Blood Sugar Battles As Diabetes Cases Multiply, Duke Caregivers Are Mobilizing in New Ways to Keep the Disease Under Control—In the Hospital and Out

volume 7 issue 1 SPRING/SUMMER 2007

Advances in research, education, and patient care at Duke

Inside, read how

The diabetes epidemic is hitting the country hard—and complicating care in almost every medical specialty. Duke is working to win the

24 Help for kids who weigh too much BATTLES 32 Exploring the mysteries of melanoma 40 The lowdown on high blood pressure BLOOD SUGAR from the chancellor

From Beijing to Broad Street: Improving health at home and abroad

This April, Duke Medicine was privileged to of integrated academic health systems to as a leading academic health system, we host a team of leaders from Peking University address these important global issues. can make an even greater impact on health Health Science Center, one of the most The problem of health disparities and lack disparities—both locally and globally—by respected health care systems in China. As of access to care is hardly unique to China. applying our energies and intellectual capital some of our readers may recall, Duke and Even in the United States, which spends more to develop innovative models for delivering Peking University last year signed a letter of money on health care than any other country care more effectively and efficiently to people intent to work together to improve health in the world, nearly 47 million people have no across the economic and geographic spectra. care management and cardiovascular medical health insurance. Many of these individuals I am particularly excited about one such education, research, and care. have difficulty obtaining even basic preventive effort: the new Duke Center for Community During their recent visit, the Chinese services—including thousands living right here Research (DCCR). Part of the Duke delegation spent 10 days here learning about in Durham, the “City of Medicine.” Translational Medicine Institute, the DCCR, Duke University Health System, with the goal Duke Medicine has worked to meet the led by Lloyd Michener, MD, will work closely of gathering ideas for better integrating their needs of the poor and underserved in Durham with local leaders, clinicians, and residents own system of eight hospitals and 11 schools. and the Carolinas since its founding. In fiscal to develop model systems for improving the health status of Durham County. By figuring We are applying our energies and intellectual capital to develop out better ways to bring advances in scien- innovative models for delivering care more effectively and tific and medical knowledge to the people of Durham, the DCCR hopes to better address efficiently to people across the economic and geographic spectra. the needs and concerns of our community while producing measurable improvements As Peking University executive vice in its health within five years. [Editor’s note: president Ke Yang, MD, stated, “Since Read more about the effort on page 52.] the late 1980s, Chinese hospitals have Even more encouragingly, the knowledge been losing their subsidies from the we gain here about the best ways to prevent government, so they are faced with and treat illness on a community-wide basis operating in a market-based economy. will benefit people far beyond Durham. Duke’s experience with establishing a Thanks to our Duke Global Health Institute multi-hospital system should provide and relationships with other health care us with important lessons that we can providers in China, Singapore, Tanzania, and take back to China.” beyond, we have an unprecedented ability to Duke Medicine and Peking share the lessons we learn here with others University’s mutual goal is to find worldwide—and to benefit from their experi- solutions to the widespread problem ence and expertise in turn. of health disparities. While some For 76 years, Duke Medicine has been hospitals in Chinese urban centers committed to improving health care in the are comparable to Western medical Carolinas. As we develop these new initiatives centers, good care is scarce and often unaf- year 2006, for example, Duke provided and collaborations at home and abroad, we fordable for the 900 million people living in charity medical care at a cost of $40.4 million, are well on our way to doing the same on a impoverished rural areas. By finding ways to plus $63.9 million in unreimbursed care to truly global scale. operate more efficiently, Peking University Medicare/Medicaid patients and $7.1 million hopes to be able to extend medical services to in in-kind service contributions and direct a greater percentage of the country’s growing support payments to Lincoln Community victor J. Dzau, MD population. Accordingly, Duke and Peking Health Center and Durham County EMS. Chancellor for Health Affairs, University Health Science Center will establish Such contributions make a tremendous duke University a strategic partnership to develop models difference for many in our community. But president and CEO, duke University Health System James B. Duke Professor of Medicine DukeMed volume 7, issue 1, SPRING/SUMMER 2007 m a g a z i n e

Blood sugar battles As diabetes cases multiply, Duke caregivers are mobilizing in new ways to keep the disease under control—in the hospital and out. 16

DUKEMED MAGAZINE Editor: Minnie Glymph 32 Designer: Jennifer Sweeting Beneath the surface Creative Director: Kevin Kearns Delving into the mysteries of Production Manager: melanoma—one of the few cancers that Margaret Epps remains stubbornly on the rise. Publisher: Dorothea W. Bonds Contributing Writers: 24 Sarah Chun Catherine Macek June Spence Thinning a generation Angela Spivey Kathleen Yount Strategies to help children Contributing stay healthy in a super-sized world. Photographers: Bruce DeBoer Scott Dingman Kyle Hood Will & Deni McIntyre Duke University Photography 3 From the Dean 40 Clinician Q&A Editorial Advisory Board: “Duke Med Scholars (or, How to Build Michael Blazing, MD, and Laura Svetkey, MD, Martha Adams, MD a Great Faculty When Times Are Tight)” on managing high blood pressure Kathryn Andolsek, MD Nelson Chao, MD by R. Sanders Williams, MD Ellen Luken Giving Rex McCallum, MD 44 Lloyd Michener, MD 4 DukeMed Now Molly O’Neill Appointments, Honors, Awards Debra Schwinn, PhD Our shiny new ED, a postcard from 46 Joseph St. Geme III, MD Singapore, honoring the doctor who Robert Taber, PhD changed the outlook for “bubble boys” 51 New MDs DukeMed Magazine is and girls, more published twice a year by the 52 Three Questions Office of Creative Services and Marketing Communications. 9 Clinical Update Answered by Robert Califf, MD, director of the new Duke Translational Medicine Institute DukeMed Magazine Duke experts weigh in on drug-eluting DUMC 3687 stents and a surprisingly long-lasting Duke University Medical Center Durham, NC 27710 osteoporosis drug, how to find Duke 919-419-3271 [email protected] clinical trials online, a gentler kind of Web: dukemedmag.duke.edu gynecology, more ©2007 Duke University Health System MCOC-4911 Inside Back Cover CME Calendar from dukemed DUKE MEDICINE administration Victor J. Dzau, MD Cell Biology: Chancellor for Health Affairs, Brigid Hogan, PhD Duke University Community and Family Medicine: President and CEO, J. Lloyd Michener, MD Duke University Health System Immunology: R. Sanders Williams, MD Myozyme: More on a big story Thomas F. Tedder, PhD Dean, School of Medicine We were delighted to receive dozens of letters from Dean, Duke-NUS Graduate Medicine: Medical School Singapore Harvey Jay Cohen, MD readers in response to our last issue—many commenting on the new Senior Vice Chancellor for Molecular Genetics and Academic Affairs design of the magazine, and even more on the contents. Microbiology: Catherine Lynch Gilliss, DNSc, RN Thomas D. Petes, PhD One story in particular seemed to strike a chord: “The Making of Dean, School of Nursing Neurobiology: Vice Chancellor for Nursing Affairs a Miracle,” which chronicled the development of a lifesaving therapy James McNamara, MD Peter C. Agre, MD Obstetrics and Gynecology: for Pompe disease, a genetic disorder that was previously fatal in new- Vice Chancellor for Science and Haywood Brown, MD Technology borns. The new treatment, Myozyme, discovered by Y.T. Chen, MD, Ophthalmology: Asif Ahmad David L. Epstein, MD PhD, and his team at Duke, was approved by the FDA in April 2006. Vice President for Diagnostic Services and Chief Information Pathology: Reader Jesse Samuels, MD’67, a medical director of Aetna in Officer, Duke University Salvatore Pizzo, MD, PhD Connecticut, was especially enthusiastic. He wrote: “The article in Health System Pediatrics: Monte D. Brown, MD Joseph St. Geme III, MD this current issue, ‘The Making of a Miracle’ by Marsha Green and Vice President for Administration, Pharmacology and Cancer Biology: Kathleen Yount, was superb! It was (from what I know) clinically Duke University Health System Anthony R. Means, PhD Robert M. Califf, MD Psychiatry: quite correct, beautifully written, had a very important message about Vice Chancellor for Clinical Ranga R. Krishnan, MB, ChB Research the value of medical research, and makes Duke look very good. I will Radiation Oncology: Michael Cuffe, MD Christopher Willett, MD share this article with our nurses Vice President for Medical Affairs, Duke University Health System Radiology: who are involved in decisions Carl E. Ravin, MD Mary Ann Fuchs, RN about [insurance] coverage for Chief Nursing and Patient Care Surgery: Services Officer, Duke University Danny O. Jacobs, MD these patients. Health System Duke University Health System “It was such an excellent William J. Fulkerson Jr., MD Board of Directors piece of writing that I hope you CEO, Duke University Hospital Ernest Mario, Chair Vice President for Acute Care, Thomas M. Gorrie, Vice Chair have thought of submitting Duke University Health System Daniel T. Blue Jr. David P. McQuaid Richard H. Brodhead it to a lay publication, such as CEO, Durham Regional Hospital Harvey J. Cohen, MD Eugene F. Dauchert Jr. the New Yorker, or the Sunday Kenneth C. Morris Victor J. Dzau, MD Senior Vice President, Chief Frank E. Emory Jr. New York Times Magazine, so Financial Officer, and Treasurer, James F. Goodmon Duke University Health System Duke and its researchers can Danny O. Jacobs, MD Michael J. Morsberger Kimberly J. Jenkins receive wider recognition that If you missed the story of Duke researchers’ Vice President, Duke Medicine Rebecca Trent Kirkland, MD is so well deserved.” successful search for a treatment for Pompe Development and Alumni Affairs John H. McArthur Ralph C. Moore disease in our Fall/Winter 2006 issue, find it on Paul Newman We agree that this inspiring Vice President for Ambulatory Uwe E. Reinhardt story deserves a broad audi- our Web site: dukemedmag.duke.edu. Care, Duke University Health Robert King Steel System Peter Van Etten ence—and are happy to report Karl M. von der Heyden Molly K. O’Neill R. Sanders Williams, MD that it is finding one. Pulitzer Vice Chancellor for Integrated Planning Duke Medicine Prize-winning reporter Geeta Anand wrote an article about two fami- Vice President for Business Board of Visitors lies of Pompe patients treated at Duke that appeared in the December Development and Chief Strategic Tina S. Alster, MD Planning Officer, Duke University William G. Anlyan, MD* 12, 2006 Wall Street Journal; she also authored a book on the topic, Health System Leslie E. Bains Gwynn T. Swinson, JD Philip J. Baugh Jr. The Cure, which is available through major booksellers. Vice President for Government Santo J. Costa As any member of the Pompe team at Duke will tell you, even and Community Affairs and Duncan McLauchlin Faircloth External Relations, Duke Michael T. Gminski better than these stories is the reality behind them. To date, Myozyme University Health System Thomas M. Gorrie, PhD* Robert A. Ingram Robert L. Taber, PhD has provided a new lease on life to more than 700 patients in over 35 Richard E. Jenkins Vice Chancellor, Corporate and Richard S. Johnson Venture Development countries around the world. John D. Karcher Now that’s a happy ending. Douglas B. Vinsel Peter A. Karmanos Jr. CEO, Duke Raleigh Hospital David L. Katz, MD Huntington F. Willard, PhD Gary S. Lachman Vice Chancellor for Genome Anthony J. Limberakis, MD Sciences Brandt C. Louie We’d like to hear from you, too! Christy King Mack Gordon D. Williams Susan B. Meister, PhD, RN Comments, criticisms, suggestions? Write to DukeMed Executive Vice Dean and COO, Robert B. Mercer School of Medicine George James Morrow Magazine at [email protected] or Editor, Vice Chancellor for Operations Stelios Papadopoulos, PhD Mary D.B.T. Semans* DukeMed Magazine, DUMC 3687, Durham, NC 27710. DEPARTMENT CHAIRS John Bush Simpson, MD, PhD Anesthesiology: Stewart Turley Mark Newman, MD Sheppard W. Zinovoy Biochemistry: *honorary member Peter C. Agre, MD DukeMed Magazine is proud to have received the 2007 (interim chair) Grand Award for special-interest magazines from the Biostatistics and Bioinformatics: Stephen George, PhD, Council for the Advancement and Support of Education Thomas Kepler, PhD, and Ross McKinney Jr., MD District III (CASE III), whose members include academic (interim co-chairs) institutions throughout the Southeast. from the dean Duke Med Scholars (or, How to Build a Great Faculty When Times Are Tight)

by R. Sanders Williams, MD Dean, Duke University School of Medicine Founding Dean, Duke-NUS Graduate Medical School Singapore

wi ll mc i nt y re Senior Vice Chancellor for Academic Affairs

A faculty appointment at a private medical school like Duke has waggishly been Their charter reads:“The Duke Med Scholars likened more to a hunting license than a job. This description exaggerates a bit, but program seeks to honor and support a unique group of faculty members at Duke University the truth of the matter is that medical school faculty members are, to a large degree, School of Medicine who have distinguished individual entrepreneurs. Each one, through successful competition for grants or by fee- themselves through past achievements and for-service medical practice, must generate revenues to pay most of their own salaries who hold promise of still further achievements and to support staff and other costs of their research and academic activities. of particular distinction. The two major goals of this program are to attract exceptional new In the most extreme circumstances “safe science,” i.e. pursuing work most likely faculty to Duke and to accelerate progress of this state of affairs has been termed, rather to attract grant funding in the near term to current faculty who are judged most likely to uncouthly, “eat what you kill”—a strange the detriment of more daring research with generate high-impact work. Scholars will be directive for persons skilled in the healing potential to lead to major breakthroughs. In chosen from basic, translational/clinical, and arts, but apt enough to be an oft-spoken addition, a sense of uncertainty and insta- educational investigators who represent the phrase. Tuition dollars contribute to the bility inherent to such an economy may, in best of Duke academic medical sciences.” salaries of faculty active in teaching, but are lean times, become Recipients will be a minor component of faculty support overall. too much to bear for diverse in all respects, Endowed chairs are wonderful, but are some faculty, who may but will share a common available only for a very few (Note: we need depart academic life c h a r a c t e r i s t i c — e a c h more!). Further, they usually are awarded only for other, more lucra- will be poised to make after a senior faculty member has become an tive and (ostensibly) rapid progress towards established star. For junior faculty we provide safer and more pre- a position of true a modicum of institutional support as start-up dictable jobs in private intellectual leadership funding while they establish themselves, but practice or industry. in their respective fields. within a few years they are expected to be Finally, the system pro- Financial support from largely self-sufficient. vides little opportunity the award is designed This economic system is fundamentally for faculty to seize the to come at just the time the same at all the leading private academic moment—to follow in their career when medical centers, and has served us well through aggressively extra resources can have for many decades. Its Darwinian principles on a brilliant idea. the most impact, and have provided powerful selective pressures There should be a is generous enough to to enhance faculty quality. Its drawbacks, better way, you will say, allow faculty to focus however, are being magnified by the recent and now there is, or at least the beginnings fully on their research—instead of on how downturn in federal grant funding and by of such, under the umbrella of the School they are going to fund it. The program, almost a decade of declining reimbursement of Medicine’s strategic plan: the Duke Med now in its first year, awarded the inaugural to clinicians per unit of work performed. Our Scholars program. A faculty committee, led Duke Med Scholar Awards in February to faculty feel the squeeze in their personal by Vice Chancellor Peter Agre, MD, has been six extraordinarily gifted young investigators. and professional lives, and there are other formed to evaluate candidates for this new We expect great things of them, and will be dangers that threaten academic medicine type of award, and this group has codified a calling upon our alumni and supporters to more broadly: An overemphasis on individual process and a set of criteria by which candi- help us to expand this program to reach a entrepreneurism in research may discourage dates for Duke Med Scholar awards should larger fraction of our faculty in future years. collaboration or sharing, and it encourages be judged. Read more about the first class of Scholars on page 48. D uke M ed 3 dukemed now

Honoring a life’s work: saving lives

Some diseases can kill before they scientists, nurses, researchers, and staff. A are even diagnosed. Among them are the grant from Talecris Biotherapeutics will help primary immunodeficiency diseases, or PIDs— purchase equipment to aid the center in one and these are among the most heartrending, of its central missions: diagnosing PIDs with because PIDs often claim the lives of the very, speed and accuracy. very young. Some PIDs, when caught early, can be Pediatric immunologist Rebecca Buckley, successfully treated, and most are very easy MD, has made a career of turning such to screen for. But they almost never are—at tragedy into miracle. A longtime Duke faculty least not until a person becomes dreadfully member, she has treated and researched PIDs ill, says Buckley. For example, she says, one of for some 40 years—almost as long as the field the easiest screenings of pediatric immunology has been around. involves a simple blood “Since 1982 we’ve performed 158 bone Now a designation honoring the work of count with manual Buckley and other Duke experts in pediatric differential to check for marrow transplants in ‘bubble-boy’ infants immunology will help reinforce their efforts. a low lymphocyte count, here at Duke, with an overall survival rate The Immune Deficiency Foundation, a which can signal serious of 78 percent.” —Rebecca Buckley, MD national patient organization, has named immune disorders Duke a Center of Excellence for Primary such as severe combined immunodeficiency Such measurements are useful in diagnos- Immunodeficiency Diseases. Buckley directs disorder (SCID), or “bubble boy” disease. tics as well as in research. Buckley is currently the new center, which supports 21 physician- “When I was an intern and resident, we would following children who have received stem- do these kinds of tests all the time,” says cell transplants to treat SCID, a condition that Buckley. “But nowadays, HMOs don’t want is uniformly fatal in infancy unless diagnosed to pay for that.” and treated properly. Buckley pioneered Did You Know: In the absence of screening, PID diagno- the lifesaving transplant in 1982; her oldest Duke earned its designation of excellence sis can take years—primarily because these patient is now 25. “When we transplant SCID because of its longstanding strengths in diseases are unfamiliar to both patients and infants in the first 3.5 months of life, our sur- treating primary immunodeficiency diseases, health-care providers. Additionally, there vival rate is 96 percent,” she says. including: aren’t many medical centers in the country “When I first came into this field, only one n the most faculty in the United States with that specialize in diagnosing PIDs. “Those [PID] was known,” adds Buckley. “Before expertise in primary immunodeficiency who are familiar with PIDs are already famil- 1952 these illnesses were attributed to some iar with Duke’s experience in treating them,” bad germ in the environment. And there’s n the development of sophisticated says Buckley. “But most people aren’t aware just been an explosion of information since diagnostic testing utilized nationwide of either. This new center of excellence will then—more than 150 PIDs have been identi- n the largest center in the world that help that; now, when the IDF gets calls from fied so far. performs non-ablated T-cell-depleted new patients, they can refer them here.” “I used to watch these babies die all the haploidentical bone marrow transplants The grant from Talecris will buy Duke’s time. Since 1982 we’ve performed 158 bone in SCID infants center a new real-time PCR (polymerase chain marrow transplants in ‘bubble-boy’ infants n extensive experience in immunoglobin reaction) machine. “This equipment gives us here at Duke, and we have an overall survival treatment for antibody deficiency what we need to determine, in conditions rate of 78 percent. It makes me enormously n the world’s only center performing where T-cell function is abnormal, whether happy for these children and their families.” thymic transplants for infants with it’s due to something external or to a genetic complete DiGeorge syndrome (led by defect,” says Buckley. Louise Markert, MD). A recent Duke study showed that 75 percent of infants who received the transplant were alive after one year. D uke M ed 4 Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) dukemed now

Duke in Singapore An update on the Duke-NUS Graduate Medical School 2007 is shaping up to be a banner The Estate’s generous gift will enable year for the Duke-National University the GMS to substantially accelerate and of Singapore (NUS) Graduate Medical strengthen its planned research pro- School Singapore (GMS). grams, which are focused on medical and In January, the Estate of Tan Sri Khoo health care problems of significance to Teck Puat announced a gift of S$80 Singapore and Asia. The gift will support million to the GMS to grow the school’s groundbreaking research across GMS’s biomedical research initiatives. The gift, four Signature Research Programs in the largest single donation granted by infectious diseases, cancer and stem cell the Estate to date, will be matched by biology, neurobehavioral disorders, and the Singapore government, bringing the cardiovascular and metabolic disorders. total sum to S$160 million (about $104 In recognition of the Estate’s generosity, million US dollars). the GMS will name its new signature The GMS also announced that gradu- building the “Khoo Teck Puat Building.” ates of the four-year GMS program will To be completed in 2009, the building be awarded a joint medical degree from will house state-of-the-art research, Duke University and the NUS. This follows educational, and administrative facilities. the recent decision by Duke’s Board of The GMS, established in April 2005, Trustees to approve the granting of the will enroll its first class of 25 students joint degree. in August 2007; subsequent classes will comprise 50 students each year.

