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Carolina Partners Neuropsychiatrist Is on the Cutting Edge of Treating Brain-Based Disorders

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

Treating Constipation The Age of Ultrasound


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“When Atrial Fibrillation Sent My Heart Rate To 200, I Was Thankful That Johnston Health Had Two Accredited Chest Pain Centers Just A Few Minutes From My Home And Even More Thankful For Their Excellent Care!” Caleb Thornton Four Oaks, NC A short time ago, Caleb Thornton feared his carefree days of coastal fishing might be over. One evening, Caleb’s heart rate suddenly became extremely elevated, and his family wisely called 911. A few minutes later he was rolled into Johnston Medical Center - Smithfield, one of Johnston Health’s two accredited Chest Pain Centers. He was quickly diagnosed with Atrial Fibrillation, a condition that, left untreated, could lead to stroke and other complications. He was given treatment that converted his heart rhythm back to normal, and kept overnight for observation. But, the event left Caleb with a fear of getting out of reach of a hospital - especially to do the things he loves, like off shore fishing. “My cardiologist with Johnston Health restored my confidence. He gave me a “pill-in-pocket”- a set of medications I can keep with me to protect me and get my heart back in rhythm, should I have another episode - wherever I might be.” This May, Caleb landed a 70 lb. white marlin, over fifty miles out on his uncle’s boat Miss Shell. Caleb is delighted to report, “Thanks to Johnston Health, life is back to normal with no long term complications.” Please make sure your patients are familiar with the symptoms of heart attack and heart failure, and know when to go to the nearest accredited Chest Pain Center.

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Category

COVER STORY

6

Carolina Partners

Neuropsychiatrist Is on the Cutting Edge of Treating Brain-Based Disorders

September 2 0 1 3

FEATURES

9

Vol. 4, Issue 8

DEPARTMENTS 10 Women’s Health

Gastroenterology

Constipation: Chronic Functional vs. Irritable Bowel Syndrome Dr. Douglas Drossman reviews Rome III diagnostic distinctions, along with causes and various treatment strategies.

12

Exploring Weight-Loss Tools That Help Improve Quality of Life

14 Endocrinology

Adrenal Incidentalomas

16 Practice Management

Cash Flow for Building Owners

17 Duke Research News

Biochemical Mapping Helps Explain Who Will Respond to Antidepressants

18 Duke Research News

Orthopedics

The Age of Ultrasound: Its Expanding Role in Musculoskeletal Medicine Dr. Matthew Kanaan discusses the increasing role of ultrasound in his practice, its cost benefits and patient satisfaction.

COVER PHOTO: Sandeep Vaishnavi of The Neuropsychiatric Clinic at Carolina Partners.

Discovery Could End Sunburn Pain

20 UNC Research News - Molecular Role of Gene Linked to Blood Vessel Formation Uncovered - The Triangle Physician Editorial Calendar

21 UNC News

Lineberger Cancer Center Appoints Sharpless as Director

22 News

- North Carolina Health Systems are Among Nation’s Most Wired - Raleigh Hand Announces Its Relocation

23 News

- Kanaan Leads Wake Sports Medicine - Garner Healthplex Opens

24 Welcome to the Area & Events

september 2013

3


From the Editor

Mind Expanding This month’s cover story on The Neuropsychiatric Clinic at Carolina Partners gives interesting insight into neuropsychiatry. The subspecialty combines expertise in neurology and psychiatry to definitively diagnose brain-based mental illnesses and

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

determine course of treatment, using psychopharmacology, psychotherapy and cognitive rehabilitation. Diagnosis and treatment is supported by the results of standardized tests and rating systems. The assessments often include genetic testing, which helps the neuropsychiatrist more accurately target individualized treatment, particularly the medication that is likely to be most effective. Understanding is growing about the great many neurological disorders that can affect mood, behavior or cognitive problems. Traumatic brain injury and attention deficit hyperactivity disorder are among them. Innovative treatments are producing encouraging results. Transcranial magnetic stimulation, which uses electrical currents to re-stimulate underactive circuitry within the brain, is found to be effective in treating depression and other brain-based conditions.

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Douglas A. Drossman, M.D. Matthew G. Kanaan, D.O. Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G. Joe Reddy Michael J. Thomas, M.D., Ph.D.

Photography Jack Deere

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This issue of The Triangle Physician introduces us to Matthew Kanaan, a doctor of osteopathic medicine with a special interest in primary care sports medicine. In his article, “The Age of Ultrasound: Its Expanding Role in Musculoskeletal Medicine,” he explains why

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ultrasound is “here to stay.” Gastroenterologist Douglas Drossman gives readers an overview of the subtleties of diagnosing constipation, and endocrinologist Michael Thomas provides an in-depth discussion about adrenal incidentalomas. Gynecologist Andrea Lukes outlines new weight-loss prescriptions and techniques that are helping to improve lives, and practice management consultant Joe Reddy shares a tax strategy for accelerated and significant cash flow.

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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.


Cover Story

Carolina Partners

Neuropsychiatrist Is on the Cutting Edge of Treating Brain-Based Disorders By Heidi Ketler

Neuropsychiatry is a rapidly growing field,

and virtually any neurological disorder that

“Our evaluation involves data collection,

especially at a time when health care re-

affects the brain is shown to have issues

which is more extensive than what a gen-

form is challenging general psychiatry to

with mood or trouble controlling behavior

eral neurologist or psychiatrist offers,”

incorporate more biologically based diag-

or cognitive problems,” says Dr. Vaishnavi.

says Dr. Vaishnavi. “We use computerized

nostic criteria.

“The advantage with neuropsychiatry is

cognitive battery screens and standard-

we often understand where in the brain a

ized rating scales and neurological exams,

“We’re already doing that, so we’re on the

problem stems, and we have the expertise

including those that reveal neurological

leading edge. It’s really where general psy-

to conduct and evaluate standardized as-

soft signs – abnormalities that indicate

chiatry is going in the future,” says Sandeep

sessments and rating scales.”

non-specific cerebral dysfunction. We integrate all of the data sources and come

Vaishnavi, M.D., Ph.D., who heads The Neuropsychiatric Clinic at Carolina Partners. Specialists in the critical subspecialty of

Dr. Vaishnavi sees a wide range of condi-

up with the best hypothesis. Evidence-

tions in three specific clinical types:

based medicine – what has the best data

• A neurological diagnosis that gives

for treatment – follows.”

neuropsychiatry, which is at the nexus

rise to mood, behavioral or cognitive

of neurology and psychiatry, assess, di-

issues such as traumatic brain injury,

Dr. Vaishnavi is fellowship-trained in Be-

agnose and treat disturbances in the cen-

multiple sclerosis, stroke, brain tumor,

havioral Neurology and Neuropsychiatry

Parkinson’s disease, etc.

at Johns Hopkins. He is board certified in

tral nervous system that result in mental

• Cognitive concerns, such as memory

Behavioral Neurology and Neuropsychia-

and Alzheimer’s disease. Diagnoses are

problems or attentional problems.

try by the United Council for Neurologic

based on standardized assessments and

• Complicated mood or anxiety prob-

Subspecialties and in General Psychiatry

diseases, such as traumatic brain injury

rating scales, in addition to patient medi-

lems that could benefit from extensive

by the American Board of Psychiatry and

cal history and neurological examination.

evaluation and testing, including those

Neurology. He completed his residency at

Based on the findings, neuropsychiatrists

where there may be the possibility of

Duke University.

provide individualized treatment plans, us-

a neurological component, but none

ing the full range of options – psychophar-

has been diagnosed.

thored more than 15 articles in medical

macologic, psychotherapeutic, cognitive rehabilitation, and brain stimulation.

Widely published, Dr. Vaishnavi has au-

Testing, evaluation and treatment are avail-

journals, several chapters in textbooks

able at The Neuropsychiatric Clinic for the

and numerous conference proceedings

“I would argue that neuropsychiatric

following brain-based neurological and

and abstracts.

clinical assessment is better oftentimes

psychiatric disorders:

in the sense that we are able to collect a

• ADHD

Dr. Vaishnavi has particular expertise in

lot more information and data. So I feel

• Traumatic brain injury

traumatic brain injury.

like the diagnoses we come up with are

• Dementia

well supported,” says Dr. Vaishnavi. “With

• Stroke

According to the Centers for Disease Con-

an accurate diagnosis, we can more ef-

• Epilepsy

trol and Prevention (CDC), traumatic brain

fectively treat patients…. The whole point

• Brain tumor

injury (TBI) is a worldwide public health is-

of having extensive evaluation is to make

• Multiple sclerosis

sue, affecting military service members and

sure people are on the right track with the

• Movement disorders

veterans, motorists, athletes and victims of

treatment they receive.”

• Mood disorders

interpersonal violence, among others.

