MARCH 2010

Wake Heart & Vascular Associates

On Cardiology’s Leading Edge

Also in this Issue

Heart Disease:
Equal Opportunity
Killer

Treating Painful
Spine Fractures
Beyond Imagination.
Working in partnership with physicians
for over 50 years to bring the benefits
of biomedical technology to patients
around the world.
His treatment
of heart failure
yields success
Duke cardiologist Joseph Rogers, MD, and
colleagues are defining the best strategies to help
heart failure patients.
Heart failure is pretty common, isn’t it?
Nearly six million Americans are living with heart failure—when the
heart can’t adequately do its job of pumping blood through the body.
The good news is that we’ve seen dramatic improvements in the treat-
ment of heart failure in the past decade.

What’s new in the treatment of advanced heart failure?

At the advanced stage—affecting about 150,000 Americans—
medications typically become ineffective, and heart transplantation is
not an option for most. We have recently learned that these patients
can benefit greatly from permanent implantation of a left ventricular
assist device (LVAD), which works to pump blood more efficiently
through the body.* Duke has been a leading center in this research.

What does the future hold?

I believe the next step is the use of mechanical blood pumps for heart
failure patients earlier in their illness to extend quality and years of life.
Also, we could potentially begin testing stem cell therapies that would
promote recovery of the heart and removal of the pump.

Why would you encourage heart failure patients to come

to the Duke Heart Center?
At Duke we have a top-tier program: outstanding doctors, a team ap-
proach, close collaboration with our colleagues in heart surgery and heart
rhythm disorders, a dedication to advancing our knowledge of heart
failure through research, and a passion for understanding and treating
the unique aspects of each patient’s disease. Also, Duke is one of the
vanguard centers of the Heart Failure Research Network, a consortium
of institutions providing insights into new treatments for heart failure.

Only 69 centers in the United States offer destination LVAD therapy for
advanced heart failure.† Duke is one of them.

Learn more about treatment options for heart failure offered by

Dr. Rogers and his colleagues, Drs. Michael Blazing, G. Michael Felker,
Adrian Hernandez, Andrew Lodge, Carmelo Milano, Christopher
O’Connor, and Eric Velazquez, by visiting our Web site.

Duke Heart Center

dukehealth.org/heart 888-ASK-DUKE

* Dr. Rogers presented these findings on November 17 at the American

Heart Association’s Scientific Sessions 2009.
† Source: cms.hhs.gov
 Contents

COVER STORY

6 Wake Heart & Vascular Associates:

On Cardiology’s Leading Edge
FEATURES MARCH 2010 VOLUME 1 ISSUE 2
DEPARTMENTS

14 16
HEART DISEASE: TREATING 11 RADIOLOGY
On Balancing the Benefits and Risks
Equal Opportunity PAINFUL SPINE
of CT Radiation Exposure
Killer FRACTURES
12 WOMEN’S HEALTH
Patient Selection Is the Key A Clinical Study on Osteoporosis
Many are not aware that heart disease is
the No. 1 killer of women, and they often
Given the current controversy over verte- 19 PHLEBOLOGY
experience a very different and more subtle
broplasty—a minimally invasive treatment Patients with Tired, Achy, Heavy Legs?
set of symptoms than men.
performed by interventional radiologists in
individuals with painful osteoporotic vertebral 20 BRAIN TRAUMA
compression fractures that fail to respond
Brain Injury as a Chronic Disease

to conventional medical therapy—what’s a

22 ELECTROPHYSIOLOGY
patient to do? Lead Extraction

23 INSURANCE
The Liability of a Nurse

24 NEWS
Welcome to the Area
Events & Opportunities
New and Relocated Practices

25 CARDIOLOGY
What You Should Know about
Peripheral Arterial Disease

26 GOOD BUSINESS
Averting Data Disasters

28 MARKETING
COVER PHOTO: Center – James R. Foster, M.D. F.A.C.C., Michael Jay Zellinger M.D., F.A.C.C., William N. Newman, M.D., Gregory C.,
Rose, M.D. F.A.C.C., Joel Evan Schneider, M.D., F.A.C.C. 1st row – Crystal Keen, ANPPA, Robert Lee Jobe, M.D. F.A.C.C., Christian N.
Have You Been Branded?
Gring, M.D., Diane E. Morris, ACNP, Ravish Sachar, M.D., Eric M. Janis M.D. F.A.C.C, Matthew S. Forcina M.D., Nyla Thompson, PA-C,
Mateen Akhtar, M.D., Jimmy Locklear, M.D. F.A.C.C., Randolph Arend Stratton Cooper, M.D., F.A.C.C., Jeffrey Richard Daw, M.D.,
F.A.C.C., Benjamin G. Atkeson M.D., Mary Kathryn Bumgarner, PAC. Not pictured – Kevin Ray Campbell, M.D., Arthur Y. Chow, M.D.,
F.A.C.C., Matthew A. Hook, M.D., Andrew C. Kronenberg M.D., F.A.C.C., James Tift Mann III, M.D., Sameh K. Mobarek, M.D., John F.
Rhodes Jr., M.D., Bruce Warren Usher M.D., F.A.C.C., Robert B. Wesley II M.D., F.A.C.C. PHOTO BY JIM SHAW

2 The Triangle Physician | MARCH 2010

FEBRUARY 2010 | The Triangle Physician 15
 From the Editor

L
ooking at this edition reminds me of how much I love my job, and perhaps it will Editor
Mark Westphal mark@trianglephysician.com
affect you similarly. Since my job is to ensure Triangle Physician stays on the cutting
edge with you, my days are awe filled. I am constantly struck by the depth of Contributing Editors
compassion and courage to push the envelop within the region’s medical community. Heidi Ketler heidi@trianglephysician.com

Mateen Akhtar, MD; Chris Doane; Anil Gehi, MD;

Here again, our cover story takes an in-depth look at an international pioneer—Wake Heart & Stephen P. Loehr, MD; Andrea S. Lukes, MD, MHSc,
Vascular Associates. Not only is this practice cutting edge and comprehensive, it has a strong FACOG; Lindy McHutchinson, MD; Thomas L. Presson
community service mission to promote prevention and its underlying culture is based on Jr., MD; Mike Riddick; Mark Wiener

genuine compassion for its patient. Wake Heart is all heart, and it shows in words and actions.
Photography
Jim Shaw Photography jimshawphoto@earthlink.net
Also in this issue, widely held public misconceptions about heart disease—particularly with
Creative Director
regard to gender differences—are brought to light. Prevention is at the crux of this major
Dan Early dan@trianglephysician.com
public health issue. And medical professionals have an important role to play in risk-factor Van Early van@trianglephysician.com
intervention.
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Carolyn Walters carolyn@trianglephysician.com
Keep reading and you’ll gain a greater awareness of phlebology, and treatments for varicose
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are not the responsibility of The Triangle Physician.
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4 The Triangle Physician | MARCH 2010

 From the Cover
Wake Heart
& Vascular Associates:
On Cardiology’s Leading Edge
Wake Heart & Vascular Associates, founded in
1985, has grown to become eastern North
Carolina’s largest cardiology practice. Its
growth is a reflection of founding principles to
provide the highest level of cardiac care and
cutting-edge technology in the region. Its
mission is to serve patients and work with their
primary doctors in the prevention and treatment
of complex cardiac and vascular disease.
6 The Triangle Physician | MARCH 2010
PHOTO BY BRIAN STRICKLAND
The practice has broadened beyond cardiac
care to include expertise in peripheral vas-
cular and carotid artery disease, including
the treatment of stroke. This extension of
the practice is a result of the similar nature
of the disease processes and treatment
strategies for most types of vascular disease.
Many of the techniques are transferable to
other vascular beds, but all have their own
nuances. The basic primary and secondary
preventive strategies are similar. In fact,
the overlap of patients with atherosclerosis
involving more than one vascular territory
is over 50 percent.
Today, 24 cardiolovascular specialists at
Wake Heart & Vascular Associates provide
the full complement of cardiology and
vascular services: clinical cardiology, echo-
cardiography, nuclear cardiology, cardiac
catheterization, interventional cardiology,
electrophysiology, cardiac magnetic reso-
nance angiography; treatments for periph-
eral vascular, carotid artery and cerebrovas-
cular diseases; even pediatric interventional
cardiology.
“All 150 staff members at
Wake Heart are integral to our
excellent patient care and
services. Like our doctors, they
come from diverse backgrounds,
and are dedicated to supporting
the physicians in their delivery
of the best possible cardio-
vascular care. We all treat our
patients like family, with the
utmost care and understanding.”
Dee Darkes
Chief Operating Officer
“The strength of Wake Heart lies in the
broad range of services we provide, the
excellent doctors and the commitment to
excellent care,” says Eric M. Janis, M.D.,
F.A.C.C., a cardiologist at Wake Heart’s
Smithfield office. “What this group brings
is the ability to work together, to collabo-
rate and get input from colleagues who are
experts in their fields, and to take care of all
patients with any cardiovascular problem
under one big umbrella.”
MEDICAL LEADERS
“Over the years, each new physician who
has come to the practice has brought a new
set of skills to enhance our comprehensive
care and keep us on the leading edge,” says
Dr. Janis, whose areas of expertise include
echocardiography, nuclear cardiology and
cardiac catheterization. In addition to
advanced training, most of the medical staff
are board certified and many are Fellows of
the American College of Cardiology.
PHOTO BY BRIAN STRICKLAND
Joel Schneider, M.D., F.A.C.C.
Joel Schneider, M.D., F.A.C.C., was recruited
by Wake Heart in 1993, after completing an
interventional cardiology fellowship at Emory
University Hospital. Interventional cardiology
specializes in the prevention and repair of
atherosclerotic arteries, caring for a range of
issues from acute myocardial infarction to
stable chronic angina. He was instrumental in
starting the coronary stent program at
WakeMed, introducing the new and now widely
accepted technology to the region.
James Tift Mann III, M.D., F.A.C.C.
Dr. Schneider went on to establish the first
endovascular program in 1998, when the new
WakeMed Heart Center opened. The
expansion of angioplasty and stenting in
patients with peripheral vascular disease was
a natural extension of his interventional
cardiology work. The program has since
expanded to include carotid artery stenting,
acute stroke management and endovascular
repair of abdominal and thoracic aneurysms.
Nearly 50 patients underwent endovascular
repair of abdominal aortic aneurysm last year,
allowing minimally invasive care to patients
who otherwise would require a complex
open operation.
This past December, Dr. Schneider performed
the first elective endovascular thoracic
aneurysm repair, in collaboration with cardio-
thoracic surgeon Abdul Chaudhry, M.D., of
Capital Cardiovascular Surgery. “This
advanced technology allows patients far easier
and safer approaches to managing aneurys-
mal disease,” says Dr. Schneider.
Wake Heart founding partner James Tift
Mann III, M.D., is one of the world leaders in
radial artery catheterization and interventions,
and helps train physicians in the United States
in that technique. Robert Lee Jobe, M.D.,
F.A.C.C., F.S.C.A.I; Jimmy Locklear, M.D.,
F.A.C.C.; William N. Newman, M.D.; and
Gregory C. Rose, M.D., F.A.C.C., are all
actively involved in the Wake Heart cardiac
stenting program.
PHOTO BY BRIAN STRICKLAND
MARCH 2010 | The Triangle Physician 7

