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m ay 2 0 11

Thrives on a Tradition of Excellence
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

Cary Orthopaedic & Sports Medicine

LASIK in the Military Image-guided Pain Relief

Also in This Issue

FDA-Approved for MRI Use
The First and Only Pacing System to Break the Image Barrier
Introducing the Revo MRITM Pacing System engineered with SureScan® Technology – the only pacing system to provide proven cardiac care that’s designed to be used safely with MRI.

www.medtronic.com

The Revo MRI SureScan pacing system is MR Conditional designed to allow patients to undergo MRI under the specified conditions for use. A complete system, consisting of a Medtronic Revo MRI SureScan IPG implanted with two CapSureFix MRI® SureScan leads is required for use in the MRI environment.

Brief Statement The Revo MRI™ SureScan® pacing system is MR Conditional and as such is designed to allow patients to undergo MRI under the specified conditions for use. Indications The Revo MRI SureScan Model RVDR01 IPG is indicated for use as a system consisting of a Medtronic Revo MRI SureScan IPG implanted with two CapSureFix MRI® SureScan 5086MRI leads. A complete system is required for use in the MRI environment. The Revo MRI SureScan Model RVDR01 IPG is indicated for the following: • Rate adaptive pacing in patients who may benefit from increased pacing rates concurrent with increases in activity • Accepted patient conditions warranting chronic cardiac pacing include: – Symptomatic paroxysmal or permanent second- or third-degree AV block – Symptomatic bilateral bundle branch block – Symptomatic paroxysmal or transient sinus node dysfunctions with or without associated AV conduction disorders – Bradycardia-tachycardia syndrome to prevent symptomatic bradycardia or some forms of symptomatic tachyarrhythmias The device is also indicated for dual chamber and atrial tracking modes in patients who may benefit from maintenance of AV synchrony. Dual chamber modes are specifically indicated for treatment of conduction disorders that require restoration of both rate and AV synchrony, which include: • Various degrees of AV block to maintain the atrial contribution to cardiac output • VVI intolerance (for example, pacemaker syndrome) in the presence of persistent sinus rhythm

Contraindications The device is contraindicated for: • Implantation with unipolar pacing leads • Concomitant implantation with another bradycardia device • Concomitant implantation with an implantable cardioverter defibrillator There are no known contraindications for the use of pacing as a therapeutic modality to control heart rate. The patient’s age and medical condition, however, may dictate the particular pacing system, mode of operation, and implantation procedure used by the physician. • Rate responsive modes may be contraindicated in those patients who cannot tolerate pacing rates above the programmed Lower Rate • Dual chamber sequential pacing is contraindicated in patients with chronic or persistent supraventricular tachycardias, including atrial fibrillation or flutter • Single chamber atrial pacing is contraindicated in patients with an AV conduction disturbance • ATP therapy is contraindicated in patients with an accessory antegrade pathway

See the device manuals before performing an MRI Scan for detailed information regarding the implant procedure, indications, MRI conditions of use, contraindications, warnings, precautions, and potential complications/ adverse events. For further information, call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts this device 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) Patient Line: Tel: 1 (800) 551-5544 7:00 am to 6:00 pm CT M-F Fax: (763) 514-1855 24-hour information available on www.medtronic.com

UC201004100 EN © Medtronic, Inc. 2011. Minneapolis, MN. All Rights Reserved. Printed in USA. 02/2011

Antitachycardia pacing (ATP) is indicated for termination of atrial tachyarrhythmias in bradycardia patients with one or more of the above pacing indications. 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 bradycardia patients with atrial septal lead placement and one or more of the above pacing indications. The device has been designed for the MRI environment when used with the specified MR Conditions of Use.

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. Use of the device should not change the application of established anticoagulation protocols. Do not scan the following patients: • Patients who do not have a complete Revo MRI SureScan pacing system, consisting of a SureScan device and two SureScan leads • Patients who have previously implanted devices, or broken or intermittent leads • Patients who have a lead impedance value of < 200 Ω or > 1,500 Ω • Patients with a Revo MRI SureScan pacing system implanted in sites other than the left and right pectoral region • Patients positioned such that the isocenter (center of MRI bore) is inferior to C1 vertebra and superior to the T12 vertebra

We help you get back to your life
After a disabling illness or injury, all you want to do is get back to your life—as quickly as possible. Durham Rehabilitation Institute at Durham Regional Hospital helps you regain your independence with care delivered in a warm, compassionate environment. Durham Rehabilitation Institute is an award-winning facility that provides comprehensive, state-ofthe-art care. Treatment programs are led by a board-certified rehabilitation physician. Other team members include nurse practitioners, rehabilitation nurses, physical therapists, speech therapists, and others dedicated to providing personalized care to meet each patient’s needs. Top-rated rehabilitation care with the convenience of a community hospital: this is Durham Regional Hospital.
For physician referrals, call 919-470-7226.

durhamregional.org
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Contents

6

COVER STORY

Cary Orthopaedic & Sports Medicine Thrives on a Tradition of Excellence
Vol. 2, Issue 5

m ay 2 011

10
situ keratomileus.

FEATURES
Ophthalmology

21

DEPARTMENTS
11 Orthopedics
Total Ankle Replacement Is Revolutionizing Care of Ankle Arthritis

Radiology

LASIK Advances Benefit the Military
Dr. Dean Dornic explains how the military has embraced advances in laser-assisted in

Raleigh Radiology’s Musculoskeletal Team Offers Image-Guided Pain Management
Dr. Jeffrey Browne gives an overview of the pain management uses and methods of image-guided injections.

12 Your Financial Rx
Reduce Your Investment Pain Threshold

14 Sleep Medicine
Sleep Apnea Requires Specialized Attention

16 Orthopedics
Double Bundle Technique Improves Anterior Cruciate Ligament Outcomes

18 Cardiology
Atrial Fibrillation: A Perspective on Treatment Evolution

22 Women’s Health
New Findings in Losing Weight

24 WakeMed News
County’s fifth hospital, new Brier Creek Healthplex and more

26 GHS News
Distinction for knee and hip replacement, and Hospital of Choice Award

27 Durham Regional News
U.S. News Best Hospital ranking

27 News
2
Upcoming events, welcome, new offices and clinical trials
The Triangle Physician

JOHNSTON HE ALTH

From the Editor

Spring into Health
It’s spring, a time to sweep out the cobwebs, which for many means self reflection about our health and lifestyle. Outdoor activity ramps up and body mechanics become a focus. Watching our back and every part of our musculoskeletal being in times of injury are orthopedic specialists and physical therapists, such as those at Cary Orthopaedic Sports Medicine and Spine Specialists. This finely tuned team is standing by to provide early and proper diagnosis so patients can get back to the games of life faster, more fully and with less pain. Weight management increases in importance as the weather warms. Overweight and obesity comprise a national problem. Its toll on human life weighs heavy on the economy. And despite all the marvels of modern medicine, data suggests overweight and obesity are increasing. A beacon of hope is the Medi-Weightloss Clinic. Its regimen that includes ongoing counseling and medical supervision is possibly the surest, healthiest approach to long-term weight management. Also on the orthopedic front, Dr. Mark Galland reviews how a new double-bundle surgical technique improves anterior cruciate ligament outcomes. Dr. Selene Parekh focuses on the improvements in total ankle replacement in the treatment of ankle arthritis. Dr. Andrea Lukes enters the weight management discussion with an overview of the use of phentermine to suppress appetite. In this issue we get several points of view on pain management. Certified financial planner Paul Pittman talks about avoiding the very real pain felt when investment returns are poor. Dr. Jeffrey Browne explains image-guided pain management. The Triangle Physician welcomes two new contributors. Dr. Dean Dornic writes about the benefits of laser-assisted in situ keratomileus (LASIK) surgery to the military. Dr. Giridhar Chintalapudi (aka Dr. Chin) reviews the diagnosis and treatment of sleep apnea. Spring also is a great time to evaluate your practice marketing strategies. If you haven’t done so already, incorporating The Triangle Physician into the mix makes a lot of sense. Consider that it is the only publication of its kind, dedicated to the Triangle medical profession. Our sincere gratitude for all you do. Happy spring!
Editor Heidi Ketler, APR [email protected]
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

Contributing Editors Ker Boyce, M.D., F.A.C.C., F.A.C.P. Jeffrey Browne, M.D Giridhar Chintalapudi, M.D. Dean Dornic, M.D. Mark Galland, M.D. Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G Selene G. Parekh, M.D., M.B.A. Paul Pittman, C.F.P. Photography Jim Shaw Photography Creative Director Joseph Dally

[email protected]

[email protected]

Advertising Sales Carolyn Walters [email protected] News and Columns Please send to [email protected]

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.

Heidi Ketler
Editor

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The Triangle Physician

On the Cover

Cary Orthopaedic & Sports Medicine
Thrives on a Tradition of Excellence
By Heidi Ketler

Known as a hotbed of athletic activity, the Greater Raleigh and Triangle region experiences its share of sports-related injuries. For 29 years Cary Orthopaedic & Sports Medicine Specialists has been filling the need for high quality diagnosis and treatment of these injuries and many other orthopaedic related conditions. Since opening its doors in 1982, Cary Orthopaedic has grown with the community to offer a comprehensive range of surgical, non-surgical and rehabilitative services. The practice is comprised of a team of orthopaedic sports medicine and spine-specialized surgeons, physiatrists and physical therapists at three separate locations.

All nine orthopedic surgeons are fellowship trained. In addition to general orthopedics and sports medicine, the range of specialization includes arthroscopic and reconstructive surgery, total joint replacement and minimally invasive spine surgery. Cary Orthopaedic Sports Medicine and Spine Specialists is distinguished by its tradition of excellence that ensures every initial patient encounter begins with an orthopaedic physician evaluation. “A hallmark of this practice is continually striving to provide early and proper diagnosis which can help prevent prolonged difficulties and provide the greatest value for the health care dollar spent,” says Michael Mazzella, Cary Orthopaedic Chief Operating Officer.

