BluePrint 2018

TEAM PERFORMS RARE THIRD DOUBLE-LUNG TRANSPLANT 6

THE FUTURE OF ECHO: DR. ALINA NICOARA 34

BOTULINUM TOXIN FOR ATRIAL FIBRILLATION? 46

VOLUME 9 | 2018

From Base Camp to Bedside

XTREME EVEREST RESEARCHERS TREK TO THE TOP OF THE WORLD TO UNDERSTAND CRITICAL ILLNESS

What We Do Changes The World

MISSION: Extraordinary care through a unique culture of innovation, education, research, and professional growth.

Volume 9 | 2018

Contents

DEPARTMENTAL 02 Message from the Chair 04 Full Frame: Run for the Warriors 12 Highlights

64 Departmental Listing 65 ASA Highlights

68 Closing Shot: The House that Duke Built

DREAM CAMPAIGN 39 Donor Honor Roll

40 DIG Award Leads to Novel Finding of Intestinal Healing 42 2018 DREAM Innovation Grant Recipients

INNOVATIVE RESEARCH 48 No Advantage Found in Using Stem Cells for AKI Treatment

6 28

On the Cover

FEATURE Duke Said Yes. Medical Team Performs Rare Third DoubleLung Transplant COVER STORY How Low Can You Go? Xtreme Everest Researchers Went High Up in the Clouds to Find Out

34

FACULTY SPOTLIGHT Dr. Alina Nicoara

46

INNOVATIVE RESEARCH Botulinum Toxin for Atrial Fibrillation? Maybe, but More Study is Needed

50 Star-Shaped Brain Cells Orchestrate Neural Connections

GLOBAL HEALTH 54 Heading to Haiti

55 Scenes from Rwanda

56 A First-Place Tie for Pie

RESIDENCY CORNER 58 Residency Program Ranks Top 5 in the Nation 59 Welcome Match Class of 2022

ALUMNI NOTES 60 David McDonagh, MD 62 Robert Thiele, MD

BluePrint 2018

|

1

Message from the Chair “Go Big or Go Home!”

BluePrint is published once a year

by Duke Anesthesiology. This issue was published on October 29, 2018.

Your comments, ideas and letters are welcome.

Such was the title of my State of the Department Grand Rounds presentation last month intended to remind all of us that as a department, Duke Anesthesiology was aiming for big things…for things that will paint the face of anesthesiology with a bit of Duke blue.

View this issue and past issues online: BluePrint.DUHS.Duke.edu Please contact us at : Duke Anesthesiology BluePrint Magazine DUMC 3094 Durham, NC 27710 blueprint@duke.edu Editor in Chief Stacey Hilton Assistant Editor Kelsey Steller Contributing Writers Stacey Hilton Lindsay Key Kelsey Steller Ratna Swaminathan Duke Anesthesiology Faculty & Staff Duke Health Marketing & Communications Duke Today Duke University School of Medicine Art Director & Designer Kelsey Steller Photographer John “Jack” Newman Website Administrator Christopher Keith

Connect with Duke Anesthesiology: WEBSITE:

Anesthesiology.Duke.edu FACEBOOK:

@DukeAnes TWITTER:

@Duke_Anesthesia YOUTUBE:

Duke Anesthesiology

In keeping with that theme, I am proud to report that through our Community Division’s hard work, Duke Anesthesiology is now the provider for anesthesiology services at Duke Raleigh Hospital, a goal that has been more than a decade in the making. Equally impressive, under Dr. Sol Aronson’s guidance, was the launch of the Perioperative Anesthesia and Surgical Screening (PASS) clinic, which through preoperative optimization aims to align the department with population health standards. In a similar vein, Dr. Padma Gulur developed and launched the Integrated Pain Population Health Model, a first-of-its-kind for the Duke University Health System, and Dr. Tom Buchheit established the Duke Regenerative Pain Therapies Program.

Prior initiatives that involved “thinking big” also bore fruit as Dr. Paul Wischmeyer secured a $19 million grant through the Duke Clinical Research Institute (DCRI) and oversaw the establishment of the first two DCRI fellow positions ever granted to anesthesiology. Another key initiative started under the guidance of our new vice chair for faculty development, Dr. Madhav Swaminathan, is the Academy for Building Leadership Excellence (ABLE) Program, which is designed to accelerate career development for junior faculty through coaching. I am sure you will hear more about this effort in the years to come. Finally, we welcome Dr. Evan Kharasch as our vice chair for innovation. More importantly, he is the editor of our specialty’s leading journal, Anesthesiology, and is the department’s only member of the National Academy of Medicine.

It is my privilege to introduce our 2018 BluePrint publication and share the exciting news and highlights of Duke Anesthesiology over the past year. As you read through, I hope you will appreciate the many ways in which Duke Anesthesiology is “going big.”

Sincerely,

Joseph P. Mathew, MD, MHSc, MBA, FASE 2

|

DUKE ANESTHESIOLOGY

At Duke, we believe that continued engagement with our alumni is the key to our future success. We take great pride in these talented men and women who play an integral role in strengthening our department and making it an ideal environment in which future generations of trainees can learn, work and achieve excellence.

As a graduate of Duke Anesthesiology, you are automatically enrolled as a member of the Duke Anesthesiology Alumni Association! Help us grow our department’s alumni outreach by staying connected to your peers, fellow alumni and faculty.

• Register or update your profile in our Alumni Database to receive special offers, our annual BluePrint publication by mail, and invitations to exclusive department events

Y OG

NESTHESIOL EA

TinyURL.com/DukeAnesAlumni NI A

IO

U

M

N

AL

Duke Anesthesiology Alumni Association

DU K

• Consider continuing your legacy with a donation to the Duke DREAM Campaign and have your name featured on our website’s Donor Honor Roll

SSOC

I AT

BluePrint 2018

|

3

FULL FRAME

4

|

DUKE ANESTHESIOLOGY

RUN FAST BLEED BLUE The Duke Anesthesiology team won first place for fundraising ($11,895) for the seventh consecutive year at the 2017 ASA-sponsored Run For The Warriors race in Boston. Proceeds benefit the men and women wounded during service, their families, and families of the fallen through the many Hope For The WarriorsÂŽ programs.

BluePrint 2018

|

5

Feature

Medical Team Performs Rare Third Double-Lung Transplant

BY STACEY HILTON

O

n May 23, 2017, Ally Jenkins fell short of breath at the gym and was admitted to the emergency room where she was diagnosed with pneumonia. Just a few days later, doctors determined that she was suffering from Stage 4 acute rejection resulting from her second lung transplant seven years prior.

6

|

DUKE ANESTHESIOLOGY

From left: Drs. Jon Andrews, Brandi Bottiger, Michael Manning Nationally-Recognized Duke Lung Transplant Program: Established in 1992, it has grown to be one of the highest volume centers in the world, performing more than 1,800 transplants.

BluePrint 2018

|

7

Presurgical RISK FACTORS

At the young age of 22-years-old, Jenkins’ outcome proved grim without undergoing what was deemed a medically-necessary, yet rare, high-risk, third double-lung transplant – a procedure that has only been performed 27 times, worldwide. Other hospitals declined her case, likely unwilling to incur the risk of a poor early survival rate typically associated with redo transplants. So, Jenkins did her research and found a young man who had received a third-time lung transplant at Duke; he helped connect her with a Duke surgeon. Seven months later, on December 23, Jenkins was transported from her home in Oakland, California to North Carolina to undergo evaluation that would ultimately determine her eligibility for this procedure at Duke University Hospital.

“Given her medical stability, young age, positive attitude and overall great support network, she was deemed eligible here at Duke for this procedure,” says Dr. Brandi Bottiger, a cardiothoracic anesthesiologist who is actively involved with national transplant societies and in selecting candidates for transplant at Duke. “The physicians involved decided she needed a third transplant based on her graft function; the alternative was to go home and do her best with medical therapy and ventilator dependence, but it probably would have been terminal for her.”

According to Bottiger, while she previously received a tracheostomy, which made the case more medically challenging, that procedure did not negatively impact Jenkins’ other organ systems – her kidneys, heart and liver were preserved. “Really, we were dealing with a single organ transplant in a very young person with

8

|

DUKE ANESTHESIOLOGY

family members who have proven their capability of taking care of medical challenges, which all worked in her favor.”

This decision proved paramount for Jenkins who received what her family calls “her miracle” on April 29, 2018. “We have all of the resources at Duke to manage these very difficult cases and a high enough volume to absorb the risk that other centers can’t take on,” adds Bottiger. “We try to give each patient the best shot they have knowing that we have substantial anesthesia and surgical faculty support, and we can provide mechanical circulatory support in the longer term if needed.”

Once Jenkins completed physical and pulmonary rehabilitation, she was placed on Duke’s Lung Transplant Program’s wait list for a match, which has an average wait time of just 15 days (compared to 116 days, nationally). This was a narrow yet crucial window for Bottiger, clinical lead for the transplant team, to build the presurgical care plan in which resource management, equipment preparedness, and communication between the Duke medical teams were key.

Jenkins presented several presurgical risk factors that required data-driven decision making for realtime application. Due to her physically petite size, along with scar tissue from a previous tracheostomy, Bottiger ensured the availability of a variety of neonatal, pediatric and adult-sized bronchoscopes for optimal intubation. “We were concerned about

her airway. If she had copious secretions the day of surgery, it was important to note that she may benefit from a bronchoscopy before they insert the double lumen tube and begin dissection.” Jenkins also had chronic respiratory infections and was on a complicated pharmaceutical regimen prior to surgery.

Knowing Jenkins needed more than the standard antibiotic treatment, Bottiger confirmed appropriate medication availability – an extensive list of antibiotics, immunosuppressants and pain medications. Also knowing that Jenkins had significant scar tissue from her previous lung transplants, it was critical to ensure the blood bank had a sufficient supply of her blood type for possible resuscitation in the OR and that bypass was on standby. “When surgeons go back into a chest that has been entered multiple times before, the anatomy becomes distorted and there’s an increased risk of bleeding. We had to be mindful that this patient had many central accesses, ports, lines and tubes that would make re-entry more challenging,” says Bottiger.

A transplant patient’s bleeding risk is assessed based on previous chest surgery, presence of scar tissue, pulmonary hypertension, and the need for mechanical circulatory support (extracorporeal membrane oxygenation or bypass). According to Bottiger, Jenkins presented many risk factors for bleeding, so they not only ensured that blood products for her would be available, but that they also had medications, such as tranexamic acid, prothrombin complex concentrates and Factor VII, on hand.

The primary anesthesia team also paid early vigilance

toward Jenkins’ neurocognitive function, acutely aware of the roughly 50 percent delirium rate in transplant patients. Jenkins was at risk of developing neurologic complications, such as stroke and posterior reversible encephalopathy syndrome (PRES*) - a rare, but potentially catastrophic complication following lung transplantation that has been noted with increased prevalence in patients like Jenkins who are young, female, immunosuppressed and have cystic fibrosis. So, Bottiger recommended cerebral saturation monitoring to observe the oxygen saturation of Jenkins’ brain during the operation.

“The multidisciplinary team approach and having Dr. Bottiger to help set the standards of care for our transplant patients is a big part of Jenkins’ success story,” says Dr. Michael Manning, the cardiothoracic anesthesiologist who was on call the night a match was found for Jenkins. “I didn’t know she was my patient until I walked into the room and I saw her. Then I thought, ‘Oh, you’re her.’ The biggest challenge was that she was high-profile, like a movie star, which can impact performance. So, it was crucial that our team proceeded like we would with any other transplant patient, while being mindful of her particular risks,” such as excessive blood loss during the dissection of the lungs from scar tissue adhering to the chest wall and ongoing bleeding due to Jenkins’ being anticoagulated for a portion of the bilateral orthotopic lung transplantation.

During those two hours before surgery, Manning and the team, including CA-2 resident, Dr. Jon Andrews,

BluePrint 2018

|

9

15 Intraoperative PROVIDERS ATTENDING ANESTHESIOLOGIST ANESTHESIOLOGY RESIDENT

SURGICAL RESIDENT TRANSPLANT FELLOW

went through their dynamic to-do list, prepping the OR (for what would be a nearly 10-hour surgery) with drips, medications, infusions and airway devices, and reviewing the case, specifically walking through concerns and action plans.

“Before we took her back, I asked Ally to think about how she felt on Christmas Eve when she was a little girl; that while she may be nervous and anxious, much like a child before Christmas morning, I was going to help her get some sleep. I reassured her that while she’s asleep, we were going to keep her stable and maintain her bodily functions from head to toe. And, just like the little girl on Christmas morning, after opening all of her presents, it will seem, to her, like in the flash of an eye, she is waking up in the ICU and all of that anticipation and excitement will be over.”

Once in the OR, Manning says he and Andrews were constantly assessing; taking in new information, evaluating it and determining whether that changed their “to-do” list – utilizing advice that Duke Anesthesiology teaches its trainees, asking ‘what’s coming next’ and ‘what else can I be doing right now.’

“Jenkins’ physical size made this operation more challenging because things happen much quicker and you can get into the woods a lot faster,” says Manning, which required their close attention to the placement and location of invasive lines, the size of the IVs, the amount of fluid they gave her, and maintaining acid base and electrolyte balances, knowing that a patient her size can’t tolerate significant blood loss before they get behind, acidosis occurs and they become underresuscitated. Another challenge they overcame was sustaining regular heartbeat and blood pressure levels while the surgeons manipulated Jenkins’ heart, which can impede blood flow from the heart, causing blood pressure and cardiac output to drop.

“We had to be very in tune with the surgical manipulation so that we maintained physiological homeostasis without over or under treating (with pressors or inotropes). This is a real challenge in light 10

|

DUKE ANESTHESIOLOGY

ATTENDING SURGEONS

PERFUSIONISTS CIRCULATING NURSES SCRUB NURSES

of one lung ventilation, bleeding and mechanical compression of the heart. So, the key was constant communication, anticipating next steps, and being ready.”

With newly-implanted lungs, the medical team implemented protective ventilation strategies using the ICU ventilator in the OR. The goal was to avoid causing barotrauma and maintain a low FiO2 (inhaled oxygen level) to prevent acute respiratory distress syndrome or primary graft dysfunction. Bottiger notes that at Duke, they routinely use inhaled pulmonary vasodilators; either inhaled iloprost or inhaled nitric oxide. Her colleague, Dr. Kamrouz Ghadimi, also a cardiothoracic anesthesiologist, has been leading outcomes research comparing these two types of medications.

Postsurgery, Jenkins was transported to the ICU where anesthesiologists, Drs. Nazish Hashmi and Jerrold Levy, among others, actively managed her care - thoroughly analyzing every aspect of her recovery by organ system, each day. Their initial goals in the early part of Jenkins’ recovery process were to ensure that her bleeding had stopped, her hemodynamics were stable, and to begin the process of weaning her off of some of the medications to support her blood pressure; then, extubating Jenkins as quickly as possible. Before extubation, they placed an epidural, which is traditionally used for pain management in patients post-transplant. Lung transplant patients, specifically, receive a sternotomy and bilateral inferior thoracotomy; this large incision creates a high incidence of post-thorocotomy pain – nerve damage from the tubes or persistent pain along the incision**.

