Dukemedmed FALL/WINTER 2004 MAGAZINE

VOLUME 4 ISSUE 2 DukeDukeMedMed FALL/WINTER 2004 MAGAZINE

Taking action against aortic disease What’s next in prostate cancer care Controversies in medicine: Antidepressants for adolescents ADVANCES IN RESEARCH, EDUCATION, AND PATIENT CARE AT DUKE

PLUS: Earn CME credit for reading our STRETCHING Clinician Q&A THE LIMITS Advances in arthritis treatment put patients back on track FROM THE CHANCELLOR

Changes and continuity

It has been less than a year since I first visited Over the past year, I have read a great deal In the coming year, 2005, Duke will cel- Duke while interviewing for the job as chan- about my new home and had many conversa- ebrate the 75th anniversary of the opening cellor for health affairs. Looking back, I still tions with individuals on campus, throughout of those medical institutions in 1930. We clearly recall the sight that greeted me after the health system, and in the community. will also bring forth a strategic plan to guide I stepped off the Jetway into Raleigh-Durham In the course of learning about Duke’s proud the future of medicine at Duke for the next International Airport: a billboard for Duke past and exceptional accomplishments, I was five years. Medicine that read, “The Future of Medicine, particularly struck by the words of James As we look to the future, it seems to me Delivered Today.” That bold statement made B. Duke, founder of Duke University, in the that our fundamental goals remain much the a lasting impression on me, and I am honored Indenture of Trust establishing The Duke same as those mentioned by James B. Duke to have been given the opportunity to help Endowment. many decades ago. We still seek to advance Duke fulfill that vision for its patients. He wrote: “I recognize that [hospitals] have the quality and span of human life by making I knew Duke from a distance for many become indispensable institutions, not only by new discoveries and bringing new inventions years before becoming chancellor in July. I way of ministering to the comfort of the sick from the lab to the bedside. We still seek the had always greatly admired and respected the but in increasing the efficiency of mankind “best results” for our patients by adopting the medical center and health system for its first- and prolonging human life. The advance latest evidence-based care practices, and by rate patient care, education, and research, in the science of medicine growing out of setting and meeting high standards for quality and thought it fortunate in its excellent discoveries, such as in the field of bacteriol- and safety. We still work to ensure that our leaders, including Chancellor Emeritus Ralph ogy, chemistry and physics, and growing out health system meets the needs of patients in Snyderman, MD. of inventions such as the X-ray apparatus, the different communities we serve, and we Now that I have had a chance to get to make hospital facilities essential for obtaining still continue Duke’s tradition of giving special know Duke for myself, I have been truly the best results in the practice of medicine attention to the needs of those who have dif- impressed and inspired. Not only is Duke and surgery. ficulty accessing or affording health services. among America’s best academic medical “So worthy do I deem the cause and so I am proud to be part of an institution with centers, its people are among the most great do I deem the need that I very much such a long history of excellence and service. devoted, proud, and committed to excellence. hope that the people will see to it that ade- It is my goal and privilege to carry on those To me, they embody the true meaning of quate and convenient hospitals are assured traditions as we embark on the future of Duke Medicine. in their respective communities, with especial medicine at Duke. I have had a long journey to Duke, arriving reference to those who are unable to defray by way of Shanghai, Hong Kong, Montreal, such expenses of their own.” VICTOR J. DZAU, MD San Francisco, and Boston. Having lived To help meet the needs he saw, Mr. Duke PROFESSOR OF MEDICINE in many different places throughout my left in his will instructions that $4 million be CHANCELLOR FOR HEALTH AFFAIRS, life, I have always striven to adapt to each used to establish a medical school, hospital, DUKE UNIVERSITY new environment by learning about its and nurses’ home at Duke University—the PRESIDENT AND CEO, history, traditions, and culture—and Duke is “capstone” of his vision for a “network of DUKE UNIVERSITY HEALTH SYSTEM no exception. hospitals so located . . . that they . . . would be adequate and accessible to all who might need,” as his attorney put it. Duke 18 down since. down hasn’tslowed 1—and July office took affairs health for Duke’schancellor new days early Dzau’s

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Med E N I Z A G A M “A thoroughlymodern medical education” “Antidepressantsfor childrenand adolescents: DukeMed Now DukeMed Dean the From Controversies in Medicine in Controversies Transfusion-freesurgery, treating atrial fibrillation, Plus: track. on back patients put treatment arthritis in Advances limits the Stretching Clinical Update Clinical servicefor regional clinicians,Duke’s newpresident espouses globalhealth, and more. Dangerous medicine?” Improvingaccess to Dukespecialists, improving byJohn March, MD,MPH bedbugsbounce back, and more. byR. Sanders Williams,MD Arthritis care for kids for care Arthritis 26

36 FALL/WINTER2004 2, ISSUE 4, VOLUME get the attention it deserves. it attention the get to starting is disease aortic strikes, disaster until overlooked Often heart the of highway Workingthe on

54 54 CME Calendar CME 71 60 80 80 INSIDE BACK COVER BACK INSIDE “Useof opioids foroutpatient pain management” New Physicians New Appointments, Honors, AwardsHonors, Appointments, Clinic Catherine LynchGilliss, DNSc, RN, newdean ofDuke’s School of Nursing byAnne Marie Fras,MD Three Questions Three

ian Q ian &A options than ever before. ever than options more men offers team cancer Duke’sprostate man’scancer the Fighting

credit! CME Earn

FROM DUKEMED DUKE UNIVERSITY MEDICAL CENTER AND HEALTH SYSTEM ADMINISTRATION

Victor J. Dzau, MD Community and Family Medicine: Chancellor for Health Affairs, J. Lloyd Michener, MD Duke University Immunology: President and CEO, Thomas F. Tedder, PhD Duke University Health System Medicine: The great CME experiment R. Sanders Williams, MD Pascal J. Goldschmidt, MD Dean, School of Medicine Vice Chancellor for Molecular Genetics and Academic Affairs Microbiology: We thought our clinician readers might like a little extra credit for Thomas D. Petes, PhD Catherine Lynch Gilliss, DNSc reading DukeMed Magazine. Dean, School of Nursing Neurobiology: James McNamara, MD So, in this issue, we are offering an opportunity to earn up to 1.0 Vice Chancellor for Nursing Affairs William J. Donelan Obstetrics and Gynecology: Category 1 credit toward the AMA Physician’s Recognition Award for Vice Chancellor for Health Affairs Haywood Brown, MD reading our Clinician Q&A feature, “Use of Opioids for Outpatient Pain Executive Vice President and COO, Ophthalmology: Duke University Health System David L. Epstein, MD Management,” by Anne Marie Fras, MD, assistant clinical professor in the William J. Fulkerson Jr., MD, MBA Pathology: CEO, Duke University Hospital Salvatore Pizzo, MD Duke Department of Anesthesiology and interim director of the Division of Vice President, Duke University Health System Pediatrics: Pain Management. Dennis Clements, MD, PhD, MPH Kenneth C. Morris (interim chair) The article—and full instructions for claiming credit—can be found on Senior Vice President, Chief page 54. Financial Officer, and Treasurer, Pharmacology and Cancer Biology: Duke University Health System Anthony R. Means, PhD Is it a great experiment? Only you can tell us. Let us know whether you Molly O’Neill Psychiatry: think we should offer a CME opportunity again—and what topics would be Vice Chancellor for Integrated Ranga R. Krishnan, MB, ChB Planning Radiation Oncology: of interest to you. Vice President for Business Christopher Willett, MD Development and Chief Strategic Drop us a line via e-mail at [email protected] or write to Editor, Planning Officer, Duke University Radiology: Carl E. Ravin, MD DukeMed Magazine, DUMC 3687, Durham, NC 27710. Health System Asif Ahmad Surgery: A reminder from the Duke Office of Continuing Medical Education Vice President and Chief Danny O. Jacobs, MD, MPH that you may also be able to receive self-claim credit for reading Information Officer, Duke University Health System and DUKE UNIVERSITY Duke University Medical Center MEDICAL CENTER DukeMed Magazine: BOARD OF VISITORS Physicians licensed by the North Carolina Medical Board (NCMB) must com- Steven A. Rum Tina Alster, MD Vice Chancellor for Development William G. Anlyan, MD* plete 150 hours of practice-relevant continuing medical education (CME) and Alumni Affairs Leslie E. Bains every three years in order to be relicensed. Up to 90 of the 150 required Robert L. Taber, PhD Philip J. Baugh Vice Chancellor, Science and Santo J. Costa hours for NCMB relicensure can be “self-claim” credit for physician-initiated Technology Development Duncan McLauchlin Faircloth activities such as practice-based self study, consultations with colleagues, Mike T. Gminski Gordon D. Williams Robert Pinkney Gorrell teaching, M&M conferences, journal clubs, and reading clinically relevant Vice Chancellor for Operations Thomas M. Gorrie, PhD Vice President for Administration, Terrance K. Holt articles in DukeMed Magazine. The North Carolina Medical Board even Duke University Health System Richard S. Johnson provides a form that can be downloaded from its Web site for your use in Huntington F. Willard, PhD John D. Karcher Vice Chancellor for Genome Peter A. Karmanos, Jr. tracking physician-initiated activities: Visit www.ncmedboard.org/cme1.htm. Sciences David L. Katz, MD Bruce W. Knott For additional information regarding CME credit for NCMB relicensure, DEPARTMENT CHAIRS Milton Lachman Anesthesiology: Anthony J. Limberakis, MD please contact the NCMB at 919-326-1100, 919-326-1109, or 800-253- Mark Newman, MD Brandt C. Louie 9653 (toll-free in-state long distance). Physicians licensed by other state Thom A. Mayer, MD Biochemistry: George James Morrow boards may also be able to receive “self-claim” CME credit; for informa- Christian Raetz, MD, PhD Mary D.B.T. Semans* tion please contact your state medical board. Biostatistics and Bioinformatics: John Bush Simpson, MD, PhD William E. Wilkinson, PhD Sheppard W. Zinovoy (interim chair) *honorary member Cell Biology: Brigid Hogan, PhD

DUKEMED MAGAZINE VOLUME 4, ISSUE 2, FALL/WINTER 2004 Editor: Contributing Writers: Editorial Advisory Board: Minnie Glymph Karyn Hede Kathryn Andolsek, MD Carol Krucoff Patrick Casey, PhD Designer: Dennis Meredith Nelson Chao, MD Jessica Schindhelm Ellen Luken Contributing Rex McCallum, MD Contributing Editor: Photographers: Lloyd Michener, MD Catherine Macek, PhD Butch Usery Molly O’Neill Chris Hildreth Vicki Saito Creative Director: Jim Wallace Debra Schwinn, PhD Jeff Crawford Raymond Goodman Robert Taber, PhD DukeMed Magazine is online at dukemedmag.duke.edu Production Manager: DukeMed Magazine is published twice a year Margaret Epps by the Office of Creative Services and Marketing Communications. Publisher: Dorothea W. Bonds DukeMed Magazine DUMC 3687 Duke University Medical Center Durham, NC 27710 919-419-3271 [email protected] Web: dukemedmag.duke.edu Copyright 2004 Duke University Medical Center MCOC-3717 huad o hus ic 20. hs monu This 2000. since hours of thousands many administratorsfor faculty,and students, of scores occupied has that process a pleting overhaulofDuke’s major curriculum first in40 the years, com of product final the students andscholars of American medicine. leaders become to out students our sending goal— overarching our be to declared have medical educationhas accomplished precisely what to we approach unique This under standing. current of limits the pushes student the which in knowledge medical of domain small a of exploration focused and opportunities deep for with knowledge medical of span full the with familiarity some providing of task broad impossibly almost the balanced have also we manner, this In creativity. vidual greater opportunitiesforfocused scholarship andindi provided have we and experience, school contact medical their in intensive earlier patients with into students brought greater of intellectualmaturity. stage a at patients with contact direct reestablish students which in cialties, subspe clinical in clerkships of year fourth a facultymentor.a of followedbeenhasThisby research on a specific topic under original the guidance and scholarship focused of year full inestimablerewardvalue—aofstudentsa our Surviving these pressures, however, has earned processingmassive amounts ofinformation. rapidly for capacity high a and effort of intensity extraordinary an demands schedule erated year.accelsecond Thisthe rotations in clinicalbegin may students our that so schools,other at years two over taught customarily is that sciences medical basic with dealing material the year one into compressed has curriculum Duke the effect, In school. medical American other S INCETHE 1960 This year we are rolling out to current medical have we schools, other to Compared

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d e a n 3 - - - DukeMed DukeMed “IT WAS PRETTY OBVIOUS PRETTY WAS “IT Special access Special is getting easier 4 Getting in to see a Duke specialist call and couldn’t get an appointment, and and appointment, an get couldn’t and call access problem,” says Theodore Pappas, MD, MD, Pappas, Theodore says problem,” access administrative director for operations. “We “We operations. for director administrative PDC’s the Gable, Bill says change, culture a better provide to need we system, health a education, and research around organized anappointment within seven days (see box). such as scheduling templates that varied varied that templates scheduling as such service—bothstaycompetitiveto becauseand wait to had oftenpatients new fact, in years,recent Inpatients. its suit to busy toosometimes demic institution, many of our divisions were divisions our of many institution, demic uncovered several artificial barriers to access, access, to barriers artificial several uncovered effort to overhaul the scheduling process and process scheduling the overhaul to effort were physicians care primary own our even Duke’sPDC, theexecutivedirectormedical for thecommunities weserve.” into evolved we’ve that “Now says. he time,” thoughtthe situation wasunacceptable.” from doctor to doctor.” Now, templates are templates Now,doctor.” to doctor from would people “Frequently practice. faculty more than a week. The project is ongoing, ongoing, is project The week. a than more With With over 1.1 million outpatient visits annually, Duke’s Private Diagnostic Clinic (PDC) stays busy— we have a responsibility to meet the needs of needs the meet to responsibility a have we remaining the of out carved care clinical with system, the into built practically were waits no to down times wait appointment whittle weeksfor an appointment. Pappas points out. “Because Duke is an aca an is Duke “Because out. points Pappas Duke specialty clinics routinely offer patients patients offer routinely clinics specialty Duke having trouble referring patients in. We We in. patients referring trouble having DukeMed coor appointment and standardized, being alreadyscoredsuccesses.Today,has but many That’s why the PDC recently launched an an launched recently PDC the why That’s Hitting that target hasn’t been easy. Long Long easy. been hasn’t target that Hitting Becoming more patient-friendly requires requires patient-friendly more Becoming Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) 1-888-ASK-DUKE call consumers and patients (633-3853), 1-800-MED-DUKE call Physicians DUKEMED NOW DUKEMED DUKEMED NOW DUKEMED that we had an an had we that - -

“They’re now providing less than one-week one-week than less providing now “They’re “We’re guaranteeing the service, not the the not service, the guaranteeing “We’re Gable says. “We wanted to give our schedul our give to wanted “We says. Gable cian, they may still have to wait, says Pappas. Pappas. says wait, to have still may they cian, Medicine. of Department the in affairs clinical acrossour department.” summer,offerone-next to“By adds: hope we access,” he says. “It’s been a dramatic change.” forchair viceaccordingCuffe, Michael MD,to sometimescalledaround consultingthe getto a for seen be to needs patient a If schedules. dinators have improved access to the doctors’ doctors’ the to access improved have dinators ulethe patient withthe nextavailable doctor. erstheability tooffer anappointment thefirst of list a up pull can schedulers the example, to increase availability. For example, Cardiology time patientsor referringphysicians called.” Other divisions are rapidly following suit, he he suit, following rapidly are divisions Other physician’s approval to override the system,” system,” the override to approval physician’s sched and problem the treat who physicians week access for most types of appointments appointments of types most for access week physicians community booked, were we has recruited 11 new faculty members since since members faculty new 11 recruited has for murmur, heart a or hernia, a injury, hand last July, in addition to revamping scheduling, scheduling, revamping to addition July, in last “In the past, if the scheduling system said said system scheduling the if past, the “In Some divisions are also hiring more faculty faculty more hiring also are divisions Some If patients want to see a particular physi particular a see to want patients If

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Those efforts will continue, PDC leaders leaders PDC continue, will efforts Those cialists who treat the same problem, we as a as we problem, same the treat who cialists an ongoing commitment to improve access toimprove accesscommitmentto ongoing an agedto see the efforts being made to improve 50 in is clinics those in appointment available or financial to due turnaround seven-day a offer to unable be will clinics Some week.” a servicefor patientsand referring physicians.” done, but it is getting better. We’re encour We’re better. getting is it but done, MD, Anderson, John says problem,” difficult be will that 30, to it move can we and days within patient that see to commit can group tionalservices nowtooffer newappointments nextyear,” saysGable.“We partof thisassee Affiliated University Duke for director medical very a is access “Improving direction. right lde “er wrig ih eea addi several with working “We’re pledge. Physicians. “There’s still a lot of work to be be to work of lot a still “There’s Physicians. Dukeclinical services.” individual. But if there are 10 other Duke spe Duke other 10 are there if But individual. in seven days, and plan to have more online online more have to plan and days, seven in better foreveryone.” logistical constraints, he adds. “But if the next the if logistical“Butadds.constraints, he So far, things seem to be moving in the the in moving be to seem things far, So ·Urology ·Pediatric Cardiology ·Ear, Nose, andThroat ·Cardiology ·General Surgery ·Orthopaedics 1-888-ASK-DUKE. Tomake anappointment, physicians PDC, PDQ (PDC) call 1-800-MED-DUKE, patients call physicianinclude: within seven days with the next available available next the with days seven within DUKE PRIVATE DIAGNOSTIC CLINIC CLINIC DIAGNOSTIC PRIVATE DUKE services now offeringservicesnowappointments

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Brodhead says “I do”

TODAY WE SOLEMNIZE MY NEW UNION. Let’s do it right. Do I, crowd at his inauguration. “A student I knew put her dismay this way: Richard, take you, Duke, to be my chosen life? I do. ‘See, it was like Dean Brodhead was married to Yale—and now we Forsaking all others, will I do everything in my power to further the learn that he’s leaving us for someone younger and more athletic.’” aims of this university? I will. Brodhead went on, in a more serious tone, to outline his thoughts As we pursue these goals, will I work to promote the welfare of on what Duke is and what it can become: “I was lured here by the every member of the Duke community . . . every single person whose spectacle of a school that has established itself in the top rank of labor and devotion make this place thrive? Yes, I will. research universities and professional schools but that habitually With wit and a charming smile, Richard H. Brodhead, PhD, said these connects the pursuit of knowledge with the search for the social good.” words to a crowd of over 1,700 people in Duke Chapel September 18 While committing to build intellectual strength in every field, to mark the ceremonial beginning of his tenure as ninth president of Brodhead presented several initiatives that he believes Duke should Duke University. concentrate on to continue to impact society—including global health. Brodhead, who succeed- “Duke medical researchers are already active from Tanzania to “Others have given us ed Nannerl O. Keohane on Singapore to Honduras and back to the Carolinas and are working on July 1, was formerly dean virtually every health challenge a growingly populous, growingly inter- this great place. Let’s of Yale College and the A. dependent world will face,” he said. “In my dream, Duke would be the see what we can build Bartlett Giamatti Professor place where people from around the world come to learn and contrib- of English and American ute to a growing understanding of our shared health future; and no together.” Studies at Yale University. An student would leave without a deeper understanding of this dimension

President Richard H. Brodhead expert in American literature, of our common lot.” he earned his bachelor’s, Other areas touched upon included the need for continued invest- master’s, and doctoral degrees from Yale before joining that universi- ment in faculty, maintaining Duke as a place of self-discovery and ty’s faculty. “As you may know, I had a deep attachment to my former self-enlargement for undergraduate and graduate students, and school, having spent my whole adult life there, and when the news recruiting financial support “to assure that this school never closes its broke that I was leaving, not everyone took it well,” Brodhead told the doors to a worthy applicant.” “I know that whatever I will do will be accomplished with your partnership and help,” he told the crowd. “Others have given us this great A gift for global health . . . place. Let’s see what we can build together.” A NEW DUKE CENTER will seek to improve the health of people Read more at http://www.duke.edu/inauguration/. throughout the world through research, education, and service. The Hubert-Yeargan Center for Global Health was established this fall with $4 million from The Yeargan Charitable Foundation Trust of Garner, N.C., and $2.5 million from the Hubert Family Trust . . . And a grant, too of Atlanta. IN AUGUST, DUKE RECEIVED A $4 MILLION NIH GRANT to study The center, directed by G. Ralph Corey, MD, will further expand infectious diseases that plague AIDS patients in Tanzania. The award, a research and education program on HIV infection, malaria, and one of the largest of its kind ever given, will be used to improve tuberculosis originally started by Duke in Tanzania in 1986. The initial detection, prevention, and understanding of diseases that often program and additional sites in Tanzania, Brazil, China, Thailand, and co-infect HIV/AIDS patients, such as tuberculosis, meningitis, and Kenya have provided research and training opportunities to more cervical cancer, according to principal investigator John Bartlett, MD. than 200 physicians, while giving more than 40 foreign physicians Much of the grant will help create a medical research infrastruc- opportunities to participate in clinical care and research at Duke. ture in a region of northwest Tanzania where about 10 percent of the population have HIV/AIDS. The investment in equipment, laboratory space, and training will enable scientists in Tanzania to continue research independently after the grant ends.

For details visit www.dukemednews.org. DUKEMED NOW

20 percent leap in NIH funding sets 30-year record New radiation oncology DUKE UNIVERSITY SCHOOL OF MEDICINE RANKED #5 among medical schools nationally in funding from the National Institutes of clinic takes the cake Health (NIH) in fiscal year 2003, according to the federal agency’s DUKE RADIATION ONCOLOGY staff at a September open latest figures. With a total of $305.4 million received, the school saw house had the rare opportunity to dig into their new digs, a funding increase of more than 20 percent—the highest among the thanks to a fancy cake decorated to resemble the redesigned nation’s 20 top-ranked institutions. Radiation Oncology Clinic (above). The fifth-place finish marks the highest ranking Duke has received The new clinic, located at the rear of the Morris Cancer since 1973, says Dean R. Sanders Williams, MD, who calls NIH Building, has 12 exam rooms instead of the previous six, funding “critical to Duke’s ability to play a transformative role in the two pediatric waiting rooms, a dedicated MRI for treatment advancement of human health and biomedical science.” planning and hyperthermia, an additional Computerized The Department of Medicine received more funding than any Tomography (CT) Simulator for treatment planning, five new other at Duke with more than $100 million and a fifth-place finish linear accelerators, a patient education room, and expanded nationally. The Department of Surgery won more NIH funding than space for staff workrooms and breakrooms. any other in the nation with $42 million in awards. Other medical Of course, as Department of Radiation Oncology chair school departments among the nation’s top 10 included anesthesiol- Christopher Willett, MD, reminded those gathered at the ogy, biology, biostatistics, pediatrics, pharmacology, psychiatry, public open house, “While this is a wonderful building, what is truly health and radiology and radiation oncology. important is the people inside.” Guess that would make the new facility just the icing on the cake.

Genomic information: public or private? SHOULD HARD-WON ADVANCES in The Duke center will gather and analyze “Over the past 10 to 20 years there’s been genomic knowledge become public territory information about the role of publication, data a real bashing of heads over public versus or remain proprietary? As federally funded and materials sharing, patenting, database private approaches to genomic innovation,” institutions and private corporations pour protection, and other practices that may affect adds IGSP director Huntington Willard, PhD. billions of dollars into developing new genom- the flow of information in genomics research. “With its virtually unique combination of ics-based products and services, it’s become a “The incentive of intellectual property rights strengths in laboratory research, public policy, pivotal question—one a new center at Duke can stimulate investment in genomic research, and business, this is exactly the kind of issue will be working to answer. but it can also be an impediment to informa- Duke is equipped to address.” The Duke Institute for Genome Sciences tion-sharing that could more quickly bring To read an overview of the new center and Policy’s Center for Genome Ethics, Law, about practical benefits for the public,” says published in Duke Law Magazine, visit and Policy (GELP) received a $4.8-million NIH GELP director Robert Cook-Deegan, MD. http://law.duke.edu grant to support its new Center for the Study “We hope that providing better data about of Public Genomics. The interdisciplinary center information flow will lead to better policy in is one of four nationwide to receive funding this arena.” as a Center of Excellence in Ethical, Legal and Social Implications from the NIH’s National Human Genome Research Institute. DukeMed 6 DUKEMED NOW

Big building for big ideas DUKE’S NEWEST CAMPUS LANDMARK and biotechnology, among other fields. The opened this August after two years of complex features the Jim Wyngaarden Hall of construction—the $97-million, 322,000- Honor, named after the former chairman of square-foot Center for Interdisciplinary medicine at Duke and chief of staff of Duke Engineering, Medicine, and Applied Sciences Hospital, who was appointed director of the (CIEMAS). The facility expands the Pratt School National Institutes of Health in 1982. of Engineering’s partnership with the School of Medicine, providing laboratories for collaborative research in health care, genomics,

Fishing for a good science idea SCHOOLTEACHER TREVA FITTS knows where she’ll be fishing to keep her fifth graders interested in science. After a 15-minute tour of Duke’s zebra fish facility with graduate student Richard Roberts this summer, she was ready to go back for more. “This is awesome,” she Missing persons said. “I can definitely see using this information in my classroom. This would be such an interesting way to teach our students about ecosys- THE SULLIVAN COMMISSION ON DIVERSITY in the Healthcare tems and animal adaptations.” Workforce, a national blue-ribbon panel formed in 2003 to address The fishing trip was part of a weeklong series of idea-boosting tours the under-representation of minorities in health-related fields, recently and discussions for Fitts and a dozen other elementary and middle released its report Missing Persons: Minorities in the Health Professions. school teachers sponsored by BOOST (Building Opportunities and The report calls for a variety of systemic changes to make health care Overtures in Science and Technology). A partnership between Duke education and training more attainable for minority students, includ- University Medical Center, Durham Public Schools, and the North ing shifting from student loans to scholarships; reducing dependency Carolina School of Science and Mathematics, BOOST reaches out to on standardized tests for admission to medical, nursing, and dentistry underrepresented minority students and their teachers to promote schools; and expanding the role of two-year colleges. their interest in science. The Commission is administered by Duke University School of Medicine According to Brenda Armstrong, MD, director of admissions for the as part of a $3.6 million grant from the W.K. Kellogg Foundation. Duke School of Medicine and program director for BOOST’s multiyear grant from the Howard Hughes Medical Institute, underrepresented The report is available online at www.sullivancommission.org minorities comprise nearly 25 percent of the U.S. population, but less than 9 percent of physicians. “Our ultimate aim is to inspire these students to make positive contributions in science by pursuing careers in medicine and related fields,” she says. In addition to the Summer Science Immersion program for teachers, BOOST works with fifth- and sixth-grade classes throughout the year by providing speakers and mentors.

For more information, visit www.duke.edu/~dbc4/boost DukeMed Visit Duke University Health System online at dukehealth.org 7 8 Exploring environmental health hazards AIR POLLUTION,AIRWASTEANIMAL Not yourtypical health plan Sciences and an additional $1 million in university support, the multidisciplinary, multidisciplinary, the support, university in million $1 additional an and Sciences concernto North Carolina residents will serveto guidenew linesof research. unraveling for facilities laboratory and training provide will center cross-campus occur. Described as a “pioneering program” program” “pioneering a as Described occur. and preventing diseases and chronic conditions and other groups about environmental health. In turn, environmental issues of public public of issues environmental turn, In health. environmental about groups other and ageshifts environmentalin policy, saysdirector DavidSchwartz,A. MD.Thecenter also environmental of testing laboratory controlled for facility toxicology inhalation an and agents,while others remain healthy. to disease and hazards such between link the explore will Populations Vulnerable of of variety a to exposed are Carolinians North floods: after flourish that bacteria and such as hypertensionassuch diabetesandbefore they exposures. environmental with challenged when disease develop people certain why explain this year as a means of identifyingriskshealthof means a as yearthis a for on signed have members family their MORE THAN 4,000 THAN MORE program that just might redefine health care care health redefine might just that program potential environmental health hazards. Duke’s new Center for Comparative Biology Biology Comparative for Center Duke’snew hazards. health environmental potential will include a strong community outreach effort to educate North Carolina schools schools Carolina North educate to effort outreach community strong a include will Health,introducedwas Dukeleadersby earlier inthis country. DukeMed includeDNAanalyticala facilitywill capable screeningof theactivity thousandsof genesof Facilities disease. to lead environment the and genes between interactions how The center team will apply its findings both to medical advancements and to encourmedicaladvancementsto toandfindings both its apply will teamcenter The Prospective Duke called program, The Launched with $2.6 million from the National Institute of Environmental Health Health Environmental of Institute National the from million $2.6 with Launched Duke faculty, staff, and and staff, faculty, Duke DUKEMED NOW DUKEMED fromcommercial operations,pesticides, moldsthe

controlgroup received traditional carewithout health personalized a to sticking and creating way a aschampioning prospectivecarehealth as well as coaching on making and maintain and making on coaching as well as onan individual level. specificstrategic health planning. for then-Chancellor when ago, years several designed to bring individuals and physicians physicians and individuals bring to designed expanded the model to offer prospective prospective offer to model the expanded tracked the health of patients with particular particular with patients of health the tracked that model care a operating by approach the evidence- and genomics in advances apply to for Medicaid and Medicare Services to test test to Services Medicare and Medicaid for One set of patients was given assistance in in assistance given was patients of set One risk factors such as diabetes, hypertension, hypertension, diabetes, as such factors risk viduals participating in two Duke-sponsored Duke-sponsored two in participating viduals plan based on their own risks and behaviors, behaviors, and risks own their on based plan health a received group this in Patients plan. Health Affairs Ralph Snyderman, MD, began began MD, Snyderman, Ralph Affairs Health health to its employees. “The program is is program “The employees. its to health the in Patients changes. lifestyle needed ing smoking. cigarette or pressure, blood high health plans. basedmedicinepredicttoprevent and disease the by The initial results were so good that Duke Duke that good so were results initial The planted were program the of seeds The In 2002, Duke partnered with the Centers Centers the with partnered Duke 2002, In Wall Street Journal StreetWall , it is offered to indi offeredto is it , -

- - “The first step is to raise awareness of health health of awareness raise to is step first “The can provide the support to help people make make people help to support the provide can are important health issues where we have have we where issues health important are before sick become to people for waiting of and employers nationwide, leaders say. seeing a doctor,” says Peter Jacobi, MD, MD, Jacobi, Peter says doctor,” a seeing greatly improve the health of the workforce and, difference.” vdne ht al itreto mks a makes intervention early that evidence tobacco-related illnesses, says Jacobi. “These “These Jacobi. says illnesses, tobacco-related their quality oflife.” improveor maintain to changesnecessary the instead services care health of delivery the improve to way proactive more a in together riskfor heart conditions, diabetes, obesity, and prog their intense More links. track educational find and ress, tips, health daily receive we Then resources. available as well as risks Health. Prospective Duke for director medical participants can create their health plans, plans, health their create can participants interventions are focused on patients at at patients on focused are interventions in turn,reducein health carecosts foremployees in its first year, the program has the potential to The program offers a robust Web site where With a goal of reachingof10,000participantsgoal a With www.dukeprospectivehealth.org. For moreinformation, visit -

DUKEMED NOW A Duke connection The Physician Liaison Program gives every community physician a personal contact at Duke DR. EDWIN FUENTES’S PATIENT came into doctors know about the office with back pain, but still hoped to go CME opportunities and on vacation later that day as planned. When clinical trials, help coor- an ultrasound showed a life-threatening dinate patient referrals abdominal aortic aneurysm, though, Fuentes and appointments, and knew the man needed a trip to the operat- act as ombudsmen ing room instead—and fast. So the Danville, to resolve complaints Virginia physician called his best connection at and concerns. Duke: physician liaison Christine Sasser-Perry. Importantly, both “Chris put me in touch with all the right liaisons have clinical people right away,” recalls Fuentes. “When backgrounds and a deep the patient arrived the team was waiting knowledge of Duke. for him and rushed him up to the OR. His Sasser-Perry was a nurse aneurysm actually burst while he was on the in the Duke Emergency operating table, but because he’d gotten there Department for 11 years, in time they were able to save his life.” while Fowler spent 15 On the road again: Duke physician liaisons Christine Sasser-Perry (left) Fuentes had referred patients to Duke years as an ICU and and Phyllis Fowler hit the highway almost every day to bring infor- before, but says the personal service from a ER nurse at Durham mation and assistance to regional physician practices. Fowler covers physician liaison helped him with the process. Regional Hospital, territory north of I-40, including Raleigh and southern Virginia, while “The transfer went beautifully,” he says. “Chris part of Duke’s Health Sasser-Perry visits clinicians south of I-40 from southern Wake County definitely made it easier.” System. “We have a into South Carolina. Making things easier for physicians is the good understanding whole point of the Duke Physician Liaison of clinical processes and can give clinicians i Program—although, fortunately, most of detailed information about new services,” their interactions are not nearly so emergent. Sasser-Perry explains. “And being so familiar Duke physician liaisons are available Launched in 2002, the program deploys two with the Duke system, we can quickly help to help regional physicians 24 hours a liaisons—Sasser-Perry and Phyllis Fowler—to them access almost any information or service day, 7 days a week. For assistance with some 150 medical practices a month to offer they might need.” a specific need or to request a visit to information and practical assistance to region- “We also understand how busy our referring your practice, page 919-970-8008. al clinicians. physicians are,” adds Fowler. “We’re careful “The program works along the lines of the to respect their time. We’re on page 24 hours pharmaceutical representative model,” says a day, and we are committed to helping them director Alan Millikan, who developed the get the answers they need in a timely way.” program. “But instead of marketing phar- Nandini Lahiri, MD, a family medicine maceuticals, our goal is to build better practitioner in Apex, North Carolina, has relationships between Duke and commu- appreciated the service. “I think many of us nity physicians by meeting with doctors in the community would like to send patients in a meaningful way to see how we can to Duke but sometimes it’s difficult to get an serve them better. We want physicians and appointment,” she says. “Our liaison helps us other providers in the community to see arrange appointments whenever we ask her. Chris and Phyllis as a resource—someone She’s also helped us understand what Duke they can call with any question or request. offers—she told us about the specialty services We promise to get them answers and solu- at Duke’s new clinic near Southpoint Mall, and tions quickly.” even brought a new Duke cardiologist based The liaisons share information about new in Raleigh by the office to meet us and tell us and existing clinical services at Duke, let about his practice. It’s been very helpful to us.” DukeMed 9 DUKEMED NOW

Rankings roundup DUKE RANKED HIGH in this year’s U.S.News & World Report lists of The rankings of 177 medical centers, winnowed from 6,012 hospitals the nation’s top graduate and professional programs and best hospitals. across the country, highlight 17 specialties. Duke was ranked in 16: Three educational programs showed up in the top 10 lists of their peers: 3rd Heart & Heart Surgery 9th Kidney Disease The Physician Assistant program retained its first-place ranking, and 4th Geriatrics 9th Rheumatology the Duke School of Medicine maintained its position as fourth among 6th Cancer 11th Psychiatry the nation’s research schools (preceded only by Harvard, Washington 6th Gynecology 15th Hormonal Disorders University, and Johns Hopkins). The Physical Therapy program ranked 7th Urology 18th Neurology & Neurosurgery #10. The Duke School of Nursing was ranked #29 in the nation. Its 7th Respiratory Disorders 21st Pediatrics nurse anesthesia program maintained its position as #6 and its geriatric 8th Orthopedics 27th Ear, Nose and Throat nursing program ranked #8. 8th Digestive Disorders On the magazine’s Honor Roll of best hospitals, Duke University For more information, visit 8th Eyes Medical Center ranked sixth in the nation. Others rounding out the top www.usnews.com six included Johns Hopkins, the Mayo Clinic, Massachusetts General Hospital, Cleveland Clinic, UCLA Medical Center, and the University of California-San Francisco Medical Center (tied for #6).

Duke is one of five top American medical schools featured in the new book U.S.News Ultimate Guide to Medical Schools.