The practice now encompasses Cary Orthopaedic Spine Specialists, offering a total approach to spine care. Garner Orthopaedic Sports Medicine & Spine Specialists provides a similar offering to that community and surrounding counties. All three orthopaedic locations have a dedicated Performance Physical Therapy facility on site.

Teamwork a Practice Hallmark
“Excellence in Sports medicine and Orthopedics requires that we’re all on the same page to meet patient goals as quickly and safely as possible,” says Douglas L. Gollehon, M.D., senior partner. “To ensure the very best outcome ideally we involve the physician, parents, the athletic trainer and coach as part of the team focused on returning that athlete back to the desired level of activity. “

PHOTO BY BRYAN REGAN PHOTOGRAPHY

Sports Medicine Expertise
Over the years, Cary Orthopaedic Sports Medicine and Spine Specialists services to patients has represented the Triangle’s wide world of sports, from the Carolina Hurricanes, Carolina RailHawks and Carolina Ballet to scholastic athletes, recreational weekend warriors and elite triathletes. “This is a very diverse athletic market, not just for professional sports,” says Susan McArdle, Cary Orthopaedic Business Manager. “We see everything from acute injuries to arthritis that may be manifested in the older recreational athlete.” Patients seek out Cary Orthopaedic Sports Medicine and Spine Specialists for the levDr. andersen provides diagnosis and treatment of an injured wrist

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The Triangle Physician

el of care that provides enhanced freedom of movement without pain for all types of musculoskeletal problems. “Our patient’s goals can be as diverse as walking down the driveway to get the newspaper to the highest level of training to qualify for a career in professional athletics,” says Douglas J. Martini, M.D. “Even if a patient is not a high-level athlete or a recreational or scholastic athlete, we treat them all with the same high level of expertise and expectation.”

order to withstand the repetitive stresses of sports activities. Most orthopaedists recommend a minimum of six months of progressive physical therapy before returning to competitive sports. ACL rehabilitation involves a progression of therapeutic and sport-specific activities. The experienced physical therapist makes the best determination as to whether or not the patient is able to safely progress.

Approach to Arthritic Joints Knee ligament reconstructive surgery
Injury to the anterior cruciate ligament, or ACL, is common among the high-level athletes and the recreationally active population. This ligament serves as the primary restraint to forward and pivoting motion of the shin bone. An ACL tear can be a debilitating sports injury. Viscosupplementation is commonly used With the appropriate diagnosis and treatment approach, “the prognosis for recovery is excellent,” says William K. Andersen, M.D. Surgical reconstruction of a torn ACL is usually recommended for patients who are less than 25 years old, regardless of activity level, because they tend to have problems with instability and frequent episodes of the knee giving way. Given the advances in ACL reconstruction and the accelerated approach to rehabilitation, this surgical procedure is often recommended to a wider active patient population than in the past. Preoperatively, “it is important to regain motion in the knee as soon as possible after injury to prevent stiffness and secondary problems,” says Dr. Andersen. “Resolution of swelling and stiffness prior to ACL reconstruction surgery improves post-operative joint function.” A torn ACL must be entirely removed and a new one reconstructed. The new ligament is positioned within the knee with screws or other fixation devices. The reconstructed ligament then has to heal in this position in
Dr. armour performs specific orthopaedic maneuvers to assess the extent of a knee injury MAY 2011

Osteoarthritis is a common, progressive and debilitating disease that occurs commonly at the knee, hip and shoulder. The first line of treatment for osteoarthritis aims to relieve pain with nonsteroidal anti-inflammatory drugs, along with physical therapy, applications of a topical analgesic and injections of a corticosteroid. tive overhead activities. “Those susceptible to overuse-related problems are athletes who engage in repetitive overhead arm movements, like throwing. Degenerative changes in the shoulder may contribute to the problem in active older adults,” says Raymond M. Carroll, M.D. Most patients experience pain relief and improved shoulder function through non-surgical treatment, including anti-inflammatory medicine and strengthening exercises. Surgery may be considered if a rotator cuff tear is acute and painful, if it is in the dominant arm of the active individual or if maximum overhead arm strength is required for work or sports. to treat chronic osteoarthritis of the knee if conservative treatments fail. It involves the injection of gel-like substances (hyaluronates) into the knee joint to supplement the viscous properties of synovial fluid. The patient will receive three to five injections over the course of several weeks. Positive effects can last several months.
Dr. Carroll evaluates for a rotator cuff injury

Shoulder Injuries and Treatment
A rotator cuff injury may result from a traumatic event or develop gradually with repeti-

7

Proactive Approach to Recovery
Cary Orthopaedic & Sports Medicine Specialists’ rehabilitation service, PERFORMANCE Physical Therapy, provides highly trained and experienced physical therapists to guide patients through “prehabilitation” in the weeks leading up to surgery. Pain and loss of strength and function can spiral preoperatively and can prolong a successful post-operative outcome. The goal of physical therapy preoperatively is to regain the patient’s range of motion, reduce pain and swelling, and enhance basic strength, setting the stage for a quicker comeback. Therapy pre- or post-operatively allows for accelerated recovery. “So, they’re a step ahead of the game,” says Marc Capannola, Clinical Director of PERFORMANCE, adding, “Patients also get a mental lift knowing they will be able to be active sooner.” PERFORMANCE Physical Therapy also provides an important therapeutic tool called the SwimEx. “This aquatic therapy approach to rehabilitation allows for quicker initiation of the rehabilitation program for a patient who is not ready to do an activity on a hard surface but may be able to do it in the water,” says Mr. Capannola.

Spine Specialists Center Offers
“Dedicated Care for the Spine”
Given the prevalence and variance of neck and back pain in our society, Cary Orthopaedic Spine Specialists has put together a dedicated medical team providing advanced non-surgical and surgical options to treat the sources of pain. Neck pain is typically caused by poor posture at work while seated in front of a computer or during recreational activities, according to Sameer Mathur, M.D. “Fortunately, associated problems are not serious in approximately 80 percent of cases and can be treated non-surgically through a tailored physical therapy program or spinal injections.” When symptoms don’t improve after two or three months of conservative treatment, surgery may be a solution. Traditional surgical treatment for a degenerative or herniated disk, one of the most common problems, is cervical diskectomy and fusion. In select patients, a new surgical procedure can be performed without fusion. Similar to total knee and hip replacement, the degenerated cervical disk can be replaced with an artificial implant that replicates the function of the diskjoint complex. This allows the neck to maintain motion and prevents adjacent-level arthritis. Approximately two-thirds of adults suffer from low back pain at some time in their lives. Common causes include myofascial dysfunction, degeneration of the disc or facet joints, spondylolisthesis, spinal stenosis and compression fractures. Spinal stenosis occurs when there is narrowing of the spine, resulting in compression of the spinal nerves. The traditional surgical approach involves wide lumbar decompression and possible fusion. Patients are in the hospital for several days and may suffer from chronic back pain. The minimally invasive X-STOP procedure revolutionized the treatment for spinal stenosis. It is placed between the spinous processes to prevent extension of the spine. The outpatient procedure is performed under local anesthesia. Recovery and return to normal activity is much quicker. Compression fracture of the vertebral body is common in older adults. Conservative treatment includes bed rest, pain control and physical therapy. If that approach is unsuccessful kyphoplasty is a minimally invasive treatment option. Through two small incisions at the level of the fracture, cement is introduced into the vertebral body to reinforce it. This is done under local anesthesia, and patients experience immediate pain relief in the recovery room. Most often surgery is not necessary. If surgery is determined to be the best option, Cary Orthopaedic Spine Specialists will first consider minimally invasive alternatives that produce equal or better results than traditional surgery. Cary Orthopaedic Spine Specialists’ physiatrists are experienced in the use of fluoroscopic-guided epidural joint injections to treat chronic back pain. The treatment applies a numbing agent and anti-inflammatory on or near the inflamed nerve. Additional procedures available in this comprehensive spine center are nerve conduction and EMG (electromyogram) studies. Acupuncture also is offered for pain relief or resolution and may serve as a reasonable alternative to longterm narcotic analgesics. Spine-Focused Physical Therapy The physical therapists at the Spine Center are completely focused on the spine and specially trained in manual therapy techniques. Patients also learn proper lifting and moving techniques, and are guided on maintaining proper body mechanics. Physician Referrals Cary Orthopaedic Spine Specialists accepts direct referrals for neck and back problems requiring evaluation, management, surgical treatment, physical therapy and/or interventional spinal injections.

Physician Referrals
Cary Orthopaedic accepts referrals from all physicians, regardless of specialty or hospital affiliation. For more information, visit the practice at www.caryortho.com or call (919) 467-4992.

Sports Medicine Specialists:
Douglas L. Gollehon, M.D. Brian T. Szura, M.D. Douglas J. Martini, M.D. William K. Andersen, M.D. Derek L. Reinke, M.D. Mark A. Curzan, M.D. Raymond M. Carroll, MD. Edouard F. Armour, M.D.

Spine Specialists
Orthopaedic Spine Surgeon Sameer Mathur M.D., Physiatry Team: Scott S. Sanitate, M.D. Gary L. Smoot, M.D. Chris Lin, M.D. Nicole P. Bullock, M.D.

