Inside Duke Medicine - September 2008 (vol. 17 No. 9)

VOLUME 17 NO. 9 n inside.dukemedicine.org n September 2008

Great honor for Lefkowitz President Bush on Aug. 25 named Robert J. Lefkowitz, M.D., Howard Hughes Medical Institute investigator at Duke University Medical Center, a recipient of the National Medal of Science for contributions to the biological sciences. Lefkowitz is being honored for a lifetime of research into understanding the largest, the most important and most therapeutically accessible receptor system that controls the body’s response to drugs and hormones. The president will present Lefkowitz with the medal, which is the nation’s highest honor for science, at a ceremony on Sept. 29 at the White House. “Even for a highly decorated and often recognized scientist like Bob, this represents a remarkable and extraordinary achievement,” said Victor J. Dzau, M.D., chancellor for health affairs and CEO, Duke University Health System. “I am particularly excited and pleased to see Dr. Lefkowitz’ work recognized in this way as his discoveries represent the very best in translational science and medicine and have served to ultimately improve the health and lives of millions of people around the globe.”

moving

forward

Tram to retire Oct. 15—walkway, shuttles will take its place. By Mark Schreiner

T

he PRT tram is retiring. After nearly 30 years of service, the Personal Rapid Transit system between Duke North and Duke South will cease permanently on Oct. 15. Rather than an ending, it’s the first step in a series of projects that will grow and improve Duke Medicine.

Alternative transportation for patients, visitors and hospital employees has been planned, and there will be service outages on the quartermile North-South PRT link in September while those plans are tested and perfected. See PRT, p.6

The National Medal of Science was established by Congress in 1959 as a presidential award to be given to individuals “deserving of special recognition by reason of their outstanding contributions to knowledge in the physical, biological, mathematical, or engineering sciences.” A committee of 12 scientists and engineers is appointed by the president to evaluate nominees for the award. Lefkowitz, a Duke faculty member since 1973, received the award for his concept, proof and studies of G-protein-coupled receptors and related enzymes, proteins and signaling pathways. These receptors, which are located on the surface of the membranes surrounding cells, are the targets of almost see LEFKOWITZ, p.15

w h at ' s n e w ?

inquiry

on the job

No bones about it

Going with the flow

Code Pink in action

School of Medicine's impressive new Gross Anatomy lab opens. Page 16

Radiation Oncologist Mark Dewhirst tells how the tides pulled him to tumor research. Page 10

Learn how clinic staff reacted when a child was seemingly abducted one recent day. Page 15

Inside Duke Medicine

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September 2008

ON THE WEB

INSI D E S C OO P

Highlighting the best health, science and employee news from Duke Web sites

The PRT and me I

t may sound strange, but when I was a student health volunteer on the pediatric ward during my sophomore year at Duke University, riding the PRT to Duke North gave me a small thrill. To me, the tram signified leaving academia and entering into the real world of a hospital, where top-notch physicians and nurses were busy saving lives. Interacting with these professionals and with patients gave me an improved perspective on life as a student. On my ride back to campus, I’d often stare out the window, PRT to end service on October 15. Photo by mark schreiner. thankful to be even a small part of such a great institution. Now, the to move to downtown Durham (see Duke for life-saving transplants approaching PRT closure represents page 13). A new anatomy and live (page 12) or geriatrics care (page 7). steady improvement, as Duke tissue lab marks new growth for the At Inside Duke Medicine, Medicine continues to grow. School of Medicine (page 9). And, we’re growing, too. Stay tuned That growth is reflected elseDuke employees are improving the for news about a new employee where, too. Duke’s renown physician lives of children in Haiti (page 5), news Web site. assistant program is getting ready as well as patients that travel to – Kelly Malcom

■ ■ lo c a l r esou r c e

Home away from home Since 1980, the Ronald McDonald House of Durham has provided shelter to more than 20,000 families whose children were being treated in local hospitals, weaving their stories into the fabric that makes this House a home. http://www.ronaldhousedurham.org/

■ ■ a r ti c les

Preventing HIV Combination prevention—a combination of behavioural, medical, and structural approaches based on sound evidence—offers the best hope for future successful HIV prevention, concludes Michael Merson, M.D., Duke Global Health Institute director. http://globalhealth.duke.edu/newsevents/global-health-news-at-duke/ lancet-merson

■ ■ r ese a r c h

BY THE NU M BERS

Reducing hospital infections

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DOWN

DOWN

DOWN

18%

22%

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3

■ ■ I N S I D E V olume 1 7 , I ssue 9

DOWN

DOWN

23%

27%

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40%

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In 1997, the Duke Infection Control Outreach Network (DICON) was formed to advance efforts that improve quality of care and enhance patient safety. A collaboration between Duke and 35 community hospitals, DICON is focused on improving infection control programs through monitoring and education. The latest data have shown a significant reduction in nosocomial infections in DICON-affiliated hospitals:

1 2

E mployee exposures to blood and body fluids: DOWN 18%

3 4 5

Nosocomial blood stream infections: DOWN 23%

 osocomial infections due to N methicillin-resistant Staphylococcus aureus (MRSA): DOWN 22%

F oley-associated urinary tract infections: DOWN 27% Ventilator-associated pneumonias: DOWN 40%

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.

FILE PHOTO

Tiny teeth Miniature fossilized teeth excavated by Duke anthropologists from an Indian open-pit coal mine could be the oldest Asian remains ever found of anthropoids, the primate lineage of today's monkeys, apes and humans. Just 9-thousandths of a square inch in size, the teeth are about 54.5 million years old. http://news.duke.edu/2008/08/anthrasimias.html.

Contact us Campus mail: DUMC 104030 Deliveries: 2200 W. Main St., Suite 910-B, Durham, NC 27705 Phone: 919.660.1318 E-mail: [email protected] Credits Cartoon: Josh Taylor

Staff Editor: Anton Zuiker Managing Editor: Mark Schreiner Science Editor: Kelly Malcom Calendar Editor: Erin Pratt Designer: Vanessa DeJongh Copyright © 2008 Duke University Health System

September 2008

Inside Duke Medicine

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C A L EN D AR

September Your insider's guide to what's happening at Duke Medicine

do

Oct. 1 4:30-6 p.m. University Seminar in Global Health Stephen Lewis will talk about the HIV/AIDS disease burden on women in Africa. He will also discuss how education access is a means to obtain better health outcomes for women. John Hope Franklin Center, Erwin Road and Trent Drive. Free parking across the street in the Pickens Clinic lot

through Nov. 9 “El Greco to Velázquez: Art during the Reign of Phillip III” The exhibition features 53 paintings, including seven late works by El Greco, three early works by Velázquez and works by their contemporaries. The exhibition will include monumental altar pieces, life-size portraits, some of the earliest still-life paintings in Europe, full-length carved and painted wooden sculptures of Spanish mystics and more than 50 pieces of Spanish glass and ceramics. Many of the works included are traveling to the U.S. for the first time, some from the churches which they were originally commissioned. Nasher Museum of Art at Duke. Details: http://www.nasher.duke.edu/elgreco

Oct. 17 5:30 p.m. Don’t let Injuries Slow You Down Ann Marie Husk, P.T., will discuss common walking and running injuries, tips for prevention, and treatment suggestions. Alumni Box at Wallace Wade Stadium. Details: http://www.hr.duke.edu/runwalk/education

give

Sept. 20 10 a.m.–4 p.m. Asian American Health Fair will offer health talks about diseases that afflict the Asian American population such as diabetes and heart and lung diseases. Nutrition, fitness, and safety demonstrations including yoga and healthy cooking will be available. Duke Raleigh Hospital will provide an information booth with educational materials and giveaways. Colonial Baptist Church in Cary. Details: http://www.aac-nc.org/ healthfair2008/Welcome.html

Sept. 27 8 a.m. 7th Annual Blow the Whistle on Asthma Walk on the Centennial Campus of N.C. State University in Raleigh. Sign up to be a captain or participant to raise money and awareness for asthma and other pulmonary diseases. The event, sponsored by the American Lung Association, will include a 5K walk. Lung disease is responsible for one in seven deaths. Today, more than 35 million Americans are living with chronic lung disease such as asthma, emphysema and chronic bronchitis. Details: http://www.mrsnv. com/evt/home.jsp?id=2037

Sept. 21 1-4 p.m. Free prostate screening. The American Cancer Society recommends that all men over 40 be screened annually. Durham Regional is hosting free screening for the public, open to men 40 years of age or older. Registration not required. Info: James Amos, 470-4278. Sept. 26 11 a.m.–2 p.m. Festival: Feast on Fall’s Fresh Harvest at Duke’s final farmers market for the season. The festival will include cooking demonstrations, apples and roasted corn, pumpkins and gourds. In front of the Medical Center Bookstore. Details: http://www.hr.duke. edu/farmersmarket/

The Immaculate Conception by Diego Rodríguez de Silva y Velázquez, on view at the Nasher Museum of Art, Sept.1–Nov.9. Details below. courtesy of the national gallery, london

learn

Sept. 16 5:30 p.m. It’s in the Way You Walk/Run Al Buehler, former Duke men’s track and cross country coach, will discuss and demonstrate the basics of good walking and running form. Alumni Box at Wallace Wade Stadium. Details: http://www.hr.duke.edu/runwalk/education