Robert Lee Jobe, M.D., F.A.C.C., F.S.C.A.I
At about the same time that the Food and
Drug Administration approved carotid
stenting in 2004, Ravish Sachar, M.D., F.A.C.C.,
was recruited from The Cleveland Clinic to
develop the carotid stenting program at
WakeMed. Since then, more than 1,000
carotid stenting procedures have been per-
formed, with a less than 1 percent stroke risk.
Dr. Sachar, one of the authors of the book:
Manual of Peripheral Vascular Intervention,
also has helped develop what has become
the region’s largest peripheral vascular
disease treatment program at WakeMed
Heart Center.
Matthew A. Hook, M.D., joined Wake
Heart from The Cleveland Clinic in 2007 to
expand the WakeMed coronary artery
stenting program. He also brought with him
solid expertise in peripheral vascular
procedures, carotid stenting and intracranial
interventions.
Christian N. Gring, M.D., F.A.C.C., also
trained at The Cleveland Clinic in dedicated
non-invasive heart imaging, including cardiac-
computed tomography, angiography and
cardiac MRI. He brought his skills to Wake
Heart in 2006.
8 The Triangle Physician | MARCH 2010
Matthew A. Hook, M.D.
The newest member of the Wake Heart
medical staff is electrophysiologist Matthew
S. Forcina, M.D., from Duke University
Medical Center and the Medical University
of South Carolina. Soon after joining the
practice in 2009, Dr. Forcina led the devel-
opment of a specialized lab at WakeMed
Heart Center that now provides the newest
procedures to treat and potentially cure
atrial fibrillation.
Wake Heart’s team of electrophysiologists,
who specialize in the study and treatment of
rhythm disorders of the heart, include: Kevin
Ray Campbell, M.D., F.A.C.C.; Randolph Cooper,
M.D., F.A.C.C.; and James R. Foster, M.D.,
F.A.C.C. Therapeutic modalities include antiar-
rhythmic drug therapy; surgical implantation
of pacemakers, cardioverter-defibrillators and
resynchronization devices; and radiofrequency
Randolph Cooper, M.D., F.A.C.C.
PHOTOS BY BRIAN STRICKLAND
Christian N. Gring, M.D., F.A.C.C.
ablation, a non-surgical technique for treating
atrial fibrillation and restoring normal rhythm.
Wake Heart electrophysiologist Randolph
Cooper, M.D., F.A.C.C., says his colleagues are
encouraged by the use of wireless-monitoring
capabilities of implantable defibrillators and
pacemakers. “We’re expanding our ability to
follow patients with heart failure and not only
treat them but diagnose them remotely. That
way we can manage patient care over the phone
instead of in the hospital,” says Dr. Cooper.
COMMUNITY-BASED CARE
As Wake Heart & Vascular Associates’
services have expanded, so too has its reach.
Today, 15 Wake Heart locations serve an
area from southern Virginia to multiple
locations in eastern North Carolina. Wake
Heart’s newest office in Oxford, N.C., opens
in association with Granville Medical Center
this summer. The Goldsboro office is being
relocated across from Wayne Memorial
Hospital, and will offer expanded services and
more examination rooms. “The new office
will allow us to see more patients and offer
additional noninvasive services, such as
echocardiology, nuclear cardiology, stress
testing and peripheral vascular studies,”
says Dr. Schneider.
Mateen Akhtar, M.D.; Benjamin G. Atkeson,
M.D., F.A.C.C.; Arthur Y. Chow, M.D., F.A.C.C.;
Joseph M. Falsone, M.D., F.A.C.C.; Andrew C.
Kronenberg, M.D., F.A.C.C.; Robert B. Wesley II,
M.D., F.A.C.C.; and Michael Jay Zellinger, M.D.,
F.A.C.C., are all instrumental in providing
care to the community in locations like Cary,
Clayton, Knightdale, Lewisburg, North Wake
and Smithfield. “We want to bring cardiology
care to the community, so the community
doesn’t have to travel long distances to us,” says
Dr. Zellinger, a founding Wake Heart partner.
Dr. Janis points to the case of a 77-year-old
Clinton woman who suffered from
dizziness. She was referred to Dr. Hook in the
Wake Heart Smithfield office, saving her a
30-to-40-minute drive to Raleigh.
After testing in the office showed she had
blockages in both neck arteries and a loud
heart murmur due to a heart valve problem,
she was set up for a specialized transesoph-
ageal echo test and heart catheterization in
Smithfield. The procedures showed both
coronary artery disease and a severe heart
Dr. Gring reading a CT angiogram of the heart.
valve problem. Surgery was scheduled at
WakeMed, where Dr. Hook first placed a
stent in one of the patient’s neck arteries
and then referred the patient for heart valve
surgery. “By providing services in multiple
locations at different hospitals, we were
able to give superior service for the patient,
with a minimum of difficulty for her and
her family,” says Dr. Janis.
Dr. Zellinger says many of Wake Heart’s
relationships with referral physicians began
with the practice founders some 25 years
ago. “Wake Heart values and nurtures its
working relationships in the various com-
munities. That’s what’s helped build the
practice,” he says. It also assures continuity
of care. As soon as patients have been
treated for their cardiovascular problems by
Wake Heart, they are returned to the care
of their referring physician, with ongoing
communication between all doctors
involved in their care.
“No. 1, Wake Heart has always
been available, reliable and
provided great expertise;
response for follow up has
been excellent. It’s just a great
group to work with,” says Dr. Samuel
B. McLamb Jr., who practices internal medicine
with Dr. William J. Stackhouse at Goldsboro
Medical Specialists. They’re referral relation-
ship traces back to Wake Heart’s early years.
TIME AND EXPERIENCE
OF THE ESSENCE
By virtue of its expertise, size and proximity,
Wake Heart physicians have been at the
forefront of advances in cardiac and vascular
care at WakeMed Heart Center in Raleigh,
and have been integral to its success. With
more than 27,900 total procedures performed
each year, it is the busiest heart center in
North Carolina, making Wake Heart &
Vascular the busiest cardiology practice.
Dr. Schneider points to Wake Heart’s participa-
tion in WakeMed’s “STEMI” (ST-Segment,
E-Elevation, M-Myocardial, I-Infarction)
program, designed to achieve the national
“door-to-balloon time” standard for opening
an infarct-related artery in under 90 minutes.
The Code STEMI program boasts an average
door-to-balloon time of 55 minutes. The
STEMI team is activated as soon as the
emergency medical technician reaches the
patient in the field and takes an EKG, which
is sent to the WakeMed Emergency
Department to be analyzed. If an acute
myocardial infarction is suspected, a special
cardiac team prepares for the patient’s
arrival and alerts the on-call interventional
cardiologist.
“This past year, Wake Heart physicians
achieved a 100 percent success in reaching
the 90-minute goal, meaning that a patient
experiencing a heart attack can count on
receiving the best care possible,” says Dr.
PHOTO BY BRIAN STRICKLAND
Schneider. “What we do is life changing, not
only life saving.”
Dr. Schneider points to a complicated case
recently involving a 51-year-old man who
arrived at the hospital having a heart attack.
With the Code STEMI team ready, the man
was taken directly from the ambulance to
the catheterization lab. The patient’s heart
MARCH 2010 | The Triangle Physician 9

PHOTO BY BRIAN STRICKLAND
Ravish Sachar, M.D., F.A.C.C.
repeatedly stopped and had to be defibrillated
16 times. The blocked artery was opened within
30 minutes of arrival and afterward the patient
was transferred to the coronary care unit.
When delivering the good news to the family,
Dr. Schneider recalls noting that only the
patient’s young daughter and her grandmother
were in the waiting room. He came to learn
the girl’s mother had died of cancer last
year, and by saving the patient, he also had
prevented the child from becoming an orphan.
“The most rewarding part of our work, probably
for all of us, is the impact we make for patients
and their families,” says Dr. Schneider.
PERIPHERAL VASCULAR AND
CEREBROVASCULAR PIONEERS
“We are expanding the frontiers at both ends
of the body, in the brain and in the feet,”
says Dr. Sachar.
“Advances in restoring blood flow to the legs
and feet are saving legs that would have been
amputated five or 10 years ago,” he says. The
technology uses a combination of balloons,
stents, lasers and atherectomy devices to go
into the small arteries below the knee and
into the feet. “Procedures that result in limb
10 The Triangle Physician | MARCH 2010
salvage result in a dramatic improvement in
quality of life.”
Drs. Sachar and Hook also helped lead the
development of Wake County’s first acute
interventional stroke program at WakeMed
Heart Center, which is the only Joint
Commission-certified primary stroke center
in Wake County. Until recently, stroke could
only be treated by giving clot-dissolving
agents intravenously, called thrombolysis.
With FDA approval, Wake Heart physicians
are now able to remove clots directly from
the brain, often with dramatic clinical
results. “It’s very cutting edge. No one else
in Wake County is doing this and there are
only a handful of centers of this kind in the
country,” says Dr. Sachar.
He recalls the case last March of a 37-year-
old woman who had delivered twins by
C-section two weeks prior. She arrived at
WakeMed completely paralyzed on her left
side, after suffering a stroke on the right side
of her brain. During an eight-hour procedure,
Dr. Sachar removed all the blood clots and
the woman made a complete recovery.
Today, he calls the case a “career standout.”
Had intravenous thrombolytic agents been
administered, the outcome may not have
been so successful.
“Everything we do in our practice is done in
an evidence-based way or as part of clinical
trials,” says Dr. Sachar. “The physicians who
are doing these procedures are very well-
trained. They are leaders in their field
nationally and internationally, and they bring
that expertise to the area. They are involved
Christy Moore, P.A. making rounds at WakeMed
in and lead numerous cutting-edge clinical
trials for new devices, drugs and protocols.”
COMMUNITY COMMITMENT
Wake Heart & Vascular Associates cardiol-
ogists are involved in the community, serv-
ing on boards and committees, speaking at
community forums and promoting good
cardiovascular health for all.
On Saturday, Feb. 27, the practice will join
WakeMed Heart Center in hosting the fifth
annual cardiovascular education symposium
to share information on advances in cardiology
and heart/vascular care, with an emphasis on
prevention. This year’s “Health Care in Evolu-
tion: Opportunities and Challenges for the
Cardiovascular Patient” will shed light on health
care reform. The symposium will be from 8:30
a.m. to 3:45 p.m. at WakeMed Heart Center
Conference Center. It is open to all medical
professionals. Call (919) 350-8547 for details.
For their quality of life contributions, the
cardiologists at Wake Heart have won
numerous accolades and awards. Two have
been named Health Care Heroes by The
Triangle Business Journal, Dr. Sachar in 2009
and Dr. Janis in 2007. Drs. Mann and Janis
were selected by The Triangle Business
Journal and Best Doctors Inc. as two of the
Best Doctors in America for 2009-2010.
Janis reflects on all the rewards of his calling:
“being a part of the medical community and
the community as a whole; helping patients
work on preventing heart disease; helping
people focus on staying healthy; keeping a
positive attitude even in the face of serious
illness or a disabling medical condition; and
allowing people to stay healthy and active.”
PHOTO BY JIM SHAW