• Neurodevelopment disorders, includ“It’s becoming clear that lots of psychiatric

ing autism spectrum and intellectual

Every year in the United States, at least 1.7

illnesses have a brain-based connection,

disability/mental retardation

million TBIs occur either as an isolated in-

6

The Triangle Physician


jury or along with other injuries. About 75 percent of TBIs that occur each year are concussions or other forms of mild TBI. Dr. Vaishnavi’s advanced clinical TBI expertise is included in Management of Adults with Traumatic Brain Injury, an evidence-based manual published this year. The manual covers “core topics in brain injury medicine, including the epidemiology and pathophysiology of TBI, the medical evaluation and neuropsychological assessment of persons with TBI and the common cognitive, emotional, behavioral and other neurological disturbances that follow a TBI.” In the chapter, “Sleep and Fatigue,” Dr. Vaishnavi and two colleagues share the latest understanding of the nature, causes

Dr. Vaishnavi’s advanced clinical expertise is included in Management of Adults with Traumatic Brain Injury, an evidence-based manual published this year.

and treatment strategies for common TBI symptoms, based on clinical research. pression is thought to be the result of an

“It seems most patients retain benefits,

At The Neuropsychiatric Clinic of Carolina

imbalance of these chemicals in the brain,

which is really important and actually

Partners, assessments are used to confirm

TMS works by restoring that balance and

quite remarkable. With medication, pa-

TBI and suggest treatments. Treatment

relieving depression.

tients don’t retain benefits without con-

may include cognitive behavior therapy and pharmacologic treatments.

tinuing Medication. Without medication, TMS is less invasive and has fewer side

they will relapse,” he says.

effects than electro-convulsive therapy. It Neuropsychiatric treatment and assess-

doesn’t require anesthesia or sedation; the

Dr. Vaishnavi has found similar results

ment often involves use of technological

patient remains awake and alert during the

among his patients who are participating

advances. Among the most cutting edge is

treatment.

in TMS therapy. “The majority of them are

transcranial magnetic stimulation (TMS),

getting better, beyond a reduction in symp-

which has shown to be effective therapy

The magnetic fields, which are the same

toms to remission, meaning no depressive

for medication- and treatment-resistant de-

type and strength as those produced by

response, which is really the goal.”

pression.

a magnetic resonance imaging scans, are delivered via a figure-eight coil placed

The typical treatment course involves 30

Dr. Vaishnavi and many other doctors

above the left prefrontal cortex, the part

treatments – five per week for six weeks.

believe TMS could be used to treat even

of the brain involved in mood regulation.

Each session lasts approximately 37 minutes.

more conditions. Clinical trials are cur-

Described as non-systemic, they only

rently under way on the use of TMS to treat

reach about 2-3 centimeters into the brain,

Another advanced technology used in The

cocaine addiction, Tourette’s syndrome,

directly beneath the treatment coil, and

Neuropsychiatric Clinic is genetic testing.

Alzheimer’s disease, and other conditions.

don’t directly affect the whole brain.

Recent advances in neuroscience, genomic, proteomic, and metabolomic knowl-

Available at The Neuropsychiatric Clinic,

Two studies recently presented at the

edge and technologies offer more exciting

the FDA-approved Neurostar TMS therapy

American Psychiatric Association found

opportunities for improved diagnosis and

generates highly concentrated magnetic

long-term benefits six months after treat-

treatment of many illnesses, mental dis-

fields that produce tiny electrical currents.

ment. The studies are continuing to follow

orders included. Dr. Vaishnavi uses avail-

These activate the brain cells thought to

patients to determine one-year data, ac-

able genetic testing for guiding medication

release neurotransmitters like serotonin,

cording to Dr. Vaishnavi.

management.

norepinephrine and dopamine. Since de

september 2013

7


Genetic testing leads to more effective

“ADHD is an area of intense interest. Many

of theta and beta brain waves. In ADHD

pharmacologic treatment in patients suf-

adults wonder if they or their child has it.

children and adolescents, the theta:beta

fering from depression, many of whom

There also is controversy over the use of

ratio is higher than in youngsters without

have had problems finding the right drug

ADHD medication by those who may not

the disorder.

and dose. “Patients metabolize drugs dif-

have the condition. So it’s important that

ferently due to a variety of factors, and

individuals are properly diagnosed. We cer-

Quotient is another FDA-cleared device

research points to a variation in genes as

tainly don’t want to undertreat or overtreat

to objectively assess ADHD. It uses com-

one reason why,” says Dr. Vaishnavi.

someone with ADHD,” says Dr. Vaishnavi.

puterized testing and sensors to quantify

“Genetics is the future of medicine as a

The Neuropsychiatric Clinic at Carolina

of clinical tools is likely to be more com-

whole,” he says. “While genetics in neu-

Partners has unique capabilities for diag-

mon in the future.

ropsychiatry is just getting started, the

nostic accuracy and effective treatment

individualized genetic data helps us indi-

of ADHD, a disorder marked by cognitive

“Primary care and psychiatric practices

vidualize pharmacology for more effective

and attention problems. Objective mea-

without the latest neuropsychiatric tech-

treatments.”

sures at the clinic include neurocognitive

nology and tools go by symptoms as de-

batteries to identify patterns that can con-

scribed by the patient. A lot of times with

The Neuropsychiatric Clinic also has spe-

firm an ADHD diagnosis or other contrib-

ADHD, symptoms are really general,” ex-

cialized testing for ADHD.

uting disorders. The testing offers a defini-

plains Dr. Vaishnavi, adding that anxiety

tive diagnosis, according to Dr. Vaishnavi.

or mood disorders can involve attentional

ADHD symptoms. The use of these kinds

problems.

According to the CDC, more than 8 percent of children in the United States are

The United States Food and Drug Admin-

diagnosed with attention deficit hyper-

istration recently approved the Neuro-

Treatment of ADHD at The Neuropsychiat-

activity disorder (ADHD). That’s about

psychiatric Electroencephalogram-Based

ric Clinic at Carolina Partners may include

5.3 million of those ages three to 17 years

Assessment Aid (NEBA), the first medical

medications, behavioral intervention strat-

old who have this disorder. In North Caro-

device to help assess ADHD in children

egies, parent training, and nutritional and

lina, 10 percent of children are diagnosed

and adolescents six to 17 years old based

lifestyle counseling.

with ADHD.

on brain function. The non-invasive NEBA system calculates the ratio of frequencies

The Neuropsychiatric Clinic is part of Carolina Partners. Carolina Partners in Mental HealthCare P.L.L.C. offers the full continuum of mental health care services via a network of 13 locations throughout the Triangle area, four in Raleigh and three in other regions of North Carolina. The medical staff is comprised of 15 psychiatrists, 11 physician assistants and nurse practitioners and 31 clinical associates. Together they offer the expertise to treat the full spectrum of mental health services. For more information about Carolina Partners and The Neuropsychiatric Clinic at Carolina Partners, visit online at www.carolinapartners.com.

For

more

information about Neurostar TMS, visit online at www.carolinapartners.com. Appointments can be scheduled at The NeuNeuropsychiatrists, like Dr. Viashnavi, assess, diagnose and treat disturbances in the central nervous system that result in mental diseases, such as traumatic brain injury and Alzheimer’s disease.

8

The Triangle Physician

ropsychiatric Clinic at (919) 929-9610 or toll free at (877) 876-3783.


Constipation

Gastroenterology

Chronic Functional vs. Irritable Bowel Syndrome By Douglas A. Drossman M.D.

Constipation is a term patients often use to

constipation by measuring the time it takes

describe symptoms that include straining

for a stool to travel through the colon. Also,

with bowel movements, infrequent bowel

anorectal manometry can help in diagnos-

movements or hard stools. Everyone can

ing pelvic floor dysfunction.

have these symptoms on occasion. However when these symptoms occur frequently

Irritable bowel syndrome (IBS) is a term

or continuously, a patient may have a func-

used to describe recurrent abdominal dis-

tional bowel disorder. When evaluating

comfort that is associated with a change

and managing these patients, it is impor-

in stool frequency or appearance when it

tant to differentiate between the two syn-

begins. (See editorial in July issue of The

dromes - chronic functional constipation

Triangle Physician.) The key element that

and

defines this diagnosis is abdominal dis-

constipation-predominant

irritable

bowel syndrome (IBS-C).

comfort. The discomfort may improve with a bowel movement. Individuals with IBS

Individuals with chronic or functional con-

can experience associated bloating and

stipation are diagnosed, based on Rome

gurgling in the gut, the feeling of incom-

III criteria, as at least six months of two or

pletely evacuating after a bowel movement

more of the following symptoms more than

or the passage of mucus in the stool.

25 percent of the time: • Straining

IBS with constipation (IBS-C) is indicated

• Passing lumpy or hard stools

when an individual has hard or lumpy

• A feeling of incompletely evacuating

stools at least 25 percent of the time and

after a bowel movement • Feeling a sense of blockage when trying to pass stool

loose or watery stools less than 25 percent of the time. IBS-C can be caused by problems with motility through the gastro-

Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation.org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www. drossmancenter.com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patient-provider relationship. Drossman Gastroenterology P.L.L.C. (www. drossmangastroenterology.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management of GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.

