduces them to

mistakes in cell division that are lethal.

14

The Triangle Physician


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october 2014

15


Duke Research News

Insight on Ancient Plague Could Lead to New Treatments for Infections As dangerous new pathogens, such as the

use to spread so that we can be prepared with

Ebola virus, invoke scary scenarios of deadly

new strategies to treat infection.”

a safe haven for microbial multiplication.” The bacteria are then able to travel from

epidemics, ancient scourges, such as the bubonic plague, are providing researchers

While bubonic plague would seem a blight

lymph node to lymph node within the

with new insights on how the body responds

of the past, there have been recent outbreaks

dendritic cells and monocytes, eventually

to infections.

in India, Madagascar and the Congo. And

infiltrating the blood and lungs. From there,

it’s mode of infection now appears similar

the infection can spread through body fluids

In a study published online Sept. 18 in the

to that used by other well-adapted human

directly to other people or via biting insects,

journal Immunity, researchers at Duke

pathogens, such as the HIV virus.

such as fleas.

of Singapore) Graduate Medical School

In their study, the Duke and Duke-NUS

Drs. Abraham and St. John and colleagues

Singapore detail how the Yersinia pestis

researchers set out to determine whether the

note that there are several potential drug

bacteria that cause bubonic plague hitchhike

large swellings that are the signature feature of

candidates that target the trafficking pathways

on immune cells in the lymph nodes and

bubonic plague – the swollen lymph nodes,

that the bubonic plague bacteria use. In

eventually ride into the lungs and the

or buboes at the neck, underarms and groins

animal models, the researchers successfully

blood stream, where the infection is easily

of infected patients – result from the pathogen

used some of these therapies to prevent the

transmitted to others.

or as an immune response.

bacteria from reaching systemic infection,

The insight provides a new avenue to develop

It turns out to be both.

Medicine and Duke-NUS (National University

markedly improving survival and recovery. “This work demonstrates that it may be pos-

therapies that block this host immune function rather than target the pathogens themselves –

“The bacteria actually turn the immune cells

sible to target the trafficking of host immune

a tactic that often leads to antibiotic resistance.

against the body,” said senior author Soman

cells and not the pathogens themselves to ef-

Abraham, Ph.D. a professor of pathology at

fectively treat infection and reduce mortality,”

“The recent Ebola outbreak has shown

Duke and professor of emerging infectious

Dr. St. John said. “In view of the growing emer-

how highly virulent pathogens can spread

diseases at Duke-NUS. “The bacteria enter the

gency of multi-resistant bacteria, this strategy

substantially and unexpectedly under the

draining lymph node and actually hide unde-

could become very attractive.”

right conditions,” said lead author Ashley L.

tected in immune cells, notably the dendritic

St. John, Ph.D., assistant professor, Program

cells and monocytes, where they multiply.

In addition to Drs. Abraham and St. John,

in Emerging Infectious Diseases at Duke-NUS

Meanwhile, the immune cells send signals

study authors include W. X. Gladys Ang, Min-

Singapore. “This emphasizes that we need to

to bring in even more recruits, causing the

Nung Huang, Christian Kunder, Elizabeth W.

understand the mechanisms that pathogens

lymph nodes to grow massively and providing

Chan, and Michael D. Gunn.

Gene Interacts With Stress and Leads to Heart Disease in Some People A new genetic finding from Duke Medicine

netic susceptibility, and knowing this could

tor of computational biology at the Duke

suggests that some people who are prone

help them reduce heart disease with sim-

Molecular Physiology Institute. Dr. Hauser

to hostility, anxiety and depression might

ple interventions, such as a healthy diet,

is senior author of a study detailing the

also be hard-wired to gain weight when ex-

exercise and stress management.

findings in the Oct. 1 online issue of the European Journal of Human Genetics.

posed to chronic stress, leading to diabetes and heart disease.

