VOLUME 17 NO. 8 n inside.dukemedicine.org n August 2008

W O R K I N G

Work Culture Survey results

Feedback shows that satisfaction improved in eight of nine catego-ries and highlighted areas needing focus. Page 6

I N Q U I R Y

The obesity battle

Duke research is making great strides in understanding the complex connections between nutrition and health. Page 7

b U I l d I N G b l O C K S

On the grow

A new regular feature debuts – news about Duke Medicine's many expansion projects. Page 11

s t r e t c h e D tofitInnovative therapy – and a Wii – help a young man maintain his independence

By La-Tasha Davis

Surrounded by a smorgasbord of color in a room filled with games and playthings to suit the fancies of any

young person, 17-year-old Michael Dennos is beaming. His hands are planted firmly behind him on a cushioned platform as his physical therapist manipulates his upper body, elongating his spine and broadening the span of his shoulders. His long, thin frame yields to the doctor’s maneuvering as if it were instinctive.

The rising college freshman from Durham has been attending physical therapy sessions at Duke's Lenox Baker Children’s Hospital for more than 16 years, but start-ing in the fall he’ll have to adapt to a whole new way of living: a life of independence.

see MICHAEL, p.14

PhOtO ILLUstrAtION

O N T H E W E bI N S I d E S C O O P

Inside Duke Medicine

f E E d b a C K

2 August 2008

Highlighting the best health,

science and employee news

from Duke Web sites

I N S I D E V O L U M E 1 7 , I S S U E 8 nConTACT us Campus mail: DUMc 104030 Deliveries: 2200 W. Main st., suite 910-B, Durham, Nc 27705 Phone: 919.660.1318 E-mail: editorinside@mc.duke.edu

CrEDITs Cartoon: Josh taylor Cover photo: Jared Lazarus

sTAFF Editor: Anton Zuiker Managing Editor: Mark schreiner science Editor: Kelly Malcom Calendar Editor: erin Pratt Designer: Vanessa DeJongh Intern: La-tasha Davis copyright © 2008 Duke University health system

Inside Duke Medicine, the employee newspaper for the Duke University health system, is published monthly by Duke Medicine News & communications.

Your comments, story ideas and photo contributions are always welcome and appreciated. Deadline for submissions is the 15th of each month.

More than just food for thoughtEven though he first expressed

the idea that Americans today summarize as “You are what you eat,” the great insight that 18th century French lawyer Jean Anthelme Brillat-Savarin gave the world was not about food.

Instead, it was that one can write about food as one writes about any subject. And more than that, that writing about food, in and of itself, is nourishing to the mind. If the mind accepts those ideas, ideas can be beneficial to the body as well.

In the pages of this month’s Inside Duke Medicine, you’ll find intellectual nourishment on the subject of the body and its relation-

ship with food.On Page 3, get the latest details

about the late-summer freshness on sale at the Duke Farmer’s Market.

In Inquiry, read a report from Kelly Malcom about how Duke research is helping to fight the battle against obesity.

In this Olympic month, remi-nisce with coach Al Buehler about track and field glory on Page 13.

And, on Page 16, Anton Zuiker writes about how the act of thinking changes the way we eat.

A nourishing diet for the mind, no doubt – and all of it calorie free.

— Mark Schreiner

r E S O U r c E n

Around Town

A new Web site provides a comprehensive listing of the many arts, entertainment and cultural opportunities in Durham. Plan your next outing with this searchable database.

http://www.durhamculture.com/

P O D c A S T n

Arming the Donkeys

Predictably Irrational author Dan Ariely hosts a new podcast that lets listeners in on the kind of casual, clever conversations that research-minded Duke faculty members like to have over a cup of coffee.

http://www.dukenews.duke.edu/2008/07/ariely_podcast.html

r E A D I N G S n

Dr. Yes

Duke Magazine features 82-year-old physician and alumna Evelyn schmidt, M.D., who has worked for nearly 40 years to provide decent, affordable care for low-income patients at Durham’s Lincoln community health center.

http://dukemagazine.duke.edu/duke-mag/issues/070808/dryes1.html

PhOtO BY MIchAeL ZIrKLe

Last month, we asked for your comments about

Inside Duke Medicine, as it has changed shape, gone monthly and sharpened the focus on science, people and the growth of the Health System.

Our thanks goes to those who shared their feedback. Your comments were invalu-able. And, congratulations to Laura Delbridge, a laboratory technologist at Duke North. She won our drawing for a $25 gift certificate to the Medical Center Bookstore.

Please continue to send your comments to us. Our feedback form is always open. Go to our Web site – http://inside.dukemedicine.org – and follow the “share your thoughts” link.

On the topic of feedback, once a year, Duke Medicine employees are asked to complete the Work Culture Survey about what it means to work here. Participation in the 2008 survey was the highest yet,

with responses from 80 percent of eligible respondents (that’s more than 9,000 of us). Read about the results of the Work Culture Survey on Page 14.

One important statistic from that survey, we think, is that nearly all of the employees who completed the Work Culture Survey did so via the online form. We know that computers are indispensable tools

of communication in our work and lives.

With that in mind, later this month, we

expect to launch Inside Online, a daily news Web site

that will include far more than the newspaper ever could.

But don’t worry, the newspaper version of Inside Duke Medicine isn’t going anywhere – it will be both a newspaper and a Web site.

Look for more about Inside Online in the Sept. 1 issue.

— The Editors

What you told us

C a l E N d a R

learnAug. 13 7–8:30 p.m. Seminar “Oh My Aching Feet.” Explore the causes and solutions for common foot pain with speaker Jeremy Frye, P.T. Register: 416-3853

Aug. 19 6:30–8 p.m. 8-week grief support group. Open to those grieving the death of friends or family members. The group focuses on sharing and moving towards healing. Register: 416-3853

Aug. 19 7 p.m. Tools for your health: Stroke Durham Regional presents a free seminar to educate men on important health issues. Larry Goldstein, M.D., director of the Duke Stroke Clinic and medical director for stroke at Durham Regional Hospital, will discuss how to prevent strokes and how to care for yourself or a loved one after a stroke. The Ameri-can Stroke Association’s Power to End Stroke will also have representatives at the seminar. Durham Regional Hospital, First Level Classroom. Register: http://www.durhamregional.org

Aug. 23 9 a.m.–5 p.m. Thriving Through Cancer: An Integrative Approach Duke Integrative Medicine invites patients, survivors, friends and family members to explore cancer from the whole-person perspective. Discover how an integrative medicine approach, including both appropri-ate complementary and conventional therapeutic care, can make a difference for you and those you love. Join expert physicians and providers at Duke Integrative Medicine in Workshop AB. Register: 660-6826

sept. 3 4:30-6 p.m. University Seminar on Global Health with speak-er Mark Ottenweller, M.D., Global AIDS Coordinator for HOPE worldwide. Ottenweller has 18 years of HIV/AIDS experience in Africa. In 1993, he and his family moved to South Africa where he founded Soweto AIDS Program and HOPE worldwide South Africa. Refreshments will be served. John Hope Franklin Center. Free parking in Pickens Clinic lot

Aug. 11CRSO Lunch and Learn "Privacy vs. Confidentiality: Impacts on Research" presented by Wesley Byerly, Pharm.D., associate dean for research support ser-vices. Room 1014, School of Nursing. No registration necessary. Details: http://crso.som.duke.edu/modules/crso_resrch/index.php?id=1

doAug. 1–sept. 26 11 a.m.-2 p.m. Duke Farmers Market is now open every other Friday until Sept. 26. The Farmers Market offers a wide variety of produce and recipes to help you get the servings of fruits and vegetables you need to be healthy. Each week produce is collected from participating farmers for free drawings. Each market also offers healthy lunch vendors. The market is located in front of the Medical Center Bookstore.

Aug. 4–sept. 30Fred Kessler: Stories in Steel This North Carolina artist uses flat pieces of steel to create animal and plant sculptures. Come and see his art in the Reception Gallery at Duke Eye Center.

Aug. 8Duke School of Medicine “white coat ceremo-ny” to welcome new students. Speakers include Dean Nancy Andrews, and doctors Louise Markert and Caroline Haynes. 7 p.m., Reynolds Auditorium.

Aug. 10–13Fourth Annual Pink Ribbon Yoga Retreat for Breast Cancer Survivors sponsored by the Duke Cancer Patient Support Program. The retreat offers the opportunity to relax on the beach at The Trinity Retreat Center in Salter Path. The retreat combines yoga, health information and healing modalities for breast cancer survivors. Yoga experience is not neces-sary to attend. http://www.pinkribbonyoga.org

Aug. 22 12 p.m. Osler Literary Roundtable for patients, families and staff. Topic: Ray Bradbury’s The Veldt. Room 1993, Duke Clinics South

givesept. 27 8 a.m.Seventh Annual Asthma Walk on the Centennial Campus of North Carolina State University in Raleigh. Sign up to be a captain or participant to raise money and awareness for asthma and other pulmonary diseases. Lung disease is responsible for one in seven deaths. Today, more than 35 million Americans are living with a chronic lung disease such as asthma, emphysema and chronic bronchitis. Register: http://www.lungnc.org/index.php

C a l E N d a R

3August 2008 Inside Duke Medicine

August / SeptemberYour insider's guide to what's happening at Duke Medicine

How to submit:Send calendar listings to editorinside@mc.duke.edu

Want more info?Visit us online at http://inside. dukemedicine.org

The Calendar is a monthly selection of events that feature the best of happenings at Duke and Duke Medicine.