Nursing school aims for PhD School leaders believe a new doctorate program could send it into the top tier

CHANGES KEEP COMING at the Duke Elizabeth Clipp, PhD, who co-chairs the pro- more than 100 million citizens living with University School of Nursing. With a success- posal steering committee along with professor chronic illness. The program would also build ful new bachelor’s degree program and a new Ruth Anderson, PhD. “They first appeared on the school’s already strong ties with other dean (see page 80), school officials are now in the 1970s, and started to flourish only in researchers across the university, and help proposing another ambitious initiative: estab- the 1980s. These programs have proven that Duke address a growing shortage of PhD lishing a PhD program. nursing research generates valuable knowl- nursing faculty nationwide. Nationwide, Duke’s is the highest-ranked edge and empirical information.” The proposal was seconded by new nursing nursing school without a PhD program, and If approved by Duke University’s Academic dean Catherine Gilliss, DNSc, who arrived at officials say the program could help boost the Council and Board of Trustees, the PhD Duke Oct. 1. Gilliss praised the faculty and university’s smallest school into the nation’s program would start in fall 2006 with four former dean Mary Champagne for bringing elite. The initiative also recognizes that nursing to six students in a 54-credit, four-to-five- the proposal to fruition. “I’m excited about education, while still focusing on professional year program. what this will mean for the school,” she said. training, can play an important scholarly role The program would focus on “Trajectories in the study of human care. of Chronic Illness and Care Systems”— This article originally appeared in the Duke “The idea of a doctoral program in nursing addressing one of the critical health care Dialogue. is still relatively new,” says nursing professor issues facing the U.S., which currently has DukeMed 10 Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) DukeMed CLINICAL UPDATE

A-Mazing treatment for A-Fib A NEW TREATMENT for recalcitrant atrial placed on the surface of the beating heart fibrillation (A-Fib) uses microwave technology heats the desired locations, creating lesions to block the irregular electrical signals respon- in the atrial wall without cutting. Scar tissue sible for the heart arrhythmia. forms around these lesions in the months Thoracoscopic Maze (or MicroMaze) is a following the procedure. During MicroMaze, minimally invasive variation of the Cox-Maze, the surgeon can also staple off the left atrial developed by Duke surgeon James Cox, MD, appendage, significantly reducing the risk of around 1990 to treat A-Fib. In the original ischemic events, stroke, or blood clots. Maze procedure, small precise cuts are made Appropriate candidates for thoracoscopic into the atrial wall, creating a maze around Maze include any adult with atrial fibrillation the areas in which abnormal electrical signals and no prior history of chest surgery, espe- are traveling. Scar tissue created by these cuts cially those at high risk for embolic events. In the minimally invasive thoracoscopic Maze permanently blocks the abnormal paths and Performed in conjunction with other cardiac procedure, a flexible microwave probe placed form a single maze-like route for the electrical procedures (such as CABG or mitral valve on the heart’s surface creates lesions that later impulses to travel from the top to the bottom replacement), MicroMaze adds only 15 or scar over, blocking irregular electrical signals. of the heart. But Cox-Maze requires the 20 minutes to the surgery. Most patients are surgeon to open the sternum and place the released the day after the two-hour proce- nique is Sinan Simsir, MD, who performed the patient on cardiopulmonary bypass, so it was dure and can return to work within the week. world’s first six MicroMaze procedures at the usually performed in conjunction with another About 70 percent of patients are cured by University of Massachusetts before coming to open-heart procedure, such as coronary artery MicroMaze. Duke this year. Because MicroMaze has only bypass surgery (CABG) or valve replacement. Duke is one of only four U.S. medical been in use for about two years, says Simsir, By contrast, MicroMaze is a video-assist- centers currently offering the procedure, long-term outcomes are not yet available. ed thoracoscopic surgery (VATS) performed which is fully FDA-approved and Medicare- However, he adds, “If my dad had chronic through six small incisions (<1mm each) on the reimbursed. Among the handful of surgeons A-Fib, I would recommend it for him.” side of the chest. A flexible microwave probe nationwide with expertise in the unusual tech-

Don’t let the bedbugs bite THE BEDBUGS ARE BACK! No, it’s not a reunion of an obscure ‘60s rock group. It’s the tiny insect—once associated with cheap motels and dirty boarding houses—that is checking into upscale hotels and pristine homes in a number of states. DDT wiped the pests out in the 1950s, but experts believe they’re hitching rides in the suitcases of international travelers and becoming bedfellows with their favorite source of food—humans. These apple seed-sized nocturnal nuisances reside not only in mattresses and box springs, but also in the cracks and crevices of the room they infest, including behind and beneath baseboards, beneath area rugs, between carpeting and walls, and even in the folds of curtains and drapes. Since they only come out at night, it can be difficult to figure out exactly what’s bugging you while you sleep. They leave red welts reminiscent of fleabites, but one of the bedbugs’ calling cards is a smell in the room often described as “sickly sweet.” Duke pediatric dermatologist Neil Prose, MD, first became aware of the bedbug’s reappearance two years ago when he saw a 10-year-old girl with itchy red sores on her feet. A biopsy revealed that she had been bitten by an unknown insect. Her mother went on a nighttime raid, captured a few of the perpetrators among the girl’s bedclothes, and found an exterminator that got rid of them. The experience prompted Prose to coauthor an article about the recurrence of bedbugs for Pediatric Dermatology [manuscript accepted]. Changes in pesticide practices may be contributing to the bedbug explosion, Prose says. DDT is outlawed, of course, and exterminators are turning more toward ridding homes of insects with gel baits, which don’t attract bedbugs, instead of sprays. In addition, exterminators more often apply narrow-spectrum insecticides that target specific infestations. Although they can harbor pathogens, there’s no evidence that bedbugs transmit disease. Secondary infections are not uncommon, anemia occasionally occurs in those with numerous bites, and allergic reactions are possible. And thinking about them makes most people’s skin crawl. Are you scratching yet? DukeMed Visit Duke University Health System online at dukehealth.org 11 CLINICAL UPDATE

A new weapon against breast cancer A NEW BREAST CANCER DRUG called lapatinib inhibited tumor growth in nearly half of women who took it for eight weeks in a national Phase I clinical trial. The results are quite encouraging because lapatinib is one of the first drugs to elicit a response in women whose tumors did not respond to at least two traditional therapies, including trastuzumab (Herceptin), says oncologist Kimberly Blackwell, MD. Trastuzumab is the frontline drug used to treat women whose tumors overproduce a growth- regulating protein called Her-2. The drug blocks the Her-2 receptor on cancer cells and inhibits its signaling, thereby shrinking or stabilizing the tumor. But nearly one-third of tumors with Her- 2 over-expression do not respond to trastuzumab, and 59 percent of the patients in this trial had progressed through three or more traditional cancer drugs. Lapatinib represents a new type of therapy because it targets not only Her-2 but epidermal growth factor (EGFR). “Blocking the action of two growth factors has a more profound effect on inhibiting cell growth than blocking a single growth factor, and we think this dual action is responsible for the positive effects we’re seeing,” says Blackwell. The study was funded by GlaxoSmithKline, the maker of lapatinib.

Acupuncture fights nausea, vomiting, pain after breast surgery IN THE FIRST SUCH CLINICAL TRIAL OF ITS KIND, Duke research- the lower arm with wrist. ers have found that acupuncture is more effective at reducing nausea According to Chinese and vomiting after major breast surgery than ondansetron (Zofran), the healing practices, there are leading medication. In addition, patients who underwent the 5,000- about 360 specific points year-old Chinese practice reported decreased postoperative pain and along 14 different lines, increased satisfaction with their postoperative recovery. In conducting or meridians, that course the trial, the researchers also demonstrated that the pressure point they throughout the body just stimulated possesses previously unknown pain-killing properties. under the skin. Recent About 70 percent of women who undergo major breast surgery research suggests that acu- requiring general anesthesia experience postoperative nausea and vom- puncture stimulates the iting (PONV), says anesthesiologist Tong Joo (T.J.) Gan, MD, who led release of endorphins, the the trial. These adverse side effects are important factors in determin- body’s natural painkillers, ing how soon patients can return home after surgery. Gan says. In the trial, Gan employed an electro-acupuncture device in which Interestingly, low-fre- an electrode—like that used in standard EKG tests—is attached at the quency modulation of the appropriate point. Instead of actually breaking the skin with the tradi- electro-acupuncture device appears to release one type of endorphin tional long slender needles, the electro-acupuncture device delivers a that produces analgesia of slower onset but longer duration. When small electrical pulse through the skin. Electro-acupuncture enhances or higher frequencies are used, the body appears to produce another type heightens the effects of traditional acupuncture and is more convenient of endorphin that provides rapid analgesia, but of shorter duration. in a busy operating room, Gan says. Study results appeared in the September 22, 2004 Anesthesia The electro-acupuncture was applied at the sixth point (P6) along & Analgesia. the pericardial meridian, which is located two inches below the bottom of the palm of the hand and between the two tendons connecting DukeMed 12 Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) CLINICAL UPDATE

Surgery sans transfusions Duke University Hospital opens North Carolina’s first center for patients seeking surgery without the use of blood products

WHEN DERL G. STALLARD recently under- “We now have a variety of medications to went surgery for nose and sinus cancer, he increase the production of red blood cells, and his family were able to concentrate on his boost blood volume, reduce bleeding, and recovery instead of worrying about violating enhance blood clotting,” Hill explains. These their religious beliefs. may include the use of surgical devices such as As Jehovah’s Witnesses, the dentist from a beam coagulator (which clots blood during Maggie Valley, North Carolina, and his family surgery) and techniques such as electrocautery chose Duke University Hospital (DUH) because (cauterizing behind the incision) to help reduce the surgery could be performed without using blood lost during surgery. Hemodilution, a blood products. process that involves drawing off, then reinfus- “This means a great deal, not only for me ing the patient’s own non-stored blood at the and my family, but for literally thousands end of his or her surgery, is another important of those who would appreciate it because clinical strategy within the transfusion-free of our religious beliefs,” says Stallard. medicine and surgery program. New sub-q heparin “Jehovah’s Witnesses go anywhere across Patients requesting blood conservation ser- the country seeking medical attention where vices through the CBC will meet individually more convenient we feel there is the skill and the ability to do with members of the care team, including a THREE STUDIES led by Duke Clinical surgery without blood.” physician, to discuss the available options. Research Institute cardiologists have While bloodless health care services are pri- The concept of blood conservation and shown that the ease and convenience of marily requested by people for reasons of faith, avoiding transfusion is gaining broad appeal a newer formulation of the blood-thinner others are increasingly choosing this health not only among patients but among medical heparin, called enoxaparin, appear to care alternative because of concerns about professionals because it is simply good make it the drug of choice for treating blood-borne diseases such as Hepatitis C or medicine, says CBC program manager Pam patients with suspected heart attacks. HIV, personal preferences, or other health ben- Pennigar, a nurse practitioner. Benefits of Enoxaparin has comparable and some- efits associated with transfusion-free medicine bloodless surgery include faster recovery times, times better mortality outcomes than the and surgery. shorter hospital stays, reduced costs, and older formulation, found the researchers. To help meet those needs, DUH became better management of the increasingly scarce However, they said, the studies’ results did one of the few tertiary care medical centers in resource of donated human blood. not provide clear-cut evidence of superiority the nation to offer a formal program for the of enoxaparin. Additionally, they stressed For more information about the Duke Blood use and advancement of bloodless or trans- that based on their results, patients should Conservation Center or to make an appoint- fusion-free surgery with the opening of the not be switched from one formulation to ment, call Pam Pennigar at 919-668-2467 Duke Center for Blood Conservation (CBC) the other during the course of treatment. or 1-866-500-4515, or call 1-888-ASK-DUKE. September 1. Unfractionated heparin is given “We offer patients a number of treatment intravenously and requires continuous options to eliminate the need for blood trans- monitoring to ensure proper blood levels fusions,” says anesthesiologist Steven Hill, MD, of the drug. Enoxaparin is given by sub- who co-directs the CBC with Jeffrey Lawson, cutaneous injection in fixed dosages and MD, PhD, a general and vascular surgeon. does not require blood level monitoring. Blood conservation techniques involve optimiz- The results on nearly 22,000 patients were ing red blood cell production before surgery, published in three reports in the July 7, 2004 as well as using alternative surgical techniques Journal of the American Medical Association. to decrease blood loss during surgery. DukeMed Visit Duke University Health System online at dukehealth.org 13 CLINICAL UPDATE

Use statins early and often after MI PATIENTS SUFFERING from acute coronary Decaf with dinner, diabetics syndromes should be treated with cho- PEOPLE WITH TYPE II DIABETES who have trouble controlling their blood glucose levels lesterol-lowering drugs known as statins should consider eschewing caffeinated drinks, according to Duke researchers who found a early and aggressively, according to strong correlation between caffeine intake at mealtime and increased glucose and insulin levels an international clinical trial involv- in that population. ing investigators at the Duke Clinical The researchers examined how oral caffeine capsules affected carbohydrate metabolism in Research Institute, the University of Texas 14 habitual coffee drinkers with Type II diabetes. Although they found that caffeine did not Southwestern Medical Center, and the affect fasting levels of blood glucose or insulin in comparison to placebo, they did find signifi- Brigham and Women’s Hospital. cant effects on both following a meal. The benefits of statins in reducing the Diabetics do not metabolize glucose as efficiently anyway, and if caffeine is further impairing risk of heart attacks have been demonstrat- their metabolism of meals, they ought to consider avoiding it altogether, says James D. Lane, ed in patients with stable coronary artery PhD, lead author of the study published in the August 2004 Diabetes Care. disease or those at risk for a future heart attack. However, the current trial was one of the first to examine the benefits of giving patients statins in the hospital shortly after treatment for their heart attack symptoms. Protein at the heart of cardiovascular Physicians have traditionally taken a less aggressive approach to lowering cholesterol disease in diabetics in their heart patients after discharge from DUKE RESEARCHERS BELIEVE that increased these drugs have been shown to decrease the hospital, researchers said. Typically, phy- levels of a receptor and an inhibitory protein in cardiac Gαi levels,” says Duke pharmacolo- sicians have tried to lower cholesterol levels the heart may explain why heart patients with gist Madan Kwatra, PhD, principal investigator by beginning with dietary approaches and diabetes are at a much greater risk of cardio- of the study published in the Aug. 26, 2004, then slowly adding or increasing the use of vascular disease or heart attacks than patients Diabetes. “That class of drugs is already very statins, they said. without diabetes. well understood and has very few side effects.” “The results of the current trial, as well as The researchers found that while levels of In collaboration with Duke endo- two previous trials, suggest that an early the protein, called Gαi, gradually increase crinologist Mark Feinglos, MD, the and aggressive use of statins can reduce the with age, this increase is almost twice as researchers will soon begin a study to measure long-term incidence of heart attacks, death high in diabetic patients. The finding is levels of Gαi in the from heart attack, stroke or readmission important, the researchers said, because blood cells of to the hospital for a cardiac event,” says elevated levels of this receptor protein can the patients Duke cardiologist Michael Blazing, MD. He lead to dilated cardiomyopathy, in which the with Type II presented the results of the trial in Munich heart loses its ability to pump blood effectively diabetes. at the annual scientific sessions of the throughout the body. Untreated, this condi- European Society of Cardiology meeting in tion often leads to congestive heart failure. late August. “Beta-blockers, which have been quite effective in improving the heart function of patients with congestive heart failure, would seem to be a likely candidate to reduce the risk of heart disease in people with diabetes because DukeMed 14 Cardiac risk minimal for migraine Full-body CTs: Buying peace of mind? patients using triptans and Zomig to patients with severe migraines migraines severe with patients to Zomig and CARDIACSTRESS TESTS ship with cardiac disease, according to Duke Duke to according disease, cardiac with ship drugs’effects. (NSAIDS). Migraines are caused by abnormal abnormal by caused are Migraines (NSAIDS). these drugs can constrict blood vessels in the in vessels blood constrict can drugs these with associated symptoms other and pain the first-time users of the class of migraine drugs drugs migraine of class the of users first-time migraine. However, studies have shown that that shown have studies However, migraine. Triptans inflammation. and activation nerve the on data analyzed have who researchers with heartdisease. drugs anti-inflammatory non-steroidal treatment with first-line to respond not do who known as triptans, even though concerns have heart, which could be hazardous to people people to hazardous be could which heart, relieve can and processes these with interfere been raised about the drugs’ possible relationpossibledrugs’ the about raised been H GOIG POPULARITY GROWING THE cedure may actually increase health risks and risks health increase actually may cedure a convenient location and the scan may only only may scan the and location convenient a subject the body to far greater levels of radia of levels greater far to body the subject essarily,” says Duke radiologist Nancy Major, Nancy radiologist Duke says essarily,” unnec therapy radiation to yourself expose of downsides potential the about educated toms of disease, you probably don’t want to to want don’t probably you disease, of toms tion thana standard X-ray. be to need consumers minutes, few a take the concern of many in the medical community. full-body CT scans among consumers raises raises consumers among scans CT full-body sn C a a ery ies-eeto pro disease-detection early an as CT Using voluntary total-body scanning, which can can which scanning, total-body voluntary possibly have other negative consequences. MD. “There are some very sensitive organs organs sensitive very some are “There MD. I yur feig el n hv n symp no have and well feeling you’re “If Clinicians prescribe triptans such as Imitrex Imitrex as such triptans prescribe Clinicians Even though a scanning facility may be in in be may facility scanning a though Even are notnecessary for of voluntary voluntary of - - - - - The research is featured in the July 2004 issue 2004 July the featuredinresearch is The cardiac disease do not need exercise testing testing exercise need not do disease cardiac would otherwise who and disease cardiac author on the paper. “The risk of cardiac cardiac of risk “The paper. the on author senior and Center Medical University Duke at of sufficiently low that any reduction in the like the in reduction any that low sufficiently simplytoscreen them prior tostarting triptans. known without patients However, scientists. disease in a person with no signs of disease is disease of signs no with person a in disease Duke the saidtriptans, use not shoulddisease unnecessary test may be a roadblockunnecessarya besomemayfor test the Center for Clinical Health Policy Research Research Policy Health Clinical for Center the treated. Over-stressing cardiac risk or adding an not be considered for an evaluation for for evaluation an for considered be not patients,”Matchar,Davidsays directorMD, of lihood of a heart attack is far outweighed by outweighed far is attack heart a of lihood studies may not alter what will ultimately ultimately will what alter not may studies sive tests and doctor doctor and tests sive symptomatic. gonadal tissue, just to name a few that are are that few a name to just tissue, gonadal the thyroid gland, the lens of your eye, eye, your of lens the gland, thyroid the X-ray: this to exposed getting be would that that turns out to be be to out turns that may identify something something identify may becomes it before malignancy a nosing very radiosensitive.” visits that may not not may that visits ain otoe il mrv b, a, diag say, by, improve will outcome patient have not yet been done, it’s not known if if known not it’s done, been yet not have studies comparative Since them. to happen the of end the at given they’re information einatr expen benign—after “Migraines are under-diagnosed and under- and under-diagnosed are “Migraines Individuals who exhibit signs of cardiac cardiac of signs exhibit who Individuals Headache On the flip side, the scan scan the side, flip the On Patients also should understand that the the that understand should also Patients .

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“After menopause, when a woman’s risk of of risk woman’s a when menopause, “After 30 percent of migraine sufferers are women women are sufferers migraine of percent 30 cardiac events. “Migraines are most commonly a low-risk group for heart disease. Twenty to to Twenty disease. heart for group low-risk a drop bytwo-thirds.” the substantial likelihood of continued suffer continued of likelihood substantial the foundinyounger women, who are considered migraines occur in individuals at low risk for for risk low at individuals in occur migraines ingfrom debilitating migraines.” heart disease increases, the rates of migraine migraine of rates the increases, disease heart between ages 25 and 30,” Matchar says. says. Matchar 30,” and 25 ages between and at a steep price, Major says. She recom She says. Major price, steep a at and they what “sometimes anxiety, of lot a ating find, you could have lived with forever and not mendsnot having full-bodya CTscan unless a selling effect, in is, disease of symptoms no physicianorders it. consumers affluent to usually mind, of peace havespent a cent,”Major notes. be covered by insurance. Along with gener with Along insurance. by covered be Another consideration is that most most that is consideration Another CLINICAL UPDATE CLINICAL Doingafull-body CT scan on someone with 15 - DukeMed - - 16 Watch your Rxs for the elderly course of a year one in five elderly Americans elderly five in one year a of course commonly by presented risks the about cians according to established criteria known as as known criteria established to concern” of according “drug a as classified drug one prescription monitor to measures additional physi among awareness greater for need a scriptions for drugs considered potentially risky drugs with potential for severe adverse effectssevereadversepotentialfor withdrugs druguse, the team said. ers in the U.S. filled a prescription for at least at for prescription a filled U.S. the in ers the Beers list. Of those claims, half were for for were half claims, those Of list. Beers the manag benefits pharmaceutical largest the for elderly patients, according to a new study new a to according patients, elderly for MANY AMERICANS OVER AGE 65 AGE OVER AMERICANS MANY prescribed medications as people age and for and age people as medications prescribed whose benefits were processed by one of of one by processed were benefits whose n le pol—nldn te antidepres the people—including older in DukeMed emphasizes finding The researchers. Duke by The Duke researchers found that over the the over that found researchers Duke The Seething begets C-reactive protein considerable attention for its role in both promoting and and promoting both in role its for attention considerable researchers Duke stroke, and disease cardiovascular ne, otlt, n ml t mdrt dpesv symp depressive moderate to mild and hostility, anger, TEWS HATY PEOPLE HEALTHY OTHERWISE to underlie the plaque that forms inside arteries as they clog. promotes that substance a of levels higher produce toms predicting cardiovascular disease and stroke in initially initially in stroke and disease cardiovascular predicting inflammation, and inflammation has recently been shown shown been recently has inflammation and to inflammation, response in liver the by produced is It people. healthy havediscovered. CLINICAL UPDATE CLINICAL The Duke study is the first to link this combination of of combination this link to first the is study Duke The garnered has (CRP), protein C-reactive substance, The negativepsychological attributes higherwithlevelsof hold pre hold - - - - Archivesof Internal Medicine 2003, issue. [The article is available online at at online available is article [The issue. 2003, cations or classes of medications to avoid avoid to medications of classes or cations of California Los Angeles developed the the developed Angeles Los California of the (Valium), diazepam drug antianxiety and sant amitriptyline (Elavil, Endep, Vanatrip) Vanatrip) Endep, (Elavil, amitriptyline sant update of the Beers list, including 48 medi 48 including list, Beers the of update nenl Medicine Internal to have potentially severe adverse outcomes outcomes adverse severe potentially have to considered medications of classes or tions researchers reported in the Aug. 9, 2004, 2004, 9, Aug. the in reported researchers panel deemed 14 of those 28 medications medications 28 those of 14 deemed panel medica 28 named list The experts. of panel when taken by older people. people. older by taken when er ls b clig pnos rm a from opinions culling by list Beers http://archinte.ama-assn.org/ 8, Dec. their in older, or 65 age adults in The patients. elderly in use for inappropriate Mark Beers and a team at the University University the at team a and Beers Mark CRP in people without without people in CRP who are prone to to prone are who k s i r l a n o i t i d a r t factors for heart heart for factors disease, says psy says disease, chologist Edward Suarez, PhD. In In PhD. Suarez, earlier studies, studies, earlier published a more recent recent more a published . ] - -

Archives of of Archives Suarez said his findings could also explain why people with people why explain also could findings his said Suarez anger,hostility,to prone are who people that found Suarez clearly established but without an underlyingmechanismto anwithout established clearlybut at increased risk for cardiovascular disease and stroke. stroke. and disease cardiovascular for risk increased at appar why for account could symptoms depressive and and system immune the of arm inflammatory the activates increased with stress to respond symptoms depressive and Results ofthe studyare published inthe September2004 grade inflammation. This inflammation is characterized by by characterized is inflammation This inflammation. grade explain why. entlyhealthy individuals have higher CRPlevels andare thus hormone stress this in increase an that suggests evidence triggers the expression of genes that cause chronic, low- chronic, cause that genes of expression the triggers riskcardiacfor eventsearlyand death—a linkthatbeenhas increased at are depression of symptoms moderate to mild production of the stress hormone norepinephrine.Scientifichormone stress the ofproduction PsychosomaticMedicine highlevels of CRP, hesaid. The DukestudyThedemonstrates thatanger, hostilebehavior, - -

Genetic Economics and lead author of the the of author lead and Economics Genetic obntos sy Lse Cri, h, a PhD, Curtis, Lesley says combinations, drug or drugs inappropriate prescribe cians databas claims a useful tool tool useful a study. Physicians’ compliance with the guide the with compliance Physicians’ study. she adds, noting that the elderly are rarely rarely are elderly the that noting adds, she es could offer offer could es the clinical evidence for the risks presentedby risks the forevidence clinical the and prescriptions screening by problem reduce the help to member of the Duke Center for Clinical and and Clinical for Center Duke the of member particular drugs when taken by older patients, older by taken when drugs particular sun ptetseii aet we physi when alerts patient-specific issuing included in the clinical trials that generate generate that informationabout drugs’ side effects. trials clinical the in included lines might also be improved by bolstering bolstering by improved be also might lines Pharmaceutical Pharmaceutical . - CAUTION - - -

CLINICAL UPDATE

First stop for globetrotters FOR YEARS RALEIGH-BASED WRITER Elaine globetrotters cope during their visit and return malaria, there are no existing vaccines, so Neil Orr longed to revisit her native Nigeria. home disease-free. If a patient does catch a everyone traveling one of the 100+ countries But as a kidney-pancreas transplant recipi- bug, however, clinic medical directors Ralph where malaria occurs should take antima- ent on immunosuppressive medication, Orr Corey, MD, and Daniel Sexton, MD, are certified larial medications with them. Malaria, caused couldn’t risk receiving a booster for yellow in tropical and travel medicine and knowl- by four species of the Plasmodium parasite fever, a live virus vaccine. “I was always con- edgeable about numerous diseases not seen in and transmitted by mosquito bites, remains vinced that the dream of returning to the land this country. the most prevalent serious infectious disease of my birth and youth kept me alive through A new-patient visit involves reviewing the worldwide. Plasmodia that are resistant to my health crisis,” Orr says. “But receiving a traveler’s medical history, along with pro- chloroquine, the long-used preventive therapy, yellow fever vaccination could kill me.” viding individualized educational materials, have developed in several regions, includ- So Orr turned to the Duke International general information about safety, security, ing the Indian subcontinent, so it’s vital that Travel Clinic for help. Clinic nurse Karen and health issues, and prescriptions for nec- patients take the right antimalarial medication Angelichio coached Orr on ways to repel mos- essary medications. Trip-specific required for the area being visited. quitoes, the vectors for yellow fever as well as vaccinations can be administered during the Duke also has an International Travel Clinic malaria, and to avoid visiting during the rainy initial visit, and it’s important to consider for children and an International Adoption season, when mosquito populations soar. After receiving the recommended vaccina- Clinic, both directed by pediatric infectious making two trips to Nigeria without problems, tions as well: Foreign governments require disease specialist Emmanuel Walter, MD. One Orr completed a recently published memoir immunizations to prevent travelers from car- of only three in the country, the Adoption about her youth, The Gods of Noonday: rying a disease into their country and are not Clinic offers pre-adoption counseling and A White Girl’s African Life. necessarily concerned with illnesses travelers review of any medical records, photographs, Americans make an estimated 45 million may contract during their visit. It’s also essen- or videotapes the prospective parents have trips to international destinations each year, 20 tial to bring your standard U.S. immunizations received, and consultation or complete primary million of them to rural settings or developing up to date before embarking on any foreign care services once the child arrives here. countries. Staying healthy during foreign travel, Angelichio says. The overall greatest risk to globetrotters travel requires more than vacci- Preventive measures are is traveler’s diarrhea, so knowing what foods nations—before departure, especially crucial when and beverages to avoid and what actions general and destination- people have to to take if symptoms develop is key to avoid- specific information travel on short ing dehydration and the need to seek out about health and safety notice and don’t medical care. And the leading cause of death issues helps have time to in international travelers under the age of 55 receive all is something that no medication can prevent— the immuni- vehicle crashes, largely due to poor road zations. And conditions and vehicle maintenance. About for certain 750 Americans die and 25,000 are injured in d i s e a s e s , vehicle crashes abroad each year. Travel Clinic notably personnel can discuss ways to reduce these risks. Travelers can also check the Web site of the Association for Safe International Road Travel (http://www.asirt.org/) for country-specific information.

For appointments at the adult International Travel Clinic, call 919-668-3190; for the pediatric clinics, call 919-620-5374.

For more information visit dukehealth.org (search under “International Travel Clinic.”) DukeMed Visit Duke University Health System online at dukehealth.org 17 18 DukeMed Dzau’s Victor J. Dzau, MD, has been Duke’s wrapping up paperwork at home late in the evening, between whirlwind trips to Boston (where medical centerandhealthsystemtostuffseveralfilingcabinets. hundreds of meetings with people inside Duke and out and absorbed enough data about the about data enough absorbed and out and Duke inside people with meetings of hundreds occa the and organization) nonprofit busy a of president as term her completing is wife his already packed in enough activity to keep a regular Joe busy for six years. In the office by 7 a.m., chancellor for health affairs for just under just for affairs health for chancellor sional jaunt to Washington for an NIH meeting or Berlin to pick up a research prize, he’s held he’s prize, research a up pick Washingtonto to Berlin jaunt or sional meeting NIH foran he’s seems sometimes it but months, six early B Braunwald,MD, putsDzaualreadyit,has created significant leadershipnew positions, Gynecology, who served as vice chair of the search committee that recruited Dzau. “It’s major campus-wide initiative in global health, and sketched out early priorities for a for priorities early out sketched and health, global in initiative campus-wide major forgedstrongworking relationships acrossuniversity,the helpedplantseeds thefor a ly quick study with “extraordinary creative energy,” as his Harvard mentor Eugene Eugene mentor Harvard his as energy,” creative “extraordinary with study quick ly clear he’s already making a major impact.” pressed they are with how quickly and effectively Dr. Dzau has advanced on the field,”the onadvanced has Dzau effectivelyDr. andquickly how with are theypressed the Herculean task of moving the institution forward in new directions. A famous A directions. new in forward institution the moving of task Herculean the says Charles B. Hammond, MD, former chairman of the Department of Obstetrics/ of Department the of chairman former MD, Hammond, B. Charles says strategic plan to guide Duke medicine over the next five years. “I’ve had several administrators and faculty members come up and tell me how im how me tell and up come members faculty and administrators several had “I’ve Duke health enterprise in such a short time, but the fact that he’s already begun chancellor is not just how well he has gotten to know the sprawling and complex ut what seems to have impressed the Duke community most about their new new their about most community Duke the impressed have to seems what ut

the ground running ground the hits affairs health for chancellor new duke’s BY MINNIEGLYMPH days 19 - - - DukeMed 20 TAKING THE REINS TAKINGTHE 62,000 inpatient admissions and 1.6 mil 1.6 inpatientadmissionsand62,000 June 2004, a 14-member search com search 14-member a 2004, June Health funding. And there’s the health health the there’s And funding. Health Health Affairs Ralph Snyderman, MD, MD, Snyderman, Ralph Affairs Health There’s the research engine, among the the among engine, research the There’s withcomponent,educational the There’s Chancellor Emeritus William Anlyan, MD, mittee drew up a long list of requirements deep a requires today centers medical of Institutes National in five top nation’s health the in students and residents thor a resemble does enterprise medical forsuccessorhis scouredandcountrythe organization complex a such jockey fully oughbred in superbly synchronized stride. Duke the gallop”—and full at horse a of changing of process the compared once over 100 nominees—including some of some nominees—including 100 over coor to ability the component—and each academic facing hurdles myriad the over by then-Duke President Nannerl O. O. Nannerl President then-Duke by for Chancellor longtime After leader. success To year. each visits clinic lion combined a handle that services health academic medicine—the field narrowed narrowed field medicine—the academic meet could whosomeone forbeyond and in down step would he that announced during which the committee considered considered committee the which during multitasking multitalented, ceptionally instituthe moveactivities theirtodinate 2,500 some training programs of dozens reins the over “handing to chancellors physician practices and community community and practices physician sciences. biological and professions pointment was announced April 27, 2004, to one: Victor Dzau of Harvard. His ap His Harvard. of Dzau Victor one: to in leaders successful most country’s the search, seven-month a After all. them tion forward as a whole. understanding of the needs and goals of goals and needs the of understanding DukeMed far-flung and hospitals system—three It’s a big job, one that demands an ex an demands that one job, big a It’s ------

“Life is about people and family,” and people about is “Life Dzaushave two daughters: Merissa, 2004a graduate of the University for women and children who are victims of domestic violence. The violence. domestic of victims are who children and women for Keohane and Richard H. Brodhead (who (who Brodhead H. Richard and Keohane this fall. of Rochester, and Jacqueline, who entered medical school at Duke at school medical entered who Jacqueline, and Rochester, of fessional experience with the personal personal the with experience fessional extremely well.” enough to tackle a job of the breadth and breadth the of job a tackle to enough capa stronger had Dzau Dr. opinions and enthusiastically Dzau ommended bilities in more areas,” he says. “He had had “He says. he areas,” more in bilities became president July 1). yet he seemed young enough and vibrant and enough young seemed he yet a proven track record as an administra an as record track proven a strategistasa andleader inBoston’s com physician-scientist,a and asbalance and says Dzau, shown here with his wife of 31 years, Ruth. Mrs. Dzau is Dzau Mrs. Ruth. years, 31 of wife his with here shown Dzau, says urnl peiet f eod tp a opot hrtbe organi charitable nonproﬁt a Step, Second of president currently ceremony. “His impressive experience experience impressive “His ceremony. qualitiesandvision neededlead tooneof pro of breadth remarkable a combines petitive health care arena, will serve Duke ters,” Keohane said at Dzau’s introduction cen medical academic great world’s the tor, educator, scientist, and practitioner, practitioner, and scientist, educator, tor, rec Bostock, J. Roy emeritus trustee ain n otn ht rvds rniinl rgas n housing and programs transitional provides that Boston in zation unanimously, adds Hammond. “We con “We Hammond. adds unanimously, scope Duke offered. our in but people, amazing some sidered “He also combined the strong academicstrongcombinedthealso “He Dzau Victor that believe us of “All The search committee, led by Duke Duke by led committee, search The ------THE ROAD TO DUKE TO ROAD THE Blending business and academics comes academics and business Blending China, in 1947, Dzau is the son of a busi a of son the is Dzau 1947, in China, medicine at an early age, through his fa his through age, early an at medicine manu chemical a owned who nessman Shanghai, in Born Dzau. to naturally the of complexities strategic and nancial fying it can be to help people and care forcarepeoplehelpand to becan fyingit chemistry taught and company facturing of health care during the illnesses of his his of illnesses the during care health of Kong, Hong to fled family The ernment. where Dzau spent the next 13 years. fi the manage to savvy business the with health system. and understand to needed background young child his father’s factory was closed and stroke. “I learned early on how grati how on early learned “I stroke. and gov Zedong’s Mao by taken assets its and a was Dzau When level. university the at chart the direction of the medical center center medical the of direction the chart ther’s influence and his own observations that in the country.” grandparents, who died of tuberculosis tuberculosis of died who grandparents, “There aren’t a whole lot of people like like people of lot whole a aren’t “There Dzau became interested in science andscience interestedin became Dzau ------

He then crossed to the West Coast, tak Coast, West the to crossed then He (BWH). Hospital Women’s & Brigham Dzau there, From Canada. Montreal, Massachusetts General Hospital, and and Hospital, General Massachusetts Theory and Practice of Physic—the old Physic—the of Practice and Theory ing on a variety of leadershipvarietyofpositionsaat on ing Unitedanothercountry:theyet to moved and colony, the in available was than ing reasonsI’mdoing whatdonow—to I keep for the sick and relieve suffering, to im to suffering, relieve and sick the for est endowed professorship in medicine medicine in professorship endowed est ogy and chair of medicine. he earned both bachelor’s and medical medical and bachelor’s both earned he train medical better for overseas him better system.” long way to go. That is probably one of the academic medicine has to offer. A dedi A offer. to has medicine academic a and BWH at research of director and physician-in-chief,medicine, of chair as well 1791—as in established Harvard, at prestigious the at atherosclerosis and medicine vascular of chief becoming ally joined he Harvard, at fellowships and much a create to management good and leadership good through perhaps and Stanford, including the chief of cardiol of chief the including Stanford, citizen him grant would which States, community hospitals and clinics. residenciesand Cornell at internshipcal in University McGill from degrees prove care through advances in research, research, in advances through care prove tem, a vast concern that includes BWH, BWH, includes that concern vast a tem, the of Professor Hersey the become to eventu school, latter the at faculty the care to commitment fundamental that tremendously a had medicine that me to apparent also was “It says. he sick,” the self with enthusiasm into everything everything into enthusiasm with self sys HealthCarePartners of leader senior medi a completing After 1990. in ship Dzau’s family saved money to send send to money saved family Dzau’s In 1996 Dzau returned to Harvard Harvard to returned Dzau 1996 In Over the years, Dzau has thrown him thrown has Dzau years, the Over ------

“ Maybe I can be described as a multitasker,” Duke isn’t uni-dimensional, it’s multi it’s uni-dimensional, isn’t Duke like institution An exciting. that find I educational support to School Medical NIH grants supporting his efforts to de to efforts his supporting grants NIH The high standards it holds as an aca an as holds it standards high The Council to spark collaborations, provide provide collaborations, spark to Council velop gene- and cell-based therapies therapies cell-based and gene- velop medical students to share their perspec their share to students medical inviting for known is and innovation, directionsnew forresearch, amongother make it among the best American medi American best the among it make education—all innovative the provides, it it’s what is forward institution the move for cardiovascular disease, and is pas is and disease, cardiovascular for how youcanmovetheinstitutionforward iswhatit’sallabout.” efforts. An award-winning teacher, he he teacher, award-winning An efforts. of its parts.” whole becomes even greater than the sum house calls during his early years of prac of years early his during calls house Harvard at Academy the found helped strategize and programs, research ling and compelling about coming to Duke. Duke. to coming about compelling and all about. That’s what I found so attractive Research a created he BWH At well: as dimensional, and thinking multidimen thinking and dimensional, created new programs to improve care for by stops now even who researcher cated cal institutions today. I want to bring bring to want I today. institutions cal demicenterprise, highthequality ofcare practical and financial support for fledg for support financial and practical tasker,” he says (putting it mildly). “But “But mildly). it (putting says he tasker,” the underserved. and physicians of thousands with tems sys delivery care guided has Dzau tice, made who clinician A meetings. at tives the lab at least twice a week, Dzau has four says Dzau. “But I ﬁnd that exciting. An institution like Duke is multi dimensional, and thinking multidimensionally and creatively about synergy to all these pieces so that the the that so pieces these all to synergy cancreativelyyou sionallyhow andabout scientistssupportingotheraboutsionate “Maybe I can be described as a multi a as described be can I “Maybe ------

