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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The Triangle Physician
Neuropsychiatrist Is on the Cutting Edge of Treating Brain-Based Disorders
September 2 0 1 3
Vol. 4, Issue 8
DEPARTMENTS 10 Womenâ€™s Health
Constipation: Chronic Functional vs. Irritable Bowel Syndrome Dr. Douglas Drossman reviews Rome III diagnostic distinctions, along with causes and various treatment strategies.
Exploring Weight-Loss Tools That Help Improve Quality of Life
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
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
- North Carolina Health Systems are Among Nationâ€™s Most Wired - Raleigh Hand Announces Its Relocation
- Kanaan Leads Wake Sports Medicine - Garner Healthplex Opens
24 Welcome to the Area & Events
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
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
Creative Director Joseph Dally
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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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
“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
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
clinical assessment is better oftentimes
in the sense that we are able to collect a
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
well supported,” says Dr. Vaishnavi. “With
According to the Centers for Disease Con-
an accurate diagnosis, we can more ef-
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,
million TBIs occur either as an isolated in-
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
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
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.”
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.
norepinephrine and dopamine. Since de
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
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-
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
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
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
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.
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.
The Triangle Physician
ropsychiatric Clinic at (919) 929-9610 or toll free at (877) 876-3783.
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
defines this diagnosis is abdominal dis-
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-
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
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
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
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
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.
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
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
fat cells. This ultimately reduces the
six months with medical assistance. She
thickness of the fat layer.
was thrilled, felt more confident and had
cooling technology to eliminate fat in
reduced her HgA1c. Before she left my
specific areas of the body. “We
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
Expert, cost effective and timely care is what Carolina Endocrine has to offer your patients. • Neck Ultrasounds (ECNU certified) • Fine needle aspiration biopsies • Nuclear medicine studies
All in one convenient location at 3840 Ed Drive, behind Rex Hospital.
www.CarolinaEndocrine.com Dr. Michael Thomas, Ph.D. Dr. Khushbu Chandarana Courtney Kovalick, PA-C Eileen Andres, PA-C
The Age of
Its Expanding Role in Musculoskeletal Medicine By Matthew G. Kanaan, D.O.
Itâ€™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-
The Triangle Physician
tient satisfaction seems to be higher when using point-of-care ultrasound. The lack of
radiation that a patient is subjected to with
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CT and fluoroscopy is another important benefit.
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And what of cost? Some would argue that guided injections are not needed and this ultimately drives up health care costs. The answer to this is far more complicated than comparing a blind injection to a guided injection. Take a hip injection, for example. With ultrasound, an intra-articular hip injection can be performed during an outpatient office visit for about 10 percent of the direct patient and total health care cost of a CT or fluoroscopic-guided injection. The same could be said for most other peripheral joints that might otherwise be performed with CT and fluoroscopy. As for more common injections that might be performed blindly, the research is still being performed. It is possible that if treat-
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ment failures decrease due to improved accuracy of injection, long-term costs to
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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
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
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-
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
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.
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-
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
Initial Screening Diagnostic Test(s)
Serum metanephrines, 24 hr urine catecholamines (VMA, metanephrine of Epi/Norepi)
Overnight dexamethasone suppression test, 24 hr urine free cortisol, midnight salivary cortisol
Serum aldosterone/renin ratio, saline suppression test
Androgenization, early puberty
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.
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
trauma during phlebotomy. However, a
to establish whether a gradient exists, sug-
normal serum metanephrine has a very
gesting a unilateral aldosterone-producing
low false-negative rate (less than 1 per-
tumor or bilateral nodular adrenal hyper-
cent), which can be further monitored by
Young, WF., N Engl J Med 2007; 356:601-610.
follow-up surveillance and/or a 24-hour urine catecholamine. Evaluation (Cushingâ€™s
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
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-
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
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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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
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,
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-
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,
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
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
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.
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-
Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.
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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Maybe it’s happiness in a child’s eyes. Whatever the desired outcomes, count on us to ensure your key messages have the 20/20 clarity to deliver.
burned patients feel to scratch their skin.
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
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.”
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-
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.
Kanaan Leads Wake Sports Medicine hyaluronic acid and platelet-rich plasma.
tral Florida and a bachelor’s of science de-
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-
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-
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
percent of all WakeMed stand-alone emergency department patients are children. Saturday, September 14, 2013
Start time: 8:00am september 2013 WakeMed Soccer Park
News Welcome to the Area
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
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
NORTH CAROLINA HEART & VASCULAR
North Carolina Heart & Vascular Benson | Cary | Clayton | Clinton | Garner | Goldsboro | Granville | Knightdale | Lillington Louisburg | Mount Olive | Raleigh | Rocky Mount | Smithfield | Wakefield | Wake Forest | Wilson
Heart & Vascular Specialists
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
The Triangle Physician September 2013 Carolina Partners