On Balancing the
Benefits and Risks of
CT Radiation Exposure
Over the past 25 years, computed tomography (CT) scans
have become one of the most powerful tools in medicine. Recent
news, however, has highlighted potential health risks from radiation
exposure associated with CT. One study projected a sizeable number
of new cancers that could arise from all CT studies performed in
the U.S. in 2007. Another found a wide variation in radiation doses
(1)
for common CT exams.(2) Also in the
headlines: alarming instances of high
radiation overexposure from CT scans. (3)
Yes, our medical community
should be concerned. While we have
recognized the potential risks of CT
exams for years, the new numbers
reflect a remarkable increased use of
this extremely valuable diagnostic tool.
By some estimates, 72 million CT scans
were performed in 2007 in the US.(1)
Let’s remember two key points.
Statistically, an individual’s presumed
increased risk of cancer from one CT,
or even a handful, is very low. And,
while overuse and overexposure are
always concerns, this data must be
weighed against what may happen to a
patient if he or she does not have a CT scan. Is the population at large
better off or worse off? We don’t yet have an answer.
Our challenge, then, is to use CT most appropriately while
minimizing the risk it imposes. At Wake Radiology, we approach this
on a variety of fronts.
Wake Radiology employs stringent dose reduction guidelines for
adult and pediatric CT exams; our protocols have been well below
recommended levels for some time. It is critical that children not
receive adult doses, and Wake Radiology participates in the Image
Gently® initiative sponsored by the Alliance for Radiation Safety in
Pediatric Imaging.
We also are proactive in suggesting alternative modalities to
avoid radiation altogether. The number of indications for which
MRI and ultrasound may be used continues to grow, including most
diseases of the abdominal organ systems.
Thus, we put great stock in helping clinicians select the most
appropriate imaging to minimize exposure, and each Wake Radiology
subspecialty section maintains a consultation hotline for this
purpose. Our annual Radiology Today seminar, open to all physicians,
Radiology
by Thomas L. Presson Jr., MD
Director, Radiation Safety Programs, Wake Radiology
introduce state-of-the-art imaging and provide guidance on appropriate
ordering. Our web site carries a link to the American College of
Radiology’s most current ACR Appropriateness Criteria®.
Experience and expertise are vital to minimizing exposure. All
Wake Radiology outpatient locations have a radiologist on site, and 100
percent of technologists are CT certified by the American Registry
for Radiologic Technologists. This caliber
of care provides a multitude of benefits.
One example is the work-up of a patient
found to have an incidental mass on a
chest x-ray. With a radiologist on site,
the CT technologist can ask him or her
to define the area to be scanned. If the
suspect nodule is in the upper part of
the lung, a scan of a third or a half of
the lung often will allow a diagnosis.
In addition to the above, we
reduce exposure to breast and thyroid
tissue by using bismuth shielding. Our
CT scanners utilize dose modulation, a
feature that dynamically measures body
density during the scan and decreases
the dose depending on the density of
bone it must penetrate. We also record
the dose of each scan in the patient’s permanent chart.
Behind the scenes, part of my mission is to organize and maintain
safety protocols and oversee the rigorous American College of
Radiology CT scanner certification program. All scanners in our
outpatient offices are certified or have certification underway, as is the
case for our two newest scanners. We very closely and continuously
monitor settings and output.
Overall, we believe it’s reasonable to conclude that the radiation
patients receive from CT scans does pose a small but real risk, one
that will slightly increase with each additional scan. With care taken
at every level, this risk can be minimized. That being said, CT remains
one of our most essential diagnostic tools to evaluate and follow a
great number of medical conditions.
References:
1) Berrington de González A, Mahesh M, Kim K-P, et al. Projected cancer risks from computed
tomographic scans performed in the United States in 2007. Arch Intern Med. 2009; 169(22): 2071-2077.
2) Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed
tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med.
2009; 169(22): 2078-2086.
3) “New Focus on Dangers of CT Scans.” Jonathan LaPook. CBS Evening News. 14 Dec 2009. Accessed
17 Jan 2010 at http://www.cbsnews.com/stories/2009/12/14/eveningnews/main5979332.shtml.
MARCH 2010 | The Triangle Physician 11
 Women’s Health

A Clinical Study on
Osteoporosis

sorption, endocrine disease, chronic renal

Bone health is an important concern for women. The
problem of osteoporosis affects approximately 30% of
postmenopausal women and 40% of those women will
sustain one or more fractures in their lifetime.
The worldwide prevalence of osteoporosis makes it a
serious public health concern with estimates of over
200 million people worldwide currently suffering from
this disease. In the US alone osteoporosis or
(3)
failure, chronic liver disease, COPD, immobility,
and certain drugs (including aromatase
inhibitors, androgen deprivation therapy). Of
these risk factors, most of us recognize that
(1, 2)
age is one of the leading risk factors, however, it
is important to realize that even young women
can develop osteopenia and osteoporosis.
Our staff is focused on bone health and has
been fortunate to begin a FDA clinical trial on

osteoporosis. The most common medications

osteopenia will affect over 40 million Americans and for osteoporosis are the bisphosphonates, such
as alendronate or clodronate or ibandronate.
result in more than 1.5 million fragility fractures per year. This class of drug prevents bone resorp-
tion; whereas, evidence has emerged that a
new type of drug which is anabolic or helps
Most women know that osteoporosis is a problem involving bone, yet many do not recognize bone grow may help treat osteoporosis.
the many risks factors for osteoporosis. These can be divided into 2 different categories: one
that is independent of bone mineral density and one that is dependent on bone mineral Our IRB approved consent form for our
density. The specific risks factors that are independent of bone mineral density include: age, clinical study on osteoporosis is posted on our
previous fragility fracture, maternal history of hip fracture, glucocorticoid therapy, current website at www.cwrwc.com and the IRB
smoking, alcohol intake, rheumatoid arthritis, low body mass index, and falls. The specific risks approved ad for our clinical study on osteo-
factors that are dependent on bone mineral density include: untreated hypogonadism, malab- porosis is shown on the next page:

12 The Triangle Physician | MARCH 2010

by Andrea S. Lukes,
MD, MHSc, FACOG
Dr. Lukes received her
bachelor’s degree in religion
from Duke University (1988),
followed by a combined
medical degree and master’s
degree is statistics from Duke
(1994). She completed her
Ob/Gyn residency at the UNC (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 Thrombosis
|Clinic at Duke. Dr. Lukes left her academic position at Duke in
2007 to begin Carolina Women’s Research and Wellness Center
(CWRWC), and to become Founder and Chair of the Ob/Gyn
Alliance. Phone: (919) 251-9223. www.cwrwc.com
What is a Clinical Research Study?
Clinical research studies try to answer specific
question about investigational study drugs.
A new investigational drug must go through
several phases of clinical research, the study
drug could later be available to the public.
A clinical research study participant works
with a research team that includes doctors,
nurses, and sometimes social workers and
other health care professionals. The participant’s
and study team’s commitment is important to
help meet the objectives of the research study.
Participating in clinical research is an
important decision and should be thought
through carefully. You should never feel you
have to take part in a clinical research study.
If you do participate, you will be free to
withdraw from the study at any time, for any
reason. You will keep the right the same
routine medical care you received before
study participation. Your study doctor will
discuss any other treatment that may be
helpful to you.
How Do I Qualify?
You may qualify for this study if you:
• Are female and 45 to 85 years of age
• Have not had a period in at least 5 years
• Have taken oral medication to treat your
osteoporosis for 3 years or more
• Have taken alendronate therapy for the
past 1 year or more
If you qualify, you will receive study-related
care, study medication and bone mineral
density testing (to assess bone health), at no
charge.
What to Expect
Study participants will be asked to visit a
research site 9 times over a 2-year period.
Participants will have bone mineral density
testing, blood drawn at each visit, and will
be asked to take the study drug once a day.
In conclusion, although we offer such clinical
trials—our focus is on women’s health. We
offer all options including identifying the most
convenient location for bone density
evaluations for the women we see. Osteoporosis
is a health issue that should to be addressed
by healthcare providers. Better management
of the disease will result in improved outcomes
for our patients through reductions in both
morbidity and mortality. Our staff is devoted
to combining our clinical expertise and our
interest in high quality research to provide a
range of options for our patients.
References:
(1) 1. Melton III L, Chrischilles EA, Cooper C, Lane AW, Rigs BL:
Perspective: How many women have osteoporosis? J Bone Miner Res
1992;7: 1005-º10
(2) Randell A, Sambrook PN, Nruyen TV, Lapsey H, Jones G, Kelly PJ,
Eisman JA. Direct clinical welfare costs of osteoporotic fractures in
elderly men and women. Osteoporosis Int 1995;5:427-32
(3) Cooper C. Campion G Melton LJ 3rd. Hip fractures in the elderly:
a world-wide projection. Osteoporosis Int. 1992 Nov;2(6): 285-9.
MARCH 2010 | The Triangle Physician 13
 Heart Disease
Heart Disease:
Equal
Most of us are familiar with the classic heart
attack symptoms — the “movie heart attack,”
where a middle-aged man suddenly clutches
Opportunity
his chest complaining of
crushing chest pain and
pain radiating down the
left arm.
Killer
What many are not aware
of is that heart disease is the No. 1 killer of
women, and they often experience a very
different and more subtle set of symptoms.
In fact many heart attacks in women start
slowly, with mild pain or discomfort. Wom-
en may also present with symptoms such
as nausea, fatigue, jaw or neck pain that
are often overlooked by patients and mis-
diagnosed by physicians as being related to
stress or other illnesses.
Physicians, nurses and other healthcare pro-
viders who care for women need to be aware
of some fatal facts. Cardiovascular diseases
(CVD), especially coronary heart disease
and stroke, are the leading causes of death
in women in the United States. They claim
more female lives than the next five causes
of death combined.
Consider the facts:
• Nearly 37 percent of all female deaths in
the United States occur from CVD.
• The death rate due to CVD is higher in
black women than in white women.
• One in 2.7 females who die, die of heart disease, stroke and other
cardiovascular disease compared with one in 30 who die of breast
cancer.
• Women who have heart attacks are more likely than men to die
from them within a few weeks.
• Misperceptions still exist that CVD is not a real problem for women.
In 2005, more than 36 million American women were age 55 or older.
The risk of cardiovascular disease increases with age, and that’s one
reason it’s important to raise awareness of this major public health
issue, particularly for older women.
Physicians can take an assertive role in risk factor intervention
14 The Triangle Physician | MARCH 2010
and in acknowledging gender differences
in the treatment of CVD in women.
Research shows that prevention of risk
factors for cardiovas-
cular disease is the best
practical solution. The
challenge is to commu-
nicate to your patients
the importance of taking preventive steps
on an everyday basis.
Much attention has been directed toward a
better appreciation of the influence of gender
on cardiovascular risk and management,
but important gaps in knowledge remain.
Recent developments in cardiovascular
research undoubtedly will have a significant
impact on prevention, clinical care and out-
comes of women and will provide direction
for future work. Epidemiological studies and
randomized clinical trials provide compelling
evidence that coronary heart disease is largely
preventable. Therefore, prevention of risk
factors for cardiovascular disease is an
important practical solution for women.
Is it gender difference
or gender bias?
Probably some of both. Several factors may
explain the apparent disparity in treatment
of men and women:
• In the past, many of the major cardiovas-
cular research studies were conducted on
men. Results of current clinical studies may
help clarify the gender differences that affect pathophysiology,
diagnosis and treatment of women with heart disease.
• Clinicians and patients often attribute chest pains in women to
noncardiac causes, leading to misinterpretation of their condition.
• Women may have a greater tendency than men to have atypical
chest pain or to complain of abdominal pain, difficulty breathing
© ISTOCKPHOTO.COM/ALEXRATHS
(dyspnea), nausea and unexplained fatigue.
• Women may avoid or delay seeking medical care, perhaps partly
due to denial or their lack of awareness of both typical and atypical
heart attack symptoms.
• Since women tend to have heart attacks later in life than men do,
they often have other diseases (such as arthritis or osteoporosis)
 that can mask heart attack symptoms. Age and the more advanced
stage of coronary heart disease in women can affect the treatment
options available to physicians as well as the greater mortality of
women after heart attacks.
• Some diagnostic tests and procedures may not be as accurate
in women, so physicians may avoid using them. That means the
disease process resulting in a heart attack or stroke may not be
detected in women until later, with more serious consequences.
• The exercise stress test, or stress ECG, may be less accurate in
women. For example, in young women with a low likelihood of
coronary heart disease, an exercise stress test may give a false
positive result. In contrast, single-vessel heart disease, which
is more common in women than in
nutrition, alcohol consumption, physical inactivity and smoking can
be controlled.
Awareness of factors such as increasing age, race and heredity that
cannot be controlled is critical. About four out of five people who die
of coronary heart disease are age 65 or older. At older ages, women
who have heart attacks are more likely than men are to die from them
within a few weeks.
Heredity and race are perhaps some of the strongest indicators of risk.
Children of parents with heart disease are more likely to develop it
themselves. Women often assume that even though the men in their
family have suffered heart disease, they are

Heart Attack
men, may not be picked up on a routine not at risk. African Americans have a higher
treadmill test. percentage of hypertension than whites and
• Noninvasive and less invasive diagnostic
tests that are more precise tend to be
Warning Signs their risk of heart disease is greater.

more expensive. These include thallium, How do I enhance

sestamibi, or echocardiographic stress • Chest discomfort. Most heart attacks patient compliance?
involve discomfort in the center of the chest
tests. The predictive value and cost- Studies have shown that only about one-
that lasts more than a few minutes, or that
effectiveness of newer technologies, such third of eligible patients continue risk factor
goes away and comes back. It can feel like
as electron-beam computed tomography uncomfortable pressure, squeezing, fullness interventions over the long term. However,
(EBCT), are not well defined. or pain. data also show that this proportion can be
Because the number of women who are significantly increased by a team approach.
• Discomfort in other areas of the
older and at risk in the population is growing, When healthcare professionals — including
upper body. Symptoms can include pain
diagnosing and treating heart disease, stroke physicians, nurses, dietitians, other clinicians
or discomfort in one or both arms, the back,
and other cardiovascular diseases is vital. neck, jaw or stomach. and health educators — manage risk reduction
Clinicians must act to prevent these diseases therapy with follow-up methods such as
before warning signs appear or a heart attack • Shortness of breath with or without office or clinic visits and telephone contact,
chest discomfort.
occurs. Prevention and control of risk factors patient compliance is enhanced.
must start when a woman is young and
• Other signs may include breaking out in a
continue throughout her life. cold sweat, nausea or lightheadedness Women are learning more about heart
disease now than ever before and have been
Do clinicians provide As with men, women’s most common heart told to talk with their healthcare providers
attack symptom is chest pain or discomfort.
“equal opportunity” medical care about developing an effective heart disease
But women are somewhat more likely than
to patients? prevention plan. If women know their
men to experience some of the other common
Though the situation is improving, research symptoms, particularly shortness of breath, numbers and assess their risks now, they can
suggests that fewer women than men with nausea/vomiting, and back or jaw pain. work with you to significantly reduce their
suspected acute heart attack symptoms chances of getting heart disease tomorrow,
are referred for noninvasive tests, and next year, or 30 years from now.
fewer women than men who test positive for heart disease are
recommended for further testing and treatment. Because of the Join the Movement
high fatality rate associated with first heart attacks in women, it is Join the Go Red for Women movement to connect with colleagues
important to evaluate women with suspected heart attacks promptly, and patients nationwide who share your commitment to prevent
carefully and completely. heart disease. Register now at GoRedForWomen.org/professionals
and see how you can help women live longer and stronger.
It is even more important to emphasize prevention through reduction
of risks. Discussing a patients risk factors and developing a plan Healthcare providers can also take advantage of American Heart
together to address them is an important step in helping patients Association resources such as professional journals, treatment
take control of their heart health. Risk factors such as obesity or guidelines, patient education tools and the latest in research at
overweight, high cholesterol, high blood pressure, diabetes, poor http://my.americanheart.org/professional.

MARCH 2010 | The Triangle Physician 15

 Radiology

Patient Selection Is Key in

Treating Painful
Spine Fractures
Society of Interventional Radiology supports additional scientific studies, fights negative
backlash from two controversial studies that compared vertebroplasty to placebo that
possibly places patients with osteoporosis in jeopardy of losing beneficial treatment.

Given the current controversy over vertebroplasty—a dedicated to improving health care through minimally
minimally invasive treatment performed by interventional invasive treatments. “Before treatment, many of these
radiologists in individuals with painful osteoporotic osteoporotic patients are in constant pain and cannot
vertebral compression fractures that fail to respond manage everyday activities. Many are confined to
to conventional medical therapy—what’s bed for up to six weeks. These are the
a patient to do? Trust your medical people we help; with vertebroplasty
team to decide if you are an they can go home in one to
appropriate candidate for two days. Candidates for the
vertebroplasty and trust the procedure are those who
experience of hundreds have failed to respond to
of thousands of other conventional medical
patients who have under treatment (such as rest,
gone the spine treat- analgesics and narcotic
ment successfully and drugs). Vertebroplasty
received life-improving can give patients their
effects, says the Society of lives back,” said Stainken,
Interventional Radiology. president of the Imaging Image ©2007 SOCIETY OF INTERVENTIONAL RADIOLOGY. WWW.SIR.ORG

“Hundreds of thousands Network of Rhode Island and

of patients have greatly
benefited from vertebroplasty
with almost complete resolution of
their pain; tens of thousands dependent
on intravenous narcotics have been discharged from
the hospital virtually pain- and drug-free following their
treatment,” noted SIR President Brian F. Stainken, M.D.,
FSIR, who represents the national organization of nearly
4,500 doctors, scientists and allied health professionals
chair of the diagnostic imaging
department at Roger Williams
Medical Center in Providence, R.I.
“Interventional radiologists have the critical
skills in imaging and patient care that make them experts
at determining which patients are the most appropriate
candidates to receive the treatment,” he added.
Image: In vertebroplasty, a needle about the width of a cocktail straw is inserted through the
skin into the fractured bone. A bone cement is injected. The cement hardens, stabilizes the
bone and prevents further collapse. This stops the pain caused by bone rubbing against bone.

