Treatment Alternatives in Charcot Arthropathy of the Foot

December 2015
10
CASE STUDY
Treatment
Alternatives
in Charcot
Arthropathy
of the Foot
A patient avoids amputation
Resources for Staying
Current in Your Field 4
Personalizing Options
for Vaginal Repair
8
Transitioning Young Patients
to Adult Heart Care 14

Clinical Practice Today
Duke Medicine Marketing
and Communications
Editor
Mary Jane Gore, MA
Publisher
Med-IQ
Editorial Management
Laura Rafferty
Lisa R. Rinehart, MS, ELS
Sherri Damlo
Writers
Karen Appold
Frank Celia
Meredith Lidard Kleeman
Emily Paulsen
Tim Pittman
Shelly K. Schwartz
About Duke Medicine
U.S. News & World Report consistently
ranks Duke University Hospital in
its Honor Roll of top hospitals in the
United States.
We strive to transform medicine and
health locally and globally through
innovative scientific research, rapid
translation of breakthrough discoveries,
educating future clinical and scientific
leaders, advocating and practicing
evidence-based medicine to improve
community health, and leading efforts
to eliminate health inequalities.
To refer patients, call 844-790-2013.
For more details on the services we
offer your patients, please visit
DukeMedicine.org.
Duke University Hospital, Durham, NC
Duke Regional Hospital, Durham, NC
Duke Raleigh Hospital, Raleigh, NC
Duke University, 3100 Tower Blvd., Suite 1008
Durham, NC 27707-2575
Materials may not be reprinted without
written consent from the publisher.
If you wish to be removed from the mailing
list, please email info@med-iq.com or
call 866-858-7434.
©2015 Duke Medicine. All rights reserved.
in Clinical Practice Today
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Resources for Staying Current in Your Field
Review updates in your clinical area with these easy tools
Pediatric Brain Tumor Surgery
The most common types of pediatric tumors are those
in the posterior fossa, such as gliomas, medulloblastomas,
and ependymomas
Four Strategies for Managing Patients
Who Refuse Vaccinations
Consider following these approaches to encourage patients
to vaccinate themselves and their children
Personalizing Options for Vaginal Repair
Prolapse can be surgically corrected with vaginal, minimally
invasive, or abdominal surgery
Safeguarding Medical Identities
Keep your practice and your patients safe by implementing
a few basic precautions
CASE STUDY
Treatment Alternatives in Charcot Arthropathy
of the Foot
A patient avoids amputation
Essential Tech Functions for Office-Based Doctors
Think beyond electronic health records by using products
that help fulfill the Triple Aim
Lowering HbA1C in a Patient With Other
Health Challenges
Clinicians should consider barriers to health care and
psychosocial factors when managing patients with
complex needs
Transitioning Young Patients to Adult Heart Care
Speak with pediatric patients with congenital heart disease
even before they enter their teens
To learn more or
to refer a patient,
call 844-790-2013

News Briefs
Life-Changing Dialysis
Graft Reduces Patient
Pain, Saves Costs
A life-changing arteriovenous graft developed at
Duke could prevent pain and bruising for dialysis
patients and help prevent complications responsible
for millions of dollars in annual health care costs.
The device is progressing toward commercial use.
The Bullet Proof graft includes 2 penetrationresistant
chambers that prevent needles from
damaging the soft tubing used in dialysis.
Standard dialysis grafts ensure a strong blood
flow through the hollow tube or conduit, but
during dialysis, they are vulnerable to needle
pokes that accidentally push through both sides
of the graft. These inadvertent pokes create
painful injuries that can be expensive to repair.
With support from Duke’s clinical translational
funding programs, a team of researchers plans to
release the medical device within 1 year.
ICDs Underused
Among Older Patients
After Heart Attack
Research from Duke’s Sean D. Pokorney, MD, MBA,
published in the June 23-30, 2015, JAMA issue,
reported data regarding concerns about the underuse
of implantable cardioverter-defibrillators (ICDs) in
older patients who experienced a heart attack.
According to the findings, among Medicare
patients who experienced a heart attack from
2007 to 2010, fewer than 1 in 10 eligible patients
with low ejection fraction (a measure of how well
the left ventricle of the heart pumps blood with
each beat) received an ICD within 1 year after the
heart attack, even though ICD implantation was
associated with a lower risk of death at 2 years after
the heart attack. (X-ray above shows an ICD.)
Modified Poliovirus
Being Tested Against
Incurable Prostate Cancer
Duke’s success in early clinical trials using modified
poliovirus to treat a deadly form of brain cancer may
lead to new applications for the virus in the battle
against incurable metastatic prostate cancer.
An interdisciplinary team applied the new therapy,
known as PVSRIPO, to late-stage prostate cancer.
PVSRIPO has been modified and managed with the
addition of rhinovirus. The engineered virus specifically
targets and destroys tumor cells while leaving
healthy cells unscathed. Animal testing is underway
in mice. Smita Nair, PhD, a principal investigator and
cancer immunotherapy researcher in Duke’s Surgery
Department, is working to apply the modified virus
to non–central nervous system challenges.
Daniel J. George, MD, a medical oncologist, says
physicians are focused on finding new therapies
that can extend lives and attack prostate cancer.
December 2015
ClinicalPracticeToday.com
3

