j u n e 2 0 11
Waverly Hematology Oncology Excellence with Compassion
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 Headache and Imaging: When Is It Appropriate? Special Spotlight Debuts with Pretty In Pink
Introducing Protecta™ XT
CRT-D, DR and VR ICDs with SmartShockTM Technology
Fewer Shocks. Greater Living. The only ICD with SmartShock technology that dramatically reduces the incidence of inappropriate shocks while maintaining sensitivity.1,2
With Protecta XT, 98% of ICD patients are free of inappropriate shocks at 1 year and 92% at 5 years.*2 Changes in a patient’s disease and/or medications may alter the efficacy of a device’s programmed parameters or related features. * Primary prevention patient programmed for detection rate cut off at 188 bpm.
References 1 2
Protecta Clinical Study, Medtronic data on file. Volosin KJ, Exner DV, Wathen MS, et al. Combining shock reduction strategies to enhance ICD therapy: A role for computer modeling. J Cardiovasc Electrophysiol. Published online October 11, 2010.
Brief Statement Indications: The Protecta™ XT CRT-D system is indicated for ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias and for the reduction of the symptoms of moderate to severe heart failure (NYHA Functional Class III or IV) in those patients who remain symptomatic despite stable, optimal medical therapy and have a left ventricular ejection fraction less than or equal to 35% and a prolonged QRS duration. Atrial rhythm management features such as Atrial Rate Stabilization (ARS), Atrial Preference Pacing (APP), and Post Mode Switch Overdrive Pacing (PMOP) are indicated for the suppression of atrial tachyarrhythmias in ICD-indicated patients with atrial septal lead placement and an ICD indication. The Protecta DR and VR system is indicated to provide ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias in patients with NYHA Functional Class II/III heart failure. The Protecta DR is also is indicated for use in the above patients with atrial tachyarrhythmias, or those patients who are at significant risk of developing atrial tachyarrhythmias. Atrial rhythm management features such as Atrial Rate Stabilization (ARS), Atrial Preference Pacing (APP), and Post Mode Switch Overdrive Pacing (PMOP) are indicated for the suppression of atrial tachyarrhythmias in ICD-indicated patients with atrial septal lead placement and an ICD indication. Additional Protecta XT DR System Notes: • The ICD features of the device function the same as other approved Medtronic market-released ICDs. • Due to the addition of the OptiVol® diagnostic feature, the device indications are limited to the NYHA Functional Class II/III heart failure patients who are indicated for an ICD. • The clinical value of the OptiVol fluid monitoring diagnostic feature has not been assessed in those patients who do not have fluid retention related symptoms due to heart failure. • The use of the device has not
been demonstrated to decrease the morbidity related to atrial tachyarrhythmias. • The effectiveness of high-frequency burst pacing (atrial 50 Hz Burst therapy) in terminating device classified atrial tachycardia (AT) was found to be 17%, and in terminating device classified atrial fibrillation (AF) was found to be 16.8%, in the VT/AT patient population studied. • The effectiveness of high-frequency burst pacing (atrial 50 Hz Burst therapy) in terminating device classified atrial tachycardia (AT) was found to be 11.7%, and in terminating device classified atrial fibrillation (AF) was found to 18.2% in the AF-only patient population studied. Additional Protecta XT VR System Notes: • The ICD features of the device function the same as other approved Medtronic market-released ICDs. • Due to the addition of the OptiVol diagnostic feature, the device indications are limited to the NYHA Functional Class II/ III heart failure patients who are indicated for an ICD. • The clinical value of the OptiVol fluid monitoring diagnostic feature has not been assessed in those patients who do not have fluid retention related symptoms due to heart failure. Contraindications: The Protecta XT CRT-D, DR and VR system is contraindicated for patients experiencing tachyarrhythmias with transient or reversible causes including, but not limited to, the following: acute myocardial infarction, drug intoxication, drowning, electric shock, electrolyte imbalance, hypoxia, or sepsis. The device is contraindicated for patients who have a unipolar pacemaker implanted. The device is contraindicated for patients with incessant VT or VF. Contraindications specific to Protecta XT CRT-D and DR: The device is contraindicated for patients whose primary disorder is chronic atrial tachyarrhythmia with no concomitant VT or VF. Contraindications specific to Protecta XT VR: The device is contraindicated for patients whose primary disorder is atrial tachyarrhythmia. 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. Additionally, for CRT-ICDs, 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 manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. 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)
UC201003400 EN © Medtronic, Inc. 2011. Minneapolis, MN. All Rights Reserved. Printed in USA. 05/2011
NeWS FROm DUke meDiciNe
Comprehensive Duke Orthopaedics center to open in RTP in July Scope of Care The new center will deliver all Duke Orthopaedics services except for those that require the care of subspecialists in oncology, pediatrics, and/or trauma. Offerings will include: Foot and ankle
evaluation and care of arthritis, avascular necrosis, and other degenerative conditions
Hand and upper extremity Joint/total joint replacement
Duke Orthopaedics will soon be seeing patients in a brandnew, state-of-the-art outpatient clinic in Research Triangle Park (RTP)*. The comprehensive center will serve as Duke’s primary orthopaedics presence. Slated to open on July 18, 2011, the center will occupy the majority of a 60,000-square-foot, freestanding facility and was designed with patient convenience in mind: Full-time staffing
On-site physical therapy
Free, on-site parking
On-site surgical scheduling
Two covered drive-up lanes
Nonoperative orthopaedics, including the management of minor fractures
Sports medicine Physical therapy
Nonoperative spine care
Providers Samuel B. Adams Jr., mD
Gloria G. Liu, mD, mS
David e. Attarian, mD
Fraser J. Leversedge, mD
Blake R. Boggess, DO
Richard c. “chad” mather iii, mD
michael P. Bolognesi, mD
James A. Nunley ii, mD, mS
James k. DeOrio, mD
David S. Ruch, mD
mark e. easley, mD
Samuel D. Stanley, mD
* Please note that the Duke Medicine clinics at 10950 Chapel Hill Road in Morrisville and 6301 Herndon Road at Southpoint will not offer orthopaedic services after July 1, 2011.
Grant e. Garrigues, mD
Samuel S. Wellman, mD
Look for additional information about this clinic in the coming months.
Stephanie L. Bonham, PA-c, mS, mPT
Location Duke Medical Plaza Page Road 4709 Creekstone Drive Durham, NC 27703
Duke Orthopaedics has been ranked among the nation’s top ten centers of its kind since 1992 by U.S.News & World Report.
800 -MED-DUKE for providers 888 -ASk- DUke for patients
Anand B. Joshi, mD, mHA
christopher cole, PA-c, mmSc Diane B. covington, mHS, PA-c Scott D. Gibson, PA-c, mHS Ashley N. Grimsley, mHS, PA-c John H. Lohnes, PA-c, mHS Raymond c. malaguti, mPAS, PA-c P. cody malley, PA-c, LAT, ATc Joseph P. Shinnick, mHP, PA-c Steven T. Silverman, PA-c elizabeth J. Turner, PA-c, mHS
Questions? Your Physician Liaisons and the Duke Consultation & Referral Center are here to help you navigate Duke Medicine.
Waverly Hematology Oncology
Personalized care delivery, primary nursing, cancer genetics and clinical trials define success at Waverly Hematology Oncology.
j u n e 2 011
Vol. 2, Issue 6
“Doc, I’ve Got This Headache” Dr. Cynthia Payne explores the appropri-
DEPARTMENTS 13 Women’s Health Opportunities for Clinical Research at Women’s Wellness Clinic
Breast-Specific Gamma Imaging
18 Neurology Goal of Minimally Invasive Surgery Is to Reduce Approach-Related Morbidity
20 Your Financial Rx
ateness of imaging when headache is the
Dr. Eithne Burke reviews the advent of
complaint. Is it a common malady of life or
molecular-based imaging of the breast and
something more serious?
its increasing role in moderate-risk screening
and problem solving.
Risk Is a Four-Letter Word
Carpel Tunnel Syndrome Has Multiple Causes
24 Community Service Pretty In Pink: When Breast Cancer Is Present and Insurance Is Not
25 Rex Healthcare News Awards for Organ Donation and Patient Satisfaction
26 WakeMed News Board Members Appointed and new baby-friendly designation Cover Image: Age Before Beauty. Suzanne Kirby M.D., PhD (left) and Mark Graham, M.D. (right) of Waverly Hematology Oncology flank their midlevel providers: Brittani Boehlke, PA-C; Ann Shine, A.N.P.; and Susan Blumenthal, PA-C. They all defer to their senior colleague Bill Bobzien, M.D., in the lobby of the Waverly practice site in Cary. The practice at 300 Ashville Ave. provides comprehensive cancer services for patients, including sophisticated breast imaging, PET, CT and MRI by Wake Radiology, along with radiation oncology services by Scott Sailer, M.D.; and Andrew Kennedy, M.D.
The Triangle Physician
28 News New Physicians, Medical Practice Partnership and Clinical Trials
JOHNSTON HE ALTH
From the Editor
The Might of Clinical Trials 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 cover story this month spotlights Waverly Hematology Oncology, a practice whose cancer care is founded on the physicians’ experience at large academic medical centers, yet delivered in a more familiar setting to patients. Clinical trials within the Waverly Hematology Oncology medical arsenal level the playing field, so to speak, bringing to the practice the latest in medical science in a cost-effective manner.
Editor Heidi Ketler, APR
metastatic breast cancer.
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.
Also in this issue, radiologist Eithne Burke reports on the benefits of breast-specific
Photography Jim Shaw Photography email@example.com
Drs. Mark Graham and Suzanne Kirby carefully consider how available clinical trials will best serve their clients. Dr. Graham pushes the envelope of medical science in his own right, with ongoing surveillance of circulating cancer cells to guide treatment of
gamma imaging (BSGI) over mammography, in which at least 15 percent of breast cancers are mammographically occult. BSGI has been able to detect breast cancers as small as 1 millimeter, a significant improvement. Radiologist Cynthia Payne discusses the role of imaging in diagnosing headaches.
