DukeHealth.org: Duke Health Features

Making His Mark ... Just Barely: Scarless Gynecologic Surgery

Mon, 15 Feb 2010 08:48:22 -0500

New technology allows Craig Sobolewski, MD, and colleagues to offer, among other things, a hysterectomy that hardly leaves a mark.

What is "belly button" surgery?

Often referred to as “belly button” surgery, minimally invasive gynecologic surgery (MIGS) uses advanced technology to perform surgery that provides a much shorter and less painful recovery than traditional surgery.

We use slender instruments and a telescope so we can perform the surgery using only tiny incisions. In many instances, this approach lessens the risks associated with the same surgery done through a traditional, "open" incision.

What kinds of conditions do you treat with this approach?

MIGS can be used to perform virtually any surgery for benign gynecologic conditions. Some of the problems that our patients see us for include fibroids, endometriosis, ovarian cysts, pelvic pain, and abnormal menstrual bleeding.

Many of these conditions can be managed with medications. For those that cannot, there is often a laparoscopic or hysteroscopic approach that can help.

Is there really such thing as a scarless hysterectomy?

With laparoscopy, a hysterectomy can be essentially scarless. Sometimes it’s called a natural-scar hysterectomy because we actually make the tiny incision inside or near the belly button -- a natural scar. Since everyone’s belly button is naturally wrinkled, once it’s healed, it’s barely visible!

How do I know if MIGS is right for me?

Our skilled providers tailor the treatment plan and surgical approach to each individual patient. We can help you decide which approach is best and safest for you and your condition.

Rinkside, Vancouver. Bedside, Duke.

Thu, 11 Feb 2010 15:28:24 -0500

Duke’s Fraser Leversedge, MD, takes care of Olympic hockey players and is here to give you gold medal care the rest of the year.

What is your role with the Vancouver Olympics?

I am a site physician for the ice hockey venue, so I treat the orthopaedic injuries of the athletes from all countries.

I had a similar role at the basketball venue at the Olympic Games in Athens -- an exciting experience filled with many inspiring moments courtside and in the medical room.

Back home at Duke, what is your specialty?

I’m a hand and arm surgeon. I treat conditions from the fingertip to the shoulder including trauma, fractures, arthritis, nerve and tendon damage, sports injuries, pediatric and congenital disorders, and microvascular reconstruction.

Has your work with athletes taught you about teamwork?

Absolutely! But really, there’s no better place to learn about teamwork than at Duke Orthopaedics. I collaborate on a daily basis with colleagues who specialize in hand and arm surgery and in other specialties from sports medicine to pediatric neurology.

Whether an injury affects an Olympic athlete, a student athlete, or a "weekend warrior," we have an extensive team of specialists to provide comprehensive care, whether it requires surgery or conservative management.

In addition to collaboration, what else do you think distinguishes Duke Orthopaedics?

At Duke patients have access to some of the best surgeons in the world and the most advanced technology and treatments. People come from all over the country to receive care here, and we take on some of the most complex cases.

At the same time, I think you’ll be impressed with our emphasis on patient-centered, compassionate care for all injuries; no matter how simple or complex the injury, we recognize the importance of helping our patients return to an active, healthy lifestyle.

A Super Subspecialist: Q&A with Donald Glower, MD

Mon, 08 Feb 2010 15:08:43 -0500

Duke cardiothoracic surgeon Donald Glower, MD, and colleagues help patients look forward to healthier lives.

Talk about your unique specialty.

I am what you would call a super-subspecialist because of what I do with heart valves. My work focuses upon minimally invasive valve surgery, which didn't even exist 20 years ago. It’s a very narrow niche -- not many people do this.

Minimally invasive valve surgery simply minimizes the cuts and allows us to get into the body and disturb a lot less tissue than with other types of procedures, so the recovery is typically much quicker and less painful.

You've been a surgeon for 30 years. You must have learned a lot about the concerns of a patient facing heart surgery.

Yes, and that's why I think it's important to have a lot of interaction with patients before surgery. This can be a very scary situation for most people. Giving people some hope is important, and I enjoy this aspect of my work.

How does Duke stand out in the field of cardiothoracic surgery?

Duke is a world leader in minimally invasive valve surgery, heart and lung transplantation, and endovascular therapy for cardiovascular disease.

The Duke faculty are great to work with and it really is true that here at Duke, you can come up with almost any idea and you'll find someone at Duke who wants to collaborate with you. It's very exciting -- lots of bright people on the leading edge.

And Duke is rapidly adaptable. If you have a good idea, lots of people could get behind you and support you. By golly, if it makes sense, the research happens.

Why would a patient travel a great distance to come to Duke?

Duke is an exciting place with lots of bright people focused on developing new ways to help patients. Whatever problem might arise, there are expert physicians who would love to help solve the problem.

There's a lot of good quality care available elsewhere, but patients who come to us are looking for something unusual -- something not available just anywhere. We have world experts who are able to deal with the most complex needs.

Dr. Glower and colleagues are committed to excellence in the treatment of heart disease, lung disease, aneurysms of the great vessels, and disorders of the esophagus.

Podcast: Terry Kim, MD, on Duke Eye Center

Tue, 02 Feb 2010 12:38:27 -0500

In this podcast, Terry Kim MD, Associate Director, Cornea and Refractive Surgery Services, answers questions about Duke Eye Center’s vision correction options using LASIK and cataract surgery.

Listen to the Podcast

(Download audio)

Podcast Transcript

Announcer: Our first guest tonight is Dr. Terry Kim, who is a refractive surgery specialist over at the Duke Eye Center, and he's the ophthalmology consultant for the Duke men's basketball team.

Terry thanks a lot for joining us. First of all maybe you could tell us what you do as the official team eye doctor?

Dr. Kim: John, first of all thank you for having me. I went to college and medical school here and I've been listening to you for 12 years and it's great to be here on your radio show.

Basically how this happen was, back about 1997-98 when David Henderson and Quinn Snyder were here I started to do the trauma eye care for the team -- in other words if somebody got bumped in the eye I would take care of it.

So I asked these guys, ‘Hey, who does your vision screening?’ I was surprised to find out that there was no official vision screening.

So I started doing an annual vision screening prior to the start of the season, where we check the vision and the pressure in the back of the eye. That evolved into doing the eye care for Coach K, the players, the staff, the families -- and its been a real special experience and I think it has proven really valuable.

We've been able to catch some high eye pressures and visual errors that we've been able to treat with LASIK and other surgeries.

Announcer: When you do those screenings over that period of time, has it led to any corrective eye surgery to help the vision of any of the players that you could talk about?

Dr. Kim: Yeah, it definitely has. One point and example, someone who couldn't be with us tonight -- Chris Carrawell, has come back as head team manager. It’s great to have him back on the team.

He was having problems with his contacts during seasonal play, so when he finished and before he got drafted by the Spurs, he came to me and said, "Hey can we look at LASIK?"

So we pride ourselves at the Eye Center of doing a very good pre-operative screening exam. He was a good candidate. He did his LASIK and he did great. In fact, we're celebrating his 10-year anniversary.

Announcer: Oh, wow.

Dr. Kim: He told me the other day that he is seeing well. It's made a tremendous difference in terms of his playing and coaching career. Now it's time to get him back for his routine eye exam.

Announcer: Ok we'll have to tell him about that.

We're speaking with Dr. Terry Kim, a refractive eye specialist over at the Duke Eye Center.

Now, obviously healthy eye vision is important for athletes, Duke athletes and all athletes. But, how about for the rest of us? How important are eye exams and how often should eye exams be held for the average person?

Dr. Kim: Well, good question John. That’s a very important issue. We take our eyes for granted and it's only until you lose our vision that you start worrying about things.

So I recommend if its a healthy individual, every one to two years. But certainly if you have diabetes, cataracts, glaucoma, macular degeneration -- that may mean more frequency when it comes to follow up.

Announcer: Now as I said before you're a refractive surgeon or LASIK surgeon over at Duke. What sort of options do people have for vision correction these days?

Dr. Kim: Well, you know, that’s a good question. Vision correction surgery has now involved not only vision correction surgery, but cataract surgery as well. So we perform cataract and vision correction, meaning LASIK, at Duke Eye Center.

And some of the special advances we've seen on the LASIK side John, are the ability now to use a special laser, called a femtosecond laser, to create what's called a flap. So we don't have to use a blade anymore, so it's blade-less, which patients really like.

We also have some new software, which can perform what's called a customized ablation, which means better visual outcomes for the patient.

Now on the cataract surgery side, we have a host of new lenses that allow us to correct for astigmatism and also give patients better up-close and distance vision after cataract surgery. And that’s with the so-called premium lenses that we offer with cataract surgery.

So those have been the major advances over the last 10 years.

Announcer: Very interesting.

Well I know now that the Duke Eye center is one of the most highly ranked programs in the country. Does that mean you guys focus mostly on specialized cases, or can anyone go to the Duke Eye Center and receive your treatment and services?