Resources for
Staying Current
in Your Field
By Shelly K. Schwartz
Review updates in your clinical area with these easy tools
It began like any other journal club meeting.
Anesthesiology residents were gathered in a
Duke University School of Medicine classroom
to review the latest medical literature from their
specialty—evidence-based research that might
move the needle on treatment protocols and
patient outcomes. As the discussion on aspirin use
in patients undergoing noncardiac surgery got
underway, moderator Ankeet Udani, MD, began
reading aloud comments from thought leaders
across the globe who had weighed in remotely via
Twitter. Sporadically, he also read relevant tweets
from clinicians outside of the Duke University
system who were participating in real time. “We
were looking for a way to augment the current
classroom format using social media and realized
that most medical students and residents are already
using Twitter,” says Udani, an assistant professor
of anesthesiology and co-creator of the Duke
Anesthesiology Twitter Journal Club with colleague
Jeff Taekman, MD. “We wanted to provide a broad
perspective for our residents of what people are
doing in our field around the world.”
Topics for the quarterly journal club, drawn from
recent studies and journal articles, get posted to
Twitter 1 week before the in-person meetings,
Udani explains, inviting clinicians, academics, and
experts to contribute. The input they provide and
the online comments sent in during classroom
discussions are later organized and posted online,
which sets the Duke Anesthesiology Twitter
Journal Club apart. “Ours is not the first online
journal club, but we are unique because we
moderate the online Twitter feed and curate the
entire discussion to create an everlasting resource
for all anesthesiologists,” says Udani.
Social media is among the many tools that
clinicians are using to keep current in their field,
a matter of critical importance to patient safety
and the quality of care. In a 2014 survey by online
medical network Doximity, 98% of physicians
reported that reading medical literature was either
“important” or “very important” to their practice,
and 16% believed that staying current directly
helped save the life of a patient in the last year.
But reading every published article is neither practical
nor possible. Moreover, not all are relevant
to every specialty; in addition, some lack scientific
validity and still others are tainted by bias. To
keep their knowledge base fresh, physicians must
become adept at separating the wheat from
4 Clinical Practice Today from Duke Medicine