The fourth annual Pink ribbon Yoga retreat for Breast cancer Survivors takes place Aug. 10-13. Details below. ILLUstrAtION BY VANessA DeJONGh

b U l l E T I N SaT a G l a N C E

I N S I D E J O K E n I T f I G U r E S n

News briefs, notices, events,

and the IDM Book club

G l O b a l H E a lT H

A ‘rare opportunity’ in singapore

”“Tell me what you eat, and I will tell you what you are.—Jean Anthelme Brillat-Savarin, Physiologie du Gout, 1825.

1,470,000The number of meals served in a year to

patients at Duke Medicine Hospitals. Of those:

830,000 are served at Duke University Hospital

576,082 are served at Durham Regional

68,106

are served at Duke Raleigh

source: Hospital Administration

4 Inside Duke Medicine August 2008

sInGAPorE

An internationally renowned Duke psychiatrist has been named dean

of the Duke-National University of Singapore Graduate Medical School (Duke-NUS).

Ranga Krishnan, MB, Ch.B., began his new post on July 1.

“Ranga is a multi-talented individual and he has already played a major role in the success of Duke-NUS over the past year as executive vice dean,” said Victor J. Dzau, M.D., chancellor for health affairs at Duke University and CEO of Duke University Health System. “He is an accomplished leader and physician-researcher and has an ambitious vision for the future of the school.”

Tony Chew, chairman of the Governing Board for Duke-NUS, and Shih Choon Fong, NUS President, also expressed confidence in Krishnan as Duke-NUS continues to develop and expand.

Krishnan succeeded R. Sanders Williams, M.D., who has served as dean over the past few years, leading up to the welcoming of the first class of students in August 2007 and through the first academic year.

“NUS would like to thank Dr. Williams for his invaluable contribu-tions in helming Duke-NUS during its

formative years,” Shih said. “Building on the strong foundations laid by Dr. Williams, we are confident that Dr. Krishnan will lead Duke-NUS to yet another level of excellence that will further strengthen Singapore’s standing as a global hub for medical education and research, and health care.”

Krishnan believes that within one to two years, Duke-NUS will offer an M.D.-Ph.D. program, as well as a research Ph.D. program.

“This is a rare opportunity to help establish a legacy of excellence and

progressive medical education in the new era of technology,” Krishnan said. “Methods of teaching and learning are very different today than they ever have been before, and building a modern medical education system that, from the start, includes all of the new tools, technologies and strategies can be a model that other medical schools might be able to learn from.”

A native of India, Krishnan received his medical degree from Madras Medical College. He came to Duke in 1981 as a psychiatry resident. n

A N N O U N c E M E N T S n

new division in surgery

the Department of surgery is celebrating the newly created Division of surgical sciences.

the new division, which succeeds the former Division of experimental surgery, collabo-rates with researchers and clinicians within the department and across Duke Medicine on the rapid translation of groundbreaking research breakthroughs into advances in clinical therapies and surgical care.

this team of physician-scientists is led by Division chief Bruce A. sullenger, Ph.D., and Vice chief Kent J. Weinhold, Ph.D.

Programs include Molecular/Nano therapeutics, which applies state-of-the-art molecular and nanotechnologies to the development of novel therapeutic strategies for cancer as well as autoimmune and infectious diseases, and cardiovascular Biology, among others.

the department will host a reception on Wed., Aug. 6 from 4 to 6 p.m. in the searle center Lecture hall. rsVP to laura.wrightson@duke.edu.

http://sciences.surgery.duke.eduKrishnan appointed dean of Duke-NUS Graduate Medical School

Internationally prominent Duke psychiatrist ranga Krishnan, MB, became Dean of the Duke-National University of singapore Graduate Medical school on July 1. FILE PHoTo

A c T I V I T I E S n

Calling all artists: 30th Employee Art show

this show spotlights the work of former and current Duke University employees and volunteers.

Participate in this well-loved tradition by submitting up to three pieces.

registration forms will be accepted until Aug. 8. registration forms are available at hospital and clinic information desks and online.

Drop off artwork on Aug. 27 in the Duke south corridor between 6:30 a.m. and 9:30 a.m.

Winning entries will be selected Aug. 27 by a panel of professional artists. Fifty-dollar cash Awards of excellence, and honorable mentions will be give out. the prizes are funded by human resources.

Winning work will be displayed in the Mars Gallery of Duke North from Aug. 29-sept. 28.

For more information, contact samuel Morrison at morri031@mc.duke.edu.

Online registration forms: http://www.hr.duke.edu/events/artshow.html

5August 2008 Inside Duke Medicine

We’re all refugees, this hot June dawn, plucked out of our own

hectic lives, riding in buses headed for Lenoir Community College.

I’m one of some 250 Duke students participating in a major disaster drill. For two days, experts have stuffed us full of new disaster response skills and nightmarish facts: How to run a decontamination tent while dressed in chemical-proof suits, what to do in the aftermath to a bomb blast, how to triage the injured, and a discussion of medical ethics in the midst of a plague.

As we step off the bus, it’s look-ing eerily like a real disaster. Smoke from a nearby forest fire veils us in acrid twilight. Uniforms loom out of the smog — the National Guard, firefighters, state medical assistance teams and public health officials.

Our role is to provide simulated care, or play victims.

I’m picked first for a patient gig, a frantic mom who’s lost her child –

“Where’s my Baby!”My smirking classmates in the

triage crew want to triage me on the basis of my hyperventilating, but I’m having none of that. I duck out of custody, follow a father and child who’ve been sorted to pediatrics.

“Is this your baby?” a resourceful Duke PA student asks, showing me a six-foot “infant.”

“You mean I can just claim a kid and stop yelling?” I ask. “OK, yeah, that looks like him.”

Everyone cheers as I retreat to the exit. After a barbecue lunch, its back to roles, but this time I’m a nurse.

Guards bring us patients in states of catatonia, dementia, and screeching psychosis. We’re supposed to take histories and then confer with the med students regarding medicines and treatment. But is my subject a surly Alzheimer’s patient or a paranoid schizophrenic? We can’t find her records and it’s so hard to think with six patients shrieking at once. We settle on a fast-acting antipsychotic, then jab it into her thigh, simulated, of course.

One thing is becoming very clear to me. Disaster is a tumble down an ethical and physical rabbit hole. Surviving an incident – and surviving with grace – is all about flexibility, improvisation, and keeping your sense of humor. And hanging on hard to your compas-sion, while you deal with human nature stressed to its limit.

Despite the barbecue, they didn’t invite us out on a picnic, I conclude drowsily, as they bus us home again. We’ve helped the N.C. Office of Emergency Medical Services assess a medical evacuation in the midst of an unfolding disaster. And we Duke students have gained a glimpse of the complexities and tragedies inherent in such an event.

Fingers crossed that all we ever see is the dress rehearsal. n

Disaster, simulated

In June, 250 Duke nursing, physician assistant, physical therapy and medical students participated in a major disaster simulation in eastern North Carolina. Here is a report from one of them, nursing student – and accomplished novelist – Peggy Nicholson:

S P O r T S n

Employee athletic pass now available

Purchase a 2008-09 Duke employee Athletic Pass presented by the Duke credit Union.

save big on season tickets to football and women’s basketball.

Back by popular demand, this year the employee

Pass will once again give holders a chance to purchase

men’s basketball tickets.

As an extra benefit this season, all football season tickets will be reserved seats in sections 8-10 around the 30 yard line.

Purchase a single pass for $90, or a family pass for four at $199 and get:

• Reserved season tickets to all 2008 Duke football games (section 8-10)

• Season tickets to all 2008-09 Duke women’s basketball games

• A chance to purchase tickets to select men’s basketball games

• An opportunity to attend select men’s and women’s basketball open practices

• A gift for every ticket ordered

the ticket office inside cameron Indoor stadium is open Monday through Friday from 8:30 a.m.-4:30 p.m.

Or, contact Duke Athletics at (877) 375-DuKE or online at http://goduke.com

IdM bOOK C lU b

Great books inspire great minds

Members of the Professional Development Institute (PDI) Book club are reading The Confidence Course: seven steps to self-Fulfillment by self-help guru Walter

Anderson, editor of Parade magazine.

“We read books that can aid in both our personal and professional growth and development,” said book club creator and coordinator c.t. Woods Powell.

the group, made up of professionals from across the health

system, meets every third Wednesday during their lunch hour.

the books are chosen to stimulate improvement in a professional environment and encourage critical thinking.

“I’m thinking about putting myself through the program,” says group facilitator Paul Dudemhefer of the book’s impact on him.

the confidence course: seven steps to self-Fulfillment (harper, $13) is available at bookstores or from the Durham, Orange or Wake county libraries.