• Having to press around the anal open-

intestinal (GI) tract, increased sensitivity to

ing to help a bowel movement pass

GI sensations, altered bacteria within the

• Fewer than three bowel movements

bowel and poor regulation of the brain-gut

if they have concomitant slow colonic tran-

connection.

sit or pelvic floor dysfunction.

These criteria take into consideration the

Treatments for slow-transit chronic con-

If the abdominal discomfort associated with

two main components of chronic constipa-

stipation may include dietary changes;

constipation becomes more persistent, this

tion: the slow movement of food through

laxatives, like polyethylene glycol; or the

may require treatment directed at the brain-

the colon, known as slow-transit constipa-

chloride channel activators lubiprostone

gut pathway, including low-dose tricyclic

tion; and/or problems with passing the

and linaclotide. If pelvic floor dysfunction

antidepressants or serotonin–norepineph-

stool once it reaches the rectum, known as

is revealed, biofeedback can be used to

rine reuptake inhibitors. IBS-C patients may

outlet dysfunction or pelvic floor dysfunc-

teach the patient how to properly relax the

also benefit from psychological treatments

tion. An x-ray may be helpful to evaluate

sphincter muscles when they are straining

like cognitive behavioral therapy.

the amount of stool within the colon. A sitz

to have a bowel movement. Patients with

mark study can evaluate for slow-transit

IBS-C may also respond to these treatments

per week

september 2013

9


Women’s Health

Exploring Weight-Loss Tools that Help Improve Quality of Life By Andrea Lukes, M.D., M.H.Sc., F.A.C.O.G.

“How can I lose weight?” It’s a common

At one point, it was combined with fen-

question among women and men.

fluramine or dexfenfluramine and called “Fen-Phen,” This was a lethal combination

While I was in academic medicine, I

that led to 24 cases of heart valve disease,

encouraged exercise and change in diet

as well as cases of pulmonary hyperten-

without offering much more. Now that I

sion and some deaths among Fen-Phen

am in private practice, I have changed

users.

my approach and continue to learn more about management of obesity and just

Studies showed that 30 percent of the

“losing a few pounds.”

people taking fenfluramine or dexfenfluramine had abnormal valve findings. The

Certainly, exercise and good nutrition

finding led to the voluntary removal of

are indispensible to long-term success

fenfluramine (or dexfenfluramine) from

in losing weight. What you eat and drink

the market. However, the FDA has never

makes a difference. I also believe that

asked manufacturers to remove phenter-

losing 3-5 pounds with assistance can

mine from the market.

help motivate individuals to make better choices in diet and increase exercise.

Recent evidence has emerged that fenfluramine

and

its

metabolites

Phentermine and Weight Loss

has activity at the 5HT2B receptor;

So for the last five years, I have prescribed

whereas, phentermine does not. This

phentermine because of the positive impact

led researchers to determine that the

it has had for many of my patients. Phen-

increased risk of cardiac valvulopathy

termine was first approved by the United

was not due to phentermine. (See the

States Food and Drug Administration as an

FDA website.)

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, and to become founder and chair of the Ob/Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.

appetite-suppressing drug in 1959. The new medication Qsymia, which combines phentermine with topiramate, has emerged as an important medication for treating obesity. I have written about this in a prior issue of The Triangle Physician. Having prescribed this medication over the past 10 months, I find it to be both effective and well tolerated. A newer medication, Belviq is indicated for chronic weight management. It is used in combination with a reduced-calorie diet and exercise. Although my experience is more limited with Belviq compared to phentermine and Qsymia, I have begun to incorporate it into my approach to weight management.

10

The Triangle Physician


area. This nonsurgical technology is a huge step in body contouring.” For more information about CoolSculpting, call (919) 381-5540 or visit www.diehlplastics.com or www.coolsculpting.com. New

weight-loss

procedures

can

medications be

life

and

changing.

Supporting someone in this effort can make a huge difference.

New Non-Invasive CoolSculpting

a release of cytokines and additional

Just recently I saw a woman for a return

inflammatory mediators that over two

visit who is married and in her mid-40s.

CoolSculpting is a revolutionary non-

to four months eliminate the affected

She had lost 21 pounds during the past

surgical

fat cells. This ultimately reduces the

six months with medical assistance. She

thickness of the fat layer.

was thrilled, felt more confident and had

procedure

using

advanced

cooling technology to eliminate fat in

reduced her HgA1c. Before she left my

specific areas of the body. “We

have

seen

very

high

patient

office, she gave me a hug.

The science involves cryolipolysis, which

satisfaction with CoolSculpting,” said

cools adipose tissue to induce lipolysis

Cynthia Diehl, M.D., who offers the

Although she wants to give me credit,

(breaking down fat cells) without damage

procedure at Diehl Plastic Surgery. “In the

I emphasized that she was the one who

to other tissues. The cooling causes fat

appropriate patient, we can expect a 20-25

made the positive change in her life.

cell apoptosis (death), which leads to

percent fat reduction to a specific problem

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919-571-3661

www.CarolinaEndocrine.com Dr. Michael Thomas, Ph.D. Dr. Khushbu Chandarana Courtney Kovalick, PA-C Eileen Andres, PA-C

september 2013

11


Orthopedics

The Age of

Ultrasound

Its Expanding Role in Musculoskeletal Medicine By Matthew G. Kanaan, D.O.

It’s indisputable that technology has, and

of physicians. Fields like radiology, ob-

is, changing the way medicine is prac-

gyn, emergency medicine and anesthesia

ticed across the globe. Every time a physi-

have for years used this technology, both

cian thinks he or she has learned the next

through the use of sonographers and

and greatest skill or procedure, yet an-

through their own training. And within

other technological advance has arrived.

the last few years, ultrasound has found

While physicians are sometimes skeptical

its way into the musculoskeletal fields,

of the potential effects on patient care, re-

such as orthopedics, sports medicine

imbursements and the implications that

and physical medicine and rehabilitation.

new skills have on their own knowledge

Ultrasound not only allows direct visual-

base, there is no doubt patients latch on

ization of needle placement for common

Dr. Matthew Kanaan is a primary care sports medicine specialist at Wake Sports Medicine in Raleigh. He completed his medical residency training at Duke Medical Center. During his fellowship training at Duke Sports Medicine, Dr. Kanaan received special instruction in musculoskelatal ultrasound, a unique, state-ofthe-art technology in the orthopedic field. While completing training in primary care sports medicine, Dr. Kanaan served as an assistant team physician for Duke football, basketball and lacrosse, and he assisted with Elon University football. For more information, contact Wake Sports Medicine at (919) 719-2270 or visit wakesportsmedicine.com. study that has ever been performed in the literature has proven ultrasound to be significantly more accurate than a blind injection. This matters for several reasons, including unintended trauma to surrounding structures, the decision to consider an injection a failure and the ability to place medications precisely where they have the greatest potential for maximal effect.

to these new technologies almost instant-

injections, but enables the physician to

ly. It seems akin to the visceral urge that

perform more difficult injections that were

As for patients, they love it. Not only are

consumers have to purchase the latest

once only performed under computed to-

they able to see the pathology that is be-

and greatest smartphone despite having a

mography or fluoroscopic guidance.

ing discussed in real time, but they often

more-than-capable current model.

seem to enjoy seeing the needle hit its The reason ultrasound-guided injections

target. The ultrasound machine becomes

Ultrasound has been around a long time

may be more beneficial really comes

both a point-of-care teaching tool and a

in the medical field, but with significant

down to accuracy, patient satisfaction and

much-needed distracter for an otherwise

advancements in portability, cost and

cost concerns. Not only can the physi-

unpleasant visit. Both in the literature and

resolution, it is now finding its way out

cian perform targeted injections of spe-

anecdotally, patients seem to experience

of the hospital and into the direct hands

cific joints, tendons and nerves, but every

less pain and discomfort, and overall pa-

12

The Triangle Physician


tient satisfaction seems to be higher when using point-of-care ultrasound. The lack of

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the patient and the health care system will be decreased. Regardless of the discussion for and against using point-of-care ultrasound, it is here to stay and will only grow in both the number of applications and in popularity among patients. In fact, most United States medical schools are either creating or looking to create comprehensive ultrasound curricula for their incoming students. It won’t be long before the physical

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exam portion of a physician’s note has an ultrasound-finding section. References 1. Daley, Bajaj, Bisson, Cole. Improving Injection Accuracy of the Elbow, Knee, and Shoulder: Does Injection Site and Imaging Make a Difference? A Systematic Review Am J Sports Me. January 21, 2011 2. Bankhurst et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol 2009; 36(9): 1892–902. 3. https://www.aamc.org/newsroom/reporter/ dec2012/323592/ultrasound.html

september 2013

13


Endocrinology

Adrenal Incidentalomas By Michael J. Thomas, M.D., Ph.D.