“If patients have a lot of pain in the thoracic area in particular,” says Bottiger, “they may have trouble breathing deeply, which could impact their pulmonary recovery. We use epidurals as the primary means to numb this area so they can begin walking and breathing without the use of opioids. However, the downside is that epidurals can cause vasodilation and reduce their blood pressure.” *Posterior Reversible Encephalopathy Syndrome After Lung Transplant: Clinical Characteristics and Outcomes. B Bottiger, MD, J Klapper, MD, V Esposito, L Snyder, MD, N Hashmi, MD, M Berger, MD, M Hartwig, MD, PJ Smith, PhD.

KEY ANESTHESIA Management: • Create a presurgical care plan using a multidisciplinary team approach • Work with experts to optimize the patient’s perioperative health

Key Anesthesia Management: Ally Jenkins with her fiancé, who proposed to her at Duke.

Photo by Sarah Krueger

Jenkins spent about one month at Duke University Hospital (nearly four days in the ICU) with ongoing physical, nutritional and cognitive support (including from the Acute Pain Service), before being discharged on May 24. Throughout the next year, her doctors will closely monitor her for signs of rejection while she looks ahead to moving back to California to focus on her recovery, marry her childhood love, and establish an organization to “pay it forward.”

“Ally’s perseverance and the great communication between the teams at Duke is really the success of her story, which gives me a lot of intrinsic reward,” says Bottiger. “We as anesthesiologists have a unique capacity to think about this patient population, applying our knowledge of physiology and pharmacology. If there are active and engaged anesthesiologists taking care of these patients, who are communicating and helping to identify and address concerns, that can and does change the direction of care.”

“We at Duke said yes because our practice is primarily based on doing what others deem as impossible,” adds Manning. “We do it every day and I think we do it really well, but we can only do so much. Ally’s support system and positive attitude played a significant role. She came through our doors and said ‘I’m where I need to be. I know I’m going to be fine. This is what I want.’ People like that, you can’t hold back.” **Cunniff, C, Cooter, M, Klinger, R, Hopkins, T, Gray, A, Ingle, K, Hartwig, M, Haney, J, Bottiger, B. Assessing Post-Thoracotomy Pain After Lung Transplantation: Preliminary Results Using An Electronic Pain Assessment Tool; Society for Cardiovascular Anesthesiologists 39th Annual Meeting and Workshops, Orlando, FL 2017; SCA176.

• Operationalize resources • Detailed action plans to address anticipated risks, such as highvolume blood loss • OR preparedness: access to inotropes, pressors, blood, adult and child-sized equipment (IVs, tubes and bronchoscopes), and mechanical circulatory support • Careful selection of an appropriately-sized double lumen tube to prevent additional airway trauma during intubation, available ICU ventilator and inhaled pulmonary vasodilators • Multimodal pain management strategy with input from pain specialists and usage of blocks (thoracic epidural) when possible; patients with end stage respiratory disease (and post-transplant) are especially susceptible to respiratory depression effects of opioids • Coordinate postsurgical care with ICU team to optimize comorbidities BluePrint 2018

|

11

DIVISIONAL NEWS

AMBUL ATORY ANESTHESIA

CARDIOTHOR ACIC ANESTHESIA

DR. KENT COLLABORATES WITH DEPARTMENT OF DEFENSE

DR. SWAMINATHAN APPOINTED TO VICE CHAIR

Utilization of biopsychosocial measures in the acute and subacute perioperative phases to improve recovery is a rapidly emerging field.

Expanding on measures of pain intensity and analgesic use, comprehensive measures including function, mood, sleep, and social modulators are increasingly being used in a variety of surgical settings. However, the natural history of such variables following surgery is still unclear.

Madhav Swaminathan, MD, FASE, FAHA, was appointed vice chair for faculty development at Duke Anesthesiology in January. In his new role, he is responsible for nurturing departmental faculty with the vision, mentorship, opportunities and infrastructure they need to be leaders in “changing the face of anesthesiology.”

Having recently joined Duke Anesthesiology after leaving active duty service, Dr. Michael Kent continues to collaborate with the Defense and Veterans Center for Integrative Pain Management as the lead investigator in two large Department of Defense longitudinal studies focused on patient reported outcomes. Leveraging a variety of measures (i.e. NIH’s PROMIS measures) focused on recovery and long term analgesic use, these two studies aim to map the natural biopsychosocial postoperative history in patients undergoing total knee arthroplasty, total hip arthroplasty, mastectomy, thoracic surgery, major abdominal surgery, lumbar fusion, knee arthroscopy, and shoulder arthroscopy.

In 2019, final results are expected to provide a more comprehensive view of perioperative recovery with a focus on measures and outcomes that are important to patients and providers.

12

|

DUKE ANESTHESIOLOGY

“It is an honor and privilege to serve the department in any capacity. This particular position is important as it helps faculty at all levels achieve their professional goals while advancing the mission of the department,” says Dr. Swaminathan.

His short-term goals are to 1) develop robust methods to assess faculty needs, 2) make institutional resources for developing professional skills, such as writing, public speaking and collaborative research opportunities, readily available to departmental faculty, 3) streamline mentorship pathways for mentees and mentors, 4) simplify the pathway for navigating the appointments, promotions and tenure process, and 5) establish new programs for wellness, inclusion, leadership and skills development.

Swaminathan, professor of anesthesiology, arrived at Duke in 2000 as a cardiothoracic anesthesiology fellow. Two years later, he joined the department as faculty and developed his research interests in kidney outcomes after cardiac surgery. In 2004, he assumed a leadership role as the director of perioperative echocardiography at Duke. And in 2013, he was appointed as clinical director of cardiothoracic anesthesiology.

DIVISIONAL NEWS

COMMUNIT Y DIVISION

42,927 TOTAL CASES PERFORMED

BY DIVISION

CRITICAL CARE MEDICINE

FIRST MAJOR RESULTS OF “AMERICAN GUT PROJECT” PUBLISHED Researchers at University of California San Diego School of Medicine and collaborators [including Duke Anesthesiology’s Dr. Paul Wischmeyer] have published the first major results from the American Gut Project, a crowdsourced, global citizen science effort.

The project (described in mSystems) is the largest published study to date of the human microbiome — the unique microbial communities that inhabit our bodies. This publication provides the largest public reference database of the human gut microbiome, which may help drive many future microbiome

studies. The project’s goal is to better understand the human microbiome — which types of bacteria live where, how many of each, and how they are influenced by diet, lifestyle and disease.

— UCSD School of Medicine

“Our data shows a massive loss of the normal ‘health-promoting’ organisms (or dysbiosis) in ICU patients as soon as 48 hours after ICU admission; particular ‘health-promoting’ bacteria are persistently lost and could be given back as targeted probiotics based on our new findings, which we are currently exploring. We also show that loss of normal bacterial diversity is associated with poor ICU outcomes. Giving back healthy bacteria via stool transplant or targeted probiotics could likely improve hospital outcomes.”

EMERGING TRENDS: Diet: Participants who ate 30+ different plant types/ week had more diverse gut microbiomes than those who ate 10 or fewer.

Antibiotics: Participants who ate 30+ plants/ week had fewer antibiotic resistance genes in their gut microbiomes than people who ate 10 or fewer.

Mental Health: The research team found some indications that specific bacteria types may be more common in people with depression.

— Paul Wischmeyer, MD, EDIC

BluePrint 2018

|

13

DIVISIONAL NEWS

GENER AL, VASCUL AR AND TR ANSPL ANT ANESTHESIA

NEUROANESTHESIOLOGY

VICE CHAIR FOR INNOVATION APPOINTED

DUKE RESEARCHERS EARN COLLABORATIVE SCIENCES AWARD

One of the great leaders in the specialty, Evan Kharasch, MD, PhD, joined Duke Anesthesiology on July 1 as professor of anesthesiology and vice chair for innovation. He was also appointed as the director of academic entrepreneurship within the Duke University School of Medicine. Kharasch is a nationally-renowned academic anesthesiologist and physician-scientist, specifically in the field of translational research, who has made significant contributions in advancing the understanding and practice of clinical pharmacology. He joins the department from Washington University School of Medicine in St. Louis. Kharasch is widely-known for his current role as editor-in-chief of Anesthesiology, the official medical journal of the American Society of Anesthesiologists and the leading journal in this specialty.

FIRST DUKE POM FELLOWS GRADUATE The inaugural fellows of Perioperative Medicine (POM), Elena Koepke, MD, MBA, and David Williams, MD, MPH, graduated in June.

The POM Fellowship is a collaboration between Program director, Dr. Timothy Miller Duke Anesthesiology (center), with Drs. David Williams and and University College Elena Koepke London; it provides a unique opportunity for anesthesia trainees to complete a master's degree and perioperative medicine fellowship at the same time.

This program provides an internationally-recognized qualification and uniquely equips fellows to pioneer progress in this new field.

Williams remains at Duke as an assistant professor in anesthesiology in the GVT Division.

14

|

DUKE ANESTHESIOLOGY

The American Heart Association awarded its prestigious Collaborative Sciences Award (a three-year, $750,000 grant) to Drs.Ulrike Hoffmann (Neuroanesthesiology), Wei Yang and Junjie Yao for their project aimed at improving recovery of neurologic function in cardiac arrest patients: “Decrypting the Role of Epinephrine on Brain Function after Cardiac Arrest in Mice.” This research among scientists from two broadly disparate disciplines could ultimately revolutionize cardiac arrest guidelines and the use of epinephrine in clinical environments.

“For us, this award exemplifies future collaborations within our department’s newly-established Center for Perioperative Organ Protection and its mission to advance science within a team of multidisciplinary investigators fueling proposed research with their unique expertise, ultimately resulting in synergistic, complex, highly-efficient research that will benefit patients,” said Hoffmann.

DIVISIONAL NEWS

ORTHOPAEDICS, PL ASTICS AND REGIONAL ANESTHESIOLOGY

WELLNESS PROGRAM LAUNCHES In July, Duke Anesthesiology launched the Wellness Connection, a new program aimed at educating and empowering house staff and faculty to cultivate empathy, job satisfaction, work-personal life balance and individual well-being.

The web page includes a wellness events calendar, healthy-living resources, a “What Keeps me Grounded” section, and more.

Dr. Ellen Flanagan spearheaded the development of the program. The wellness team includes Drs. Jennifer Anderson, Julien Cobert, Theresa Crowgey, Jennifer Dominguez, Jeffrey Gadsden, Jennifer Hauck, Kendall Smith, Madhav Swaminathan, and Ankeet Udani.

PAIN MEDICINE

DR. GULUR APPOINTED EXECUTIVE VICE CHAIR Padma Gulur, MD, was appointed as executive vice chair for performance and operations within the department in June.

In her new role, she is responsible for driving program development in key areas throughout the Duke University Health System.

“It’s a real honor and a privilege to have this opportunity to help grow and ensure our department’s continued success,” said Gulur, who is board certified in anesthesiology and pain medicine, and specializes in advanced interventional pain management.

DUKE RALEIGH HOSPITAL PAIN CLINIC OPENS On July 1, Duke Anesthesiology began providing medical services at Duke Raleigh Hospital Pain Clinic.

The new team of pain medicine specialists includes Drs. Kevin Vorenkamp and Thomas Van de Ven. The clinic delivers state-of-the-art diagnostic and interventional therapies, and provides population health-level care for chronic pain patients.

BluePrint 2018

|

15

DIVISIONAL NEWS

PEDIATRIC ANESTHESIA

VETER ANS AFFAIRS ANESTHESIOLOGY SERVICE

DUKE PEDIATRIC PERIOPERATIVE TEAM WINS REBECCA KIRKLAND AWARD

DR. BARBEITO APPOINTED CHIEF OF VETERANS AFFAIRS DIVISION

In March, Duke Health hosted the 13th Annual Quality and Safety Conference at the Durham Convention Center. A pediatric perioperative team at Duke Children’s Hospital, including Duke Anesthesiology’s Brad Taicher, DO, MBA, was awarded the highest honor, the Rebecca Kirkland award, for their work in lowering surgical site infections among children. Authors of the project, titled “Eliminating Surgical Site Infections at Duke Children’s Hospital,” include Vani Sistla, Caroline Kalbaugh, Rebecca Ellis, Heather McLean, Brad Taicher, Megan Nute, Dulce Lessard, Caitlin Curtis, Aaron Rose, Henry Rice, Ira Cheifetz, Michelle Frey, Jeff Langdon and Alexander Allori.

“Implementing a team-based approach, from pre-admission testing through patient discharge, to focus on evidence-based strategies to eliminate surgical site infections was critical in our success,” said Taicher, assistant professor of anesthesiology and assistant professor in pediatrics. “Our multidisciplinary team approach is the reason for the dramatic reduction throughout pediatric surgical services, which we’re quite proud of.”

This year’s institution-wide meeting brought more than 600 participants and 150 abstracts.

Children’s specialties earned each of the three top awards.

16

|

DUKE ANESTHESIOLOGY

Atilio Barbeito, MD, MPH, was appointed the chief of the Veterans Affairs Anesthesiology Service Division on July 22. This appointment comes on the heels of Jonathan Mark, MD, retiring from his distinguished post as division chief, which he has held since 1992.

“The veterans we serve are among the most vulnerable.

Many of them suffer the sequelae of war, with a high incidence of chronic illnesses and mental health conditions. We have the privilege of caring for and celebrating these modern-day heroes daily, and this gives our work special meaning,” said Barbeito, associate professor of anesthesiology. “I am excited and humbled by the opportunity to lead the talented group of individuals that make the Veterans Affairs Anesthesiology Service Division at Duke and carry on Dr. Mark’s legacy.”

FORMER DIVISION CHIEF EARNS ECHOCARDIOGRAPHY ACCOLADE The American Society of Echocardiography selected Duke Anesthesiology’s Jonathan Mark, MD, as the 2018 recipient of the Outstanding Achievement in Perioperative Echocardiography Award. This awardee is selected by the Council on Perioperative Echocardiography and recognized Mark for his significant clinical, research, and/or educational contributions to the development of the field.

DIVISIONAL NEWS

WOMEN’S ANESTHESIA

A STRONG REPRESENTATION AT SOAP’S 50TH ANNUAL MEETING Duke Anesthesiology’s Women’s Anesthesia Division was well-represented at this year's Society for Obstetric Anesthesia and Perinatology conference in Miami in May. In total, the group presented eight abstracts, and faculty delivered three lectures at the meeting. Dr. Terrence Allen, assistant professor of anesthesiology, presented in the Best Paper Session with his work, "Progesterone Receptor Membrane Component 1, 2 and Glucocorticoid Receptor mRNA Expression in Fetal Membranes and its Association with Preterm Births." The Best Paper Session is a presentation of obstetric anesthesia research judged by peers as the best quality research currently taking place, and includes a question and answer period.