Richard Frothingham, MD

Defense against man and mosquito The best-dressed docs at Duke Duke has built a new stronghold of defense against an array of biologic Forget the respect commanded by a public health threats, from anthrax to West Nile Virus. The nation’s first Regional white coat—this ensemble takes the Biocontainment Laboratory, funded by the National Institutes of Health, has opened cake. Personnel who work in the Global here to develop the next generation of vaccines, treatments, and diagnostics for Health Research Building must undergo a protecting citizens against emerging threats to public health. federal background check and be trained ”Because we live in a global society, infections that arise anywhere in the world in handling dangerous pathogens. Then, can quickly become relevant to us,” says Richard Frothingham, MD, director of when they get to work in the morning, the facility, which will be available to researchers at Duke and other universities those who work with pathogens don throughout the Southeast. Twelve similar facilities nationwide will follow close on special attire, including seamless gowns, the heels of Duke’s lab, which was named the Global Health Research Building. gloves, foot covers, and respirators. Their An “open fortress” may be the best way to describe the $22.4-million build- work stations are biological cabinets whose ing. The research conducted there is not classified, and open collaboration across air is individually filtered. The rooms are campus and with other institutions is encouraged, yet the sealed by an epoxy floor and epoxy paint building has been constructed under the most stringent on the walls. Before heading interpretation of federal guidelines for security and home, personnel are safety. Surrounded by a fence, monitored by security able to “freshen up” guards, and supported by pillars capable of withstand- in showers designed ing both hurricanes and tornadoes, the building to remove potential houses research on pox viruses, plague, influenza, contaminants. All this in and tuberculosis. These microbes are handled a security-zoned complex, at Biosafety Levels 2 and 3, the levels the so no wandering to the building was designed to accommodate. neighbor’s yard without No research will be conducted on authorized access. Biosafety Level 4 microbes, such as smallpox or Ebola virus. D uke M ed Visit Duke Medicine online at dukemedicine.org 5 Stubbing out tobacco T 2007, all 2007, 6 July 4 transition, designed to promote a promote to designed transition, 4 July completely tobacco-free, with no smokingtobacco-free,no completely with and employees.and dukemedicine.org/tobaccofree. smoke-free facilities since 1989, the last the 1989, since facilities smoke-free gasps of a smoking section are just now just are section smoking a of gasps outdoor smoking areas. smoking outdoor designated previously in out—including or indoors permitted use tobacco or For moreinformation, visit ments had the family physician endorsing endorsing physician family the had ments waiting rooms held ashtrays and advertise- and ashtrays held rooms waiting Long Duke L healthy environment for patients, visitors, patients, for environment healthy being extinguished for good. As of July 4, July of As good. for extinguished being riangle-area hospitals in making the the making in hospitals riangle-area DukeMed uckies, University one are the are gone C Duke hesterfields,or edicine campuses will be will campuses Medicine Medical (275-3853) 1-888-ASK-D UKE call consumers and patients (633-3853), 1-800- MED-DUKE call Physicians now dukeme da C uke joins other joins Duke enter has had has Center

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three • a • computers • 91 ws eind o 40,000 for designed was 1981, a • two • secured • decontamination • A us to movetousmost ourofpatient care outtheofold complete,” says Finch, “we will will “we Finch, says complete,” that as well. By well. as that his is still only phase three of our complete plan,” says says plan,” complete our of three phase only still is sanctuary.“This life-saving this room, emergency an visiting to forward look ever people few though facility offers the best in technology as well as some soft touches to bring life into into life bring to touches soft some as well as technology in best the offers facility sees aroundsees 60,000. athy Finch, Kathy In to handle 90,000 patients per year.”per patients 90,000 handle to from uke currently year—Duke per patients have doubled our space and be able “ stations, supply areas,supply resuscitationstations, and bays frontdoor isolation roomsisolation he high-tech units are decorated throughout with scenic, soothing images taken taken images soothing scenic, with throughout decorated are units high-tech The When the renovationsthe When arenew the complete, P O new Duke’s April separate, 7,000-square-foot erhaps the best thing about the new the about thing best the erhaps arolina beauty: Duke’sbeauty: Carolina new nce all of our renovations are are renovations our of all nce North fully 12-bed, doorways, equipped Carolina’slandscape. varied in construction coordinator. “But opening the new building allowed building new the opening coordinator.“But construction ED 18-bed every ecember 2007, we hope to have all of the work done.” work the of all have to hope we 2007, December self-sufficient showers, a pediatric x-ray patient ambulance security Emergency rooms, as room adult-care area, checkpoint, well bay a epartment opened its doors for business. And And business. for doors its opened Department including dedicated as with decontamination units, and most beautiful scenery,mountains beautiful the most from and to the to features a 20-foot collage of collage 20-foot a features Natural touch: Natural ED an and two is its size. its is entry CT iedmont to the coast. the to Piedmont equipped an will be home to: home be will ED scanner, critical-care ED office located so thatsocanwenow renovate he front entrance to the to entrance front The capability with for T and he previous he well police their rooms D opens ED a away fluoroscopy North for own liaison. and the from Duke’snew Carolina’sbest ED nursing

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“Bundle up” to prevent bloodstream infections bloodstream prevent to up” “Bundle That’s job.” our “And a single case of infection can cost from cost can infection of case single a “And “100,000 28,000 deaths every year are attributable attributable are year every deaths 28,000 T $25,000 to $65,000,” says $65,000,” to $25,000 V also cause dangerous and costly bloodstream costly and dangerous cause also catheterizations. of percent 48 actually,as catheter)—several, course—mandatory. ologist o ahtrrltd losra infections. bloodstream catheter-related to to all to to every to to reduce preventable hospital deaths. hospital preventable reduce to nudsen’s strategy was to make to was Knudsen’sstrategy patients in intensive care units require these these require units care intensive in patients provided for training in all 35 35 all in training for provided MD infections. optl ta ae ebr o the of members are that hospitals ing—long available to house staff as an online ur responsibility is not only to to only not is responsibility “Our o ever o isit Duke isit he training course, created by created course, training The nudsen led Knudsen , and John Grant, Grant, John and , deliver high-quality care, but but care, high-quality deliver also to deliver care equitably.care deliver to also uke staffDuke students. medical and Nancy , there is a is there ICU, ives” campaign conducted last year year last conducted campaign Lives” y ho ationally, between 14,000 and 14,000 between Nationally, edicine online at online Medicine Knudsen, spi uke’s effort for the national the Duke’sfor effort U tal, nfortunately, nfortunately, William J. Fulkerson, J. William T MD as also to deliver caredeliver to equitably.also Stu responsibility is not only to deliver high-quality care, but care, high-quality deliver to only not is responsibility ur “Our injustices. such right to obligation our is it says, MD, atinos suffer persisting inequalities in cardiac care. And, care. cardiac in inequalities persisting suffer Latinos there is an an is there MD. aking on care disparities care on aking (central venous (central CVC , is available online online available is , D di uke uke anesthesi Duke e s S have U outheastern outheastern niversity Keith CVC train- CVC ICU dukemedicine.org It’s also art of of Part s can can s Duke , and and , Kaye, s MD ho H

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William ince January 2006, 1,300 people people 1,300 2006, January ince ces program, Success” D k’ oln tann includes training online Duke’s uke’s participation uke’sparticipation Outreach R obert Wood Wood obert , the five compo- five the CVC, DICON. CVCs. etwork (DICON), Network T he he Paul he concept concept The care. “We’re raising awareness of disparities at both the the both at disparities of awareness raising “We’re care. staff training for cultural competency, and information for for information competency,and cultural for training staff every day, two extra info items per patient is a tremendous a is patient per items day,info every extra two his process “This hospital. the in register who patients all from major medical centers acrosscenters country.”medical the major visitorsand patients. paratory campaign, including retooling of retooling including campaign, paratory patient and the provider levels,” he says, “in addition to to addition “in says, he levels,” provider the and patient will help greatly to describe populations and understand and populations describe to greatly help will MD it will have big implications for improvements in patient in improvements for implications big have will it data. in increase patients 4,000 sees that hospital a in and information, help us develop a strategy to minimize disparities.” minimize to strategy a develop us help cardiologist says served,” are patients how information ethnicity and race collecting begun now have leveraging the experiences and knowledge of nine other nine of knowledge and experiences the leveraging Thacker, At DICON V But race and ethnicity are also sensitive and personal personal and sensitive also are ethnicity and race But , the programdirectorthefor , elazquez says the process has started off well, and that that and well, off started has process the says elazquez CVC uke, the process begins with information, so staff so information, with begins process the Duke, o er mr aot h 5 ilo Lives Million 5 the about more learn To Control Infection Duke about more Tolearn Outreach Network, visit Network, Outreach campaign, visit the Institute for Healthcare Healthcare for Institute the visit campaign, harms. patient potential to attention ticipating hospitals saved some 122,000 lives 122,000 some saved hospitals ticipating Improvement site at site Improvement which will run throughrun will which edd y the by headed mprovement (IHI). Improvement has launched a “5 a launched has IHI by improving hospital standards and bringing and standards hospital improving by of catheter-relatedof CVC reporting near elimination elimination near reporting s that implementthat ICUs bloodstream infections. bloodstream e 100,000 The now dukeme o the hospital underwent a massive pre - massive a underwent hospital the So bundling well are are well bundling E vs apin a spear was campaign Lives xpecting siue for Institute n 18 months, 3,100 par 3,100 months, 18 In www.ihi.org. Million ecember 2008. December dicon.mc.duke.edu. 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Pressing question: What should doctors do to protect patients Drug-eluting stents: with drug-eluting stents? the end of an era? A large study published in March in the New England Journal of Medicine con- If drug-eluting stents can sometimes lead to formation of lethal blood clots, as firmed the mounting results of smaller recent much-publicized studies have shown, just how long should stent patients stay studies, including those conducted at on the anti-clotting medication clopidogrel (Plavix)? The new studies have physicians Duke, showing that drug-eluting stents speculating that an update may be in order for the current have a limited ability to prevent future recommendation, which is 12 months of post-stenting aspirin cardiac events. Robert M. Califf, MD, who and clopidogrel therapy. Duke cardiologist David F. Kong, MD, co-authored one of the Duke stent studies, co-authored one of the recent stent studies (published in the says that this crop of research may cause December 5, 2006 JAMA), so we asked him for some input. He some shift away from drug-eluting stents; says that this issue, like most others in medicine, is more about cardiologists may recommend more of judgment than juggling statistics. their patients for bare-metal stents, bypass surgery, or secondary prevention such as David F. Kong, MD lifestyle modification and drug therapy. But he emphasizes that drug-eluting Given the revelations about drug-eluting How do you apply the results of your stents will not lose their place in the car- stents, should physicians prepare these study to each patient? In general, the diology tool-chest. “They are still a very patients to remain on clopidogrel indefi- probability that a clotting event will happen good thing to have for patients with nitely? We choose the word indefinitely, as isn’t determined in a vacuum. So the statis- unstable symptoms,” he says. “These opposed to forever, for a reason—because tic that we have—eight clotting events per studies have been on patients whose we don’t yet know what the endpoint might thousand—isn’t the ultimate measure of symptoms were stable.” Califf also says be. We’re in a situation where our technol- one individual’s risk. Some patients may be that it’s important to remember that ogy has leapt beyond our understanding of at higher risk than that, others at lower risk. medical technology is always evolving. “In the biology of the systems the technology If you are in an auto accident, your a reasonable period of time,” he believes, is affecting. For now, we recommend most chance of dying in that accident is six per “this issue will be obsolete.” patients on clopidogrel continue with it until thousand. Now, we don’t stop driving cars we learn more. based on this risk, but at the same time, the risk is big enough that we want to do There is difference of opinion on how to what we can to minimize those odds, such advise patients who took clopidogrel but as including airbags and seatbelts in cars. have since stopped. What’s your take? In It’s the same principle. What about cost? People have debated my opinion, if that patient has been off the that a lot. Plavix costs between $3.50 and drug for a year and is doing well, then his or Do side effects of clopidogrel factor in $4.00 per day. But again, this is a factor that her risk for an event is comparatively low. If your decision? The principal risk of this drug is weighed in terms of the patient—for some an event were likely to happen, it is most likely is bleeding events. Few of these are fatal, but that’s a greater burden than for others. And, that it would have occurred within that year. there’s a 1 percent chance per year, if you’re if you think about it on a grander scale, you However, it’s important to emphasize that taking clopidogrel and aspirin, that you’ll can say that while this drug costs $1.5 to $2 each patient should discuss this decision with have a bleeding event serious enough to see billion a year worldwide, we spend about $30 his or her physician, because there might be your doctor about. So that’s a higher risk than billion per year on potato chips. other reasons for that patient to be on this clotting, though it’s for a less serious event. Our job as physicians is to help patients kind of drug. Another thing to consider is that the make informed decisions about treatment. In patients who are on clopidogrel now are a every situation we’re implicitly making those self-selecting population; we know they toler- judgments and prognostications, to help a ate it well or they wouldn’t be taking it. patient make the choice that’s best for him or her. That’s what makes medicine an art. D uke M ed Visit Duke Medicine online at dukemedicine.org 9 0 1 he trials of Duke of trials The T ot your mother’syour Not hysterectomy ometimes that means prescrib- means that “Sometimes Specialties. raig J. Craig explains life,” of quality affecting adversely alike can learn about many trials activelytrialsrecruitingmanyabout researchlearn canalike subjects online at offers an alternative to hysterectomy. 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The tales garbage tells Give Fosamax five years, it gives you 10: Cardiologist Svati Shah, MD, says it’s What a recent study may mean for osteoporosis patients a bit like going through someone’s garbage can to learn more about him. She and a team of Duke researchers have sorted through the bloodstream’s metabolic “trash” to identify The bisphosphonate drug alendronate (Fosamax) new markers for measuring cardiovascular is doubling its returns to women with osteoporosis, health. These markers, called metabolites, according to a recent national study. Patients who may prove useful as early warning signals for take the drug for five years have nearly the same impending coronary artery disease. protection from bone fractures as patients who take The analysis is among the first to use it for 10 years. metabolomics—the systematic study of the We asked Duke geriatrician Cathleen Colón-Emeric, MD, what physicians should unique chemical traces that specific cellular take away from this study. Colón-Emeric, who wrote the editorial that accom- processes leave behind—to better understand panied the study in the December 27, 2006 Journal of the American Medical underlying biological pathways in families with Association, says patients who have done well on alendronate can safely consider coronary artery disease. a “holiday” from the drug. This option would apply only to those who have not Researchers led by Christopher Newgard, suffered a fracture and have had a significant improvement in their bone density. PhD, of Duke’s Sarah W. Stedman Nutrition and Metabolism Center, studied these Should osteoporosis patients on other bisphosphonates consider switching chemical traces in blood samples of people to alendronate? The study was a comparison of alendronate versus a placebo. whose extended family members developed So it doesn’t make any comparisons in the effectiveness between alendronate and coronary artery disease at an early age. The other medications. team then identified which metabolic profiles signify increased susceptibility to heart disease Should all patients who are now taking alen- and showed that these profiles were heritable dronate—who don’t develop fractures or drops in families. “With this advance notice of in bone density—expect to be able to quit after genetic predisposition to heart disease, we five years? Patients who have a high risk of spine could start strategies, such as drugs or fractures, either because of extremely low bone lifestyle changes, to stop or slow down the density or previous vertebral fractures, would want disease process,” says Shah, who presented to consider their risks carefully before they stopped the findings at the 2006 American Heart taking the medication. This is because the 10-year Association scientific sessions. course was significantly better in reducing new vertebral fractures. But for those who have had a good response to the drug and have not had previous fractures, a holiday would be a reasonable choice. A new clue to heart disease Researchers sifting through the genomes If a patient has opted not to take a bisphosphonate, should she reconsider? of siblings in families with high incidence of It depends on why she chose not to take the drug. Those who are at high risk of heart disease may have unearthed a genetic serious side effects such as uveitis, esophageal ruptures, or osteonecrosis of the gold nugget. On chromosome 3 they identified jaw when taking this class of medications should not be offered the drug. a new gene, called kalirin, that may indicate a However, lots of patients and prescribers choose not to take this high risk for the disease. The gene implicates drug because of concern over acid reflux. If that is the case, they may find it a biological mechanism never before linked worth reconsidering. to cardiovascular disease—and its discovery may lead to new clinical tools to treat or even After five years off of alendronate, is it likely that most patients would prevent heart disease. The Duke study was need to go back on medication? We don’t currently know the effect of published in the April 2007 American Journal restarting alendronate or a similar medication after a drug holiday. It will be of Human Genetics. increasingly important to carefully monitor patients’ bone density during therapy and during the drug holiday. If there were a drop in bone density, the patient would need to consider going back on the drug, or switching to another class of medications. D uke M ed Visit Duke Medicine online at dukemedicine.org 1 1 Clinical Update

Growing new cartilage: Like biomedical basket weaving

A graduate student in Duke’s Orthopedic scaffold will slowly dissolve, leaving the new Bioengineering Laboratory has built a type of cartilage tissue,” says Moutos. weaving machine that can make three-dimen- Biomedical engineer Farshid Guilak, PhD, sional fabric scaffolds to improve repair of senior investigator in a study of the scaf- damaged joints. The student, Franklin Moutos, fold, says that current treatments for joint says the technology will allow physicians will cartilage damage are fairly limited. The only to use their patients’ own stem cells to repair bioengineering approach available requires a hips, shoulders, and ultimately any type of weeks-long process of growing new cartilage cartilage damage. from a patient’s cells, and, unlike the scaf- In laboratory tests, the synthetic fabric fold, can only be used for small repairs. “This

Nestling ground: Most machines that produce scaffold was shown to have the same mechan- scaffold will give surgeons the opportunity bioengineered tissue fabrics weave one set of ical properties as native cartilage. In the near to treat their patients immediately—patients fibers that are oriented perpendicularly to another future, surgeons will be able to impregnate won’t have to wait for months with a painful set of fibers. However, the machine that Duke’s the custom-designed scaffolds with carti- joint,” he says. “And one of the beauties of Franklin Moutos (above right, with Farshid Guilak) lage-forming stem cells and chemicals that the system is that since the cells are from the developed adds a third set of fibers, which creates stimulate their growth and then implant same patients, there are no worries of adverse a three-dimensional product. Also, since the them into patients during a single procedure. immune responses or disease transmission.” scaffold is a woven material, there are tiny spaces “Once implanted, the cartilage cells will grow The study appeared in the February 2007 where cartilage cells can nestle and grow. throughout the scaffold, and over time the Nature Materials.

Meds for kids: a Congressional battle reheats Unexpected, ineffective, even danger- Critics of the current policy believe that ous outcomes: The problem of prescribing drug manufacturers earn far more in patent adult drugs to kids goes way beyond dosage, profits during the six-month extension than according to a Duke study published in the they spend on the tests. They also say that February 7 JAMA. Its authors hope the study Medicare ultimately foots the bill, as it must will help sway Congress to renew a pediatric pay for name-brand drugs instead of generic drug testing law that expires this year. during that time. Duke pediatricians Jennifer Li, MD, and The Duke study found that most drugs in Daniel Benjamin, MD, analyzed financial and the program made an additional few weeks’ medical data on 59 drugs that were tested in worth of sales profits—according to the children under the “pediatric exclusivity provi- researchers, a modest return on the vital drug sion” of the Best Pharmaceuticals for Children studies in children, which have led to more Act, which took effect in 1997. The provi- than 122 labeling changes. The study also sion encourages companies to run separate showed that most drugs awarded the exten- pediatric testing of their drugs by allowing sion are not among the 200 top-selling drugs. a six-month patent extension to drugs that Benjamin says critics will push to eliminate undergo the extra study. the program or reduce the patent extension A full third of the drugs tested under that period to three months. “Either step could limit policy were found to work differently in chil- the benefits to children,” he says, by cutting dren than in adults. In some cases the drugs the incentive to the drug companies who will were more dangerous for kids, and in other “likely cut the number of studies conducted.” cases they had no effect. Researchers say this At press time a bill to renew the law had finding is unsurprising, since children absorb passed the Senate and was to go before the and metabolize drugs differently than adults. House later this summer. D uke M ed 1 2 Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) Clinical Update

Teenage wasteland

It’s easy to think that urban adolescents have the highest risk for dangerous behaviors. But when it comes to alcohol abuse, rural teens rise to the top. Four percent of rural teens ages 12 and 13 are regular drinkers, compared with 1.5 percent of their urban counterparts. “For the 14- to 15-year olds, it goes up to 12 percent,” says Duke psychiatrist About 40 percent of youth between the ages of 12 Ashwin Patkar, MD, who, along with principal to 20 report regular binge drinking (five or more investigator Robert Hubbard, PhD, is leading a new effort to address underage drinking in drinks in one event) within the last month. In North these communities. Carolina, 15- to 20-year-olds were responsible for Duke is one of four sites in the country to nearly 15 percent of all DWIs in 2004 and 2005. receive a PARTNER (Prevention Approaches to Underage Alcohol Use) grant from the National Institute on Alcohol Abuse and Alcoholism. The three-year, $1.6-million grant will fund Duke to work with commu- treatment services available are much more PARTNER will also establish a referral nities in Durham, Franklin, Granville, Halifax, limited (and access is more difficult) than in system with churches, schools, police, and Person, Vance, and Warren counties to create urban areas. Also, he notes, drinking is a part the social services system, so that adolescents prevention and treatment interventions for of the cultural fabric of many rural areas, and who are identified in incidents involving underage drinking designed specifically for stigma in these tight-knit communities pre- alcohol can be recommended for treatment. these underserved areas, which are home to cludes the privacy and anonymity that some “It’s really an exciting opportunity to build about 45,000 teens. families need to feel comfortable seeking a stronger relationship between Duke and Patkar explains that the barriers to preven- help for substance abuse. these communities,” says Patkar. “We want tion and care in rural communities can be Duke’s PARTNER program will begin to get these kids the help they need now, and profound. Widespread poverty means that by building upon relationships with Duke- find out what will help them best, instead of many are uninsured, and many others have affiliated primary-care clinics in these counties trying to address even worse problems 20 inadequate insurance for alcohol abuse treat- to find the best ways to screen for alcohol years down the road.” ment. Even for those who can afford it, the use as part of standard clinical care.

