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Rex Heart & Vascular Specialists

Multidisciplinary Excellence in Cardiology

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 PET/CT and Melanoma Staging Disability Insurance


Introducing Consulta® CRT-P now with Proactive Heart Failure Management

I N N O V A T I O N Consulta CRT-P Leading Edge Innovation for Proactive Heart Failure Management

S O P H I S T I C A T I O N Exclusive OptiVol® Fluid Status Monitoring and remote care with CareLink® Network

N O C O M P R O M I S E Programming Flexibility

S I M P L I C I T Y Completely Automatic

Brief Statement Medtronic Consulta® CRT-P System Indications: The Consulta CRT-P System is indicated for NYHA Functional Class III or IV patients who remain symptomatic despite stable, optimal medical therapy, and have a left ventricular ejection fraction of ≤ 35% and a prolonged QRS duration. Rate adaptive pacing is provided for those patients developing a bradycardia indication who might benefit from increased pacing rates concurrent with increases in activity. Dual chamber and atrial tracking modes are indicated for patients who may benefit from maintenance of AV synchrony. Antitachycardia pacing (ATP) is indicated for termination of atrial tachyarrythmias in patients with one or more of the above pacing indications. Atrial rhythm management features such as Atrial Rate Stabilization (ARS) and Post Mode Switch Overdrive Pacing (PMOP) are indicated for the suppression of atrial tachyarrhythmias in patients with atrial septal lead placement and one or more of the above pacing indications. Contraindications: The Consulta CRT-P system is contraindicated for: • Concomitant implant with another bradycardia device • Concomitant implant with an implantable cardioverter defibrillator. There are no known contraindications for the use of pacing as a therapeutic modality to control heart rate. The patient’s age and medical condition, however, may dictate the particular pacing system, mode of operation, and implant procedure used by the physician. • Rate-responsive modes may be contraindicated in those patients who cannot tolerate pacing rates above the programmed Lower Rate • Dual chamber sequential pacing is contraindicated in patients with chronic or persistent supraventricular tachycardias, including atrial fibrillation or flutter • Asynchronous pacing is contraindicated in the presence (or likelihood) of competition between paced and intrinsic rhythms • Single chamber atrial pacing is contraindicated in patients with an AV conduction disturbance • ATP therapy is contraindicated in patients with an accessory antegrade pathway. Warnings and Precautions: • Changes in a patient’s disease and/or medications may alter the efficacy of the device’s

programmed parameters • Patients should avoid sources of magnetic and electromagnetic radiation to avoid possible underdetection, inappropriate sensing and/or therapy delivery, tissue damage, induction of an arrhythmia, device electrical reset, or device damage • Do not place transthoracic defibrillation paddles directly over the device • Certain programming and device operations may not provide cardiac resynchronization. Potential Complications: Potential complications include, but are not limited to, rejection phenomena, erosion through the skin, muscle or nerve stimulation, oversensing, failure to detect and/or terminate tachyarrhythmia episodes, acceleration of ventricular tachycardia, and surgical complications such as hematoma, infection, inflammation, and thrombosis. See the device manuals for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. Medtronic CareLink® Monitor/CareLink® Network Intended Use: The CareLink Monitor and the CareLink Network are indicated for use in the transfer of patient data from some Medtronic implantable cardiac devices based on physical instructions and as described in the product manual. These products are not a substitute for appropriate medical attention in the event of an emergency and should only be used as directed by a physician. Contraindications: There are no contraindications for the CareLink Monitor. Warnings and Precautions: The CareLink Monitor must only be used for interrogating compatible Medtronic implantable devices. The CareLink Monitor is intended for use within the prescribing country. For further information, please call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.

www.medtronic.com World Headquarters Medtronic, Inc. 710 Medtronic Parkway Minneapolis, MN 55432-5604 USA Tel: (763) 514-4000 Fax: (763) 514-4879 Medtronic USA, Inc. Toll-free: 1 (800) 328-2518 (24-hour technical support for physicians and medical professionals)

UC201105940 EN © Medtronic, Inc. 2011. Minneapolis, MN. All Rights Reserved. Printed in USA. 03/2011

Changes in a patient’s disease and/or medications may alter the efficacy of a device’s programmed parameters or related features.


Contents

COVER STORY

6

Rex Heart & Vascular Specialists Multidisciplinary Excellence in Cardiology

j u ly 2 011

Vol. 2, Issue 7

FEATURES

12

Radiology

16

DEPARTMENTS 14 Your Financial Rx The Dissection of

Women’s Health

PET/CT Is Useful in Melanoma Staging and Restaging

Folate Supplement Recommended with Birth Control Use

Dr. William Way Jr. explains the value

Dr. Andrea Lukes urges greater awareness

of PET/CT in determining the spread of

about the importance of taking folate

melanoma and deep, local lesions to help

supplements in women who are on birth

guide treatment decisions.

control pills.

Disability Insurance

18 Radiology Ultrasound and Laser Technology Are Key to Treating Venous Insufficiency

18 Neurology Overview: Diabetic Neuropathy

20 WakeMed News Broadcaster contributes $100,000 to Kids Kampaign

21 Rex News New cardiologist joins Garner specialty practice

23 UNC News Ob/Gyn Accolades and Achievements

24 News Welcome, new partnership and clinical trials

Cover Image: Dr. James Zidar, president of Rex Heart & Vascular Specialists.

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The Triangle Physician


JOHNSTON HE ALTH


From the Editor

Health Care Tectonics 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

The Triangle health care landscape is in an active state of shifting strategic alliances. In this issue of The Triangle Physician, we get an introduction to one of the newest specialty practices to emerge, Rex Heart & Vascular Specialists, led by cardiologist James Zidar. It was clear when the practice opened last fall that Rex Healthcare leaders were making good on their plans to create a specialty cardiology practice to raise their heart and vascular program to the next level. Their careful selection process resulted in a comprehensive medical team with impressive credentials. The cardiologists, some of whom were recruited from within the Triangle, are recognized not only for their skill and leadership in advancing medical science, but their compassion and dedication to patient

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Eithne Burke, M.D. John Grant Buttram, M.D. Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G Cynthia Payne, M.D. Paul Pittman, C.F.P. Henry Tellez, M.D.

care.

Photography Jim Shaw Photography jimshawphoto@earthlink.net

New this month in The Triangle Physician is radiologist William Way Jr., who provides

Creative Director Joseph Dally

an overview of positron emission tomography/computerized tomography in melanoma

jdally@newdallydesign.com

of ultrasound and laser technology in treating venous insufficiency.

Advertising Sales Carolyn Walters carolyn@trianglephysician.com Natalie Snapp natalie@trianglephysician.com

Neurologist Henry Tellez returns with an article on diabetic neuropathy. Gynecologist

News and Columns Please send to info@trianglephysician.com

staging and restaging. Radiologist Jason Harris makes a debut with his article on the role

Andrea Lukes writes about the importance of educating patients on the benefits of folate supplementation before conception. On fiscal health, certified financial planner Paul Pittman returns with another wellreasoned article, this one on the value of disability insurance for high-income earners. As the Darwinian side of Triangle health care plays out in an era of active realignment, perhaps it’s time to consider adding The Triangle Physician to your marketing mix. The only magazine for health care professionals in the greater Triangle area, it is mailed to approximately 9,000 medical professionals. With this exclusive reach, it can be a costeffective tool for reinforcing your brand and your competitive edge. With deep gratitude for all you do,

Heidi Ketler Editor

The Triangle Physician is published by New Dally Design 9611 Ravenscroft Ln NW, Concord, NC 28027 Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401 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. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, 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.

4

The Triangle Physician


On the Cover

Rex Heart & Vascular Specialists

Multidisciplinary Excellence in Cardiology Rex Heart & Vascular Specialists is an

is a team of accomplished, board-certified

interventional cardiology. Dr. Mohit Pasi

extension of Rex Healthcare and its

cardiologists, who offer general cardiology

also is board certified in nuclear cardiology

commitment to quality cardiovascular care,

services, in addition to a complementary

and echocardiography. Dr. Mobarek is

increasing access to top-ranked cardiologists

range

Frequent

board certified in electrophysiology and

and the latest technology throughout Wake

involvement in device development for the

cardiovascular medicine, with a special

County and beyond.

management of coronary and peripheral

interest in stress echocardiography. Dr.

vascular disease keep them on the cutting

Smith is board certified in internal medicine

edge.

and vascular medicine. He is a registered

“We are dedicated to saving patient lives, by

of

sub-specializations.

treating and preventing heart and vascular

vascular

technologist

and

diagnostic

disease, with compassionate, excellent care

The physicians at Rex Heart & Vascular

medical ultrasonographer. Dr. Usher is

when and where it is most needed,” says

Specialists are: George L. Adams, M.D.,

board certified in internal medicine and

James P. Zidar, M.D., F.A.C.C., F.S.C.A.I.,

H.M.S., F.A.C.C.; Sameh K. Mobarek,

cardiology.