the chaff or rely on resources that vet scientific
literature on their behalf.
Professional Groups
A good starting point is the medical guidelines
from reputable professional organizations, which
provide clinical recommendations regarding
the diagnosis, management, and treatment of
diseases, says Bernard Sklar, MD, a family physician
and Webmaster for CMElist.com. “Most doctors
are guided by their professional organizations, each
of which have their own set of competencies that
they think doctors need to be updated on,” he says.
RSS Feeds
Most professional organizations also offer a
subscription-based RSS feed, enabling clinicians to
automatically download relevant articles to their
computers. Many peer-reviewed medical journals
offer the same service, including the British
Medical Journal. RSS feeds appear as a series of
headlines and summaries, enabling doctors to
quickly locate content that matters to them.
Review Organizations
To answer specific clinical questions related to
patient care, the American College of Physicians
suggests that doctors begin their literature
search with a resource such as PubMed, a free
online search engine from the US National Library
of Medicine that acts as a database for the
most important abstracts and journal citations
published in MEDLINE. The PubMed search tool
allows users to create filters that help weed out
irrelevant content. For example, the systematicreviews
filter displays citations for systematic
reviews, meta-analyses, reviews of clinical trials,
guidelines, and other reviews.
Mobile Health
Mobile apps also help bring the current body of
medical knowledge into the examination room.
Two of the most widely used apps are DynaMed
and UpToDate®—evidence-based, clinical decisionsupport
resources that integrate findings from
research studies. Docphin and Read by QxMD
also provide access to medical literature from a
wide range of journals. In addition, groups like
Cochrane Library offer a collection of high-quality,
independent evidence to inform health care
decision making. Many medical organizations
enable specialists to download clinical guidelines,
white papers, and best-practice statements to
their personal devices.
Modern Medicine
Facebook, Twitter, and Google+ offer yet another
platform for keeping current, as sites like Cochrane
Library become active on social media. Blogs,
including those from PLoS One, can also shed new
light on evidence-based therapies. In addition,
audio podcasts from influential medical journals
and medical schools, including the New England
Journal of Medicine and Johns Hopkins Medicine,
can help keep practicing physicians informed
about current medical news while delivering the
added benefit of expert opinion.
Whatever tools physicians use to help keep pace
with innovation, they must always evaluate the
literature with a critical eye, says Brian Alper, MD,
MSPH, a family physician and founder of DynaMed.
Threats to validity abound—some due to bias
and some due to error. “It’s complicated how
many different factors can bias our science,” says
Alper. “You have to look at the details of how the
research came together.”
The best resources are timely, trusted, and
capable of condensing the complete body of
medical literature into summaries that are useful
to physicians at the point of care. “Health care
professionals need the best information available
to help guide their practice, and the information
keeps changing,” says Alper.
December 2015
ClinicalPracticeToday.com
5

Pediatric Brain
Tumor Surgery
Although pediatric neurosurgeons assess and
treat a wider variety of conditions than their
colleagues who treat adult patients, specialized
centers for pediatric tumors and spine conditions
offer specific programs for some patients.
Eric Thompson, MD, a Duke pediatric neurosurgeon
and tumor specialist, leads the Duke
University Medical Center multidisciplinary
pediatric brain tumor board composed of
neurosurgeons, neuro-oncologists, radiation
oncologists, neuroradiologists, neuropathologists,
and trainees from those fields. The board
discusses cases and reaches a consensus on treatment
plans for the most challenging tumor cases.
The most common types of tumors treated in
children are those in the posterior fossa, including
gliomas, medulloblastomas, and ependymomas.
Metastases, although fairly rare, occur in up to 5%
of children with solid tumors.
Larger centers often offer the advantage of
cutting-edge technology as well as clinical expertise.
Intraoperative magnetic resonance imaging
(MRI) is frequently used at Duke to facilitate the
maximal safe removal of brain tumors. Another
significant advantage is the ability to enroll
children in clinical trials, especially patients whose
cancer has progressed. Duke is a member of both
the Pediatric Brain Tumor Consortium and the
Children’s Oncology Group.
When to Refer
Parents most commonly ask pediatric neurosurgeons
the following 2 questions:
• Is the child’s head an abnormal shape?
• Is the child’s head too large?
The answers to these questions suggest when
referral to specialists might be prudent. If a child’s
head is flat in the back and the head is clearly not
getting rounder after several months of prohibiting
the child from laying on his or her back, then
it is time to refer to a pediatric neurosurgeon.
Regarding head size, there is usually not cause for
alarm unless the head has begun to grow at an
accelerated rate. “If a child’s skull size is crossing
multiple percentiles, that would be a good time to
refer,” Thompson says.
Duke welcomes the opportunity to work closely with
community physicians to treat pediatric patients with
brain and spine tumors, craniosynostosis, vascular
disease, epilepsy, spina bifida, hydrocephalus, and
spasticity. To learn more or to refer, call 844-790-2013.
(T2-weighted MRI reveals a medulloblastoma.)
6 Clinical Practice Today from Duke Medicine