16 The Triangle Physician | MARCH 2010

 Two studies published in the New
England Journal of Medicine in August
were the first clinical trials to test vertebro-
plasty against a placebo, and many experts
were stunned by the results that suggested
that patients got equal amounts of modest
pain relief whether they got vertebroplasty,
where medical-grade bone cement is injected
into broken vertebrae, or a dummy injection.
“SIR supports the use of vertebral augmentation
(vertebroplasty and kyphoplasty) for patients with
painful compression fractures. In addition, SIR
supports the important role of research regarding the
role of vertebral augmentation, but we should take
note that it is increasingly clear that these studies did
not tell the whole story,” said Stainken. “The groups
of patients studied and the analysis raised as many
questions as were answered,” he said. Based on the NEJM
findings, the society recommended that interventional
radiologists inform patients of the studies’ controversial
results during consultation. “The studies demonstrate
the importance of debate and rigorous analysis of all data
prior to rushing to conclusions. We must closely monitor
trends in vertebroplasty research. There will be additional
studies at SIR’s Annual Scientific Meeting in March that
will provide new perspective on the aforementioned
studies and reaffirm our perspective that vertebroplasty
provides long-term and rapid pain relief for appropri-
ately selected patients,” said Stainken.
“We are concerned about the possibility that
insurance coverage may be withdrawn for
vertebroplasty and possibly kyphoplasty because
of the controversy generated by the two NEJM
studies,” said Stainken. If that occurs, access to
these procedures would be limited to patients
enrolled in approved trials, leaving many
patients in severe pain without a solution.
SIR is keeping a watchful eye on this to
protect patients’ access to medical
treatment. SIR will continue to serve
as a leader in future trials of vertebro-
plasty that may confirm or contradict
these studies or may identify subsets
of patients more likely to benefit
from vertebral augmentation,
Image © ISTOCKPHOTO.COM/MPABILD
noted the SIR president.
SIR member and vertebro-
plasty expert J. Kevin McGraw,
M.D., FSIR, agrees. “While we
welcome the two studies by
researchers David F. Kallmes, M.D., and Rachelle
Buchbinder, Ph.D., to the body of literature
on this technique, the results of these trials
are discordant with personal experience and
more than 15 years of accumulated medical
literature espousing the benefits of verte-
broplasty,” said McGraw, section head,
interventional radiology, at Riverside
Radiology and Interventional Associates
in Columbus, Ohio. “SIR recognizes the
value of randomized controlled trials
and evidence-based medicine; however,
the weakness in the studies and the
degree of discordance between
the outcomes of these studies, prior
studies and experience, suggest
that it is premature—and possibly
incorrect — to conclude that
vertebroplasty is no better than a
control sham procedure,” he noted.
Criticisms of both studies
include the small numbers of
patients treated; the small per-
centage of eligible patients who
were actually enrolled in the trial;
inclusion of patients with milder
degrees of pain and disability than
are usually treated in a typical
practice; the small amount of cement
injected; treatment of patients with
chronic compression fractures; the
incomplete use of MRI or CT to
confirm that the fracture was the likely
source of pain; and the high rate of cross-
over from placebo to vertebroplasty in one
of the studies, explained McGraw.
Criticism has also come from one of
the studies’ investigators. William Clark, M.D.,
St. George Private Hospital, Sydney, Australia,
an investigator with the Kallmes study, said he
regarded that study as “meaningless.” In addition, he
called the Buchbinder study “a rush to judgment on
‘science-based medicine’ without applying scientific
technique in appraising the studies” in comments
posted to the Arthritis Today Web site. Clark noted
numerous flaws in the studies, indicating they had
“inappropriate patient selection, terrible recruitment and
selection bias with the majority not followed.”
(continued on next page)
MARCH 2010 | The Triangle Physician 17
 Osteoporosis, the most common in multiple studies. We must not rush
type of bone disease, is characterized to new conclusions, especially based on
by low bone mass and structural dete- these recent controversial studies,”said
rioration of the bone resulting in an in- McGraw.
creased susceptibility to fractures. Os-
teoporosis affects 10 million Americans More information about the Society
and is responsible for 700,000 vertebral of Interventional Radiology, interven-
fractures each year. Multiple vertebral tional radiologists and vertebroplasty
fractures can result in chronic pain and can be found online at www.SIRweb.
disability, loss of independence, stooped org. SIR’s Research Reporting Standards
posture and compression of the lungs for Percutaneous Vertebral Augmenta-
and stomach. tion were published recently in the
Journal of Vascular and Interventional
Vertebroplasty, a minimally invasive Radiology as an additional reference for
treatment performed by interventional physicians. SIR’s Commentary on Ver-
radiologists under imaging guidance, tebroplasty and the August Studies in
stabilizes collapsed vertebra with the the New England Journal of Medicine is
injection of medical-grade bone cement also available on the society’s Web site.
into the spine. “This reduces pain and
can prevent further collapse of the ver-
tebra, thereby preventing the height loss
and spine curvature commonly seen as
a result of osteoporosis. Vertebroplasty,
when used appropriately in accordance
with established practice standards by
expert providers, dramatically improves
back pain within hours of the procedure,
provides long-term pain relief and has a
low complication rate, as demonstrated

18 The Triangle Physician | MARCH 2010

 Phlebology

Tired, Achy,
Patients
with

by Lindy McHutchinson, MD
Heavy Legs?
Lindy McHutchinson began training with notable physicians Venous disorders diagnosed and treated by responsible for most of the symptoms and
in the field of Phlebology, first at Duke University as an
observational fellow with Dr. Cynthia Shortell, chief of Phlebologist include: chronic venous insuf- physical findings of chronic venous
vascular surgery at Duke. Subsequently, Dr. McHutchison
completed an extended clinical preceptorship with Dr. John ficiency, varicose veins, spider veins, venous leg insufficiency which include: leg discomfort,
Mauriello, fellow of the American College of Phlebology
and nationally known educator in the field. She also trained
ulcers, congenital venous abnormalities, cramping, tenderness, burning, throbbing,
with Dr. John Kinglsey in Birmingham, Alabama, another venous thromboembolism and other disorders swelling, varicose veins, skin changes and
nationally known phlebologist. Prior to her interest in varicose
veins, Carolina Vein Center – Southpoint. of venous origin. eventual venous ulcers.

Diagnostic evaluation includes H&P and Treatments are usually short, outpatient
Many patients think their leg symptoms are office procedures focused on closing
duplex ultrasound. Duplex ultrasound is usually
from aging, poor physical condition, or just unhealthy veins with either endovenous laser
performed in the office by a specialized
long, hard days. In fact, most patients, ablation and/or sclerotherapy (injections.)
technician and is considered the “gold
physicians and other providers, don’t even Bulging varicose veins are usually extracted
standard” to evaluate venous insufficiency.
know leg symptoms could be caused by via micro phlebectomy. Recovery time is
Using duplex ultrasound, the technician
venous disease or unhealthy circulation in brief, and patients usually return to normal
evaluates the flow of blood in the leg veins
their leg veins. Patients don’t tell their activities the same or following day. Watch a
and “maps” the veins.
physician, because they usually aren’t asked short informational dvd on our website to
about the symptoms, and most patients don’t learn more about these office procedures at
Normally, leg veins have functional, one way
realize their leg symptoms could be a medical www.carolinaveincenter.com
flow valves to keep blood flowing against
problem, easily treatable and covered by most
gravity towards the heart. If these flow valves
insurance plans, including Medicare. Sadly, If you have any questions about Phlebology, please do
are defective, absent or other conditions are not hesitate to contact me at the Carolina Vein Center,
many patients are suffering unnecessarily. Lindy McHutchison, MD, (919) 405-4200,
present, blood flows retrograde or backwards
lindy@carolinaveincenter.com We are committed to
down the leg causing venous congestion educating the community, both physicians and patients,
What is Phlebology? and are happy to do a short presentation in your office.
and increased venous pressure.
Phlebology is one of the newest recognized
This venous congestion and
fields of medicine and is dedicated to the
hypertension are ultimately
diagnosis, treatment and study of vein disease,
which afflicts 80 million Americans or
approximately 20% of the adult population.
Phlebology treats both the medical (venous
insufficiency) and cosmetic (spider veins)
aspects of venous disease. If a medical problem,
most insurance companies, including
Medicare, will cover the evaluations and
treatments.

ankle swelling painful stinging

Symptoms of leg swelling
tired
purities
throbbing
numbness
restless legs
Venous Leg achy
heavy
cramping
burning
© ISTOCKPHOTO.COM/SZEFEI