“He has really reached out to sample a very to have laurels—we our on rest can’t “We A MAN WITH A PLAN A WITH MAN A William J. Fulkerson, MD, CEO of Duke Duke of CEO MD, Fulkerson, J. William Dzau has lost no time in pursuing that that pursuing in time no lost has Dzau Duke University Health System (DUHS). (DUHS). System Health University Duke me impressed has that thing “One Duke. University Hospital and vice president ofpresident vice and HospitalUniversity in research funding, unacceptable levels levels unacceptable funding, research in and costs rising uninsured, of number is the tremendous amount of time he he time of amount tremendous the is medicineat Duke to look like in five years want we what determine to process ning fairest decisions.” of medical errors and safety problems. problems. safety and errors medical of broad base of opinions to help get the the knowledgeneedsmakebesttheandheto get help to opinions of base broad many as with talk and meet to taken has at medicine about learning in himself fu the for prepared be and efficient be and as part of the larger university as well.” phy system, health schools, nursing and vi shared a create to want I beyond. and and well to benefit our patients. competitionbetween providers, cutbacks increased reimbursements, dwindling growing a inequalities, care—health health facing challenges of host a citing come together and see themselves as one— people as possible—leaders and staff in in staff and possible—leaders as people to facetodifficult times ahead,” predicts,he tem as well as in the community,” says says community,” the in as well as sys tem health the and center medical the early thing right the do to have We ture. goal, and with good reason. “We are going sician practices, and so forth so that they that so forth so andpractices, sician medicaltheamongsharedgoals and sion “So we are engaging in a strategic plan strategic a in engaging are we “So Toward that end, Dzau has immersed immersed has Dzau end, that Toward - 21 DukeMed - - - - - 22 “Just buying other hospitals does not make As in-depth planning gets under way, way, under gets planning in-depth As Dzau has already outlined several early early several outlined already has Dzau ing groups across the institution. In his his In institution. the across groups ing work creating and assessments, market and organizational directing group, ning need to continuethinkingtogetheraboutto need for Partners HealthCare, as chief strategic also he chancellor, as appointment first how to deliver the right care in the right right the in care right the deliver to how has Dzau 2005, spring by plan hensive EARLYPRIORITIES charged DUHS leaders with forming a forming with leaders DUHS charged DUHS. within integration greater create posi strategist high-level new, a created planning efforts—forming a core plan core a efforts—forming planning place at the right time.” to is says, he goal, major One priorities. planning officer for DUHS (see page 62). tem, Dzau believes. Toward that end, he he end, that Toward believes. Dzau tem, tive director of specialty care development execu former O’Neill, Molly hiring tion, us a health system,” he points out. “We out. points he system,” health a us DukeMed sys the across care top-quality same the orchestrating begun simultaneously With the goal of proposing a compre a proposing of goal the With Patients should be able to expect the the expect to able be should Patients ------“ Victor and I both came here as relative strangers relative as here came both I “ and Victor “I’ve seen this in Massachusetts, where where Massachusetts, in this seen “I’ve Frush, MD, was appointed as DUHS’s DUHS’s as appointed was MD, Frush, needs in Wake County, for example, and and example, for WakeCounty, in needs unmet and burden, disease mographics, de population the understand to need think to need “We locations. various in first patient safety officer; she will reportofficer;willpatientsafetyfirst she we need there.” has also emphasized the need to create create to need the emphasized also has aggressively about how to encourage more Systems Alignment group to share best best share to group Alignment Systems directly to Dzau.) Karen October, (In safety. and quality practices and learn from each other. He He other. each from learn and practices patients to come to Duke,” he says. “We says. he Duke,” to come to patients ter of economic survival, he points out. out. points he survival, economic of ter specialistsand services what decide then strategically about which services to build for standards measurable system-wide, adopt toinformation sharedandsystems Brodhead, PhD (left), who became president of Duke University July 1. to Duke, but we share an immense enthusiasm for what we’ve foundwe’veenthusiasmimmensewhat for an share we butDuke, to ee n fr h opruiis ht i aed” as ihr H. Richard says ahead,” lie that opportunities the for and here At the same time, Duke will be thinking Suchnetwork planningsimple ais mat - - “Victor brings a perspective on systems systems on perspective a brings “Victor And five years later it makes an acute dif acute an makes it later years five And California and Boston health care mar care health Boston and California com the for programs or scanners, CT integration from a more mature health health mature more a from integration investin improving patient care, which is have we sure make to want We munity. ference, because those hospitals aren’t aren’t hospitals those because ference, of a group that worked out the merger of merger the out worked that group a of our fundamental purpose.” re to and job our do to resources enough kets should prove valuable in achieving achieving in valuable prove should kets competitive the in systems care health margin. profit a make couldn’t hospitals and also oversaw mergers and specialty specialty and mergers oversaw also and rooms, operating better in invest to able care development at Partners, which which Partners, at development care the Stanford and UCSF health systems, systems, health UCSF and Stanford the part was Dzau Fulkerson. says goal, that some that intense so is competition the started five years earlier than DUHS. DUHS. than earlier years five started Dzau’s experience leading academic academic leading experience Dzau’s - - - -

“continuum that links the most abstruse abstruse most the links that “continuum As Dzau told faculty members at a recent a at members faculty told Dzau As ACADEMIC ASPIRATIONSACADEMIC rded eety hrceie a a as characterized recently Brodhead translation, discovery, Duke—inquiry, very exciting.” need to clear the pathway.” ization,conflicts of interest, etcetera. We therapies and methods diagnostic into ob an have we discoveries, great making to improvements practical with research ambitious have to want “We meeting, It’s further. even Duke take can we ning it should not be something we do solely solely do we something be not should it for society by translating those advances advances those translating by society for one of the great academic medical cen medical academic great the of one entrepreneurial. “Some may say that’s that’s say may “Some entrepreneurial. overthenext fewyears, looking atways to walking away from the fundamental aca fundamental the from away walking hasn’t made it easy for us to do that, withthat, do to usfor easy it madehasn’t ligation to think about how we can do good enter academic the and clinical the both all the barriers surrounding commercial surrounding barriers the all actual lives.” President service—which and adoption, commercialization route.” discoveriespatientswithouttakingtheto socialdoimprove and healthcareto it do indeed and university, a of values demic prise.” And he believes those efforts will efforts those believes he And prise.” partner with industry and become more more become and industry with partner to make money,” he stresses.“Wemoney,”hemake to should that benefit man,” Dzau says. “But society plan strategic with believes he but ters, good. And there is often no way to bring bring to way no often is there And good. go furthest when pursued in tandem. of terms in aspirations bold and goals strengthening translational medicine medicine translational strengthening already “We’re says. Fulkerson system,” “As a university and as a medicalschoola asuniversity anda “As He points to five core endeavors at at endeavors core five to points He Dzau says he will make a priority of of priority a make will he says Dzau ------“Victor clearly se clearly “Victor MD, CEO of Duke University Hospital (left). “In the short time he’s time short the “In (left). Hospital University Duke of CEO MD, in Durham.” en ee h hs led bgn okn wt cmuiy lead community with working begun already has he here, been and outside the walls of the medical center,” says WilliamFulkerson, says center,” medical the of walls the outside and ers to identify ways Duke can be an even greater positive force here force positive greater even an be can Duke ways identify to ers Duke’s interdisciplinary strengths, per strengths, interdisciplinary Duke’s Medicine,Engineering,Interdisciplinary scientistsbringto need wethink do I But Corgentech,shepherdingis development vironment that lets science flourish. Duke en of kind the build to Lange Peter vost] in fields such as the humanities and so and humanities the as such fields in in clinical trials. of this,” Dzau adds. “I think we can create ence lie and how we can prepare ourselves sci offrontiersopportunities—where the is two the between distance the and ers, has that graft bypass artery coronary a of hapsareasinsuchsystems as biology and research clinical and basic excellent has been genetically modified to help prevent on based companies two create helped additional opportunities to capitalize on capitalize to opportunities additional and Applied Sciences] are great examples for [Center CIEMAS and Policy and [medical with working to committed am currently is therapy the atherosclerosis; cial sciences, to think about our future future our about think to sciences, cial to reach them. researchers with together and together, I and face, investigators challenges the One, lab. his in developed technologies shorter than any other place I’ve seen. seen. I’ve place other any than shorter [pro and Williams Sandy dean] school “The Institute for Genome Sciences Sciences Genome for Institute “The As a researcher, he says, “I understand“I says,researcher, he a As Dzau knows whereof he speaks: He has Hespeaks: whereofhe knows Dzau es our responsibilities both inside both responsibilities our es ------Dzau Era at Duke, but I’d say everyone can measures as applied to patients—‘clinicalto applied asmeasures human to relevant discoveries notable regenerative medicine.” firsts’histerminology.in We arestilla in biology and disease, and to pioneer new new pioneer to and disease, and biology says discussions, such to insight” keen be entirelyinspiringconfidentsomebethat and creative new initiatives will emerge.” diagnostic, preventive, and therapeutic therapeutic and preventive, diagnostic, advancing for passion my shares clearly “Victor MD. Williams, Sanders R. dean planning stage with respect to the signa the to respect with stage planning ture programs that will characterize the the characterize will that programs ture truly make to faculty our of ability the Dzau has brought “fresh energy and and energy “fresh brought has Dzau

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DukeMed

24 “Addressing health disparities is one of the deﬁning issues of our time. our of issues deﬁning the of one is disparities health “Addressing “We’re on the same campus, we should be should we campus,same“We’re the on And he is determined to make their inteltheirmakedetermined tois he And Williams has done a lot to reach out and and out reach to lot a done has Williams Dzau believes one of Duke’s chief advan chief Duke’s of one believes Dzau Besides, we like each other and like test like and other each like we Besides, How can you have a country with such enormous wealth, such amazing technologies and medicines, and medicines, and technologies amazing such wealth, enormous such with country a have you can How GOING GLOBAL GOING ing out ideas on each other.” interaction.” in which Duke has a special opportunity opportunity special a has Duke which in yet have so many people who don’t have access to it?” Dzau says. “If you translate it to the rest of the world, first days, Victor and I have had a closely a had have I and Victor days, first the on center medical its having is forts of the defining issues of our time,” Dzau Dzau time,” our of issues defining the of to committed we’re and success, other’s We often. more even talk and week ery with Richard Brodhead and Peter Lange Lange Peter and Brodhead Richard with him in championing the issue. partnership.productive highly a building system health the that understand both working we’re and bridges, those build lectual connection as close as the physical. and the university are essential to each each to essential are university the and described global health as crucial area area crucial as health global described ev meet relationship—we consultative “Sandy says. he together,” things doing technologies and medicines, and yet yet and medicines, and technologies joined has Dzau and 5), page (see lead to Brodhead speech, inaugural his In ties. dispari health global address to tiative closer for opportunities about think to ef interdisciplinary pursuing in tages the discrepancybecomesevenmoreapparent.” such enormous wealth, such amazing amazing such wealth, enormous such with country a have you can “How says. ini university-wide a steam—creating university.oftherest the campus assame

DukeMed one is disparities health “Addressing Indeed, says Brodhead, “From our our “From Brodhead, says Indeed, One big idea is already gathering gathering already is idea big One ------“genius” grant recipient who has devoted devoted has who recipient grant “genius” Dzau, Brodhead, and Lange began that that began Lange and Brodhead, Dzau, Tracy Kidder that was required reading reading required was that Kidder Tracy Mountains more apparent.” from Paul Farmer, MD, a Harvard phy Harvard a MD, Farmer, Paul from our citizens. was followed by a two-day campus visit visit campus two-day a by followed was and together all this bring to ought we compassionate— and passionate are who people young have we resources,have we himself to improving health care for the the for care health improving to himself lieves.“We have 90percent of the market be he doors, Duke’s outside right begins ac have don’t who people many so have MAKING A DIFFERENCE A MAKING a health system, we have a medical school, address to work wonderful doing already responsibility the fact, In abroad. and difference.” have We locally. and globally disparities for thing right the do to obligation dous tremen a have we care, of provider cipal home at both discrepancies, such dress of rest the to it translate you If it? to cess cussion on global health during the the during health global on cussion poor in Haiti and other communities. His summit That inauguration. presidential dis panel a with September in process think about ways in which we can make a make can we which in ways about think discrepancyevenbecomesthe world, the story is the subject of subject the is story MacArthur and alumnus, Duke sician, prin the “As says. he Durham,” in share “We have people across Duke who are are who Duke across people have “We Dzau thinks Duke can do much to ad to much do can Duke thinks Dzau , a book by Pulitzer prizewinner Mountains Beyond Beyond Mountains ------Hr i a ia o boeiie a re a biomedicine, of titan a is “Here During his visit,FarmerDuringhisleaders with met Inequalities to create a sustainable sustainable a create to Inequalities Health and Medicine Social of Division Dzau helped develop divisions of women’s beyond looked also he “But says. Farmer munity to share ideas and information information and ideas share to munity nowned researcher, an astute leader, a leader, astute an researcher, nowned from across Duke and the Durham com Durham the and Duke across from year. this Duke at freshmenincoming for famous educator . . .. Social medicine and edu research, training, for framework as them strengthen I can how and fields, other for several years—in fact, as chair chair as fact, years—in several for other of medicine at BWH, Dzau was Farmer’s Farmer’s was Dzau BWH, at medicine of work would outlast its founders. training for pathway a create to wanted world’s great medical visionaries.“ health equity were not on the front burn front the on not were equity health healthand pharmacoepidemiology as well he says, Farmer years, the Over boss. about current global health activities un activities health global current about and his colleague Jim Kim, MD, start a start MD, Kim, Jim colleague his and as a Center for Genetics and Genomics. der way at Duke and Harvard. cation, and service. In particular, Dzau Dzau particular, In service. and cation, departmentchair?’” For example, hesays, the of “one as Dzau of think to came to redress health inequalities, so that the thatinequalities, healthsoredress to physicians young of generation next the cutting-edge the are ‘What say, to that department,” our of vision research the to central remained science basic that “I was very surprised,” says Farmer. Farmer. says surprised,” very was “I “Victor was very sensible in making sure Dzau and Farmer have known each each known have Farmer and Dzau In 2001, Dzau proposed that Farmer Farmer that proposed Dzau 2001, In - - - - -

THE REAL BOTTOM LINE BOTTOM REAL THE As Dzau begins the balancing act that is is that act balancing the begins Dzau As But our decisions can’t be driven by the the by driven be can’t decisions our But firming our value system and communi and system value our firming er of any other American teaching hospi teaching American other any of er we went into medicine, to do the right right the do to medicine, into went we we’ve become close friends, I’ve seen that wrong.Ididn’t know these things were so here—which is the fundamental reason reason fundamental the is here—which reaf keep don’t we If itself. line bottom he will weigh those decisions. pay that those with efforts humanitarian balance to how to research, grow to how to system, delivery care the shape to how decisions—from tough of host a faces he a compassionate business.” cating to people why we are doing things, doing are we why people to cating don’t have infinite resources, and we need cherishes most of all.” dear to him, but over the last few years, as portanttomake plain the values bywhich was I central. was felt he what of purview thing for our patients. we’re why ourselves reminding keep to second- to them for reason every is there to be efficient and look at the bottom line. im it’s thinks he And bills. electric the Duke, at medicine of chancellorship the he ones the be may values humane these the of out fall would it thought I and tal, guess our decisions. That’s why we need need we why That’s decisions. our guess “Health care may be a business, but it’s but business, a be may care “Health “We do run a business,” he says. “We says. he business,” a run do “We - - - - In the spring Dzau will present a strategic plan strategic a present will Dzau spring the In is clear: “I want to create a common vision and shared goals among all the components of medicine at Duke,” says Dzau, “so that the whole the that “so Dzau, says Duke,” at medicine of components the the next ﬁve years. While details are being over discussed, the system ultimate aim health and center medical the of development guide to becomes greaterthanthe sum of itsparts.”

25 DukeMed 26 DukeMed ADVANCES IN ARTHRITIS TREATMENT PUT PATIENTS BACK ON ON TRACK BACK PATIENTS PUT TREATMENT IN ARTHRITIS ADVANCES

STRETCHING THE LIMITS

Psychological interventions and relax and interventions Psychological more on the horizon. Exercise—once ta Exercise—once horizon. the on more and action is message new the ignation, early, aggressive treatment. New and and New treatment. aggressive early, ways to relieve pain and restore function. restore and pain relieve to ways boo—is now encouraged as one of the best with available, are drugs effective highly ation techniques can enhance the quality the enhance can techniquesation disease chronic a as viewed was arthritis cally changed. Instead of rest and res and rest of Instead changed. cally that progressed inexorably to disability. But today, arthritis care has dramati has care arthritis today, But was considered an inevitable inevitable an considered was osteoarthritis of tear and wear bed to “save their joints.” The The joints.” their “save to bed ar with people offer to little part of aging, and rheumatoid rheumatoid and aging, of part thritis besides painkillers, and painkillers,besides thritis generation ago physicians had had physicians ago generation sufferers were often sent to to sent often were sufferers BY CAROL KRUCOFF sicians are leading the push to improve treatment—and working to address the the address to working treatment—and improve to push the leading are sicians Rapid strides in research and treatment are yielding new strategies to relieve pain,relieve to strategies new yielding are treatment and research in strides Rapid national shortage of rheumatologists so more patients can get the care they need. improve function and slow—or even stop—disease progression. At Duke, phy Duke, At progression. stop—disease even slow—or and function improve - - - - - PhD. But those outdated notions are rap are notions outdated those But PhD. joint destruction can be averted. view that offers numerous opportunities opportunities numerous offers that view idly being replaced by “a more holistic holistic more “a by replaced being idly rheumatologistVirginia ByersKraus, MD, researchers,areDuke, includingat many fast identifying new ways to prevent ar prevent to ways new identifying fast except treat the symptoms,” says Duke Duke says symptoms,” the treat except pos and arthritis with people for life of we can do to help people feel better and and better feel people help to do can we lead productive, vigorous lives.” cal treatmentscalavailablelot there’s now,a arthritis about anything do really can’t to take action,” she adds. we replacement, joint of short that, tion thritisor pinpoint it early on, so pain and sibly even slow the disease process. And And process. disease the slow even sibly “With the self-care practices and medi and practices self-care the “With misconcep the have still people “Many 27 - - - - - DukeMed - 28 15 percent of the total U.S. population— U.S. total the of percent 15 Already, musculoskeletal conditions conditions musculoskeletal Already, approximately affects arthritis America, inflam joint means literally Arthritis A COSTLYA GROWING AND 70s. “OA consumes a major proportion proportion major a consumes “OA 70s. Kraus, “of a chronic, severe recession.” This is the financial equivalent, notes notes equivalent, financial the is This results from a combination of environ of combination a from results impact of OA.” find to important more even becomes it population, the of longevity increasing dif 100 than more to refers and mation mental factors, including trauma, occu trauma, including factors, mental ferent diseases that affect the joint and and joint the affect that diseases ferent of pathologic processes,” says Kraus. “The among ranking dollars, care health of ways to decrease the clinical and financial be the final common pathway of a number up affecting disease, the of form lent in disability of cause leading The bones. HEALTHPROBLEM about 40 millionadults—andprojected40aboutis challenge of the next decade is to define define to is decade next the of challenge disease,“Osteoarthritis isnowthought to one than Rather components. cartilage process This swelling. and pain ciated developeddomesticcountries.productin grossofpercent 3 ofaverage an consume pation, and lifestyle, as well as hereditarypation,lifestyle,asandwell as traits, such as gene mutations that affect affect that mutations gene as such traits, asso and inflammation, joint tendons, surrounding of stretching bone, in tures microfrac causing joints, cushions that cartilage the erodes gradually OA thritis, “With says. Kraus in world,” developed the problems care health three top the and 60s their in people of percent 70 to 2020. by million 59 than more strike to DukeMed surroundingtissues, musclessuchas and Osteoarthritis (OA) is the most preva most the is (OA) Osteoarthritis Sometimes called “degenerative” ar “degenerative” called Sometimes

------is diagnosed, irreversible damage has has damage irreversible diagnosed, is OAtimethe often, tooby all that, is ment on X-ray, and that’s where the process process the where that’s and X-ray, on dis through progresses “OA occurred. osteoarthritis, and improving treatment. begins.”Other imaging techniques—such as MRI and ultrasound—have the poten the ultrasound—have and MRI as including OA, of subsets the classify and commonly used in clinical practice. “We practice. clinical in used commonly invisible is “Cartilage says. Kraus cess,” pro the in late relatively occur changes leading currently is Kraus causes.” cific spe on based therapies specific devise peo predispose that genes the defining processof being validated, butare not yet predisposition to arthritis, detecting early pletovarious forms of thedisease, andto tial to detect disease earlier and are in the these but X-rays, with visiblestages tinct several studies aimed at mappinggeneticseveralatstudiesaimed A major problem with current treat current with problem major A • GET MOVING.GET Arthritis action plan Solution Thenew message aboutarthritis is simple: Don’t takejoint disease lyingdown. says Virginia Byers Kraus, MD, PhD, co-author of the new book book new the of co-author PhD, MD, Kraus, Byers Virginia says aerobically five to six days per week. To avoid overdoing exercise, remember the Two-Hour sity or duration of your exerciseyour time. of next duration or sity day of aerobic activity with a day of easy stretching, eventually progressing to exercising to progressing eventually stretching, easy of day a with activity aerobic of day enhances well-being.) People who have been sedentary should begin by alternating one one alternating by begin should sedentary been have who People well-being.) enhances the joints. (Kraus’s own studies of water exercise for people with OA have shown that it it that shown have OA with people for exercise water of studies (Kraus’s own joints. the Numerous self-care strategies can relieve pain and inflammation and improve function, function, improve and inflammation and pain relieve can strategies self-care Numerous progression. Water exercise and recumbent bicycling are particularly well-suited to people progression.to Waterwell-suited are particularly recumbentbicycling exercise and with arthritis, since they activate the large muscles of the body while minimizing stresson minimizing while body the of muscles large the activate they since arthritis, with Rule: If you have more than two hours of discomfort after exercise, cut back on the inten the on back exercise,cut after discomfort of hours two morethan have you If Rule: improves a patient’s ability to walk on land, decreases overall disability,and overall decreasespain, reduces land, on patient’swalk a improvesto ability .Kraus advises people with arthritis to: Exercise can be as important as medication to control disease severity and severity disease control to medication as important as be can Exercise ------Biomarkers Network, funded by a $4.6 $4.6 a by funded Network, Biomarkers joint destruction.” is a thermal scanner sensitive enough to enough sensitive scanner thermal a is at intervene can we so tools better need for new biochemical markers of OA in in OA of markers biochemical new for future, the In osteoarthritis. of stage first of a degree Fahrenheit. Kraus used this this used Kraus Fahrenheit. degree a of prevent “and says, she stages,” earlier bodyfluids. chairAsof theOsteoarthritis osteo of effectiveness the evaluate help average—a sign of inflammation—in the the inflammation—in of sign average—a arthritis treatments. clinical hand osteoarthritis, and found found and osteoarthritis, hand clinical withpeople 91 of studyrecent a indevice tenthtemperaturedetectdifferences a of that the finger joints are warmer than than warmer are joints finger the that temperature with thermography could could thermography with temperature signs of the disease, Kraus is searching searching is Kraus disease, the of signs joint in changes for checking says, she Tofurther help clinicians identify early One potential tool for early diagnosis diagnosis early for tool potential One The Everyday Arthritis Arthritis Everyday The - - “Yet surprisingly, if that excess weight is is weight excess that if surprisingly, “Yet • • • • • • THE OBESITY CONNECTION OBESITY THE PhD, director of orthopedic research. research. orthopedic of director PhD, they biomarkers identifying team Duke of group a leads she (NIAMS), Diseases Obesity has long been recognized as a as recognized been long has Obesity risk of OA.” To try to solve this and other and this solve to ToOA.”try of risk same the carry doesn’t it fat, not muscle, reason the “but OA, for factor risk major rently available. InstituteNational the from grant million overloading the joints with excess weight excess with joints the overloading of Arthritis and Musculoskeletal and Skin eral other Duke colleagues began meet began colleagues Duke other eral wears them down,” says Farshid Guilak, Guilak, Farshid says down,” them wears was thought to be purely mechanical—that hope will be much more specific indica specific more much be will hope puzzles about OA, Guilak, Kraus, and sev and Kraus,Guilak, OA, about puzzles tors of joint degeneration than are cur are than degeneration joint of tors scientists at five institutions, including a institutions,includingfive at scientists REACH AND MAINTAIN A HEALTHY WEIGHT. TAKE SUPPLEMENTS. ADOPT A HEALTHYATTITUDE.A ADOPT EATRIGHT. REVIEW YOUR PRESCRIPTIONS WITH YOUR PHYSICIAN. YOUR WITH PRESCRIPTIONS YOUR REVIEW selenium (the amount in a standard multivitamin), calcium (1,200 mg/day) and vitamin D vitamin and mg/day) (1,200 calcium multivitamin), standard a in amount (the selenium (400 IU/day). A multivitamin, plus a calcium supplement, should suffice.should supplement, calcium a plus multivitamin, A IU/day). (400 evaluating the risks and benefits of other drugs in its class—it’sits in drugs other regularlyof reviewto benefits important and risks the evaluating tively can lead to improvements.33.] to page lead [See can tively recently withdrawn due to concerns about increased cardiovascular risk, and experts still still experts and risk, cardiovascular increased about concerns to due withdrawn recently your prescriptionyour regimenphysician. drug your with pharmacologic treatments for arthritis—with the popular pain medication rofecoxib (Vioxx) (Vioxx) rofecoxib medication pain popular the arthritis—with for treatments pharmacologic arthritis. exacerbate can that pounds excess avoid to fromdiet portions well-balanced a help relieve arthritis symptoms and prevent the disease from getting worse. Eat appropriate Eat worse. getting from disease the prevent and symptoms arthritis relieve help Proper nutrition, including eating at least five fruits and vegetables a day, may a vegetables and fruits five least at eating including nutrition, Proper Those that have been shown to potentially benefit joint health include Taking a “can-do” approach to arthritis and thinking posi thinking and arthritis to approach “can-do” Taking a - - - - inflammationarthritis,”relatesto Guilak notes Guilak. destruction,”cartilage and inflammation, factors, biomechanical among interplay well as experiments laboratory of range mul the netted that proposal a was result The 2002. in back lunch over weekly ing obesity relates to inflammation and how how and inflammation to relates obesity and arthritis plays a central role in the re arthritisthecentralandin roleplays a un on is focus “Our study. clinical a as condition linked to a number of diseases,ofnumber a to conditionlinked inflammatory mild a is obesity that cates coveringmechanismsthe governthat the to arthritis.” Emerging evidence indi evidence Emerging arthritis.” to relates obesity how explore to pieces two tidisciplinary team a five-year, $7 million grant from NIAMS to carry out a broad broad a out carry to NIAMS from grant such asatherosclerosis and some cancers, the together put had one no “But says. literaturehowlargesearch.“There’s ona arthritis affects about The leading cause of disability in America, and is projected to strike more than million by 2020. Ideally, keep yourBody Mass Index under 25. Unraveling the link between obesity obesity between link the Unraveling In an era of uncertainty about about uncertainty of era an In 40 million adults - - - - - “We’re exploring a variety of interactions, interactions, of variety a “We’reexploring TheArthritis Rehabilitation Program specializedtreatment plan, which andinsurance companies reimburse andland-based exercise. Medicare atDuke’s Center for Living offers a theArthritis Foundationaquatic class vestigatorspeFrancispainPhD,Keefe, a imposes on joints, it also causes a sys a causes also it joints, on imposes ing skills can actually alter underlying underlying alter actually can skills ing cop people teaching whether including much ofthe cost. Call 919-660-6659. may includeaquatic exercise, such as osteoarthritis of the knee to determine determine to knee the of osteoarthritis will study 280 overweight patients with with patients overweight 280 study will heightened a in body the put can which he notes. “What we now think is that, in in that, is think now we “What notes. he biological factors,” says co-principal in co-principal says factors,” biological physi inflammation, of biomarkers management weight lifestyle-based how addition to the mechanical load obesity obesity load mechanical the to addition and/orcopingskills training impactpain, circulating molecules, called cytokines, cytokines, called molecules, circulating cialist (see page 33). distress. psychological and disability, cal this predisposes people to OA changes.” temicfailure,” says.he “Fat cells produce state of inflammation. We want to see if if see to want We inflammation. of state The clinical portion of the research research the of portion clinical The ,

59 29 DukeMed - - - - - 30 “Since this would be the person’s own tis own person’s the be would this “Since Guilak, who recently proved that the the that proved recently who Guilak, in osteoarthritis, the team will perform perform will team the osteoarthritis, in flammation can interfere with this pro this with interfere can flammation mechanical that shown “We’ve factors. of different biochemical and immune immune and biochemical different of build new matrix.” a building block of cartilage, give rise to to rise give cartilage, of block building a outside cartilage build to attempting are cartilagetestingpigisolatedofpieces are disease transmission,” he says. en be can cells fat of tissue connective liposuc using “We’re cartilage. damaged cess,causing cartilage tolose itsability to cise—can help rebuild the matrix,” Guilak placed under pressure in the presence presence the in pressure under placed premature onset of osteoarthritis and we and osteoarthritisof onset premature three parallel studies with mice. “Severalmice. with studiesparallel three cartilage.makereprogrammed to be then notes surgery,” plastic from waste tion replace to used be could that body the exer normal in occur as knee—such the when affected is tissue the how see to genetic mutations in collagen, which is is which collagen, in mutations genetic can which cells, stem adult into gineered DukeMed no and rejection no be would there sue, in that shown also we’ve“However, says. stressesmatrixtheonof cartilage cellsin In a related experiment, the scientists scientists the experiment, related a In In the laboratory, Guilak and colleagues To help uncover the role of genetics genetics of role the uncover help To VirginiaKraus, MD, PhD ------“Our working hypothesis is that compro that is hypothesis working “Our Kraus to identify predictive biomarkers biomarkers predictive identify to Kraus XI is mechanically weaker, making it it making weaker, mechanically is XI more susceptible to the normal wear and wear normal the to susceptible more type collagen in low cartilage joint mised for OA. At the end of the five-year proj five-year the of end the At OA. for will collect blood samples and work with with work and samples blood collect will ate professor of biomedical engineering. engineering. biomedical of professor ate don’t understand why,” says co-princi says why,” understand don’t pal investigator Lori Setton, PhD, associ PhD, Setton, Lori investigator pal tear of everyday life.” In all of their experiments, the team team the experiments, their of all In - - - - When people begin noticing morning morning noticing begin people When MD, PhD, director of the Duke Arthritis Arthritis Duke the of director PhD, MD, midlife, “Many just assume this is what it’s that treatment preventative a identifying ect, Setton says, “We hope to have a bet a have to hope “We says, Setton ect, osteoarthritis, with the ultimate goal of goal ultimate the with osteoarthritis, like to get older,” says David S. Pisetsky, Pisetsky, S. David says older,” get to like could protect cartilage from erosion.” RARX:EARLY, AGGRESSIVE TREATMENT ter understanding of the mechanism of mechanism the of understanding ter stiffness in their joints, often around around often joints, their in stiffness Thermal scanning Thermal enough to detect differences of a tenth of a degree a of tenth a differencesof detect to enough osteoarthritis before joint changes are apparent on apparentare changes joint before osteoarthritis severity, joints tend to cool. Images, from left, show left, from Images, cool. severity,to tend joints X-rays—the current clinical standard for diagnos for standard clinical current X-rays—the the first stage of the disease, when X-rays produce X-rays when disease, the of stage first the are joints Finger osteoarthritis. of severity the to proportional is joints finger of temperature the mixed-temperature, warm, and cool joints. cool and warm, mixed-temperature, warmer than average—a sign of inflammation—in of sign average—a than warmer inconclusive findings. As symptoms increase in increase symptoms As findings. inconclusive sensitive scanner a using study a In disease. the ing Fahrenheit, Virginia Kraus, MD, PhD, showed that showed PhD, MD, Kraus, Virginia Fahrenheit, “For many patients, than single agents.” more effective combinations of medications are holds promise for detecting for promise holds —WilliamSt. Clair, MD -

“The data clearly show that the earlier you treat Americans—mostly women—their stiff women—their Americans—mostly joint tissue, causing inflammation and and inflammation causing tissue, joint Center. But for more than 2 million million 2 than more for But Center. nosed, a unique opportunity to slow—or slow—or to opportunity unique a nosed, actually aching and joints, swollen ness, even stop—the disease may have passed. body’s defense systems attack healthy healthy attack systems defense body’s complex a RA, to approach lutionary you treat rheumatoid arthritis, the better better the arthritis,rheumatoid treat you autoimmune disease in which the the which in disease autoimmune arrestactually can we therapy,aggressive the disease in many people.” early, “With says. Pisetsky outcome,” the diag are and physician a see finally they signal rheumatoid arthritis. By the time time the By arthritis. rheumatoid signal With early, aggressive therapy, we can actually arrest the disease in many people.” rheumatoid arthritis, the better the outcome. “The data clearly show that the earlier earlier the that show clearly data “The This early assault represents a revo a represents assault early This —David S.Pisetsky, MD, PhD,director of theDuke Arthritis Center - - -

1999, were another major breakthrough, breakthrough, major another were 1999, early in the course of the disease. These These disease. the of course the in early ease-modifying antirheumatic drugs such we parsed them out over time.” “so involved,”says,toxicityPisetsky with havelimiteda number of therapies, often years ago with the widespread use of dis of use widespread the with ago years als of infliximab at Duke. Still, anti-TNF Still, Duke. at infliximab of als in approved (Remicade), infliximab as Trexall) (Rheumatrex, methotrexate as drugs are “well tolerated at the doses we doses the at tolerated “well are drugs therapy only partially controls disease ac diseasecontrolspartiallyonly therapy such agents (TNF) factor necrosis tumor use for RA,” according to Pisetsky. Anti- Pisetsky. to according RA,” for use says E. William St. Clair, MD, who led tri ledWilliamMD,Clair, whoE.St. says to used “We damage. joint subsequent The picture began to change about 10 10 about change to began picture The

- - - Pisetsky, who is researching this “window ing to determine if such a window exists, exists, window a such if determine to ing itisuniquely responsive totherapy,” says riod of time early in the course of RA when more while images, X-ray as by measured damage, joint halted methotrexate plus infliximab with treatment that ing show study major a conducted recently responder rates are as high as 40 percent. of a recent $3.4-million federal grant grant federal part $3.4-million as recent a of examined be will that orders try are “We hypothesis. opportunity” of and if so how long it is open?” ceived the combination also reported reported also combination the re ceived who Patients worsen. to continued patients treated with methotrexate alone methotrexate with treated patients timing as well. “There appears to be a pe a be to appears“There well. as timing He says. Clair St. agents,” single than effective more are medications of tions tivitymostpatients,in notes,henon-and greater reductions in disability. RA is one of several autoimmune dis autoimmune several of one is RA combina patients, many “For Indeed, Treatment effectiveness depends on on depends effectiveness Treatment 31 DukeMed ------32 “Children just stop doing things that hurt. that things doing stop just “Children symp their about physicians tell “Adults Arthritis careArthritis And because they say they’re fine they of they fine they’re say they because And JRA kept diaries reporting their daily lev daily their reporting diaries kept JRA af (JRA), Arthritis Rheumatoid Juvenile Many people think of arthritis as a disease fects an estimated 150,000 children in in children 150,000 estimated an fects of aging, but it’s surprisingly common in commonsurprisingly it’s but aging,of els of pain (2 or 3 on a scale of 10) causedscaleof10) a on 3 or (2ofpain els saidchildren the diaries their In pain.of els of pain, activity, and stress. “One thing arthritis, even when treated, have more more have treated, when even arthritis, children to cut back on social activities. activities. social on back cut to children levels low report typically children clinic childrenwell.asThemost common form, percent of the days, and 31 percent said said percent 31 and days, the of percent pain than we realize,” says Schanberg. “In toms and complaints,” Schanberg says. says. Schanberg complaints,” and toms their pain was severe.” 70 than more on pain experienced they with children that is clear became that stiffness,pain,causingStates, United the DukeMed swelling, and even growth disorders. In a recent Duke study, children with with children study, Duke recent a In The study also found that even low lev low even that found also study The “Children just stop say they’re fine that hurt. And undertreated.” —Laura Schanberg, MD they often go because they doing things of Duke’s division of of division Duke’s of Schanberg,MD, co-chief pediatric rheumatology. treatment, says Laura Laura says treatment, subpar to lead can that their about adults than less complain to tend tis symptoms, however—and hlrn ih arthri with Children

for kids for ------

JRA flare-ups may frequently be mood- mood- be frequently may flare-ups JRA EglaRabinovich, MD, aredevoted makto n atclr uo ncoi factor- necrosis tumor particular in the methotrexate, as such drugs matory much that making are medications new ing sure children with arthritis receive the medication and stress reduction may be be may reduction stress and medication next few years, Schanberg says. found it particularly success particularly it found anti-inflam disease-modifying and fen child’spainthebring topriorities first is ful in treating inflammatory inflammatory treating in ful effectiveness in adults, and and adults, in effectiveness easier, says Schanberg. eye disease, a common con common a disease, eye highly inflammatory form that often often that form inflammatory highly biologic agents for systemic-onset JRA—a infliximab, etanercept, as such blockers her colleagues Deborah Kredich, MD, and and stress-related, treatment combiningtreatment stress-related, and and adalimumab. control—and under symptoms other and causes rash and fevers—will begin in the the in begin fevers—will and rash causes ditionchildrenin with arthri treat JRA based on the drug’s the on based JRA treat agents, biologic newer uses now team tailored treatment they need. One of their Carolinas,Schanbergtheand tologists in ten go undertreated.” tis. Trials of other promising promising other Trialsof tis. As three of the four pediatric rheuma pediatric four the of three As Duke has used infliximab to ibupro as such NSAIDS to addition In Since their research has shown that that shown has research their Since ------

“We also pay attention to the child’s school ing skills training, and man in effectivemost rheumatologists to fill the fellowship po fellowship the fill to rheumatologists techniques relaxation way to trainwaytomore doctors meettothepar walk with a child every step of the way.” adjust parents helping and needed when aging the condition. arthritis center for children, we can really schools the calling situation, family and counseling, pain-cop counseling, disorders.” pediatric become to want who doctors ticular needs of children with rheumatic rheumatic with children of needs ticular specialized a As illness. child’s their to Schanberg. says up,” come that things ‘daily-hassle’ with deal children help to group is working on solutions. Besides Besides solutions. on working is group sitions,” Schanberg says. “This is a great a is “This says. Schanberg sitions,” specialiststomeet demand. But the Duke “We recommend recommend “We As with adults, there aren’t enough enough aren’t there adults, with As “med-peds” fellowship program program fellowship “med-peds” rheumatologist to join their their join to rheumatologist pediatric fourth a recruiting boarded in both pediatric and and pediatric both in boarded adult rheumatology. that produces physicians fully fully physicians produces that innovative an started have they group (hopefully by July 2005), 2005), July by (hopefully group “Generallytherearen’tenough - - - -

“ By learning to manage pain, stress, and negative affect, you may be able to improve the function of the immune system and slow the course of the disease.” to establish one of nine nationwide —Francis Keefe, PhD, Duke pain specialist Autoimmunity Centers of Excellence at Duke. “This funding provides an exciting opportunity to expand our knowledge of fundamental disease mech- Another form of arthritis, gout, is the can make them miserable, and they have anisms and improve clinical care,” says subject of a study by assistant professor no other options. This could be a promis- St. Clair, principal investigator for the of medicine John Sundy, MD, PhD, who ing new therapy.” center. Current research includes two ba- received an FDA “orphan drug” grant to sic science projects aimed at developing examine the effect of intravenous PEG- EASING THE SHORTAGE autoimmune therapies and three clinical uricase (Puricase) on patients who don’t A frustrating factor, for both patients trials of specific medications for autoim- respond to standard therapy. “There is a and physicians, is that these advances in mune disorders including RA, systemic group of people who are intolerant to al- arthritis treatment come at a time when lupus erythemotosus, and primary lopurinol, the medication commonly used there is an international shortage of the Sjogren’s syndrome. to treat gout,” Sundy notes. “The disease very specialists who know most about

Pain, pain, go away It’s a common scenario: Someone with arthritis goes on vacation, is more physically active, yet hurts less.