Dr. Kim: I feel real fortunate to be part of a world-class eye center at Duke. It covers all the specialties -- cornea, glaucoma, retina -- and it has some of the top specialists in the country.

But we also, and surprising perhaps to most people, we provide comprehensive eye exams, we work with our network of providers that assist us in this endeavor, because healthy eyes are very important.

So we encourage folks to check us out. We're a full-service eye center. We've been here for over 50 years, we're going to be here for another 50 years, and probably longer than that.

Dental Emergency: What to Do When Your Child Damages a Tooth

Tue, 26 Jan 2010 13:44:55 -0500

Kids being kids, accidents are unavoidable. Sometimes those accidents involve a blow to a child’s mouth. Teeth can be broken, loosened, or knocked out completely.

If this happens, it’s important to know what steps to take to give the best possible chance of saving a damaged tooth.

According to Martha Ann Keels, DDS, PhD, division chief of Pediatric Dentistry at Duke, injuries to children’s teeth are both common and preventable.

“The good news is most dental injuries can be avoided. But if an accident does occur, don't worry –- most times even a tooth that’s been knocked out completely can be saved if proper care is taken in the first 20 minutes,” Keels said.

How Dental Injuries Happen

Dental trauma can occur any time. The most common types of injuries are the results of toddlers falling down and children and teens injured while playing sports.

According to Dr. Keels, the peak period for trauma to primary, or baby teeth, is between 18 to 36 months –- a time when children are curious, yet uncoordinated.

With permanent teeth, sports accidents are the most common cause of dental trauma, especially in teenagers. Swinging arms and elbows and butting heads are common causes of injuries in football, baseball, and basketball.

Keels said that parents of cheerleaders should also take caution, as dental injuries in that sport are skyrocketing.

How to Save a Tooth

“No matter what type of injury occurs, the first 20-30 minutes are crucial in determining if a tooth can be repaired or saved,” Keels said. Steps to take depend on the type of tooth that has been injured and what kind of injury occurred.

If a tooth has been knocked out of place

If the tooth has been knocked backwards or out of position but is still in the socket, simply wash your hands, then pinch the crown of the tooth and snap it back into place. The teeth on either side will guide it into position.

Use a cold compress (a cold, wet towel or washcloth pressed firmly against the area) to reduce swelling, then go to the dentist -- the same day if possible. The dentist will then fine-tune the placement of the tooth.

If a tooth has been chipped or broken

If possible locate the fragment of the broken tooth, wash it gently with water, then go to the dentist as soon as possible.

If the tooth has been shattered or more than half of the tooth is broken, find the tooth fragments and go to the dentist immediately. The dentist can re-bond your tooth fragment with special tooth glue. If the fracture is over half the tooth, then the nerve of tooth may be exposed and need immediate treatment to protect the nerve.

If a tooth has been knocked out

If a baby tooth has been knocked out, don’t worry about replacing it. Clean the child’s mouth gently with water and use a cold compress to reduce swelling. Then make an appointment with your child's dentist to determine how serious the injury is.

If it’s a permanent tooth, it’s critical that you put it right back into the socket within 20 minutes to avoid serious nerve damage. Even if you’re a bit squeamish, you must get the tooth back into the socket.

“Just think to yourself: You can get it done. You’re saving a smile, “ said Dr. Keels.

If for some reason you can't get the tooth back in, place it in milk or saline. These liquids help protect the delicate cells around the root much better than water. The important thing is to keep the tooth moist but avoid washing or rubbing it, and avoid touching the root.

Most dentists have an emergency number to call in case of such and emergency. It’s important to have a dental home -- a dentist dedicated to your child's oral health -- and maintain regular visits. You don’t want your child’s first visit to the dentist to be for a potentially frightening situation such as this.

Avoiding Dental Injuries

Dental injuries can be the cause of lifelong expense, yet most can be prevented.

If you have a toddler, childproof your home by placing gates across stairs and padding sharp edges of tables.

A mouth guard is mandatory for teens who are active in sports or other activities like skateboarding. While a store bought guard is a good start, a custom-fitted mouth guard provides much more protection.

Parents are often concerned about the appearance of their child after he or she suffers a dental injury. However, if you provide first aid after an accident and visit your dentist regularly as your child grows up, beginning at your child's first birthday as recommended by the American Academy of Pediatric Dentistry (AAPD), you can correct almost any problems arising from dental trauma, Keels said.

For more tips, visit the AAPD's Parent Resource Center at www.aapd.org/parents.

Thin Is In: AFib and Anticoagulants

Fri, 15 Jan 2010 08:55:14 -0500

Because atrial fibrillation is strongly associated with strokes, the majority of AFib patients should be taking anticoagulants to thin the blood and prevent clot formation, says Thomas Ortel, MD, PhD, director of Duke's Clinical Coagulation and Platelet Immunology Laboratories and the anticoagulation management service.

Warfarin (often prescribed as Coumadin) is currently the only oral anticoagulant available, and those taking it must minimize their risk of bleeding by monitoring their blood and maintaining a steady amount of vitamin K in their diets.

Even certain medications can disrupt the coagulation balance -- including amiodarone, an antiarrhythmic drug commonly prescribed to AFib patients. Thus, a medical juggling act ensues.

Current practice for using anticoagulants in AFib patients is "all over the place," Ortel says. "There is a general assessment that the higher the risk for thrombosis, the greater the need for anticoagulants," but individual physicians can vary quite a bit in how they manage these drugs.

Newer anticoagulants are now in development to treat venous thrombosis as well as atrial fibrillation, and such drugs may reduce the need for close monitoring. But they aren't available yet and when they are, they could be costly, Ortel says.

For now, clinical staff use handheld monitors to test the patient's international normalized ratios (INR), which provide a measure of the tendency for blood to clot. In Ortel's clinic, the staff enter the values into an Internet-based system called CoagCare that Ortel helped develop and test.

The CoagCare system helps health care providers track patient INR values and offers the opportunity for certain patients to test their own INR and enter the data. He believes this type of tracking, along with more choices for anticoagulants, will ultimately allow for a more personalized approach to medication management.

"I think that in a few years, with more drug development, we're going to be very flexible in how patients on anticoagulants are managed," he says.

Balancing medications to minimize risk of both clots and bleeding events is especially complex in patients who will require surgery.

Ortel is currently enrolling AFib patients in a multi-site study called BRIDGE, which will investigate the use of low-molecular-weight heparin -- a blood thinner that works and wears off more quickly than warfarin -- as a bridge before and after elective procedures.

This article was first published in the Fall 2009 edition of DukeMed Magazine.

Poll: Do You Buy Organic Foods?

Tue, 12 Jan 2010 08:56:35 -0500

Organic foods have become a staple of supermarket shelves and farmers' markets worldwide.

Some recent studies have indicated that organic foods offer no nutritional benefit when compared to conventional foods. Organics are thought to be safer than foods that are treated with pesticides.

Do you seek out organic foods? Take our poll and let us know.

Do you seek out organic food?

Research Highlights: Stem Cell Research

Mon, 11 Jan 2010 09:39:57 -0500

James White was in his 60s when he was diagnosed with myelodysplasia, which progressed to leukemia. The traditional treatment for patients like White is standard chemotherapy, which brings a median survival time of about a year.

But Duke oncologist David A. Rizzieri, MD, offered White a regimen developed at Duke that includes less-intense chemotherapy and a stem cell transplant of halfmatched donor cells.

More than two years later, White is still in remission and doing well.

Traditionally, older, more infirm patients have not been candidates for treatment with stem cell transplants and the accompanying intense preparative chemotherapy.

“The combination of this less-toxic preparation with a mismatched immune system donor opens up transplant to the overwhelming majority of patients who don’t have a matched donor,” Rizzieri says.

In 1999, Duke pioneered the use of cord blood cells for adults who don’t have a matched donor. Today, under the leadership of Nelson Chao, MD, professor of medicine and cellular therapy, Duke physician-scientists have continued to expand the use of cord blood transplants.

For instance, Duke has developed a regimen that combines cord blood units from two different donors to perform transplants in adults. “Very few other places in the country attempt to perform cord blood transplants in adults,” Rizzieri says.

New innovations under way include novel approaches to improve immune-system function after transplant. Duke is conducting clinical studies of these immune-system boosting protocols, including vaccine therapies and selected lymphocyte boosts from donors.

Duke is also expanding the use of cellular therapy to other diseases, including autoimmune diseases such as sclerosis. Keith Sullivan, MD, leads a trial of stem cell transplant as a treatment for severe systemic sclerosis.

“It is very exciting and rewarding to see patients return to an almost normal life following a very debilitating and life-threatening illness,” says Sullivan.

Myth or Fact: Wait 30 Minutes after Eating to Go Swimming

Fri, 08 Jan 2010 08:29:20 -0500

You probably recall your mother’s emphatic warning to wait at least 30 minutes after eating before getting back in the pool. Apparently, mother does not know best when it comes to swimming after eating.

The common belief that the blood going to your digestive tract after eating steals the blood needed to keep your arms and legs pumping during swimming is unfounded, says Gerald Endress, exercise physiologist and director of the Duke Diet & Fitness Center.