Next month, the PDI Book club will discuss You and Your Network by Fred smith (executive Books, $10)

— La-Tasha Davis

reading a good book? tell us about it at editorinside@mc.duke.edu

E D U c A T I O N n

Duke HomeCare & Hospice offers end-of-life workshop

Despite undisputed technical and interper-sonal skills, professional nurses may not be completely comfortable with the specialized knowledge and skills needed to provide quality end-of-life care to patients.

the end-of-Life Nursing education consortium core curriculum gives nurses the knowledge and skills required to provide this specialized care and to positively affect the lives of patients and families facing the end of life.

eLNec is a national education initiative to improve end-of-life care in the United states by providing consistent, advanced education on end-of-life nursing care.

A two-day workshop is being offered sept. 8-9 and Dec. 4-5. cost is $25 for health system nurses and $75 for others. Fee includes instructional materials and snacks and lunch both days. space is limited.

to register, call 620-3853 or visit http://www.dhch.dukehealth.org

H I S T O r Y n

new exhibit honors Duke Medicine women

Using recorded interviews, the Duke Medical center Archives has created a new exhibit honoring “Women in Duke Medicine."

this online exhibit explores the stories of women at Duke, particularly those who blazed trails during a time when there were generally fewer women in medicine. It features biographies, transcripts, and sound clips of Duke scientists, physicians, pioneers, and leaders. Interview topics included treatment as a female in a mostly male culture, particular scientific breakthroughs, leadership, work-family balance, and many others.

Jessica roseberry, oral historian for the Duke Medical center Archives, conducted the interviews.

the primary impetus of the exhibit has been a joint project between the archives, which provided extensive research, and Ann Brown, M.D., of the Office of the Associate Vice Dean for Faculty Development. Many of the interview transcripts were made possible by a grant from the Josiah charles trent Memorial Foundation.

see the exhibit: http://medspace.mc.duke.edu/medwmn/index.php

suited Duke nursing, PT, PA and medical students listen to the Army's Jean-Louis Gomes during a disaster

simulation at Lenoir Community College in June. PhOtO BY JULIe chONG

6 Inside Duke Medicine August 2008

W O R K I N G

Most Duke University Health System employees are satisfied with their work environment,

according to the more than 9,000 employees who took this year’s Work Culture Survey.

The 80 percent participation rate this year was the highest since the survey began in 1999. Nearly 11,400 invitations were sent to Health System employees to take the survey. Responses were received from 9,070, which included people who worked in the hospitals, PDC, PRMO, DUAP, clinical labs and corporate services. The schools of nursing and medicine are not part of the survey.

Compared to the 2007 survey, overall satisfac-tion across Duke University Health System improved in eight of the nine categories. The Work Culture Index, which is based on a subset of questions in the survey, increased nearly 2 percent from last year.

“I’m pleased with this year’s results. They reflect our continued focus on creating the type of culture in which we can all take pride,” said Steve Smith, chief Human Resources officer for DUHS.

The areas of highest favorability for the survey were all related to delivering excellent patient care. The highest-rated category was Service Climate, which had an overall satisfaction score of 79.9 percent. Also highly rated were questions related to being a “world renowned patient-care organization” (78.5 percent) and “challenging work that provides positive impact to patients” (79.8 percent).

“Without question, patient care and customer

service are the foundation upon which we are building our desired culture,” Smith said.

The most significant improvement from last year’s survey dealt with questions related to “op-portunities to develop” which climbed from 57.2 percent in 2007 to 60.9 percent in 2008.

While most areas had higher scores than in 2007, Smith said that there are still areas requiring focus.

The lowest rated category was “rewards that promote accountability,” which received a favorable response from only 32.9 percent of those who took the survey. Still, this result reflected a 2.5 percent increase over last year.

Also of interest was that 94 percent agreed that “I feel that patient/customer service is an important part of my responsibilities,” yet 56 percent agreed that “I receive excellent service from the other departments I interact with in the Health System.”

“This finding is significant because the service and support we provide each other ultimately impacts the quality of care and service we provide our patients,” Smith said. “One of the best ways to ensure quality patient care is to respect each other and realize that everyone contributes to the team.”

Smith thanked those employees who partici-pated in the Work Culture Survey.

“The survey is key to measuring our perfor-mance as a health system, and helps determine future areas of focus,” he said. “We couldn’t improve without your input.” n

Work Culture survey shows progressParticipation rate – 80 percent – was highest yet

survey says …10 Interesting findings from the 2008 Work Culture survey

1this year’s 80 percent participation rate marked the Work culture survey’s highest

response rate since it began in 1999.

2 the Work culture Index, which is based on a subset of questions in the survey,

increased nearly 2 percent from last year.

3 Duke raleigh Hospital had the highest Work culture Index score (75.4 percent)

among all DUhs entities.

4Duke homecare and hospice improved its scores by at least 2 percent points in

all nine categories of the survey.

5“Opportunities to Develop” had the highest increase from last year (from

57.2 percent to 60.9 percent). this reflects a 12.9 percent point improvement since 2002.

6the PrMO had the highest overall participation (98.1 percent) among all

DUhs entities.

7All categories of the survey improved since last year with the exception of

“Innovative Benefits,” which declined 1.3 percent points from last year.

8 only 46 percent agreed that “Overall, DUhs has better benefits than other

employers do in this geographic area.”

9 the highest rating category was “service climate” and the lowest rated category

as “rewards that Promote Accountability,” which improved 2.5 percent points.

10Over 94 percent agreed that “I feel that patient/customer service is an

important part of my responsibilities,” yet only 56 percent agreed that “I receive excellent service from the other departments I interact with in the health system.”

sATIsFACTIon rATInGsthis chart reflects percentages of survey participants who answered "agree" and "strongly agree" in the following categories:

AFFILIATION WITH A WORLD RENOWNEDPATIENT CARE ORGANIZATION

CHALLENGING WORK THAT PROVIDESPOSITIVE IMPACT TO PATIENTS

TEAM ENVIRONMENT

APPRECIATION OF INDIVIDUALAND TEAM PERFORMANCE

REWARDS THAT PROMOTEACCOUNTABILITY

INNOVATIVE BENEFITS

OPPORTUNITIES TO DEVELOP

SERVICE CLIMATE

DUHS OPERATING PRINCIPLES

78.5%77.2%

79.8%79.2%

66.9%64.4%

66.5%64.6%

32.9%30.4%

66.9%68.2%

60.9%57.2%

79.9%79.7%

74.9%73.1%

0% 20% 40% 60% 80% 100%

FAVORABILITY RATINGS

2008 DUHS FAVORABILITY 2007 DUHS FAVORABILITY

This chart reflects percentages of survey participants who answered “agree” and “strongly agree” to the following questions:

f E aT U R E

The science & research supplement to Inside Duke Medicine

VOLUME 17 NO. 8 n inside.dukemedicine.org n August 2008

Winning the obesity battleBy Kelly Malcom

Eat less and move more. The secret to losing weight comes down to this

rather simple prescription. However, for the one-third of Americans considered obese, defined as having a body mass index, or BMI, of 30 or higher, losing weight is not a simple endeavor. And surprisingly, scientists have few answers as to why certain people lose or gain weight while others do not or why certain obese individuals go on to develop life-threatening conditions, such as cardiovascular disease and type II diabetes. A lot of the difficulty lies in the complex processes that make up metabolism.

Researchers at the Sarah W. Stedman Center for Metabolism and Nutrition Research at Duke are working to uncover some of these answers. The center was founded in 1988 as a research entity to study how nutrition impacts health. Today, under director Christopher Newgard, Ph.D., the Center has taken on a translational approach to metabolism and nutrition research, one that translates scientific discovery to new methods for treating obesity and related diseases. “Our goal for the center was to build a group of strong basic sciences investigators in the general area of metabolism, build a clinical research capability, and to build a state-of-the-art

analytical platform specifically designed for metabolic analysis,” Newgard said.

Currently, that group is com-posed of clinical investigators looking for nutritional interventions for common conditions such as obesity, high blood pressure and diabetes and researchers in the basic sciences investigating the biological mecha-nisms of weight and disease.

Laura Svetkey, M.D., director of clinical research, was instrumental in the landmark DASH (Dietary Approaches to Stop Hypertension) study, the first major study involving the Stedman center. The DASH study demonstrated that patients could help lower their blood pressure by simply increasing the amount of fruits, vegetables, and low-fat dairy they consumed, without weight loss or salt restriction and led to a nationwide change in dietary guidelines in 2005.

With this firm clinical foundation in place, it was up to Newgard, who came to Duke in 2002, to strengthen the center’s basic science approaches. Today, the Stedman Center is a leader in the translational field called metabolomics.

“Like the other major basic science initiatives to understanding human disease, such as genomics, that study on the level of the gene, metabolomics is the study of the concentration of small molecules that are the result of metabolic processes and make us who and what we are,” explained Newgard.

Metabolism refers to the set of chemical reactions in the body that

sustain life, including the conversion of food into energy. Using instruments like mass spectrometers, scientists are able to quantitatively

measure metabolites, or the chemicals created by the body’s metabolism, in organisms including humans. These metabolite readings can be used to create profiles that can be used to identify the molecular level differences between obese and lean people and that can potentially be used to predict the development of diseases associated with obesity. Center member Lillian Lien, M.D. is using metabolic profiling to predict who will lose weight and who will benefit from weight loss.