“This isn’t a fantasy,” says Duke pain special- his research suggests that the way a partner ist Francis Keefe, PhD. “Emerging evidence responds might influence the patient’s pain suggests that distraction and mood may influ- and disability. ence whether or not a pain signal gets from While the mechanisms underlying these your spinal cord to your brain. This opens up effects are not yet known, “We do know that the idea that self-management can make a stress and negative mood can adversely affect major difference—not just in how a person the immune system,” Keefe says. “Since rheu- feels, but in disease activity and progression.” matoid arthritis has an immunologic basis, it Arthritis pain and disability arise from more could be influenced by factors that affect the than just biological factors, Keefe notes. immune system. By learning to manage pain, “Arthritis can make it difficult for people to stress, and negative affect, you may be able to engage in basic activities. This can result in improve the function of the immune system psychological changes, such as feelings of and slow the course of the disease.” In osteo- Francis Keefe, PhD helplessness, depression, and anxiety, and arthritis, inflammation may be a key factor, social changes, such as decreased ability to says Keefe, who is exploring these biological work and do chores.” and psychological connections in a current A wide range of self-help interventions are Helping patients cope with these changes study of people with knee osteoarthritis. available to encourage more active coping, can reduce their pain and disability, notes For now, Keefe says, “It’s clear that patients which Keefe says is associated with reduced Keefe, who teaches arthritis patients ways to do better with active coping rather than psychological distress, less swelling and pace their activity, how to relax in the face of passive coping. The patient I’d worry about fatigue, and improved marital adjustment. severe pain, and strategies for restructuring most is the one who is feeling helpless, resting negative thinking. Keefe also teaches spouses in bed too much, relying more and more on how to cope with their partner’s disease, as medications, and depending on others.” DukeMed 33 34 DukeMed 40 U.S. and 40 European sites and will will and sites European 40 and U.S. 40 Arthritis Rheumatology. “For a variety of reasons, reasons, of variety a “For Rheumatology. Pisetsky, St. Clair, and renowned Duke Duke renowned and Clair, St. Pisetsky, InflammatoryArthritis Study will include “ For a variety of reasons, fewer people have United States as were needed given the the given needed were as States United joined Duke’s division of rheumatology rheumatology of division Duke’s joined Ongranda scale, Pisetsky is coordinating matology,” says Lisa Criscione, MD, who MD, Criscione, Lisa says matology,” diseas related and arthritis of incidence managing the condition. also MD, Haynes, Barton immunologist fewer people have been going into rheu into going been have people fewer es, according to the American College of College American the to according es, early RA as a way to distribute the work the distribute to way a as RA early early treatment. begin enrolling patients in early 2005. 2005. early in patients enrolling begin Early The care. patient improve and load the in rheumatologists many as half a study focused on helping primary care care primary helping on focused study a counter runs which rheumatologist, a the as “And 2003. in immunology and date information about diagnosing and and diagnosing about information date textbook, new a co-edited ex not is which supply, than demand physicians identify and treat patients with re The soon.” anytime change to pected greater a there’s older, gets population tackling this problem on several fronts. fronts. several on problem this tackling and action urging message new the to about were there 2000, In disorder. the sult is often long waiting periods to see see to periods waiting long often is sult greater demand than supply, beennot goingexpected into which to rheumatology. change is anytime soon.” And as the population gets older, there’s a Duke researchers and clinicians are are clinicians and researchers Duke On the home front, Duke recently hired , that provides detailed, up-to- detailed, provides that , Rheumatoid Rheumatoid - - - - -

And in spring 2004, Criscione headed headed Criscione 2004, spring in And This accompanies a shift to “operatingas to shiftaccompanies Thisa very frustrating to sit idle when you knowyou when idlefrustratingvery sit to rheumatology consultation is necessary.” necessary.” is consultation rheumatology a if determine and management initial April, “In care. improve and times ing ity diagnoses. “For example, if someone someone if example, “For diagnoses. ity implementing a treatment plan.” four weeks with the next available available next the with weeks four we know we have a doctor to work with inwith work doctorto a havewe know we way we know someone has been evaluated from appointments accepting started we has—or is suspected to have—rheumatoidsuspectedto is has—or perform to physician care primary a by wait shorten to place in put been have arthritis,” she says, “our goal is to sched to is goal “our says, she arthritis,” appointmentscreatehubtolistof a prior because recommendations provide and time one patient a see we’ll “Often adds. she practice,” consultative more much a practi day every you calling doctors and wind we’d “then says, appointment,”she ac patient improve help to force task a Shanahan, MD, and Rob Geletka, MD. MD. Geletka, Rob and MD, Shanahan, cally begging you to see a patient.” “It clinics. rheumatology Duke’s to cess physicians only,” Criscione says. “That “That says. Criscione only,” physicians there are patients who need to see you, you, see to need who patients are there Joseph rheumatologists: additional two up with a 22 percent no-show rate. It’s It’s rate. no-show percent 22 a with up an get to months six to five take to used ule that person’s appointment within within appointment person’s that ule In recent months, several strategies strategies several months, recent In Criscione’s team also worked with the the with worked also team Criscione’s —Lisa Criscione, MD

- - - - -

eiw h cnut euss o non- for requests consult the review ists spend their time treating patients patients treating time their spend ists to someone refer possibly and mation working closely with referring doctors doctors referring with closely working a greater need and fewer specialists,” specialists,” fewer and need greater a pain a as such treatments alternative ae “er fcsn o inflamma on focusing “We’re care. their for one appropriate an is condition also rheumatologists The doctor.” clinic or orthopedics.” syndrome,” fibromyalgia like ditions priority diagnoses to make sure the the sure make to diagnoses priority patient care.” to do everything we can to improve improve to can we everything do to theycanhelpmost, Criscione says.“With special help will services core tology con tissue soft non-inflammatory rather than diseases autoimmune and tory she says, “there’s a strong emphasis on on emphasis strong a “there’s says, she infor more for ask may “We says. she Educating physicians about rheuma about physicians Educating For a list of Duke clinical trials The Duke Rheumatology Clinic ac currently enrolling patients with call 919-668-7630. cepts appointments from physicians; duke.edu arthritis, please visit . dukemedmag. i - 35 - - - - -

DukeMed 36 DukeMed Duke physicians are taking action Working on the vascular surgeon Robert Messier, MD. “It ing causes of death in the United States, States, United the in death of causes ing ing can easily identify patients at risk forrisk atpatients identifyeasily can ing is a large, conspicuous vessel, and screen over 15,000 people per year. with ruptured aortic aneurysms killing killing aneurysms aortic ruptured with heart and its coronary arteries—even arteries—even coronary its and heart on reliance total our despite But body. greater under works aorta the limbs, aortic disease is often overlooked.” symp no or few with But disease. aortic cardioDuketrouble,”says thethat’s and pressures than any other vessel in the the in vessel other any than pressures though aortic disease is one of the lead the of one is disease aortic though the of diseases to next shrift short get to tends health aortic artery, singular this toms until the situation becomes critical,becomessituation the until toms gists, and cardiologists are trying to shiftcardiologists totrying andgists,are a gallon of blood a minute to organs and organs to minute a blood of gallon a against aortic disease “Aortic disease is hidden in plain sight, plain in hidden is disease “Aortic At Duke, a group of surgeons, radiolo surgeons, of group a Duke, At blood vessels. blood the big kahuna of of kahuna big the duit to the body, body, the to duit heart’s con heart’s BY KARYN HEDE

Routing over over Routing It is the is It ------

The aorta is sometimes described as as described sometimes is aorta The venting a disastrous result. resembling a garden hose, but it is no no is it but hose, garden a resembling pre of chance best the has intervention cause that factors environmental and ic for Aortic Surgery combines state-of-the- eling in response to the forces it encoun it forces the to response in eling diagnosis, early prevention, to education, crisis medical a it’s when only ease lose its flexibility, grow stiff with age, and when screening, early for identified be andserious this on focusingattention by SPOTTING THE PROBLEM THE SPOTTING aims to understandtounderlyingaims the genet surgi and diagnostic comprehensive art, sur proactive appropriate, when and, develop ominous bulges—weaknesses in bulges—weaknesses ominous develop cal expertise with a research program that passive pipeline. It is constantly remod constantly is It pipeline. passive na disease aortic to devoted programs the vessel wall called aneurysms, which which aneurysms, called wall vessel the can aorta the tire, bike old an Like ters. theaorta tofail. The physicians hope that Southeast,the theirnewly formed Center in kind its of one only the and tionwide, gery. As one of the few interdisciplinary interdisciplinary few the of one As gery. underserved disease, more patients will will patients more disease, underserved from dealing with aortic dis aortic with dealing from e c n a l a b e h t

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OF THEHEART HIGHWAY

37 DukeMed 38 just under the collarbone all the way down most commonly affected. In addition, addition, In affected. commonly men most with (AAA), aneurysm aortic nal blood allowing open, split also may ing have historically fallen through the cracks, age 60 are estimated to have an abdomi an have to estimated are 60 age as dissection. lin aortic The rupture. to prone are diagnosed with thoracic aneurysm or aor thoracicaneurysmdiagnosedorwith to the lower abdomen, where it splits to to splits it where abdomen, lower the to archaortic the extendingfrom body, the tic dissection. are year per people of thousands of tens ves the of layers the between flow to specialty covers that much ground. medical one No legs. the to blood supply of much so traverses aorta the that is son rea the of part Ironically, Messier. says known condition lethal highly a wall, sel DukeMed Robert Messier, MD Despite their frequency, aortic diseases Some 5 to 7 percent of Americanspercentofover 7 to 5 Some Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) 1-888-ASK-DUKE call consumers and patients (633-3853), 1-800-MED-DUKE call Physicians - - - - -

‘You’ve got a good doctor.’” Anultrasound orCTscan of thechest and in the door with a historysmokingofanda with door the in more are physicians most since riphery, for an aortic aneurysm. I’ve had two pa two had I’ve aneurysm. aortic an for excellent internist, someone who is really were found that way, and I told them, them, told I and way, that found were you’ve got a 70-year-old guy who comes comes who guy 70-year-old a got you’ve abdomen provides a good initial screen screen initial good a provides abdomen screening. routine through disease aortic diabetes or elevated lipid levels. But if if But levels. lipid elevated or diabetes like things for screening with concerned training,” physician in enough quently cardiovascular disease, it’s a mark of an an of mark a it’s disease, cardiovascular paying attention, to palpate the abdomenpalpatethe toattention,paying tients in the last week whose aneurysms aneurysms whose week last the in tients so making it feasible to identifypotentialfeasibleto itmaking so pe the on falls often “It surgery. profes of sor assistant MD, Gray, John says “Aortic disease is just not featured fre featured not just is disease “Aortic Advances in imaging techniques are al are techniques imaging in Advances - - - - - 50 who have a history of carotid or coro or carotid of history a have who 50 rupture, which which rupture, patients high-risk benefit also can ing Messier, says smoking, and disease nary of heart attack with EKG. Routine screenRoutineEKG. with attack heartof or chest intense with presents who one with a family history of aortic disease, disease, aortic of history family a with bicuspidconnectiveaorticavalves, tisor as should emergency screening for any for screening emergency should as aorta or one with a visible aneurysm. Such cent of cases, cases, of cent in fatal be can po the to determine imperative comes tential risk of of risk tential inelastic distended, a up pick can that p o 0 per 80 to up evidence no shows but pain back upper sue disorder such as Marfan syndrome. screeningshould beroutine for menover Once aortic disease is detected, it be it detected, is disease aortic Once ------

In addition, the MRI enables velocity-enenablesMRI addition,the In which (DCMRC), Center Resonance For that reason, the MRI is a tremendousa is MRI reason,theForthat medi of professor assistant MD, Elliott, Visit Duke University Health System online at at online System Health University Duke Visit vessel involvement. to way noninvasive completely a vides in multipleobliqueMichaelangles,”insays without time over dissections and rysms magnetic resonance imaging, which gives entire aorta that allows them to quickly quickly to them allows that aorta entire of these cases, the dissection twists and and twists dissection the cases, these of branchpotential and flow blood aorticof radiation. ionizing to patients exposing MRI an contains 2002, June in opened help in surgical planning.” locate and assess any abnormality. and blood vessels. The cardiac MRI pro MRI cardiac The vessels. blood and cine in cardiology. “We can track dissec track can “We cardiology. in cine from aorta entire the image to capability gives that technique a mapping, coded doctors an exquisitely detailed view of the high into swings approach disciplinary patient undergoes three-dimensional three-dimensional undergoes patient physicians information about obstruction turns and is not always easy to make out. out. make to easy always not is and turns lot a In vessels. branch involving tion it at look to and iliac the to thoracic the aneu aortic in change and size the track gear. Immediately, any newly diagnosed diagnosed newly any Immediately, gear. specially designed for imaging the heart heart the imaging for designed specially inter Duke’s when is This Messier. says “The advantage of 3D MRI is its unique its is MRI 3D of advantage “The The Duke Cardiovascular Magnetic Magnetic Cardiovascular Duke The “ disease. But with few or no symptoms until the situation becomes critical, the disease is often overlooked.” and screening can easily identify patients at risk for aortic AORTICDISEASE ISHIDDEN IN PLAINSIGHT, —Robert Messier, MD, Duke cardiovascular surgeon and that’s the trouble. It is a large, conspicuous vessel, ------“Preliminary evidence suggests that in in that suggests evidence “Preliminary TREATMENTOPTIONS If caught early, aortic aneurysms can can aneurysms aortic early, caught If McCann, MD, chief of Duke’s vascular vascular Duke’s of chief MD, McCann, face it, the disease doesn’t know it’s sup it’s know doesn’t disease the it, face es, surgery becomes necessary. high Since medically. treated be often ease was handled by thoracic surgeons, surgeons, thoracic by handled was ease late in the process, he adds. In these cas these In adds. he process, the in late wall. artery the along plaque of buildup hopeful about the new statin drugs, which de to beta-blockers and pressure blood to contributor major a is pressure blood abdominal aortic disease by an entirely entirely an by disease aortic abdominal athero peripheral reducing to addition the aneurysm—atherosclerosis, aortic often are patients dissection, aortic to as disease gives no signs or symptoms until symptoms or signs no gives disease disease,” Messier points out. crease the forcefulness of the heartbeat. cally didn’t interact very much. But let’s let’s But much. very interact didn’t cally typi groups two the and group, different prescribed anti-hypertensives to lower lower to anti-hypertensives prescribed posed to be different in the chest than in thanchest the differentin be to posed target another condition associated with with associated condition another target well as aneurysms, of development the the abdomen. An aortic dissection can can dissection aortic An abdomen. the start in the chest and extend into the the into extend and chest the in start dis aortic “Thoracic section. surgery Richard says location,” its by segregated aortic reduce also may statins sclerosis, “Traditionally, aortic surgery has been been has surgery aortic “Traditionally, Messier says physicians are also very very also are physicians says Messier Unfortunately, in many cases, aortic aortic cases, many in Unfortunately, dukehealth.org ------

visceral organs. re-line the aorta from the inside. Starting in weeks more two and care, intensive in fering a minimally invasive method to to method invasive minimally a fering re and head the below body the to flow of a handful of major medical centers of centers medical major of handful a of a with up end we that is hope the organs, experi and the to perfusion chest better securing at enced the in operations in experienced team a have we If eases. with a high mortality rate, risks of para of risks rate, mortality high a with better result.” an aortic aneurysm was to shut off blood blood off shut to was aneurysm aortic an the to flow blood impairing abdomen, plegia and renal failure, eight to 10 days days 10 to eight failure, renal and plegia prosthetic graft. This is a major operation a with aorta of section diseased the place perspec multiple our bringing proach, the hospital. Now, however, Duke is one one is Duke however, Now, hospital. the dis aortic with patients to treatment comprehensive offer to together tives Ta’ wy er tkn a em ap team a taking we’re why “That’s Until recently, the only way to repair repair to way only the recently, Until

Michael Elliott, MD

39 ------

DukeMed 40 Aneurysmsofascendingthe archaortaor Because it’s much less invasive than tra than invasive less much it’s Because vessel to prop it open). is a fabric-covered mesh sleeve that sur that sleeve mesh fabric-covered a is eliminaterysmand threat theof rupture,” in a clinical trial testing a new-generation centers medical major other of number a with participating is Duke 2004, fall in outpatient follow-up. only a two- to three-day hospital stay with segment. diseased the exclude to ends best the “Currently, McCann. explains we use to relieve pressure on the aneu the on pressure relieve to use we aortaand anchor it in good tissue on both the inside stent the deposit They artery. femoral the up catheter a threading and aorta by making a small incision in the leg are not appropriate for this surgery.” aorta. descending the on aneurysm an a inside inserted cylinder (a stent aortic ditional surgery, the procedure requires requires procedure the surgery, ditional patientspatientsforsurgerythisarewith geons place in the descending thoracic thoracic descending the in place geons

DukeMed that stent big really a is this “Basically, The investigational thoracic stent graft stent thoracicinvestigational The Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) 1-888-ASK-DUKE call consumers and patients (633-3853), 1-800-MED-DUKE call Physicians to patients with aortic disease.” together to offer comprehensive treatment bringing our multiple perspectives “WE’RE TAKING A TEAM APPROACH, - - - While treating patients is central to its its to central is patients treating While Duke team discovered that people with with people that discovered team Duke GENETIC TEST AHEAD? TEST GENETIC s osaty eoee b cls n a in cells by remodeled constantly is dissections,”orMessier.rysms “Butsays is team disease aortic Duke’s mission, others are spared? we have recently learned that the aorta aorta the that learned recently have we happen correctly.” biologi a as acts that material a down lay aortic disease make fewer endothelial endothelial fewer make disease aortic about questionsfundamental asking also cal mortar in response to stress. It ap It stress. to response in mortar cal damage to the lining of blood vessels. The called endothelial progenitor cells, repair cells, These bloodstream. the in culating aneurysms—and with associated dition predispositions, including high blood blood high including predispositions, genetic certain and age with that pears aneu aortic to susceptible are people progenitorcells. Messier says hebelieves pressure,the remodeling process doesn’t the very nature of the disease. Why do do Why disease. the of nature very the the level of certain bone marrow cells circellsmarrowcertainofbonelevel the severity of atheroscleroticseverityof disease—a con cells These aorta. the of layer specific some people develop aortic disease, while “It is not well understood why some some why understood well not is “It Duke scientists have recently linked the —Richard McCann, MD, chief of Duke’s vascular surgery section - - - - -

Department of Medicine, showed that in that showed Medicine, of Department Goldschmidt. “Up until three years ago, ago, years three until “Up Goldschmidt. the of chair MD, Goldschmidt, vessel together.” endothe these know we Now vessels. ment of age-related aortic disease, and and disease, aortic age-related of ment interior the recoating and remodeling blood repair to cells of source a marrow bone the considered have would one no rosis in the aortas of older mice. atheroscle slow significantly could mice repair itself. timeaorta,overrepairtheanddamageto bone marrow cells and the aorta could could aorta the and cells marrow bone for responsible are cells progenitor lial bone marrow fails to make enough cells to yield novel therapies for the aging aorta, aorta, aging the for therapies novel yield atherosclerosiswhopeople general,in in trans disease, aortic of model mouse a a major cause of aortic disease is that aging damage outstrips the body’s ability to to ability body’s the outstrips damage planted donor bone marrow from young young from marrow bone donor planted stem cells may be used to slow develop slow to used be may cells stem transplanted Eventually, Messier. says surface that acts as a mortar and holds the pristine a with vessels blood of surface “This is a huge switch in thinking,”switchhugein asays “Thisis This newly discovered link between between link discovered newly This Studies in the laboratory of Pascal Pascal of laboratory the in Studies

- - - -

But if the repair capacity becomes over becomes capacity repair the if But MD, a Duke cardiologist. The research The cardiologist. Duke a MD, Visit Duke University Health System online at at online System Health University Duke Visit Goldschmidt and his Duke colleagues colleagues Duke his and Goldschmidt volved in the inflammatory/repair cycle, cycle, inflammatory/repair the in volved is designed to trigger a repair response. response. repair a trigger to designed is identify clusters of genes that may help us atherosclerosis, of development the in ers indicate bad things happening to the to happening things bad indicate ers ers analyzed the patterns of gene activ gene of patterns the analyzed ers we took the novel approach of trying to to trying of approach novel the took we accelerated inflammation see you where placeintofalls feedback loop whelmed, a better understand the progression of the of progression the understand better a specific gene that might be implicated implicated be might that gene specific a find to trying of “Instead disease. aortic and eventually a ruptured aorta.” aorta,”saysGoldschmidt. “Inflammation specific inflammation, between link a are predisposed to the disease. disease,” says lead researcher David Seo, Seo, David researcher lead says disease,” of signature genetic a for look to decided genetic markers, and aortic disease. W ko ta ifamtr mark inflammatory that know “We Using their understanding of genes in genes of understanding their Using The scientists have also uncovered uncovered also have scientists The and atherosclerosis in general.” gene-based diagnostic test for aortic disease, in a matter of a few years we will have a “I FEEL CONFIDENT THAT - - - - -

“We’ve now got most of the gross infor gross the of most got now “We’ve 1-888-ASK-DUKE (patients). For more information on aortic disease disease aortic on information more For mation we need, and it’s just a matter matter a just it’s and need, we mation Goldschmidt. says aorta,” the of rosis journal the in normalaortaidentifiedand specific gene and diseased from harvested tissue in ity in general.” con feel now I but this, said have not fident that in a matter of a few years we we years few a of matter a in that fident of refining the data. A year ago, I could could I ago, year A data. the refining of will have a gene-based diagnostic test forgene-baseddiagnostictest a have will percentgreateraccuracywith93than the aortic disease, and atherosclerosis atherosclerosis and disease, aortic appearedstudytheirofresults The aorta. person’s a in atherosclerosis of amount patterns that allowed them to predict predict to them allowed that patterns genes that will be telltale for atheroscle for telltale be will that genes call 1-800-MED-DUKE (physicians) or or (physicians) 1-800-MED-DUKE call and Vascular Biology diagnosis and treatment at Duke, please please Duke, at treatment and diagnosis —Pascal Goldschmidt,MD, chairof theDepartment of Medicine “What we’ve done is gone shopping for shopping gone is done we’ve “What dukehealth.org Arteriosclerosis, Thrombosis, Thrombosis, Arteriosclerosis, in October 2004. - - -

ated by an aneurysm. Duke is currently enrollingcurrently is Duke aneurysm. an by ated pressurecre the of some relieve and aorta the in flow blood improve to designed is device, tional investiga artery.an femoral stent, the The in placed catheter a via aorta the of section eased dis the into above) (pictured graft stent a thread procedure,surgeons invasive minimally the In disease. aortic thoracic for treatment new a exploring sites U.S. 40 among is Duke and patients may call 919-684-2620. call may patients and Tostudy,participate. the about physicians inquire to eligible be may complication of risks moderate to repair,low surgical have for and candidates ulcer,penetrating aortic are thoracic or aneurysm aortic thoracic with diagnosed been have who Patients device. the of trial clinical a in patients RESEARCH HIGHLIGHT RESEARCH

- - 41 DukeMed FIGHTING THE MAN’S

CANCEROffering an array of treatments and an integrated approach to care, Duke physicians are powerful allies in men’s battles against prostate cancer.

BY DENNIS MEREDITH

“A MAJOR CHANGE IN THE DIRECTION OF MY LIFE” read the cu- For many men of my generation, prostate cancer has be- rious subject line of the e-mail message from my close friend come an unexpected and unwelcome rite of passage, turning an of many decades. In our earlier years, I had certainly witnessed innocuous gland somewhere in our nether regions into a malig- other major changes in his life. I had watched him receive nant agent of unsettling life changes. Some 230,000 American much-deserved awards for his talents as a writer. I had watched men, many of them younger than 65, are diagnosed with pros- him proudly walk his daughter down the aisle. But now, with tate cancer each year—and as baby-boomers reach their middle both of us in our settled “middle” years—with grown offspring, years, the number of new cases is expected to rise to 300,000 happy marriages, and magically gorgeous grandchildren— a year by 2010, according to the National Prostate I wondered what possible change could be “major.” Cancer Coalition. He had prostate cancer, he announced. The fact shook me, though certainly not as much as it must have shaken him. The message and those that followed over the next few months introduced unfamiliar terms—Gleason score, brachytherapy, laparoscopic prostatectomy—that only dimly reflected the unfamiliar territory my friend’s disease had brought him into. DukeMed 42 “ The key challenge for the ‘incidental’ cancers.” over-treating what we call to kill people, while not treat cancers that are going out how to aggressively new millennium is to figure —JuddW. Moul,MD, chief ofurology

43 DukeMed 44 [see page 62]. “But it’s a double-edged double-edged a it’s “But 62]. page [see Ironically, one of the greatest has resulted centers medical leading other and Duke PSA remains the best clinically available available clinically best the remains PSA Yet there are challenges ahead as well. well. as ahead challenges are there Yet man—particularly if he is older.” need never may that cancer prostate ing ment modalities—from surgery, radiation promisingdecadeahead,thankstheto in life their in cancer prostate with nosed in fact have prostate cancer—has caused caused cancer—has prostate have fact in maywhopercent ofmen 15 to missing up from a major clinical advance—the advent other one in six men who will be diag be will who men six in one other other Duke specialists emphasize that that emphasize specialists Duke other and Moul But screening. widespread of re was who MD, W.Moul, Judd says er,” of levels blood for testing widespread of who may not need treatment—while treatment—while need not may who biomarker for detecting and tracking tracking and detecting for biomarker younger and the cancers tend to be smallbe tocancerstend theyounger and EARLYDILEMMA DETECTION and even nutritional therapies. treat of spectrum the across advances at researchers and clinicians among cently appointed chief of urology at Dukeappointedurologycently atofchief the that means which earlier, cancers disease. And there is enormous optimism population of men we’re seeing is gettingpopulationseeing we’reis ofmen to have been diagnosed. It may grow so so grow may It diagnosed. been have to tigen (PSA). an specific prostate marker telltale the vaccines to chemotherapy and therapy, further improve will percentage this that the survive will percent 85 that is time, some physicians to question the wisdom wisdom the question to physicians some slowlyitwill never affect the health of the diagnos we’re sometimes that in sword,

DukeMed these catching is screening “Better The good news, for my friend and the the and friend my for news, good The The fact that PSA tests flag some men men some flag tests PSA that fact The Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) 1-888-ASK-DUKE call consumers and patients (633-3853), 1-800-MED-DUKE call Physicians ------American men (who seem to be affected affected be to seem (who men American When treatment is warranted, says Moul, says warranted, is treatment When Duke’s goal is to offer patients expertise expertise patients offer to is goal Duke’s He recommends that white men without a PSA levels, digital rectal exams, and bi and exams, rectal digital levels, PSA in the full range of treatment possibili treatment of range full the in significantmorecancers,Moulwith men aggressively to how out figure to is nium millen new the for challenge key The it.’ of rid get ‘Doc, say and that to respond to well very public the trained is—we’ve it big or small bad, or good how matter nutritional therapy, and even “watchful “watchful even and therapy, nutritional medications,cryotherapy,chemotherapy, therapy hormonal oral injections, riodic with castrationbrachytherapy, radiation, my, robotic prostatectomy, external beam family history start the testing at age 40. getting start disease the of history family opsies to determine whether and when when and whether determine to opsies waiting”—carefully monitoring a slow- a monitoring waiting”—carefully ‘incicallover-treating notwewhile what live with the effects of treatment for 30 30 for treatment of effects the with live Moul. says lives,” of thousands saved has years. So we need to consider how we canconsiderwe tohow need we years. So adds. “If the man is younger, he may may he younger, is man the “If adds. at an earlier age) and those with a positive African- while 50 age at tests PSA annual dental’ cancers.” BRINGING CARE FULL CIRCLE FULL CARE BRINGING potency and urinary function. including life,” of quality his preserve that test valuable a “It’s cancer. prostate treat cancers that are going to kill people,kill to going are thatcancers treat them nerve-sparing radical prostatecto radical nerve-sparing them ties. And there are lots of options—among growing cancer’s course with surveillance surgery or medications in the form of pe ofform the inmedications or surgery cancer—no prostate say we “When says, But because of fear of the “C word,” he word,” “C the of fear of because But Over-treatment is a concern even for for even concern a is Over-treatment ------

dispersion of information “a much more organized says Cary Robertson, MD. screening clinic enables plinary prostate cancer decision-making time,” to patients at a critical Duke’s new multidisci-

GUIDANCE Moul. “They all fit into the armamentari the into fit all “They Moul. Visit Duke University Health System online at at online System Health University Duke Visit vantages and disadvantages, and we try try we and disadvantages, and vantages not to emphasize one over another,”says over emphasizeone to not options and help men and their families families their and men help and options together to educate patients about their their about patients educate to together tiononcologists, andmedical oncologists treatment is needed. um. Our goal is to bring urologists,radiabring to is goal Our um. “All of these treatments have their ad their have treatments these of “All - - - Cancer Foundation report released in in released report Foundation Cancer multidisciplinary care is still not the the not norm in prostate cancer treatment. still is care multidisciplinary make informed decisions.” aware of all the options available to them to available options the all of aware September 2004, too many men are un are men many too 2004, September common. According to a major Prostate Prostate major a to According common. until they have late-stage disease, since since disease, late-stage have they until Such an approach is surprisingly un surprisingly is approach an Such dukehealth.org Cary Robertson, MD - - “We plan to invite patients to become partbecome“We patientsinviteto to plan VA Medical Center will also be offered offered be also will Center Medical VA MD, “The clinic has allowed for a much much a for allowed has clinic “The MD, The center will not only support Duke’s Duke’s support only not will center The Center(DPC) that will bring teams of spe mately 3,500-square-foot DukeProstate 3,500-square-foot mately making time.” informa of dispersion organized more research efforts, working with Duke uro Duke with working efforts, research oncologyscreening clinic, where patients ous treatments.” to contributing by team research the of with prostate cancer going into clinical clinical into going cancer prostate with lished a multidisciplinary genitourinary genitourinary multidisciplinary a lished logic oncologist and Durham VA chief of chief VA Durham and oncologist logic vari of effectiveness the and biomarkers and samples tissue and serum of banks can receive opinions from two or or two from opinions receive can estab year this earlier Duke at cians data to better understandprostatebettercancer to data We’ll registry. research disease cancer nationallyrecognizeda and unit trials cal damental understanding of the disease. 2005. in location one in together cialists participating in a comprehensive prostate Walterpostat ReedArmyMedicalCenter. former his in database research prostate in o ains t ciia decision- critical a at patients to tion Says setting. single a in specialists three the opportunity to participate in these these in participate to opportunity the resulting the use and cancers their track re in participating otherwise or trials fun advance but care, to approach team urologic oncologist Cary Robertson, Robertson, Cary oncologist urologic urology Philip Walther, MD, Moul adds. search,” says Moul, who created a clini a created who Moul, says search,” “Right now there are not enough men men enough not are there now “Right ProstateDurhamthecancerpatients at o, ue s lnig n approxi an planning is Duke Now, o one ta polm physi problem, that counter To 45 ------

DukeMed 46 “We can now perform it in approximately approximately in it perform now “We can in the post-operative course, we are im are we course, post-operative the in us by dysfunction erectile new the of some ing “And says. Moul intercourse,” surgeonsprostatectomy,radicalwhich in eliminating the entire gland. The most most The gland. entire the eliminating other treatments are available for sexual sexual for available are treatments other who are fully potent prior to the operation with no need for a transfusion.” nerves surrounding the preserving while nerve-sparing is technique used widely have multiple (and likely biologically biologically likely (and multiple have SURGICAL STRIKES SURGICAL Since men with prostate cancer typically typically cancer prostate with men Since drugsaidmen’stosexual recovery earlier sexual for sufficient erections regain can Moul. says prostatectomies,” for dard prostate diseased the remove carefully throughout scattered tumors distinct) proving our results.” In addition, many many addition, In results.” our proving tion, he adds. “Up to 90 percent of men men of percent 90 to “Up adds. he tion, smallhours,incision,throughtwoquitea that control urinary and erectile function. at aim today therapies most prostate, the good chance of keeping their sexual funcsexualtheirkeeping of chance good

DukeMed stan gold the remains operation “This Men who undergo the procedure have a Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) 1-888-ASK-DUKE call consumers and patients (633-3853), 1-800-MED-DUKE call Physicians David Albala,MD - - - - In this technique, surgeons perform the the perform surgeons technique, this In recog nationally Urology’s Duke MD, very small incisions. Although he cautions new technologies—such as robotic pros robotic as technologies—such new nized expert in male sexual function. Donatucci, Craig to according recovery, ing time currentlytimeingaveraging four threeto operation via a two-arm robotic system system robotic two-arm a via operation with the results. surgeries robotic 70 approximately with hours and most patients well-satisfied well-satisfied patients most and hours patient who has been detected early with early detected been has who patient tatectomy, offered at Duke since 2003. 2003. since Duke at offered tatectomy, ht h poeue s tl yug sur young, still is procedure the that through manipulation fine enables that geon David Albala, MD, says experience experience says MD, Albala, David geon so far has been promising, with operat with promising, been has far so “The best candidate for this surgery is a issurgery thiscandidatefor best “The ThomasPolascik, MD Urologic surgeons are also exploring exploring also are surgeons Urologic via thin catheters (right). pellets are strategically delivered into the prostate (above), and brachytherapy, in which radioactive forming ice bulbs that kill the surrounding tissue needles are inserted into the prostate and frozen, prostate cancer, including cryotherapy, in which fine Duke offers a wide range of treatments for - - - -

Cryotherapy to ablate the prostate is an an is prostate the ablate to Cryotherapy including attributes, physical Certain not recognize the added expense, Moul Moul expense, added the recognize not more currently is prostatectomy robotic option for older men who do not want want not do who men older for option sur standard than perform to expensive from patient a eliminate would obesity, we have to balancepatientdesirestoforthehave we lenges of modern medicine.” therealitiesof the approacheswithlatest added costs,” he says. “Such are the chal the are “Such says. he costs,” added Albala. says cancer,” of amount small a consideration, he adds. FREEZING IT OUT IT FREEZING points out. “Duke clearly wants to be on on be to wants clearly “Duke out. points the cutting edge of new technology, but but technology, new of edge cutting the gery, and most insurance companies do do companies insurance most and gery, Despite the encouraging early results, results, early encouraging the Despite