According to Endress, the body does supply extra blood to aid in digestion, but not enough blood to keep your arm and leg muscles from properly functioning. Your biggest danger related to eating and swimming is probably a minor cramp.

Eating-Exercise Connection

Even though this particular example is a myth, the relationship between eating and exercise is important. Knowing when and what to eat can make a difference in how many calories you burn and how effective your workout is.

Elisabetta Politi, RD, nutrition director at the Duke Diet & Fitness Center, gives some tips for how to effectively combine eating and exercise:

Eat for energy. Two to three hours before exercise, eat a combination of carbohydrates and protein. The carbohydrates will give you energy, and the protein will sustain that energy. Suggested meals or snacks include half a whole wheat bagel topped with peanut butter or a cup of yogurt with fruit.
Break your fast. If you exercise first thing in the morning, it’s important to break your fast before exercising. When you eat before you workout, you actually fuel your workout and burn calories more effectively. If you can't stomach a big meal, just eat half a banana or a small apple to get your metabolism working.
Hydrate properly. During your workout, you do not need to consume calories if you are exercising for less than an hour. If your workout is longer than an hour, drink a sports drink with calories or eat a piece of fruit to keep your blood sugar up. Avoid fruit juices and sodas that are high in sugar.
Make healthy food choices. Remember that just because you work out doesn't mean you can eat whatever you want. Watch your caloric intake and make healthy food choices that support the work you're doing in the gym.

Most Liked Articles of 2009

Fri, 18 Dec 2009 11:13:25 -0500

It's end-of-the-year list time -- a time to look back before we look forward to 2010.

In 2009 we introduced a new feature to DukeHealth.org: you can "like" an article that you think is worth others' attention. The feature turned out to be a great way for you to tell us what matters most when it comes to your health. To capture health information that you liked the most, we've created this list of the most liked articles in 2009.

The list shows health trends new and old. H1N1 flu dominated your attention and is represented by three different articles. You'll also find an article about the connection between vaccines and autism -- a debate that has interested our visitors for many years.

Here are the most liked articles of 2009. We hope DukeHealth.org will provide you many more articles to like in the coming year.

Thanksgiving the Perfect Time to Share Family Health History

Tue, 24 Nov 2009 10:02:05 -0500

It’s well documented that many medical conditions have a strong genetic component. From cardiovascular disease, diabetes, and cancer to mental health conditions, blood-clotting disorders, and cystic fibrosis, a number of diseases can run in families.

The good news is that by creating a record of your family’s health conditions, you can help medical professionals better understand -- and possibly reduce -- the risk that you and your relatives will develop them, too.

Documenting Your Family Health History

This Thanksgiving -- or any occasion that brings relatives together -- take the opportunity to discuss and document your family’s medical history. After all, Thanksgiving is also National Family History Day, as declared by the U.S. Surgeon General in 2004.

To underscore the value of the family medical history as a risk-assessment tool, the Surgeon General’s office recently rolled out an updated, more user-friendly version of the online tool My Family Health Portrait.

For more tips on how to start the conversation with your relatives and resources to help you record your family health history, check out Duke Medicine’s Does It Run in the Family? guides. These booklets were customized especially for the Duke and Durham community with local stories and resources.

Does It Run in the Family? A Guide to Family Health History (PDF)

A Guide for Understanding Genetics and Health (PDF)

Family History Collection Guide (PDF)

Family History Guide to Share with Provider (PDF)

Putting Your History to Work: From Family Tales to Personalized Medicine

Whether your family documents its health history on paper or online, you and your relatives will be taking a proactive step toward keeping healthy.

By sharing your history with your health care providers, you will give them valuable information that may help them make better decisions about your care.

At Duke Medicine, for example, clinicians work to help each patient reduce the odds of disease and improve outcomes by considering his or her unique needs and risks -- including those identified by family history.

We also offer a growing array of customized therapies, risk assessment tests, and prevention programs to provide personalized care for patients with cancer, heart disease, and a range of other conditions.

How much of your family's medical history do you know?

Duke Medicine's Plan to Expand

Mon, 23 Nov 2009 14:03:59 -0500

Cranes, bulldozers, and a corps of construction workers have swarmed onto the Duke University Medical Center campus, signaling the start of an ambitious expansion project designed to dramatically enhance the experience of patients, families, students, and staff at Duke for decades to come.

Following rigorous rounds of project reviews and approval by the State of North Carolina, Duke Medicine leaders announced in August 2009 their decision to move ahead with the historic initiative, which has been on the drawing board for several years.

"Duke Medicine is all about people -- it's about the patients we serve, it's about the people who work here to deliver the best care, discover new things, and train the next generation," says Victor J. Dzau, MD, chancellor for health affairs.

"To support those people in the years to come, we must make sure that we have the state-of-the-art facilities we need to provide the best care and the best environment to work and learn in."

This vision is now becoming a reality with the official start of two landmark buildings. Together, the new Duke Medicine Cancer Center and the Duke Medicine Pavilion, along with related renovations, will add more than 800,000 square feet of space, with 160 intensive- and intermediate-care inpatient rooms, 16 new operating suites, 130 exam rooms and 75 infusion spaces dedicated to cancer care, and expanded and updated imaging platforms. Total project costs are estimated at more than $700 million.

Planning is also under way for a new School of Medicine learning center that will provide an optimal environment for medical student and interdisciplinary team training. The larger, modernized facilities are greatly needed not only to accommodate an increasing demand for patient care, but also to support the broader vision for medicine at Duke, according to administrators.

The new facilities are thoughtfully designed to:

Improve the patient experience by making clinic visits more efficient, increasing inpatient room size, better accommodating visitors and family members, and providing amenities such as resource centers, healing and spiritual spaces, and green spaces
Support multidisciplinary care by co-locating a wide range of providers within fast-growing specialty services such as cancer and heart
Accommodate leading-edge clinical technologies including advanced imaging and diagnostic equipment and linear accelerators for cancer radiation therapy
Enhance education and research by providing state-of-the-art facilities that support training, facilitate study of new techniques and treatments, and bring clinical research teams closer to patients
Incorporate advances in information technology to improve communications between clinical teams and individual patients -- not only within each building, but across the continuum of Duke Medicine services and sites

Although the global economic crash in 2008 diminished Duke’s capital reserves,
Duke Medicine leaders remained committed to moving ahead -- describing the efforts as a mission-critical investment in the future.

"Without expansion and modernization, the quality of our patient care could suffer and our long-term goals could be significantly stunted," Dzau says.

"Years of conservative and prudent fiscal management, combined with careful cost-cutting measures, have put us in a strong position to move forward with these projects -- which we believe are essential to our ongoing ability to meet the growing demand for patient care services and to conduct cutting-edge research and training in an era of population growth and accelerating innovation.

"At heart, we believe we have a responsibility to meet our patients' needs for high-quality health care in the years ahead."

In addition to institutional investment, fund-raising initiatives have been launched to raise $75 million toward the costs of the Duke Medicine Cancer Center, $50 million toward Duke Medicine Pavilion, and $15 million toward the learning center, which is also supported by a $35-million gift from The Duke Endowment.

"The vision for the future of the campus is to continue to support what makes
Duke Duke: excellence in clinical care, teaching the next generation of all kinds of providers, and generating innovations that we can push through the enterprise," says Kevin Sowers, RN, MSN, CEO of Duke University Hospital.

"It's about supporting incredible people who work here every day and do incredible things in people’s lives, by giving them facilities designed to enhance their efforts to care for Duke's surrounding communities, the residents of North Carolina, and beyond."

Training Spaces

Besides serving hundreds of thousands of patients every year, Duke University Medical Center is also home base for one of the country’s largest health-care training programs, with more than 900 medical residents and fellows on the house staff, plus more than a thousand students in the medical, nursing, physical therapy, and physician assistant programs. The planned campus expansion will benefit these next-generation caregivers as well as the patients they’ll serve:

State-of-the-art technology from new linear accelerators in the cancer center to interoperative imaging technologies in Duke Medicine Pavilion’s surgical platform will allow clinicians to better practice -- and therefore teach -- to their full potential, facilitate research that will improve care and support training of academic physicians, and enable trainees to gain experience in cutting-edge care.
A School of Medicine learning center located in the heart of the medical center campus -- the first new building dedicated to medical education since 1930 -- is being planned to provide the team-oriented, technology-based experiences today’s curriculum demands. “New learning space for our students was the top priority for our own leadership and the main recommendation during our recent accreditation process,” says Dean Nancy Andrews, MD, PhD. “Medical education has changed dramatically since our current facilities were built. The vision for this new space is to provide our students with the laboratories and training facilities that will best help them prepare for their future careers.”

The new buildings have been preceded by new facilities for the School of Nursing (completed 2006) and the physician assistant program, which in early 2009 moved into a freshly renovated building designed to accommodate future growth.

Read more about the planned learning center in the summer 2009 issue of DukeMed Alumni News, online at medalum.mc.duke.edu.