Newgard’s group and researchers Deborah Muoio, Ph.D., Dennis Thiele, Ph.D., Jeffrey Rathmell, Ph.D., and Jennifer Moss, Ph.D. are using the ap-

scientists don't yet have a clear understanding of why certain people lose or gain weight. At right, a fat molecule. ILLusTrATIons BY VAnEssA DEJonGH

see oBEsITY, p.9

By Mary Jane Gore

Have you ever wondered how your body knows exactly

how to fight off the very particular bacteria, viruses and toxins that you encounter? How is it equipped to deal with anything and everything that comes down the pike?

The answer lies in the T cells and other cells that the immune system manufactures. Mike Krangel, Ph.D., a T cell expert, says that these cells are fascinating.

For every antigen (an invader, like a toxin or bacterium) that attacks, the body strives to offer a solution that will wage a counterattack, literally dismantle and dispose of the antigens. That counterattack starts with recognizing the antigen, and the T cells have receptors to “read” the attacking molecules; one T cell should fit the antigen via its receptor.

The T cells all begin in the thymus gland, where these early white blood cells develop.

Krangel is an expert in the forma-tion of receptors, which sense antigens, on the surface of the T cells, which direct the attack in different ways. His team accumulated the best evidence to date of how the genes in these cells go about creating the receptor proteins that become the just right match to take on the antigens. Says Chair Thomas Tedder of the Department of Immunology, “I think his findings are fundamental to the field of immunology and are critically important.” His findings might apply beyond the field of immunology to other gene function studies.

Krangel recently published in Nature Immunology his findings about

Krangel and the T cellsMike Krangel, Ph.D. PhOtO creDIt

Half of the world's disease problems

are due to overnutrition.

see KrAnGEL, p.9

N E W S

Inquiry August 20088

By Michelle Gailiun

New research into the earliest events occurring immediately

upon infection with HIV-1 shows that the virus deals a stunning blow to the immune system earlier than was previously understood. According to scientists at Duke, this suggests the window of opportunity for successful intervention may be only a matter of days — not weeks — after transmission, as researchers had previously believed.

Appearing in the August issue of the Journal of Virology, the finding may make the challenge of designing an effective HIV/AIDS vaccine appear daunting. But researchers say the study has also yielded a blueprint for what a successful vaccine should look like, and moreover, when such a vaccine would need to work.

Until now, scientists believed that the window of opportunity to inter-vene in the process of HIV-1 infection lay in the three to four weeks between transmission and the development of an established pool of infected CD4 T cells. HIV-1 cripples the immune system by invading and killing CD4 T cells, key infection-fighters in the body.

“But this new study shows that HIV-I does a lot of damage to the immune system very early in that time frame, and now we feel that the opportunity to intervene most ef-fectively may range from about five to seven days after infection,” said Barton

Haynes, M.D., the senior author of the study and director of the Center for HIV/AIDS Vaccine Immunology (CHAVI) at Duke University Medical Center.

Haynes said the findings suggest that an optimal vaccine strategy would have to pack a double punch: First, establishing as much immunity as possible before infection, much as classic vaccines do, and then following a few days later with a mechanism to provoke a strong, secondary, broad-based antibody response. “Vaccine candidates to date have pretty much

followed a single strategy. Now we know that we need to activate multiple arms of the immune system and we have a better idea of when to do it.

“These and other studies that recently revealed more about the singular nature of HIV-1 have given us valuable information that is helping us move closer to establishing a basic science foundation that can lead to novel technologies for vaccine design,” Haynes said. “It is becoming clearer why we have failed in our efforts to date, and what we need to confront to succeed in the future.” n

HIV knocks out immune system faster than thought

science Editor: Kelly Malcom

Inquiry features science and research- related news items from Duke Medicine News and communications and other Duke departments. to submit content, contact us at editorinside@mc.duke.edu

Lee awarded by the American statistical Association

Kerry Lee, Ph.D., of the Department of Biostatistics and Bioinformatics has been selected as a Fellow of the American statistical Association. each year, AsA members nominate their peers as fellows of the AsA. From the AsA By-Laws: “By the honorary title of Fellow the Association recognizes full members of established reputation who have made outstanding contributions in some aspect of statistical work.” Given annually, this is a great honor as the numbers of recipients are limited to no more than 1/3 of 1% of the AsA membership.

Duke selected as one of 3 AHA PrT outcomes centers

the American heart Association Pharmaceutical roundtable (AhA-Prt) has awarded Duke one of three outcome centers grants, which will provide 4 million dollars over the next 4 years. the Outcomes research centers Grant Program funds cardiovascular and stroke research that focuses on improving healthcare delivery and the end result of that care, patient outcomes. Duke was selected because of its long history in cardiovascular outcomes research, with work ongoing in the center for health services research in Primary care, the Duke center for clinical health Policy research, the school of Nursing, and the Duke clinical research Institute. “the grant will be used to recruit and train 6 outcomes fellows, bring Duke's outcomes research communities together, and to carry out some important and hopefully practice-changing research,” said eric Peterson, professor in the division of cardiology and director of cardiovascular research at the DcrI.

Arshavsky receives Alcon Award

Vadim Arshavsky, Ph.D., scientific director and professor of ophthalmology, pharmacology, and cancer biology, received a prestigious $100,000 Alcon research Institute Award. the Alcon research Institute seeks and honors outstanding ophthalmology research-ers from around the world.

Arshavsky conducts research on the molecular and cellular mechanisms of signal transduction and has also focused on how the malfunction-ing of signaling mechanisms in photoreceptors may impair vision or lead to retinal degenera-tion, as observed in retinitis pigmentosa and age-related macular degeneration.

Multiple round bumps on cell surface represent sites of assembly and budding of HIV virions. PhOtO BY c. GOLDsMIth, WIKIMeDIA cOMMONs

The Duke Eye Center’s Spring/Summer 2008 issue of their

newsletter, Vision, announces Duke’s selection as a site for an important nationwide, multi-center study spon-sored by the National Eye Institute. In the study, two drugs used to treat age-related macular degeneration (AMD), Lucentis and Avastin, will be put head to head to compare their safety and effectiveness.

Nearly two million Americans are visually impaired by AMD, while more than seven million are at an increased risk of vision loss from the disease.

“This trial is unique in that it is really driven by a financial outcome,” says Karl Csaky, M.D., Ph.D., associ-

ate professor of ophthalmology on the Duke Eye Center’s retina faculty and director of the Ophthalmic Clinical Trials Unit at the Duke Clinical Research Institute. “We already have many studies showing that Lucentis can effectively treat wet AMD, but each dose of Lucentis costs more than

40 times as much as a dose of Avastin. From a practical perspective, it’s important to compare the outcomes from each drug because if Avastin works just as well as Lucentis, that could mean billions of dollars in cost savings for both patients and government health care programs like Medicare and Medicaid.” n

To read this article in its entirety and to learn more about this clinical trial, please visit http://www.dukehealth.org/HealthLibrary/HealthArticles/macular_degeneration_drugs_go_head_to_head_in_large_scale_clinical_trial. For more information on other clinical trials at Duke, visit http://www.duke-health.org/clinicaltrials

Duke takes part in macular degeneration drug trial

PHoTo CourTEsY oF WIKMEDIA CoMMons

Inquiry 9August 2008

Discovery explains how cold sore virus hides

Now that Duke University Medical Center scientists

have figured out how the virus that causes cold sores hides out, they may have a way to wake it up and kill it.

Cold sores, painful, unsightly blemishes around the mouth, have so far evaded a cure or even prevention. They’re known to be caused by the herpes simplex virus 1 (HSV1), which lies dormant in the trigeminal nerve of the face until triggered to reawaken by exces-sive sunlight, fever, or other stresses.

“We have provided a molecular understanding of how HSV1 hides and then switches back and forth between the latent (hidden) and active phases,” said Bryan Cullen, Ph.D., Duke professor of molecular genetics and microbiology.

His group’s findings, published in Nature, also provide a framework for studying other latent viruses, such as the chicken pox virus, which can return later in life as a case of shingles, and herpes simplex 2 virus, a genitally transmitted virus that also causes painful sores, Cullen said.

Most of the time, HSV1 lives quietly for years, out of reach of any

therapy we have against it. It does not replicate itself during this time and only produces one molecular product, called latency associated transcript RNA or LAT RNA.

“It has always been a mystery what this product, LAT RNA, does,” Cullen said. Usually viral RNAs exist to make proteins that are of use to the virus, but this LAT RNA is

extremely unstable and does not make any proteins.”

In studies of mice, the team showed that the LAT RNA is

processed into smaller strands, called microRNAs, that block production of the proteins that make the virus turn on active replication. As long as the supply of microRNAs is sufficient, the virus stays dormant.

After a larger stress, however, the virus starts making more messenger RNA than the supply of microRNAs can block, and protein manufacturing

begins again. This tips the balance, and the virus ultimately makes proteins that begin active viral replication.