The incidentally discovered adrenal mass

In either instance, repeat adrenal imag-

is a common radiologic finding, typically

ing at six-12 months can determine if an

witnessed on a computed tomography or

adrenal mass is radiographically stable.

magnetic resonance imaging scan that

The presence of calcium deposits in an

was performed for some other clinical

adrenal lesion can suggest granulomatous

reason. Endocrine evaluation of adrenal

disease (e.g. tuberculosis).

masses is necessary to establish whether an adrenal lesion is benign and/or func-

Adrenal incidentalomas are usually non-

tional (i.e. producing hormones). The

functional, but about 5 percent secrete

overall incidence of adrenal “inciden-

hormones. The type of hormones being

talomas” increases with age, but is esti-

produced depends upon whether the tu-

mated to be between 2-4 percent of the

mor is arising from the adrenal medulla

adult population, depending on the de-

(catecholamines) or the adrenal cortex

mographic background and the imaging

(steroid hormones). Therefore, functional

study. Typically, these lesions are greater

adrenal incidentalomas typically produce

than1 centimeter and may be unilateral or

hormones that may produce clinical syn-

bilateral.

dromes in one of four broad categories: catecholamine excess, corticosteroid ex-

The vast majority of adrenal lesions are

cess, aldosterone excess and adrenal an-

benign. (Less than 1 percent is malig-

drogen excess (see Table I).

nant.) Generally, nodules greater than 4-5 centimeters in size should be considered

History and physical examination findings

for surgical excision (to rule out malignan-

can help guide the evaluation. Reviewing

cy). However, it is important to exclude

the reason for the imaging study might

pheochomocytoma,

Dr. Michael Thomas of Carolina Endocrine P.A. graduated from the School of Medicine at West Virginia University in Morgantown, with a doctor of medicine and doctor of philosophy in pharmacology and toxicology. He completed his post-graduate medical training at Barnes Hospital at Washington University in St. Louis, including his internship, residency and fellowship in endocrinology. Dr. Thomas was previously a faculty member in endocrinology/medicine at Washington University, the University of Iowa and the University of North Carolina at Chapel Hill. He established Carolina Endocrine in the summer of 2005. Board certified in internal medicine and endocrinology, Dr. Thomas is licensed to perform endocrine nuclear medicine procedures and therapies at Carolina Endocrine. He is a fellow of the American College of Endocrinology (FACE) and has completed endocrine certification in neck ultrasound (ECNU). For more information and patient referrals and appointments call (919) 571-3661 or visit the practice website at carolinaendocrine.com.

catecholamine-

suggest associated parts of a syndrome.

producing tumor that can cause marked

Determining whether it might have been

hypertension, anxiety/depression, body

fluctuations in blood pressure and heart

noted (perhaps overlooked) on a previous

habitus, diabetes mellitus, hypokalemia,

rate (see below).

imaging study can help establish stability

changes in hair/skin texture or masculin-

or growth. Reviewing physical biochemi-

ization/acne.

a

Adrenal carcinoma is relatively rare, but

cal clues for functionality might include

other malignancies found in the adrenal gland include metastatic cancers (e.g.

Table I – Types of Hormonally-Active Adrenal Tumors 1

lung). Certain radiologic features, such as

Hormone

Syndrome

Initial Screening Diagnostic Test(s)

Catecholamine

Pheochromocytoma

Serum metanephrines, 24 hr urine catecholamines (VMA, metanephrine of Epi/Norepi)

Corticosteroid

Cushing’s Syndrome

Overnight dexamethasone suppression test, 24 hr urine free cortisol, midnight salivary cortisol

Aldosterone

Primary Hyperaldosteronism

Serum aldosterone/renin ratio, saline suppression test

Androgens

Androgenization, early puberty

DHEA, Testosterone

density on CT scan, can predict whether a tumor is likely to be benign of malignant. Unenhanced CT lesions that have a Hounsfield unit value of less than 10 are likely to be benign adrenal adenomas. Similarly, enhanced CT lesions that display greater than 50 percent washout at 10 minutes after washout are likely to be benign.

14

The Triangle Physician


Laboratory evaluation includes either se-

ARR values greater than 20 suggest the

Finally, adrenal tumors can infrequently

rum metanephrines and/or 24-hour urine

presence of primary hyperaldosteronism,

cause hirsutism, and sometimes viriliza-

catecholamines (either VMA/metaneph-

although additional confirmatory endo-

tion in women, and less commonly, pre-

rines or epinephrine/norepinephrine)

crine testing is needed to establish this

mature pubertal problems in children and

to rule out the most serious functional

diagnosis. Hypokalemia is often seen in

adolescents. Once size, functionality and

tumor, pheochromocytoma. Elevated se-

primary hyperaldosteronism. Sometimes,

stability of adrenal incidentalomas have

rum metanephrines have a false-positive

a saline suppression test can determine

been excluded, then patient may forego

rate as high as 10 percent, particularly if

if aldosterone is suppressible. Additional

any further diagnostic or therapeutic in-

the patient is not supine for several min-

diagnostic confirmation usually requires

tervention or undergo periodic follow-up

utes or if there is significant needlestick

bilateral adrenal vein sampling, in order

surveillance.

trauma during phlebotomy. However, a

to establish whether a gradient exists, sug-

normal serum metanephrine has a very

gesting a unilateral aldosterone-producing

Reference

low false-negative rate (less than 1 per-

tumor or bilateral nodular adrenal hyper-

1

cent), which can be further monitored by

plasia.

Young, WF., N Engl J Med 2007; 356:601-610.

follow-up surveillance and/or a 24-hour urine catecholamine. Evaluation (Cushing’s

of

corticosteroid

syndrome)

is

excess usually

screened with an overnight dexamethasone suppression test: administration of 1 milligram dexamethasone at 11 p.m. the night before an 8 a.m. cortisol. The normal physiologic response is suppression of serum cortisol to less than 1.8 mcg/dL. This test has a very low falsenegative rate, but frequently can yield false-positive rates in very heavy individuals, persons under excessive physiologic or emotional stress or deviations from clinical protocol. In those instances, a 24-hour urine free cortisol may be preferred. Again, elevations in cortisol production can include a variety of environmental stressors, which need to be further evaluated by more specific diagnostic tests. Pituitary adrenocorticotrophin hormone (ACTH) in the presence of cortisol-producing adrenal tumors is typically suppressed. In hypertensive or hypokalemic patients, the aldosterone/renin ratio (ARR) can be measured, usually in the morning, after the patients have been upright for at least two hours. However, these results cannot be interpreted in patients who are taking diuretics, which should be discontinued for about four weeks before attempting to interpret the absolute risk reduction (ARR). Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

september 2013

15


Practice Management

Cash Flow for Building Owners By Joe Reddy

In keeping with the survivalist theme of

depreciation. The study accelerates the

health care providers, I want to introduce

depreciation of your building/renovation

a tax strategy that could lead to significant

components into faster depreciation cate-

cash flow acceleration for those who own

gories such as 5-, 7-, and 15-year schedules

their building. Unless you retain the servic-

rather than conventional 27.5 and 39-year.

es of a Big 4 accounting firm, you’ve likely

Moreover, this can be achieved without

never heard of this strategy.

amending returns. The study to support

A tax strategy that could lead to significant cash flow acceleration for those who own their building The strategy is known as “cost segrega-

the accelerated depreciation covers the

tion.” This is an Internal Revenue Service-

building walls, flooring and ceilings; and

approved method. Most certified public

its plumbing, electrical, lighting, telecom-

accounting firms don’t have cost-effective

munications, HVAC, etc.

Joe Reddy is the owner of RevMedRx, a North Carolinabased revenuecycle management company. RevMedRx offers sophisticated, yet affordable, solutions to today’s complex practice management needs with a focus on efficiency and cash-flow optimization. Joe Reddy can be reached at joe.reddy@ revmedrx.com. To learn more, visit www.revmedrx.com.

As a commercial property owner, you could qualify for cash flow from tax savings

engineering specialists who can produce an IRS-defined study to support the appli-

Hundreds of thousands of taxpayers have

of 7 percent to 10 percent of your building

cation. Yet, all tax professionals can apply

utilized cost segregation studies to defer

cost within five years of ownership. That

the tax-saving strategy when provided the

millions of tax dollars. The best economic

translates to $70,000-$100,000 for each $1

correct documentation from an engineer-

results are achieved for properties built or

million in building costs. A no-cost predic-

ing study.

purchased in the last 15 years, although all

tive analysis can be done to estimate the

are eligible post-1986, with the exception

tax-saving amount and eligibility before

The core of the strategy is justifying the

of non-profit businesses. Keep in mind that

you engage a study. Feel free to send me

reclassification of real property as per-

the cost of land is not part of a deprecia-

an e-mail or call my office for additional

sonal property in order to obtain faster

tion schedule.

information.

Cary Endocrine & Diabetes Center, P.A.

CEDC provides diagnosis and treatment for patients with hormonal and metabolic disorders including: diabetes, lipid disorders, PCOS, thyroid disorders, osteoporosis and other bone disorders, pituitary disorders, adrenal disorders, and sex hormone disorders.

Celebrating our first year in Cary!