- - TREATMENT The cooling forms an ice bulb aroundthebulb coolingiceforms The an Visit Duke University Health System online at at online System Health University Duke Visit radical surgery or radiation therapy, or or therapy, radiation or surgery radical manipulate the needles to ablate the en the ablate to needles the manipulate Guided tissue. prostate kills that needle insertedinto the prostate and frozen with for those who have failed radiation ther radiation failed have who those for by ultrasound imaging, the surgeons can surgeons the imaging, ultrasound by a mixture of cooled helium and argon. argon. and helium cooled of mixture a are needles fine technique, this In apy. tire prostate without need for surgery. MitchellAnscher, MD - - “About 80 percent of patients experience experience patients of percent 80 “About Anscher, MD. “As imaging improves, we improves, imaging “As MD. Anscher, MD,leadinga authority procedure,theon This will enable us to more selectively selectively more to us enable will This volves inserting radioactive seeds or pel or seeds radioactive inserting volves invasive alternative to surgery for certainforsurgery alternative invasiveto erectile lack they if But them. for be not counselconpatientsimpotence,weto so nized DPC radiation oncologist Mitchell Mitchell oncologist radiation DPC nized surrounding to delivered radiation mize function and want a less invasivelessmethod, a functionwant and focus radiation doses in those areas.” of radiation therapy—brachytherapy in therapy—brachytherapy radiation of form radiation—another beam external will be able to produce a ‘metabolic map’ map’ ‘metabolic a produce to able be will kill the tissue, ablating the prostate. they whereprostate, the into directly lets younger and have erectile function, it may aging enables precise placement of the the of placement precise enables aging cryotherapy is truly minimally invasive.” pellets to ablate the prostate, yet mini yet prostate, the ablate to pellets Unlike disease. early-stage with patients protect surrounding tissues from radia from tissues surrounding protect tion damage. are. tumors the where exactly shows that recog nationally to according tissues, so studying drug therapies to better better to therapies drug studying so sider this option very carefully. If they are nce ad i clege ae al are colleagues his and Anscher Brachytherapy is another minimally minimally another is Brachytherapy Careful planning with ultrasound im ultrasound with planning Careful Says DPC urologist Thomas Polascik, Polascik, Thomas urologist DPC Says dukehealth.org ------

(mammalian target of rapamycin), which rapamycin),of target (mammalian TARGETEDTREATMENTS AHEAD Duke oncologists are also making prog making also are oncologists Duke MD, and colleagues are currently testing testing currently are colleagues and MD, Genome Sciences and Policy, is launching ress in treating patients whose cancers cancers whose patients treating in ress ics of prostate cancer,” he says, “I think think “I says, he cancer,” prostate of ics genet the of knowledge growing rapidly inhibit cancer cell growth. to Xinlay, and Docetaxel drugs, of nation over the next decade we’ll gain a far better help. For example, DPC’s Dan George, George, Dan DPC’s example, For help. where stage the beyond progressed have allow detailed analyses of genes in both both in genes of analyses detailed allow a broad research program to better define and how to treat them.” technolo new promising developing also mTOR protein the inhibits that drug a cer. His research program will organize organize will program research His cer. one-twopunch,a in Andgrow. cancersto the DPC’s planned tissue banks and and banks tissue planned DPC’s the can prostate of sub-types molecular the toolsfor investigating the disease and our combi novel a testing clinically are they prostate of cells aberrant the triggers genetic and molecular levels. “Withthe better on cells cancer characterize to gies understanding of the subtypes of cancer cancer of subtypes the of understanding scientist with Duke’s Institute for for Institute Duke’s with scientist can alone therapy radiation or surgery Daniel George,MD hli Fbo M, physician- a MD, Febbo, Phillip Meanwhile,says George, scientists are 47 - - - - -

DukeMed 48

DukeMed —PhillipFebbo, MD “ Our ultimate goal is to provide and the tumor so that clinicians can predict [what an individual’s cancer will do].” a comprehensive understanding of the genetics of both the patient Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) 1-888-ASK-DUKE call consumers and patients (633-3853), 1-800-MED-DUKE call Physicians

ANTI-CANCER VACCINESANTI-CANCER For cancers that have metastasized,haveForDukethatcancers Urology’s Johannes Vieweg, MD, is mak is MD, Vieweg, Johannes Urology’s vinced that over the next decade, such such decade, next the over that vinced match molecularly targeted therapies therapies targeted molecularly match cause and bone the into metastasize patient the both of genetics the of ing identifygenetic events critical toprostate much more immune-competent.” specific counteracting by system mune im the on “brakes” to cellular the release seeking they’re And nourishment. response immune useful clinically a ing ingrapid progress in developing vaccines life of duration and quality the improve from early clinical tests, the researchers researchers the tests, clinical early from for patients diagnosed with cancer. otherwise doing no harm.” Febbo is con is Febbo harm.” no doing otherwise will serve as adjuvants to other treatments, to tumors susceptible biologically with human disease and cancer models to to models cancer and disease human better,” says Vieweg, vice chief for re for chief vice Vieweg, says better,” their for essential vessels blood the but and the tumor so that clinicians can pre can clinicians that so tumor the and against cancer. produc at aimedmountingtrialsnow are death, or whether it will remain in the the in remain will it whether or death, will cancer individual’s an whether dict cancer’s growth. cells, your vaccine works much, much much much, works vaccine your cells, responseimmune the suppress that cells prostate—perhaps causing local symp local causing prostate—perhaps understand comprehensive a provide proaches that target not only cancer cells cancer only not target that proaches toms such as difficulty in urination, but but urination, in difficulty as such toms to the cancer. They’re testing new ap new testing They’re cancer. the to results promising by Buoyed body. the system prostatecancerthroughoutcellsattack to immune body’s the alert that genetic insight will allow physicians to to physicians allow will insight genetic search in urology. “You make the patient the make “You urology. in search “Our ultimate goal,” says Febbo, “is to to “is Febbo, says goal,” ultimate “Our “In principle, if you eliminate these these eliminate you if principle, “In According to Vieweg, current vaccines vaccines current Vieweg, to According ------

DETECTION mrcn e, as rlg cif ud W. Judd chief urology says men, American 40, using a PSA threshold of

American—and return rates were also also were rates return American—and of Nursing faculty member and family nurse nurse family and member faculty Nursing of screened 1,593 men. Early on, only about about only on, Early men. 1,593 screened so often community screening is a one-day, one-day, a is screening community often so decision to take part in screenings, both ini both screenings, in part take to decision upindividually witha physician.” identify are MD, Robertson, Cary urologist 60 percent who came in one year also came came also year one in came who percent 60 tion resources that encourage them to follow to themencourage resourcesthat tion informa good them offer and patients track we that inunique screeningis ourclinic think we and screening, the of advantage taking tiallyand continually. elgo eet ih o olwtruh I follow-through. no with event feel-good men to them comparing and screenings for rate is improving, she says. This year’sscreen This says. she improving, is rate return the education, and outreach munity a In tested. be to reluctant be may men practitioner Marva Mizell Price, DrPH, and and DrPH, Price, Mizell Marva practitioner explor are researchers Duke cancer, prostate were screened, about half of them African- them of half about screened, were notreturn.whodo Thus,Price andRobertson Department of Defense-funded study,Defense-fundedSchool of Department higher. “We’re getting a steady increase in in increase steady a getting “We’re higher. men yet—508 best-attended the was ing com with But observed. Price next, the in man’s a governing factors uncover to hope year each return to likely are who men ing African-American some why reasons the ing hopeto sustain thatincrease,” says Price. both Caucasian and African-American men men African-American and Caucasian both long-term, carefully designed project, because Says Robertson, “It’s important to have a have to important “It’s Robertson, Says Between 1998 and 2003, the study study the 2003, and 1998 Between for screenings annual free offering By dukehealth.org ------

The incidence of pros African-American men than in Caucasian tate cancer is 60 rate twice as high. percent higher in males, and the death

- 49 DukeMed 50 DukeMed RESEARCH HIGHLIGHT RESEARCH Better health after prostate cancer cancer, heart disease, diabetes, and osteopo and diabetes, disease, heart cancer, of prostate cancer is like a knock on the door the on knock a like isprostate cancerof saying, ‘It’ssaying,exercisingeating startand to time days, but they may face additional health health additional face may they but days, their risk of dying from cardiovascularfromdyingdisease of risk their cancer, prostate of diagnosis a had have they second a for risk increased at are cancer tate ment side effects, she adds. “The diagnosis diagnosis “The adds. she effects, side ment rosis.“Men sometimes don’t realize that once PhD, data clearly show that men with pros with men that show clearly data PhD, these cancer prostate beating are men More Duke researcher Wendy Demark-Wahnefried, Demark-Wahnefried, Wendy researcher Duke healthier.’” issues, lifestyle to due be may risks health to According ahead. years the in hurdles jumps 44 percent,” she says. The increased increased The says. she percent,” 44 jumps ikd eei fcos ad osby treat possibly and factors, genetic linked - - - cancer survivors. The research teams are cur are teams research The survivors. cancer Canada. In February 2005, the team will will team the 2005, February In Canada. of 543 survivors throughout the U.S. and and U.S. the throughout survivors 543 of study ongoing an and survivors 182 among the improving in interventions exercise and diet home-based of efficacy the testing are duke.edu. eases, Demark-Wahnefried and her colleagues tate, breast, and colorectal cancer who are at are whocolorectal cancerbreast,and tate, or (five long-term 640 in interventions the more years past diagnosis) survivors of pros of survivors diagnosis) past years more studies, NIH-funded three on working rently theRENEW study maye-mail RENEW@geri. including a recently completed initial study study initial completed recently a including colorectal and breast, prostate, of health least 65years ofage. test will which RENEW, study, new a launch To help survivors stave off these other dis other these off stave survivors Tohelp Patients or physicians’ office interested in - - - With so many treatment options available, Demark-Wahnefried, PhD, have demon have PhD, Demark-Wahnefried, Visit Duke University Health System online at at online System Health University Duke Visit ing a larger clinical trial, as well as studies conduct now are researchers The rates. medmag.duke.edu/article.php?id=414 for men and their families, Moul says. others are finding that simple lifestyle lifestyle simple that finding are others of how diet and exercise can help prostate well as tumors with lower proliferation proliferation lower with tumors as well lower prostate specific antigen levels as as levels antigen specific prostate lower SUPPORT SYSTEM SUPPORT and other researchers fill such trials more and dietary lignans, both of which disrupt visit work, Vieweg’s on article an progres cancer slow increase to aiming cians to help them decide what strategieswhatdecidethem help tocians sooner answers yield can they so quickly es The 50). page (see survivors cancer table three with supplemented diets low-fatate who thosethat showed cancer pilot A cancer. to lead that changes cell Wendy by led Studies help. may changes patients will rely heavily on their physi their on heavily rely will patients prostate with men 25 involving project richest the is Flaxseed cancer. prostate tablishment of the DPC will help Demarkhelptablishmentwill DPC theof have to tended and levels testosterone treatments, sophisticated technically tion a primary treatment in itself. [To read spoons of ground flaxseed daily had lower source of plant-based omega-3 fatty acids retarding in flaxseed of value the strated vaccinamake to isultimate goalthesays, he However, survival. prolong and sion While some Duke researchers pursue pursue researchers Duke some While duke .] ------“Once we’ve determined whether a patient Indeed, if his experience is any indica any is experience his if Indeed, onour Web site, therapies offered atDuke totreat the problem—transurethral microwave therapy (TUMT)— ofall middle-aged men and upto 90percent of those over 70.Read about oneof thelatest is thecondition known as benignprostatic hypertrophy (enlargedprostate), which troubles half Even more common than prostate cancer Cary Robertson, diagnostic and treatment ment or can be treated less aggressively, aggressively, less treated be can or ment treat of form aggressive really a needs ing well after his diagnosis with cancer, cancer, with diagnosis his after well ing expertise must be accompanied by a fun a by accompanied be must expertise our comments and educate not only the the only not educate and comments our the into research Our self-education. of was saidwaskeepandtrackthemtermsonin about carefully them educate to need we helped us understand the need to tailor tailor to need the understand us helped and conversations the to listen board—to ally do need somebody to be a sounding sounding a be to somebody need do ally re they And friend. person— or child, spouse, support a social significant a damental understanding that the disease the that understandingdamental course of treatment and a supportive wife. far is who friend, my for evident clearly has Duke at support spousal of dynamics presents complex human dimensions. patient, but his support person.” take notes and remind the patient of what their options. Robertson. says support,” social and tion DPC’s the emphasizes But, pursue. to thanks to both a carefully considered considered carefully a both to thanks “Most of these gentlemen will have have will gentlemen these of “Most educa patient are priorities major “Our Wendy Demark-Wahnefried, PhD The benefits of social support are are support social of benefits The dukehealth.org dukemedmag.duke.edu . ------

reasonable to hope even more men will will men more even hope to reasonable it’s ahead, prospects encouraging more in women. the of effects The first. flash hot his ish experiencesimiofprostateacancer with larly sunny outlook. he joked, had left him with a much deeper prostate, his shrink to therapy hormone appreciation of the joys of menopause menopause of joys the of appreciation paused friend my restaurant, crowded a in closer—sometimes even women and during the salad course and announced announced and course salad the during tion, a bout with cancer may bring men men bring may cancer with bout a tion, that he had to take a brief moment to fin to moment brief a take to had he that unexpected ways. When next we met in in met we next When ways. unexpected soon be able to go through the common common the through go to able be soon 1-888-ASK-DUKE. For more information on prostate Diane Dowdee at 919-681-6768 or Terry Patients or physicians’ office can contact Witting at 919-668-8108 to make an call 1-800-MED-DUKE, patients cancer services at Duke, physicians may appointment at Duke’s multidisciplinary prostate cancer screening clinic With excellent care available and even even and available care excellent With .

- - DukeMed 52 DukeMed controversiesin medicine * Selective serotonin reuptake inhibitor reuptakeserotonin Selective * (Prozac), received FDA approval, some approval,FDA received (Prozac), the describes that black) in (bordered COE LOOK. CLOSER A Medication Guide advising patients of patients advising Guide Medication Patient a that deemed FDA the Finally, balance to encouraged are Prescribers October issued a “black box” directive directive box” “black a issued October Antidepressantsfor children and ill youth is warranted. Seventeen years Seventeen warranted. is youth ill moni to and need clinical with risk and thinking suicidal of risk increased numerousphonecalls andvisits phy to the in articles of spate a prompted ing withdepressivetreateddisorder major isted in adolescents and children. The children. and adolescents in isted still community psychiatric the in for all antidepressants: drug manufac drug antidepressants: all for behavior in children and adolescents adolescents and children in behavior antide of dangers the about press lay ago, when the first SSRI,* fluoxetine fluoxetine SSRI,* first the when ago, risk. the about caregivers alerts and hear The medications. antidepressant hearing public and panel advisory an doubted whether depression even ex even depression whether doubted prescrip filled every with distributed comprehensivedata review, the FDA in IN FEBRUARY 2004, FEBRUARY IN pressants in young people, as well as as well as people, young in pressants pressants in the treatment of mentally mentally of treatment the in pressants antide of place the about perspective tion and refill. be precautions offering and risks the antidepressantsclosely.on patients tor warning a add to required are turers of rates increased of reports discuss to sicians from concerned parents. After a with patients pediatric in suicidality adolescents:Dangerous medicine? by John March, MD, MPH MD, March, John by At this point, some some point, this At the FDA convened convened FDA the ------4,400 patients with major depressive depressive major with patients 4,400 (SSRIs and others) involving more than 100 with placebo over one year would would year one over placebo with 100 24 trials of nine antidepressant drugs drugs antidepressant nine of trials 24 Thesewere case reports, notcontrolled velopmentof suicidal ideation inyouth. reports began to emerge hinting that that hinting emerge to began reports for antidepressants newer-generation for work don’t fact in and overdose, in enough patients in this age group par group age this in patients enough of 2 percent. In other words, a doctor doctor a words, other In percent. 2 of antidepressants—twice the placebo risk during suicidality of risk percent 4 a included directive box black the about SSRIs may be associated with the de the with associated be may SSRIs clinical studies; only recently have have recently only studies; clinical case1990s, the indisorders.However, compulsive disorder (OCD), and eating of efficacy the demonstrate 18 age der depression in young people. antide tricyclic the were depression iodr. lhuh o ucds oc curred in the trials, the analysis suicides showed no Although disorders. psychiatric other or OCD, disorder, pression in young people is real, and and real, is people young in pression pressants—likeimipramine (Tofranil)— for prescribed medications primary ticipated in trials that the FDA could could FDA the that trials in ticipated treatingdepression, anxiety,obsessive- dangerous effect-ridden, side are that treating 100 patients with an SSRI and SSRI an with patients 100 treating receivingthose in months few first the systematically review the data. un patients in trials medication some de that concur clinicians then: since We’ve made tremendous progress progress tremendous made We’ve The FDA meta-analysis that brought that meta-analysis FDA The ------12-17withprimarya diagnosis of major

TADS trial (Treatment of Adolescents Adolescents of (Treatment trial TADS mental illness, major life stresses, and stresses, life major illness, mental of context the in occur attempts most nitive behavioral therapy (CBT), and and (CBT), therapy behavioral nitive examined study the group, age this in nism by which this risk increases. etineplus CBT isbetterthan fluoxetine of its kind to compare psychotherapy of with Depression), conducted at mul at conducted Depression), with the against small) (very risk the weigh be attributed in part to the SSRI. Since SSRI. the to part in attributed be happenedanyway,whichtwo andcould havewouldthatactivedrugs on twobo, benefits (modest to moderate but still still but moderate to (modest benefits likely is impossible—in part because we alone, which is better than CBT alone, alone, CBT than better is which alone, medication antidepressant to type any to need kids and parents, doctors, als, Since effect. adverse real but small a dicated that the combination of fluox of combination the that dicated in analysis The disorder. depressive first The findings. noteworthy ditional medica the of meaningful) clinically mechathe or risk at is whoknow don’t their combination in 439 patientsages 439combination theirin cog fluoxetine, placebo, of effect the ad some make and analysis FDA’s the confirm Duke, including sites tiple tions for most youth treated with them. demonstrate medications these that small risk associated with medication medication with associated risk small very the out picking abuse, substance place on two attempts: suicide six see suicidality was uncommon in these tri these in uncommon was suicidality Nonetheless,doubtthere’slittlenow The results of the recently publishedrecently the ofresults The ------We would be doing our young patients a real

which is statistically no better than pla- disservice if we shun antidepressants altogether cebo. The finding that CBT is no better because of the FDA’s “black box” warnings. than placebo is surprising in light of its success in previous studies. (In fact, about the risks of medication, patients Left untreated, childhood and ado- another recent Duke-led trial, POTS and families should receive a written lescent depression can have serious, (Pediatric OCD Treatment Study), found list of symptoms that may foreshadow even fatal, consequences. Depressed that treatment with CBT alone was more suicidal thoughts and behaviors—in- young people have ongoing problems effective than sertraline alone for youth cluding agitation, impulsivity, panic at school, with friends, and at home, with OCD; again, a combination was attacks, akathesia (restlessness), irrita- and are at increased risk for substance most effective. No POTS participants bility, insomnia, hostility, hypomania, abuse, eating disorders, and preg- experienced suicidality.) and mania. They should also be aware nancy. Over half (more than 500,000 However, in the TADS study CBT that major life stress as well as alcohol each year) will attempt suicide, and at did demonstrate an important ben- or drug use compounds the risk. least 7 percent eventually succeed. On efit—it reduced suicidal thoughts and Understandably, primary care physi- the other hand, there’s clear evidence behaviors, both alone and in con- cians may now be wary of treating de- that SSRIs, particularly fluoxetine, are junction with fluoxetine treatment. pressed youth with medication. Before effective for most of these patients and CBT—which teaches patients how to treatment begins, young people with should be considered first when pre- overcome negative, pessimistic atti- symptoms of depression need a com- scribing a medication. Most clinicians tudes—may help patients by providing prehensive evaluation and accurate di- agree that the benefits still outweigh coping skills for dealing with suicidal agnosis, including the use of normed the risks, and concomitant CBT seems impulses and problem-solving skills rating scales for general psychopa- to reduce the risk and enhance the ef- when confronted with family conflict. thology and specifically for depression fectiveness of medication. controversies controversies Based on the study results, I would and perhaps anxiety. Not every patient Every suicide is a tragedy. But it’s strongly encourage the use of combi- needs medication—those with milder also tragic that so many young people nation therapy as the best treatment cases often respond well to psychother- suffer with depression and don’t get for teenagers with major depressive apy. If the patient has mild depression the treatment they need. We would be disorder, especially when there is a or uncomplicated major depression doing them a real disservice if we shun history of past or present suicidal ide- with little comorbidity and no prior or antidepressant medications altogether ation or behavior. current suicidality, then the primary because of the black box warnings. care physician may feel comfortable BEST PRACTICES. So, how does our way treating the patient with medication John March, MD, MPH, is a professor of treating the adolescent with depres- and/or CBT (if available)—with the ca- of psychiatry and chief of Child and sion change in light of recent data and veat that weekly monitoring is essen- Adolescent Psychiatry. He led the FDA directives? In some respects, it tial, especially during the first weeks Treatment of Adolescents with Depression doesn’t. It’s long been known that of treatment. The more severely de- (TADS) study, published in the August 18, some patients with depression become pressed patient, particularly if suicidal, 2004 Journal of the American Medical suicidal as part of recovery. Every pa- should be referred to someone who Association (JAMA), as well as the tient beginning a course of medication regularly deals with such patients—a Pediatric OCD Treatment Study (POTS), should be told that any hint of suicidal child psychiatrist, an adult psychiatrist published in the October 27, 2004 JAMA. ideation or self-harm needs to be re- who also specializes in adolescents, or a medicine in ported to the physician right away. developmental pediatrician who treats Moreover, along with being informed children with severe mental illnesses.

The opinions expressed in “Controversies in Medicine” are those of the author and do not necessarily reflect those of Duke University Medical Center as a whole. clinician 54 · Identify signs that a patient may be at risk for abusing opioids. abusing for · risk at be may patient a that signs Identify opioids. prescribing for principles Discuss · · opioid of use inappropriate with associated problems Describe · and pain neuropathic versus nociceptive of features the Describe 1. 1. objectives, learning accreditation, on information the Read 1) off-label,are discussed proceduresbeing or products When Assistant Clinical Professor,Anesthesiology Clinical of Assistant Department 2. 2. activity.self-study entire the Complete 2) as such presented, is that information the on limitations Any AMA Physician’s Recognition Award. Each physician should claim Physician’sshould AMA physician Award.Each Recognition (ACCME) Education Medical Continuing for Council Accreditation Bureau. Speakers’ Ortho-McNeil of member a and Board; Advisory for consultant a is she that indicated has MD Fras, Marie Anne Director) Medical (Activity MD Fras, Marie Anne to: able be should activity, this learner of the conclusion the At AAFP Credit Statement Credit AAFP Accreditation: TargetAudiences: To receive CME credit, ToCME receive This activity has been reviewed and is acceptable for up to 1.0 to up for acceptable is and reviewed been has activity This educa this designates Medicine of School University Duke The the by accredited is Medicine of School University Duke The continuing for is activity CME this in provided information The 3. 3. on form evaluation/claim and self-assessment the Complete 4. 4. along addressappropriate the to form evaluation/claim the Mail education purposes only and is not meant to substitute for the for substitute to meant not is and only purposes education article. this in uses investigational and/or experimental, only those credits that he/she actually spent in the activity.the in spent actually he/she that credits those only and opioids prescribingappropriately for guidelines follow and Credit Designation Credit tional activity for a maximum of 1.0 Category 1 credit toward the towardcredit 1 Category 1.0 of maximum a for activity tional physicians. for education medical continuing provide to patient’sspecific condition. a medical of options treatment and tic 5. 5. call please credit, regardingCME questions any have you If Duke University School of Medicine of School University Duke unnecessary referrals to specialists. Clinicians need to understand to need Clinicians specialists. to referrals unnecessary Interim Director, Division of Pain Management Director,Pain Interim of Division monitoring long-term use of the drugs. the of use long-term monitoring prescribed credit by the American Academy of Family Physicians. Family of Academy American the by creditprescribed Statement of Need: of Statement Unapproved Use Disclosure: Use Unapproved Learning Objectives: Learning Participants must: Participants Inc.’sRegistrat, of Pfizer,member and a Pharmaceuticals Inc.; Endo assistants physician practitioners, nurse Physicians, Disclaimer: Disclosure: Faculty Faculty: Under- and over-prescription of opioid drugs are common prob common are drugs over-prescriptionUnder-opioid and of Dr. Fras has indicated that she does not discuss any off-label, any discuss not does she that Dr.indicated has Fras learners: to disclose to faculty requiresCME Medicine of School Duke and/or effects, side pain, patient unnecessary to lead can that lems independent medical judgment of a physician relative to diagnos to relative physician a of judgment medical independent drugs, including underuse. including drugs, DukeMed present. pain of type the on based selection drug the understand approved); and approved); disclosure information, and the disclaimer.the and information, disclosure unlabeled, experimental, and/or investigational (not FDA (not investigational and/or experimental, unlabeled, data that are preliminary or that represent ongoing research,representongoing that or preliminaryare that data amount of $20.00physicians)amount(forof $15.00 non-physicians). (for or interim analyses, and/or unsupported opinion. unsupported and/or analyses, interim pages 58-59. pages with a check made payable to the Duke Office of CME in theOfficeDukein thepayableCMEcheck made toof awith please call 1-800-274-2237 ext. 6542. ext. 1-800-274-2237 call please 919-684-6485. If you have any questions regarding AAFP credit, regardingAAFP questions any have you If 919-684-6485.

- - q a T Use of Opioids for Outpatient Pain Management Estimated Time toComplete: Expiration date: Release date: cause many primary care physicians to under- to physicians care primary many cause and pain, cancer pain, acute treat to cations medi opioid of use the with agree clinicians attention medical requires that complaint aberrant opioid use, and develop strategies strategies develop and use, opioid aberrant potential of signs the identify class, analgesic appropriate the choose pain, assess to ability which medications, these over-prescribe or accepted. widely as not is pain “benign” or Most drugs. opioid addictive potentially of adequately assess and manage pain. during their lifetime. effectsand unnecessary referrals to specialists. to maximize patient compliance with pain pain treatments. with compliance patient maximize to their improve clinicians care primary help to knowledgethenecessaryhave tonot do they United States will experience a chronic pain pain chronic a experience will States United may lead to unnecessary patient pain and side patients seek medical attention. In fact, it it fact, In attention. medical seek patients pain caused by a terminal illness. However, However, illness. terminal a by caused pain Moreover,misconceptions opioiddrugsabout P Continuing Medical Education presents: in clinicians’ ambivalence toward the use use the toward ambivalence clinicians’ in the in people three in one that estimated is long-term use of opioids for non-cancer non-cancer for opioids of use long-term AIN IS THE MOST MOST THE IS AIN he Duke Ofﬁce of This uncertainty is particularly apparent apparent particularly is uncertainty This The principles outlined below are intended are below outlined principles The : : Whatare current recommendations for using Anne Marie Fras, MD, assistant clinical professor in the Duke Department of Anesthesiology and interim q director of the Division of Pain Management, responds: carearena? opioidsto treat chronic pain in the primary December1,2004 December 31,2005 1 Yet most clinicians report & common reason that that reason common a 1hour

2, 3 Earnup to 1CME credit! 4 -

The International Association for the Study of Study the for AssociationInternational The andfunctional. for purpose adaptive an serve not does and or injury to us alert to signal warning a as point. beginning definite a without often generally is pain acute of onset The acute. or in described or damage potential or with actual associated experience emotional and CATEGORIZINGPAIN subdivided into four major types of pain, pain, of types major four into subdivided local well and sharp is pain the and sudden itnt ye o pi wt dfeet under different with pain of types distinct each requiring a different approach to treat to approach different a requiring each theorganism. treatments. fits pain all While damage.” such of terms for clinicians to recognize there are several several are there recognize to clinicians for ment: nociceptive, inflammatory,nociceptive, ment: neuropathic, Whileacute pain serves animportant purpose potential injury, chronic pain is pathologic pathologic is pain chronic injury, potential within that broad definition, it is imperative imperative is it definition, broad that within Pain defines pain as “an unpleasant sensory sensory unpleasant “an as pain defines Pain ized. Chronic pain tends to be more diffuse, diffuse, more be to tends pain Chronic ized. lying mechanisms and, therefore, different different therefore, and, mechanisms lying These broad distinctions can be further further be can distinctions broad These Broadly speaking, pain can be either chronic 5

AnneMarie Fras, MD

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Nociceptive Pain DOCUMENTING PAIN HISTORY Nociceptive pain is most familiar to patients normally mildly painful stimulus becomes Effective pain management starts with a and clinicians. Nociceptors are peripheral intensely painful), and hyperpathia (where thorough medical history and physical exami- receptors that help the body sense pain, the patient continues to report pain well nation. The history should document the sending the signals through the spinal cord, after a painful stimulus has ended). Another nature and intensity of the pain, current and brain stem, and thalamus to the cerebral feature of neuropathic pain is spontaneous past interventions (including over-the-counter cortex. Nociceptors respond to noxious heat, pain. When nerves are damaged they may medicines), underlying or coexisting diseases intense pressure, or irritant chemicals, but not fire automatically, resulting in the constant, (such as diabetes or a recent stroke, which to innocuous stimuli such as warming or light burning sensation frequently experienced may suggest a neuropathic pain state), and a touch. They activate the body’s sensory system by patients with peripheral neuropathy. substance abuse history. before actual tissue damage occurs, thus Neuropathic pain is a form of “maladaptive It is also crucial to assess the pain’s impact warning us to avoid further injury. Examples pain” where there is signaling of pain despite on physical and psychologic functioning. of nociceptive pain include pain from a minor a lack of tissue trauma.5 Neuropathic pain In the primary care setting, more than 50 burn or a needle prick. Nociceptive pain does not respond to non-steroidal anti- percent of patients who present with depres- responds to both opioids and non-steroi- inflammatory drugs. It tends to respond sion report somatic complaints only and at dal anti-inflammatory drugs. poorly to opioids, many times requiring least 60 percent of these somatic complaints very large doses. Frequently, drugs such as are pain-related.6 In addition, when pain is Inflammatory Pain anticonvulsants and tricyclic antidepressants moderate to severe, impairs physical func- Inflammatory pain occurs in response to tissue are used to decrease the spontaneous firing tioning, and/or is refractory to treatment, it is damage. It can either be acute (as in response of nociceptors. (An in-depth presentation of more likely to be associated with depression. to surgery) or chronic (as in the chronic the choice and use of anticonvulsants and Patients with multiple pain syndromes (e.g. inflammation seen in diseases such as rheu- tricyclic antidepressants is beyond the scope back pain, headache, abdominal pain, chest matoid arthritis). The tissue damage causes of this discussion. A detailed description of pain, and facial pain) are three to five times the body to release prostaglandins, mediators the assessment and management of neuro- more likely to be depressed than patients of inflammation which hypersensitize nocicep- pathic pain can be found in Neuropathic Pain: without pain.7 tors. In this sensitized state, stimuli the body Incorporating New Consensus Guidelines into Co-existing conditions (depression and would normally sense as innocuous cause the the Reality of Clinical Practice Adv Stud Med anxiety) which may accompany the pain com- nociceptors to fire, producing a sensation of 2004;4(7B):S550-S556). plaint can result in poor response to treatment pain (a process called allodynia). This sensi- when ignored. In addition, failure to recog- tization prompts us to guard the injured area Functional Pain nize that somatic complaints may serve as a of the body, minimizing further damage and Another example of maladaptive pain is proxy for mood complaints can lead to misdi- allowing repair to begin. Inflammatory pain functional pain, in which the body processes agnosis and mistreatment of mood disorders also responds to both opioids and non- sensory signals abnormally. In contrast to neu- with analgesics. For these reasons, effective steroidal anti-inflammatory drugs. ropathic pain, which stems from lesions in pain management requires a global approach the nervous system, there is no recognizable to the patient. Neuropathic Pain cause of functional pain—the central nervous Neuropathic pain is caused by a lesion in system simply seems to amplify sensory WHEN TO CONSIDER AN OPIOID— the peripheral nervous system (as in dia- signals. Examples of functional pain include AND CONSIDERATIONS betic neuropathy, HIV sensory neuropathy, or fibromyalgia, irritable bowel syndrome, and WHEN STARTING TREATMENT an entrapment neuropathy such as carpal tension headache. As with neuropathic pain, Pain management with an opioid may be con- tunnel syndrome) or in the central nervous functional pain tends not to respond to sidered following the complete assessment system (as in stroke or spinal cord injury). The opioids or non-steroidal anti-inflamma- and documentation that non-opioid treat- changes within the nervous system itself lead tory drugs. Instead, drugs such as tricyclic ment has failed. to sensitization of nociceptors and appear- antidepressants and interventions such as The establishment of realistic goals for ance of allodynia, hyperalgesia (where a behavioral therapy may be helpful. treatment should be discussed and jointly DukeMed 55 56 Although there is no consensus in the the in consensus no is there Although The potential for cognitive impairment (espe impairment cognitive for potential The the of aware made be should patient The clinician cially in the days following a dose escalation) escalation) dose a following days the in cially ucm o oii therapy, opioid of outcome patient. and clinician the by to agreed and document the specification that opioid opioid that specification the document and communicate should clinician the addition, rather scores, pain increased in results opioid opioid high to moderate following algesia sensitivity pain opioid-induced paradoxical a day, per equivalents morphine of more or escalation. any should be discussed and documented. In In documented. and discussed be should dosing). mnfse b dfue loyi ad hyper and allodynia diffuse by (manifested escalations, re-assessing the patient prior to to prior patient the re-assessing escalations, (up below or range moderate the in erally thanan improvementin painreport. tude mg 1000 as high as doses reaching tions, escala dose to approach liberal more a take day). per equivalents morphine mg 180 to gen are studies controlled in used doses the INFORMED CONSENT FOR TREATMENTFOR CONSENT INFORMED necessary that the patient demonstrate demonstrate patient the that necessary risks and benefits of opioid management. management. opioid of benefits and risks patients receiving opioid doses of this magni this of doses opioid receiving patients prescriptionsbe written by asingle clinician or of escalations dose further sensitivity, pain which is five times the dose validated in the the in validated dose the times five is which dose opioid modest very use generally we with opioids. improved function improved treatment trial a after functioning improved In the Pain and Palliative Care Clinic at Duke, Duke, at Clinic Care Palliative and Pain the In DukeMed that suggests evidence Anecdotal literature. reasonable a constitutes what on literature In most of the literature on opioid therapy, opioid on literature the of most In • • • • • • TREATMENT OPIOID AGREEMENT AN OF BASICS TABLE1:

Emergency issues Education Patient responsibilities termination of Points Prohibited behavior Termsof treatment Adapted fromFishman SM etal rarely report satisfactoryreportrarelyanalgesia of heavy equipment) heavy of inappropriatebehavior) 10 In the patient with opioid-induced opioid-induced with patient the In (side effects, risks of respiratory depression, risks of addiction, operation operation addiction, of risks depression, respiratory of risks effects, (side 9 However, some clinicians clinicians some However, 8 and in fact may develop develop may fact in and (use of Emergency Department, prohibitionrefills”)Department, “early Emergency for of (use (single prescriber,(single levels) medication urine/serum random (unsanctioned dose escalations, use of illicit drugs) illicit of use escalations, dose (unsanctioned (positive urine screen for illicit drugs, missed appointments, appointments, missed drugs, illicit for screen urine (positive (compliance with appointments, safeguardingappointments, with medication) (compliance 8 I believe it is is it believe I JPain Symptom Manage q & or a - - - - -

1. Amendments can be added to tailor the the tailor to added be can Amendments 1. The recommendation that patients “at risk risk “at patients that recommendation The clinician’s preconceived notions of addicted addicted of notions preconceived clinician’s Clinicians frequently cite concerns about about concerns cite frequently Clinicians or psychiatric history to differentiate true true differentiate to history psychiatric or factors, family and social patterns, use opioid opioids found no differences in pain condition, clinic pain university a to referred patients of Complicating opioids. prescribing about able agree treatment Limiting backgrounds. and agesall addictionofwomen andincludemen agreementconstitutes unsound logic. Patients about use of an “informed consent and agree sistent use of treatment agreements makes makes agreements treatment of use sistent drugdiversion as a reason they are uncomfort general formto individual patient needs. treatment agreement are found in Table Table in found are agreement treatment patients all have to is practice My treatment. biased of charges to susceptible clinician the family history of pain and substance abuse, abuse, substance and pain of history family with associated behaviors” “problematic for study A patients. drug-seeking identifying for treatment a sign to asked be addiction” for radar” to go undetected. In addition, incon addition, In undetected. go to radar” thoseonlypatientsmentstotheintofall who medications. opioid for treatment” for ment atr, hr ae o adadfs rules hard-and-fast no are there matters, patients allows patients who are “under the the “under are who patients allows patients practiceand filled at asingle pharmacy. painpatients from addicted patients. who are receiving opioid management enter enter management opioid receiving are who for factors risk or addiction of history a with FROM THE DRUG-SEEKING PATIENTDRUG-SEEKING THE FROM DIFFERENTIATINGPAINPATIENTTHE into a treatment agreement which is signed signed is which agreement treatment a into byboth the patientand myself. Earnup to 1CME credit! There is lack of consensus in the literature literature the in consensus of lack is There oe sus o osdr drsig n a in addressing consider to issues Some 1999;18:27-37 oee, hr ae eti characteris certain are there However, 11 - - - - -

“pseudo-addiction.” Pseudo-addiction has has Pseudo-addiction “pseudo-addiction.” ADHERENCE WITH OPIOID TREATMENTOPIOID WITH ADHERENCE cystic fibrosis, kidney disease, epilepsy, and and epilepsy, disease, kidney fibrosis, cystic the to addition In 3). (Table suspicions cian’s calls for additional medication or the emer the or medication additional for calls of signs or grooming, personal in changes the of complexity forgetfulness, constipation, Clues that a patient is not adhering to opioid to adhering not is patient a that Clues opioid treatment. Studies have documented documented have Studies treatment. opioid aforementionedstudy. were detoxification previous and addiction of abusingopioids(Table “redflag”aswell as 2), able relationships with other providers (e.g., (e.g., providers other with relationships able opioids (e.g.euphoria, senseof well-being). or nausea as such effects side addiction, of gence of irrational or demanding behavior behavior demanding or irrational of gence depression) or for the reinforcing properties of (refer to Tables 2 and 3), history of unfavor of history 3), and 2 Tables to (refer tounderuse and misuse. can which encounter patient the about tics testing for the presence or absence of drugs drugs of absence or presence the for testing tion—whichrevealmay affective disturbances, interview patient the including sources, tiple treatanother symptom (e.g. insomnia, anxiety, following transplantation. Nor is medication medication is Nor transplantation. following aiy ebr, n te hscl examina physical the and members, family STRATEGIES FOR MAXIMIZING PATIENTSTRATEGIESMAXIMIZING FOR non-adherence limited to overuse; it extends extends it overuse; to limited non-adherence the in patients addicted in common more must be undertaken with caution (see (see caution with undertaken be must from information discharges), clinic multiple mul from come may regimens medication medical regimen, ormedication costs. poor patient adherence with treatments for for treatments with adherence patient poor provide clues—such as frequent telephone telephone frequent as clues—such provide these treated, adequately is pain Once pain. DETECTING NON-COMPLIANCE DETECTING Medication non-compliance is not limited to to limited not is non-compliance Medication help the clinician identify patients at risk for for risk at patients identify clinician the help in a previously compliant patient. Laboratory Laboratory patient. compliant previously a in intoxicationor withdrawal. behaviors listed in Table 3, personal history history personal 3, Table in listed behaviors clini the increase should which behaviors behaviors resolve. of undertreatment to response in behaviors, demanding and hostile including behavior, patient problematic describe to used been Causes of misuse include use of opioids to opioids of use include misuse of Causes Overuse may be a sign of addiction or or addiction of sign a be may Overuse Patient behavior in between visits may also may visitsbetween in behaviorPatient underuseanalgesicsPatientsmayfromfear 11

12 - - - - - below). Traditional methods of assessing TABLE 3: BEHAVIORS ASSOCIATED PRACTICE GUIDELINES FOR patient adherence such as pill counts, diaries, PRESCRIBING OPIOID MEDICATIONS WITH DEVIANT OPIOID USE and patient interviews tend to overestimate FOR THE TREATMENT OF PAIN • Forging prescriptions patient adherence.12 • Abusing illicit drugs Patient Evaluation • Losing prescriptions multiple times LABORATORY TESTING • Thorough history and physical exami- • Selling prescription drugs In order to effectively use laboratory data, nation documenting the nature and • Taking more than the prescribed dosage intensity of the pain, current and past the clinician must have an understanding of multiple times physiology, pharmacology, and toxicology. interventions (including over-the-counter • Stealing medications or borrowing pre- medicines), underlying or coexisting dis- The most commonly used laboratory mea- scribed drugs from others surements of opioid/illicit drug use in patients eases (such as diabetes or history of a • Obtaining prescription drugs from recent stroke, which may provide clues are from urine or blood sources. The clinician non-medical sources must understand the limits of the screening to a neuropathic pain state), and a sub- tests in use in his/her office. For instance, with Kirsh KL et al Clin J Pain 2002;18(4Suppl):S52-60 stance abuse history. urine testing some agents are detected with • Assessment of how the pain impacts routine screening (usually morphine, codeine, physical and psychologic functioning. CONCLUSION heroin), some agents are not (fentanyl, meth- • Documentation of a diagnosis which is Effective pain management necessitates a adone), and some agents will cross-react in opioid-responsive. thorough evaluation, an individualized treat- the test, resulting in false positives (labet- ment plan, and careful re-assessment of the Treatment Plan alol screening as amphetamine, or sertraline patient at regular intervals. Opioid medica- • Documentation of treatment goals for screening as a benzodiazepine). Use of urinary tions can successfully be used to treat pain pain relief/ improvement in functioning. drug screening by family physicians is reviewed from nociceptive, inflammatory, and to some • Documentation of an individualized treat- at http://www.familydocs.org/news. (See degree neuropathic sources. Clinicians should ment plan based on the type of pain and monograph at http://www.familydocs.org/UDT. apply consistent policies to patients who are physical and psychologic needs. pdf and Quick Reference Card at http://www. treated long-term with opioid medications familydocs.org/UDT_Ref_Card.pdf). Re-assessment and inform patients of the potential risks of • The patient should be assessed at regular such treatments. Treatment agreements are intervals for adequacy of therapy, side a convenient tool to inform patients of the effects, improvement in functioning, and treatment expectations and potential risks. adherence to treatment including laboratory studies as indicated.