Rex Heart & Vascular Specialists president.

M.D., F.A.C.C.; Deepak Pasi, M.D., F.R.C.P.,

“People in outlying areas often present with

F.A.C.C., F.S.C.A.I., F.A.A.C.; Mohit Pasi,

In August, Rex Healthcare will welcome

more advanced disease, because access to

M.D., F.A.C.C., F.S.C.A.I.; S. Wayne Smith,

Robert R. Mendes, M.D., a vascular

primary care is less available.”

M.D.; and Bruce W. Usher Jr., M.D., F.A.C.C.

surgeon, who will practice at Rex Vascular

Dr. Zidar is fellowship trained in cardiology

Drs. Adams, Deepak Pasi and Mohit Pasi

and interventional cardiology. Joining him

are board certified in cardiology and

Surgical Specialists further rounding out Rex’s expertise in heart and vascular care.

PHOTO BY BRIAN STRICKLAND

Members of the Rex Vascular Surgical Specialists nursing team are board-certified nurse practitioners with advanced degrees. They are Priya Kos, R.N., M.S.N., A.N.P.B.C.; Pamela T. Thompson, R.N., M.S.N., A.N.P.-B.C.; and Tracey Wright, R.N., B.S.N., M.S.N., F.N.P.-B.C. From expert surgeons and cardiologists to highly-trained nurses, “Our heart and vascular team provides exceptional care in the most critical medical conditions,” said Dr. Zidar. “We make available less-invasive diagnostic and interventional technologies to optimize clinical outcomes for our patients.” Several management initiatives are aligned with Rex Healthcare, such as providing more efficient care, according to Dr. Zidar. Rex has chosen a new vendor (Fugi) for vascular Dr. Zidar discusses patient test results.

6

The Triangle Physician

imaging and storage, and designed state-of-


Clinical team members at Rex Hospital’s Heart and Vascular Services.

the-art cardiac and vascular catheterization

average rating in the country. Medicare

labs with Philips Medical Systems. The

quality rankings in the last two years show

The practice works closely with the UNC

health system has combined peripheral

that Rex placed first in heart attack survival

electrophysiology

endovascular skills with a comprehensive

rates among Triangle hospitals. It also was

Mounsey, M.D., B.M., B.Ch., Ph.D., M.R.C.P.,

wound clinic, led by Rex Surgical Specialists

the first hospital in the Triangle to be a

F.A.C.C., who is a professor and director

in two locations to offer comprehensive

nationally recognized chest pain center by

of electrophysiology. “He is a very skilled

services for the most aggressive vascular

the Society of Chest Pain Centers (SCPC) in

electrophysiologist who performs complex

disease. “The creation of our specialty

2005. In 2011 Rex was accredited for the third

electrical ablations in the left atrium that are

practice was a way to take Rex cardiovascular

time. To become an Accredited Chest Pain

not performed in Raleigh,” Dr. Zidar says.

services to the next level,” says Dr. Zidar. Rex

Center, Rex Healthcare engaged in rigorous

Heart & Vascular Specialists has offices at Rex

evaluation by SCPC for its ability to assess,

A new mission for the Rex heart and

Healthcare’s main campus in Raleigh, as well

diagnose and treat patients who may be

vascular program is the clinical education

as Rex facilities in Cary, Wakefield and Garner.

experiencing a heart attack.

and training of the senior cardiology fellows

Rex Healthcare’s leadership in cardiology

Rex Heart & Vascular Specialists also is

in the cardiac catheterization labs with Drs.

is well-established. Recently, it became

partnering with the University of North

Zidar, Pasi and Adams to gain exposure to,

one of three hospitals in North Carolina

Carolina (UNC) Health Care Center for Heart

and experience with, complex coronary

to be named among the 50 best hospitals

and Vascular Care to broaden its expertise

and vascular intervention. Physicians at Rex

in America by Becker’s Hospital Review.

even further. “By having this network of

Heart & Vascular Specialists also are actively

Specifically, the hospital was recognized for

physicians, we’re providing excellent patient

involved in the development of regional

its ongoing commitment to patient needs

care,” says Dr. Zidar. “We can leverage our

systems of care for the treatment of ST-

and investment in innovations.

close working relationships with the UNC

elevation myocardial infarction and critical

faculty to bring to Raleigh quaternary services

limb ischemia. Dr. Adams has been working

In 2009, Rex Healthcare was rated best for

– advanced heart failure care, cardiac

closely with local EMS teams on this effort.

heart attack survival in Wake County by

transplantation and left ventricular assist

Hospital Compare, with the only above-

devices (LVADs) – for our sickest patients.”

group,

under

Paul

from UNC. Currently, two fellows are working

july 2011

7


Cardiologists Sam Mobarek, M.D., and Mohit Pasi, M.D., of Rex Heart & Vascular Specialists.

Comprehensive Cardiology

Most of these patients have the common risk

Advanced Skill in Treating PAD

Rex Heart & Vascular Specialists is a single

factors of hypertension, dyslipidemia and

“Minimally invasive medical technology to

source for multidisciplinary cardiovascular

diabetes.”

treat peripheral artery disease and restore

care, from prevention and diagnosis to

blood flow below the knee and prevent

treatment and rehabilitation. This is of

Interventional cardiology and electrophys-

limb loss is more successful than ever,”

particular benefit to patients with multiple

iology

says Dr. Zidar. It is a specialty area of Rex

cardiovascular

the

issues

who

historically

services

are

comprehensive

integrated practice,

Dr.

within

with

Sam

an

Heart & Vascular, and Dr. George Adams

Mobarek,

is recognized as a leader in this rapidly

required more than one cardiovascular

electrophysiologist,

specialist. For these patients at Rex Heart

on staff. He follows a large population of

& Vascular Specialists, the continuity of

pacemaker and defibrillator patients. “It

care is managed within one practice by one

makes sense for us to be involved on both

The high prevalence of peripheral artery

physician.

fronts,” says Dr. Zidar.

disease (PAD) and increased risk for other

“There is a lot of overlap” between the

Electrophysiology services at Rex Heart

about symptoms or PAD’s seriousness

disciplines of cardiac and vascular disease,

& Vascular Specialists include invasive

create an urgent need for vigilance among

says Dr. Zidar. “We see many patients over

and noninvasive treatment of cardiac

physicians to identify at-risk patients, says Dr.

65 who have both coronary and peripheral

arrhythmias, such as catheter ablation of

Zidar. Yet, PAD often goes undiagnosed.

artery disease. We focus on primary

supraventricular

prevention when we can catch the disease

fibrillation, and pacer and defibrillator

According to American College of Cardiology

process early and secondary prevention

implantation and lead extraction.

(ACC)/American Heart Association (AHA)

when we encounter more advanced disease.

guidelines, physicians should consider

evolving field.

conditions, combined with low awareness

8

The Triangle Physician

tachycardia

and

atrial


From left to right: Mohit Pasi, M.D., James Zidar, M.D., Priya Kos, R.N., A.N.P., Bruce Usher, Jr., M.D., Deepak Pasi, M.D., Pam Thompson, R.N., A.N.P., Sameh Mobarek, M.D., S. Wayne Smith, M.D., Tracey Wright, R.N. and George Adams, M.D.

referring the following patients for PAD

Success in Treating Problem Wounds

based procedure used to modify plaque in

testing:

When surgery is necessary to restore

the smaller arteries above and below the

• Diabetics less than 50 years old with at

blood flow in patients with critical limb

knee, before reopening them using balloon

least one other risk factor – smoking,

ischemia below the knee, peripheral

angioplasty. It is designed to reduce the risk

hypertension or abnormal cholesterol;

vascular interventions increasingly include

of dissecting or tearing the vessel.

• Age 50 to 69 with a history of smoking or

revascularization of the leg or foot using

diabetes;

laser, orbital and directional atherectomy.

• Age 70 years and older;

closely with the Rex Wound Healing

• Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain; • Adults with abnormal lower extremity pulse examination; and • Adults

with

known

Rex Heart & Vascular Specialists works

atherosclerotic

Among the most experienced and skillful

Center, whose arsenal to treat PAD includes

in the use of this cutting-edge technology

hyperbaric oxygen therapy (HBOT). “We

is Dr. Adams, who has a special interest

have excellent synergy with the Rex Wound

in amputation prevention in the most

Healing Center,” says Dr. Zidar.

complex cases. Atherectomy is a catheter-

coronary, carotid or renal artery disease. ACC/AHA individuals

guidelines with

recommend

asymptomatic

that lower

extremity PAD be identified using the anklebrachial index, or ABI. The painless, noninvasive screening compares the blood pressure in the ankles with the blood pressure in the arms. Treatment for PAD focuses on reducing symptoms

and

preventing

further

progression of the disease. In most cases, lifestyle changes, exercise and claudication medications are enough to slow PAD or reverse its symptoms. Cardiologist James Zidar performs a procedure in Rex Hospital Cath Lab.

july 2011

9


Cardiologists James Zidar and Deepak Pasi collaborate on clinical issues.