Duke Medicine Pavilion: Answering Demand for Surgical and Intensive-Care Services

Since its current bed tower opened in 1980, Duke University Hospital has grown not only in patient volume but also in reputation as one of the most advanced hospitals in the country. And frankly its success has the 29-year-old building bursting at the seams.

From Monday through Friday, the hospital fills at least 90 percent of its 924 inpatient beds, many of them with critically ill patients sent here for the best medicine has to offer.

A 2005 study showed Duke's OR usage to be 93 percent -- compared to 80 percent for the average academic medical center. And with every upgrade to new technology, Duke electricians and IT experts have to figure out how to rearrange the guts of the building to support the state-of-the art tools in play.

The plans for the new Duke Medicine Pavilion -- a 580,000-square-foot addition to the hospital housing OR suites, intensive care units, step-down units, and diagnostic facilities -- have focused on maximizing flexibility of space and technology, leaving Duke Medicine room to grow.

Operating Space

The 16 new OR suites will be larger than the current operating rooms in order to accommodate advances in technology that enhance precision and safety. The new suites are designed to be flexible, allowing both multipurpose and specialized use: interoperative MRI and CT are located between suites, for instant access that won’t crowd the room when not in use.

A hybrid OR is already under construction in the current hospital, and will open in 2010; it will allow interventional cardiologists and surgeons on-the-spot, highly detailed vascular imaging capabilities -- and enable easy transition between catheter-based, minimally invasive, and open procedures within the same space.

Built-in technology will enable the surgical team to review critical information without going to multiple places or even stepping away from the table: multiple plasma screens will allow surgeons to review x-rays and other imaging studies, as well as pathology specimens.

"Duke’s surgical faculty are nationally and in many cases internationally respected, and demand for their services is exhausting our current facility," says Danny Jacobs, MD, MPH, chair of the Department of Surgery.

"The Duke Medicine Pavilion will be critically important to our ability to meet surgical demand and train the next generation of surgical leaders."

Roomier Rooms

Duke Medicine Pavilion’s 96 critical-care and 64 intermediate-care beds won’t just add more space, but better space -- reflecting dramatic changes in care since the hospital’s Anlyan bed tower was built.

Then, patients arrived for surgery the night before the procedure; their families awaited results in the waiting rooms and sat with their loved ones in brief stints during visiting hours. Today families want to stay with patients around the clock, and the new patient rooms are designed to accommodate more people -- clinicians and family alike.

These and other features of Duke Medicine Pavilion reflect input from current patients, families, physicians, nurses, and other staff, says Mary Ann Fuchs, RN, Duke University Health System's chief nursing officer.

"The building’s entire layout will allow patients much more access to their families, allow the staff more interaction with patients, and allow the staff to work in a more streamlined fashion. We strove to create a place where multidisciplinary teams could work well together and where patients could feel comfortable and cared-for."

High-Tech Hospital

In addition to upgrades in the OR, a high-tech, centrally located imaging center will streamline access to MRI, CT, and nuclear testing for patients and clinicians. The building will also accommodate new tracking and electronic medical record (EMR) technology, enabling better coordination of care within the hospital, across the health system, and beyond Duke.

"Most medical errors and patient safety issues emerge when a patient transitions from a hospital to a primary care setting," says Asif Ahmad, chief information officer for the health system.

"Our EMR technology already coordinates a patient’s information among all three of our hospitals; our plan for this building is to go ‘EMR-plus’—to use technology to improve patient education and help prevent glitches in the translation of information when they leave the hospital."

Patients -- and Providers -- in Motion

The layout of the hospital -- as well as the cancer center -- began with studying all the traffic that flows through current service areas, from shift changes to patient transport.

For example, neurology patients have to go for CT scans frequently, so designers worked to locate the neurology ICU near CT. And all heart services throughout Duke University Hospital will be located on the same level, regardless of what building they are in.

A two-story concourse -- just about the same width as an airport concourse -- will be the "Main Street" that connects Duke Clinic to Anlyan Tower. The totally enclosed and climate-controlled concourse will simplify the journeys of patients and staff as they move around the medical center.

Healthful and Healing Spaces

Great care is being taken to create an environment that is pleasant and supportive for patients and their families. A major component of that philosophy is linking patients to the world beyond the facility walls -- by providing green spaces that can be seen from patient rooms and waiting rooms alike.

The Duke Medicine Quadrangle: The doors of the cancer center and the new hospital addition will open onto a park designed by Laurie Olan, the landscape architect who redesigned both Columbus Circle in New York City and Philadelphia’s Independence National Historic Park. Similarly designed courtyards within the hospital will provide more green views for patient rooms.

Patient resources: The main doors of the hospital addition will open into a two-story entryway that leads visitors to a patient library, a café, and a quiet meditation or reflection space.

Letting the sunshine in: The overall facility design brings natural light into staff and patient-care areas. "That actually is really helpful to patient and staff morale," says Fuchs, "just having a pleasant environment in which to do our work."

Green in more ways than one: Besides its visual connection to the outdoors,
Duke Medicine Pavilion -- targeted for LEED Silver status -- is designed to be environmentally friendly, with green roof space, sustainable building materials, and energy-efficient mechanical systems.

Duke Medicine Cancer Center: Creating the Optimal Experience for Cancer Patients

When Harry Rhoads was diagnosed with stage 4 melanoma three years ago, his Duke oncologist told Rhoads he most likely had about 11 months to live -- but that he could join a clinical trial of a promising new interleukin drug.

The treatment schedule would be difficult: two weeks of treatment and two weeks off, for a total of six treatments. Each round of interleukin was followed by "six days of hell," Rhoads says -- nausea, vomiting, hallucinations.

"I was scared."

But PET scans showed that the tumors were shrinking with each session. Despite a few setbacks, Rhoads is cancer-free today.

Rhoads’s experience of cancer treatment isn’t representative of all cancer patients; as every tumor type is unique, every cancer patient has his or her own treatment experience. But in many ways, Rhoads says, "every patient goes through the same thing" -- a complex balancing act of fear and faith, suffering and grace.

Rhoads lives near Washington, DC, so his choosing Duke for his treatment went beyond the considerations of distance and convenience.

William J. Fulkerson Jr., MD, Duke Medicine’s senior vice president for clinical affairs, says patients like Rhoads travel to Duke for access to world-class specialists and the promise of the newest and most comprehensive treatments for the disease that threatens their lives.

As one of only 40 National Cancer Institute-designated Comprehensive Cancer Centers in the nation, Duke offers options that simply aren’t available in many hospitals.

"There are two things that set academic medical centers like Duke apart from other health care organizations," says Fulkerson. "One is that highly focused specialists from many disciplines work together under one roof to provide comprehensive care; the other is that academic medical centers are in the business of bringing innovation to the table as quickly as possible."

The impetus for building Duke Medicine’s new cancer center facility, say its leaders, is to continue to deliver on that promise to an ever-growing number of patients. By more closely integrating clinician and clinical research teams, the design of the building seeks to promote the best of academic medicine’s multidisciplinary and research-driven nature.

In addition, the space must provide the most healing, patient-centered environment possible to support patients like Rhoads as they go through the journey of fighting, living with, and surviving cancer.

Combining these mandates of form and function is a tall order -- and that's why the vision for the project goes far beyond adding square footage. In fact, leaders say, the goal is nothing less than to create the best possible cancer treatment experience.

What Makes "Multi-D" Work?

A key part of that is enhancing the multidisciplinary approach that distinguishes cancer care at Duke -- and that studies show is associated with better patient outcomes. But the buzzword multidisciplinary has multiple meanings.

Depending on the cancer type, multidisciplinary care at Duke might mean having different specialists working in the same space on parallel schedules for easy "collaboration on the fly," or it might mean scheduling clinicians around each patient -- such as in the Duke Prostate Center, in which a newly diagnosed patient is visited by a surgeon, radiation oncologist, and medical oncologist who confer with each other to develop a coordinated, comprehensive care plan.

And then there is the expertise of specialized nurses, nutritionists, psychologists, social workers, and physical therapists, all of whom work in concert to provide Duke cancer patients with whole-person care.

If the fuel that powers these many modes of multidisciplinary care is the talent pool of the clinicians on staff, then the rate-limiting factor is space -- which in Duke’s current buildings is growing tighter due to swelling patient volume and the continual introduction of new and better imaging and radiotherapy technology.

This is why the most talked-about feature of the new building is space: 267,000 square feet of it, including ample room to bring clinicians, counselors, and research staff from their current far-flung locations into dedicated space closer to patient exam rooms.

"Physicians want their patients to have multidisciplinary care that doesn’t require coming to Duke three or four times to see different doctors," says Carolyn Carpenter, the health system’s associate vice president for oncology services.

"Adding space to our facility will allow us to schedule patients and clinicians in a way that's more efficient -- and that will lead to a better experience for the patient."

Designed to Heal

Not only the exam rooms but the entire building is designed to deliver an ideal patient experience. Planners began by mapping out all the stops cancer patients have to make during a visit to Duke, from registration and the pharmacy to mammography, MRI, labs, chemotherapy, or radiation therapy.

