Triangle Physician

m a y 2 0 11

T H E M A G A Z I N E

F O R H E A L T H C A R E

P R O F E S S I O N A L S

Also in This IssueLASIK in the Military

Image-guided Pain Relief

Cary Orthopaedic & Sports Medicine

Thrives on a Tradition of Excellence

FDA-Approved for MRI Use

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.

www.medtronic.com

World HeadquartersMedtronic, Inc. 710 Medtronic ParkwayMinneapolis, MN 55432-5604USATel: (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) 551-55447:00 am to 6:00 pm CT M-FFax: (763) 514-185524-hour information available on www.medtronic.com

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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.

IndicationsThe 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

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.

ContraindicationsThe device is contraindicated for:• Implantation with unipolar pacing leads• Concomitant implantation with another bradycardia device• Concomitant implantation with an implantable cardioverter defibrillatorThere 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

Warnings and PrecautionsChanges 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

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.

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.

201004100_RevoAd_8.25x11_1-pager.indd 1 3/2/11 3:33 PM

FDA-Approved for MRI Use

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.

www.medtronic.com

World HeadquartersMedtronic, Inc. 710 Medtronic ParkwayMinneapolis, MN 55432-5604USATel: (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) 551-55447:00 am to 6:00 pm CT M-FFax: (763) 514-185524-hour information available on www.medtronic.com

UC2

0100

4100

EN

© M

edtr

onic

, Inc

. 201

1. M

inne

apol

is, M

N. A

ll Ri

ghts

Res

erve

d. P

rinte

d in

USA

. 02/

2011

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.

IndicationsThe 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

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.

ContraindicationsThe device is contraindicated for:• Implantation with unipolar pacing leads• Concomitant implantation with another bradycardia device• Concomitant implantation with an implantable cardioverter defibrillatorThere 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

Warnings and PrecautionsChanges 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

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.

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.

201004100_RevoAd_8.25x11_1-pager.indd 1 3/2/11 3:33 PM

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-of-the-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.

We help you get back to your life

durhamregional.org

8114

For physician referrals, call 919-470-7226.

2 The Triangle Physician

Contents

COVER STORY

DEPARTMENTS11 Orthopedics

Total Ankle Replacement Is Revolu-tionizing Care of Ankle Arthritis

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 replace-ment, and Hospital of Choice Award

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

27 News Upcoming events, welcome, new offices and clinical trials

FEATURES

6V o l . 2 , I s s u e 5m a y 2 0 1 1

Cary Orthopaedic & Sports Medicine Thrives on a Tradition of Excellence

21Radiology

10LASIK Advances Benefit the Military

Dr. Dean Dornic explains how the military

has embraced advances in laser-assisted in

situ keratomileus.

Ophthalmology

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.

JOHNSTONHEALTH


From the Editor




EditorHeidi Ketler, APR [email protected]

Contributing EditorsKer 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.

PhotographyJim Shaw Photography [email protected]

Creative DirectorJoseph Dally [email protected]

Advertising Sales Carolyn Walters [email protected]

News and ColumnsPlease send to [email protected]

The Triangle Physician is published byNew Dally Design9611 Ravenscroft Ln NW, Concord, NC 28027

Subscription Rates:$48.00 per year$6.95 per issue

Advertising rates on requestBulk 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 photog-raphy 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.

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!

Heidi KetlerEditor


On the Cover

Known as a hotbed of athletic activity, the

Greater Raleigh and Triangle region experi-

ences its share of sports-related injuries. For

29 years Cary Orthopaedic & Sports Medi-

cine 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 Or-

thopaedic 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 orthopae-

dic sports medicine and spine-specialized

surgeons, physiatrists and physical thera-

pists at three separate locations.

All nine orthopedic surgeons are fellowship

trained. In addition to general orthopedics

and sports medicine, the range of specializa-

tion includes arthroscopic and reconstruc-

tive surgery, total joint replacement and

minimally invasive spine surgery.