Four Strategies for Managing
Patients Who Refuse Vaccinations
By Meredith Lidard Kleeman
Thanks to immunizations, the United States has very low rates of vaccine-preventable diseases such as
measles, mumps, and polio, according to the Centers for Disease Control and Prevention (CDC). Yet, despite
the success rates of immunizations, some patients refuse to vaccinate themselves and their children.
Understanding your patients’ objections is the first step in trying to encourage them to get vaccinated, says
Robert Wergin, MD, board chair of the American Academy of Family Physicians. Wergin shares his strategies
for responding to common patient concerns.
1
Emphasize safety. Many of the patients in
his practice are concerned about vaccine
safety, Wergin says. They may have heard
about the infamous article linking autism
to the measles, mumps, and rubella (MMR)
vaccine. Physicians can address this concern by
informing patients that there is clear proof that
the MMR vaccine does not cause autism and
letting them know that the antivaccine study
has since been discredited. Wergin also advises
physicians to explain that, although vaccines are
associated with some risks, they are extremely
low. He tells his patients that the risks are about
the same as being struck by lightning.
Explain herd immunity. Most people,
2 including many medical professionals, have
never experienced polio, measles, or mumps
firsthand. This lack of first-hand knowledge can
make patients believe that these diseases are no
longer a threat. Remind patients that because
of herd immunity, as long as everyone around
them continues to get vaccinated, the threat of
contracting those diseases remains low; however,
if enough members of a community do not get
immunized, those diseases could reemerge.
3
Practice “cheerful persistence.” Wergin
talks to his patients about vaccines at
every visit and begins the conversation about
immunizations as early as possible, starting
with prenatal and well-baby checkups. “I have
a group of patients who have a lot of concerns,
but sometimes with my ‘cheerful persistence’
technique, their kids will get immunized, but it
may be a little late,” he says.
4
Define your practice’s policies. Some
pediatric practices strictly adhere to the
CDC-recommended immunization schedule
to motivate patients to get vaccinated, whereas
other practices are willing to alter the schedule
for patients with concerns. As the only doctor
in his rural community, Wergin wants to
remain a trusted resource for his patients.
“I try to adhere to the CDC guidelines, but,
personally, I choose to keep fostering the
[doctor-patient] relationship…and keep
prodding gently toward getting the vaccines,”
he says. “But each practice has to decide
how they’ll handle those issues.”
December 2015 ClinicalPracticeToday.com 7

Personalizing
Options for
Vaginal Repair
A married 65-year-old woman with 2 adult
children called her primary care physician because
she had noticed a concerning bulge near the
opening of her vagina. At a Duke Primary Care
clinic, she described something bulging from her
vagina that seemed to grow in size after straining
to have a bowel movement on a day she had
gardened for hours. The doctor informed her that
the condition was vaginal prolapse.
She was referred to Duke Urogynecology for an
evaluation of pelvic organ prolapse. The patient
said she now had to push the bulge inside daily.
An otherwise healthy, active woman, she was not
experiencing pain but felt incomplete bladder
emptying and hesitancy when voiding.
Amie Kawasaki, MD, the treating urogynecologist
at Duke, discovered that the anterior vaginal
wall supporting the bladder as well as the uterus
had prolapsed beyond the opening of her vagina.
After measurements, the patient was diagnosed
with stage 3 uterovaginal and anterior vaginal
prolapse. Several nonsurgical and surgical
treatment options were discussed.
“Some prolapse is very mild and can be observed
and treated with physical therapy, but more
significant prolapse can either be managed with
a silicone pessary or with surgery,” Kawasaki says.
Prolapse can be surgically corrected with vaginal,
minimally invasive (laparoscopic and/or roboticassisted),
or abdominal surgery. Some surgical procedures
are performed with native tissue, whereas
others incorporate synthetic mesh material.
Aware of all options, the patient wanted the
longest-lasting repair so that she could resume
gardening and other activities for years to come.
The urogynecologist performed robotic-assisted
laparoscopic hysterectomy with mesh sacrocolpopexy.
The indication for this procedure is
advanced vaginal prolapse involving the uterus, or
vaginal vault in the case of a prior hysterectomy.
Afterward, the patient was comfortable and ate a
regular dinner in the hospital. Six weeks later, she
returned to all of her typical activities.
Duke Urogynecology specializes in treating
vaginal prolapse, bladder control problems, and
bowel leakage. Duke’s team of doctors, nurses,
and physical therapists works with patients to
find the right nonsurgical and surgical solutions
for their activity level.
To refer, call 844-790-2013. (Image above shows
robotic-assisted laparoscopic hysterectomy.)
8 Clinical Practice Today from Duke Medicine