MARCH 2010 | The Triangle Physician 19

 Brain Trauma
Brain Injury
Classifying
as a Chronic
Disease
Implicit in the nomenclature, Traumatic Brain
Injury (TBI), is the notion that trauma to the
brain is the result of an injury and that the
injury will heal. Medical conditions that are
referred to as injuries most often have a
prescribed protocol for treatment that almost
always results in significant improvement and
possibly a cure. However, this is not the case
with TBI.
By its very nature, each TBI has its own unique
signature, which will manifest as one of, or a
constellation of, neurological effects. While
many of the 1.4 million TBIs sustained
annually in the U.S. are, indeed, injuries from
which each patient recovers, or is cured, over
125,000 of these are permanent and incurable.
For these TBIs, the classification of “disease”
is more appropriate than that of “injury.”
Disease is defined in the Free Online
Dictionary as representing a “deviation from
or interruption of the normal structure or
function of any body part, organ or system that
is manifested by a characteristic set of
symptoms and signs and whose etiology,
pathology and prognosis may be known or
unknown.” And, the results of a TBI can be
described in these terms.
20 The Triangle Physician | MARCH 2010
...a TBI impacts multiple organ systems, is
disease-causative, and disease-accelerative.
Take the first phrase of the definition: a
“deviation from or interruption of the normal
structure or function of any body part, organ
or system…” The results of a TBI do cause
these things to affect the individual’s brain
and neurological system. The next part states
that these deviations and interruptions “…are
manifest by a characteristic set of symptoms
and signs…”, which applies to the constellation
of symptoms associated with a TBI. The
definition concludes with “…whose etiology,
pathology and prognosis may be known or
unknown,” which speaks to the progressive
disease process initiated by a TBI.
In general, the insurance industry uses the term
“sickness” rather than “disease” to describe TBI.
Sickness is defined by one medical insurance
industry provider as: “illness, disease of
condition of a covered person. Sickness includes
any complications of recurrences that relate
to such sickness.” (H. Kelso, personal com-
munication, June 30, 2008). When applied to
TBI, this definition implies that TBI is a
one-time illness that has a beginning and a
resolution. While this is the case for many
individuals who sustain a TBI, it is not the case
it is
for quite a few. This is why
imperative that the medical
insurance industry, medical
community, and the commu-
nity-at-large, understand TBI
as a disease state that is
progressive in that, over time, it
has deleterious effects on other
organ systems.
Scientific data exist that supports the fact
that neither an acute TBI, nor a chronic TBI,
is a static process – that a TBI impacts mul-
tiple organ systems, is disease-causative, and
disease- accelerative. Classification of TBI
as the beginning of a disease process would
facilitate treatment as outlined for the full
continuum of care, which should be paid for
by medical insurers and managed on a par
with other diseases.
Despite the fact that individuals with a TBI
who survive the acute event do not die of
 by Brent Masel, MD Individuals with a TBI appear to have higher
President and Medical Director, Transitional Learning Center, Galveston, Texas;
Board Member, Brain Injury Association of America rates of depressive disorders, anxiety disorders
Dr. Masel graduated from Loyola Medical School in Maywood, Illinois in 1974. He completed his and substance abuse, and often have suicidal
internship and Neurology residency at the University of Texas Medical Branch (UTMB) at Galveston,
Texas in 1978. plans, suicidal behavior, or suicide completion
Following his training, Dr. Masel established a Neurology private practice in Galveston, and in the context of these illnesses.
received certification in 1980 from the Board of Psychiatry and Neurology. He is a Clinical
Assistant Professor in the Departments of Neurology, Family Medicine, Internal Medicine, Physical
Therapy and Occupational Therapy at UTMB. He has conducted research and published in the
area of headache pain management.
A TBI clearly may cause decades-
In 1992, Dr. Masel became the Medical Director of The Transitional Learning Center (TLC), and in January of 1994, he left his private
practice to become the President of this post acute brain injury rehabilitation facility.
long, and possibly permanent,
Dr. Masel is in demand as an international speaker on the topic of Growth Hormone Deficiency and Hypopituitarism and Rehabilitation vulnerability to psychiatric
following an Acquired or Traumatic Brain Injury.
illness.
their brain injury per se, TBI is a disease. accounting for five percent of all epilepsy in Historically, individuals living with a brain
There are many similar examples in the field the general population. Visual disturbances injury have been referred to as brain injury
of medicine. Chronic kidney disease is an are common with TBI, as are sleep dis- survivors. Perhaps this concept of merely
independent risk factor for cardiovascular turbances and hypersomnia. TBI can be a staying alive was used because, as little as 30
disease. Patients with chronic kidney disease risk factor for the development of Alzheimer’s years ago, the majority of individuals with a
are more likely to die of cardiovascular disease disease. It also can cause Chronic moderate-to-severe TBI succumbed soon
than end-stage renal failure. Patients do not Traumatic Encephalopathy (CTE). after their injury. Perhaps the terminology was
succumb to AIDS. They die from other diseases, used to imply that the individual outlived their
such as pneumonia, caused by the AIDS disease. A moderate-to-severe TBI is associated with injury and persevered despite the hardship of
And indeed, diseases can be caused by external a host of neuroendocrine disorders the trauma.
forces such as injuries. An individual sustaining including hypopituitarism: cortisol deficiency,
a severe chemical burn to the lungs will develop growth hormone (GH) deficiency/insufficiency; “Survivor” however, does not address the
chronic lung disease that may then cause or hypothyroidism; and gonadotropin reality of brain injury. Cancer survivors are
accelerate car diac disease. Although the deficiency. Each of these disorders has survivors because it is believed they are
phenomenon is not clearly understood, negative effects associated with them and leads cured—and they indeed have outlived their
following chemotherapy, many patients may to a progressive disease process. disease. Many individuals who sustain a TBI
develop disabling problems with memory, recover 100 percent. They have truly survived
attention, multi-tasking and other domains Incontinence, both of the bladder and their injury. However, in the U.S. alone, every
of cognitive function, known as “chemo brain.” bowel, can frequently occur with TBI. TBI also year, over 125,000 individuals who sustain a
causes sexual dysfunction. Additionally, TBI become disabled.
In a 2004 study on mortality one year post TBI it causes musculoskeletal dysfunction
among 2,178 individuals with a moderate-to- including spacticity, which requires life-long This article discusses only a small percentage
severe TBI, it was reported that individuals treatment, and a high incidence of fractures that of the causes of disability and the ongoing and
with a TBI were twice as likely to die as a similar places the individual at risk for heterotopic developing medical conditions individuals
non-brain-injured cohort and had a life ossification (HO), which may not develop with TBI face. Presently, more than 4 million
expectancy reduction of seven years. Follow-up for as long as three months post injury. individuals in the U.S. are disabled due to the
studies on causes of death revealed that myriad of consequences of a TBI. Their brain
individuals surviving more than one year with It is critical to note that psychiatric trauma has resulted in a condition that is
a TBI are 37 times more likely to die from disease and psychological deficits are disease-causative and disease-accelerative. As a
seizures, 12 times more likely to die from among the most disabling consequences of result of their brain trauma, these individuals
septicemia, four times more likely to die from TBI. The overwhelming majority of individuals now have life-long brain injury disease.
pneumonia, and three times more likely to who survive a moderate-to-severe TBI are left
die from other respiratory conditions than a with significant long-term neurobehavioral Care and treatment of brain injury disease
matched cohort from the general population. consequences. In addition to the aggres- should be reimbursed by medical insurers and
The greatest proportion of deaths in the study sion, confusion and agitation seen in managed on a par with all other diseases. Only
—29 percent—was from circulatory problems. the acute stages, TBI is associated with an then will the individuals with this disease of
increased risk of developing numerous Traumatic Brain Injury get the medical
Several neurologic disorders are psychiatric diseases, including obsessive surveillance, support and treatment they
associated with TBI, all of which present compulsive disorders, anxiety deserve. Only then will brain injury research
a level of disability, with varying degrees of disorders, psychotic disorders, mood receive the funding it requires. Only then will
severity. TBI is a major cause of epilepsy, disorders, and major depression. we be able to truly talk about finding a cure.

MARCH 2010 | The Triangle Physician 21

 Electrophysiology

Lead
by Anil Gehi, MD
Undergraduate | Massachusetts Institute of Technology 1996
Medical School | University of California at San Francisco, 2000
Internal Medicine | University of California at San Francisco, 2003
Fellowships | Mt. Sinai Medical Center, 2006 (Cardiovascular Medicine),
Emory University, 2008 (Cardiac Electrophsiology)
Certification | Internal Medicine, Cardiology, Electrophysiology
Clinical Interests | Pacemaker (including biventricular) & defibrillator

Extraction
implantation, device extraction, catheter ablation for SVT, VT, and atrial
fibrillation.

Over the last 20 years, there has been
tremendous growth in the use of implantable
device for cardiac rhythm management,
including pacemakers, implantable cardiac
defibrillators, and biventricular pacemakers.
Accompanying this growth is an increasing
incidence of lead dysfunction and device-
related infection. Additionally, as patients are
routinely implanted with devices that may need
to be maintained for decades, abandoning
dysfunctional leads is becoming more and
more problematic. Abandoned leads can lead
to vein occlusion or even valvular dysfunction
and these potential complications can be
ameliorated or avoided completely if the
problematic leads are extracted.
A recent consensus statement from the Heart
Rhythm Society clarified the indications for
transvenous lead extraction. These indica-
tions include: 1) evidence of device system
infection (including pocket infection), 2) venous
stenosis or occlusion preventing access to
the venous circulation, and 3) unused leads
that interfere with device function or
number in excess of 4 leads on one side.
With the general aging of the device patient
population, and the increasing complexity
of implantable devices there is an increasing
need for leads to be removed or replaced.
Over time leads usually are fixed in place
by scar tissue and become impossible to
extract by simple traction. Due to the risk
and technical challenges of lead extraction,
many physicians who implant devices are
reluctant to extract implanted leads. Over
the last decade, several developments have
greatly reduced the risk of extraction. The
basis of all of these techniques is first to
transmit lead traction to the tip of the lead
in the heart rather than to the available
proximal end of the lead in the pocket. This
is achieved using a stylet that locks to the tip
of a lead. This countertraction to the tip of
the lead is coupled with some form of sheath
that is passed over the lead and used to cut
away the fibrous adhesions that fix the lead
to the heart. In its simplest form this can
be achieved with a simple sheath, although
several tools have been developed to assist
in breaking through fibrous adhesions. The
most common sheaths utilize either laser
energy (Spectranetics) or a rotating stainless
steel cutting tip (Cook Medical). With such
techniques, a sheath is advanced through
the vein over lead with the capability of
delivering controlled laser energy or mechanical
disruption to cut through any scar tissue and
free the lead from the heart. In this way, lead
extraction with a >90% success rate and a
2-3% overall complication rate can be achieved
with only a 0.5% major complication rate.
Any lead extraction program requires a
multi-disciplinary team. Besides the primary
operator (often a cardiac electrophysiologist)
who must be experienced in lead extraction
and also well-versed in device implantion
and management, it is critical to have support
from cardiothoracic surgery and anesthesia
personnel familiar with all potential
complications of lead extraction and re-im-
plantation. This collaboration is critical to
maintaining the safety of the procedure. The
reason for this is the small but finite risk of
cardiac rupture with tamponade as this can
require immediate thoracotomy to control
hemorrhage.
As the benefit and utilization of cardiac
implantable devices continues to expand, it is
critical that there is supporting capability for
lead extraction. Patients with 2 or 3 unused,
abandoned leads who may be living with
an implantable device for many years are at
unacceptable risk from long-term lead
related complications. It is far better to extract
unused leads early in the course when it can
be achieved with minimal complications. The
coming years will likely see lead extraction
expand from a treatment for device related
infection to an expanding role in removing
dysfunctional or abandoned leads.

22 The Triangle Physician | MARCH 2010

 Insurance

Liability
by Mike Riddick
Mike Riddick is the president of Riddick Insurance
Group Inc, an independent insurance agency in
Raleigh, NC. For 10 years, Mike has been helping
professionals protect their assets through
The
of a
Nurse
insurance and financial planning. The motto of
Riddick Insurance Group is to help clients protect
their standard of living by being better protected
today and better prepared for tomorrow. Riddick
Insurance Group specializes in helping small
business owners with property, casualty, liability,
and life insurance planning.

The nurse is a critical team member in any health services business. The
nurse is one of the key faces that everyone sees at a medical practice,
whether it’s the beginning of the visit or the end of a long procedure.
Their friendly smile and steady hands help the client feel calm and
secure about the procedure they are about to have. And although they
play such a friendly role, nursing professional liability claims are at an
all time high.
Secondly, know what your coverage limits mean and
if legal costs are included. Many policies will pay legal costs
(the cost to defend you) in addition to whatever the limits of the policy
are. Many policies will use a per claim limit and an aggregate limit. For
example if your policy reads $1,000,000/$2,000,000 under the coverage
amount, that often means the insurance company will pay out up to $1
million for any one claim and up to $2 million in total for the policy.