Cary Orthopaedic Sports Medicine and

Spine Specialists is distinguished by its tradi-

tion of excellence that ensures every initial

patient encounter begins with an orthopae-

dic 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 Ortho-

paedic Chief Operating Officer.

The practice now encompasses Cary Ortho-

paedic Spine Specialists, offering a total ap-

proach to spine care. Garner Orthopaedic

Sports Medicine & Spine Specialists pro-

vides a similar offering to that community

and surrounding counties. All three ortho-

paedic locations have a dedicated Perfor-

mance Physical Therapy facility on site.

Teamwork a Practice Hallmark

“Excellence in Sports medicine and Ortho-

pedics requires that we’re all on the same

page to meet patient goals as quickly and

safely as possible,” says Douglas L. Golle-

hon, 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 return-

ing that athlete back to the desired level of

activity. “

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 Hurri-

canes, Carolina RailHawks and Carolina Bal-

let to scholastic athletes, recreational week-

end warriors and elite triathletes.

“This is a very diverse athletic market, not

just for professional sports,” says Susan

McArdle, Cary Orthopaedic Business Man-

ager. “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 lev-

Cary Orthopaedic & Sports Medicine Thrives on a Tradition of Excellence

Dr. andersen provides diagnosis and treatment of an injured wrist

PHO

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By Heidi Ketler

MAY 2011 7

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 ca-

reer in professional athletics,” says Doug-

las 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 ex-

pectation.”

Knee ligament

reconstructive surgery

Injury to the anterior cruciate ligament, or

ACL, is common among the high-level ath-

letes and the recreationally active popula-

tion. This ligament serves as the primary

restraint to forward and pivoting motion of

the shin bone. An ACL tear can be a debili-

tating sports injury.

With the appropriate diagnosis and treat-

ment approach, “the prognosis for recov-

ery 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 ac-

tivity level, because they tend to have prob-

lems with instability and frequent episodes

of the knee giving way. Given the advances

in ACL reconstruction and the accelerated

approach to rehabilitation, this surgical pro-

cedure is often recommended to a wider

active patient population than in the past.

Preoperatively, “it is important to regain mo-

tion 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 recon-

struction 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

order to withstand the repetitive stresses of

sports activities.

Most orthopaedists recommend a minimum

of six months of progressive physical ther-

apy 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

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, applica-

tions of a topical analgesic and injections of

a corticosteroid.

Viscosupplementation is commonly used

to treat chronic osteoarthritis of the knee if

conservative treatments fail. It involves the

injection of gel-like substances (hyaluro-

nates) into the knee joint to supplement the

viscous properties of synovial fluid. The pa-

tient will receive three to five injections over

the course of several weeks. Positive effects

can last several months.

Shoulder Injuries and Treatment

A rotator cuff injury may result from a trau-

matic event or develop gradually with repeti-

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 Ray-

mond M. Carroll, M.D.

Most patients experience pain relief and im-

proved shoulder function through non-sur-

gical treatment, including anti-inflammatory

medicine and strengthening exercises. Sur-

gery 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.

Dr. armour performs specific orthopaedic maneuvers to assess the extent of a knee injury

Dr. Carroll evaluates for a rotator cuff injury


Proactive Approach to Recovery

Cary Orthopaedic & Sports Medicine

Specialists’ rehabilitation service, PER-

FORMANCE Physical Therapy, provides

highly trained and experienced physical

therapists to guide patients through “pre-

habilitation” 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, re-

duce pain and swelling, and enhance ba-

sic 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, add-

ing, “Patients also get a mental lift know-

ing 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 quick-

er initiation of the rehabilitation program

for a patient who is not ready to do an ac-

tivity on a hard surface but may be able to

do it in the water,” says Mr. Capannola.

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.

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 surgi-

cal 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-sur-

gically through a tailored physical therapy pro-

gram or spinal injections.”