"Then we went to focus groups [of Duke cancer patients] and said, 'Here’s what we think the experience is like. Do we have it right? And what would you change?'" says Sowers.

The central premise behind every focus group -- and there were several -- was how to make cancer care revolve around the patient instead of the patient's disease.

In the case of radiology, for example, patients didn’t want to have to walk to one part of the building to get a CT and then another to get an MRI, as they do in the current facility; in the new building a full floor of the cancer center hosts all of the radiology platforms in one consolidated area.

When patients enter the new building, they'll be welcomed by a resource center -- no long registration queues or full waiting rooms in sight. The boutique, food court, and outdoor spaces are designed to provide pleasant options for patients who are waiting before or between appointments.

And the waiting areas themselves are designed to accommodate comfortably both the patients and the family members who travel with them.

"We did studies of how many people typically accompany a clinic patient and an infusion patient," says Carpenter. "And we used that information to determine how big our waiting areas should be."

Betty Lamar, a member of Duke Comprehensive Cancer Center’s Citizens Advisory Council, says the intangible effects of a patient-friendly atmosphere make all the difference -- and she should know. Her first husband died of leukemia, while her second had bladder cancer, and she experienced the full spectrum of cancer care in a variety of clinical settings.

As a veteran caregiver, Lamar says she’s seen how cancer treatment has shifted over the years to a patient focus.

"At Duke they are now really treating the whole person and not the disease," she says. "It didn’t use to be like that, it was all focused on the disease."

Lamar serves as a volunteer at Caring House, a home away from home for many Duke cancer patients. She says she has seen many patients and families who reflected her own experience.

"They would arrive so afraid and anxious," she says. "They came from all over the country and world. They were desperate for help."

Room to Advance

The draw for these patients is often the clinical trials offered at Duke, such as the interleukin trial Rhoads is part of. In fact, Duke is currently conducting more than 700 cancer trials.

"Cancer care, almost more than anything else that we do at Duke Medicine, is a fast-evolving field -- new treatments and new understandings emerge all the time," says Fulkerson.

Clinical trials are what drive these discoveries into cancer care practice, and the studies are "fundamentally intertwined with clinical care," says breast oncologist P. Kelly Marcom, MD.

"We need efficient clinical space to ensure a seamless approach to clinical research, as well as patient care. With the new building, we will have additional space to educate patients about clinical trials and accrue individuals to participate in these trials."

The new building will include dedicated space for clinical trial consultation and coordination, making standard what was previously a rare luxury for clinical trial coordinators -- complete privacy and uninterrupted quiet space near patient exam rooms to discuss clinical trials, informed consent, and any questions a patient has about clinical research.

Also, says radiation oncologist and Duke oncology services medical director Christopher Willett, MD, the new building will house brand-new, first-in-world imaging and radiotherapy technologies that will supplement both patient care and research.

"In addition to expanding the space and bringing in more tools, we are intensifying our focus on the patient’s experience. The new building will be more efficient for them and for us -- and very user-friendly. I think that all of us feel extraordinarily positive about the plans for it."

Lamar made the first gift to the Cancer Center building fund, which Duke hopes will raise $75 million toward the project’s estimated $220-million cost.

"Where you're treated is a very important part of treatment and cure -- it's important to be in a happy place," she says. "And the new building will really make you feel that way.

"It’s a place that makes you realize that you’re being considered as a whole person."

This article was first published in the Fall 2009 edition of DukeMed Magazine.

Outside Influences

Mon, 23 Nov 2009 14:01:04 -0500

H. Kim Lyerly, MD, director of the Duke Comprehensive Cancer Center (left), and William Chameides, PhD, dean of Duke’s Nicholas School of the Environment.She was standing at the kitchen sink, washing dishes, just as she had dozens of times in my childhood when I had walked in with a question about something I didn’t understand.

But the question we were discussing was not one between a young mother and a curious kindergartner; it was between a 50-year-old woman whose breast cancer had been in remission for a year and her college-aged daughter who wondered what sort of fortunes might await her own body, yet to be told.

My mother was convinced that stress -- losing her father, moving to a new state -- had caused her disease, for there was no history of it in our family. I was thinking about the other tapestries of her life: the coal mining she grew up around; the chemical plants that billowed clouds of smoke and dotted the landscape of the region where we made our home for the first 16 years of my life.

Could any or all of these factors have caused her cancer? Would they one day haunt me or my children?

For most of us -- even for many researchers -- the relationships between nature and nurture remain murky.

But scientists at the Duke Comprehensive Cancer Center and the Nicholas School of the Environment believe that such questions are answerable, that our lifestyles, our environments, even the possible effects of what’s stored underneath that kitchen sink, can be shrunk from imposing questions to understandable relationships, from theory to therapy, from perhaps to prevention.

The partnership is one-of-a-kind: No other institution in the country boasts such a level of collaboration between environmental and cancer researchers.

The effort began in 2005, seeded with a series of joint projects funded by Fred and Alice Stanback of Salisbury, North Carolina (who have since contributed an additional $6 million to the cause).

Over the years the initiative has grown and given rise to new research in both domains, with scientists coming together to explore questions that once ended where another discipline’s research lab began.

Researchers are visiting their neighboring schools, borrowing the proverbial cup of sugar, and getting personal -- just like the disease itself.

"You can find the big answers if you have the culture and the willingness to work together," says William Chameides, PhD, dean of the Nicholas School. "You have to be willing to say, 'Yeah, I’m going to stretch a little bit, and I’m going to get a little bit out of my element, because I see the big payoff.'"

In pinpointing our environmental enemies more precisely, the eventual payoff could indeed be huge -- and more than a little alarming.

"I have three kids: an eight-year-old, a six-year-old, and a four-year-old," says H. Kim Lyerly, MD, director of the Duke Comprehensive Cancer Center. "So there’s stuff in the backseat of the car. There are plastic drinking cups, toys, balls, and other man-made things."

To contemplate the spectrum of dyes, paints, and coatings on the endless odds and ends that we dig out from between the car seats and behind the sofa cushions, all the materials that end up on our skin or -- more likely -- in our children’s mouths, it’s easy to spin into paranoia or a sense of futility.

But the goal, says Lyerly, is not to "panic about the things we find; it’s to discover what kind of impact they have. If something is harmful, we want to know why. We want to link actual biology with detection in the environment.

"Let’s say we find a new type of molecule that causes cells to duplicate themselves uncontrollably," he explains.

"That’s a new insight that might help us understand cancer and therapies for the disease. But it’s also an insight we can give to the Nicholas School and say, 'Do you find this molecule in populations that are at greater risk based on your screening?'"

Mapping Cancer Risk

Marie Lynn Miranda, PhD and Amy Abernethy, MD are using Miranda’s mapping techniques to track cancer incidence in North CarolinaNew tools such as geospatial mapping are making these collaborations efficient for both sides. Researcher Marie Lynn Miranda, PhD, who leads the Nicholas School’s Children’s Environmental Health Initiative, has helped advance this mapping technique -- which uses a range of spatial data layers -- in North Carolina and nationally through her work on environmental contributors to maternal and child health.

Now, geospatial mapping is being expanded to other fields as well, including cancer.

The mapping tools herald an age of "personalized environmental health," paving the road to a better grasp on where cancers occur and why, says Amy Abernethy, MD, associate director for IT and informatics at the Cancer Center, who often works with Miranda.

Using a database of Duke cancer patients, Abernethy says, researchers are compiling where patients with different kinds of tumors live and then correlating their information with geographic maps of known heavy metals or other kinds of exposures considered potential carcinogens -- arsenic, radon, and even the sun itself.

As more and more information is gathered and other databases are folded in, those maps will be not only heavy-duty tools for research, says Abernethy, but eventually clinical tools to help drive home the importance of proper screening. Like the old picture of lungs blackened from smoking, physicians can pull out a map during an office visit that details their patients’ risk based on geography.

"It allows people to see that, 'Wow, I live in Johnston County and these are the things that I need to worry about, and this is based on real-life data,'" Abernethy says. "It becomes much more meaningful.

"I think ultimately we'll become more and more sophisticated in our risk-modeling.
We'll be saying: 'This is a 33-year-old woman living in Johnston County, near Highway 242, who has lived in Wake and Durham counties at prior points in her life, and her risk of having this type of cancer by the time she turns 70 is x.' And it may influence the screening we recommend."

What’s in the Water

Avner Vengosh, PhDCancer is an intimate foe; when you have it, and even when you no longer do, reminders of its presence pockmark your body and your psyche.

And many of the environmental insults that are linked with oncogenesis, as Nicholas School professor Avner Vengosh, PhD, knows, also pockmark the landscape that surrounds us.

Vengosh is a geochemist who is known internationally for his expertise on the chemical and isotopic composition of water contaminants, developing tracers for contaminants in water supplies from the Middle East to the mountains of western North Carolina, where harmful radon in groundwater was exposed.