The new supply of viruses then travels back down the trigeminal nerve, to the site of the initial infection at the mouth. A cold sore always erupts in the same place and is the source of viruses that might infect another person, either from direct contact, or sharing eating utensils or towels, Cullen said.The approach to curing this

nuisance would be a combination therapy, Cullen said. "Inactive virus is completely untouchable by any treatment we have. Unless you activate the virus, you can’t kill it,” he said.

Cullen and his team are testing a new drug designed to very precisely bind to the microRNAs that keep the virus dormant. If it works, the virus would become activated and start replicating.

Once the virus is active, a patient would then take acyclovir, a drug that effectively kills replicating HSV1.

“In principle, you could activate and then kill all of the virus in a patient,” Cullen said. “This would completely cure a person, and you would never get another cold sore.”

He and the team are working with drug development companies in animal trials to begin to answer questions about how to deliver this drug most effectively. n

plied tools of metabolomics to determine the mechanisms of weight gain and the development of associated co-morbidities, especially type II diabetes, which is predicted to affect 300 million people worldwide by 2020.

“I like to call it retro-translation,” said Newgard. “We’re making observa-tions in humans and then we’re going backward to the animal models to test our hypotheses.”

In a review published in Nature Reviews: Molecular Cell Biology, Muoio and Newgard examine the metabolic mechanisms that lead to type 2 diabetes, mechanisms that involve the various affects of overeating and a lack of exercise on the body’s metabolism.

So far, Muoio, Newgard, and others have revealed previously unappreciated mechanisms by which the food we eat leads to weight gain.

The Stedman Center’s research into the connections between metabolism and disease is bolstered by collabora-tions with clinical research departments throughout Duke Medicine. These include ongoing research projects with collaborations throughout Duke, such as the ones with Svati Shah, M.D, William Kraus, M.D., and Kristen Newby, M.D., in the division of cardiol-ogy and Elizabeth Hauser, Ph.D. in the section of medical genetics.

“Half of the world’s disease problems today are due to overnutrition and yet we know little about why. Do we understand what’s happening biochemi-

cally when obese individuals lose weight? By having that understanding, can we come up with new intervention strategies that allow obesity interventions to be sustained? A big problem with weight loss is weight rebound. Why is that?” said Newgard. Research at the Stedman center and in other departments is directly addressing these looming issues.

Svetkey also acknowledged the

issue of weight regain after an initial successful loss. “A big issue is support,” said Svetkey, who is running further studies using the DASH diet to examine its effects on weight loss. In six -month long lifestyle change studies, patients in residence at the Stedman Center’s Center for Living location met in support groups every week. “People do a great job making a significant lifestyle change with this kind of support and encourage-ment,” she said. “It’s after that when people try to sustain the lifestyle changes that we know very little about how to help them do that. It’s very difficult to do and we live in an environment that’s really begging us to eat badly and too much. It’s going to take more research to learn how to help people withstand these societal forces.” n

oBEsITY, continued

“In principal, you could activate and then kill

all of the virus in a patient, and they would

never get another cold sore.“

how each developing T cell makes only one receptor protein, even though it has two genes (alleles), either of which is capable of being activated and making the protein.

T cell receptor genes are created through a genetic recombination process, called V(D)J recombination, that cuts and pastes together pieces of T cell receptor genes in immature T cells. Most immunologists had thought that the course of the receptors was predetermined in each cell – there was one allele destined to try to make the receptor first, and the other had basically no chance.

“We addressed the fact that we think the process is more random than that,” Krangel says. “It comes down to physical location in the nucleus ... both alleles have the same probability to be in a particular location in the nucleus. Some cells may end up with a well positioned and a poorly positioned allele, some with two in poor loca-tions, and a minority of cells may have two well-positioned alleles in the cell nucleus. But even though it is random, almost all of the time the process seems to work.”

Krangel’s work on genes and their location could be applied more widely, perhaps to other types of cells. “Where a gene is within a given nucleus, can influence the activity of that gene,” he says. n

KrAnGEL, continued

[ ]building blOCKS

10 Inquiry August 2008

I N T E R V I E W

“How do a people come to see themselves as a people? Is it a social construction? Is it a matter of genetic identity?” asks David Goldstein, Ph.D., of the Institute for Genome Sciences and Policy. He has written a book, Jacob’s Legacy (Yale, 2008), that describes his attempts to illuminate Jewish history from a genetic point of view. While genetics cannot replace anthropology, oral history or other investigational methods, he says, it can be used to lend scientific support to some of the stories that have been passed on from generation to generation. In an interview recorded by Duke Medicine News & Communications, Goldstein describes what his genetic findings reveal about the famous story of the Lost Tribes of Israel:

The beginnings of the legend of the Lost Tribe go back to

the northern parts of the Israelite kingdom. Initially the kingdom was a single kingdom under King David and King David’s son, Solomon. Shortly after that, the kingdom was split into a northern part and a southern part and the northern part was conquered by the Assyrians. And these guys were nasty, truly nasty.

When they conquered a place, they practiced what’s prob-ably the first recorded instance of ethnic cleansing. What they did to make sure there wouldn’t be any subsequent rebellions was take the leadership of any place they conquered and distribute them elsewhere so they couldn’t reestablish themselves. And they did that with the northern part of the Israelite kingdom, which was called

Israel and all the tribes that had been allotted that portion of the Israelite territory disappeared.

That is what we now think of as the “Lost Tribe,” because the story in the Bible is told from the perspective of the southern kingdom called Judah; these individuals were gone. Now, what happened to them nobody knows but some people think that Kurdish Jews and other Jews from that region may trace back to that early dispersal. But that’s the origin of the idea of the Lost Tribes. The idea had such an impact on people over time that you’ve got groups literally everywhere in the world at differ-ent points in time, from Japan to Holland to Afghanistan, that have been identified with the Lost Tribes.

As such, we took the view that it wouldn’t be sensible to start genotyp-ing anyone that had some kind of a

claim to Jewish connection. However, there was one group in particular that really was quite intriguing and that’s the Lemba from southern Africa. While they didn’t consider themselves a lost tribe in the narrow sense, they did consider them-selves to have an origin in the ancient Israelite kingdom. They have a story of dispersal from that part of the world around 3,000 years ago.

That part is not so distinctive by itself because there are other groups that have similar stories. But there had been a study done perhaps 10 or 15 years back now, by a South African geneticist, that showed that some of the Y chromosomes in the Lemba were Semitic as opposed to Bantu. And that was surprising because the

Lemba look like their Bantu neighbors and yet they have a lot of Y chromo-somes that are Semitic.

While that’s intriguing, it doesn’t make it a Jewish connection. With that starting point we thought “might there be some way to see whether the Semitic Y chromosomes that these Lemba carry might have a specifically Jewish origin.” So that’s what got us started.

When you think about Jewish chromosomes as opposed to Semitic chromosomes, that’s a hard distinction to make because we know that that’s where Jewish Y chromosomes come from in that part of the world. For a lot of Y chromosomes, it’d be hard to tell whether they got into the Lemba from specifically a Jewish source or, for example, from Arab traders.

However, the studies we had done with the Jewish priesthood had identified one chromosomal type,

which we called the Cohen modal haplotype, that is not very common in non-Jewish populations; in fact, it’s pretty rare. So if we happened to bump into that type in the Lemba we can say, “Hey, it’s pretty likely it’s of Jewish origin.” That’s about all we had to go on. And off we went. And sure enough, when we looked at the Lemba, 10 percent or more had this

type, which is primarily found in Jewish populations. And that was a stunner, I have to say. Every so often you do this work and you see some-thing and say, “That’s amazing.” n

To watch Goldstein's interview, visit http://www.youtube.com/watch?v=_tu4ApArBkU&

Jacob's Legacy

W O R K S H O P

bioinformatics

The IGSP will sponsor a Duke Bioinformatics Workshop on Aug. 18-20: A three-day course led by faculty including the IGSP's Holly Dressman, Phil febbo, Terry furey, and others. To register, go to http://www.chg.duke.edu/education/dbw.html

O P P O R T U N I T I E S

Call for abstracts

All Duke doctoral trainees and junior faculty conducting AIDS-related research are encouraged to submit an abstract for presen-tation at the fourth annual cfAr fall Scientific retreat. Email rachell Snipes (rachell.snipes@duke.edu) for more information.

R E S E a R C H

Clinical trials

Participate in clinical trials and you can gain access to new research treatments before the treatments are widely available. To find active clinical trials, visit http://www.dukehealth.org/clinicaltrials

David Goldstein, Ph.D. in northern Israel. PhOtO cOUrtesY OF the AUthOr

building blOCKS Your guide to construction and expansion projects at Duke Medicine

A 1,900-space deck with 300 spaces reserved for patient parking is being built in the sands Parking Lot between research Drive and the entrance to the Duke eye center on erwin road.

During construction, patients continue to enter via erwin road and drive to the newly located ticketing kiosk where they receive additional parking information if needed. In anticipation of losing 40 patient parking spaces as well as employee parking, Duke eye center and Duke Parking made plans early to provide additional patient parking assistance and to relocate employee parking.