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The Triangle Physician

Childhood Obesity Within a Generation
By National Dairy Council

Help End

Nutrition Article

America’s children are fatter, weaker and more sedentary than ever before. In fact:
• 33 percent of American children and adolescents are overweight • 17 percent of children ages 2 to 19 are obese • Only 14 percent of teens consume three servings of milk per day • Only 2 percent of school age children consume the recommended servings from all the major food groups

What’s contributing to this onslaught of childhood obesity? First, distorted portion sizes mean that our children are overeating foods and beverages high in calories, fat and sodium, but low in key nutrients. In addition, today’s working families eat more meals away from home. Did you know that the average fast food meal contains more saturated fat than the American Heart Association recommends we consume in two days? Finally, children ages 8 to 13 spend nearly six hours in front of TV and computer screens each day instead of being physically active. These three primary factors have caused the percentage of overweight children and adolescents to triple in the past 40 years. America’s children are overweight, but what’s even more alarming is that they are undernourished in calcium, vitamin D, potassium and fiber, key vitamins and minerals that they need to grow into healthy adults. Feeling helpless? Don’t. Ending the childhood obesity and nutrition crisis within a generation is possible, and with these three counseling tips, physicians and other health professionals can help move the needle. First, review the beverage basics with families. The American Academy of Pediatrics recommends low-fat or fat-free white or flavored milk, water and 4 to 6 ounces of 100 percent fruit juice daily for children ages 1 to 6. “When sodas, sweet tea or sports drinks replace milk in the diet, it’s hard for children to get the calcium and vitamin D they need for bone growth

and development,” said Dr. Cathy Wood, pediatrician, Montgomery, Ala. The new 2010 Dietary Guidelines notes it is especially important to establish the habit of drinking milk in young children, as those who consume milk at an early age are more likely to do so as adults. The Dietary Guidelines encourages all Americans to consume more low-fat dairy foods for better bone health and recommends 2 cups for children 2 to 3 years, 2.5 cups for children 4 to 8 years, and 3 cups for those 9 years and older. Next, take a short assessment of the number of meals eaten away from home. Most restaurant portions are oversized for children and adults alike. Research shows that when larger portions are served, both adults and children eat more, despite fullness, and load up on extra calories. Physicians should encourage parents to prepare and eat more nutrient-rich meals at home. Tammy Beasley, registered dietitian and author of Rev It Up Fitness, said kids tend to eat more fruits, vegetables and low-fat dairy foods at meals shared with their parents. “Family meals

have long-lasting health and social benefits,” she said. “Children learn by modeling themselves after their parents, including food behaviors. Eating together lets parents show their children by example how to choose nutrient-rich foods, know when they are full and try new foods.” Lastly, physicians should encourage families to put muscles in motion for at least 60 minutes daily and engage children in more play time and less screen time. Many schools have eliminated physical education, recess and exercise to increase time spent in class, but programs are being introduced to help combat the lack of physical activity in schools. One school-based program that is gaining momentum nationwide is Fuel Up to Play 60, a nutrition and physical fitness initiative created by the National Dairy Council and the National Football League and supported by the U.S. Department of Agriculture, along with 13 national health organizations including the American Academy of Pediatrics. Now in more than 12,000 schools across the Southeast, Fuel Up to Play 60 empowers youths in grades four through 10 to take action and motivate their peers to improve nutrition and physical activity in school and at home. “Fuel Up to Play 60 is making a difference with our students,” said Manny Barocco, Director of Athletics, Health and Physical Education, Jefferson Parish, La. “It mixes competition, fun and nutrition to help students win the biggest prize of all – a healthy future.” Childhood obesity is a problem as serious as it is solvable, so talk to your patients and their parents to help bring the statistics down. Together, physicians, dietitians, parents, teachers and communities can end this alarming epidemic. It’s serious. It’s solvable. It’s time.
MAY 2011

9

LASIK
By Dean Dornic, M.D.

Opthalmology

Advances Benefit Military’s Effectiveness
The United States armed forces have embraced LASIK as a way to make troops “combat ready.”
During the first three months of the Iraq war in 2003, the military airlifted 60 service members out of the region because of severe corneal ulcers caused by contact lens wear. The military now forbids contact lenses because of the risks associated with dusty and dirty conditions. And while contact lens wear can be dangerous in combat situations, eyeglasses can be impractical. Even if the glasses don’t break, they often can hinder soldiers on missions. The spectacles can fog up, fall off or make putting on a gas mask a cumbersome and time-consuming task when seconds matter. Many people want to get laser eye surgery so they can be free of the hassles of glasses or contacts. But many service members deploying to Iraq and Afghanistan are rushing to get it done for much different reasons. They are getting the surgery because it could save their life. Over the years, vision correction technology has evolved such that LASIK (laser-assisted in situ keratomileus) has proven to be a safe and effective procedure. This has led to a growing acceptance of LASIK in the military. The United States armed forces have embraced LASIK as a way to make troops “combat ready.” Laser vision correction has been allowed for all aspects of military service, including aviation, special operations and support personnel. It also is approved for NASA astronauts. The Air Force Innovations, such as blade-free and wavefront-guided technology, have made the LASIK procedure better and safer. The Navy is currently undertaking a study on Naval aviators. To date, more than 200 aviators have been enrolled in the study. The results of the study have been outstanding. Aviators were able to return to flight status within four weeks after LASIK. Patient satisfaction has been excellent. One hundred percent were able to achieve 20/20 levels of vision. There were no complaints of significant glare, halos, haze or sharpness of vision. Ninety-eight percent felt that LASIK helped their effectiveness as a naval aviator and 98 percent indicated they would definitely recommend LASIK to their fellow aviators.
Dr. Dean Dornic is founder and medical director of the Laser Eye Center of Carolina. A board-certified, fellowship-trained vision correction specialist, he has more than 15 years of surgical experience and has performed thousands of successful LASIK procedures. He was selected as one of “America’s Top Ophthalmologists” by Consumer’s Research Council of America and was named a LASIK Gold surgeon – an honor bestowed upon the top 50 LASIK surgeons nationwide by Sightpath Medical. Dr. Dornic has lectured at international meetings and trained other surgeons on LASIK. For more information, visit www.visionauthorities.com.

now allows LASIK in all aviators, including those in high-performance aircraft. Although the most common types of laser eye surgery can cost between $2,500 and $5,000 for both eyes at a private doctor, active military personnel can now receive LASIK free at one of 25 Warfighter Refractive Eye Surgery Program centers. Since its introduction to the Armed Forces in 2000, more than 300,000 refractive surgery procedures have been performed at military hospitals, and more than 45 studies have been conducted to determine the safety and efficacy of laser vision correction among military personnel.

Acceptance of the new and improved LASIK eye surgery by the Department of Defense has helped make our troops better and safer.

10

The Triangle Physician

Orthopedics

Total Ankle Replacement
By Selene G. Parekh, M.D., M.B.A.

Is Revolutionizing Care of Ankle Arthritis
The third-generation implants require smaller bone cuts, are more anatomical and better able to restore natural ankle motion.

Ankle arthritis is a chronic condition that causes substantial pain, disability and loss in quality of life. In fact, a recent study published in 2008 demonstrated end-stage ankle arthritis to be as debilitating as hip arthritis.

of motion. The third-generation implants require smaller bone cuts, are more anatomical and better able to restore natural ankle motion. The ideal candidate for a TAR suffers from

Until recently, conservative options, such as injections, bracing and anti-inflammatories, have been used to delay surgery. When surgery was needed, the best option was a surgical ankle fusion. This would relieve pain, but unfortunately, leave patients with a loss of motion in the ankle, a limp, and make the knee and subtalar joints susceptible to arthritic changes. These issues have made clinicians, orthopedic surgeons, researchers and ankle implant companies seek other solutions. Total ankle replacement (TAR) has been available in the United States since the 1970s. The earlier generations of ankle replacements were plagued with failures. However, the most recent, third-generation implants have overcome many of the shortcomings of these earlier implants. This has renewed the interest in TAR. Currently in the United States, there are three TAR systems available: the STAR, the Salto and the Inbone. These implants have been available in Europe for years, with promising medium- and long-term results. In the U.S., the Inbone was approved in 2005, the Salto in 2006 and the STAR in 2009. The goals of TAR surgeries are to reduce pain, while preserving a natural range

post-traumatic ankle arthritis or rheumatoid arthritis, is less than 250 pounds and is 50 years of age or older with little or no major ankle deformity. However, this is changing as orthopedic foot and ankle surgeons gain more experience with these implants and techniques. Depending on the specifics of a patient, TAR surgery is being performed at an earlier age, with greater deformities and with a larger body mass index. The evaluation of a patient with ankle arthritis begins with a thorough history

Dr. Selene G. Parekh is an associate professor of orthopedic surgery at the North Carolina Orthopaedic Clinic and Duke University, Department of Orthopaedic Surgery. His research and clinical interests include total ankle replacements, foot and ankle injuries of athletes, minimally invasive foot and ankle trauma surgery, tendon injuries of the foot and ankle, and the adoption and development of novel technologies in foot and ankle surgery. Dr. Parekh has been an active speaker at regional, national and international meetings, helping to teach other orthopedic surgeons about novel techniques for the care of foot and ankle patients.

and physical exam, followed by weightbearing radiographs. At times, a computed tomography scan may be needed to provide more anatomical details. Based on these findings, treatment options are reviewed with the patient. If a patient is a candidate for a TAR, a medical clearance and dental evaluation to eliminate a possible source of infection are requested. The surgery for TAR requires an overnight stay. The patient is made non-weight bearing for four to six weeks. Thereafter, intense physical therapy is required to gait train and strengthen the ankle. Most patients note a tremendous improvement in their quality of life, being able to perform activities, such as walking, yoga, golf and swimming, which they may have lost for years. Total ankle replacements are revolutionizing the care of ankle arthritis. Pain relief, preservation of adjacent joints, restoration of ankle motion and a more normal gait are some of the benefits of third-generation TAR procedures. Patients should be made aware of this treatment option, as it holds the promise of transforming their quality of life.
MAY 2011

11

Your Financial RX

Pain Threshold Pain Threshold
By Paul Pittman, C.F.P.