He has collected samples of the coal-ash waste that spilled from the Tennessee Valley Authority’s Kingston coal-burning plant on December 22, 2008, covering 300 acres of land and water with sludge and damming a tributary of the Emory River there.

Coal ash has relatively high levels of toxic elements such as radium and arsenic; long-term exposure to either has been deemed a cancer risk by the Environmental Protection Agency.

"The massive coal-ash spill contaminated associated surface water -- specifically with arsenic—but the good news is, we detected only trace amounts of arsenic in waters beyond the dammed tributary," Vengosh says.

"The data suggest that river flow has diluted the arsenic content. The river is relatively clean, but the water from areas like the dammed tributary, where the coal ash accumulated, still contains high arsenic levels."

The Tennessee coal-ash spill is a wake-up call, as about 70 million tons of coal ash are stored around the United States.

Avner and fellow Nicholas School investigators worked with Julia Kravchenko, MD, PhD, of the Cancer Center on a paper (published in May in Environmental Science & Technology) that examines the link between environmental contaminants found in the Kingston coal ash, contaminated water, and health risks -- the first of several planned studies of the biomedical implications of environmental disasters.

Chameides is particularly interested to see what the Vengosh team finds as its research into these links unfolds during the coming year; hundreds of coal-ash retention ponds exist in the United States, he says, and if high levels of carcinogens are found in Tennessee, those data could ultimately unlock clues about cancer incidence in other areas of the country.

"If you try to understand in general the impact of environmental pollution on human health,” Chameides says, “it’s sometimes useful to look at places where you see a really high impact, a larger signal such as the coal-ash spill, and then work backward from that to see what’s happening in a more subtle way in other places."

The Hopeful Science

Duke epigenetics expert Randy Jirtle, PhDIn 2003, Duke epigenetics expert Randy Jirtle, PhD, proved that while our genome is fixed when we’re born, our epigenome -- the collection of chemical switches that tell the genes what to do -- is not.

If the genome is the hardware of our bodies, the epigenome is the reprogrammable software capable of yielding to outside influences, says Jirtle.

In his study, baby mice suffered from a flawed gene that led to increased susceptibility to obesity, diabetes, and cancer -- except among those whose mother had been fed a prenatal diet including folic acid.

In that group, the extra nutrients acted at the molecular level to latch onto the troubled gene, resulting in its appropriate regulation. Those mice were born healthy.

Jirtle reported a similar finding last year on folic acid countering the negative effects of BPA, a chemical found in many plastics.

What’s more, says Jirtle, once this good-guy methylating gang does its work in the embryo, the genomes of those mice’s offspring are permanently mended, carrying the good alteration throughout the individual’s life. It is, he says, a hopeful new way of looking at life, and at medicine.

Of course, it also means that, as more is learned about the epigenomic switches, clinicians will have to ask their patients to sidle up to the responsibility trough and get smart about their lifestyle and environment choices based on the findings.

"What you eat, what you drink, and so on can affect not only yourself, but generation upon generation after you," Jirtle says.

That is why, although researchers continue to study the effects of nutrition and lifestyle on cancer incidence, Jirtle believes doctors should urge their pregnant patients -- and women thinking of starting a family -- to start limiting their exposure to BPA now by avoiding food from cans coated in plastic and water from plastic containers made from BPA, which may mimic estrogen(s) in the body.

Along with oncologist Victoria Seewaldt, MD, Jirtle also is working with a subset of our genome called "imprinted genes" to learn more about the influence of environment on breast cancer.

Unlike other genes we’re born with, in imprinted genes, only one of the two copies inherited from the mother and the father works. This nonworking gene is epigenetically switched off, or methylated, in a normal gene. But, if either both copies or no copies are working, susceptibility to disease increases.

Jirtle estimates that only about 200 of the 25,000 genes in our makeup are imprinted, but these are the ones Jirtle believes will unlock the mysteries behind many diseases, especially cancer.

The researchers are looking at people with a high risk of breast cancer to see if there are epigenetic changes in the KCNK9 imprinted gene, a potassium channel that has been shown in previous studies to result in breast cancer when overexpressed. Jirtle says they have already seen some evidence of a relationship at the epigenetic level.

Jirtle’s studies even investigate how the environment within the body may affect the epigenome -- specifically, he’s researching the link between neurological disorders and cancer, because patients with schizophrenia are known to have low incidence of cancer.

He believes that one day, when these ties are better understood, therapies might be introduced to turn off disease-causing genes and turn on protective mechanisms at the cellular level.

"With epigenetics," he says, "for the very first time, the word prevention comes into cancer. To get to the answers, though, you have to bring together groups of people that possibly have never been brought together before; and in fact, that’s what’s happening right now between the Nicholas School and the Cancer Center."

Disrupting the Status Quo

Donald McDonnell, PhDBPA is one of several known endocrine disruptors -- though it has received by far the most attention, causing certain plastic water bottles, baby bottles, and other goods to be shunned almost overnight.

But Jirtle’s colleague, Duke molecular cancer biologist Donald McDonnell, PhD, discovered startling information regarding endocrine disruptors and pharmaceuticals that should give pause to doctors prescribing medications with hormonal components.

McDonnell’s team showed why a common solvent used in industrial cleanrooms and one of the most popularly prescribed drugs in the country could lead to increased risk of cancer in some individuals.

His team tested a cleaning agent known as ethylene glycol methyl ether (EGME) that’s used in varnishes, paints, dyes, fuel additives, and the semiconductor industry; and valproic acid (Depakote), a drug with a similar chemical makeup that is prescribed for migraines, seizures, and attention deficit and bipolar disorders.

They discovered that EGME, when metabolized, and valproic acid both act as hormone sensitizers—they enhance progesterone and estrogen activity inside cells.

When that hormonal activity is accelerated in a person who is already ingesting a drug that contains synthetic progestin and estrogen (such oral contraceptives or hormone replacement therapy), the extended, double exposure of hormones in the body is likely to increase cancer risk.

McDonnell says the results are a break from more traditional thinking on the work of endocrine disruptors, where the focus has been on agents that mimic estrogen in the body rather than those that change the way cells see estrogen.

That mimicking also has been the main focus of drug testing for such disruptors, and until testing strategies take this new mechanism into account, he says, physicians need to act cautiously before prescribing any drug in combination with hormone-containing pharmaceuticals.

"This adds fuel to the debate as to the effectiveness of the currently used tests for endocrine disrupters," says McDonnell. "The drug-testing programs are outdated and do not adequately incorporate our current understanding of hormone action."

McDonnell suggests taking particular caution with tamoxifen, which is widely used in the treatment and prevention of breast cancer but is chemically altered from an antagonist to an agonist in the presence of EGME and valproic acid.

And while he has received some feedback from oncologists who do check with their patients about valproic acid use, for the most part, he says, "the message hasn’t yet hit home" in the medical community.

McDonnell adds that there’s no doubt in his mind that the environment contributes in a very significant manner to cancer susceptibility.

"Endocrine disruptors have received a lot of attention of late but there are likely to be hundred of other types of agents in the environment that impact cancer risk."

Ready for Its Close-up

Environmental effects on cancer are taking center stage in the medical research community and likely will become a greater topic of conversation around dinner tables, too.

It’s precisely that growing curiosity among the public about what’s safe around us and what isn’t that is fueling the partnership between the Nicholas School and the Cancer Center.

Patients want answers; researchers want to give doctors the right tools to provide those answers.

In the coming months, Lyerly and Chameides will see the connections they’re making at Duke unfold nationally. The President’s Cancer Panel, a group Chameides spoke to last fall which is tasked with appraising the National Cancer Program, will focus its annual report to President Barack Obama on the links between the environment and cancer.

Lyerly and Chameides also are co-chairs of a state cancer-plan task force on the same topic, and the foundation Susan G. Komen for the Cure also will be putting a brighter spotlight this year on environmental links to breast cancer.

"When I first called Bill to get directions to his office, he told me, 'Just follow the
Birkenstocks to the Levine Center,'" Lyerly says.

Now that trail has becoming a well-beaten path -- and a road that the two hope others may follow.

"The more we work with the School of the Environment, the more we understand that there are few people at the Cancer Center who couldn’t find ways to interact with their expertise," says Lyerly. "We’re hoping this will be a model for other places, for balancing individual research accomplishments with the collective good.

"We can find the answers if we work together."

This article was first published in the Fall 2009 edition of DukeMed Magazine.

Dueling Guidelines

Mon, 23 Nov 2009 13:41:17 -0500

Erik Paulson, MDAlthough colon cancer has been well-publicized as the second leading cause of cancer deaths in the United States, only about half of the people who should get screened for the disease actually do.

It’s not hard to imagine why: colonoscopy, the current gold standard for screening, is no fun. The rigors of “bowel prep.” Sedation. An endoscope inserted into the colon. But in 1993 a less invasive option came on the scene -- "virtual colonoscopy," or CT colonography, which involves the same bowel prep as colonoscopy, but neither sedation nor scope.