Advancing Science

designed to capture debris that may be

and any health problems that may have

Through its work in clinical trials, Rex

released during the procedure and reduce

occurred since hospitalization or the last

Healthcare

to

the chance of stroke) in the treatment of

phone interview.

improvements made in medical science.

obstructive (blocked) carotid artery disease.

actively

contributes

CHOICE Study

The following are current studies available at Rex.

AMPLIFY Study

The CHOICE Study is for patients with carotid

The AMPLIFY Study evaluates the effects of

artery blockages who are considered high-

ALERTS Study

an investigational blood thinner, apixaban, in

risk surgical patients. This study is designed

The objective of the ALERTS Pivotal Study is

preventing venous thromboembolic (VTE)

to assess the outcomes of stenting with distal

to provide an assessment of the safety and

recurrence (the formation or presence

protection in the treatment of obstructive

effectiveness of the AngelMed Guardian

of a blood clot) or death in patients with

(blocked) carotid artery disease. In addition,

System. The AngelMed Guardian System

deep vein thrombosis (DVT) or pulmonary

this study will assess clinical outcomes

is designed to track significant changes in

embolism (PE) over six months.

for possible extension of the Centers for Medicare and Medicaid Services (CMS)

the heart’s electrical signal and then alert patients to seek medical attention.

TRANSLATE Study

coverage to a broader group of patients.

The TRANSLATE Study is for patients who

SAPPHIRE Registry

have had a heart attack and were treated

For more information, visit the

The SAPPHIRE Registry study is for patients

with a procedure to open blocked blood

Rex Heart & Vascular Specialists at

with carotid artery blockages who are

flow in the heart and placed on clot-

www.rexheartvascular.com or call

considered to be high-risk surgical patients.

preventing medications. This study will

(919) 784-5600 for the Raleigh/Garner

It is designed to assess the outcomes of

collect information about symptoms that

offices, (919) 387-3260 for the Cary office or

stenting with distal protection (a tiny filter

may have related to the heart, medications

(919) 570-7590 for the Wakefield office.

10

The Triangle Physician


Radiology

PET/CT

Is Highly Useful in Melanoma Staging and Restaging By William G. Way Jr., M.D.

PET/CT serves to answer the two big questions: Has the tumor already spread beyond the loco-regional lymph nodes, and is there a second primary skin tumor we didn’t know was there?

extends from the lower part of the brain down to the mid-thighs. Melanoma, on the other hand, occurs not only on the trunk, proximal extremities, and head and neck, but also on the peripheral extremities and, in particular, the sun-exposed areas. Not long ago, for instance, I evaluated a patient with a melanoma on the foot. Since the skin, in essence, is one large organ, and melanoma can occur anywhere on the skin, we perform

While the worldwide incidence of many

melanoma becomes invasive, it has a

cancers has been decreasing, the incidence

tendency to spread first to loco-regional

of melanoma of the skin, unfortunately, is

lymph nodes and then throughout the

While PET/CT is capable of detecting

on the rise. In the United States, according

entire body.

metastatic disease in the draining regional

to the World Health Organization, the

a full-body scan on these patients.

lymph nodes, such as those behind the

incidence of malignant melanoma has

PET/CT’s usefulness comes not from

knee, in the groin or in the axilla, its

increased an average of 4 percent every year

screening for the disease, but rather for

primary value in the setting of malignant

since the early 1970s.1 Early detection and

detecting more widespread disease once

melanoma is in the detection of more

accurate staging are vital to determining,

metastatic loco-regional nodal disease is

widespread metastases in sites, such as the

without delay, the most effective treatment

confirmed. The exception might be for

lungs, bones or liver. Because these tumors

for the patient. PET/CT (positron emission

a deep and/or aggressive local lesions

tend to be very hypermetabolic, they

tomography/computerized tomography) is

where positive loco-regional lymph nodes

often are very easy to detect. Thus, PET/

an extremely useful test for the evaluation of

were expected but none were found, since

CT serves to answer the two big questions:

patients with malignant melanoma because

it is possible for this disease to skip these

Has the tumor already spread beyond the

the tumor tends to be very hypermetabolic,

lymph nodes and metastasize directly to

loco-regional lymph nodes, and is there a

thus allowing for ready detection of

the brain, bone, lung, liver, etc. Thus, PET/

clinically occult sites of disease.

CT plays a very important role in the initial staging of malignant metastatic melanoma

Melanoma can be a very aggressive disease.

and in helping guide decisions for the most

In one study of patients diagnosed with a

promising treatment.

single melanoma, their risk of developing a second primary melanoma was increased

The unique procedure that we perform for

roughly 200 times over that of the general

malignant melanoma is to scan the patient

population. That study also showed that

from the top of his or her head all the way

for patients diagnosed with melanoma,

to the toes. This is a more comprehensive

most second melanomas occurred within

scan than our standard PET/CT scan

two years of the first.2 When a malignant

for other malignancies, which generally

12

The Triangle Physician

PET/CT image consisting of coronal whole-body CT image (A), PET image with CT attenuation correction (B).


Dr. William Way Jr. is a body imaging radiologist and PET/CT (positron emission tomography/ computerized tomography) imaging specialist. He serves as chief medical officer and medical director for imaging at Wake Radiology, Raleigh. His expertise is in cross-sectional body imaging, and his special clinical interests include PET, CT, nuclear medicine and ultrasonography. Dr. Way, who joined Wake Radiology in 1992, is board certified by the American Board of Radiology and the National Board of Medical Examiners. A native of Winchester, Va., he is a graduate of the University of Virginia School of Medicine. He completed his internship at Denver Presbyterian Hospital in Denver, Colo., and residency at the Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, Mo. He then completed a fellowship in cross-sectional imaging at the University of Michigan Medical Center in Ann Arbor, Mich. He is a member of the American College of Radiology, the Radiologic Society of North Carolina, the North Carolina Medical Society and the Wake County Medical Society.

previously diagnosed with locally or

staging of melanoma when it is initially

regionally advanced disease, as it allows

diagnosed and that allows for the early

for the early detection of recurrent disease

detection of recurrent disease at remote

at more remote locations. These patients

and often clinically unsuspected locations.

often will undergo periodic PET followup, since they are at increased risk for the

1

World Health Organization. WHO - Health

subsequent development of widespread

Effects of UV Radiation. Web. 2010. Accessed at

metastatic disease. In this circumstance,

http://www.who.int/uv/health/uv_health2/en/

a whole-body PET scan serves as a single examination to search the entire body for evidence of disease recurrence.

index1.html. 2

Burden, AD, Vestey, JP, et al. Multiple Primary Melanoma:

Risk

Factors

and

Prognostic

Implications. Journal article. 1994. BMJ 376-309.

In summary, PET/CT is a very sensitive

http://www.bmj.com.

imaging study that facilitates accurate

second primary skin tumor we didn’t know was there? There could be another primary melanoma, for example, in an armpit or hidden by hair on the scalp, that might have escaped detection despite a very thorough physical examination by the patient’s referring physician. PET/CT also can be used to direct where and what to biopsy for definitive diagnosis in the setting of widespread metastatic disease. In one instance, for example, several unexpected tumors were discovered on PET/CT in addition to the primary tumor that was initially detected in the patient’s eye at the time of an ophthalmology exam. In this particular case, we were able to direct the referring physician to the site that would be safest and most appropriate to biopsy in order to properly diagnose and stage the patient. PET/CT’s unique ability to detect clinically occult tumors is equally important with regard to ongoing surveillance of patients Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

july 2011

13


Your Financial RX

The Dissection of

Disability Insurance By Paul Pittman, C.F.P.

Since last month, I have had several e-mails

important as retaining more of your assets

asking questions about disability insurance.

from fees and taxes! Even if you don’t have

This type of insurance is critical for

an immediate need for disability income

physicians for a variety of reasons. As a high-

insurance, having it can give you some

wage earner who depends on a completely

peace-of-mind.

sound mind and body, protection of income is a major component of a sound

Some experts argue that disability income

financial plan. If you were unable to work

insurance is the most important type

for an extended period of time due to an

of insurance you can own, even more

injury or illness, how long would you be

important than homeowner’s, auto or even

able to pay your bills and meet your daily

life insurance. I wouldn’t say that it is more

insurance policies. Employer-sponsored

living expenses? Do you know how much

important, but rather it is an integral part of

policies, or “group” policies, are relatively

income you would receive from outside

a sound financial plan. Disability insurance

inexpensive to purchase and generally

sources and for how long?

protects one of your most valuable assets:

remain in effect as long as the individual continues to work for the business.

Protection of your income and lifestyle is as important as retaining more of your assets from fees and taxes.