Reduce Your Investment
Did you know 94 percent of all active money managers under-perform their respective indexes? Are you in the 94 herd or the elite 6?
“Are you having any pain today? On a scale of 1 to 10, what is your current pain level?” The nurse asked me these questions during my last few doctor visits. Thank goodness, I have not had any pain for quite awhile, but it makes me wonder: What is a level 1? What is a level 10? I have had a physician tell me that I was going to feel some “pressure” during a procedure. “Pressure” must be the buzzword for “this is a 5 on the pain scale.” (By the way, using the word “pressure” instead of “pain” doesn’t minimize the experience.) Anyway, back to my question on what each level means. I have experienced what I can only imagine was a 10. I had a kidney stone rear it’s ugly head during my daughter’s dance recital. It was my first, and I was sure that a rhino had rammed his horn into my back. I went from a 0 to a 10 in about 30 minutes. My wife took me to the emergency room, and thank goodness it was closer than the gun shop. As I writhed on the floor of the ER, the triage nurse said it was probably a kidney stone. I was certain that it was the size of a Buick. But I was one of the lucky ones; mine was How could something so small bring a rough and tough six-foot man to the ground? If this wasn’t a 10, then I can only hope that a 10 involves blacking out. I had been on painkillers that could have stopped that charging rhino in his tracks, and the stone wasn’t much bigger than a decimal point on this page.

The same way opening your investment statements might be doing to you right now.

Is the decimal point causing pain?
Are you experiencing any pain right now? On a scale of 1 to 10, what is your current level? What I have witnessed in 24 years in this business is that something as small as a decimal point can raise an investor’s pain level immediately to a 10. Usually the source of pain is not the decimal point, but the location of that decimal point. Your broker might be telling you that this is “pressure.” Now we all understand this term much better.

so small I was going to be able to pass it on my own. Sure enough, 12 hours later, I heard the unmistakable “clink” in my urine screen.

12

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 [email protected].

This is not to say that owning these positions is a bad thing, but owning them several times is. It raises your risk level many times over. True allocation is broad, covers many asset classes, styles and countries, but most importantly, it is designed specifically for you. Your investment profile, risk tolerance and goals are as individual as your fingerprint. Here again, I strongly advise you to find a qualified person to help you develop your personal allocation. Do not live with your

pain and accept what is shoveled at you. Take the time, break the chain, find out what is right for you and your family! It is too important to keep on doing what you have always done and expect a different outcome. Did you know 94 percent of all active money mangers under-perform their respective indexes? Are you in the 94 herd or the elite 6? Until next month, good health and happiness.

How does the movement of the decimal point affect your stress level, your emotions, your retirement, your child’s education? All of these items should be fully taken into account when you develop your Investment Policy Statement in the very beginning. Do you have clear and concise steps to lower the pain level, or are you just trying to live with the pain? Pain in the investment world not only brings doubt and fear into play, but can also seriously derail a sound financial plan. What you do not want is for this pain to create a knee-jerk reaction. This is when pain breeds panic, and panic develops into bad decision-making. Pain does crazy things to emotions. If you are properly allocated, then secular bear markets shouldn’t shoot your pain level to a 10 and create bad decisions. Look back over one of my previous articles on proper allocation to better understand this concept. (If you cannot locate it, I am happy to e-mail it to you.)

Is overlap killing your allocation?
I’ll wager that right now you have a large degree of “overlapping” in your portfolio. Overlapping is a killer of proper allocation. This is where you own certain positions more than once and probably many times in a standard, brokerage-firm allocation. You may very well own Cisco Systems or Coca-Cola or General Electric, three or four or five times in your portfolio!
Womens Wellness half vertical.indd 1 12/21/2009 4:29:23 PM

MAY 2011

13

Sleep Medicine Category

Sleep Apnea
Requires Specialized Attention
By Giridhar Chintalapudi, M.D.

Doctors usually can’t detect the condition during routine office visits. Also, there are no blood tests for the condition. Most people who have sleep apnea don’t know they have it because it only occurs during sleep.
About 70 million Americans suffer from a sleep problem and nearly 60 percent of them have a long-term disorder. Even though sleep problems are very common, they are very often undiagnosed and untreated. One of the most common sleep problems is sleep apnea. It is estimated that 4 percent of middle-aged men and 2 percent of middleaged women suffer from sleep apnea. In sleep apnea, you have one or more pauses in breathing while you sleep. You often move out of deep sleep and into light sleep when your breathing pauses or becomes shallow. This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness. Doctors usually can’t detect the condition during routine office visits. Also, there are no blood tests for the condition. Most people who have sleep apnea don’t know they have it because it only occurs during sleep. A family member and/or bed partner may first notice the signs of sleep apnea. Untreated sleep apnea also can lead to changes in how your body uses energy. These changes increase your risk of obesity and diabetes. The frequent drops in oxygen level and reduced sleep quality trigger the release of stress hormones. These compounds raise heart rate and increase your risk of high blood pressure, heart attack, stroke and arrhythmias (irregular heartbeats). The hormones also raise the risk of, or worsen, heart failure oxygen causes the brain to send a signal for you to wake up, so you open up the airway in your throat and start breathing again. If you have sleep apnea, this cycle may repeat as often as 50 or more times an hour.

One of the most common signs of obstructive sleep apnea is loud and chronic (ongoing) snoring. Pauses may occur in the snoring. Choking or gasping may follow the pauses. You’re asleep when the snoring or gasping happens. You likely won’t know that you’re having problems breathing or be able to judge how severe the problem is. Your family members or bed partner often will notice these problems before you do. Other signs and symptoms of sleep apnea may include: morning headaches; memory or learning problems and not being able to concentrate; feeling irritable, depressed, or having mood swings or personality changes; urination at night; and a dry throat when you wake up. Another common sign is fighting sleepiness during the day, at work or while driving. You may find yourself rapidly falling asleep during the quiet moments of the day when you’re not active.

Sleep Apnea Can Contribute to Serious Medical Conditions
During normal sleep, throat muscles relax. When this happens, if there is too little room inside your throat or too much tissue pressing on the outside of your throat, your airway can become blocked. This blockage stops the movement of air, and the amount of oxygen in your blood drops. The drop in

14

The Triangle Physician

Dr. Giridhar Chintalapudi (“Dr. Chin”) earned his medical degree from Kurnool Medical College, India. Before moving to the United States, he worked in United Kingdom for five years, with special interest in neuropsychiatry. He completed his internship and residency at State University of New York, Stony Brook. He is board certified in general neurology, vascular neurology and sleep medicine. He also is a board member of North Carolina Academy of Sleep Medicine. In addition to being active in private practice, he also is involved in teaching both neurology and sleep medicine. Dr. Chin can be reached at 919-708-5008.

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If a patient has problems breathing during sleep, even if he doesn’t have daytime sleepiness, he should talk with his doctor.

Treatment Can Restore Regular Breathing
Doctors diagnose sleep apnea based on medical and family histories, a physical exam and results from sleep studies. Usually, your primary care doctor evaluates your symptoms first. He or she then decides whether you need to see a sleep specialist for diagnosis and treatment. A sleep study is the most accurate test for diagnosing sleep apnea. It records what happens with your breathing while you sleep. The goals of treating sleep apnea are to restore regular breathing during sleep and relieve symptoms, such as loud snoring and daytime sleepiness. Lifestyle changes, mouthpieces, breathing devices and surgery may be used. Medicines typically aren’t used to treat the condition. Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke and diabetes. If a patient has sleep apnea, he should talk with his doctor or sleep specialist about the treatment options that will work best.
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MAY 2011

15

Orthopedics

Double-Bundle Technique
By Mark Galland, M.D.

Improves Anterior Cruciate Ligament Outcomes
The double-bundle technique is much more technically demanding to perform, but there is little doubt that one day it will be “The Standard.”
Treatment of a once devastating knee injury has evolved! In the all-too-recent past, tearing one’s anterior cruciate ligament meant the end of an active lifestyle and certainly the end of many promising athletic careers. New advances in surgical technique and an enhanced understanding of the anatomy of the ligament have improved the prognosis for athletes suffering this once-devastating injury. The anterior cruciate ligament (ACL) is a ligament located in the middle of the knee that connects the femur to the tibia. It is a critical ligament that stabilizes the knee during sports and physical activity. The ACL is usually injured during a pivoting or cutting motion and can occur with or without contact. ACL injuries have become more common as participation in sports has increased. As a result, ACL reconstructive surgery is now one of the most common orthopedic procedures. New advances have greatly improved the surgical technique of ACL reconstruction. Traditionally ACL reconstruction has The latest research may explain these uninspiring results. Through extensive laboratory analysis, we have learned that the ACL is composed of two separate and distinct portions, or “bundles.” Currently only a select few surgeons are trained in and are performing this groundbreaking technique. It is much more technically demanding to perform, but there Each functions independently and in concert. Knowing this, it is reasonable to conclude that reconstruction of only one Unfortunately, many still experience some pain portion (and ignoring the other) will only focused on reconstruction of a single strand or “bundle” of fibers. The results have been largely successful in restoring knee stability and returning athletes to play. This success is accomplished in the doublebundle technique by accurately replacing and restoring the native ACL.
aCl Reconstruction single Bundle technique. Reproduced from: Vangsness CT. aCl Reconstruction orthopaedic Procedures, 2010.

and feelings of instability even after successful surgery and rehabilitation. Still, others are unable to return to their previous levels of activity, and once-promising athletic careers are ended. Moreover, knees reconstructed with the traditional single-bundle technique may be more prone to re-injury and often develop arthritis many years later.
a dissection depicting the double-bundle nature of the native aCl (the medial femoral condyle has been removed). Reproduced from: Fu F. Femoral insertion site of the anterior cruciate ligament (letter to the editor; http://www.ejbjs.org.) Journal of Bone and Joint surgery american, may 24, 2005.

accomplish part of the goal – which is to stabilize the knee and preserve the joint from degenerative arthritis. The newest and most progressive surgical technique for ACL reconstruction is called the anatomic double-bundle technique and is superior to the single-bundle technique in many ways. Early results suggest that the anatomic double-bundle technique decreases the likelihood and severity of the post-surgical problems associated with traditional singlebundle technique, while increasing overall knee stability. In addition, the knee is more likely to regain normal range of motion as compared to knees treated non-operatively or with the traditional single-bundle technique.