Patients have the option of parking in the 90 remaining spaces in front of the eye center or using valet parking, which is provided at no additional charge. Parking continues to cost a dollar an hour. surgery patients are being identified and asked to use valet parking. Additionally, the eye center advises incoming patients about parking changes by providing parking information in the pre-appointment packet, signage, and Web site.

“Naturally, construction has had a major impact on patient traffic flow,” said charles Mansfield, administrative director of the eye center. “to minimize the impact, additional valet parking attendants have made patient parking run smoothly. Patients are generally very understanding.”

When the new parking deck is completed in less than two years, Duke administrators will continue with plans for the eye center Pavilion, a clinical facility that will be located in front of the Wadsworth Building. currently, the 35-year-old Wadsworth accommodates more than 80,000 patient visits annually in a building that was renovated to serve 35,000 patients, while another 40,000 patients are seen in satellites. For more information: http://www.dukeeye.org n

New parking deck paves the way for convenience

A new home for Duke Diet and Fitness Center

By Debbe Geiger

The finishing touches are being made in preparation for the Duke

Diet and Fitness Center’s move to the former Metrosport Athletic Club, just off Erwin Road in Durham later this month.

The 46,000-square foot facility has been undergoing extensive renova-tion for nearly a year. The opening is highly anticipated by DFC clients and employees alike.

The DFC has been in its current building, a former YMCA on West Trinity Avenue, for 25 years, said Howard Eisenson, M.D., the center’s executive director.

“During that time, our program offerings have evolved and become more comprehensive, our clientele has increased, and our staff has grown too,” he said. “It will be terrific to finally have modern, expanded facilities to better serve our clients, and adequate office/treatment space for our multidisciplinary team.”

The new Diet and Fitness Center will include a larger, more spacious dining room, up-to-date demonstration kitchen, more common areas for social-izing, and bigger classrooms outfitted with audiovisual teaching equipment.

The new privacy-conscious, glass-enclosed saline swimming pool and spa-like amenities including massage suites, a meditation room, whirlpools, steam rooms and dry saunas will be welcome additions. The fitness suite

will feature a dedicated aerobics floor, separate areas for physical therapy and Pilates exercising, and a “cardio theater” to enhance aerobic and strength training routines.

A greatly improved medical clinic, nutrition suite and private consultation

rooms are also included.

Just as impor-tant, Eisenson said, is the address: 501

Douglas Street, near Duke University Hospital, specialty clinics, the univer-sity campus, and the complementary services available on the Center for Living campus.

“We are proud to have evolved into a world-class program, and now we’ll have a world class facility to match that reputation,” Eisenson said. “Before this move, our facility was really the bare bones, but that didn’t matter to most of our clients,

who cheerfully accepted our cinder block walls, antiquated heating and air conditioning system. That they have continued to return is a tremendous validation of our team’s efforts. Now, however, they will get a facility they truly deserve. Our staff will too.”

And, in the coming months, the local community will be able to benefit from the new location as well.

“We will be expanding our services by offering multi-disciplinary, outpatient weight-loss programs to local residents,” said Martin Binks, Ph.D., director of behavioral health at the center. “We’ll offer more resources too, such as informational seminars. We are already working with businesses to train health care providers who work in employee assistance and wellness programs so they can deliver important messages and information about healthy weight management. We hope to offer more services like that.” n

this pool, once readied, will be filled with salt water, which provides better buoyancy. PHoTo BY DEBBE GEIGEr

“Now we'll have a world-class facility to

match that reputation.”

AuGusT 2008: Preparations begin for construction of the Major Hospital Addition (MHA) at Duke University Medical Center; expected to open early 2013.

Gross Anatomy labs open, dramatically improving medical student learning.

noVEMBEr 2008: DUAP Duke Medicine at Morrisville, new clinic.

Renovation to the Durham Regional Hospital cardiac catheterization laboratory complete.

JAnuArY 2009: New 12-bed end-of-life facility for Duke Hospice on Roxboro Road in Durham opens.

sEPTEMBEr 2008: Duke Clinical Research Institute to relocate to downtown Durham Centre

WInTEr 2010: Construction begins for a new underground parking structure between the Morris Cancer Center and School of Nursing; expected to open summer 2012.

sPrInG 2009: Demolition of the Bell Building and excavation for the MHA takes place.

11August 2008 Inside Duke Medicine

Douglas Street building will house modern, expanded facilities

T I M E l I N E

Growth sPurTThis timeline will be a recurring Building Blocks feature. Note that dates are subject to change.

f I R S T P E R S O NPaT I E N T C a R E

Q&A with William Fulkerson Jr., M.D.

Any health care worker who has been involved in a medication-related error can

recount their experiences for you in vivid detail.It sticks in their minds, and you immediately

see the lasting impressions these events have made; they have reinforced the need to make "safe choices.”

Whether the health care worker was directly involved in an incident, or was simply working in an area when an incident occurred, for the individuals involved, medication errors become lasting impressions, and these experiences continually change our practice environment.

No one comes to work expecting to make or be involved in a medication error that day. Staff at all levels and in all parts of the medication administration process work diligently every day to minimize something like that from happening to their patients. And they all take pride in their knowledge and diligence and their efforts to assure a high level of safety for their patients. Nevertheless, incidents and errors may occur in any environment in which, daily, thousands of medications and biologicals are processed and administered to patients.

According to a 2006 report published by the Institute of Medicine of the National Academies, each year, approximately 1.5 million people are harmed by medication errors. The report, Preventing Medication Errors, quantified the cost of these potentially fatal errors at an estimated $3.5 billion a year. The report started a nation-wide conversation about medication safety.

At Duke University Hospital, the Medication Safety Education Committee, in conjunction with the Medication Safety Leaders of the system, has developed the “6 Rights in 6 Months” campaign

to help raise awareness about safe medication administration practices. The committee’s efforts address all people, including patients and families and all parts of the medication administration process, not just the frontline med giver.

There are a number of simple, basic steps that can be done by each professional and patient/family member to help assure the right drug in the medication use process.

These include steps include:• Always knowing each drug you are

administering/receiving – indica-tions, effect, side effects and the resources available if you don’t have needed information.

• Taking the package containing the medication into the patient’s room with the medication administration record or order.

• Closely checking the name and labeling on all medication packaging, including single-dose packages, prescription bottles, IV bags, and the like.

• Being aware and on the look-out for look-alike and sound-alike medications such as Xanax and Zantac, or Celebrex and Cerebyx.

• Engaging the patient and family in obtaining a thorough

medication history and review of allergies.Helping assure that we have the right drug for

every patient, every time is a collaborative effort. Each member of the health care team — from prescriber to processor to the professionals who administer them — and the patients who receive them all have important roles. And all strive daily to achieve the goal of safe, high-quality care for all patients in our hospital and clinics. n

If you are interested in more informa-tion about the Medication Safety Education Committee’s efforts, contact committee co-coordinators John Howe, R.N. at howe0003@mc.duke.edu , or Lynn Eschenbacher, Pharm.D. at lynn.eschenbacher@duke.edu.

The second part of 'Six Rights in 6 Months' patient safety series.

focus on: The right Drug

6 Rights of the Medication Use Process :

1 ) Right patient

2) Right drug

3) Right dose

4) Right route

5) Right time

6) Right outcome

As part of his job as senior vice president for clinical affairs at Duke Medicine, Bill Fulkerson spends a lot of time thinking about health care quality. Fulkerson, a medical doctor who has been with Duke for 25 years, leads a broad effort to improve the quality of care delivered in Duke’s hospitals and clinics. recently, he talked about how quality improvement is becoming even more critical.

To start, what is quality?

To me, quality in health care is what we all want – the right care at the right time. And

when you have that quality, it hopefully leads to the best outcomes.

How do you improve quality?

We constantly measure what we do, analyze the information, review with our providers, and put changes in place if needed.

For complex issues we use a performance improvement method called Six Sigma. This system employs sophisticated analytical and statistical tools to help identify the correct issue that requires attention.

Do you share this performance data?

We share it widely with our staff, and more and more hospital quality data is available to the public. Patients, and prospective patients, can see how our hospital performs. We’re posting quality information on DukeHealth.org – and not just where we shine, but where we have opportunities, too. I’m very proud of how our hospital compares.

What’s been the big lesson of this effort?

Consistent evidence-based care is the key and making it easier for staff to do the best thing. For instance, at Duke and Durham Regional hospitals, and soon at Duke Raleigh, we have fully computerized physician order entry. If a patient comes in with suspected heart attack and a physician chooses that order set, the patient will get aspirin, the patient will get a beta blocker, will get an ACE inhibitor, and will get the proper tests they need every time.

What’s next for quality?

We need to continue to look for opportunities to “hard wire” our practice. Also, payors for health care are increasingly interested in paying for quality, and not paying for poor quality. More and more, quality care is going to be linked to reimbursement. I fully support that.

Interview by Mark Schreiner

find hospital quality data at:

http://www.hospitalcompare.hhs.gov

http://www.ncha.org

http://www.dukehealth.org (follow

‘Quality and Safety’ link)

WILLIAM FULKERSON JR., M.D.

12 Inside Duke Medicine August 2008

l E G a C I E S

special to Inside Duke Medicine

Victor Murdaugh, M.D., described himself as “a young

man in a hurry” when the photo at right was taken.