"We insufflate the colon with carbon dioxide, and in a single breath-hold take a CT scan of the abdomen," says Erik Paulson, MD, chief of abdominal imaging at Duke.

"Then the study is over. After the procedure, patients can return to work."

Physicians at Duke offer CT colonography as a clinical option, participate in its development, and train physicians in its use. Some studies suggest that CT colonography is comparable with colonoscopy in terms of effectiveness for most patients, especially when weighed in terms of its comparative ease.

But it isn’t perfect; even the major organizations that promote colon cancer screening have not yet recommended it as the procedure of choice for routine screening for average-risk adults.

In 2008, in the first-ever joint guidelines for colon cancer screening, the American College of Radiology, the American Cancer Society, and the U.S. Multi-Society Task Force on Colorectal Cancer specifically included CT colonography among several recommended options for screening and prevention in average-risk adults.

These guidelines differ from those issued that same year by the U.S. Preventive Services Task Force, which express doubt about the widespread accuracy of CT colonography because most physicians still have little experience with it.

A Big Change in Coverage

For some patients, the dueling guidelines won’t matter because of a practical issue -- payment. Medicare and Medicaid, as well as some insurance companies, still do not cover CT colonography for patients at average risk for colon cancer.

Medicare and Medicaid pay for the procedure only for patients whose condition makes a standard colonoscopy riskier than usual, such as if they’re taking anticoagulants or can’t be sedated for some reason. It may be covered for patients who have had an attempted colonoscopy that wasn’t completed because of bowel blockage.

Those rules aren’t likely to change soon. In a final decision released in May 2009, Medicare and Medicaid announced they would not cover CT colonography for routine screening. But some private insurance companies have begun paying for CT colonography for routine screening for patients 50 and older.

"That’s a big change," Paulson says. Multiple studies showing that CT colonography rivals colonoscopy are what have turned the tide.

Paulson points in particular to a multi-institutional trial published September 18, 2008, in the New England Journal of Medicine.

"That study showed that the sensitivity and specificity of CT colonography is competitive with colonoscopy," Paulson says.

In the study, 2,800 patients underwent CT colonography and then a colonoscopy, and the CT version identified 90 percent of patients with polyps or cancers that were 10 millimeters or more in diameter.

Some previous studies, including one at Duke in which Paulson was involved (published in Lancet in 2005), showed that while CT colonography was good at detecting actual cancers, it was not as good as colonoscopy at detecting polyps.

But Paulson says the technology has since made big leaps thanks to advances in bowel preparations, the three-dimensional technology used to interpret the scans, computer-aided detection software which increases the accuracy of interpretation, and the ability to label residual fecal matter in the colon so it doesn’t show up on the test.

He and other Duke researchers continue to study the technique -- leading research including multi-institutional clinical trials, the causes of false-negative and false-positive interpretations, and evaluation of computer-aided detection software.

Duke Radiology has for the past five years offered CT colonography as part of its routine clinical practice.

"We have six radiologists in our department who are skilled and experienced at CT colonography," Paulson says. "We’re doing more of them now than we’ve ever done."

Colonoscopy: Still the Gold Standard

Joanne Wilson, MDDuke gastroenterologist Joanne Wilson, MD, does think that less-invasive tests can increase screening rates.

"Definitely the biggest impact something like CT colonography will have is getting more people screened who are at average risk," Wilson says.

But she sees the technology as one that’s not ready to be widely implemented.

"CT colonography has promise, but there probably needs to be some further development of the technology," she says.

Also, many current physicians aren’t prepared to offer the procedure.

"One of the points raised in the literature is that radiologists who were trained just in standard CT would need to gain additional training in order to conduct and read CT colonographies," Wilson says.

"When new technology is introduced, there’s always a concern about how you’re going to train currently practicing physicians."

Wilson also points out that if alternative tests such as CT colonography or stool tests come back positive, the patient likely will have to have a colonoscopy anyway in order to remove or sample the lesion.

"The colonoscopy is both diagnostic in the sense that you can see polyps, and it’s therapeutic because you can take them out, or you can mark them or sample them. The final diagnosis of cancer is a histological diagnosis; you want to look at the tissue with the microscope," she says.

She also emphasizes that colonoscopy will remain the recommended test for patients at high risk for colon cancer -- those with a prior history of colon polyps and colon cancer and those with a family history of polyps and cancer.

Paulson acknowledges that colonoscopy is still the tried-and-true gold standard.

"There’s no doubt that colonoscopy is a great test," he says. "For many people it makes all the sense in the world. But as good as it is, it has some risk and requires sedation and is more invasive."

And, he says, while colonoscopy is a mature technology, the virtual version can be expected to continue to make technological leaps.

This article was first published in the Fall 2009 edition of DukeMed Magazine.

New Angles on AFib

Mon, 23 Nov 2009 13:39:51 -0500

Atrial fibrillation is the most common heart arrhythmia. It’s also among the most challenging to control -- first-line therapies don’t work for up to half of patients, raising their risk of heart failure and stroke.

By pinpointing the often-mysterious origins of AFib, fine-tuning drug strategies, and pushing the boundaries of catheter ablation, physicians in Duke’s new Center for Atrial Fibrillation are now restoring healthy heartbeats in more than 90 percent of patients -- and counting.

The heart’s beat begins with an impulse. The sinoatrial node -- our natural pacemaker -- generates electrical signals that travel through the atria and into the ventricles.

These signals set off synchronized contractions in each chamber of the heart, creating the comforting lub-dub sound of the heart’s pumping as it trades spent blood for a freshly oxygenated supply.

Atrial fibrillation (AFib) is the most common disruption of this powerful rhythm, affecting around 2.2 million Americans. It can stem from coronary artery disease, high blood pressure, structural heart defects, or even arise seemingly out of the blue.

Whatever the cause, abnormalities in the heart’s electrical system make the atrial chambers contract too quickly -- up to 350 times per minute. This quivering in the atria causes chaos in the ventricles, which react with a flurry of rapid, irregular beats. The lub-dub becomes more like a pitterpat -- one that is disconcerting at best, life-threatening at worst.

For some patients, AFib is barely noticeable: they have mild symptoms, such as fatigue, or no symptoms at all.

Others feel their hearts racing or experience frightening episodes of heart palpitations. These individuals often live in dread of such events: they don’t want to travel or go to work or school. Others give up exercise and other activities that could trigger the irregular beats.

"AFib symptoms and the anticipation of the episodes are so dramatic for some patients that it almost turns their lives upside down," says James Daubert, MD, the new director of the Duke Heart Center’s electrophysiology (EP) program.

Even worse than unpleasant symptoms, says Daubert, the irregular rhythm can contribute to heart failure, while ineffective pumping allows blood to pool in the ventricles and atria -- turning the chambers of the heart into a breeding ground for blood clots.

In fact, atrial fibrillation is responsible for about 15 percent of strokes.

Managing these symptoms and sequelae has long been a hit-or-miss proposition. The usual front lines of defense -- drug therapy to alleviate the arrhythmia and prevent stroke -- are often ineffective or fraught with complications.

But recent advances in understanding the physiology of AFib are leading to new treatment strategies, including safer, more effective medical management and sophisticated catheter ablation techniques that are providing a new alternative to drug treatment.

At Duke, electrophysiologists, cardiologists, cardiovascular surgeons, and other specialists on the forefront of these efforts are banding together to mount a new attack on AFib -- the Duke Center for Atrial Fibrillation (DCAF).

"The spectrum of therapies necessary to treat AFib today falls under different specialties, and we created the DCAF to draw on our depth of resources," says the center’s director, electrophysiologist Tristram Bahnson, MD.

"As treatment for AFib becomes more precise and personalized, we are bringing together a convergence of specialists to formulate how best to care for each individual patient."

A New Aproach to AFib

Treatment of AFib usually begins with a constellation of drugs, each selected to slow the heart rate, restore the heart’s normal rhythm, or prevent stroke. But medical management of AFib can be problematic.

More than half of patients treated with antiarrhythmic drugs report recurrences of atrial fibrillation within a year of the start of treatment, according to several nationwide studies. And when not used carefully, these drugs can actually trigger dangerous heart rhythms or other serious side effects.

For example, one of the most effective antiarrhythmics, amiodarone, can produce side effects such as skin discoloration, photosensitivity, thyroid imbalance, liver inflammation, or decreased lung function in as many as 30 percent of patients who take the drug for long periods. It also can interfere with the action of anticoagulant drugs, which most AFib patients should take to help prevent stroke.

And while antiarrhythmic drugs may improve symptoms, they do not improve mortality rates compared with those of AFib patients treated with rate-control drugs such as beta-blockers.

Catheter ablation, which cauterizes and neutralizes small spots of heart tissue that generate abnormal electrical patterns, is gaining ground as a strategy to help AFib patients who don’t respond to antiarrhythmic medication. According to a collective review of six smaller studies published in 2003 and 2004, roughly 80 percent of patients in their 50s and 60s who received the minimally invasive procedure were free from recurrent episodes.

"In the past, people who could not get good control of their AFib with medication just had to suffer the symptoms as best they could or perhaps undergo major surgery," says Bahnson.