16

The Triangle Physician

Women’s Health Diabetes
Dr. Mark Galland of Orthopaedic Specialists of North Carolina is a board-certified orthopedic surgeon, specializing in sports medicine and practicing in Wake Forest and North Raleigh. He serves as team physician and orthopedic consultant for the Carolina Mudcats, the AA affiliate of the Cincinnati Reds, as well as several area high schools and colleges. Dr. Galland is a recognized expert in knee injuries and doublebundle ACL reconstruction. He can be reached at (919) 562-9410 or by visiting www.orthonc. com or www.drmarkgalland.com.

The Triangle Physician Orthopaedics Allergies 2011 Editorial Calendar
June Vision 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

May







is little doubt that, one day, this doublebundle technique will be “The Standard.” We have entered a new era in sports medicine. Athletes suffering a once potentially devastating injury may now have a reconstructive surgery to truly restore the knee to its normal state. When suffering a major knee injury such as an ACL tear, surgeons who perform the anatomic double-bundle technique may restore the



schematic shows double-bundle aCl reconstruction. Reproduced from: Casagranda BC, maxwell NJ, Kavanagh eC, Towers JD, shen W, Fu FH. Normal appearance and Complications of Double-Bundle and selective-Bundle anterior Cruciate ligament Reconstructions using optimal mRI Techniques. american Journal of Radiology. 2009; 192:1407-1415.









structures in the knee to a near normal state. You can resume your life of physical activity and sport participation with the confidence that your knee is structurally sound.



Im

Clo Dec

SANDHILLS SLEEP DISORDERS CENTER

Dr. G. Chin, (Chintapudi) MD, DABSM Board Certified Sleep Medicine Board Certified Neurology

Dr. H. Tellez, MD Board Certified Neuromuscular Medicine Board Certified Neurology

Our Priority Is Your Sleep!
The Specialities • Sleep Apnea • Sleep Studies • Memory Disorder • Brain/Spine MRI • Gait Problem • EEG • Neuropathy, ie: CTS • NCV- EMG Laboratory

888-614-7420
295 Olmstead Blvd., Suite 12 Pinehurst, NC 28374 (910) 235-0595

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112 Dennis Drive Sanford, NC 27331 (919) 708-5008 609 Attain Street, Unit 101 Fuquay-Varina, NC 27526 (919) 552-8917

MAY 2011

17

Cardiology

Atrial Fibrillation
By Ker Boyce, M.D., F.A.C.C., F.A.C.P.

A Perspective on Treatment Evolution
Today, new catheter ablation devices are in development. Other energy sources are being evaluated. Hybrid procedures are being developed and refined. A new class of agents targeting the IKur channels are in development.
Atrial fibrillation is the most common rhythm disorder resulting in hospitalization. With the increasing population and the aging of the baby boomers, it is becoming more prevalent in every cardiologist’s practice. Atrial fibrillation (AF) was probably first described by the Chinese emperor physician Huang Ti in his classic medical treatise about 2000 BC. The first modern description of AF is credited to William Harvey in 1628, with his observations of animal hearts. Willem Einthoven published the first echocardiogram recording of AF in 1906, calling it “pulsus inequalis et irregularis.” William Withering reported in 1785 That has changed in the last two decades, as we have seen a phenomenal growth in our understanding of its pathophysiology. Michel Haissaguerre’s group first reported the recording of pulmonary vein potentials in 1998. This quickly led to the concept that paroxysmal AF is often triggered by ectopic atrial tachycardias that commonly arise from one or more of the pulmonary veins. Persistent/permanent AF is usually associated with enlarged atria and myocardial fibrosis, which supports multiple wavelets.
Dr. Ker Boyce earned his bachelor of science in chemistry from the Georgia Institute of Technology at age 18. After graduating with his medical degree from Emory University School of Medicine, he completed an internal medical residency at Emory. He then went on active duty in the United States Navy, serving first as a naval flight surgeon and force medical officer in support of the U.S. Antarctic Research Program. He then completed his cardiology fellowship at Naval Medical Center San Diego and his electrophysiology fellowship at the University of California San Diego. Dr. Boyce then returned and joined the faculty of the Naval Medical Center San Diego, eventually becoming the division chief and fellowship program director. In 1999, Dr. Boyce transferred to the U.S. Naval Reserve and entered private practice. He started the electrophysiology program at FirstHealth Moore Regional Hospital. He continued to serve in the Navy, mentoring the electrophysiology program at Naval Hospital Portsmouth and serving as an advisor to the Naval Aerospace Medical Institute until his retirement from the Navy in 2006.

New Treatment Frontier
This progress in understanding has led to new options for therapy. The treatment of AF still has three goals: prevention of thromboembolism by anticoagulation, ventricular rate control and rhythm control to restore a sinus mechanism. Numerous studies have been completed showing the benefit of warfarin in AF. The recent release of dabigatran, a direct thrombin inhibitor, now offers an alternative. Rate control is usually accomplished with verapamil, dilitiazem and/or betablockers. A nonpharmacologic alternative is AV junction ablation and permanent pacemaker implantation. Rhythm control has historically been

amiodarone, to name a few. Most recently dronedarone was released. Unfortunately, no agent works well, and not all are appropriate for every patient due to coexisting conditions. The current frontier of AF management is nonpharmacologic treatment of AF to restore sinus rhythm. This was first done by James Cox with his cut-and-sew Maze operation in 1987. It evolved into the Maze III procedure by 1992. This surgery works well but is open chest/open heart. It is difficult to perform as a concomitant procedure to other cardiac surgery. For these reasons, it has not been widely adopted.

administering digitalis leaf to patients with heart failure. He noted that those with an irregular pulse would improve and their pulse would become steady. Karel Wenckebach in 1914 reported the use of quinine for AF after a Dutch sailor told him how his palpitations improved while taking quinine for malaria. Walter Frey later reported that quinine’s stereoisomer, quinidine, was more effective. Atrial fibrillation was often categorized as paroxysmal, persistent or chronic (now permanent) for clinical purposes. However, for most of the next century, our understanding and treatment of AF did not change significantly.

relegated to medications. There are numerous agents such quinidine, flecainide, sotalol, and

Electrophysiologists

later

developed

percutaneous ablation techniques. There was

18

The Triangle Physician

a rapid evolution from targeting potentials inside the pulmonary veins, to pulmonary vein isolation, to antral isolation. This has been aided by the development of 3-D mapping systems, importing of cardiac computed tomography or magnetic resonance studies, irrigated-tip radiofrequency catheters and robotics. Despite these advances, the overall success rate for patients with paroxysmal AF for a single ablation procedure is in the range of 6070 percent. It is less successful for the persistent AF patient with an enlarged left atrium. In the March 2011 issue of The Triangle Physician, there was an article on a new hybrid AF procedure. This work was pioneered by Dr. Andy Kiser at FirstHealth Moore Regional Hospital in Pinehurst. Dr. Kiser started with an open-chest approach to assess the epicardial ablation device and to develop a lesion set. He then developed a minimally invasive approach through the pericardium. In collaboration with electrophysiologists, a hybrid approach was subsequently developed. The surgeon begins the ablation procedure epicardially, and then the electrophysiologist completes the various lines and tests for pulmonary vein isolation endocardially. With Dr. Kiser’s return to his alma mater, this work will be continued at the University of North Carolina at Chapel Hill. So what does the future hold? New catheter ablation devices are in development. Some use balloons to deliver a circumferential ablation around each pulmonary vein ostium. Other energy sources are being evaluated. Hybrid procedures are being developed and refined. A new class of agents targeting the IKur channels, found predominantly in atrial myocardium, are in development. And what does this mean for patients? Each patient is different. Some are asymptomatic and only require anticoagulation. A few only need a little more rate control. Many are devastated with AF and require restoration of sinus rhythm. With so many treatments now available, it is imperative that the treating physician be aware of the risks and benefits of each, and then tailor therapy to each patient. In the meantime, my kudos to all the researchers, basic science and clinical, who are continuing to explore new frontiers in atrial fibrillation.
Call (540) 650-3686 or send inquiries to [email protected].
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MAY 2011

19

INTRODUCING
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All health care professionals and health related businesses have a new outlet for a direct publication that targets up to 6000 physicians, PAs, NPs, medical centers and related health care professionals. The regional physician publication is coming to the Eastern Region of North Carolina! DF Marketing Consulting and Associates will be handling the advertisements for the publication in the following counties:

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Radiology

Raleigh Radiology’s Musculoskeletal Team
Offers Image Guided Pain Management
By Jeffrey Browne, M.D.

When a local mail courier’s hip pain became so debilitating that he could no longer perform his job, he discussed his options with his physician. His arthritis would eventually require hip replacement, but he was not quite ready for the operation. He was an ideal candidate for fluoroscopic-guided hip joint injection, and his results were very gratifying. He was able to return to work within a week and his pain was markedly improved. Whether an athlete or everyday patient, the team of seven subspecialty-trained musculoskeletal radiologists at Raleigh Radiology has you covered for your interventional needs. When conservative management of your patient’s joint or tendon pathology fails or if the cause of pain is uncertain, an image-guided injection of a short-acting anesthetic and longacting corticosteroid is very useful in managing patients. The injections can be used to: • Delay or eliminate need for surgery • Diagnose cause or site of pain • Control pain in non-operative patients • Offer pain relief quicker than conservative measures Fluoroscopic-, ultrasound- and computed tomography (CT)-guided injections increase the precision of these procedures by confirming correct needle placement. After administering a local anesthetic, the needle is directed to the site of interest, using minimal or no radiation exposure. If a joint is the target, a small amount of contrast is injected during fluoroscopy to confirm intra-articular position. A combination of a long-acting anesthetic and an intermediateto-long-acting corticosteroid are then injected. The anesthetic can provide immediate pain relief lasting four to six hours and also confirm the site of pain. The corticosteroid begins to work approximately one to two days after injection, reaching its maximum effectiveness within five to seven days.