TABLE 2: CHARACTERISTICS OF CHRONIC PAIN PATIENTS VERSUS Documentation SUBSTANCE ABUSERS • The clinician should document the above Chronic Pain Patients: information in a clear and accurate way. • Are interested in and cooperate with efforts to confirm their diagnosis In addition, the amount of medication • Rarely rush to close the encounter prescribed and time to follow-up should • Demonstrate self-control in their use of analgesics be documented. • Follow the treatment plan the clinician recommends • Have improved quality of life (QOL) from analgesics • Are likely to complain about any side effects • Tend to have leftover medications, rarely “run out early,” rarely misplace medications

Drug Abusers: • Are frequently in a hurry and may not be interested in an accurate diagnosis • Cannot control their use of analgesics • Do not follow the clinician-recommended treatment plan • Have a decreased QOL from opioids • Want medications even when experiencing negative side effects • Rarely have medication left over (and often return “early” for more) • Lose their medication and present numerous excuses for doing so

Heit HA Eur J Pain 2001;5 Suppl A:27-29 DukeMed 57 58 12. 12. al et Fishman 11. al. et Compton J Mao 10. JA Markenson 1. . al Vonet Korff 7. Treatment of Pain” can be found on the Webthe on Treatmentfound be can Pain” of clinician . al et E 2. Loder . Turkal et 4. . al 3. et JH VonRoenn consensus statement on the use of opioids opioids of use the on statement consensus advocacy/opioids.htm a issued have Society Pain American and at site for the Federation of State Medical Boards . Woolf, 5. for the treatment of chronic pain which can can which pain chronic of treatment the for the for Substances Controlled of Use the for . 9. al et Urban REFERENCES RESOURCES . al et MJ Bair 6. Further information on “Model Guidelines Guidelines “Model on information Further be accessed at at accessed be DukeMed J 8. Mao and JC Ballantyne The American Academy of Pain Medicine Medicine Pain of Academy American The http://www.fsmb.org 1998;16:355-363 1119(2):121-6 2000;20:293-307 2003;349(20):1943-1953 2445 82(1):65-8 Pain Ann of Intern Med Intern of Ann Pain 2002;100:213-217 Pain Arch Intern Med. Intern Arch J of Physical Med and Rehab and Med Physical of J J Pain Symptom Manage Symptom Pain J 1994;59:201-8 Am J Med J Am Pain J Pain Symptom Manage Symptom Pain J http://www.ampainsoc.org/ 1986;24:191-6 1988;32:173-183 Ann Int Med Int Ann . . N Engl J Med J Engl N 1996;101(1A): 6S-18S 1996;101(1A): 2004;140:441-451 2003;163:2433- 1993; q

2003; a

1. Whichof thefollowing features Clinicians may submit questions for future “Clinician Q&A” columns by . They are interested e. in an accurate Theyrarely lose ormisplace d. Theyare likely tocomplain about c. Theyfail to see animprovement b.in Theyuse analgesics ina controlled a. Allof theabove are true e. Misconceptions about opioids d. Widespreadacceptance of opioids for c. Lackof knowledgeabout opioids b. Physician concernsabout drug a. Allof theabove e. Spontaneous pain d. Hyperpathia c. Hyperalgesia b. Allodynia a. (MD, PA, NP, etc.), city and state, daytime phone number, and e-mail . 4. All ofthe following statements are . 2. All ofthe following arebarriers to are not possible. address. We regret that comments on specific cases and individual replies e-mailing [email protected]. Please include your degree . 3. True or false? Earnup to 1CME credit! Use of Opioids for Pain Management Self-Assessment Quiz neuropathicpain? may bepresent ina patientwith sion inpatients with pain. patients without substance abuse physicians prescribingopioids except: necessary toroutinely screen fordepres true aboutopioid use in chronic pain issues except: inpatients with pain,therefore itis not “benign” pain opioid-inducedside effects. diagnosis. quality oflife. diversion fashion. medications. Depression seldom presents

- . Documentation shouldbe ina clear e. Obtaining asubstance abusehistory d. is Documentation shouldinclude an c. Re-assessment foradequacy oftreat b. Athorough history andphysical a. . Concurrent abuseof illicitdrugs e. Prescription forgery d. Onelost prescription c. Borrowing medications from others b. Obtaining prescriptiondrugs from non- a. . 6. Behaviorswhich should cause thephy . 5. Allof thefollowing statements reflect except: good practice foropioid management allof the following except: apatient on opioidanalgesics include sician toconsider aberrant drug usein andaccurate format. diagnosis. examinationare neededto establish a type ofpain, aswell asphysical and totreatment shouldoccur atregular notnecessary. ment,side effects, and adherence medical sources psychologicalneeds. individualizedtreatment plan based on intervals.

Answers: 1. e 2.c 3. false 4. b 5.d 6.c 5.d b 4. false 3. 2.c e 1. Answers: - - Use of Opioids for Pain Management Enduring Material Evaluation and CME Claim Form Please identify your profession (circle one): a. Physician (Specialty: ) b. Nurse Practitioner c. Physician Assistant d. Other (Please specify):

Evaluation of “Use of Opioids for Pain Management” by Anne Marie Fras, MD Please CLEARLY circle the number that best reflects your response. RATING SCALE: 5 - Strongly Agree 4 - Agree 3 - Neutral 2 - Disagree 1 - Strongly Disagree

1. Content was evidence-based 5 4 3 2 1 2. Material was well organized 5 4 3 2 1 3. Material was communicated clearly 5 4 3 2 1 4. Content was balanced, objective, and scientifically rigorous 5 4 3 2 1 5. Do you feel this article was commercially biased in any manner? YES or NO If YES, please explain:

To what degree did the activity meet the stated learning objectives? Please CLEARLY circle the number that best reflects your response. RATING SCALE: 5 - Completely 4 - Mostly 3 - Moderately 2 - Slightly 1 - Not At All

6. Describe the features of nociceptive versus neuropathic pain and understand the drug selection based on the type of pain present 5 4 3 2 1 7. Describe problems associated with inappropriate use of opioid drugs, including underuse 5 4 3 2 1 8. Discuss principles for prescribing opioids 5 4 3 2 1 9. Identify signs that a patient may be at risk for abusing opioids 5 4 3 2 1

10. Please describe any changes in your medical practice you make as a result of completing this self-study CME activity:

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APPOINTMENTS

Gilliss new dean of nursing school Catherine Lynch Gilliss, DNSc, RN, FAAN, as encourage more In addition to her 1971 BSN degree from has been named dean of the Duke University scholars from minor- Duke, Gilliss earned a master’s degree in School of Nursing and vice chancellor for ity populations to psychiatric nursing from The Catholic nursing affairs. Gillis has been a professor and pursue careers in University of America in Washington, DC; an dean of the nursing school at Yale University nursing. In 2002, adult nurse practitioner certificate from the since 1998. She succeeds Mary Champagne, under Gilliss’ lead- University of Rochester in Rochester, NY; and PhD, RN, who announced in May 2003 that ership, Yale and Gilliss a doctorate of nursing science from UCSF, she would not seek another five-year term as Howard University established the Yale- where she also completed a postdoctoral fel- dean after serving 13 years in the post. Howard Partnership Center to Eliminate lowship. She has authored two books—The An adult nurse practitioner, Gilliss has Health Disparities. Nursing of Families and Toward a Science of been an active researcher in family manage- Before becoming dean at Yale, Gilliss was Family Nursing—in addition to writing numer- ment of diabetes, prevention of diabetes, and chair of the Department of Family Health ous peer-reviewed journal articles and book health disparities. She is the lead investigator Care Nursing at the University of California chapters. She also serves on the editorial for a series of grants totaling more than $3.5 at San Francisco (UCSF) from 1993 to 1998. boards of several journals. million from the National Institutes of Health’s As director of UCSF’s Family Nurse Practitioner A fellow in the American Academy of National Institute for Nursing Research. Program from 1988 to 1995, Gilliss led her Nursing, she is now serving her second term During her tenure at Yale, Gilliss led program to a Pew Primary Care Achievement as an elected director on that board. efforts to strengthen the school’s programs Award for Excellence. Read more on pages 10 and 80. of research and doctoral education as well O’Neill to oversee strategic planning Molly K. O’Neill Prior to joining Partners in 1998, O’Neill research. The four-hospital system included has been named was the national vice president of disease a physician hospital organization, specialty chief strategic plan- management and network development for physician networks, long-term care facilities, ning officer and Gambro Healthcare, an international spe- home health services, behavioral health service president for cialty healthcare company with revenues of vices, and other ambulatory care services. business develop- $2.6 billion. At Gambro, O’Neill built physi- “By focusing on strategic planning and O’Neill ment for the Duke cian networks that worked with managed business development, the health system is University Health System. She also has been care organizations and provided “full-risk” investing in its future and building on the out- appointed vice chancellor for medical center comprehensive disease management to standing infrastructure that already exists,” integrated planning. renal patients. In this role, she served as the O’Neill says. “It’s a great privilege and chal- In a newly created position at Duke, O’Neill president of two Florida-based independent lenge to assist in the growth and development will direct organizational strategic planning, practice associations. of a world-class institution.” business development and network services Previously, O’Neill was the assistant vice O’Neill is a summa cum laude graduate of for all clinical operating units. president of strategic alliances and new busi- the Medical College of Virginia, where she Before coming to Duke, O’Neill served ness development at Inova Health System, an received a master of science in health care as the executive director of specialty care integrated delivery system in Springfield, VA. administration. She received her bachelor of development for Partners Healthcare System, During her eight-year tenure at Inova, she science in journalism/mass communications which includes The Brigham and Women’s was responsible for mergers and acquisitions, from Virginia Commonwealth University. Hospital and Massachusetts General Hospital. strategic planning, marketing, and market DukeMed 60 DUKEMED PEOPLE

Petes tapped as MGM chair Thomas D. Petes, PhD, a professor of biology MD, dean of the Duke defects underlying cancer. For example, yeast and member of the Lineberger Comprehensive University School of cells lacking particular DNA mismatch repair Cancer Center at the University of North Medicine. “His lead- enzymes exhibit genetic instabilities also found Carolina at Chapel Hill, was named chair of ership and expertise in human colorectal cancer cells, a finding that the Molecular Genetics and Microbiology will push the MGM suggested the repair defects might play an (MGM) Department at Duke in October. department to the important role in the disease process, he said. Petes specializes in the study of yeast next level by build- Petes received his undergraduate education as a model for understanding genomic ing on the group’s at Brown University and his PhD in genetics Petes instability and chromosomal aberrations many strengths and at the University of Washington in Seattle. commonly found in cancer cells. He suc- encouraging a global approach to the study He then went on to postdoctoral fellowships ceeds Joseph Nevins, PhD, who became of genetics. We are pleased to welcome him.” at the National Institute for Medical Research director of the Center for Applied Genomics Petes’ group has discovered striking simi- in London and the Massachusetts Institute of and Technology, part of the Duke Institute larities between yeast and human cells in the Technology in Cambridge. He served as presi- for Genome Sciences and Policy (IGSP), in structure and function of proteins involved dent of the Genetics Society of America in November 2003. in DNA repair and in the protection of the 2002, and has been a member of the National “Tom is an outstanding scientist—a first- tips of chromosomes. In turn, those simi- Academy of Sciences since 1999. rate scientific mind,” said R. Sanders Williams, larities have yielded new insight into genetic Kuo promoted to chief of general surgery Paul C. Kuo, MD, a hepatobiliary and trans- opportunity to work in many leading University. He then completed a six-year sur- plant surgeon, has been named chief of the academic centers and brings different per- gical residency at Brigham and Women’s Division of General Surgery. He replaces R. spectives to surgery at Duke. Lastly, he has Hospital in 1991, followed by fellowships at Randal Bollinger, MD, who was promoted to demonstrated his commitment to academics Beth-Israel-Deaconess Hospital and Harvard vice chairman of education for and patient care in an open, collab- Medical School. He also earned an MBA in Duke’s Department of Surgery. orative, and cooperative manner.” 2001 from Johns Hopkins. Kuo will oversee the clini- Kuo came to Duke in 2000 after From 1993 to 1995 he served as a cal enterprises and direct the serving for two years as chief of transplant surgeon on the faculty of Stanford research activities of a diverse kidney and pancreas transplantation University Medical Center, followed by division that includes surgeons and chief of laparoscopic surgery three years as a transplant surgeon at the who specialize in such areas as at Georgetown University Medical University of Maryland Medical Center, transplantation, gastrointestinal Center. He performs liver, kidney, Baltimore. He then joined the faculty of surgery, and vascular surgery, Kuo and pancreas transplants as well as Georgetown in 1998. as well as those who specialize in surgi- other surgical procedures involving the liver. In cal approaches to cancers of the breast and the laboratory, Kuo is principal investigator for digestive system. long-term NIH research grants aimed at better “Dr. Kuo is one of the premier surgical sci- understanding iNOS expression in liver cells entists in the country and one of a very few and the relationship between nitric oxide and individuals who are true ‘quadruple threats’ ostepontin, and a training grant in the biology as surgeons, scientists, administrators, and of reperfusion injury and inflammation. educators,” said surgery chairman Danny Kuo received his undergraduate and O. Jacobs, MD. “He also has had the medical school education at Johns Hopkins DukeMed 61 DukeMed DUKEMED PEOPLE

APPOINTMENTS

Frush named chief Moul becomes chief of urology patient safety officer Judd W. Moul, MD, formerly professor of programs that unify Karen Frush, MD, chief medical director surgery at the Uniformed Services University efforts and benefit for children’s services at Duke Hospital, was of the Health Sciences (USUHS) in Bethesda, patients.” appointed chief patient safety officer for Duke MD, and an attending urologic oncologist Moul is nation- University Health System (DUHS) in October at the Walter Reed Army Medical Center in ally recognized for after a national search. Washington, DC, was named the new chief of his creation of a U.S. “Patient safety is one of the most impor- the division of urology. military-based pros- Moul tant responsibilities Moul, a retired colonel in the United States tate disease research database that houses we have as caregivers, Army Medical Corps, also was director of information on more than 20,000 prostate and I am confident the Center for Prostate Disease Research, a cancer patients treated at nine collaborating that Dr. Frush, with Congressionally mandated, Department of institutions. Moul will continue his work with her depth of knowl- Defense (DoD) research program based at the database as a DoD consultant. edge of Duke and her USUHS and Walter Reed. He is a noted author- While at Walter Reed, Moul developed a passion for strong ity on prostate cancer in African-American prostate clinical trials and care unit. He plans patient safety systems, men, biochemical recurrence of prostate to establish a prostate cancer center at Duke, Frush is the right person to cancer, prostate biopsy techniques, and nerve- a multidisciplinary clinic that will improve guide our efforts,” said Victor J. Dzau, MD, sparing radical prostatectomy. patient access to clinical trials. chancellor for health affairs. “Judd is a dynamic leader who will build Moul graduated summa cum laude from In her new role, Frush will develop a com- upon the strengths of the division of urology Pennsylvania State University. He earned an prehensive patient safety program across while cultivating new research and recruiting MD degree from Jefferson Medical College DUHS. Working with the leaders of each new faculty,” said surgery chairman Danny and completed his urologic-oncology fellow- entity, Frush will provide leadership in strategic O. Jacobs, MD. “He has an established track ship at Duke. planning, analysis, development, implementa- record of bringing together multidisciplinary tion and measurement of patient care quality and safety initiatives. She will report directly to the chancellor. Sutton-Wallace promoted to chief of staff “Patient safety is a collaborative effort that Pamela Sutton-Wallace has Office, and director of special requires commitment on the part of many been appointed as the new chief projects. individuals to raise awareness of the possibility of staff to Chancellor for Health As chief of staff—a new posi- of error, and to establish safeguards to mini- Affairs Victor J. Dzau, MD. She tion—Sutton-Wallace will work mize risk and prevent errors,” Frush said. has held several positions within closely with Dzau and will have “I am excited about the high level of enthu- the Duke University Health System, primary oversight for the central siasm throughout our health system, and am beginning in 1997 with her initial coordination of all activities of the confident that we can create a model patient appointment as a health services Chancellor’s Office. She will serve Sutton-Wallace safety program that will benefit all our patients, fellow. Most recently, she was as the key representative of the regardless of where they receive their care.” the associate operating officer for Medical/ chancellor, working closely with the executive Frush plans to develop a Patient Safety Surgical/Critical Care and Digestive Services. management team of the Medical Center and Center at Duke to further the clinical under- Sutton-Wallace has also served as the admin- Health System. standing of the science of safety. The Center istrative director for the Adult Bone Marrow Sutton-Wallace graduated from Yale with a will support educational initiatives, clinical Transplant Program, strategic services asso- Master of Public Health degree. research and outreach opportunities related ciate for Hospitals’ Operations Integration to safety. DukeMed 62 in bringing the right therapy to the right right the to therapy right the bringing in successefficiency, andoptimize effectiveness, “to practice and research clinical for markers bio predictive and therapies novel develop promote anew eraof personalized medicine. to effort Duke’s larger of part key individual a patients, for plans health-care tailor preventive to used be can data genetic detailed PhD MD, Ginsburg,Geoffrey S. Ginsburg Ginsburg named director of genomic medicine of surgery and the executive advisory group group advisory executive the and surgery of chair the with closely work will he addition, In region. VA’ssoutheastern the within VAs Asheville and Durham the with relationships Tyler will build upon the department’s strategic appointment,new this researchIn endeavors. andisanimportant site forcurrent andfuture programs training Surgery’s of Department the of impor component tant critically a VA is The (VA). Affairs Veterans for surgery been of chair vice appointed has Surgery, General of Division the in professor associate Tyler,MD S. Douglas Tyler, Donatucci new vice chairs in surgery Ginsburg said he seeks to discover and and discover to seeks he said Ginsburg - approaches by which which by approaches , to develop new new develop to Hewill oversee efforts Medicine. Genomic for Center new the of director Policy as (IGSP) & Sciences Genome for Institute University’s Duke Tyler , has joined has , - Medical School since1990. Harvard of faculty the on served and 1980s, late the in Hospital Ginsburg Israel Beth at service ogy Boston. developedand directed the preventive cardiol Hospital and Hospital Israel Children’s Beth at cardiology lar molecu in fellowships his research and clinical completed He University. Boston from clinicalprediction and diagnosis. condition—andtheuse of those indicators for measure the effects or progress of a disease or ery of biomarkers—genetic characteristics that responsible for crafting strategy on the discov was Ginsburg Millennium, At medicine. ized personalmolecularpresidentand viceof was PharmaceuticalswhereCambridge,heMA, in patient atthe righttime.” cedures for delivery of outpatient surgical surgical outpatient of delivery for cedures pro and policies clinical new implement and develop will Donatucci role, new his In sion. divi the for chief interim the as serving recently most years, 11 for Urology of Division the with professor the associate an been for has services Surgery.Donatucciof Department patient chair of vice appointed been has General Surgery. of Division the in oncology gical sur of head section and VA Durham the at the VA. Tyler at continues to serve as chief of surgery endeavors faculty and missions core department’s the of components address to Ginsburg received MD and PhD degrees degrees PhD and MD received Ginsburg Millennium from Duke to came Ginsburg ri F Dntci MD Donatucci, F. Craig - , Donatucci ------sonalized medicine—in which patient care care focusesonthe individual with anemphasis on patient which medicine—in sonalized per of realities the for appreciation strong and adoption ofpersonalized understanding medicine. the advance to works that group non-profit a Coalition, Personalized Medicine the of directors of board the effortsin personalized medicinea reality.” towardlongwaya makingtionwillgoDuke’s Geoff’suniqueperspective focusedandatten andmedicine, genomic to time his percentof a real need for a leader who could devote 100 directorIGSP HuntingtonWillard. “We’ve had said clinic,” to the into findings overcome scientific bring be must that challenges the prevention—and and detection disease early ingmaximal functionality. preserv and costs managing effectively more while efficiency maximize to processes dant as well as (PDC), Clinic Diagnostic Private the of members staff senior chiefs, division Surgery of Department the with closely work will and roomsoperating of exclusive services DUKEMED PEOPLE DUKEMED A a idsr lae, ef big a brings Geoff leader, industry an “As to appointed was Ginsburg November, In productivity measurements and and redun consolidating and standards measurements establishing productivity be will focus initial Donatucci’s management. process and utilization, resource efficiency, practice including systems delivery care health ambulatory of ponents com major all on surgery of chair the advising include will duties leaders. His departmental key other 63 - - - - - DukeMed 64 RAYMOND GOODMAN DukeMed [email protected]. Taubor Bill To919-681-5349 contact more,at learn have. to able be wise other not might they experience childhood a enjoy to chance HIV,a problemsasthma, health other and cancer,disease, with cell kids sickle gives camp mer sum community,supervised the medically and the volunteers from support of lots with staff, and faculty Children’sDuke by staffed and Founded reunion. camp’sthe anniversary at 25th September this ers lead programquarter-century with reunitedpast the over Kaleidoscope Camp attended have who children friends: of Circle Ralph Snyderman, MD, Genome Sciences Research Building Some of the more than 1,000 than more the of Some RalphSnyderman, MD DUKEMED PEOPLE DUKEMED - - - inJuly. DukeUniversity Boardof Trustees. scientific the of chair Nicholas, M. Peter said frontiers,” advancing to devoted building a thinkbetternoof wayhonorto himthan with distinguishedcouldresearchera wehimself, is Dr.Snyderman“Since issues. policy and legal, ethical, of spectrum a as well as health and Policy, and which is advancing genome Sciences sciences in biology Genome the for of Institute creation the is tenure Snyderman’s computers, alongwith other research facilities. high-speed and facility, genotyping advanced Snyderman’s honor Building named in rose through the ranks to become a tenured tenured a become to ranks the through rose and faculty the joined Stack 1982, in Duke endowmenttotal to $1.5million. Faculty Leadership Initiative Fund, bringing the Nicholas The from funds with supplemented be will gift million $1 Foundation’s The Guidant care. patient and education, physician development, professor technology his for known well cardiology emeritus the honors MD established newly The Professorship established Stack/Guidant Cardiology Victor J. Dzau, MD, succeeded Snyderman Snyderman succeeded MD, Dzau, J. Victor during innovations many Among After completing cardiology training at at training cardiology completing After /Guidant Foundation Professorship Professorship Foundation /Guidant contains a DNA banking facility,bankingDNA containsa an Duke research units. The building building The units. other research Duke and Genetics Human for scientificCenteroffromteams the home the is building $41-million 15 years. The 120,000-square-foot, past the university’s for officer medical senior the as affairs, served who health for emeritus MD lor of honor Snyderman, in I named Building Research Sciences has Genome the University Duke Richard Sean Stack, Stack, Sean Richard chancel , Ralph Ralph -

andprograms. legislation health for responsibilities key with offices branch executive or legislative in work will fellow each orientation, of period a After communities.localinstitutions and home their of mission the to relate activities research cal biomedi and health ment govern how of understanding better a and foster process the public-policy of knowledge their enrich to designed ties activi of rangewide settings—will completea community-based and academic in working professionals health mid-career outstanding, fellows— The fellowship. RWJF the awarded 2004-2005. for Fellows Policy Health (RWJF) Foundation Johnson Wood Robert seven Medicine of of one Institute named been has School Nursing, Duke of the of dean assistant and sor Short, Nancy Policy Fellowship IOM Health Short awarded patents pending. 41 with devices, therapeutic patents and vascular on worldwide current 35 holds Stack companies. device medical new of generator a Synecor, of partner managing became and a founded became then He 2002. in emeritus professor and 1983–2002 from Cardiology Program Interventional and Duke’s founded directed He cardiology. of professor Short is the first nurse from Duke to be be to Duke from nurse first the is Short - - DrPH Short a assat profes assistant an ,

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cal residency in 1949, when Duke Forest Forest Duke when 1949, in residency cal surgi his of start the at Durham to came an as University Anlyanstudent.medical undergraduate and Yale attended Anlyan avocation practicing throughout(hispiano adulthood), hours many and Alexandria in school prep British a at education rigorous includeda childhoodthat tectorate).a After pro British a time the (at Egypt in up grew who heritage Armenian of parents to Egypt Memoirsof a Life inMedicine book, published newly his in medicine—in of world Duke, the in and in Durham, life, his of transformations—in series a chronicles Anlyan institutions. researchforemosteducational,medical,and America’s of one into school medical and hospital regional fledgling Duke’s of tion transforma of remarkable the practice of and the medicine in period a change spans extraordinary University, Duke of and affairs health for emeritus chancellor of career The Metamorphoses: Memoirs of a Life in Medicine demic and administrative ranks, Anlyan saw Anlyan ranks,administrative and demic aca the through rose he As resides. now Division North the where land the covered Anlyan was born and raised in Alexandria, Joseph R. Nevins, PhD Paul Lawrence Modrich, PhD ila G Ala, MD Anlyan, G. William Metamorphoses: Metamorphoses: . - - - - , youmay be in the wrongsituation.” morning,theyourwhenjobinwakeyouup forwardto lookdon’t you If critic.best own your Be . . . . yourself with honest “Be and good,15percent isbad orcould beworse”; factthat 85 percent of the average person is the accept beings, human fellow your with dealing “In mistakes”; making of capable all are We forget! and “Forgive philosophy: personal his reveal Others desk. a behind hiding of instead comfort arrangement a seating able in them with conversing and office the of outside visitor your greeting as alike—such president and custodian one, every with interacting of way gracious and kind well-known Anlyan’s reflect wisdom of pearls the of Some resident. medical a to as CEO a to useful as prove should that Experience”—adviceof “Lessons some with Hospital”to the south. toweringfacilitycomplement to “Mr. Duke’s a build and donations, and grants research hugeadministrators, attract and faculty lent excel hire segregation, eschew and cocoon its shed Center Medical the oversaw) (and wereamongthe202men andwomen elected as Duke President well as members, faculty Center TwoMedical Sciences academy elected to Arts and Modrich, Nevins • • include: its members. among winners PrizePulitzer 50 laureatesand Nobel 150 than more has currently academy the 1780, in Founded May. in Sciences and Arts of Academy American prestigious the to memoir forthright this off caps Anlyan Professor of Molecular Genetics and and Genetics Molecular investigator.HHMI of Professor PhD Nevins, R. Joseph Hughes Medical Institute (HHMI) investigator Howard and Biochemistry of Professor Duke PhD Modrich, Lawrence Paul New members from the medical center center medical the from members New Richard H. Brodhead, PhD , James B. Duke Duke B. James ,

, James B. B. James , - - - , Building, andDuke Hospital’sAnlyan Tower. Davison the House,Baker the ofnamesakes the to guide a as well as institution their of perspectiveunique a with them provide will of medical students and crop residents—the book current the for As style. direct its enjoy l also a c will i d e history m d n a biographies of Lovers chronicles. Anlyan that ses metamorpho the witnessed who members faculty and alumni Duke to appeal course $29.95clothback ISBN 0-8223-3378-3 Publicationdate: August2004 DukeUniversity Press by William G.Anlyan, MD Metamorphoses:Memoirs of aLife inMedicine

This book will of of will book This health, according tothe AHA. nation’s the on stroke of the impact of devastating awareness public raise to goal sonal per his advanced committee, passionately has Goldstein advisory ASA’s the of chair as (ASA), Association Stroke American divi the sion, its and AHA serving While November. in Disease, Cerebrovascular for Center Duke to Award, Chairman’s the service, volunteer in excellence for award national top its sented pre (AHA) Association Heart American The AHA honors Goldstein DUKEMED PEOPLE DUKEMED Larry B. Goldstein, MD, Goldstein, B. Larry -

director of the the of director 65 DukeMed - - - 66 DukeMed JosephHeitman, MD, PhD H. KimLyerly, MD JohnPerfect, MD DUKEMED PEOPLE DUKEMED ResearchUnit. Mycology University Duke the of director also Medicine’s Division of Infectious Diseases. He is Genetics in Program andGenomics. University Duke the of the and director Pathogenesis Microbial the for Center and Duke also is Biology, He Cancer Medicine. and Pharmacology Microbiology, and Genetics Molecular ments: and logicalsciences. originality, microbio the of subspecialties all in creativity excellence, recognizes academy the group, leadership honorific An Microbiology. of Academy American the in PhD MD Perfect, MD, Heitman, Joseph elected AAM fellows Heitman, Perfect anddevelopment. discovery intervention anticancer of field the who those in leaders recognized are awards and the received NCI, the by awarded kind their of grantsfirst theare These trials.clinical into treatments cancer discovered newly late trans to required time the in reduction a in result will partnerships these that The hopes NCI interventions. imaging and diagnostic, prevention, therapeutic, cancer new research to partners all of expertise the leverage to be institutions,and governmententities. Center and other academic, industry, nonprofit Cancer Duke the among partnerships of ation cre the plan to used Institute be will grant The Cancer (NCI). National the from Grants Planning Program Partnership Private Public Academic 14 only of one awarded been has Center, Cancer Comprehensive Duke the of director and Cancer in Research for Professor Lyerly,MD Kim H. planning grant Lyerly awarded NCI Perfect is a professor in the Department of Department the in professor a is Perfect depart three in professor a is Heitman will partnerships these of goal overall The , have been elected to fellowship to elected been have , , the George Barth Geller Geller Barth George the , , and and , John John - - - -

America (GSA). This distinguished honor is is honor distinguished This (GSA). America GSA award for Cohen ture ofviruses. struc genetic the and mechanism replication discoverieshisconcerningthe for 1969 in cine medi or physiology in Prize Nobel the shared who biologist and physicist German-born a award Oct. 14,2004, at aceremony in Berlin. Molecular thereceived Germany.DzauBerlin, Medicine, for Center Delbruck Max the by 2004 for Medal Delbruck Max the awarded was System, Health University Duke of CEO and president and University Duke at affairs MD Dzau, J. Victor Delbruck for Dzau medical andhealth care programs. bio on Taiwan and Africa, South Canada, of governments the to advisor an as served has GreatMedicineBritain,SocietyinRoyalofand the of Fellow Honorary an named been has He Arts. and Science of Academy European of Science,Academiathe SinicaChinaof theand Academy National U.S. the Medicine, of andserve as expert consultants. conferences, its at present programs, ment develop career early association’s the active in role an American play the Members of Association. Heart Scientist Distinguished research. translationalcardiovascular in specializes Dzau Center for Aging and chief of the division of of division the of chief and Aging for Center ontology to the larger society.largerreceived theCohen to ontology given annually to a GSA member who best best who member GSA a to annually given P. Donald 2004 the awarded was geriatrics, xmlfe te ihs sadrs o pro for standards highest the exemplifies the award at the GSA’s annual meeting on on meeting annual GSA’s the at award the ger of interpretation and service, teaching, fessional leadership in gerontology through through gerontology in leadership fessional Kent Award by the Gerontological Society of of Society Gerontological the by Award Kent Harvey Jay Cohen, MD Cohen, Jay Harvey Nov.20. An internationally known physician-scientist, Delbruck, Max after named is award The Dzau is also a member of the Institute Institute the of member a also is Dzau a named was Dzau November, In , chancellor for health health for chancellor , , director of Duke’s of director , ------

Three faculty elected AAAS Fellows feted at Founder’s Day Moylan, Pizzo and highly competitive scholarship program program scholarship competitive highly and prestigious the Francisco, San at California of in administeredand1885 throughUniversity the Launched 2004. for Scholars Biomedical Pew 15 of one as chosen been has biology, micro and genetics molecular in PhD professor Valdivia, H. Raphael Valdivia chosen as a Pew Biomedical Scholar Association for the Advancement of Science Science of Advancement the for Association was honored Also School. Graduate the by time first the for awarded Mentoring, in Excellence for Dean’sAward a received (MSTP), Program Training Scientist Medical the of director and families. MD Pizzo,Salvatore urban low-income of students for development moral and physi social, and spiritual, cal, education provides that school and founder the middle a School,Nativity Durham as presidentof work his for rec ognized was who Center, Patient International the of director medical and surgery of fessor included J celebration Day Founder’s Duke year’s this at honored faculty Center Medical andpublisher of thejournal genetic and genomic analyses of root devel root of analyses genomic and genetic three The AAAS. the to according guished,” (AAAS), the world's largest scientific society society scientific largest world's the (AAAS), efforts to advance science or its applications applications its or science advance to efforts that are deemed scientifically or socially distinsociallyscientificallydeemedor are that namedfellows this year. were among 308 members of the associationthe of members 308 amongwere Department of Biology, was honored for for honored was Biology, of Department been elected as Fellows of the American American the of Fellows as elected been PhD, PhD Benfey, Philip oseph Anthony Moylan, MD Moylan, Anthony oseph Benfey, professor and chair of the the of chair and professor Benfey, Fellows are elected “because of their their of “because elected are Fellows SamuelKatz, MD and and Miguel Nicolelis, MD, PhD MD, Nicolelis, Miguel , , , chairman of pathology of chairman , Joseph Heitman, MD, MD, Heitman, Joseph (see page70). Science