Nature’s call—and answer A common herbal extract available in health food “Ideally, use of this herb would expel the bacteria, where stores can greatly reduce urinary tract infections and could it would then be hit with antibiotics. With the reservoir of potentially enhance the ability of antibiotics to kill the hiding bacteria cleared out, the infection should not recur.” bacteria that cause 90 percent of bladder infections. Abraham says that a new and effective approach for Duke researchers found that E. coli hides in cells lining treating urinary tract infections is needed because constant the bladder, where it cannot be reached by antibiotics. But antibiotic use has many drawbacks, including high expense, they also found that forskolin, an extract from the Indian possible liver and kidney damage, and the potential for coleus plant, flushes out hiding colonies of bacteria. creating strains of antibiotic-resistant bacteria. “This type of treatment strategy may prove beneficial for The results were published April 8 in the online patients with recurrent urinary tract infections,” says Duke Nature Medicine. microbiologist and lead researcher Soman Abraham, PhD.

The herb forskolin can fend off urinary tract infections. D uke M ed Visit Duke Medicine online at dukemedicine.org 1 3 Clinical Update

Blood test for a better aftermath

A nuclear or radiological catastrophe could There appears to be a critical window of 48 to 72 hours expose thousands of people to radiation. The scenario is for administering treatments aimed at halting the devastat- bad enough on its own—but compounding matters is ing effects of radiation, investigators say. But existing tests the fact that, until now, there has been no way of quickly for measuring radiation exposure take several days and are determining how much of the deadly substance has seeped not practical for testing large numbers of patients at once. inside an individual’s body. Now, Duke scientists have developed a blood test to “If a terrorist attack involving radioactive material were to rapidly detect levels of radiation exposure so that potentially occur, hospitals might be overrun with people seeking lifesaving treatments could be administered to the people treatment, many of whom have actually been who need them most. The new test scans thousands of exposed and many of whom are simply genes from a blood sample to identify distinct genomic “sig- panicked,” says John Chute, MD, natures” reflecting varying radiation doses. Patients can then of Duke’s Adult Bone Marrow be handled according to whether they received no exposure and Stem Cell Transplant to radiation, intermediate exposure that may respond to Program. “We have to be medical therapies, or an inevitably lethal dose. able to efficiently screen a Investigators are currently working to refine the test, large number of people for and say that the identification of genes that play a role in radiation exposure in order radiation response could also lead to development of new to respond effectively to a anti-radiation treatments. Study findings appear in the mass casualty event.” April 3, 2007, Public Library of Science (PLoS) Medicine.

Illuminating altruism

Altruism is a matter of perception, accord- altruistic tendencies. ing to a new Duke study. Researchers in the Brain MRI scans showed Imaging and Analysis Center explored the brain’s that the poste- activity while subjects played a video game to rior superior temporal earn money for themselves or for a charity, and sulcus—a region of they say their findings may help improve under- the brain that works standing of disorders such as autism, antisocial to interpret social behavior, and others that are characterized by relationships—was activated to a greater degree deficits in interpersonal interactions. when people watched the computer play than Led by Dharol Tankersley, a graduate student when they played themselves. The level of activ- in the lab of neuroscientist Scott A. Huettel, PhD, ity in this area was strongly related to a person’s researchers scanned the brains of 45 people reported tendency toward altruistic behavior. while they either played a computer game or The researchers, who now plan to study the watched the computer play the game on its development of this brain region, say these own. In both cases, success in the game earned results suggest that altruistic behavior may origi- money either for the player or for a charity of nate from people’s abilities to perceive others’ the participant’s choice. The participants also actions as meaningful. Their study appeared in answered questions about how often they the February 2007 Nature Neuroscience. engaged in different kinds of helping behaviors, so that the team could characterize each person’s D uke M ed 1 4 Physicians call 1-800-MED-DUKE (633-3853), patients and consumers call 1-888-ASK-DUKE (275-3853) Clinical Update

Cholesterol: from scourge to supplement? So much energy goes into lowering cholesterol levels in adults that it’s easy to overlook how important the much-maligned lipid is. Pregnant women with very low levels of cholesterol are actually at risk of giving birth to babies with developmen- Hammering home tal problems. This is because cholesterol is essential to the proper development of the importance fetuses. It works to regulate a crucial pathway that governs the pattern of tissue of nail gun safety development. This same pathway is vulnerable to the effects of alcohol. According to a new According to new statistics that Duke study, even as little as a 12-ounce beer can interfere with this process by would make Bob Vila cringe, the number of blocking the activity of cholesterol. How much interference—and which tissues are weekend carpenters treated each year for affected—depends on at what point in pregnancy the alcohol is consumed. nail gun injuries in U.S. emergency rooms But the news from these researchers, led by Yin-Xiong Li, MD, PhD, isn’t all bad. more than tripled between 1991 and They found that they could restore normal development in zebrafish embryos that 2005, increasing to about 14,800 per year, were exposed to alcohol by giving supplemental cholesterol. according to a new analysis by research- “This new insight into the molecular basis of fetal alcohol syndrome could have ers at Duke and the National Institute for far-reaching implications,” says Li. “It suggests new prenatal care tactics that Occupational Safety and Health. might prevent the developmental defects caused by alcohol “These kinds of injuries are often seen as consumed during pregnancy.” The team published its bizarre accidents, but they actually occur findings in the March 2007 fairly frequently and we know quite a bit Laboratory Investigation. about factors that contribute to them,” says author Hester Lipscomb, PhD, an associate professor of occupational and environmental medicine at Duke. She has long studied nail gun injuries among construction workers, but says this is the first such analysis of injuries among consumers. Nail guns typically use compressed air to drive nails into wood. Researchers say that Success stops a cancer trial many injuries caused by nail guns could A large clinical trial has been halted early because patients taking a new anti- be prevented by using tools that fire only cancer drug did so much better than patients who did not. when the nose piece is depressed before The National Cancer Institute halted the trial in April 2007 so all eligible patients the trigger is pulled. This “sequential” could start taking imatinib (trade name Gleevec) before the planned release of the trigger mechanism is designed to prevent trial’s findings in June. rapid, unintentional firing, but it has not The multicenter trial, coordinated by the American College of Surgeons Oncology been used as much as tools that allow the Group (ACOSOG) at the Duke Clinical Research Institute and the Mayo Cancer Center, user to rapidly “bounce fire” nails. involved over 600 patients with gastrointestinal stromal tumor. This form of cancer, Lipscomb believes the use of nail guns which develops in muscle tissue and blood vessels within the stomach or small intes- with sequential-trip triggers will “go a long tine, is estimated to occur in more than 5,000 Americans each year. way toward reducing injuries among con- The researchers found that 97 percent of the patients who received imatinib were sumers and professional carpenters.” Kits cancer-free one year after surgery to remove their tumor. In comparison, 83 percent are available to convert many nail gun trig- of patients who did not take the drug were cancer-free after surgery. gers to the safer type. “This is a whole new kind of cancer treatment…that represents the future of Findings appear in the April 13, 2007, oncology,” says Duke surgeon and ACOSOG co-chair David Ota, MD. “Instead Morbidity and Mortality Weekly Report. of one-size-fits-all drugs with many side effects, we can target the disease with a specific drug.” D uke M ed Visit Duke Medicine online at dukemedicine.org 1 5 ttLes ba

ood sugaRAs diabetes cases multiply, Duke caregivers are mobilizing in new bL ways to keep the disease under control—in the hospital and out

by Angela Spivey

D uke M ed 1 6 Diabetes Management Service 20 years ago, when diabetes was diabetes when ago, years 20 Service Management Diabetes Duke’s founded he Nutrition, and Metabolism, Endocrinology, dia- of advance relentless the seen has MD, Feinglos, Mark Disease Control, the percentage of North Carolinians who report report who Carolinians North of percentage the Control, Disease need to back off,” Spratt says. They will reduce his dose of short- of dose his reduce will They says. Spratt off,” back to need not nearly as common as it is today. While type 1 diabetes, in diabetes, 1 type While today. is it as common as nearly not istered, and each patient’s sensitivity to it. istered, andeachpatient’ssensitivitytoit. increasinglysedentaryoverfed. andAccording Centers the forto becomes population America’s as exploded inactivity—have from rounds,” Spratt exclaims. exclaims. from rounds,”Spratt observations. “When we visited he was just getting a puree, green observations. “When we visited he was just getting eating, is foodpatient the the between equilibriumeffort reach to which the body produces no insulin at all, has remained rela- remained has all, at insulin no produces body the which of Division the of chief Currently lines. front the from betes beans,” Corsino says. “No, he was eating a lot when I came back back came I when lot a eating was he “No, says. Corsino beans,” being diagnosed with type 2 diabetes has nearly doubled in just in doubled nearly has diabetes 2 type with diagnosed being acting insulinbecausehemaynotbeeatingallof hisfood. any tube feeds, the short-acting and long-acting insulin admin- insulin long-acting and short-acting the feeds, tube any defend patients against an enemy that gains ground with each with ground gains that enemy an against patients defend checking the latest numbers in the chart. They make a continual continual a make They chart. the in numbers latest the checking passing year. passing year. to struggle caregivers as clinics, outpatient Duke’s in and pital patient has consumed, based on notes in his chart and their own own their and chart his in notes on based consumed, has patient to 8.5percentin2005. the past decade, rising from 4.5 percent of the population in 1995 and obesity with diabetes—associated 2 type of cases rare, tively such small battles are happening every day, both inside the hos- the inside both day, every happening are battles small such more and More decision. then—a and math, the doing session, At one stop, and Spratt Corsino debate just how many calories a door, patient’s the outside gathers team the stop, each At They check his latest blood glucose reading; it’s a bit low. “Welow. bit a it’sreading;glucose blood latest his checkThey It is this way at each stop: reviewing the numbers, a strategy a numbers, the reviewing stop: each at way this is It single-minded mission—controlling blood glucose levels. visit every S coyoc, endocrinology f loor o MD • f or , work their w a Ma bout f I n the hospit a t’s 2:15 on aFrid gement S a f n hour. Attending endocrinologist ellow a a y through ervice h l, L eonor f or most o a y af a C ve been rounding in D orsino, “There are now clear data, at least in intensive-care-unit settings, settings, intensive-care-unit in least at data, clear now are “There Duke physicians now try to get to the bottom of such fluctuations fluctuations ofsuch bottom the to get to try now physicians Duke Duke’s Richard Surwit, PhD, and Feinglos suggests that people people that suggests Feinglos and PhD, Surwit, Richard Duke’s more vulnerable to infection. Moreover, Feinglos points out, points Feinglos Moreover, infection. to vulnerable more even stationing endocrinology nurse practitioners on two other other two on practitioners nurse endocrinology stationing even has eyebrows raises that sugar blood of level “The hospital. the of blood sugar could be a marker of things to come. Research from from Research come. to things of marker a be could sugar blood out turn don’t patients if Even average months. three over of glucose blood marker a is which A1C, hemoglobin a checking by whose blood glucose is easily perturbed by stress are more likely likely more are stress by perturbed easily is glucose blood whose bothered to call us—they might have handled it themselves—unless hyperglycemia is worse because of stress, probably have some some have probably stress, of because worse is hyperglycemia at least 15 to 20 percent of patients in Duke University Hospital University Duke in patients of percent 20 to 15 least at cent above normal.” The team has expanded to meet the demand, demand, the meet to expanded has team The normal.” above cent changed,” Feinglos says. “In the past, other services might not have can target that, the better off they’llbe.” can targetthat,thebetter the stress of being sick can cause a temporary increase in blood blood in increase temporary a cause can sick being of stress the just Sometimes, diabetes. with diagnosed previously not patients that estimates Feinglos specialty. medical every almost in care to have diabetes at present, those stress-related increases in increases stress-related those present, at diabetes have to than ever, with consult requests coming from almost every area every almost from coming requests consult with ever, than that havinglowerglucosedecreasesmorbidityandmortality.” blood high since problem, a That’s glucose. abnormal have today to go on to develop diabetes. “Many of these folks, even if their their if even folks, these of “Many diabetes. develop to on go to glucose was at least twice normal. Now we might get a call at 50 per- 50 at call a get might we Now normal. twice least at was glucose patients those making function, cell blood white impairs glucose underlying glucose impairment,” Spratt says. “The sooner we sooner “The says. Spratt impairment,” glucose underlying sugar. But because so many people have undiagnosed diabetes, undiagnosed have people many so because But sugar. services—cardiology andcardiothoracicsurgery—full-time. a ternoon, a long list o Asresult,a the Diabetes Management Service finds itself busier The team also stands sentry against elevated glucose even in even glucose elevated against sentry stands also team The The epidemic is hitting the community hard—and complicating f the MD af , ternoon. a nd resident nd members o f p a tients. S us T uke U heir a T n E hey will rin S f D niversity H pr uke’s D a Va tt, n MD i , a ospit betes a l l 7 1 DukeMed On patrol: Attending endocrinologist Susan Spratt, MD, and endocrinology fellows Leonor Corsino, MD, and Bryan Batch, MD (left to right) discuss a patient’s glucose levels during their regular rounds. With up to 20 percent of patients in Duke University Hospital now suffering from abnormal glucose, the Diabetes Management Service’s caseload has roughly doubled over the past three years.

Patrolling the wards Corsino says that she and the other fellows learn a lot from the As the diabetes management team troops from floor to floor, they nurse practitioners, who spend most of their days conducting the are joined by Sarah Gauger, the endocrinology nurse practitioner balancing act it takes to achieve the right combination of food who has been stationed on the cardiology unit permanently and insulin that will add up to normal blood glucose levels. To since last year. Her colleague, endocrinology nurse practitioner help house staff and nurses navigate this territory, Spratt, nurse Jonathan Warren, has a similar role on the cardiothoracic surgery practitioner Melanie Mabrey, and Lillian Lien, MD, have devel- service. Fueling those assignments were Duke data showing that oped protocols for determining insulin dose, and when to use tighter glucose control results in lower rates of mediastinitis—a subcutaneous versus intravenous insulin. life-threatening infection of the mediastinum, the chest cavity Their protocol for dosing IV insulin, for instance, uses that contains the heart. The efforts have resulted in faster recovery multipliers that reflect how much insulin the patient is already times as well: “The Diabetes Management Service has shown that receiving, rather than increasing the dose in set amounts. In a just by getting us involved on day one of hospitalization, rather small study published in 2005 in Endocrine Practice, the team than day three or four, we decrease the length of stay for patients found that the protocol reduced errors and improved glucose with diabetes on the cardiology services by .6 days—more than control compared to an older method. “We are continuously half a day,” Spratt says. updating our protocols and trying to improve our teaching of house staff and nurses,” Spratt says. D uke M ed 1 8 Enlisting help for the community Medications can improve insulin secretion and insulin sen- If managing diabetes in the hospital requires a small army of sitivity. But if the patient doesn’t also watch his or her diet, the doctors, nurse practitioners, and nurses, how can a person do it enhanced glucose transport can actually exacerbate the prob- at home? It’s not easy. Many have to monitor their glucose levels lem, Feinglos says. “If you don’t control the caloric intake, then several times a day, interpret the results, and use the data to all you’re going to do is facilitate transport of the extra calories, adjust their dose of insulin and other medications. which means they’re going to be stored, which means you’re But even harder than all that, for many people, is changing going to gain weight. This contributes to the problem, because it what they eat. “Without an appropriate diet, there is no medica- makes insulin resistance worse. tion that will work,” Feinglos says. “That’s why this is so difficult “You see that notoriously: people come in and their sugar’s to do. Because giving people medications is easy. Altering life- uncontrolled, and you start them on medication, and six months styles is hard.” later their sugar is still not very well controlled, but they weigh Why is diet so crucial? “Diabetes is basically a fuel-distribution about 50 pounds more. That’s a terrible problem,” he says. problem,” Feinglos says. “If you have a problem processing fuel, Dietary recommendations vary depending on whether a patient and you put too much fuel through the line, you flood the engine.” has type 1 or type 2 diabetes, their weight, and what other chronic Normally, the body breaks food down into glucose (sugar). The conditions they must manage. “For patients with type 2 diabetes, hormone insulin helps transport glucose inside the muscles and who are often overweight or obese, learning how to decrease cal- cells, where it can be converted into energy to power a 30-minute ories, control portions, and eat a balanced diet is very important,” walk on a treadmill or 15 minutes of vacuuming. Spratt says. “Our concept of portion size is very skewed—to a lot But in type 2 diabetes, either not enough insulin is produced of people, super-size looks normal.” by the beta cells (insulin-producing cells in the pancreas), or the muscles and other tissues aren’t as sensitive to insulin as they Medications complete the arsenal should be, so they don’t take in the glucose they need. Then the While managing diet is the first line of defense, Feinglos points excess sugar is left to circulate in the blood, over time causing out that medications have to be added early. In theory, diet and damage to the eyes, the kidneys, the nerves. exercise can completely control diabetes in some patients. But, in the real world, most people find it’s just too hard. And waiting can be dangerous. “The problem with a damaged beta cell is that if you keep stressing it, it’s going to get more damaged,” Feinglos says. “Even slightly high glucose causes you to put out more insulin, and if you’re continuing to tell this damaged beta cell, ‘do it, do it, do it,’ it’s going to run out. It’s like spending the principal in your “Without an appropriate diet, bank account.” there is no medication that will work [to control diabetes]. That’s why this is so difficult. Because giving people medications is easy. Altering lifestyles is hard.” —Mark Feinglos, MD D uke M ed 1 9 What’s so bad about eating too much? comes about is that the muscle begins to tivity very quickly—within two to four weeks. Duke researchers are learning inappropriately accumulate lipids and byprod- [A 2004 meta-analysis published in JAMA more about the LINK between ucts of lipid metabolism,” says Stedman found that over time diabetes was completely Center director Christopher Newgard, PhD. resolved in 76.8 percent of patients who obesity and diabetes—and The scientists are also starting to see that underwent bariatric surgery.] overloading on fat can lead to reduced secre- The pancreas was once thought to be the believe the startling results tion of insulin. “We can show in our cellular primary producer of hormones that regulate models that if you bombard insulin-secretion metabolism, but now scientists know that of gastric bypass surgery may cells—islet cells—with elevated fat, for a fat tissue itself as well as the gastrointestinal couple of days for example, then you can see tract makes hormones that regulate energy provide new clues an impairment in insulin secretion.” The balance and appetite. “So if you’ve rerouted researchers are currently working to pinpoint the stomach and the intestinal system exactly which lipid-derived metabolites are the through bariatric surgery, it stands to reason Type 2 diabetes is known to be associated culprits, he says. that you may have altered the production of with obesity, but it’s not clear exactly why. The researchers are also hormones that are normally Some explain it this way: obesity itself may not finding that an overload of produced in the gut during cause diabetes, but the behaviors that lead to all the nutrients, not just fats, food ingestion,” Newgard weight gain—taking in too many calories and is probably what’s wrong says. If this is really what’s burning too few—probably do. with the typical American happening, he, DeMaria, A few years ago, research from Duke’s meal of a fast-food sand- and Svetkey want to Richard Surwit, PhD, Mark Feinglos, MD, and wich, fries, and a soda. Their find out exactly why. To colleagues showed that in a particular strain work suggests that byprod- do so, they will measure of mouse which is genetically predisposed to ucts of metabolizing too metabolites and other diabetes and obesity, those who ate a high-fat much protein, for instance, markers in patients both diet went on to develop diabetes, while those can have bad effects as well. Christopher Newgard, PhD before and after bariatric fed a lower-fat diet did not—even when “That hamburger has protein surgery, and compare them eating the same number of calories. in it too, and the 32-ounce soft drink has a to patients who lose weight by other means. Now basic research from Duke’s Sarah ton of carbohydrate in it,” Newgard says. “We think this is going to be a very excit- W. Stedman Nutrition & Metabolism Center Newgard is also in the very early stages of ing model for understanding biochemical is beginning to suggest why. Basically, an studying, in collaboration with Eric DeMaria, changes that drive improved insulin action,” overload of the byproducts created during fat MD, chief of endosurgery, and Laura Svetkey, Newgard says. metabolism can damage the machinery that MD, director of clinical research at the regulates insulin sensitivity and production. Stedman Center, why patients who undergo “We think that part of how insulin resistance bariatric surgery show improved insulin sensi- D uke M ed 2 0 Subcutaneous insulin is still the backbone of treatment. Short- acting insulin is now available in an inhaled form, which could be used as a complement, though it takes some training for patients to use it correctly, Feinglos says. (A CME/CE activity covering inhaled insulin is available online at www.medscape. com/viewprogram/5726.*) For some patients, enhancing the body’s sensitivity to their own insulin with oral drugs such as metformin is enough. “I think the best drug for type 2 diabetes is still metformin because it isn’t associated with weight gain, and it attacks several of the problems of type 2 diabetes—insulin sensitivity changes, and production of glucose by the liver,” Feinglos says. A new class of drugs, DPP-4 inhibitors, prevents the breakdown of a hormone that enhances insulin secretion. These drugs can be Mark Feinglos, MD taken orally and have the happy side effect of decreasing appetite in some people. The first of this class, Januvia (sitagliptin), is now on the market. “If they really do increase insulin secretion and are not associated with weight gain, and maybe cause a little outcomes. Individual practices use the data to measure how well weight loss, they should be quite popular,” Feinglos says. they are caring for patients, and the data are also shared among practices in the collaborative so that they can learn which aspects Mobilizing in the community of the model are working. An individual doctor’s office can find it almost impossible to do “We’re trying to make sure that everyone in our practices is get- all that’s needed to take care of a patient with a chronic disease ting better,” Michener says. “We’re making steady improvement, such as diabetes. Feinglos says he can spend almost an hour and we’re comparing our practices to some of the best practices studying a particular patient’s lab results, trying to tease out in the country.” the reasons why blood sugar is still not well controlled. Most To develop more effective ways of delivering care, “We looked community practitioners don’t have that kind of time. And, adds at our whole process starting from how you call for an appoint- Lloyd Michener, MD, chair of the Department of Community and ment, to what information patients want, and redesigned our Family Medicine and director of the Duke Center for Community system to try to provide that,” Michener explains. “Traditionally, Research, because many patients with diabetes have to make we’ve left it to people to call us to tell us when they need to be seen, fundamental changes in their lives, a lot of patient education has and they’re seen one at a time, the patient and the doctor in the to happen. “Doctors, with all due respect to us, aren’t always the office.” But with the chronic care model, a team of caregivers such best at educating about lifestyle change.” as physician assistants, nurse practitioners, social workers, health So Duke and 21 other institutions nationwide are changing educators, physical therapists, and nutritionists work together to the way they offer care for chronic disease, through the Robert help patients take a more proactive role in their health. Wood Johnson-funded Academic Chronic Care Collaborative For example, as part of the ACCC efforts, patients with diabetes (ACCC). Members of the collaborative try different strategies for in Duke community clinics are encouraged to attend monthly managing chronic diseases such as diabetes, then evaluate the Diabetes Group Visits. Each 90-minute session includes a class on some aspect of diabetes care, as well as time for discussion. *Reference provided for information only; this activity is not sponsored or endorsed by Duke Medicine. Patients are much more likely to ask questions of a nurse, health educator, or even another patient than they are a doctor, Editor’s note: At press time a study in the New England Journal of Michener says. • Medicine (May 21, 2007) linked the diabetes drug Avandia (rosiglitazone) to increased heart attack risk. Visit dukemedmag.duke.edu to read a letter to patients from Duke General Internal Medicine on the issue. D uke M ed 2 1 As the diabetes epidemic swells, Duke caregivers are expanding their efforts from wards and clinics to apartment complexes and community centers, offering a variety of classes, support groups, and even in-home care management services to help people keep their disease under control. For information on many of these programs, visit communityhealth.mc.duke.edu.