Safeguarding
Medical Identities
By Frank Celia
Cyber criminals are now turning their sights on
the less-protected area of medical data, experts
say. According to the research firm Ponemon
Institute, medical identity theft affected 1.4
million people in 2009 and 2.3 million in 2014.
Rick Kam, CIPP/US president and co-founder of ID
Experts, which designs security software, says,
“One reason to take this seriously is that it can
be a threat to the continued operation of your
business.” To discourage identity theft, consider
following some basic precautions.
Know your weaknesses. Earlier this year, several
large health care organizations fell victim to data
breaches. The most common point of ingress?
Email. Always use a secure email system, especially
if patients communicate with your practice
this way. (ProtonMail, Tutanota, and Lavaboom
are examples of secure email providers.)
Encryption is the key to digital security, says Kam.
Almost all digital devices offer encryption for free
or as a built-in function. “As soon as you pull the
device out of the box, make sure the encryption is
on,” he says. “That’s about as complex as it needs
to get.”
Another point of weakness: the telephone.
Thieves may pose as health care professionals
seeking patient information over the phone.
With access to just 1 patient’s data, Medicare
or insurers can be bilked of thousands of dollars.
When unknown clinicians call, take their contact
information and offer to call them back. Then, check
their geographic location against the patient’s.
Staff training. Every practice needs a written
data security policy. Topics should include procedures
for transporting data offsite and using
mobile devices, protocols for departing staff (eg,
changing passwords), and parameters on personal
device use (eg, surfing the Internet). At least
1 staff member should be in charge of implementing
and continually updating this policy.
Additionally, make sure that staff members can
recognize the hallmarks of “phishing” emails
(ie, ones designed to infect systems with malware
or viruses). Just opening such an email can infect
an entire system.
Paperwork. Never sign referrals for unknown
patients. Because payers are sometimes the first
to detect discrepancies, keep enrollment information
updated. Make sure to promptly inform
payers when opening, closing, moving, or separating
from a practice. Lastly, compare remittance
notices with patient records whenever possible.
December 2015
ClinicalPracticeToday.com
9

CASE STUDY
Treatment
Alternatives
in Charcot
Arthropathy
of the Foot
Early postoperative phase with foot stabilized
in thin-wire frame construct.
A patient avoids amputation
A 72-year-old man with type 2 diabetes mellitus
was referred to Duke Medicine in October 2014
for treatment of Charcot arthropathy of the foot,
a sequela of diabetes. Although his blood glucose
levels had been well controlled for 5 to 6 years,
he developed numbness, pain, and peripheral
neuropathy in both feet.
In October 2014, he was referred to a local
orthopaedic surgeon who diagnosed Charcot
arthropathy of the midfoot based on radiographic
findings. Due to severe arthropathy, osteomyelitis,
and skin ulceration, the patient was offered
below-the-knee amputation or referral for a
second opinion.
“Charcot arthropathy is an uncommon complication
in patients with long-standing diabetes
and peripheral neuropathy,” says Beatrice Hong,
MD, a diabetologist at Duke, who did not treat
the patient. “The presentation is variable, initially
with warmth and swelling that progresses into a
characteristic collapse of the arch of the midfoot,
resulting in bony prominences.”
One month earlier, the patient had noticed
redness and swelling in his left foot and was
treated for presumptive cellulitis. Fragmentation
went unnoticed on radiographs. He continued
walking on the foot and developed a skin ulcer
on the lateral plantar aspect. Subsequently, he
received local debridement and more antibiotics.
If it is diagnosed before destructive changes of
the bone/joint take place, Charcot arthropathy
can often be managed with casting, offloading
braces, custom shoes, and orthotic devices.
However, when the bones and joints have become
unstable, fragmented, and malaligned with
compromised skin and soft tissue, surgery is
typically necessary. Reconstructive surgery might
be a viable option to avoid amputation.
In Charcot arthropathy of the foot, the goal of
surgical intervention is to realign and stabilize the
foot with osteotomies, arthrodesis, and internal
and/or external fixation. Unfortunately, the foot
cannot always be salvaged, and amputation may
be necessary for some patients. Many factors
10 Clinical Practice Today from Duke Medicine