“Genetic susceptibility, psychosocial stress and metabolic factors act in combination

Dr. Hauser and colleagues analyzed ge-

An estimated 13 percent of people, all of

to increase the risk of cardiovascular dis-

nome-wide association data from nearly

whom are Caucasian, might carry the ge-

ease,” said Elizabeth Hauser, Ph.D., direc-

6,000 people enrolled in the Multi-Ethnic

16

The Triangle Physician


Duke Research News Study of Atherosclerosis (MESA). The MESA

Further studies will focus on additional ge-

could reduce disease risk.”

study began in 2000 to better understand

netic factors and why there might be differ-

how heart disease starts, compiling the par-

ences in the genetic factors among racial/

In addition to Drs. Hauser, Singh and Wil-

ticipants’ genetic makeup, as well as physi-

ethnic groups, including African-Ameri-

liams, study authors include Michael A.

cal traits, such as hip circumference, body

cans, Hispanics and Asians.

Babyak, Daniel K. Nolan, Beverly H. Brummett, Rong Jiang, Ilene C. Siegler, William

mass index, cholesterol readings, glucose levels, blood pressure and other measures.

“We need to figure out how these genetic

E. Kraus, and Svati H. Shah.

factors influence the increased accumulaIn the Duke analysis, the researchers first

tion of fat in the central body and increased

The National Heart, Lung, and Blood In-

pinpointed a strong correlation between par-

blood glucose levels in persons exposed to

stitute provided grant support (HL095987,

ticipants who reported high levels of chronic

high life stress and why there are also dif-

HL073389-01 and HL036587). Data were ob-

life stress factors and increased central obe-

ferences with ethnicity,” Dr. Hauser said.

tained from the National Institutes of Health

sity, as measured by hip circumference.

“This knowledge could help identify targets

database of Genotypes and Phenotypes.

for behavioral and drug interventions that They then tested genetic variations across the genome to see which ones, in combination with stress, seemed to have the biggest influence on hip circumference. It turns out that variations called single-nucleotide polymorphisms (SNPs) in the EBF1 gene showed a strong relationship with hip circumference, depending on levels of chronic psychosocial stress, according to a Duke press advisory. What’s more, among those with this particular genotype, hips grew wider as stress levels increased. “With further analysis, we found a significant pathway from high chronic life stress to wide hip circumference, to high blood glucose and diabetes, to increased cardiovascular disease, notably atherosclerosis,” said Abanish Singh, Ph.D., a researcher in computational biology at Duke and the study’s lead author. “But we found this only in people who were carriers of the EBF1 single-nucleotide polymorphism, and this was limited to participants who were white.” The researchers reproduced their findings using data from another study, the Framingham Offspring Cohort. “These findings suggest that a stress reduction intervention, along with diet and exercise, could reduce the risk of cardiovascular disease and may be most effective in individuals with this specific genotype,” said Redford Williams, M.D., one of the study’s senior authors and director of Duke’s Behavioral Medicine Research Center.

Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

october 2014

17


UNC News

First-in-Kind Study Hopes to Fill Knowledge Gaps about Sexual Assault One in five women in the United States experience sexual assault during their lifetime, yet little is known about the experiences and health Samuel McLean, outcomes of sexual M.D., M.P.H. assault survivors. A new study seeks to change that. The study is the first large-scale effort to longitudinally evaluate health outcomes after sexual assault. Nine hundred female sexual assault survivors from around the nation will be enrolled at the time that they present for emergency care. Study participants will then be followed for one year and interviewed over time to better understand their physical and mental health during the recovery process, as well as their experiences with law enforcement, the legal system and the medical system. The study will be based at the University of North Carolina School of Medicine. Samuel McLean, M.D., M.P.H., director of the TRYUMPH Research Program in the UNC Department of Anesthesiology,