Sept. 11 12–1:30 p.m. Spirituality, Theology & Health Seminar Series Pamela Reed, Ph.D., R.N., professor at the University of Arizona College of Nursing in Tucson, will present “Spiritual Perspectives and Health Science.” School of Nursing Building Room 1014. Complimentary lunch. Register: 660-7556

Sept. 16 7 p.m. Ladies Night Out: Total Joint Replacement Part of a free seminar series to help women stay on top of important health issues. Scott Kelley, M.D., of N.C. Orhopeadic Clinic, will discuss total joint replacement. Durham Regional Hospital, first level classroom. Registration: http://www.dukehealth.org/durhamregional/events/20080630134217541

Sept.15 3–5 p.m. State of the Duke University School of Nursing Address by Dean Catherine Gilliss, R.N. School of Nursing Building Room 1014

Sept.18 5:30–7 p.m. How to find “Five Good Minutes at Work” presented by Jeffrey Brantley, M.D., director of the Mindfulness Based Stress Reduction Program at

Duke Integrative Medicine. Come and explore the possibilities of making your work a source of deeper satisfaction. Discover how simple, easy-to-learn principles of presence, intention, and wholeheartedness can be applied for on the job stress reduction. Duke Integrative Medicine Building, Workshop AB. Register: 416-3853 Sept. 26, Oct. 31, and Nov. 14 7:30 a.m.–4:30 p.m. Safe Choices Workshops designed to build a culture of safety at Duke Medicine. Durham Hilton Hotel. Register with Education Services through: http:// stellar.oit.duke.edu/wwwactivestaffer Oct. 1 12:15–1:05 p.m. Meeting Emerging Challenges: Global Health at Duke with Michael Merson, Director of Duke’s Global Health Institute. N.C. College of Veterinary Medicine, 4700 Hillsborough St., Raleigh

Sept. 27 10:30 a.m. 6th Annual Gail Parkins Memorial Ovarian Cancer Walk as part of Ovarian Cancer Awareness Month. Duke and UNC GYN oncologist will host an educational forum. Sanderson High School in Raleigh. Details: http://www.ovarianawareness.org Oct. 19 3 p.m. Heart Walk Duke Medicine steps out in the fight against heart disease and stroke, the nation’s No. 1 and No. 3 killers, at the 2008 Start! Triangle Heart Walk at the Imperial Center in RTP. Details: http:// www.starttriangle.org

How to submit: Send calendar listings to [email protected]

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.

Inside Duke Medicine

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September 2008

BU L L ETINS

AT A G L AN C E

“

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Walking is the very best exercise. Habituate yourself to walk very far.

—Thomas Jefferson (1743–1826)

■ ■ it f i g u r es

News briefs, notices, events, and the IDM Book Club ■ ■ hono r s

Nominations sought for Clark Award

■■INSIDE JOKE

Last year, the Health System created the Susan B. Clark Award for Administrative Leadership, an honor that is given annually to a Duke Medicine administrative professional who demonstrates the qualities exemplified by the late Susan Clark during her remarkable career at Duke – dedication to the institution, service to others, and personal strength of character.

1,417,723 Outpatient visits in 2007; that averages out to more than

These qualities enabled Susan to rise through the ranks from an entry-level position to strategic services associate in the Office of the Chancellor, and made her a role model for all office support staff across Duke Medicine. By establishing this award, Duke Medicine honored Susan’s contributions and recognized her legacy.

3,800 a day. Source: dukehealth.org

Consider nominating one of your colleagues for this award. Nominations can be made by any Duke Medicine employee.

gl o b a l h e a l t h

The winner of will be honored at a luncheon hosted by CEO Victor J. Dzau, M.D., in December and receive a “weekend getaway” that includes two nights hotel lodging and dinner for two.

In the community Initiative eases Latinas’ stress in adapting to a new culture

Nominations must meet specific criteria and be submitted on an official form. If you have questions or need a form mailed to you, please contact Monica Pallett at 684-5314 or [email protected].

A

new pilot research program for Durham and Chatham counties recently was launched to ease Latinas’ transition to life in North Carolina and to improve their ability to cope and help one another so far from their homelands. Called ALMA, it is a collaboration between the Duke University School of Medicine and the University of North Carolina School of Medicine. Funding for the project, called the Duke-UNC GlaxoSmithKline Health Disparities Initiative, comes from the GlaxoSmithKline (GSK) Foundation in Research Triangle Park. ALMA stands for Amigas Latinas motivando el alma—Latina Friends Motivating the Soul (or Alma), a name chosen by the project’s community advisory committee. The study was launched in early February 2008, when the research team recruited 18 socially and economically diverse adult Latinas in Durham; Chatham participants will be recruited later this year. ALMA teaches the women skills to handle emotional stress and sadness, function in their new environment, and share those skills with other Latinas. The goal is to create health, especially the capacity for mental health, within the individual and the community. The amigas—friends—element is

■ ■ L E AR N I N G

Medical Spanish classes offered A great opportunity: classes geared toward spoken Spanish and tailored to individual needs.

ALMA works to ease the transition of Latinas to life in North Carolina. FILE PHOTO

central to its success. After 10 weekly sessions learning and testing skills, the 18 Latinas qualify as promotoras —literally “promoters”—but in reality, far more. Already recognized before ALMA as effective natural helpers in their local communities, they fan out after the training as lay health advisers to teach their newly learned self-help skills to family members and friends. “We train the trainers, who go out in their community and train other people,” says project director Tia Simmons of Duke’s Division of Community Health. “We want to

provide ways for these women to help themselves, based on their common bond—coming here—and using their varied backgrounds to help them understand our cultural practices, education, and health systems.” Georgina Perez, MSW, LCSW-P, of the Division of Community Health, agrees. “The ALMA project is teaching the promotoras new, positive, and creative ways to cope with stress, along with the chance to build their social network of other Durham Latinas and learn more about the Durham community,” Perez says. n

Starting Sept. 22, through Dec. 4, 10-week courses are offered by El Centro Hispano through the HISPAmericano Institute in collaboration with Duke School of Nursing and the Latino Health Project at Duke University. Two-hour classes will be held once a week as follows: Level 1 – Monday, 5:30-7:30, at Duke South; Wednesday, 3:30-5:30 p.m at Durham Regional Hospital. Level 2 – Tuesday, 3:30-5:30 p.m., Durham Regional; Thursday, 5:30–7:30 p.m., Duke South Level 3 – Tuesday, 5:30-7:30 p.m., Duke South Clinic. Level 4 – Available upon request. Cost: $200, but $10 off when you bring a new student. Book not included. Payment by check or credit card. No refunds. Call Adriana at 680-3333.

Inside Duke Medicine

September 2008

■ ■ T r a ns p o r t a tion

Duke Transit adds LaSalle St. loop

Haitian journal

Students, staff and faculty who live near Duke in the LaSalle Street area have a new way to get to and from campus. Duke Transit has rolled out a new LaSalle Loop to provide transportation to and from apartment complexes between Erwin Rd. and Hillsborough Rd. Free rides are available from 7 a.m. to 9 p.m. Monday through Friday, with stops made approximately every 30 minutes in a continuous loop at existing Durham Area Transit Authority (DATA) bus stops along the route. The service, which is being provided under a contract with Carolina Livery, will serve apartment complexes along LaSalle St., Morreene Rd. and Campus Walk Ave. Apartments include: Belmont, Blue Crest, Bradford Ridge, Campus Walk, Chapel Tower, Duke Manor, Erwin Terrace, Holly Hill, Lofts at Lakeview, Morreene Road, Partners Place Condos, Poplar Manor, Poplar West, Martin Court and Yester Oaks. Find a route map and schedule at http:// siren.auxserv.duke.edu/parking/ busschedules/LaSalle_Loop.htm

The 2007 Thomson Reuters 100 Top Hospitals: Performance Improvement Leaders sets national benchmarks for the rate and consistency of improvement in clinical outcomes, safety, hospital efficiency, and financial stability. Findings from the fifth edition of the Thomson Reuters 100 Top Hospitals appeared in the Aug. 11 issue of Modern Healthcare.

Duke social worker Shelia Rittgers rehydrates an infant at a Haitian clinic last July. PHOTO courtesy of shelia rittgers

The Caribbean nation of Haiti is the poorest in the Western Hemisphere. On her own time, Shelia Rittgers, a clinical social worker at Duke Children’s Health Center, has traveled there to work at a rural clinic. Here are selections from her most recent journal:

Patient safety: Call for abstracts

I remembered the mom from last year. She says she cannot breastfeed because she has not eaten. She looks worn. She has the baby and two others in tow. All small, with classic red tint to their hair. The baby is hot with fever. After a quick check, it’s time to re-hydrate her a little, then check her again. The mother seems so sorrowful. She says she has good water but hasn’t eaten much. She was able to give the child some breastmilk after her second syringe of ORT [oral re-hydration solution]. The baby is hungry, hanging onto the breast tightly with one hand. She perks up after an hour. We talk to the clinic nurse about ways to help the mother. We ask her to come and talk with the pastor. After we teach her how to give the rest of the ORT, she takes the children, goes to the mission kitchen and is given two bowls of rice. She says she will talk to the pastor and go to another place the nurse recommends. So they eat today. What about tomorrow?