When symptoms don’t improve after two or

three months of conservative treatment, sur-

gery may be a solution.

Traditional surgical treatment for a degenera-

tive 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 disk-

joint 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. Com-

mon causes include myofascial dysfunction,

degeneration of the disc or facet joints, spon-

dylolisthesis, 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 possi-

ble fusion. Patients are in the hospital for sever-

al days and may suffer from chronic back pain.

The minimally invasive X-STOP procedure revo-

lutionized 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 treat-

ment includes bed rest, pain control and physi-

cal 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 un-

der 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 Or-

thopaedic 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-guid-

ed 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 compre-

hensive 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 long-

term 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 tech-

niques, 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 interven-

tional spinal injections.

Spine SpecialistsOrthopaedic 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.

Spine Specialists Center Offers “Dedicated Care for the Spine”

MAY 2011 9

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.

Childhood Obesity Nutrition Article

Within a Generation

Help End

By National Dairy Council


Opthalmology

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

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.

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.

Innovations, such as blade-free and

wavefront-guided technology, have made

the LASIK procedure better and safer.

Acceptance of the new and improved

LASIK eye surgery by the Department of

Defense has helped make our troops better

and safer.

LASIKAdvances Benefit Military’s EffectivenessBy Dean Dornic, M.D.

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.

The United States armed forces have embraced LASIK as a way to make troops “combat ready.”

MAY 2011 11

Orthopedics

Total Ankle Replacement Is Revolutionizing Care of Ankle ArthritisBy Selene G. Parekh, M.D., M.B.A.

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.

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

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

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

and physical exam, followed by weight-

bearing 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.

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.


Your Financial RX

Reduce Your Investment

Pain ThresholdBy Paul Pittman, C.F.P.

“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

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.

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.

How could something so small bring a

rough and tough six-foot man to the ground?

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.

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?

Pain Threshold

MAY 2011 13

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!

This is not to say that owning these posi-

tions 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.

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].

Womens Wellness half vertical.indd 1 12/21/2009 4:29:23 PM

Category


Sleep Medicine

Sleep Apnea By Giridhar Chintalapudi, M.D.

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 middle-

aged 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.

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

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.

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

Untreated sleep apnea also can lead to

changes in how your body uses energy.

These changes increase your risk of obesity

and diabetes.

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.

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.

Requires Specialized Attention

MAY 2011 15

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.

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.

Financial Rx for Physicians:• AidingWealthCreation,Preservation andProtection• BusinessManagement• Tax-strategies• LiabilityProtection• AssetPreservation

Trust your wealthcare to a specialist.

Managing your patients’ health is your life’s work.Managing physicians’ wealth is mine.

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Orthopedics

Double-Bundle Technique Improves Anterior Cruciate Ligament OutcomesBy Mark Galland, M.D.

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

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.

Unfortunately, many still experience some pain

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.

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.”

Each functions independently and in

concert. Knowing this, it is reasonable to

conclude that reconstruction of only one

portion (and ignoring the other) will only

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 single-

bundle 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.

This success is accomplished in the double-

bundle technique by accurately replacing

and restoring the native ACL.

Currently only a select few surgeons are

trained in and are performing this ground-

breaking technique. It is much more

technically demanding to perform, but there

The double-bundle technique is much more technically demanding to perform, but there is little doubt that one day it will be “The Standard.”

aCl Reconstruction single Bundle technique. Reproduced from: Vangsness CT. aCl Reconstruction orthopaedic Procedures, 2010.

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.

MAY 2011 17

is little doubt that, one day, this double-

bundle 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

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.

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 double-bundle ACL reconstruction. He can be reached at (919) 562-9410 or by visiting www.orthonc.com or www.drmarkgalland.com.

Our Priority Is Your Sleep!