can influence patient outcomes, including loss
of protective sensation in the lower extremities,
obesity, poor bone and soft-tissue quality, peripheral
arterial disease, and immunosuppression.
At Duke Orthopaedics, the patient met with
foot and ankle specialist Karl Schweitzer, MD, to
discuss possible treatment options.
“In a normal foot, the innervation to the joints keeps
us from putting too much pressure on our feet, but
in patients with peripheral neuropathy, that protective
sensation is diminished or absent,” he explains.
This particular patient was in the fragmentation/
dissolution stage of Charcot arthropathy. “Many
of these folks get missed because, clinically, it
looks like an infection and x-rays are not obtained
or considered,” Schweitzer surmises.
Schweitzer offered reconstructive surgery as an
alternative to amputation. “I told him that if he
was on board, we could try to salvage his foot,”
Schweitzer says. The patient agreed, and the
procedure took place in November 2014.
weeks, Schweitzer added a rocker attachment
on the bottom of the frame so that the patient
could walk on it, thus gaining some mobility and
independence.
At 3.5 months, computed tomography revealed
that the foot had healed and that no residual
osteomyelitis was present. Schweitzer removed
the frame and transitioned the patient to a
fracture boot and then, finally, to a custom
diabetic shoe.
“Now he’s ulcer free, and, more importantly, he
still has his foot,” Schweitzer adds.
Schweitzer stresses the importance of a multidisciplinary
approach. “Surgery is only one
component. It takes infectious disease and
hospitalist medicine specialists, along with
physical therapy, nursing, and nutrition services,
to appropriately care for these patients,” notes
Schweitzer.
Osteotomies were performed to help realign
the patient’s foot and prepare the bone surfaces
for fusion. Rather than using internal fixation,
which can be a site for infection, Schweitzer
applied an Ilizarov frame, a specialized form of
external fixation that is stronger than conventional
external fixation systems. Thin metal wires were
positioned in the bone at points along the foot,
ankle, and lower leg and then attached to a frame
of aluminum rings and stainless steel rods.
Schweitzer says the wires are tensioned within
the frame. “It is so strong,” he explains, “that we
allow the patients to weight bear in the frame.”
The patient wore the apparatus for 3 to 4
months, which is how long it takes to achieve
adequate stabilization. However, after 4 to 6
Preoperative photograph of patient’s foot revealing
deep plantar foot ulceration that probes to
bone (left).
Healed soft-tissue envelope, including prior plantar
foot ulceration area, following frame removal (right).
December 2015
ClinicalPracticeToday.com
11