On one such Tuesday night, six people attend the Diabetes diabetes in September 2006. Group Visit at Duke’s Family Medicine clinic. Exercise physi- Aiken mentions that for about two weeks she stuck to a routine ologist Michelle Mosberger talks to the group about ways to get of walking at night, but then lost the motivation. The mother of more activity into their routine. She shows them simple exercises four would like to join a gym, to get some exercise and some “me they can do in a chair while watching TV, such as arm or leg lifts. time,” but she finds memberships too expensive. Participants ask whether walking a few extra trips to the copier Another group member tells her that she could try walking at at work or parking farther away at the grocery store really counts. the mall. “Absolutely!” Mosberger says. “Every little bit helps.” An intern who’s there with Mosberger tells Aiken that the During the class, participants slip out for a mini-exam, in YWCA offers scholarships, if you ask. which a physician’s assistant takes vital signs, measures glucose Clinical associate Sarah McBane, PharmD, answers Aiken’s levels, and reviews medications. question about her insulin. No, she doesn’t need to pack it on ice The participants get especially engaged when it’s time to just when she goes out for the day. talk. “It’s a good place to talk out loud, no matter what you say or Another patient. The exercise physiology intern. A pharmacist. how stupid it may sound,” says Jackie Aiken, who started attend- On that night, the army helping Aiken battle diabetes was made ing the monthly classes shortly after she was diagnosed with up of three. o D uke M ed 2 2 Rx for diabetes: Look on the b right side

First, the bad news. Or, depending on how you look at it, the good news. Depression doesn’t seem to affect blood glucose levels, while stress does. But there are simple ways to do something about both.

In a study published in the April 2007 only nine days, and blood samples revealed Psychosomatic Medicine, Richard Surwit, PhD, that their cortisol levels were measurably chief of Duke’s Division of Medical Psychology, lower than the control group’s. and colleagues found that cognitive behav- “When the patient is having trouble control- ioral therapy—basically teaching people to ling their glucose, physicians might suggest Lower Stress, Lower Sugar see life as a glass that’s half full, rather than that they monitor their blood glucose in half empty—improved depression in a group situations where they feel they’re under stress, Tips on managing stress from The Mind- of patients with diabetes. and in situations where they feel they’re not,” Body Diabetes Revolution: But treating depression did not have any Surwit says. “And if there’s a pattern there, a • Tense, then relax. There are different effect on blood sugar control. Surwit was physician can recommend that they do some- variations, but the main idea behind surprised at the results because previous thing about it behaviorally.” progressive muscle relaxation is research, though mixed, had suggested that For instance, self-help books such as to consciously tense one group of depression and glucose control were linked. Surwit’s The Mind-Body Diabetes Revolution muscles, such as your feet or your His own study, with Duke colleague Mark can help people learn simple techniques to thigh muscles, for about 10 seconds, Feinglos, MD, had shown a small connection manage stress on their own. “The reason I then let them fall limp. Notice how in patients with type 1 diabetes. did this book was, for most people, insurance the complete relaxation feels. “I was just stunned,” Surwit says. “Cognitive is not going to pay for behavioral intervention • Practice regularly. When performed behavioral therapy’s effect on depression was unless there’s a psychiatric diagnosis,” he says. over time, such exercises can help so significant, and yet there was no effect on Muscle relaxation sounds easy enough, but people sense the first signs of muscle A1C [a marker of glucose levels over time].” can people really practice cognitive-behavioral tension, and learn to instantly relax Even though treating depression doesn’t therapy on their own? Yes, Surwit says. them when feeling anxious. Surwit seem to have any effect on diabetes, it’s well “We created a structured set of exercises suggests working up to 30 daily known, from research by Surwit and others, that you can do to look at a situation, analyze “mini-practices” of 30 seconds each, that stress can raise blood it, decide whether the whenever you feel your muscles sugar. Stress causes the way you are responding feeling tense, your heart racing, or body to make more hor- is appropriate or not, and your palms sweating. mones such as epinephrine, then change how you are • Observe your thoughts and test norepinephrine, and cortisol, responding if necessary. them for accuracy. When you find which can lead to disrup- “A lot of stress that we yourself feeling irritated or stressed, tions in the body’s normally put on ourselves has to stop and write down your mood. What tight control of blood sugar. do with how we appraise thoughts led to it? Are those thoughts But cognitive behavioral what’s going on around us,” based in truth? List alternative beliefs therapy, as well as progres- he says. For example, if and test them for accuracy as well. sive muscle relaxation, can your work supervisor snaps Richard Surwit, PhD produce reliable decreases at you, you might assume in these hormones. For that he’s unhappy with you. example, in one of their earliest studies Or, you could assume that he’s just having a of stress and diabetes control, Surwit and bad day. “People have to be able to figure Feinglos had 12 diabetes patients stay in a out which is which. If your boss is having a dormitory setting. Half of them learned and bad day, that’s too bad for your boss, but it’s practiced progressive muscle relaxation. That not something that should make you upset.” group showed decreased blood sugar after D uke M ed 2 3 4 2 DukeMed Kathleenby Yount THINNING A GENERATION “High blood pressure, adult-type diabetes, adult-type pressure, blood “High all them Generatthem Call ion hn eitiin aa Armstrong, Sarah pediatrician When Healthy Lifestyles Program, that is the the is that Program, Lifestyles Healthy left she year, last Baltimore left MD, ur increasingly sedentary,increasingly Our tripled have rates obesity Pediatric trouble. big in are kids overweight disease to type 2 diabetes. diabetes. 2 type to disease liver fatty treat—from to expected never them of many illnesses encountering routinely are reverse weight gain in children and treat and children in gain weight reverse ing a disturbing trend among patients in patients among trend disturbing a ing notic already was she but career, her in for overweight and obese children. The children. obese and overweight for medi- the at clinic multidisciplinary first factor for heartdisease.” overweight of percent “Sixty frequency. clinic to community-based interventions, Duke caregivers are adopting sweeping new strategies strategies new sweeping adopting are caregivers Duke interventions, community-based to clinic pediatricians grandparents, and parents their of diseases chronic debilitating the develop children oping asaresultof achild’sobesity. to address the health of a generation. a of health the address to kids are already exhibiting a clinical risk clinical a exhibiting already are kids early still is Armstrong purpose. a with on Drugs—Like on Kids ill,it’s not merely asocial issue—it’s afull-blown medical crisis. F assessments and interventions to help to interventions and assessments cal center devoted exclusively to caring to exclusively devoted center cal diagnoses she was making with increasing cal and research niche, by trying to catch to trying by niche, research and cal the medical conditions that may be devel - be may that conditions medical the family individual provides program to form a new clinic, the Duke Children’s Children’s Duke the clinic, new a form to of list a off ticking says, she puberty,” worked. she where clinics inner-city the these kids before their health problems health their before kids these since 1980, with one out of every three every of out one with 1980, since sleep apnea, cholesterol problems, early problems, cholesterol apnea, sleep Armstrong joined the faculty at Duke Duke at faculty the joined Armstrong

It’sbemoan to thing one Healthy Lifestyles fills a new clini- new a fills Lifestyles Healthy Lipitor America’s children our making obesity with But waistline. expanding - merican children now overweight or obese. or overweight now children American T Armstrong and her staff have carved out a outcarved have staff her Armstrongand Road, Roxboro on Clinic Duke the At Program. Within its first four months, four first its Within Program. Lifestyles begins with a two-hour-plus a with begins Lifestyles ing an already robust array of initiatives of array robust already an ing join- it’s But care. specialty necessitate it getsanyworse. offered here. of them referred by local pediatricians, local by referred them of a than more drawn had word-of-mouth hood obesity for a decade, from individual evaluation by three specialists. Armstrong Armstrong specialists. three by evaluation who haven’t time during a typical office office typical a during time haven’t who program—most the to families hundred visit for the type of intensive intervention intervention intensive of type the for visit at Duke that have been battling child- battling been have that Duke at assesses the patient’s weight-loss needs weight-loss patient’s the assesses dedicated space for the Healthy Lifestyles Lifestyles Healthy the for space dedicated doing to help reverse the problem before problem the reverse help to doing they important, more But illness. chronic treat a mounting wave of obesity-related of wave mounting a treat programs. Researchers and clinicians here community-wideinterventionspatientto say, there’s much that doctors can be be can doctors that much there’s say, to prepare to need pediatricians that say It aking A patient’s experience with Healthy with experience patient’s A F Box.X amil y by F amil rom anew childhood obesity y “We help them find dancing, swimming, dancing, find them help “We ity and making healthy choices. “Some kids kids “Some choices. healthy making and ity month follow-up. modifications. All families return for a six- meets with the family to go through their their through go to family the with meets with an information packet—a sort of battle with an intensive program of five monthly monthly five of program intensive an with family (such as depression), then helps then depression), as (such family worker screens for behavioral and emo- and behavioral for screens worker prac- recommend and history diet entire lems or health risks. A registered dietitian are also offered the option to continue continue to option the offered also are Patients Armstrong. says appropriate,” ofcouple a are, that’s if plans meal sample recommendations specific their what are, and addresses any related medical prob medical related any addresses and don’t like group sports,” says Armstrong. says sports,” group like don’t plan. “We write in what their specific goals permanent—lifestyle changes. hopefully healthy—and create family the the and patient the in problems tional social A plans. meal healthful and tical skating—things thatthey’llenjoy.” they because activities any do don’t they say sessions that address specific lifestyle lifestyle specific address that sessions exercise The team doesn’t use the words the use doesn’t team The Patients leave their initial assessment initial their leave Patients s these these As . Instead, the game is all about activ- about all is game the Instead, . diet or or 5 2 DukeMed - 5 6 2 Armstrong. She picks up a plastic bagel plastic a up picks She Armstrong. In the Healthy Lifestyles nutrition room, nutrition Lifestyles Healthy the In fruit—all plastic replicas in properly por- properly in replicas plastic fruit—all drumsticks, steaks, tiny flank grits form of fresh fruits and vegetables. Healthy vegetables. and fruits fresh of says is,” bread of serving single a what free- and corn cut of Rounds bowl. a of search in cornflakes and beans green of half thatof youraveragebagel-standfare. size— intended originally bread’s boiled a shelf overflows with plateless mounds plateless with overflows shelf a clinic—one displays an enticing rainbow enticing an displays clinic—one this in room every of walls the decorate Full- tioned sizes. “Most people have no idea idea no have people “Most sizes. tioned that looks miniature but is actually the the actually is but miniature looks that DukeMed Families Healthy for Five High otr wt pstv fo images food positive with Posters at Environment

At the final session, families are presented with a new, customized cookbook, filled cookbook, customized new, a with presented are families session, final the At Lifestyles is an oasis of healthful eating healthful of oasis an is Lifestyles Community Health, says that addressing that says Health, Community component. “ component. exercise the of Armstrong says best,” their beat to kids the tell just activity.“We cal call 919-681-3187 or visit or 919-681-3187 call visit we need to bring a lot of forces to bear in a a in ofbear forceslot to a bring to need we all of Because home. the in observances pro- of success long-term the to essential when theyleave. live and work and play,” she says. “Foodsays. is she play,” and work and live focus on integral—and easily attainable—lifestyle changes that kids and families can families and kids that changes attainable—lifestyle easily integral—and on focus in participants month, a Once advertising that looks quite different from For more information about Duke’sabout information more For programs nutrition and activity community-based For more information about the Healthy Lifestyles Program, Program, Lifestyles Healthy the about information more For combined, collaborativeeffort.” religious of part it’s familial, it’s cultural, with all of the family’sthe of all with recipes—madefavorite dietitian. morethe by healthful parents will buy a pedometer too and the family does it together. it does family the and too pedometer a buy will parents that, to help a family make lasting changes, kids which in environment the change to is obesity of causes climate-related these families awaiting world fast-fried the grams such as Healthy Lifestyles. “We have jump-ropes and exercise bands for “active for bands exercise and jump-ropes implement to achieve a healthy weight. healthy a achieve to implement big results:big looks kinda like a pager; some of the kids think that’sthink kids the of some pager; a like kinda looks cool.” n n n n n

day a minutes 60 for active Be At every session, kids get a take-home toy that’s also a tool for that topic—from that for tool a that’salso toy take-home a get kids session, every At Her group has devoted attention to attention devoted has group Her Susan Yaggy, chief of the Division of of Division the of chief Yaggy, Susan at right-sized meals with family at home at family with meals right-sized Eat T Limit health good for right Sleep rade sugar-sweetenedrade water for juice and sodas, drinks, Todukehealth.org/healthylifestyles. 919-620-5356. call please patient, a refer to two hours a day (or less) (or day a hours two to TV E very night they write down how many steps they took; sometimes the sometimes took; they steps many how down write they night very communityhealth.mc.duke.edu. Duke Children’s he modifications are basic, but they can yield yield can they but basic, are modifications The TV watching” to a pedometer for physi for pedometer a to watching” 1996. “When our division was formed, was division our “When 1996. Healthy our first projects were studying asthma, studying were projects first our of organizing, and a sustained effort,”Yaggy sustained a and oforganizing, a hle cmuiis throughout communities helped has asthma is yet another chronic illness more because says, she there,” was obesity and and nutrition programs. Many of these of Many programs. nutrition and are increasing opportunities now, including common among obese kids. Her division Her kids. obese among common in inception its since obesity childhood continues to worsen. continues toworsen. with success great had have communities the state to implement physical activity physical implement to state the rbe i Nrh aoia overall Carolina North in problem obesity the but enrolled, families the says.“And those are hard.” However, there “It’s a problem that takes a lot of work, a lot Lifestyles

P rogram gather to gather Program lus,” she adds, “it “it adds, she lus,”

- People 2010 initiative. Yaggy serves as serves Yaggy initiative. 2010 People Department—the Health County Durham infrastructure offering obesity-combat- offering infrastructure for a Healthy Durham, established by the the by established Durham, Healthy a for weren’t that programs, new for funding home, from farmer’s markets and trails to to trails and markets farmer’s from home, physical find families help to map based local organization for the national Healthy Healthy fornational organization the local activitynutritionand resources their near committee. That group has created a Web-a created has group That committee. disease chronic and obesity its of chair people makegoodchoices.” to willingness more “There’s before. there gyms andafter-schoolprograms. use the social good of government to help help to government of good social the use h hp i ta a e community new a that is hope The One example, she says, is the Partnership is needed to reinforce your decision to decision your reinforce to needed is nutritious food choices will take root, take will choices food nutritious and opportunities, exercise programs, ing iors,” Yaggy says. “So when a parent walks walks parent a when “So says. Yaggy iors,” whether it’s at the parent’s workplace or or workplace parent’s the at it’s whether they child, his with door clinic the out make families and patients help to work long-term changes in their health behav- health their in changes long-term at home. That kind of community support support community of kind That home. at change yourfamily’shealthbehaviors.” church, to support changes that they make oi etn evrnet “Research environment. eating toxic the child’s school or weekend events at events weekend or school child’s the what interventions—are single gies—not shows that multiple, reinforcing strate- reinforcing multiple, that shows well-entrenched our supplanting slowly should know about healthful options, healthful about know should Sixteen-year-old Rachel Creel one is doing drugs. This programgives me eat less,” says Rachel’s mother, Trish somewhere to go. Idon’t have to be Armstrong, MD(right). “It can be of the first patients to enroll in the Duke Children’s Healthy Lifestyles Creel. “It’s not like talking to your tricky to have to tell your child to behaviors, like not smoking, not kids about other kinds of risky program, directed by Sarah the bad guy anymore.”

7 2 DukeMed 8 2 DukeMed Healthy Lifestyles feels doable. “Salads dressing. Now Iknow to make smaller Healthy Lifestyles staff.“They’re so all Lifestyles program, the so team based shown to reduce hypertension aswell breakfasts to curb hunger throughout upbeat,” says Rachel. “And they never Trish Creel. talk “They about activity my problem was that Iloaded on the as cholesterol and weight. Compared her nutrition plan on the DASH diet, are my favorite thing,” she says. “But to other programs she’s tried, Rachel use theuse words dietor exercise.” “It’s moved atelevision into the family’s home fitness room, which shesays and nutrition instead. it So doesn’t of dressing Ilike and not overdo it.” says what she has learned through the day, and her dad, Chuck Creel, really refreshing,” agrees her mom, salads, Ican so enjoy the amount Rachel also started eating regular Rachel Creel’s blood pressure was high when she began the Healthy makes exercising more attractive. But her biggest inspiration the is seem like an obligation, but an opportunity to be healthy.”