However, there are significant limits on the benefits provided by group policies, so it is important to understand your spending needs. Private insurance policies are paid for by individuals and provide coverage when group policies don’t apply or don’t provide enough income. On one level, a

could

your ability to earn income. After all, it is

private policy is usually more expensive to

jeopardize any financial plan and can occur

this ability that enables you to have the

purchase than a group policy. However, a

at any time. Keeping that in mind, your best

lifestyle that you have, and you need to

private policy’s potential to provide much

defense may be a good offense. Look into

protect your net worth and the financial

greater benefits over time may make it

disability insurance as a defense against a

well-being of your family.

a smarter long-term choice. When you

A

long-term

illness

or

injury

consider that group policies often end up

financial meltdown. Many brokers and financial planners do

providing inadequate benefits, even those

Disability insurance replaces part of your

not even touch on the subject because

employees with group coverage should

income should you become unable to

they may see it as too complicated or too

consider purchasing a private policy to

work due to accident or illness. It provides

time-consuming. Many investment firms

fill the voids associated with group-only

you with income to meet your daily living

don’t want their agents to offer it because

coverage.

expenses, such as mortgages, groceries,

of the liability it can bring on the firm. The

tuition, etc.

bottom line is this; it takes a specialist to

The manner in which an insurance

fully understand disability insurance, how

company defines “disability” can determine

Now, if you are like me, insurance is not

to structure it, finance it, and how (and

your eligibility to receive benefits should

high on the list of preferred topics, but it is

where) to own it.

you become disabled. Generally speaking, you want a policy with the most liberal

one of the main pieces of a sound financial plan. It all comes back to my mantra, “It’s

For most people, there are two main forms

definition of disability. There are three basic

not what you make, it’s what you keep.”

of disability income insurance to consider,

definitions of disability:

Protection of your income and lifestyle is as

employer-sponsored policies and private

14

The Triangle Physician


Paul J. Pittman is a Certified Financial Planner™ with The Preferred Client Group, a financial consulting firm for physicians in Cary, N.C. He has more than 25 years of experience in the financial industry and is passionate about investor education. He is also a nationally sought-after speaker, humorist and writer. Mr. Pittman can be reached at (919) 459-4171 and paul.pittman@pcgnc.com.

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consider your occupation as the job you were performing at the time of your disability. 2)

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coverage

usually defines disability as sickness or injury that doesn’t allow you to perform the material and substantial duties of your own occupation and typically stipulates that you are not currently engaged in any other occupation. 3) Gainful Occupation. This is definitely the least desirable definition. These policies define disability as your inability to perform the material and substantial duties of any occupation that you are considered to be reasonably qualified for by way of your education, skills or training. As you can see, there are many important facets to disability income insurance, and I would recommend that you consult with a specialist in this field. As you are no doubt aware by now, I am a big proponent of getting the best advice and guidance from the most experienced and qualified advisor. Until next month, I wish you good physical health and good fiscal health.

july 2011

15


Women’s Health

Folate Supplement In Birth Control By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G.

Despite evidence and official recommendations, a 2008 Gallop poll conducted by the March of Dimes showed that only 11 percent of women were aware that folate supplementation should begin prior to conception.

pills, followed by one week of placebo pills. At this point, the oral birth control pill is the most common form of birth control in the United States, compared to the intrauterine device (IUD), which is the most common form of birth control worldwide.

Birth Control Plus Folate Some of the newer birth control pills in the United States, specifically Beyaz and Safryl, launched this year, now offer folate supplementation within all 28 pills. Both

Early descriptions of birth control included

the Comstock Law in 1965 and ruled that

brands use levomefolate calcium (451

a gummy substance to cover the ‘mouth of

the private use of contraceptives was a

mcg), which is a synthetic folate that is

the womb’ (1850 B.C.). Honey and sodium

constitutional right.

absorbed unchanged and is identical to L-5-

carbonate within the vagina, and a pessary

methytetrahydrofolate, the form of folate

1

from crocodile dung. Many advances have

The first birth control pill (Enovid) was

occurred since these initial choices. Just

approved in 1960. The initial pills had high

last year, the birth control pill celebrated its

doses of hormones and resulted in blood

There is a large body of evidence that

50th anniversary in the United States.

clots, strokes and depression. Since it first

folate supplementation prevents neural

that is ready to be used by the body.

tube defects. This evidence Initially

within

the

has resulted in the official

United States, the most

recommendations

common forms of birth

Center for Disease Control,

control were withdrawal

the United States Preventive

and rhythm methods.

Task Force, and the American

Then in 1839, Charles

Congress of Obstetricians and

Goodyear

Gynecologists to recommend

produced

the rubber condoms,

folate

intrauterine

reproductive-aged

devices,

of

supplementation

the

for

women

douching syringes and

for prevention of neural tube

diaphragms.

defects.

Late

in

the 19th century, the Comstock Law was enacted which made

emerged, the trend during the past 50 years

Despite

it illegal to send contraceptive devices

has been to lower the strength of estrogens

recommendations, a 2008 Gallop poll

and information (including educational

and offer different progestins. In addition,

conducted by the March of Dimes showed

information). Then early in the 1900s,

the initial pill had 21 days of active pill and

that only 11 percent of women were aware

Margaret Sanger opened the first birth

then seven days of placebo.

that folate supplementation should begin

control clinic in America, and in 1936 she

evidence

and

official

prior to conception2.

helped bring forth a legal case that allowed

More recently, birth control pills offer

physicians to legally mail birth control

24 days of active pills and four days of

Why is it important to take folic acid prior

devices and information throughout the

placebos, or the choice of having a period

to conception? The timing of neural tube

country. The Supreme Court overturned

“once a season,” with 12 weeks of active

closure is the answer. Within the first month

16

The Triangle Physician


after conception is when the neural tube closes – often before a woman realizes she is pregnant. Thus, health care providers must emphasize to reproductive-aged women that folate supplementation is important before conception. When we consider the birth control pill and the typical failure rate of 8 percent of all birth control pills, then the advantage of supplementing folate through the birth control pill makes sense. Further, given that after one month of stopping the pill, 21 percent of women will become pregnant; and that after three months from stopping the pill, 46 percent of women will become pregnant3 – again, the logic of folate supplementation within the birth control pill emerges. Folate supplementation is recommended for all women of reproductive age. Women who choose to take oral birth control pills now have two options that include folate supplementation (Beyaz and Safryl). In my opinion, in 15 to 20 years most birth control pills will include folate supplementation.

References 1

http://en.wikipedia.org/wiki/Birth_control.

2

March of Dimes.

3

Cronin M et al. Obstet Gynecol. 2009;114:616-622.

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july 2011

17


Neurology

Overview: Diabetic Neuropathy By Henry Tellez, M.D.

The term neuropathy is derived from the

Foot slapping and toe deterioration or

Greek word “neuron” (nerve) and the

frequent tripping may be early symptoms

English suffix “-pathy” (feeling, suffering).

of foot weakness. Symptoms of proximal extremity

weakness

include

difficulty

Neuropathies are characterized by a

climbing up and down stairs, difficulty

progressive failure of nerve fiber function. A

getting up from a seated or supine position,

generally established definition of diabetic

falling due to the knees giving way and

peripheral neuropathy is “the presence of

difficulty raising the arms above the

symptoms and/or signs of peripheral nerve

shoulders.

dysfunction in people with diabetes after exclusion of other causes.”

In the most common presentation of diabetic neuropathy with symmetrical

Dr. Henry Tellez is in private practice with Sandhills Neurologists PA. He obtained his medical degree from Valley University, Colombia. He then completed his internship and neurology residency at Saint Louis University, Miss. This was followed by a fellowship in nerve conduction (nerve conduction velocity/electromyography) studies and neuromuscular diseases at the University of North Carolina, Chapel Hill. Dr. Tellez is currently board certified in general neurology, neuromuscular medicine and vascular neurology by the American Board of Medical Specialties.

Neuropathies are the most common

sensorimotor symptoms, minor weakness

complication of diabetes mellitus (DM),

of the toes and feet may be seen. It is

affecting up to 50 percent of patients with

important to note that severe weakness is

Type 1 and Type 2 DM.

unusual and should prompt investigation

spine disorders) may generate poor urinary

into other causes, such as chronic

stream, feeling of incomplete bladder

The Symptoms

idiopathic demyelinating polyneuropathy

emptying and straining to void.

Diabetic neuropathy can present as a wide

(CIDP) or even vasculitis. Severe weakness

mixture of sensory, motor and autonomic

can be observed in asymmetrical diabetic

Sudomotor neuropathy may produce heat

symptoms. A well thought-out list of

neuropathy

intolerance, intense sweating the head,

symptoms can be used to help screen all

amyotrophy).

may

neck and trunk, with lack of sweat in the

diabetic patients for possible neuropathy.

occur along with sensory neuropathy

lower trunk/extremities, and gustatory

(sensorimotor neuropathy).

sweating.