Essential Tech
Functions for Office-
Based Doctors
By Emily Paulsen
As electronic health record (EHR) adoption
among office-based physicians continues to
climb, an EHR alone may not be enough to meet
the needs of health care professionals and their
patients. In response to Medicare’s goal of tying
50% of payments to quality or value by 2018,
medical offices may need to expand their
capabilities in several areas that an EHR may
not adequately address.
“EHRs were originally built to capture charges
and for billing; they don’t necessarily improve
the quality of care or workflow for physicians,”
says Neil Versel, health information technology
reporter for MedCityNews.
Newer products—especially those designed for
small ambulatory practices—have added more
clinical features, says Andrey Ostrovsky, MD, CEO
of Care at Hand, a population health management
system, and co-author of the 2014 Institute
for Healthcare Improvement report, A Framework
for Selecting Digital Health Technology. But, he
adds, medical offices should not expect one
product to do it all. Instead, he suggests starting
with the essential functions required to fulfill the
Triple Aim (improving the patient experience of
care and population health while reducing
the cost of care) and then looking for the best
products to fulfill those functions, which include:
• Population health management. As reimbursement
becomes increasingly tied to prevention
and avoiding unnecessary hospitalizations,
medical offices need functions that can identify
patients who might be at risk of disease, relapse,
or readmission.
• Care management/coordination. Members of
the care team must work together to ensure
that patients have a care plan that incorporates
evidence-based disease guidelines.
• Patient engagement. Effective and efficient
care involves the patient through patient
portals and other patient-facing technology.
For example, medical offices may save time and
obtain a more detailed medical history with
technology that allows patients to enter data
themselves, Versel says.
• Quality measurement/improvement. Quality
measurement and improvement help ensure
that care teams are working effectively.
Unfortunately, Ostrovsky points out, few products
have been developed for this function.
• Integration and interoperability. Most importantly,
the systems should be able to share
information. “Patients and providers need to
very seamlessly and securely be able to access
the technology,” says Ostrovsky, thereby
allowing clinicians to focus on effective care
rather than navigating the technology.
12 Clinical Practice Today from Duke Medicine

Lowering HbA1C in
a Patient With Other
Health Challenges
In February 2014, a 51-year-old woman who
had been living with type 2 diabetes mellitus
for 21 years was referred to Duke Medicine’s
Endocrinology, Metabolism, and Nutrition division
by her primary care physician.
Her hemoglobin A1C (HbA1C) had been 14% for at
least 2 years and had not been below 9% since 2010.
The patient was on a basal-bolus insulin regimen,
but she reported difficulty adhering to the
treatment plan.
Her body mass index (BMI) was 33 kg/m 2 , and she
had diabetes-associated complications: stage 3
chronic kidney disease, gastroparesis, and neuropathy
in her feet. She also had hepatic steatosis,
hypertension, hyperlipidemia, chronic pain, and
fibromyalgia. Leonor Corsino, MD, learned that
the patient also had bipolar affective disorder.
“It’s critical to ask the patient about barriers to
health care and to assess psychosocial factors,”
Corsino notes. The biggest challenges in this case
were pain and bipolar disorder.
Corsino discussed with the patient that her
mental health probably played a role in glucose
control and slightly adjusted the insulin doses,
prescribing 130 units of insulin glargine at
bedtime and 40 units of rapid-acting insulin
aspart at meals. The insulin glargine was
prescribed as 2 injections of 65 units. The patient
took no other antihyperglycemic medications,
such as metformin, because of diminished
kidney function. To manage obesity, she was
prescribed lorcaserin.
Corsino sends patients “with mental health
issues that could affect information processing
for individual diabetes education,” she says.
The patient had been prescribed pregabalin,
duloxetine, and gabapentin for the management
of neuropathy and chronic pain without success,
so Corsino also referred her for a neurology
consultation and contacted the patient’s mental
health care clinician to discuss her proposed goals.
The patient had 4 follow-up visits in the first year—
a step that Corsino considers crucial for success
with patients who have complex needs. By August
2014, the patient’s HbA1C had decreased to 7.8%,
her lowest value since at least 2009. Her fasting
and mealtime blood glucose levels were mostly
at goal, and she had very few readings above
180 mg/dL after eating. Her BMI had decreased
to 31 kg/m 2 . To refer, call 844-790-2013. (Image
shows a blood glucose meter.)
December 2015
ClinicalPracticeToday.com
13