is the principal investigator of the study. “There have been thousands of longitudinal studies of patient experiences and health outcomes after other common traumatic events, such as car accidents, but no such studies of sexual assault survivors have been performed,” Dr. McLean said. “Our goal is to give sexual assault survivors a voice and learn from them about what is working with our legal and health care responses and what isn’t.” Another important goal of the study is to learn about any physical symptoms that develop after sexual assault. “It is commonly understood that some women experience adverse psychological outcomes, such as posttraumatic stress disorder, after sexual assault,” said Dr. McLean. “Evidence suggests that some women also develop symptoms such as fatigue and pain, but we know very little about when or how this occurs. More information about such outcomes is urgently needed.” This type of information is important, because while medical advances dur-

ing recent decades have revolutionized the care of many trauma survivors, little progress has been made in the types of treatments available to survivors of sexual assault. “A woman sexually assaulted in 1970 would receive risk stratification and treatment to prevent sexually transmitted diseases and sexual assault,” said Dr. McLean “More than 40 years later, the types of preventive interventions that we can offer haven’t changed. No treatments are available to prevent other adverse physical and mental health outcomes, despite the fact that such outcomes appear to be common, may well be very treatable or preventable.” This study is being funded by a consortium of six National Institutes of Health institutes and centers: the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute of Neurologic Diseases and Stroke, the National Institute of Mental Health, the Office of the NIH Director, the National Institute of Nursing Research and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Award Is Nation’s Highest Honor for Supporting Guard, Reserve Employees UNC Health Care is one of 15 recipients of the 2014 Secretary of Defense Employer Support Freedom Award, the highest recognition given to employers for exceptional support of Guard and Reserve employees. UNC Health Care was selected for several reasons, including: • UNC Health Care employees volunteered to maintain a military couple’s

18

The Triangle Physician

house while both were deployed and actively took on extra work responsibilities to support the service of their colleagues. • The health system recognizes veteran employees and actively recruits military members and their spouses for employment. • UNC Health Care is currently developing a master’s degree physician assistant (PA) program for veteran medics

to continue their medical careers after leaving the military. The plan to establish a PA master’s degree program at UNC Chapel Hill was announced in December 2012. Blue Cross and Blue Shield of North Carolina and the UNC School of Medicine, with input from United States Army Special Forces Command, developed a plan for a program that could provide a pathway for U.S.


UNC Research News ognizing these 15 exceptional employers, the Department of Defense celebrates the contributions made by American employers to our ‘citizen warriors’. I commend these extraordinary employers for their unwavering commitment to service members and their families.” The Freedom Award was instituted in 1996 under the auspices of Employer Support of the Guard and Reserve (ESGR) to recognize exceptional support from the employer community. In the years since, 190 employers have been honored with the award. To learn more about ESGR, visit www.ESGR.mil. From left, Defense Secretary Chuck Hagel, Timothy M. Weiner, M.D., and UNC Hospitals President Gary Park meet at the Pentagon in Washington, D.C., with the Secretary of Defense Employer Support Freedom Award. (U.S. Army photo by Alfredo Barraza).

Army Special Forces medical sergeants to translate the skills and expertise gained through military service into a civilian career. The new PA program assists military veterans while also helping to meet the growing need for highly trained health care professionals in North Carolina. “We are deeply honored to be selected for this (Freedom) award,” said Timothy M. Weiner, M.D., a pediatric surgeon at UNC Health Care and a Navy Reserve Commander in 4th Medical Battalion, Detachment 2. “As a member of the Navy Reserve myself, I am very proud of the support that UNC Health Care provides to our many National Guard and Reserve employees.” This year’s Freedom Award recipients were selected from 2,864 nominations received from guardsmen and reservists for going far beyond what the federal law requires to support their military employees. The award is presented by Employer Support of the Guard and Reserve, a Department of Defense office. “Guardsmen and reservists across the nation rely on strong bonds with their civilian employers,” said Defense Secretary Charles Timothy “Chuck” Hagel. “By rec

october 2014

19


WakeMed News

Three Leading Health Systems to Form Company that will Share and Economize Three health systems in North Carolina will be working together to improve quality and affordability for patients across the state. Vidant Health in Greenville, Wake Forest Baptist Medical Center in WinstonSalem and WakeMed Health & Hospitals in Raleigh are forming a shared services operating company that will allow the organizations to gain benefits of scale while maintaining current governance and independence. This relationship will not include a merger or acquisition of organizations, according to a WakeMed press advisory. This unique relationship came about because the individual health care systems share similar missions, visions, values and strategic focus. Leaders from all three systems “are confident success will come from partnering with other like-minded health care organizations to provide enhanced access and high quality, affordable health care to patients and consumers,” the advisory said.

