s e p t e m b e r 2 015
Tolnitch Surgical Associates Nipple-Preserving Expertise Leads to Better Outcomes, Greater Satisfaction
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Table of Contents
Tolnitch Surgical Associates Nipple-Preserving Expertise Leads to Better Outcomes, Greater Satisfaction o c to b e r 2 0 15
Vol. 6, Issue 9
DEPARTMENTS 9 Practice Marketing
20 Powerful Reasons to Brand Your Practice: Part 1
12 Womenâ€™s Health
Thyroid Disease and Pregnancy
George Stamataros reviews critical thyroid distur-
14 Practice Management
bances that can lead to pregnancy complications, their diagnosis and treatments.
AID Takes Aim at Physician Burnout Marni Jameson shares physician frustrations and that joining a unified, nationwide voice is a solution.
The Triangle Physician
New Options for Losing Weight
Physician Role in Practice Management
18 Duke Research News
Model Shows Meningitisâ€™s Creep into the Brain of Transparent Zebrafish
19 UNC Research News
Study Shows Affect of Diabetes Drug on Bone Health and Benefit of Exercise
20 UNC News
Web-based Calculator Helps Providers Better Counsel on Prenatal Screening On the Cover: Meet the breast surgeons at Tolnitch Surgical Associates (from left): Gayle Ackerman DiLalla, M.D., F.A.C.S.; Laura Lazarus M.D., F.A.C.S.; and Lisa Tolnitch M.D., F.A.C.S.
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From the Editor
Knowns and Unknowns Breast conservation advances have led to a surge in nipple-sparing mastectomies because of improved cosmesis. But why aren’t all breast cancer patients candidates? Tolnitch Surgical Associates shares its breast surgery expertise in this month’s cover story, by bringing to the forefront the complex considerations to be weighed in appropriate patient selection. Endocrinologist George Stamataros of Carolina Endocrine is a new contributing editor. This month, he discusses thyroid conditions that occur during and after pregnancy. Practice management consultant Margie Satinsky provides invaluable guidance on effective physician leadership. Physician advocate Marni Jameson explains that the Association of Independent Doctors is working on eliminating unfair pressures that can break the spirit. One variable in the practice-success formula is clear, consistent marketing. The Triangle Physician removes guesswork by offering options that range in price from free to competitive. You can make your practice news and specialized expertise known – space permitting, at no cost. Really make an impression by getting on the cover of the magazine and regularly advertising – both available at competitive rates. One decision today seems clear: Decide to keep the medical community in the know. Submit your medical news and inquire about advertising opportunities via email to: firstname.lastname@example.org. With respect and appreciation of all you do,
Heidi Ketler Editor
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Editor Heidi Ketler, APR email@example.com Contributing Editors Wendy Coulter Marni Jameson Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Margie Satinsky, M.B.A. George Stamataros, D.O., F.A.C.E. Creative Director Joseph Dally firstname.lastname@example.org
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Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinions expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. The Triangle Physician makes no warrant to the accuracy or reliability of this information. All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.
The Triangle Physician
Tolnitch Surgical Associates
Nipple-Preserving Expertise Leads to Better Outcomes, Greater Satisfaction During the past decade there has been a
misleading, as nipple-sparing mastectomies
Both SSM and NSM have advantages over
trend towards patients who are eligible to
were performed as early as the 1960s and
traditional mastectomy in that more breast
undergo breast conservation (BCS) sur-
called “subcutaneous mastectomies.” The
skin is preserved, improving the ability
gery to choose mastectomy as treatment
change in terminology is deliberate, as sub-
of the plastic surgeon to reconstruct the
for their early-stage breast cancer. The
cutaneous mastectomies were performed
breast at the time of mastectomy with less
number of women who are BCS-eligible
by plastic surgeons for fibrocystic disease
visible scarring. However, preservation of
and choose to undergo mastectomy in-
and risk reduction, with a bias toward cos-
the nipple areolar complex allows for a
creased from 34.3 percent in 1998 to 37.8
metic outcomes and little concern for com-
more natural-looking breast contour with
percent in 2011, with the greatest increase
plete removal of the breast tissue.
improved central projection of the breast that is difficult to achieve when recon-
occurring after 2006.
In fact, B.S. Freeman, the plastic surgeon
structing the nipple areolar complex.
In part, this trend is due to improved cos-
who first described the technique in 1962,
metic outcomes from mastectomy and re-
proscribed that a small amount of breast
Multiple studies have shown that patients
construction – surgical options that have
parenchyma be left attached to the der-
have improved self-esteem and self-image
been fueled by the media and celebrities.
mis.2 John E. Woods, M.D., Ph.D., of the
due to the improved cosmesis with NSM.
Most notably Angelina Jolie and Christina
Mayo Clinic in describing the procedure
A recent study demonstrated improved lev-
Applegate have come forward with their de-
stated, “This procedure leaves approxi-
els of satisfaction with the reconstructed
cisions to undergo bilateral mastectomies.
mately 1 centimeter of breast tissue under
breasts, outcome and sexual well being
the nipple areola, which is essential for the
compared to women undergoing SSM
preservation of blood supply.”
with no differences noted in cancer-related
Improved screening has increased the
percentage of breast cancers that are identified early. In addition, advances in
By the 1980s reports of cancer developing
treatment have improved outcomes. These
in the residual breast tissue led to aban-
A surgical oncologist, breast surgeon or
advancements have contributed to more
donment of subcutaneous mastectomy un-
general surgeon now performs NSM with a
attention being focused on the technical
til the late 1990s, when new literature was
focus on maximizing breast tissue removal,
aspects of the surgical treatments offered
published supporting its safety. Since that
while attempting to optimize the cosmetic
time, after careful “re-branding,” NSM has
result. Just as in a traditional mastectomy,
again slowly gained footing as a surgical
during a NSM the surgeon removes nearly
option for carefully selected patients.
all of the contents of the breast except for a
Nipple-sparing mastectomy (NSM) is one of the most recent advances in surgical
thin layer of fat and blood vessels needed
techniques to improve the cosmetic out-
Like NSM, skin-sparing mastectomy (SSM)
to preserve the skin with all visible breast
comes of mastectomy. NSM is defined as
is an option that preserves most of the
tissue being excised.