The division's chief, Dr. Ashraf Habib, delivered the "Gerald W Ostheimer: What’s New in Obstetric

Anesthesia" lecture; it is considered a highlight of the meeting and reviews important, relevant and practicechanging literature related to obstetric anesthesia, obstetrics, perinatology, and allied medical disciplines that were published during the year.

CENTERS AND PROGR AMS CENTER FOR PERIOPER ATIVE ORGAN PROTEC TION

CENTER FOR PERIOPERATIVE ORGAN PROTECTION OPENS

The Center for Perioperative Organ Protection (CPOP) opened in July. Its ultimate goal is to develop innovative therapies to improve

organ protection and patient outcomes during critical illness and throughout the perioperative period. The collaborative group of physicians and scientists are working to transform the way they care for patients before, during and after surgery. The center focuses on gaining a better understanding of molecular, cellular and organ system interactions during acute injury and recovery in the perioperative period across the aging spectrum. Team members use a multidisciplinary research approach, including preclinical, translational and population health science to make new discoveries that benefit our patients.

BluePrint 2018

|

17

CENTERS AND PROGR AMS

CENTER FOR TR ANSL ATIONAL PAIN MEDICINE

DR. TERRANDO RECEIVES PRESTIGIOUS R01 AWARD The National Institutes of Health/National Institute on Aging has awarded Duke Anesthesiology’s Niccolò Terrando, PhD, a five-year, $2,815,756 R01 grant for his project, titled “Neurovascular Dysfunction in Delirium Superimposed on Dementia.”

Millions of Americans live with dementia and require common surgical interventions, such as orthopaedic surgery. According to the research statement, these potentially life-saving procedures often increase the risk for further cognitive deterioration and in many cases, even death.

Terrando with his team of investigators at Duke University (Carol Colton, Gurpreet Baht, William Wetsel, Zhiquan Zhang, and Miles Berger) and University of Rochester Medical Center (Harris Gelbard) will address this public health concern by providing fundamental knowledge expected to help reduce the burdens of neurologic complications after common surgical procedures, and improve the quality of life for these high-risk patients.

The rationale for the proposed research is that successful completion of these studies will advance and expand the understanding of how surgery affects the blood-brain interface, and will provide new insights into molecular mechanisms of relevance to delirium, neurodegeneration and aging.

Such knowledge is highly significant because it has the potential to improve surgical outcomes and quality of life for millions of vulnerable, elderly patients in the United States by using new therapeutic approaches tested in this grant.

18

|

DUKE ANESTHESIOLOGY

DR. JORDT AWARDED R01 GRANT TO STUDY THE EFFECTS OF E-CIGARETTES The National Institutes of Health’s National Institute of Environmental Health Sciences has awarded Duke Anesthesiology’s Sven-Eric Jordt, PhD, a three-year, $1,456,395 R01 grant for his project, titled “Anesthetic and Synthetic Cooling Flavors in E-Cigarettes: Chemistry and Respiratory Effects Modulating Nicotine Intake.”

The Family Smoking Prevention and Tobacco Control Act prohibits the addition of artificial or natural flavors to tobacco cigarettes, with the exception of menthol; it acts as an analgesic and counterirritant by activating the cool-sensing ion channel, TPRM8, in sensory neurons. Intriguingly, the proportion of menthol cigarette smokers has increased, suggesting that menthol may promote initiation and maintain addiction. The flavor industry has developed a range of synthetic cooling agents with novel sensory properties, which have been detected in unregulated electronic cigarette liquids and are sold by online vendors as powders or solutions to mix into e-liquids.

Preliminary data from the Jordt lab shows that synthetic coolants and eugenol strongly active TRPM8 channels. “Based on these findings, we hypothesize that some e-cigarette liquids contain pharmacologically-active flavorants that produce vapors with counterirritant or anesthetic effects, suppressing respiratory irritation and facilitating initiation of product use,” said Jordt. “Data resulting from this R01 grant could ultimately support efforts to regulate some flavorants as pharmacologically active agents.”

CENTERS AND PROGR AMS PERIOPER ATIVE ENHANCEMENT TEAM (POET )

NUTRITIONAL GUIDELINES LAY ROADMAP FOR OPTIMIZING OUTCOMES IN SURGICAL PATIENTS

Surgical nutrition guidelines published in Anesthesia & Analgesia highlight how perioperative nutritional interventions can improve surgical outcomes and reduce infectious morbidity and mortality in surgical patients.

Duke Anesthesiology's Dr. Paul Wischmeyer chaired the new Surgical Nutrition Guidelines for the Perioperative Quality Initiative, which together with the American Society for Enhanced Recovery, formed a group of international experts – surgeons, anesthesiologists and dieticians – with the goal of providing consensus statements and recommendations on surgical nutrition screening and therapy.

The published guidelines propose

1 in 3 people who come into a hospital in the U.S. are malnourished

a well chalked out plan of action before and after surgery. The researchers have developed and proposed the perioperative nutrition screen (PONS) score, which determines nutrition risk based on a patient’s body mass index, recent changes in weight, reported recent decrease in dietary intake and preoperative albumin level, which is a predictor of postoperative morbidity and mortality.

“The PONS can be administered quickly, in less than five minutes, by nursing staff in surgical or preoperative clinics and its results can be instantly uploaded into a patient’s electronic medical record, automatically triggering a nutritional consult and intervention,” said Wischmeyer.

“We are currently using PONS at the Duke POET Perioperative Nutrition Clinic, which is designed exclusively for helping patients improve their nutritional health

Only 1 in 5 of all major hospitals in the U.S. have a pre-surgical nutrition screening process

"We hope we can build a care model that other hospitals can replicate and implement.”

- Dr. Paul Wischmeyer before and after they undergo surgical procedures,” he said.

The end goal, according to Wischmeyer, is to screen all surgical patients in the United States before they have a major procedure into clinics that specialize in dealing with any nutritional issues, challenges and treatments, that would benefit and optimize a patient’s recovery from surgery and appropriately channel their postoperative care.

In addition to Wischmeyer, other researchers included Duke Anesthesiology's Timothy E. Miller and alumni Robert H. Thiele.— Read the full story: dcri. org/nutritional-guidelines

Less than 15% of new doctors feel adequately prepared to discuss nutrition issues with their patients

BluePrint 2018

|

19

Duke Anesthesiology B Y T H E NUMBE R S

BILLED, PUBLISHED AND AWARDED: JULY 1, 2017 - JUNE 30, 2018

179,127 TOTAL CASES 16,389 30,639

ACUTE PAIN*

42,972

17,180

17,142

13,953

10,011

8,110

6,583

6,157

5,622

*At Duke University Hospital + At Duke Pain Medicine, Davis Ambulatory Surgical Center, DIPT, Duke Spine & Pain Management of Raleigh, Perioperative Pain Care Clinic, & Duke Spine Center ~At Duke Regional & Duke Raleigh Hospitals

COMMUNITY

CRITICAL CARE MEDICINE*~

CHRONIC PAIN+

VETERANS AFFAIRS ANESTHESIOLOGY SERVICE*

GENERAL, VASCULAR AND TRANSPLANT ANESTHESIA*

PEDIATRIC ANESTHESIA*

PAIN MEDICINE

9,463

ORTHOPAEDICS, PLASTICS AND REGIONAL ANESTHESIOLOGY*

CARDIOTHORACIC ANESTHESIA*

NEUROANESTHESIOLOGY*

WOMEN’S ANESTHESIA*

AMBULATORY ANESTHESIA*

CARDIOTHOR ACIC ANESTHESIA 53 GENER AL, VASCUL AR AND TR ANSPL ANT ANESTHESIA 24 CRITICAL CARE MEDICINE 24 NEUROANESTHESIOLOGY 24 OTHER 24 CENTER FOR PERIOPER ATIVE ORGAN PROTECTION 23 VETER ANS AFFAIRS ANESTHESIOLOGY SERVICE 22 WOMEN’S ANESTHESIA 20

453 AUTHORS

20

|

DUKE ANESTHESIOLOGY

PEDIATRIC ANESTHESIA 11 ORTHOPAEDICS, PL ASTICS, & REGIONAL ANESTHESIOLOGY 11 CENTER FOR TR ANSL ATIONAL PAIN MEDICINE 10 PAIN MEDICINE 7 AMBUL ATORY ANESTHESIA 3

243

PUBLICATIONS

BY THE NUMBERS

35 NEW GR ANTS TOTALING MORE THAN

$ 5.4

million

BASIC SCIENCES

7 | $1,289,002

NEUROANESTHESIOLOGY

8 | $1,286,166

GENERAL, VASCULAR AND TRANSPLANT ANESTHESIA

3 | $906,333

PAIN MEDICINE

4 | $593,317

PEDIATRIC ANESTHESIA

2 | $423,090

CARDIOTHORACIC ANESTHESIA CRITICAL CARE MEDICINE VA ANESTHESIOLOGY SERVICE CENTER FOR TRANSLATIONAL PAIN MEDICINE ORTHOPAEDICS, PLASTICS AND REGIONAL ANESTHESIOLOGY

4 | $396,339 3 | $249,275 2 | $203,941 1 | $79,750 1 | $66,299

$3.6 million 102 TOTAL OF 17 NON-COMPETING CONTINUING GR ANTS

CURRENT OPEN GR ANTS

11 RESEARCH LABORATORIES Chemical Sensing, Pain and Inflammation Research Laboratory Sven-Eric Jordt, PhD FG Hall Environmental Laboratory Richard Moon, MD, CM, MSc, FRCP, FACP, FCCP Human Pharmacology and Physiology Laboratory David MacLeod, MB BS Molecular Neurobiology Laboratory Wei Yang, PhD

Molecular Pharmacology Laboratory Madan Kwatra, PhD Multidisciplinary Neuroprotection Laboratory David Warner, MD The Nackley Lab Andrea Nackley, PhD Nerve Injury and Pain Mechanism Laboratory Thomas Van de Ven, MD, PhD

Neuroinflammation and Cognitive Outcomes Laboratory Niccolò Terrando, PhD Sensory Plasticity and Pain Research Laboratory Ru-Rong Ji, PhD Systems Modeling of Perioperative Cardiovascular Injury & Adaptation Laboratory Mihai Podgoreanu, MD, FASE

BluePrint 2018

|

21

DEPARTMENTAL GRANTS $100,000+ JULY 1, 2017 - JUNE 30, 2018 SORTED BY OWNING DEPARTMENT

Niccolò Terrando, PhD

Neurovascular Dysfunction in Delirium Superimposed on Dementia Funding Agency: National Institutes of Health Grant Amount: $564,455 Bioelectronic Rescue of Cognitive Impairment After Surgery Funding Agency: National Institutes of Health Grant Amount: $238,047 Omegaven and Postoperative Cognitive Dysfunction Funding Agency: Fresenius Kabi AG Grant Amount: $121,999

Wei Yang, PhD

Decrypting the Role of Epinephrine on Brain Function After Cardiac Arrest in Mice Funding Agency: American Heart Association Grant Amount: $250,001 C A R DIOTHOR ACIC A NES THESI A

Madhav Swaminathan, MD, FASE, FAHA Sentien SB-101 Funding Agency: Sentien Biotechnologies, Inc. Grant Amount: $130,569

Ian J. Welsby, MB BS

Aridis AR-105 Aerucin Funding Agency: Aridis Pharmaceuticals, Inc. Grant Amount: $185,770 CR ITIC A L C A R E MEDICINE

Paul E. Wischmeyer, MD, EDIC Fresenius Kabi Project Funding Agency: Fresenius Kabi AG Grant Amount: $103,962 22

|

DUKE ANESTHESIOLOGY

GENER A L , VA SCUL A R A ND TR A NSPL A NT A NES THESI A

Richard E. Moon, MD, CM, MSc, FRCP(C), FACP, FCCP

PulseOx Study Funding Agency: Naval Sea Systems Command Grant Amount: $174,482 Altitude Study Funding Agency: Naval Sea Systems Command Grant Amount: $347,414

John Whittle, MBBS, MD, FHEA, FRCA, FFICM

Takeda Funding Agency: Takeda Pharmaceuticals USA, Inc. Grant Amount: $384,437 NEUROA NES THESIOLOG Y, OTOL A RY NGOLOG Y A ND OFFSITE A NES THESI A

Miles Berger, MD, PhD

Neuro-inflammation in Postoperative Cognitive Dysfunction: CSF and fMRI Studies Funding Agency: National Institutes of Health Grant Amount: $243,000

Michael L. James, MD, FAHA, FNCS Intrepid- BMD-1111 Funding Agency: Bard Medical Division Grant Amount: $144,980 Novartis Phase II BAF312 in Stroke ICH Funding Agency: Novartis Pharmaceuticals Corporation Grant Amount: $151,408

Evan Kharasch, MD, PhD

Optimizing Outpatient Anesthesia: Improving Analgesia and Reducing Opioid Misadventure Funding Agency: National Institutes of Health Grant Amount: $558,182

Richard L. Boortz-Marx, MD, MS

Semnur CLEAR Funding Agency: Semnur Pharmaceuticals, Inc. Grant Amount: $205,543 Scintilla RTX Phase 1b Funding Agency: Scintilla Pharmaceuticals, Inc. Grant Amount: $183,473

Thomas J. Hopkins, MD Medtronic OPuS One Funding Agency: Medtronic, Inc. Grant Amount: $129,078

Allison K. Ross, MD

West-Ward Pharma Peds Oral Morphine Sulfate Funding Agency: West-Ward Pharmaceuticals Grant Amount: $102,984

Brad M. Taicher, DO, MBA

Merck Phase IV MK8616-089 Pediatric Sugammadex Funding Agency: Merck Grant Amount: $320,106 V E TER A NS A FFA IR S A NES THESIOLOG Y SERV ICE

Raquel R. Bartz, MD, MMCi

Visterra VIS410 + Osetamivir (Tamiflu) Compared with Oseltamivir Alone Funding Agency: Visterra, Inc. Grant Amount: $130,750

BUSINESS OFFICE

From Duke to Pyeongchang The 2018 Winter Olympics provide indelible memories for Duke Anesthesiology's IT Manager The first time Ken Childs remembers watching a bobsled race was in 1988. As a nine-year-old watching coverage of the races from the Winter Olympics in Calgary, Childs was captivated by the racers who barreled down twisting courses in sleds travelling upwards of 90 miles per hour.

For the IT manager at Duke Anesthesiology, the fascination with bobsleds never left. And in February, it took him to Pyeongchang to experience his first Olympic Games.