Creative Director Joseph Dally
Advertising Sales Carolyn Walters firstname.lastname@example.org Natalie Snapp email@example.com
According to one study, headache was a symptom of metastatic or primary tumor in 47 percent of patients in one study, but only 8 percent presented with headache as an isolated symptom. Obstetrician/gynecologist Andrea Lukes discusses her practice’s focus on clinical research. Neurosurgeon John Grant Buttram reviews the history of minimally invasive surgery. Neurologist Henry Tellez gives an overview of carpel tunnel syndrome, from symptoms to treatment. Our resident financial planner gives us a lot more insight on risk and how it impacts your practice. Also on the practice management side, remember when you’re evaluating your marketing dollars that The Triangle Physician covers a lot of ground, as the only publication dedicated to the Raleigh-Durham Medical Triangle and beyond. Let summer begin! With deep gratitude for all you do,
Heidi Ketler Editor
News and Columns Please send to firstname.lastname@example.org
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.
The Triangle Physician
On the Cover
Waverly Hematology Oncology Excellence with Compassion As the only remaining independent, private
300 Ashville Ave. site since the practice
Suzanne L. Kirby, M.D., Ph.D., provides
hematology oncology practice in Wake
opened in October 2004.
PHOTO BY BRYAN REGAN PHOTOGRAPHY
County, Waverly Hematology Oncology P.A.
malignancies and pure hematology. At UNC,
(WHO) sees patients with all types of cancer
Mark Graham, M.D., sees all tumor types
she worked both the clinical side and the
and hematologic disorders.
and pure hematology and recently has been
research side of hematology and brings her
studying circulating tumor cells (CTCs) as
unique perspectives to patient care.
Located in Cary near the intersection of
a unique predictor of the clinical course of
Route 1 and Highway 64 in southwest
metastatic breast cancer (MBC). His findings
In 1971, William F. Bobzien, M.D., completed
provide strong evidence of the value of this
a fellowship in clinical pharmacology, the
Oncology (WHO) has three physician
approach as a complement to radiology
forerunner of the field later named medical
specialists, three mid-level practitioners
and clinical evaluation. He has reported
oncology. Present at the origin of this
and four full-time oncology nurses who
on the data from WHO patients at national
field, Dr. Bobzien has developed a broad
staff the infusion clinic. The practice
meetings, with the hope of improving the
spectrum of interest and experience in all
admits to the adjacent WakeMed Cary
lives of patients with MBC beyond the
types of cancer, as well as hematology, over
Hospital and has been a fixture at the
borders of Wake County
the ensuing decades.
Primary Nursing at the Heart of Practice at WHO - Primary nurse Marcie Lorbacher, R.N., O.C.N., administers treatment to Waverly patient Michelle Avent in May.
The Triangle Physician
And She Keeps It All Straight. Lab Director Patti Covington, M.L.T., heads up the CLIA (Clinical Laboratory Improvements Amendments)-approved Waverly lab, processing lab specimens from 12,000 annual patient visits. Patti and her staff ably handle everything from on-site CBCs (complete blood count) and PT/INRs (to measure blood-clotting tendency) to complex bone marrow, circulating tumor cell, cancer genetics and molecular biology studies from the blood, marrow, CSF (cerebrospinal fluid), pleural and peritoneal fluid, and urine of Waverly patients.
WAKE COUNTY’S ONLY INDEPENDENT, PRIVATELY OWNED CANCER CLINIC
a comprehensive electronic medical records
(LP), intrathecal therapy by LP or Ommaya
(EMR) system to manage each patient’s
catheter, thoracentesis and paracentesis.
The WHO clinic philosophy is a direct
never been a paper record in the practice
“Here, patients benefit from the personalized
reflection of Dr. Graham’s passion for cancer
since we opened. We programmed the EMR
care of a private community practice,and
treatment and initial training in medial
for our own use, which has managed the
medical advances often available only at
school at the Mayo Clinic, as well as his past
practice well. Importantly, we can access the
major medical centers,” says Dr. Graham.
clinical experience at the University of North
EMR remotely when we are off site, at home
Research at the practice also extends to
Carolina (UNC), Chapel Hill.
or at the hospital,” says Dr. Graham.
participation in clinical trials through the
extensive medical database. “There has
Dr. Graham was instrumental in the
WHO is the only Wake County cancer
Program) of the National Cancer Institute
development of the Multidisciplinary Breast
program – hospitals and private practices,
(NCI) and a handful of clinical trials with
Cancer Program at UNC in the early 1990s,
alike – to offer formal genetic counseling
pharmaceutical companies, which reflect
along with surgeon William Cance, M.D.;
and testing with a trained genetic counselor.
the scientific interests of the Waverly
and mammographer Etta D. Pisano, M.D. He
“Many are surprised a small practice would
physicians. (See call-out box, page 8.)
served as program co-director for 11 years.
offer this,” says Dr. Graham. Today, WHO’s published database of more
“The principles of this first multidisciplinary cancer program at UNC have gone on to
The practice also provides the convenience
than 100 MBC patients shows the clinical
become the unifying theme for all clinical
of on-site infusion therapy, with one-on-one
utility of CTCs. “We are proud to be one of
cancer programs at UNC,” says Dr. Graham.
primary nursing, a comprehensive lab, and
the few small private practices nationwide
many diagnostic and therapeutic procedures
actively contributing to clinical research in
Dr. Graham founded WHO Oct. 11, 2004 on a
performed in the practice: bone marrow
this area,” says Dr. Graham. (See call-out box
solid technological foundation that features
aspirate and biopsy, lumbar puncture
on page 10, and Figure 2, on page 11.)
SPECIALIZATIONS Hematologic Malignancies and Pure Hematology Hematologic malignancies account for 10 percent of new cancers nationwide. By virtue of her medical education that focused on hematologic malignancies and bone marrow transplantation, Dr. Kirby sees the majority of these patients at WHO, though she diagnoses and treats all forms of cancer. “Having a physician who is focused on hematologic
processes in the clinic,” says Dr. Kirby, who has been with the practice for four-and-a-half years. Patients who require a bone marrow stem cell replacement as part of their longterm therapy have the procedure at UNC or Duke University Health System and then return to Dr. Kirby for maintenance therapy and follow up. Prior to joining WHO, Dr. Kirby was
Advancing Medical Science Community-based Clinical Research Supported by the NCI • “Today’s clinical trial treatment may become tomorrow’s standard of care,” says Dr. Mark Graham of Waverly Hematology Oncology (WHO). “Community-based clinical trails offer novel therapy normally found at large academic facilities.” • WHO is the only Triangle site of the Southeast Cancer Control Consortium Inc. (SCCC), a noted consortium of 23 practices in five states that offers National Cancer Institute-sponsored clinical trials to community-based practices and provides funding. • Of the 54 regional Community Clinical Oncology Programs (CCOPs) in the United States, SCCC has consistently ranked in the top five for national CCOP accruals during the past 20 years. For information on CCOPs, visit the SCCC website at
www.southeastcancercontrol.org, click on “About Us” and the “History of the SCCC.” • WHO has focused on large NCI Phase 3 clinical trials in breast, lung, colon and kidney cancers. These trials ask the most important questions regarding the practical integration of new oncology drugs into standard treatment regimens. • With training and education programs from the SCCC, and under the direction of WHO clinical trials specialist Gena Boyd, the practice has performed well on all audits that judge the quality of the clinical trial process. • All Waverly clinical trials are carried out with the approval of the Institutional Review Board (IRB) from WakeMed, among the first cancer trials overseen by WakeMed in its 50-year history.
an associate professor at UNC, where
chemotherapy and antibody therapy for
especially for the first treatment,” says Dr. Kirby.
she conducted laboratory research on
Primary nursing by the Oncology Nursing
hematologic development and immunology.
Society-certified nurses at WHO facilitates
“One thing that’s different in patients with
“We determine what clinical trials are the
continuity of care for the patient and
hematologic malignancies, as opposed to
most appropriate for our patient population,”
accountability of the nurse for that care.
other malignancies, is they have a greater
says Dr. Kirby. “Sometimes the drug studies
The treatment program is comprehensive,
risk of more and unusual infections,
can offer patients drugs they may not be able
individualized and coordinated. Medical
because of the disease and the drugs used
to get because they are not yet FDA (Food
problems are more likely to be detected
in treatment that suppress the immune
and Drug Administration) approved or not
earlier when the same nurse consistently
system. This awareness enables us both to
covered by insurance. Cost of the study
sees the patient, Dr. Kirby explains
use appropriate preventive measures and to
drug, which can be up to $100,000 for new
recognize such infections early.”
therapies, is absorbed by the clinical trial.”
“Our clinic is very dedicated to the patient. All the staff here thinks of the patient as a
According to Dr. Kirby, there are several
Infusion Therapy and Primary Nursing
whole person, along with the family. We
new biologic antibodies and growth factor receptor inhibitor drugs used to treat
The care of each infusion patient at WHO is
is here to make things as easy as possible
hematologic malignancy. “A background
managed by one of four primary nurses, who
for the patient and his or her family,” says
in that type of science helps me explain to
coordinates all facets of a patient’s treatment,
Marcie Lorbacher, R.N., a primary nurse who
families how they work and describe the
schedules all tests and procedures, cares for
has been with the practice for six years.
possible infectious complications,” she says.
the patient on the day of infusion and is the point of contact for all patient concerns.
Dr. Kirby is preparing for two new clinical
realize how important the support system
Primary nurses form trusting relationships with their patients, explains Ms. Lorbacher. “We get
trials at WHO. The first will follow patients
Before the patient meets his or her primary
to know our patients really well, and that’s very
with chronic myelogenous leukemia being
nurse for the first time, they visit with oncology
important. This allows us to be better advocates
treated with tyrosine kinase inhibitors
nurse educator Ellen Beidler, R.N. “Ellen
for the patient. We give them their treatments
to determine which is the best first-line
spends as much time as necessary with the
and the supportive care they need. They know
treatment. Another clinical trial will involve
patient and helps ensure things go smoothly,
from the beginning that we can speak for them
The Triangle Physician
Warm, Cold and Irish - The WHO midlevel providers, from left, Brittani Boehlke, PA-C; Anne Shine, A.N.P.; and Susan Blumenthal PA-C – bring spirit and knowledge to their daily work with patients. They hail from Waverly, Minn.; (for which the practice is named) Tipperary, and Florida respectively. And that’s no blarney!