the removal of the breast tissue while pre-
breast skin and is equally as effective at
serving the entire skin envelope, including
removing breast cancer as the more tradi-
NSM is more difficult to perform than tra-
the nipple areolar complex (NAC).
tional mastectomy. It is different from NSM,
ditional or skin-sparing mastectomies, be-
as the nipple areola is commonly removed
cause the incisions are smaller and in direct
along with the breast tissue during SSM.
contrast to the technique used for subcu-
To state that NSM is “new “ is somewhat
The Triangle Physician
taneous mastectomies. The surgeon must remove the ductal tissue directly behind the nipple yet preserve sufficient blood supply to the skin and nipple to prevent tissue necrosis. To assure oncologic and cosmetic success, it is important that women considering nipple-sparing mastectomy choose a surgeon with experience in this procedure. Lisa Tolnitch M.D., F.A.C.S., of Tolnitch Surgical Associates was the first breast surgeon in the Triangle Region to perform NSM. She and her partners â€“ breast surgeons Gayle Ackerman DiLalla, M.D., F.A.C.S., and Laura Lazarus M.D., F.A.C.S. â€“ have the combined experience of performing more than 400 NSM. In 1999, Lynn C. Hartman, M.D., et al from the Mayo Clinic performed a retrospective review evaluating the efficacy of prophylactic mastectomy in high-risk patients and identified no significant difference in the incidence of subsequent breast cancers between the women who underwent subcutaneous mastectomy and those who underwent total mastectomy.5 That same year Christine Laronga, M.D., F.A.C.S, from MD Anderson first published data suggesting that NSM using appropriate selection criteria could be performed safely with occult tumor being missed in less than 2 percent of cases.6 In 2003, Bernd Gerber, M.D., Ph.D., et al from Ludwig Maximilian University of Munich, Germany, compared recurrence and survival data from patients undergoing simple mastectomy, SSM and subcutaneous mastectomy showing no difference and concluding that NSM could be performed safely with appropriate selection criteria.7 Since that time many retrospective analyses and larger, single institution experiences have been published with varying inclusion
This set of before (top photo)-and-after photos demonstrates the improved outcome after advanced nipple-sparing mastectomy.
criteria, technical considerations and outcomes results. Despite the inconsistencies between studies, they have shown favorable
suits her individual needs. Though the cosmetic benefits of keep-
outcome data in carefully selected women undergoing NSM, both
ing oneâ€™s own nipple and areola are readily apparent, women who
in the prophylactic and therapeutic settings, and NSM has contin-
are considering NSM must be aware of the potential risks of the
ued to gather support.
At the American Society of Breast Surgeons annual meeting in Or-
Additionally, not all patients are good NSM candidates. It is impor-
lando in May, Lucy De La Cruz, M.D., from the University of Miami
tant to note that the patients chosen for this procedure and includ-
reported in an interview with Sanjay Gupta, M.D., editor of Med-
ed in the studies have all been carefully evaluated prior to surgery
Page Today, that the Surveillance, Epidemiology and End Results
and again once surgical pathology is completed to ensure that the
(SEER) registry demonstrates that the rate of nipple-sparing mas-
primary goal of removing the cancer was achieved.
tectomy has increased 202 percent since 2005.6 In a systematic review of the literature Dr. De La Cruz, et al identified eight studies
In situations where NSM is either not recommended or desired,
comparing NSM to SSM and modified radical mastectomy (MRM)
SSM is frequently an option that can provide excellent cosmetic
demonstrating a consistent rate of local recurrence between treat-
results with delayed reconstruction of the nipple and areolar tattoo-
ing to complete the result.
Like all surgical procedures, NSM has benefits and risks. A woman
In deciding if a patient is a candidate for NSM, we evaluate both
considering this procedure must discuss it carefully with the mem-
oncologic factors and patient factors. From an oncologic perspec-
bers of her breast management team and make a choice that best
tive inclusion criteria have varied somewhat between series, but
factors include breast size and ptosis, body habitus and body mass index. Additionally, some surgeons will not consider women who have had prior radiation therapy or collagen vascular diseases due to higher risks of complications. Similar to other types of mastectomy there is a potential risk of skin flap ischemia or necrosis. The risk increases as the length of the skin flap increases, so inherently women undergoing NSM will have higher risks than women undergoing SSM, which is higher than that of a simple, or modified radical mastectomy. Additionally, immediate reconstruction of the breast increases this risk. In NSM there is the additional risk of nipple necrosis, with the overall incidence of nipple complications in the literature varying widely. However, Laura Esserman, M.D., M.B.A., and her group at the University of California, San Francisco has published data showing increased experience decreases the incidence of complications.10 While individual patients may be eligible for NSM, it may not always yield the best cosmetic outcome for a patient. Therefore, a good oncologic and reconstructive surgical team will be able to provide this critical information to patients prior to the surgical procedure, so the results meet patient expectations. Resources
This set of before (top photo)-and-after photos shows the outcome following traditional mastectomy.