These are subtle in onset and show a

Autonomic Symptoms

Etiology

stocking-and-glove distribution in the distal

Autonomic neuropathy may entail the

The factors important to the development

limbs. Sensory symptoms may be negative

cardiovascular,

and

of diabetic neuropathy are not understood

or positive, diffuse or focal. Negative

genitourinary systems, and the sweat

completely, and various hypotheses have

sensory symptoms include feelings of

glands. Patients with generalized autonomic

been proposed. It is commonly accepted to

numbness or deadness, which patients

neuropathies may report near syncope/

be a multifactorial problem.

may express as “wearing gloves or socks”

syncope.

syndromes Motor

(i.e.

diabetic

neuropathy

Sensory Symptoms

gastrointestinal

Development of symptoms depends on

or “walking on thick pads.” Loss of balance, especially in poorly lit environments or with

Gastrointestinal

neuropathy

many factors, such as total hyperglycemic

closed eyes, and painless injuries owed

may produce dysphagia, abdominal pain,

exposure and other risk factors, such as

to loss of sensation are frequent. Positive

nausea/vomiting,

elevated lipids, blood pressure, smoking,

symptoms may be described as burning,

incontinence, diarrhea and constipation.

high

prickling pain, tingling, electric shock – like

Cardiovascular

neurotoxic agents, such as ethanol and

feeling aching, tightness or hypersensitivity

may produce persistent sinus tachycardia,

to touch.

orthostatic hypotension, sinus arrhythmia

autonomic

malabsorption, autonomic

fecal

neuropathy

exposure

to

other

potentially

increased height.

and decreased heart variability in response

Genetic factors may also play a role.

Motor Symptoms

to deep breathing. Also, not unusual is near

Important

These may include distal, proximal or more

syncope upon changing positions from

mechanisms in the development of the

focal weakness. In the upper limbs, distal

recumbent to standing.

more common symmetrical forms of

contributing

biochemical

diabetic polyneuropathy likely include the

motor symptoms may consist of impaired fine-hand coordination and trouble with

Bladder neuropathy (which must be

polyol pathway, advanced glycation end

tasks, such as opening jars or turning keys.

entertained after exclusion of prostate or

products and oxidative stress.

18

The Triangle Physician


Risk Factors

diabetes diagnosis – because failure to

more localized pain or those in whom

Risk factors that are associated with more

diagnose diabetic polyneuropathy can

interactions with existing oral medications

severe symptoms include poor glucose

lead to serious consequences, including

is a concern.

control,

disability and amputation.

long

advanced

duration

age,

hypertension,

DM,

dyslipidemia,

of

Diabetic Gastroparesis

smoking, heavy alcohol intake, HLA-DR3/4

Consider any patient with clinical evidence

Erythromycin, cisapride, metoclopramide,

phenotype and tall height.

of diabetic peripheral neuropathy to be

MiraLax (polyethylene glycol 3350) are the

at risk for foot ulceration, and provide

most frequent medications used for this

Diagnosis

education on foot care. If necessary, refer

condition.

The diagnosis of diabetic neuropathy is

the patient to a podiatrist.

Erectile Dysfunction

based on the symptoms, their distribution Patients with diabetic peripheral neuropathy

Overall, erectile dysfunction from diabetic

require more frequent follow up, with

neuropathy is a very difficult condition to

Fasting plasma glucose and hemoglobin

particular attention to foot inspection and

treat. All other causes of impotence must

A1c are important laboratory screening

reinforcement of the need for regular self

be excluded. Once the diagnosis has been

tests for diabetic neuropathy. Other blood

care. Regular foot examinations and patient

confirmed, the oral agent sildenafil (Viagra)

test(s) to rule out Vitamin B12 deficiency

education about foot care have been shown

may be tried. Referral to a urologist is suggested.

and paraproteinemias (SIEP, or serum

in several studies to significantly reduce

immunoelectrophoresis)

rates of ulceration and even amputation.

and a detailed neuromuscular examination.

are

essential.

Orthostatic hypotension Increasing the dietary fluid and salt intake,

More specific blood work may be required depending on the clinical presentation

The importance of involving a neurologist

along with use of compression stockings,

(inflammatory conditions, paraneoplastic

(preferably with expertise in peripheral

may help. If these modalities do not

processes and others).

neuropathy) in the treatment of patients

improve symptoms, then medication (i.e.

with

midodrine) may help.

Multiple consensus panels recommend

diabetic

neuropathy

cannot

be

overemphasized.

Gustatory sweating

the inclusion of electrodiagnostic testing in the evaluation of diabetic neuropathy.

Glycemic Control

Glycopyrrolate can be used for the handling

A proper selection of electrophysiological

Of all treatments, tight and stable blood

of diabetic gustatory sweating. It is applied

tests includes both nerve conduction testing

sugar control is probably the most important

topically to the affected area and can give a

and needle electromyography (EMG). The

for slowing the progression of neuropathy.

marked reduction in sweating while eating

diagnosis is strongly supported when a nerve

Rapid changes from hypoglycemia to

a meal.

conduction

hyperglycemia have been suggested to

velocity/electromyography

(NCV/EMG) test is abnormal.

bring and exacerbate neuropathic pain, so

Surgical Treatment

the stability of glycemic control may be as

This is indicated in patients with infected

The first part of the test involves measuring

important as the actual level of control in

foot ulcers when the infection cannot be

the rate of speed for electrical impulses as

relieving neuropathic pain.

controlled medically. Jejunostomy can help patients with intractable gastroparesis.

they travel down a nerve. The second part of the test, EMG, is essential to exclude or detect

Pain Management

When impotence is a continual problem,

other conditions that might mimic neuropathy

Oral agents include antidepressants and

the patient may pursue the option of a

(lumbar radiculopathy, cervical radiculopathy,

anticonvulsant drugs. Usually, pregabalin

penile prosthesis. Charcot foot can be

tarsal tunnel syndrome and others).

is recommended for treatment of diabetic

treated with bracing or special boots. In

neuropathic

some cases, surgery is used to correct the

pain.

Yet,

physicians

deformity.

In the appropriate clinical setting, magnetic

should determine if the drug is clinically

resonance imaging of the cervical, thoracic

appropriate for their patients on a case-

and/or lumbar regions may help exclude

by-case

another cause for symptoms mimicking

antidepressants and sodium valproate

Physical and occupational therapy should

diabetic neuropathy.

should also be considered for diabetic

be considered when activities of daily living

neuropathy pain management.

are being compromised. It is quite essential

basis.

Gabapentin,

tricyclic

Rehabilitation

to prevent falls in patients with significant

Treatment The primary care physician needs to be

Topical

therapy

with

capsaicin

alert for the development of neuropathy –

transdermal lidocaine may be useful

or even its presence at the time of initial

in some patients, especially those with

or

sensory ataxia from underlying diabetic neuropathy.

july 2011

19


Hospital News

Block and Armstrong Join Executive Staff

to work closely with SAHA. The regional health care alliance was established in 2004 to develop and foster relationships among member hospitals in order to improve the quality of health care, with a focus on

Vicki Block, M.H.A., is joining WakeMed

member of the senior leadership team, she

quality and safety, cost savings, compliance,

Health & Hospitals as senior vice president

also will help shape the strategic direction

knowledge sharing and education.

and Raleigh campus administrator, and

of the health system.

Dale Armstrong as vice president of

WakeMed was a founding member of Block earned a master’s degree in hospital

SAHA, which today includes 15 hospitals

and health care administration from Xavier

representing 4,400 beds, 28,000 employees

Vicki Block, whose

University in Cincinnati, Ohio, and a

and an annual net revenue of $2.7 billion.

position will begin

bachelor of science degree in biology from

SAHA’s reach stretches from the coast

July 25, comes from

The University of Akron in Akron, Ohio.

through central piedmont North Carolina.

regional operations.

Moses Cone Health System, a five-hospi-

Dale Armstrong is

Mr. Armstrong earned his master’s degree in

tal, 1,168-bed system

joining WakeMed by

business administration from the University

with more than 7,000

Aug. 1. He is presently

of Georgia at Valdosta and his bachelor’s

employees, where she has served for five

chief executive officer

degree in medical technology from the

years as vice president of heart, vascular

of the Cary, N.C.,-

University of Maryland. He began his career

and imaging services. Ms. Block brings

based

Southern

as a medical lab technologist and then spent

more than 20 years of experience in health

Atlantic

Healthcare

several years overseeing lab operations

care operations, having been in leadership

Alliance (SAHA) and brings more than 20

for numerous hospitals in Georgia. Prior

roles at numerous well-renowned health

years of hospital and health care senior

to joining SAHA, Mr. Armstrong was the

systems across the state and country,

leadership experience.

chief executive officer of several hospitals,

including The University of North Carolina

including Monroe Hospital in Bloomington,

Hospitals, Carolinas Healthcare and The

In his position as vice president of regional

Ind., Brynn Marr Behavioral Health System

Cleveland Clinic.

operations with WakeMed, Mr. Armstrong

in Jacksonville, N.C., and most recently at

will focus on current and future linkages

Central Carolina Hospital in Sanford, N.C.