Figure 1: Waverly Hematology Oncology features the only regular cancer genetics clinic in Wake County, meeting on a monthly basis with its physicians and senior genetic counselor Cecile Skrzynia, C.G.C., M.S. The family history below shows how testing and counseling impacts a patient and her immediate and extended family.
A 42-year-old woman (Red arrow) presented to the Waverly practice with concern for her risk for breast cancer. Her older sister had developed bilateral breast cancer at ages 40 and 48, and was proven to have a mutation in BRCA2. Dr. Mark Graham recommended testing for the same mutation carried by the sister, a two-base pair deletion in BRCA2, causing a “frame shift.” The patient herself was also positive, and a further recommendation of heightened screening and eventual prophylactic breast and ovarian surgery was made. The sister’s son and daughter were tested and both were positive for the same gene mutation.
The patient herself developed a breast cancer before she could decide finally to pursue the prophylactic surgeries. Plans were then made to test other family members. Two of the patient’s daughters are both negative. Neither they, nor any of their descendants, will be affected by this BRCA2 mutation again. The patient’s mother was also tested and was negative, confirming that the source of the mutation in the patient and her sister was their father, which was not clear from the pedigree. Cousins on the paternal side of the pedigree can now be tested and correctly assigned their cancer risk.
regarding any emotional, spiritual, family, and
“The mid-1990s were a heady time for
recurrence, and review available testing
financial issue. If they have any problems, they
the field of clinical cancer genetics, with
options with the family.
know they can call us.”
the discovery of the breast and ovarian cancer susceptibility genes, BRCA1 and
Genetic Cancer Testing
“Patients in our clinic are not a number.
BRCA2 (see next section), and the colon
Five to 10 percent of all cancers have a
Families are important. We have a setting
cancer susceptibility genes, as well,” says
known genetic cause. This means that the
in which the patient can come in and feel
Dr. Graham. “Dr. Evans and Ms. Skrzynia
majority of cancers are sporadic and not
comfortable,” adds Dr. Kirby.
remain at the heart of the UNC program to
this day, and Cécile is also a member of the
Genetic Cancer Counseling
WHO health care team.”
(See Figure 1, on page 9.)
However, Dr. Graham says, “for families that have the genetic predisposition to develop
“WHO offers special expertise in genetic
Ms. Skrzynia conducts a monthly cancer
cancer, there is a lot of information and
testing and counseling, making it a unique
genetics clinic at Waverly along with the
many ways to reduce their risk.”
resource in Wake County,” says Dr. Graham,
WHO physicians. She provides information
who co-founded a cancer genetics program
and guidance to the patients and their
Genetic testing is the analysis of the
at UNC in the early-1990s, with renowned
families who have genetic conditions
molecular structure of the gene and is done
cancer geneticists Larry Silverman, Ph.D.;
or might be at risk for inheriting genetic
on a blood or saliva sample. The test is very
Edison T. Liu, Ph.D.; Elizabeth Rohlfs, Ph.D.;
conditions. She also works with the WHO
sensitive, but not perfect and misses a very
and Jim Evans, M.D., Ph.D.; and the cancer
physicians to identify families at risk,
small percent of all possible mutations,
genetic counselor Cécile Skrzynia, C.G.C.
analyze inheritance patterns and risks of
according to Dr. Graham.
An Observational Study of CTCs at WHO (See the chart on page 11, and text on page 12.) The following are major findings by Dr. Mark Graham of Waverly Hematology Oncology (WHO) in his observational study of circulating tumor cells (CTCs) in patients with metastatic breast cancer at WHO. • Goal 1: To determine if there are differences in CTC behavior in the three general molecular subtypes of MBC patients whose tumors are: o ER+ and HER2-; o Triple Negative (i.e. negative for ER, PR and HER2); and o HER2+ and ER+ or -. • Goal 2: To determine if the highest level of CTCs (0 to 4 CTCs, 5 to 99 CTCs and 100 or more CTCs) measured at any time during long-term follow up can define the biologic character of a tumor, and in turn, predict survival. • A surprising finding: A distinct group of patients with persistently low CTC has been noted in each of the three molecular subtypes of MBC. “Generally, HER2+ and Triple Negative MBC have been considered more aggressive and life
The Triangle Physician
The most common genetic test is used for predisposition to breast and ovarian cancers. Mutated BRCA1 and BRCA2 genes are responsible for most cases of familial
threatening. Yet, the great majority of lowCTC patients do well over long periods of time, independent of molecular subtype,” says Dr. Graham.
breast and ovarian cancer. A mutation in the
• The patients with 0 to 4 CTCs have much longer life expectancy and can be treated using “kinder-gentler” therapies and treatment breaks, according to Dr. Graham.
for a BRCA1 mutation than for the BRCA2
• “In a corollary fashion, there is a distinct group of patients who are at special risk for early death from MBC who have a CTC greater than 100. We found early on that despite all our efforts, these patients died quickly,” Dr. Graham says. • WHO physicians are now focused on separately advising and treating patients with 100 or more CTCs, which make up about 20 percent of those within each of the molecular subgroups of MBC. “These cancers clearly behave differently than those in patients with very low or intermediate CTCs,” says Dr. Graham.
BRCA1 and BRCA2 genes confers an up to 80 percent lifetime risk of developing breast cancer. The risk of ovarian cancer is different mutation (up to 30 percent). Men with a mutated BRCA1 gene have less than a 5 percent chance of developing breast cancer, and with BRCA2, it is about 6 percent. Sometimes patients with personal histories and strong family histories of breast and ovarian cancer get a negative test result, i.e. no mutation is detected. In those cases, Ms. Skrzynia considers the results to be “false positive” or suspects that there is a different gene other than BRCA1 or BRCA2 involved. “This expensive testing is reserved only for those whose family history strongly suggests a genetic cancer syndrome. We want to test only when it is appropriate and not over-test. We also want to prepare the patient and family for interpretation of results,” Dr. Graham states.
If you have it…they’ve probably seen it. The WHO physicians – from left, Bill Bobzien, M.D.; Suzanne Kirby, M.D., Ph.D.; and Mark Graham, M.D. – bring a wealth of experience and breadth of interest to the complex field of hematology and oncology.
Figure 2: Research on circulating tumor cells (CTCs) in metastatic breast cancer conducted at WHO from 2007 to 2011 and presented at the largest national and international clinical research meetings: the San Antonio Breast Cancer Symposium, and ASCO Breast and ASCO (American Society of Clinical Oncology).
N=114 Metastatic Breast Cancer Patients by Max CTC Level 1.00
Probability of D isea se Specific S urvival
0 - 4 CTC
5 - 99 CTC >=100 CTC
13 10 0
11 7 0
8 5 0
6 2 0
0 0 0
Time from First CTC Blood Draw (Months)
Number at risk maxctc_group3 = 0 - 4 CTC maxctc_group3 = 5 - 99 CTC maxctc_group3 = >=100 CTC
50 43 21
47 42 19
45 40 17
42 38 39 38 15 14
37 38 13
31 36 11
29 34 10
25 24 33 31 10 10
23 25 9
21 24 8
19 20 5
19 18 5
18 16 15 10 4 3
CTCs give independent and complementary data to the molecular subtypes (defined by ER, PgR and HER2/neu) in metastatic breast cancer. Measured longitudinally, persisting low CTCs (0-4) predict a low death rate, and the cause of death is principally from central nervous system (CNS) metastases. Very high levels of CTCs (≥ 100) are an oncologic emergency. CTCs should be considered as a stratification factor for Phase 2 and 3 clinical trials for new agents.
Meet the WHO Physicians • Dr. William Bobzien graduated from Georgetown University in Washington, D.C. He completed his residency and fellowship at the University of North Carolina, Chapel Hill. He has been an associate professor of medicine at UNC and a clinical professor of medicine at East Carolina University. Dr. Bobzien has practiced widely in areas of general hematology and oncology and brings an experienced and practical perspective to care of patients at Waverly.
The Cure to Your Cancer Might Well Be Under That Hood - Pharmacy tech Mike Rigsbee, C.Ph.T., mixes a patient treatment, in addition to being responsible for all aspects of the on-site WHO cancer and hematology pharmacy. Timely inventory purchase has helped the practice avoid shortages of key drugs that have plagued other cancer treatment centers nationwide.
Predicting Tumor Behavior
I felt I had a responsibility to present these
(See Figure 2, on page 11.)
data at meetings,” says Dr. Graham.
Dr. Graham has a special interest in developing the use of CTCs in the
To this end, since 2008 WHO data have been
management of patients with metastatic
presented at top national and international
breast cancer. CTCs originate in a tumor
cancer research meetings, including the
and move to another site through the
San Antonio Breast Cancer Symposium,
the American Society of Clinical Oncology
as metastasis. For patients, a simple
(ASCO) and the society’s specialty meeting,
7.5-milliliter blood draw is all that is needed
ASCO Breast, and in an invited lecture at the
to determine the CTC level. “Technology
Association of Molecular Pathology in San
now exists to measure accurately even a
Jose, Calif., in November 2010.
single nucleated tumor cell in the sea of White Blood Cells,” says Dr. Graham.
Comprehensive Cancer and Hematology Care in a Community Setting
“Since late 2006, when I started using
WHO provides comprehensive cancer and
this tool, it has completely changed how
hematology services at the convenient
I manage patients with MBC. I believed
location in Cary where Route 1 and Highway
before 2007 that we managed these patients
64 intersect. The interested and experienced
about as well as anyone. Now I can tell you
WHO physicians and staff believe in and
that in 2011, we do a much better job with
the use of CTCs.”