Dr. G. Chin, (Chintapudi) MD, DABSMBoard Certified Sleep MedicineBoard Certified Neurology

Dr. H. Tellez, MDBoard Certified Neuromuscular Medicine

Board Certified Neurology

S A N D H I L L S S L E E P D I S O R D E R S C E N T E R

• Sleep Apnea • Sleep Studies• Memory Disorder • Brain/Spine MRI• Gait Problem • EEG• Neuropathy, ie: CTS • NCV- EMG Laboratory

The Specialities

295 Olmstead Blvd., Suite 12 Pinehurst, NC 28374

(910) 235-0595

112 Dennis DriveSanford, NC 27331

(919) 708-5008

609 Attain Street, Unit 101Fuquay-Varina, NC 27526

(919) 552-8917

888-614-7420 • www.SNSleepSolutions.com

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.

2011 Editorial Calendar

JanuaryEndocrinology

Glaucoma

FebruaryCardiologyLung Safety

MarchDigestive Health Care

Men’s Health

AprilWomen’s Health

Diabetes

May Orthopaedics

Allergies

June Vision

Neurology

JulyImaging Technologies

Interventional Radiology

AugustInfectious Diseases

Pediatrics

SeptemberSports MedicineProstate Cancer

OctoberBreast CancerNeurosurgery

NovemberUrology

Alzheimer’s

DecemberPain Management

Sleep Disorder

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The Triangle Physician2011 Editorial Calendar


Cardiology

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

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.

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.

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

relegated to medications. There are numerous

agents such quinidine, flecainide, sotalol, and

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.

Electrophysiologists later developed

percutaneous ablation techniques. There was

Atrial FibrillationBy Ker Boyce, M.D., F.A.C.C., F.A.C.P.

A Perspective on Treatment EvolutionDr. 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.

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.

MAY 2011 19

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 60-

70 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.

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TheEastern

Physician

MAY 2011 21

Radiology

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 long-

acting 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 intermediate-

to-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 fluoroscopic-

guided 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 that can be

performed under ultrasound

include aspiration of fluid for

analysis, bursitis, treatment of

calcific tendinitis, drainage or

decompression of ganglion

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.

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,

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.

ReferencesBoswell 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. Fluoroscopy-guided sacroiliac joint injections. Radiology 2000 214:273-6.

Raleigh Radiology’s Musculoskeletal TeamOffers Image Guided Pain Management

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.


Women’s Health

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

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.

Adults evaluated in the study had a BMI

between 27-45 kg/m2, and two or more

comorbidities, including diabetes or

prediabetes, hypertension, dyslipidemia

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).

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

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

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 group), triglycerides, high-

sensitivity C-reactive protein (hs-CRP),

fasting glucose and total cholesterol. For

most of the risk factors, the improvement

was more in the higher dose group.

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

dexfenfluramine) and called Fen-Phen.

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

the effects of Fen-Phen. Following these

reports, fenfluramine (or dexfenfluramine)

was taken off of the market voluntarily.

Afterward, studies showed that 30

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-or-

flight 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.

Local Treatment Using Phentermine

More than 300 patients have been treated

using the drug phentermine through a

limited program at Women’s Wellness Clinic.

The medication is used for three to six

months to suppress appetite. When patients

start this program, they are told of a remote

chance of pulmonary hypertension is

possible.

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

Although not yet approved by the Food and Drug Administration, the findings of the CONQUER study showed significant weight loss.

Article Review:

MAY 2011 23

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feon,

ppYour n

co

w

loss continues through 12 weeks, then

continuation through 16 weeks is tolerated.

Weight-loss basics

Given that two-thirds of the United States

population is overweight (BMI greater or

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.

References1Gadde KM, Allison DB, Ryan DH, et al. Effects of low-dose, 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.

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.


WakeMed News

WakeMed North to Become Wake County’s Fifth Hospital

Construction Commences on Healthplex

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

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.

“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.

Currently WakeMed North

Healthplex offers a full-

service, 24/7 emergency

department, ambulatory

surgery center, imaging

and laboratory services

and a host of additional

clinical capabilities. The

campus also features

an 85,000-square-foot

medical office building.

