2015 BluePrint

BluePrint

Volume 6

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2015

BLUEPRINT.DUHS.DUK E.EDU TRIBUTE

The Passing of a Pioneer Dr. Merel Harmel INNOVATIVE RESEARCH

Tear Gas and Pain Research Dr. Sven-Eric Jordt

A Shorter Path to Recovery Dr. Timothy Miller

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THE DUKE HUMAN SIMUL ATION AND PATIENT SAFET Y CENTER

Developing the Future of Medicine One Game at a Time

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We empower great minds to turn dreams into reality.

BY ENCOUR AGING THE ENTREPRENEURIAL SPIRIT, UNFET TERED IMAGINATION, AND UNCHECKED AMBITION, THE DREAM CAMPAIGN INSPIRES DUKE ANESTHESIOLOGY FACULT Y AND PROVIDES THEM WITH THE WHEREWITHAL TO ACHIEVE THE IMPOSSIBLE. TOGETHER WITH OUR SUPPORTERS, WE ARE TR ANSFORMING THE FUTURE OF PATIENT CARE.

HELP US CONTINUE TO TR AIN THE LEADERS OF TOMORROW, DEVELOP THE CAREERS OF OUR FACULT Y, AND PROTECT QUALIT Y OF LIFE FOR YEARS TO COME.

DEVELOPING RESEARCH EXCELLENCE IN ANESTHESIA MANAGEMENT DREAMCAMPAIGN.DUHS.DUKE.EDU 01_BluePrint2015_TOC.indd 2

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BluePrint Contents

Volume 6

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2015

BLUEPRIN T.DUHS .DUK E.EDU

18 THE DUKE HUMAN SIMUL ATION AND PATIENT SAFET Y CENTER

2 Message From The Chair

Dr. Joseph Mathew

Developing the Future of Medicine One Game at a Time

6 Highlights

Dr. Jeffrey Taekman describes how Duke’s globally recognized HSPSC team is just scratching the surface of the crucial role human simulation plays in the medical world and the profound effects it will have on patient care.

Education • The Flipped Classroom • Introducing the DARE Blog

Global Health

Divisional News • Historic Separation Surgery

Rankings

TRIBUTE

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The Passing of a Pioneer – Dr. Merel Harmel

The Department of Anesthesiology Pays Tribute to Its Founding Father

Message From The Dean

24 Duke DREAM Campaign

2015 DIG Recipients

30 Innovative Research

Tear Gas: A Novel Perspective in Pain Research

22 Targeting Anemia, Improving Outcomes

A Shorter Path to Recovery

Duke anesthesiologists take on the global health issue of anemia with the opening of the Duke Preoperative Anemia Clinic – an innovative solution to a serious surgical issue, worldwide.

FEATURES

36 New Chairman at the Helm – Dr. Joseph Mathew This internationally respected physician-scientist launched his path to chairman at Duke nearly seventeen years ago. In this feature, learn about Dr. Mathew’s visions for the Department of Anesthesiology and his driving passion for patient care.

34 From The Lab From Mountain High to Valley Low: Exploring New Scientific Frontiers with the Duke Human Pharmacology and Physiology Lab

40 Alumni Notes 42 Departmental Listing 44 Faculty Corner

Appointments • Nominations • Promotions

45 Honor Society

Awards • Grants • Honors

BluePrint 2015

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Message From The Chair BluePrint is published once a year by Duke Anesthesiology. This issue was published on September 21, 2015.

Your comments, ideas and letters are welcome.

View this issue and past issues online: BluePrint.DUHS.Duke.edu Please contact us at : Duke Anesthesiology BluePrint Magazine DUMC 3094 Durham, NC 27710 Tel: (919) 613-0469 E-mail: blueprint@duke.edu Editor Stacey Hilton Assistant Editor Leighanne Tillman Contributing Editors Adam Hartz Duke Anesthesiology Faculty & Staff Contributing Writers Stacey Hilton Leighanne Tillman Ratna Swaminathan Lauren Marcilliat Tiffany Nickel Jill Boy Duke Anesthesiology Faculty & Staff Art Director & Designer Leighanne Tillman Contributing Photographers John “Jack” Newman Elizabeth Perez, RN, BSN Duke Anesthesiology Faculty & Staff Website Administrator Christopher Keith BluePrint Taskforce Members Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE Richard L. Boortz-Marx, MD Jennifer E. Dominguez, MD, MHS David B. MacLeod, MB, BS, FRCA Allison Kinder Ross, MD Kerri M. Wahl, MD, FRCP(C) Connect With Duke Anesthesiology: WEBSITE:

Anesthesiology.Duke.edu FACEBOOK:

@DukeAnes TWITTER:

@Duke_Anesthesia YOUTUBE:

@DukeAnesthesiologyVideos LINKEDIN:

Coming Soon!

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Greetings! It is my privilege to introduce the 2015 BluePrint publication which highlights our department’s research, innovations, educational strides and medical excellence throughout this year, from the best and the brightest in the nation.

Duke Anesthesiology has the opportunity to impact the world and as you’ll see in these spotlight stories, our team is bringing patient care to new heights at Duke and around the globe.

Earlier this year we lost one of the pioneers of anesthesiology when Dr. Merel Harmel, the founding Chairman of Duke Anesthesiology passed away. The beloved “gentle giant” will be missed greatly but he leaves behind a legacy of excellence for all of us to emulate.

In the clinical arena, several initiatives including the Perioperative Enhancement Team (POET), a Data Mart to leverage the value of an electronic health record, and Quality Dashboards are coming to fruition. We have also just established a new Division of Critical Care Medicine led by Dr. Raquel Bartz. Dr. Bartz’s goals are to continue Duke’s legacy as a leader in anesthesiology and the care of perioperative patients and to see the Division of Critical Care Medicine become a leader in the discovery of knowledge in perioperative critical illness to improve patient outcomes.

In the basic science environment, Dr. Ru-Rong Ji continues to pioneer new treatments for chronic pain including the first monoclonal antibody based therapy and the use of intrathecal stem cells. The recent recruitment of Dr. William Maixner and his team to establish the Center for Pain Research and Innovation will also propel our pain program to new heights. I am also proud to note that Dr. Quintin Quinones (mentored by Dr. Mihai Podgoreanu) became the first anesthesiologist to win the Vivian Thomas Young Investigator Award from the American Heart Association and that Dr. David Warner will receive the FAER Mentoring Excellence in

Research Award at this year’s American Society of Anesthesiologists conference.

Our education team has also been very active, creating a simulation instructor course, a new skills course for third year medical students, crisis resource management training, and a Twitter-augmented journal club. Two of our faculty received recognition for their educational skills: Dr. Nancy Knudsen was the winner of the 2015 Clinical Faculty Golden Apple Award from the School of Medicine and Dr. Madhav Swaminathan became the first anesthesiologist to provide the Harvey Feigenbaum lecture at the American Society of Echocardiography.

The legacy of excellence that began with Dr. Harmel continues to this day. As you read through this issue of BluePrint, I hope you will feel the spirit of collaboration within our department and get a glimpse of the ways in which Duke Anesthesiology is excelling and changing the face of anesthesiology. I’m honored to be leading a team that continually strives to change the world around them and works together in building a “100 year vision.”

Sincerely,

Joseph P. Mathew, MD, MHSc, MBA Jerry Reves, MD, Professor of Anesthesiology and Chairman, Department of Anesthesiology

DUKE ANESTHESIOLOGY

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

Service

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Education

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Research

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Capacity Building

Anesthesia plays a critical role in global health care, not only in times of crisis, but in day-to-day events, such as childbirth. Things that we consider routine or trivial in the U.S., such as hernia repair, can be life-threatening in third world countries lacking adequate supplies or medical education. There is a great need for the skills possessed by the anesthesiologist abroad. In response, Duke University has taken several large steps to encourage its global presence in countries that need it the most.

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Quality Improvement

Ready to make a difference?

E-mail blueprint@duke.edu for more information on how you can get involved.

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Tribute

“As a human being, the focus was always on you, your family, and on things that he could do to make your opportunity and the department better.”

Mark Newman, MD Merel H. Harmel Professor of Anesthesiology Former Chair of the Department of Anesthesiology (2001-2014) President of the Duke Private Diagnostic Clinic

become one of the finest in the nation.

Born in 1917, Dr. Harmel witnessed and chronicled the evolution of anesthesiology throughout the many years of his career. Early on, he fought hard to make anesthesiology an independent discipline of medicine, when many at that time considered it a sub-specialty of surgery.

Dr. Harmel always kept his finger on the pulse—literally and figuratively. Acutely perceptive of the changing times, he was quick to recognize the boost that the Second World War had given to the upcoming field of anesthesiology. Military physicians returning from war were introducing more sophisticated, intravenous and regional anesthetics to the civilian population.

With a vision for this emerging specialty, Dr. Harmel became the first anesthesiology resident at Johns Hopkins in 1945. At the recommendation of his mentor, Austin Lamont, MD, Dr. Harmel participated in the first Blalock-Taussig shunt procedure, also known as the “blue baby operation,” which was developed to shunt blood to the lungs in children with tetralogy of Fallot, the most common cause of blue baby syndrome.

Taking place in just his eleventh month of residency, Dr. Harmel acted as the anesthesiologist for the procedure which was pioneered by surgeon, Alfred Blalock, MD, cardiologist, Helen Taussig, MD, and assistant, Vivien Thomas.

Following his time at Johns Hopkins and later at the University of Pennsylvania, Dr. Harmel went on to found the first anesthesia departments at State University of New

The Passing of a Pioneer The Department of Anesthesiology Pays Tribute to Its Founding Father

By Ratna Swaminathan It was an unusually cold Thursday in the Research Triangle when the world of anesthesiology lost not only one of its most influential clinicians but also one of its sincerest advocates. On February 19, 2015, the founding father of Duke Anesthesiology, Merel Hilber Harmel, MD, passed away at the age of 97. Dr. Harmel served as Chair of the Department of Anesthesiology from 1971 to 1983, and had a profound impact on all those with whom he came in contact.

His legacy will forever be engrained within the very department he helped establish.

If two words could succinctly capture the conviction of this revered professor emeritus, they’d be “we can.”

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Dr. Harmel was a gentle giant: kind in nature yet a trailblazer when it came to accomplishing his grand goals. It was with this attitude, 44 years ago, that Dr. Harmel accepted the invitation from the chairman of the Department of Surgery at that time, David C. Sabiston Jr., MD, to chair Duke’s new but very small Department of Anesthesiology. With a team of just six faculty members, 12 student nurses, 15 graduate nurses, and $250,000 of start-up money, Dr. Harmel carefully recruited the best and brightest minds to his department.

Focusing on research and education, he established a residency program and shepherded a fledgling department that would

DUKE ANESTHESIOLOGY

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Tribute “His method was simple.

He knew that clinical care had to be exemplary, that research must be an important faculty activity, and that resident and medical student teaching was crucial to leaving a legacy.”

Joseph “Jerry” Reves, MD (Pictured left to right: Joseph “Jerry” Reves, MD, Merel Harmel, MD, and Mark Newman, MD) Two former chairs pose with the Department of Anesthesiology’s founding father, known for recruiting the best and brightest minds to grow his department.

York, Downstate Medical Center in 1952 and the University of Chicago in 1968. In 1971, Dr. Harmel became chair of the new Department of Anesthesiology at Duke.

“His method was simple. He knew that clinical care had to be exemplary, that research must be an important faculty activity, and that resident and medical student teaching was crucial to leaving a legacy,” according to Joseph “Jerry” Reves, MD, former Chair of the Department of Anesthesiology (from 1991–2001).

“As a human being, the focus was always on you, your family, and on things that he could do to make your opportunity and the department better,” said Mark Newman, MD, Merel H. Harmel Professor of Anesthesiology, former Chair of the Department of Anesthesiology (from 2001-2014) and current President of the Duke Private Diagnostic Clinic. Dr. Newman visited Dr. Harmel in the hospital the day before he passed away and couldn’t help but notice his very characteristic caring manner. Dr. Harmel turned the focus of the conversation away from himself and his illness to his visitor, his family and “the department.”

Dr. Newman fondly remembers his friend, advisor and role model as “a gentleman across the board, both as an individual and a leader.” He points to the very collegial and supportive way that Dr. Harmel could push for progress from faculty, residents and the institution. Besides building an excellent clinical department, Dr. Harmel championed for increased research and improved patient outcomes as well as automating anesthesia records and developing a basic science laboratory.

During his time at Duke, Dr. Harmel led the development of the world’s first electronic vital signs-monitoring system.

It was originally known as Duke Automatic Monitoring Equipment (DAME) and was installed in Duke University Hospital when it was built in 1980. Similar equipment is now standard in all operating rooms nationwide.

Dr. Harmel laid the groundwork for a culture of clinical and academic mentorship at Duke, and inspired many physicians to pass the baton of excellence to the next generation. It is no surprise that Duke-trained faculty members can be found heading important programs in prestigious institutions across the country. He brought international prominence to Duke’s Department of Anesthesiology and was a strong advocate for medical student and resident education. Even after his retirement in 1983, Dr. Harmel continued his deep connection with Duke, serving on the Medical School Admissions Committee. Many remember seeing him on campus holding audiences in rapt attention as he passionately recounted the history of anesthesia. The Annual Merel Harmel Lecture series, instituted in his honor, is now in its 25th year and has given several distinguished speakers the opportunity to address the Duke medical community.

Undoubtedly, Dr. Harmel had a profound impact on many, both in his professional and personal life. “His love and devotion to his family always rivaled that of the departments, faculty and residents he was responsible for,” according to Dr. Reves. After his first wife, Armide, lost her battle with cancer, he later married Ernestine Friedl,

Former Chair of the Department of Anesthesiology (1991–2001)

PhD, former Dean of Arts and Sciences and Trinity College at Duke University. Together, they looked after their combined family of four daughters, three grandchildren and two great grandchildren. “He maintained a loving family where mutual support was a hallmark,” added Dr. Reves.

In addition to their professional relationship at Duke Anesthesiology, Eugene Moretti, MD, Professor of Anesthesiology, got to know him personally as a friend during his multiple hospitalizations in the last decade of his life. Expressing his heartfelt respect and regard, Dr. Moretti praised this courageous man for retaining his unique style and grace until his final hours. With his charming wit, he noted how the extremely eloquent Dr. Harmel could lighten up any situation. “Regardless of how serious the topic, he would splice in little bits of humor.”

The founding father of Duke Anesthesiology has left a lasting impact on the lives of those who knew him. Dr. Harmel believed in working toward a brighter tomorrow by investing in Duke’s legacy of excellence, and his legacy will truly live on through the Merel Harmel Professorship in Anesthesiology, awarded to Mark Newman, MD. The compassionate, guiding hand of Dr. Merel Harmel will be missed but never forgotten. n

To learn more about the Merel H. Harmel Professorship in Anesthesiology and ways to support the Duke DREAM Campaign, please visit DreamCampaign.duhs.duke.edu

BluePrint 2015

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Highlights

GLOBAL HEALTH

Photos Courtesy of Dr. Brad Taicher

Duke Anesthesiology Makes Medical Strides for Global Health

The ‘Gift of Life’ Mission

Mending Hearts and Saving Young Lives in the Philippines Congenital heart defects are the most common of all birth defects in America and in every country throughout the world. Each year, one million babies are born with a congenital heart defect worldwide. One tenth of those babies (100,000) will not live to see their first birthday and thousands more will not reach adulthood.

Those numbers reveal a frightening future for thousands of children and their families worldwide. Congenital heart defects (CHD) are known as a serious and underappreciated global health problem, but doctors with Duke Anesthesiology are on a mission to change that.

In September of 2014, about twelve

doctors and staff from different departments at Duke took their first step In September 2014, about 12 doctors and staff from Duke Anesthesiology visited the Philippines to toward making a global change. They save the lives of 10 children all suffering from advanced congenital heart disease. set out on a trip to the Philippines (called the Gift of Life Mission) to save the lives of ten children, as young as ten months old to 16 years old, all suffering from advanced congenital heart disease.

Their mission? To perform two cardio pulmonary bypass operations a day on each of those children over a 10-day period at the Philippine Children’s Medical Center. Pediatric Anesthesiologist, Warwick not come without major obstacles. The Ames, MBBS, FRCA is one of those twelve facilities were limited so the Duke doctors doctors who was up to the challenge. took most of their supplies with them, “I’ve wanted to do mission work for a long time and while this wasn’t my first mission, but they had to leave behind their anesthesia machine. Once they arrived to the I saw this as a great opportunity to make a real difference in the lives of these families,” Philippines, they realized that the ventilator on the anesthesia machine they were says Dr. Ames. “Some families were waiting provided with did not work. And, they did for months outside of the hospital for mednot have ultrasound devices for putting in ical teams like ours to arrive. Many of them catheters, as they do in the United States. didn’t have anything to eat and the hospital Dr. Ames refers to it as practicing “old there was not handing out food while they school anesthesia.” stood in line. I felt a strong sense of urgenAfter ten long days, these Duke doctors cy to help these children beat the odds took home the realization that it is possible that were stacked against them.” to perform complex surgery in distant sites More than half of all children born with with very limited resources. In this case, a congenital heart defect will need to possible enough to save each one of those have at least one invasive surgery in their lifetime. But that is not always an option for the families of these children who don’t have the luxuries of first world medicine.

This team’s surgical challenge in Manila did

“Hearts were mended in more ways than one during our trip.”

Warwick Ames, MBBS, FRCA

Photos Courtesy of Gift of Life Mission

For nearly a decade, the Duke Global Health Institute has aimed to bring distinct knowledge and skill from every corner of Duke University to tackle some of the most significant global health issues we face today. Duke Anesthesiology’s doctors and staff are committed to actively taking mission trips to countries across the globe to achieve DGHI’s vision to meet the health challenges of today and tomorrow to achieve health equality worldwide.

The Duke anesthesiologists highlighted in these stories broke medical barriers and saved children’s lives in two under-privileged areas of the Philippines and Guatemala. Duke doctors arrived to those countries with their world-class medical knowledge and supplies, but they walked away from their mission trips with more than they could have ever imagined.

Watercolor painted by Pete Morris

By Stacey Hilton

Associate Professor of Anesthesiology and Pediatrics

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Highlights

GLOBAL HEALTH

Photos Courtesy of Dr. Brad Taicher

“A simple surgery makes a very big impact in the lives of these families.”

Brad M. Taicher, DO, MBA Assistant Professor of Anesthesiology and Pediatrics

Photos Courtesy of Gift of Life Mission

Watercolor painted by Pete Morris

In November 2014, about 18 Duke staff, including Pediatric Anesthesiologist, Dr. Brad Taicher, visited Guatemala City to provide anesthesia and surgical care for 50 kids in need.

Their goal? To provide humanitarian assistance and medical assistance for basic healthcare and critical care needs to under-privileged children, including providing A watercolorist painted the Duke Pediatric team in action during their recent trip to Guatemala City. anesthesia and The paintings were on display in late July in the Hospital Addition For Surgery (HAFS). surgical care for fifty kids in need.