• Knowledgeable and compassionate care
other nucleated cells in the blood, namely
• Dr. Suzanne Kirby earned her medical degree from the University of North Carolina, Chapel Hill, where she completed her residency and fellowships in hematology/oncology and pathology. Dr. Kirby trained with the Nobel laureate Dr. Oliver Smithies at UNC. She has been an adjunct associate professor in the UNC Department of Pathology for the past four years. She has published and lectured on hematology/oncology, with an emphasis on molecular markers in the management of heme malignancies, and in bone marrow transplantation for the treatment of malignant and nonmalignant diseases. • Dr. Mark Graham earned his medical degree at Mayo Medical School in Rochester, Minn. He completed his residency in internal medicine at Duke University Medical Center and fellowships in cell biology at Mayo Clinic and hematologyoncology and clinical pharmacology at the University of Colorado Health Sciences Center, where he trained under the noted laboratory and clinical scientists, Kathryn Horwitz, Ph.D., and Paul Bunn, M.D. Dr. Graham served on the faculty at University of North Carolina, Chapel HIll for 14 years. He has published and lectured in hematology/oncology with an emphasis on breast cancer diagnosis and treatment. At the community practice level, his work centers on breast and colon cancer genetics, clinical trials and the use of circulating tumor cells.
• Full on-site infusion therapy and “It has been surprising to us that our
small clinic could generate data, such as
• Primary nursing
these, but the findings are clear: We can
• Counseling and testing for cancer genetics
dramatically improve the management of
• Clinical trials
For more information about WHO, call (919) 233-8585 and ask to speak with new patient coordinator Elizabeth Barnard or visit www.waverlyhemeonc.com.
MBC patients by monitoring CTC levels. So
• Unique specialty research projects.
Heidi Ketler contributed to this article.
The Triangle Physician
Women’s Wellness Clinic Opportunities for Clinical Research By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G.
We continue to offer clinical research
ourselves about the newest technologies
approved clinical information is on page 28
studies for our patients. Such opportunities
and medications for women’s health.
under Clinical Trials.
different types of FDA clinical trials that
One of our newest clinical trials is a Phase
Please call us at 919.251.9223 for
we offer at the Women’s Wellness Clinic
1 study entitled: Clinical Research Study on
Ovulation and Ovarian Activity. The IRB
include FDA clinical trials. There are
Phase 1 trials: Usually involves experimental drug or treatment in a small group of people (20-80) for the first time to evaluate its safety, determine safe doses, and identify side effects Phase 2 trials: Experimental drug or treatment is given to larger group of people (100-300) to see if it is effective and to further evaluate safety, doses, and side effects Phase 3 trails: Experimental drug or treatment is given to large groups of people (1,000-3,000) to confirm effectiveness, monitor side effects, and to compare it to commonly used treatments, and to collect information to allow the drug or treatment to be used safely Phase 4 trials: These are post marketing studies (done after approval of a drug) to help delineate additional information on a drug’s risks, benefits, and optimal use. The types of studies done through the Women’s Wellness Clinic focus on women’s health, including causes of heavy periods and treatments for heavy periods, PMS, migraines, ovarian function, birth control, menopause, vaginal atropy, and more. We hope to offer personalized medical care. Both of the physicians at the Women’s Wellness Clinic consider it a privilege to care for women. Our hope is to provide evidence based medicine which is personalized for a woman. Providing clinical trials to our patients allows us to educate patients and Womens Wellness half vertical.indd 1
12/21/2009 4:29:23 PM
“Doc, I’ve Got This Headache”
Imaging a Common Malady By Cynthia Payne, M.D.
The yearly incidence of primary malignant brain tumors in the United States is only 7 in 100,000. Headache was a symptom of metastatic or primary tumor in 47 percent of patients in one study, but only 8 percent presented with headache as an isolated symptom. Whether you practice pediatrics or geriatrics,
sudden onset of severe unilateral
headache is a frequently heard complaint.
headache with neck pain and a
Headache prevalence has been reported as
Horner syndrome is predictive
high as 71 percent in adults and 48 percent
of arterial dissection with 68
in children. When is headache a simple
percent of patients reporting
malady of life, and when is it the harbinger of
headache. On the other hand,
serious disease? When should you image the
the yearly incidence of primary
headache patient and with what modality? No
malignant brain tumors in the
one wants to “miss” the brain tumor causing an
United States is only 7 in 100,000.
innocuous-sounding headache, but how often
Headache was a symptom of
does that happen?
metastatic or primary tumor in 47 percent of patients in
The American College of Radiology (ACR) and
one study, but only 8 percent
the American College of Emergency Physicians
presented with headache as an
(ACEP) recently updated their guidelines on
isolated symptom. In a study of
imaging of headache. They are formatted by
children with isolated headache,
clinical scenario for ease of reference, based
sleep-related pain and absent
upon statistical review of the evidence-based
migraine family history were the
literature. Links are available on the Raleigh
strongest predictors of tumor.
Radiology website www.raleighrad.com.
Dr. Cynthia Payne joined Raleigh Radiology in 2001. She earned her medical degree from University of Toledo Medical School. She completed an internship in internal medicine at Mount Auburn Hospital/Harvard Medical School. She completed residencies in neurology and diagnostic radiology; and fellowships in molecular neurogenetics, neuroradiology and vascular and interventional radiology from the Duke University Medical Center. Dr. Payne is a former faculty member with the Department of Medicine (Neurology) and assistant professor of radiology at Duke. She is the former director of neurointerventional radiology at Greater Baltimore Medical Center, and former vice-chief and chief of radiology at Rex Hospital. Dr. Payne is board certified in neurology and diagnostic radiology.
The highest predictive factors of positive
medical-legal considerations accounted for 17
Imaging of headache, not surprisingly, has a
studies are focal neurological signs; HIV+ or
percent of reasons for neuroimaging studies
low yield. Some populations have significantly
other immunocompromised state; cancer;
in one Canadian study. According to the ACR
seizures; meningeal irritation; and pregnancy.
Expert Panel (see reference), “…the costs of imaging headache are always overstated when
Imaging may arguably be warranted sometimes
subarachnoid hemorrhage (SAH) has a
for the reassurance factor or medical-legal
reported yield of 47 percent. Similarly, the
the value of negative results is not considered.” Computed tomography (CT) is utilized most because of availability, rapid-image acquisition
Equipped with the Latest in Imaging
and lower cost than magnetic resonance
Raleigh Radiology has a fellowship-trained neuroradiologist at Rex Hospital for consultation on weekdays. A board-certified radiologist is inhouse 24/7.
scanners. Its Blue Ridge and Cedarhurst facilities have 1.5T Open Bore MRI scanners for obese and claustrophobic patients and offer intravenous sedation.
imaging (MRI). Concerns of over-utilization and
Raleigh Radiology has eight outpatient sites in the Triangle, from Brier Creek to Clayton and Wake Forest to Cary, offering 16-slice multidetector computed tomography scanners and 1.5T magnetic resonance imaging (MRI)
Images are immediately available for viewing on Raleigh Radiology’s picture archiving and communication systems (PACS), with rapidreport turnaround, and Software for Training and Testing (STAT) reads by phone or fax, if requested.
The Triangle Physician
radiation exposure, especially in the pediatric population, are being raised in the medical and lay communities. Raleigh
technologists have taken the “Image Wisely” pledge. Our CT protocols adhere to the “Image Gently” campaign to reduce pediatric dosing. This follows the time-honored ALARA
(As Low As Reasonably Achievable) dictum
60 with new onset temporal headache and
All Raleigh Radiology routine brain MRI
on radiation exposure, which is learned by
erythrocyte sedimentation rate greater than 55.
studies include diffusion weighted imaging (DWI), able to detect ischemia immediately;
every first year radiology resident. Radiation exposure was addressed clearly in a recent
In the patient with mild traumatic brain
FLAIR for white matter lesions, edema and
RaleighRad Note, also available at www.
injury (TBI), American College of Emergency
subarachnoid blood; and gradient echo (GRE)
raleighrad.com. Practitioners will find useful
Physicians (ACEP) guidelines answer the
T2*, exquisitely sensitive for even petechial
tables on exposure rates and relative risks.
question of which patients should have a non-
or remote parenchymal blood. Gadolinium
contrast head CT. “Head trauma patients with
is indicated for tumor, infection and other
In general, CT is preferred in urgent situations
loss of consciousness (LOC) or posttraumatic
pathologies associated with breakdown of the
such as “thunderclap” headache and closed-
amnesia only if one or more of the following is
head injury. MRI is preferable in non-urgent
present: headache, vomiting, age greater than
scenarios, barring contraindications. (MRI-
60 years, drug or alcohol intoxication, deficits
“Contrast as needed” ordering allows use of
compatible pacemakers are fortunately being
in short-term memory, physical evidence
established protocols for the stated indication.
introduced.) CT angiography (CTA) and CT
of trauma above the clavicle, posttraumatic
Images can be reviewed while the patient is
venography (CTV) can be obtained quickly
seizure, Glasgow Coma Score (GCS) less than
on the scanner for “as needed” MRI exams.
with a diagnostic CT. CTV is highly sensitive for
15, focal neurological deficit or coagulopathy.”
This can reduce cost, time, IV discomfort
venous sinus thrombosis.
In patients with no LOC or posttraumatic
and gadolinium exposure for the patient.
amnesia, recommendations for non-contrast
HIV-positive patients, those with known or
CT angiography (CTA) and MR angiography
CT are “focal neurological deficit, vomiting,
suspected neoplasm, and other high-risk
(MRA) can detect aneurysms as small as
severe headache, age 65 years or greater,
patients should be imaged with gadolinium,
3 millimeters. Below this size, the risk of
physical signs of a basilar skull fracture,
except in pregnancy. The pregnant headache
rupture is small. Intracranial MRA is routinely
GCS score less than 15, coagulopathy or a
patient is at risk for serious intracranial
performed without contrast. All CTA and
dangerous mechanism of injury.”
pathology, such as venous sinus thrombosis and stroke secondary to hypercoagulability,
extracranial MRA are performed with contrast. CTA and MRA are useful for arterial dissection,
MRI is more sensitive than CT for a wider
hypertension and other pregnancy-associated
range of pathology. The role of gadolinium
states. MRV is performed without contrast, an
other vascular abnormalities associated with
has been reduced with techniques beyond the
advantage over CTV in this population, as well
headaches, such as vasculitis. The latter may
traditional spin-echo T1 and T2 that have high
no ionizing radiation exposure for the fetus.
still require conventional angiography. A high-
sensitivity for stroke, hemorrhage, edema and
risk vasculitis patient is one over the age of
white matter abnormalities.