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On-Site Services: • Thyroid, parathyroid and neck ultrasound • Ultrasound guided FNA • DEXA bone density scans and interpretation • Osteoporosis therapy • Comprehensive diabetes management including diabetes education, insulin pump therapy, and continuous glucose monitoring • LabCorp in-house Introducing Jeanne Hutson, NP-C Board Certified in Advanced Diabetes Management

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16

The Triangle Physician


Duke Research News

Biochemical Mapping Helps Explain Who Will Respond to Antidepressants Duke Medicine researchers have identified

SSRI treatment. Others may respond to pla-

leading to melatonin and methoxyindoles

biochemical changes in people taking anti-

cebo, while some may not find relief from

were seen in patients taking the SSRI who

depressants – but only in those whose de-

either. This variability in response creates

responded to the treatment; these changes

pression improves. These changes occur

dilemmas for treating physicians where the

were not found in those who did not re-

in a neurotransmitter pathway that is con-

only choice they have is to test one drug at

spond to the antidepressant.

nected to the pineal gland, the part of the

a time and wait for several weeks to deter-

endocrine system that controls the sleep

mine if a patient is going to respond to the

The results suggest that serotonin metabo-

cycle, suggesting an added link between

specific SSRI.

lism in the pineal gland may play a role in the underlying cause of depression and

sleep, depression and treatment outcomes. Recent studies by the Duke team have used

its treatment outcomes, based on the bio-

The study, published on July 17, in the jour-

metabolomics tools to map biochemical

chemical changes that were seen to be as-

nal PLOS ONE, uses an emerging science

pathways implicated in depression and

sociated with improvements in depression.

called pharmacometabolomics to measure

have begun to distinguish which patients re-

and map hundreds of chemicals in the

spond to treatment with an SSRI or placebo

“This study revealed that the pineal gland

blood in order to define the mechanisms

based on their metabolic profiles. These

is involved in mechanisms of recovery

underlying disease and to develop new

studies have pointed to several metabolites

from a depressed state,” said Dr. Kaddurah-

treatment strategies based on a patient’s

on the tryptophan metabolic pathway as

Daouk. “We have started to map serotonin,

metabolic profile.

potential contributing factors to whether pa-

which is believed to be implicated in de-

tients respond to antidepressants.

pression, but now realize that it may not be serotonin itself that is important in depres-

“Metabolomics is teaching us about the differences in metabolic profiles of patients

Tryptophan is metabolized in different

sion recovery. It could be metabolites of

who respond to medication and those

ways. One pathway leads to serotonin and

serotonin that are produced in the pineal

who do not,” said Rima Kaddurah-Daouk,

subsequently to melatonin and an array of

gland that are implicated in sleep cycles.

Ph.D., associate professor of psychiatry

melatonin-like chemicals called methoxy-

and behavioral sciences at Duke Medicine

indoles produced in the pineal gland. In

“Shifting utilization of tryptophan metabo-

and leader of the Pharmacometabolomics

the current study, the researchers analyzed

lism from kynurenine to production of mel-

Research Network.

levels of metabolites within branches of the

atonin and other methoxyindoles seems

tryptophan pathway and correlated chang-

important for treatment response but some

es with treatment outcomes.

patients do not have this regulation mecha-

“This could help us to better target the right

nism. We can now start to think about ways

therapies for patients suffering from depres-

to correct this.”

sion who can benefit from treatment with

Seventy-five patients with major depressive

certain antidepressants and identify early on

disorder were randomized to take sertra-

patients who are resistant to treatment and

line (Zoloft) or placebo in the double-blind

The identification of a metabolic signa-

should be placed on different therapies.”

trial. After one week and four weeks of tak-

ture for patients who have a milder form

ing the SSRI or placebo, the researchers

of depression and who can improve with

Major depressive disorder – a form of depres-

measured improvement in symptoms of

use of placebo is critically important for

sion characterized by a severely depressed

depression to determine response to treat-

streamlining clinical trials with antidepres-

mood that persists two weeks or more – is

ment, and blood samples were taken and

sants. The Duke team is the first to start to

one of the most prevalent mental disorders

analyzed using a metabolomics platform

define in-depth early biochemical effects

in the United States, affecting 6.7 percent of

build to measure neurotransmitters.

of treatment with SSRI and placebo, and a molecular basis for why antidepressants

the adult population in a given year. The researchers observed that 60 percent

take several weeks to start showing benefit.

Selective serotonin reuptake inhibitors (SS-

of patients taking the SSRI responded to

In future studies, researchers may collect

RIs) are the most commonly prescribed

the treatment, and 50 percent of those tak-

blood samples from patients during both

antidepressants for major depressive dis-

ing placebo also responded. Several meta-

the day and night to define how the circa-

order, but only some patients benefit from

bolic changes in the tryptophan pathway

dian cycle and changes in sleep patterns,

september 2013

17


Duke Research News neurotransmitters and hormonal systems

of Duke-NUS Graduate Medical School in

additional members of the Pharmacome-

are modified in those who respond and do

Singapore; Mikhail B. Bogdanov of Weill

tabolomics Research Network.

not respond to SSRIs and placebo. This can

Cornell Medical College in New York;

lead to more effective treatment strategies.

Wayne Matson and Swati Sharma of Bed-

Dr. Kaddurah-Daouk and several of the

ford VA Medical Center in Massachusetts;

study authors hold patents in the metabo-

In addition to Dr. Kaddurah-Daouk, study

Samantha Matson of Bedford VA Medical

lomics field. A full list of author disclosures

authors include Hongjie Zhu, Stephen H.

Center and Massachusetts General Hospi-

can be found in the manuscript. The re-

Boyle and Erik Churchill of Duke; Ranga R.

tal; Oliver Fiehn of the University of Cali-

search was supported by the National In-

Krishnan of Duke and Duke-NUS Graduate

fornia, Davis; Eve Pickering and Marielle

stitute of General Medical Sciences (RC2-

Medical School in Singapore; John A. Rush

Delnomdedieu of Pfizer Global R&D; and

GM092729) and Pfizer.

Discovery Could End Sunburn Pain The painful, red skin that comes from too

Blocking this molecule, called TRPV4,

the National Academy of Sciences (PNAS)

much time in the sun is caused by a mol-

greatly protects against the painful effects

online edition. The research, which was

ecule abundant in the skin’s epidermis, a

of sunburn. The results were published

conducted in mouse models and human

new study shows.

the week of Aug. 5 in the Proceedings of

skin samples, could yield a way to combat sunburn and possibly several other causes of pain. “We have uncovered a novel explanation for why sunburn hurts,” said Wolfgang Liedtke, M.D., Ph.D., one of the senior authors of the study and associate professor of neurology and neurobiology at Duke University School of Medicine. “If we understand sunburn better, we can understand pain better because what plagues my patients day in and day out is what temporarily affects otherwise healthy people who suffer from sunburn.” The vast majority of sunburns are caused by ultraviolet B or UVB radiation. In moderation, this component of sunlight does the body good, giving a daily dose of vitamin D and perhaps improving mood. But if people get too much, it can damage the DNA in their skin cells and increase their susceptibility to cancer. Sunburns are nature’s way of telling people to go inside and avoid further damage. Dr. Liedtke worked together with a multiinstitutional team of researchers: Elaine Fuchs, Ph.D., a professor at Rockefeller University and an investigator with the Howard Hughes Medical Institute who is a widely renowned skin biologist; and

18

The Triangle Physician


Duke News Martin Steinhoff, M.D., Ph.D., professor of

To test whether these findings in mice and

cluding skin cancer or skin photo-aging,

dermatology and surgery at the University

mouse cells have human relevance, the

though more work must be done before

of California in San Francisco who is well-

researchers used human skin samples to

TRPV4 inhibitors can become part of

known for his studies on sensory function

successfully demonstrate increased acti-

the sun-defense arsenal, perhaps in new

of skin in health and disease.

vation of TRPV4 and endothelin in human

kinds of skin cream or to treat chronic sun

epidermis after UVB exposure.

damage,” said Steinhoff, co-senior author of the study.

Together, they investigated whether the TRPV4 molecule, which is abundant in

To see if they could block this novel pain

skin cells and has been shown to be in-

pathway, the researchers used a pharma-

“I think we should be cautious, because

volved in other pain processes, might

ceutical compound called GSK205 that

we want to see what inhibition of TRPV4

play a role in the pain and tissue damage

selectively inhibits TRPV4. They dissolved

will do to other processes going on in the

caused by UVB over-exposure. TRPV4

this compound into a solution of alcohol

skin,” Dr. Liedtke added. “Once these con-

is an ion channel, a gateway in the cell

and glycerol – basically, skin disinfectant

cerns will be addressed, we will need to

membrane that rapidly lets in positively

– and then applied it to the hind paws of

adapt TRPV4 blockers to make them more

charged ions, such as calcium and so-

normal mice. The researchers found that

suitable for topical application. I could

dium.

the mice treated with the compound were

imagine it being mixed with traditional

again largely resistant to the pain-inducing

sunblock to provide stronger protections

First, the researchers built a mouse model

and skin-disrupting effects of sunburn.

against UVB exposure.”

that was missing TRPV4 only in the cells

Similarly, when they administered the

of the epidermis, the outermost layer of

compound to mouse skin cells in culture,

The research was supported by grants

the skin. They took these genetically en-

they found that it stopped the UV-trig-

from the National Institutes of Health

gineered mice and their normal coun-

gered influx of calcium ions into the cells.