All abstracts will be compiled on a CD for distribution at the conference, allow us to share successes and learn from each other throughout Duke Medicine. Two abstracts rated highest by the judges will be selected for podium presentation at the conference. Abstract applicants not selected are welcomed to present their project as a poster presentation. All applicants will be notified by Nov. 5. Abstracts should: • Focus on completed or in-process patient safety and quality improvement initiatives. • Refrain from reference specific events or comparative data that may cause unintended legal exposure if published. • Not exceed two pages. • Be sent as an MS Word document to: [email protected] (email Pamela for the abstract format.) • Abstracts are due by 5 p.m. EDT, Sept. 19 to: [email protected]

Reuters: DUH among performance leaders

The hospital was recognized for being one of 100 hospitals making the greatest progress in improving hospital-wide performance from 2002-2006.

July 5

Posters and abstracts should tell the story of safety and quality improvement efforts at the unit, department or institution level. The top 25 rated abstracts will be awarded up to $100 toward preparation for a poster.

■ ■ RA N K I N G S

Duke University Hospital was named one of the nation's performance improvement leaders by Thomson Reuters, an information provider for businesses and professionals.

■ ■ o p p o r tunities

All staff and faculty are invited to submit abstracts for Duke Medicine’s 4th Annual Patient Safety & Quality Conference to be held Dec. 12.

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July 7 About midday, my name is being called. Someone is here to see me. As I turn the corner I recognize them

immediately. The grandmother stood there with him in her arms. She explained that she came last year with the boy. I remembered them well. He was so tiny, sitting in her lap, very alert. He was about nine months old and weighed less than 10 pounds. His mother died shortly after his birth ... Today, he’s about 21 months. He’s small but healthy, as alert as ever. Grandma just wanted to say thanks and let us see how he was doing. It was good to see him, so good. July 10 There are many people today. Two of us come out onto the porch as we are preparing to re-hydrate a toddler when she is spotted. She is laying on a sheet on the concrete. She is thin and old and there are flies buzzing around her face. There are two women with her. After a brief study, we move grann to the church. She is in heart failure and we can do nothing. Her breathing is very sporadic. We sit her up to make her more comfortable. April and our Haitian friends talk to her and her daughters about the situation ... Tears, anguish that she had been surrounded by flies. How long had she been there? We do not have much time to process. There are about a hundred people waiting ... n

I D M BOO K C L UB

Gray’s Anatomy @ 150 Quick: Its name is that of probably the best-known medical book in the world. Change a letter, and it becomes a cult TV show. The answer is easy: Gray’s Anatomy. This esteemed atlas of the human machine is celebrating its 150th birthday this year. “It’s like it’s always been there, the go-to book for virtually every physician,” said Duke’s Nancy Major, M.D., who just finished editing the on musculoskeletal portion of the next American edition of Gray’s. “But it’s doesn’t stay the same – it gets better, more detailed with each edition. When we know more, it goes into Gray’s.” The new edition features computer disks and other electronic aids to the text. But, it got its start in 1855, when namesake Henry Gray and illustrator Henry Vandyke Carter, both surgeons at St George’s Hospital in London, began collaborating on a practical anatomy text. They performed dissections over 18 months, with Gray writing and Carter sketching. Their work was published in 1858. It was immediately acclaimed for its elegant layout and clear images. According to London’s Telegraph, Gray earned £150 for every 1,000 copies. Carter, who’d by then gone to India to study tropical disease, received no royalties.

Reading a good book? Tell us about it at [email protected]

Inside Duke Medicine

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September 2008

on the cover

PRT, cont. PRT rapid transit facts Meanwhile, the PRT link between North and Parking Garage II will continue. The covered walkway between Duke North and South will remain open and will always be open even after the tram’s discontinuation. Even so, the retirement of the quarter-mile stretch of the PRT will be a big change for the entire Duke University Medical Center community. But, it is one that is necessary so that work on multiple expansion projects can begin. “The PRT was a state-of-the-art transportation solution when it began operation in 1979,” said William Fulkerson Jr., M.D., Duke Medicine senior vice president for clinical affairs. “Now, its retirement is making way for a state-of-the-art, 21st century medical facility.” When construction is complete in approximately five years, that part of the Medical Center will have something it has never had – climatecontrolled, interior walkways between buildings and a glass-fronted atrium that will offer shelter to patients, visitors, employees and faculty.

• Service between Duke North and Duke South will end permanently on Oct. 15. • Service between Duke North and Parking Garage II will continue. • The walkway between North and South will stay open. • Expect service outages on the NorthSouth PRT as Oct. 15 approaches.

Transport alternatives • Walking – Many do this already. The walkway won’t close. • Electric Vehicles – A building-to-building (North/South) electric vehicle service for those who have trouble walking long distances. • H-5 shuttle bus – This service, already in place, takes just minutes, with shuttles leaving every 15 minutes. • Ambulances will shuttle patients who must travel by stretcher. A new lift van will shuttle patients in wheelchairs.

Maps and more • Maps and more details will be published in the Oct. issue of Inside Duke Medicine.

Alternatives Even after the PRT system is retired, people will still have to get to North and South, as well as points in between, such as the Medical Center Library and Searle conference center. Health System leaders engaged a broad range of employees and caregivers in developing a post-PRT transport plan. There will be several alternatives: • Walking – Many do this already, and there are added benefits. Regular walking is excellent exercise – improving lung capacity, strengthening the heart and reducing stress. According to LIVE FOR LIFE, a 160-pound person burns 57 calories during 15 minutes of moderate walking, on average. • Electric Vehicles – A buildingto-building (North/South and vice versa) electric vehicle service for those who have trouble walking long distances. New six-seat, pollutionfree Global Electric Motorcars will travel between the Blue Zone entrance off Research Drive Extension at Duke South and the CARL Building walkway at Duke North. • H-5 shuttle bus – This service, already in place, takes just minutes, with

Since 1979, the PRT tram has shuttled patients, visitors and employees between Duke University Hospital's North and South buildings. The service is to end Oct. 15. Photo by mark schreiner

shuttles leaving every 15 minutes. The shuttle serves Duke South at the bus stop on Trent Drive near the pedestrian overpass and Duke North at the circle (inbound) and at the Erwin Road bus stop (outbound). • Ambulances will shuttle patients who must travel by stretcher. A new lift van will shuttle patients in wheelchairs. In October, see Inside Duke Medicine for more details about transportation alternatives and a map of shuttle pick-up and drop-off locations. A larger plan Construction in preparation for the expansion projects has already started. Crews are building a tunnel roughly parallel to the railroad tracks

between Erwin road and the PRT line to relocate the utilities. This tunnel must be completed first. By this fall, that tunnel project will cross the PRT area. “Safety during construction is of utmost importance,” said Kevin Sowers, R.N., M.S.N., interim CEO and COO of DUH, who is leading the expansion effort. “Retiring the PRT now keeps everyone safe and allows for the construction to continue.” A little history Duke Medicine made news in the 1970s when it was announced that a futuristic “horizontal elevator” would ferry employees, patients, visitors and cargo between the Duke Hospital and its planned North Division. An Associated Press report on the

inaugural ride on Dec. 8, 1979, told readers worldwide how Otis Elevator Co. had designed an innovative, pilot-less shuttle that travels “on a cushion of air.” In the decades since, a dedicated crew of technicians has kept the Duke PRT going, even though Otis has long since left the PRT business. “This is the only system of its type in the world, and it has required a team of highly-skilled mechanics to maintain its 99-percent dependability rating,” said Robert Guerry, director of facilities. An Engineering and Operations staff of 11 has kept the PRT going, day and night, since 1979. Get ready for Oct. 15 The PRT will not go away without Duke Medicine recognizing what role it – and its crew of dedicated technicians – has played. Watch for additional coverage in the October issue of Inside Duke Medicine. Additional PRT announcements and details about transportation alternatives will be sent to employees via e-mail as the Oct. 15 PRT shut down approaches. n

The Science & Research Supplement to Inside Duke Medicine VOLUME 17 NO. 9

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inside.dukemedicine.org

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September 2008

F EATURE

Innovative program recruits research subjects at NC church By Kelly Malcom

O

ne year ago, a team of Duke reasearchers from the Joseph and Kathleen Bryan Alzheimer’s Disease Research Center (Bryan ADRC) traveled to Jacksonville, NC to go to church. But, this was no ordinary visit. It was the pinnacle of a collaborative effort of church and community leaders, along with the Bryan ADRC, to increase participation of African Americans in Alzheimer’s disease (AD) research. Current figures indicate that African Americans appear to be afflicted by the devastating disease at a higher rate than whites, and yet participation of African Americans in AD research is low. “In the mid 1990s, there was a push by the National Institutes of Aging to involve the broader population in Alzheimer’s research. We decided to address this by reaching out to the African American community in North Carolina,” said Kathleen WelshBohmer, Ph.D., director of the Bryan ADRC. In 1995 the African American Community Outreach Program (AACOP) was formed with aims to help disseminate information regarding AD. This program, now coordinated by Henry Edmonds, M.Ed., assembled a group of community leaders from across the state to advise and help the Center in its mission to reach underserved groups. “Historically, there has been a lot of mistrust of medical research programs because of offenses, like the Tuskegee experiment, against African Americans,” said Edmonds. “The AACOP was established to build trust in these communities.” To that end, AACOP invited key members of the community from across North Carolina as research ambassadors, including from the outset the Rev. James Brown, pastor of the First Baptist Church (Broadhurst) in Jacksonville. Brown, whose own mother had suffered from AD, was an influential and dynamic leader devoted to helping his congregation and community get involved. see CHURCH, p.9

Duke is addressing the challenges of aging with multidisciplinary research investigations. At right: Top image shows a PET scan of a brain with Alzheimer's. The scan at bottom is a normal brain. File photo at left. Photo at right provided by the duke center for the study of aging and human development.