Raleigh Radiology physicians are committed to being available partners in appropriate, cost-
ACR Appropriateness Criteria Chart Clinical Condition Headache CT, head, without contrast
CT, head, without and with contrast
MR imaging, brain, w/o and with contrast
MR imaging, brain, without contrast
MR angiography, head, with or without contrast
CT angiogram, head
Worsened chronic headache. History of headache.
Sudden onset of severe headache (“Worst headache of one’s life, thunderclap headache”).
Sudden onset of unilateral headache, or suspected carotid or vertebral dissection or ipsilateral Horner syndrome.o
Headache, suspected complication of sinusitis and/or mastoiditis.p
New headache in patient older than age 60. Sedimentation rate higher than 55, temporal tenderness. Suspected temporal arteritis.
New headache in HIV+ individual
effective and expertly interpreted imaging in
MR angiography, head and neck, with or w/o contrast
CT angiogram, head and neck
New headache in pregnant patient.q
New headache. Suspected meningitis/encephalitis.
all subspecialty fields. This review should help simplify the imaging approach to a common complaint encountered by colleagues on the frontlines of patient care.
References and Links
1. Moran and Browne RaleighRad Note. This issue also contains useful links for information, radiation risks, etc. www.raleighrad.com/note 2. ACR APPROPRIATENESS CRITERIA: John E. Jordan for the Expert Panel on Neurologic Imaging. Headache. AJNR Am. J. Neuroradiol., Oct 2007;28:1824-1826. www.ajnr.org -> search “ACR headache”, or under “search archives” for referenced issue. 3. ACR Appropriateness Criteria. www.acr.org -> “Special Sections” -> ACR Appropriateness Criteria -> Neurologic Imaging -> Headache and Head Trauma. Pediatric criteria under “Pediatric”. Downloadable mobile web app available. (This website is an excellent resource for the entire field of diagnostic imaging criteria.)
Note: Appropriateness criteria scale from 1 to 9 – 1, least appropriate; 9, most appropriate a - may be helpful after CT depending on CT findings; b - with diffusion-weighted sequences; c - usage of CT versus MR imaging depends on local preference and availability; d - include sinuses; e - if noninvasive imaging unrewarding; f - if MR imaging not available; g - if vascular lesion suspected; h - pregnancy is a relative contraindication to gadolinium administration, reserve for urgent medical emergency; i - MR venography (MRV) should also be performed; j - if MR imaging not available, contraindicated or inconclusive; k - to exclude intracranial pressure changes; l - MR imaging preferable, depending on availability; m - needs contrast; n - useful for problem solving or if there is a strong suspicion of vascular disease; o - US, neck (carotid duplex) rating of 3; p - x-ray skull rating of 4; q - CT, head, with contrast rating of 3.
4. American College of Emergency Physicians. Clinical Policy: Neuroimaging and Decision-making in Adult Mild Traumatic Brain Injury in the Acute Setting; and Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Headache. www.acep.org -> Clinical and Practice Mangement -> Clinical Policies. june 2011
Breast Specific Gamma Imaging By Eithne Burke, M.D.
Molecular-based imaging of the breast, or breast-specific gamma
Currently 25 millicurie of Tc-99m Sestamibi are injected intravenously,
imaging, uses a functional approach to imaging breast pathology,
and imaging begins immediately. Both breasts are imaged in the
rather than the anatomic approach, on which mammography and
cranio-caudal (CC) and mediolateral-oblique (MLO) projections,
ultrasound are based.
mirroring the mammographic views. The study takes about 45 minutes and is performed with the patient comfortably seated with
Mammography remains the mainstay for breast cancer screening
minimum breast compression. Its cost is significantly less than MRI.
and diagnosis; however, it has well-documented limitations, resulting in limited sensitivity and specificity. At least 15 percent of breast cancers are mammographically occult. Additionally, differentiation of benign from malignant lesions is limited with both mammography and ultrasound. Breast-specific gamma imaging (BSGI) is proving a valuable, evolving adjunct tool in the diagnosis of breast cancer. BSGI utilizes the functional difference between tumor and normal cells that results in different levels of radiotracer uptake, independent of tissue density. The development of gamma cameras, uniquely configured for breast imaging, with images mirroring the standard mammographic views, has resulted in significantly improved detection of small, less than 1 centimeter breast cancers, with reports of 1 millimeter cancers being detected. There is no patient preparation for this study. As the images, like those in magnetic resonance imaging (MRI), are adversely affected by high-circulating estrogen levels, the procedure should be performed between Day three and Day 10 of the menstrual cycle. Figure 1, 2, and 3: Patient with palpable mass. Right breast marked with bb. Proven invasive ductal carcinoma.
BSGI clearly demonstrates a focal hot spot correlating with the carcinoma.
The Triangle Physician
Breast tissue is very dense, and it is difficult to see the mass with mammography.
Dr. Eithne Burke is a fellowship-trained breast imaging radiologist who joined Wake Radiology in 1999. Her special clinical interest is breast imaging and intervention. Dr. Burke is board certified in diagnostic radiology. A native of Galway, Ireland, she is a graduate of the National University of Ireland, Galway, where she earned her medical degree. She trained in internal medicine as A resident and fellow in Galway, Dublin and at Boston University School of Medicine before completing a residency in diagnostic radiology at the University of North Carolina at Chapel Hill. Dr. Burke completed a fellowship in breast imaging at the University of North Carolina School of Medicine. She is a member of the American College of Radiology and the Society of Breast Imaging.
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Studies to date have shown that BSGI has sensitivity about equivalent to breast MRI for breast cancer detection, with a higher breast MRI. It provides a good alternative to
Janet Clayton, CCIM 919.420.1581 email@example.com
breast MRI in patients who are claustrophobic
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specificity. Indications for BSGI are similar to
or whose weight is above the MRI table limit, or who have other contraindications to MRI, such as having a pacemaker, etc. The current radiation dose is about the same as for an upper gastrointestinal
Managing your patients’ health is your life’s work. Managing physicians’ wealth is mine.
series. However, the company is currently completing a trial to evaluate lower doses of the radiotracer (8-10 mCi), with positive results. This will facilitate use of BSGI for screening select patients, including those at moderate risk for breast cancer, who would not qualify for MRI, in particular those with dense breast tissue, which significantly limits mammographic sensitivity. Molecular based breast imaging, with its high sensitivity and specificity relative to other
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Goal of Minimally Invasive Surgery is to Reduce
Approach-Related Morbidity By John Grant Buttram, M.D.
MED not only accomplished the goal of decompressing the symptomatic nerve root, but also significantly reduced the approach-related morbidity through its ability to dilate through the muscle, instead of dissecting it free from the spine. What is minimally invasive spine surgery? This
performed in a seated position, with the
is a question I frequently hear from physicians
patient awake, using local anesthesia, a
and patients, alike. Most people think it is
battery-operated light source and a modified
simply surgery designed to minimize scars.
cystoscope. As you can imagine, the results at
But in fact, minimally invasive spine surgery is
that time were quite variable. through its ability to dilate through the muscle,
not about the incision size at all; it is about the approach-related morbidity.
Dr. Grant Buttram is a partner with the Raleigh Neurosurgical Clinic Inc. He earned his bachelor of science degree in biological science, bachelor of arts degree in chemistry and his master of science degree in physiology from North Carolina State University. He earned his medical degree from East Carolina University School of Medicine and completed his internship and residency through the University of Tennessee at Memphis/Semmes-Murphey Clinic. Dr. Buttram completed his minimally invasive spine fellowship at the Semmes-Murphey Clinic under the direction of Kevin T. Foley, M.D. Dr. Buttram is a member of the American Association of Neurological Surgeons, Congress of Neurological Surgeons and American Medical Association.
With this foundation, a wide variety of
instead of dissecting it free from the spine.
minimally invasive techniques developed,
From this, expanded applications began to
The detriments of open or maximally invasive
develop, including far lateral discectomies,
surgery have been well documented in
discectomy, automated lumbar percutaneous
the literature. For example, trunk muscle
discectomy (APLD), foramenoscopy and
pleural thoracic discectomies, spinal tumor
strength is weaker in patients that have
resections, short and long segment fusions,
undergone open fusions versus the less-
these procedures were limited by unreliable
invasive microdiscectomy. Patients with
efficacy (29-85 percent), free fragments,
advanced techniques, discectomies can be
poor outcomes after lumbar surgery are
bony pathology, mechanical limitations and
performed through incisions as small as 1/2
more likely to have persistent pathological
inch and fusions through incisions as small as
changes in their paraspinal muscles. Patients who undergo open discectomies have
It wasnâ€™t until the 1990s that two neurosurgeons
significantly higher levels of inflammatory
at the Semmes-Murphey Clinic in Memphis
Therefore, using the same surgical principles
markers, such as C-reactive protein and
Tenn., Kevin Foley, M.D., and Maurice Smith,
Interleukin-6 and -10, compared to minimally
M.D., asked the question, â€œCan we combine
implants, minimally invasive spine surgery
the efficacy of the open discectomy with the
allows one to perform the same surgical
benefits of a minimally invasive approach?â€?
procedures as are performed through larger,
(EMG) results demonstrate significantly less
more traumatic incisions using smaller
nerve-root irritation in minimally invasive discectomies.
Out of their work developed the MetRx tubular
access ports. This results in such benefits
retractor system and the microendoscopic
as significantly decreased blood loss, lower
Minimally invasive spine surgery traces its
infection rates, shorter hospital stays, lower
roots to the 1930s, when Poole, et al. first
accomplished the goal of decompressing the
healthcare costs, and a faster recovery and
symptomatic nerve root, but also significantly
return to work.
approach to the lumbar spine that was
reduced the approach-related morbidity
The Triangle Physician
Orthopaedics Allergies June
The Triangle Physician Vision 2011 Editorial Calendar Neurology July Imaging Technologies Interventional Radiology August Infectious Diseases Pediatrics September Sports Medicine Prostate Cancer October Breast Cancer Neurosurgery November Urology Alzheimer’s December Pain Management Sleep Disorder
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Your Financial RX
RISK Is a Four-Letter Word By Paul Pittman, C.F.P.