(BMI). “Pediatricians think they can iden- can they think “Pediatricians (BMI). MD, MPH, many pediatric practices don’t don’t practices pediatric many MPH, MD, Physicians, says Bravender, can be pivotal pivotal be can Bravender, says Physicians, obesity long so for because Bravender, Often, Yaggy says, a key trigger for a for trigger key a says, Yaggy Often, implications thatI’mworried about. kid a if frankly and ‘normal,’ what’s in my if care don’t “I says. he all,” after it, based one to conversation the changing in even chart their patients’ body mass index index mass body patients’ their chart even Terrillmedicine, Bravender, adolescent of physi- a is decision that make to family even moral issue more than anything else. else. anything than more issue moral even on health. “That’s why we’re talking about about talking we’re why “That’s health. on weight with their parents. “Some parents “Some parents. their with weight ‘normal’ what’s children For 30. at obese director Duke’s to according But weight. he says, “and I remember he went to the the to went he remember I “and says, he less I’m poorly, eat doesn’t and active he’s but weight for percentile 90th the in be to determined genetically he’s like looks variation wide a always There’s healthy. cosmetic, private, a considered been has Hav“The ing you’re overweight with a BMI of 25, and 25, of BMI a with overweight you’re are shocked when you bring it up,” says says up,” it bring you when shocked are doctor and the doctor didn’t mention his mention didn’t doctor the and doctor health the It’s child. that about concerned changes fromyeartoyear.” child’s a about concern expressing cian patient is overweight, if that individual is is individual that if overweight, is patient that child, but that’s simply not true,” he he true,” not simply that’s but child, that at looking by overweight who’s child a tify uncomfortable discussing children’s over- children’s discussing uncomfortable says. “The normal BMI for adults is static; static; is adults for BMI normal “The says. “My father smoked when I was young,” was I when smoked father “My Many pediatricians also report feeling report also pediatricians Many T alk” with F amiles “It’s very easy—even for kids—to make it make kids—to for easy—even very “It’s And I think it’s the same with obesity. If obesity. with same the it’s think I And often enough to stop weight gain.” weight stop to enough often Freemark, MD, says that’s why it is incum- is it why that’s says MD,Freemark, pediatric the about fact ugliest Perhapsthe Pediatric Insulin Resistance Clinic since since Clinic Resistance Insulin Pediatric readily available food, the cheapest of of cheapest the food, available readily stuff every day,” she says. “If I can get them to switch to water, milk, or diet drinks, that alone is alone that drinks, water,diet to or switch milk, to them get can I “If day,”says. every stuffshe ior. Pediatric endocrinologist Michael endocrinologist Pediatric ior. it’s diseases, behavior-related many in it was established 10 years ago. He says He ago. years 10 established was it for transportation and the sedentary style style sedentary the and transportation for was, ‘Well, I guess I don’t smoke too much ‘Well,much was, too smoke don’t I guess I of much of our work and entertainment. and work our of much of because the doctor didn’t say anything.’ say didn’t doctor the because whichgenerallyis mostthenutrient-poor extremely hard for people to permanently permanently to people for hard extremely evidenced as because, That’s fails. often modifi- lifestyle that is epidemic obesity overweight andobesitybefore itemerges. bent upon pediatricians to try to prevent to try to pediatricians upon bent you don’t say anything, many patients and and patients many anything, say don’t you Duke dietitian Gwen dietitian Duke her first target when she works with kids struggling with obesity. “Some kids drink liters of this of liters drink obesity.kids with “Some struggling kids with works she when target first her an obesityepidemic.” about it, it’s really no surprise that we have all patients my tell “I calorie-dense. and change entrenched patterns of behav- of patterns entrenched change loss, weight lasting for strategy a as cation, the time,” he says, “that when you think you when “that says, he time,” the parents interpretthatastacitapproval.” the expansive variety of pre-prepared, of variety expansive the with that Combine all.” at energy physical any expending without day the through Don’t Diets genic one, noting our dependency on cars cars on dependency our noting one, genic that this patient population has not only not has population patient this that smoking. So my dad’s take-home message Bravender calls our culture an obesi- an culture our calls Bravender reak a oese Duke’s overseen has Freemark Al urphy makes calorie-dense drinks like soda, sweet tea, and even fruit juice fruit even and tea, sweet soda, like drinks calorie-dense makes Murphy w a Work ys Meanwhile, pediatric obesity remains a remains obesity pediatric Meanwhile, For the legions of children who are already research component. He’ll coordinate coordinate He’ll component. research in adults, can be useful in helping obese obese helping in useful be can adults, in a metformin, that suggest investigators families. “We want to determine whether whether determine to “We want families. from birth can prevent weight gain within within gain weight prevent can birth from excess weight. “For the highest-risk group, earlier,” he says. Among the interventions the taken has Freemark why is which eliminating those sugary drinks right drinks sugary those eliminating obese, Freemark’s group is exploring is group Freemark’s obese, we could intervene more aggressively and and aggressively more intervene could we babies, to learn at the physiologic level how beverages for infants born into high-risk into born infants for beverages Program’s Lifestyles Healthy the of helm ht egtls mdctos might medications weight-loss what be safest and most effective to use in use to effective most and safest be Help vention, and treatment. vention, andtreatment. abolic function of obese mothers and their adolescents with impaired glucose glucose impaired with adolescents children is banning sugar-sweetened banning is children drug developed to treat type 2 diabetes 2 type treat to developed drug other and Freemark by Studies children. to identify the children at greatest risk for risk greatest at children the identify to that will be studied in these very young very these in studied be will that understood— poorly that’s phenomenon the firsttwoyears.” polycystic ovary syndrome. Among drugs Among syndrome. ovary polycystic or resistance, insulin severe tolerance, understand the disease’s etiology, pre- etiology, disease’s the understand used to treat obesity, metformin likely has studies with Armstrong’s clinic to better better to clinic Armstrong’s with studies swelled, but also worsened in health status. Studies will aim to characterize the met- the characterize to aim will Studies n a Pill? a in

9 2 DukeMed Should weight-loss medications be used in children and teens? Duke’s Terrill Bravender, MD, and Michael Freemark, MD, have different takes on the issue, but they agree on a key point—as Bravender puts it, “We need to find a safe and effective medical treatment for this condition, because there is no behavior modification that consistently works.”

Terrill Bravender, MD Michael Freemark, MD

the fewest side effects and the best benefit- it often comes down to the particular failure speaks to the level of pathology to-risk ratio. Other medications approved patient one sees in the clinic. “Everyone in the environment around us, as well as for treatment of obesity, including orlistat agrees that lifestyle intervention should the intense, inborn drive to eat. “There’s and sibutramine, may cause diarrhea be initiated before drug therapy and nothing more basic than the needs to eat and hypertension, limiting their use in should be maintained during and after and drink to survive,” he says. “When the general population. Freemark and such therapy if possible,” he says. “But if you’re surrounded by food, what else are his colleagues will study metformin’s my patient has multiple family members you going to do?” usefulness in preventing problems in with type 2 diabetes and early-onset But then what exactly do you do about overweight children who are at highest cardiovascular disease, and the kid has a disease whose etiology is rooted in our risk for developing type 2 diabetes and been obese and insulin-resistant despite most fundamental impulses? Yaggy says fatty liver disease. lifestyle counseling, my feeling is, it’s the solution needs to come from an evo- Freemark notes that early weight-loss justified to try to do something more. But lution in our overall culture. “It won’t just drug intervention is a topic of much debate. this idea is not accepted by everyone.” be one clinic or one community program,” “A lot of people are not wild about the idea,” she says. “It needs to be an interrelated he says. “They believe that only lifestyle Baby Steps to Better Health community, government, medical, and interventions are justified until major Bravender would count himself among family enterprise.” In short, she says, complications have developed. I’ve argued those who are more leery than Freemark the issue of obesity must, like smok- that medications may be considered if of using drug therapies in obese children. ing, become something “that’s civic, not pre-diabetic conditions persist despite a But he does agree with Freemark in the something seen only as a personal respon- good-faith effort at lifestyle change.” most important way: “We need to find a sibility and a personal failure.” Freemark explains that the debate stems safe and effective medical treatment for Armstrong echoes that sentiment. “In from the many questions that need to be this condition,” he says, “because there this country there are a lot of organizations answered about the effects of anti-obesity is no behavior modification that consis- working on the problem of childhood drugs in still-changing bodies. He thinks tently works.” He thinks this behavioral obesity,” she says, “but they tend to D uke M ed 3 0 Overfed but undernourished

Many obese kids are also malnourished—their caloric intake is not only excessive, but also nutrient-poor. This could be because so many of our lowest-priced foods are also our least healthful. That’s the epidemic’s ironic twist: this disease of surfeit strikes disproportionately among the poor. And like most other chronic illnesses, it runs rampant in these communities that often have fewer resources with which to combat the problem. Low- income neighborhoods generally have few large grocery stores and instead have to rely on quick marts; lean cuts of meat and fresh fruits and vegetables are often unavailable, and if available are expensive compared to canned goods. And in some neighborhoods, it’s often simply safer to keep kids indoors, even if it means they are less active. Sarah Armstrong, MD, says that in the Healthy Lifestyles Program, the families who have struggled the most to implement healthy changes are those also dealing with issues such as homelessness and poverty. Duke dietitian Gwen Murphy notes that a scarcity of healthy food can be a major contributor to overeating and to eating unhealthy, calorie-dense foods. When she discusses the many community nutrition programs she works on in the Division of Community Health, poverty is often an underlying theme. One such program sends kids home on Fridays with their backpacks full of fresh fruits and vegetables. “A person who worked on that program told me that one day he watched a child sit down and eat all the food in his backpack before he even left school,” Murphy says. operate in silos.” She hopes that the Healthy Lifestyles Program will be Read more about the many community programs and funding opportunities something that doctors throughout North to combat poverty-related obesity on the division’s Web site: Carolina will be able to use and replicate communityhealth.mc.duke.edu in their own communities. Armstrong notes that the program is little more than a toolkit to help inform and equip individual families to make healthy choices. “Only they can do it,” she says. “We can make the recommendations, but it’s totally the determination of these folks— that they want their kids to be healthy.” And the changes affect more than just the kids— the health of the whole family improves. “For some of these parents, changing their lifestyle habits for themselves wasn’t enough, but now they want to change it for their children. The kids become the inspiration they needed.” o D uke M ed 3 1 “A melanoma the size of an eraser head,

if it’s aggressive

and invading deep down

into the lower layers of the skin, is able to get into

the lymphatic system and blood vessels and travel,

spreading to the lymph nodes and organs.

It’s not well understood whereas basal cell cancers why melanoma does that, almost never do and squamous cell cancers have to be very advanced and large before they metastasize. There’s still much to be learned about D uke M ed 3 2 the biology of melanoma. to be very advanced whereas basal cell cancers

about learned be metastasize. metastasize. of melanoma. of There’s to much still

squamous cell cancers have have cancers cell squamous the biology biology the and large before they almost never do and and do never almost BENEATH A healthy, sun-kissed glow! A safe alternative A healthy, sun-kissed glow! A safe alternative Maine, she feels certain it was the indoor the was it certain feels she Maine, Caddell moved to North Carolina from Carolina North to moved Caddell ment withadermatologist.” tell could I mole. this on focused really no educationonskincancerwhatsoever.” Though Caddell. Jane enrage salons ning of her knee, however, she took notice. “I notice. took she however, knee, her of eyed, which makes you a little more suscep- more little a you makes which eyed, dozing sometimes week, a days four or a and year a about For melanoma. ening her sun exposure increased a bit when bit a increased exposure sun her half, she’d go with friends from work three life-threat- her spurred that thirties late a sense of urgency, so I made an appoint- an made I so urgency, of sense a there was some activity with it. Then it Then it. with activity some was there tible,” says Caddell. “But I just had no clue, clue, no had just I “But Caddell. says tible,” the glowingbulbs. of warmth the in hour lunch the through tanning beds she began frequenting in her started to bleed a little bit. That gave me me gave That bit. little a bleed to started to sunlight! No harmful UVBrays! to sunlight!Noharmful “Of course, I’m blond-haired and blue- and blond-haired I’m course, “Of When a new mole appeared on the back back the on appeared mole new a When False reassurances like these from tan- from these like reassurances False

INTO DELVING According to the American Cancer Society, Society, Cancer American the to According University Medical Center. “It’s not well not “It’s Center. Medical University nosed at a localized stage, meaning they meaning stage, localized a at nosed me that I had nothing to worry about.” me thatIhadnothingtoworryabout.” of the Biologic Therapy Program at Duke Duke at Program Therapy Biologic the of director MD, Gollob, Jared says organs,” lymphatic system and blood vessels and vessels blood and system lymphatic the into get to able is skin, the of layers of layers outer the beyond spread not have borders came out clear, so he reassured he so clear, out came borders year survival rate is 98 percent. year survivalrateis98percent. and invading deep down into the lower lower the into down deep invading and around 83 percent of melanomas are diag- are melanomas of percent 83 around area of skin,” she recalls, “and said the the said “and recalls, she skin,” of area can often stop melanoma in its tracks. its in melanoma stop often can the size of an eraser head, if it’s aggressive potential to spread or recur. “A melanoma silver-dollar-sized a out took “He cancer. travel, spreading to the lymph nodes and nodes lymph the to spreading travel, five- average the cases, these In skin. the the rarest but most deadly form of skin of form deadly most but rarest the signs, however, melanoma still has the has still melanoma however, signs, Even when combated at its earliest its at combated when Even Indeed, treatment at an early stage stage early an at treatment Indeed, Caddell was diagnosed with melanoma, with diagnosed was Caddell SURFACETHE MELANOMA Melanoma Clinic are seeking to unlock to seeking are Clinic Melanoma Each year more than 500 of those patients patients ofthose 500 than more year Each make the strongest possible first strike strike first possible strongest the make including treatment, and detection in rated one of the leading specialty clinics in ever before. of melanoma diagnoses continues to creep whereas basal cell cancers almost never do advanced melanoma more options than options more melanoma advanced with those offer disease—and the against stages early the in patients help to aims Duke therapies, experimental to access metasta- they before large and advanced very be to have cancers cell squamous and cases annually in the United States alone. States United the in annually cases thereby uncover more ways to combat it—a and cancer aggressive this of secrets the the United States. By providing the latest the providing By States. United the Duke, at Clinic Melanoma the to travel the biologyof melanoma.” goal becoming more urgent as the number upwards, now nearing some 53,000 new 53,000 some nearing now upwards, understood why melanoma does that, does melanoma why understood size. There’s still much to be learned about Researchers and clinicians at Duke’s at clinicians and Researchers BY JUNE SPENCE JUNE BY ’S MYSTERIES

3 3 DukeMed As Luck Would Have It can offer high-dose IL-2 therapy. “It “I thought I’d been lucky,” says Caddell of requires very intense monitoring, spe- her initial brush with melanoma. About cialized nursing, specialized physician a year after Caddell’s mole was removed, care, and patients have to be well enough however, she developed a bronchial infec- to be treated.” tion with a low-grade fever. Even with IL-2 hyperactivates the immune system, antibiotics, the fever continued, and she explains Gollob, so the symptoms can be developed a “relentless, croupy cough” severe, “like what you might get if you that plagued her day and night. had a serious blood infection—fevers A chest x-ray indicated pneumonia, and chills, low blood pressure, the heart but it also revealed something far more rate can speed up, fluid may leak into menacing—shadows. A CT scan showed the lungs, kidneys may temporarily shut “This disease is too fast, too nodules on her lungs, her liver, and the down, blood counts go down, liver func- furious—it’s too big not to lymph nodes in her chest. One tumor had tion can be compromised. We have to pay encircled her esophagus. very close attention during treatment so be in the hands of someone “An oncologist told me that my mela- that we know when to pull back. It sounds who can offer you all the noma was in stage IV,” recalls Caddell. “I harsh, but put it in perspective: the aver- options,” says Jane Caddell, said, ‘Well, how many stages are there?’ age life expectancy for someone with stage who was treated for stage IV He said, ‘There’s four.’” IV melanoma is less than a year.” melanoma. “At Duke, all the “Stage IV refers to the fact that the mela- “The stuff kicks your butt,” confirms knowledge is under one roof. noma has already spread to other organs Caddell, who was treated with IL-2 under or to new places in the body, far from Gollob’s care after her oncologist referred There’s hope here.” where it started, and is usually no longer her to Duke. “It was a bit like having curable with surgery,” explains Gollob. entirely too many drinks and the flu at “High-dose interleukin-2 [IL-2] is what the same time. After each treatment I felt we give to patients with stage IV mela- like I’d just challenged the heavyweight noma who are healthy enough to tolerate champion of the world, I was so battered. the severe side effects, for it remains the One of the amazing things about this only treatment that can actually cure a treatment, though, is how quickly you can small percentage of these patients.” rebound from it after it stops. It’s tough Gollob says Duke is among a limited but doable.” number of centers in the country that Caddell’s tumors shrank in response D uke M ed 3 4 Jared Gollob, MD, directs the Biologic Therapy Program at Duke—one of about 30 places in the country that offer high- dose interleukin-2, the only therapy to date with the potential to cure advanced melanoma or kidney cancer.

to the intensive treatment, and in June of explains. But after reducing the tumors stage melanoma. The founder of the 2006 she was told she was in remission with biochemotherapy, the treatment Duke Melanoma Clinic and a pioneer in and disease-free. She has since become “switches” to a combination of two other melanoma research and care, Hilliard F. an advocate for melanoma education and drugs: sorafenib, an experimental antian- Siegler, MD, began studying melanoma prevention through the organization she giogenic drug approved for kidney cancer tissue antigens in 1968. His legacy contin- founded, Operation Sun Shield (opera- but not yet for melanoma, and a very low ues in Duke’s enduring quest to perfect a tionsunshield.org). daily dose of temozolomide, a chemother- vaccine to treat melanoma. apy agent. “This appears to be a potent way “The body can have an immune response Scratching the Surface of jumping on the tumor once it has begun to melanoma,” says Scott Pruitt, MD, The successful outcome of Caddell’s to shrink. There’s evidence that by giving PhD, a surgical oncologist whose research treatment is cause for celebration, but those two drugs together like that once focuses on melanoma vaccine develop- she’s among only 5 percent of patients you’ve begun to shrink the tumors with the ment. “But our immune response is with late-stage melanoma for whom IL-2 ‘big-gun’ chemotherapy, you can get the designed to fight infection rather than provides a cure. Hope for greater numbers cancer into durable remission in animals. cancer, so there are hurdles to over- may lie in combination therapy, the focus We hope to see it do the same in humans.” come. Cancer cells are so close to normal of Gollob’s research. For patients with late-stage melanoma, cells, and there are a variety of control “We use drugs with some track record in who have no chance of a cure with surgery mechanisms in our bodies to prevent us melanoma, like high-dose IL-2 or alpha alone, Gollob says such trials offer addi- from making immune reactions against interferon [standard therapy for stage II tional treatment options to the current our own antigens. One way to get around or stage III melanoma] and combine them standard of high-dose IL-2 therapy. “The that is to get rid of those regulatory cells; with new drugs that might be able to make fact that the standard is still a long shot another way is to more effectively direct them work better,” says Gollob. Among makes us feel comfortable saying let’s try the immune response against the appro- his new phase-two trials now open to something different, using drugs that may priate targets. Ultimately we’d like to patients at Duke is one that involves what have the potential to help in a meaningful, combine the two approaches.” animal researchers call “chemo-switch,” long-lasting way.” Toward that end, Pruitt is studying an an approach that begins with biochemo- immunotherapy protocol that involves therapy—a combination of IL-2, alpha Shooting for regulatory T-cell depletion. “Regulatory T- interferon, and three chemotherapy drugs. More Effective Vaccines cells dampen the immune response,” he “We know that this combination can Duke is considered a leader in the field explains, “so if we can remove those cells shrink tumors in melanoma; the prob- of immunotherapy, another tactic with from the body, we hope to boost a more lem is the tumors don’t stay shrunk,” he the potential to help patients with late- vigorous response against melanoma.” D uke M ed 3 5 “If there are only one or two nodules, you can surgically excise them, but sometimes there will be hundreds of nodules, almost like a rash of cancer

He’s also pursuing an immunization response to give us hope that we can keep can get a dose of chemotherapy 10 times protocol involving dendritic cells loaded working to overcome these regulatory greater than you could give someone by with melanoma antigen RNA. “We think mechanisms, get the right targets, and mouth or in a vein,” explains Tyler. “The that altering the dendritic cell will make more headway. We’re continually regional therapies are associated with generate T-cells that are more effective trying to come up with a better under- about a 50 percent chance for complete against melanoma.” standing of the regulatory mechanisms of disappearance of the disease, which is Ideally, immunotherapy would be used the immune system and get the next big much higher than is seen with any sys- to treat all patients with melanoma, “but breakthrough.” temic treatment.” The procedure has that’s way down the road,” cautions Pruitt. become far less invasive as it has evolved, “Our focus right now is on patients with “A Rash of Cancer” no longer requiring incisions or the use of metastatic disease.” Successful vaccine Sometimes when melanoma recurs, it a heart-lung machine, and Tyler is seeing protocols over the past two decades have does so as multiple nodules located similar response rates. been shown to induce a clinical response between where the primary tumor was Building on this regional therapy model, in about 5 percent of patients with meta- and the regional lymph nodes. “If there Tyler and colleagues are designing trials static melanoma. “That’s just enough are only one or two nodules, you can that combine both regional and systemic surgically excise them,” says Doug Tyler, approaches. The strategy involves first MD, surgical oncologist, “but sometimes giving a targeted therapy—a drug target- there will be hundreds of nodules, almost ing a specific protein that that may be like a rash of cancer, and you can’t really abnormally expressed in a tumor cell—to remove that short of an amputation.” For the whole body. Targeted therapies can patients experiencing local or regional be introduced systemically because they recurrences in their extremities, Tyler’s usually don’t have many side effects. In specialty, regional therapy—the treatment the middle of that treatment, the regional program he established at Duke—may be chemotherapy is introduced. the best defense. “Systemic treatments seem to make Regional therapy allows much higher the tumor cells much more sensitive to doses of chemotherapy than could be tol- the high-dose regional chemotherapy,” erated systemically. During infusion, the says Tyler. “We’ve seen some incredible

Scott Pruitt, MD, PhD, is developing vaccines limb’s circulation is cut off from the rest responses with some of these combina- against melanoma. of the body, which helps to minimize che- tions in our preclinical animal test models, motherapy’s side effects. “The extremity especially when we were systemically D uke M ed 3 6 he Stem The The model could help demystify the oftenmelanoma of behaviors strange James Grichnik, MD, PhD, associate professorandassociate dermatology PhD, of directorMD, Grichnik, James James Grichnik, James andtumor dormancy. are lots of papers being published now identifying differentidentifying now published dermal being of arepapers types of lots able toimmediately predict what underlyingpathways havebeen amole. of the melanocytic diseases section in Duke’sin section diseases melanocytic the of Dermatology,of Division stem cells, so cells, stem despite a stronga response.despite immunologic differentmoles and melanoma types. We anticipate thatsomeday we growth that results in the secondary development of a melanoma within within melanoma a of growthdevelopment resultssecondary that the in producemole. to benign going a (surface microscopy) we can identify specific growth patterns of of growthspecific microscopy)identify patterns (surface can we out to be true, it will have major ramifications for the diagnosis, prognosis,diagnosis, the and for ramifications major have will it true, be to out of mutations but suffer an additional malignant mutation during that that during mutation suffermalignant but additional mutations an of melanoma. a they’reform mutations, to of going treatmentmelanoma. of themselves. cells stem the overlook but cells daughter malignant the apparent.become would tumor the body,the environmentalwhen arethen conditions and appropriate, those and offerand more towardclues detection and treatment. fromsprings melanoma that hypothesis new a mutant explains stemcells. fourths of melanomas develop directlydevelop melanomas from of skin. fourths normal mutated stem cells could again give rise to differentiatingto rise give and again cells could daughter cells stem mutated malignant. or benign is it whether and mutated moles. What is also interesting is that through the use of dermoscopy dermoscopy interestingthroughof also that use is is the What moles. we’reseeing. will beable tolook ata lesionand, based on itsgrowth pattern, be he stem cell model is consistent with the clinical phenomena that that phenomena clinical the with consistent is model cell stem The he mutated stem cell may also start growingstart also may cell stem mutated The complement benign a with We still haveyet to conclusively prove the existence of these cells, but there T his mayexplain the one-fourthof melanomas thatdevelop in think it’sthink I time. of matter a just t could more easily explain behaviors like delayed onset onset delayed like morebehaviors could explain It easily MD, PhD Cell C ells couldexist unstimulated for long periodsin