Caring for an aging population By Kelly Malcom

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riting in a recent issue of the journal Virtual Mentor, second year Duke resident Jeanne Lee echoed many of the sentiments of clinicians and researchers throughout Duke who are actively engaged in caring for elderly people: “Physicians are frequently the ultimate advocates for their patients’ autonomy…[They] must learn how to preserve quality of life even as they prolong it.” By the year 2020, 60 percent of hospital patients nationwide will be age 65 or older. Many of these patients will struggle with multiple ailments. Lee isn’t alone in thinking about how physicians should best treat older patients so that they don’t lose their independence. “It is important for physicians to think beyond the disease paradigm,” said Harvey Cohen, M.D., chair of the Department of Medicine and chief of the Center for the Study of Aging and Human Development. “We have to focus on the consequences of aging and look for ways improve function in old age.” Duke has a long history of focused geriatrics research, hallmarked by the nationally renowned, universitywide Center for Aging and Human

functional decline,” said co-principal investigator Miriam Morey, Ph.D. Duke researchers are exploring ways to intervene in what can seem like an inevitable break-down of physical function. One method may be as simple as taking a brisk walk. For 20 years, Morey has been investigating how regular physical activity can keep older adults out of nursing homes and independent. "It's important to remember that older Her most recent study, called Project Life, people should be able to remain active partnered with primary and achieve their goals in life." care physicians at the Durham VA to look at how counseling older patients number of translational and clinical during doctor visits can help motivate care research efforts. “Within the them to exercise. division of geriatrics, we’re investigatThe Pepper Center houses a numing long-term and end-of-life care, transitions of care, adverse drug events, ber of other aging studies by junior and osteoporosis and fractures, just to name senior faculty. These include looking at how the body ages on a cellular level, a few. Our work is very collaborative and very extensive.” looking at stem cells to understand Duke’s efforts for improving regenerative capacities, and examining the function of older persons were genetic predispositions for conditions acknowledged in 1992 with its designa- such as osteoporosis, diabetes, cardiovascular disease, and others, as well as tion as a Claude D. Pepper Older the genetics of successful aging. Americans Independence Center, a Cognitive declines can be just as, program administered by the National if not more, devastating as functional Institute on Aging. ones. Diseases like Alzheimer’s and de“The aim of the Pepper Center see GERIATRICS, p.8 is to explore modifiable pathways to Development. Created 50 years ago, the center has more than 30 core faculty and more than 100 affiliated faculty interested in the physical and mental well being of the elderly. Kenneth Schmader, M.D., division chief of geriatrics and director of the Geriatrics Research Education and Clinical Center at the Durham Veterans Administration (GRECC), oversees a

Inquiry

8

September 2008

NEWS

Dietary supplements may be risky for cancer survivors By Bill Stagg

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any older people who have survived cancer five years or more take vitamins, minerals or other dietary supplements in hopes of remaining free of the disease. A new study by researchers at Duke University Medical Center, Pennsylvania State University and the University of Texas’ M.D. Anderson Cancer Center, however, shows that cancer survivors are not heeding warnings that supplement use actually may backfire. “One of the most common behavioral changes cancer survivors make – sometimes without a doctor’s advice, often on their own – is using dietary supplements in hopes of bolstering their health,” said researcher Denise Snyder, LDN, clinical trials manager at the Duke School of Nursing. “Still, it’s unclear whether supplements really help keep cancer survivors healthier or put them at further risk.” The study of 753 people 65 years old or above, recently published in the Journal of Cancer Survivorship, is the first to focus on older, long-term survivors of colorectal, prostate or female breast cancer. Almost 75 percent were taking dietary supplements ranging from multivitamins (60 percent), calcium/vitamin D (37 percent) and antioxidants (30 percent) to herbs, amino acids and glandular extracts. Snyder said older cancer survivors should talk with their healthcare provider or a registered dietitian about supplements.

GERIATRICS, cont. mentia can rob an older person of their memories and personalities. At Duke’s John and Kathleen Bryan Alzheimer’s Research Center, founded in 1985, and the Aging Center, Kathleen WelshBohmer, Ph.D., P. Murali Doraiswamy, Ph.D., and other physicians are looking for clues into the causes and management of Alzheimer’s disease (AD) and other dementias. “One of the biggest obstacles facing physicians with regard to Alzheimer’s is the lack of a reliable method for diagnosis,” said Doraiswamy. Alzheimer’s is usually diagnosed after the patient has died and the brain is examined for the protein

Fruits and vegetables may be a safer source of vitamins and minerals than supplements. WIKIMEDIA COMMONS

products can upset the body’s nutrient balance and thus affect the ability to fend off cancer. “It’s controversial, but more research is pointing to not recommending supplements for cancer survivors because of the associated risk "It's unclear whether supplements really of the disease’s return,” Snyder said. “With the help keep cancer survivors healthier or number of older cancer put them at further risk." survivors growing rapidly, the better we understand the use of In addition, antioxidant supplements can interfere with chemotherapy supplements, the more valuable the insight we gain in our effort to improve for survivors still getting that treathealth outcomes in cancer survivors.” ment, according to research published Simply eating right may be a better in 2006 in an American Cancer Society option, said Snyder, who is also a Journal. registered dietitian.“Recent research The American Institute for Cancer indicates that it is probably best to get Research and the World Cancer your nutrients from foods, not suppleResearch Fund have recommended ments,” she said. n against supplements, saying the “While they may need a particular vitamin because they don’t get enough of it, they may not need a multivitamin or supplement because of the increased risk of cancer recurrence or a secondary cancer.”

plaques and tangles characteristic of the disease. At the recent meeting of the International Association of Alzheimer’s Disease, Doraiswamy presented a study of imaging techniques he collaborated on with Edward Coleman, M.D., of Radiogy, that may make it easier to detect the presence of plaques and tangles in a living person. “The Bryan Center is an interdisciplinary effort using different approaches to study Alzheimer’s. We’re looking at how environmental and lifestyle effects, like dietary habits and pharmaceuticals affect the onset and progression of AD. It now appears that good cardiovascular health is an important factor for maintaining cogni-

tive function,” said Welsh-Bohmer. As the American population ages, geriatrics research and care will become increasingly pressing. Indeed, this year, the Centers for Medicare & Medicaid Services, which administers Medicaid, the nation's largest health insurance program, for the first time released a list of research priorities for diseases and conditions affecting the elderly. Duke researchers in the Division of Geriatrics and the Center for Aging are leading the way in investigating many of these. To learn more about geriatrics research and resources available to Duke employees and patients, visit http://www.dukehealth.org/Services/ Geriatrics/. n

Young receives Wasserman grant Terri Young, M.D., of the departments of Ophthalmology and Pediatrics, has been granted a $60,000 Research to Prevent Blindness Lew R. Wasserman Merit Award. Young, who came to Duke in 2005, has served as a clinician and researcher at the Duke Eye Center and is the inaugural director of the Ophthalmic Pediatric Genetics Research Center. As a clinician, she treats children with eye disorders and children and adults with eye misalignment disorders. As a researcher, Young has been instrumental in bringing the field of genetics to help understand the causes of severe myopia, or nearsightedness, with hopes of one day treating or preventing this common ailment. While at Duke, she began a unique collaboration with researchers at the Singapore Eye Research Institute of the National University of Singapore to study the environmental and genetic origins of myopia. Read more about her work in the Duke Eye Center’s magazine, Vision, at http://www.dukeeye. org/newsroom/publications.html.