Are you putting funds on a watch list? Are you removing and replacing funds that are not in line with your investment policy statement? How often is your broker-of record performing all of these things?
Here is another painful thing. With every plan, there is a fee associated and charged that pays the broker-of-record. Every quarter, every year, that person is collecting the fee for having her name on your statements. Are you getting what you are paying for? Do your employees know that person? You (and they) should be extremely familiar with that person. If you are not getting the kind of service and guidance that you deserve,
One of the most difficult aspects of my job is
getting overlooked by you every month; this
you can simply change the broker-of-record
helping a client understand risk.
is your employment-sponsored retirement
on your plan at any time. Take a look at that
plan. If you are the employer, you may have
person’s name. If you and your employees
Risk is a four-letter word, just probably not
infinite and personal liability for your plan.
aren’t 100 percent thrilled to be working with
the four-letter word you mutter as you open
Being compliant with Employee Retirement
him, then replace him.
your investment statements or your cell
Income Security Act (ERISA) standards is
not enough to protect you and to properly
Attorneys call me in on a regular basis to
take care of your employees.
meet with their business-owner clients, because that client asked one simple thing:
Some risk is a necessary evil for most investors, and, if properly managed, it is not
How often are you reviewing the investments
“Do I, as the business owner, have any
a bad thing. However, unnecessary risk is
that you offer inside your retirement plan?
personal liability with my plan?” The short
one of the worst components to be a part of
Are you putting funds on a watch list? Are you
answer is this: Yes. In the case of LaRue v.
removing and replacing funds that are not in
DeWolff, the United States Supreme Court
line with your investment policy statement?
unanimously held that participants in 401(k)s and other defined contribution
I preach every day that if you do not have to take on any risk to accomplish your goals,
How often is your broker-of record performing
plans can sue for investment losses incurred
then don’t do it! If all of your goals can be
all of these things? Contacting you, meeting
in their individual accounts as a result of a
met by putting your money in CDs, then by
with the employees?
fiduciary’s breach of duty.
all means, do that. Everyone does not need to be in the stock market, but when the markets are good, everyone wants to be in the stock market. This is where you need to take a good, long look at your financial picture. I have written before about allocation, diversification,
etc. etc. But one huge risk factor may be
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 firstname.lastname@example.org.
Mr. LaRue sued his former employer for investment losses that resulted in an alleged failure to respond appropriately to requests for investment changes. A prior Supreme Court decision (Russell v. Mass Mutual) seemed to state that a claim for losses due to a fiduciary breach could be brought only for the plan as a whole and not by individual participants for losses in their own accounts. In LaRue, however, the Supreme Court limited its prior decision in Russell to defined benefit plans, explaining
a cash balance plan. A cash balance plan
to be credited to each participant and the
is a type of retirement plan that belongs to
investment earnings to be credited based on
the same general class of plans known as
those contributions. Each participant has
“qualified plans.” A 401(k) is a qualified
an account that resembles those in a 401(k)
plan. These plans “qualify” for tax deferral
or profit sharing plan. Those accounts
and creditor protection under ERISA.
are maintained by the plan actuary, who generates annual participant statements.
In a cash balance plan, each participant has an account. The account grows annually in
two ways: first, a contribution and second,
dependent. The older the participant, the
an interest credit, which is guaranteed,
higher the amount allowed. The reason for
rather than being dependent on the plan’s
this difference is that an older person has
fewer years to save toward the approximate
$2.5 million lump sum that is allowed in a Many owners and partners are looking
cash balance plan.
for larger tax deductions and accelerated retirement savings. Cash balance plans
As an example, if you were born in 1950,
may be the perfect solution for them. 2006
you can defer $150,261 into a cash balance
legislation is encouraging more and more
plan plus $20,500 into your 401(k) for a total
professionals and successful business
of $170,761 for that year! Most advisers are
owners to adopt this type of plan.
not aware of the cash balance plan. Find someone who is and have a discussion to
A cash balance plan is a defined benefit
see if it is right for you.
plan that specifies both the contribution
that the Russell decision did not apply to individual account plans like 401(k) plans, which dominate the retirement landscape today. The case is likely to generate a significant increase in 401(k) plan litigation. One way to limit the infinite and personal fiduciary liability to a company, its owners, and board members is to consult a qualified adviser to review and oversee the plan, and advise the participants. Is a qualified, fiduciary advisor counseling you and your employees now? Now, if that isn’t enough talk about risk, what about the risk of not putting away enough money for your own retirement? With the economy the way it is, you have no doubt asked yourself that question when you look at your statements. Do not let this stop you from putting money away. You may want to make some changes as to where the money is placed, but definitely make the deposit. If you already have a qualified retirement plan, such as a 401(k), you can also start
Carpel Tunnel Syndrome Has Multiple Causes By Henry Tellez, M.D.
Carpal tunnel syndrome is a condition that
symptoms are usually worse at night and are
affects almost 5 percent of the population
sometimes temporarily relieved by “shaking
and is most common in middle-aged women.
out” the hands.
The word carpus comes from the Greek
karpos, which means “wrist.” The wrist is
An increased number of specialists believe
enclosed by a band of fibrous tissue that
there is a congenital predisposition – the
normally functions as a support for the
carpal tunnel is just smaller in some people
joint. The narrow space between this fibrous
than in others. Any condition that applies
manufacturing; sewing; finishing; cleaning;
band and the wrist bone is called the carpal
pressure on the median nerve at the wrist
and meat, poultry, or fish packing. In fact,
tunnel. The median nerve passes all the
can cause carpal tunnel syndrome.
carpal tunnel syndrome is three times more
Dr. H. Tellez of Neurology Sandhills Neurology P.A. and Sandhills Sleep Study Disorders Centers is board certified in neuromuscular medicine and neurology.
common among assemblers than among
Carpal tunnel syndrome is three times more common among assemblers than among data-entry personnel.
Diagnosis The diagnosis of carpal tunnel syndrome is based on the symptoms, the distribution of the hand numbness and a detailed
way through the carpal tunnel to receive
For most patients, the specific etiology of
neurological examination of the extremity
sensations from the thumb, index and
their carpal tunnel syndrome is unknown.
involved. Examination of the neck, shoulder,
middle fingers of the hand.
Frequent conditions that are associated with
elbow and pulses is done to rule out other
carpal tunnel syndrome include diabetes,
entities that can mimic carpal tunnel
Any condition that causes swelling or a
syndrome. Frequently, tapping the front of
change in position of the tissue within the
obesity and trauma. Tendon inflammation
the wrist can reproduce tingling of the hand
carpal tunnel can compress and irritate the
resulting from repetitive work, such as
(called “Tinel’s sign”), a symptom of carpal
median nerve. Impingement of the median
continuous typing, can also cause carpal
tunnel. Symptoms can also be reproduced
nerve in this manner triggers tingling and
tunnel symptoms. Some rare diseases can
by the examiner by bending the wrist
numbness of the thumb, index and the
cause deposition of abnormal substances
forward (Phalen’s maneuver).
middle fingers – a condition known as
in and around the carpal tunnel, leading
“carpal tunnel syndrome.” This entity almost
to this condition (amyloidosis, sarcoidosis,
exclusively affects adults and is frequently
multiple myeloma, leukemia and others).
more severe on the dominant hand.
Risk Factors Symptoms
Studies have shown some risk factors for
Most patients present with numbness, pain
carpal tunnel: sex (women are three times
(usually a burning, aching pain), and tingling
more likely than men), metabolic disorders
in the thumb, index, and middle fingers.
(such as diabetes, hypothyroidism and
Quite often the tingling, numbness or pain,
disorders that directly affect the body’s
radiates up to the arm. It is not uncommon
nerves and make them more susceptible
for the patient to complain of hand weakness
to compression). Carpal tunnel syndrome
at times manifested by “dropping objects.”
is not confined to people in a single
when a Nerve Conduction Velocity /
Frequently the patient describes difficulty
industry or job, but is especially common
feeling and handling small objects. The
in those performing assembly line works –
abnormal. The first part of the test involves
The Triangle Physician
measuring the rate of speed of electrical impulses as they travel down a nerve. In carpal tunnel syndrome, the impulse is delayed as it passes through the carpal tunnel. The second part of the test, electromyography (EMG), is performed to exclude or detect other conditions that might mimic carpal tunnel syndrome (peripheral neuropathy, cervical radiculopathy, brachial plexopathy or others). Blood tests may be performed to identify medical conditions associated with carpal tunnel syndrome. These tests include thyroid
pressure on the median nerve can result in persistent numbness
hormone levels (TSH), fasting glucose and, if clinically necessary,
and weakness. In order to avoid serious and permanent nerve
complete blood counts and protein analysis. X-ray tests of the wrist
and muscle consequences of carpal tunnel syndrome, surgical
and hand might also be helpful to identify abnormalities of the
decompression should be strongly considered. It is sometimes
bones and joints of the wrist.
performed with an arthroscope, or usually by open decompressive surgery. After carpal tunnel release, patients often undergo exercise
rehabilitation. Though it is uncommon, symptoms can recur.