Hypothesis f they have a malignant complement complement malignant a have they If called upon to produce to (cells upon melanocytes called develops from mutatedstem cells. T that producepigment), if they have a mutations.When these stem cells are inthe skin, andthey accumulate idea isthat thereare stem cells sitting benign complementof mutations, they’re lines support the hypothesis that melanoma melanoma that hypothesis the support lines t might also explain death fromdeath explain melanoma also might It O urstudies of metastaticmelanoma cell he immune system might easily destroyeasily might system immune The f the stem cell hypothesis turns turns hypothesis cell stem the If his explains why three-why explains This he micrograph of a melanoma cell melanoma a of micrograph olored scanning electron scanning Colored

7 3 DukeMed

HOTO P ENCE I C S / NER ISS CHME GS TEVE S RAR IB L Y James Grichnik, MD, PhD, developed a CD-ROM-based medical record system that captures multiple images to create a standardized, comprehensive “map” of a patient’s body. The total-body photography provides a baseline for mole comparison at future examinations.*

targeting a protein called N-cadherin. detection of melanoma and prompt, thor- does a disservice by driving anxiety and That protein is not expressed much in ough surgical intervention and follow-up. unnecessary excisions.” normal nevi [moles] or pigmented legions, “Our effort is to catch melanomas as early For patients with extensive dysplastic but in melanoma, N-cadherin expression as possible,” says James Grichnik, MD, nevi, especially in the setting of a personal starts to increase, and it makes tumors PhD, director of the melanocytic diseases or family history of melanoma, or those much more invasive and aggressive.” section in Duke’s Division of Dermatology. who have had melanoma and have a The protein B-raf is also expressed “We can’t identify a melanoma at the two- great deal of anxiety about reoccurrence, abnormally in melanoma patients. The cell or four-cell or eight-cell stage; there Grichnik uses total-body photography to drug sorafenib, currently approved for is a threshold that these tumors need to provide a baseline for mole comparison renal cell cancers, targets B-raf. “There cross before they can be identified. Thus, at future examinations. Grichnik seems to be benefit in giving sorafenib we all overlook early melanomas. Our developed MoleMapCD, a CD-ROM- systemically, then in the middle of this effort is to help our patients and other based medical record system that captures two-week systemic treatment giving physicians to identify melanomas as early multiple images to create a standardized, regional therapy to the extremity,” says as possible—well before the tumors have a comprehensive “map” of a patient’s body.* Tyler. “We’re interested in seeing what chance to metastasize.” Change is one of the most important this drug may do for controlling meta- There’s no advantage to removing every features of early melanoma, emphasizes static melanoma.” mole, says Grichnik. “There are roughly Grichnik. “For patients with dysplastic Studies of these combination therapies 200 thousand [benign] moles for every nevi, the old ABCD criteria alone [sus- in animals have been promising, and have melanoma. Dysplastic nevi [atypical pecting melanoma based on a mole’s led to phase-one clinical trials which are moles] cause a lot of anxiety among asymmetry, border, color, and diameter] currently approved and open to patient doctors and patients. There’s this idea just falls apart.” Recently E for “evolution” accrual. “It’s an exciting time,” notes Tyler. that it’s just a matter of time before they has been added to the criteria in an effort “Hopefully things that we learn in this turn into melanomas—this is nonsense. to boost its utility in melanoma detection. regional setting can then be extrapolated The large majority of dysplasic nevi will Grichnik favors instead an approach to help treat patients with more advanced never turn into melanoma. About three- termed “the smoking GUN of melanoma systemic disease.” quarters of melanomas develop in normal detection.” GUN stands for growth, skin. We need to think of dysplastic nevi unusual appearance, and non-uniform The Big Picture as markers of patients who have increased structure. “In clinic this can be used While researchers are making headway risk of developing a melanoma. Don’t use efficiently by first looking for moles that with novel treatments for advanced mela- the terms ‘precancerous’ or ‘premalignant’ don’t match the others or are pointed out noma, the best defense remains early to describe dysplastic nevi—that really by the patient as concerning,” he explains.

*MoleMapCD is a proprietary technology being marketed through DigitalDerm, Inc. for general use. Grichnik is a founder and major shareholder. D uke M ed 3 8 Melanoma in Minorities: Rarer but Deadlier

While melanoma is more common among Caucasians, with fair-skinned “Then by looking at the lesions very closely we’d do a sentinel lymph node biopsy, people with blond or red hair and blue, using dermoscopy [a type of surface a PET scan, a staging workup, and how green, or gray eyes at even greater risk, microscopy] and determining whether widely we’d excise.” melanoma affects people of all races. they are uniform, showing the same pat- Though the melanoma incidence is tern from the center to the edge in all Life After Melanoma lower among minorities, the five-year directions. And then third, by checking Beyond treatment, ongoing vigilance is mortality rate from a melanoma is the lesions against baseline photos for key for the melanoma survivor. “Once higher. “The heavier pigmentation growth. Lesions that have grown and are you have melanoma, your lifetime risk of helps reduce superficial spreading unusual are already of some concern; if having another one is five times greater,” melanomas [the most common type] they are also non-uniform they are very notes Fisher. “You need total body and lentigo-type melanomas [which typically occur on sun-damaged skin] worrisome for melanoma.” surveillance forever.” but not acral lentiginous melanomas,” Surgeons typically don’t encoun- For Caddell, who has amassed a vast says Grichnik. Acral lentiginous ter melanoma patients until after the collection of hats, preaches the gospel melanoma (ALM) represents a greater diagnosis is made, but their ability to of sunblock and tanning bed avoidance percentage of the melanomas among effectively treat the disease relies in part to whomever will listen, and endures minority populations. ALM accounts for on the quality of the data collected before an anxious day of CT scans every three 50 percent of melanomas that arise in the referral. “Melanoma is a surgical dis- months to confirm she’s still cancer-free, dark skin. ease, and you don’t cut corners with it,” life will never be the same, but she’s ALM is found on areas not commonly says Samuel Fisher, MD, a pediatric oto- finding her peace with that. “My prize is thought to be important sites for laryngologist specializing in melanomas waking every morning and getting to still melanoma development, as they are of the head and neck, which statistically be here with my family.” not often sunburned: the palms and soles, beneath nails, and on mucous are more aggressive and lethal than those While she credits Gollob and his team membranes. ALM in its early stages elsewhere on the body. When diagnos- for saving her life, she’s also grateful can look similar to a bruise or nail ing melanoma, he recommends a punch to the oncologist who sent her to Duke. streak. “The differences in presentation biopsy or an incision biopsy in the thick- “This disease is too fast, too furious—it’s can make these melanomas more est area of the growth to determine its too big not to be in the hands of some- difficult to recognize by the patient true depth. “A shave biopsy doesn’t give one who can offer you all the options. At and physician and may delay diagnosis,” you the full information.” Duke, all the knowledge is under one warns Grichnik. As early detection is “Pretty much everything else we do roof. There’s hope here.” o critical to survival, this underscores the springs from knowing the depth of inva- need for greater awareness among patients and health care providers alike. sion,” attests Pruitt, “such as whether Learn more about clinical trials at Duke Comprehensive Cancer Center online: cancer.duke.edu/ctrials. D uke M ed 3 9 clinicianQ+A What are the latest approaches to managing high q: blood pressure? a: Duke cardiologist Michael Blazing, MD, responds:

Despite all we know about the adverse health a lack of knowledge about the seriousness of age 55 have a 90 percent lifetime risk of consequences of hypertension, it remains uncontrolled hypertension, a fear of potential developing hypertension, according to data underdiagnosed and inadequately managed side effects associated with treatment, and from the Framingham study.4 in the United States. Many of the estimated limited access to care. Some patients assume 3. Prehypertension begets hypertension, so 65 million Americans with hypertension they will be faced with taking medications think prevention. Lifestyle modification are not aware that they have the disease, that they don’t want to take or can’t afford, should be a part of treatment for all patients and a significant portion of those who are and they don’t want to be bothered with the with hypertension or prehypertension. known to have the problem do not have inconvenience of regular office visits. Consider 4. Use thiazide diuretics, either alone or in their blood pressure under adequate control. how many patients postpone seeing a physi- combination with drugs from other classes, Yet improved diagnosis and control has the cian even when they have alarming symptoms, unless there are compelling reasons to potential to yield huge benefits to society like angina. do otherwise (such as renal disease and with regard to the prevention of cardiovascu- recent myocardial infarction). The results lar disease, especially stroke. The JNC 7 Guidelines of ALLHAT (Antihypertensive and Lipid- What can be done to address this persistent Once the diagnosis is confirmed, the health Lowering Treatment to Prevent Heart Attack problem? The obvious first step is to identify care provider is then faced with manag- Trial), the largest hypertension trial of its the millions of Americans who don’t know ing the condition. Here, there’s guidance kind with more than 42,000 participants they have elevated blood pressure. Screening from the most recent report of the Joint aged 55 and older, provided strong scien- programs sponsored by employers, senior National Committee on Prevention, Detection, tific evidence for this recommendation.5 centers, health departments, civic groups, Evaluation, and Treatment of High Blood 5. Most patients will require two or more and religious organizations are a great way Pressure (JNC 7), published in 2003.1,2 The drugs to achieve goal blood pressure. to make people aware of their blood pres- JNC 7 report offers a classification system that 6. For patients with higher blood pressure sure reading and reinforce the importance of includes changing the term “high-normal” (>20 mmHg systolic or 10 mmHg diastolic periodic evaluation for hypertension. The edu- blood pressure to “prehypertension” because above goal pressure), start therapy with cational message should begin long before the committee felt the former term did not two agents, including a thiazide diuretic. adulthood, however, and given the scope of adequately alert patients to their risk of 7. Work with the patient to build adher- the problem, the problem of hypertension becoming hypertensive (Table 1). The report ence. Build empathy, trust, and motivation should be a recurrent component of health provides a treatment algorithm (Figure 2) by making sure the patient understands education in our school systems. that is also a component of a quick-reference and agrees with the goals of therapy (by Once identified, an affected individual must office card that can be downloaded for free providing current and goal blood pres- be encouraged to seek out a care provider or purchased in a laminated form.3 sure readings verbally and in writing) and to confirm the diagnosis—and an elevated The JNC 7 also listed seven key points for removing barriers to care whenever pos- blood pressure reading taken in the mall is clinicians: sible (such as the cost of medications and often not enough impetus. The benefits of 1. After age 50, systolic blood pressure > 140 the complexity of care). treating hypertension are well established, is a much more important risk factor for and especially the benefits with regard to cardiovascular disease (CVD) than elevated Another key point worth adding to the long-term stroke risk reduction. Some of the diastolic pressure. list is to treat the disease aggressively when reasons why people don’t seek out medical 2. Most older patients will become hyperten- the blood pressure readings indicate that attention include the absence of symptoms, sive; even people who are normotensive at medication is needed. The old adage “start D uke M ed 4 0 The his move to combination therapy requires therapy combination to move This e omr rsrbn pten f sequen- of pattern prescribing former The 7 commit- 7 JNC the convene to decision The

clinicians to be aware that certain populations populations certain that aware be to clinicians clinical trials since the release of the previous the of release the since trials clinical Table 1. Cardiac Anglo- the is 2003 in available onr clig o udts o h current the to updates for calling country such as the elderly and patients with diabetes diabetes with patients and elderly the as such switching to a different drug when the first the when drug different a to switching olhs ot ao t te diie strat- additive the to favor lost goal—has guidelines in 1997. in guidelines tage 1 hypertension 1 Stage tage 2 hypertension 2 Stage until late 2004 and have some experts in this this in experts some have and 2004 late until or autonomic dysfunction will require addi- require will dysfunction autonomic or egy (and, as noted in #5 above, patients are patients above, #5 in noted as (and, egy one doesn’t lower the blood pressure to to pressure blood the lower doesn’t one tional instruction and monitoring to minimize minimize to monitoring and instruction tional tion strategy that addresses these mechanisms. combina- a from benefit will and disease their the vast majority of patients have essential essential have patients of majority vast the tial monotherapies—trying one drug, then then drug, one monotherapies—trying tial e i 20 t udt te udlns was guidelines the update to 2003 in tee from this long-term study of 19,000 new hypertension observational studies and studies observational hypertension new potential side effectsmedications. side the potential of pathophysiologic mechanisms contributing to contributing mechanisms pathophysiologic patients with hypertension were not available available not were hypertension with patients Category hypertension, it’s likely that they have several several have they that it’s likely hypertension, Health andumanServices. ae i pr o te ulcto o many of publication the on part in based Prehypertension Blood Institute,NationalnstitutesofHealth,U.SDepartment likely to need more than one drug). Althoughdrug).one morethanneed tolikely low and go slow” no longer seems prudent. seems longer no slow” go and low Normal beta-Blocker T Outcomes able 1andFigure 2courtesyNationalHeart,Lung,and BLOOD PRESSURE CLASSIFICATIONPRESSURE BLOOD

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he standard standard he T H he he eart, D A L SH ung, and Bloodandung, eating plan plan eating D DASH. A SH plan plan The Adult Inpatient Cardiology Service at Duke Duke at Service Cardiology Inpatient Adult American diet is already in the food and not and food the in already is diet American caused by this silent disease. silent this by caused lentv mdctos n ls complex less and medications alternative as areas mostfast-food items. cooking.addedtabletheinator adopting lowering from increment additional small a sodium intake, so our emphasis should be on be shouldemphasis our so intake,sodium dosage schedules. We hope that our efforts to University Hospital. University difficult for our patients because about 85 85 about because patients our for difficult even more effective, but this is not possible not is this but effective, more even on these foods in the in foods these on is store grocery the in zone salt-free real only Michael Blazing, MD,is director of the the fresh produce section, and the emphasis the and section, produce fresh the the current government dietary guidelines of guidelines dietary government current the not practical for most patients. most for practical not manage this huge and costly medical problemmedical costly and huge this manage no more than 2,400 mg of sodium a day.a sodium of mg 2,400 than more no without eating special foods and is therefore is and foods special eating without processed foods are especially high in sodium, sodium, in high especially are foods processed whenever possible, choosing less expensive less choosing possible, whenever will help reduce the morbidity and mortality and morbidity the reduce help will percent of the sodium consumed in a typical typical a in consumed sodium the of percent Further lowering salt intake makes makes intake salt lowering Further bloodpressure effect comesfrom educing sodium intake can be especially be can intake sodium Reducing DASH. plan certainly plan DASH I n fact,nabout the C D he bigger The annedand A SH

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I n addition n Meta- - “established plus plus “established T . datlc; n te ls a ite weight little a lost they and diastolic); 3.8 assigned advice-only group was not counseled aoi ad oim nae n exercise. and intake sodium and calorie any treatmentany prescribe.we a 30-minute session with a nutritionist that that nutritionist a with session 30-minute a advice- An intervention. behavioral by assisted a comparable extent (11.1 systolic and 5.5 and systolic (11.1 extent comparable a as increased intake of fruits, vegetables, and and vegetables, fruits, of intake increased as such diet in improvementshealthy made also several lifestyle changes at the same time if if time same the at changes lifestyle several ru as eprecd mrvmns in improvements experienced also group six months. six group and the established plus plus established the and group diastolic). diastolic). undergo the required extensive screening screening extensive required the undergo (three pounds vs. 13 pounds for established established for pounds 13 vs. pounds (three extent as the other groups (6.6 systolic and and systolic (6.6 groups other the as extent on a weekly basis, we can assume they were they assume can we basis, weekly a on only control group got printed materials and materials printed got group control only of the studies. the of g systolic and 6.4 diastolic), and and diastolic), 6.4 and systolic mmHg 10.5 of ny otl cusln atr h first the after counseling monthly only received they though even months, 18 over agt o olw the follow to taught hi srig o fut, eeals dairy vegetables, fruits, of servings their those following the the following those their hypertension status (an average decrease from a health care professional can have on on have can professional care health a from role patient motivation plays in the success of of success the in plays motivation patient role received 20 weekly counseling sessions about about sessions counseling weekly 20 received process. We should never underestimate the underestimate never should We process. and trial clinical this enter to willing were plus plus products, and fat. and products, intervention). ihy oiae idvdas eas they because individuals motivated highly included minimal counseling on making making on counseling minimal included it points out the significant effect that advice that effect significant the out points it increased their physical fitness, and improved and fitness, physical their increased hypertension status of our patients. our of status hypertension blood pressure, although not to the same same the to not although pressure, blood behavioral changes. behavioral lifestyle modification and kept track of their their of track kept and modification lifestyle lifestyle changes alone can improve the the improve can alone changes lifestyle looked at whether individuals could institute institute could individuals whether at looked ot egt rdcd hi sdu intake, sodium their reduced weight, lost o-a diy ad erae itk o fat. of intake decreased and dairy, low-fat hese lifestyle changes were largely sustained largely were changes lifestyle hese The Both the established lifestyle modification modification lifestyle established the Both trsigy hwvr te advice-only the however, Interestingly, D A ra dmntae that demonstrates trial PREMIER SH T 10 and 11 pounds for established established for pounds 11 and he established plus plus established he

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alternatives to our patients? our to alternatives to not afford we can drugs, antihypertensive clinicalresearch at theSarah W.Stedman Laura Svetkey,Laura the of director is MD, Nutrition and Metabolism Center at Duke. at Center Metabolism and Nutrition mhsz tee o-ot side-effect-free low-cost, these emphasize our patients. our time to spend counseling patients. But we we But patients. counseling spend to time Duke Hypertension Center and director of of director and Center Hypertension Duke materials has a real and positive effect on on effect positive and real a has materials healthy- the reinforcing that remember must we often feel like we do not have sufficient have not do we like feel often we patients. ing more than 65 million Americans with with Americans million 65 than more ing lifestyle message verbally and with written written with and verbally message lifestyle 10 1 7 4 3 2 5 9 6 8

references E Appel L JE, Neter M S X, Xin N D S Appel L 2006;144:485-495. 2003;289:2083-2093. 2005;165:1298-1303. Med Intern Arch . 1999;159:285-293. Med. Inter Arch alcohol reductionon blood pressure: a andthe al,for the dash/new_dash.pdf. Guidelines for Americans 2005. Americans for Guidelines Guide to ofweight reduction on bloodpressure: a ofalcohol drinking pattern to risk of et al. et of a randomized trial. randomized a of ondiet, weight, physical fitness,and 2003;42:878-884. Hypertension 2004;44:813-819.Hypertension 2001;38:1112-1117. Hypertension meta-analysisof randomizedcontrolled trials. meta-analysisof randomizedcontrolled trials. risk ofhypertension: resultsthe of pressureblood on modification control: trial ofthe effects ofdietary patterns onblood pressure. www.nhlbi.nih.gov/health/public/heart/hbp/ E E loss inoverweight adults andthe long-term study.population-based a hypertension: healthierus.gov/dietaryguidelines/ D blood pressure control: 18-monthresults lmer P tranges S vetkey LP ffectsof comprehensive lifestylemodification ffectsof dietary patterns onblood pressure. ational H epartment of A oore LL SH n the current health care climate, care health current the In Effectscomprehensiveof lifestyle

e J, FrontiniJ, He C J, J, J, ollaborative D , tam BE, Stam onsidering the cost of treat- of cost the Considering O L C M 1997;336:1117-1124. NEJM epartment ofAgriculture. D , ,Wu D owering Blood eart, L V barzanek E hampagne S oore T A isioniAJ, Qureshi M imons- SH clinical trial. clinical PREMIER H T

, ung,and Blood ealth and C J, D ollaborative ok FJ, et al. et FJ, Kok M orn J orn O G, et al. et MG, R T orton D esearchGroup. Aclinical barzanek E , Ann Intern Med Intern Ann heFramingham CM V M ollmer W P , ,et al. ressurewith D H H uman , arsha V R Effects of ollmer W , et al.Weight esearchGroup. nfluence Influence www. ,et al,for the I nstitute. Your

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Gifts from individuals and organizations are the largest source of non-government support for Duke’s research, education, patient care, and service missions. Here are some recent examples of philanthropic partnerships that will make a difference to human health for generations to come. To learn more about how you can support medical education, research, and patient care at Duke, please call 919-667-2500 or visit development.mc.duke.edu.