“Unmet surgical care contributes to ten children’s lives, an exceptional feat in at least 11 percent of the global burden the eyes of Dr. Ames. of disease,” according to Duke pediatric “These children’s diseases were very adsurgeon, Dr. Henry Rice. And Guatemalan vanced so it’s a blessing they all survived,” children are no strangers to that stark says Dr. Ames. “Medical missions like this figure. “For children, surgical care can are critical because it changes the lives of decrease mortality, improve overall health kids completely. Hearts were mended in and decrease costs for care of disabilities. more ways than one during our trip – a So, our work with partners in Guatemala trip I hope to do again in the near future.” is particularly important for families and communities in this low-income setting.”

Breaking the Barrier of As Dr. Brad Taicher will tell you, mission Pediatric Surgical Care trips don’t come free of challenges, and Pediatric Mission Work in Guatemala this recent one was no exception. “We faced infinite challenges on this trip. A Guatemala is the most populous nation major concern was the health of our own in Central America, but among the “land team due to the lack of quality water and of trees” and mountains, are families who food. It was not an option for our team to have little access to surgical care. That’s get sick,” says Dr. Taicher. why a team of doctors from Duke is makOther obstacles this team faced including it one of their global health missions ed high altitudes and exhaustion due to to provide the children of that country long hours, lack of breaks and no rotationlife-saving surgery and healthcare. al relief. Additionally, they had to rely on About eighteen Duke staff members, their own medical supplies they brought including the core team of Pediatric Suron the trip due to the limited resources geon, Henry Rice, MD, Pediatric Urologist, at the Moore Pediatric Surgery Center. “It Sherry Ross, MD, and Pediatric Anesthesiwas also tough for our team to have to ologist, Brad Taicher, DO MBA, packed up reject certain cases, despite our desperate for their third mission trip to Guatemala desire to provide care. If a child’s condition City in November of 2014.

was too complicated or high risk, our team had to make the difficult decision whether they could take on that specific case or have to deny care,” adds Dr. Taicher.

Along with those tough obstacles came fun highlights. The Duke team hiked a volcano and roasted marshmallows at the top, and did their best to strike a pose and stay still for a watercolorist who was painting their team in action (the paintings were on display in late July in the Hospital Addition For Surgery (HAFS)). And a top highlight from the mission in 2013 that still has the Duke team talking was a tweet from a country star! During one of their surgical procedures, a song from the popular band, Sugarland, came on the radio. So, the team tweeted singer, Jennifer Nettles, about the coincidence that they were on a mission trip helping children in partnership with the Shalom Foundation, a cause that she actively supports. And, she replied back to their tweet! (See Below) CONTINUED ON NEXT PAGE à

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Highlights

Brad M. Taicher, DO, MBA Assistant Professor of Anesthesiology and Pediatrics à CONTINUED FROM PREVIOUS PAGE

Through these yearly mission trips to Guatemala City, Duke doctors also train Guatemalan health workers on safe surgical practices and teach them how to overcome challenges in their own environment. And each year, the Duke team hopes to walk away with research they can run with for years to come.

This year, the Duke team surveyed all of the families to see if they understood the role of an anesthesiologist.

The goal is to identify knowledge gaps that exist so on their next mission, they can provide targeted education to the families of Guatemala City so they can better understand what anesthesiologists do. Through chart review, this team also found that they were limited in how many medications they had with them in Guatemala.

They didn’t have enough anti-nausea medications to give to everyone as they do in the United States. So, Duke doctors rationed them out and learned how to maximize non-pharmacologic techniques to minimize post-operative nausea and vomiting. Looking ahead, their goal is to study the factors that typically influence those families to seek surgical care.

This team certainly walked away with a new understanding about the Guatemalan healthcare system; they say it’s very capable of providing quality care to patients but the country’s healthcare providers lack the necessary resources to do so. This trip also “gave us a perspective about how fortunate we truly are,” says Dr. Taicher. “We are filled with joy to provide care for these kids. A simple surgery makes a very big impact in the lives of these families.”

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An inter-professional team from the Human Simulation and Patient Safety Center (HSPSC) traveled to Kampala, Uganda in March as part of a Global Health Education Program. The initiative, funded

by Social Entrepreneurship Accelerator at Duke (SEAD), is focused on delivering postpartum hemorrhage education using screen-based simulation. Using multi-player screen-based simulation will ultimately improve global health by addressing gaps in care and decreasing disparities in healthcare education.

Each day, learners along with our teams in Uganda and Durham connected in a shared virtual environment. More than 50

Screen-based simulation education in Kampala, Uganda

learners, including physician and non-physician anesthesia providers, midwives, and nurses were trained during the interprofessional simulations.

The preliminary data generated during these training exercises will be used to expand screen-based simulation in developing countries.

Key personnel included: Megan Foureman, Jeff Taekman, Yemi Olufolabi, Amy Mauritz, Michael Steele, and contest winner, Emily Comstock. n

Pie-in-the-Face Global Health Fundraiser

Dr. Thompson (Left) and Dr. Mathew (Right) after the pie toss.

Dr. Joseph Mathew graciously accepted a pie in the face as the “winner” of Duke Anesthesiology’s first annual Pie-in-theFace Global Health Fundraiser to support resident travel expenses related to their Global Health Project.

The fundraiser, on November 5, 2014,

made possible through partnerships with the Shalom Foundation and Mending Kids International. The three core members of this Duke team, including Dr. Taicher, plan to go back to Guatemala City for their fourth mission trip in November. And, plans for a fifth mission trip in April of 2016 with a team of 18 Duke staff, is already in the works.

“My hope is that we can collaborate

gave people within the department the opportunity to donate money towards Dr. Annemarie Thompson, Dr. Mark Stafford-Smith or Dr. Mathew. The person who received the most donations in their name would receive the celebratory pie. Dr. Eddie Sanders from Duke Regional Hospital had the honor of throwing the pie as a result of donating the largest amount of money.

Despite Dr. Mathew receiving $1,356 towards him and being the official winner, Dr. Stafford-Smith, with $231, and Dr. Thompson, with $1,191, were not safe from the flying pies. Dr. Adeyemi Olufolabi surprised Dr. Thompson with a pie to the face, and Dr. Stafford-Smith never saw Dr. Mathew coming with surprise pie leftovers. We look forward to this year’s fundraiser! n

with teams from different institutions to better coordinate care for some of the more complicated patients we care for,” says Dr. Taicher. “We are making great strides for global health and I’m excited what the future holds for those families and our team at Duke.” n Sources: The Children’s Heart Foundation, DGHI website

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Photo Courtesy of Dr. Quintin J. Quinones

Human Simulation in Uganda

Photo Courtesy of Michael Steele

“We are making great strides for global health and I’m excited what the future holds for those families and our team at Duke.”

GLOBAL HEALTH

Highlights

CARDIOTHOR ACIC ANESTHESIOLOGY

Photo Courtesy of Dr. Quintin J. Quinones

Photo Courtesy of Michael Steele

BASIC SCIENCES

Patent Activity

The Chair of the SCA Research Committee, Paul Heerdt, MD, PhD (Left), and Duke Anesthesiology’s Quintin J. Quinones, MD, PhD (Right).

Duke Cardiothoracic Anesthesia and Critical Care at the 37th SCA The Duke Cardiothoracic Anesthesia and Critical Care Division had another strong showing at the 37th Annual Meeting of the Society of Cardiovascular Anesthesiologists that was held at the Marriott Marquis in Washington, D.C. on April 11-15, 2015.

Please see the summary of participation below.

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Quintin J. Quinones, MD, PhD – 2015 recipient of SCA Starter Grant: Innate immune adaptations of hibernation as a new approach to protection against acute organ injury

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Divisional Faculty – Involved in 20 lectures, five PBLDs and six workshops

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Abstracts/Poster Presentations by Fellows, Residents and Faculty – 19 out of 188 meeting abstracts

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Best Of Meeting Oral Presentations by Fellows, Residents and Faculty – seven out of 16 best of meeting presentations:

a. Increased Sirtuin 3 Expression and Signaling Confers Natural Cardioprotection in Hibernating Mammals – Mihai Podgoreanu, MD; Qing Ma, MD; Zhiquan Zhang, PhD; Quintin Quinones; Brian Barnes, PhD; Duke University; University of Alaska b. Improved Ability to Predict Postoperative Atrial Fibrillation With the McSPI AFRisk Index Versus the CHA2DS2Vasc or POAF Scores – Nathan Waldron; Mary Cooter, MSc; Rebecca Klinger, MD MS; Miklos Kertai, MD PhD; Mihai Podgoreanu, MD; Mark Stafford-Smith, MD; Mark Newman, MD; Joseph Mathew, MD; Duke University c. Acute Right Ventricular Failure After Heart Transplantation: Trends and Patient Characteristics – David Ruffin, MD; Mary Cooter, MSc; Mark Stafford-Smith, MD; Raquel Bartz, MD MMCI; Madhav Swaminathan, MD FASE; Carmelo Milano, MD; Chetan Patel, MD; Alina Nicoara, MD; Duke University d. PPARγ Agonist Rosiglitazone Provides Neuroprotection in Atherosclerosis-Prone JCR Rats Following Deep Hypothermic Circulatory Arrest: A Pivotal Role of Sirtuin 6 – Qing Ma, MD; Zhiquan Zhang, PhD; Mihai Podgoreanu, MD; Duke University e. Effects of Race and Common Genetic Variation on Therapeutic Response Disparities in Postoperative Atrial Fibrillation – Nazish Hashmi, MB BS; Mary Cooter, MSc; Yi-Ju Li, PhD; Miklos Kertai, MD PhD; Joseph Mathew, MD; Mark Stafford-Smith, MD; Mark Newman, MD; Madhav Swaminathan, MD FASE; John Alexander, MD MHS; Mihai Podgoreanu, MD; Duke University f. Intravenous Lidocaine Reduces Transcerebral Inflammatory Response During Cardiac Surgery – Rebecca Klinger, MD MS; Igor Akushevich; Miles Berger, MD PhD; Mihai Podgoreanu, MD; Mark Stafford-Smith, MD; Mark Newman, MD; Thomas Ortel, MD PhD; Ian Welsby, MBBS FRCA; Jerrold Levy; Joseph Mathew, MD; Duke University g. Flow Cytometry Reveals Species-Specific, Tissue-Specific, and Hibernation-State-Specific Differences in Innate Immunity and Response to Surgical Ischemia-Reperfusion – Quintin Quinones; Qing Ma, MD; Michael Smith, MS; Janet Staats, BS; Cliburn Chan, MBBS PhD; Kent Weinhold, PhD; Brian Barnes, PhD; Mihai Podgoreanu, MD; Duke University; University of Alaska Fairbanks n

Duke Anesthesiology continues to lead the way in healthcare innovation.

The following numbers reflect patent activity within the Department of Anesthesiology in fiscal year 2015 (July 1, 2014 – June 30, 2015), according to the Duke Office of Licensing and Ventures.

Zhiquan Zhang, PhD David Warner, MD

Joseph Mathew, MD, MHSc, MBA, FASE

Hagir Suliman, PhD

Qing Ma, MD

Mark Stafford Smith, MD, CM, FRCPC, FASE

Miklos Kertai, MD, PhD

Tong Liu, PhD

Mihai Podgoreanu, MD Ru-Rong Ji, PhD Mark Newman, MD

Manuel Fontes, MD

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R ECENT IN V ENTIONS

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NE W IN V ENTION DISCLOSUR ES SUBMIT TED TO DUK E

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INVENTORS

REGIONAL ANESTHESIOLOGY

Duke Anesthesia Leading the Way in Regional Anesthesia and Care Redesign Duke Anesthesiology was among the first anesthesiology departments in the nation to adopt Regional Anesthesia techniques such as patient-controlled anesthesia and ambulatory pain pumps, ultrasound for the administration of peripheral nerve blocks (PNBs), continuous epidural catheters, and PNB catheters. Ever since, faculty members have continuously sought out ways to hone this technology. The Regional Division continues to explore new methods to improve continuous peripheral nerve blocks and ultrasound technologies. We have continued to invest in the newest ultrasound technology thus allowing us to further improve our patient care with the performance of newer regional nerve blocks and perform our blocks with greater efficacy. We continue to recruit highly trained faculty with an international reputation in the delivery of regional anesthesia.

Care redesign of hip and knee replacement program has seen a 0.5 day reduction in length of stay and improved patient pain scores placing us in the the top 90th percentile in the nation. This has been achieved by working closely with our orthopedic colleagues. The major changes have been the modification of the perioperative pain medications and the addition of two new blocks: the adductor canal block and posterior capsule block, both placed under ultrasound. Patients are now going home with adductor canal pain pump which allows continued pain relief while at home without restricting mobilization. n BluePrint 2015

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Photo Courtesy of Duke Medicine

PEDIATRIC ANESTHESIA

On June 18, 2015, two full teams of Duke anesthesiologists assisted surgeons with the separation of eight-month-old conjoined twins, Josiah and Aryan Covington. Pictured above: Dr. Shelly Pecorella, Dr. Brad Taicher, Dr. Lisa Einhorn and Dr. John Eck.

Unparalleled Separation Surgery of Conjoined Twins

By Stacey Hilton Duke anesthesiologists take us inside the operating room for an in-depth look at their medical mission to save baby brothers It wasn’t the typical news for an expecting mother to receive at her routine, eighteen week ultrasound. What Vanessa Covington’s doctor told her that day changed her life forever; news that prompted only the second pediatric surgery of its kind at Duke University Medical Center.

Vanessa was expecting twin boys who were facing a difficult future because they were conjoined at the abdominal wall and part of the sternum. Facing each other, they also shared a liver. On June 18, 2015, more than two dozen Duke doctors, nurses and perioperative team members scrubbed-in for a ten hour surgery that would leave a lasting impact on the twins, their families and the medical world.

The twin boys, Josiah and Aryan, were born at Duke Hospital in September of 2014 where they received care for 21 days after delivery.

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“There was an incredible amount of uncertainty surrounding the birth of the twins. When they were born, we didn’t know exactly how much anatomy they would share, whether they would be able to breathe on their own, or whether they would need assistance from the medical team,” says pediatric anesthesiologist, Brad Taicher, DO, MBA. “We were in the delivery room if there were any breathing issues right after they were born. Planning for anesthesia began at that point,” adds pediatric anesthesiologist, John Eck, MD. But even before their birth, the team of doctors was deciding how they were going to surgically separate the boys to allow them to live healthy, normal lives. The answer was not one, but two surgeries.

The boys’ first surgery took place in February of 2015 when they were about five months old. It was an initial operation where

Duke doctors inserted tissue expanders, balloon-like devices placed under the skin, to help create extra skin needed to perform the separation. This extra skin would later help plastic surgeons seal the incision after surgery. But first, the boys needed an MRI examination (for doctors to better understand their shared anatomy) which created some challenges for the anesthesiologists.

“One of the problems with an MRI is that it can take many hours to do and it’s hard for babies to hold still for that, so the twins needed to be under anesthesia,” says Dr. Eck. “The other concern was that we’ve never taken care of two patients in one operating room at the same time before, so that created a lot of logistical issues that we had to sort through.”

Due to the anesthesia needs for both the MRI and the tissue expander procedures, doctors decided to combine them.

“Not only did the boys have to be still for the MRI, but they also had to be transported from the operating room to the MRI room while they were asleep,” says Dr. Eck. Working in two different places and then transporting them while anesthetized to rooms on different floors created its own challenge. “Also, the children needed to be intubated (have breathing tubes) for the procedures. Because of the way they were oriented face-to-face, we were concerned about the potential difficulty of that part in particular,” adds Dr. Eck. Dress rehearsals were a critical part of the first surgery; sitting down in the operating room with the equipment and talking through the logistics. The setup was significant and included two separate anesthesia machines in one operating room.

Everything needed to be planned and practiced. “We took some pictures and walked through possible scenarios to make sure we understood everything so when we went back for the separation surgery, we would be able to recreate what we did. That was a very important part of this,” says Dr. Eck. Doctors also spent a day working with staff in the scheduling office who created imaginary patients in the medical records so they could simulate bringing them up in time and making sure they could record all vital signs. “I guess in a sense, we were simulating it at that point. It helped us feel more confident for the separation surgery.”

The first surgery was a success and Dr. Eck says they learned a lot that day about

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PEDIATRIC ANESTHESIA

Photo Courtesy of Duke Medicine

“Having to coordinate your anesthetic with someone else’s anesthetic was a new and unique challenge that we had to develop a plan for and overcome.”

Brad M. Taicher, DO, MBA Assistant Professor of Anesthesiology, Pediatric Division

the boys’ anatomy and physiology. Before the MRI and initial surgery, they were uncertain about how much blood circulation the boys shared; if doctors gave medications to one child, they weren’t sure how that would affect the other. With the help of pediatric anesthesiologist, Mayumi Homi, MD, they administered a couple of medications separately to the boys that day and noted the response in the other twin. They were encouraged that there didn’t seem to be a lot of blood that was crossing from one to the other. “Ultimately, we discovered that although their livers were conjoined, there wasn’t a lot of cross circulation,” adds Dr. Eck. This information would be crucial for the upcoming surgical separation.

After the first surgery, the twins had to go back to the clinic on a regular basis to have additional volume added to their balloon (with saline injections) so it would continue to expand over several months and the excess skin would grow around that.

Then, after four more months of preparations from some of the most experienced surgeons and anesthesiologists at Duke, June 18 arrived. It was a historic day for Vanessa and her eight-month-old twin boys. Surgery to separate conjoined twins is so rare that it hasn’t been done at Duke in more than 20 years. What awaited Vanessa’s twin boys that day required two operating rooms and two full teams of Duke anesthesiologists.

“Everyone had a specific role to play because there were so many details that we each had to worry about,” says Dr. Taicher.

“Every detail was mapped out, down to

which baby would move to a different OR after separation and what type of bed would they be moved onto. How would that bed function? How would it roll? What was the path it was going to take to the new OR? We made a plan for everything we anticipated and a plan for complications that we feared.”

During surgery, it was crucial for the Duke team to make sure they kept everything separate for the twins. Each baby had their own team of doctors, including pediatric anesthesia fellow, Shelly Pecorella, MD, and rising fellow, Lisa Einhorn, MD. With colored tape, the Duke team labeled everything separately for each child from the equipment they were using, to the drug syringe and breathing tubes, right down to the children themselves.

“As anesthesiologists, our job isn’t solely to make a plan, it’s also to make a backup plan, and to make a backup plan for that backup plan. We need to be prepared for all of the different scenarios that could go wrong,” says Dr. Taicher.

This surgery was specifically unique for the anesthesiology team for two reasons, according to Dr. Taicher. First, there is no other opportunity where they will be anesthetizing a patient next to someone else anesthetizing another patient. “You simply would never do this,” says Dr. Taicher.

“Having to coordinate your anesthetic with someone else’s anesthetic was a new and unique challenge that we had to develop a plan for and overcome.”

Secondly, there is no opportunity in this profession where doctors would induce and start an anesthetic with a patient not

MEET THE DUKE ANESTHESIOLOGY TEAM

John B. Eck, MD

Brad M. Taicher, DO, MBA

Hercilia Mayumi Homi, MD, PhD

Lisa Einhorn, MD

Shelly Pecorella, MD

Dr. Lisa Einhorn (above) labeled with identifying colored tape for “Baby A’s” (Aryan Covington) team.

Critical Anesthesia Management:

à Understand the children’s shared anatomy à Map out every detail with dress rehearsals à Provide each child with their own team of doctors à Anesthetize each child separately but simultaneously à Keep everything separate for each child and label with colored tape

laying on their back. “It would take extenuating circumstances to not have a patient perfectly on their back, facing up and relaxed as they go to sleep,” says Dr. Taicher.