(DE018549,

DE018549S1,

DE018549S2,

AR059402, AR31737, AR050452 and P41

terparts and exposed their hind paws – which most resemble human skin – to

“The results position TRPV4 as a new tar-

EB015897) and the German Research

UVB rays. The hind paws of the normal

get for preventing and treating sunburn,

Foundation (DFG; DFG STE 1014/2-2, DFG

mice became hypersensitive and blis-

Ce165/1-1 and probably chronic sun 8/5/10 damage, 12:57 inNEWSOURCE-JUN10:Heidi PM Page and 1 DFG Ke1672/1-1).

tered in response to the UVB exposure, while those of the mutant mice showed little sensitization and tissue injury. Next, they used cultured mouse skin cells

Do They Like What They See?

to dissect the activities of TRPV4. Using a device engineered by Nan Marie Jokerst, Ph.D., a professor of electrical and com-

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puter engineering at Duke’s Pratt School of Engineering, the researchers showed that UVB caused calcium to flow into the skin cells, but only when the TRPV4 ion channel was present.

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Further molecular analysis uncovered the entire sequence of events in this pathway, with each event affecting the next: UVB exposure activates TRPV4, which causes the influx of calcium ions, which brings in another molecule called endothelin,

newsource & Associates

which triggers TRPV4 to send more calcium into the cells. Endothelin is known to cause pain in humans and also evokes itching, which could explain the urge sun-

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burned patients feel to scratch their skin.

september 2013

19


UNC Research News

Molecular Role of Gene Linked to Blood Vessel Formation Uncovered University of North Carolina researchers have discovered that disrupting a gene that acts as a regulatory switch to turn on other genes can keep blood vessels from forming and developing properly. Further study of this gene – a “transcription factor” called CASZ1 – may uncover a regulatory network that influences the development of cardiovascular disease. A number of other studies have already shown a genetic link between mutations in CASZ1 and hypertension. The UNC research, which was carried out in a frog model as well as human cells, was published April 29 in the journal Developmental Cell. “There has been a lot of interest in studying the vasculature, because of its role in a wide range of disease states, as well as human development. But there are very few transcription factors that are known to affect the vasculature,” said senior study author Frank Conlon, Ph.D., an associate professor of genetics in the UNC School of Medicine. “To find a new one is quite unique and then to be able to link it up to a known network of vascular development is surprising and encouraging.” During vascular development, specialized cells coalesce into three-dimensional

“cords” that hollow out to provide a path for transporting blood throughout the body. This process involves the complex coordination of molecular entities like growth factors and signaling molecules, defects that have been associated with human illnesses such as cancer, stroke and atherosclerosis. Dr. Conlon has long been interested in understanding how these various molecular players come together in the cardiovascular system. In 2008, his laboratory showed that a gene called CASZ1 is involved in the development of heart muscle. In this study, he and his colleagues decided to look for its role in the development of blood vessels. Marta S. Charpentier and Kathleen S. Christine, lead authors of the study and graduate students in Dr. Conlon’s laboratory, removed CASZ1 from frog embryos and looked to see how its absence affected the development of the vasculature. Without CASZ1, the frogs failed to form branched and functional blood vessels. When they removed the CASZ1 gene from cultured human cells, Ms. Charpentier and Ms. Christine saw similar defects: the cells did not sprout or branch correctly due to their inability to maintain proper adhesions with the surrounding extracellular matrix.

“If you take out CASZ1, these cultured human cells try to migrate by sending out these filopodia or little feet, but what happens is it is like someone nails down the back end of those growing vessels. They try to move and keep getting thinner and thinner, and like an elastic band it gets to be too much and just snaps back. It appears to cause an adhesion defect that makes the cells too sticky to form normal vessels,” said Dr. Conlon. CASZ1 is a transcription factor, a master switch that controls when and where other genes are expressed. Therefore, Ms. Charpentier and Ms. Christine did a series of experiments to explore CASZ1’s influence on a known vascular network, involving other genes called Egfl7 and RhoA. When they added the Egfl7 gene to the CASZ1-depleted cells, the defect in blood vessel formation went away, suggesting that the two genes are connected. They then showed that CASZ1 directly acts on the Egfl7 gene, and this activity in turn activates the RhoA gene, which is known to be required for cellular behaviors associated with adhesion and migration. Transcription factors themselves are so essential that they are generally considered to be “undruggable,” but the researchers said that further studies into how specific transcription factors work and the targets

The Triangle Physician 2013-2014 Editorial Calendar October Cancer in Women, COPD - Lung Health Medical Software - EMR

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November Alzheimer’s Disease Diabetes, Financial Planning

December Pain Management, Spine Disorders Practice Management

January Diabetes Endocrinology

April Pediatrics Infectious disease

July Sports medicine Rheumatology

October Cancer in women Wound management

February Cardiology Ophthalmology

May Women’s health Neurology

August Gastroenterology Nephrology

November Urology ADHD

March Orthopedics Hematology

June Cancer in men Pulmonary

September Bariatrics Neonatology

December Otorhinolaryngology Pain management

The Triangle Physician


UNC Research News they control could eventually lead to new drug candidates. “Egfl7 is a therapeutic target of interest, because companies such as Genentech are already working on it for cancer therapy,” said Ms. Charpentier. “Figuring out how it is regulated is important not just for

understanding the biology of it, but also for discovering targets that could trigger the development of innovative therapeutic strategies for cardiovascular disease.” Study co-authors from UNC were Nirav M. Amin, Ph.D.; Kerry M. Dorr; Erich J. Kushner, Ph.D.; Victoria L. Bautch, PhD; and

Joan M. Taylor, Ph.D. The research was a collaboration among the labs of Drs. Conlon, Taylor and Bautch at the McAllister Heart Institute at UNC and was funded by the National Institutes of Health and the American Heart Association.

Lineberger Cancer Center Appoints Sharpless as Director Norman “Ned” Sharpless, M.D., has been appointed director of the University of North Carolina Lineberger Comprehensive Cancer Center, effective Jan. 1, 2014. Dr. Sharpless succeeds H. Shelton “Shelley” Earp, M.D., who will continue as director of UNC Cancer Care, a role in which he coordinates cancer care and research across the School of Medicine, the university and UNC Health Care System. “Ned Sharpless is an exceptional choice to become only the third director in UNC Lineberger’s history,” said William Roper, M.D., M.P.H., dean of the school of medicine, vice chancellor for medical affairs and chief executive officer of University of North Carolina Health Care System. “Our Cancer Center has grown dramatically in multidisciplinary clinical capability, research productivity, funding and national stature. As an outstanding clinician, nationally recognized researcher and scientific entrepreneur, Ned will lead UNC Lineberger to even greater accomplishments in its second half century.” Dr. Sharpless is a Morehead scholar and honors graduate of UNC and the UNC School of Medicine. He is currently the Wellcome distinguished professor of cancer research, professor of medicine and genetics and UNC Lineberger’s deputy director. A practicing medical oncologist, trained at the Dana-Farber Cancer Institute and Massachusetts General Hospital, Dr. Sharpless leads a well-funded, 20-person

cancer research laboratory. His program uses genetically engineered mouse models to study cancer and aging. His more than 100 fundamental and translational scientific articles have been published in the world’s best journals, among them Cell, Nature, New England Journal of Medicine, Cancer Cell and The Journal of Clinical Investigation. “Ned is a star in the world of oncology,” said Marschall Runge, M.D., Ph.D., executive dean of the school of medicine. “He is a unique individual who has made major contributions to understanding the fundamental aspects of cancer biology. He is not only a renowned physician and researcher but a great leader, as well.” Edward Benz, M.D., president, Dana-Farber Cancer Institute and a member of the University Cancer Research Fund Committee, said, “Ned is the ideal leader to carry forward Dr. Joe Pagano’s and Dr. Shelley Earp’s legacy of distinguished leadership. He possesses the academic talent and stature, the personal qualities, the vision and the energy to make certain that UNC Lineberger Comprehensive Cancer Center plays its leading role in the campaign to conquer cancer.” Dr. Sharpless is an inventor with 12 patents that form the core intellectual property for two Research Triangle start-up companies he co-founded. He established and co-leads two major UNC Lineberger initiatives: the Mouse Phase 1 unit, which tests innovative therapies in preclinical models

of cancer; and UNCSeq, which coordinates a large faculty team using massively parallel sequencing technology for the benefit of individual patients with cancer. A recipient of numerous foundation awards, including those from the Sidney Kimmel, Ellison and Burroughs Wellcome foundations, Dr. Sharpless has advanced the science of biomarkers, aging and cancer and novel approaches to therapy. He serves as an editor of The Journal of Clinical Investigation and Aging Cell and has been named a member of the American Society of Clinical Investigators, to which he was recently elected a member of the governing council. “Ned is a creative force with an encyclopedic knowledge of clinical oncology and a remarkable grasp of the core sciences, cancer biology and genomics,” said Dr. Earp. “His stature as a nationally-recognized clinician scientist, his energy and his North Carolina roots make him the perfect choice as the next leader of North Carolina’s public comprehensive cancer center.”