Chance and friendship combine to launch Anesthesia DREAM Campaign Five years ago Peter Waweru was a farmer racic anesthesiology at Duke and medical and high-school English and biology director of CARE. Over a series of seafood teacher in Kenya. Today he is a clinical trials purchases, Mrs. Mathew and Waweru specialist in Duke’s Clinical Anesthesiology became friends; on his wife’s recommenda- Research Endeavors (CARE) Program. tion, Mathew invited Waweru to interview Community rallies for Chance played a major role in getting for a research position, and later hired him. Duke Children’s People and organizations across Waweru where he is today, but people-to- In the meantime, Waweru and his North Carolina dialed in to help raise people connections helped him contribute family had found a place to live through $1,004,591—a new record—during to his new community in a powerful way. St. Mark’s Anglican Church, which once the 13th Annual Radiothon for Duke The chain of events started when held services in an old church building Children’s Hospital & Health Center on Waweru, 43, and his wife, Gladwell, won on the property of the former Methodist MIX 101.5 and 99.9 Genuine Country the U.S. State Department-sponsored Retirement Home. A local developer, in February. The Radiothon is one of the Diversity Visa lottery and received perma- Anthony & Co., is now redeveloping the most successful and longest running nent-resident status in the U.S. The lottery Erwin Road property as Lakeview, but until events of its kind. didn’t include housing or employment, but the construction started, the church and the Wawerus planned their move none- the developer decided to sponsor housing theless and the couple arrived in Durham on the property for numerous immigrant brain and other organs during surgery in 2002 with their two young sons. Peter families like the Wawerus. and general anesthesia. began taking night classes toward an An attorney for Anthony & Co. and Waweru introduced the DREAM associate’s degree in clinical research while church member, Jack Markham, introduced campaign director, Elizabeth Perez, to working a day job at the seafood counter Peter Waweru to Bud Doughton, one of Doughton. Soon, Anthony & Co. signed of a local grocery store. the investor-owners and a developer on as the founding sponsor with an initial That’s where he met the wife of Joseph of Lakeview. gift of $100,000 to the DREAM campaign. P. Mathew, MD, division chief of cardiotho- “Jack brought Peter to us at the perfect “It has been our goal since the day we time, since we needed someone on the acquired the [Erwin Road] property to property to handle security, property find ways to serve the community,” says management, and groundskeeping,” says Catherine Miller, president of Anthony & Co. Doughton. Waweru’s initiative and Anthony & He and Waweru forged an immediate Co.’s support will lead to the official Duke friendship. “My wife and I will forever be DREAM campaign kickoff later in 2007, grateful to Bud for his generosity and kind- completing a full circle of community

EL IZ A B ETH ness,” says Waweru. “He is also a good partnership at the personal, academic, and friend and mentor to my two sons, Wilson business levels. T . P ERE Z . and Kelvin.” “Anthony & Co. is about transform- As Waweru became more involved ing communities, and that translates to Peter Waweru (left), a recent immigrant with his work at Duke, he learned about people’s lives,” said Jim Anthony, CEO and from Kenya, connected community the Department of Anesthesiology’s founder. “We are thrilled to be part of the entrepreneur Bud Doughton (right) with plans to launch a fundraising drive, the DREAM to assist with the transformational Duke’s Anesthesiology Department to Duke DREAM (Developing Research mission of improving patients’ quality of help launch a fundraising campaign Excellence in Anesthesia Management) life after anesthesia and surgery.” for research to improve outcomes after Campaign. The campaign will support surgery and anesthesia. anesthesia management research, partic- For more information, visit dreamcampaign. ularly developing methods to protect the duhs.duke.edu. D uke M ed 4 4 DukeMed Giving

Bassett Professorship honors former Duke team doctor a December gathering honor- A few months before his death in March, planned gift from his estate. ing Bassett’s contributions to professor emeritus of orthopedic surgery The lead gift, a $400,000 medicine. Bassett taught some Frank Bassett, MD, learned that his friends planned estate gift, came from 350 orthopedic residents and and colleagues had contributed nearly $1 Doris, N’48, and Richard N. fellows during his time at million to establish the Frank Bassett, MD, Wrenn, T’43, MD’47, HS’47-’54, Duke, including a cohort of Assistant Professorship in Orthopedics. of Charlotte, North Carolina. Dr. fellows from the University Bassett served as head team physician Wrenn is a retired orthopedic of Ioannina, Greece—one of for Duke Athletics for 30 years. He also surgeon who trained at Duke. The comple- whom, Panayotis N. Soucacos, MD, HS’74, contributed to the professorship with a tion of the professorship was announced at attended the gathering.

Mandel gift funds hypertension and atherosclerosis research New fellowship honors Wilfert A commitment of over $2 million Duke pediatric HIV/AIDS researcher and from the Edna and Fred L. Mandel Jr. children’s global health advocate Catherine Foundation will support Duke research Wilfert, MD, was honored in March with on the causes and treatment of ath- the establishment of an endowed fellow- erosclerosis and hypertension, as well ship in pediatric infectious diseases in her as collaboration among scientists at name. Wilfert, a Duke professor emerita Duke and other medical centers. of pediatrics and microbiology, is interna- An initial $750,000 grant has tionally known for her research into the established the Mandel Center for natural history and treatment of AIDS in Pictured from left are Chancellor Dzau; Hypertension and Atherosclerosis at children and her Mandel Foundation trustees Edwin Ruthman, Duke and is renewable for an addi- involvement in Henry Lawrie Jr., and Judith Pieper; and tional two years. Senior Investigator clinical trials to test Thomas Coffman, MD. Awards went to Victor J. Dzau, MD, the effectiveness of James B. Duke Professor of Medicine and chancellor for health affairs; Thomas new anti-HIV medi- Coffman, MD, chief of nephrology; Laura Schanberg, MD, associate professor of cations, particularly pediatrics in rheumatology; and the team of Michelle Winn, MD, assistant professor the use of AZT to of medicine in nephrology, and Paul Rosenberg, MD, assistant professor of medi- block transmis- cine in cardiology. A separate Young Investigator Award went to Thomas Povsic, MD, sion of the AIDS assistant professor of medicine in cardiology, to study the cells that repair damage in virus from mother to baby. Friends and atherosclerosis and their possible use in predicting heart attack and stroke risk. colleagues of Wilfert and her husband, To increase scientific collaboration among scientists at Duke and other research Samuel Katz, MD, chair emeritus of pedi- institutions, the Mandel Center will offer monthly seminars at Duke beginning in atrics, contributed more than $850,000 May 2007, and later an off-campus scientific retreat. toward the endowment fund.

Golfers unite against melanoma Melanoma cut short the career of former professional golfer to raising money for melanoma research,” Michael Muehr, T’94, and now he’s enlisted the help of fellow says Muehr, who played on the PGA Tour golfers to beat the disease. Muehr and the organization he leads, and in the U.S. Open during his nine-year Golf Pros Beating Cancer, have given $175,000 in proceeds from career. “The response I have received the first and second annual Capital City Pro Am, held in the from all those who support our events has Washington, D.C. area, to fund a melanoma clinical trial at Duke. elevated this effort well beyond my own The clinical trial, led by Doug Tyler, MD, professor of surgery, expectations and dreams.” and Scott Pruitt, MD, associate professor of surgery, with Hilliard Proceeds from the third annual Capital Siegler, MD, professor of surgery, as advisor, will test a potential City Pro Am, September 9-10, 2007, at immunotherapy vaccine. Lowes Island Club in Potomac Falls, Virginia, will also fund mela- “I enjoy an overwhelming feeling of gratification when it comes noma research at Duke. D uke M ed 4 5 DukeMed appointments

New leadership structure for School of Medicine In a move to position Duke Medicine for continued growth and president and CEO of the Duke University Health System. academic success, R. Sanders Williams, MD, the current dean “The scale and complexity of the academic, research, and of the Duke University School of Medicine, has been appointed clinical care missions of the school have quickly grown to a to the newly created position of senior vice chancel- point that they now demand a greater breadth and intensity lor for academic affairs. of high-level leadership,” Dzau says. “This new leadership Williams will continue to serve as dean of the framework will facilitate greater strategic effectiveness for the medical school until a new dean has been identified School of Medicine and will distribute leadership responsibilities, through a search process now under way. Williams allowing a higher degree of focus by the deans and the senior will also retain his title as dean of the Duke/National vice chancellor.” University of Singapore Graduate Medical School Over the past six years under Williams’s leadership, Duke’s (GMS) through the completion of the 2007-08 aca- School of Medicine has experienced significant growth, includ- demic year. Both the new dean of the Duke School of Medicine ing an annual budget that now exceeds $800 million, a near and the new dean of the GMS will report directly to Williams. doubling of research funding from the National Institutes of In his new role, Williams will have primary responsibility Health to almost $350 million, the construction of five new for academic success across the entities that comprise Duke research buildings, the creation of the GMS in Singapore, the Medicine, enhancing collaboration between the Duke University development of several new national and international research School of Medicine and the GMS in Singapore. He will also institutes, and an increase of several hundred new faculty. lead the implementation of the strategic plans for the schools “I am excited about the opportunities presented by this new of medicine, working closely with the medical school deans as role and believe strongly that the addition of a new senior a team, and lead the Duke University School of Medicine’s phil- leader in the role of dean of the Duke University School of anthropic and fundraising efforts. Williams will report directly Medicine will greatly increase our strategic effectiveness,” to Victor J. Dzau, MD, chancellor for health affairs at Duke and Williams says.

McKinney to direct Trent Center Executive vice dean for GMS Singapore After five years as vice dean for research with the Duke University School of Ranga Krishnan, MD, has been appointed executive Medicine, Ross McKinney, MD, has vice dean for the Duke-National University Singapore accepted the role of director of the Trent Graduate Medical School (GMS), effective July 1, 2007. Center for Bioethics, Humanities, and In this role, Krishnan will work closely with R. Sanders History of Medicine. Williams, MD, senior vice chancellor for academic In his new role, McKinney will report affairs and GMS dean, with full administrative, opera- to the dean of the medical school, and tional, and educational decision-making authority for will continue to provide administrative the GMS subject to Williams’s oversight as dean. leadership and oversight to the Conflict Krishnan will continue to serve concomitantly as chair of Duke’s of Interest committee. In addition, Department of Psychiatry, working with a team of three vice chairs— McKinney will continue Marvin Swartz, MD, clinical affairs, Richard Surwit, PhD, research, and to be a major contribu- Dan Blazer, MD, PhD, education—to continue to provide the exemplary tor to the new Duke leadership that has been characteristic of his tenure as chair, Williams said Translational Medicine in announcing the appointment. Institute initiative. “Dr. Krishnan’s deep familiarity with the region and GMS, as well as his track record of successful leadership, made him an ideal choice to take on this responsibility,” Williams said. “I am confident that he is fully capable of succeeding in both of these important roles.” D uke M ed 4 6 Cohen named chair of medicine Harvey Jay Cohen, MD, has been named chair of Duke’s and served as division chief until becoming chair of medicine. Department of Medicine by R. Sanders Williams, MD, senior He was also the architect of Duke’s fellowship program in vice chancellor for academic affairs. The appointment in March geriatric medicine. He is a professor of medicine and director of follows Cohen’s service as the department’s interim Duke’s Center for the Study of Aging and Human Development. chair beginning February 2006. “I have been at Duke for many years and have worn several “Harvey brings the right combination of achieve- hats in my career. I am honored to be able to continue serving ment, leadership experience, communication skills, Duke in this position of such great tradition and importance,” and sound judgment to this important position,” says Cohen. Williams says. “During his period of interim service, Duke’s program in internal medicine has been consis- he has earned the respect of faculty and senior lead- tently recognized as one of the best in the nation in National ership of Duke Medicine alike.” Institutes of Health funding. Under Cohen’s leadership, Duke’s Cohen previously served as the Department of Medicine’s vice program in geriatric medicine was ranked fourth in the nation chair for faculty development and academic affairs. He helped in the U.S.News & World Report 2006 rankings. to establish Duke’s Division of Geriatric Medicine in the 1970s

New leaders in cardiovascular medicine Benfey to lead new Duke’s Department of Medicine in May systems biology center announced the formation of a new leader- The Duke Institute for Genome Sciences & Policy ship team for the Division of Cardiovascular (IGSP) in March announced the establishment of Medicine. Howard Rockman, MD, was the IGSP Center for Systems Biology. named division chief, and Chris O’Connor, Philip Benfey, PhD, Paul Kramer Professor and MD, was named director of the Duke current chair of the Department of Biology, has Heart Center. been appointed director of the center. Benfey will “Dr. Rockman is an outstanding clinician Rockman O’Connor step down as department chair effective June 30. and basic scientist who has done ground- Systems biology is a relatively new field that breaking work to enhance our understanding of the molecular pathogenesis of uses the massive amounts of data produced by heart failure,” said Harvey Cohen, MD, chair of medicine, in announcing the automated and computerized laboratory equip- appointments. “Dr. O’Connor is a highly regarded clinician and clinical researcher ment to look for large patterns and networks who has played a leading role in the development of our heart failure service and among the molecular components of individual patient-oriented research in cardiology. I am confident that this team can work cells. The IGSP Center for Systems Biology has the with our faculty to enhance our academic success, while forging effective and primary goal of nurturing interactions between productive relationships with the Health System.” experimental scientists and theorists with a Rockman succeeds Pamela Douglas, MD, who is stepping down to join the common interest in Duke Clinical Research Institute (DCRI). As division chief, Douglas ably repre- biological systems. sented Duke on the international scene as president of the American College of “Under Philip’s Cardiology, and oversaw an outstanding group of faculty and fellows, said Cohen. leadership, the new Also in May, Rockman named Thomas Bashore, MD, as division vice chief; Bashore center will build on will play a vital role in cardiovascular medicine education and clinical programs. the growing use of genome-level data Benfey to describe and Network Services appointments understand the complex interactions among the full set of gene products in cells of many organ- Duke cardiologist Harry Phillips III, MD, has been appointed as chief medical isms, from yeast to plants to mammals,” says officer of Duke University Health System (DUHS) Network Services. In this role, IGSP Director Huntington Willard, PhD. “This new Phillips will work closely with both affiliate communities and clinical leadership at center nicely complements the other IGSP centers Duke to strengthen clinical care delivery across the region. In and further strengthens our interdisciplinary ties addition, Paul Lindia was named associate vice president across campus.” of Network Services, succeeding Malcolm Isley, who will join Greenville Hospital System in South Carolina. The appointments were announced in May by Molly K. O’Neill, DUHS chief strategic planning officer.

Phillips D uke M ed 4 7 n n n

8 4 , professor of medicine and and medicine of professor MD, Noble, Paul cell of Terryprofessor assistant Lechler, PhD, PhD, Guilak, Farshid Investing in the future of science of future the in Investing chief of pulmonary medicine, whose research whose medicine, pulmonary of chief divisions asymmetric that and asymmetrically caused by osteoarthritis. by caused chronicinflammation.lung studying ways to slow cartilage breakdown breakdown cartilage slow to ways studying goes awry.goes damaged joints, Guilak’s research blends bio- Guilak’sblends researchjoints, damaged a creating to cells fat from cartilage growing epithelial cells. cells. epithelial to form a protective barrier. protective a form to that skin cells can divide either symmetrically or that regulate chronic lung inflammation and inflammation lung chronic regulate that fibrosis. fibrosis. mechanisms the understanding on focuses functional orthopedic surgery. Guilak is also also is Guilak surgery. orthopedic functional repairing in assist can that “scaffold” fabric From engineering. biomedical of fessor role of the extra-cellular matrix in regulating in matrix extra-cellular the of role layers cell multiple of formation promote medical engineering and a keen interest in in interest keen a and engineering medical oesr of Professor its shape and what happens when the shape the when happens what and shape its investigatinghow cell’sa function depends on biology, who studies the morphogenesis of morphogenesis the studies who biology, who appear poised to make the next big step forwardresearchstep their big in next careers.the their make and to poised appear who people, places, and programs. the of part as conceived was program n February the February In ictured are five of the six the of five arePictured Farshid Guilak, Farshid

DukeMed groupfirst The of I n particular, he has focused on the the on focused has he particular, n PhD, Orthopedic L chool of School echler’s research has shown shown has research echler’s ob Wechsler-Rob Reya, cholars includes: Scholars Duke edicine announced its inaugural six inaugural its announced Medicine L rey n pro- and Surgery Med aszlo The awards provide additional financial support to faculty members echler is also is Lechler cholars: (from left) (from Scholars: O , and PhD, rmandy Awards chool of School T annishtha n n n

assat profes- assistant MD, Winn, P. Michelle PhD Wechsler-Reya, Rob professor assistant PhD, TannishthaReya, Genetics, whose current research interest is interest research current whose Genetics, cell renewal may allow the development of development the allow may renewal cell common malignant brain tumor in children. in tumor brain malignant common approaches to enhance regeneration and thus r amd t eeoig e mdl for models new developing at aimed are signals that control development of the the of development control that signals sor in nephrology and the and nephrology in sor cells. stem hematopoietic studies ), a kidney disorder. Although most disorder.Although kidney a (FSG), sis eei o mdlolsoa te most the the and medulloblastoma, of genesis cerebellum the of development up to 20 percent of patients on dialysis. percenton 20 patients to of up effectivetreatment strategies. important genes identified and stages early of pharmacology and cancer biology, who who biology, cancer and pharmacology of familial focal and segmental glomerulosclero- segmental and focal familial formation. tumor for nderstanding the normal regulation of stem stem of regulation normal the Understanding more common sporadic disease, which affects which disease, sporadic common more medulloblastoma and identifying more more identifying and medulloblastoma rfso o pamclg ad cancer and pharmacology of professor do not have a family family a have not do FSG by affected people tumor’sthe on light shed has research His netgtos ol se lgt n the on light shed could investigations hematopoietic system and its effectsits and system hematopoietic cancer.in increase prevention and treatment for the the for treatment and prevention increase therapies.for implications have itr o kde dsae Wn hps to hopes Winn disease, kidney of history biology, whose research centers on the the on centers research whose biology, T edicine’s strategic plan, which focuses on focuses which plan, Medicine’sstrategic erry Reya, Lechler, PhD. & PhD, ot pictured: Not H Duke Michelle onors Med P . Winn, Winn, . Paul gig studies Ongoing Scholars. enter for Center Noble, MD, assistant , MD.

he new The uman Human Her America’s prize top This article is excerpted from a profile a from excerpted is article This in medicine in L Albany Albany Albany S of Lefkowitz published in published Lefkowitz of ooay er dsae schizophrenia, disease, heart coronary century, andhe’s notthrough yet,”saysR. and sensitizers, insulin contraceptives, including ailments, and Biomedical Biomedical and career,$500,000sharingone-thirdthe of niersat, srgn, androgens, estrogens, antidepressants, effective more and added another trophy to the extensive extensive the to trophy another added dukemedmag.duke.edu. sis, asthma, arthritis, and diabetes. diabetes. and arthritis, asthma, sis, sensory inputs like sight, taste, and smell. smell. and taste, sight, like inputs sensory environ- surrounding their from signals eeain f safer of generation obesity pills. obesity of to understanding of elusive chemical chemical elusive of understanding to the “fight or flight” response and most and response flight” or “fight the for a wide variety of variety wide a for ht nprd new a inspired that for a lifetime of work work of lifetime a for n April 26, April On University eetr hv bcm te agt of target the become have receptors cells. of surface the on receptors ment, an essential function that mediates mediates that function essential an ment, prescription drugs drugs prescription prize in medicine. in prize pioneering work on how cells receive receive cells how on work pioneering vice chancellor for academic affairs, and a Hopkins with protégéof . To read the full article visit article full the read To Medicine. Evans, key to all of this was his researchleadinghis was this of all to key Biological honors he has collected over his 35-year his over collected has he honors I breast and ovarian cancer, atherosclerocancer,- ovarian and breast beta blockers, cortisone, antihistamines, cortisone, blockers, beta nstitute investigator, shared the prize prize the shared investigator, nstitute anders Williams, Williams, anders “Bob’s one of the great scientists of the scientistsgreatof“Bob’s the of one efkowitz receives T H efkowitz, the James B. James the Lefkowitz, M hey will each receive one-third of the the of one-third receive each will hey e was recognized edicineand Solomon M rize’s $500,000 award for their for award Prize’s$500,000 of PhD, chool of School edical edical tudies. Studies. chool of School Lefkowitz’s. Robert J. Lefkowitz, MD, Lefkowitz, J. Robert R C Snyder, H esearch—America’s top esearch—America’stop The enter enter MD oward edicine, and Medicine, edicine and senior and Medicine , dean of the of dean , Salk P rize in in rize H o Johns of MD, Duke ughes INSIDE siue for Institute M Professor M edicine edicine Ronald T edical Duke D hese hese T uke he he dukemed people

Darell Bigner, MD, PhD Pamela Edwards, EdD, RN Larry B. Goldstein, MD Robert Jennings, MD

Darell Bigner, MD, PhD, was nursing fulfill the goals of Sigma receive the Hartwell fellowship. care. He is the immediate past recently awarded the Tug Theta Tau and exemplify nursing The Duke research award chair of the American Stroke McGraw Researcher of the Year leadership qualities. winners are: Guopeng Feng, Association and president-elect of Award from the Tug McGraw PhD, of the Department of the AHA Mid-Atlantic Affiliate. Foundation for his outstanding Michael Ehlers, MD, PhD, asso- Neurobiology, for his work to leadership in the field of brain ciate professor and Wakeman identify the genes involved in Robert Jennings, MD, James tumor research. Scholar in the Department of obsessive-compulsive disorder; B. Duke Professor of Pathology, Bigner is the Edwin L. Jones Neurobiology and Howard and Jingdong Tian, PhD, of has received the 2007 Gold- Jr. and Lucille Finch Jones Cancer Hughes Medical Institute inves- the Department of Biomedical Headed Cane Award, the highest Research Professor and the direc- tigator, received the 2007 John Engineering, Pratt School of honor of the American Society tor of the Preston Robert Tisch J. Abel Award. The award, spon- Engineering, and the Institute of Investigative Pathology (ASIP), Brain Tumor Center at Duke. The sored by Eli Lilly & Co., is given for Genome Sciences & Policy, which recognizes long-term con- Tug McGraw Foundation, named to a single young investigator for for new technologies and tributions to pathology. in memory of the baseball legend, outstanding research contribu- methods to develop optimized Jennings’s contributions in raises funds to support brain tions in pharmacology. Ehlers’s quick-response DNA vaccines for renal disease and cardiovascu- cancer research and seeks to research focuses on brain plas- infectious diseases. lar research span over 50 years. increase awareness of the disease. ticity and specifically on the Nancie Jo MacIver, MD, “He is the ‘founding father’ of In 2004 a grant from the founda- cell biological basis of neural PhD, an endocrinologist in the modern ischemic biology,” tion supported the creation of the plasticity. He received the award Department of Pediatrics, was said Roberto Bolli, MD, of the Tug McGraw Center for Neuro- April 28 at the annual meeting selected to receive the fellowship University of Louisville Health Oncology Quality of Life Research of the American Society for for her work on the hormone Science Center. “More than at Duke. Pharmacology and Experimental leptin, which may help prevent anyone else, Dr. Jennings must Therapeutics/Experimental Biology. infection in children with be credited with crafting the Pamela Edwards, EdD, RN, suppressed immune systems conceptual, pathophysiological, received the 2006 Juanita Long The Hartwell Foundation has caused by malnutrition in infancy and preclinical framework that Award of the Beta Epsilon (Duke selected two Duke researchers or in utero. enabled the development of School of Nursing) chapter of to receive its inaugural Hartwell thrombolysis, percutaneous coro- Sigma Theta Tau in December. Individual Biomedical Research Larry B. Goldstein, MD, pro- nary angioplasty, and other forms Edwards is an associate consult- Awards for 2006. fessor of medicine in neurology, of therapeutic recanalization ing professor and director of the The awards provide support has received the American Heart in patients with acute myocar- Nursing Education Program at to individual researchers at eli- Association (AHA) 2007 Award of dial infarction—one of the most the Duke University School of gible research facilities across Meritorious Achievement for his spectacular triumphs of modern Nursing, serves as deputy direc- the country for three years at work on stroke-related initiatives. clinical cardiology.” tor of the Duke AHEC program, $100,000 per year. Duke was Goldstein, director of the Duke Jennings received the Gold- and is the associate chief nursing one of nine qualifying institu- Center for Cerebrovascular Headed Cane, a mahogany cane officer for education at DUHS. tions and one of three to receive Disease and the Duke Stroke topped with a 14-karat-gold head Since 2004, Sigma Theta Tau two individual research awards. Center, also chairs AHA’s Stroke and engraved band, at the ASIP has presented the Juanita Long Each participating institution also Council, a body charged with annual meeting on April 29. Award each year to an outstand- received funding for a postdoc- developing scientific policy and ing nurse whose contributions to toral candidate of its choice to advancing the science of stroke D uke M ed 4 9 Awards&Honors

chromatographic separation and allowing efficient diagnosis of inherited metabolic diseases with very small quantities of blood. “Tandem mass spectrometry revo- lutionized newborn screening and is now commonplace around the country, and it is wonderful to see David honored for his Pictured from left are the medical school’s 2007 faculty award winners: L. Scott Levin, MD, John D. York, PhD, Robert P. work in this area,” says pediatrics Drucker, MD, William St. Clair, MD, Emma (Mimi) Jakoi, PhD, and Mohamed Noor, PhD. Not pictured: Neil Prose, MD. chair Joseph St. Geme III, MD.