Childs was there to cover bobsled, luge and skeleton events for SlidingOnIce.com, a sliding sports news website he runs. Childs started the site in 2011 after finding that it was hard to find information on sliding sports.

Ken Childs (in a Durham Bulls hat) traveled to the Winter Olympics to cover sliding sports for the website he founded, SlidingOnIce.com.

In the years since, his site has become one of the main sources of information and analysis for fans and racers alike. In addition to posting results and reactions from races he watches online, Childs often treks to Lake Placid, New York to cover the major events held there each winter.

As one of the few journalists who cover the sport constantly, Childs offered perspective that others couldn’t. If an athlete overcame injury or endured a winding road to the medal stand, he knew.

But this year's Olympic Games was by far his biggest assignment.

Due in part to that insight, the

traffic on his site, which usually peaks around 10,000 hits per week during major non-Olympic competitions, spiked to around 40,000 hits per week during his time in South Korea.

“It’s a labor of love,” Childs said of running the site. “The hours are terrible and the pay is bad, but I love it.” ­— WORKING@DUKE BluePrint 2018

|

23

EDUCATION

Celebrating 26 Years of Academic Evening More than 150 faculty, trainees, staff and students attended Duke Anesthesiology’s 26th Annual Academic Evening in May to share their research pursuits. Eighty-seven poster abstracts were presented by the department's junior-level investigators and faculty.

“It’s really inspiring to be a part of this department and see the work that my colleagues and our trainees are producing,” said Dr. Jeffrey Gadsden, co-program director.

This year’s guest judge and speaker was Dr. Sean Mackey, chief of Stanford University’s Division of Pain Medicine. He served as president of the American Academy of Pain Medicine and currently serves as the co-chair of the Oversight Committee for the NIH/Health and Human Services National Pain Strategy. Mackey spoke highly of the department’s research, discovery and culture. “Of all the places I travel, Duke feels the most like home,” said Mackey. His speech also offered advice to the young trainees and scientists. “Bad research takes just as long to do as good research, so ask impactful questions and choose to do good research.”

Top: Judge Dr. Sean Mackey and former Duke Anesthesiology statistician, Bill White.

2018 WINNERS

Bottom: Anesthesiology resident, Dr. Rosalie Yan, presents her abstract.

MEDICAL STUDENT:

Scott Scarneo

Alison Brown, MD

QUALITY IMPROVEMENT PROJECTS : 24

|

“Academic Evening showcases some of the biggest strengths of our department – collaboration, scientific excellence and academic merit.

From cutting-edge studies to the management of high acuity patients in difficult procedures, everybody has such impressive work to show,” said Horazeck.

Benjamin Andrew, MHS, RD

NON-MEDICAL STUDENT: CASE REPORT:

The Resident Research Award’s namesake, Bill White, was another special guest of the evening. White was involved in the design, data control and examination, and statistical analysis of biomedical studies in both observational and clinical trials within Duke Anesthesiology for more than 20 years. He presented the award to runners up, Drs. Michael DeVinney and Sarah Cotter, and winner, Dr. Christian Horazeck.

DUKE ANESTHESIOLOGY

Adrien Wang, MD

POST-DOC BASIC SCIENCE RESEARCH:

Xin Zhang, MD, PhD

POST-DOC CLINICAL RESEARCH (DICK SMITH AWARD): Santiago RESIDENT RESEARCH (BILL WHITE AWARD):

Uribe Marquez, MD

Christian Horazeck, MD

EDUCATION

ANNOUNCING DUKE ANESTHESIOLOGY'S ACADEMY FOR BUILDING LEADERSHIP EXCELLENCE (ABLE) PROGRAM Duke Anesthesiology has long been recognized, both nationally and internationally, for its outstanding academic leadership.

Anesthesiologists trained at Duke have gained remarkable visibility at the frontiers of perioperative medicine globally. A fundamental aspect of Duke’s tradition of leadership excellence is the emphasis placed on mentorship for trainees and faculty. A focus on the value of coaching has prompted the creation of the ABLE program to accelerate career development among junior faculty.

The new initiative strives to provide personalized coaching to junior faculty in four domains – clinical research, education, operations, and translational research. ABLE aims at creating a culture of coaching to ensure that every faculty member is invested and engaged in professional growth. It includes

programs to develop coaching and leadership skills, increase productivity, build resilience, and enhance professional growth.

Successful applicants will be paired with a faculty coach and receive a

yearlong opportunity to learn from a visible leader in the field. Two faculty members will be selected for personalized coaching in each domain. While each domain will have a customized curriculum, all domains will have shared goals to help faculty develop strategies to manage time, stress and fatigue; enhance professional skills, such as writing and presenting; improve applications for external funding; and build leadership skills. The program features Drs. Dhanesh Gupta, Brad Taicher, Allison Ross, Ashraf Habib, Brandi Bottiger, Jonathan Mark, Andrea Nackley and Niccolo Terrando as coaches.

Drs. Padma Gulur and Bill Maixner will lead the operations and translational research domains, and Drs. Luke James and Mark Stafford-Smith will lend their expertise to the domains of clinical research and education, respectively.

DUKE ANESTHESIOLOGY HOSTS 19TH ANNUAL CONFERENCE The 19th Annual Duke Anesthesiology Conference, Controversies in Perioperative Medicine, was held in June at Disney’s Contemporary Resort in Orlando, Florida. Over the course of five days, attendees discussed

issues surrounding the management of patients undergoing surgery via lectures, panel discussions, lively debates and hands-on practical workshops.

BluePrint 2018

|

25

DUKE UNIVERSIT Y SCHOOL OF MEDICINE

MESSAGE FROM DEAN MARY KLOTMAN, MD It has been an exciting first year as dean of the School of Medicine, and I am pleased to update you on many important recent milestones.

welcome two new School of Medicine leaders.

Colin S. Duckett, PhD, is our new vice dean for basic science. He will be instrumental in enhancing the environment for our laboratory scientists and will have oversight of the biomedical graduate programs, postdoctoral office, animal care program, core facilities, and research lab space utilization.

Almost a year ago, the Michael Pencina, PhD, was named vice dean for data school embarked on a science and information technology for the school. strategic planning initiative, He is responsible for developing and implementing engaging over 100 faculty quantitative science strategies as they pertain to the members to guide the future school’s education and training and laboratory, clinical of our research mission. In July, we shared the research science, and data science missions. plan, “Leading the Next Generation of Discovery and Impact,” and embarked on its implementation.

I am continually amazed at the work of my colleagues The plan provides a focus and clarity on the school’s across the School of Medicine and campus. I am so research priorities and reinforces our commitment to proud of our school and of the quality of our research, conduct research of the highest caliber and integrity as care for patients and educational programs we offer well as our commitment to recruit visionary scientists, here at Duke. develop state-of-the-art resources and support, and enhance our current infrastructure. We are ambitious The future holds exciting opportunities, and I want to with our goals and excited for what the future holds. thank our faculty, staff, students, alumni, and friends for all of their efforts and continued support of the As we embark on new projects and initiatives, we School of Medicine.

SCHOOL OF MEDICINE FACULTY HONORED AT SPRING MEETING 2018 The Duke University School of Medicine has selected Duke Anesthesiology’s Mark StaffordSmith, MD, CM, FRCPC, FASE, as a recipient of the Master Clinician/ Teacher Award for 2018. It was established to honor individuals for superlative accomplishment and service in the area of medical school/medical center teaching and/or clinical care. Award recipients are noted for making an extraordinary commitment “above and beyond” normal expectations; those who may be considered “unsung heroes” at Duke.

26

|

DUKE ANESTHESIOLOGY

A distinguished faculty committee at Duke has selected Duke Anesthesiology’s Allison Kinder Ross, MD, chief of the Pediatric Anesthesia Division, as a recipient of the 2018 Excellence in Professionalism Award.

She is notably the first anesthesiologist to receive this award, which recognizes faculty members who exemplify professionalism and personify Duke’s guiding principles of respect, trustworthiness, diversity, teamwork, and learning.

R ANKINGS

FORBES NAMES DUKE A ‘BEST EMPLOYER’ Forbes named Duke University among its “Best Employers,” ranking the university 18th among large employers on its 2018 list.

Working with online statistics partner Statista, Forbes surveyed 30,000 workers across the country who are employed by companies or institutions that employ at least 1,000 people. Duke ranked 27th on last year’s list.

“Our faculty and staff remain among some of the most talented individuals in the country,” said Duke Vice President for Administration Kyle Cavanaugh. “Over the years, Duke has consistently been recognized as one of the top employers in the nation, and this most recent recognition helps to reinforce the amazing culture that represents our Duke community.”

— Duke TODAY

DUKE MEDICAL SCHOOL RANKED TOP 10 AND DUKE ANESTHESIOLOGY TOP 5 The Duke University School of Medicine is once again ranked among the top 10 of all medical schools in the nation (#10 for research). The rankings were published by U.S. News & World Report.

Duke Anesthesiology ranked fifth among the "Best Medical Schools for Anesthesiology." This is the first year specialty rankings were reported in anesthesiology, obstetrics and gynecology, psychiatry, radiology and surgery.

“This is a testament to our outstanding faculty, staff and students who work tirelessly to provide the best education for our students, deliver the most advanced care to our patients, and make seminal discoveries that evolve our knowledge of the body and ways to improve health in our community and globally.”

— Dean Mary E. Klotman, MD, Duke University School of Medicine BluePrint 2018

|

27

28 28

||

The oxygen levels high in the mountains are similar to those experienced by patients in the Intensive Care Unit.

DUKE ANESTHESIOLOGY DUKE ANESTHESIOLOGY

Xtreme Everest researchers went high up in the clouds to find out

BY LINDSAY KEY

When a patient’s blood oxygen levels drop below 90 percent in the emergency room in the United States, many doctors panic. The body needs oxygen in order to transfer the energy stored in food into usable energy. If the body is deprived of oxygen for too long, organs begin to shut down. However, on top of Mount Everest - the tallest mountain (above sea-level) in the world at 29,029 feet—many people reach oxygen levels of 60 percent and yet manage to function reasonably well.

An international medical research team, known as Xtreme Everest, studies how people respond to lowoxygen levels at high altitudes in order to develop novel therapies to improve the survival rates and

long-term outcomes of critically ill patients. The organization, which was started by scientists in the United Kingdom, has hosted more than five expeditions over the past 15 years in which teams of investigators, scientists, volunteer trekkers, and Sherpas were monitored during ascent and descent of Mount Everest.

Three Duke researchers participated in the 2013 and 2017 expeditions - Richard Moon, MD, a professor of anesthesiology and medicine, and medical director of Duke’s Center for Hyberbaric Medicine and Environmental Physiology; and Chris Young, MD, and Eugene Moretti, MD, both professors of anesthesiology and critical care specialists.

BluePrint 2017 BluePrint 2018

||

29 29

Drs. Chris Martin (Duke Undersea and Hyperbaric Medicine fellow) and Richard Moon evaluate data on a rugged tablet computer at Pheriche (altitude 14,340 ft).

At a symposium held June 14 at Duke University, hosted by Duke Anesthesiology, scientists from Duke, the University of Southampton, University College London (UCL), and University of Cambridge, met to discuss their most recent findings. Listeners from all over the world - including Australia, Portugal, Croatia and Argentina - tuned in live.

“We wanted to have the opportunity to present an up to date summary of what we have learned so far, including data from our Sherpa volunteers,” said Kay Mitchell, senior research manager in the critical care research area at the NIHR Southampton Biomedical Research Center and co-founder of Xtreme Everest.

Last year, in 2017, the group published a paper in the journal Proceedings of the National Academy of Sciences reporting their finding that there are metabolic adaptations in the Sherpas who guide people up Mount Everest that allow their tissues to use oxygen more efficiently. This adaptation, which is reinforced by 30

|

DUKE ANESTHESIOLOGY

genetic differences, allows Sherpas to conserve muscle energy at high altitudes and possibly contributes to their superior climbing abilities at extreme altitudes.

The ways in which individuals adjust differently to low-oxygen environments is a key point of study for Xtreme Everest. Over the past several years, the researchers have been able to identify what the body can withstand when it acclimates, such as a disruption to the cardiovascular system’s microcirculation, an alteration in mitochondrial function and, in some cases, high-altitude cerebral edema - the potentially fatal condition in which the brain swells and fills with fluid. However, they are still working to solve the mystery as to why some people acclimate differently than others. In many cases, those considered most physically fit prior to the trip are not the ones who make it up the mountain and back most quickly or easily.

“It’s very counterintuitive,” said Michael Grocott, MD,

professor of anaesthesia and critical care medicine at the University of Southampton and co-founder of Xtreme Everest. “We have this delightful phenomenon where by those who are fittest lose the largest amount of oxygen, not just in absolute terms, but proportionally. This completely fits with the anecdotes you get from guides at Everest who take people up every year.”

Understanding how an individual might uniquely acclimate to lower oxygen levels is important not only on mountain tops, but also in the hospital room.

Patients suffering from any lung-related condition, such as an asthma attack, pneumonia, pulmonary edema, lung injury, or some drug overdoses in which hypoventilation occurs, may receive oxygen treatment while in the hospital. However, there is debate in the scientific literature about whether critical care doctors are overusing oxygen, or rather, giving higher concentrations of oxygen to patients than is needed.

“Administering oxygen can be toxic to the lung,” said Moon. “An alternative approach to that would be to give a drug, if it existed, to reacclimatize the person to low-oxygen levels. If there were such a medicine, it would be extremely useful and maybe life-saving to a lot of people.”

Moon uses the word ‘reacclimatize’ because everyone has been exposed to a low-oxygen environment as a fetus in the mother’s womb. Over time, our bodies acclimated to the oxygen-rich environment outside of the fetus. A person can re-acclimate to a low-oxygen environment if given enough time. This is why Mount Everest climbers must carefully plan their journeys over days to allow the body time to acclimate.

Moon, who has studied the body’s response to altitude since 1980, first participated in an Xtreme Everest BluePrint 2018

|

31

The Process of ACCLIMATIZATION Xtreme Everest researchers are working to understand why certain people climatize differently than others. Here are some baseline ways that most people climatize:

Team members pose at the Everest Memorial at Dughla Pass (altitude 16,200 ft).

Hyperventilation. A person begins to breathe more frequently in order to increase oxygen levels in the body.

Increased red blood cell production. Red blood cells carry oxygen, and so the body begins to produce more of these.

However, too many red blood cells at once can cause blood to become dangerously thick.

Normal increase of red blood cell production should take place over the course of 10 days.

Downward trek from Gorak Shep (altitude 16,942 ft) after an overnight snowfall.

Increased development of capillaries. Capillaries carry blood in muscle and other tissues. Since there is less oxygen per milliliter of blood, additional blood flow facilitates maintenance of oxygenation.

Walker Thomas from the University of Nebraska performs an echo study on a team member at Pheriche.