fundamentally they comprise factors that influence the risk of occult nipple involvement that varies between 0-53 percent in the reported literature with an overall incidence of 11.5 percent.9 Primary tumor characteristics influencing occult nipple malignancy include: • Tumor-nipple distance that is less than 2 centimeters, • Grade, • Lymph node metastasis (with studies showing it is likely safe to retain the nipple if fewer than three lymph nodes are involved on final pathology, • Lympho-vascular invasion (focal LVI is likely ok), • Tumor size that is greater than 5 centimeters, • Retroareolar/central location, • Multicentric tumors (defined as two or more separate invasive tumors occupying more than one quadrant of the same breast). Variability between individual surgeon’s determinations of their patient’s eligibility for NSM is based on patient factors. The patient
The Triangle Physician
1 Kummerow KL, Du L, Penson DF, et al. “Nationwide trends in mastectomy for early-stage breast cancer.” JAMA Surgery. 2015; 150(1):9-16. 2 Freeman BS. “Subcutaneous mastectomy for benign breast lesions with immediate or delayed prosthetic replacement.” Plastic and Reconstructive Surgery. 1962; 30:676-82. 3 Woods JE. “Detailed technique of subcutaneous mastectomy with and without mastopexy.” Annals of Plastic Surgery.1987; 18(1)51-61. 4 Bloomberg LS. “Long-term psychosocial functioning in women with bilateral prophylactic mastectomy: Does preservation of the nipple areolar complex make a difference?” Annals of Surgical Oncology. 2015 Oct; 22(10): 3324-30. 5 Hartman LC, Schaid DJ, Woods JE, et al. “Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer.” New England Journal of Medicine. 1999; 340:77-84. 6 Laronga C, Kemp B, Johnston D, Robb GL, Singletary SE. “The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy.” Annals of Surgical Oncology. 1999; 6(6), 609-13. 7 Gerber B, Krause A, Reimer T, et al. “Skin-sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction is an oncologically safe procedure.” Annals of Surgery. 2003; 238:120–127. 8 The Gupta Guide, May 1, 2015. Source Reference: DeLaCruz L., et al “Nipple-sparing mastectomies as safe as more radical procedures for appropriate patients.” American Society of Breast Surgeons. 9 De La Cruz L, Moody AM, Tappy EE, et al. “Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: A meta-analysis and systematic review.” Annals of Surgical Oncology. 2015; 22:3241–3249. 10 Garwood ER, Moore D, Ewing C, et al. “Total skin-sparing mastectomy – complications and local recurrence rates in two cohorts of patients.” Annals of Surgery. 2009; 249:26–32.
20 Powerful Reasons to
Brand Your Practice: Part 1 By Wendy Coulter
In order to create a strong brand, your
what your practice stands for. This helps set
practice must differentiate its product or
patients’ expectations and tell a story that
service from others. This differentiation
will resonate through all your media outlets
helps build a collection of perceptions in
and patient contact points.
the mind of the patient. Increase Credibility Patients who believe in your practice’s
Establishing and keeping a brand promise
brand will spread the word about its ben-
will help build credibility for your practice
efits, increasing the value of the brand as
with patients, prospective patients and
an asset of the practice. If your practice
vendors, as well as in your industry and
does not live up to its brand promises to
community. Keep in mind that even a very
patients, it will suffer.
creative marketing strategy will not render as high of an ROI (return on investment),
This is the first of a four-part series. Below
if you are not believable. Believable prac-
are the first five of 20 powerful reasons to
tices gain trust with patients with less ef-
brand your practice.
fort, and people prefer to use businesses they trust.
Create an Experience Patients by nature are looking for an
Create an Emotional Tie
experience when they interact with your
with Your Target Market
brand. All their experiences with your
By gaining insight into what your patients
brand make an impression and help set an
want and need, you can learn how to con-
expectation of what your brand is about. An
nect with your target market on an emo-
example of a brand focused on creating an
tional level, so they feel good when they
experience is Disney. Whether you are at
buy from you. Purchasing is an emotional
one of their amusement parks, watching a
experience, so make sure to tell your
Disney movie, or visiting a Disney store, you
brand story in a unique way that resonates
have an expectation that your experience
emotionally with patients!
will be filled with wonder and the highest level of service with a smile.
Motivate Patients to Come Back Next Time
Wendy Coulter is president of Hummingbird Creative Group Inc. She is a graduate of 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.
Develop Clear Messaging
Once patients trust your brand, they will
Going through the process of branding your
be more loyal and visit more often. A
practice will help you develop clear market-
strong brand helps foster business growth.
ing messages. From your mission and vi-
According to a study by Gartner Group, on
a well-known soap brand, which made it
sion, to your core values, value proposition
average 8 percent of a company’s future
easy to increase sales when the brad intro-
and competitive advantages, it’s important
profits come from 20 percent of its exist-
duced body washes, lotions and deodor-
to have very clear messages that represent
ing customers. For example, Dove became
ants to their existing happy customer base.
Thyroid Disease and Pregnancy By George Stamataros, D.O., F.A.C.E.
In general, thyroid disease is five times more
Anti-thyroid drugs – propylthiouracil (PTU)
common in women than men. The coinci-
and methimazole – may be used in preg-
dent occurrence of thyroid disease before,
nancy, but they can both cross the placenta
during and after pregnancy involves special
and may harm the fetus by causing fetal hy-
considerations for the health of the infant
pothyroidism and goiter. PTU is usually the
and the mother. This article will discuss four
drug of choice, due to a lower transplacental
common thyroid disturbances during preg-
passage into the fetal circulation. PTU also
nancy and post-partum.
appears to a lesser extent in breast milk and is advantageous during breast-feeding. Infre-
quently, the transplacental passage of mater-
Early pregnancy is associated with several
nal antibodies can lead to transient neonatal
hormonal changes that alter thyroid func-
hyperthyroidism (about 2-5 percent), par-
tion. Estrogen alters production of thyroxine-
ticularly if titers of TRAb or TSI are very high.
binding globulin (TBG), a carrier protein
Graves’ disease may become quiescent dur-
for thyroid hormone. Human chorionic
ing pregnancy, but may intensify two to three
gonadotropin (hCG) bears structural resem-
blance to thyroid stimulating hormone (TSH, thyrotrophin) and may weakly stimulate the
thyroid and suppress TSH production during
The most common cause of hypothyroidism
the first trimester.
in women of childbearing age is autoimmune (Hashimoto’s) thyroiditis.
About 10 percent of women may have a mild-
George Stamataros was born in Queens, N.Y., and grew up near Princeton, N.J. He completed his undergraduate studies at Rutgers University with a focus in biological Sciences. He earned his medical degree from the University of Medicine and Dentistry of New Jersey and completed his graduate medical training in internal medicine and subspecialty training in endocrinology at UMDNJ-Robert Wood Johnson Medical School in New Brunswick, N.J. Dr. Stamataros is board certified in internal medicine and endocrinology. He has worked in private practice in New Brunswick for three years before relocating to North Carolina. He was active in teaching medical students and served as a director at Somerset Medical Center. Dr. Stamataros is also a member of the American Association of Clinical Endocrinology and Endocrine Society. Dr. Stamataros now practices at Carolina Endocrine P.A., 3840 Ed Drive, Suite 111 Raleigh, NC 27612. He can be reached by calling (919) 571-3661 or sending an email to gstamataros@ carolinaendocrine.com.