Common indications for CT or fluoroscopicguided procedures include: • Extremity (upper, lower, ankle, foot) joint injection for pain or arthritis • Joint aspirations • Shoulder brisement for adhesive capsulitis • Sacroiliac joint injections Ultrasound is a very effective modality when soft tissue or fluid is the region of interest. Procedures performed that under can be ultrasound

Complications are infrequent, but patients should be aware of signs of infection at the injection site. An allergic reaction to steroid injection or iodinated contrast is rare and often mild. Since the corticosteroid can take five to seven days to reach maximum effectiveness,

include aspiration of fluid for analysis, bursitis, treatment of calcific tendinitis, drainage or decompression of ganglion
Dr. Jeffrey Browne is a musculoskeletal radiologist at Raleigh Radiology and medical director of computed tomography for Rex Hospital. He graduated from the University of Connecticut School of Medicine and completed an internship at St. Raphael’s Hospital in New Haven, Conn. He completed his residency and a fellowship in musculoskeletal radiology Duke University Medical Center. Dr. Brown is a member of the American College of Radiology, Radiological Society of North America and American Roetgen Ray Society. He joined Raleigh Radiology in 2008.

cysts, Baker’s cysts, hematomas, and abscesses. In many cases of calcific tendinitis, the calcifications can be aspirated from the tendon or bursa prior to the injection of steroids, a procedure referred to as shoulder barbotage.

The duration of the pain relief varies depending on the severity and reversibility of the patients’ condition, as well as other factors. In the case of arthritis, the steroid will reduce the inflammation; however, it will not reverse the condition. If therapeutic effect is achieved, a maximum of four injections per year can be performed. Patients are asked to assess changes in their pain shortly after their injection and report the effectiveness to their physician. Pain relief immediately following the procedure is diagnostic of a problem at the site of injection. Before arriving for the procedure, patients are requested to inform the staff if they are diabetic, taking blood thinners or have had previous reactions to iodinated contrast. Prior to the injection, a radiologist will question the patient about his or her symptoms and correlate them with any imaging findings.

we ask patients to avoid excessive activity that could potentially prohibit the steroid from reaching its full potential effect. Our team of MSK radiologists offer these injections at three convenient locations within Raleigh: Our Blue Ridge and Cedarhurst outpatient offices and at Rex Hospital. To schedule a joint injection, call our Blue Ridge facility at 781-1437 or Cedarhurst at 877-5400. For more information, go to our website at www.raleighrad.com.

References

Boswell MV, Trescot AM, Datta S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007 10:7-111. Silbergleit R, Mehta BA, Sanders WP and Talati SJ. Imaging-guided injection techniques with fluoroscopy and CT for spinal pain management. Radiographics 2001 21:927-39. Dussault RG, Kaplan PA, Anderson MW. Fluoroscopyguided sacroiliac joint injections. Radiology 2000 214:273-6.
MAY 2011

21

Women’s Health

New Findings in Losing Weight
By Andrea S. Lukes, M.D., M.H.Sc., F.A.C.O.G.

Article Review:

The alarming fact is that approximately two thirds of Americans are overweight or obese. So when a study on the effects of a combined drug (low-dose phentermine plus topiramate) on excess weight and associated comorbidities was published in Lancet in April, health care providers took note. Although not yet approved by the Food and Drug Administration, the findings of the CONQUER1 study showed significant weight loss. Upon FDA approval, the combined drug will be marketed as Qnexa. In the CONQUER trial, two doses of phentermine plus topiramate were compared in overweight/obese subjects as an adjunct to diet and lifestyle changes. The term “overweight” refers to a body mass index (BMI) greater or equal to 25 but less than 30. Obesity refers to a BMI of greater or equal to 30.

than the placebo group, which had a weight loss of 1.4 kg, or 3.1 pounds. At one year, this study showed that weight loss of 10 percent or greater at one year was seen in 7 percent of the placebo group, in 37 percent of the low-dose group and in 48 percent of the high-dose group. This was a statistically significant difference for both doses, compared to placebo. Further, the cardiometabolic issues

percent of people taking fenfluramine, or dexfenfluramine, had abnormal valve findings. The FDA did not ask manufacturers to remove phentermine from the market. Phentermine works on the hypothalamus portion of the brain to release norepinephrine (a neurotransmitter that signals a fight-orflight response, reducing hunger). The most common side effects are dry mouth, insomnia, dizziness, mild increase in blood pressure (rarely more severe) and heart rate. Monitoring blood pressure in important. The precise mechanism of action for topiramate is not clear, but theories suggest energy expenditure increases with reduced caloric intake, reduced salivary enzyme activity, reduced leptin and corticosteroid concentrations, and potential reduction in serum glucose and insulin concentrations. Of concern are the adverse events associated with topiramate, including parasthesias, memory impairment, taste distortion, fatigue, insomnia, difficulty concentrating, and dizziness.

associated with obesity improved in those treated with the combined drug. Specifically, there were significant reductions in systolic blood pressure, diastolic blood pressure (high-dose sensitivity group), C-reactive triglycerides, protein high(hs-CRP),

fasting glucose and total cholesterol. For most of the risk factors, the improvement was more in the higher dose group.

Although not yet approved by the Food and Drug Administration, the findings of the CONQUER study showed significant weight loss.
Adults evaluated in the study had a BMI between 27-45 kg/m2, and two or more comorbidities, prediabetes, including hypertension, diabetes or dyslipidemia

Local Treatment Using Phentermine Taking Note of Side Effects
Phentermine was first approved by the FDA as an appetite-suppressing drug back in 1959. At one point it was combined with a medication (fenfluramine, or The medication is used for three to six months to suppress appetite. When patients start this program, they are told of a remote Eventually, dangerous side effects surfaced in Fen-Phen users, with 24 cases of heart valve disease, as well as cases of pulmonary hypertension. Some individuals died from At the lower dose, the mean weight loss was 8.1 kg, or 17.8 pounds. At the higher dose the mean weight loss was 10.2 kg, or 22.4 pounds. These were both statistically higher the effects of Fen-Phen. Following these reports, fenfluramine (or dexfenfluramine) was taken off of the market voluntarily. Afterward, studies showed that 30 It is recommended by the FDA that phentermine be used short-term (up to 12 weeks), while incorporating healthy dieting and exercise. In our experience and through discussions with peers, if weight chance of pulmonary hypertension is possible. dexfenfluramine) and called Fen-Phen. More than 300 patients have been treated using the drug phentermine through a limited program at Women’s Wellness Clinic.

or obstructive sleep apnea. Of the 2,487 subjects, 994 were assigned to placebo (979 analyzed), 498 to 7.5 mg phentermine plus 46 mg topiramate (488 analyzed), and 995 to 15.0 mg phentermine plus 92 mg topiramate (981 analyzed).

22

The Triangle Physician

After earning her bachelor’s degree in religion from Duke University (1988), Dr. Andrea Lukes pursued a combined medical degree and master’s degree in statistics from Duke (1994). Then, she completed her ob/gyn residency at the University of North Carolina (1998). During her 10 years on faculty at Duke University, she co-founded and served as the director of gynecology for the Women’s Hemostasis and Thombosis Clinic. She left her academic position in 2007 to begin Carolina Women’s Research and Wellness Center, and to become founder and chair of the Ob/ Gyn Alliance. She and partner Amy Stanfield, M.D., F.A.C.O.G., head Women’s Wellness Clinic, the private practice associated with Carolina Women’s Research and Wellness Clinic. Women’s Wellness Clinic welcomes referrals for management of heavy menstrual bleeding. Call (919) 251-9223 or visit www.cwrwc.com.

equal to 25) or obese (BMI greater or equal to 30), effective regimens for weight loss are important to help individuals lose weight. While effective medications are available, there is basic information providers should emphasize to their patients, including the following: • Healthy lifestyle changes in diet and exercise should be emphasized. • In order to lose one pound in a week, you must have a deficit of 3,500 calories in that week (500 calories per day for 7 days). • Do not consume less than 1,200 calories per day to avoid slowing down your metabolism. • Eat less and more often to boost metabolism. Try to consume five to six small meals during the day, beginning with breakfast, within 45 minutes of walking. • Keep a food journal – potentially an online version that will keep a calorie count for you. For example: www.thedailyplate. com, www.calorieking.com, www. sparkspeople.com, www.nutrihand.com

and www.mypyramid.com. • Exercise! – This is so important to do for weight loss and weight control. • Be mindful of the food you are eating, both in terms of quality and quantity. • Do not multitask when you are eating, and chew your foods well. • Give yourself a pantry and refrigerator/ freezer makeover – Get rid of the foods that tempt you. • Do not eat late at night. As new developments in weight loss emerge, Women’s Wellness Center staff weighs the risks and benefits. Call (919) 251-9223 for available appointments and support with helping patients to make healthy lifestyle changes through weight loss.

loss continues through 12 weeks, then continuation through 16 weeks is tolerated.

References
1

Weight-loss basics
Given that two-thirds of the United States population is overweight (BMI greater or

Gadde KM, Allison DB, Ryan DH, et al. Effects of lowdose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults CONQUER: A randomized, placebo-controlled, phase 3 study. Lancet 2011; DOI:10.1016/S0140-6736(11)60505-5. Available at http:// www.thelancet.com.