The choice of treatment for carpal tunnel syndrome depends on the severity of the symptoms and the presence of any underlying disease that might be causing the symptoms. First step of treatment frequently includes periodic hand rest, range of motion stretching, immobilization of the wrist in a splint and use of nonsteroidal anti-inflammatory drugs. Those whose occupations are exacerbating the symptoms need to modify their activities (i.e. computer keyboards and chair height may need to be adjusted to optimize comfort). Underlying conditions are treated separately. Fractures require orthopedic management. Obese persons will be advised about weight reduction. Wrist swelling usually is associated with pregnancy and resolves frequently after delivery of the baby. The second step of treatment if symptoms persist usually includes corticosteroids that can be given by mouth or injected directly into the involved wrist joint. They can bring speedy relief of the persistent symptoms of carpal tunnel syndrome. Side effects of steroids, when given in short courses, for carpal tunnel syndrome are minimal. However, corticosteroids can aggravate underlying medical problems, such as diabetes, and should be avoided in the presence of infections. Most patients with carpal tunnel syndrome improve with conservative measures and medications. Occasionally, chronic
Pretty In Pink
When Breast Cancer Is Present and Insurance Is Not New for The Triangle Physician, this community service section is an opportunity to recognize charities that are making a difference and are among those within the health care community endorse. We start with Pretty In Pink Foundation, a charity with local roots that is embraced by Wake Radiology. Pretty In Pink Foundation has carved
“We acknowledge the value of this network
out a unique niche in the breast cancer
in the fulfillment of our mission and we
community, as one of the few organizations
appreciate the assistance of like-minded
To support PIPF in its mission to assure
in the country that dedicates its resources to
individuals and corporations to our cause,”
access to treatment when breast cancer
assisting patients post-diagnosis.
says Dr. Tolnitch.
is present and insurance is not, call (919)
The ultimate vision of this 501(c)(3) not-
According to Dr. Tolnitch, more than 90
for-profit corporation is to provide financial
percent of donations go directly to providing
assistance to uninsured and underinsured
the funding required for necessary treatment, are1 appreciated. NEWSOURCE-JUN10:Heidi 8/5/10 12:57 resources PM Page
surgery, support and resources.
532-0532 or visit their website at www. volunteers
breast cancer patients, so they can access quality, (surgery,
radiation), regardless of their ability to pay. Since its creation in 2004 by Raleigh breast surgeon Dr. Lisa Tolnitch, Pretty In Pink
Do They Like What They See?
Foundation (PIPF) has helped more than
Make sure you connect with your key audiences using strategic, cost-effective advertising, marketing and public relations.
700 900 patients throughout North Carolina pay for treatment they could not otherwise afford. What started as a professional courtesy became an innovative program
Our services range from consultation, to design, to creation and implementation of strategic plans.
that provides hope, treatment, and guidance which helps in closing the ever-expanding gap in access to healthcare. The foundation also has sights set on creating a national presence by growing to all 50 states by 2020. PIPF operates through partnerships with community-based organizations, physicians and health care facilities. More than 153
newsource & Associates
physicians throughout North Carolina have volunteered their services, and 49 medical facilities help PIPF maximize resources and leverage dollars efficiently.
The Triangle Physician
Call (540) 650-3686 or send inquiries to email@example.com.
Our network of smart, creative, award-winning specialists serves the health care industry throughout the Mid-Atlantic.
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.
Rex Healthcare News
Rex Recognized for Organ Donation Practices
Rex Healthcare Earns Eight Patient Satisfaction Awards
The United States Department of Health and Human Services
Rex Healthcare won eight Excellence in Healthcare Awards from
(HHS) has awarded Rex Healthcare the Silver Medal of Honor
PRC Inc., a nationally known health care marketing research
for Organ Donation for achieving and sustaining national goals,
including a donation rate of 75 percent or more of eligible donors. Five of the awards recognize Rex service lines for scoring in the Only 307 hospitals nationwide, including five North Carolina
top 10 percent nationally for “excellent” responses in patient
hospitals, have earned this award this year. This is Rex Healthcare’s
perception and satisfaction. Rex Medical Oncology, for the third
second time receiving this distinction, a Rex press release reported.
time in four years, won the Overall Top Performer distinction.
“Rex Healthcare is committed to honoring the choice patients
“Service excellence and patient focus is a top priority at Rex
make to donate and give life,” said Rex’s Kathy Quattrocchi,
Healthcare,” said David Strong, president of Rex Healthcare. “We
cardiovascular care clinical manager. “Because Rex is neither a
are honored to receive top honors for so many of our service lines.
transplant nor a trauma hospital, receiving this award for our organ
The awards show that Rex is doing all it can to achieve excellence
donation program’s excellence reflects a strong collective effort by
across the entire system, and I am grateful to our many coworkers
all our coworkers.”
who make that possible.”
Each day in the United States, an average of 75 people receive
The following Rex facilities earned PRC awards:
organ transplants. However, an average of 20 people die each day
Medical Oncology - Top Performer and Five Star award
waiting for transplants that can’t take place because of the shortage
Catheterization Lab - Five Star award
of donated organs. Around 3,000 North Carolinians need life-saving
Three Women’s - Five Star award
Wakefield Surgery - Five Star award Three East - Five Star award
To get much needed transplants to patients in need, Rex Healthcare
Outpatient Services - Four Star Award: Outpatient awards
partners with Carolina Donor Services, a federally designated
combine outpatient services (diagnostics, wound clinic, medical
organ procurement organization. Carolina Donor Services works
oncology, etc.) and outpatient surgery (Same Day Surgery, Cary,
with 107 hospitals and four transplant centers that perform heart,
Wakefield, Minor Procedures).
lung, liver, kidney, pancreas and intestine transplants. Three West also received an achievement award for improving its Rex Healthcare also has a designated Donation Resource Team,
identification strategy driver. PRC Achievement Awards are based
comprised of representatives from all areas of the hospital who
on entries submitted by PRC patient loyalty clients, according to
meet every other month to discuss organ, tissue and eye donation
a Rex press release. This award recognizes organizations at the
at Rex Hospital. “Their efforts ensure that Rex provides the best
hospital, facility, department or unit level that have enhanced their
opportunity for patients to receive the highest organ donation
patients’ perception of care by focusing on their Key Drivers of
services possible,” according to the press release.
Excellence. Unlike the other PRC awards, the PRC achievement awards are based on entries and responses submitted by patients.
Ms. Quattrocchi, and Pat Shackleton, case manager for Rex Healthcare, accepted the award at the sixth National Learning
This group of eight awards is the largest Rex Healthcare has
Congress for the Donation and Transplantation Community of
received from PRC in one year, to date. Rex Healthcare and other
Practice in Grapevine, Texas.
award recipients were recognized at PRC’s conference in Omaha, Neb., in May.
The award was presented to the Rex Healthcare team in Raleigh last month. Burt Mattice, vice president and chief operating officer
For more information on Rex Healthcare, visit www.rexhealth.com.
of Carolina Donor Services, and members of the Rex leadership team attended the awards ceremony.
WakeMed Board of Directors Announces New Board Chair, Officers, Board Members Thomas B. “Tom” Oxholm was named
Education Partnership’s Friend of Education
with Raleigh Pediatric Associates for
WakeMed Health & Hospitals Board of
Award. He was elected to the Wake County
more than 36 years and has played a
Directors chair, a position he will hold
Board of Education in 1999 and served
vital role in shaping pediatric health care
for two years. Additionally, the WakeMed
four years. In 2008, he co-authored with
service at WakeMed and throughout Wake
Board of Directors appointed William H.
former schools Superintendent Bill McNeal
County. Among his contributions is the
“Wally” as vice chair, Jerry C. Bernstein,
A School District’s Journey to Excellence
development of the WakeMed Children’s
M.D., F.A.A.P., as secretary and three new
(Corwin Press). He is currently a trustee of
Emergency Department, which opened
the Wake Education Partnership.
in 1997 as the first of its kind in our state. He also spearheaded the proposal to build
“WakeMed sincerely thanks outgoing board
William H. “Wally” McBride, Vice Chair
the WakeMed Children’s Hospital, the
chair Billie Redmond,” said William K.
Elected to serve as the board’s new vice
first dedicated children’s hospital in Wake
Atkinson II, Ph.D., M.P.H., M.P.A., WakeMed
chair, Mr. McBride is a senior partner within
County. The Pediatric Intensive Care Unit
president and chief executive officer. “Billie
the Public Finance Group of the Hunton &
within the Children’s Hospital is named
has been a strong and vocal advocate for
Williams law firm in Raleigh. He focuses
after Dr. Bernstein, thanks to a $1 million
the system during her 10-year service to the
on tax-exempt public finance transactions,
pledge to the WakeMed Foundation’s Just
board. We appreciate her leadership and
primarily as bond counsel and tax counsel
For Kids Kampaign (JFKK) from his good
guidance over the past decade and look
for arbitrage, securities law and general
friends Wes and Janet Chesson. The JFKK is
forward to Tom’s leadership for the next
corporate matters. As a longtime member
a campaign to raise funds for the WakeMed
of the WakeMed Board of Directors, Mr.
Children’s Hospital and the expansion of its
McBride was instrumental in assisting Wake
Newly elected as chair of the WakeMed
County with conveyance of WakeMed to
Board of Directors, Mr. Oxholm has given
private, not-for-profit status in 1997 and
Dr. Bernstein has been a member of the
service to the board for the past eight years
in entering the bond market in 2009. He
WakeMed Board of Directors for several
and to the WakeMed Foundation Board
has been particularly helpful in advising
years. He also served as the first chair of the
of Directors for more than 12 years. Prior
WakeMed on its bond issuances since that
WakeMed Foundation’s Board of Directors,
to his role as chair, Mr. Oxholm served
as well as chairman of the Foundation’s
as secretary for the WakeMed Board of
Physicians’ Council. Dr. Bernstein continues
Directors. He has also served as chair of the
board’s Finance Committee for six years
organizations, Mr. McBride has devoted his
and chair of the WakeMed Foundation
time to the Triangle Chapter of the American
New Board Members Appointed
Board of Directors.
Red Cross (13 years on the board), the
Also effective May 25, WakeMed appointed
to lend his time and talents to the JFKK.
Eastern North Carolina Princeton University
three new board members: Leslie “Les”
Thomas B. “Tom” Oxholm, Chair
Alumni Schools Committee and the North
Merritt, executive director of the Foundation
As vice president and chief financial officer
Carolina Museum of Natural Sciences. Mr.
for Ethics in Public Service; Christina
of Wake Stone Corp. in Knightdale, N.C., Mr.