32

|

DUKE ANESTHESIOLOGY

study in 2013, along with Young and Moretti. They were also joined by Anna Grodecki, a former Duke fellow, Nelson Diamond, a former Duke medical student, and Richard Moon’s son, Peter Moon.

Moon will never forget the moment the group landed in Lukla, Nepal, which is historically home to the world’s most dangerous airport; at an altitude of 9,383 feet, it is precariously situated on a cliff in the Himalayan mountains with a short runway that leaves little room for error. High winds, cloud cover, rain and unpredictable visibility complicates landing.

Lukla serves as an entryway to Everest, and this is where most people begin the excruciating 40-mile climb to base camp, which is located at 17,500 feet.

From there, trekkers ascend more than 10,000 feet to the summit of Everest. Since Sir Edmund Hillary’s initial summit in 1953, only about 4,000 people have summited Mount Everest. Each year, approximately 800 people attempt the climb, and a handful of people, on average, die every year as a result. In addition to the physical fitness required, trekkers face the dangers of avalanche, ice collapse, frost bite, exposure, and the mountain’s “death zone” - the area above 26,000 feet where the oxygen level is not sufficient to sustain human life. Trekkers who reach that altitude without supplemental oxygen have a limited amount of time before major organs begin to fail from oxygen deprivation.

Moon was there to participate as a volunteer for Xtreme Everest, which was sending groups of 14 people up the mountain in two-day intervals, and monitoring their heart rate, blood pressure, and weight throughout the course of the trip. But he was also there to collect his own data from 10 people wearing pulse oximeters in order to determine the level of oxygen saturation in their blood. The numbers that Moon began to see on the pulse oximeters as the group ascended from Lukla to base camp to the village of Namche and beyond were alarming.

“It was quite surprising to me, and I think to the other physicians, because in the United States we all start getting nervous when a patient’s oxygen saturation

drops below 90 percent, but when we landed in Lukla and our oxygen saturation was in the mid-80s, everyone felt perfectly fine,” said Moon. “And then, when we started walking, it dropped further, and over the next few days we realized we were in the 70s and then the 60s at night. The human body is much more resilient than we think, or at least the healthy human body. Obviously, when people have disease, it’s different.”

Moon said the data, which is still being analyzed, along with data collected from the follow-up trip in 2017, will provide some degree of reassurance to doctors that low oxygen levels are not intrinsically harmful to most people, even very low oxygen levels.

The 2013 and 2017 expeditions were extremely successful with just a few hiccups. One member of Moon’s group during the 2013 expedition had to be helicoptered back to Lukla when the group noticed she was having trouble putting sugar in her tea.

A neurologist back home confirmed high altitude cerebral edema and the group member received care for weeks afterwards. Likewise, during the 2017 expedition, two physicians in his group had to leave due to high altitude cerebral edema. Luckily, everyone recovered once back at lower altitude.

“The view of so many 8,000 meter plus peaks was both unique and magnificent,” said Moretti. “It was a formidable challenge on the part of the UCL and Duke teams to manage the logistics involved in the research endeavor. However, this provided us with an extraordinary opportunity to conduct high quality research in multiple areas of physiology. Doing this in one of the most extreme environments in the world made this a truly remarkable experience.”

The Duke group continues to analyze data from the 2013 and 2017 expeditions, and has their sights set on 2020 for another potential data-gathering adventure in the mountains.

BluePrint 2018

|

33

“Luck is what happens when preparation meets opportunity.”

— Roman philosopher Lucius Seneca (4 B.C. – A.D. 65).

By Ratna Swaminathan

F

or general surgeon, Alina Nicoara, MD, the opportunity to practice cardiac anesthesia at Duke was the result of an interesting interplay of determination, preparedness and, in her own words, luck. The only child of her parents, both teachers, Nicoara traces her first memory of wanting to be a physician to first grade.

Her tenacious resolve saw her through six years of medical school, followed by a tough five-year surgical residency.

The 1990s, she informs, weren’t the easiest of times to practice

34

|

DUKE ANESTHESIOLOGY

medicine in Romania. Infrastructural deficiencies made things harder. “For the longest time, we had cloth drapes, cloth gowns and re-sterilized gloves.

We didn’t have glove sizes for women surgeons. Try suturing with size eight gloves.” Surgeons worked under the stress of running out of antibiotics from one day to another, Nicoara recollects. Money, too, was scarce. “My salary as a resident in Romania was $50 per month. Working into the wee hours of the morning was routine and expected. It was almost like a badge of honor to go through a hard surgical training and survive at the end of it.” Hardships notwithstanding, she thrived in a grueling residency program guided by her charismatic mentor, Dr. Corneliu Dragomirescu, chairman of surgery. “But at the end, there were no plans, no perspective, and no future that I could even imagine,” she adds.

A turning point in her career came in 2002 when she began her residency, this time not in surgery but in anesthesiology, at St. Luke’s Roosevelt Hospital Center in New York. This pragmatic switch enabled her to work in the operating room, her favorite setting.

She fell in love with anesthesiology, but after her first cardiac rotation, she was hooked. “I’ve seen the light … between the vocal cords,” she quips smilingly. She was sure to stay in New York, a city she loved, when one day in 2005, Dr. Daniel Thys, her department chair, suggested that she should look into Duke’s Adult Cardiothoracic Anesthesiology Fellowship program.

Taking his advice and listening to her own intuition, Nicoara made her way to Durham.

Duke felt like home during her fellowship. “The people here made me very comfortable. It was truly a no-brainer to come back as an attending in the Cardiothoracic Anesthesia Division here after the J-1 waiver term at Yale in 2010,” adds Nicoara, now an associate professor in anesthesiology and director of the Perioperative Echocardiography Service.

“Everything I achieved in my professional life would not have happened if I hadn’t ended up at Duke.”

Fortune favors the brave, they say. Nicoara was in her fourth year of general surgery residency at Bucharest’s Carol Davila University of Medicine and Pharmacy when destiny intervened. Her husband, Liviu, received a job offer in the United States. While the reasons to move were compelling for her, the decision to do so too was excruciating. Not only was she leaving behind her parents and a general surgery residency she loved, “Alina’s rise to prominence in cardiac anesthesia isn’t but also her comfort zone, which was Romania. In a surprise to those who know her. She puts her heart 2001, Nicoara accompanied her husband to New and soul into everything she does. Echocardiography Jersey with two suitcases, a carry-on bag and $100 is like fuel for her soul. You should see her eyes light between them. Also tucked along somewhere was the hope to practice medicine and a resolve to make it in America. Resilient in the face of challenges, Nicoara studied hard to clear the USMLE, overcame visa hurdles, In April, the Society of Cardiovascular Anesthesiologists researched and practiced how selected Dr. Nicoara as the recipient of the inaugural Echo Week Co-Directors’ Award. to interview for residency in a foreign country, and lived apart from her husband, whose job In May, the Council on Perioperative Echocardiography of took him from New Jersey to the American Society of Echocardiography appointed Dr. Boulder, Colorado. “I had such a Nicoara as chair-elect; she will assume her role in 2019. resolve in me that once I did it, I did not look back,” she informs.

2018 ACCOLADES

BluePrint 2018

|

35

up when you start discussing echo with her,” says Madhav Swaminathan, MD, who mentored Nicoara during her fellowship year and encouraged her to follow her passion for echo onto the national stage. A representative of perioperative echocardiography in the American Society of Echocardiography, Nicoara also serves on the board of directors in the Division of Echocardiography of the Intersocietal Accreditation Commission. “In my latter role, I will be a part of writing the standards and guidelines for accreditation of perioperative echocardiography.”

Duke’s Legacy in Perioperative Echo Duke Anesthesiology has always been a leader in perioperative echocardiography.

From the early experimental use of transesophageal echo (TEE) for cardiac surgery, to the use of echo simulation for teaching, Duke has been a pioneer in the field. Prominent experts like Dr. Fiona Clements started the use of TEE in the operating room. Dr. Jonathan Mark was the first chair of the exam committee in perioperative TEE, and this year, he was honored with the American Society of Echocardiography achievement award in perioperative echo (see Highlight on page 16). Drs. Sol Aronson, Joseph Mathew, and Madhav Swaminathan led the Council on Perioperative Echo at the ASE and co-authored several national guidelines on the practice of echo. Two of the bestknown books on the subject have been co-authored by Drs. Mathew, Aronson, Swaminathan, and Nicoara.

36

|

DUKE ANESTHESIOLOGY

If it’s cardiac anesthesia that holds her heart, it’s echo that rules it. A pivotal case early in her career ignited Nicoara’s passion for echo. She correctly diagnosed an undetected pulmonary embolism with echo in a patient undergoing an urgent coronary bypass surgery. An initially skeptical surgeon confirmed her diagnosis and changed the surgical plan that saved the patient’s life; Nicoara was convinced that echo was the key to improving patient outcomes in cardiac surgery.

At Duke, she found the culture of teamwork between anesthesiologists and surgeons to be most gratifying.

“Echo is a like a language that we can both speak relating to patient care. It’s a way to bind this team.

Here, we have the opportunity to create a special bond with the person on the other side of the drapes,” says Nicoara, recipient of the Society of Cardiovascular Anesthesiologists “Anesthesiology Women of Excellence” award as well as its Echo Week CoDirectors’ award. Nicoara’s goal is to follow in the footsteps of Drs. Joseph Kisslo and Fiona Clements, echo stalwarts who started the first perioperative echocardiography service at Duke, and continue their legacy of excellence by empowering fellows with skills

and knowledge that can turn them into independent, astute echocardiographers.

Reflecting on echocardiography as a subspecialty, she feels that artificial intelligence and deep learning will become pervasive and change the way echocardiographers learn and teach others.

“Interventional echo is also the new frontier,” she opines confidently. “It is likely that as procedures will become more daring and incisions get smaller with technology advances on transcatheter procedures, echo will become more important.”

Nicoara sees application of echocardiography and ultrasound outside of the cardiac surgery arena and into the perioperative space. “There is no doubt that ultrasound is a versatile tool and echocardiography, in particular, provides a wealth of real-time anatomic and physiologic information. Anesthesiologists also have always been at the forefront of advancing standards of patient care by incorporating new technology.”

However, she cautions that echo should be integrated in everyday practice in an accountable way. With the advent of handheld echocardiography devices, she feels it is imperative to convey the benefits and limitations of this technique when used by physicians without specialized training. “The need for implementation of educational pathways, guidelines and credentialing processes cannot be overstated.”

What’s next in periop echo?

Visiting Preceptorship in Intraoperative Transesophageal Echocardiography Join Duke Anesthesiology for one of the 3-day, TEE preceptorship courses (led by Dr. Nicoara) designed for physicians involved in perioperative care of patients with cardiovascular disease who desire to enhance their diagnostic skills with transesophageal echocardiography.

Learn more: tinyurl.com/DukeAnesTEE

Nicoara is willing to evolve along with this continuously evolving field. “I would say this to myself and to the next generation of echocardiographers that we have to adapt, be malleable, and continuously learn new skills. It is the only way to stay relevant and meaningful.” Her research interests, in addition to echocardiography, include cardiac function and outcomes after heart transplantation. While Nicoara is clear-eyed and disciplined about everything she does, she still turns to luck when contemplating the future. “If I am lucky, I will be doing the same, but better. I would like to expand the ‘discover’ part of my professional life, creating knowledge, not only consuming it. I am looking forward to that.”

Echocardiography is a diagnostic technique. Perioperative echo has relied on improvements in technology that have enabled better visualization and definition of the structure of the heart. These refinements help surgeons plan and execute surgery better, eventually improving surgical outcomes. The field of diagnostic echo is rapidly moving toward automated methods of creating accurate three-dimensional (3D) models of the heart, especially its valves. These allow more precise deployment of devices that fix heart defects or replace diseased valves. Artificial intelligence techniques are already used to display ultrasound-based images that mimic the real internal heart structure. Future refinements will permit virtual dissection of 3D echo images in real time to improve diagnostic capabilities.

BluePrint 2018

|

37

We empower great minds to turn dreams into reality By encouraging the entrepreneurial spirit, unfettered imagination, and unchecked ambition, the DREAM Campaign inspires Duke Anesthesiolog y faculty and provides them with the wherewithal to achieve the impossible. Together with our supporters, we are transforming the future of patient care.

Help us continue to train the leaders of tomorrow, develop the careers of our faculty, and protect quality of life for years to come.

DEVELOPING RESEARCH EXCELLENCE IN ANESTHESIA MANAGEMENT 38

|

DUKE ANESTHESIOLOGY

Thank you to our valued 2017-2018 donors DR. AND MRS. SOLOMON ARONSON

DR. ANDREW G. LUTZ

DR. K ARSTEN BARTELS

DR. AND MRS. WILLIAM MAIXNER

DR. ELLIOT T BENNET T-GUERRERO

MARTIN MARIET TA MATERIALS, INC.

DR. MILES BERGER

DR. AND MRS. JOSEPH P. MATHEW

MR. AND MRS. JOHN A. BORRELLI

DR. GR ACE CHUNG-YEE MCCARTHY

MR. ROBERT MICHAEL AND MS. CARRIE CL ARKE

DR. DAVID L. MCDONAGH

MR. AND MRS. JAMES H. DOUGHTON

DR. AND MRS. TIMOTHY MILLER

DW GENER AL FUND

DR. JOHN VERNON PARHAM JR.

DR. AND MRS. ROBERT FREDERICK EVANS

MS. HELEN MARIE PAVILONIS

DR. JENNA FALCINELLI

DR. MICHAEL J. PL AKKE

DR. ELISABETH J. FOX

MR. FR ANCIS T. QUINN JR.

DR. WILLIAM J. GREELEY

DR. LLOYD F. REDICK

DR. JAMES GRICHNIK

DR. CHRISTINA REITER

DR. K ATHERINE PARKER GRICHNIK

DR. EDWARD G. SANDERS

MRS. ANNE W. ISK ANDAR

DR. PAUL R. SHOOK

DR. PAUL MICHAEL JAKLITSCH

DRS. MARK STAFFORD-SMITH AND GILLIAN AYLWARD

DR. AND MRS. MICHAEL LUKE JAMES

STANLEY RESEARCH FOUNDATION

DR. RU-RONG JI

DR. ANNEMARIE THOMPSON

DR. SVEN-ERIC JORDT

DR. AND MRS. DAVID S. WARNER

DRS. DOUG AND K ATHIE KING

DR. AND MRS. DERYL HART WARNER

DR. AND MRS. STEPHEN ISSAC KUSHINS

DR. RICHARD BALDWIN WATSON

DR. MICHAEL L ASECKI

DR. AND MRS. ANDREW WIKSTEN

DR. GARY WAYNE L ATSON

JOHN AND BONNIE WOLFE

DR. MARK URI L AZ AR

DR. SUR AJ MANJUNATHA YAL AMURI

TEN YEARS OF GIVING: DREAMCAMPAIGN.DUHS.DUKE.EDU

BluePrint 2018

|

39

DIG Award Leads to Novel Finding of Intestinal Healing attached to a number of proteins (transcription factors, enzymes, signaling molecules, stress response molecules) in order to alter their function, stability and/or cellular localization. As a result, changes in global levels of SUMOylated proteins alters a wide array of cellular responses.