“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

to expand to meet the needs of women, men

and children, alike.”

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

second year of hospital operation. The cost

of the project is estimated to be nearly $62

million.

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.

Construction has begun on WakeMed Brier

Creek Healthplex located at the corner of

US-70 on T.W. Alexander Drive.

The facility will include the county’s third

24/7 full-service, stand-alone emergency de-

partment with 12 private treatment rooms. It

will be staffed by the same board-certified

physicians that serve WakeMed’s five addi-

tional emergency departments.

Laboratory and imaging services, including

computed tomography and X-ray, also will

be available for emergency department pa-

tients and outpatient visits.

The facility, which will be owned, de-

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.

Construction is slated to be completed by

November 2011 and the building will be op-

erational by January 2012. The project Cer-

tificate of Need was granted in September

2009 for $36 million. WakeMed’s total invest-

ment in the project is $14 million.

WakeMed Brier Creek Healthplex will ini-

tially 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, al-

lowing room for future development.

For more information, visit www.wakemed.org.

MAY 2011 25

WakeMed News

CON to Add 101 BedsWakeMed 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, cost-

effectively and efficiently,” says Taylor.

Physicians’ Office Pavilion at WakeMed North Healthplex

Medical Office Space Available

Capture the High-Growth, Affluent North Raleigh Market!

Janet Clayton, [email protected]

Independently Owned & Operated


Granville Health System News

GHS Named Blue Distinction Center for Knee and Hip Replacement

Granville Health System in Top 10 of Most Customer-Friendly Hospitals

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

Centers for Knee and Hip Replacement must

present clinical-based evidence to establish

that they meet the selection criteria.

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

replacement program, performing

required annual volumes for certain

procedures

• An experienced knee and hip

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

• 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 for specific

procedures that meet objective

thresholds, such as complication rates

and length of stay.

“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

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.”

The American Alliance of Healthcare Pro-

viders 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 cus-

tomer-friendly hospitals,” according to Ric

Vincent Parr, president of American Alli-

ance of Healthcare Providers (AAHCP). It is

“designed to find America’s most customer-

friendly hospitals based either on an exten-

sive 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-

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 train-

ing, systems of communication, good citi-

zenship, and educational and promotional

consumer material.

“We are pleased to be chosen as one of the

top hospitals in the nation,” says L. Lee Is-

ley, Granville Health System chief executive

officer. “This award recognizes the high lev-

el of quality care provided by our dedicated

doctors, nurses and staff to the patients of

Granville County and the surrounding ar-

eas. As we move forward, Granville Health

System will continue to invest further in the

hospital, supporting our commitment to de-

liver new medical programs, technologies

and expanded services to the community.”

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.

Past Hospital of Choice Award recipients

include The Johns Hopkins Hospital, the

Mayo Clinic and the Cleveland Clinic.

MAY 2011 27

Durham Regional News

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 Hos-

pitals” 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 high-

quality 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 per-

formance 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 inoper-

able, and delicate pancreatic procedures. Duke

and UNC also have achieved this U.S. News na-

tional 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 proce-

dures in one or more specialties, according to a

Durham Regional Hospital press release.

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 re-

lease.

“Durham Regional is honored to be recognized

for our treatment of kidney disorders, orthope-

dics and urology,” said Kerry Watson, Durham

Regional Hospital president. “This recognition

reflects the dedication of our team of physi-

cians, employees and volunteers who care for

our patients every day.”

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.

“All of these hospitals provide first-rate care for

the majority of patients, even those with seri-

ous conditions or who need demanding proce-

dures,” said Health Rankings Editor Avery Co-

marow. “The new Best Hospitals metro rankings

can tell you which hospitals are worth consider-

ing for most medical problems if you live in or

near a major metro area.”

For the full list of metro area rankings visit

www.usnews.com/hospitals.