McBride is a past president of the National
Alvarado Shanahan, a registered nurse and
Oxholm helps lead a company that owns
Association of Bond Lawyers, a published
captain in the U.S. Navy Reserves, who also
and operates four stone quarries in eastern
author and an accomplished speaker
served as president and chief executive
North Carolina and one in South Carolina.
within his field.
officer of Be Active North Carolina; and
Additionally, Mr. Oxholm has been very
William R. “Bill” McNeal, the former
active in supporting Wake County Public
Jerry C. Bernstein, M.D., F.A.A.P.,
superintendent of the Wake County Public
Schools. In 1997, he was named Citizen of
School System and now executive director
the Year in Knightdale for his work in public
Elected to serve as the board’s new secretary,
of the North Carolina Association of School
education, and in 1998 he won the Wake
Dr. Bernstein has been a pediatrician
The Triangle Physician
WakeMed Pursues Baby-Friendly Designation This past Mother’s Day, WakeMed Health & Hospitals Women’s Pavilion & Birthplaces in Raleigh and Cary took major steps to become a baby-friendly hospital, as defined by the World Health Organization and the United Nations Children’s Fund. WakeMed is the first hospital in the region to pursue this designation and conform to the standards outlined in the Ten Steps to Breastfeeding (at right).
Ten Steps to Successful Breastfeeding 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants. 6. Give newborn infants no food or drink other
than breastmilk, unless medically indicated. 7. Practice rooming-in – allow mothers and infants to remain together – 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. If you would like additional information on the Baby-Friendly Hospital Initiative, visit http:// babyfriendlyusa.org/.
One of the first steps in the journey to encourage breastfeeding is to discontinue
By reviewing where the hospital stands
“The staffs at both WakeMed Raleigh
the distribution of the formula samples
and adapting these 10 steps, WakeMed is
Campus and Cary Hospital are working
and diaper bags provided for free by the
confirming its belief that breast milk is the best
closely with the lactation consultants, so
formula companies. While WakeMed will
form of nutrition for infants, the release said.
they can offer new mothers the information
provide formula to infants for feeding when
Currently, the Women’s Pavilion & Birthplace-
and support they need. Our hope is that
it is requested by the parent or guardian,
Cary has a 98 percent breastfeeding rate, and
mothers leave WakeMed with the confidence
the hospital will no longer distribute
the Women’s Pavilion & Birthplace-Raleigh has
and knowledge they need to continue
formula samples, according to a Wake Med
a 72 percent breastfeeding rate, both of which
breastfeeding their babies,” said Elizabeth
press release. WakeMed will also no longer
are well above the national average. With the
Rice, director, Women’s Pavilion & Birthplace.
have pacifiers available on demand in the
10-step process, the hospital can continue
“Of course, we will continue to provide
Women’s Pavilion & Birthplace. These
to improve these rates, and give mothers the
support and education equally to those who
changes took effect May 8.
support and confidence they need to commit
choose to bottle feed their newborns.”
to breastfeeding, according to the press release.
News Welcome to the Area
Triangle Physicians Alisa Patricia Alker, MD Internal Medicine, Infectious Diseases, Internal Medicine University of North Carolina Hospitals Chapel Hill
Carmen Je Vonne Beamon, MD Obstetrics and Gynecology University of North Carolina Hospitals Chapel Hill
Thomas Norton Bernard, MD Emergency Medicine Duke University Hospitals, Durham
Melissa Antoinette Briggs, MD
Jason Ian Koontz, MD Cardiovascular Disease, Internal Medicine Duke University Medical Center, Durham
Michelle Lecher Kushnir, MD Pediatrics Duke University Hospitals, Durham
Eleonora Georgeta Lad, MD Duke Ctr for Macular Diseases, Durham
Matthew Preston Lungren, MD Radiology Duke University Hospitals, Durham
Frederick Harrison Mabry, MD Sandhills Pediatrics, Southern Pines
Eastern Physicians Robert Nicholas Agnello, DO Clark Clinic, Fort Bragg
Brian Lee Beacham, MD Piedmont Surgical Associates, Eden
Marica Bijelac, MD Psychiatry Pitt County Memorial Hospital, Greenville
Mary Neeley Boyce, PA Coastal Carolina Family Practice, Hertford
Jodie April Calain, DO Family Medicine New Hanover Regional Medical Center Wilmington
Pediatrics, Internal Medicine Duke University Hospitals, Durham
Jennifer Marie Mabry, MD
Alaina Marie Brown, MD
Joseph Nissim Martel, MD
Cape Fear Retinal Associates, Wilmington
Duke Eye Center, Durham
Courtney Allison Devlin, MD
Pediatrics Duke University Hospitals, Durham
David Andres Carbonell, MD Emergency Medicine University of North Carolina Hospitals Chapel Hill
Christopher Allen Wright Caulfield, MD Internal Medicine University of North Carolina Hospitals Chapel Hill
Brooke Alison Chidgey, MD Anesthesiology University of North Carolina Hospitals Chapel Hill
Gabriel Tsing-Tzong Chong, MD Ophthalmology Raleigh Ophthalmology, Raleigh
Sandhills Pediatrics, Southern Pines
Philip Brandeis McDonald, MD Duke University Medical Center/Department of Radiology, Durham
Joshua Daniel McKinney, MD Emergency Medicine University of North Carolina Hospitals Chapel Hill
Amanda Renee McNabb, MD Pediatrics Duke University Hospitals, Durham
Pediatrics Duke University Hospitals, Durham
Grant Edward Garrigues, MD Orthopedic Surgery Duke University Medical Center, Durham
Nicole Renee Guinn, MD Anesthesiology Duke University Hospital, Durham
Raymond Martin Harrell, MD Anesthesiology University of North Carolina Hospitals Chapel Hill
Emergency Medicine University of North Carolina Hospitals Chapel Hill
Benjamin Miriovsky, MD Hematology and Oncology, Internal Medicine Duke Hematology/Oncology Fellowship Program, Durham
Carrie Rebecca Muh, MD Duke Univ Medical Center, Durham
Eliza Myung Park, MD University of North Carolina, Dept of Psychiatry Chapel Hill
Frederick Harrison Mabry, MD
Sandhills Pediatrics, Southern Pines
Carolina Digestive Health Associates, Monroe
Tammy Nicole Moore, MD Naval Hospital Camp Lejeune, Camp Lejeune
Warees Tabber Muhammad, MD Children’s Acute Care, Fayetteville
Vishal Mungal, MD Internal Medicine, Pediatrics Pitt County Memorial Hospital, Greenville
Juan Antonio Ortiz, MD Womack Army Medical Center, Fort Bragg
Donald Paul Saxon, PA North Carolina Inpatient Medicine Associates, Jacksonville
Sarah Patton Towne, DO CommWell Health, Ocean Isle Beach
Rajat Varma, MD
Angela Lea Scott, MD
Randolph Dante Scott, MD Women’s Health Alliance, PA, Centre OB/Gyn Raleigh
Katherine Barbara Johnson, MD
Brad Matthew Taicher, DO
Psychiatry University of North Carolina Hospitals Chapel Hill
Duke University Department of Anesthesiology Durham
Rujin Ju, MD UNC Dept of OB-GYN, Chapel Hill
Internal Medicine Duke University Hospitals, Durham
James Kim, MD
Mary Hamlin Womble, PA
James William Wisler, MD
Ovulation and Ovarian Activity 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.
Internal Medicine, Pediatrics Pitt County Memorial Hospital, Greenville
Family Medicine University of North Carolina Hospitals Chapel Hill
Anesthesiology Duke University Hospitals, Durham
The Triangle Physician
Matthew Ronald Ledoux, MD
Caleb Evans Pineo, MD
Hung-Lun John Hsia, MD
Shauna Ashley Mikec, PA
Internal Medicine Duke University Hospitals, Durham
Duke Eye Center, Durham
Md Abu Zahed Karim, MD
Alan Saul Miller, MD
Pediatrics University of North Carolina Hospitals Chapel Hill
Marcono Raymond Hines, MD
Internal Medicine Wilmington
Jennifer Marie Mabry, MD
Sarah Jean Mills, MD
Christopher Michael DeRienzo, MD
Ashley Lauren Forystek, DO
Hematology and Oncology, Internal Medicine University of North Carolina Hospitals Chapel Hill
Anesthesiology Duke University Hospitals, Durham
Internal Medicine University of North Carolina Hospitals Chapel Hill
Albemarle Hospital, Elizabeth City
Sandhills Pediatrics, Southern Pines
Alamance Regional Medical Center, Burlington
Kathryn Middleton DePlatchett, MD
Leon David Charkoudian, MD
Autumn Jackson McRee, MD
Torijaun D’Aundre Dallas, MD
Clinical Trials Do you have patients with any of these problems?
East Carolina Dermatology and Skin Surgery, New Bern
Svetlana Zoueva, MD Psychiatry Elizabeth City
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.
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.
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
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.
©2011 Wake Radiology. All rights reserved. Radiology saves lives.
Are Tired Legs Holding Your Patients Back?
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Think of the decisions your patients make in life based on how fatigued their legs are. Many men and women are affected by the discomfort and unsightly appearance of varicose veins; fortunately, advances in vein therapies allow us to offer your patients new choices and relief. Most of our treatments, including spider vein therapies, are minimally invasive or laser-based, have little or no downtime and are performed in our convenient outpatient setting. Wake Radiology’s comprehensive approach to vein therapy is unlike others around. Our skilled interventional physicians have training and expertise in minimally invasive vein treatments, evaluating each patient personally and discussing the best treatment plan for their unique situation. There are beaches to be combed, trails to be explored, and greenways to be enjoyed—so help your patients stop thinking about their tired legs and start thinking about what they want to do. Call us or go online to request a free consultation where we’ll help your patients determine how they can step back into great-feeling legs. Wake Radiology. Making tired legs a thing of the past.
You or your patient can request a free consultation online today at wakerad.com Wake Radiology Cary | 300 Ashville Avenue, | Cary, NC 27518 | 919-854-2180 | wakerad.com
The Triangle Physician June 2011 The magazine for the healthcare professionals in the greater Triangle area of North Carolina
Published on Jun 7, 2011
The Triangle Physician June 2011 The magazine for the healthcare professionals in the greater Triangle area of North Carolina