ly suppressed TSH during the first trimester,
Most women with Hashimoto’s thyroiditis
especially with hyperemesis gravidarum
have thyroid peroxidase (TPO) antibodies,
(“morning sickness”). This cause of sup-
which often precede the onset of primary
pressed TSH needs to be distinguished from
hypothyroidism. Recent studies have shown
Graves’ disease, which is the most common
that the presence of TPO antibodies in euthy-
cause of clinically significant hyperthyroid-
roid women is associated with an increased
or to pregnancy and should have thyroid func-
ism in pregnancy.
risk of miscarriage, particularly in the first
tion tests reevaluated six to eight weeks later.
trimester, and treatment with low doses of leSince nuclear medicine studies are contrain-
vothyroxine may lower the miscarriage rate
Nearly half of women on thyroid hormone
dicated during pregnancy (e.g., radioiodine
to that of unaffected women.
replacement therapy will see an increase in
uptake/thyroid scan), diagnosis of Graves’
their dosage requirement. Following deliv-
disease must either be made on clinical
During the first 10 to 12 weeks of gestation,
ery, most women will return to their original
grounds (goiter, bruit, exophthalmus) or
the developing fetus is completely depen-
thyroid hormone dosage requirement.
the measurement of thyrotrophin receptor
dent upon maternal thyroid hormone levels
antibody (TRAb) or thyroid stimulating im-
for normal brain development. Untreated
Women should be reminded to separate
munoglobulin (TSI), which are present in
maternal hypothyroidism is associated with
their thyroid hormone supplement from
the serum of about 70-80 percent of patients
a decrease in neonatal IQ, in addition to an
their prenatal vitamin by at least a couple
with Graves’ disease. Women who require
increased rate of miscarriage and pre-term
hours, since the iron contained in prenatal
therapeutic intervention during pregnancy
vitamins can bind and inhibit absorption of
are usually placed on anti-thyroid drugs, or
uncommonly they may undergo thyroidec-
Women who are hypothyroid and are taking
tomy (usually during the second trimester).
thyroid hormone supplementation should
Thyroid Nodules and Cancer
have their TSH in the low range of normal pri-
There is an increased incidence of thyroid
The Triangle Physician
Endocrinology nodule discovery during pregnancy, thought
ACNE • MOHS SURGERY • SKIN CANCER • PSORIASIS • ECZEMA • DERMATITIS
to mostly be due to increased clinical surveil-
Thyroid ultrasound can confirm additional
“He wanted his confidence back.”
characteristics of thyroid nodules, and fine-
I REFERRED HIM TO SOUTHERN DERMATOLOGY
lance during the prenatal period.
needle aspiration (FNA) biopsy may be safely performed during pregnancy. However, nuclear medicine studies (e.g., thyroid scans) are contraindicated. If a thyroid FNA biopsy reveals the presence of cancer or if a nodule is found to be suspicious for malignancy, then the patient may elect to undergo surgical resection (usually during the second trimester) or may defer thyroidectomy until after delivery (in most cases). Women with thyroid cancer who are on thyroid hormone suppressive therapy FOR THE MOST ADVANCED DERMATOLOGY TREATMENTS, REFER YOUR PATIENTS TODAY!
should usually permit their thyroid function tests to normalize, either by lowering the dose or auto-correcting from a suppressed TSH to normal.
ROSACEA • HIVES • VITILIGO • KERATOSIS • WART REMOVAL • ALOPECIA
Post-Partum Thyroiditis This is usually a painless, transient disturbance in thyroid function that develops two
DER131_AD_Triangle Physican I Want 4.indd 2
55 Vilcom Center Drive Boyd Hall, Suite 110 Chapel Hill, NC 27514
to six months after delivery. Incidence is estimated to be anywhere from 3-15 percent, depending on the population being studied. This condition is characterized by a thyrotoxic phase, followed by a hypothyroid phase, each of which may last for several weeks or months. Anti-thyroid drugs are rarely of benefit during the thyrotoxic phase, although thyroid hormone supplementation can be used for the hypothyroid phase.
3/18/15 3:56 PM
Drossman Gastroenterology PLLC a patient-centered gastroenterology practice focusing on patients with difficult to diagnose and manage functional GI and motility disorders. The office is located within the multidisciplinary health care center, Chapel Hill Doctors. Dr. Douglas Drossman is joined by physician’s assistant, Kellie Bunn, PA-C. Appointments are scheduled on Tuesday and Wednesday and most laboratory studies are available.
A low radioiodine uptake (RAIU) will distinguish this condition from Graves’ disease (which has a high RAIU), although women who are breastfeeding should not undergo this procedure unless they temporarily suspend breastfeeding. Recurrence of post-partum thyroiditis in subsequent deliveries is uncommon. About 10 percent of women with post-partum thyroiditis will remain permanently hypothyroid.
New Options for Losing Weight By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.
We know that obesity is on the rise. In the
freezer makeover – get rid of the foods
United States, 34.9 percent of adults are
that tempt you
obese, which is defined as a BMI (body
• No late-night eating!
mass index) of 30 or greater.1 Commit to Weight-loss At Women’s Wellness Clinic women often
and Set Goals
ask for weight-loss assistance. Sometimes
The first step to meaningful and lasting
receiving recommendations is all the incen-
weight loss is committing to do it. However,
it is important to recognize that the triggers
• A deficit of 3,500 calories per week (500
that cause stress eating aren’t likely to go
calories per day for seven days) is need-
away. It requires understanding the reasons
ed to lose one pound per week. A deficit
for overeating and managing the triggers.
of 4,900 calories per week (700 per day) is needed to lose two pounds per week.
Next, weight loss requires setting realistic
• Do not consume less than 1,200 calories
goals. In general, losing 1-2 pounds per week
per day to avoid slowing down your me-
is achievable. Calorie counting can be an ed-
ucational process. Did you know that a glass
• Eat less but more often to boost metab-
of wine can range between 300-500 calories?
olism. Try to consume five to six small
So having a glass of red wine at night may
meals during the day beginning with
wipe out a day’s efforts.
breakfast within 45 minutes of walking. • Keep a food journal – potentially an
Becoming more active is important to weight-
online version that will keep calorie
loss success. Exercise also comes with a
count for you: www.thedailyplate.com,
number of other health benefits, including
improved mood, cardiovascular system and
ple.com, www.nutrihand.com, as well as
www.mypyramid.com. • Exercise! This is so important for weight
Any extra movement helps burn calories!
loss (and weight control), although what
The simple decision to use the steps instead
you eat is more important.
of the elevator can burn calories.