In her position as senior vice president

and the development of both day-to-

He is a fellow in the American College of

and Raleigh campus administrator with

day and long-term relationships with

Healthcare Executives and long-standing

WakeMed, Ms. Block will be responsible for

hospitals, physicians and other health care

member of Rotary International.

the overall administrative management and

organizations outside Wake County and

operations for the Raleigh campus. As a

across North Carolina. He will continue

$100,000 Contribution Made to Advance Children’s Health Care Capitol Broadcasting Co. Inc., through

campaign in WakeMed’s history, seeks to

The “hospital within a hospital,” located

its CBC/WRAL Community Fund, has

accomplish a number of health care goals

on the fourth floor of a new patient tower

contributed $100,000 to the initiative that will

for children and families in Wake County

at WakeMed’s Raleigh campus, expanded

expand and enhance children’s health care

and the surrounding region. The initial goal,

patient

services at WakeMed Health & Hospitals.

to raise the first $8.5 million and open Wake

overcrowding due to area population

County’s first-ever children’s hospital, was

growth

achieved last summer.

pediatric facility. The next phase of the

The WakeMed Foundation’s $20 million Just for Kids Kampaign, the largest fund-raising

20

The Triangle Physician

capacity, and

relieved

created

a

consistent

state-of-the-art

campaign will include a much needed


Hospital News expansion of WakeMed’s Level IV (highest

community and most importantly for our

in WakeMed’s history to be fully funded

level) Neonatal Intensive Care Unit (NICU),

children. Families in Wake County and

by community donations,” said Dr. Bill

for which WakeMed already has received

beyond will benefit from this impressive

Atkinson, WakeMed president and chief

state approval.

new facility,” said James F. Goodmon,

executive officer. “Capital Broadcasting’s

president and chief executive officer of

generous donation is truly an investment in

Capitol Broadcasting Co.

our community’s children and families.”

throughout the Triangle area, the campaign

“As a result of the commitment and

Capitol Broadcasting Co. is a diversified

recently reached the $10 million milestone.

dedication of good corporate citizens

communications

and leaders like Capital Broadcasting Co.

broadcasting

“The expansion of children’s health care

and Jim Goodmon, the children’s hospital

Charlotte, Wilmington and Durham, among

services at WakeMed is an asset to our

and NICU expansion are the first projects

other business interests.

Due to community generosity, including from diverse corporations and organizations

company

operations

in

with Raleigh,

Cardiology Practice Adds New Physician and Garner Location Rex Healthcare recently expanded its

Rex Heart & Vascular Specialists offers

physician team at Rex Heart & Vascular

a comprehensive team of renowned

Specialists, with the addition of George

cardiologists at offices throughout Wake

For more information on Rex Healthcare,

Liell Adams, M.D., M.H.S., at a new practice

County, including Cary, Raleigh, Wakefield

visit www.rexhealth.com or call

location in Garner.

and now Garner. Rex is the only hospital

(919) 784-5600.

rating for heart attack survival.

in Wake County to earn an above-average “The addition of Dr. Adams and the new office allows us to provide the same comprehensive heart care to the Garner community that other patients around Wake County have come to expect,” said James Zidar, M.D., president, Rex Heart & Vascular Specialists. “His track record of providing quality, compassionate care makes him an excellent addition to our team and great start for the new practice.” Dr. Adams joins Rex Heart & Vascular Associates with more than 11 years of experience in cardiology and internal medicine. He earned his doctorate of medicine from East Carolina University, completed his residency at the University of Texas Southwestern, and achieved his master’s of health sciences in clinical research and his fellowship in cardiology from Duke University. Dr. Adams has received several honors, including an American College of Cardiology Young Investigator’s award. He also serves on the advisory board and selection committee for the North Carolina Albert Schweitzer Fellowship.

Managing your patients’ health is your life’s work. Managing physicians’ wealth is mine. Financial Rx for Physicians: • • • • •

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july 2011

21


Radiology Article

Ultrasound and Laser Technology Are Key to Treating Venous Insufficiency A significant number of patients with varicose veins suffer symptoms related to venous insufficiency, such as, aching leg pain, fatigue and/ or itching and swelling.

lower-extremity venous anatomy to establish the precise sources of venous insufficiency. Treatment usually involves techniques for eliminating the greater saphenous vein. As the primary superficial vein in the leg, dysfunction within this vein most often

Dr. Jason R. Harris, who joined Raleigh Radiology in 2008, has expertise in vascular and interventional and musculoskeletal radiology. He earned his bachelor of science degree at Brigham Young University and medical degree at Harvard Medical School. He completed his internship at Newton-Wellesley Hospital, Newton, Mass., and residency at Massachusetts General Hospital, Boston, Mass.; and a fellowship in vascular and interventional radiology at Duke University Medical Center. Dr. Harris is a member of the American College of Radiology, Society of Interventional Radiology.

results in varicosities and the symptoms of venous insufficiency.

Venous insufficiency affects an estimated 50

vein. Through a small puncture near the knee,

percent of men and women over the age of

Traditional treatment used to involve a surgical

the physician accesses and ablates the length

50 and 15 percent to 25 percent of all adults.

vein stripping or ligation procedure, using

of the greater saphenous vein from its origin.

general anesthesia. This procedure often Insufficiency results from a dysfunction

resulted in significant trauma to the leg and

All immediate postoperative care is usually

of valves that normally keeps the blood

required weeks, or even months, of recovery.

handled through the clinic. A follow-

moving in one direction toward the heart.

up exam allows the physician to ensure

As the valves fail, gravity causes blood to

Today, endovenous ablation has replaced

proper recovery and determine necessary

pool within the superficial veins of the

stripping and ligation to eliminate saphenous

management of the patient’s varicose

legs, resulting in the thickening and bulging

vein

invasive

disease. Adjuvant therapies might include

typical of varicosities.

procedure requires only a local anesthetic,

further ablation, ambulatory phlebectomy or

is performed as a same-day procedure in an

sclerotherapy.

reflux.

The

minimally

Varicose veins are much more than a

office setting and has a quick recovery time

cosmetic issue, as a significant number of

with a low risk of complications.

patients suffer from symptoms related to

Given the proven effectiveness of venous ablation, most insurance companies will

venous insufficiency. Symptoms may include

The entire procedure is performed using

cover the procedure, based on failed

aching leg pain, fatigue and/or itching and

ultrasound guidance, giving the physician

conservative therapy and medical necessity

swelling, all of which will typically increase

direct visualization of the greater saphenous

for symptom relief.

as the day progresses. The disease is usually progressive and will worsen with time. In later stages, venous insufficiency can lead to skin discoloration and even difficult-to-treat skin ulcers. The most common risk factors for venous insufficiency include age, family history, female gender and, especially, pregnancy. Diagnosis begins with a review of the patient’s medical history and a physical exam, and is usually followed by ultrasound. A key component of diagnosis, ultrasound allows the physician to confirm valve dysfunction, determine if the patient is a candidate for laser therapy and map the

22

The Triangle Physician

The treatment of varicose veins is a natural extension of Raleigh Radiology, given ultrasound’s key role in both the diagnosis and treatment of lower extremity venous insufficiency. Related venous access procedures and applications of ultrasound for minimally invasive therapies have long been a part of its interventional practice. Pictured here, Dr. Jason Harris (center) stands with fellow Raleigh Radiology vascular and interventional radiologists Satish Mathan (left) and Mark Knelson.


UNC News

OB/Gyn Accolades and Achievements Honors and Awards Dr. Champa Woodham was featured in the May 2011 edition of Ob.Gyn. News for her study entitled “Maternal 25(OH)D Levels and sFLT-1/PlGF Ratio Improves Predictability of Severe Preeclampsia in Early Pregnancy.” This research was selected for presentation in the fellows oral plenary session at the Society for Maternal-Fetal Medicine Annual Meeting in San Francisco, Calif., in February. Dr. Alison Stuebe was awarded an ECHO Pilot Grant for Alamance/UNC Breastfeeding Collaboration (ABC) Project. Dr. Stuebe is the principal investigator for the study, and Dr. Wanda Nicholson is the mentor. The 16-month grant is for $12,000. The 6th annual Society for Women’s Health Research Medtronic Prize for Scientific Contributions to Women’s Health was presented to Denniz Zolnoun M.D., M.P.H., associate professor in the Department of Obstetrics & Gynecology at the Society for Women’s Health Research (SWHR) annual gala dinner May 9.