“I don’t suspect I’ll ever again place a central line in a patient who is in a lateral position.”

“Even though this is the first time I’ve ever participated in a surgery like this, it didn’t feel like it was the first time because we had talked about it so much. It wasn’t a surprise when it actually happened,” says Dr. Taicher. “For the most part, we had already discussed and simulated everything that occurred, so we were able to function very smoothly.” And, a smooth surgery it was.

The twins were able to leave the hospital just one week after undergoing surgery, and the doctors expect they will have relatively healthy, productive, normal lives. “As much as it was nerve-wracking with a lot of uncertainty and challenging at times, it was enjoyable to be a part of,” Dr. Eck adds.

“I can’t emphasize enough how much of a team effort this was. Our little piece of this was something we obviously spent a lot of time on, but it was part of a much bigger endeavor that involved a lot of people who deserve a lot of credit,” says Dr. Eck. “It’s really satisfying to work with a crew who works so well together, doing something that none of us have ever done before. Working with that kind of team on a daily basis really makes it feel like we chose a great place to work: Duke Children’s Hospital.”

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à CONTINUED FROM PREVIOUS PAGE

“You can’t over emphasize the importance of the teamwork for this case,” agrees Dr. Taicher. “No one showed up that day to that OR because it was their assigned shift. Every single person was committed and dedicated to what was happening and it was amazing to see an enormous team dedicated to one mission.”

Dr. Eck and Dr. Taicher give special credit to Henry Rice, MD (Division Chief, Pediatric General Surgery) who they say brought together resources from countless departments, even from outside of Duke when necessary, in order to gather all of the pieces he needed to have a big, inclusive team.

Despite the delight in the operating room, you could say Dr. Eck and Dr. Taicher felt the most joy post-surgery when they saw Vanessa watching both of her boys, side-by-side, but now… separate. “It was a neat thing to see because she was a little uncertain at first. She only knew them together,” says Dr. Eck. “I don’t know if it could have come to a better conclusion.”

“To me, that was one of the most incredible things. To think that we were able to reach a definitive endpoint for such a major case,” adds Dr. Taicher. “It felt good, seeing them separate, talking to their mom, and wishing them well. I always joke to patients, “Thanks for coming. I hope you never have to come back again.” I hope and expect it’s true for the two of them, that they can lead normal lives and won’t ever need our care again.” n

Allison K. Ross, MD Chief, Division of Pediatric Anesthesiology Professor of Anesthesiology POSTOPER ATIVE PAIN STUDIES 1. A Phase IIA, Open-label, Safety and Pharmacokinetic Study

of Zorvolex® Capsules in Pediatric Subjects 6 to <17 Years of Age with Mild to Moderate Acute Postoperative Pain Following Elective Surgery

2. An evaluation of the efficacy and safety of tapentadol oral

solution in the treatment of post-operative acute pain requiring opioid treatment in pediatric subjects aged from birth to less than 18 years old. (KF5503/65)

3. A Phase 4, Open-Label Study of the Pharmacokinetics and Safety

of XARTEMIS (TM) XR (7.5 mg Oxycodone Hydrochloride/325 mg Acetaminophen) in Postsurgical Adolescent Subjects (Ages 12 to 17) with Moderate to Severe Acute Pain

4. An Open-Label Study of the Pharmacokinetics and Safety

Is Autologous Umbilical Cord Blood Infusion Beneficial in Children with Cerebral Palsy A Prospective, Randomized, Blinded, Placebo-Controlled, Crossover Study

Warwick A. Ames, MBBS

Hercilia Mayumi Homi, MD, PhD

Two pediatric anesthesiologists are part of a first-ofits-kind study at Duke to see if umbilical cord blood can make a difference in the lives of toddlers living with cerebral palsy. It’s a physical disability that

Figure. Study Flow Chart

Enrolled on Study

R A N D O M I Z E D

Visit 1

Visit 2

(Time 0)

(1st Year)

Evaluation

Evaluation

Arm 1

UCB

Placebo

Arm 2

Placebo

UCB

Evaluation

SOURCE: Is Autologous Umbilical Cord Blood Infusion Beneficial in Children with Cerebral Palsy: A Randomized, Blinded, Placebo-Controlled, Crossover Study

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Visit 3

(2nd Year)

of MNK-155 (7.5 mg Hydrocodone Bitartrate/ 325 mg Acetaminophen) in Postsurgical Adolescent Subjects (Ages 12 to 17) With Moderate to Severe Acute Pain

affects a person’s posture, and their ability to move and control their muscles. Nearly 10,000 babies born each year in the United States will develop cerebral palsy. Many cases are silent in newborns and only detected when the child exhibits paresis, spasticity and developmental delay in the first few years of life.

The study aims to determine the efficacy of a single intravenous infusion of autologous umbilical cord blood (UCB) for the treatment of pediatric patients with spastic cerebral palsy (specifically caused by stroke, periventricular leukomalacia or hypoxic ischemic encephalopathy). Dr. Warwick Ames and Dr. Hercilia Homi provide anesthesia for patients taking part in the study, including 120 children from all over the world, ages one to six years old.

Currently, available treatments for patients with cerebral palsy are supportive but not curative. Umbilical cord blood has been shown to lessen the clinical and radiographic impact of hypoxic brain injury and stroke in animal models. UCB also engrafts and differentiates in the brain, facilitating neural cell repair in animal models and human patients with inborn errors of metabolism undergoing allogeneic, unrelated donor UCB transplantation.

Duke doctors hypothesize that in the setting of brain injury, infusion of autologous UCB will facilitate neural cell repair resulting in improved function in pediatric patients with cerebral palsy.

The primary measure of efficacy will be improvement of standardized measures of neurodevelopmental function. Biomarkers associated with stroke, neural repair and inflammation will also be studied. The study began in August of 2010 and is expected to be complete in January of 2016. n

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DEPARTMENT STATISTICS

Duke Anesthesiology by the Numbers CA SES

62,660 TOTAL C A SES

11,569

10,193

Regional Anesthesiology

8,571

Pediatric Anesthesia

6,953

6,442

General, Vascular & Women’s Transplant (GVT) Anesthesia

6,223

6,121

5,500

NeuroCardiothoracic Ambulatory VA Anesthesia anesthesiology Anesthesia Anesthesiology Pain Medicine 1,088

Billed July 1, 2014 – June 30, 2015 (FY 2015)

PUBLICATIONS Women’s Anesthesia

167

56

PUBLICATIONS

Cardiothoracic Anesthesia

27

15

14

14

General, Vascular & Transplant (GVT)

Basic Sciences

VA Anesthesia

Other

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10

10

Pediatric NeuroAnesthesia anesthesiology Regional Anesthesiology 9

Published July 1, 2014 – June 30, 2015 (FY 2015)

Pain Medicine 1

GR ANTS

TOTALING MORE THAN

23

118

NEW GR ANTS

$4.3MILLION

6

CURRENT OPEN GR ANTS

4

3

3

Basic Sciences

Neuroanesthesiology Regional Anesthesiology Grants within July 1, 2014 – June 30, 2015 (FY 2015)

2

Cardiothoracic Anesthesia

2

2

General, Pediatric Women’s Vascular & Anesthesia Anesthesia Transplant (GVT)

1

VA Anesthesia

RESEARCH L ABOR ATORIES Chemical Sensing, Pain and Inflammation Research Laboratory Sven-Eric Jordt, PhD

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Human Pharmacology and Physiology Lab (HPPL) David B. MacLeod, MB BS

RESEARCH L ABOR ATORIES

Molecular Neurobiology Laboratory Wulf Paschen, PhD

Molecular Therapeutics Laboratory Madan Kwatra, PhD

Perioperative Cognitive Outcomes Laboratory Niccolo Terrando, PhD

Multidisciplinary Neuroprotection Laboratories David S. Warner, MD

Systems Modeling of Perioperative Cardiovascular Injury & Adaptation Laboratory Mihai Podgoreanu, MD, FAHA

Pain Signaling, Plasticity and Therapeutic Laboratory Ru-Rong Ji, PhD

Translational Pain Research Laboratory Thomas Van de Ven, MD, PhD

RESIDENC Y 2012 2011

2010

ACADEMIC YEAR 2014 -2015 2013

100%

2014

BOARD CERTIFICATION PASS R ATE FOR THE PAST FIVE YEARS

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PUBLISHED ARTICLES

928

APPLICANTS

132

APPLICANTS INTERVIEWED

14

MATCHED POSITIONS BluePrint 2015

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Building Classrooms Without Walls “The Flipped Classroom” The modern medical professional is a master of adaptation. He or she must continuously stay abreast of, and flawlessly implement new scientific discoveries, technologies, pharmaceuticals, techniques and policies. At Duke Anesthesiology, we believe that in order to equip the leaders of tomorrow for the continuously evolving landscape of medicine, our approach to education should follow suit. One way this is being accomplished is through a unique educational model commonly referred to as the “flipped classroom.”

“This presents a much more modest class agenda, leaving room for active group discussion,” says Mark Stafford-Smith, MD, Vice Chairman of Education.

The Twitter Journal Club, brainchild of Jeffrey Taekman, MD and Ankeet Udani, MD, is an example of the “flipped classroom.” It’s an innovative twist on a traditional practice, using technology to meet the needs of the modern day learner. Participants from around the world can take part in this online discussion about medical journals and discoveries, allowing Duke scholars to engage with a broader, more diverse audience.

“As best we know, this is the first place in the country where anesthesia trainees are participating in sessions of this nature,” explains Dr. Stafford-Smith. “This is just one more example of how we are using technology to take our educational

EDUCATION

program to the next level.”

The first two Twitter Journal Club discussions, tweeted about earlier this year, were regarding aspirin use in patients undergoing non-cardiac surgery and intraoperative hypothermia. Moderators kicked-off their latest discussion in August about a published article by Duke anesthesiologist, Dr. Jeffrey Gadsden, titled “Opening Injection Pressure Consistently Detects Needle-Nerve Contact During Ultrasound– Guided Interscalene Brachial Plexus Block.” After that discussion, the Twitter Journal Club reached a new milestone.

To date, this educational journal club has gathered more than 125 participants on Twitter, generated nearly 1,000 tweets and formed more than one million impressions!

Twitter has become an invaluable resource for learning and thought-sharing with about 316 million active users each month. Journal club participants are not limited by time constraints or physical location.

Here’s how it works. Before each session, club members tweet topic suggestions and the moderators pick an article for discussion from the best topics suggested. Once the session begins, a series of questions are distributed daily from the department’s Twitter handle. Participants can join the discussion simply by responding with the hashtag “#AnesJC” during a specified time frame. Moderators then review responses and post a series of highlights during a classroom-based discussion. The session is live-tweeted and the curated discussion is archived on the Duke Anesthesiology website .

The Twitter Journal Club is led by a team of moderators, including Drs. Andrew Peery (@andrew_peery), Ankeet Udani (@ankeetudani), Jeffrey Taekman (@jeffreytaekman), and Dan Moyse (@danmoysemd).n

A lively conversation about injection pressure in regional anesthesia at the third Twitter Journal Club discussion held at the Mary Duke Biddle Trent Semans Center and live via Twitter.

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For more information and to view curated discussions of the Twitter Journal Club, please visit tinyurl.com/nc87v88

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EDUCATION

The DARE blog authors are Duke Anesthesiology Residency Program Director Dr. Annemarie Thompson (Left), and Residency Program Assistant Directors Dr. Ankeet Udani (Center) and Dr. Brian Colin (Right).

Introducing the Duke Anesthesia Residency Education (DARE) Blog Duke Anesthesiology is proud to have one of the top ranked residency programs in the nation. And three of the doctors who oversee this highly regarded program have developed one more way to connect – the DARE blog!

The authors, Drs. Annemarie Thompson, Brian Colin and Ankeet Udani, will use the DARE blog to: 1. Answer common questions directed towards the Residency Program office 2. Share educational experiences (both successes and failures) 3. Open communication between medical students, residents and educators regarding medical education With this blog, the Duke anesthesia residency program director and assistant directors hope that individuals will feel they can reach out to them online with any questions they may have about the department and Duke as a whole, ultimately creating beneficial conversations.

With a new academic year in full swing, below is just a taste of the Q&A you’ll see on the new DARE blog…

Q:

What advice do you have for starting residency at Duke Anesthesiology?

A:

Starting anesthesia residency at Duke is exciting! Our advice is simple and likely applicable to all residencies: 1. Bring a positive, inquisitive attitude to work each day 2. Arrive early and work hard 3. Study daily (briefly) – bridge book knowledge to real patients 4. Introduce yourself to everyone you meet; try and remember names 5. Unwind, relax, and enjoy time spent away from the hospital 6. Find a best friend at work

Q:

A:

What fellowships do Duke Anesthesia residents commonly pursue?

The most common fellowship pursued by our residents is cardiothoracic anesthesia. Here is a list of our 2015 graduates and their post-graduate plans: 1. Brad Berndt – Adult Cardiothoracic Anesthesia Fellowship, Duke 2. Kayla Bryan – Pediatric Anesthesia Fellowship, Medical College of Wisconsin/Children’s Hospital of WI 3. Eric Ehieli – Critical Care Medicine Fellowship, Duke 4. Lisa Einhorn – Pediatric Anesthesia Fellowship, Duke 5. Brittani Hale – Private practice (Metropolitan Anesthesia Consultants), Dallas, TX 6. Jenny Hauck – Adult Cardiothoracic Anesthesia Fellowship, Duke 7. Michele Hendrickson – Duke faculty 8. S. Todd Hobgood – Private practice (Northeast Anesthesia and Pain Specialists), Concord, NC 9. Ying Low – Adult Cardiothoracic Anesthesia Fellowship, Duke 10. Dan Moyse – Pain Medicine Fellowship, Duke 11. Patrick Nailer – Adult Cardiothoracic Anesthesia Fellowship, Duke 12. Bronwyn Southwell – Pain Medicine Fellowship, Duke 13. Justin Wikle – Pain Medicine Fellowship, University of Pennsylvania

Q: A:

What is the simulation experience during residency?

Simulation-based education at Duke has three main functions during residency training. First, orientation. All anesthesia residents spend their first week at Duke in small groups practicing the basics of anesthesia preparation, induction, maintenance and emergence. Orientation allows students to ask questions in a controlled, safe environment so they are well prepared when they are in the clinical setting. The second feature is offering a consistent curriculum to all residents. New this year, we are implementing a three-year, graduated simulation curriculum covering all important events identified by faculty and residents as must-manage cases. The cases will cover general, vascular, transplant, pediatric, cardiac anesthesia and more. The goal is to make sure all residents learn and manage common and rare events in simulation, regardless of their clinical exposure. Finally, the third function of simulation is to verse our residents in principles of crisis resource management. Similar to the training aviation pilots receive, the CRM-simulation curriculum spans all three years of residency with increasing complexity.

The course prepares our residents to be effective leaders and team members in times of crisis in the perioperative environment. We have additional exciting aspects of simulation including gaming and patient safety efforts that are currently being studied and will be implemented into the residency curriculum in the future. n

Please send your questions and comments to DAREBlog@duke.edu.

For more information, visit tinyurl.com/oxeshzc

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R ANKINGS

Duke Anesthesia Residency Ranked #6 in Doximity Poll

Duke University Hospital

U.S. News Ranks Duke Hospital as Leader in Nation and N.C.

Photos Courtesy of Duke Medicine

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Duke University Hospital was again included on the Honor Roll of top hospitals in the nation by U.S. News & World Report, ranking #14 in the magazine’s 2015-16 listings.

The flagship hospital in the Duke University Health System, Duke University Hospital was also ranked #1 in North Carolina and #1 in the Raleigh-Durham area. In addition, Duke Regional Hospital and Duke Raleigh Hospital were ranked eighth and 12th, respectively, in North Carolina, and third and fifth in the Raleigh-Durham area.

Honor Roll designations were awarded to just 15 hospitals out of nearly 5,000 evaluated by U.S. News for its rankings. Hospitals on the exclusive list achieved high scores Duke Regional and Duke Raleigh Hospitals in at least six of the 16 medical specialties that form the basis of the magazine’s survey.

Among specialties receiving top scores at Duke were cardiology and heart surgery (sixth), pulmonology (seventh), ophthalmology (eighth), urology (ninth), rheumatology (12th) and nephrology (17th).

Duke University Hospital is ranked nationally in another six adult specialties (cancer, diabetes/endocrinology, geriatrics, gynecology, neurology/neurosurgery, orthopedics), along with eight pediatric specialties (cancer, cardiology/heart surgery, diabetes/endocrinology, gastroenterology/GI surgery, neonatology, nephrology, pulmonology and urology). It was also high-performing in one adult specialty (gastroenterology/GI surgery). n 16

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Doximity, in collaboration with U.S. News & World Report, has released the results of its 2015 ranking of residency programs. The Duke Anesthesiology Residency Program is in the top ten in the country (#6). U.S. News & World Report is the largest and most publicly recognized higher education ranking system, and although rankings are neither the only nor the definitive measure of a program’s strength, it is gratifying to know the quality of our program is recognized nationally. n

Anesthesiologists Named One of the Most Meaningful Jobs in U.S. Business Insider’s list of the 13 most meaningful jobs in America is out... and anesthesiologists made the top ten! PayScale asked more than two million professionals whether their work is meaningful, and ranked almost 500 professions, with anesthesiologists landing at #9 on that list. 91 percent of the people polled said it’s a highly meaningful job and 83 percent said it’s a highly satisfying job. Among the other most meaningful jobs, surgeons, English literature teachers, and clergy were ranked in the top three. Curious to see who else made the list? n R E A D MOR E:

tinyurl.com/okyzotd

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DUKE UNIVERSIT Y SCHOOL OF MEDICINE

Message From The Dean

Dear Colleagues and Friends: This year has been particularly exciting with significant activity and growth at the School of Medicine.

Our new Chancellor for Health Affairs and President and CEO of Duke University Health System, Eugene Washington, MD, MSc, arrived in April and has hit the ground running. He has met and continues to meet with faculty, staff, and students as well as community leaders, alumni, and supporters to gain perspective on the Duke Medicine enterprise.

This summer, Dr. Washington embarked on a strategic planning initiative. The first phase of this process has been an internal assessment including interviews, focus group meetings, and surveys for all faculty, employees, students, and trainees.

Since March, the School of Medicine welcomed four new department chairs and added a new department. Edward Buckley, MD, was named the new chair of the Department of Ophthalmology.

Dr. Buckley also serves as Vice Dean for

Education and will continue in that role.

Joseph Mathew, MD, MHSc, MBA, was named the new chair of the Department of Anesthesiology. Dr. Buckley and Dr. Mathew are proven leaders who bring energy and innovation to these two important clinical departments.

In July, the Division of Neurosurgery, within the School’s Department of Surgery, was elevated to department status. This has been an exciting process, and this elevation will undoubtedly increase the visibility and reputation of our outstanding neurosurgery faculty. John Sampson, MD, PhD, MHSc, MBA, who served as chief of the Division of Neurosurgery, has been named chair of the new department.