, an assistant assistant an , , clinical pro clinical , . have have ------Society award Mitchell wins Mycology and the recognition of mycoses, infections infections caused byyeast or molds. mycoses, of recognition the and diagnosis, medical laboratory in of particularly mycology, applications clinical the to tially substan contributed has who individual an to Award Cooper H. Billy the presents Americas procedures,and teaching. research,diagnosticclinicallaboratory in lence excel for Award Cooper H. Billy the awarded been has Mycology Training Program, Pathogenesis and Molecular tri-institutional the of director the and Microbiology Molecular and of Genetics Department the in PhD professor Mitchell, G. Thomas es,and obstacles across subspecialties. challeng ideas, discuss to and regularly meet to them enabling nation, the across oratories lab in workscientistswho thecommunity for unique a provides also program The period. four-year a over research her or his support help to $240,000 scientistsearly-career offers coding of sensory information and neuroen and information sensory of coding othercells via signal transduction cascades. patterning radial that demonstrating opment scriptionalregulator. gineering, leading to breakthroughs in the development the ofbrain-machine interfaces. in breakthroughs to leading gineering, their environment and communicate with with communicate and environment their nisms controlling how infectious fungi sense sense fungi infectious how controlling nisms mecha the including pathogenesis, microbial on studies fundamental for fellow a named Molecular Genetics and Microbiology, was was Microbiology, and Genetics Molecular honored for contributions to the fields of of fields the to contributions for honored tran a of movement cell-cell by controlled is The Medical Mycological Society of the the of Society Mycological Medical The Heitman, a James B. Duke Professor of of Professor Duke B. James a Heitman, Nicolelis, professor of neurobiology, was was neurobiology, of professor Nicolelis, , an associate associate an , ------DUKEMED PEOPLE DUKEMED Miguel Nicolelis,MD, PhD SalvatorePizzo, MD JosephAnthony Moylan, MD RaphaelH. Valdivia, PhD

67 DukeMed 68 DukeMed director of the Databank and information information and Databank the of director chief of cardiology, and Eugene Stead, MD, Stead, cardiology,Eugene of and chief architect of the Duke Heart Center; Don Don Center; Heart Duke the of architect Cardiovascular Diseases, past and and past Diseases, Cardiovascular present: present: the DCRI; David Pryor, MD; Robert Rosati, Rosati, Robert MD; Pryor, David DCRI; the founder of the Databank. Standing (from (from Standing Databank. the of founder Leaders of the Duke Databank for for Databank Duke the of Leaders MD, MBA; and Kerry Lee, PhD, director of director Tardiff, PhD, Lee, Kerry and MBA; Barbara MD, PhD; Harrell, Frank MD; Biostatistics atthe DCRI. Fortin, MD; Rob Califf, MD, director of of director MD, Califf, Rob MD; Fortin, leftright)to are JamesTcheng, MD,current Christopher D. Lascola, MD, PhD Brenda Nevidjon, MSN,RN E.Ralph Heinz, MD Seated are Pamela Douglas, MD, MD, Douglas, Pamela are Seated DUKEMED PEOPLE DUKEMED DUKEMED PEOPLE DUKEMED AAN Fellow Heinz receives Cardiovascular Diseases Databank turns 35 The medal, reserved for individuals who are are who individuals for reserved medal, The Nevidjon named neuroradiology medal cardiology databank in the world. The The world. the in databank cardiology Current researchers and former directors directors former and researchers Current arrivalin 1978. Neuroradiology. of Society Medal American the Gold of the awarded been has ology, vast a with organization multifaceted a anniversaryofthelargest andlongest-running several procedures, and he helped establish establish helped he and procedures, several During 1962. in inception society’s the since sci or clinicians, neuroradiologists, superb diovascular disease. In the ’90s, it spawned spawned it ’90s, the In disease. diovascular car for strategies treatment and diagnostics Duke only including database a from grew 35th the celebrate to September in gathered entists, has been given to only 17 individuals individuals 17 only to given been has entists, the neuroradiology section at Duke after his his after Duke at section neuroradiology the (DCRI), Institute Research Clinical Duke the range of activities, including the conduct of of conduct the including activities, of range of cost-effectiveness the at closely more patients to a diversified one that looked looked that one diversified a to patients . ap Hiz MD Heinz, Ralph E. Duke Databank for Cardiovascular Diseases Diseases Cardiovascular for Databank Duke his career Heinz designed and perfected perfected and designed Heinz career his large, multisite clinical trials and outcomes outcomes and trials clinical multisite large, care, creating innovative work environments, environments, work innovative creating care, clinicalprofessor inthe Duke University School academic environments to advance patient patient advance to environments academic her for noted was Nevidjon care. health and of Nursing, has been selected as a 2004 Fellow developing leaders. for outstanding contributions to nursing nursing to contributions outstanding for for theAmerican Academy ofNursing (AAN). promoting scholarship in practitioners, and and practitioners, in scholarship promoting rna eijn MN RN MSN, Nevidjon, Brenda leadership in bridging practice settings and and settings practice bridging in leadership The 63 fellows were selected by their peers their by selectedwere fellows 63 The a rfso o radi of professor a ,

, an associate associate an ,

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Guyton NLA president Lascola wins cardiovascular risk, the NLA’s primary goal is is goal NLA’sprimary the risk, cardiovascular andfunction. structure brain in changes activity-dependent John R. Guyton, MD Guyton, R. John career development hitpe D Lsoa M, PhD MD, Lascola, D. Christopher scholarship to formalize the specialty of “lipidology” and and “lipidology” of specialty the formalize to manage who professionals health serve to tant professor of radiology and neurobiology, and radiology of professor tant ae h mngmn o lpd iodr a national priority inmedicine. disorders lipid of management the make Clinic, Lipid Duke’s of director and medicine molecular imaging approaches for studying studying and for approaches resonance imaging molecular magnetic functional new patients with lipid disorders and increased increased and disorders lipid with patients RoentgenRay Society (ARRS)Scholarship. Lipid Association (NLA). Launched in 2002 2002 in Launched (NLA). Association Lipid has been elected president of the National National the of president elected been has is one of two recipients of a 2004 American American 2004 a of recipients two of one is build a research program for developing developing for program research a build of data helps researchers deduce the most most the deduce researchers helps data of technolo mobile using bedside patient the at systems, including the ability to collect data data collect to ability the including systems, gies such as PDAs and wireless laptops. Morelaptops. wireless and PDAs as such gies effective treatments for diseases and improve and diseases for treatmentseffective tion with other Duke information technology technology information Duke other with tion integra through advance to continues today the and patients, 160,000 than more on tion researchstudies. patient care. DCRI has entered more than 500,000 people 500,000 than more entered has DCRI importantly, however, the databank’s wealth wealth databank’s the however, importantly, databank The studies. research clinical into Lascola plans to use the scholarship to to scholarship the use to plans Lascola h dtbn crety nlds informa includes currently databank The , associate professor of of professor associate ,

assis ,

- - - - Michael M. Frank, MD, Research Prize awarded to Buckley Hellinga wins new NIH Pioneer Award children. Buckley, a renowned pediatrician pediatrician renowned a Buckley, children. ate atthe NIH. associ clinical and fellow allergy/immunology aspects of immunopathology. award honors the 2004, May Children’sin Duke Hospital of recogniresearcher,in and award the received sig made has who community Duke the member of a to annually given be will award the diagnosis and treatment of patients with with patients of treatment and diagnosis the significanthertionof lifetime contributions to University of Wisconsin and attended Harvardattendedand Wisconsin Universityof nificant contributions to the health care of of care health the to contributions nificant residency at Johns Hopkins and served as an an as served and Hopkins Johns at residency clinical and damage immune of mechanisms Medical School. He completed his pediatric pediatric his completed He School. Medical The Prize. Research MD, Frank, M. Michael of professor a and Pediatrics of Professor Department of Pediatrics from 1990 through 1990 from Pediatrics of Department KatzProfessorL. Pediatricsof chairedwho the immune deficiency disorders. first the awarded been has immunology, FebruaryresearchHis2004. interests onfocus Rebecca Buckley,MD Rebecca chemistry, is among nine research scientists scientists research nine among is chemistry, ofhuman health. ofHealth geared topromote innovation. series of awards from the National Institutes Institutes National the from awards of series exceptional researchers and thinkers from from thinkers and researchers encourage exceptional to 2004 January in established for Medical Research, the Pioneer Awardwas Pioneer Research,the Medical for new a win to States United the across from multiple disciplines to conduct high-risk, high-high-risk,conduct todisciplines multiple porary challenges inbiomedical research. Homme Hellinga, PhD Hellinga, Homme innovative ideas and approaches to contem to approaches and ideas innovative highly with thinkers and scientists individual impact research related to the improvement improvement the to related research impact NIHdirector Elias A.Zerhouni, MD, tosupport Established by the National Board of Advisors Frank was a FordFoundationtheascholar at was Frank A central component of the NIH Roadmap Roadmap NIH the of component central A The NIH Pioneer Award was designed by by designed was Award Pioneer NIH The Michael Frank, MD , James Buren Sidbury Sidbury Buren James , , a professor of bio of professor a , , the Samuel - - - - - chiefof one of the country’s leading programs NIAID’s of chief and NIAID of director clinical ClinicalInvestigation Laboratory. adjacentDuketoHospital. The66,000-square- studying hostdefense mechanisms. h Ciia Ifciu Dsae n Allergy/ and Disease Infectious Clinical the Nationalthe Institute Allergyof Infectiousand for a variety of specialized, state-of-the-art state-of-the-art specialized, of variety a for footoutpatient center, whichopened2000,in Child of Institute National at year one for pediatricservices. setting family-friendly attractive, an provides was in chargewasintheNIAID of clinical service and Health and Human Development, then joining McGovern-Davison Children’s Health Center Center Health Children’s McGovern-Davison Diseases (NIAID) as chief of the Humoral Humoral the of chief as (NIAID) Diseases serving NIH, the to returned Frank London, Immunology Training Programs, NIAID. He He NIAID. Programs, Training Immunology appointedwas he 1977, InSection.Immunity Frank’sconstructionleadershipthethewas of Research, Medical for Institute National pcrm f cetfc icpie includ disciplines scientific of spectrum ent, allowing them the time and resources resources and time the them allowing ent, tion andbioengineering. cellular and molecular research, clinical tional to potential the far-rangingwith testideas to for five years to each Pioneer Award recipi Award Pioneer each to years five for nihroadmap.nih.gov/highrisk/index.asp. research. medical to contributions extraordinary make ahgnss eieilg ad transla and epidemiology pathogenesis, will provide $500,000 in direct costs per year per costs direct in $500,000 provide will Pioneer Award Program, including awardee awardee including Program, Award Pioneer information, please visit the Web site at biology, mathematical and quantitative ing biology, integrative physiology, instrumenta physiology, integrative biology, After training in immunology at the the at immunology in training After The nine recipients represent a broad broad a represent recipients nine The NIH the program, new this inaugurate To One of the major accomplishments of of accomplishments major the of One From 1977 to 1990, Frank codirected codirected Frank 1990, to 1977 From For more information on the NIH Director’sNIH the oninformation more For

http:// - - - - DUKEMED PEOPLE DUKEMED Homme Hellinga,PhD Michael M.Frank, MD Rebecca Buckley, MD

69 DukeMed 70 DukeMed JoRae Wright, PhD Randy Jirtle, PhD Samuel L.Katz, MD DUKEMED PEOPLE DUKEMED Goldner given ethics award followed by a residency in pediatrics at the the at pediatrics in residency a by Hospital followed com Israel Beth at Katz internship an School, pleted Medical Harvard and year’sFounder’s Day celebrations. this of part as Medal Katz University the received world-changing.’” been have results ‘The says, colleagues his of one As globe. the around vaccines measles provide to nizations working with government and nonprofit orga implementation, the into From moved he lives. laboratory, of millions saved has that vaccine measles a of development successful a in collaborated “He Katz, of said Brodhead H. Richard honor—President highest Duke’s asa fundamental humanright. time—immunizationour essentialofideas the of one shaped He true. rings statement the Professorchairmanand emerituspediatrics, of MD Katz, L. millions of lives, but when speaking of person’sonesaved worksay we It’soften not Duke honors Katz, champion of immunization tion only. invita by is participation the Institute, at Karolinska Forum Nobel the of capacity the to limited Due IQ. human reduces gene IGF2R M6P/ imprinted the a in mutation that point single finding the shared presentation His 19. June on Sweden Stockholm, in Medicine in Symposium Nobel 2004 the at spoke ogy, pathol in professor associate and oncology PhD Jirtle, Randy at Nobel Symposium Jirtle speaks The Clinical Orthopaedic Society awards this this awards Society Orthopaedic Clinical The . enr Glnr MD Goldner, Leonard J. dic surgery, is the recipient of the Dr. and and Dr. the of recipient the is surgery, dic Mrs. J. Elmer Nicks Ethics Award for 2004. 2004. for Award Ethics Nicks Elmer J. Mrs. orthopae of emeritus chief and Professor An honors graduate of Dartmouth College College Dartmouth of graduate honors An Medal— University the Katz awarding In , the Wilburt Cornell Davison Davison Cornell Wilburt the , , professor of radiation radiation of professor ,

, James B. Duke Duke B. James , Samuel - - - - - thoracic society award Wright receives hostdefense mechanisms. the to understanding rolethelungsurfactantofof in contributing for award the received Wright disease. lung of treatment and tion, preven understanding, the to scientific contributions distinguished made have who als individu to given is award This (ATS). Society Thoracic American the has from Accomplishment Scientific for Medicine, Award of Recognition a School received the in sciences PhD Wright, Rae Jo n acn plc dvlpet n pediat and development policy vaccine in SocietyPediatrics,of continuesheactive be to until department 1990. A recent president the of the American led and 1968 in pediatrics virus vaccine. JohnEnders to develop the attenuated Laureate measles Nobel of laboratory the in worked Katz Hospital, Children’s Boston staff at a member While School. Medical Harvard and Hospital Children’s Boston at diseases tious infec and virology in fellowship research a the and Children’s Hospital Boston completedalso HeHospital. General Massachusetts todisease prevention. contributionsexemplaryrecognize to Institute sentedannually bythe Albert B.Sabin Vaccine pre Medal, Gold In Sabin the received he 2003 Information. Immunization for Network National the India- and Program Action the Vaccine US cochairs and Vaccines, AIDS for Committee Health of Institutes National the on serves He care. and research HIV/AIDS ric the highest level of professional ethics and and ethics professional of level highest the morals. honor to a physician whose life and work work and have been exemplary life in conveying by example whose physician a to honor Katz joined the Duke faculty as chair of of chair as faculty Duke the joined Katz , vice dean for basic basic for dean vice ,

- - - - -

DukeMed NEW PHYSICIANS

ANESTHESIOLOGY COMMUNITY DUKE UNIVERSITY AND FAMILY MEDICINE AFFILIATED PHYSICIANS

Lisa W. Faberowski, MD G. Burkhard Mihai V. Podgoreanu, MD Jeffrey M. Taekman, MD Blake R. Boggess, Karen L. Hill-Garrett, MD 919-668-4202 Mackensen, MD 919-681-4781 919-660-0332 DO, CAQSM 919-845-2125 Particular Clinical 919-684-6025 Particular Clinical Interests Particular Clinical Interests 919-668-1400 Particular Clinical Interests Interests and Skills: Particular Clinical Interests and Skills: Focus of and Skills: Neurosurgical Particular Clinical Interests and Skills: General inter- Craniosynestosis, venous and Skills: Critical care research interest is to anesthesiology, neural and Skills: Sports medi- nal medicine including air embolism, neurosci- medicine and cardio- identify genetic factors monitoring cine, care of athletes diabetes mellitus, preven- ences, anesthesia and thoracic anesthesiology, involved in adverse myo- Division: Anesthesiology of all ages, non-operation of coronary artery brain development, neu- transesophageal echocar- cardial outcomes follow- Faculty Rank: Assistant tive orthopedics, family disease, treatment of rocognitive outcome in diography ing cardiac surgery. This is Professor medicine osteoporosis pediatric ICU patients Division: Anesthesiology accomplished through a MD Degree: MD, Wake Division: Family Medicine Division: Harps Mill Division: Anesthesiology Faculty Rank: Associate combination of candidate Forest University, North Faculty Rank: Clinical Internal Medicine Pediatric Critical Professor gene association stud- Carolina, 1991 Associate Faculty Rank: Clinical Care Medicine MD Degree: MD, ies in a well phenotyped Residency: Anesthesiology, Degree: DO, Midwestern Associate Faculty Rank: Assistant University of Hamburg, cardiac surgical popula- Penn State University, University, Illinois, 2000 MD Degree: MD, Professor Germany, 1994 tion, as well as functional Pennsylvania, 1996 Residency: Family University of Texas Health MD Degree: MD, Ohio Residency: Anesthesiology, genomic approaches in Fellowship: Neurosurgical Medicine, Duke University Science Center State University, 1990 Technische Universitaet, humans and animal mod- Anesthesiology/Neural Medical Center, North at Houston Residency: Pediatric Germany, 1997 els of saphenous graft Monitoring, Penn Carolina, 2003 Residency: Internal Internship, Duke Fellowship: Cardiothoracic disease. State University, Fellowship: CAQSM, Medicine/Pediatrics, University Medical Center, Anesthesia, Duke Division: Anesthesiology Pennsylvania, 1997 Primary Care Sports University of Texas Health North Carolina, 1991 University Medical Center, Faculty Rank: Assistant Medicine, Duke University Science Center Pediatric Residency, North Carolina, 1998- Professor B. Craig Weldon, MD Medical Center, North at Houston Bowman Gray School 2000; Intensive Care MD Degree: MD, Carol 919-668-0976 Carolina, 2004 of Medicine, North Medicine, Technische Davila University School of Particular Clinical Interests Carolina, 1993 Universitaet, Germany, Medicine, Romania, 1993 and Skills: Currently Anesthesia Residency, 2001-2002 Residency: Anesthesiology, working in both the OR University of Florida, 1996 Yale University Medical and PICU with a special Fellowship: Center, Connecticut, interest in blood manage- Neuroanesthesia, 1996-2000 ment, mechanical ventila- University of Florida, Fellowship: Cardiothoracic tion, and postoperative 1997; Pediatric ICU, Anesthesia, Duke delirium University of Florida, University Medical Division: Anesthesiology 1998; Pediatric Anesthesia Center, North Carolina, Pediatric Critical Matthew S. McGlothlin, and Critical Care, Boston 2000-2002; Critical Care Care Medicine MD Children's Hospital, Medicine, Duke University Faculty Rank: Associate Samuel W. Warburton, 919-693-3972 Massachusetts, 2001 Medical Center, North Clinical Professor MD Particular Clinical Interests Carolina, 2002-2004 MD Degree: MD, St. Louis 919-684-6721 and Skills: General fam- Ellen M. Flanagan, MD University, Missouri, 1978 Particular Clinical Interests ily medicine, adolescent 919-286-6938 Residency: Pediatrics, St. and Skills: Family practice, health, geriatrics Particular Clinical Interests Louis University, Missouri, quality improvement, Division: Oxford Family and Skills: Perioperative 1981; Anesthesiology, practice efficiency, Physicians ethics, research involving Washington University, chronic disease care, Faculty Rank: Consulting patient and physician per- Missouri, 1987 patient satisfaction Associate spectives on management Fellowship: Pediatric Division: Family Medicine MD Degree: MD, of DNR orders in the peri- Critical Care, Children's Faculty Rank: Consulting University of Missouri- operative period Hospital Philadelphia, Professor Columbia, 1995 Division: Anesthesiology Pennsylvania MD Degree: MD, Residency: Family Practice Faculty Rank: Assistant University of Pennsylvania, Residency, Scottsdale Clinical Professor John R. Schultz, MD 1969 Healthcare, Arizona, 1998 MD Degree: MD, 919-681-6535 Residency: Family BS, Zoology, Louisiana University of North Particular Clinical Interests Medicine, Hunterdon State University - Baton Carolina at Chapel Hill, and Skills: Anesthesia resi- Medical Center, New Rouge, 1990 1999 dent research, obstetric Jersey, 1969-1972 Residency: Internal anesthesia research Medicine, Moses Cone Division: Anesthesiology Health System, North Faculty Rank: Assistant Carolina, 1999-2000 Clinical Professor Anesthesiology, Duke MD Degree: MD, University Medical Center, Loma Linda University, North Carolina, 2000- California, 1991 2003 Residency: Loma Linda University, California, 1999 Fellowship: Obstetric Anesthesia, Loma Linda University, California DukeMed To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) 71 72 DukeMed 1985 MercyMedicalCenter, Residency: 1982 HealthSciencesCenter, UniversityColoradoof Degree:MD ConsultingAssociate FacultyRank: UrgentDukeCare Division: familyeralmedicine sportsmedicinegenand Skills:and ParticularClinicalInterests 919-572-1868 RichardL. Wheeler, MD FamilyPractice,2001 Residency: 1998 Medicine,Collegeof PennsylvaniaState Degree:MD Associate FacultyRank: FamilyPhysicians Division: cine Skills:and ParticularClinicalInterests 919-570-6060 GraceTang, MD

WakeForest Urgentcare, FranklinSquare Familymedi FamilyPractice, MD, MD, Clinical To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) 1.800.MED.DUKE call Physicians (275.3853). 1.888.ASK.DUKE call physician, Duke a with appointment an make To

- - NEW PHYSICIANS NEW Duke UniversityDuke Fellowship: Carolina,2002 MedicalCenter, North Medicine,UniversityDuke Residency: 1999 Medicine,NorthCarolina, UniversitySchoolof Degree:MD FacultyRank: Division: carcinoma thyroiddisease,including cardiovasculardisease, ticularlysettingtheofin Skills:and ParticularClinicalInterests 919-684-9036 Bethel,MD MaryAngelyn 1986-1990 UniversityHospital, Fellowship: 1983-1986 Hospital,Massachusetts, Residency: YorkUniversity, 1983 Degree:MD FacultyRank: Division: Skills:and ParticularClinicalInterests 919-681-5816 PeterB. Berger, MD MEDICINE Carolina,2004 MedicalCenter, North Endocrinology Cardiology Internal Diabetespar Cardiology Boston BostonCity Endocrinology, MD, DukeMD, MD, NewMD, Associate Professor

Maryland,1981-1984 HopkinsUniversity, Gastroenterology,Johns Fellowship: 1978-1981 University,Maryland, Medicine,JohnsHopkins Residency: Washington,D.C.,1978 GeorgetownUniversity, Degree:MD FacultyRank: Division: SteatoHepatitisNASH)- Alcoholic(e.g.Nonease especiallyfattyliverdis chronicliverdisease— Skills:and ParticularClinicalInterests 919-684-3262 DivisionChief AnnaMae E. Diehl, MD 1992-1995 Center,NorthCarolina, UniversityDuke Medical Gastroenterology, Fellowship: 1989-1992 NorthCarolina, UniversityMedicalCenter, Medicine,InternalDuke Residency: 1989 Medicine,NorthCarolina, UniversitySchoolof Degree:MD ClinicalProfessor FacultyRank: Division: disease refluxdisease,peptic ulcer lance,gastroesophageal screeningcer surveiland enterology,colorectal can Skills:and ParticularClinicalInterests 919-684-1817 WendyZ. Davis, MD Gastroenterology Gastroenterology Acuteand Generalgastro

Internal General MD, DukeMD, MD, Assistant Professor

- - - - Medicine,Walter Reed Residency: Washington,D.C.,1975 GeorgetownUniversity, Degree:MD Professor FacultyRank: Transplantation Oncologyand Division: malignancies treatmenthematologicfor stagingandofment developinvolvedthein interestbeenhasand in Skills:and ParticularClinicalInterests 919-684-8964 LouisF. Diehl, MD 1978-1981 Washington,D.C., MedicalArmyCenter, Oncology,Walter Reed Fellowship: 1975-1978 Washington,D.C., MedicalArmyCenter, 2001-2004 Center,NorthCarolina, UniversityDuke Medical Gastroenterology, Fellowship: 2001 Medicine,Georgia,1998- UniversitySchoolof Medicine,Emory Residency: Jersey,1998 DentistryandNewof UniversityMedicineof Degree:MD FacultyRank: Division: colorectalcancer Barrett'sesophagus, refluxdiseaseand gastroesophageal gastrointestinalbleeding, therapeuticendoscopy, Skills:and ParticularClinicalInterests 919-684-1817 MichaelJ. Feiler, MD Medical Gastroenterology Internal Longstanding Diagnosticand Internal Hematology- MD, MD, Clinical Associate

- Carolina,2004 MedicalCenter, North UniversityDuke Rheumatology, Fellowship: 2001 NebraskaMedicalCenter, Medicine,University of Residency: Medicine,1997 UniversitiesCollegeof NortheasternOhio Degree:MD FacultyRank: Division: Skills:and ParticularClinicalInterests 919-681-6928 RobinC. Geletka, MD : “Veryrapidly. A: would I ago decade A : treatmentQ: non- is for How changing Rheumatology “One of the most critical things critical most the of “One course of treatmentbeginning. of the course at are available, when to use them, and them, use areto when available, optimist. an for techniques new especially and developing therapies have made me made have therapies developing utmost importance. So many promisingmany So importance. utmost es in bone marrowbone that in transplantation, es treatmentsarefrom available, coming the but lymphoma, of curability the Understanding what new therapies new what Understanding new drugs such as rituximab to advanc to rituximab as such drugs new therapies recentnew of development patients’ futurepatients’ options.” we want to do all we can to preserveto can we all do to want we of compromiseis would use what their entirean plan to is learned have we Hodgkin’slymphoma? have been a pessimist when discussing when pessimist a been have Internal Rheumatology

MD, Associate

ON THE THE ON

UniversitySchoolof Degree:MD AssociateProfessor FacultyRank: TransplantationUrology MedicalOncologyand Division: tumors biologicforactivity of graphicsurrogate markers molecularradioand targetedandtherapy, patients,angiogenesis kidneycancerandtate developmentprosin Skills:and ParticularClinicalInterests 919-668-8650 DanielJ. George. MD 1995-1998 Hospital,Maryland, Oncology,JohnsHopkins Fellowship: 1992-1995 Hospital,Maryland, Medicine,JohnsHopkins Residency: Medicine,1988 — Louis F.Diehl, MD SPOT

New drugNew Internal Medical MD, DukeMD,

- NEW PHYSICIANS

Roosevelt Gilliam, III, MD Vern Juel, MD Gretchen G. Kimmick, Ahmad A. John L. Petersen, MD Thomas J. Povsic, MD, PhD 919-681-3776 919-668-7600 MD, MS Mahmood, MD 919-286-0411 919-681-5821 Chief, Electrophysiology Particular Clinical Interests 919-684-3877 910-671-5730 ext. 5224 Particular Clinical Interests Particular Clinical Interests and Skills: Neuromuscular Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests and Skills: Advanced and Skills: Cardiac rhythm transmission disorders and Skills: Breast cancer and Skills: and Skills: Coronary artery coronary disease, cellular disorder especially in (particularly myasthenia with particular interest All aspects of adult medi- disease, percutaneous therapy of cardiovascular patients with implantable gravis and Lambert-Eaton in breast cancer in older cal oncology and hema- coronary intervention, disease, research interest devices, syncope, palpita- syndrome), peripheral women and management tology diabetes and coronary in the role of stem cells in tions, atrial fibrillation, nerve and muscle dis- of symptoms in breast Division: Hematology disease cardiovascular disease atrial flutter, ventricular orders, focal/segmental cancer survivors Faculty Rank: Consulting Division: Cardiology Division: Cardiology tachycardia or fibrillation, dystonia (including Division: Medical Associate Faculty Rank: Assistant Faculty Rank: Assistant survivors of near spasmodic torticollis) and Oncology and MD Degree: MD, Professor Professor sudden death chemodenervation for Transplantation Mosul Medical School, MD Degree: MD, PhD, California Institute Division: Cardiology dystonia, clinical electro- Faculty Rank: Assistant Iraq, 1973 University of Washington, of Technology, 1991 Faculty Rank: Clinical myography Professor Residency: General 1995 MD Degree: MD, Harvard Professor Division: Neurology MS, Epidemiology, Wake Internal Medicine, Residency: Internal Medical School, 1995 MD Degree: MD, Duke Faculty Rank: Instructor Forest University School of Danbury Hospital, Medicine, Duke University Residency: Internal University School of MD Degree: MD, Medicine, 2000 Connecticut, 1975-1978 Medical Center, North Medicine, Duke University Medicine, North Carolina, University of MD Degree: MD, Wake Fellowship: Hematology, Carolina, 1995-1998 Medical Center, North 1981 Illinois College of Forest University School of Henry Ford Hospital, Fellowship: Cardiology, Carolina, 1998 Residency: Internal Medicine, 1989 Medicine, 1989 Michigan, 1978; Medical Duke University Medical Fellowship: Cardiology, Medicine, Duke University Residency: Internal Residency: Internal Oncology, Henry Ford Center, North Carolina, Duke University Medical Medical Center, North Medicine, Northwestern Medicine, Shands Hospital, Michigan, 1980 1998-2004 Center, North Carolina, Carolina, 1983-1985 University Medical Center, Teaching Hospitals, 2003; Interventional Fellowship: Cardiology, Illinois, University of Florida, Cardiology, Duke Duke University Medical 1989-1990 1989-1992 University Medical Center, Center, North Carolina, Neurology, Duke Fellowship: Medical North Carolina, 2004 1985-1988 University Medical Center, Oncology, Wake Forest North Carolina, 1990- University School of 1993 Medicine, 1992-1994 Fellowship: Neuromuscular Disease and Electromyography, Duke University Medical Center, North Carolina, Stephanie L. Perry, MD James W. Peterson, MD 1993-1994 919-684-5350 919-862-5100 Particular Clinical Interests Particular Clinical Interests and Skills: Thrombotic and Skills: Clinical and Adrian F. Hernandez, MD and hemorrhagic disor- consultative cardiol- Joseph G. Rogers, MD 919-668-7515 ders, antiphospholipid ogy, echocardiography 919-681-6833 Particular Clinical Interests antibody syndrome, hepa- (including stress echo and Particular Clinical Interests and Skills: Advanced heart Monica Kraft, MD rin induced thrombocy- transesophageal echo- and Skills: Acute and failure, cardiac trans- 919-684-8401 topenia, anticoagulation cardiography), nuclear chronic heart failure, plantation, cardiology Particular Clinical Interests and factor replacement cardiology, cardiac transplantation, consultation, mechani- and Skills: Diagnosis management diagnostic cardiac mechanical circulatory cal circulatory support and treatment of airway Division: Hematology catheterization support devices/ventricular assist diseases such as asthma, Faculty Rank: Associate Division: Cardiology Division: Cardiology devices, preoperative/peri- COPD and bronchiectasis MD Degree: MD, Wake Faculty Rank: Consulting Faculty Rank: Instructor operative consultation Division: Pulmonary, Forest University, Bowman Associate MD Degree: MD, Division: Cardiology Allergy and Critical Care Gray School of Medicine, MD Degree: MD, University of Faculty Rank: Assistant Faculty Rank: Associate North Carolina University of Rochester Nebraska, 1988 Professor MD Degree: MD, Residency: Internal School of Medicine Residency: Internal MD Degree: MD, University of California- Medicine, University and Dentistry, New Medicine, University of University of Texas San Francisco, 1987 of Alabama at York, 1988 Nebraska, 1991 Southwestern Medical Residency: Internal Birmingham, 2000 Residency: Internal Fellowship: School at Dallas, 1997 Medicine, Harbor- Fellowship: Hematology, Medicine, University of Cardiology, Washington Residency: Internal UCLA Medical Center, Duke University Iowa Hospital and Clinics, University, 1995 Medicine, University of California, 1987-1991 Medical Center, North 1988-1991 California-San Francisco, Fellowship: Pulmonary & Carolina, 2003 Fellowship: Cardiology, 1997-2000 Critical Care Medicine, The Ohio State University, Fellowship: Cardiology, University of Colorado 1991-1994 Duke University Medical Health Sciences Center, Master of Arts in Center, North Carolina, 1991-1995 Theological Studies, 2000-2004 McCormick Theological Duke University Clinical Seminary, Chicago, Illinois, Research Training 1984 Program, North Carolina DukeMed To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) 73 74 DukeMed Center, North Carolina,Duke 2002 University Medical Fellowship: Carolina,2000 MedicalCenter, North Medicine,UniversityDuke Residency: Medicine,Schoolof1997 Jersey,RobertWood DentistryandNewof UniversityMedicineof Degree:MD AssistantProfessor FacultyRank: Division: sclerodermalupusandfor evaluatingnoveltherapies syndrome;clinicaltrials derma,CRESTlupus,and todisease activity in sclero- dysfunctionpertainsit as study of vascular endothelial Skills:and ParticularClinicalInterests 919-681-6780 LupusClinic AssociateDirector, ResearchCenter Scleroderma ClinicalDirector, Joseph C. Shanahan, MD 2001-2002 Center,NorthCarolina, UniversityDuke Medical PsychologyInternship, Residency: Nevada,Reno,2002 Degree: ClinicalProfessor FacultyRank: Psychology Division: disordersmoodand nosticpatients,anxiety disorder,PTSD,multi-diag borderlinepersonality behaviortherapy(DBT); dialectical(CBT)andapy cognitivebehavioral ther grouppsychotherapy; Skills:and ParticularClinicalInterests 919-684-6714 Rosenthal,PhD M.Zachary Rheumatology Medical PhD, UniversityPhD, of Rheumatology, Internal Medical Researchthein Individualand

MD,

To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) 1.800.MED.DUKE call Physicians (275.3853). 1.888.ASK.DUKE call physician, Duke a with appointment an make To Assistant

- -

NEW PHYSICIANS NEW 1998-1999 Center,NorthCarolina, UniversityDuke Medical HepatologyBiliary,and 1998 NorthCarolina, 1997- UniversityMedicalCenter, Dermatology,Duke Gastroenterology/ 1993-1997 Hospitals,U.K., GlasgowTeaching Gastroenterology, Fellowship: 1991-1993 Hospitals,U.K., LiverpoolTeaching Gastroenterology, MedicineInternaland 1988-1991 Hospitals,U.K., AberdeenTeaching Gastroenterology, Medicineand Residency: (U.K.),MRCP1992 U.K.,1988 UniversityAberdeen,of Degree: Professor FacultyRank: Division: colonoscopy liverbiopsy, EGD, tation,celiacdisease, rencefollowingtransplan liverdisease,recurand automimmuneformsof specialwithinterest in transplanthepatology Skills:and ParticularClinicalInterests 919-681-4044 ChB,MRCP AlastairD. Smith, MB, MB, ChB,MB, Gastroenterology Internal Generaland Assistant

- - Carolina,2001-2004 MedicalCenter, North Oncology,UniversityDuke Fellowship: Carolina,1998-2001 MedicalCenter, North Medicine,UniversityDuke Residency: Medicine,Schoolof1998 LouisianaStateUniversity Degree:MD Associate FacultyRank: Transplantation MedicalOncologyand Division: Hematology/Oncology munity-basedgeneral practicecomtheofin Skills:and ParticularClinicalInterests 919-954-3050 GinaM. Vaccaro, MD

Interested Internal Hematology/ MD, Consulting - Washington,DC UniversityMedicalCenter, OB/GYN,Georgetown 1999 Medicine,NorthCarolina, ForestUniversity Schoolof Degree:MD ClinicalAssociate FacultyRank: HealthAssociates Division: gynecology,sterilization obstetrics,adolescent Skills:and ParticularClinical 919-684-9696 LindsayC. Gray, MD OB/GYN Carolina,2003-2004 MedicalCenter, North Oncology,UniversityDuke Fellowship: 1999-2003 combinedresidency, GeneralHospital Hospital/Massachusetts BrighamWomen'sand Residency: GraduateSchool,1999 Texasof Southwestern Development,University GeneticsPhD,and School,1999 SouthwesternMedical UniversityTexasof Degree:MD ClinicalAssociate FacultyRank: GynecologicOncology Division: hereditaryovariancancer catedgynecologic surgery, lasersurgery, compli structivepelvicsurgery, radiationtherapy, recon immunotherapyand surgery,chemotherapy, vagina,andradical pelvic cervixdiseasesnanttheof malignancies,premalig Skills:and ParticularClinicalInterests 919-684-3765 MD,PhD MoniqueA. Spillman, Duke Women'sDuke

Gynecologic OB/GYN, Routinegyn, Gynecologic MD, WakeMD, MD,

Interests - - - Medicine,UniversityDuke Fellowship: Pennsylvania,2001 UniversityPittsburgh,of Residency: Medicine,Schoolof1997 CarolinaChapelHillat UniversityNorthof Degree:MD FacultyRank:Associate Maternal-FetalMedicine Division: nancy complicationspregof fetalgrowth, maternal Skills:and ParticularClinicalInterests 919-681-5220 GeetaK. Swamy, MD 1990-1992 NorthCarolina Hospitals, Oncology,University of Fellowship: 1990 CarolinaHospitals, 1987- UniversityNorthof 1985-1987;OB/GYN, NorthCarolina Hospitals, Surgery,University of Residency: Medicine,1985 StonyBrookatSchool of UniversityYorkNewof Degree:MD AssociateProfessor FacultyRank: GynecologicOncology Division: tion MedicalStudenteduca cer,Fellow, Residentand genitaltract,cervixcan lowerfemaletheof gery,pre-invasive disease laparoscopiccancersur surgicalmanagement, Skills:and ParticularClinicalInterests 919-684-3765 OB/GYN Program,Department of Director,Residency FidelA. Valea, MD Carolina,2004 MedicalCenter, North

Post-operative OB/GYN, General Pretermbirth, Maternal-Fetal Gynecologic MD, MD, StateMD,