In it, he is demonstrating Duke’s new Kolff twin coil artificial kidney for visiting physician F. Howard Hall, M.D., of Richmond County, Va.

The photo of Murdaugh, a 1950 Duke medical graduate, during a Heart Disease Institute at Duke in 1957 appeared in the Winter 2008 issue of DukeMed Alumni News, along with several other “mystery photos” in a photo identification project sponsored by Duke University Medical Center Archives. Murdaugh saw his photo and called to identify it.

Invented by Willem Kolff, M.D., a researcher at the Cleveland Clinic Foundation, Duke’s kidney machine was the first in the Carolinas and among the first half-dozen in the Southeast.

“Dr. Stead told me to get a committee of three and set up a kidney program,” remembers Murdaugh. “So, we ordered a machine. We were told it was the 13th artificial kidney in the world at that time.”

Eugene A. Stead, M.D., then chair of medicine, hoped the machine would save the lives of patients whose kidneys had shut down following major trauma or due to poisoning or complications from blood transfusions. It would also make major surgery an option for patients with compromised kidney function.

For Murdaugh, it was the primitive beginning of a long and pioneering career in kidney disease treatment, including founding programs in dialysis and transplan-tation in Birmingham, Ala., and Pittsburgh.

He writes: “The twin coil dialyzer, which I am holding in my hand in the picture, consisted of two long semi-permeable cel-lophane tubes rolled up in a coil between two layers of nylon

screen with spacers to keep the tubes open. Blood was pumped from a prepared artery, through the cellophane tubes in the coil, and back to a prepared vein. The fluid pumped through the dialyzer changed the chemical concentra-tion of the blood to approach that of the dialysis fluid. Of course the dialysis fluid composition also changed with time … requiring the dialysis fluid to be replaced about every two hours.

“A sizeable number of people was required to monitor for blood leak, the vital signs of the patient, clinical status of the patient, the electrocardiogram, the condition of the dialysis fluid, and to keep detailed records, since we were all learning.

“There were no commercially

available bath concentrates in those days, and we had to weigh out the chemicals to mix with water to prepare each new bath. When the bath was to be changed, the dialysis fluid was pumped out of the large tank and the pump … was turned off. The tank was again filled with water, the prepared chemicals put in the bath, and stirred with a paddle like a canoe paddle.

“Of course, we were all excited and somewhat nervous when doing the first few dialyses until we learned what to do and when. Even so, the first few patients with acute renal failure that we dialyzed all lived, and no patient was lost during a dialysis for the rest of the time Henry and I were at Duke.”n

This article first appeared in Duke Med Alumni News.

‘Mystery Photo’ identified

Duke graduate Victor Murdaugh, M.D., right, explains the Kolff artificial kidney to a visiting physician in this recently identified photo from the 1950s. PhOtO cOUrtesY OF DUKe UNIVersItY MeDIcAL ceNter ArchIVes

13August 2008 Inside Duke Medicine

Duke’s Buehler recalls olympic glory

By Michelle Gailiun

When America tunes in to the opening ceremonies of the Olympics August 8, there may be no one in the Duke community watching more closely than former track and field coach Al Buehler. After all, he probably has more history with the games than any other person in Durham, having served as coach or manager of the U.s. Olympic track and field teams in 1972, ’84 and ’88.

At his home in the Forest at Duke, official Olympic gear hangs pristinely in his closet. And just how many people do you know that have a real Olympic torch tucked into a corner of the office?

“I’ll never forget that day in Munich when we walked in the opening parade. My parents were there, my wife was there, it was one of the proudest moments of my life,” he says.

Long ago, Buehler’s track buds dubbed him, the “silver Fox of the Piedmont.” But these days, Buehler has earned the title of “Mr. Fitness.” community leaders credit Buehler with being the driving force behind community-wide fitness initiatives that eventually led to the creation of Duke’s center for Living.

“I’ve always been fit. In junior high, I was on five basketball teams. I’ve never thought I was obsessive about it; it was just the way we used to live back then.”

to keep fit these days, Buehler and his wife, Delaina, walk for about an hour almost every day – usually, along the trail named after Buehler when he left his job as chair of the physical education department in 2000.

the Buehlers will celebrate their 50th wedding anniversary this year. Delaina says Al told her he married her because she didn’t know anything about sports.

“I really didn’t. I thought ‘cross-country’ meant running from New York to california.” And a little secret about the coach? “Believe it or not, he hardly ever watches sports on television.”

Bet he’ll be watching this month.

14 Inside Duke Medicine August 2008

O N T H E C O V E R

Dennos was born with spastic diplegia cerebral palsy, which prevents normal motor control and muscle tone in all four of his limbs, but affects his legs the most. The neurological disorder affects his ability to walk and speak as well as the fine motor skills required to fasten buttons and tie shoe laces. But physical therapy can improve motor control, minimize musculoskel-etal problems, and aid in development of gross motor skills such as walking or using a wheelchair. Such therapy can mean physical independence for a person with cerebral palsy.

Though the condition has made life all but easy, Dennos remains enthusiastic about continuing his education. After choosing to pursue a degree in creative writing at St. Andrews Presbyterian College in Laurinburg, the young writer finds that the most difficult decision he has had to face thus far came with deciding which of his many dreams he wished to accomplish first.

“Well, I’m still trying to decide between being a professional movie critic and being a screenwriter,” said Dennos.

Activity is abundant in the room, as other pediatric physical therapy patients are escorted in and are coached through their exercises.

“This past year we’ve been looking at all the ways we can help him transi-tion so that he’ll be more independent with his exercise program when he’s off to school,” said Laura Case, DPT, who teaches courses in Duke’s Doctor of Physical Therapy Program. Her clinical interests include pediatric physical therapy, with particular emphasis on

children with neuromusculoskeletal diagnoses, such as cerebral palsy.

Case helped Dennos develop ways that he might do his stretches independently on campus, which will help him remain limber and maximize use of muscles over which he maintains control. Case was looking for more ways for him to work independently on balance and coordination as well as strengthening while at college.

One day, one of the students in the DPT program brought in a Wii.

Dennos’ positive response to

strength building exercises on the Nintendo game system prompted physical therapy students to rally

together and purchase a Wii for Dennos to take to college with him. This physically engaging video game

system, with its innovative wireless handheld controller, shows promise of becoming a vital instrument in home-based health care.

The system’s growing use in physi-cal therapy has spawned a new clinical term: “Wiihabilitation.”

This isn’t the first time the teen has been involved in the use of innovative medical technology. Twelve years ago, a five-year-old Dennos made front page news in Duke Dialogue when he assisted engineering students in the modification of both a child-sized toy

car and a Nintendo video game system so that they could each be used by physically disabled children.

“Anytime they needed a guinea pig they’d pretty much ask for him,” said the teenager’s mother and 33-year Duke Hospital employee Patricia Dennos.

The Power Wheels toy had been transformed from a two-speed, foot-pedal operated vehicle to a variable speed car with modifications that allowed its driver to control the speed with a pedal that could be controlled by moving one’s head. The Nintendo video game’s controllers were converted from a standard two-hand, thumb-operated panel to a joystick for use by those with limited dexterity. When it came time to test the newly altered toys, the five-year-old was more than happy to help.

The Wii Phenomenon

With all of the recent attention sur-rounding both the Nintendo Wii and the newly released Nintendo Wii Fit and their expected potential in certain areas of physical therapy and muscle training, a few pressing questions arise.

What could one hope to gain from using the Nintendo Wii Fit?

Contrary to popular belief, the Wii Fit video gaming system was not designed as an alternative to regular exercise nor is its purpose to aid in weight loss. In fact, Wii creator Shigeru Miyamoto is often quoted as saying that the Wii Fit console is little more than a complicated scale with the ability to track its users’ progress. When used properly, users can expect to improve strength, endurance, balance, and posture. As new levels of endurance are achieved, new and more complex games are unlocked for more vigorous training.

Wii Fit, an add-on to the original Wii video gaming system, comes with a wireless, pressure-sensitive peripheral known as the Wii Balance Board. This scale-like device measures body mass and weight while Wii Fit’s software tracks changes and sets goals.

Its use in research as a data collec-tion device is being explored. Duke’s Department of Community and Family Medicine will use the Wii as part of a study of postpartum weight loss.

In Dennos’ case, however, the Wii module will serve as more than a gaming system or weight-monitoring device. It is a tool that will support his independence from the physical therapy he has participated in his entire life.

“For me, it’s just the joy of seeing him go off to college and be indepen-dent,” said Case with tears welling in the corners of her eyes, “I’m just proud of him.” n

La-Tasha Davis studies mass communications at

N.c. central University and is a summer intern

at Duke Medicine News & communications.

this 1996 photo from Duke Dialogue shows a five-year-old Michael Dennos testing a modified Nintendo joystick with Dr. rajan Gupta. FILE PHoTo

“...it’s just the joy of seeing him go off to

college and be independent...“

MICHAEL, continued

l I V E Sa N N O U N C E M E N T S

Headline headline

15August 2008 Inside Duke Medicine

new step-Down Bedsstaff in patient-care unit 4300 at Duke university Hospital celebrate the opening of six new step-down beds with a ribbon cutting ceremony on July 17. Each step-down room is equipped with a GE Health Care T-series V6 Dash 4000 monitor constantly overseen by nurses at a central station.