Most recently, Jiaoti Huang, MD, PhD, was named the new chair of the Department of Pathology. His official start date is January 1, 2016. Dr. Huang currently is professor of Pathology and Urology, the Frances and Albert Piansky Endowed Chair, chief of Surgical Pathology, and director of Urologic Pathology at the David Geffen School of Medicine at UCLA. He is also a member of

UCLA’s Jonsson Comprehensive Cancer Center and Broad Center of Regenerative Medicine and Stem Cell Biology.

Other exciting news includes the launch of our newest master’s degree program and the creation of a first-in-the-nation, dual-state health collaborative. The Master of Biomedical Sciences welcomed 33 students this summer. The goal of the program is to enhance the scientific and professional preparation of students aspiring to a career in the health professions or in a related field requiring graduate-level biomedical sciences. This summer, Health Sciences South Carolina (HSSC) and the health systems and medical schools of UNC-Chapel Hill, Duke, and Wake Forest Baptist Medical Center joined forces in a unique partnership to share information, methods, tools, opportunities and expertise with the goal of improving health and health care for the populations of those states and beyond.

I am continually amazed by the excellence, innovation and leadership of our remarkable students, trainees, faculty and staff. Our success is enhanced by the wonderful commitment and support from our alumni and friends, and for that, we are very grateful.

With warm wishes,

Nancy C. Andrews, MD, PhD

Duke Enters First-of-its-Kind Collaboration with Wake Forest, UNC & Health Sciences South Carolina to Improve Health JUNE 2 , 2 015

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MEDSCHOOL .DUK E .EDU

South Carolina and North Carolina have many things in common: southern heritage, a love of good food and family, beautiful beaches and mountains. The two states also share burdensome health issues like unacceptably high rates of diabetes, stroke, obesity, heart disease, and health disparities.

Now, the Carolinas have a new commonality: a first-in-the-nation, dual state health collaborative made possible by a $15.3 million grant to Health Sciences South Carolina (HSSC) awarded by The Duke Endowment, a private foundation based in Charlotte, North Carolina.

HSSC was established in 2004 by leaders of South Carolina’s largest research universities and health systems who shared the vision of improving health through research. As a result of The Duke Endowment grant, HSSC is collaborating with the health systems and medical schools of the University of North Caroli-

“Three of the major research universities and health systems in North Carolina will now partner with those in South Carolina to share information, methods, tools, opportunities and expertise with the goal of improving health and healthcare for the populations of those states and beyond.”

Iain Sanderson, BM, BCh

Vice Dean for Research Informatics, Duke University School of Medicine

na-Chapel Hill (UNC), Duke University, and Wake Forest Baptist Medical Center in efforts to build upon the infrastructure and enable the use of data to improve health in both states.

This work is partially supported at Duke with funds from the Duke Clinical and Translational Science Award (Duke CTSA). n R E A D MOR E:

tinyurl.com/pr2sfq3 BluePrint 2015

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DUKE ANESTHESIOLOGY

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THE DUKE HUMAN SIMUL ATION AND PATIENT SAFET Y CENTER

Developing the Future of Medicine One Game at a Time

By Lauren Marcilliat

Duke’s internationally esteemed Human Simulation and Patient Safety Center (HSPSC) has been paving the way for the use of technology and simulation in medical education and research for the past fourteen years.

“We are only just starting to scratch the surface of how simulation and technology can be used to improve learning, quality and safety,” says HSPSC Director, Jeffrey M. Taekman, MD. The Professor of Anesthesiology and Assistant Dean for Educational Technology for the School of Medicine also adds, “In the future, virtual environments and computer-based simulation will continue to have a profound effect on how we educate not only Jeffrey M. Taekman, MD healthcare workers, but also patients.”

With Dr. Taekman’s efforts, Duke is now recognized as one of only six founding sponsors of the Society for Simulation in Healthcare, a multi-disciplinary, international, profes-

sional simulation society with more than 3,000 members.

The HSPSC is a collaborative project of the School of Medicine with the Department of Anesthesiology. The HSPSC has close ties with its neighbor in the Trent Semans Center for Health Education, the Surgical Education and Activities Lab (SEAL). It has expertise throughout the continuum of simulation—from lab-based to in-situ to virtual. The physical facility features three simulation theaters which house an OR suite, ICU suite, fully integrated audiovisual capture and playback system, and three multimedia classrooms.

Comprised of physicians, nurses, educators, human factors engineers, and computer scientists, Dr. Taekman attributes the past and future success of the HSPSC to its dynamic, interdisciplinary team. Each team member brings to the table a unique, knowledge-based skill-set, perspective, and approach to problem solving which enables the center to meet the individual needs of an incredibly broad audience.

Students, allied health professionals, Duke Medicine residents and staff, along with nationwide industry partners rely on the HSPSC as an invaluable educational tool and technological resource. Duke Anesthesiology Simulation Specialist, Paul Tonog, MS, believes that sharing information, contingency planning and good communication is essential for safe anesthetic management of patients. “Simulation allows the learner to make mistakes, in BluePrint 2015

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CoverStory

“In the future, virtual environments and computer-based simulation will continue to have a profound effect on how we educate not only healthcare workers, but also patients.”

Jeffrey M. Taekman, MD Director, Duke University Human Simulation and Patient Safety Center

Duke Anesthesiology Fellows, Dr. Bronwyn Southwell (Left) and Dr. Bradford Berndt (Right), participating in simulation scenarios from the inaugural ACRM workshop.

turn allowing them to learn from those mistakes without harming real patients. This provides great potential to improve patient safety.”

In recent months, the center has been enriched by the addition of several new team members who are helping to expand its offerings. This new growth is possible thanks to the ongoing efforts of new staff member, Andrea Fiumefreddo, MS, who serves as the director of operations for the HSPSC. She is responsible for the creation of several new programs and has added greater organization and structure to pre-existing programs. Ankeet Udani, MD, has also been a key player in the success of these new programs. He joined the Duke faculty after completing a fellowship in Patient Safety and Simulation-based Medical Education at Stanford University Medical Center last year. Dr. Udani has not Ankeet Udani, MD only enhanced the HSPSC’s faculty training program but he also started a Twitter augmented journal club and has spearheaded an Anesthesia Crisis Resource Management (CRM) course for residents.

This CRM course is part of a larger initiative to revamp the resident education program and include a greater John B. Eck, MD focus on sub-specialty areas. Led by Duke Anesthesiology faculty member, John B. Eck, MD, the result will be a more formalized program that incorporates weekly simulation activities with traditional didactics.

In addition to increased collaboration with the School of Medicine, the HSPSC is working with several other entities across Duke Medicine, such as the School of Nursing and the Department of Surgery. Furthermore, Holly A. 20

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Muir, MD, has recently been tasked with leading a hospital-wide simulation training program for non-anesthesia faculty and trainees. Finally, the HSPSC offers continuing medical education to board-certified anesthesiologists across the country through its Simulation Training for Maintenance of Certification in Anesthesiology® (MOCA®) course.

One of the many benefits of simulation is that it has the ability to transcend borders with the click of a mouse, and the HSPSC has taken advantage of this through the pursuit of various grants and internaHolly A. Muir, MD tional projects.

For example, HSPSC faculty and staff recently led a training session in Uganda to educate African healthcare workers about postpartum hemorrhage ⎯ the leading cause of maternal mortality worldwide. Duke Anesthesiology Simulation and Media Specialist, Jack Newman, created a video summarizing this experience, which is available online at tinyurl.com/omgu4yx.

In the future, Dr. Taekman hopes to place a stronger emphasis on a new research trend in simulation called

HSPSC Director, Dr. Taekman (Left), instructing learners on proper airway management and technique.

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THE DUKE HUMAN SIMUL ATION AND PATIENT SAFET Y CENTER

DE VELOPING THE FUTURE OF MEDICINE ONE GAME AT A TIME

CoverStory

Figure. Crisis Resource Management

learning analytics. Computers have the unique ability to meticulously track every movement during a simulated exercise. This data can be harvested and studied, providing limitless opportunities for medical research.

“Duke is one of the few places where you have a combination of an incredible academic environment, great people, and leadership that allows you the freedom to pursue your dreams,” says Dr. Taekman. “It’s a winning combination.”

By working together and combining our unique talents, there is no doubt that the growing HSPSC team will continue to be recognized globally as a transformative force in healthcare simulation. n To learn more about the HSPSC, please visit our new website SimCenter.duke.edu

Designate Leadership Establish Role Clarity

©2008 Diagram: S. Goldhaber-Fiebert, K. McCowan, K. Harrison, R. Fanning, S. Howard, D. Gaba

Call for Help Early

Anticipate and Plan Know the Environment

CRM Key Points

Distribute the Workload

Allocate Attention Wisely

Communicate Effectively Use Cognitive Aids

Use all Available Information

Mobilize Resources

HSPSC Hosts Simulation Instructor Workshops ACRM course instructors prepare for a case with anesthesiology residents.

Inaugural Anesthesia Crisis Resource Management Course at HSPSC The Human Simulation and Patient Safety Center (HSPSC) hosted its inaugural Anesthesia Crisis Resource Management (CRM) course for CA3 residents this past April. The course focused on teaching key principles of CRM, including leadership, communication, using cognitive aids, calling for help and more.

During the full day course, all CA3 residents were put into unique, challenging, and rare scenarios designed to push their CRM skills in various ways. Each scenario was followed by a debriefing session between the faculty and learners. These debriefing sessions provide a forum for reflection on the simulated experience and promote positive change in daily clinical practice. The Duke HSPSC had a wonderful time working with the Duke Anesthesiology residents and the enthusiastic faculty while supporting continuing education and patient safety initiatives. n

Participants of the June 2015 Simulation Instructor Workshop after completing the two-day curriculum.

The HSPSC has now completed two iterations of its Simulation Instructor Workshop for 22 educators within the Duke Anesthesiology Department. During these two-day workshops, hosted in December 2014 and June 2015, Drs. Ankeet Udani, Jeffrey Taekman, and John Eck, taught principles of adult learning, simulation-based education and experiential learning. The course culminated with workshop participants designing, implementing and debriefing scenarios on one another. The HSPSC will host another Simulation Instructor Course in March 2016. For those within the department interested in participating, please keep an eye out in the weekly newsletter for how to register. n BluePrint 2015

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Feature

Targeting Anemia, Improving Outcomes

By Ratna Swaminathan

A paradigm shift is occurring within Duke.

Anesthesiologists here are redefining their role in perioperative medicine by proactively identifying risks, modifying them and improving outcomes after surgery.

In the post-healthcare reform environment that is focused on the cost-effective improvement in patient outcomes, Duke anesthesiologists are enhancing care delivery in a financially responsible manner.

This time, they’re taking on anemia. It’s a global health problem that afflicts populations indiscriminately, both in the developed and developing nations. Anemia is a well-known risk factor for patients undergoing surgery. In fact, a 2002 Veterans Affairs study estimates that up to one-third of surgical patients have anemia.

“Complications of anemia in surgical patients primarily relate to the risks of blood transfusion, for which they are at higher risk than non-anemic patients. These risks include lung injury, renal failure, hemolysis, and transfusion reaction, as well as mortality,” according to former Assistant Professor, Jason Guercio, MD, MBA. On September 24, 2014, the Duke Pre-operative Anemia Clinic (PAC) opened its doors to patients with chronic anemia who are at an increased risk for blood transfusion and adverse outcomes when undergoing surgery. The PAC is a multidisciplinary anemia management program set up and operated by the Duke Department of Anesthesiology’s Perioperative Enhancement Team (POET).

Nurturing the project since its conception, Assistant Professor, Thomas J. Hopkins, MD, reflects on the vision of the PAC. “The concept is to do everything that you can to improve patient outcomes and reduce costs, essentially to provide cost-effective care for patients in a way that 22

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enhances their outcomes perioperatively.”

“The PAC is unique,” adds Duke Anesthesiology Executive Vice Chairman, Solomon Aronson, MD. It is an effort to identify anemia before surgery and treat it so that it no longer poses a risk to the patient – an innovative upstream solution to a serious downstream problem.

The clinic helps identify patients at high risk based on their preoperative screening and enables better blood management care during surgery. It also allows the team to better understand patients from a population health standpoint. Dr. Aronson adds, “What we implemented is a low risk, low cost point of care test (POCT) – a screening device for patients who are designated or likely to be designated as surgical candidates.”

According to Dr. Guercio, a POCT called Hemocue is used to identify anemic patients in the Duke Orthopedic Clinic.

Currently, patients undergoing elective total joint surgery of the hip and knee, as well as those in the perinatal clinic, are being tested.

Assistant Professor of Obstetrics and Gynecology, Andra James, MD, MPH, recommends treating moderate to severe anemia in pregnant patients before surgery. Citing large studies, she adds that anemia increases both the risk for postpartum hemorrhage and transfusion, while adversely affecting both length of stay in the hospital and maternal outcomes. “Some women fail oral therapy, and intravenous iron is an essential alternative to transfusion. We are very grateful

that the PAC has expanded services to women who are approaching delivery.”

Pregnant patients at high risk for cesarean section are routinely screened for anemia during their 28 week mark at the prenatal clinic. Out of the 1,000–1,250 patients seen here every month, approximately 25 percent are new pregnant patients and are screened for anemia.

If they are found to be anemic, they are referred to the Center for Blood Conservation (CBC), where their tests are interpreted. Aime Grimsely, nurse practitioner and program manager for the CBC, evaluates and speaks with patients utilizing the clinic workspace of the Pre-Anesthesia Testing Clinic (PAT). If appropriate, she schedules them for treatment in the Infusion Center to correct their anemia prior to surgery.

“The PAC is an outgrowth of the CBC,” informs Nicole R. Guinn, MD, Medical Director of the CBC. The original purpose of the CBC was to manage and treat pa-

Natisha Wiley, a patient with a history of three C-sections, had her fourth C-section on March 12, 2015. She was referred to the Pre-op Anemia Clinic with hemoglobin of 8.4. After treatment her hemoglobin was 11.1. Natisha delivered her newborn baby, Ayden Noel, without blood transfusion.

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PRE- OPER ATIVE ANEMIA CLINIC (PAC)

THE DUKE ANESTHESIOLOGY PERIOPER ATIVE ENHANCEMENT TE AM (POET )

Feature

Left-hand Photo: “Iron deficiency anemia blood film” by Dr Graham Beards - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Iron_ deficiency_anemia_blood_film.jpg#/media/File:Iron_deficiency_anemia_blood_film.jpg

“The concept is to do everything that you can to improve patient outcomes…and provide cost-effective care for patients in a way that enhances their outcomes perioperatively.”

Thomas J. Hopkins, MD Director, Quality Improvement Assistant Professor of Anesthesiology (Left to Right) POET team: Dr. Nicole Guinn, Dr. Jason Guercio, Dr. Thomas Hopkins, Dr. Michael Bolognesi, Maria Jimenez, and Dr. Solomon Aronson. September 24, 2014: Pre-op Anemia Clinic Go-Live Day at Duke Orthopaedics Clinic, Page Road.

A certified medical assistant gets ready to prick patient finger to obtain blood sample during Pre-op Anemia Clinic Go-Live Day at Duke Orthopaedics Clinic, Page Road.

tients who refuse blood transfusion. “With the PAC, we are beginning to expand our patient blood management program to all perioperative patients undergoing potential high blood loss procedures.”

According to Dr. Guinn, “Based on a patient’s hemoglobin and risk factors for transfusion, they are referred to the PAC. At the time of referral, further labs, including iron studies, B12, folate, reticulocyte count and creatinine, are ordered to help us evaluate the type of anemia. We treat iron-deficiency anemia and anemia of chronic disease. All patients, at the time of referral, are also given letters with their hemoglobin count for long term follow-up by their primary care physician.”

In past years, this was not always the case. Surgical patients were not treated for anemia preoperatively before this clinic was set up, says Dr. Guercio. “Typically, a surgical patient might be determined to be anemic by the Pre-Anesthesia Testing (PAT) Clinic and routine laboratory testing was sent. Additionally, no specific

thresholds that account for surgical type and comorbidity were available to guide treatment,” he adds. Before the PAC, the only option that was available to high risk obstetric patients was intravenous iron treatment included in a one-day stay in Labor and Delivery. However, due to space and logistical constraints, the availability of treatment could not be guaranteed, Dr. Guercio informs.

The PAC stems from successful teamwork between POET in anesthesiology, the CBC, PAT and Duke Orthopedic clinics. “For the PAC, the POET members identified the potential for improving transfusion rates by improving patients’ hemoglobin levels,” according to Maria Jimenez, Project Manager for POET. In collaboration with Drs. Guercio, Guinn, Aronson and Hopkins, Ms. Jimenez has worked tirelessly to make sure all pieces were in place before this clinic, the first of its kind, went live, the first of its kind in the region. Ms. Jimenez has been a critical member of the PAC since its inception, liaising with outpatient clinic administrators, purchasing testing equipment, training staff, and developing protocols and performance metrics.

A two-pronged cost-effective strategy works in the PAC. Firstly, says Dr. Hopkins, there is cost savings in avoiding transfusion, measured in terms of improved perioperative patient outcomes, such as decreased morbidity and length of stay. Secondly, fixed costs, associated with the physical storage and delivery of blood, are lowered.

As an added bonus to the initial business plan, the PAC will generate revenue for the

department and the Duke University Health System, adds Dr. Hopkins. The predicted net value of the clinic is more than $100,000 in the first year and more than $2.5 million over the next five years as more service lines are added. The PAC model has the flexibility to accommodate similar, future initiatives in other areas. According to Dr. Guinn, the team is evaluating expansion in other areas, such as the spine center.

Additionally, measurable outcomes are being recorded both before and after implementation of the clinic, providing data for research in perioperative anemia and blood product utilization management.

Data generated by the PAC has been developed into a research abstract, titled “Financial Implications of Launching a Preoperative Anemia Clinic (PAC).” The POET members will present this poster abstract at the ANESTHESIOLOGY® 2015 Annual Meeting, hosted by the American Society of Anesthesiologists (ASA) in San Diego, California, October 24-28, 2015.

As leaders in perioperative medicine, Duke anesthesiologists remain committed to improving patient outcomes. A valuable asset for the perioperative service, the PAC is fulfilling the Duke University Health System mission – striving to transform medicine through innovative scientific research and practice of evidence-based medicine to improve community health. n

For more information about PAC or POET please contact (919) 684-2918.

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Dream Big, Think Big, Live Big

Campaign Goals

à Establish endowed professorships ($1.5-2.5 million) to invest in world-class faculty who would, in turn, secure funding from the National Institutes of Health.

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.

The Duke DREAM (Developing Research Excellence in Anesthesia Management) Campaign was established to support Duke Anesthesiology’s research programs and initiatives. As implied by our motto, we empower great minds to turn dreams into reality.

By encouraging the entrepreneurial spirit, unfettered imagination, and unchecked ambition, the DREAM Campaign inspires Duke Anesthesiology faculty and provides them with the wherewithal to achieve great strides in the medical world. Together with our supporters, we are transforming the future of patient care.

The purpose of the DREAM Campaign is to raise philanthropic support for research initiatives focused on improving patient outcome, pain management, and quality of life, as well as to establish endowed professorships. Rather than depending solely on extramural agencies to support essential programs within the department, we place power in the hands of our community. One of our primary objectives is to educate the public on the importance of perioperative research and highlight the influential role the anesthesiologist plays in the medical arena.