• Be mindful of the food you are eating both in terms of quality and quantity. • Do not multitask when you are eating, and chew your foods well. • Give yourself a pantry and refrigerator/
Medication Support For those who need extra support, medications can help change eating habits by easing cravings.
After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she cofounded and served as the director of gynecology for the Women’s Hemostasis and Thrombosis Clinic. She left her academic position (2007) to begin Carolina Women’s Research and Wellness Center. She and partner Amy Stanfield, M.D., F.A.C.O.G., head the Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals. Call (919) 251-9223 or visit www.cwrwc.com.
Most recently, the drugs Contrave (Takeda Pharmaceuticals) and the injection Saxenda (Novo Nordisk) were approved for chronic weight management in 2014. Three yeas ago (2012), Qsymia (Vivus) and Belviq (Arena Pharmaceuticals) were approved for chronic management. Probably the oldest available medication for weight loss is phentermine, which now is available in generic forms. This is indicated for short-term weight loss and works as an appetite suppressant.
Take Care of Yourself Women’s Wellness Clinic is offering these fall offers to encourage self care: • 50 percent off pain-free laser hair removal. Six underarm treatments for $300 or six bikini-line treatments for $475. • 30 percent off laser treatment for facial age spots ($240, includes topical anesthetic). • $75 visit with a provider to review weight-loss strategies. Subsequent visits for those who choose medical assistance for weight loss can then be billed under their medical insurance. Those without medical insurance can receive further medical assistance at a reduced cost this fall.
Call (919) 251-9223 to learn more about or take advantage of these offers. 12
The Triangle Physician
Duke Research News
Meridia (Knoll Pharmaceutical) was ap-
Family Physician Needed
proved in 1997 and withdrawn from the United States market in October 2010. This was to be used for treatment of obesity, but there was increased risk of serious heart events.
Family Physician Needed at Avance Primary Care, Raleigh, NC
The support of family members and friends, a
Avance Care, P.A. is seeking a Board Certified Family Physician at our new Oberlin Rd practice opening in late 2015. Avance Care’s model was created to benefit our patients AND our physicians.
support group or even a professional coach is helpful. Given the increase in the number of medications for weight loss, consultation with a health care provider who is knowledgeable about what works is recommended. Whether the goal is to lose five pounds or 105, there are healthy options. At the Women’s Wellness Clinic, we are dedicated to helping each woman become healthy and familiar with weight-loss strategies. Appointments can be made by calling (919) 251-9223.
• Work/life balance – our providers work 40 hours per week or less • Average patient load of less than 3 patients per hour • Proprietary operating and provider support systems – paperless facilities • Highly trained support staff • State of the art facility with onsite Pharmacy, X-Ray, Nutritionist, Behavioral Health Services, Allergy Testing and Immunotherapy • Operation that has consistently met or exceeded NCQA PCMH level 3, BQPP level 3, United Bridges to Excellence, Meaningful Use, NCQA DRP • Market leading private practice compensation package
Learn more about us at avancecare.com/about/about-us Apply online at avancecare.com/about/careers-providers
Spend Time c Your Patients, Not Battling IT. Get HIPAA Compliant Solutions
Let’s Talk Tech! Call (919) 296-1089 SAMIT-Medical.com
Physician Role in
Practice Management By Margie Satinsky, M.B.A.
Just as patients schedule a visit to discuss
nobody is doing the job, and it shows.
one symptom when they really want to talk about a different one, we receive re-
Second, many physicians don’t know how
quests for help on a myriad of practice
to move from science to business. The
management issues when the real issue is
difference in disciplines appears may be
the role that physicians themselves play or
smaller than you think. The same diagnos-
don’t play in managing their practices.
tic and problem-solving skills that apply to clinical care also apply to practice man-
Last month we dealt with two situations
in which the practice managers were not meeting expectations regarding accounts
receivable, escalating expenses and poor
The body of knowledge that practice man-
staff morale caused by delayed perfor-
agement encompasses includes many
mance reviews. The real issue in these sit-
topics that need to be mastered individu-
uations wasn’t money or staff competence.
ally and then related to each other. These
It was the role that physicians played in
topics include, but are not limited to, orga-
the management of their practices.
nization and management, financial man-
Margie Satinsky, MBA, is President of Satinsky Consulting, LLC, a Durham, NC consulting firm that specializes in medical practice management. She’s provided strategic planning and operational guidance to more than 100 practices in North Carolina. Margie is the author of numerous books and articles, including Medical Practice Management in the 21st Century. For additional information, go to www.satinskyconsulting.com.
agement, human resources, compliance
administrator may designate and com-
Get Past the Obstacles
and operations, including information
pensate one physician as the managing
Medicine is a challenging field but no less
technology and quality management.
partner. Other practices divide managerial responsibilities among the physician
challenging than running a small business. As a small business owner, you need to
Let’s look at the role that physicians
owners. Either way, the physician(s) col-
know what must be managed and how to
should play in order to actively manage
laborate with a practice manager whose
provide guidance to staff. It is unlikely that
experience and skill level are below those of a practice administrator.
you learned about business in medical school, so perhaps you are reluctant to get
Organization and Management: Physi-
involved. Where do you start? How do you
cians have three options for organizing
Finally, the practice can hire an office man-
learn what practice management means,
and managing the practice.
ager to execute the instructions issued by the owners. Notice that we haven’t listed
and once you understand the scope, how do you master the skills that will help you
If the practice is large enough to support
the option of rotating physicians as manag-
a professional practice administrator, that
ing partners, so nobody gets “stuck” with
individual can take a leadership role in ini-
the job. We think rotating the managerial
In our experience, two concerns deter
tiating strategic and operational programs
responsibility is avoidance of a job that no-
many physicians from taking proactive
subject to physician approval on major
body wants to do.
roles in the management of their practices.
decisions. Financial Management: Financial man-
One, believe it or not, is the presumption that someone else is doing the job. Often
The Triangle Physician
Practices that don’t have a professional
agement involves both revenue cycle man-
Practice Management agement (e.g., managed care negotiations,
tify problems and take corrective action.