Communicating Science Workshops Beyond job-specific technical expertise and scientific knowledge, one trait is universally sought by both academic and industry employers— outstanding communication skills. Noted speaker Scott Morgan, co author of Speaking About Science: A Manual for Creating Clear Presentations (Cambridge, 2006) and partner at the Washington, DC consulting firm Premiere Public Speaking, will be returning to Duke September 23-25 to reprise his popular workshops on developing effective communication skills. Three morning workshops scheduled from 9-11AM will be followed each afternoon by small group practice sessions from 1-3PM. Registration is required for both the morning workshops and the afternoon small group sessions. This 3-day event is sponsored by the Office of Postdoctoral Services, the Career Center, and Graduate Student Affairs. To register for the workshops, visit the online calendar at http://www.postdoc.duke.edu/ and register via the online links in the event listings. Registration for the three morning workshops is open to all members of the Duke community. Preregistration is required for the small group sessions, and is limited to postdoctoral associates, postdoctoral scholars, and selected graduate students. For questions about the workshops, contact Molly Starback, director of the Office of Postdoctoral Services, at [email protected]

Science Editor: Kelly Malcom Inquiry features science and researchrelated news items from Duke Medicine News and Communications and other Duke departments. To submit content, contact us at [email protected]

September 2008

Inquiry

9

Team shows how DNA repairs may reshape genome By Mary Jane Gore

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esearchers at Duke and at the National Institute of Environmental Health Sciences (NIEHS) have shown how broken sections of chromosomes can recombine to change genomes and spawn new species. “People have discovered high levels of repeated sequences in the genomes of most higher species and spun theories about why there are so many repeats,” said Lucas Argueso, Ph.D., a research scholar in the Department of Molecular Genetics and Microbiology. “We have been able to show with yeast that these repeated sequences allow the formation of new types of chromosomes (chromosome aberrations), and represent one important way of diversifying the genome.” The scientists used X-rays to break yeast chromosomes, and then studied how the damage was repaired. Most of the chromosome aberrations they identified resulted from interactions between repeated DNA sequences located on different chromosomes rather than from a simple re-joining of the broken ends on the same chromosome. Chromosome aberrations are a

pair changes or small deletions and insertions. No one expected to see that one person would have two copies of a gene, while others would have one or three copies of the same gene.” These human studies also showed that many of the rearrangements found in humans are at sites of repeated DNA, which may occur through a mechanism similar to what this study found in yeast. Petes said this work with yeast also could prove "Some sequences may prove to be more relevant to cancer research. successful in natural selection, and “Most solid have eventually you may get a new species." tumors a high level of these rearchange in the normal chromosome only from the same chromosome, but rangements, as well as a high level of complement because of deletion, also from a similar repeated sequence extra chromosomes; recombination duplication, or rearrangement of in many other places in the genome.” between repeated genes is clearly one genetic material. On rare occasions, Sequencing the genomes of way of generating rearrangements, the development of one of these different humans has turned up although some rearrangements also new chromosome structures is benefioccur by other pathways,” he said. a surprising amount of structural cial, but more often DNA changes can “It is an evolutionary battle between variation between individuals, said be detrimental, leading to problems Thomas D. Petes, Ph.D., chair of normal cells and tumor cells. One like tumors. Molecular Genetics and Microbiology way that tumor cells can break free “Every so often the rearrangeand co-author of the yeast study. “We of normal cell growth regulation is to ments may be advantageous,” Argueso expected to see primarily single base rearrange their genomes.” n said. “Those particular differences may prove to be more successful in natural selection and eventually you may get a new species.” In the yeast used for this study, the repeated DNA sequences account for about 3 percent of the genome. In higher species, like humans, about half of the genome consists of these repeated sequences, “which makes for an Achilles heel among humans,” Argueso said. “If you have a break in this repeated part, you can repair not

Senator Burr visits Duke’s GHRB lab U.S. Sen. Richard Burr, R–N.C., toured Duke’s Global Health Research Building on Aug. 20. A member of the Senate Intelligence and the Health, Education, Labor and Pensions committees, Burr is the sponsor of a bill that would standardize training for employees in biocontainment laboratories across the country. Burr visited Duke to see a laboratory featuring state-of-the-art equipment and safety features. “A lot of what we talk about doing is already being done here in this lab,” he said. Richard Frothingham, M.D., director of the laboratory, along with several researchers briefed Burr on the safety and design of the building as well as some of the research studies under way at the facility. The laboratory supports basic research and the development of new diagnostics, drugs and vaccines for biodefense and emerging infections. It is one of 13 federally-funded Regional Biocontainment Laboratories and was designed to support public health efforts in the event of a biodefense emergency.

U.S. Sen. Richard Burr, R–N.C., left, listens to Duke scientists as he tours the Global Health Research Building on Aug. 20. Burr is the sponsor of a bill that would standardize training for employees in biocontainment laboratories and wanted to see a state-of-the-science lab with the latest safety features.

CHURCH, continued Brown helped organize a partnership between his church and the Bryan ADRC. The partnership began one year ago with a health fair, which brought together the Duke researchers and the church members. Of the 127 participants, 30 enrolled in the research program. “I’m delighted to report that this research partnership has been, and continues to be, an unprecedented success,” he said. Duke clinicians will return to Jacksonville on Sept. 27th to recruit more volunteers. Next, AACOP will turn its attention to Duke’s own backyard. “Many of the potential participants in the Triangle remember a time when they weren’t allowed to come to Duke for treatment. We hope to replicate Jacksonville’s positive outcomes and bring the advances being made in medical research to the African American community here in Durham.” n

Inquiry

10

September 2008

ESSAY

Turning the tides It’s always intriguing to hear about how Duke’s world-class physicians and researchers got their start. Take Mark W. Dewhirst, DVM, Ph.D., for example. Trained as a veterinarian, he is now the Gustavo S. Montana Professor of Radiation Oncology and Director of the Radiation Oncology Program at the Duke Comprehensive Cancer Center. Here, he describes how he made a career of going with the flow. by Mark Dewhirst, DVM, Ph. D.

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often tell my students to pay attention to unexpected opportunities. Sometimes it’s better to take the road less traveled, because in doing so, one can discover unique ways to address problems. There are many examples of such opportunities in my career. Some were fruitful and others a dead-end. By far the best, though, came during my first post-doctoral fellowship at the University of Arizona. My program director, Eugene Gerner, met with me shortly after arriving in Tucson and asked me the following question, “Since you are a veterinarian, you must know something about physiology, correct?” I said of course, I had taken a couple of courses on this in veterinary school. However, that combined with my B.S. in chemistry was the extent of my knowledge. Undaunted by my lack of expertise, he suggested that I meet with the chair of chemical engineering to discuss a novel “window chamber” method that he had established to study tumor physiology in mice. This “window” is literally a glass-covered chamber surgically implanted in the skin of mice that permits direct observation of tumor growth and

Blood flow to tumors can resemble waves and tides. Photo from wikipedia commons

vascular function. My lab has gone on to use this model for many different applications after my arrival at Duke in 1984, but the one that has been the greatest challenge has dealt with why tumors have inadequate oxygen delivery, or hypoxia. When I entered into this field, it had been known since the 1950s that tumors were hypoxic and that this lack of oxygen led to resistance to radiation treatment. We decided that to overcome hypoxia we had to start with understanding why tumors are hypoxic to begin with. In going through this discussion, keep in mind the concept of how tides and waves in the ocean influence how far waves travel up the beach. What we know now is that tumors are not in a stable state of oxygen deprivation – in fact they experience continuous fluctuations in oxygen in a manner very similar to ocean tides. In 1980, the belief was that hypoxia was caused by inadequate numbers of vessels in tumors, leading

to what is still termed diffusion limited hypoxia. That is, cells that reside far away from blood vessels would not get adequate oxygen because it is used up by the cells that are closer to the vessels. An implicit assumption in this paradigm was that all vessels contained some oxygen. One of our major discoveries was that some tumor blood vessels are completely devoid of oxygen, in spite of the fact that they have blood flow. The real breakthrough on this came in 2005, when Brian Sorg, Ph.D., a postdoctoral fellow in my group, established a method to visualize hemoglobin saturation in tumor microvessels. Armed with the ability to see entire vascular networks in one image, we discovered that tumor vessels that traverse through larger tumor regions are often stripped of all of their oxygen. We can think of such regions as “low tides.” Alternatively, tumor vessels with adequate oxygen content can be thought of as “high tides.” Another concept that was just emerging at the time that I started in the field was that some blood vessels

may temporarily experience a stop in blood flow and that when this occurs, it will cause the surrounding tumor cells to experience acute hypoxia. Most investigators believed that acute hypoxia was relatively rare in tumors and there was considerable debate as to how important it was therapeutically. We published our first studies relating to this phenomenon in 1996, showing for the first time that the flux of red blood cells (number of red cells traversing a vessel per unit time) in tumor microvessels was unstable and that this flux instability led to fluctuations in oxygen concentration. Think of such fluctuations as the ‘waves’ in the ocean analogy. We subsequently proved that tumor regions could experience injury as a result of these instabilities. Still, this concept was largely ignored by most investigators. Undaunted by a lack of attention to our work, we perservered, using modern sophisticated optical methods to show that the oxygenation of tumor vascular networks is most often unstable. Thus, we changed the paradigm from one in which acute hypoxia was thought to be a rare event to a ubiquitous phenomenon that involves large tumor regions. Why care about all of this in the first place? When we started in this work, the only scientists and clinicians who cared were those who worried about the tumor cell resistance to radiation. Today, we know that the oxygenation state of a tumor contributes to altered cellular functions that drive the tumor toward a more malignant state. Thus the problems extend far beyond the simple application for radiation treatment. n

IGSP

DCRI

bioethics

Genomic forum

Duke clinical medicine series

Human Enhancement

The first Genomic Medicine Forum for the Fall 2008 semester will be held on Thursday, September 11 from 9:00am to 10:00am in Room 2240 CIEMAS. Geoffrey S. Ginsburg, MD, PhD will give a lecture on the topic of Genomic Medicine.

The DCRI hosts monthly webcast conferences in cardiology, endocrinology, nephrology and gastroenterology. Visit http://www. dcri.duke.edu/research/meetings for full schedule and details.