à Raise funds to support research

through the DREAM Innovation Grant, known as DIG. (learn more on page 26)

à Establish philanthropic support as

a long-term mechanism of limiting the adverse consequences of cyclical federal funding.

Growing the DREAM Campaign

Since our inception, we have encouraged innovative research ideas and programs with the capacity to generate independent federal funding. The DREAM Campaign provides support to Duke Anesthesiology in two primary ways: endowed professorships and internal grants.

Endowed professorships, or endowed chairs, are the most prestigious faculty appointments at Duke University Medical Center made possible by generous individuals and/or families who want to invest in Duke’s legacy of excellence and create a partnership with the department to work toward a brighter tomorrow. Endowed professorships are awarded to the department’s most distinguished physician-scientists or used to recruit the best and brightest individuals who have exhibited both outstanding achievement and strong potential for future accomplishment. Those who choose to establish an endowed chair are given the honor of naming it after an individual of their choice.

“Duke Anesthesiology has a number of endowed chairs,” explains former chair and DREAM Executive Board member, Joseph “Jerry” Reves, MD. “That’s what sustains the department through the years . . . to have that sort of support and effort to strengthen the fundamental wherewithal of the academic department.” It was the legacy of Dr. Reves that inspired the DREAM Campaign’s first philanthropic initiative: The Jerry Reves Professorship Campaign. In 2011, the DREAM team celebrated the naming of Dr. Mathew as the first Jerry Reves, MD, Professor of Cardiac Anesthesiology.

In 2012, we were proud to announce the Joannes H. Karis Professorship, named in honor of the legacy of one of Duke Anesthesiology’s most distinguished former faculty. The Karis Professorship has been made possible through the generous donations of the Karis family. Like the Jerry Reves Professorship, this endowment is used as a means to attract new world-class faculty to Duke Anesthesiology for generations to come.

At Duke University, the cost of funding a professorship is $2.5 million. We invite you to take advantage of this opportunity to create a permanent legacy in honor of a mentor or a loved one.

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Executive Board Members Elizabeth Allardice Dr. Maria Arias Bud Doughton Joe Farrell James Forrest Jaime Kulow

Dr. Jerrold Levy Asun Mathew Dr. Joseph Mathew Steve Steff Jon Stewart

Learn more about the many ways to give to the Duke DREAM Campaign DREAMCAMPAIGN.DUHS.DUKE.EDU

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gn

THE DUKE ANESTHESIOLOGY DRE AM C AMPAIGN

DE VELOPING RESE ARCH E XCELLENCE IN ANESTHESIA MANAGEMENT

“Duke Anesthesiology has a number of endowed chairs.

That’s what sustains the department through the years . . . to have that sort of support and effort to strengthen the fundamental wherewithal of the academic department.”

Fiscal Year

2015

Whether you are …

à An alumnus or alumna whose career blossomed at Duke

à A current or former faculty

member who was given dedicated time in the laboratory to make critical scientific discoveries

à A member of our community who relies on Duke to deliver cutting-edge techniques and top-notch clinical care to you and/or your loved ones

… chances are Duke Anesthesiology’s research program has positively impacted your life.

Here is what the Duke DREAM Campaign has achieved in the fiscal year 2015 from individual donations ( July 1, 2014 – June 30, 2015 ) …

$90,015.84

52%

1 S T TIME DONOR S

Joseph “Jerry” Reves, MD Former Chair of the Department of Anesthesiology (1991–2001) Former DREAM Executive Board Member

Campaign Update

4

ENDOWED PROFES SOR SHIPS ES TA BLISHED

10%

A DV ISORY BOA R D MEMBER S

22%

46%

A LUMNI

Who are our donors?

FR IENDS OF THE DEP T.

22%

25% DON ATED $1,0 0 0 OR MORE

49%

DON ATED 3 + Y E A R S IN A ROW

111

FACULT Y

Give Where You Live

Duke Anesthsiology faculty and staff see firsthand the need for private support, as well as the impact those donations have on the residents, fellows, faculty, and programs here. That is why they are one of our strongest advocates, and why their own giving plays a crucial role in reaching the campaign’s goal.

DREAM Donors Across America

n 40+ Donors n 3 Donors n 2 Donors n 1 Donor

DONORS

MORE THAN

$1.5

MILLION RAISED TO-DATE

RAISED IN FY 2015

51%

DON ATED MORE TH A N L A S T Y E A R (F Y 2014)

December

C A LENDA R MONTH WHEN MOS T DON ATIONS RECEI V ED

*Number s reflec t July 1, 2014 - June 3 0, 2015, individual donations only

DRE AMC AMPAIGN.DUHS.DUKE.EDU BluePrint 2015

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DREAM Innovation Grant (DIG) The DREAM Innovation Grant (DIG) supports innovative high-risk and potentially highreward investigations to accelerate anesthesia and pain management research.

The concept behind the DREAM Innovation Grant, or DIG, is simple, yet brilliant. First launched in 2010, DIG is an annual competition held among Duke Anesthesiology faculty members. Competitors submit their most innovative research ideas to a panel of judges for review. Proposals that demonstrate the perfect blend of ingenuity and practicality are selected, and winners are announced at the department’s annual alumni reception.

DIG recipients can receive up to $30,000 in seed money for their innovative pilot studies which ultimately helps them apply for and obtain extramural funding.

None of the funds awarded are to pay for faculty salary or overhead expenses.

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.

Another unique aspect of DIG is that it encourages the participation of both junior and senior faculty. DIG helps to bridge the gap between training and progression to independent investigator status.

Funding provided by DIG will support a researcher for one year, during which pilot studies can be conducted. Investigators must submit quarterly reports to track their progress. Not only do these reports give each researcher an edge over their competition when submitting National Institutes of Health (NIH) applications, but they are also shared with DREAM Campaign supporters to provide them with tangible evidence that their donations are making a difference.

At the conclusion of the one-year period, a new group of DIG winners are announced, and the cycle of innovation and discovery begins again. Help us extend this opportunity to a greater number of worthy applicants! With a gift of $30,000, you can independently sponsor one DIG applicant. And, the chances are strong that your initial gift will be matched or multiplied in the future by extramural funding sources. Please consider making a donation of any amount to support this worthy cause.

To-date, $452,900 in DIG donations have led to...

NEARLY

$4

MILLION EXTRAMURAL FUNDING RECEIVED TO-DATE

Dr. Michael Manning (DIG winner, 2013) working on his research project with his mentor Dr. Mihai Podgoreanu (DIG Winner 2012).

Dr. Huaxin Sheng (DIG winner, 2012) working on his research project in the Duke Anesthesiology laboratories.

à Private donors à Private companies à Alumni à Faculty à Executive Board members 26

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Images Courtesy of Dr. Terrence Allen

DREAM Innovation Grants are funded through a combination of:

Dr. Boyi Liu (DIG winner, 2015, on the far-right) pictured with the team of researchers who work in Dr. Sven-Eric Jordt’s laboratories.

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DRE AM INNOVATION GR ANT (DIG) 2015 RECIPIENTS

DE VELOPING RESE ARCH E XCELLENCE IN ANESTHESIA MANAGEMENT

2015 DIG Recipients Final Progress Reports & Findings

Images Courtesy of Dr. Terrence Allen

Terrence K. Allen, MBBS

Background

I grew up in Montego Bay and earned my medical degree from the University of the West Indies medical school in Jamaica. My interest in both anesthesia and obstetrics 2015 DIG RESEARCH PROJECTS began during my internship at the Cornwall The Role of Progestins and PGRMC1 in Regional Hospital in Montego Bay. As a new Inflammation-Induced Fetal Membrane Weakening intern, providing health care to high-risk pregnant women on a busy delivery unit with limited resources was extremely challenging.

However, this first-hand experience with To date, we have determined that the novel progesterone adverse maternal and neonatal outcomes receptor PGRMC1 is expressed in the amnion layer of fetal associated with preterm delivery, preecmembranes and possibly plays a role in regulating the fetal lampsia, major obstetric hemorrhage, and obstetric anesthesia complications drives my membrane’s response to inflammatory cytokines implicated in DIG Progress report and preterm births. research interests today. preterm premature rupture of membranes Terrence K. Allen, MBBS DIGProgress Progress report I completed my anesthesiology residency Progestins alsoDIG inhibit cytokinereport induced molecular pathways Assistant Professor of Anesthesiology in West Yorkshire and Manchester, England, Womens Division weaken theand amnion layer and on leadcytokine-induced to fetal membrane MMP-9, MMP-1 and IL-8 Aim 1: Determine the effect ofthat progestins PGRMC1 where I worked in a multidisciplinary Aim1:1:Determine Determinethe theeffect effectofrupture. ofprogestins progestins and PGRMC1 oncytokine-induced cytokine-induced MMP-9,MMP-1 MMP-1 andIL-8 IL-8 Aim and PGRMC1 and Currently we are in theon process of investigatingMMP-9, environment with obstetricians and neonaexpression and production. expressionand andproduction. production. whether this anti-inflammatory effect of progestins is mediated expression tologists during my obstetric anesthesiology We We harvested amnion mesenchymal cells from fetal membranes ofterm termnon-laboring non-laboring pregnant patients at in part through PGRMC1 and the glucocorticoid receptor. rotations.

These harvested amnion mesenchymal cellsfrom from fetalmembranes membranes pregnant patients We harvested amnion mesenchymal cells fetal ofofterm non-laboring pregnant patients atat experiences solidified my cesarean section and were able to successfully culture these cells in vitro.

We firstly confirmed that these cells anesthesioldecision to pursue an cesareansection sectionand andwere wereable abletotosuccessfully successfullyculture culturethese thesecells cellsininvitro. vitro.We Wefirstly firstlyconfirmed confirmedthat thatthese thesecells cellsobstetric cesarean ogy fellowship. express PGRMC1 protein (figure 1).

IMAGES. Amnion Mesenchymal Cells Express Vimentin (A). Amnion mesenchymal cells express PGRMC1 particularly in the nucleus and express PGRMC1 protein (figure 1). express PGRMC1 protein (figure 1).

Fellowship training in obstetric anesthesia perinuclear as well (B). Merged image demonstrating that mesenchymal cells which express vimentin also express PGRMC1 (C). at Duke University Medical Center enhanced Figure 1.skills Amnion mesenchymal Figure Amnion mesenchymal Figure 1. 1.

Amnion mesenchymal my clinical and expertise in managing cells express vimentin (A). cells express vimentin (A). and cells express vimentin (A). high-risk obstetric patients introduced Amnion cells Amnion mesenchymal cells fellowAmnion mesenchymal cells me tomesenchymal research.

During this one-year express PGRMC1 particularly in express PGRMC1 particularly inreexpress PGRMC1 particularly ship, my research focused oninmethods to nucleus and perinuclear thethe nucleus and perinuclear as as nausea, the nucleus and perinuclear as and duce or eliminate hypotension, well (B).

Merged image well (B).

Merged image vomiting, complications well (B).common Merged image associated demonstrating that demonstrating that mesenchymal with spinal anesthesia cesarean delivery. demonstratingmesenchymal thatformesenchymal cells which express vimentin also for cells which express vimentin also This experience laid the groundwork my cells which express vimentin also express PGRMC1. express PGRMC1. research career. express PGRMC1.

(A) Vimentin

(B) PGRMC1

(C) Merged PGRMC1 and Vimentin

Basedononemerging emergingevidence evidencethat thathas hasbeen beenpublished publishedsince sincethe theDIG DIGsubmission submissionthat thatPGRMC1 PGRMC1may mayexert exertitsits Based Based onindependent emerging evidence that haswebeen published since the DIG submission that PGRMC1 may exert its effects independent progesterone, wefirstly firstly determined the role PGRMC1ononcytokine cytokine induced MMP1 effects ofofprogesterone, determined the role ofofPGRMC1 induced MMP1 effects independent of progesterone, we firstly determined the role of PGRMC1 on cytokine induced MMP1 expressionininamnion amnionmesenchymal mesenchymalcells. cells.Using UsingPGRMC1 PGRMC1siRNA siRNAtotospecifically specificallyinhibit inhibitPGRMC1 PGRMC1protein protein expression expression inweamnion mesenchymal cells. regulates Using PGRMC1 siRNA to specifically inhibit PGRMC1 protein expression wedemonstrated demonstrated thatPGRMC1 PGRMC1 regulates Interleukin-1 induced MMP1gene gene expression, protein expression that Interleukin-1 induced MMP1 expression, protein DRE AMC AMPAIGN.DUHS.DUKE.EDU BluePrint 2015 | expression we demonstrated that PGRMC1 regulates Interleukin-1 induced MMP1 gene expression, expression and activity in amnion mesenchymal cells (Figure 2 and 3).

Interestingly TNFα did not induce expression and activity in amnion mesenchymal cells (Figure 2 and 3). Interestingly TNFα did not induce protein MMP1gene gene expression proteinexpression. expression. cells (Figure 2 and 3). Interestingly TNFα did not induce expression andexpression activity inoror amnion mesenchymal MMP1 protein

MMP1 gene expression or protein expression.

Figure 2.IL-1β (but Figure 2.IL-1β (but notnot 08_BluePrint2015_DIG.indd 27

TNFα) induced MMP1 gene TNFα) induced MMP1 gene Figure 2.IL-1β (but not expression amnion expression in in amnion

TNFα) induced MMP1 gene

Figure 3.IL-1β (but Figure 3.IL-1β (but notnot TNFα) induced MMP1 TNFα) induced MMP1 Figure 3.IL-1βin(but not protein expression protein expression in

TNFα) induced MMP1

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DREAM Innovation Grant (DIG) 2015 Recipients Final Progress Reports & Findings

Atilio Barbeito, MD, MPH 2015 DIG RESEARCH PROJECTS

Using Health Information Technology to Bridge the Quality Gap in Anesthesiology

Atilio Barbeito, MD, MPH

Assistant Professor of Anesthesiology VAMC Division

The DIG Award is allowing us to develop and implement an intuitive and easy-to-use web-based quality improvement dashboard for anesthesiologists. Progress so far includes a literature review on audit and feedback interventions, and the initial stages of the development of quality metrics using a ‘human-centered’ approach. Simultaneously, there has been significant progress towards the development and refinement of the dashboard using data visualization tools, and coordination with the Health System for the acquisition and implementation of the IT infrastructure necessary for its deployment.

FIGURES. Personal Quality Improvement Dashboard for Anesthesiologists (Prototype)

Background

I grew up in Buenos Aires, Argentina, where I studied medicine. My father, also an anesthesiologist, exposed me early on to this specialty.

When the time came to find a residency program, I sought Duke as a place where I could find excellent training in clinical care and a solid foundational training for an academic career in anesthesiology. I found this and much more.

After completing internship, residency, and a fellowship in Cardiothoracic Anesthesiology, I accepted a position as faculty in the department.

As I began my practice, I was heavily influenced by the words of Dr. Urbach and others, who pointed out, “The immediate challenge to improving the quality of surgical care is not discovering new knowledge but rather how to integrate what we already know into practice.”

Taking these words very seriously, I began trying to find solutions to common problems in order to make healthcare delivery safer and more effective. To do this, I pursued training in Public Health at the University of North Carolina – Chapel Hill, which I completed in 2012. Since then, I have been working to improve the way we deliver care around the time of surgery both at Duke and at the Veterans Affairs Medical Center.

While anesthesiologists know a lot about each patient they care for, they rarely ‘see’ their practice as a whole in one place, or have the opportunity to compare the different aspects of their performance to that of their peers or to internal or external benchmarks. This dashboard will allow clinicians to (literally) see and interact with large amounts of information about their operating room (OR) practice, so they can learn continuously and focus their improvement efforts.

After choosing a date range for exploration, the dashboard will display the total number of cases and hours spent in the OR, and the proportion of cases done under each anesthetic technique (top-left figure). The tree map (bottom-left figure) shows the time spent with each surgical specialty (color) and each surgeon (boxes). The map can be used as a filter, allowing drill-down into those specific cases as needed. On the top-right, the dashboard displays information on the provider’s patient population: ASA class (a measure of the degree of sickness), and age distribution. On the bottom-right, an efficiency metric (anesthesia ‘prep time’ - theFigure number of taken to induceofanesthesia and place lines), and an effectiveness metric (mean PACU length of stay - how long patients stay in the 2.minutes Latest version the Quality Improvement Dashboard for Anesthesiologists. recovery area before being discharged to the ward) are displayed. This last metric is also shown over time, so that provides can track their progress.

Figure Courtesy of Dr. Atilio Barbeito

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DRE AM INNOVATION GR ANT (DIG) 2015 RECIPIENTS

DE VELOPING RESE ARCH E XCELLENCE IN ANESTHESIA MANAGEMENT

Jennifer E. Dominguez, MD, MHS 2015 DIG RESEARCH PROJECTS

Obstructive Sleep Apnea in Pregnancy: Development of a Pregnancy-Specific Screening Tool

Our study, Obstructive Sleep Apnea in Pregnancy: Development of a Pregnancy-Specific Screening Tool, is well underway with the help of a team of energetic coordinators from Clinical Anesthesiology Research Endeavors (CARE), funded by the DREAM Innovation Grant.

TJ GAN DIG AWARD To date, we have enrolled 35 percent of our target enrollment for this Jennifer E. Dominguez, MD, MHS pilot study, and we hope to complete enrollment in January 2016.

Assistant Professor of Anesthesiology The pilot data we are collecting will be crucial towards securing Womens Division additional funding to expand this work. We are applying for a number of grants to continue this line of research this fall. Dr. Dominguez was recently awarded a Faculty Flex Voucher to build a REDCAP database for the study, and that project is nearly completed. Plans are underway for collaboration with another sleep medicine researcher at Duke, as well as for a multi-center study with researchers from other institutions.

Boyi Liu, PhD 2015 DIG RESEARCH PROJECTS

Investigating Mechanisms Underlying Pathological Itch Conditions

In our previous study, we found that blocking endogenous pruritus signaling pathways reduces pruritus responses in a mouse model of oxazolone-induced allergic contact dermatitis (ACD). Therefore, our central hypothesis is that pruritus associated with Boyi Liu, PhD poison ivy-induced ACD is ameliorated by Assistant Professor of Anesthesiology blocking the endogenous pruritogens and Basic Sciences Division pruritus pathways identified in the proposed study. To test our hypothesis, we have established a unique mouse model of poison ivy-induced ACD using the major allergen urushiol. Preliminary studies have shown that urushiol-challenged mice experience skin inflammation and chronic pruritus that mimic key features of poison ivy ACD in humans. To determine the global gene changes and seek for novel itch mediators in the skin, we performed the most up to date mouse transcriptome microarray (Affymetrix GeneChip® Mouse Transcriptome Assay 1.0).

The expression of typical inflammatory mediators or immune markers in urushiol and oxazolone-treated skin are studied. We have identified some promising targets that are involved in the pruritus caused by urushiol-induced ACD. These data will inform the development of mechanism-based treatments to ameliorate skin inflammation and itch in this increasingly prevalent dermatitis condition in the U.S.

Background

I am a first-generation American, born to Cuban parents who immigrated to the U.S. as children following the Cuban Revolution. I graduated from Duke University with a Bachelor of Arts. While I was an undergraduate, my interest in women’s health was kindled out of personal tragedy when my mother died of breast cancer at a young age. I saw the need for additional research in women’s health, and for three years prior to medical school, I worked on a clinical study looking at the effects of anorexia nervosa on the skeletons and reproductive systems of young women.