This innovative model provides support for health care reform initiatives − including Accountable Care Organization development and implementation and care coordination for population health − and creates business and clinical efficiencies. Services ranging from supply chain to select IT infrastructure to clinical protocols will be available by the new company to its member institutions. “By joining together in this shared services company, we are able to take advantage of the collective talents of all of the members and have the opportunity to invest more in the care of our patients,” said David C. Herman, M.D., president and chief executive officer of Vidant Health. The new company, which will be named in the near future, will assist in meeting the challenges posed by declining Medicare/ Medicaid reimbursement and technological changes while creating a platform for innovation and enhanced clinical care for patients.

“These three organizations have joined resources to more quickly innovate care models and support infrastructure that reduce cost and best meet the needs of the diverse patient, consumer and workforce populations that we serve throughout the state,” said John D. McConnell, M.D., chief executive officer, Wake Forest Baptist Medical Center. All three organizations’ boards have approved moving forward with creating a shared services organization as a key strategy for improving all of the health systems’ efficiencies and value. “This new collaborative fits perfectly with our mission and goals of seeking preferred partners to deliver an exceptional level of health care service while leveraging our structures and technological resources,” said Donald Gintzig, president and CEO of WakeMed Health & Hospitals. “We want to deliver the best value to our state’s citizens and do so in a cost-effective manner that is beneficial for all.”

News

Nurses Named to the “Great 100” across the state. Ms. Pritchett, along with 99 other registered nurses, was selected on the basis of outstanding professional ability and commitment to improving health care.

Robin Pritchett, R.N., with WakeMed Health & Hospitals, has been selected as one of The Great 100 Nurses in North Carolina by The Great 100 Inc., an organization that recognizes nursing excellence and provides scholarships to nursing students

20

The Triangle Physician

Pritchett, who wanted to be a nurse for as long as she can remember, has over 30 years of experience, including 14 years at WakeMed. She has spent the past four years as a staff nurse in WakeMed’s Chest Pain Unit where she is involved in the staff unit council and has served on several hospital-wide committees.

The following nurses from throughout the Triangle medical community also were selected among The Great 100 Nurses. University of North Carolina - Donna Balint, Rex Healthcare - Elaine Javellana, UNC Hospitals - Laurey Munch, UNC Hospitals Duke University Hospital - Taylor Honeycutt - Laura Dickerson - Melissa “Missy” Moreda - Cheryl Thaxton Wake Forest Baptist Medical Center - Kathleen Nelson - Mechelle Mumford


News Welcome to the Area

Physicians

Andrew Jacob Lobonc, MD

Adam Gregory Wolk, MD

Karina Jordan, PA

Jonathan Gilbert Martin, MD

Anesthesiology - Pain Medicine

Internal Medicine

Family Medicine

UNC Hospitals Chapel Hill

Alignment Healthcare Raleigh

4130 Garrett Road Durham

Sunil Ramakrishnan Iyer, MD

Lee Daniel Baylis, MD

Phillip Bernhard Lee, PA

Cardiology

Allergy and Immunology

Surgery

UNC Hospitals Chapel Hill

2126 Roland Glen Rd Cary

1533 Ellis Road Durham

William Sprunt Stoudemire, MD

Kristalyn Kay Gallagher, DO

Amanda Eileen McGiveron, PA

Diagnostic Radiology

Duke University Hospitals Durham Dustin Stephen Morrow, MD Emergency Medicine

Duke University Hospitals Durham Sana Arif, MD Infectious Diseases, Internal Medicine

Duke University Medical Center Durham Farhat Ghaznawi, MD Pediatric Hematology-Oncology