september 2013

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News

North Carolina Health Systems are Among Nation’s Most Wired Six health care systems in North Carolina were named among nearly 300 across the country as “Most Wired” by Hospitals & Health Networks magazine. The state’s “Most Wired” health care systems are: Alamance Regional Medical Center in Burlington; Carolinas HealthCare System in Charlotte; FirstHealth of the Carolinas in Pinehurst; Mission Hospital in Asheville; Vidant Health in Greenville; and Womack Army Medical Center, Fort Bragg. Results of the 2013 Most Wired Survey were released in the July issue of H&HN. This year marks the 15th anniversary of Health Care’s Most Wired Survey. Since the first survey, “hospitals and health care systems have made great strides in establishing the basic building blocks for creating robust clinical information systems aimed at improving patient care. This includes adopting technologies to improve patient documentation, advance clinical decision support and evidence-based protocols, reduce the likelihood of medication errors and rapidly restore access to data in the case of a disaster or outage,” an H&HN press advisory reported. The next step is “harnessing IT for the real work of improving care delivery.”

ducted between Jan. 15 and March 15, asked hospitals and health systems nationwide to answer questions regarding their information technology initiatives. Respondents completed 659 surveys, representing 1,713 hospitals, or roughly 30 percent of all United States hospitals.

• Sixty-six percent of Most Wired hospitals share patient discharge data with affiliated hospitals, in comparison to 49 percent of the total responders. Thirtyseven percent of Most Wired hospitals do so with non-affiliated hospitals versus 24 percent of total responders.

“This year’s Most Wired organizations exemplify progress through innovation,” said Rich Umbdenstock, president and chief executive officer of the American Hospital Association. “The hospital field can learn from these outstanding organizations ways that information technology can help to improve efficiency.”

“The concept of health information exchange is absolutely correct,” says Russell P. Branzell, president and CEO of the College of Healthcare Information Management Executives. “We need to do it and do it in a robust, refined way. The answer here is standards, standards, standards. We need to standardize the entire process, which we’ve done in almost every other business sector.”

H&HN reported the following key findings of the survey this year: • Sixty-nine percent of Most Wired hospitals and 60 percent of all surveyed hospitals report that medication orders are entered electronically by physicians. This represents a significant increase from 2004 results when only 27 percent of Most Wired hospitals and 12 percent of all hospitals responded, “Yes.” • Seventy-one percent of Most Wired hospitals have an electronic disease registry to identify and manage gaps in care across a population compared with 51 percent of total responders.

The 2013 Most Wired Survey also covered some new areas, such as big data analytics and patient-generated data. An emerging practice, big data analytics looks at large amounts of data to uncover patterns and correlations. The 2013 Most Wired Survey is conducted in cooperation with McKesson Corp., AT&T, the College of Healthcare Information Management Executives and the American Hospital Association.

Raleigh Hand Announces Its Relocation “We are proud of the work done here at FirstHealth, and are honored to once again be recognized for our commitment to improved processes and outcomes through the use of technology,” says Dave Dillehunt, FirstHealth’s chief information officer. “Our sustained strategic investments in information technology continue to enhance our ability to fulfill our mission of providing the best patient experience, including ongoing enhancements in care quality, safety and state-of-the-art facilities.” Health Care’s Most Wired Survey, con-

22

The Triangle Physician

Raleigh Hand Center has opened its new office at 3701 Wake Forest Road and Dresser Court, off the 440 Beltline. The new facility features convenient patient parking, onsite therapy, digital X-ray and electronic medical records.


News

Kanaan Leads Wake Sports Medicine hyaluronic acid and platelet-rich plasma.

tral Florida and a bachelor’s of science de-

joined

Dr. Kanaan completed his fellowship at

gree in psychology from Liberty University.

Wake Internal Medi-

Duke Sports Medicine Center in primary

cine Consultants Inc.

care sports medicine and his internship

“We are excited to have Dr. Kanaan join

to lead its new Wake

and residency at Duke Medical Center in

the Wake Internal Medicine Family of Ad-

Sports Medicine at

Family Medicine. While at Duke, he served

vanced Healthcare Practices,” said Arvind

the 3100 Blue Ridge Road, Raleigh office

as an assistant team physician for the foot-

Jariwala, M.D., practice president. “The

as of Aug. 1.

ball, basketball and lacrosse teams. He

opening of Wake Sports Medicine pro-

earned his medical degree from Lake Erie

vides our patients with a new resource for

College of Osteopathic Medicine in 2009.

their orthopedic medical needs, while ad-

Matthew D.O.,

has

Kanaan,

Dr. Kanaan specializes in nonsurgical

vancing our philosophy of providing con-

orthopedic care, sports injuries, arthri-

venient and exceptional medical care.”

tis, tendonitis and other common ortho-

Prior to medical school, Dr. Kanaan spent

pedic issues. Additionally, he performs

five years as a college psychology professor.

ultrasound-guided joint injections and ad-

He has a master’s of science degree in clini-

Call (919) 781-7500 or visit

vanced injections, including prolotherapy,

cal psychology from the University of Cen-

wakeinternalmedicine.com.

Event

WakeMed News

Garner Healthplex Opens Run Your Saturday, September 14, 2013 Heart Out

WakeMed Garner Healthplex opened Aug.

WakeMed Garner Healthplex also will

19 to bring emergency and other outpa-

serve as the base for WakeMed’s Air

tient services to the growing community

Get8:00am ready for 5k Run Your Heart Out, Start time: Mobile medical helicopter operations.

of southeast Wake County and Johnston

In addition, several WakeMed affiliated

County, including the 87,000 households within a five-mile radius. It joins six other WakeMed emergency departments, all of which are staffed by the same emergency physicians and backed by the health system’s Level I trauma center and children’s hospital. In addition to the 10-bed, 24/7 emergency department, the 50,000-square-foot facility offers lab and imaging services, including diagnostic X-rays, ultrasounds, computed tomography scans and magnetic

a benefit for the Children’s Organ

WakeMed Soccer Park Transplant Association, Saturday, physician offices will open at the site. Sept. 14, starting 201 Soccer Park Drive at 8 a.m., at WakeMed Faculty Physicians-Carolina WakeMed Soccer Park in Cary. Cardiology and Wake Specialty Cary, Physi- NC 27511 cians-Garner Primary Care will both open

The event is in honor of Lucas Santos, 23. WakeChildren’s SpecialtyOrgan Physicians–ENT Head Transplant Association a Cary High honor of its Lucas & Neck Surgeryinwill open newSantos, location School a Cary High School student who received a life-saving heartstudent at the Healthplex Oct. 1. transplant who received a in November of 2012 lifesaving heart WakeMed’s total investment in the project transplant in November 2012. to date is approximately $17 million. The at WakeMed GarnerBenefiting Healthplex theon Sept.

addition of the new Healthplex created Register online now at www.RunTheEast.com 175 new jobs, and many of the employees live in or near Garner, the advisory said.

Register for the event at

www.RunTheEast.com. Susan Stallings

resonance imaging, as well as physician offices.

WakeMed Garner Healthplex is located at 400 Highway 70, in east Garner near the

According to a press advisory, 12,000 to

White Oak Crossing shopping center.

15,000 patients are expected to receive treatment in the new emergency depart-

For more information, visit

ment during the first year. It also said that 30

www.wakemed.org.

percent of all WakeMed stand-alone emergency department patients are children. Saturday, September 14, 2013

Start time: 8:00am september 2013 WakeMed Soccer Park

23


News Welcome to the Area

Physicians

Julie Ann Paula Casani, MD

Gregg Harrison Goldin, MD

Milan Petrovic, MD

Public Health; Preventive Medicine NC Public Health Raleigh

Radiation Oncology University of North Carolina Hospitals, Chapel Hill

Family Medicine 1203 Front Street Raleigh

Alan David Chap, MD

Maria Mercedes Guerra, MD

Ramya Pinnamaneni, MD

Pediatrics kids first pediatrics Raleigh

Internal Medicine UNC Chapel Hill

General Surgery; Surgical Oncology Rex Surgical Specialists Raleigh

Thoracic Surgery; Vascular Surgery; Surgical Oncology; Abdominal Surgery; Colon and Rectal Surgery; General Surgery; Head and Neck Surgery; Surgical Critical Care Person Memorial Hospital Roxboro

Adam Dean Hall, MD

Roman Palivela Raju, MD

Camtu Nguyen Karrenbauer, DO

Neuroradiology; Radiology Duke University Hospitals Durham

Kaleena Christine Chilcote, MD

Orthopedic Surgery; Orthopedic, Hand Surgery; Orthopedic Sports Medicine Triangle Orthopaedic Associates, P.A. Durham

Jane Anne Healy, MD

Orthopedic Surgery University of North Carolina Hospitals Chapel Hill

Elizabeth Heather Chisholm, DO General Preventive Medicine; Family Medicine; Family Practice (and OMT) Duke University Hospitals Durham

