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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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
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.
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
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
Nurses Named to the “Great 100”
- Welcome to the Area
Kellie Bunn reports on recent evidence that supports dietary management for irritable bowel syndrome.
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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 firstname.lastname@example.org 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 email@example.com
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 firstname.lastname@example.org
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
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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.
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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
The Triangle Physician
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www.kendallmurphyphotography.com email@example.com Maternity
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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.
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
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
cedures include comprehensive, targeted
cerclage procedures, including emergent
WakeMed Raleigh Campus
ultrasound CVS, amniocentesis, cordocen-
3000 New Bern Avenue Third Floor, Medical Office Building
tesis (PUBS), intrauterine fetal transfusions, and evaluation and surveillance of multiple
Seamless Transition to
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
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.
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-
The Triangle Physician
For more information visit www.wakemed.org.
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
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,
preventive care information and other resources.
• Website designs should be clean, crisp
• Tell your company story with video.
and well organized. Information should
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
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
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
discount, but more of an incentive, like
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
increase your conversion ratio (i.e., the
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
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
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
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
particularly if they are integrated into
such as location, ease of parking, customer
Make print and online information
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-
The Triangle Physician
Regularly assess the experiences of both patients and medical colleagues. Patient perceptions of your scheduling system,
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
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
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
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
strategy and budget. Many practices allocate marketing dollars according to the medium (e.g., website, print, outreach) –
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
maintaining professional websites using industry-standard
and is committed to providing the timely ongoing support that requires.
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,
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.
The Triangle Physician
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
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
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
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
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
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-
MAPs). The study was able to
recommend a full FODMAP
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
specific high-FODMAP foods.
FODMAP foods are poorly absorbed in
Getting started with a low-FODMAP diet
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;
experiencing associated symptoms.
FODMAPs are also osmotically active,
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
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.
Causes of Infertility
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
level, there can be problems with sperm,
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
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
harvested fluid and introduces them to
mistakes in cell division that are lethal.
The Triangle Physician
These mistakes occur more frequently in women as they age. Error in embryo cell division can be
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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
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
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
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
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
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.”
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
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
Andrew Jacob Lobonc, MD
Adam Gregory Wolk, MD
Karina Jordan, PA
Jonathan Gilbert Martin, MD
Anesthesiology - Pain Medicine
UNC Hospitals Chapel Hill
Alignment Healthcare Raleigh
4130 Garrett Road Durham
Sunil Ramakrishnan Iyer, MD
Lee Daniel Baylis, MD
Phillip Bernhard Lee, PA
Allergy and Immunology
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
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
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
Nathan David Montgomery, MD Anatomic and Clinical Pathology
UNC Hospitals Chapel Hill Anatomic and Clinical Pathology
UNC Hospitals Chapel Hill
Kristen Virginia Dicks, MD
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
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
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
UNC Hospitals Chapel Hill
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
Duke University Medical Center Durham
Lincoln Community Health Center Durham
Rachael Lynn Hadley, PA
Anna Blair Strandberg, PA Family Medicine
201 Park at North Hills St Raleigh
141 Steeplechase Rd Rocky Mount
Odinaka Gabriella Idada, PA
Kelsey Marie Walch, PA
4923 Cedar Glen Dr. Durham
Piedmont Health Services Inc Carrboro
Travis Allen Johnson, PA
Robert Louis Wheeler, PA
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
However much you value wildlife conservation in North Carolina,
Thatâ€™s right! Your conservation effort is increased by a 3-to-1 matching gift. So, when you are one of the first to display the new North Carolina Wildlife Habitat Foundation NCDMV license tag, your $10 tag contribution to the organization becomes $40 in lands preserved. The all-volunteer North Carolina Wildlife fe Habitat Foundation assists in acquisition, on, management, and protection of land in North Carolina for the conservation of habitats needed to preserve wildlife
right here in the Old North State. Conservation education efforts are preparing future generations to sustain your concern for the lands we protect today. At www.ncwhf.org, download the license tag application and see the good works in process. pp Your new tag shows your support and your n contribution is put to workâ€Śtimes four. co
3D MAMMOGRAPHY WE’RE TALKING WAY BETTER IMAGING, EARLIER DETECTION, FEWER FALSE POSITIVES AND LESS CHANCE OF A CALL BACK. END OF DISCUSSION.
3D MAMMOGRAPHY • GREATER ACCURACY • REDUCED ANXIETY • NOW AT WAKE RADIOLOGY Let’s have a frank discussion. You can’t treat what you can’t detect. And 3D mammography, along with your regular 2D exam, is revolutionizing breast cancer detection. How? By significantly improving clarity for earlier detection and fewer false positives. Which, of course, reduces recall rates and the anxiety that comes with additional tests. To learn more about 3D mammography or to schedule an appointment, visit wakerad.com. Like we said, you can’t treat what you can’t see. And now we’re seeing better than ever. Wake Radiology | North Hills Breast Center | 919-232-4700 | wakerad.com Daily, evening and Saturday appointments | 20 minutes from check-in to exam completion
The Triangle Physician October 2014