Bioethicist Julian Savulescu of Oxford University makes the case for human enhancement through biotechnology in the 2008 Crown Lecture in Ethics on Sept. 25. For more information, go to http:// calendar.duke.edu/cal/event/ showEventMore.rdo.

September 2008

Inside Duke Medicine

pat i e n t c a r e

11

F IRST P ERSON

Q&A with Steve Smith

Focus on: The Right Dose

As the Health System’s chief human resources officer, Steve Smith spends a lot of time thinking about people. Particularly, he thinks about how the Health System’s 11,300 employees work together, something called “work culture.”

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

What is a positive ‘work culture?’

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Work culture is what we want the Health System to be. Each person knows what they want their job to be – they want a challenging job, for example, and one that is connected to a greater, larger purpose. The organization shares those values. steve smith Improving work culture, then, is about doing what is necessary to make those values a reality. As we do make those changes, we need to know how we are progressing. That’s why we conduct the annual Work Culture Survey.

healthcare team involved in the process of getting the ccording to a 2006 report published by the Institute of Medicine of the National Academies, correct dose to the patient. A few examples of steps that can be taken to help assure the right dose of a each year, approximately 1.5 million people are medication include the following: harmed by medication errors. The report, Preventing • For prescribers, assuring the medication is Medication Errors (PME), also quantified the cost ordered in correct units of measure (e.g., mcg, units) of these potentially fatal errors at an estimated $3.5 and evaluating the dose for the patient’s condition. billion a year. PME emphasized the need for hospi• For pharmacy processors, checking for the tals to implement best practices related to medication correct concentration or number of tablets of a delivery and started a nationwide conversation medication being prepared. about medication safety. • For a nurse administering a medication, checkAs part of the ongoing efforts to promote ing the dose against the medication administration medication safety at Duke University Hospital, the record or order, or checking the concentrations and Medication Safety Education Committee, in conjuncsettings on an administration pump. tion with the Medication Safety Leaders of the • For patients or family members, being comfortsystem, has developed the “6 Rights in 6 Months” able and assertive in asking campaign to help raise awarequestions they might have about a ness about safe medication dose of a medication they or their administration practices. The family members are receiving. committee’s efforts address Throughout our “6 Rights in all people, including patients 6 Months” effort, the Medication and families and all parts of 6 Rights of the Safety Education Committee the medication administration Medication Use Process : continues to stress the importance process, not just the frontline 1 ) Right patient of following the basic steps to medication giver. help maximize the safety of our This month the focus is on 2) Right drug medication use processes. It the Right Dose. 3) Right dose involves much more than just the Of the thousands of nurse or tech giving a medication medications in a typical 4) Right route or contrast medium to a patient. hospital pharmacy, the major5) Right time It involves all of us doing everyity are available in multiple thing we can every day to assure strengths or pre-made doses. 6) Right outcome our patients that they are in a safe This multiple availability makes and caring environment. it easier, more effective, safer At Duke, we have also and more economical to deliver identified a set of non-negotiable the correct dose of a medicine critical behaviors that reinforce to each patient. Yet, this same these six rights: using two identifiers when ordering, choice of strengths or dose can lead to problems. preparing, or dispensing a medication and transcribing Is that order for 1.25, 12.5, 2.5 or 25? What is orders for medications; labeling any medication the usual dose? What dose is going to be the most prepared at the time of preparation; always taking appropriate for this patient? and using the medication administration record with In today’s hospital, assuring the proper dose you to obtain and administer medications; using name of a medication entails more than just reading a alerts for patients with similar sounding names; taking bottle correctly. It is a complex process with multiple medications in the original packaging into the patient’s steps along the way. Thousands of medications, room; minimizing interruptions when involved in any biological preparations and IV solutions are handled part of the medication administration process; and and administered daily at Duke University Hospital. reviewing or returning to the last step made prior to Everyone involved in the process works hard to any interruptions that occur in the process. assure the highest degree of accuracy at each step. If you are interested in more information about Simply put, it is the job of the people involved in the medication delivery process to assure the correct dose the Medication Safety Education Committee’s efforts, contact committee co-coordinators John is ordered, prepared and administered safely and Howe, R.N. at [email protected], or Lynn correctly. And making “safe choices” is the job of Eschenbacher, Pharm.D. at lynn.eschenbacher@ every one at each point in the process. duke.edu. Also, visit the Medication Safety Web site: As with each of the Rights, there are multiple http://PatientMedSafetyEd.duhs.duke.edu/ n steps and considerations for each member of the

Results just came back from the 2008 survey. What did we learn?

There has been a lot of progress from the first survey in 1999. I’ll give you an example. In 1999, 61 percent of employees said they had challenging work that provides positive impact to patients. This year, 79.8 percent said so – an 18.8-point increase. The survey also showed where our challenges are. More people need to know about Duke’s innovative benefits, and there needs to be greater understanding that fellow employees are our customers, too. What is done with all this information?

It fuels a process that develops ideas that we put into action. Work culture improvement teams comprised of employees, managers and leaders in every entity in the Health System gather ideas and implement the best ones. A good example is Strength, Hope and Caring, a program that helps recognize the extra efforts of our employees that help make this place special. That idea came up through the improvement team process. What’s next?

We are committed to doing a Work Culture Survey every year, and listening and seeking ways to improve. We are also introducing a new exit survey to better understand why people leave and how we can use that information to strengthen the work culture. Also, expect to hear more, in Inside Duke Medicine and elsewhere, about the Work Culture Survey results and how that information is forging positive change across the Health System. — Interview by Mark Schreiner

Inside Duke Medicine

12

September 2008

P ATIENT C ARE

Surviving and thriving Unlikely transplant gives new life Reprinted from Duke Comprehensive Cancer Center newsletter orty-five-year-old Gayle Serls had been living a healthy life: she exercised and ate right and had never really been sick except for an occasional cold. But in the summer of 1995, her life completely changed. When a lymph node in her neck became enlarged, she made a doctor’s appointment. By the time she went to the doctor several days later, lymph nodes in her neck, under her arms, and in her groin area were swollen. After blood work was completed, Serls was told she had acute lymphocytic leukemia (ALL), a cancer of the blood that is diagnosed in approximately 5,000 people a year. “I was stunned,” she recalls of learning the diagnosis. “How could this be happening to me?” She was admitted to Duke University Hospital and began receiving chemotherapy, which appeared to be working. Although tired and scared, she was hopeful that she would be cured. More tests were administered. One of the tests indicated that she had a rare type of ALL known as Philadelphia chromosome positive acute lymphocytic leukemia. This type, found in only about 25 percent of ALL cases, cannot be treated with conventional chemotherapies. “This obviously wasn’t good, but my oncologist, Dr. Joseph Moore, never said anything negative,” Serls says. “He offered options, and I still had hope. We were simply moving from Plan A to Plan B.” The best solution seemed to be a bone marrow transplant. Serls’s siblings were tested for a match. Coincidentally, their bone marrow matched one another, but neither matched hers. The search began for an anonymous donor who would be a match, and Serls made arrangements to go to Johns Hopkins Hospital for her transplant.

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Gayle Serls, the longest-surviving adult cord blood transplant patient, holds a photo of her children, Corbin and Matthew. Photo courtesy of duke comprehensive cancer center

being tested, Serls was apprehensive but realized it would buy her time until she could find a better solution. To prepare for the transplant, Serls discontinued her chemotherapy. But before flying to Hopkins for the transplant, she felt a lump on her neck. The cancer had returned and the doctors would not perform the autologous transplant. “This was even worse than first finding out I had cancer,” Serls says. “Now I had no hope and didn’t know what would happen.” Serls went back to Duke and received large doses of chemotherapy in an attempt to control her disease. She felt very sick and was in pain with “If I hadn't received treatment at Duke, colitis, a disease of the colon. In the midst of her treatment, Serls’ mother happened to watch a I don't think I would be alive today.“ story on the evening news that described how newborn babies’ umbilical cord blood could In 1995, Duke had a prominent children’s bone help leukemia patients. The stem cells found in the marrow program led by Joanne Kurtzberg, M.D., cord blood replace the cancerous cells after they are that is still very highly regarded, but no such program destroyed through chemotherapy and radiation. for adults. Duke’s Adult Bone Marrow Program was “Even with approximately seven million formed in 1996 by Nelson Chao, M.D.. donors in the adult donor registry database, it can At Hopkins, Serls was told that she was too old be hard to find an exact match needed for a bone for a bone marrow transplant from an unrelated marrow transplant,” Kurtzberg says. It’s even donor, but she could receive an autologous harder to find matches for minorities because transplant. With this type of transplant, Serls’s own there are fewer donors. However, with cord cells would be harvested and treated to kill the blood, only a partial match is needed to be cancer cells. Then, her own treated cells would be successful, so matches are more likely. infused back into her. In 1995, cord blood transplants were being Since this type of procedure was new and still

performed successfully in children at Duke by Kurtzberg, who performed the world’s first cord blood transplant of unrelated children in 1993. “Many researchers did not think the transplants could be done in adults because of the small amount of cord blood each newborn has, compared to that of bone marrow,” Kurtzberg says. But on May 1, 1996, Serls received a cord blood transplant at Duke, becoming one of the first adults in the world to receive this treatment. Twelve years later, Serls is the longest-surviving adult cord blood transplant patient. Today, Serls works for Kurtzberg at the Carolinas Cord Blood Bank, a public facility located at Duke that collects cord blood from newborns at local hospitals whose mothers grant permission. The blood is then tested, processed, stored, and listed on the national donor registry until it is needed for a transplant. Serls says. “I feel so fortunate to have lived near Duke and received treatment here. If I hadn’t, I don’t think I would be alive today.” Cord blood transplants are now more common, with about 3,000 performed annually, approximately a third of those for adults. Duke continues to be a leader in cord blood research for both adults and children. n Learn more about the Carolinas Cord Blood Bank at http://www.cancer.duke.edu/ccbb