However much you value wildlife conservation in North Carolina,

DEC NC

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right here in the Old North State. Conservation education efforts are preparing future generations to sustain your concern for the lands we protect today. At www.ncwhf.org, download the license tag application and see the good works in process. pp Your new tag shows your support and your n contribution is put to work…times four. co

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MAY 2011

23

WakeMed News

WakeMed North to Become Wake County’s Fifth Hospital
WakeMed Health & Hospitals will begin expansion in fall 2011 of the existing WakeMed North Healthplex into Wake County’s fifth hospital – WakeMed North Hospital. With an anticipated opening date of October 2013, WakeMed North Hospital will be a 61-bed acute care hospital, with a focus on inpatient women’s specialty services, offering a full range of obstetric and gynecological services, including “Transitioning to a hospital is the next logical step, as the infrastructure is already in place and the community has a critical mass of 262,000 residents living within a seven-mile radius of the facility,” said Dr. Atkinson. “While the hospital will initially open with a women’s focus, our plan is for it to continue “Since opening in 2002, WakeMed North Healthplex’ consumer-driven volumes have consistently outpaced projections, demonstrating the great demand for health care services in this community,” said Dr. Bill Atkinson, WakeMed president and chief executive officer. Construction is expected to create 500 construction jobs. Hospital officials also said the current 150 employees will be expanded to about 442 full-time equivalent employees, with an average salary of $48,760, by the to expand to meet the needs of women, men and children, alike.” WakeMed received approval to add 41 licensed acute care beds to WakeMed North Hospital in 2009. These beds were in addition to the 20 acute care beds already approved for relocation from WakeMed Raleigh Campus, making the total bed count for WakeMed North Hospital 61. The inpatient beds will be constructed in an approximate 90,000-square-foot addition to the existing North Healthplex. second year of hospital operation. The cost of the project is estimated to be nearly $62 million. comprehensive preventive, diagnostic and therapeutic care. The facility will continue to serve men and children through the existing emergency department, outpatient surgery, imaging, lab and physician services already offered at the facility. Currently WakeMed North Healthplex offers a fullservice, 24/7 emergency department, ambulatory surgery center, imaging and laboratory services and a host of additional clinical capabilities. The campus an also features 85,000-square-foot

medical office building.

Construction Commences on Healthplex
Construction has begun on WakeMed Brier Creek Healthplex located at the corner of US-70 on T.W. Alexander Drive. The facility, which will be owned, deThe facility will include the county’s third 24/7 full-service, stand-alone emergency department with 12 private treatment rooms. It will be staffed by the same board-certified physicians that serve WakeMed’s five additional emergency departments. Construction is slated to be completed by Laboratory and imaging services, including computed tomography and X-ray, also will November 2011 and the building will be operational by January 2012. The project CerFor more information, visit www.wakemed.org. veloped, and managed by Duke Realty, will be 50,000 square feet, including a 26,000-square-foot emergency department and 24,000 square feet of medical office space. WakeMed Brier Creek Healthplex will initially employ 74 full-time employees and will serve northwest Raleigh and Wake County. It is located at 8001 T.W. Alexander Drive in Brier Creek, less than one mile from I-540 and US-70. The complex sits on 12 acres, allowing room for future development. be available for emergency department patients and outpatient visits. tificate of Need was granted in September 2009 for $36 million. WakeMed’s total investment in the project is $14 million.

24

The Triangle Physician

WakeMed News

CON to Add 101 Beds
WakeMed Health & Hospitals today submitted two complementary Certificate of Need (CON) applications to add 101 beds in accordance with the bed-need allocation identified in North Carolina’s 2011 State Medical Facilities Plan. WakeMed is proposing to add 79 acute care beds to Raleigh Campus and 22 acute care beds to Cary Hospital. Both Raleigh Campus and Cary Hospital currently operate above the state’s CON performance occupancy threshold of 71.4 percent for hospitals the size of Cary Hospital and 75.2 percent for hospitals the size of Raleigh Campus. By 2015, growth coupled with an aging population, will cause Raleigh Campus and Cary Hospital to have occupancy rates at or above 90 percent if no additional beds are opened at these facilities, according to a press release. “WakeMed is the leading provider of inpatient health care services in Wake County – the second fastest-growing county in North Carolina. And, WakeMed’s high inpatient occupancy drove the allocation of 101 beds in North Carolina’s State Medical Facilities Plan,” said Stan Taylor, WakeMed vice president corporate planning. “Additionally, the other hospitals in Wake County currently have unutilized or under-utilized acute care beds and have not shown a good track record in providing the inpatient capacity that the community needs.” Wake County will have five hospitals, with the opening of WakeMed North Hospital in October 2013, and four stand-alone emergency departments. “Wake County does not need more hospitals. It needs to add more inpatient capacity in the county’s two busiest existing hospitals, leveraging existing infrastructure and support services already in place to add beds quickly, costeffectively and efficiently,” says Taylor.

Medical Office Space Available
Physicians’ Office Pavilion at WakeMed North Healthplex
Capture the High-Growth, Affluent North Raleigh Market!

Janet Clayton, CCIM 919.420.1581 [email protected]
Independently Owned & Operated

MAY 2011

25

Granville Health System News

GHS Named Blue Distinction Center for Knee and Hip Replacement
Centers for Knee and Hip Replacement must present clinical-based evidence to establish that they meet the selection criteria. Granville Health System has been named a Blue Distinction Center for Knee and Hip Replacement. Blue Distinction is a Blue Cross and Blue Shield Association (BCBSA) program that recognizes facilities that meet objective, evidence-based thresholds for clinical quality. These facilities have demonstrated experience in offering comprehensive inpatient knee and hip replacement services, including total knee replacement and total hip replacement. BCBSA collaborated with expert physicians and medical organizations to determine the selection criteria for all Blue Distinction programs. Candidates for Blue Distinction Examples of some of the criteria GHS met include: • An established acute care inpatient facility, including intensive care, emergency care, and a full range of patient support services • An established knee and hip “When it comes to spine surgery, and hip and knee replacement, there is compelling evidence that institutions with experience that also adheres to their care protocols knee and hip deliver better outcomes,” said Don Bradley, M.D., chief medical officer of Blue Cross and Blue Shield of North Carolina. “We’re providing that information to our members to help them make informed choices about where to receive care that’s proven to meet national quality standards.” replacement procedures • An experienced replacement surgery team, including surgeons with board certification, subspecialty fellowship training, and case volumes that meet selection criteria • Preoperative patient education • Processes to support transitions of care program, performing • Multidisciplinary teams and clinical pathways to coordinate and streamline care • Use of an internal registry or database to track patient outcomes over time • Clinical outcomes that for meet specific objective procedures

thresholds, such as complication rates and length of stay.

required annual volumes for certain

Granville Health System in Top 10 of Most Customer-Friendly Hospitals
The American Alliance of Healthcare Providers named Granville Health System one of the top 10 hospitals in the country in its 2011 Hospital of Choice Awards. The award recognizes America’s “most customer-friendly hospitals,” according to Ric Vincent Parr, president of American Alliance of Healthcare Providers (AAHCP). It is “designed to find America’s most customerfriendly hospitals based either on an extensive application process, or by a review of a facility’s public communication and staff interaction with customers,” according to an AAHCP press release. Each year, AAHCP evaluates approxi“We are pleased to be chosen as one of the top hospitals in the nation,” says L. Lee Isley, Granville Health System chief executive officer. “This award recognizes the high level of quality care provided by our dedicated doctors, nurses and staff to the patients of Past Hospital of Choice Award recipients include The Johns Hopkins Hospital, the Mayo Clinic and the Cleveland Clinic. mately 400 hospitals for consideration of this award. Approximately 100 hospitals are recognized annually. The application process requires a review of six principal areas of consideration including standards of conduct, performance management and improvement, staff development and training, systems of communication, good citizenship, and educational and promotional consumer material. Granville Health System ranked third after first-place University of Kansas Hospital and second-place UCLA Medical Center. The Top 10 winners will have an opportunity to compete for the Hospital of the Year Award, to be announced this month. Granville County and the surrounding areas. As we move forward, Granville Health System will continue to invest further in the hospital, supporting our commitment to deliver new medical programs, technologies and expanded services to the community.”

26

The Triangle Physician

Durham Regional News

Upcoming Event
National prosthetic expert to host clinic
Ruben Preciado knows the power of a prosthetist. A below-knee amputee for three years, Preciado, 57, of Raleigh has forged a lifelong bond with nationally recognized prosthetist David R. Sickles, a certified prosthetist/orthotist and certified pedorthist with Peak Prosthetic Performance Clinic. Sickles and his team will share their expertise with Raleigh/Durham amputees and friends or family members, by providing free, no-risk, one-on-one prosthetic evaluations May 17-19, 8 a.m. to 8 p.m., behind the Duke Raleigh Hospital. Registration is required. Sickles has three decades of experience and service in the design, fit and manufacturing of prosthesis. He is the current chief operating officer of the Center for Orthotic and Prosthetic Care (COPC) of North Carolina and New York. He is director of the National Commission on Orthotic and Prosthetic Education (NCOPE) Accredited Residency Program at COPC of North Carolina and president-elect of the North Carolina Chapter of the American Academy of Orthotics and Prosthetics (AAOP). “The aim of Peak Prosthetic Performance Clinic is to provide anyone who has suffered a traumatic limb loss the chance to be heard, the chance to know what technology is available today and the ability to reach their peak prosthetic performance,” said Sickles, who is certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics Inc. (ABC). “From microprocessor-controlled knee units to vacuum-assisted suspension sockets, my team and I have coupled the latest technology with exceptional patient care for countless amputees on their path to independance.” To contact Sickles or to register for a complementary prosthetic evaluation, call (919) 821-5221 or (919) 684-2474. For more information on the Peak Prosthetic Performance Clinic, visit www.centeropcare.com.