Unfortunately any customer, for any given reason, can sue a nurse at any Finally, do some research on the financial stability
time. The nurse doesn’t have to be wrong, it just happens. As with anyone and claims history of the company offering you the
else, being sued makes the nurse feel embarrassed and insecure about coverage. There are many insurance companies in business today
his or her job. Immediately emotions of fear, anxiety, and uncertainty and you always want to do business with a company that has a good
take over. reputation and a solid rating with A.M. Best (I recommend A or
higher). If you aren’t sure about the company offering you coverage,
Where does this put a nurse and what can they do to be prepared? contact your insurance agent and see if they have suggestions.
Nurses Professional Liability is a great way to calm these fears.
People are coming from all over the country to receive treatment
Historically the areas of nursing that have been the most prone to here in the Triangle. Please make sure you are covering yourself and
claims are anesthesia, medication administration, midwifery and your career from disaster!
monitoring roles; however, claims today are expanding to all areas of
the field. Higher standards of care, failure to follow procedure and
failure to document conditions and treatment are some of the biggest
causes of law suits. All medical offices should have professional
liability insurance for their doctors and staff. However, today nurses
can get coverage for themselves independently of what their employer
offers. This coverage is called Nurses Professional Liability.

There are two ways a nurse can purchase Professional Liability. First,
is a stand-alone Nurses Liability policy, which many carriers offer.
Secondly, many home insurance companies offer Nurses Professional
Liability coverage as a rider on existing home insurance policies.
Having the rider added to the home policy is probably the cheapest
and most efficient way to have the coverage added and still give nurses
the security they need.

There are three key things that I recommend to nurses who are
looking at purchasing this coverage:

First, is the coverage on a claims made basis or on an

occurrence basis? There is a very big and important difference.
Claims Made means that the policy will only pay the claim if the
claim is made while the policy is in force. Occurrence basis means
the policy will pay the claim if the error or omission was done while
the policy was in force. With Occurrence basis it does not matter if
the policy is in force when the claim is made. As you can see there is
a very big difference between the two.

MARCH 2010 | The Triangle Physician 23

 News
Welcome to the Area Events and Opportunities

February 5, 2010
ANDREW BABCOCK, MD GRACE MCCARTHY, MD NATIONAL WEAR RED DAY
Family Medicine Anesthesiology Show your support for the fight against heart disease in women
University of North Carolina Hospitals Chapel Hill Duke University Hospitals, Durham and the American Heart Association’s Go Red For Women
movement by sporting your best red outfit Feb. 5th. For a free
downloadable Wear Red Day kit, visit GoRedForWomen.
KATHLEEN BALLAS, MD HEATHER PADDOCK, MD org/WearRedDay or contact the AHA at 919-463-8307.
Pediatrics Pediatric Surgery
Cary Duke Division of Pediatric Surgery, Durham February 13, 2010
25TH ANNIVERSARY
BRIAN BRITT, MD RICHARD RUNKLE III, MD TRIANGLE HEART BALL
Internal Medicine Anesthesiology Raleigh Convention Center, Downtown Raleigh
Duke Raleigh Hospital, Raleigh University of North Carolina Hospitals, Chapel Hill 463-8353
www.triangleheartball.org
TODD BROMBERG, MD STEFANIE SCHUMAN,MD 25th Anniversary event raises funds to support American Heart
Association research and education for heart disease and
Anesthesiology Pain Management Ophthalmology
stroke, the #1 and #3 leading causes of death in America. Feb.
Chapel Hill Duke Eye Center, Durham
13, 2010 from 6 p.m.– 11 p.m.

KALLOL CHAUDHURI, MD RAJDEEP SINGH, MD February 13, 2010

Anesthesiology Neurology BLUE JEAN BALL
Duke University Medical Center, Durham Duke University Medical Center, Durham The third annual Blue Jean Ball, a women’s health benefit , will
be held at the Sheraton Imperial, on Page Road, Durham, NC.
SWAPNA CHAUDHURI, MD RYAN STANGER, MD The event date is Saturday, February 13, 2010. Join the “dress
Anesthesiology Anesthesiology down,sparkle up” event where Blue Jeans are the expected
attire. A silent auction, dinner and live band are a part of what
Duke University Medical Center, Durham University of North Carolina Hospitals, Chapel Hill
you will enjoy during an evening dedicated to raising awareness
and funds to provide surgical and medical care to women in East
CHIH-CHENG CHEN, MD ERIC STROTHER, MD Africa. For ticket or program information, please visit http://
Neurology Anesthesiology bluejeanball.mc.duke.edu or call (919) 660-2378.
Carrboro Raleigh Family Health Care, Raleigh
February 27, 2010
DAN COTOMAN, MD MILLIE SURATI, MD CARDIOVASCULAR DISEASE 2010,
Psychiatry Otorhinolaryngology HEALTH CARE IN EVOLUTION:
Durham Duke University Hospitals, Durham OPPORTUNITIES AND CHALLENGES FOR
THE CARDIOVASCULAR PATIENT
PHILIP DAVENPORT, MD PRIYANKA UPPAL, MD WakeMed Heart Center, Conference Center
Neurology Internal Medicine WakeMed Raleigh Campus
3000 New Bern Avenue
Duke Neurology of Raleigh, Raleigh Cary
Raleigh, NC 27610
Jointly sponsored by Wake Heart And Vascular Associates and
MARK FASZHOLZ, MD CREIGHTON VAUGHT, MD Wake AHEC
Anesthesiology Otorhinolaryngology This program will present comprehensive insights into cardiology
Durham Alamance ENT & Facial Plastic Surgery, Burlington and care of the patient with or at risk for cardiovascular
conditions. Register online: www.wakeahec.org
ARASH FOROUGHI, MD CLAUDIA VISSAGE SCRUGGS, MD
Neurology Internal Medicine April 7, 2010
Duke University Hospitals, Durham University of North Carolina Hospitals, Chapel Hill NATIONAL START! WALKING DAY
Lace up your sneakers and take a walk to celebrate National
Start! Walking Day. Walking has been proven to lower heart
PEARLINE GRANT, MD JOSEPH WILSON, MD disease risk and improve wellness. For free walking resources
Family Medicine Orthopedic Surgery visit StartWalkingNow.org or contact the AHA at 919-463-8353.
Raleigh Triangle Orthopaedics, Durham
April 16 and 17, 2010
ANDREW GREEN, MD TAYLOR WOFFORD, MD CME: 2ND ANNUAL EMILY BEREND ADULT
General Surgery Internal Medicine RECONSTRUCTION SYMPOSIUM
Wilson University of North Carolina Hospitals, Chapel Hill A comprehensive hip and knee course presented by Adult
Reconstruction, Division of Orthopaedic Surgery, Duke University
WAYNE KELLEY, JR., MD JORDAN YOUNG, MD Medical Center
• Lectures on hot topics in hip and knee arthroplasty and live
Orthopedic Surgery Internal Medicine
video demonstrations on the latest operative techniques
Duke University Hospitals, Durham Wayne Memorial Hospital, Goldsboro
• Visiting professor Adolph V. Lombardi, MD, FACS
Friday, April 16, 2010 (Knee session)
AARON LENTZ, MD ROBIN ZENICK, MD Saturday, April 17, 2010 (Hip session)
Urological Surgery Pediatrics Duke University Medical Center
University of North Carolina Hospitals, Chapel Hill Premier Pediatrics, Southern Pines Register and get more information at
cmetracker.net/DUKE/Courses.html
This activity has been approved for AMA PRA Category 1 credit.TM
Sponsored by Duke University School of Medicine
New and Relocated Practices May 7, 2010
TRIANGLE GOES RED
FOR WOMEN LUNCHEON
Crabtree Marriott, Raleigh
DUKE GENERAL SURGERY OF RALEIGH (two locations) 919-463-8307
www.trianglegoesred.org
Duke Medicine Plaza American Institute Celebrate the power of women to join together in the fight against
3480 Wake Forest Road, Suite 506 their No.1 killer – heart disease. Enjoy heart health seminars,
of Healthcare & Fitness Offices
networking, a healthy lunch and powerful keynote address.
Raleigh, NC 27609 8300 Health Park, Suite 211
office 919-420-5000 Raleigh, NC 27615
office 919-847-8235

24 The Triangle Physician | MARCH 2010

 Cardiology

What
You
Should Peripheral
by Dr. Mateen Akhtar
Know
About
Arterial
Disease
Dr. Akhtar is a clinical cardiologist with Wake Heart & Vascular
Associates. He has offices in Clayton and Smithfield and
welcomes new patient referrals. Phone: (919) 989-7909.
Email: mateenakhtarmd@gmail.com

Peripheral arterial disease (PAD) is atherosclerotic disease of the arteries, excluding Lower Extremity
the coronary and cerebral arteries. Risk factors for development of PAD are similar to Atherosclerotic Disease
those for coronary artery disease and include age, diabetes mellitus, hypertension, Symptoms: Claudication — exertional calf,
dyslipidemia, and tobacco use. There is significant morbidity and mortality caused thigh, or buttock pain (20-30%), Atypical leg
by PAD and it remains an under-recognized condition. In this article, I will review pain (30-35%), Asymptomatic (30%), Critical
symptoms, screening, and treatment options for the three most common forms Limb Ischemia (1-2%)
of PAD: abdominal aortic aneurysm, carotid atherosclerosis, and lower extremity At-Risk Patients
arterial atherosclerosis (based upon ACC/AHA guidelines):
• Age 40-49 with diabetes mellitus + one
Abdominal Aortic Aneurysm (AAA) Carotid Artery Stenosis other risk factor
Definition: Prevalence: • Age 50-69 with history of smoking or
Abdominal aortic diameter exceeding 3 cm. Carotid artery stenosis causes up to 7% of diabetes mellitus
Prevalence: all strokes. • Age ≥70
Up to 13% in men and 6% of women over Symptoms: Screening:
age 65. Rare under age 60. Often asymptomatic. May have symptoms Ankle-brachial index (ABI) — ratio of blood
Symptoms: of stroke or TIA. pressure measurements taken in the arms
Majority are asymptomatic. May present Diagnosis: and ankles. ABI <0.9 is abnormal. An ABI
with rupture/sudden death (80-90% of AAA Carotid duplex ultrasound is highly sensi- < 0.4 indicates severe PAD. The ABI test is
ruptures are fatal). May have abdominal tive and specific. Other modalities include highly specific. Sensitivity may be reduced
pain or back pain. MRA and CTA. in subjects with calcified arteries. If clinical
Risk Factors: Screening: suspicion is high, suggest further evaluation
Age, male gender, tobacco use, family history Auscultation for carotid bruits. No role for such as CTA, MRA, or angiography.
of AAA, connective tissue disorder, diabetes screening asymptomatic individuals. Treatment:
mellitus, dyslipidemia. Treatment: For mild-to-moderate PAD, recommend
Diagnosis: • Mild-to-moderate carotid stenosis: aggressive risk factor modification, exercise
Abdominal ultrasound is highly sensitive Antiplatelet agents, statin therapy, anti- rehabilitation programs, anti-platelet agents,
and specific. hypertensive therapy, and annual carotid ± cilostazol. For severe PAD, revascularization
Screening: duplex for monitoring. via vascular surgery or percutaneous angio-
The US Preventive Task Force guidelines • Symptomatic, severe carotid stenosis: plasty/stent may be indicated.
recommend AAA screening for: Revascularization is indicated with carotid
• Males over age 65 with a history of smoking endarterectomy vs. carotid stenting.
• Males over age 60 with a family history • Asymptomatic, severe carotid stenosis: In conclusion, maintaining a high index
of AAA Controversial — need to weigh risks vs. of suspicion for PAD and remembering
Treatment: benefits of revascularization vs. medical to screen patients is important since early
Risk of rupture increases with aneurysm therapy on case-by-case basis. detection of PAD allows for early aggres-
size. Recommend treatment once AAA di- sive medical therapy and improved
ameter > 5.5 cm or for rapid expansion. Op- outcomes. Cardiovascular consultation
tions include open surgical repair vs. endo- is recommended for your at-risk or
vascular stent grafting. symptomatic patients.