Inside Duke Medicine

September 2008

building BLOCKS

13

Your guide to construction and expansion projects at Duke Medicine

Duke’s Physician Assistant program makes history with new home By Bill Stagg

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he School of Medicine’s Physician Assistant (PA) Program will be moving into the Blue Cross and Blue Shield of North Carolina (BCBSNC)’s former downtown Durham headquarters in an effort to improve access to health care and expand primary care services for North Carolinians. The agreement represents a collaborative effort by the school of medicine and the state’s largest health insurer to foster the critically needed growth of primary care medicine in North Carolina, where the ratio of physicians to population is expected to drop by 21 percent by 2030. “The physician assistant profession was created at Duke 40 years ago to respond to a societal need for access to care,” said Justine Strand, M.P.H., director of the PA program. “The impending physician shortage, increasing burden of chronic disease and the graying of America make the need for PAs greater than ever. This

Ribbon cutting at the renovated CCU..

CCU renovated at Durham Regional What was once a Durham Regional Hospital unit with patient beds separated only by curtains is now a 22-bed critical care unit (CCU) with all private rooms. Each patient room is equipped with the latest technology. Every room is dialysis-ready and contains:

Duke's Physician Assistant program will move into this downtown Durham building in January 2009. Photo by kelly malcom

helping the communities in which we work and live,” said Bob Greczyn, president and CEO of BCBSNC. “Our collaboration with Duke will help to increase access to primary care services and improve the health and wellness of North Carolinians. “The new facility gives us space with our That’s a combination own identity and signature, something of resources that we all benefit from and we've never had before.” one that has to be a new facility will allow us to graduate priority for our state.” more PAs to meet that need.” Relocation of the PA program from The move will make possible a the main medical center complex also potential expansion from the two-year puts the students and faculty from the PA program’s current enrollment of 56 nation’s oldest physician assistant students per class. It also stands to program within walking distance of significantly boost primary care in North Duke’s community-based clinics. Carolina, since 40 percent of Duke’s PA “It’s a wonderful opportunity,” graduates stay in the state to work. Strand said. “The new facility will give “As a company that’s been around us space with our own identity and for 75 years, we believe strongly in our signature, something we’ve never had responsibility and our commitment to in our history. We’re deeply

appreciative to Blue Cross for its vision and leadership for the role of primary care in North Carolina.” Duke officials said the agreement underscores the university’s role in supporting downtown Durham’s renaissance and follows on the recently announced lease at the Durham Centre. BCBSNC’s brick structure at 800 S. Duke St. dates to the early 1960s and has been vacant since the fall of 2006. Following renovations to the 32,000-square-foot building, the PA program will relocate in January 2009 as the 15-year lease begins. The Charlotte-based Duke Endowment will help support the costs associated with expanding the PA program, including the hiring of additional faculty. Duke’s top-ranking PA program began in 1965 and graduated its first students in 1967. n

• Stryker InTouch Smart Bed, a bed that can talk to patients in English, French and Spanish, calculate weight, wheel itself while steered by a caregiver and alert the care team when a patient needs to be turned. • A moveable utility pole that can better accommodate suction and blood pressure readings. • Other amenities in each room are a sink, toilet and flat-screen TV. Half of the rooms also have lifts for patients weighing up to 1,000 pounds. “In redesigning the unit, we wanted to bring the care to the patient, not the patient to the care,” said Earl Dalton, RN, director of the CCU. As a result, items such as the Computers on Wheels now enable nurses to have the patient’s medical information at their fingertips.“We are thrilled with the design of our unit,” says Dalton. Nurses were involved in every stage of the CCU renovation, providing input on the overall layout of the unit and the type of equipment selected. The nurses based their decisions on functionality for caregivers and with patients’ needs in mind. The hospital began the three-stage renovation of the CCU in February 2007. The $8.6 million renovation was jointly funded by Durham County Hospital Corporation Board and Duke University Health System. – Carol Clayton

timeline August 2008: School of Medicine opened new gross anatomy and fresh tissue learning labs. See p. 16

NOVEMBER 2008: Durham Regional Hospital opens a renovated cardiac catheritization lab. See story above about DRH critical care unit changes.

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

OPENED

&Closed

october 2008: The PRT tram connecting Duke University Hospital’s North and South buildings retires from operation Oct. 15. See cover story and p. 6 for transport options.

This timeline is a recurring and changing Building Blocks feature. Note that dates are subject to change.

SPRING 2009: Demolition of the Bell Building and excavation for the expansion of DUH takes place.

Inside Duke Medicine

14

Working

benefits

Time Out

Open Enrollment Sign up, change health, dental, vision insurance Oct. 4-14

Taking a break offers many benefits

S

ummer is time when many people pack their suitcases, pile in a car and head out on vacation. Now that it’s after Labor Day, a vacation may not be at the top of the agenda. Consider that idea again. At Duke, the majority of employees don’t take the vacation time they accumulate each year. Nationally, only 35 percent of workers do not use all the vacation time they accrue on the job, according to recent reports from Expedia.com and Harris Interactive. At Duke University Health System, that number is more than half. That includes people like April Ferido, clinical nurse II in Post-Anesthesia Care Unit (PACU), who has saved as much Paid Time Off as possible, hardly taking any vacations since she began working at Duke in 2006. “I work 12-hour shifts, three days a week, so I have a lot of extra days to relax and do fun stuff with my family,” Ferido said. “I prefer saving PTO for emergencies and longer vacations. I’m planning to ask for a month off next year to visit the Philippines, my native land. It’s so expensive to go home, I’ll try to be there as long as I can to make the most of it.” The main reason many staff members don’t use all their PTO is because like Ferido, they work 12-hour shifts, said Sylvia Alston, DUHS associate chief nursing officer. At Duke University Hospital, 46 percent of staff work 12-hour shifts. Alston was involved with converting the health system to the PTO model, starting in 1999. “At Duke, employees accrue more paid time off each year than many comparable employers,” said Lois Ann Green, director of Duke Benefits. “Those in the health system take advantage of the options that PTO allows, using PTO in whatever way suits their life best,” Alston said. “Still, it’s always important for staff to take time off to refresh and relax. You can only provide the best patient and customer care when you also take care of yourself.” Mental health experts agree, suggesting that time off is essential to work-life balance and overall health, said Andy Silberman, M.S.W., assistant professor, and director of Duke’s Personal Assistance Service, a free counseling service for Duke faculty and staff. “Studies have shown a link between the benefits of taking time off and better health and productivity,” he said. “Ironically, work addicts usually think they’re accomplishing more by laboring away, but they usually end up doing more harm than good. All work and no play can lead to a range of mental, physical and emotional problems that can lead to burnout and reduced productivity.” n

September 2008

It’s that time again – open enrollment, that stretch in October when faculty and staff select or make changes to health, dental, vision and reimbursement benefits. Open Enrollment packets with details about Duke’s health, dental and vision plans will be mailed this month. Health benefit information sessions will begin in late September. A schedule will be posted on the Duke Human Resources Web site at by mid-September at http://www.hr.duke.edu. For the fourth consecutive year, participants in the Duke Basic plan will not see a premium increase.

When April Ferido, clinical nurse II, isn't working, she enjoys traveling. Here, she takes a breather from exploring the Bronx Zoo in New York City. Photo courtesy april ferido

Paid Days Off By Years of Service Years

<1

5

10

15

≥20

Days For Non-Exempt Employees DUHS

30

35

40

40

45

Peer Average

30

34

38

41

42

Days For Exempt Employees DUHS

35

40

40

40

40

Peer Average

31

35

39

42

43

Duke University Health System offers more paid time off than most of its local peers. Peers include University of North Carolina Health System, WakeMed, Pitt Memorial Hospital, Blue Cross and Blue Shield, and Wake Forest University Health System. Source: Duke Human Resources

PTO at DUHS Duke University Health System staff may accrue up to 40 PTO days each year after meeting eligibility criteria. Those days first accumulate in a Short Term Bank until reaching 55 days (440 hours), and may be used for vacation, holiday and sick days. When reaching the 440 hour maximum, additional hours are deposited in a Long Term Bank, which can be used only for family or personal illness. Once a year, staff may cash-in any unused hours from the Long Term Bank. Payment at 50 percent of base rate of pay at the time of cash in. If the Long Term Bank has reached its max of 120 days (960 hours), the excess time will automatically be paid out annually. In 2007, 265 staff members cashed in PTO hours for a total of 21,257 hours. Also, PTO accumulated in both the short and long term bank can be cashed in or applied to service upon retirement.