Presentations by meetings American College of Obstetricians and Gynecologists’ Annual Clinical Meeting May 5-9, Washington, D.C. • Presidential Program: – “Misogyny and Women’s Health,” D.A. Grimes. • Poster Presentation – “Intrauterine Device Knowledge and Practices Among U.S. Obstetrics and Gynecology Residents, J. Tang, D. Bartz and R. Maurer. Gynecologic Oncology Robotic Symposium IGORS IV May 5-6, Washington, D.C. Dr. John F. Boggess served as program director and moderator for scientific session V in gynecologic oncology. In addition, he presented: • Live cadaveric dissection – “Abdominal/Pelvic Anatomy Through the Eyes of the Robot;” • Lecture – “Optimizing Robotic Approaches to Lymphadenectomy,” an interactive surgical tutorialbased session on para-aortic lymphadenectomy; • Lecture – “Optimizing Robotic Approaches to Hysterectomy and Beyond,” an interactive surgical tutorial-based session on radical trachelectomy;

• Lecture – “Optimizing RoboticAssisted Laparoscopy in Obese and Medically Compromised Patients: Tips and Tricks;” and • Surgical videos (see Dr. Rabbie K. Hanna below). Dr. Emma C. Rossi was an invited lecturer and presented “Sentinel Lymph Node Mapping Using RoboticallyAssisted Near Infrared Imaging and ICG for Endometrial and Cervical Cancer.” Dr. Rabbie K. Hanna presented these surgical videos: • Robotic-Assisted Pelvic Lymph Node Dissection During Pregnancy for Cervical Cancer,” Rabbie K. Hanna and John F. Boggess; and • “Robotic-Assisted Ureteroneocystotomy,” Rabbie K. Hanna and John F. Boggess.

Presentations by individuals Susan Nickel, C.N.M., “Safety in Pregnancy,” Triangle Association of Women’s Health Obstetric and Neonatal Nurse (AWHONN), May 2. Kathy Higgins, C.N.M., “Nutritional Supplements for Women,” UNC Wellness Center at Meadowmont, May 25. Dr. B.L. Robinson, C.A. Matthews, O.S. Palsson, E.J. Geller, M. Turner, B.A. Parnell, A.K. Crane, M.L. Jannelli, E.C. Wells, A.C. Connolly and W.W. Whitehead; poster presentation: “Influence of Stool Consistency, Urgency, and Obstetric History on Fecal Incontinence;” Digestive Disease Week, International GI Conference; May 7-10, Chicago, Ill. Dr. S.L. Young, “Progesterone Action on Human Endometrium: Clinical and Physiological Perspectives;” invited lecture at the 6th International Conference on the Female Reproductive Tract, May 20-23, Frauenworth, Germany. Dr. D. Zolnoun, “Biopsychosocial Correlates of Co-morbidity with IBS Among Women with Chronic Pelvic Pain;” invited oral presentation on overlapping conditions at the 9th International Symposium on Functional Gastrointestinal Disorders, April 7-10 , Milwaukee, Wis.

Publications G. Makrigiorgos, S. Santana, E. Sanchez, R. Sadacharan, A. Stuebe and Merewood A. “A National Website to Track Hospital Discontinuation of Formula Sample Pack Distribution: Accuracy of Self-report.” J Hum Lact. 2011 May;27(2):113-4. B. Parnell, W. Whitehead, E. Geller, J. Jannelli, and A.Connolly. “Overlapping Anal Sphincteroplasty: Impact of Suture Selection on Bowel Symptoms.” J. Repro Med. May/June 2011;56:187-191. R.F. Savaris, J.M. Groll, S.L. Young, F.J. DeMayo, J.W. Jeong, A.E. Hamilton, L.C. Giudice and B.A. Lessey. “Progesterone Resistance in PCOS Endometrium: A Microarray Analysis in Clomiphene Citrate-Treated and Artificial Menstrual Cycles.” J Clin Endocrinol Metab: 2011 96(6):1737-46. J.S. Sheffield, A. Hickman, J. Tang, K. Moss, A. Kourosh, N.M. Crawford and G.D. Wendel Jr. “Efficacy of an Accelerated Hepatitis B Vaccination Program During Pregnancy.” Obstet Gynecol. 2011 May;117(5):1130-5. Z. Zhang, D.A. Zolnoun, E.M. Francisco, J.K. Holden, R.G. Dennis and M. Tommerdahl. “Altered Central Sensitization in Subgroups of Women With Vulvodynia.” Clin J Pain. 2011 May 17. [Epub ahead of print]

From Twitter IN THE NEWS video: Rex On Call – “Rex, UNC Fighting Cancer Together.” Dr. Linda Van Le interviewed. http:// youtu.be/9slssg80EAQ. More Information for You - “Fibulin-5 and Pelvic Organ Prolapse.” http:// bit.ly/lO0tze. “Obesity and Pregnancy Complications – You Are Not Eating for Two,” references Dr. Allison Stuebe’s research. http://bit.ly/lqk806. “What’s an Obstetrician-Gynecologist to Do?” Editorial by Dr. Honor Wolfe, retweet @greenjrnl, June 2011 issue. http://bit.ly/f3XiHZ “What Vitamins Should I Take?” presentation by Kathy Higgins, C.N.M., at the UNC Wellness Center May 25. http://bit.ly/j9e6Mr. More Information for You – “HPV and Pap Tests.” http://bit.ly/iRdG8Z.

“Global Obesity and the Effect on Women’s Health,” by Dr. Nancy Chescheir, retweet @greenjrnl, May issue: http://bit.ly/kWE8ce. Trina Pugh shares her UNC midwifery story. http://bit.ly/jVgRD9. Dr. Nancy Chescheir’s responses to ACOG’s “Ask the Expert” questions about obesity and women’s health. http://bit.ly/lCVeuV. Dr. Jennifer Mersereau comments on recently published research about stress and fertility treatment. http:// on.fb.me/k1gYB9 Video: Joscelyne Brazile from Durham, N.C., shares her experience with UNC midwifery. http://youtu.be/ W1KXmouTcuE. New vaginal birth after cesarean (VBAC) guidelines. Who’s a candidate? http://bit.ly/jeytNO. “I set out to understand the nature of pain in gynecology... .” Read more of Dr. Denniz Zolnoun’s acceptance speech. http://bit.ly/luTuBd. IN THE NEWS: Dr. Denniz Zolnoun is the winner of the prestigious Society for Woman’s health Research Medtronic prize. http://bit.ly/kof32j. Do patients know enough about fertility preservation? http://1.usa. gov/hi9ncM and www.med.unc.edu/ fertilitypreservation. “It’s a Mother of a Day,” a blog by UNC OB/GYN alum Dr. Rink Murray about experiencing childless Mother’s Day. http://bit.ly/mCSCqa. Real Doctors, Real People: Featuring how Dr. John Steege applies surgical skills to woodworking. http://bit.ly/ hmbCvx. IN THE NEWS: “Misogyny Kills Women Around the Globe.” Dr. David Grimes presents. #ACOG2011. http://bit.ly/jua4S7. IN THE NEWS: “Making Strides.” Minority women as physicians. Dr. Alice Chuang is featured in this Medical Bulletin story. http://bit.ly/m4fwaJ. Video: UNC’s Dr. Catherine Matthews talks about urinary incontinence on the Rex Healthbreak. http://youtu.be/ wnpnruCNqfA. IN THE NEWS video: How misogyny hurts women’s health, by Dr. David Grimes. http://ow.ly/4LDE6. Retweet @acognews, #ACM2011.

july 2011

23


News Welcome to the Area

Triangle Physicians Julie Kristine Wood, DO Pediatrics Duke University Hospitals, Durham

Samuel Bruce Adams, MD Orthopedic Surgery Duke University Medical Center, Durham

Thomas John Bender, MD Duke Occupational & Environmental Medicine Durham

Thomas Joseph Bice, MD UNC Chapel Hill, Chapel Hill

Heather Carrick Braithwaite, MD Emergency Medicine Raleigh

Cheryl Ann Carlson, MD UNC Lineberger Comprehensive Cancer Center Chapel Hill

Khushbu Anirudhdha Chandarana, MD

Herman Aronov Naftel, MD

Timothy Michael Zagar, MD

Psychiatry University of North Carolina Hospitals Chapel Hill

Radiation Oncology University of North Carolina, Chapel Hill

Justin Eric Paulson, MD Juliessa Marta Pavon, MD Internal Medicine Duke University Hospitals, Durham

Sallie Robey Permar, MD

David Arthur Masneri Sr, DO Womack Army Medical Center, Fort Bragg

David Calvin Plitt, MD

Womack Army Medical Center, Fort Bragg

University of North Carolina Hospitals Chapel Hill

Robert Lee Young, DO

Julia Kristen Rauch, MD

Nephrology, Internal Medicine Wake Nephrology Associates, PA, Raleigh

Preeya Kshettry Gupta, MD

Benjamin Cohen Gersh, MD

Asher O Smith, MD Orthopedic - Surgery of the Hand Orthopedic Surgery Duke University Hospitals, Durham