Jorn Karhausen, MD, was

awarded a DREAM Innovation Grant (DIG) in 2012 for his project “Determinants of Intestinal Epithelial Wound Healing,” which allowed him to test his innovative ideas as they regulate the responses of the cellular lining of the gut. This work, which was recently published in Laboratory Investigations, the official journal of the United States and Canadian Academy of Pathology, establishes the importance of a regulatory mechanism called SUMOylation in gut healing from ischemia/reperfusion. SUMO (Small Ubiquitin-like MOdifyer) is a small protein that can be rapidly

In this work, accomplished in collaboration with Duke Anesthesiology researchers, Drs. Wulf Paschen and Wei Yang, and from the National Institutes of Health, the team demonstrated that SUMOylation is tightly controlled in the healthy gut but rapidly increases after cell stress.

Furthermore, genetically modified animals over-expressing critical components of the SUMOylation machinery were protected from ischemia/reperfusion injury through a coordinated down-regulation of tissuedisruptive inflammatory responses.

Using sophisticated techniques, such as laser-capture microdissection and

PCR array analysis of the isolated cells, Karhausen’s team was the first to characterize the cell specific role of SUMOylation in a complex mouse disease model.

The DIG award was instrumental in supporting this extremely innovative work in its critical initial phase. Because of the complexity of SUMO regulation, very few groups are currently able to investigate the relevance of this mechanism for health and disease in animal models.

In extension of their collaboration, Karhausen and Yang have recently submitted a R01 grant application to the National Institute of Diabetes and Digestive and Kidney diseases (NIDDK) that aims to further establish this important mechanism and to explore the translational opportunities of this pathway to modulate tissue injury and inflammation.

Background figure: Confocal microscopy of the small intestine. As visualized by immunofluorescence staining, in untreated mice, SUMO2/3 protein expression (colored red but appearing lavender due to overlay with the blue-stained cell nuclei) is restricted to cells in the epithelial crypt. The intestinal villi (finger-like protrusions that extend into the lumen of the gut) are almost entirely free of SUMO2/3 staining in control animals but rapid increase of staining was seen here after cell stress (not shown). Green signal is achieved by staining for an epithelial cell marker, e-cadherin.

40

|

DUKE ANESTHESIOLOGY

10 500 20 years of the DREAM campaign

total number of donors in campaign’s history

2017's largest single donation

11

1.6

k $

M

M $

total amount raised since 2008

of extramural funding raised with $662,900 in DIG donations

Campaign Goals 1.

Establish Endowed Professorships to invest in world-class faculty who would, in turn, secure extramural funding.

Interest dollars from these endowments are to be used to support investigator salaries and provide them with the time and resources necessary to develop research programs.

2.

3.

Raise Funds to support research through the DREAM Innovation Grant, known as DIG.

Establish Philanthropic Support as a long-term mechanism of limiting the adverse consequences of cyclical federal funding.

Visit our DREAM web pages to read more about the campaign and make a gift online! Dreamcampaign.duhs.duke.edu

BluePrint 2018

|

41

INNOVATION GR ANT 2018 RECIPIENTS

Qing Ma, MD The Role of Sirtuin-3 in Neuroinflammation and Perioperative Cerebral Injury Major surgeries, including cardiac surgery, can cause neurological complications and in some cases permanent dementia, especially to older and frail patients.

Emerging evidence from both human and animal studies highlights an association between surgery and longterm neurocognitive impairments, making perioperative cognitive dysfunction a major public health issue.

The 2018 DIG is assisting Dr. Ma and her colleagues in further researching the crucial role of SIRT3, a NAD+-dependent mitochondrial deacetylase, in limiting/ pro-resolving neuroinflammation and preventing perioperative cerebral injury (PCI) after cardiac surgery. Ma will foster a multidisciplinary and translational approach to establish novel methodologies in understanding how the brain is affected by anesthesia and surgery. This initial data will help Ma submit a National Institutes of Health grant. Ultimately, her long-term goal is to identify novel targets for the neuroprotection associated with major surgeries and develop simple, safe and effective therapeutics for surgical patients.

Background From Nanjing, China MD: Zunyi Medical College, China MASTER’S IN ANESTHESIOLOGY: Hebei Medical University Shijiazhuang, China MD: Aachen University of Technology, Germany 42

|

DUKE ANESTHESIOLOGY

Jamie Privratsky, MD, PhD The Role of Dendritic Cells in Acute Kidney Injury and Renal Healing Unresolved acute kidney injury (AKI) leads to ongoing renal injury, fibrosis and subsequent chronic kidney disease (CKD), which is a major risk factor for future cardiovascular events. To date, therapeutic modalities to treat AKI and prevent its long-term effects do not exist.

One promising therapeutic approach is to modulate the functions of immune cells that accumulate in the injured kidney and orchestrate injury or repair of renal cells.

What is a “DIG?”

The DIG is an annual competition held among Duke Anesthesiology faculty members. Recipients can receive up to $30,000 in seed money for their innovative pilot studies, which ultimately help them apply for and obtain extramural funding.

This grant creates an avenue for healthy competition among faculty, inspires ingenuity, promotes the careers of young physician investigators, enhances donor communication, and furthers the department’s academic mission.

Dr. Privratsky’s 2018 DIG offers further pursuit of studies examining the role of dendritic cells in renal injury and repair. These cells are supreme antigen presenting cells that coordinate innate and adaptive immunity; however, their role in modulating renal injury and healing following AKI is unclear. Privratsky will examine the effects of dendritic cell deletion and activation in two clinically relevant models of AKI: ischemiareperfusion injury and septic AKI. This research is expected to underpin the development of novel immunomodulatory therapies for AKI, ultimately limiting remote organ failure and positively impacting critically ill patients.

Background From Dickinson, North Dakota PHD: Medical College of Wisconsin MD: Medical College of Wisconsin RESIDENCY & FELLOWSHIP: Duke Anesthesiology

BluePrint 2018

|

43

44

|

DUKE ANESTHESIOLOGY

Providing state-of-the-art methodology for clinical, basic science and translational research empowers Duke Anesthesiology to explore revolutionary clinical inquiries by using innovative investigation methods.

Through significant research in neuroscience, molecular biology, molecular and human pharmacology endeavors, our team is making crucial advancements for patients worldwide.

BluePrint 2018

|

45

Botulinum Toxin for Atrial Fibrillation?

Maybe, but More Study is Needed From temporarily softening wrinkles to easing migraines, botulinum toxin has become a versatile medical remedy because of its ability to block nerve signals that can become bothersome or risky.

But could the toxin also quell heart flutter, known as atrial fibrillation, after cardiac surgery? That question was at the root of a study led by Duke University researchers, who reported at the Scientific Sessions of the American Heart Association meeting that the answer is … maybe.

Researchers in Duke’s Department of Anesthesiology and the Duke Clinical Research Institute launched their inquiry after a study from Russian scientists reported a 70-percent drop in atrial fibrillation episodes among a small cohort of heart surgery patients who were treated with strategic injections of botulinum toxin (commonly marketed as Botox).

Bouts of irregular heartbeat are a common complication after cardiac surgery, affecting up to 40 percent of patients and increasing the risk of stroke and death.

“The results from Russia were very interesting, 46

|

DUKE ANESTHESIOLOGY

but needed to be replicated on a larger and more medically complex group of patients,” said lead author and Duke anesthesiologist Nathan Waldron, MD. Waldron and colleagues enrolled 130 patients who were slated to undergo a coronary artery bypass grafting procedure, valve surgery, or both. During their surgeries, roughly half the patients were randomly assigned to receive shots of botulinum toxin in the fat pads around their heart — where the fibrillation is known to arise; the other half received harmless saline. The medical teams did not know which injection the patients received.

Afterward, the patients were monitored continuously by electrocardiogram to pick up signs of atrial fibrillation. Among the patients who received injections of botulism toxin, 36.5 percent had atrial fibrillation, compared to 47.8 percent of those who had the saline placebo.

The researchers also found that patients who received the botulinum toxin had shorter initial bouts of atrial fibrillation, but there were no significant differences in the length of hospital stays or post-operative complications.

“Unfortunately, while there was a numerically lower risk of atrial fibrillation among the Botox patients, it did not meet statistical significance,” said Jonathan P. Piccini, M.D., a member of DCRI and senior author of the study. “What we observed was a modest positive effect on preventing atrial fibrillation, so a larger trial is something that is needed to provide a clearer picture.”

The study received funding from the American Heart Association and the Foundation for Anesthesia Education and Research.

In addition to Waldron and Piccini, study authors include Mary Cooter, John C. Haney, Jacob N. Schroder, Carmelo A. Milano and Joseph P. Mathew.

Avery, Sarah (2017). Botulinum Toxin for Atrial Fibrillation?

Maybe, but More Study is Needed (Duke Health).

Dr. Nate Waldron is the first anesthesia fellow to present in the Innovative Therapies and Novel Applications Late Breaking Trials of the American Heart Association’s Scientific Sessions.

BluePrint 2018

|

47

FOUND IN USING STEM CELLS FOR AKI TREATMENT

A multicenter trial assessing the efficacy of using allogeneic human mesenchymal stem cells (MSCs) to treat patients with acute kidney injury (AKI) following cardiac surgery found no advantages compared with placebo in the amount of time required for recovery, rate of dialysis, 30-day mortality, or adverse events.

Dr. Madhav Swaminathan

156 cardiac surgery patients with early postop AKI randomized to receive mesenchymal stem cells (AC607) or placebo

The findings were surprising, says lead author Madhav Swaminathan, MD, a Duke anesthesiologist, because preclinical animal testing projected a robust renal recovery response following injury due to toxin exposure, inflammation, and ischemia, which are often associated with cardiac surgery.

The primary outcome of the trial, published in the Journal of the American Society of Nephrology, was defined as the time required for post-intervention creatinine level to return to baseline following cardiac surgery.

“Much to everyone’s disappointment, we didn’t see any significant differences in the primary results,” Swaminathan says. The phase 2 trial randomized 156 adult subjects undergoing cardiac surgery with early postoperative AKI at 27 centers in the United States into two groups: patients treated with MSCs and patients who received placebo.

Conducted from 2012 to 2014, the trial was the largest of its kind to date, Swaminathan says. The randomized patients were selected from 26,548 patients who were screened for eligibility for the study based on cardiac surgeries.

48

|

DUKE ANESTHESIOLOGY

After cardiac surgery, administration of allogeneic mesenchymal stem cells within 48 hours of AKI onset did not decrease the time to recovery of kidney function, provision of dialysis or mortality.

The findings are particularly significant, he adds, because they probably close the door on using MSCs to treat AKI following cardiac surgery. “From a fiscal standpoint, the scale and scope of the study will be hard to replicate,” he says.

“We will likely look elsewhere for potential benefits unless we find a better way to deliver stem cells or their benefits.”

• Mechanisms of cardiac surgery–related injury and recovery may be distinct from rodent models of ischemia perfusion • The clinical complexity of the post–cardiac surgery patient may hinder the ability of MSCs to exert a significant clinical benefit • Longer cardiopulmonary bypass times in the MSC group may have masked a beneficial effect

In the study, MSCs were injected directly into the aorta slightly above the renal artery, allowing them to flow preferentially into the kidneys.

Swaminathan notes that a secondary finding— though not statistically significant—indicates a trend toward worse outcomes based on the fact that adverse events were slightly more frequent in patients treated with MSCs. This may highlight the complex role MSCs play in altering the balance between pro- and anti-inflammatory states.

AKI is a common complication of cardiac surgery, triggered by ischemia, toxins, and inflammation. The researchers attributed the absence of a significant recovery signal to several factors: • MSCs may be less effective in treating than preventing AKI

Pittman, Tim (2017). No Advantage Found in Using Stem Cells for AKI Treatment (Clinical Practice Today).

BluePrint 2018

|

49

An astrocyte (blue) grown in a dish with neurons forms an intricate, star-shaped structure. Neurons’ synaptic proteins appear in green and purple. Overlapping proteins represent the locations of synapses. Credit: Jeff Stogsdill, Duke University 50

|

DUKE ANESTHESIOLOGY

ORCHESTRATE NEURAL CONNECTIONS Dysfunction of intricate astrocyte cells may underlie devastating diseases like autism, schizophrenia and epilepsy Brains are made of more than a tangled net of neurons. Star-like cells called astrocytes diligently fill in the gaps between neural nets, each wrapping itself around thousands of neuronal connections called synapses. This arrangement gives each individual astrocyte an intricate, sponge-like structure.

New research from Duke University finds that astrocytes are much more than neurons’ entourage. Their unique architecture is also extremely important for regulating the development and function of synapses in the brain.

When they don’t work right, astrocyte dysfunction may underlie

Dr. Ru-Rong Ji neuronal problems observed in devastating diseases like autism, schizophrenia and epilepsy.

The Duke team identified a family of three proteins that control the web-like structure of each astrocyte as it grows and encases neuronal structures such as synapses.

Switching off one of these proteins not only limited the complexity of the astrocytes, but also altered the nature of the synapses between neurons they touched, shifting the delicate balance between excitatory and inhibitory neural connections.

“We found that astrocytes’ shape and their interactions with synapses are fundamentally important for brain function and can be linked to diseases in a way that people have neglected until now,” said Cagla Eroglu, an associate professor of cell biology and neurobiology at Duke. The research was published in the November 9 issue of Nature.

Astrocytes [are an integral component of the brain].

Even simple invertebrates like the crumb-sized roundworm [Caenorhabditis] elegans have primitive forms of astrocytes cloaking their neural synapses.

As our brains have evolved into BluePrint 2018

|

51

A 3-D-printed model of a single astrocyte from a mouse brain shows the sponge-like structure of these cells.

complex computational machines, astrocyte structure has also grown more elaborate.

But the complexity of astrocytes is dependent on their neuronal companions. Grow astrocytes and neurons together in a dish, and the astrocytes will form intricate star-shaped structures. Grow them alone, or with other types of cells, and they come out stunted.

To find out how neurons influence astrocyte shape, Jeff Stogsdill, a recent PhD graduate in Eroglu’s lab, grew the two cells together while tweaking neurons’ cellular signaling mechanisms. He was surprised to find that even if he outright killed the neurons, but preserved their structure as a scaffold, the astrocytes still beautifully elaborated on them.

Credit: Katherine King, Duke University

functions had been primarily studied in neurons.

To find out what role neuroligins play in astrocytes, Stogsdill tinkered with astrocytes’ ability to produce these proteins. He found that when he switched off the production of neuroligins, the astrocytes grew small and blunt. But when he boosted the production of neuroligins, astrocytes grew to nearly twice the size.