Other insurance plans such as Duke Select will have modest increases in 2009. Premiums for Duke Select, which covers the majority of Duke employees and families, will increase $1.64 per month for individuals; $9.76 per month for families. The monthly premium increase for Blue Care is $2.70 for individuals; $12.20 for family. The increase for individuals in Blue Options is $2.60; $12 for family. Health insurance is one of the most popular benefits at Duke with 90 percent of eligible faculty and staff participating, said Lois Ann Green, director of benefits, adding that the benefit’s popularity is based largely on the value it offers. “Few employers in the area can compare with Duke’s health benefits in terms of premiums, out-of-pocket costs and coverage,” she said. “Our employees also have access to innovative programs such as Duke Prospective Health and cutting-edge medical care through Duke Medicine.” Other 2009 health plan updates include: • Out-of-pocket expenses (co-payments, deductibles) for health, dental, pharmacy and vision insurance will not change. • The vision care premium will stay the same. • The monthly premium for the comprehensive dental plan A will rise $1.82 for individuals; $5.53 for family. The premium for dental plan B remains the same. • Online enrollment will be offered through Duke@Work, the employee self-service Web site. • Dependent Care and Health Care Reimbursement Accounts do not automatically roll over. Employees must re-join during open enrollment in October.

Inside Duke Medicine

September 2008

on the job

awards

P HI L ANTHRO P Y

Palumbo grants new scholarship

F Vetus Brown, Jake Beauchaine, and Rodney Poole participated in the drill.

Code Pink drill snaps clinic staff to action “Sit in this chair, and do not move until I get back,” a man said to his young son one morning last month. “And do not talk to strangers.” Staff from Duke University Hospital's Clinic 2F/2G looked on with disapproval. Earlier, the man had approached Jeanne Wheeler, a patient services associate for 2F/2G, and had asked if she would watch his child while he went to his car. “No, sir,” she had replied. But the man had left the 10-year-old child there, anyway.

urther extending his generous support of Duke School of Medicine, E. Arthur Palumbo, a Duke graduate, honored a third year medical student with a full-year scholarship during an award ceremony held last month. The new scholarship is awarded to one member of Alpha Omega Alpha medical honors society, selected at the end of the third year, based on merit. The recipient was medical student Mrinali Patel, for her research into age-related macular degeneration. “I’ve given this award in honor of

my late brother, Leonard Palumbo Jr., who went to medical school at Duke and was a member of the prestigious AOA. This award is meant to recognize a student who is among the top of their class,” Mr. Palumbo said. He also endows the Leonard Palumbo, Jr., M.D. Faculty Achievement Award, presented to a School of Medicine faculty member who displays dedication to compassionate patient care and excellence in the teaching and mentoring of young physicians. n

Headline headline

Jeanne and her colleagues at the front desk did not like the situation. Then, a man who had not registered in the clinics but who had been sitting in the waiting area slid over into the seat next to the child, offered him candy, and led the boy away.

The good news: The abductor was caught by Duke Police within seven minutes from the time the 911 call was initiated. Even better news: The entire event was part of a drill to test staff response to a Code Pink infant/child abduction – the “dad” and the “abductor,” both policemen in training, and the child, a staff member’s son, were acting their parts.

half of the drugs on the market today, including antihistamines, ulcer medications and beta blockers for heart disease. Lefkowitz and his group first identified, purified and cloned the genes for these receptors in the 1970s and 1980s, thus revealing the structure of the receptors as well their functions and regulation. This work facilitated and fundamentally altered the way in which numerous therapeutic agents have been developed. "The National Medal of Science is a great personal Robert J. Lefkowitz, M.d. and professional honor that reflects my entire career in the life sciences,” said Lefkowitz, who is a professor of biochemistry, immunology and medicine, and also a basic research cardiologist in the Duke Heart Center.

“I really can’t imagine a more fulfilling career for me than to have been a Professor of Medicine and a scientist. I am as excited about the opportunities and challenges of our work at present as I have ever been. And I am so honored that the President will acknowledge our cumulative body of work in medicine and the biological sciences.”

“I was very impressed by how well the staff responded,” said Johnetta James, director of accreditation and patient safety for the Private Diagnostic Clinic.

Lefkowitz has received more than 50 international and national awards, earned several honorary doctorate of science degrees, and has held leadership posts in many clinical and professional organizations.

The August 25 drill was developed by James, Jessica Thompson, hospital administrative fellow and director of Emergency Management for Duke University Hospital, and Emergency Services summer intern Bryan Mallory. A multidisciplinary team helped plan and monitor the drill.

Knowing how to respond once a code alert is activated is essential to ensuring a safe environment, said Thompson. She urged all employees to review their departmental or unit emergency management sub-plans, and to review code alerts and other emergency preparedness resources at http://slytherin. duhs.duke.edu/Emergency/web.nsf/index.

LEFKOWITZ, cont.

“One of the most rewarding aspects of my career at Duke has been the opportunity to mentor more than 200 very talented students and fellows. Many of them have gone on to distinguished careers in academia and the pharmaceutical and biotechnology industries. This award honors them as much as it does me.

Before the abductor and the child made it into the hall, Wheeler was dialing 911.

Previous Code Pink drills have focused on infant abductions, said James. Committee members wanted to test the staff’s response to the abduction of a child, so the team developed the scenario based on feedback from clinic staff who had shared concerns about patients leaving children unattended. The drill was a success, Thompson told the clinic staff and drill observers, explaining their performance falls within national standards for Code Pink reaction times.

15

“I’m thrilled that Bob is being honored in this way as it really is a recognition and celebration of not only his well-documented seminal discoveries, but more importantly the incredible body of scientific work that has characterized his long and illustrious career,” said Nancy Andrews, M.D., Ph.D., dean of the Duke University School of Medicine. “He is an inspiration to the next generation of basic scientists, not only at Duke, but around the world.”

Board chair carries Olympic flame Duke University Health System board Chairman Thomas M. Gorrie, Ph.D., carries the Olympic torch through Tiananmen Square in Beijing before the start of last month's Olympic games. Gorrie was selected for this unique honor because of his many years of work with various agencies within China in his role as an executive at Olympic sponsor company Johnson & Johnson, his many years of personal volunteer work with the leading health care ministries in the suburbs of Beijing and his broad involvement and determination to understand the people of China. PHOTO courtesy of thomas gorrie

In 2007, Lefkowitz received two other major awards. He won the Shaw Prize in Life Science and Medicine for his breakthrough research “that has had a positive effect on mankind” and with that recognition won a $1 million prize. He also won the Albany Medical Center Prize in Medicine and Biomedical Research and shared the $500,000 Albany prize with two other researchers.

Inside Duke Medicine

16

September 2008

W h at ' s n e w

Modernizing Gross Anatomy T

he latest in a series of significant milestones converging to further the School of Medicine’s educational mission occurred in August with the grand opening of the new gross anatomy lab and its adjoining high-tech fresh tissue lab and teaching auditorium. All reflect Duke’s renewed commitment to merging traditional, hands-on cadaveric study with the latest information access that computer technology can offer. From anatomy atlases to 3-D images of the human body, everything is at the fingertips of faculty and fellows, and ready to go for this year’s entering class of medical students. The impact on attracting future medical students is clear. “These are valuable assets a lot of leading medical schools don’t have,” Monte Brown, M.D., Duke University Health System vice president for administration, said of the new labs. “When people walk in they just say ‘wow.’ You can bet this will now be on the tour for all trainees considering Duke School of Medicine. The new anatomy lab is equipped with state-of-the-art educational technology. photo by jared lazarus Combining traditional techniques effective responses, the anatomy lab is of the Green Zone, the new facilities with the most up-to-date technologies ticated computerized learning aids as much a part of how we see as what and equipment are a far cry from have effectively reduced the amount puts Duke in the forefront.” the former aging gross anatomy lab we know,” he said. "When people walk in they just say ‘wow.’ You in the basement of the Bell Building, Scott Levin, M.D., division chief which eventually will be removed to of plastic, reconstructive and oral can bet this will now be on the tour for all surgery, was instrumental in planning make way for the expansion of Duke University Hospital. the gross anatomy and tissue labs. trainees considering Duke School of Medicine." The new labs and auditorium are The expanded space was planned another step in the modernization to accommodate undergraduate of time spent on dissection, Buckley “Today, anatomical medical of the school’s educational facilities and graduate medical education said, the physical procedure fosters education combines the ideals of that started with the relocation and as well as the growth plans in the a spatial and tactile appreciation for the profession — the acquisition expansion of the physical therapy physical therapy, physician assistant the fabric of the human body that of scientific knowledge and skill program in Erwin Square. The faciliand continuing medical education cannot be achieved by prosections or balanced with the development of ties open new horizons and expanded programs. computerized learning aids alone. humanistic attitudes and behaviors,” opportunities in medical training, Now conveniently housed near “So whether it is our initiation said Edward Buckley, M.D., interim CME and creative collaborations the other classrooms in a well-lighted to the profession as physicians or dean for education. and ventilated facility in the basement with outside partners. n the scientific method or the use of While development of sophis-

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