U.S. News Ranks Durham Regional Fourth in Metro Area
Durham Regional Hospital has been ranked fourth out of 18 hospitals in Raleigh-Durham in U.S. News & World Report’s first-ever “Best Hospitals” metro area rankings. The newly expanded U.S. News & World Report rankings of hospitals in the 52 most-populous metropolitan areas show that in three specialties Durham Regional offers Raleigh-Durham highquality care. In those specialties, which include kidney disorders, orthopedics and urology, its performance puts it above most other hospitals that are not nationally ranked. The new rankings recognize 622 hospitals in or near major cities with a record of high performance in key medical specialties. There are nearly 5,000 hospitals nationwide. Duke University Medical Center and University of North Carolina Hospitals, respectively, ranked in the top three hospitals in the Raleigh-Durham metro area, according to the 2011 U.S. News Best Hospitals metro ranking. Wake Medical Center ranked No. 3 in nine specialty areas, including kidney disorders, orthopedics and urology. U.S. News created Best Hospitals more than 20 years ago to identify hospitals exceptionally skilled in handling the most difficult cases, such as brain tumors, typically considered inoperable, and delicate pancreatic procedures. Duke and UNC also have achieved this U.S. News national ranking. The new metro area rankings are relevant to a much wider range of health care consumers. They are aimed primarily at consumers whose care may not demand the special expertise found only at a nationally ranked Best Hospital. The added centers boast a strong record of high performance for most conditions and procedures in one or more specialties, according to a For the full list of metro area rankings visit www.usnews.com/hospitals. “All of these hospitals provide first-rate care for the majority of patients, even those with serious conditions or who need demanding procedures,” said Health Rankings Editor Avery Comarow. “The new Best Hospitals metro rankings can tell you which hospitals are worth considering for most medical problems if you live in or near a major metro area.” To be ranked in its metro area, a hospital had to score in the top 25 percent among its peers in at least one of 16 medical specialties. “Durham Regional is honored to be recognized for our treatment of kidney disorders, orthopedics and urology,” said Kerry Watson, Durham Regional Hospital president. “This recognition reflects the dedication of our team of physicians, employees and volunteers who care for our patients every day.” Patients and their families will have a far better chance of finding a U.S. News-ranked hospital in their health insurance network and might not have to travel to get care at a high-performing hospital, according to the Durham Regional release. Durham Regional Hospital press release.

MAY 2011

27

News
Welcome to the Area

Physicians
Tiffany Linn Reed, DO
Internal Medicine, Geriatrics Duke University Hospitals, Durham

Robert Aaron Lambert, MD
ECU Dept of Family Medicine, Greenville

Kanecia Obie Zimmerman, MD
Internal Medicine, Pediatrics Duke University Hospitals, Durham

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

Marshall Andrew Mazepa, MD
Internal Medicine University of North Carolina Hospitals Chapel Hill

Robert Thomas Abbott, MD
Duke Health, Durham

Kristen Elizabeth Amann, MD
Internal Medicine, Pediatrics University of North Carolina Hospitals Chapel Hill

Hannah Imwold Messer, MD
Physical Medicine and Rehabilitation University of North Carolina Hospitals Chapel Hill

Physician Assistants
Jessica Eleanor Elder, PA
Goldsboro

Pain Medicine for Shingles

William H Etheridge, PA
Roanoke Chowan Hospital Emergency Dept Ahoskie

Mark Robert Anderson, MD
Urological Surgery Duke University Hospitals, Durham

Tiffany Lynn Morton, MD
University of North Carolina Hospital Chapel Hill

Erin Christina Jones, PA
Dayspring Family Medicine Associates, Eden

Alison Dawn Bartel, MD
AGAPE Clinic, Washington

Todd Brandon Nelson, MD
Dermatology Pitt County Memorial Hospital, Greenville

Kristin Dermody Maggi, PA
Sunset Beach

Raymond Mark Bernal, MD
Duke Health - Division of Urology, Durham

Dana Michelle Neutze, MD
Family Practice University of North Carolina Hospitals Chapel Hill

Wake Research Associates Wayne Harper, MD Pain after shingles? Has your shingles rash healed, yet you are still suffering from symptoms including burning, stabbing pain, sharpness or sensitivity? If so, you may have a condition called post-herpetic neuralgia, also known as PHN. We are conducting a clinical research study for people who have experienced these symptoms for at least nine months after the onset of their shingles rash. This study will evaluate the effectiveness of an investigational medication for PHN. 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.

Jessica Kristen Roberts, PA
Atlantic Orthopedics, Wilmington

Elizabeth Jane Brant, MD
UNC Kidney Center, Chapel Hill

Kristina Marie Stover, PA
Coastal Carolina Orthopaedic Surgeons Jacksonville

Michelle Richardson Brownstein, MD
General Surgery UNC Department of General Surgery Chapel Hill

Erica Lynn O’Neill, MD
Obstetrics and Gynecology University of North Carolina Hospitals Chapel Hill

New Office
Cary Gastroenterology Associates’
The new office is located at 555 Medical Park Place, Suite 108, inside the WakeMed Clayton Medical Park. All six of Cary Gastroenterology’s boardcertified physicians will treat patients at both the Cary and Clayton offices. Phone and fax numbers will be the same for both locations. To schedule an appointment at either office, call (919) 816-4948.

Long Bao Cao, MD
ECU, Greenville

Andrew Fletcher Parker, MD
Emergency Medicine Duke University Hospitals, Durham

Devin Traer Caywood, MD
Radiology Duke University Hospitals, Durham

Jose Luis Piscoya, MD
General Surgery Durham

Rebecca Jean Chancey, MD
Pediatrics Duke University Hospitals, Durham

Alison Schmidt Powell, MD
Anesthesiology University of North Carolina Hospitals Chapel Hill

Gastroenterology Stomach Ulcers

Matthew Alan Collins, MD
Eastern Urological Associates, Greenville

Shveta Shah Raju, MD
Duke General Internal Medicine, Durham

Lauren Jamie Ehrlich, MD
Diagnostic Radiology, Pediatric Radiology Duke University Hospitals, Durham

Sarah Rodgers, MD
Dermatology Duke University Hospitals, Durham

New Office
Raleigh Orthopaedic Clinic
The new office is located near Rex at 3633 Harden Road, Suite 100. In addition to providing complete orthopedic services, this office will serve as the Raleigh Orthopaedic Clinic Pediatric Center. On-site services will include: fellowship-trained pediatric orthopedic surgeons, digital X-ray and therapy services. The new location is an extension of our main Raleigh office, located at 3515 Glenwood Ave. Raleigh Orthopaedic Clinic (ROC) is Wake County’s largest and oldest orthopedic practice. The orthopedic surgeons are fellowship trained in their respective subspecialty areas, which include: foot and ankle, hand and wrist, spine, hip, shoulder and elbow surgery, total joint replacements, sports medicine and pediatric orthopaedic care. Ancillary services include physical therapy, magnetic resonance imaging, radiology, shock wave therapy, and orthotics and pedorthics. “We are very excited to be in this facility,” says Karl Stein, executive director of Raleigh Orthopaedic Clinic. “The Raleigh area is growing rapidly and we want to ensure easy access to our services for our patients.” Complete practice information is available at www.raleighortho.com.

Amy Minchi Fang, MD
Duke Eye Center, Durham

David Hallmark Ryan, MD
Obstetrics and Gynecology University of North Carolina Hospitals Chapel Hill

Kasey Kincaid Fiorini, MD
Anesthesiology University of North Carolina Hospitals Chapel Hill

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.

Justin Richard Scruggs, MD
Physical Medicine and Rehabilitation University of North Carolina Hospitals Chapel Hill

Jillian Roxanna Foley, MD
UNC - Division of Cardiology, Chapel Hill

Thomas Andrew Gebhard, MD
Diagnostic Radiology Duke University Hospitals, Durham

Frank William Shields, MD
Diagnostic Radiology University of North Carolina Hospitals Chapel Hill

Katherine Lynn Harlow, MD
Emergency Medicine University of North Carolina Hospitals Chapel Hill

General Medicine/ Infections

David Kristofer Sutton, MD
Ophthalmology University of North Carolina Hospitals Chapel Hill

Johann Hsin-heng Hsu, MD
UNC Chapel Hill, Chapel Hill

John Edward Thordsen, MD
Retina Associates PC, Raleigh

David Paul Johnson, MD
Pediatrics Duke University Hospitals, Durham

Charles John Viviano, MD
Duke Urology of Raleigh, Raleigh

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.

Paul McPherson Johnson, MD
Internal Medicine University of North Carolina Hospitals Chapel Hill

Edward Scott Vokoun, MD
Naval Hospital Camp LeJeun

De Benjamin Winter, MD
ECEP, Wilmington

Shivanand P Lad, MD
Duke University Medical Center, Durham

Charles Ryan Woodard, MD
Duke University Medical Center, Durham

28

The Triangle Physician

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

Mateen Akhtar, MD, FACC

Benjamin G. Atkeson, MD, FACC

Kevin Ray Campbell, MD, FACC

Randy Cooper, MD, FACC

Christian N. Gring, MD, FACC

Matthew A. Hook, MD, FACC

Eric M. Janis, MD, FACC

Diane E. Morris, ACNP

cardioLogY services
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

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

the highest QuaLitY cardiovascuLar care, cLose to home.

The Easiest Imaging Order Is Now Online.
Make life easier for your schedulers today!
©2010 Wake Radiology. All rights reserved. Radiology Saves Lives.

As a referring provider, you can now place your imaging orders online with our new CMS-compliant provider portal. You or your schedulers can login and view each of our sub-specialty order forms to make ordering a breeze. The WR Provider Portal includes: • Fast ordering with auto-fill cells • Online CPT code lists for MR and CT exams for quick reference • Order logs showing archived orders and orders pending authorization • Quick access to all WR patient forms and location maps • Complete training available for your staff Get started today by calling our referral services staff at 919-788-7909.
Wake Radiology. Making your life easier.
Scan now to learn all about Wake Radiology.
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1 number to call, 17 locations serving the Triangle area. | Scheduling: 919-232-4700 | wakerad.com

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