sors, each other and the physicians and
billing, collections, management of deni-
Make sure that the appropriate policies
that communication on what is important
als) and activities that the practice per-
and procedures are in place in order to
in your practice come directly from the
forms regularly (e.g., budgeting, checks
prevent problems before they occur. Take
an active, not a passive role in the finan-
If the practice is part of an accountable
cial management and prevent problems
Here’s an example of a situation that
before they arise.
might have been avoided. A primary care practice in the eastern part of North Caro-
care organization (ACO), it also involves the relationship with that organization. In
We like the advice that hockey great
lina hired a new practice administrator to
any practice environment, there’s a great
Wayne Gretzky provided when asked what
take charge of the eight-person practice.
deal of available information. The certi-
made him such an outstanding player. He
Shortly after her arrival, the practice add-
fied public accountant provides monthly
replied: “I skate to where the puck is go-
ed a new provider by merging with an ex-
reports, and the practice management sys-
ing to be.”
isting practice. The marching orders for the practice administrator changed, and
tem (PMS) contains the details – provided one knows what he/she needs and what
Human Resources: The most valuable
the owners directed her to focus on the
to do with it.
assets of every medical practice are its
details of the merger. She did, only to find
employees. Practices that have the best
herself out of a job within nine months
Regardless of the way in which the prac-
staff retention and loyalty treat human re-
because she wasn’t devoting enough at-
tice is organized, physicians should play a
sources as a major investment.
tention to ongoing operations. In hindsight, the outcome might have been dif-
major role in financial management. Take responsibility for making sure that there
Practice owners should make sure that job
ferent had the owners been more clear
are realistic annual operating and capital
expectations and priorities are clear, that
on their priorities and the potential nega-
budgets. Use the budgets to guide both
employees are treated consistently and
tive consequences of neglecting day-to-
revenue generation and spending. Review
fairly, that training is available, that staff
reports regularly, using the data to iden-
have opportunities to meet with supervi-
Practice Management Compliance: Compliance with require-
if physicians make disparaging remarks
put the practice, the practice administra-
ments by Medicare and Medicaid, Health
about compliance and are unwilling to
tor and the patients in a risky situation.
Insurance Portability and Accountabil-
support these activities, the staff will as-
ity Act (HIPAA), Occupational Safety and
sume a similar attitude. Don’t put the prac-
Operational Management: When is the
Health Administration (OSHA), Clinical
tice at unnecessary risk.
last time the physicians in your practice looked critically at the workflow process-
Laboratory Improvement Amendments
(CLIA) and other governing bodies is an
We’ve helped more than 100 practices
essential component of running a medical
become HIPAA compliant. Our most chal-
lenging client was the practice where the
Does everybody know what happens to
physician owners chose to ignore the
patients from the time they make an ap-
If physicians convey the attitude that com-
major recommendations for privacy and
pointment to the time that they check out?
pliance is important to your practice, your
security rule compliance. Their hostility
Does the practice use patient satisfaction
staff will adopt your attitude. Conversely,
toward any type of government regulation
surveys and act on the results? How much do the owners know about the information technology applications that the practice has and about new enhancements that may become available? Is there an active quality management program? Don’t leave these important issues up to staff discretion; get involved. Conclusion Hopefully we’ve convinced you. As a physician owner you need to be knowledgeable about practice management. How do you obtain the information and the managerial skills? Professional organizations, such as the American Association for Physician Leadership, Medical Group Management Association (MGMA) and your own specialty society, offer mini courses on practice management. You also can enroll in master in business administration courses that are offered on weekends and/or online. Or you can ask one or more qualified consultants to teach you particular subjects that you want to learn. Finally, check the Internet. Many of those topics that may seem mysterious will become very clear once you begin your quest for knowledge. As physician owners of a medical practice, practice management is ultimately your job. With a methodical approach to both substance and skills, you can make a big difference.
Womens Wellness half vertical.indd 1
The Triangle Physician
12/21/2009 4:29:23 PM
AID Takes Aim at Physician Burnout By Marni Jameson
As a non-physician who talks to a lot of doc-
We are painfully aware that doctor burnout
tors, I’m often struck and saddened by how
is on the rise. A January 2015 report by Med-
frustrated they are.
scape from WebMD found that is a problem for 46 percent of physicians – up 16 percent
Not long ago, after speaking at an Ameri-
in just two years. The study defined burnout
can College of Cardiology summit, I was
as a loss of enthusiasm for work, feelings of
besieged by doctors asking for ways they
cynicism and a low sense of personal ac-
could stay independent and not succumb to
Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at (407) 865-4110 or firstname.lastname@example.org.
hospital offers of employment. Among the top reasons for burnout are too
Most doctors are by nature autonomous.
They wanted to know, privately, if we, the
much bureaucracy, too many hours, not
Most don’t go into practice to do unneces-
Association of Independent Doctors (AID),
enough income, computerization, impact
sary procedures, order unnecessary tests
could help them get fairer contracted rates
of the Affordable Care Act and not enough
and meet quotas to please their employers
with insurers; that is, reimbursement rates
time to provide quality care.
and keep their jobs.
hospital-employed physicians for the same
“How Being a Doctor Became the Most
The same week of the aforementioned Med-
procedure. It should be a fair playing field,
Miserable Profession,” an article written by
scape article, I got an email from a physician
and we’re working on it.
Daniele Drake for The Daily Beast in April
and AID member asking for help. The medi-
2014, opened with the news that nine of 10
cal staff had elected him to be chief of sur-
The physicians wanted help forming in-
doctors would discourage others from join-
gery at his hospital. However, the hospital
dependent physician associations (IPAs),
ing the profession, and that over the past few
board followed with a vote not to approve
giving them better leverage and clout with
years being a doctor has risen to become
his position. The board wanted an employed
payers. That’s a solution, and we’re working
the second-most suicidal occupation
physician in that seat.