“The shape of the astrocytes was directly proportional to their expression of the neuroligins,” Stogsdill said.

“It didn’t matter if the neurons were dead or alive -- either way, contact between astrocytes and neurons allowed the astrocyte to become complex,” Stogsdill said. “That told us that there are interactions between the cell surfaces that are Tweaking the expression of regulating the process.” neuroligins didn’t just change the size and shape of the astrocytes.

Stogsdill searched existing They also had a drastic effect on the genetic databases for cell surface synapses that astrocyte touched. proteins known to be expressed by astrocytes, and identified three When Stogsdill switched off a candidates that might help direct single neuroligin -- neuroligin 2 their shape. These proteins, called -- the number of excitatory or “go” neuroligins, play a role in building synapses dropped by 50 percent. neural synapses and have been The number of inhibitory or “stop” linked to diseases like autism and synapses stayed the same, but their schizophrenia. Previously, their 52

|

DUKE ANESTHESIOLOGY

activity increased.

“We are learning now that one of the hallmarks of neurological disorders like schizophrenia, autism and epilepsy is an imbalance between excitation and inhibition,” Stogsdill said. “Which just drives home that these diseaseassociated molecules are potentially functioning in astrocytes to shift this balance.”

Ben Barres, a professor of neurobiology at Stanford University who was not involved with the study, praised the findings as “a profoundly important, revolutionary advance” for understanding how interactions between neurons and astrocytes can affect synapse formation.

“These findings vividly illustrate once again how any important process in the brain can only be understood as a dialogue between astrocytes and neurons,” Barres said. “To ignore the astrocytes, which are vastly more numerous than neurons, is always a mistake.”

Manke, Kara (2017). Star-Shaped Brain Cells Orchestrate Neural Connections (Duke TODAY).

BluePrint 2018

|

53

GlobalHealth

Duke Anesthesiology Heads to Haiti This year, Duke Anesthesiology embarked upon a new global health mission in Haiti - collaborating with Partners in Health (PIH) and its co-founder, Dr. Paul Farmer (a Duke University alumnus), to achieve their mission to deliver high-quality health care to the destitute ill. Following the devastating earthquake of 2010, PIH built what is now Haiti’s premier academic hospital in Mirebalais; since opening its doors in 2013, the hospital has established five residency training programs. To continue moving forward, they recognized the need to develop a residency training program in anesthesiology, inviting Duke Anesthesiology to be their partner in this endeavor.

Through a mixture of regular visits to Haiti to provide on-site education and mentorship, the use of distance-education and collaboration, along with Duke observerships (where Haitian anesthesiologists and residents travel from Mirebalais to Duke), Duke Anesthesiology looks forward to helping PIH create an anesthesiology residency training program that meets international standards to propel the capabilities of Haitian health care forward, while simultaneously providing more Duke Anesthesiology faculty and trainees the opportunity to participate in a high-quality, anesthesiologist-led, global health program.

54

|

DUKE ANESTHESIOLOGY

“It has been my dream to spend extended time in Africa to see how I can make a difference.�

Dr. Adeyemi Olufolabi

GlobalHealth

In late 2017, Duke Anesthesiology’s Adeyemi Olufolabi, MB, BS, DCH, FRCA, set off on a six-month Rwandan journey to implement his Fulbright Global Scholar Award.

This lecturing and research grant allowed him to train local anesthesia leaders in the management of obstetric anesthesia service, with specific attention to high maternal and infant mortality rates.

Left to right: Senior obstetrics and gynecology residents discussing a case. Dr. Olufolabi instructing residents in a seminar. Overseeing a delivery at University Central Hospital of Kigali. Dr. Olufolabi poses with members of the Rwanda Society of Obstetricians and Gynecologists after giving a lecture.

BluePrint 2018

|

55

GlobalHealth

A FIRST-PLACE TIE FOR PIE

F

or the first time since the launch of Duke Anesthesiology’s Pie in the Face event, there was a tie for first place in fundraising. Departmental members gathered in the courtyard outside of the Trent Semans Center last November to watch the winners, Drs. Adeyemi Olufolabi and Stephen Parrillo, graciously accept a celebratory pie in the face, hand-delivered by Drs. Erin Manning and Ashraf Habib.

The three “competitors,” who arrived to the event in coordinating

17,427

$ 56

|

DUKE ANESTHESIOLOGY

outfits, raised a total of $4,185 which goes toward departmental residents’ travel expenses for their global health missions. Olufolabi and Parrillo both raised $1,590.

The runner-up, Dr. Gavin Martin, raised $1,005. Dr. Ellen Flanagan did the honors and surprised him with a pie in the face as well.

Previous Pie in the Face winners include Duke Anesthesiology’s chairman, Dr. Joseph Mathew, along with Drs. Solomon Aronson and Eddie Sanders.

TOTAL PIE IN THE FACE FUNDS R AISED

WHERE DO YOU WANT TO CHANGE LIVES? Duke Anesthesiology Global Health Program

“We have a role to play in global health to make the world a better place.” — Adeyemi J. Olufolabi, MB BS Associate Professor of Anesthesiology Program Director, Anesthesia Global Health Fellowship

Anesthesia plays a critical role in global health care, not only in times of crisis, but also in day-to-day events, such as childbirth. Things that we consider routine or trivial in the U.S. can be life threatening in third-world countries. In response, Duke Anesthesiology’s doctors and staff are committed to actively taking mission trips to countries that need help the most. Our goal is to achieve health equality worldwide by meeting the health challenges of today and tomorrow.

Ready to make a difference?

Visit tinyurl.com/DukeGlobal

BluePrint 2018

|

57

ResidencyRecap

“For our residents to have the opportunity to work oneinvolved in their projects and patient care, and receive a

RESIDENCY PROGRAM RANKS TOP 5 IN THE NATION Each year, Doximity and U.S. News & World Report collaborate to collect residency program reputation rankings across 28 specialties, nationwide.

Once again, the Duke Anesthesiology Residency Program is fifth in the country, as revealed this summer by Doximity’s 2018-2019 Residency Navigator.

These reputation rankings are compiled from physician feedback from Doximity’s Residency Nomination Survey and the Residency Satisfaction Survey, along with objective data from a variety of public sources.

58

|

DUKE ANESTHESIOLOGY

on-one with our world-class faculty, be advice during their career is a treasure.”

— Annemarie Thompson, MD Residency Program Director

Welcome Match Class of 2022

Vincent Brinker

Baylor College of Medicine

Yohannes Constable SUNY Downstate

Andre Jacobsen

Medical College of Wisconsin

Henry Lather

University of Michigan

Ashley McNeil

University of Texas Southwestern

Duke Anesthesiology’s Resident Class of 2018 gathered with their colleagues and families on June 9 at the Duke Blue Devil Tower, overlooking Wallace Wade Stadium, to receive their diplomas marking their graduation from the nationally-acclaimed Duke Anesthesiology Residency Program.

Keep in touch! Update your alumni profile by visiting: anesalumni.duhs.duke.edu/alumni

Christina Chen

Bryan Chow

University of Chicago

University of Michigan

Crosby Culp

Rebecca Himmelwright

University of Texas Medical Branch at Galveston

Savion Johnson

Brown University

Lori Jones

University of North Carolina at Chapel Hill

University of North Carolina at Chapel Hill

Erika Lodgek

Jason McGavin

University of Arizona College of Medicine at Phoenix

Tyler Poi

University of Texas Health Science Center at Houston

Temple University

Ray Shao

Harvard Medical School

By the Numbers 2017-2018

board certification

RANKED #5 in the nation

ranked #4 on nationwide livability index BluePrint 2018

|

59

AlumniNotes

David McDonagh, M.D. Anesthesiology Resident ‘05

By Stacey Hilton

D

r. David McDonagh is best known within Duke Anesthesiology for finetuning one of the most mature neuroanesthesia programs in the country. A now well-known successor of neurocritical care pioneer, Dr. Cecil Borel, McDonagh first arrived at Duke in 1999. He became board-certified in both neurology and anesthesiology; completing a fellowship in neurocritical care. It was his tenure as Duke faculty, in which he served as chief of the Neuroanesthesiology, Otolaryngology and Offsite Anesthesia Division, that proved crucial in developing his leadership skills and provided the opportunity to take on greater leadership roles at UT Southwestern Medical Center in 2015.

“Because Duke Anesthesiology has such a long tradition of academic excellence, it attracts some of the best and brightest minds from around the world. The connections I made there became invaluable and continue to have a tremendously positive impact on my career. I will always be grateful for the mentorship I received, and I encourage my current residents to complete subspecialty training at Duke Anesthesiology because of that culture of mentorship, innovation and academic excellence.”

60

|

“During my time at Duke, I was continually inspired and encouraged to look beyond the clinical practice each day; to see the bigger picture of the impact I could have at the departmental and institutional level, as well as the national level,” says McDonagh, an achievement evident in his role within UT Southwestern and the O’Donnell Brain Institute; a rapidly growing center for clinical care, and clinical, translational and basic neuroscience research. “My primary clinical mentor [Borel] instilled in me the value of practicing at the core of your skillset and the importance of building leadership on a strong clinical reputation.” McDonagh has built his career around the perioperative care of the neurosurgical patient and their complex health issues. He has advanced procedures for awake craniotomy, use of adenosine for circulatory arrest during cerebral aneurysm clipping, postoperative management of neurosurgical patients, and the

DUKE ANESTHESIOLOGY

U P D AT E Y O U R A L U M N I P R O F I L E O N L I N E

|

A N E S A L U M N I . D U H S . D U K E . E D U /A L U M N I

McDonagh has advanced procedures for awake craniotomy, use of adenosine for circulatory arrest during cerebral aneurysm clipping and postoperative management of neurosurgical patients.

education of neurointensivists. He is notably one of approximately 50 physicians in the nation who have completed advanced training in both neurointensive care and neuroanesthesiology.

“In my first couple of years at Duke Anesthesiology, I’m grateful to have been provided protected time to receive formative training in clinical research. I was also given the opportunity to develop myself as a clinician and take on leadership of the Duke Neurocritical Care Fellowship program.”

McDonagh was able to elevate the visibility of that fellowship, which became one of the earliest programs in the country to receive national accreditation through the United Council of Neurologic Subspecialties. McDonagh also went on to establish a formal Neurosurgical Anesthesiology Fellowship in 2010, through which he is credited for training many subspecialists who have gone on to academic careers in neurosurgical anesthesiology.

Looking back, some of his notable accomplishments at Duke also include the devise of the Duke Spine Center, which he says at the time, was considered a “new experiment” within the university that required the development of a co-management agreement between the spine physicians and Duke University Hospital – now the state’s most comprehensive care center for spine patients; and providing a smooth transition into the newly-built Duke Medicine Pavilion in 2013. This state-of-the-art critical care and surgery expansion of Duke University Hospital boasts 160 critical care rooms and 18 operating rooms – a move that McDonagh says presented many logistical challenges related to intraoperative MRI and CT scanning.

Since moving to Texas, McDonagh’s research projects include a trial looking at two forms of acetaminophen – intravenous vs. oral - in ear, nose and throat surgery patients, a NIH trial comparing magnetic seizure therapy vs. electroconvulsive therapy for depression, and an epidural analgesia study in spine surgery patients.

“My various leadership positions at Duke and post as chief certainly helped set me up for success and prepare me for my future roles,” says McDonagh, whose efforts as vice chair for neurosciences and medical director of Perioperative Services now point toward developing a top-notch academic anesthesiology department at UT Southwestern.

He currently serves as chief of staff for Zale Lipshy Hospital and has taken on a broader vice chair role over the university hospitals; overseeing more than 50 faculty and 70 nurse anesthetists.

From Duke, he’s applied the knowledge of recruiting world-class faculty to the institution and developing formal academic mentorship for junior faculty to provide them an academic pathway in which they can become great clinicians and world-class researchers, educators and leaders. He also learned that to remain viable as an academic anesthesiology department, there must be close partnership with the larger institution, with anesthesiology faculty being involved in every aspect of the institution.

“Duke University Health System, from the top down, is extremely ambitious and focused on being the best academic-medicine institution in the country.

Duke Anesthesiology is a shining example of what a successful academic anesthesiology department can and should be. There are a small handful of departments in the world that have been able to achieve at that level and develop, on an ongoing basis, people who become leaders across the country in academic anesthesiology,” says McDonagh. “It gives me a lot of pride to be a part of that tradition, and I’m trying to replicate Duke’s level of excellence in Texas.”

BluePrint 2018

|

61

AlumniNotes

“Everyone at Duke is incredibly collaborative – they live the ‘rising tide lifts all boats’ philosophy.”

By Stacey Hilton

W

hen Dr. Robert Thiele reflects back during his one year of critical care medicine training at Duke Anesthesiology, one word best portrays what he is most grateful for - mentorship. “I met people at Duke who were legitimately interested in me both as a person and an aspiring academic anesthesiologist,” says Thiele, who believes that is a culture unique to the institution. “My colleagues and mentors helped me frame problems and develop ways to potentially solve them by leveraging my unique background.”

Before attending medical school, Thiele earned his undergraduate degree in chemical engineering, which he says has proven critical in developing an early career as an investigator and a clinician. For him, this depth of understanding both technology and medicine is particularly important in anesthesia and critical care because they are both “technologydependent specialties.” Today, Thiele may be best known within Duke Anesthesiology for developing technology to determine mitochondrial health - a near infrared spectroscopy device capable of measuring the oxidation state of cytochrome aa3 (the terminal component of the electron transport chain) non-invasively, in real time. His goal is to use this technology to detect the onset of tissue ischemia with more sensitivity and specificity than is possible using

62

|

DUKE ANESTHESIOLOGY

Robert Thiele , M.D.

Critical Care Fellowship ‘12 traditional, hemoglobin-based oximetry equipment.

There are only two other labs in the world who have built similar technology, according to Thiele.

Transesophageal echocardiography certification first attracted Thiele to Duke, but thanks to Drs. Raquel Bartz and Claude Piantadosi, his interest in researching near infrared spectroscopy (NIRS) blossomed during his fellowship. Initial efforts to study whether mitochondria (cells’ energy producers) were oxidized or if the oxicytochrome aa3 was oxidize-reduced began at Duke in the Jobsis Laboratory in the late 1970s, with much of the foundational work performed

by Piantadosi. But those nearly 20 years of research never moved forward. Come 2012, Thiele was at Duke using frequency domain analysis to measure the venus oxygen saturation to separate the arterial and venus signal to study venus blood noninvasively. Piantadosi recognized Thiele’s unique engineering background and suggested that he use near infrared to study the

mitochondria. With Piantadosi’s mentorship, Thiele wrote his first grant which led to pilot studies and sepsis work that ultimately resulted in earning a K08 from the National Institutes of Health to specifically investigate the impact of sepsis on the oxidation state of cytochrome aa3.