While attending the Yale School of Medicine, I received a fellowship from the Howard Hughes Medical Institute to develop a study that used brain imaging to look for differences in neurotransmitter levels in the brains of new mothers that could potentially predispose them to postpartum depression.

During medical school, I was captivated by my rotations in anesthesiology. I loved that it was interdisciplinary, that you could care for a diverse patient population, alleviate pain and suffering, and provide life-saving intensive care.

I stayed on at the Yale School of Medicine for a residency in anesthesiology and completed an obstetric anesthesiology fellowship before becoming an assistant professor at Duke University Medical Center. I have had the opportunity to be constantly challenged by complex patients, and to design and implement my own research studies with the help of excellent mentors and collaborators, ultimately improving the quality of care we deliver our patients.

Background

In 1976, my hometown was struck by the Great Tangshan Earthquake, the largest earthquake of the 20th century which claimed more than 240,000 lives. My parents were among the generations who devoted their lives to the reconstruction of our hometown. The Great Earthquake taught us how to be strong, persistent and optimistic in our lives. I received my Bachelor’s Degree in Pharmaceutics from Hebei Medical University, China. After college, I went on to pursue my M.S. and Ph.D. in Pharmacology from Hebei Medical University. I received a lot of inspiration and encouragement from my mentor, Dr. Hailin Zhang, and became deeply interested in ion channel studies.

I received an award from the China-U.K. Joint Laboratory for Membrane Biology and visited Dr. Nikita Gamper’s lab at the University of Leeds, U.K., for four months. Under the guidance of Drs. Gamper and Zhang, I became the first scientist to identify the molecular mechanisms underlying bradykinin (one of the most endogenous algogens) induced inflammatory pain. This project also ignited my tremendous interest in pain and neuronal sensory biology.

After earning my Ph.D., I joined the lab led by Dr. Sven-Eric Jordt, one of the leading scientists in the world, studying mechanisms of counterirritant and neurobiology of sensing at Yale School of Medicine. After my postdoctoral training at Yale, I moved with Dr. Jordt to Duke University Medical Center and started my academic career as an assistant professor in the Department of Anesthesiology where I am currently studying the mechanisms underlying analgesia, skin inflammation and pruritus (itch).

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Police officers using tear gas during the first wave of the Ferguson, Missouri unrest.

A Novel Perspective in Pain Research

By Ratna Swaminathan In August 2014, riots broke out in Ferguson, Missouri after an African American teen, Michael Brown, was fatally shot by police. As a means of control Sven-Eric Jordt, PhD over the rioting, police used tear gas to disperse crowds.

The question remains whether the use of tear gas on the civilian population is a safe riot-control measure.

Duke researcher and Professor of Pharmacology, Sven-Eric Jordt, PhD, doesn’t think so. “I consider tear gas as a nerve gas that activates pain-sensing nerves,” said Dr. Jordt during an interview with MSNBC in the wake of this aftermath.

This leading expert describes the physiological effects of tear gas on people as: 1. Very intense pain 2. Disorientation 3. Profuse secretions in the eyes and airways 4. Skin burns 5. The feeling of potential asphyxiation due to choking For Dr. Jordt, this issue is personal and one that evokes strong emotion. As a student in Germany, he was exposed to tear gas while peacefully demonstrating against nuclear waste transport in the late 1980s.

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3D-model of CS gas, more commonly known as tear gas

Describing it as “shocking,” the experience influenced his future research. Dr. Jordt began thinking about the long-term effects of tear gas and other similar noxious, reactive gases and vapors. He sought to reveal the damage it may have on human airways and whether lung function is reduced in the people exposed to them.

Dr. Jordt expressed the need to redefine these agents as more than harmless and irritating. “They are also corrosive and form covalent bonds with proteins in the body.

The fate of this chemical damage has not been studied at all—how long it persists and what the effects on the nerves are.”

Prior to moving his laboratory from the Yale University School of Medicine to the Duke Department of Anesthesiology, Dr. Jordt spent the past nine years spearheading a $6 million study on tear gas and chlorine. It was funded by a special National Institutes of Health (NIH) program called Countermeasures Against Chemical Threats (CounterACT) which was formed after the tragic events that ensued on September 11, 2001. It focused on identifying treatments for injuries caused by chemical weapons or

other highly toxic agents, which terrorists could use to potentially cause harm. In 2006, Dr. Jordt received the Presidential Early Career Award for Scientists and Engineers, an award given by the National Science and Technology Council (NSTC) to recognize and honor outstanding scientists and engineers at the outset of their independent research careers.

The purpose of Dr. Jordt’s study is to determine whether those exposed to these agents become desensitized or develop potentially neuropathic conditions, such as chronic pain or numbness. Experts say these chemicals should be considered similar to other environmental toxins from a mechanistic perspective and studied in a similar manner.

Until now, data on tear gas exposure has been unclear. Those exposed to tear gas are typically demonstrators who disperse quickly and cannot or do not seek out follow-up care. Politics is also a factor; governments are less likely to fund studies on the impact of this riot-control measure. Interestingly, the 1993 Chemical Weapons Convention bans the use of tear gas against adversaries in warfare, but its use continues as a measure to quell domestic riots by countries worldwide.

In fact, calling tear gas a gas is actually misleading. These aerosolized canisters contain solid or liquid substances that are dispersed in chemical solvents at very high temperatures. The chemicals commonly used today include oleum capsicum (commonly referred to as pepper spray or OC spray/gas) and 2-chlorobenzalmalononitrile (commonly referred to as tear gas or CS gas). Inhaling tear gas, a highly elec-

Photo Source (Above): “CS-gas-3D-vdW ”. Licensed under Public Domain via Commons https://commons.wikimedia.org/wiki/File:CS-gas-3D-vdW.png#/media/File:CS-gas-3D-vdW.png

9/21/15 11:13 AM

Photo Source: “Exploded tear gas can on the fly” by Original: User Ντουντούκα, φτώχεια και φιλότιμο of Athens Indymedia. Cropped and enhanced

by Badseed - Athens Indymedia which is licensed under CC-BY-SA 2.0. Image page: [1], descr page: [2]. Licensed under CC BY-SA 2.0 via Commons https://commons.wikimedia.org/wiki/File:Exploded_tear_gas_can_on_the_fly.jpg#/media/File:Exploded_tear_gas_can_on_the_fly.jpg

Tear Gas

Photo Source (Above): “Ferguson Day 6, Picture 4 4” by Loavesofbread - Own work. Licensed under CC BY-SA 4.0 via Commons https://commons.wikimedia.org/wiki/File:Ferguson_Day_6,_Picture_4 4.png#/media/File:Ferguson_Day_6,_Picture_4 4.png

InnovativeResearch

Photo Source: “Exploded tear gas can on the fly” by Original: User Ντουντούκα, φτώχεια και φιλότιμο of Athens Indymedia. Cropped and enhanced

by Badseed - Athens Indymedia which is licensed under CC-BY-SA 2.0. Image page: [1], descr page: [2]. Licensed under CC BY-SA 2.0 via Commons https://commons.wikimedia.org/wiki/File:Exploded_tear_gas_can_on_the_fly.jpg#/media/File:Exploded_tear_gas_can_on_the_fly.jpg

Photo Source (Above): “Ferguson Day 6, Picture 4 4” by Loavesofbread - Own work. Licensed under CC BY-SA 4.0 via Commons https://commons.wikimedia.org/wiki/File:Ferguson_Day_6,_Picture_4 4.png#/media/File:Ferguson_Day_6,_Picture_4 4.png

trophilic agent, can lead to complications, especially in people with asthma, Dr. Jordt informs. While its impact in open spaces is reduced, in confined spaces it can even lead to death due to asphyxiation, he adds, citing a 2013 case in Egypt where 37 people died when a tear gas canister exploded inside a vehicle.

Following his PhD from Free University in Germany, Dr. Jordt’s tear gas research took direction during his post-doctoral fellowship in 1998 at the University of California, San Francisco (UCSF). In 2005, he set up a pain research laboratory at Yale.

He views his tear gas research as a logical progression from his studies on the effect of natural products, like menthol and chili peppers, among others. More specifically, these studies focused on the receptors in the peripheral sensory neurons that induce sensations like cooling, pain or irritation.

Some natural products are dangerous when inhaled, leading to bronchoconstriction and laryngospasm, and can even compromise respiratory function.

In 2003–2004, Dr. Jordt identified a new receptor that interacted with the pungent ingredients in mustard oil. The receptor detects these electrophilic chemicals based on their chemical reactivity. The mustard agents bond with the receptors and modify them. It’s basically a toxic reactivity detector that induces pain and forces people to remove themselves from the exposure. Greater exposure can lead to bodily injury through chemical reactivity, he explains. “There are a lot of very toxic elements in our environment, and this receptor’s function is to detect and warn us of their presence.”

Eventually, the Jordt team expanded its pain research to further investigate

Exploded tear gas canister on the fly.

“I consider tear gas as a nerve gas that activates painsensing nerves.”

Sven-Eric Jordt, PhD Associate Professor in Anesthesiology

the role of the transient receptor potential ankyrin-1 (TRPA1), an ion channel that detects reactive chemiDr. Sven-Eric Jordt in his Chemical Sensing, Pain and Inflammation Research Laboratory, cals. Such hazardous enlocated at the Snyderman Genome Science Research Building, Duke University. vironmental agents cause eyes to burn by activation tion. The team comprises researchers of these receptors, like Acrolein – a noxSatya Achanta, PhD, Anabel Caceres, PhD, ious irritant found in smoke emanating from fires and tobacco. Acrolein was used Melanie Kaelberer, BS, and Boyi Liu, PhD,

by French troops as a tear gas against the who accompanied him from Yale, as well German troops in World War I. It was later as postdoctoral associate, Sairam Jabba, PhD, and lab assistant, Pamela Bonner. replaced by much more toxic agents, like They also hope to further study the efchlorine gas and phosgene. fects of inhaled anesthetics on nerves, in At the Chemical Sensing, Pain and addition to their studies on skin inflammaInflammation Research Laboratory, Dr. tion in dermatitis, mechanisms of asthma Jordt and his six-member team are gainand lung injury, and the health effects of ing a greater understanding of how the smoking, including e-cigarettes. In the compounds in tear gas have a chemical Department of Anesthesiology, Dr. Jordt’s corrosive effect on the epithelial lining, lab group is advancing basic research in thus causing burns and modifying cells. pain and lung injury by carefully looking Studying the nerve pathways of pain, Dr. at the molecular components of signaling Jordt published papers in 2006 and 2009 pathways in peripheral sensory neurons explaining the neurological impact of tear that translate environmental stimuli into gas. While a study on pulmonary injury neural activity. They are also involved in is also under way, efforts are ongoing to educational efforts at the medical school. shed light on the chemical reactivity of Driven by great research on pulmonary tear gas with proteins in the skin to deinjury at Duke, Dr. Jordt finds his lab nicely termine whether the impact of exposure ensconced in the heart of a research-rich is permanent or reversible. The idea is to area and a stone’s throw away from other identify some potential treatments that major research institutions, including the can reduce the pain in the TRPA1.

National Institute of Environmental Health The lab hopes to collaborate with the Sciences, Laboratories at the Environmenpharmaceutical industry to develop tal Protection Agency, and the University countermeasures that could potentially of North Carolina, among others. Always reduce the acute pain caused in individulooking ahead, Dr. Jordt has plans to proals exposed to these noxious agents. “We cure greater NIH funding and set up a pain can also find ways to decontaminate by research center at Duke that would assist topical treatments, washing, and adding certain chemical scavengers that will in a bench to the bedside approach. deactivate the tear gas,” he adds.

Under Dr. Jordt’s direction at Duke AnIn addition to tear gas research, Dr. esthesiology, researchers are continuing Jordt’s team is researching the chemosenhis seminal work by uniting together and sory mechanisms that allow humans and increasing the department’s footprint in animals to sense touch, pain and irritapain research. n BluePrint 2015

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InnovativeResearch

A Shorter Path to Recovery Enhanced Recovery After Surgery (ERAS)

By Ratna Swaminathan Consider this. You’ve been anesthetized, operated upon, awakened with minimal pain and are ready to start eating, drinking, and even walking on the Timothy E. Miller, day of surgery! Your MB ChB, FRCA overall hospital stay is shortened by two to three days and you resume your daily activities earlier than expected after major surgery.

Early recovery is what most patients desire. At Duke University Medical Center, anesthesiologists are gaining significant progress to help make that happen. In fact, they’re ahead of the curve in helping patients who undergo abdominal surgery return to normal function more quickly.

With patient contact throughout the perioperative setting, anesthesiologists find themselves in a unique position to have significant input in the enhanced recovery of their patients.

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Enhanced Recovery After Surgery (ERAS).

These Enhanced Recovery Programs (ERPs) have the patient’s best interest in mind. They integrate the best perioperative interventions which have been proven to maintain physiological function to facilitate postoperative recovery after a patient undergoes major surgery. The ERAS protocol follows an evidenced-based structured perioperative regime and uses less invasive surgical techniques, such as laparoscopy. If need be, doctors may also recommend to avoid an operation and instead perform a different clinical treatment method, such as radiation therapy or chemotherapy, explains Dr. Miller.

The idea behind these ‘fast-track’ surgery pathways is to accelerate postoperative recovery and reduce morbidity after major surgery. The future of perioperative medicine, says Dr. Miller, will need greater partnerships between anesthesia, surgery, nursing and other providers to improve healthcare delivery (Figure 1). It starts with the pre-operative counseling of the patient, management during the surgery and increased efforts postoperatively for enhanced recovery. Dr. Miller explains, “It attenuates stress response and increases patient participation preoperatively and

Duke University Hospital Operating Room

during the recovery period.”

Recovery after anesthesia and surgery is a complex process contingent on patient, surgical and anesthetic factors, as well as the presence of any adverse pre-existing conditions. Evidence suggests that some patients experience a functional decline after major surgery. It could take up to several months before patients regain their ability to perform activities as they could prior to surgery. Dr. Miller says, “The ERPs encourage early feeding and mobilization after surgery to reduce this dip in function so patients are ready to leave the hospital and return to normal life earlier after major surgery. The ERPs also use less lines and tubes than traditional surgery, which all patients prefer!”

This is how it works (Figure 2): Patients Figure 1. The ERAS Inter-Disciplinary Team

Surgeon Anesthesiologist Nusing Staff Physical Therapist Nutritionist Social Worker Patient Educator/ Liaison ADAPTED FROM: Nanavati, A. J., & Prabhakar, S. (2014). Fast-track surgery: Toward comprehensive peri-operative care. Anesthesia, Essays and Researches, 8(2), 127–133. doi:10.4103/0259-1162.134474

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Figure 2. Components of Enhanced Recovery

Pre-operative Interventions • Evaluation and optimization of existing organ function • Ensure good nutritional status • Improve physical fitness with daily exercise encouraged • Smoking cessation advice • Patient education regarding entire process • Minimal starvation (2h -liquids, 6h -solids) • Oral carbohydrate drink • Selective mechanical bowel preparation

Intra-Operative Interventions • Antibiotics before incision • Multimodal analgesia • Regional anesthesia (wherever possible) • Goal directed fluid administration • Maintaining normothermia • Minimally invasive surgery (wherever possible) • Tubes and catheters removed in the operating room

Post-operative Measures • Continue multimodal analgesia • Postoperative nausea and vomiting prophylaxis and / or treatment • Diet and mobility begin night of surgery • Information about post-discharge resources and care • Ensure followup after discharge ADAPTED FROM: Nanavati, A. J., & Prabhakar, S. (2014). Fast-track surgery: Toward comprehensive peri-operative care. Anesthesia, Essays and Researches, 8(2), 127–133. doi:10.4103/0259-1162.134474

are first seen in the preoperative screening clinic. Here the team reviews their history and prepares them for the ERP. Patients are encouraged to drink clear fluids until one our before arriving at the hospital for surgery. “This makes patients feel better, and is safe and effective,” explains Dr. Miller.

To avoid preoperative hunger and help maintain strength, patients are also asked to consume a carbohydrate drink one hour before arrival. “If anyone was going to run a marathon they would carb load beforehand and major surgery is similar.”

While asleep during surgery, the patients are given customized fluid therapy and multimodal analgesia with different pain

medications. This typically involves placement of a nerve block, such as an epidural catheter, to reduce postoperative pain and avoid the need for opioids. Simple painkillers, like acetaminophen and ibuprofen, are important parts of this multimodal method. “With this approach, patients should awaken rapidly with minimal pain, and be ready to start eating, drinking and sitting up in a chair on the day of surgery.”

Fluid management and early ambulation are key components of the ERAS protocol.

Dr. Miller warns that the correct amount of fluid is crucial for the recovery of gut function. “Too much or too little can slow down gut function, similar to gastroenteritis, in that the patients feel bloated, sick and cannot eat normally.”

This new approach is a departure from traditional postoperative management. In fact, it’s like turning an established method on its head. Before ERPs were implemented, doctors rested the gut for two to three days after major surgery because of concerns about the anastomosis. In today’s ERAS protocol, there is evidence that feeding patients immediately after surgery is safe and beneficial. Feeding stimulates gut function and helps the patient’s nutritional state, thereby encouraging healing and reducing infection.

Additionally, the anesthesiologist must administer a suitable anesthetic that allows patients to awaken rapidly with minimal pain, prevent postoperative nausea and vomiting, and is in a fluid-optimized state.

Optimal analgesia facilitates early mobilization and reduces pulmonary and thromboembolic complications. Individualized fluid therapy enables cells to have adequate oxygen and nutrient delivery. By carefully avoiding fluid overload, the risk of ileus and other gut dysfunction is greatly reduced.

Importantly, chances of wound and urinary tract infection are also lessened when the length of stay in a hospital is reduced by two to three days. “This is a significant change in postoperative pathways that has benefitted patients,” Dr. Miller adds.

A protocol that inaugurated with colorectal surgeries has now expanded to include those in urology and gynecology as well as major surgeries of the pancreas, breast reconstruction, and hip and knee replacement. “We will shortly be starting pathways in liver surgery and kidney transplantation.”

When Dr. Miller came to Duke in 2007 from the United Kingdom, the use of this new protocol was just starting in Europe.