This much is clear: Employment is not the
As we told this doctor, and as we tell ev-
They wanted to know if we could help them
answer. We understand that for some going
eryone who is frustrated about the state of
combat the fact that hospitals direct patients
to work for a hospital seems like a good op-
health care, the only way independent doc-
only to employed physicians, cutting inde-
tion. But we know from those who have left
tors are going to gain ground, protect their
pendent doctors out of the referral network.
independent medicine, the grass is not nec-
interests and secure their professions is to
We’re working on that as well.
develop a unified, nationwide voice that pa-
closer to what insurers and Medicare pay
tients, hospitals, insurers and governments listen to, take seriously and respect.
They want a life raft, or at least a life pre-
We know, because we have many physician
server, to help them keep cash flow up and
members who were employed by hospitals
and have returned to private practice. One
That is the purpose of Association of Inde-
internist was frustrated, because her hospi-
pendent Doctors. But we can’t do this with-
AID offers assurance to independent physi-
tal employer insisted she see 25 patients a
out your support. If you’re independent and
cians. We are working with media, lawmak-
day rather than her average of 17, a number
believe in our efforts, please support us by
ers, the judicial system, insurers, doctors
she felt she could see in one day and pro-
joining our cause. To become a member of
and consumers on all of these issues. They
vide quality care. When she didn’t pick up
AID go to www.aid-us.org. Let’s do this to-
are big, complicated and entrenched, but
her pace, her employment contract wasn’t
we are making a difference.
Duke Research News
Model Shows Meningitis’s Creep into the Brain of Transparent Zebrafish Scientists at Duke Medicine are using transparent fish to watch in real time as cryptococcal meningitis takes over the brain. The resulting images are worthy of a sci-fi movie teaser, but could be valuable in disrupting the real, crippling brain infection that kills more than 600,000 people worldwide each year. Airborne cells of cryptococcus make their way into our lungs practically every day — unwelcome guests, but of little consequence for those with healthy immune systems. But for those with compromised immunities, whether by HIV infection or cancer treatment, a resulting cryptococcal meningitis infection can quickly become deadly. To be able to target the infection with medications in the future, researchers need to know more about how the organism (technically a yeast) moves from the lungs into the blood stream and through the blood-brain barrier. So they injected the organism into microscopic
A zebrafish larva is infected with cryptococcal meningitis and photographed under a microscope. Scientists observe as the infection (visible red orbs) takes over the brain. Macrophages (shown in blue) attack the infection as it travels through green blood vessels and throughout surrounding tissue. The eyes of the fish are located at the top and bottom left corners of the image. Photo by Stefan Oehlers/Duke Medicine.
zebrafish larvae, which have clear bodies, and watched the infection take hold.
while it is living with an infection,” Dr. Tobin said. “It will allow us to screen libraries of drug compounds relatively quickly. We can also
The newly developed fish model is described in mBio, a journal of the
develop and test mutant strains of cryptococcus in these larvae. This
American Society of Microbiology.
can teach us which factors play a role in infection and those could be therapeutic targets in the future.”
“What’s impressive is that, unlike in a mouse or rabbit, you can actually see the organism producing disease in the live animal,” said John
Dr. Tobin also uses zebrafish to study bacteria closely related to those
R. Perfect, M.D., chief of the division of infectious diseases at Duke
that cause tuberculosis, and findings from this model have been ap-
University School of Medicine. “Day-by-day, it’s growing and moving
plied to understanding human disease.
throughout the body. You can’t see this anywhere else.” There are some drawbacks to studying these infections in fish – their A YouTube video shows a transparent larva’s body as cryptococcus
body temperatures are cooler, and they lack lungs, which is where
fungi, made red by a fluorescent tracer, moves through tissue, blood
cryptococcus enters the human body, Dr. Perfect said. But the fish
vessels and into the brain. Blue macrophages chase and gobble up
offer a starting point to create leads that scientists can then investigate
some of the red infection as it spreads through and around green
further in more complex mammals.
blood vessels. “Our hope is that by creating this system, we can continue our own Using a zebrafish to observe the process of infection offers a small ver-
investigations into other harmful organisms and that other scientists
tebrate animal with an immune system somewhat similar to a human’s,
worldwide can adapt our zebrafish model to investigate the diseases
Dr. Perfect said. Because the fish are tiny and easy to reproduce, they
that are priorities in their communities,” Dr. Perfect said.
cost less and are easier to study than a mouse or larger mammal. In addition to Drs. Perfect and Tobin, study authors include Jennifer L. The larvae also are permeable to small molecules, which will allow
Tenor, Stefan H. Oehlers and Jialu L. Yang.
scientists to batch-test different drug compounds against the infection
The study was sponsored by the Duke University Center for AIDS
relatively quickly and easily, said co-author David Tobin, Ph.D., assis-
Research (CFAR), the National Institutes of Health (5P30 AI064518;
tant professor in molecular genetics and microbiology and immunol-
1DP2-OD008614; AI73896; AI93257), the Australian National Health
ogy at Duke.
and Medical Research Council, a Mallinckrodt Scholar Award, a Searle Scholar Award, the Vallee Foundation and a Medicine Research Col-
“This model will allow researchers to screen the whole organism
The Triangle Physician
UNC Research News
Study Shows Affect of Diabetes Drug on Bone Health and Benefit of Exercise bones
“First, we were surprised by the massive
Yet, other drugs under development that
there is fat. Diabetes
amount of bone fat caused by rosigli-
could be close to Food and Drug Admin-
increases the amount
tazone,” Dr. Styner said. “The images were
istration-approval lower blood sugar by en-
of this marrow fat.
just stunning. Also, the drug is so power-
hancing the PPAR (peroxisome proliferator-
And now a study
ful, and we used such a high dose that we
activated receptors) pathway. These drugs
from the University of
didn’t think exercise would decrease the fat
are referred to as fibroblast growth factor-21
North Carolina School
depot much, if at all. But exercise did de-
Maya Styner, Ph.D.
of Medicine shows
crease the volume of bone fat by about 10
how some diabetes drugs substantially in-
percent, which was similar to the decrease
“Early reports show that the same bone
crease bone fat and thus the risk of bone
we reported seeing in mice that were not
concerns are popping up with these new
given the drug but were instead fed a high-
drugs,” Dr. Styner said. “Doctors and pa-
tients need to be aware of this.”