“Drs. Bartz and Piantadosi taught me that a key feature of success is to find something you can do that other people can’t, but it needs to be relevant and can solve a problem in a unique way,” says Thiele. “When you study oxygenation, you’re really looking at hemoglobin, the oxygen being carried into the bloodstream. But what you truly care about is the health of the cell. Is the oxygen getting to the mitochondria and being used to generate ATP. The only way to know that is by studying the cytochromes.”

Thiele returned home to the University of Virginia in 2011. He joined the anesthesiology faculty as an assistant professor, specializing in cardiothoracic anesthesiology and critical care, and serves as codirector of its Enhanced Recovery After Surgery program. With his return, he brought this valuable insight: “There’s a tendency for anesthesiologists to feel like if we’re not in the operating room than we’re not being productive, and that’s not true,” says Thiele. “If we’re going to make anesthesia and critical care safer over the course of our lifetime, we also need to generate and disseminate knowledge. Duke Anesthesiology’s focus is not just on ‘getting the job done,’ but to also be highly-productive academically.

Most of those I interacted with had significant scientific interest. I miss that and I’ve tried to bring that back with me to UVA.”

While the underlying principles are similar, Thiele’s NIRS technology differs from that used by Jobsis and Piantadosi in that he is analyzing an entire spectrum of near infrared light (from 750 925 nm), rather than four to six discreet wavelengths, which greatly enhances the signal-to-noise ratio of his measurement device. It also allows for accurate measure of directional changes in the oxidation state of cytochrome aa3 during both hypoxia and cyanide injection, the latter of which reduces cytochrome aa3 while increasing tissue oxygenation.

As Thiele begins planning his next steps in terms of science and career development, he is looking forward to basic science collaborations with his Duke mentors, now that he has a reproducible model for sepsis in his newly-established sepsis lab. “I don’t feel like those relationships end when you leave Duke; the door and the inboxes are always open,” he says. “There is no better place in the country to spend your year or two as a fellow than Duke Anesthesiology. I cannot imagine a better place for someone who wants to become a phenomenal clinician, investigator and leader.”

BluePrint 2018

U P D AT E Y O U R A L U M N I P R O F I L E O N L I N E

|

A N E S A L U M N I . D U H S . D U K E . E D U /A L U M N I

|

63

DepartmentChairman Joseph P. Mathew MD, MHSc, MBA, FASE

Jerry Reves, MD, Professor of Cardiac Anesthesiology

CHIEF

Stephen M. Klein, MD Medical Director, Ambulatory Surgery Center Associate Professor of Anesthesiology

AMBULATORY ANESTHESIA Michael Kent, MD Steve Melton, MD Karen C. Nielsen, MD

CHIEF

Mihai V. Podgoreanu, MD, FASE Associate Professor of Anesthesiology Director, Perioperative Genomics Program

SeniorCabinet Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE John Borrelli, MBA Padma Gulur, MD Evan Kharasch, MD, PhD William Maixner, DDS, PhD

Gavin Martin, MB ChB, FRCA, MMCi Joseph P. Mathew, MD, MHSc, MBA, FASE Mark Stafford-Smith, MD, CM, FRCPC, FASE Madhav Swaminathan, MD, FASE, FAHA

CARDIOTHORACIC ANESTHESIA Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE Brandi Bottiger, MD Anne Cherry, MD J. Mauricio Del Rio, MD Kamrouz Ghadimi, MD Loreta Grecu, MD Nazish Hashmi, MBBS Mandisa Maia Jones-Haywood, MD Jorn A. Karhausen, MD Rebecca Klinger, MD, MS Jerrold Levy, MD, FAHA, FCCM Yasmin Maisonave, MD Negmeldeen Mamoun, MD, PhD Michael W. Manning, MD, PhD Joseph P. Mathew, MD, MHSc, MBA, FASE Sharon McCartney, MD Alina Nicoara, MD, FASE Quintin Quinones, MD, PhD Mark Stafford-Smith, MD, CM, FRCPC, FASE Madhav Swaminathan, MD, MMCi, FASE, FAHA Annemarie Thompson, MD Eleanor Vega, MD Nathan H. Waldron, MD Ian J. Welsby, MB, BS, BSc, FRCA

DIRECTOR

ExecutiveTeam Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE Atilio Barbeito, MD, MPH Raquel R. Bartz, MD, MMCi John Borrelli, MBA Thomas E. Buchheit, MD Dan Cantrell Adam Flowe, CRNA Jeffrey C. Gadsden, MD, FRCPC, FANZCA Padma Gulur, MD Dhanesh K. Gupta, MD (not pictured) Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA Evan Kharasch, MD, PhD 64

|

DUKE ANESTHESIOLOGY

Stephen M. Klein, MD Melinda Macalino William Maixner, DDS, PhD Gavin Martin, MB ChB, FRCA, MMCi Joseph P. Mathew, MD, MHSc, MBA, FASE Timothy E. Miller, MB, ChB, FRCA Mihai V. Podgoreanu, MD, FASE (not pictured) Allison K. Ross, MD Edward G. Sanders, MD (not pictured) Mark Stafford-Smith, MD, CM, FRCPC, FASE (not pictured) Madhav Swaminathan, MD, FASE, FAHA Annemarie Thompson, MD

Richard E. Moon, MD, CM, MSc, FRCP(C), FACP, FCCP Professor of Anesthesiology Professor of Medicine

CENTER FOR HYPERBARIC MEDICINE AND ENVIRONMENTAL PHYSIOLOGY Bruce J. Derrick, MD John J. Freiberger, MD, MPH Claude A. Piantadosi, MD Hagir Suliman, DVM, PhD

DepartmentFaculty INTERIM DIRECTOR

William Maixner, DDS, PhD

Joannes H. Karis, MD, Professor of Anesthesiology Vice Chair, Research Director, Duke Innovative Pain Therapies

CENTER FOR PERIOPERATIVE ORGAN PROTECTION Satya Achanta, DVM, PhD Ru-Rong Ji, PhD Sven-Eric Jordt, PhD Madan Kwatra, PhD Qing Ma, MD Noa Segall, PhD Huaxin Sheng, MD Niccolo Terrando, PhD David S. Warner, MD Wei Yang, PhD Zhiquan Zhang, PhD DIRECTOR

William Maixner, DDS, PhD

Joannes H. Karis, MD, Professor of Anesthesiology Vice Chair, Research Director, Duke Innovative Pain Therapies

CENTER FOR TRANSLATIONAL PAIN MEDICINE Aurelio Alonso, DDS, MS, PhD Andrey Bortsov, MD Francis J. Keefe, PhD Wolfgang Liedtke, MD, PhD Katherine Martucci, PhD Andrea G. Nackley, PhD Jongbae Jay Park, PhD, LAc Shad B. Smith, PhD

CHIEF

Edward G. Sanders, MD Assistant Clinical Professor of Anesthesiology

COMMUNITY Lu Adams, MD David S. Bacon, MD Rachel Beach, MD Ryan Bialas, MD John D. Buckwalter, MD Ajinder Chhabra, MD David Chyatte, MD Eric Ehieli, MD Matthew Glass, MD Christopher Gratian, MD Elsje Harker, MD Erica Heniser, MD Kristal Keys, MD Daniel Kovacs, MD Eugene R. Lee, MD Andrew Lloyd, MD Debabrata Maji, MD Cory D. Maxwell, MD Kristina Mayo, MD Andrea Mazzoni, MD

Scott V. McCulloch, MD Tyler McCulloch, MD Edward McKenzie Jr., MD Elizabeth Nichols, MD William P. Norcross, MD Shannon Page, MD Gary L. Pellom, MD Earl S. Ransom Jr., MD Lisette Ramos, MD Benjamin F. Redmon, MD Richard D. Runkle III, MD Siddharth Sata, DO Nicole E. Scouras, MD Kavitha Sharkady, MD Michael J. Stella, MD Frank Sutton, MD Neel Thomas, MD Danai Udomtecha, MD CHIEF

CHIEF

Dhanesh K. Gupta, MD Professor of Anesthesiology

CRITICAL CARE MEDICINE Kathleen Claus, MD Taylor Herbert, MD, PhD Vijay Krishnamoorthy, MD, PhD Nitin Mehdiratta, MD Okoronkwo Ogan, MD Jamie Privratsky, MD, PhD Paul E. Wischmeyer, MD, EDIC

CHIEF

Timothy E. Miller, MB ChB, FRCA

Clinical Director, Abdominal Transplant Anesthesiology Director, Perioperative Medicine Fellowship Associate Professor of Anesthesiology

GENERAL, VASCULAR AND TRANSPLANT ANESTHESIA Chakib Ayoub, MD, MBA Yuriy Bronshteyn, MD Brian J. Colin, MD W. Jonathan Dunkman, MD Ehimemen Iboaya, MD Evan Kharasch, MD, PhD Nancy W. Knudsen, MD Catherine M. Kuhn, MD John Lemm, MD Elizabeth Malinzak, MD Richard E. Moon, MD, CM, MSc, FRCP(C), FACP, FCCP Eugene W. Moretti, MD, MHSc Iain C. Sanderson, MD, BM, BCh Aaron J. Sandler, MD, PhD Arturo Suarez, MD Ankeet Udani, MD Kerri M. Wahl, MD, FRCP(C) John Whittle, MBBS, FRCA David A. Williams, MD, MPH Christopher C. Young, MD

Jeffrey Gadsden, MD, FRCPC, FANZCA

Associate Professor of Anesthesiology Director, Regional Anesthesiology and Acute Pain Medicine Fellowship

NEUROANESTHESIOLOGY, OTOLARYNGOLOGY AND OFFSITE ANESTHESIA Miles Berger, MD, PhD Nicole R. Guinn, MD Jennifer Hauck, MD Ulrike Hoffmann, MD, PhD Michael Luke James, MD, FAHA, FNCS Grace C. McCarthy, MD Colleen Moran, MD Charles Andrew Peery, MD, MPH, MA Bryant W. Stolp, MD, PhD Jeffrey Taekman, MD

Raquel R. Bartz, MD, MMCi

Co-Director, Surgical Intensive Care Unit (SICU) Assistant Professor of Anesthesiology Assistant Professor in Medicine

CHIEF

ORTHOPAEDICS, PLASTICS AND REGIONAL ANESTHESIOLOGY W. Michael Bullock, MD, PhD Joshua Dooley, MD Ellen M. Flanagan, MD Stuart A. Grant, MB, ChB, FRCA Amanda Kumar, MD David B. MacLeod, MBBS, FRCA Erin Manning, MD, PhD Gavin Martin, MB, ChB, FRCA, MMCi Hector Martinez-Wilson, MD, PhD Brian Ohlendorf, MD Stephen J. Parrillo, MD

CHIEF

Thomas E. Buchheit, MD

Associate Professor of Anesthesiology Director, Duke Pain Medicine

PAIN MEDICINE Richard L. Boortz-Marx, MD Jessica Carter, MD Anne Marie Fras, MD Arun Ganesh, MD Padma Gulur, MD Thomas J. Hopkins, MD Steven Prakken, MD Muhammad Yawar J. Qadri, MD Neil Ray, MD Lance A. Roy, MD Scott Runyon, MD Kevin Vorenkamp, MD

CHIEF

Atilio Barbeito, MD, MPH

Associate Professor of Anesthesiology

VETERANS AFFAIRS ANESTHESIOLOGY SERVICE Joel S. Goldberg, MD Juliann C. Hobbs, MD, MPH Hung-Lun (John) Hsia, MD Amy K. Manchester, MD Jonathan B. Mark, MD Srinivas Pyati, MD, MBBS Karthik Raghunathan, MD, MPH Rebecca A. Schroeder, MD, MMCI Timothy Stanley, MD Thomas Van de Ven, MD, PhD Dana N. Wiener, MD

CHIEF

Allison K. Ross, MD Professor of Anesthesiology Professor in Pediatrics

CHIEF

Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA Professor of Anesthesiology Professor in Obstetrics and Gynecology

PEDIATRIC ANESTHESIA Warwick Ames, MBBS, FRCA Guy de Lisle Dear, MA, MB, BChir, FRCA, FUHM John B. Eck, MD Lisa M. Einhorn, MD Nathaniel H. Greene, MD, MHS, FAAP H. Mayumi Homi, MD Edmund H. Jooste, MB, ChB Kelly Machovec, MD, MPH Brad M. Taicher, DO, MBA Andrea Udani, MD

WOMEN’S ANESTHESIA Terrence Allen, MBBS, FRCA Matthew Buck, MD Jennifer E. Dominguez, MD, MHS Jennifer Lee, MD Abigail H. Melnick, MD Adeyemi J. Olufolabi, MB BS Zaneta Y. Strouch, MD, MPH Mary Yurashevich, MD, MPH

Get to know our entire team: Anesthesiology.Duke.edu/MeetTheTeam.html BluePrint 2018

|

65

ASA Alumni Event

Highlights from ASA Duke Anesthesiology made a big impression at the 2017 American Society of Anesthesiologists (ASA) meeting in Boston. Fifty-one faculty and trainees participated in the conference which included 84 lectures, workshops, panel discussions, and presentations.

A Duke Anesthesiology team of authors, led by Drs. Suraj Yalamuri and Michael Plakke, received the Anesthesia Patient Safety Foundation Resident Quality Improvement Recognition Award for their video, titled “A Bedside Tool to Improve Safety and Efficiency of Cardiothoracic ICU Patient Transport: The Duke ICU Transition to OR (DITTO) Checklist.” The department also hosted its 29th Annual ASA Alumni Event at The Roof at Taj Boston. Nearly 200 guests (including departmental faculty, trainees, staff, alumni, donors and friends) gathered atop the 17th floor of Boston’s most iconic hotel, surrounded by panoramic views of the city for a night of celebration and a silent auction that benefited its Global Health Program.

Two of the most anticipated highlights of the evening were the announcement of the Mark F. Newman Professorship and the revealing of the 2018 DREAM Innovation Grant recipients.

66

|

DUKE ANESTHESIOLOGY

BluePrint 2018

|

67

CLOSING SHOT

DOING GOOD IN THE NEIGHBORHOOD For several years, Duke Anesthesiology has teamed with Habitat for Humanity of Durham. The group of volunteers, led by Chief Nurse Anesthetist Adam Flowe and Dr. David MacLeod, has helped build three homes.

68

|

DUKE ANESTHESIOLOGY

THREE UNIVERSITIES

ONE SHARED GOAL

...to be the leaders in perioperative medicine and enhanced recovery after surgery. visit our new website: morpheusconsortium.org

Duke Anesthesiology BluePrint Magazine DUMC 3094 Durham, NC 27710

Non-Profit Org. US Postage PAID Durham, NC Permit No. 60

Ranked Among the Best Medical Schools for Anesthesiology