The beds provide care to neurosurgical or neurology patients, orthopedic spine patients and other patients who require a higher level of monitoring than is normally provided in an intermediate care area. Care is provided to patients from age 19 to the very elderly.

PhOtO BY KeLLY MALcOM

special to Inside Duke Medicine

clinical Pharmacist Van Blalock is known for his skill, knowledge, and great sense of

humor. those who know Blalock also know he has a giving heart.

In fact, Blalock received the strength, hope, and caring Award for his commitment to making the patient first priority in 2005. three years ago, when co-worker Wanda Bride asked Blalock to join the Duke start! triangle heart Walk team to raise money for the American heart Association, he jumped at the chance.

“Wanda takes care of all of us,” said Blalock. “When she needs me to do something, I do it. she really got me involved and encouraged me to reach my goal.”

Last year Blalock earned the title of top Walker in the triangle, raising over $4,600 for cardiovascu-lar disease research. Blalock is on track to take the top spot again and has already raised $1000 from friends, family and co-workers.

“I work with great people. Our cardiologists and researchers set international and national standards in the field of cardiology and I’m proud to be a member of the team,” said Blalock. “Participating in the heart Walk is a way for me to honor them and the patients whose lives are touched by their good work everyday.”

Blalock has a personal connection to heart disease. As a clinical pharmacist on the cardiology floor, he works with patients and healthcare professionals that are examples of how research supported by the American heart Association impacts real lives.

Blalock’s heart Walk team walks in honor of his father-in-law, Neal hobart, who passed away last

year (pictured above on a t-shirt worn by Blalock's wife, terrie); heart disease survivor and friend Brady Faulkner; and all those who cared for them while they were treated at Duke.

“It’s important to me to support the American heart Association,” said Blalock. “I’ve seen how the funds we raise for the triangle heart Walk goes full circle and comes back to researchers at Duke, allowing them to discover new treatments and procedures that save lives.” n

Heart Walk team honors family, friends and co-workers

Coming full circle

Paul Killenberg, 70

Paul Killenberg, M.D., a professor emeritus of medicine and a national leader in the diagnosis and treatment of liver disease, died July 23 at Duke University hospital. he was 70.

During his 36 years on the Duke medical faculty, Killenberg was a giant in the Division of Gastroenterology and at the Duke University Medical center.

While his contributions in the field of liver disease were many, his proudest professional accomplishment was the training of hundreds of medical students, residents, and fellows. In 2002, the Division of Gastroenterology created the Paul G. Killenberg Medical teaching Award and named him the first recipient.

“he was a gifted teacher, someone we didn’t want to disappoint,” said Andrew Muir, M.D., who trained under Killenberg. “rounding with him was a wonderful experience because he enjoyed patient care so very much.”

In 1985 Dr. Killenberg helped create Duke’s Liver transplant Program – the first in North carolina.

Killenberg was named professor emeritus of medicine by the Duke University Medical center and served as ombudsman for the university. In 2006, he was honored with the Duke Medical Alumni Association’s Distinguished Faculty Award.

he earned a medical degree from the University of Pennsylvania in 1963.

he served in the U.s. Army Medical corps, earning the Bronze star for service in Vietnam. his volunteer service to the Durham community included Durham system of care, housing for New hope, and Boy scout troop 458. For his leadership of the emergency energy Fund, he received a Volunteer of the Year award.

“Paul was a physician’s physician,” said William Fulkerson, Jr., M.D., senior vice president for clinical affairs and long-time friend of Killenberg.

Louis Tedder, 58

Louis tedder, a legendary concierge and ambassador at Duke hospital, died July 3. tedder, 58, was known for going above and beyond to care for patients.

he received a strength, hope, and caring Award in 2007 for his exceptional efforts to fulfill a terminally ill patient’s request – to eat pinto beans. tedder filled the request after walking to two stores to find the pinto beans so that they could be delivered to the patient.

A memorial service for tedder was held Feb. 14 in the searle center lecture hall. he is survived by his wife, six children, his mother and brothers and sisters.

sowers, schneider and relf named to nursing academy

three Duke Nursing leaders have been elected to the American Academy of Nursing, effective Aug. 1.

Named were susan M. schneider, associate professor at the Duke University school of Nursing; Kevin W. sowers, Coo and interim ceO of Duke University hospital and clinical associate at the school; and Michael relf, incoming assistant dean for undergraduate education.

”the academy is comprised of many of the nation's top nursing executives, policymak-ers, scholars, researchers, and practitioners,” said academy President Pam Mitchell, Ph.D. “Being selected as an academy fellow is an important recognition of one's contributions to nursing and health care.”

the American Academy of Nursing (AAN) includes more than 1,500 nursing leaders from education, management, research and nursing practice.

“the recognitions of the career accomplish-ments of these faculty are well deserved, and we are proud of them,” said Dean Catherine L. Gilliss, Dnsc, r.n.

she is also vice chancellor for nursing affairs for Duke Medicine and academy president-elect.

Ninety-two nurse leaders will be inducted as Fellows during the academy's 35th annual meeting on Nov. 8 in scottsdale, Ariz.

Patricia M. Dieter, director of the Duke Physician Assistant Program, has been elected to the executive committee of the Board of Directors of the International Association for Interprofessional education and collaborative Practice (Intered).

the election occurred at the All together Better health IV conference held in June at the Karolinska Institutet in sweden.

Also, Dieter was recognized as a distin-guished fellow of the American Academy of Physician Assistants.

Ara Metjian, M.D., was selected as one of 20 to begin a unique year-long education and mentoring program as part of the American society of hematology clinical research training Institute.

each year, the institute provides aspiring hematologists with the necessary tools to begin careers in clinical research.

the program is offered to hematology and hematology/oncology fellows as well as junior faculty who are within three years of completing their fellowship training at academic medical centers in the United states and canada.

By participating in the start! triangle heart Walk, employees can help Duke Medicine reach its goal of raising $1 million for cardiovascular disease research and education. the walk will be held Oct. 19 at the Imperial center Park.

Duke Medicine is currently recruiting team captains and walkers for its heart Walk team. chancellor for health Affairs Victor J. Dzau, M.D., is past chairman of the walk.

to sign up for the Duke Medicine team, call 463-8376 or visit http://www.starttriangle.org

a R T S , C U lT U R E & M E d I C I N E

16 Inside Duke Medicine August 2008

By Anton Zuiker

Hungry employees at Duke University

Medical Center have more and more lunch options these days, with new eateries popping up each month up and down Erwin Road – burritos, noodles, crepes, doughnuts, sushi, burgers and more.

Head down the hill a bit further and turn into the Center for Living Campus to find a hidden-away gem – the café at Duke Integrative Medicine Center, where Chef Cate Smith prepares nutritious, delicious meals from local, organic produce. The Friday buffet, $9 for Duke employees, is a good time to experience what Smith does with local produce, and to learn about the Center’s efforts to promote better health and weight loss through mindful eating.

“People always say, ‘Grandma’s food tasted better,’” says Smith. “That’s because moms and grandmas put love into their food, and paid attention to nurturing their families.” We share a laugh over that wonderful scene from the movie Ratatouille: caustic restaurant critic Anton Ego (no relation), tasting Chef Remy’s take on the classic country casserole, is transported back to his childhood home and mom’s comfort food.

Trained in music education, Smith decided after college that food was her true passion. She appren-ticed for chefs and caterers and hotel food service in and around Roanoke, VA., working her way up the

kitchen ladder to chef de cuisine and executive chef. But battling and surviving cancer “changed my eating habits,” she says, helping

her recognize the connections between her

diet and her health.When she learned about

Duke Integrative Medicine and its approach to whole health, she

jumped at the opportunity to be the first chef in the welcoming new building.

“This was the job I had to have.”Mindful eating seems simple enough: Put down your fork

after your first bite, Smith suggests. Savor the flavors. Listen to your body and what it’s telling you about when to stop eating – especially hard to do with a plate of Smith’s delicious baked sweet potato fries with side of honey or the grilled vegetable wrap in front of you.

“When I’m on the line, this is my office,” Smith says, sweeping her arm to take in the café’s floor-to-ceiling windows and landscaped patio. Soon, 60 diners will make their way

through the space, minding their manners, speaking softly and savoring their every bite.

Chef Smith offers a cooking class each Monday, 4–5:30pm, $25. Integrative Medicine is also offering an eight-session Mindfulness Practices course, Monday evenings in September and October, to help people lose weight by learning to pay atten-tion to body signals and emotional states. For more

information, call 684-9901. n

min

d your food

This month: Inside Online

In mid-August, we launch a daily news site and employee blog. Watch for it at http://inside.dukemedicine.org

Online any time

You can download a PDf of this issue, suitable for emailing or printing, at http://inside.dukemedicine.org

Next issue

The next print edition will appear sept. 1. The deadline for submissions for that issue is Aug. 15.

slow down and savor your flavors