Today, with catheter ablation as a proven alternative for patients who have failed drug therapy, the Duke team is able to control symptoms in more than 90 percent of people seeking treatment, he says. The DCAF currently performs the highest volume of AFib catheter ablations in North Carolina, and Bahnson expects the procedure’s popularity to grow.

Although it’s just coming into its own as a treatment for AFib, ablation to treat other abnormal heart rhythms has been around for several decades. In fact, cutting or removing pieces of heart tissue to cure arrhythmia was pioneered at Duke.

In 1968, a Duke team performed the first successful ablation surgery to treat abnormal heartbeats in a 32-year-old fisherman who had Wolff-Parkinson-White syndrome -- a disorder that causes AFib or other fast heart rhythms.

In 1987, James Cox, MD, a cardiothoracic surgeon at Barnes-Jewish Hospital in St. Louis who had trained at Duke, showed that he could cure AFib by making and then suturing multiple incisions in a grid-like pattern of lines through the atrial chamber walls -- a technique known as the Cox maze procedure, or simply "maze."

The idea was that the incisions would leave lines of scar tissue that could act as barricades, blocking impulse propagation in the heart chamber and preventing AFib from being sustained. Maze surgery is still performed to treat AFib, but usually in conjunction with other major open-heart surgery.

The maze surgery was complex and daunting to imitate with a catheter, says Daubert, who was in training at Duke around that time. When Cox introduced the surgery, many assumed that the electrical source of atrial fibrillations originated within the atria itself.

That idea was challenged as other doctors tried maze and discovered that the pulmonary veins were usually "the money spot" for the origin of the abnormal heartbeat.

"The discovery that it was coming from the pulmonary veins made catheter-based treatment a more feasible target," Daubert says.

Other strategies were also being tested, such as the use of implantable cardioverter defibrillators, or ICDs, to shock the heart and restore normal rhythms. For patients with ventricular arrhythmias, which are sometimes accompanied by atrial fibrillation, ICDs are commonly used, and the devices have been shown to reduce the incidence of sudden cardiac death in patients with heart failure.

In the late 1990s, researchers tried ICDs as a therapy for atrial fibrillation. While the devices worked to shock the heart back into normal rhythm and to reduce the frequency of AF episodes, the shocks were painful and were needed too often to make the treatment practical, Daubert says.

In the late 1990s, Daubert and others did their first catheter ablations to treat atrial fibrillation. It was slow going in this early stage of the technique: they would put the catheters in the heart and wait for the first signs of abnormal activity. Was it coming from the left pulmonary vein, or the right? The doctors would leave the catheters in different regions of the heart, sometimes for hours.

They tried to speed the process along by artificially pacing the heart into AFib and then restoring normal rhythm with a shock, hoping to stir up the sites that led to a recurrence of AFib.

"The problem was that sometimes [the fibrillation] wouldn’t happen during that procedure," Daubert says. "Sometimes, it would come from one vein and we’d ablate there, but another day it would come from a different vein and we hadn’t ablated there."

Over the next few years, it became clear that electrophysiologists needed to ablate around all four pulmonary veins, regardless of where initiating arrhythmias were observed. By then the potential benefits of the treatment began to crystallize.

Better Ablation

Bahnson is also encouraged by the rapid development of ablation and the potential for the technique to improve lives. In fact, the results are so promising that they raise the question of whether ablation could become a first-line therapy for atrial fibrillation.

However, Bahnson cautions, a few important unknowns remain about the procedure’s long-term effectiveness. Bahnson is one of the principal investigators of a large, multi-site investigation coordinated by the Duke Clinical Research Institute that will compare catheter ablation with drug therapies for initial treatment of atrial fibrillation.

"This study will likely be a definitive one to determine whether mortality or stroke rates in AFib patients are improved by catheter ablation as compared to treatment with medications only," says Bahnson.

Meanwhile, Daubert is beginning research that will look at outcomes of ablation treatment in older patients.

"Most patients with AFib are in their 70s or even 80s," he says. "We don't have a lot of data as to whether the ablation is as safe or effective in this group as it is in younger patients."

Catheter ablation does come with risks and challenges. For example, in rare cases, the ablation procedure itself can cause blood clots and subsequent stroke. In other rare instances, parts of the body, such as the esophagus, can be injured during the procedure.

Researchers in the DCAF are investigating a range of novel technologies to make catheter ablation safer and more effective. For example, Duke recently began working with a new system, Hansen Medical’s Sensei X Robotic Catheter System, which allows catheters to be manipulated with greater control and precision within the heart. Outcomes research is under way to establish the value of this system and develop it further.

Other DCAF research is testing arrhythmia-mapping techniques to identify areas that should be targeted for ablation and to determine when enough ablation energy has been delivered at any given site within the heart.

"A big question in the catheter-ablation arena is how do you know when you’ve created a lesion in the heart that’s sufficient?" says Bahnson.

The DCAF group is now assessing catheter-created lesions in real time, working with Duke bioengineers on intracardiac ultrasound techniques that image the heart from within.

Various types of catheters in development might also make ablation safer and easier. Duke physicians are working on one new type that freezes heart tissue instead of cauterizing it, as with radiofrequency ablation. Daubert says the technique, called cryoablation, may make ablation safer than with traditional methods.

"If we’re ablating too close to the pulmonary vein, we could cause it to scar or narrow," Daubert says. "With the cryoablation, that problem is almost completely eliminated."

Another new type, an irrigated catheter, has six pin-sized holes at the tip that can be flushed with saline to prevent the catheter tip from overheating, thereby reducing the risk of blood clots. Both new catheter types, Daubert says, may help minimize the risk of stroke.

New techniques may also make catheter ablation for AFib more efficient. Daubert is currently experimenting with inflating a balloon at the opening of the pulmonary vein, which allows physicians to ablate all the way around the vein using radiofrequency energy or freezing techniques, rather than having to make small lesions, point by point, sometimes over the course of several treatments.

Personalized Rhythms

Despite the impressive advances in catheter ablation, the procedure may not be necessary or appropriate for all patients.

"There are so many players that act in the development and continuation of AFib," says Patrick Hranitzky, MD, director of the EP fellowship program at Duke, who is leading research to better understand the condition.

"It’s very difficult to decipher what all the contributors are," which can make it tough for physicians to select the best treatment.

For example, Hranitzky says, "There’s a clear difference in the mechanism of AFib in a 30-year-old marathon runner as opposed to an 80-year-old with a long-standing history of hypertension -- these differences involve not only what sustains it but what initiates it."

In the marathoner, extreme physical stress can cause changes in electrical properties within the heart, triggering episodes of AFib in athletes predisposed to the condition.

In contrast, an elderly person might develop AFib because of age-related structural changes in the heart muscle. The heart becomes less flexible, and can develop tiny scars or fibrosis that can worsen with time, especially if high blood pressure is not controlled. This fibrosis can cause atrial fibrillation.

For the marathoner, doctors aim to prevent the triggering of the arrhythmia, Hranitzky says. If the triggers can be identified -- usually they are found near the junction of the pulmonary veins and the left atrium of the heart -- the arrhythmia can often be effectively treated with antiarrhythmic medications that abate the triggers, or cured with catheter ablation.

The elderly person, however, has a more complex situation. His heart cells have undergone a process of “remodeling,” and merely eliminating the triggers does not suffice.

"We must also alter the remodeled substrate," Hranitzky says, using either drugs or ablation to target the affected heart tissue.

The researchers are now probing deeper into what makes AFib different in each person.

"Clearly there are people who have genetic predispositions to AFib," says Hranitsky, but "it’s not going to be a single gene that determines whether someone will have AFib or not."

To help untangle the complex causes of the condition, Hranitzky and his colleagues began assembling a biorepository and clinical database for arrhythmia research in 2006 -- collecting DNA, messenger RNA, and protein from consenting patients in the electrophysiology lab.

By identifying alterations in these molecules, the researchers hope to find new clues about the underlying mechanisms of atrial fibrillation. They plan to look for genetic or molecular predispositions based on gender, age, and race differences, as well as for differences in the way individuals respond to treatment. The findings could lead to better prevention strategies and more targeted treatments. Researchers at other institutions are working on these same types of studies.

"In reality it’s going to take a collaborative effort among many centers," Hranitzky says. "We’re not going to have all the answers, but personalized treatment for arrhythmias is something that we’re moving toward."

Daubert, who created and led the University of Rochester’s heart rhythm program until he returned to Duke this summer, says the range of new AFib treatment techniques and technologies introduced over the course of his career is heartening -- just a decade ago, for his patients with AFib that didn’t respond to medical therapy, he could do little more than watch their hearts quiver. He says he’s pleased to be back at his alma mater to tackle the next frontiers in atrial fibrillation.

"Coming back to head up the program that pioneered some of these ideas that have brought us this far is really an awesome opportunity. This is a team with the expertise and drive to truly make a difference in people’s lives."

This article was first published in the Fall 2009 edition of DukeMed Magazine.