Rachel Nicole Goble, DO

General Preventive Medicine; Gynecology; Family Medicine; Family Medicine - Adolescent Medicine; Family Medicine - Geriatric Medicine Duke Primary Care Hillsborough

Jignasa Sachar, DO Family Medicine; Urgent Care Raleigh

Jeanette Frances Shimkus, DO Administrative and Family Medicine 8215 Ortin Ln Raleigh

Kristen Nicole Ward, DO Emergency Medicine University of North Carolina Hospitals Chapel Hill

Noah Ojonugwa Agada, MD Pathology - Molecular Genetic Pathology; Allergy/Immunology, Diagnostic Lab, Immunology; Pediatric Allergy; Pediatrics; Public Health; Immunopathology Duke University Hospitals Durham

Ololade Olamide Akintoye, MD Pediatric Cardiology; Pediatrics Durham

Thomas Blick Alexander, MD Internal Medicine; Pediatrics; Pediatric Hematology-Oncology University of North Carolina Hospitals Chapel Hill

James William Antoon Jr., MD Pediatrics University of North Carolina Hospitals Chapel Hill

Anna Elizabeth Barton, MD Endocrinology, Internal Medicine Duke University Hospitals Durham

Jason Edward Blue, MD Anesthesiology Maria Parham Medical Center Henderson

Christine Elizabeth Bookhout, MD Pathology-Medical Examiner; Hematology Pathology; Immunopathology; Medical Microbiology; Molecular Genetic Pathology; Neuropathology; Clinical Pathology; Cytopathology; Dermatopathology; Forensic Pathology University of North Carolina Hospitals Chapel Hill

Danielle Marie Underkoffler Brander, MD Hematology and Oncology, Internal Medicine Duke Medicine Durham

24

The Triangle Physician

Addiction Psychiatry; Child and Adolescent Psychiatry; Geriatric Psychiatry University of North Carolina Hospitals Chapel Hill

Anastasiya Chystsiakova, MD Pediatrics DUMC Durham

Bradley Carl Davis, MD Diagnostic Radiology; Interventional and Vascular Radiology; Pediatric Radiology; Musculoskeletal Radiology; Neuroradiology; Nuclear Medicine; Nuclear Radiology Duke University Hospitals Durham

Neal Arledge Dejong, MD Pediatrics UNC Dept of Pediatrics Chapel Hill

Kemi Morenikeji Doll, MD Abdominal Surgery; Gynecology/ Oncology; Obstetrics & Gynecology University of North Carolina Hospitals Chapel Hill

Leslie Ann Donnelly, MD Orthopedic Surgery, Adult Reconstructive, Musculoskeletal Oncology Orthopaedic Specialists of North Carolina Wake Forest

Jacqueline Robyn Dzau, MD Ophthalmology Duke University Hospitals Durham

Jennifer Laurel Eaton, MD Obstetrics & Gynecology Endocrinology/Infertility; Obstetrics & Gynecology - Reproductive Duke Fertility Center Durham

Samuel Hamilton Eaton, MD Urological Surgery; Urology Duke Raleigh Hospital Raleigh

Monet Alonda France, MD Orthopedic Surgery Duke University Medical Center Durham

Bethany Maria Geib-Rosch, MD Psychiatry; Child Psychiatry; Addiction Psychiatry; Alcohol and Drug Abuse; Geriatric University of North Carolina Hospitals Chapel Hill

Jennifer Bushman Gilner, MD Obstetrics and Gynecology Duke University Hospitals Durham

Hematology and Oncology, Internal Medicine Duke University Hospitals Durham

Gregory Philip Helton, MD

Amanda Jo Robertson-Shepherd, MD

Charles Douglas Scales Jr., MD

Psychiatry University of North Carolina Hospitals, Chapel Hill

Urological Surgery; Urology Duke Urology Durham

Emily Gifford Holmes, MD

Zoe Alecia Stallings, MD

Psychiatry Univ of North Carolina Hospitals Chapel Hill

Family Practice Wake Forest Family Physicians Wake Forest

Mustafa Syed Mahmood Husain, MD

Jason Ryan Tatreau, MD

Psychiatry; Psychiatry, Geriatric Duke South Clinics Durham

Andrew Michael Jakubowicz, MD Emergency Medicine; Pediatric Emergency Medicine WEPPA Cary

Sarah Liesl Laughon, MD Psychiatry, Forensic; Psychiatry, Geriatric; Psychiatry; Alcohol and Drug Abuse; Child Psychiatry; Neurology/Psychiatry UNC Dept of Psychiatry Chapel Hill

Psychiatry University of North Carolina Hospitals Chapel Hill

Emily Graham Teeter, MD Anesthesiology Duke University Hospitals Durham

Kunal Dhiren Thakrar, MD Emergency Medicine University of North Carolina Hospitals Chapel Hill

Brooke Ingram Tsao, MD Anesthesiology Durham

Yan Liu, MD

Jeffrey Oriabure Urieto, MD

Cardiology; Internal Medicine; Cardiovascular Disease University of North Carolina Hospitals, Chapel Hill

Family Practice; Family Medicine North Wake Internal Medicine Raleigh

Alicia Ingerson Watson, MD

Robyn Renee Mercer, MD Child Psychiatry; Psychiatry University of North Carolina Hospitals, Chapel Hill

Psychiatry University of North Carolina Hospitals Chapel Hill

Jacob Ward Nadler, MD

Brian Michael Whitley, MD

Anesthesiology - Critical Care Medicine; Anesthesiology - Pain Medicine; Anesthesiology Pain Management Duke University Hospitals Durham

Oluwatoyosi Adefunke Onwuemene, MD Hematology and Oncology, Internal Medicine Duke University Hospitals Durham

Ceyhun Ozturk, MD

Urological Surgery; Urology Mid Carolina Crossroads Surgery Sanford

Alexis Guy Wortley, MD Emergency Medicine University of North Carolina Hospitals Chapel Hill

May Yung-Yun Yen, MD Emergency Medicine - Medical Toxicology 409 Copperline Dr. Chapel Hill

Pediatrics Kids First Pediatrics of Raleigh Raleigh

Jaime Pedraza, MD Family Medicine - Sports Medicine Orthopedic Specialists of North Carolina Raleigh

Philip Todd Pepple, MD Abdominal Surgery; General Surgery 116 Student Place Durham

Physician Assistants Sarah Mueller Coppolino, PA Gastroenterology, Internal Medicine Duke Medicine Raleigh

Krysta Jennings Cosentino, PA Family Medicine; Family Practice; Orthopedic Surgery; Urgent Care; Orthopedic Sports Medicine Orthopaedic Specialists of North Carolina Raleigh

Laura Hickey, PA Surgery Duke University Medical Center Durham

Paul Jacobson, PA Cardiovascular Surgery; Family Medicine; Family Practice Sanford

Ambria Renee Jenkins, PA Emergency Medicine Raleigh

Scott David Long, PA Geriatric, Internal, Occupational; Pediatrics; Preventive Medicine; Emergency Medicine; Urgent Care NextCare Urgent Care Burlington

Cassidy Prentice, PA Emergency Medicine; Urgent Care; Adolescent Medicine; Geriatric Medicine; Hospice and Palliative Medicine; Family Practice Wendell

Andrea Marie Steeves, PA Duke University Medical Center Durham

Events Durham Regional Look Good Feel Better Sept. 9, 5:30-7:30 p.m. Look Good Feel Better is a free American Cancer Society program that teaches women beauty techniques while they undergo chemotherapy and radiation treatments. Participants receive a free cosmetics kit and instruction by beauty professionals. Location: North Conference Room, Durham Regional Hospital Registration: Call (919) 470-7168 Stroke Support Group Sept. 9, 1-2:30 p.m. The mission of this support group is to help educate the stroke survivor, caregiver and community about stroke prevention and stroke disabilities. This group meets the second Monday of each month. Location: Durham Regional Hospital, private dining room C Weight Loss Surgery Support Group Sept. 24, 6-7 p.m. This weight-loss surgery support group encourages discussion on topics related to adjustment before and after weight-loss surgery. February’s topic will be “Healthy Tips for Dining Out.” Location: Duke Center for Metabolic and Weight Loss Surgery Durham Clinic, 407 Crutchfield St., Durham 24404 Register for these events online at www.durhamregional.org/ events or by calling (919) 4034374, unless otherwise noted.


The power of more. 34 cardiologists. 19 locations. 1 leading health system. Rex Heart & Vascular Specialists and Wake Heart & Vascular Associates have joined to create North Carolina Heart & Vascular. With the same cardiologists, locations and services right in your local community, this new group provides access to the leading research, technology and specialty care that Rex and UNC Medical Center have to offer. Discover the power of more at ncheartvascular.com. For a list of locations and contact information, call (919) 784-5500. To schedule an appointment or for more information, please call your local office.

(919) 784-5500 ncheartvascular.com

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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

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The Triangle Physician September 2013 Carolina Partners

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