The following awards were presented at the annual School of Medicine faculty meeting in May: Raphael H. Valdivia, PhD, assistant professor of molecular n Leonard Tow Humanism in n Ruth and A. Morris Williams Jr. n Master Clinician/Teacher Medicine Award: Neil Prose, Faculty Research Prize: John D. Awards: L. Scott Levin, MD, genetics and microbiology, was MD, professor of medicine York, PhD, associate profes- professor of surgery and chief selected as one of two recipi- and pediatrics sor of pharmacology & cancer of plastic and reconstructive ents of the American Society for biology and of biochemistry surgery; William St. Clair, MD, n Leonard Palumbo Jr., MD, Microbiology Merck Irving S. Sigal professor of medicine and Faculty Achievement Award: n Gordon G. Hammes Faculty Memorial Award. immunology; Emma (Mimi) Robert P. Drucker, MD, asso- Teaching Award: Mohamed The award recognizes excel- Jakoi, PhD, associate research ciate professor of pediatrics Noor, PhD, associate profes- lence in basic research in medical sor of biology professor of cell biology. microbiology and infectious disease by a young investigator. Valdivia was honored for his Vance Fowler, MD, and Eric Samuel Katz, MD, Wilburt Judith Kramer, MD, an associ- established record of creative Peterson, MD, of the Duke Cornell Davison Professor and ate professor of medicine and and independent research in the Clinical Research Institute and chairman emeritus of pediatrics, member of the Duke Clinical area of molecular and cellular Jeremy Rich, MD, of the Division has been awarded the 2007 Research Institute, has recently microbiology. of Neurology were recently Pollin Prize. been invited to serve as a member elected to the American Society The prize, which honors one on the Drug Safety and Risk Seven Duke Medicine faculty for Clinical Investigation, an person annually for contributions Management (DSaRM) Advisory members were awarded Duke honor society of physician-scien- to pediatric research and to rec- Committee of the U.S. Food and University distinguished profes- tists who translate findings in the ognize outstanding achievement Drug Administration (FDA). The sorships in April. They are:

laboratory to the advancement in biomedical and public health appointment runs through May n Ann Marie Pendergast, of clinical practice. The society research that improves child 2010. The DSaRM committee is PhD, James B. Duke Professor elects up to 80 new members health, is the largest international charged with advising the FDA of Pharmacology & Cancer each year for significant research award of its kind monetarily. commissioner on risk manage- Biology accomplishments. Katz was selected for his ment, risk communication, and n Joseph St. Geme III, MD, role in the development of the quantitative evaluation of sponta- James B. Duke Professor of Pediatrics Barton F. Haynes, MD, Frederic measles vaccine and for his neous reports of adverse events. M. Hanes Professor of Medicine work to eradicate the disease n Harvey Cohen, MD, Walter Kempner Professor of Medicine and director of the Duke Human in resource-poor nations. Katz David Millington, PhD, pro- Vaccine Institute, was elected to receives $100,000, along with fessor of pediatrics in medical n Ramon Esclamado, MD, Richard Hall Chaney, Sr. the American Academy of Arts an additional $100,000 to genetics, received the 2006 Professor of Surgery and Sciences in April. Fellows award as a fellowship stipend to Guthrie Award, which honors n Diane Holditch-Davis, PhD, are selected through a highly a young investigator working in an individual for achievement RN, Marcus Hobbs Professor competitive process that recog- a related area. Katz has selected in the field of neonatal screen- of Nursing nizes individuals who have made Michael Anthony Moody, MD, ing. In the 1980s, Millington n Danny Jacobs, MD, David C. preeminent contributions to their of Duke’s Division of Pediatric pioneered the use of tandem Sabiston, Jr. Professor of Surgery disciplines and to society at large. Infectious Diseases. mass spectrometry to detect n Salvatore Pizzo, MD, PhD, specific substances in blood Distinguished Professor of samples, eliminating the need for Pathology D uke M ed 5 0 new physicians

DUKE UNIVERSITY MEDICINE OB/GYN AFFILIATED PHYSICIANS

Richard J. Schneider, MD Deverick J. Anderson, MD Anthony G. Visco, MD Dana M. Blumberg, MD Peter H. Michelson, MD Daniel S. Wechsler, Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests Particular Clinical Interests MD, PhD and Skills: General adult and Skills: Multi-drug- and Skills: Robotic sacro- and Skills: Diagnosis and and Skills: All pediatric Chief, Division of Pediatric medicine, integrative resistant organisms, colpopexy, robotic hyster- treatment of glaucoma, lung diseases, cystic fibro- Hematology-Oncology medicine hospital epidemiology, ectomy, slings and other medical and surgical glau- sis, asthma, obesity, exer- Particular Clinical Faculty Rank: Consulting infection control, hospital- minimally invasive surgeries coma management cise, and airway anomalies Interests and Skills: Associate acquired infections for the surgical treatment Faculty Rank: Assistant Faculty Rank: Assistant Pediatric leukemia and Division: Harps Mill Internal including catheter-related of pelvic organ prolapse Professor Professor lymphoma, neuroblastoma, Medicine bloodstream infections and and urinary incontinence, Division: Glaucoma Service Division: Pulmonary histiocytosis MD Degree: Wayne State surgical site infections vesicovaginal fistula, uro- MD Degree: St. Louis Medicine Faculty Rank: Associate University School of Faculty Rank: Clinical dynamics University School of MD Degree: Jefferson Professor Medicine, Michigan Associate Division: Urogynecology Medicine, Missouri, 2000 Medical College, Division: Hematology- Residency: Internal Division: Infectious MD Degree: State Residency: Ophthalmology, Pennsylvania, 1983 Oncology Medicine, Providence Diseases and International University of New York in Case Western Reserve, Residency: St. Christopher’s MD Degree: MDCM, Hospital, Michigan, Health Syracuse, 1993 Ohio, 2001-2004 Hospital for Children, McGill University, Montreal, 1976-1979 MD Degree: Duke Residency: University of Fellowship: Glaucoma, Pennsylvania, 1986 1987 University School of Rochester, New York, 1997 Wilmer Eye Institute, Fellowship: UNC Hospitals, Residency: Pediatrics, Medicine, 2001 Fellowship: Urogynecology Maryland, 2004-2005 Pediatric Pulmonology, Johns Hopkins Hospital, Residency: Internal and Reconstructive Pelvic 1995 Maryland, 1987-1990 Medicine, Duke University Surgery, Duke University Other: MS, Clinical Fellowship: Pediatric Medical Center, Medical Center, 2000 Research, University of Hematology-Oncology, 2001-2004 PEDIATRICS Pittsburgh, 2007 Johns Hopkins Hospital, Fellowship: Infectious Maryland, 1990-1994 Diseases, Duke University Other: PhD, Physiology, Medical Center, OPHTHALMOLOGY McGill University, Montreal, 2004-2006 1987 Ananya B. Sen, MD Other: MPH, Epidemiology, Particular Clinical Interests University of North and Skills: Women’s health, Carolina at Chapel Hill, pediatrics, preventive 2007 medicine from newborn to adolescents to geriatrics Faculty Rank: Consulting Kathleen A. McGann, MD Vandana Nayal, MD Associate Particular Clinical Interests Particular Clinical Interests Division: Butner-Creedmoor and Skills: Pediatric infec- and Skills: High risk neo- Family Medicine M. Tariq Bhatti, MD tious diseases, human nates, neurodevelopmental MD Degree: Calcutta Particular Clinical Interests immunodeficiency virus follow-up, neuroprotec- Stephanie B. Wechsler, MD National Medical College, and Skills: Clinically ori- (HIV) infection, pediatric tion, neonatal resuscitation Particular Clinical Interests India, 1988 ented research interests in education, general pedi- Faculty Rank: Clinical and Skills: Congenital heart Residency: Pediatrics, optic neuritis and multiple atrics Associate disease occurring as part Vivekananda Institute of Laurie D. Snyder, MD sclerosis, giant cell arteritis, Faculty Rank: Professor Division: Neonatal-Perinatal of genetic syndromes, as Medical Sciences Particular Clinical Interests the ophthalmic complica- Division: Infectious Medicine well as other cardiovascu- Internal Medicine/ and Skills: Lung transplant, tions of endoscopic sinus Diseases MD Degree: MBBS, lar diseases with a genetic Pediatrics, MetroHealth immune mechanisms of surgery and orbital syn- MD Degree: University of Chengalpattu Medical cause including cardiomy- Medical Center, Cleveland, transplant rejection, gen- dromes Pennsylvania School of College, India, 1989 opathies and connective Ohio, 1998-1999 eral pulmonary medicine Faculty Rank: Associate Medicine, 1985 DCH, Government Medical tissue diseases such as Family Practice, 2001 Faculty Rank: Associate Professor Residency: Pediatrics, College, Nagpur, India, Marfan syndrome Division: Pulmonary, Division: Neuro-ophthal- Children’s Memorial 1993 Faculty Rank: Associate Allergy, and Critical Care mology Services Hospital, Northwestern Residency: Pediatrics, New Clinical Professor MD Degree: Duke MD Degree: New York University, Illinois, 1985- York Methodist Hospital, Division: Cardiology University School of Medical College, 1993 1889 2000-2003 MD Degree: University Medicine, 2000 Residency: Ophthalmology, Fellowship: Pediatric Fellowship: Neonatal- of Texas Medical School, Residency: Internal University of Florida, 1994- Infectious Diseases, Perinatal Medicine, Oregon 1987 Medicine, University of 1997 Children’s Hospital of Health and Sciences Residency: Pediatrics, California, San Francisco, Fellowship: Neuro-ophthal- Philadelphia, Pennsylvania, University, 2003-2006 Johns Hopkins Hospital, 2000-2003 mology, Emory University, 1989-1992 Maryland, 1990 Fellowship: Pulmonary and Georgia, 1997-1998 Fellowship: Pediatric Critical Care Medicine, Orbital Disease and Cardiology, Children’s Lung Transplant, Duke Surgery, Allegheny General Hospital, Massachusetts, University Medical Center, Hospital, Pennsylvania, 1994 2003-2006 2004-2005 Medical Genetics, University of Michigan, 2003 D uke M ed To make an appointment with a Duke physician, call 1-888-ASK-DUKE (275-3853). Physicians call 1-800-MED-DUKE (633-3853) 5 1 2 5 DukeMed Califf ound in translation: in Found directornew the of applications that improve human health. human improve that applications other research universities have always done. But done. always have researchuniversities other over five years to establish the establish to years five over the often-sluggish processspeed. often-sluggish warp the into t fall, the fall, Last institutions nationwide, the nationwide, institutions And how will this affect the health of our our affectof this health will the how And cal trials that prove something is effective to to effective is something prove that trials cal approach to moving from discovery to tech- to discovery from moving to approach second block comes in deploying a proven proven a deploying in comes block second eeae truh esnl uist about curiosity personal through generated going to work with the community of community the with work to going endeavor. different whole a is useful something into ery er with the residents of residents the with er technology so that it actually improves people’simproves actually it that so technology translational medicine process. medicine translational countries. other many in people of that than tory research—we can improve the health of health the improve can research—we tory participa- through but do, to what them telling county.our of status health the improve to years. 25 and 10 between is it deploying fully U Why do we need these new translational translational new these need we do Why nology to clinical tests to deployment. to tests clinical to nology intervention. behavioral or device, nostic people than failuremortality,heart and stroke, year into the into year We have made a bold statement: that we are we that statement: bold a made have We people who live here.live who people where medicine institutes? institutes? medicine patients—say,herethose Durham? in how nature works. But translating that discov- that translating But works. nature how health. diag- drug, new technology—a testable a into discovery laboratory a turning in inefficiency in For example, For best with a genius in the lab pursuing ideas pursuing lab the in genius a with best big bet we are making is that if we work togeth- live as long and have higher rates of infant of rates higher have and long as live . S T Cuba. We know that discovery science happens science discovery that know We . taxpayers are paying almost $30 billion a billion $30 almost paying are taxpayers . hat’s due in part to two big blocks in the the in blocks big two to part in due hat’s comes in. comes DTMI R ight now the average time from clini from time average the now ight T o do that, you need an organized organized an need you that, do o Durham , but our health is no better no is health our but NIH, of stitute In National County’sdon’t residents Durham Duke is charged with moving scientific discoveries into practical into discoveries scientific moving with charged is DTMI Duke he first is our is first The T County—not ranslational T ranslational urham Durham n the surface, that sounds like something like sounds that surface, the On That’s

A chat with chat A T he The he he - Threequestions Health Robert Medicine T This institute is a huge effort.huge a What is institute This County, whether they are in the at the most reasonable costs. We believe, for believe, We costs. reasonable most the at etaie, rjc-retd tutr for structure project-oriented centralized, administration, we raise the transactional cost, transactional the raise we administration, We world. academic the in science applied can be done, and it can make a difference to to difference a make can it and done, be can the lower to ways found and trials clinical done. example, that within five years, we could see could we years, five within that example, often talk about “transactional cost”—the cost”—the “transactional about talk often treatments for individuals and neighborhoods and individuals for treatments in everyone to records health tronic tions, lowering stroke rates. But we need to to need we But rates. stroke lowering tions, about it? about doyou see asthe greatest challenge the world. world. the and nation, our community, our of health the health. improve could we that transactionalincreaseandcost collaboration so For more information, visit information, more For not. noticeable improvements in health—reducing in improvements noticeable measure of energy it takes to get something something get to takes it energy of measure work with the community to determine how determine to community the with work eerh etr n h nto ad il e a be will and nation the in center research we have failed. have we infant mortality, preventing diabetes complica- diabetes mortality,preventing infant in the the in is recognized as the best academic clinical clinical academic best the as recognized is key part of the the of part key best to do this. do to best Medicine he challenge is to successfully create a more more a create successfully to is challenge he O We have a great model of how to do this do to how of model great a have We ne of our ideas is to offer personal elec- personal offer to is ideas our of ne Then we can see trends and target the best Califf, I D f, in adding this new layer of effort and effort of layer new this adding in f, Robert ) granted (NIH) uke uke nstitute (DTMI). Institute Institute , believes the believes MD, C linical linical f we lower it, we will succeed. will we it, lower we If DTMI Califf, R . We took decentralized decentralized took We . esearch esearch uke $52.7 million $52.7 Duke , MD, ne of 12 such 12 of One dtmi.duke.edu. will spur spur will DTMI I nstitute, which which nstitute, Duke system or o we know it know we So

uke and and Duke Durham

continuing medical education AT DUKE For more information on the courses listed below, please contact the Duke Office of Continuing Medical Education at 919-401-1200 or visit cme.mc.duke.edu. duke CME Calendar COURSE DATE LOCATION CREDIt reGISTRATION

ANESTHESIOLOGY 2nd Annual Chronic Pain Management September 29, 2007 Searle Center 4.5 credits 919-668-2386 Fall Symposium for Primary Care Durham, NC

Anesthesia Camp IV Laguna Beach October 3-6, 2007 montage Resort & Spa 18 credits 1-888-286-5815 Laguna Beach, CA 4th Annual Ultrasound Symposium: October 12, 2007 the W Hotel 7 credits [email protected] Ultrasound for Every Anesthesiologist San Francisco, CA Anesthesia Camp Costa Rica October 24-27, 2007 four Seasons Resort 15.5 credits 1-888-286-5815 Guanacaste, Costa Rica

INTERNAL MEDICINE 23rd Annual Internal Medicine Symposium July 30-August 3, 2007 hilton Head Island, SC 25 credits 919-668-5947

ONCOLOGY S i te ON Oncology Highlights 2007: Updates from ASCO July 13, 2007 Durham, NC 6 credits 919-419-5506 8th Annual Hampton Roads October 20, 2007 virginia Beach, VA 6.5 credits 919-419-5506 Oncology Educational Conference

OPHTHALMOLOGY Duke Dinner Series September 17, 2007 Durham, NC 2 credits 919-684-6593

RADIOLOGY MRI at the Workstation August 11-12, 2007 ritz Carlton 11.25 credits 919-684-7228 Washington, D.C. MRI at the Workstation October 6-7, 2007 ritz Carlton 11.25 credits 919-684-7228 Chicago, IL A Practical Approach to Musculoskeletal MRI october 13-16, 2007 las Vegas, NV 20 credits 919-684-7228 Musculoskeletal MRI & Neuroimaging October 20-23, 2007 the Grove Park Inn 20 credits 919-684-7228 Resort & Spa, Asheville, NC

UROLOGY Duke Tuesday in Urology July 17, 2007 Durham, NC 5 credits 919-684-2033

COURSE DATE CREDIt reGISTRATION

RESEARCH ETHICS Social Sciences Research in Medical Settings Protecting the Confidentiality and Privacy of Patients Protecting Research Subjects All Research Ethics courses up to 1 credit for more information or to register, visit:

What Counts as Research with Human Subjects are available through researchethics.duhs.duke.edu on L I NE Children Involved as Subjects in Research December 31, 2008 Ethical and Regulatory Considerations When Bringing a Medication to Market Informed Consent for Research Research in Emergency Settings Using Databases in Research Adolescent Participation in Research Prisoners Involved as Participants Insertion of Central Venous Catheters Through December 13, 2007 2.25 credits cvctraining.medicine.duke.edu Web Archive: 12th Annual Duke ACS Symposium through February 27, 2008 2.25 credits thrombosisclinic.com/en/11/39/6688/

COURSE DATE CREDIt reGISTRATION C D- ROM The LIFE Curriculum: Learning to Through August 31, 2007 1 credit lifecurriculum.info Address Impairment and Fatigue to Enhance Patient Safety Improving the Recognition of Wearing-Off through September 14, 2007 1.5 credits [email protected] in Parkinson Disease Defining Foundation Antithrombin Therapy through September 14, 2007 1 credit 212-866-3122

These activities have been approved for AMA PRA credit. D uke M ed 53 m a g a z i n e volume 7, issue 1, SPRING/summer 2007

When gain means pain. Nearly three times as many American youth are overweight today as just a generation ago. And along with excess weight, they’re piling on health problems—like type 2 diabetes, joint pain, and hypertension. “These are not traditional childhood illnesses, and frankly most pediatricians aren’t trained to treat them,” says Sarah Armstrong, MD (right). “If you’ve got to talk to your patient about asthma and that he’s failing math and that he’s overweight and that his cholesterol is getting too high, all in a brief office visit—at some point something’s going to have to give.” As director of Duke Children’s new Healthy Lifestyles Program, Armstrong is working to support fellow pediatricians—and save the health of a generation.