MARCH 2010 | The Triangle Physician 25

 Good Business
Mark Wiener, President of BizCom Web Services has more than twenty years experience work-

Averting
ing with medical practices, large and small, to aid them in curing their technical, regulatory,
management and communication practice ailments. He currently, works with practices to help
them manage and minimize their overall IT budgets by providing enterprise-class solutions to
small and midsized practices all the while increasing security and improving practice perfor-

Data Disasters
mance, communications and efficiencies.

by Mark Wiener www.bizcomweb.com

Physicians juggle many responsibilities: from having to
supervise the care of their patients, fighting with insurance
companies over treatment plans, managing staff, and making
sure the medical and billing records remain intact and
accessible. Today, much of the critical information that runs
the medical practice is stored in electronic form. For many
physicians, it is a disorganized file cabinet which contains:
• Employee records
• Tax records
• Patient billing records
• Patient medical records
• Insurance claim follow up letters
• Letters of Medical Necessity
• Office forms
When electronic trouble strikes and data loss occurs, the vast
majority of medical offices are unprepared to get their office
functioning again in quick order. This is the purpose of a
“backup”— the process of making copies of data
so that these additional copies may be used to
restore the original after a data loss event.
Electronic Medical Record (EMR) and Practice Management
(PM) systems use complex databases and generally have their
own backup utility. Some practices use these intrinsic utilities
while others rely on the tools within server backup software
due to ease of use and automation with the latter. Regardless of
method, someone needs to make sure the backups store all of
the required data, actually work, and can be restored easily.

© ISTOCKPHOTO.COM/RISKMS

26 The Triangle Physician | MARCH 2010

Common back up strategies: The technology exists to prevent permanent policies often are inadequate and leave your
• No backup – This places your practice and temporary data loss. Especially in the practice with a huge risk exposure.
at risk for data loss and HIPAA data retention medical industry, it is unacceptable to be
violation. prepared. According to the SBA, if a business
• Tape backup – This is a better option; loses its data for more than 10 days, there is an Don’t take unnecessary
however, high tape failure rates due to 87% probability that it will file bankruptcy
environmental issues (humidity, dust, heat and close. It is imperative that practices risk. Review your data
and overuse), regular tape replacement needs
and security issues make this a less desirable
review their data handling procedures. It is
important to also understand the data
back up and retention
choice. recovery components (and its limitations) in strategies with your IT
• Local disk backup – This creates an their office business insurance policy.
immediately readable version of the data Remember, the basic limits included in your professional.
and allows easy access to get to small amounts
of data without having to restore the entire
volume; however, in the case of a building
wide disaster like fire, your backup data
would be permanently lost.
• Online backup – This strategy
provides for the security of an offsite backup,
but it may take several hours to restore the
data when done over the internet.
• Multiple strategies – Utilizing
multiple strategies, like local disk backup
coupled with online backup, yields the best
results and does not require regular employee
intervention.

So, how does one decide?

Every practice may have a different answer
depending on available resources and their
needs. How much data do you have? Where
is the data located (server, local computers,
email, flash drives, portable hard drive)?
What is the sensitivity of the data? How do
you ensure that all required data is recover-
able in case of a drive failure or disaster?
How long will it take to restore the data?
How long will the practice not be able to
operate if the electronic medical records or
the billing system are offline?

Many practices are concerned about using off

site or online backup services due to HIPAA
rules. HIPAA should not be a concern if
backups are properly encrypted prior to
transmission to the data storage company. A
Business Associate Agreement is unnecessary
when strong encryption technology is used.
The vender has no access to your data because
the encryption key is held exclusively by the
medical practice. There are greater HIPAA
concerns with local tape and disk backup copies
being retained that are not properly secured.
Womens Wellness half vertical.indd 1 12/21/2009 4:29:23 PM
MARCH 2010 | The Triangle Physician 27
 Marketing
Have You Been
Branded?
Companies constantly bombard us with brands
in today’s culture in an effort to establish a loyal
customer base. Isn’t that what every practice
wants… a loyal customer base from which a
practice may sustain itself on a long term basis?
The Physician Already Has One Brand
Your name and who you are is, in fact, your
personal brand. Ultimately, the issue then is
not whether you have a brand, the issue is
how well your brand is managed. So what
exactly is a brand. Branding today is used
to create an emotional attachment to a
practice. Branding efforts create a sense of
higher quality. In other words, a brand is the
promise of value when a patient considers
your practice over another. These promises
can be implied or explicitly stated.
Over time, your brand should expand into
your marketing collateral including your
website, brochures, logo, slogans, etc.
Branding can be enhanced by the images you
use in your advertising, and the by words
you use to describe your practice and area of
specialization. After sufficient impressions,
the patient remembers these associations.
When combined with a well-conceived
brand management strategy, your advertising
has the power to shape your organization’s
brand image in a way that positively affects
your organization’s revenue, reputation and
patient loyalty over the long-term.
28 The Triangle Physician | MARCH 2010
Brand Management and the Benefits
of a Strong Brand
If you were to ask one of your patients,
“What comes to mind when you think of
my practice”. Would they say, friendliness,
professionalism, state-of-the-art, well-trained,
convenient, accessible? Brand image is
defined as a patients’ perceptions as reflected
by the associations they hold in their minds
when they think of your practice. Brand
management recognizes that your market’s
perceptions may be different from what
you desire while it attempts to shape those
perceptions and adjust the branding strategy
to ensure the market’s perceptions are
exactly what you intend.
Here are just a few benefits you will
enjoy when you create a strong brand:
• Branding creates trust and an emotional
attachment to your practice. This attach-
ment then causes your market to make
decisions based, at least in part, upon
emotion-- not necessarily just for logical
or intellectual reasons.
• A strong brand can command a premium
price and maximize the number of patients
that can be taken.
• Branding will help you “fence off ” your
patients from the competition and protect
by Chris Doane
Chris Doane founded Southern Crescent Solutions in 2006.
Southern Crescent Solutions, a marketing firm located in the
Atlanta, Georgia area specializes in web development, CRM
Systems, and interactive marketing for a broad range of clients.
Mr Doane holds a BFA from the University of Georgia, a Project
Management certification from Georgia Tech and a Certified
Webmaster certification from Oglethorpe University. He has 20
years of experience in marketing, corporate communications,
and information technology.
His background includes a diverse range of experience with both
small business and large corporate operations. Before starting
Southern Crescent Solutions, he managed the Internet operations
for a publicly traded insurance holding company located in
Atlanta, Georgia. During his tenure there, major projects included
the development of a patented CRM system for use in the sales
and marketing division and the design and implementation of
the company’s branding and interactive marketing campaigns.
your market share while building mind
share. Once you have mind share, your
customers will automatically think of you
first when they think of your area of specialty.
• A solid branding strategy communicates
a strong, consistent message about the
value of your services. A strong brand
helps you sell value and the intangibles
that surround your practice.
• A strong brand signals that you want to
build customer loyalty. A strong branding
campaign will also signal that you are
serious about marketing and that you
intend to be around for a while.
• Branding builds name recognition for
your practice.
• A brand will help you articulate your
practice’s values and explain why you are
competing in your market.
If a brand is successful in making a connection
with people and communicating its distinct
advantage, people will want to tell others
about it and word-of-mouth advertising
will develop naturally. This top-of-mind
awareness occurs when you ask a person to
name practices within a particular specialty
and your practice comes to mind. Once that
type of differentiation is established in the
market’s mind, advertising can help main-
tain and shape the brand.
YOUR LOCAL CARDIOLOGY PROFESSIONALS
IN JOHNSTON COUNTY

DEDICATED TO QUALITY, SERVICE, AND INTEGRITY

Benjamin G. Atkeson, MD, FACC

Cardiology, Echocardiography,
Nuclear Cardiology

Mateen Matthew S. Christian N. Matthew A.

Akhtar, MD Forcina, MD Gring, MD, FACC Hook, MD, FACC

Eric M. Diane E. Ravish Nyla

Janis, MD, FACC Morris, ACNP Sachar, MD, FACC Thompson, PA-C

2 LOCATIONS TO SERVE OUR PATIENTS CARDIOLOGY SERVICES

Smithfield Heart & Vascular Associates Wake Heart & Vascular Associates Coronary and Peripheral Vascular Interventions,
910 Berkshire Road 2076 NC Hwy 42 West, Suite 100 Pacemakers/Defibrillators, Atrial Fibrillation
Smithfield, NC 27577 Clayton, NC 27520 Ablations, Echocardiography, Nuclear Cardiology,
Phone: 919-989-7907 Phone: 919-359-0322 Vascular Ultrasound, Clinical Cardiology, CT
Fax: 919-989-3147 Fax: 919-359-0326 Coronary Angiography, Stress Tests, Holter
Monitoring, Cardiovascular Medicine,
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Catheterization

THE HIGHEST QUALITY CARDIOVASCULAR CARE, CLOSE TO HOME.

 A^iiaZ>h7^\IdJh#

BRENT A. TOWNSEND, MD | Pediatric Radiologist

CATHERINE B. LERNER, MD | Pediatric Radiologist

LAURA T. MEYER, MD | Pediatric Radiologist

©2010 Wake Radiology. All rights reserved. Radiology saves lives.

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

Wake Radiology Pediatric Imaging. Deliverying the finest care for your smallest patients.

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