Dr. Miller has taken this effort to a national level with the mentorship of former Professor of Anesthesiology and the Vice Chair of Faculty Development, Tong Joo (TJ) Gan, MD, FRCA (UK), who is now Chair of the Department of Anesthesiology at SUNY Stony Brook Medicine. Together, they organized the first national Enhanced Recovery meeting in Washington, D.C. in 2013, with more than 100 attendees. They also subsequently founded the American Society for Enhanced Recovery with Dr. Gan as its first President and Dr. Miller as Vice President. More than 450 attendees from 34 countries were present at the recent first annual World Congress of Enhanced Recovery in Washington, D.C., held in conjunction with the ERAS Society from Europe and EBPOM group from the U.K. Interest is growing rapidly in this patient-centered care protocol, both nationally and internationally. With Duke spearheading the ERAS efforts, the journey ahead is promising for Dr. Miller as he continues to develop more ERPs. The hope is that in five to 10 years, patients will receive a new standard of care that reduces complications, length of stays and healthcare costs. n Sources: • Segelman, J., & Nygren, J. (2014). Evidence or eminence in abdominal surgery: Recent improvements in perioperative care. World Journal of Gastroenterology : WJG, 20(44), 16615–16619. doi:10.3748/wjg.v20.i44.16615 • Miller, T. E., & Mythen, M. (2014). Successful recovery after major surgery: moving beyond length of stay. Perioperative Medicine, 3, 4. doi:10.1186/2047-0525-3-4

Table. Key Points Traditional unstructured perioperative care is still common The ERAS protocol is an evidence-based structured perioperative regime The ERAS program improves postoperative recovery and reduces morbidity More research is needed on cost-effectiveness, long-term outcomes, quality of life, and patientrelated outcomes Regional and national strategies to support the implementation of evidence-based perioperative care in general health care are warranted SOURCE: Segelman, J., & Nygren, J. (2014). Evidence or eminence in abdominal surgery: Recent improvements in perioperative care. World Journal of Gastroenterology : WJG, 20(44), 16615–16619. doi:10.3748/wjg.v20.i44.16615

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From the Lab

From Mountain High to Valley Low Exploring New Scientific Frontiers with the Duke Human Pharmacology and Physiology Lab

By David B. MacLeod, MB, BS, FRCA, and Lauren Marcilliat

The HPPL is housed within the Duke Clinical Research Unit (DCRU) and does a combination of anesthesia-related equipment, pharmacology, and human physiology studies on healthy human subjects. Experiments are conducted in (Left to Right) The HPPL team: Antoinette Santoro, BSRT, a controlled setting with David B. MacLeod, MB BS, FRCA, and Daniel DeMasi. extensive physiological monitoring and without the confounding issues of surgery and anesthesia. These studies are important because they provide insight into the mechanisms of human pathophysiology and help identify new drugs and technology with the potential to improve patient outcomes.

The HPPL team is comprised of Director, David B. MacLeod, MB BS, FRCA, Clinical Research Coordinator, Antoinette Santoro, BSRT, and Clinical Trial Assistant, Daniel DeMasi. Additionally, Duke Anesthesiology attending physicians and CRNAs help to run studies on an as-needed basis.

HPPL staff work closely with the Duke Institutional Review Board (IRB) to ensure the safety and well-being of their subjects. “Every study is meticulously planned and executed,” says Dr. MacLeod.

“Working with healthy subjects is challenging because they must 34

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trust you explicitly while they receive no medical benefit from the study. In my ten years as director, I am proud to say that we have safely conducted every one of the studies with no serious adverse events, totaling over 600 human subjects.”

The Human Pharmacology Lab (HPL as it was originally called) initially focused exclusively on pharmacokinetics and was established in the mid-1980s by Professor Peter Glass. Here, he made several important advances in anesthesia care, such as the initial studies on BIS monitor and the concept of context-sensitive halftimes of intravenous anesthetics and analgesics. In 1999, Jacques Somma, MD, took over the lab, and began a collaboration with Dr. MacLeod, who was a new faculty member at the time.

Under Dr. Somma’s direction, Dr. MacLeod quickly gained expertise in conducting Phase I studies and found that he thrived in the unique environment that the HPL offered. When Dr. Somma left Duke in 2006, Dr. MacLeod took over as director.

Under Dr. MacLeod’s leadership, the HPL lab expanded its focus and scope of work to become the HPPL lab. The following three studies serve as examples of how the HPPL lab has grown both at home and abroad under Dr. MacLeod’s directorship:

Hypoxia Studies at the Pyramid Lab

Dr. MacLeod’s experience in the placement jugular bulb venous catheters and controlled oxygen desaturation as part of cerebral oximeter validation studies to estimate brain tissue oxygen saturation led to an initial collaboration with the University of British Columbia, Okanagan (UBCO), Canada to study cerebral blood flow (CBF) during hypoxia in 2011. The team studied changes in regional cerebrovascular response to acute changes in blood gases with use of a Transcranial Doppler (TCD) to measure intracranial velocities of middle and posterior cerebral arteries and the simultaneous use of Duplex vascular ultrasound to measure the extracranial blood flow of the internal Arterial catheter placement at 5050m in the Pyramid Lab carotid and vertebral (Nepal) with the Lobuche Glacier in the background.

Photos and Figures Courtesy of Dr. David B. MacLeod

To work at the Duke Anesthesiology Human Pharmacology and Physiology Lab (HPPL), one must exhibit equal competence in both the clinical and research setting and the ability to seamlessly transition between the two. A passion for discovery, strong people skills, and a healthy dose of wanderlust certainly don’t hurt either.

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(Left-hand Image) Blood gas syringes in preparation for desaturation sequence.

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RespirAct screen-shot of the last 15 minutes of controlled oxygen sequence to 70%. Measured breath-by-breath end-tidal oxygen targets of 45, 42 and 37 mmHg shown.

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arteries. The study showed greatest reactivity within the vertebral arteries, with more blood flow to the brainstem than to the cortex during extreme hypoxia. The use of portable, lightweight equipment was ideally suited for cerebrovascular measurements during the team’s three-week stay at the world’s highest meteorological station, The Pyramid International Laboratory/Observatory, Nepal located just a few miles from Mt. Everest Base Camp. They were able to measure the serial changes during ascent from sea level to high altitude (5050m) and subsequent acclimitization.

Cerebral Blood Flow During Static Apnea

Photos and Figures Courtesy of Dr. David B. MacLeod

The publication of the 2011 CBF study led to an invitation from the University of Split, Croatia to collaborate in a study of CBF in elite, competitive breath-hold (apnea) divers. All procedures were conducted in the physiology lab where the subjects remained dry throughout. In the first run, the subjects performed a maximal breath-hold (apnea) during which serial arterial blood gases were drawn. This provided an arterial oxygen and carbon dioxide profile for each individual subject. For the second run, the subjects breathed a controlled gas mixture that replicated (‘clamped’) the identical arterial blood gas profile from the first run. With the subject breathing spontaneously the effects of sustained intra-thoracic pressure and involuntary breathing movements during

Single subject showing facial features at the start (top-left) and completion (top-right) of apnea with corresponding arterial blood gases. The graph depicts the mean values of arterial oxygen and carbon dioxide blood gas tensions for the study cohort during apnea (solid line) and clamp (dotted) sequences.

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apnea were eliminated. The changes in blood gases were certainly impressive to witness with some individuals attaining oxygen saturations as low as 35 percent. The key finding from this study was that cerebral oxygen delivery was maintained throughout the duration of apnea with CBF increasing 61 62 63 64 65 by nearly 100% and adequately offsetting an ever-decreasing arterial oxygen content of blood.

Compensatory Reserve Index Studies

Hemorrhage is a common cause of preventable death both on the battlefield and in civilian trauma. The Department of Defense (DOD) has a strong interest in developing a clinical monitor to assist military medical personnel on the battlefield to identify shock at the earliest possible stage. Individuals vary in their ability to compensate for blood loss, and each person will collapse at a different absolute volume loss. The DOD funded the development of the Compensatory Reserve Index (CRI) by Flashback Technologies (Boulder, CO), to model the proportion of this absolute volume loss remaining before the individual reaches cardiovascular collapse. In this way, CRI provides an estimate of an individual’s cardiovascular ability to deal with ongoing hypovolemia. A proprietary algorithm is applied to the photoplethysmograph (PPG) from a standard pulse oximeter to calculate the CRI, which ranges from 0 – 1, with a normal value greater than 0.7. The initial calibration and validation of CRI was conducted in healthy volunteers through simulated hemorrhage using lower body negative pressure chamber to divert blood from the thorax into the lower extremities until the subjects reported pre-syncopal symptoms, a sharp fall in systolic blood pressure or heart rate, or the systolic blood pressure dropped to 70 mmHg. In order to gain FDA approval for clinical use a study in healthy volunteers was performed in which 20 percent of estimated total blood volume (ranging from 600 – 1500 mL) was removed over a period of 60 min, followed by re-transfusion. The changes in CRI correlated well with the reduction in stroke volume, measured by Nexfin continuous cardiac output monitor; in contrast, the standard cardiovascular parameters such as heart rate and blood pressure showed very little change.

The results of the first cohort of 20 subjects were published in “Shock” journal earlier this year. A further study is planned for 2015 to validate a new algorithm to assess the adequacy of volume resuscitation during blood transfusion following 25 percent blood volume removal.

Examples of studies planned for the HPPL in the next year include an investigator-initiated study to develop a method to identify individuals at risk of opioid-induced respiratory depression and a sponsor-initiated Phase 1 study of new anesthetic intravenous agents. “I feel very fortunate that the department and my division chief [Gavin Martin, MB ChB, DA, FRCA] allow me the flexibility to combine my clinical time with research time in the HPPL,” says Dr. MacLeod. “It’s a very unique position in the department, and I am honored to further the Duke Anesthesiology mission by serving as its director.” n BluePrint 2015

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New Chairman at the Helm Dr. Joseph P. Mathew

By Ratna Swaminathan

On March 24, 2015, an email message arrived in the inboxes of the entire Duke faculty and staff informing them that Joseph P. Mathew, MD, Jerry Reves, MD, Professor of Anesthesiology, had been appointed the permanent Chairman of the Department of Anesthesiology at Duke University Medical Center. Immediately, in his characteristic unassuming fashion, Dr. Mathew began planning, strategizing, and diligently putting momentum into his plan to create a department that “will not be matched for another 100 years.”

Spend some time with him and you come away with the impression of a humble, yet self-assured, soft-spoken man, whose demeanor is calm and determination firm in what he wants to do and get done. Chief of the Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Dr. Mihai Podgoreanu, whose association with his mentor and friend spans 20 years, says “Joe is able to take a bigger 100-year vision and break it down into bite-size deliverables. In other words, he is able to zoom in and out and change lenses very efficiently between the big picture and project execution and management.”

Over the years, Dr. Mathew has proven to be the person who can consistently carry to fruition any research project, no matter how arduous. Recognizing this extraordinary sense of focus that he transfers to the clinical arena with equal ease, Dr. Mathew’s mentor and life coach, Paul Barash, MD, had identified him as a future leader in anesthesiology during his residency at Yale. He notes how this promising resident made patient safety his foremost priority.

“He felt he had a responsibility to the patient and did not want to be relieved until the operation was completed. Basically, Joseph leads by example. To the degree possible, he will be in a clinical setting to serve 36

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as a role model clinician and educator for future generations of Duke trainees.”

When it comes to credentials, Dr. Mathew has a resume 70 pages long! After finishing medical school from Southwestern Medical School in Dallas, Texas, Dr. Mathew completed his anesthesiology residency and fellowship in Cardiovascular Anesthesiology at Yale. There, he served as co-director of the Cardiovascular Anesthesia Fellowship, director of the Transesophageal Echocardiography (TEE) Program, and associate chief of Cardiothoracic Anesthesiology.

Coincidentally, under the chairmanship

“Joe is able to take a bigger 100-year vision and break it down into bite-size deliverables… he is able to zoom in and out and change lenses very efficiently.”

Mihai V. Podgoreanu, MD, FASE Chief, Division of Cardiothoracic Anesthesiology and Critical Care Medicine Associate Professor of Anesthesiology Director, Perioperative Genomics Program

of Joseph G. Reves, MD, Duke was recruiting outstanding faculty from other notable institutions in the 1990s. “One of the keys to building great academic departments is to be able to recruit people who share that goal,” adds Dr. Reves. Identifying Dr. Mathew as a great addition to the Duke team, the then division chief, Mark Newman, MD, recruited him in 1998.

Soon, Dr. Mathew made his mark at Duke.

He served as the director of the Perioperative TEE Service, director of the Neurological Outcome Research Group and the Clinical Research Unit, chief of the Division of Cardiothoracic Anesthesiology, and as executive vice chair of Performance and Operations for the Department of Anesthesiology. “He’s absolutely committed to all the goals of an academic health center, both in outstanding clinical care and education research. And, I think, he really has a concern for the career development and the growth of all faculty, residents and fellows, and that’s where he will continue to excel,” says Dr. Newman.

Funded by the National Institutes of Health, Dr. Mathew’s research on neurocognition and functional neuronal connectivity in the setting of cardiac surgery is path breaking. “Joseph’s research team has made outstanding contributions to an understanding in a number of areas of organ injury during and after cardiac surgery,” adds Dr. Newman. A lead editor of the textbook on perioperative TEE, Dr. Mathew’s other published work includes more than 200 manuscripts and book chapters. He is the current president of the Association of Cardiac Anesthesiologists and was recently elected into the Foundation for Anesthesia Education and Research’s Academy of Research Mentors. Along the way, he acquired an MBA degree to polish his financial and management skills.

“Everything we are is built on the shoulders of those who preceded us,” says Dr. Mathew, drawing inspiration from his predecessors. While the founding chairman,

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NEW CHAIRMAN AT THE HELM

DR. JOSEPH P. MATHEW

“Everything we are is built on the shoulders of those who preceded us.”

Joseph P. Mathew, MD, MHSc, MBA Jerry Reves, MD, Professor of Anesthesiology and Chairman Department of Anesthesiology

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Merel Harmel, MD, taught him not to be afraid of breaking new ground, Dr. Reves reinforced the value of giving credit to others, and finally, Dr. Newman demonstrated how astute financial management could blend with a sound academic mission.

“True mentors don’t hesitate to tell you when you are doing something wrong or take the opportunity to suggest if something is not optimal,” says Dr. Mathew.

To take a great department to greater heights is admittedly a significant challenge.

Dr. Mathew, however, is ready for it. He believes the best way to predict the future is to create it. His strategy: investing in projects to boost the department’s infrastructure that would help push it forward and grow beyond his chairmanship years. Hence, he is focusing on further strengthening the triumvirate of pillars that already support a strong department - clinical care, education and research. His goals are firmly rooted in Duke Anesthesiology’s mission statement which calls for extraordinary care through a unique culture of innovation, education, research and professional growth.

In the clinical arena, Dr. Mathew proudly points to novel nerve block techniques the Regional Division has developed that enable knee surgery patients to leave the hospital within 24 hours. “That’s changing practice.” Other divisions are also creating enhanced clinical care pathways to improve the quality of care for patients, he adds.

“From an educational perspective, we are trying to come up with new ways of teaching our residents and fellows. The reality is that we’ve been doing it the same way for the past 30 years with some minor tweaks, maybe some cosmetic changes.

But we have the opportunity to really address what it is that we should do substantially different,” says Dr. Mathew. Plans are afoot to hire a specialist to improve the delivery of education and measure its impact. The recently introduced Twitter Journal Club blends a traditional journal club with social media to give residents instant feedback from a global audience.

In research, steps are under way to paint the national face of anesthesiology with Duke Blue brushstrokes. Recent accomplishments include the Vivian Thomas Young Investigator award given to Quintin Quinones, MD, for his work on hibernation biology, and the national recognition for BluePrint 2015

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NEW CHAIRMAN AT THE HELM

DR. JOSEPH P. MATHEW

“He really has a concern for the career development and the growth of all faculty, residents and fellows, and that’s where he will continue to excel.”

Mark F. Newman, MD President and Merel H. Harmel Professor Duke Private Diagnostic Clinic

Madhav Swaminathan, MD, for being the first anesthesiologist to deliver the prestigious Feigenbaum Lecture at the American Society of Echocardiography. These are just two examples that Dr. Mathew cites of Duke (Above) One shared title with a combined 24 years of leadership in the Department of researchers advancing the Anesthesiology. Former chairmen, Mark F. Newman, MD and Joseph “Jerry” Reves, MD frontiers of knowledge. (shown left to right) pose with newly appointed chairman, Dr. Joseph Mathew.

(Below) Dr. Mathew’s contributions to clinical perioperative medicine have long Another big development been recognized in the fields of cardiology, surgery and anesthesiology. to complete an already strong pain program at Duke is the recruitment of a group, led by a world-renowned scientist, that would take basic science pain research to the translational environment and loop it back into the laboratory to understand its mechanisms. “That gives us the opportunity to make real advances in pain management because ultimately the research has to change the way we take care of patients and improve their life and their outcome,” informs Dr. Mathew.

Investing in human capital, leadership with a strong focus on junior faculty career development, forms the cornerstone of his mentorship program, something he learned from his first chairman, lifelong mentor and friend, Dr. Barash. For Dr. Mathew, the department’s strength lies in its people and not in the number he leads.

“I expect Joe to continue in a humanistic manner where people at all levels in the Duke department are treated with respect and their worth to the department is valued as a contribution to its success,” says Dr. Barash. “Joe is a superb mentor and I expect to see this trait infused into all levels of Duke Anesthesiology.”

Interestingly, this specialty is pursued with a passion in the Mathew family. Dr. Mathew’s father was an anesthesiologist and now his son, Jonathan, is an anesthesiology resident at Washington University in St. Louis, Missouri. Dr. Mathew lives in Durham with his wife, Asuncion, and their dog, (Above) Dr. Mathew and his wife, Asun, vacationing in Venice.

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Charlie. His older daughter, Eliza, recently joined the Duke Office of Durham and Regional Affairs, while his younger daughter, Susanna, is a senior at Cedarville University in Ohio, studying social work. His family has always been incredibly supportive of his endeavors, and he is, in turn, recognized as a committed husband, father and son.

Compassion is a hallmark of Dr. Mathew’s practice. “He is always fair, preoccupied with the wellness of the people in his team over the bottom line,” says Dr. Podgoreanu.

Those who have observed Dr. Mathew closely agree that he is self-regulated by a very strong set of core principles that include integrity, humility, faith and perseverance.

There is no place for complacency when it comes to the bottom line too. “Success isn’t owned. It’s leased, and rent is due every day. Every single day someone’s coming for your job, someone’s coming for your greatness. If you’re the greatest, someone else wants to be the greatest.

So if you’re not constantly improving your game, somebody else is.” These words of J.J. Watt, Houston Texans defensive lineman, remind Dr. Mathew that reinventing oneself and the department is what will make good even better, and what is better, great.

There are challenges ahead. A shift towards population health which Dr. Mathew feels calls for a seismic cultural change that would enable faculty engagement beyond the operating room and into the pre and postoperative spaces. With erratic federal funding for research and declining payor resources, innovation through partnership with other specialties and building networks to enroll more patients are essential to boost clinical revenue, he informs.

Dr. Mathew, however, is not worried. Life, he says, is filled with obstacles and the one who figures out how to get around them is the one who succeeds. For now, he will focus on making his vision, to have a department that cannot be matched for the next 100 years, a reality. n

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A Tradition of Excellence DUK E A NE S T HE SI OLO G Y A LUMNI A S S O CI AT I ON Duke Anesthesiology alumni bring their talents and enthusiasm to universities, hospitals, businesses, and patients worldwide. 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. At Duke, we believe that continued engagement with our alumni is the key to our future success.

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As a graduate of Duke Anesthesiology, you are automatically enrolled as a member of the Duke Anesthesiology Alumni Association. Visit the Alumni Database to create a new entry or ensure that your information is current: anesalumni.duhs.duke.edu/alumni

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AlumniNotes

Achieving New Heights Duke Anesthesiology Alumni Spotlight NESTHESIOL EA

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By Lauren Marcilliat

The Duke Anesthesiology family tree is as vast as it is varied. Faculty and trainees come to Duke from all over the world to learn, practice and teach. Some stay for a few months, others stay for a decade or more, but invariably, they disperse like seeds in the wind.