- - - - Illinois,2003 NorthwesternUniversity, Ophthalmology, Residency: Illinois,1999 NorthwesternUniversity, Degree:MD Professor FacultyRank: SurgeryService VitreoretinalDiseasesand Division: hereditaryretinal disorders diabeticretinopathy, and maculardegeneration, Skills:and ParticularClinicalInterests 919-684-3090 SrilaxmiBearelly, MD OPHTHALMOLOGY 2004 UniversityMedicalCenter, RefractiveSurgery, Duke Disease,Externaland Fellowship: University,Georgia Ophthalmology,Emory Residency: TransitionalYear, 2000 Jacksonville,Florida, Internship: Medicine,Schoolof1999 UniversityArkansasof Degree:MD ClinicalProfessor FacultyRank: DiseaseExternal Division: diseaseexternal Skills:and ParticularClinicalInterests 919-297-0900 MD DouglasM. Blackmon, Center,2004 UniversityDuke Medical Fellowship, Fellowship:

Cornea andCornea

Mayo ClinicMayo Corneal andCorneal Age-related Corneal MedicalRetina MD, MD, Assistant Assistant NEW PHYSICIANS

PATHOLOGY PEDIATRICS

Justin R. Johnsen, MD Suzanne J. Pesce, MD Michael Datto, MD, PhD Deanna Adkins, MD Ravi R. Jhaveri, MD Caren Mangarelli, MD 336-768-3240 919-684-4417 919-684-6965 919-684-3772 919-684-6335 919-620-5374 Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests and Skills: Plastic sur- and Skills: Management and Skills: Molecular diag- and Skills: General pediat- and Skills: Children with and Skills: General pedi- gery around the eyelids, of common ocular dis- nostic testing ric endocrinology includ- viral hepatitis (Hepatitis atrics and adolescent including brow and eases through medical Division: Pathology ing disorders of growth, A, B, C), research interest medicine lower facial lifts; orbital and surgical interven- Faculty Rank: Assistant adrenal glands, thyroid, in children with Hepatitis Division: Children’s and functional problems tion, management and Professor calcium and phosphorus C exposure or infection, Primary Care including tumors and treatment of low vision MD Degree: MD, Duke metabolism, hypothala- patients with problems Faculty Rank: Clinical bone fractures patients University Medical Center, mus, pituitary, sexual and related to general pediat- Associate Division: Oculoplastic and Division: Comprehensive North Carolina, 1999 pubertal development, ric infectious diseases MD Degree: MD, Reconstructive Service Ophthalmology Service PhD, Molecular Cancer and diabetes mellitus Division: University of Illinois at Faculty Rank: Assistant Faculty Rank: Assistant Biology, Duke University Division: Endocrinology Infectious Diseases Chicago, 1996 Consulting Professor Clinical Professor Medical Center, North and Diabetes Faculty Rank: Associate Residency: Pediatrics, MD Degree: MD, MD Degree: MD, The Carolina, 1999 Faculty Rank: Associate MD Degree: MD, Mount University of Chicago, Emory University Medical George Washington Residency: Pathology, MD Degree: MD, Medical Sinai School of Medicine, 1999 School, Georgia, 1999 University School of Duke University Medical College of Georgia, 1997 New York, 1996 Residency: Medicine, Washington Center, North Carolina, Residency: Pediatrics, UNC Residency: Pediatrics, Ophthalmology, D.C., 1996 2004 Hospitals, North Carolina, University of Chicago Vanderbilt University Residency: Internship, 2000 Hospital, Illinois, 1996- Medical Center, Internal Medicine, Fellowship: Pediatric 1999 Tennessee, 2003 George Washington Endocrinology, 2004 Fellowship: Pediatric Fellowship: University Hospital, Infectious Diseases, Mattel Oculoplastic, Orbital and Washington D.C., Children's Hospital at Reconstructive Surgery 1996-1997; Residency, UCLA, California, 1999- Ophthalmology, 2003 Washington Hospital Center, Washington D.C., Suhag H. Parikh, MD 1997-2000 919-668-1121 Particular Clinical Interests and Skills: Stem cell (cord blood, peripheral blood and ON THE SPOT Jeffrey W. Delaney, MD bone marrow) transplan- 919-681-2916 tation for hemoglobin- Q: What are the most encouraging Particular Clinical Interests opathies such as sickle Frank J. Moya, MD and Skills: Diagnostic cell disease and thalas- 336-768-3240 advances in glaucoma treatment? and interventional cath- Glenn T. Leonard, Jr, MD semia; inherited meta- Particular Clinical Interests eterization procedures in 919-681-2916 bolic disorders, immune and Skills: Evaluation, children and adults with Particular Clinical Interests disorders and childhood diagnosis, and treat- A: “ To me, the most encouraging advances congenital heart disease; and Skills: Evaluation and malignancies ment of adult glaucoma; are being made in the field of diagnos- valvuloplasty, angioplasty, treatment of pediatric and Division: Blood and complicated glaucoma tic devices. With new technologies like stent placement, and adult patients with con- Marrow Transplantation surgery; glaucoma surgery device closure of blood genital or acquired heart Faculty Rank: Associate complications; cataract optical coherence tomography (OCT) vessels and septal defects disease with expertise MD Degree: MD, surgery and frequency doubling perimetry, Division: Cardiology in the therapeutic treat- Government Medical Division: Faculty Rank: Clinical ment of congenital heart College, India, 1988 Glaucoma Service we can diagnose glaucoma at earlier Associate defects using transcath- Residency: Pediatrics, Faculty Rank: Assistant stages—and studies show that the MD Degree: MD, eter techniques University of Bombay, Consulting Professor earlier we institute therapy, the better Creighton University Division: Cardiology India, 1988-1991 MD Degree: MD, Yale School of Medicine, 1994 Faculty Rank: Associate Pediatrics, State University University School of patients do. We also have more thera- Residency: Pediatrics, MD Degree: MD, of New York Stony Brook, Medicine, Connecticut, pies to draw on to lower intraocular Madigan Army Medical St. George's University 1992-1995 1997 Center, Washington School of Medicine, Fellowship: Pediatric Residency: pressure, from less invasive procedures Fellowship: Pediatric Grenada, West Indies, Hematology Oncology, Ophthalmology, Yale like selective laser trabeculoplasty to Cardiology, Yale 1997 Baylor College of University School of University, Connecticut Residency: Pediatrics, Medicine, Texas, 1995- Medicine Eye Center, glaucoma drainage tube implantation. Children's Hospital of 1998; Pediatric Stem Cell Connecticut, 1998-2001 With earlier diagnosis and better treat- Buffalo, New York, 1997- Transplantation, Baylor Fellowship: Glaucoma, ment, more patients will be able to 2000 College of Medicine, Duke University Eye Fellowship: Pediatric Texas, 2002-2003 Center, North Carolina, retain their vision for life.” Cardiology, University 2001-2002 —Frank J. Moya, MD of Florida/Shands Hospital, 2000-2003; Duke Eye Center Pediatric Interventional of Winston-Salem Catheterization, Texas Children's Hospital, 2003- 2004 DukeMed To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) 75 NEW PHYSICIANS

PSYCHIATRY AND BEHAVIORAL SCIENCES

Vinod K. Prasad, MD, Jennifer W. Singleton, Martin Binks, PhD Lisa C. Campbell, PhD Lauren E. Durant, PhD Kelli E. Friedman, PhD MRCP MD 919-688-3079 919-286-2839 919-668-3690 919-660-2366 919-668-1100 919-681-6024 Particular Clinical Interests extension 232 Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests and Skills: Obesity treat- Particular Clinical Interests and Skills: Behaviorally and Skills: Assessment/ and Skills: Cord blood, and Skills: General pediat- ment and research, binge and Skills: Assessment dysregulated “at risk” treatment of depression, stem cell, and bone rics, neonatology eating and treatment of pain adolescent populations, anxiety, eating disorders, marrow transplant for Division: Neonatal- Division: Medical disorders and disease- culturally competent smoking cessation, obe- childhood cancers, inher- Perinatal Medicine Psychology related pain, coping with treatment approaches for sity, stress management, ited metabolic disorders, Faculty Rank: Faculty Rank: Assistant chronic illnesses, cogni- African-Americans, sub- individual and group immunodeficiency, Clinical Associate Clinical Professor tive behavioral therapy, stance dependant/abuse cognitive behavioral psy- Hemoglobinopathies and MD Degree: MD, Baylor Degree: PhD, Clinical ethnicity and psychosocial patients, cognitive behav- chotherapy other serious diseases; lab College of Medicine, Psychology, Fairleigh wellbeing ioral treatment approach, Division: Medical research in histocompat- Texas, 2000 Dickinson University, New Division: Medical marital/family therapy Psychology ibility (tissue typing) and Residency: Pediatrics, Jersey, 2002 Psychology Division: Faculty Rank: Assistant other determinants of Baylor College of Behavioral Medicine, Faculty Rank: Assistant Medical Psychology Clinical Professor alloreactivity with a focus Medicine and Affiliated Medical University of Clinical Professor Faculty Rank: Assistant Degree: PhD, Duke on identifying the best Hospitals, Texas, 2003 South Carolina, 2000 Degree: PhD, University of Clinical Professor University Medical Center, matched donor by cutting Post-Doctoral Fellowship, Florida, 2002 Degree: PhD, North Carolina, 2002 edge molecular tech- Obesity Treatment and Health Psychology, Duke Clinical Psychology, Durham VA Medical niques; clinical research in Research, 2000-2003 University Medical Center, Syracuse University, Center, North Carolina, post-transplant viral infec- North Carolina, 2001- New York, 2001 2002 tions with a focus on early 2002 Clinical Internship, Duke Behavioral Medicine detection and treatment Behavioral Medicine, University Medical Center, Research Center, Division: Blood and Duke University Medical North Carolina, 2000-2001 Duke University Medical Marrow Transplantation Center, North Carolina, Post Doctoral Fellow, Duke Center, North Carolina, Faculty Rank: Assistant 2002-2004 University Medical Center, 2002-2004 Professor North Carolina, 2001-2003 MD Degree: MBBS (1983), Addiction Medicine, Duke MD (Pediatrics, 1986) - William J. Steinbach, MD University Medical Center, University of Delhi 919-681-2613 North Carolina, 2001-2003 University of Delhi Particular Clinical Visiting Scholar, University Pediatrics Training, 1984- Interests and Skills: Leslie L. Bronner, MD, of California, San 1989 Immunocompromised DrPH, MPH Francisco, 2002- Present Residency: Member of pediatric patients, espe- 919-684-6725 Royal College of Physicians cially children with inva- Particular Clinical Interests (MRCP), London, 1990 sive fungal infections and Skills: Pediatric Hematology Division: Adult general psychiatry; Oncology, Hammersmith Infectious Diseases medication management; Jennifer S. Cheavens, PhD Jane P. Gagliardi, MD Hospital and Hospital for Faculty Rank: psychotherapy including 919-684-6701 919-668-0869 Sick Children, London; Assistant Professor CBT/DBT; cultural issues in Particular Clinical Interests Particular Clinical Interests and St. James' University MD Degree: MD, mental health and Skills: Cognitive and Skills: Inpatient Hospital, Leeds, University of North Division: behavioral and dialecti- general medicine and 1990-1993 Carolina School of Outpatient Psychiatry cal behavior therapy for psychiatry, areas of clinical Fellowship: Memorial Medicine, 1998 Faculty Rank: depression, anxiety, sub- overlap between medicine Sloan Kettering Cancer Residency: Pediatrics, Clinical Associate stance use, and personal- David P. Fitzgerald, PhD and psychiatry and con- Center and Cornell Stanford University, MPH, Boston University ity disorders, treatment 919-416-2096 sultation psychiatry University Medical Center, California, 1998-2001 School of Public Health, for adults (over age 18) Particular Clinical Interests Division: New York, 1994-1997 Fellowship: Pediatric Massachusetts, 1990 and couples and Skills: Aggressive and Outpatient Psychiatry Infectious Diseases, DrPH, Harvard School Division: Medical oppositional behavior, Faculty Rank: Sara P. Robert, MD Duke University Medical of Public Health, Psychology parent-child interactions, Clinical Associate 919-620-5374 Center, North Carolina, Massachusetts, 1995 Faculty Rank: Assistant psychological assessment MD Degree: MD, Duke Particular Clinical Interests 2001-2004 MD Degree: MD, Duke Clinical Professor and testing, children's University School of and Skills: General pediatric University Medical Center, Degree: PhD, Clinical peer and social relation Medicine, North Carolina, care, pediatric urgent care North Carolina, 1999 Psychology, University of development, technology 1998 Division: Children’s Residency: Psychiatry, Kansas, 2002 use in the evaluation and Residency: Internal Primary Care Duke University Medical Clinical Psychology treatment of externalizing Medicine/Psychiatry (com- Faculty Rank: Clinical Center, North Carolina, Internship, Duke disorders, ADHD and bined), Duke University Associate 2004 University Medical Center, aggression School of Medicine, North MD Degree: MD, Stritch North Carolina, 2001- Division: Medical Carolina, 1998-200 School of Medicine 2002 Psychology – Loyola University, Illinois, National Institute of Aging Faculty Rank: Clinical 1999 Training Grant – Center Associate Residency: Pediatrics, for the Study of Aging Degree: PhD, Duke University Medical and Human Development University of Notre Dame, Center, North Carolina, Fellow, 2002-2004 Indiana, 1995 1999-2002 Internship, University of Pennsylvania School of Medicine

To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) NEW PHYSICIANS

RADIATION ONCOLOGY RADIOLOGY

Priscilla F. Grissom, PhD Ashwin A. Patkar, MD Alton Williams, MD, JD John P. Kirkpatrick, MD, Caroline W.T. Carrico, MD Tracy A. Jaffe, MD 919-416-2099 919-471-3826 919-684-0275 PhD 919-684-7288 919-684-7293 Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests 919-668-5213 Particular Clinical Skills Particular Clinical Interests and Skills: ADHD evalu- and Skills: Extensive and Skills: Consultation Particular Clinical Interests and Interests: Pediatric and Skills: Abdominal ations for children, ado- clinical and research in the setting of civil and and Skills: Radiation Imaging imaging with CT, MRI lescents, and college stu- experience in the assess- criminal litigation with a oncology, particularly Division: Pediatric and ultrasound, bowel dents; psychoeducational ment and treatment of focus on competency, fit- the treatment of cancers Radiology imaging, female pelvis evaluations; consultation substance abuse and dual ness for duty, and criminal of the central nervous Faculty Rank: Assistant imaging, abdominal inter- regarding school con- diagnosis; expert in office responsibility (insanity) system, base of skull and Professor vention radiology cerns; social skills training based buprenorphine Division: head/neck, and gyneco- MD Degree: MD, Division: Abdominal Division: treatment for opioid Biological Psychiatry logic cancers; stereotactic University of Louisville Imaging Medical Psychology addiction Faculty Rank: radiosurgery, stereotactic School of Medicine, Faculty Rank: Associate Faculty Rank: Division: Clinical Associate radiotherapy and other Kentucky, 1991 MD Degree: MD, Clinical Associate Biological Psychiatry MD Degree: MD, Yale highly conformal tech- Residency: General University of Texas Degree: PhD, Faculty Rank: University School of niques employing spatio- Surgery, University of Southwestern Medical North Carolina State Associate Professor Medicine, Connecticut temporal optimization Louisville, Kentucky, School, 1996 University, 2001 Degree: G.S., Medical Residency: Adult Division: Radiation 1991-1992 Residency: Radiology, College, University of Psychiatry Residency Oncology Diagnostic Radiology, University of North Bombay, India, 1987 Program, Massachusetts Faculty Rank: Assistant Indiana University, Carolina at Chapel Hill, Residency: Psychiatry, General Hospital and Professor 1992-1996 2001 King Edward Memorial McLean Hospital, 2003 PhD, Chemical Fellowship: Pediatric Fellowship: Abdominal Hospital, Bombay, India, Fellowship: Forensic Engineering, Rice Radiology, Harvard Imaging, Duke University 1987-1990; Psychiatry, Psychiatry Fellowship, University, Texas, 1979 Medical School, Medical Center, North Queen's Medical Center, Harvard Medical Center, MD Degree: MD, Massachusetts, 1996-1997 Carolina, 2002 University of Nottingham, Massachusetts University of Texas Health England, 1990-1994; JD, University of North Science Center at San Bennett Chin, MD Lynne M. Hurwitz Psychiatry, Thomas Carolina at Chapel Hill, Antonio, 1999 919-684-7698 Koweek, MD Jefferson University 1999 Residency: Internal Particular Clinical Interests 919-684-7604 Desiree W. Murray, PhD Hospital, Pennsylvania, Medicine, University of and Skills: Positron emis- Particular Clinical Interests 919-416-2082 1995-1997 Robert E. Williams, MD North Carolina at Chapel sion tomography and Skills: Cardiac and Particular Clinical Interests Fellowship: Substance 919-684-5943 Hill, 1999-2000; Radiation Division: Nuclear Medicine thoracic imaging and Skills: Evaluation and Abuse, Mapperley Particular Clinical Interests Oncology, Duke University Faculty Rank: Associate Division: Cardiac and treatment of ADHD in Hospital, University of and Skills: Dementia, Medical Center, North Professor Thoracic Imaging children, adolescents, and Nottingham, England, Alzheimer's disease, Carolina, 2000-2004 MD Degree: MD, Faculty Rank: Assistant adults; parent training; 1994-1995 depression and psychotic University of Texas Professor academic skills support; MPhil, illness in nursing home Medical Branch, MD Degree: MD, Duke school consultation Neuropharmacology, facilities and inpatients at Galveston, 1987 University School of Division: University of Nottingham, DUMC, social interven- Residency: Internal Medicine, North Carolina, Medical Psychology England, 1995 tions including family, Medicine, Methodist 1997 Faculty Rank: MRCPsych, Psychiatry, friends, and caretakers Medical Center, Texas, Residency: Internal Clinical Associate Royal College of combined with appropri- 1987-1990 Medicine Internship, Degree: PhD, University of Psychiatrists, London, ate psychopharmacologic Fellowship: Nuclear University of Washington, South Florida, 1997 England, 1993 therapies Medicine Fellowship, 1997-1998; Diagnostic Clinical Psychology Division: Johns Hopkins Hospital, Radiology Residency, Internship, Community Laura S. Porter, PhD Geriatric Psychiatry Maryland, 1990-1991 Duke University Medical Child Specialty Track, 919-668-1987 Faculty Rank: University of Pennsylvania, Center, North Carolina, University of North Particular Clinical Interests Clinical Associate 1991-1992 1998-2002 Carolina School of and Skills: Helping MD Degree: MD, East Fellowship: Cardiothoracic Medicine, 1993-94 patients with chronic Carolina University School Radiology Fellowship, illness and their family of Medicine, North Duke University Medical members cope with the Carolina, 1998 Center, North Carolina, symptoms and psycho- Residency: Psychiatry, 2002-2003 logical demands of their University of North disease Carolina Hospital, Division: 1998-2002 Medical Psychology Fellowship: Geriatric Faculty Rank: Assistant Psychiatry, Duke University Clinical Professor Medical Center, North Search Duke’s Physician Degree: PhD, Clinical Carolina, 2002-2003 Psychology, State Referral Directory online at University of New York at Stony Brook, 1996 dukehealth.org/physician_search DukeMed To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) 77 78 DukeMed 2004 NorthCarolina, 2003- UniversityMedicalCenter, Neuroradiology,Duke Fellowship: Carolina,1999-2003 MedicalCenter, North Radiology,UniversityDuke Residency: Illinois,1998 UniversityChicago,of Degree:MD Chicago,Illinois,1997 UniversityPhD, of Professor FacultyRank:Assistant Division: imaging angiography,molecular guidedspineprocedures, tionalfluoroscopically- convenandspine,CT brainimagingandof Skills:and ParticularClinicalInterests 919-684-7218 MD,PhD ChristopherD. Lascola, 2001-2003 Center,NorthCarolina, UniversityDuke Medical Neuroradiology, Fellowship: Ireland,1996-2001 UniversityHospital, Residency: Ireland,1989 UniversityCollegeDublin, Degree:MD Professor FacultyRank: Division: Skills:and ParticularClinicalInterests 919-684-7406 SusanM. Kealey, MD Neuroradiology Neuroradiology MRI and CTand MRI Neuroradiology

St. Vincent'sSt. Diagnostic MD, MD, Assistant To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) 1.800.MED.DUKE call Physicians (275.3853). 1.888.ASK.DUKE call physician, Duke a with appointment an make To

- NEW PHYSICIANS NEW and magneticandresonance tomographyangiography includingingcomputed magneticresonance imag multidetectorandrowCT specificwithemphasis on Skills:and ParticularClinicalInterests 919-684-7325 ElmarM. Merkle, MD Carolina,2003-2004 MedicalCenter, North Imaging,UniversityDuke Fellowship: 1999-2003 Center,NorthCarolina, UniversityDuke Medical Residency: Medicine,Georgia,1996 UniversitySchoolof Degree:MD University,Georgia,1992 Biology,BS, Emory ConsultingAssociate FacultyRank: CommunityRadiology Division: radiology abdominalinterventional abdominalimagingand interestsologywith in Skills:and ParticularClinicalInterests 336-503-5787 EllieR. Lee, MD 1997-1999 Cleveland,of Ohio, UniversityHospitals ResonanceFellowship, Fellowship: Germany,1992-1997 UniversityUlm,of Residency: Germany,1991 UniversityUlm,of Degree:MD AssociateProfessor FacultyRank: AbdominalImaging Division: angiography

Body imagingBody Generalradi Radiology, Radiology, Magnetic Abdominal MD, EmoryMD, MD,

- - 1987 California-Sanof Diego, Radiology,University Fellowship: 1986 UniversityMinnesota,of DiagnosticRadiology, Hospital,1983 Paul-RamseySt. County Residency: Nebraska,1982 CreightonUniversity, Degree:MD Professor FacultyRank: InterventionalRadiology Division: embolization cedures;uterinefibroid abdominalchestandpro invasiveliver, kidney, occlusionstrauma;and includeaneurysms,to diagnosistreatmentand venousvasculardisease Skills:and ParticularClinicalInterests 919-684-7424 JosephM. Stavas, MD 2001 University,Georgia,2000- Neuroradiology,Emory Fellowship: 2000 University,Georgia,1996- Radiology,Emory Residency: University,Georgia,1996 Degree:MD University,Georgia,1991 Chemistry,PhD, Emory Professor FacultyRank: Division: craniofacialCT trastagents,pediatric visualization,novelcon computer-basedandCT braintumorimaging,3D Skills:and ParticularClinicalInterests 919-684-7218 MD,PhD SrinivasanMukundan, Jr., Neuroradiology Vascularand Arterialand AdvancedMRI, Diagnostic Radiology, Interventional MD, EmoryMD, MD, Assistant Assistant

- - SURGERY MD Degree:MD Professor FacultyRank: Surgery Division: arthritisandcopysurgery extremity,wristarthros gery,fractures upperof Dupuytren's,microsur tunnelsyndrome,pal emphasiswithcar on upperextremity surgery head;hand,wrist,and necrosisfemoraltheof Skills:and ParticularClinicalInterests 919-684-2476 III,MD JulianMack Aldridge, 2003-2004 Center,NorthCarolina, UniversityDuke Medical MicrosurgeryFellowship, Fellowship: Carolina,1998-2003 MedicalCenter, North Surgery,UniversityDuke Residency: 1998 Medicine,NorthCarolina, ForestUniversity Schoolof Orthopaedic Avascular Orthopaedic Hand andHand MD, WakeMD, Assistant - - - Center,YorkNew Medicine,JacobiMedical York;Emergency MedicalCenter, New Internship,IsraelBeth Residency: 1997 Medicine,York,New EinsteinCollegeof Degree:MD ClinicalProfessor FacultyRank: EmergencyMedicine Division: medicine,sportsmedicine Skills:and ParticularClinicalInterests 919-684-5537 DavidJ. Berkoff, MD Medicine,NorthCarolina, UniversitySchoolof Degree:MD ProfessorSurgeryof FacultyRank: Surgery Division: replacementknee minimallyinvasiveandhip orthopaedicsurgery, ment,computerassisted replacekneeandhip replacement,revision total unicompartmentalknee replacement,kneeand Skills:and ParticularClinicalInterests 919-668-4732 MichaelP. Bolognesi, MD Medicine,2003-2004 SchoolUtahofof Reconstruction,University Fellowship: Carolina,1998-2003 MedicalCenter, North Surgery,UniversityDuke Residency: 1998

Orthopaedic

Emergency Total hip Medicine Orthopaedic Adult MD, AlbertMD, MD, DukeMD, Assistant Assistant - ColumbiaCollegeof Degree:MD AssistantProfessor FacultyRank: ThoracicandSurgery Division: airwaysurgery (PDT),thorascopic surgery, photodynamic/ therapy esophagealand stenting mediastinum;bronchial lungs,esophagusand malignantdiseasestheof racicsurgery, benignand Skills:and ParticularClinicalInterests 919-684-6974 MD WilliamR. Burfeind, Jr., Center,California,1990 Harbor-UCLAMedical John’sSt. HeartInstitute, ResearchFellowship, Medicine/Cardiology Fellowship: California,1989 MedicalUCLACenter, Medicine,Harbor- Residency: 1986 CarolinaChapelHill,at UniversityNorthof Degree:MD AssociateProfessor FacultyRank: Medicine Division: acutecardiac disease ogy,oxygenmetabolism, resuscitation,ma, toxicol Skills:and ParticularClinicalInterests 919-668-8686 CharlesB. Cairns, MD Carolina,2001-2004 MedicalCenter, North Surgery,UniversityDuke Fellowship: Carolina,1994-2001 MedicalCenter, North Surgery,UniversityDuke Residency: York,New 1994 PhysiciansSurgeons,and Cardiovascular Emergency Asthma,trau Emergency General Generaltho Emergency Thoracic MD, MD,

- - - NEW PHYSICIANS

Shu S. Lin, MD, PhD Timothy N. McGlaughlin, Joy C. Martin, MD Jonathon D. Palmer, MD Homa Shahnawaz, MD Henry F. Tripp, Jr., MD 919-684-2890 DO, MS 919-684-5537 919-684-5537 919-684-5537 434-791-3009 Particular Clinical 919-684-5537 Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests Interests and Skills: Particular Clinical Interests and Skills: Socioeconomic and Skills: Clinical emer- and Skills: and Skills: Cardiothoracic Cardiopulmonary trans- and Skills: Shock resusci- barriers to healthcare, gency medicine and resi- Emergency medicine and vascular surgery, plantation (heart, lung tation, trauma health policy, minority dent education Division: Emergency CABG, aortic valve and and heart-lung trans- Division: health issues, cultural Division: Emergency Medicine mitral valve surgery, lung plantation), transplant Emergency Medicine competency/diversity Medicine Faculty Rank: Assistant resection, carotid end- immunology, adult cardiac Faculty Rank: training Faculty Rank: Assistant Clinical Professor arterectomy, aneurysm surgery including coronary Assistant Professor Division: Clinical Professor MD Degree: MD, repair (including endo- artery bypass grafting and Masters of Science, Emergency Medicine MD Degree: MD, University of North vascular) and surgery of valvular surgery, ventricu- Bucknell University, Faculty Rank: Assistant University of Arkansas for Carolina School of major vessels lar assist device Pennsylvania, 1995 Clinical Professor Medical Sciences, 2001 Medicine, 1998 Division: Cardiovascular Division: Cardiovascular Degree: DO, Lake Erie MD Degree: MD, Wayne Residency: Emergency Residency: Emergency and Thoracic Surgery and Thoracic Surgery College of Osteopathic State University School of Medicine, University of Medicine, Detroit Faculty Rank: Assistant Faculty Rank: Assistant Medicine, Pennsylvania, Medicine, Michigan, 2000 Arkansas for Medical Receiving Hospital/ Clinical Professor Professor 1999 Residency: Emergency Sciences, 2004 Wayne State University, MD Degree: MD, Duke MD Degree: MD, Duke Residency: Internship, Medicine, Brown Michigan, 2001 University School of University School of The Western Pennsylvania University/Rhode Island Medicine, North Carolina, Medicine, 1992 Hospital, 1999-2000; Hospital, 2000-2004 1985 Residency: General Emergency Medicine Residency: Keesler Surgery, Duke University Residency, Geisinger Medical Center, Medical Center, 1992- Medical Center, Mississippi, 1988-1993 2001; Thoracic Surgery, Pennsylvania, 2000-2003 Fellowship: Cardiothoracic Duke University Medical Fellowship: Trauma/ Surgery, Carolinas Medical Center, 2001-2004 Critical Care, University of Center, North Carolina, PhD, Immunology, Duke Maryland, 2003-2004 1993-1994; Vascular University, 2000 Surgery, Carolinas Medical Robert S. Park, MD Center, North Carolina, 919-684-5537 Sinan A. Simsir, MD 1995-1996 ON THE SPOT Particular Clinical Interests 919-684-4694 Judd W. Moul, MD and Skills: Clinical Particular Clinical Interests Division Chief education, emergency and Skills: Thoracoscopic Q: Disparities in health care are a growing 919-684-5057 ultrasound (in particular and other surgery for atrial Particular Clinical Interests ultrasound-guided vas- fibrillation, lung transplan- concern. What’s your experience? and Skills: Nerve-sparing cular access), biomedical tation, adult cardiac sur- radical prostatectomy, devices gery, heart transplantation A. “ Coping with patient socioeconomic treatment of PSA-only or Division: Emergency and cardiac assist devices biochemical recurrence of Medicine Division: Cardiovascular and cultural barriers is a frustrating and prostate cancer, prostate Faculty Rank: Assistant and Thoracic Surgery rewarding part of emergency room life. biopsy, prostate cancer in Clinical Professor Faculty Rank: Assistant African American men, MD Degree: MD, Professor Robert D. Zura, MD I routinely see patients with limited or multi-disciplinary manage- University of North MD Degree: MD, Marmara 919-668-0291 no health insurance suffering because ment of prostate cancer, Carolina at Chapel Hill, University, Turkey, 1991 Particular Clinical Interests they can’t afford to address a health clinical trials in prostate 1998 Residency: General and Skills: Orthopaedic disease, noted authority Residency: Emergency Surgery, University traumatology, acute frac- concern until it’s become an emergency. on early stage testicular Medicine, Alameda of Minnesota, 2000; tures of upper and lower Language barriers also present a chal- cancer County Medical Cardiothoracic extremities and pelvis Division: Urology Center - Highland Surgery, University of Division: lenge, because time is of the essence Faculty Rank: Professor Hospital, California, Massachusetts, 2003 Orthopaedic Surgery in emergency settings and the inability MD Degree: MD, 1998-2002 Fellowship: Thoracic Faculty Rank: Assistant to communicate with a patient slows Jefferson Medical College, Fellowship: Emergency Transplantation and Professor Pennsylvania, 1982 Ultrasound, Alameda Cardiac Assist Devices, MD Degree: MD, Johns down our response. However, it’s Residency: Surgery, Walter County Medical Duke University Medical Hopkins School of rewarding to know we provide a safety Reed Army Medical Center - Highland Center, North Carolina, Medicine, Maryland, 1994 Center, Washington, Hospital, California, 2003 2004 Residency: Orthopaedic net for vulnerable members of our com- DC, 1982-1983; Surgery, University of munity. We’ve also made significant Urology, Walter Reed Virginia, 1995 Army Medical Center, Fellowship: Orthopaedic progress in overcoming these barriers Washington, DC, Trauma, Carolinas Medical by connecting patients with community 1983-1987 Center, North Carolina, resources and working with interpreters Fellowship: Urologic 2001 Oncology Fellowship, who now make themselves available Duke University Medical within 15 to 20 minutes of a page.” Center, North Carolina, 1988-1989 —Joy C. Martin, MD DukeMed To make an appointment with a Duke physician, call 1.888.ASK.DUKE (275.3853). Physicians call 1.800.MED.DUKE (633.3853) 79 A 1971 graduate of Duke University School of Nursing (DUSON), Catherine Lynch Gilliss returned to lead her alma mater on October 1. She recently took a few minutes to share her plans and perspectives with DukeMed Magazine.

Are there new directions ahead for the school? We won’t be turning the ship around, because we are headed in the right direction. But, beyond the new PhD program and the building, our attentions will be directed to more fully integrating DUSON and nursing within Duke University Health System (DUHS). We have an extraordinary opportunity at Three questions Duke because of the unique governance structure in which a single chancellor presides A chat with Catherine Lynch Gilliss, DNSc, over both the health entities and the schools; RN, FAAN, dean of Duke’s School of Nursing our chancellor truly believes we’re all respon- and vice chancellor for nursing affairs sible for bringing optimum health to patients. Nursing education and nursing service should You’ve spent What are DUSON’s “outrageous be strong partners in strategically aligned your career ambitions”? efforts. For instance, the distinctive focus of at some of the Thanks to many years of work by many people, nursing research at DUSON is examination of country’s top nursing notably former Dean Mary Champagne, the trajectories of care, that is how patients schools, most recently serving as dean at several of our major ambitions will be realized with chronic health problems manage over Yale. What drew you back to Duke? in the first 100 days of my term as dean. First, time and interface with systems of health care My head was turned by the opportunity we hope to receive approval to launch a PhD delivery over time. We intend to strengthen to work at my alma mater, and by Duke’s program from Duke’s Board of Trustees when the DUHS by developing and testing success- “outrageous ambition,” as [former Duke they meet in December. A rigorous doctoral ful models of care. In turn, we know that our President] Terry Sanford put it. For over 30 program requires that many faculty be active- curriculum and learning experiences can be years I’ve looked for a place that held the ly engaged in relevant research, so we plan enhanced by the involvement of the DUHS values I learned as an undergraduate at Duke, to hire experienced scientists and expand our nurses. We believe the opportunity to work in including a strong commitment to interdisci- research portfolio. partnership will result in the development of plinary work, a commitment to clinical inquiry, We will also be looking for Board approval replicable models for nursing education and and an ambitious spirit. There is no place like to begin construction of our new building. If service for collaborations at other academic home! I am delighted to return to the univer- that happens, we expect to be in the new health centers. sity where I learned those fundamental values. space by the time the doctoral program starts My husband, Tom Gilliss, is glad to be in fall 2006. Learn more about Dean Gilliss on page 60. returning to Durham as well. We were So we are headed into a very exciting married just prior to my senior year at Duke. period. Over the next few years we expect to For more information on DUSON’s planned At that time all students lived in Hanes House, significantly expand our visibility and impact. PhD program, see page 10; for more on the and I actually had to seek permission from the planned 71,500-square-foot headquarters dean to get married and live off-campus! building, visit development.mc.duke.edu/ nursing. CONTINUING MEDICAL EDUCATION AT DUKE For more information on the courses listed below, please contact the Duke Office of Continuing Medical Education at 919-684-6485 or visit docme.mc.duke.edu. DUKE CME CALENDAR COURSE DATE LOCATION CREDIT REGISTRATION

MULTISPECIALTY Teaching and Leading EBM: April 19-22, 2005 Durham, North Carolina 36 credits 919-681-3009 or A Workshop for Educators and www.mclibrary.duke. Champions of Evidence-Based Medicine edu/limited/ ON-SITE COURSES ON-SITE EBMworkshop/

RADIOLOGY Abdominal & Musculoskeletal MRI Update January 15-18, 2005 The Atlantis, Nassau, 18 credits 919-684-7228 or Bahamas [email protected]

RADIOLOGY A Practical Approach to Musculoskeletal MRI February 19-22, 2005 Walt Disney Resort, FL 16 credits 919-684-7228 or [email protected]

RADIOLOGY Practical & Advanced Imaging: March 5-9, 2005 The Pines Lodge 18 credits 919-684-7228 or The Abdomen and Musculoskeletal System at Beaver Creek Resort [email protected]

COURSE DATE CREDIT REGISTRATION

RESEARCH ETHICS “Social Sciences Research in Medical Settings” Available through December 31, 2006 1.5 credits researchethicstraining.org

“Using Databases in Research” Available through December 31, 2006 1.5 credits researchethicstraining.org

“Prisoners Involved as Participants in Research” Available through December 31, 2006 1.5 credits researchethicstraining.org COURSES ONLINE

“Protecting the Confidentiality and Available through December 31, 2006 1.5 credits researchethicstraining.org Privacy of Patients”

“Protecting Research Subjects” Available through December 31, 2006 1.5 credits researchethicstraining.org

“What Counts as Research with Human Subjects?” Available through December 31, 2006 1.5 credits researchethicstraining.org

“Children Involved as Subjects in Research” Available through December 31, 2006 1.5 credits researchethicstraining.org

“Ethical and Regulatory Considerations Available through December 31, 2006 1.5 credits researchethicstraining.org When Bringing a Medication to Market”

“Informed Consent for Research” Available through December 31, 2006 1.5 credits researchethicstraining.org

“The Fundamentals” Available through December 31, 2006 1.5 credits researchethicstraining.org

These activities have been approved for AMA PRA credit.

Earn up to 1.0 hour AMA PRA Category 1 Credit for reading the Clinician Q&A feature, “Use of Opioids for Outpatient Pain Management,” in this issue of DukeMed Magazine. See page 54 for details. DukeMed MAGAZINE VOLUME 4, ISSUE 2, FALL/WINTER 2004 Non-profit Org. Non-profit Postage U.S. PAID NC Durham, #60 Permit

WHAT DRIVES DZAU? Victor J. Dzau, MD, became chancellor for health affairs at Duke and president and CEO of Duke University Health System on July 1. It’s a big job with broad responsibilities—but for Dzau, it boils down to a simple goal. “The most important thing is to remember why we are doing what we are doing,” he says. “It’s very easy to get pulled into management processes and a focus on the bottom line—and we need to do well in those areas—but most of all, we need to enable people to work toward the good of society.”

Read about the good things Dzau’s doing on page 18. DukeMed Magazine DukeMed 3687 DUMC Center Medical University Duke 27710 NC Durham,

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