Transitioning
Young Patients to
Adult Heart Care
Pediatric patients with congenital heart disease
generally receive the care they need to thrive
throughout childhood, but, as they make the
transition to adult care, several challenges
should be considered to keep care continuous
and tailored to adult needs.
Patients, caregivers, and physicians need awareness
about the special needs of this transitional
group of patients. Richard Krasuski, MD, who
heads the Duke Adult Congenital Heart Disease
Program, says that almost all patients with
congenital heart disease are at risk of developing
3 common problems: heart failure, rhythm
disorders, and pulmonary hypertension.
If heart failure develops, medications or pacemaking
devices can be used to help the heart
pump more effectively. Sometimes, a patient
simply needs a repair on a leaky heart valve or
a surgical patch on a hole in the heart that was
placed decades earlier. These procedures can be
done with surgery or in the catheterization laboratory.
If the disease is too advanced, some patients
may need a heart or even heart-lung transplant.
Rhythm disturbances can originate in the upper
heart chambers (atria) or lower heart chambers
(ventricles). Although patients often view atrial
rhythm disorders as just a nuisance, they can
interfere with well-being and increase the risk of
stroke. A ventricular arrhythmia, however, could
lead to more severe problems, including sudden
death. If ventricular arrhythmia is diagnosed,
patients need immediate medical attention.
Krasuski says that rhythm disturbances can be
a sign of blood flow problems, such as blockage
in arteries or leaky valves. “Each patient with a
rhythm disturbance needs a careful look at their
internal plumbing,” he says. “It may not be the
heart’s rhythm that is the primary problem.”
The third potential problem to watch out for
is pulmonary hypertension, an elevation of
pressure in the blood vessels of the lung. “This
can be due to a back-up in blood flow from the
pumping chamber to the body (so-called pulmonary
venous hypertension),” Krasuski says. “It can
be related to leaky or narrowed heart valves or a
weakened heart muscle.”
If the primary issue is an abnormality in the
lung vessels themselves, then it is referred to as
pulmonary arterial hypertension. This is often
the result of abnormal communications (shunts)
in the heart and can even occur long after they
have been successfully repaired. Pulmonary
arterial hypertension can be treated with medications,
catheter procedures, or surgery.
14 Clinical Practice Today from Duke Medicine

At Duke, some patients with complex congenital
heart disease may be treated with a hybrid
procedure involving both a cardiac surgeon and
a cardiologist.
Continuing in Adult Care
Transitioning patients into adult care as they
leave their teens is not always easy. “We can
do remarkable things to treat congenital heart
patients as they age, but first they have to
consult with a doctor and be evaluated and learn
exactly what needs to be done,” Krasuski says.
“And that is a big part of the problem.”
For example, many patients are lost to follow-up
as they fall off of their parents’ health insurance.
“Another reason is that teens naturally chafe
against authority, and this can include neglecting
their commitment to health care,” Krasuski says.
“In other countries, including Canada, there is
better monitoring and preparation—this lapse
doesn’t happen as often.”
Krasuski explains, “Young
adults may let their appointments
or medications lapse or
may avoid making the transition
to heart specialists who
work with and understand
the problems of aging hearts.”
Some patients may delay
until they are in their 20s and
30s to see a new physician. The doctor may not
be a specialist in congenital heart disease and,
therefore, may be unfamiliar with their heart
issues and the details of prior surgeries. Lack
of communication with their previous doctors
may also exist. “Patients end up unsatisfied and
often return to the comfort of seeing their earlier
expert, a pediatrician or primary care physician,”
Krasuski notes.
Education Is Key
Some patients with
congenital heart
disease may wait
until they are in their
20s and 30s to see a
new physician.
Krasuski, who established an adult congenital
heart program at the Cleveland Clinic before
coming to Duke, says it is best to begin talking
about the transition period even before children
enter their teens.
“The stakes may be higher than patients and
families know,” Krasuski says. “Because of the
potential dangers, every patient should have
a well-informed primary care physician if they
don’t have a local cardiologist who understands
their case. They may not be able to travel 5 hours
if they are having emergent problems. We’re
fortunate at Duke that we can air transport
patients here when the need arises.”
Another reason for easing the transition is a
predisposition to adult diseases earlier in life.
Some people with congenital heart disease
may not know that they have a higher risk
than the general population
of developing high blood
pressure or coronary artery
disease, Krasuski notes. Other
problems can then develop,
including liver disease,
diabetes, varicose veins, and
peripheral artery disease.
“It’s best to have an adult
congenital heart expert lined
up,” says Krasuski, particularly one who understands
all levels of congenital heart disease,
from mild to severe cases, categorized per the
2008 guidelines from the American College of
Cardiology and the American Heart Association.
To learn more or refer a patient, call 844-790-2013.
(Image on previous page depicts a hole in the heart,
which is a congenital defect.)
December 2015
ClinicalPracticeToday.com
15

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