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 Ra-leigh has forged a lifelong bond with nationally recognized prosthetist David R. Sickles, a certified prosthe-tist/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 experi-ence 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 direc-tor of the National Commission on Orthotic and Prosthetic Education (NCOPE) Accredited Residency Pro-gram 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 Perfor-mance 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 perfor-mance,” said Sickles, who is certified by the American Board for Certifica-tion 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 evalu-ation, call (919) 821-5221 or (919) 684-2474. For more information on the Peak Prosthetic Performance Clinic, visit www.centeropcare.com.

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-of-the-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.

We help you get back to your life

durhamregional.org

8114

For physician referrals, call 919-470-7226.


News

PhysiciansTiffany Linn Reed, DOInternal Medicine, GeriatricsDuke University Hospitals, Durham

Robert Thomas Abbott, MDDuke Health, Durham

Kristen Elizabeth Amann, MDInternal Medicine, PediatricsUniversity of North Carolina HospitalsChapel Hill

Mark Robert Anderson, MDUrological SurgeryDuke University Hospitals, Durham

Alison Dawn Bartel, MDAGAPE Clinic, Washington

Raymond Mark Bernal, MDDuke Health - Division of Urology, Durham

Elizabeth Jane Brant, MDUNC Kidney Center, Chapel Hill

Michelle Richardson Brownstein, MDGeneral SurgeryUNC Department of General SurgeryChapel Hill

Long Bao Cao, MDECU, Greenville

Devin Traer Caywood, MDRadiologyDuke University Hospitals, Durham

Rebecca Jean Chancey, MDPediatricsDuke University Hospitals, Durham

Matthew Alan Collins, MDEastern Urological Associates, Greenville

Lauren Jamie Ehrlich, MDDiagnostic Radiology, Pediatric RadiologyDuke University Hospitals, Durham

Amy Minchi Fang, MDDuke Eye Center, Durham

Kasey Kincaid Fiorini, MDAnesthesiologyUniversity of North Carolina HospitalsChapel Hill

Jillian Roxanna Foley, MDUNC - Division of Cardiology, Chapel Hill

Thomas Andrew Gebhard, MDDiagnostic RadiologyDuke University Hospitals, Durham

Katherine Lynn Harlow, MDEmergency MedicineUniversity of North Carolina HospitalsChapel Hill

Johann Hsin-heng Hsu, MDUNC Chapel Hill, Chapel Hill

David Paul Johnson, MDPediatricsDuke University Hospitals, Durham

Paul McPherson Johnson, MDInternal MedicineUniversity of North Carolina HospitalsChapel Hill

Shivanand P Lad, MDDuke University Medical Center, Durham

Robert Aaron Lambert, MDECU Dept of Family Medicine, Greenville

Marshall Andrew Mazepa, MDInternal MedicineUniversity of North Carolina HospitalsChapel Hill

Hannah Imwold Messer, MDPhysical Medicine and RehabilitationUniversity of North Carolina HospitalsChapel Hill

Tiffany Lynn Morton, MDUniversity of North Carolina HospitalChapel Hill

Todd Brandon Nelson, MDDermatologyPitt County Memorial Hospital, Greenville

Dana Michelle Neutze, MDFamily PracticeUniversity of North Carolina HospitalsChapel Hill

Erica Lynn O’Neill, MDObstetrics and GynecologyUniversity of North Carolina HospitalsChapel Hill

Andrew Fletcher Parker, MDEmergency MedicineDuke University Hospitals, Durham

Jose Luis Piscoya, MDGeneral SurgeryDurham

Alison Schmidt Powell, MDAnesthesiologyUniversity of North Carolina HospitalsChapel Hill

Shveta Shah Raju, MDDuke General Internal Medicine, Durham

Sarah Rodgers, MDDermatologyDuke University Hospitals, Durham

David Hallmark Ryan, MDObstetrics and GynecologyUniversity of North Carolina HospitalsChapel Hill