Duke University Hospitals Durham Nicholas Hayden Tinkham, MD Anesthesiology

Duke University Hospitals Durham Nicholas Thomas Befera, MD Radiology

Duke University Hospitals Durham Sundhar Ramalingam, MD Hematology and Oncology, Internal Medicine

Pediatrics

UNC Dept of Surgery, Division of Surgical Oncology Chapel Hill

UNC Hospitals Chapel Hill Taylor John Brueseke, MD Obstetrics & Gynecologic Surgery

UNC Hospitals Chapel Hill

Emergency Medicine

Nathan David Montgomery, MD Anatomic and Clinical Pathology

UNC Hospitals Chapel Hill Anatomic and Clinical Pathology

UNC Hospitals Chapel Hill

Kristen Virginia Dicks, MD

Concentra Raleigh

Family Medicine

Brian Nathan Boone, MD

Linda Carime Cendales, MD Plastic Surgery/Hand Surgery

Mann ENT Cary

Duke University Durham

John Louis Gentri, MD

Warren Charles Johnson III, MD Pediatrics

8809 Macedonia Lake Dr Cary

Health Pavilion Hoke Raeford

Rildia Jones Pritchett, MD

Mir Mustafa Ali, MD

103 Richelieu Drive Cary

Otorhinolaryngology

Internal Medicine

Gynecology

Hospitalist

1028 Oberlin Rd Raleigh

Albert Terry Simeone Jr, PA Thoracic Cardiovascular Surgery

Candy Hsin-Chieh Chen, PA Endocrinology, Internal Medicine

Kristina Marie Eilbacher, PA

1500 Duke University Rd Durham Kina Smith, PA General Practice

Duke University Hospital Durham

James S. Coxe III MD PA dba Capital Endocrinology Consultants Raleigh

Janelle Goodreau, PA

Jenna Lynn Staples, PA

Neurological Surgery

Family Medicine

Neurological Surgery

Duke University Hospitals Durham

Caitlin Moyer, PA

300 West Hargett St Raleigh

Physician Assistants Creedmoor Centre Endocrinology Raleigh

Spencer Louis Rusin, MD

First Care Medical Clinic Monroe

Pediatrics

Emergency Medicine

UNC Hospitals Chapel Hill

General Practice

Rachel Ortiz Serrano, PA

Katie Elizabeth Hughes, MD

Nilay Chuni Patel, DO

Pulmonary Disease and Critical Care, Internal Medicine

Timothy Laeger Laeger, MD Nash General Hospital Rocky Mount

Duke University Hospitals Durham Infectious Diseases, Internal Medicine

Surgical Oncology

Duke University Medical Center Durham

Lincoln Community Health Center Durham

Rachael Lynn Hadley, PA

Anna Blair Strandberg, PA Family Medicine

Thoracic Surgery

201 Park at North Hills St Raleigh

141 Steeplechase Rd Rocky Mount

Odinaka Gabriella Idada, PA

Kelsey Marie Walch, PA

Family Medicine

Family Medicine

4923 Cedar Glen Dr. Durham

Piedmont Health Services Inc Carrboro

Travis Allen Johnson, PA

Robert Louis Wheeler, PA

Family Medicine

Orthopedic Surgery

118 Hollow Oak Dr Durham

125 Doral Dr Pinehurst

Smithfield Pulmonology, PA Smithfield Brian Faustino Baigorri, MD Vascular and Interventional Radiology

Department of Radiology Chapel Hill Christopher Webster Howard, MD Anesthesiology

UNC Hospitals Chapel Hill Lee Elizabeth Victoria Morris, MD Pediatric Infectious Diseases

113 Cobblestone Drive Chapel Hill William Randall Adam Carter, MD Emergency Medicine

UNC Hospitals Chapel Hill Paul Diegidio, MD Surgery

UNC Plastic Surgery Chapel Hill

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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.

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Trianglephy oct14 proof3  

The Triangle Physician October 2014

Trianglephy oct14 proof3  

The Triangle Physician October 2014

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