Dana Marie Smith, MD Dept of Obstetrics and Gynecology Chapel Hill

Zebulon Zachary Spector, MD

Tobias Johannes Heye, MD

Eric Furman Strother, MD

Internal Medicine - Nephrology University of North Carolina Hospitals

Logan Leo Lechner, MD Obstetrics and Gynecology University of North Carolina Hospitals

Matthew Craig Lewis, MD

Anesthesiology Concentra, Durham

Kimberly Ann Putalik Talikoff, MD

Ronald James Viola, MD

Kristin Elinor Meade, MD Internal Medicine, Pediatrics Hospital Medicine Program, Duke University Hospitals, Durham

April Elizabeth Mendoza, MD UNC Chapel Hill, Dept of Surgery, Chapel Hill

24

The Triangle Physician

Neuro Rehabilitation, Merritt

Ashley Deane Kent, MD University Health Systems Physicians, Ahoskie

James Michael McGee, MD Emergency Medicine Womack Army Medical center, Fayetteville

Eleanor Louise Murray, MD Women’s Healthcare Associates, Jacksonville

John Livingston Powell, MD Gynecology/Oncology, Obstetrics and Gynecology 10 Crane Street, Wrightsville

BeachXiang Wang, MD 901 N. Winstead Avenue, Rocky Mount

DUMC, Durham

Radiology Duke University Hospitals, Durham

Laura Wakil, MD Psychiatry University of North Carolina Hospitals Chapel Hill

Nicole Wilde, MD Internal Medicine University of North Carolina Hospitals Chapel Hill

Women’s Wellness Clinic Dr. Andrea Lukes

If you are a healthy female age 18-40 years with regular periods, then you may qualify for a research study on the effects of an investigational medication on ovulation and ovarian function. The research study procedures include: • physical exam • PAP smear • ultrasounds • blood draws • EKG Reimbursement up to $225 per week (for up to 20 weeks if you qualify). This study is being conducted by Dr. Andrea Lukes at the Women’s Wellness Clinic. Women’s Wellness Clinic is located by the Streets of SouthPoint. For more information call (919) 251-9223 or visit www.cwrwc.com.

Gastroenterology Stomach Ulcers Wake Research Associates Charles F. Barish, MD

Have you suffered from a heart attack or stroke and take 325 mg of aspirin daily to prevent another from occurring? If so, Wake Research is conducting a research study of an investigational medication that combines aspirin with a second medication to see if It can help prevent stomach ulcers. You’ll receive investigational medication and study-related exams at no cost and compensation up to $500 for time and travel. For additional information and qualification criteria please call (919) 781-2514 or visit us online at www.wakeresearch.com.

Colleen August, PA

Elizabeth Ann Thompson, MD

Thomas Clark Litzinger, MD

Emergency Medicine Duke University Hospitals, Durham

Catherine Mary Hagerty, MD

Columbus Internal Medicine, Whiteville

Lejla Vajzovic, MD

Douglas Alvin Lyssy, MD

Psychiatry, Family Practice Pitt County Memorial Hospital, Greenville

Cape Fear Valley Health System, Fayetteville

Pediatrics University of North Carolina Hospitals Chapel Hill

Ovulation and Ovarian Activity

Coastal Carolina Neonatology, Wilmington

Pediatrics Chapel Hill

Pediatrics University of North Carolina Hospitals

2530 Erwin Rd, Durham

Marc Thomas Bartman, MD Robert Michael DiGiuseppe, MD

Ophthalmology Duke University Eye Center, Durham

Louis-Philippe Laurin, MD

Emergency Medicine Pitt County Memorial Hospital, Greenville

Radiology University of North Carolina Hospitals Chapel Hill

Pediatrics University of North Carolina Hospitals Chapel Hill

Radiology Duke University Medical Center, Durham

Yousif Zaid Alkadhi, MD

Elizabeth Ann Russ, MD

Cardiovascular Surgery, Thoracic Surgery Duke University Medical Center, Durham

Karn Gupta, MD

ECEP II, P.A., Wilmington

Cape Fear Valley, Fayetteville

Daniel John Del Gaizo, MD

Division of Cardiovascular Medicine, Durham

Jeffery Wayne Van Den Broek, DO

Division of Infection Diseases, Durham

Jacob Niall Schroder, MD

Adam David DeVore, MD

Suzanne E Kimball, DO

Internal Medicine Duke University Hospitals, Durham

Duke University Hospital, Durham

Orthopedic Surgery UNC Hospitals Dept of Orthopaedics Chapel Hill

Eastern Physicians

Gajarah Baseemah Ballard Peterson, MD

Matthew Palmer Rubach, MD

Andrei Cocieru, MD

381 Ruin Creek Road, Henderson

NC Inpatient Medicine Associates,PLLC New Bern

Sulene Liu Chi, MD

UNC Hospitals, Chapel Hill

Betsy L Loika, PA

Duke University Health System, Durham

2605 Blue Ridge Road, Raleigh

James Anders Christensen, MD

6509 Bakersfield Drive, Raleigh

UNC Pediatric Pulmonology, Chapel Hill

Internal Medicine University of North Carolina Hospitals Chapel Hill

Ophthalmology, Internal Medicine Duke University Medical Center, Durham

Ellen Beth Klaenhammer, PA

Clinical Trials Do you have patients with any of these problems?

Elizabeth Erin Bickell, PA Rita M Langworth, PA 5017 Songline St, Shallotte

Heather Shearin Page, PA Carolina Pediatrics, Wilmington

Medical Practice Partnership Effective May 9, Activcare Physical Therapy and Wellness One have combined their physical therapy and support teams, and will continue operating under the name Activcare Physical Therapy. Activcare is a privately held physical therapy practice with two locations in Raleigh and one in Fayetteville. For more information visit www.activcarept.com or call (919) 786-7434.

General Medicine/ Infections Wake Research Associates Charles F. Barish, MD

Do you have an upcoming hospitalization? You could be at risk of infection by Clostridium difficile (C.diff.), a bacteria that can cause severe gastrointestinal problems.You may qualify for this study if you are between 40 and 75 years old and have an upcoming hospitalization. Study-related medical exams and study medication are provided at no cost, and compensation will be provided for time and travel. For additional information and qualification criteria please call (919) 781-2514 or visit us online at www.wakeresearch.com.


Your LocaL cardioLogY ProfessionaLs in Johnston countY dedicated to QuaLitY, service, and integritY

Mateen Akhtar, MD, FACC

Benjamin G. Atkeson, MD, FACC

Christian N. Gring, MD, FACC

Matthew A. Hook, MD, FACC

Kevin Ray Campbell, MD, FACC

Eric M. Janis, MD, FACC

Randy Cooper, MD, FACC

Diane E. Morris, ACNP

cardioLogY services

Ravish Sachar, MD, FACC

Nyla Thompson, PA-C

2 Locations to serve our Patients Smithfield Heart & Vascular Associates 910 Berkshire Road Smithfield, NC 27577 Phone: 919-989-7909 Fax: 919-989-3147

Wake Heart & Vascular Associates 2076 NC Hwy 42 West, Suite 100 Clayton, NC 27520 Phone: 919-359-0322 Fax: 919-359-0326

Coronary and Peripheral Vascular Interventions Pacemakers/Defibrillators Atrial Fibrillation Ablations Echocardiography Nuclear Cardiology Vascular Ultrasound Clinical Cardiology CT Coronary Angiography Stress Tests Holter Monitoring Cardiovascular Medicine Echocardiography Nuclear Cardiology Cardiac Catheterization

the highest QuaLitY cardiovascuLar care, cLose to home.


Little Is Big To Us.

BRENT A. TOWNSEND, MD | Pediatric Radiologist

CATHERINE B. LERNER, MD | Pediatric Radiologist

Š2011 Wake Radiology. All rights reserved. Radiology saves lives.

LAURA T. MEYER, MD | Pediatric Radiologist

Wake Radiology is the first radiology practice in Raleigh to open a dedicated pediatric outpatient imaging center. Four fellowship-trained, pediatric radiologists have created a child-friendly environment for your young patients who range from a few days of age to eighteen years old. Our pediatric radiologists are all subspecialty trained and are keenly aware of the unique challenges that your pediatric patients present. Because children are more sensitive to radiation than adults, we strive to use the smallest doses of radiation possible that will still provide diagnostic images and offer experienced guidance in selecting the most appropriate imaging modalities for your patient. Wake Radiology Pediatric Imaging. Deliverying the finest care for your smallest patients.

Wake Radiology Pediatric Imaging | 4301 Lake Boone Trail, Ste 100 | Raleigh, NC 27607 | Scheduling 919-232-4700 | wakerad.com

July 2011  

The Triangle Physician July 2011 Serving about 9, 000 MDs, PAs, and NPs in the Triangle Area of North Carolina. If you have the need to get...

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