The study, published in the journal Endocrinology, also shows that exercise can decrease the volume of bone fat caused by high doses of the diabetes drug rosiglitazone, which is sold under the brand name Avandia. “These drugs aren’t first- or second-line choices of treatment for Type 2 diabetes, but some patients do take them,” said study first author Maya Styner, M.D., assistant professor of medicine. “And we know there are drugs in development that target the same cellular pathways as rosiglitazone does. We think doctors and patients need to better understand the relationship between diabetes, certain drugs and the often dramatic
Images of bones stained with osmium. Left: bone fat decreased due to exercise. Right: bones of mice on high dose of rosiglitazone. Far right image shows decrease in bone fat due to exercise.
effect on bone health.” Dr. Styner said that many of her patients
Bone fat, in general, isn’t nearly as well un-
According to Dr. Styner’s study, rosiglitazone
have been surprised to learn that some
derstood as other fat depots.
affects bone fat by enhancing a critical tran-
diabetes drugs can adversely affect bone
scription factor called PPAR – peroxisome
health. She also said that diabetes itself can
“Our field is just beginning to investigate
proliferator-activated receptor – which regu-
bone fat and its implications for patients,” Dr. Styner said. But she said that more bone
lates the expression of specific genes in the nuclei of cells. Essentially, rosiglitazone
Avandia fell out of favor about a decade ago
fat means less actual bone, which increases
takes glucose out of blood to lower blood
because of heart-related side effects. Physi-
the risk of bone fractures.
sugar and treat diabetes. But that glucose is
cians can still prescribe the drug, but it isn’t
then packaged into lipid droplets – fat. Other
as popular as it once was. Its cousin pio-
All of us have fat in our bones. It’s just a
researchers showed that some of that fat is
glitazone is also still available and has been
matter of how much. Dr. Styner said that
stored in tissue, such as belly fat. Dr. Styner’s
shown to cause fewer heart-related side ef-
the same kind of stem cell in our marrow
latest research showed that the drug also
fects, Dr. Styner said, but it also isn’t used as
creates bone cells and fat cells. Previously,
causes fat to be stored inside bone.
a first- or second-line drug to treat diabetes.
Dr. Styner used a new osmium-staining technique to visualize that a high-fat diet in-
UNC News creases the fat depots in the bones of mice,
Whatever the case, exercise aids bone
risk of declining bone health to find an ex-
just as a high-fat diet increases belly fat.
health. In her studies, Dr. Styner’s team add-
ercise that suits them; the default would be
ed a running wheel to mouse cages. Mice
taking very long walks.
There are still differing theories for how
are natural runners. At night, they’d run sev-
bone fat increases due to a high-fat diet and
eral miles on the wheel. Dr. Styner’s team
Also, Dr. Styner is hoping to work with exer-
how exercise lowers it. Dr. Styner said exer-
then measured the effects of running. (See
cise scientists at UNC-Chapel Hill to use ad-
cise might trigger marrow stem cells to cre-
images.) Even on a high dose of a powerful
vanced magnetic resonance imaging tech-
ate more bone cells instead of fat cells. Or
drug, such as rosiglitazone, the mice that
nologies to visualize the effects of exercise
perhaps exercise causes the body to access
exercised showed a significant decrease in
on human bone health.
bone fat as fuel.
bone fat. The National Institutes of Health funded this
“It could be that bone fat is just another de-
Dr. Styner said her findings are not yet di-
research. Janet Rubin, M.D., professor of
pot, a good energy store that allows bone
rectly relatable to human activity. For hu-
medicine and pharmacology, is the senior
cells to do what they need to do, so bones
mans, running isn’t nearly as natural. But
author of the paper that appeared in the
become stronger,” Dr. Styner said.
she said she would still advise patients at
Web-based Calculator Helps Providers Better Counsel on Prenatal Screening of
women interested in genetic testing for
tests depends on how high a patient’s risk
North Carolina De-
their pregnancies increases, said Matt
of having a baby with Down syndrome is,
partment of Obstet-
Grace, M.D., a fellow in the Division of
which ultimately depends upon her age.
rics & Gynecology,
Maternal-Fetal Medicine and lead author
The calculator offers a way for physicians
Division of Maternal-
of a paper on the topic that appears in the
and genetic counselors to better explain
Fetal Medicine has
July 2015 issue of the American Journal of
how the tests perform and to enhance
unveiled a free, web-
Obstetrics and Gynecology.
their counseling of patients both before
Matt Grace, M.D.
the testing and after.
based calculator to
help providers better counsel patients
“When communicating the results of
on the benefits and risks of the four most
these tests, it’s important for providers to
“For instance, if our calculator shows that
common screening tools for fetal genetic
help their patients interpret them. These
the positive predictive value of a test is 46
abnormalities available commercially in
tests are screening tests, and when a pa-
percent for a woman of a specific age and
the United States.
tient receives a positive result, we recom-
at a specific gestational age, there is still
mend follow up with a diagnostic test,
a 54 percent chance that the fetus does
Using age- and gestational age-related risk
such as an amniocentesis, to confirm or
not have the abnormality,” said Dr. Grace.
tables for trisomies 21, 18 and 13 (com-
rule out a genetic abnormality,” said Dr.
“This is an opportunity for the provider to
monly known as Down syndrome, Ed-
Grace. “There are a number of reasons
offer additional information and another
ward syndrome and Patau syndrome) as
why a false positive might happen, and
level of care to the patient.”
well as the previously reported sensitivity
the evidence shows that some women are
and specificity of each cell-free fetal DNA
deciding to terminate their pregnancies
The calculator can be found at The UNC
testing platform, the calculator can esti-
without further confirmatory testing.”
Center for Maternal and Infant Health website at mombaby.org/NIPS.
mate the positive predictive value (PPV) of each test or the likelihood that a posi-
All four tests – known commercially as
tive result is a true positive. Most of the
Harmony, Materniti 21, Panorama and
Also listed as authors on the paper are:
laboratories do not currently report the
Verifi – appear to perform better than
Emily Hardisty; Noah S. Green; Emily Da-
PPV of their testing platforms.
previous genetic screening tests and have
vidson, M.D.; Alison Stuebe, M.D.; and
reduced the need for unnecessary and
Neeta Vora, M.D.
The ease and accessibility of such a tool
more invasive procedures for many wom-
is especially important as the number of
en. The positive predictive value of the
The Triangle Physician
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