Justin Richard Scruggs, MDPhysical Medicine and RehabilitationUniversity of North Carolina HospitalsChapel Hill

Frank William Shields, MDDiagnostic RadiologyUniversity of North Carolina HospitalsChapel Hill

David Kristofer Sutton, MDOphthalmologyUniversity of North Carolina HospitalsChapel Hill

John Edward Thordsen, MDRetina Associates PC, Raleigh

Charles John Viviano, MDDuke Urology of Raleigh, Raleigh

Edward Scott Vokoun, MDNaval Hospital Camp LeJeun

De Benjamin Winter, MDECEP, Wilmington

Charles Ryan Woodard, MDDuke University Medical Center, Durham

Kanecia Obie Zimmerman, MDInternal Medicine, PediatricsDuke University Hospitals, Durham

Physician Assistants Jessica Eleanor Elder, PAGoldsboro

William H Etheridge, PARoanoke Chowan Hospital Emergency DeptAhoskie

Erin Christina Jones, PADayspring Family Medicine Associates, Eden

Kristin Dermody Maggi, PASunset Beach

Jessica Kristen Roberts, PAAtlantic Orthopedics, Wilmington

Kristina Marie Stover, PACoastal Carolina Orthopaedic SurgeonsJacksonville

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 board-certified 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.

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 fellow-ship trained in their respective subspecialty areas, which include: foot and ankle, hand and wrist, spine, hip, shoulder and elbow surgery, total joint replacements, sports med-icine 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.

Pain Medicine for ShinglesWake Research AssociatesWayne Harper, MDPain 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 symp-toms 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 qualifica-tion criteria please call (919) 781-2514 or visit us online at www.wakeresearch.com.

GastroenterologyStomach UlcersWake Research AssociatesCharles F. Barish, MDHave 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 medi-cation to see if It can help prevent stom-ach ulcers. You’ll receive investigational medication and study-related exams at no cost and compensation up to $500 for time and travel.


General Medicine/InfectionsWake Research AssociatesCharles F. Barish, MDDo you have an upcoming hospitalization? You could be at risk of infection by Clos-tridium difficile (C.diff.), a bacteria that can cause severe gastrointestinal prob-lems.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.


Welcome to the Area

New Office

New Office

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

Your LocaL cardioLogY ProfessionaLsin Johnston countY

dedicated to QuaLitY, service, and integritY

cardioLogY servicesCoronary and Peripheral Vascular InterventionsPacemakers/DefibrillatorsAtrial Fibrillation AblationsEchocardiographyNuclear CardiologyVascular UltrasoundClinical CardiologyCT Coronary AngiographyStress TestsHolter MonitoringCardiovascular MedicineEchocardiographyNuclear CardiologyCardiac Catheterization

Smithfield Heart & Vascular Associates910 Berkshire RoadSmithfield, NC 27577Phone: 919-989-7909Fax: 919-989-3147

Eric M. Janis, MD, FACC

Ravish Sachar, MD, FACC

Nyla Thompson, PA-C

Diane E. Morris, ACNP

MateenAkhtar, MD, FACC

Benjamin G.Atkeson, MD, FACC

Christian N. Gring, MD, FACC

Matthew A. Hook, MD, FACC

Wake Heart & Vascular Associates2076 NC Hwy 42 West, Suite 100Clayton, NC 27520Phone: 919-359-0322Fax: 919-359-0326

the highest QuaLitY cardiovascuLar care, cLose to home.

2 Locations to serve our Patients

Kevin RayCampbell, MD, FACC

RandyCooper, MD, FACC

TTPFebruary 20118.45” x 10.9”

1 number to call, 17 locations serving the Triangle area. | Scheduling: 919-232-4700 | wakerad.com

The Easiest ImagingOrder Is Now Online.

Make life easier for your schedulers today!

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Scan now to learn allabout Wake Radiology.

Download any QR Reader App foryour Smartphone!

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.

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