When they go, they take with them a unique mindset, knowledge base, and skill set that are distinctly “Duke” in nature. In this way, the Duke Anesthesiology legacy continues to grow and strengthen in new soil.

This article highlights three individuals whom we are proud to call alumni. Despite their differences, they share a common bond that goes much deeper than a school name listed on their resumes: their initial attraction to Duke, a passion for helping others, profound professional success and a shared legacy.

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Dr. Chester Buckenmaier, III A Strong Support System “I have been successful because of the excellent mentorship that I received at Duke,” says Dr. Buckenmaier. “If it weren’t for all of the people who invested in me, my story wouldn’t be all that interesting.”

Dr. Buckenmaier is an incredibly talented, driven individual who has achieved a great deal on his own merit, yet he recognizes the importance of a strong educational foundation and a network of mentors and colleagues in shaping one’s career. The ongoing relationship between Dr. Buckenmaier and faculty members at the Ambulatory Surgery Center (ASC) serves as a great example.

Dr. Buckenmaier came to Duke to study continuous peripheral nerve block (CPNB) and their potential applications to battlefield medicine. The September 11 attacks took place while he was at Duke, and upon graduation, he quickly put his new skills to the test when he was deployed to Iraq. “I was freshly trained from Duke and had this extremely unique skill that was highly effective in managing these casualties, but the technology was still very new and I had a lot of questions,” he recalls. The ASC staff provided ongoing support to Dr. Buckenmaier and his team throughout the conflict.

Dr. Buckenmaier specifically recalls a time when Army leadership was hesitant to allow him access to the medical equipment he desperately needed because they feared that the electrical signal would interfere with the aircraft electronics. Dr. Bucken-

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COL (RET) CHESTER C. “TRIP” BUCKENMAIER, III, MD, is Program Director of the Defense and Veterans Center for Integrative Pain Management and Director of the Acute Pain Medicine Service at Walter Reed Army Medical Center in Washington, D.C. Dr. Buckenmaier, who has devoted his career to battlefield medicine, is the first person in the Department of Defense (DOD) to complete a fellowship in regional anesthesia (RA), which he obtained at Duke in 2002. In 2003, he performed the first successful continuous peripheral nerve block (CPNB) for pain management in a combat support hospital in Balad, Iraq. In addition, he ran the first acute pain service in a theater of war while deployed to Camp Bastion, Afghanistan, with the British military in 2009.

maier made a call to Stephen Klein, MD, current Ambulatory Division Chief, who dropped everything and went over to the Department of Physics where they measured the electrical fields of that particular piece of equipment and proved that it was safe.

“It was extremely powerful to have the Duke name backing me and to have that level of support,” says Dr. Buckenmaier.

Thirteen years later, Dr. Klein and the ASC team continue to support Dr. Buckenmaier and the DOD by providing an annual military training activity that focuses on acute pain medicine. “Together, we have treated hundreds of casualties and are changing the way that chronic pain is perceived within the specialty,” states Dr. Buckenmaier.

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AlumniNotes

Dr. Gerald Maccioli A Different Way of Thinking For Dr. Maccioli, it was the culture of leadership that caught his eye. At the time, Joseph Gerald (Jerry) Reves, MD, was chair. “You just couldn’t help but love Jerry,” Dr. Maccioli says. “He was a magnetic guy. He created a leadership culture that Mark (Mark F. Newman, MD, chair from 2001-2014) and Joe (Joseph Mathew, MD, MHSc, current chair) have sustained and is one of the program’s greatest strengths.”

Dr. Maccioli has more than two decades of experience leading and overseeing large and complex operations, including development, integration, and implementation of healthcare systems and facilities. He has tackled a number of challenging issues related to certificate of need, scope of practice, healthcare reform and payment reform. According to Dr. Maccioli, the unique approach to problem solving that he learned at Duke has helped him not only to adapt to change but to lead change.

“The healthcare system in our country is changing,” says Dr. Maccioli. “As anesthesiologists, we must prove ourselves by adding value to the patient outcome. The one thing I would tell any new physician is that you must be willing to adapt and try new things. If you have the right decision-making architecture, you will be able to rise to the challenge.”

Dr. Torijaun Dallas A Unique Skill Set While trying to decide where he wanted to pursue his medical residency, Dr. Dallas, interviewed at thirteen different places. Duke was the very last school he interviewed at. “Everyone was so approachable ⎯ I just felt a sense of being welcomed,” he says. “After all of those interviews, I knew that Duke was the place I wanted to be.”

Like Dr. Buckenmaier, Dr. Dallas mastered a cutting edge technology at Duke that he is using to benefit our service men and women. He is not only extremely knowledgeable but he is passionate about his work. “Serving in the military and ensuring the health and safety of those who fight for peace and for our freedom is one of the most selfless things we can do as medical professionals,” says Dr. Dallas.

Dr. Dallas, who is stationed at one of the largest teaching hospitals in the Department of Defense (DOD), says that his skill in performing 3D TEE is in high demand. He is constantly educating eager trainees and staff anesthesiologists on how to

GERALD A. MACCIOLI, MD, FCCM, practiced anesthesiology, critical care medicine, and transesophageal echocardiography for 27 years in North Carolina. He obtained his fellowship in Cardiothoracic Anesthesia and Critical Care Medicine at Duke in 1988. In October of 2015, Dr. Maccioli will become the first ever Chief Quality Officer for Sheridan Healthcare with responsibility for multiple specialties. Some of Dr. Maccioli’s greatest accomplishments include serving as Director of the American Society of Anesthesiologists (ASA) for North Carolina since 2004, being the only non-academic physician ever elected to serve as President of the Society of Critical Care Anesthesiologists, and playing an influential role in developing comprehensive, progressively responsible healthcare reform strategies as the Chair of the American Medical Association (AMA) Committee of Innovators from 2011 to 2014. Dr. Maccioli continues to serve as an assistant consulting professor for Duke Anesthesiology and on several national committees relating to quality and future practice models.

When asked about the most valuable thing he took away from his training at Duke, Dr. Maccioli refers not to a specific skill or technology but to a unique way of thinking. “At Duke, they teach you not only what to do in a clinical situation but to really think about why you are doing it,” he explains. “This decision-making architecture is the most valuable tool in anesthesia training.” This unique perspective and approach to problem solving is something that Dr. Maccioli passes on to his trainees today.

MAJ TORIJAUN DALLAS, MD, completed his medical school internship, residency and fellowship in Cardiothoracic Anesthesiology at Duke. He graduated last year and has just returned from a six month deployment to Bagram Airfield, Afghanistan, where he was one of two anesthesiologists at the Heathe N. Craig Joint Theater Hospital. This promising young physician is now serving as the head of Vascular Anesthesiology and Perioperative Transesophageal Echocardiography program at the San Antonio Military Medical Center at Fort Sam Houston in San Antonio, Texas.

operate this technology.

One of Dr. Dallas’s goals is to establish an intraoperative TEE service with the ability to store images on a hospital-wide database. “This would be an invaluable reference point and research tool that would enable us to become even better at our practice,” he explains.

Dr. Dallas feels secure in the knowledge that “lifelong mentors” like Mark Stafford-Smith, MD, and Alina Nicoara, MD, are only a phone call away should he require their expertise.

The Duke Family Tree - A Lasting Legacy

The department is fortunate to have people like Drs. Maccioli, Buckenmaier and Dallas as part of its family tree. Our alumni not only make us proud, they continue to challenge us, teach us and make us stronger. Together, we are taking our specialty to new heights.

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TheDepartment E X ECUTI V E TE A M

Our department’s vision is to be the leader in advancing perioperative medicine and pain management. Our exceptional team of anesthesia physicians, nurses and staff is committed to our mission of achieving extraordinary care through a unique culture of innovation, education, research and professional growth while providing uncompromising quality in every aspect of patient care.

DEPA RTMENT CH A IR M A N

Joseph P. Mathew, MD, MHSc, MBA, FASE Jerry Reves, MD, Professor of Anesthesiology

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Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE John Borrelli, MBA Joseph P. Mathew, MD, MHSc, MBA, FASE Holly A. Muir, MD Mark Stafford-Smith, MD, CM, FRCPC, FASE David S. Warner, MD

A MBUL ATORY A NES THESI A CHIEF

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

Steve Melton, MD Karen C. Nielsen, MD Program Director, Regional and Ambulatory Anesthesia Fellowship Marcy Tucker, MD, PHD BA SIC SCIENCES CHIEF

David S. Warner, MD Vice Chair for Research Distinguished Professor of Anesthesiology in the School of Medicine Professor of Neurobiology Professor of Surgery

Ru Rong Ji, PhD Chief of Pain Research Sven-Eric Jordt, PhD Madan Kwatra, PhD Boyi Liu, MD Qing Ma, MD Wulf Paschen, PhD

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Noa Segall, PhD Huaxin Sheng, MD Niccolo Terrando, PhD Zhen-Zhong Xu, PhD Wei Yang, PhD Zhiquan Zhang, PhD C A R DIOTHOR ACIC A NES THESI A CHIEF

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

Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE Executive Vice Chair, Strategy & Finance Brandi Bottiger, MD Associate Program Director, Adult Cardiothoracic Anesthesiology Fellowship Anne Cherry, MD Claire Dakik, MD J. Mauricio Del Rio, MD Michael Fierro, MD Kamrouz Ghadimi, MD Mandisa-Maia Jones-Haywood, MD Joern A. Karhausen, MD Miklos D. Kertai, MD, PhD

Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE Raquel R. Bartz, MD, MMCi John Borrelli, MBA Thomas E. Buchheit, MD Adam Flowe, CRNA Dhanesh K. Gupta, MD Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA Stephen M. Klein, MD Jonathan B. Mark, MD Gavin Martin, MB, ChB, DA, FRCA Joseph P. Mathew, MD, MHSc, MBA, FASE Timothy E. Miller, MB ChB, FRCA Holly A. Muir, MD Mihai V. Podgoreanu, MD, FASE Allison Kinder Ross, MD Edward G. Sanders, MD Mark Stafford-Smith, MD, CM, FRCPC, FASE Annemarie Thompson, MD David S. Warner, MD

Rebecca Klinger, MD, MS Jerrold Levy, MD, FAHA, FCCM Co-Director, Cardiothoracic ICU F. Willem Lombard, MB ChB, FANZCA Yasmin Maisonave, MD Michael W. Manning, MD, PhD Joseph P. Mathew, MD, MHSc, MBA, FASE Cory Maxwell, MD Mark F. Newman, MD President and Merel H. Harmel Professor; Duke Private Diagnostic Clinic Alina Nicoara, MD, FASE Director, Perioperative TEE Services Quintin Quinones, MD, PhD Mark Stafford-Smith, MD, CM, FRCPC, FASE Vice Chair, Education Director, Fellowship Education Program Director, Adult Cardiothoracic Anesthesiology Fellowship Madhav Swaminathan, MD, FASE, FAHA Clinical Director, Cardiothoracic Anesthesiology Annemarie Thompson, MD Residency Program Director Eleanor Vega, MD Ian J. Welsby, MB, BS, BSc, FRCA

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Edward G. Sanders, MD

Assistant Clinical Professor of Anesthesiology

David S. Bacon, MD Rachel Beach, MD John D. Buckwalter, MD Nancy L. Centofante, MD Deanna Couser, MD Guy deLisle Dear, MB, FRCA William J. Fortuner, MD Joshua H. Friedman, DO Christopher Gratian, MD Daniel Kovacs, MD Eugene R. Lee, MD Debabrata Maji, MD Scott V. McCulloch, MD E. Burt Mckenzie Jr., MD Warren R. Miller, MD Ryan James Mountjoy, MD Elizabeth Nichols, MD William P. Norcross, MD Emmeline O’Leary, MD Gary L. Pellom, MD Earl S. Ransom, Jr., MD Richard D. Runkle III, MD Michael J. Stella, MD Christopher Summers, MD Neel Thomas, MD

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TheDepartment

CR ITIC A L C A R E MEDICINE

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Raquel R. Bartz, MD, MMCi

Assistant Professor of Anesthesiology Assistant Professor in Medicine

Atilio Barbeito, MD, MPH Yuiry Bronshteyn, MD Charles S. Brudney, MB BCh J. Mauricio Del Rio, MD Michael Fierro, MD Kamrouz Ghadimi, MD Ehimemen Iboaya, MD Michael “Luke” James, MD, FAHA Mandisa-Maia Jones-Haywood, MD Nancy W. Knudsen, MD John Lemm, MD Jerrold Levy, MD, FAHA, FCCM F. Willem Lombard, MB ChB, FANZCA Eugene W. Moretti, MD, MHSc Okoronkwo U. Ogan, MD Mihai V. Podgoreanu, MD, FASE Quintin Quinones, MD, PhD Karthik Raghunathan, MD, MPH Arturo Suarez, MD Madhav Swaminathan, MD, FASE, FAHA Annemarie Thompson, MD Eleanor Vega, MD Xueyuan Shelly Wang, MD Ian J. Welsby, MB, BS, BSc, FRCA Christopher C. Young, MD GENER A L , VA SCUL A R A ND TR A NSPL A NT (G V T ) INTER IM CHIEF

Timothy E. Miller, MB ChB, FRCA

Associate Professor of Anesthesiology Clinical Director, Abdominal Transplant Anesthesiology

Brian J. Colin, MD Assistant Residency Program Director Michael Fierro, MD Jake Freiberger, MD, MPH Program Director, Undersea and Hyperbaric Medicine Fellowship Ehimemen Iboaya, MD Nancy W. Knudsen, MD Catherine M. Kuhn, MD Director & Associate Dean, Graduate Medical Education; Designated Institutional Official John Lemm, MD Elizabeth Malinzak, MD Michael W. Manning, MD, PhD Grace C. McCarthy, MD Richard E. Moon, MD, CM, MSc, FRCP(C), FACP, FCCP Eugene W. Moretti, MD, MHSc

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Ronald P. Olson, MD, CCFP Medical Director, Preoperative Screening Unit Quintin Quinones, MD, PhD Iain C. Sanderson, MD, BM, BCh Vice Dean, Research Informatics; Associate Chief Information Officer, Periop Aaron J. Sandler, MD, PhD Arturo Suarez, MD Ankeet Udani, MD Kerri M. Wahl, MD, FRCP(C) Xueyuan Shelly Wang, MD Christopher C. Young, MD Program Director, Critical Care Medicine Fellowship NEUROA NES THESIOLOG Y, OTOL A RY NGOLOG Y, A ND OFFSITE A NES THESI A

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Dhanesh K. Gupta, MD

Professor of Anesthesiology

Miles Berger, MD, PhD Nicole R. Guinn, MD Director, Center for Blood Conservation Ulrike Hofmann, MD, PhD Michael “Luke” James, MD, FAHA Program Director, Neuroanesthesia Fellowship John C. Keifer, MD Grace C. McCarthy, MD Charles Andrew Peery, MD, MPH, MA Bryant “Bret” W. Stolp, MD, PhD Jeffrey Taekman, MD Director, Human Simulation and Patient Safety Center Leonard Talbot, MD David S. Warner, MD

Jennifer Parsons, FNP-BC Lisa Peoples, PA-C Steven Prakken, MD Section Chief, Medical Pain Service Srinivas Pyati, MD Neil Ray, MD Lance A. Roy, MD Scott Runyon, MD Jessica Salyer, ANP Debra Stoia, PA-C Ashley Underwood, PA-C Thomas Van de Ven, MD, PhD PEDI ATR IC A NES THESI A

CHIEF

Allison Kinder Ross, MD

Professor of Anesthesiology and Pediatrics

Warwick Ames, MBBS, FRCA Christy Crockett, MD Guy deLisle Dear, MB, FRCA John B. Eck, MD Director of Educational Development Program Director, Pediatric Anesthesiology Fellowship Andrea Goodrich, MD Nathaniel H. Greene, MD, MHS, FAAP Director of Research in Pediatric Anesthesia H. Mayumi Homi, MD Edmund H. Jooste, MB, ChB Clinical Director, Pediatric Cardiac Anesthesiology; Director of CARE (Clinical Anesthesiology Research Endeavors) Kelly Machovec, MD, MPH Brad M. Taicher, DO, MBA Chair, Anesthesiology Patient Safety and Quality R EGION A L A NES THESIOLOG Y

PA IN MEDICINE CHIEF CHIEF

Thomas E. Buchheit, MD

Gavin Martin, MB, ChB, DA, FRCA Professor of Anesthesiology

Associate Professor of Anesthesiology Director, Duke Pain Medicine

Richard L. Boortz-Marx, MD Section Chief, Interventional Pain Medicine Emily Davis, ACNP-BC Anne Marie Fras, MD Brian Ginsberg, MB, ChB Joel S. Goldberg, MD Director, VAMC Pain Service Thomas J. Hopkins, MD Director, Quality Improvement Hung-Lun (John) Hsia, MD David R. Lindsay, MD Program Director, Pain Medicine Fellowship Karen McCain, FNP-BC

W. Michael Bullock, MD, PhD Joshua Dooley, MD Ellen M. Flanagan, MD Director, Eye Center Jennifer T. Fortney, MD Jeff Gadsden, MD, FRCPC, FANZCA Andrea Goodrich, MD Stuart A. Grant, MB, ChB, FRCA Director, Medical Student Education David B. MacLeod, MB, BS, FRCA Erin Manning, MD, PhD Brian Ohlendorf, MD Stephen J. Parrillo, MD Michael R. Shaughnessy, MD Alicia Warlick, MD

V E TER A NS A FFA IR S A NES THESIOLOG Y SERV ICE

CHIEF

Jonathan B. Mark, MD

Professor of Anesthesiology

Atilio Barbeito, MD, MPH Raquel R. Bartz, MD Charles S. Brudney, MB, ChB, FRCA Thomas E. Buchheit, MD Joel S. Goldberg, MD Juliann C. Hobbs, MD, MPH Hung-Lun (John) Hsia, MD Ryan Konoske, MD John Lemm, MD David R. Lindsay, MD Amy K. Manchester, MD Cory Maxwell, MD Srinivas Pyati, MD, DA, FFARCSI Karthik Raghunathan, MD, MPH Amy M. Rice, MD Rebecca A. Schroeder, MD, MMCI Arturo Suarez, MD Thomas Van de Ven, MD, PhD Ian J. Welsby, MB, BS, BSc, FRCA Dana N. Wiener, MD WOMEN ’ S A NES THESI A

CHIEF

Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA

Associate Professor of Anesthesiology

Terrence Allen, MD Christy Crockett, MD Jennifer E. Dominguez, MD, MHS Cheryl A. Jones, MD Clinical Director, Obstetric Anesthesia Abigail H. Melnick, MD Holly A. Muir, MD Anesthesia Medical Director, Periop Services Vice Chair, Clinical Operations Adeyemi J. Olufolabi, MB BS Program Director, Anesthesia Global Health Fellowship Cathleen L. Peterson-Layne, MD, PhD, MS Program Director, Obstetric Anesthesiology Fellowship Zaneta Y. Strouch, MD, MPH DUK E HE A LTH R A LEIGH

Okoronkwo U. Ogan, MD Thomas J. Weber, Jr., MD

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FACULT Y CORNER Appointments • Nominations • Promotions

G V T & CCM

Nancy Knudsen, MD

Dr. Nancy Knudsen was selected for a three year appointment to the Duke School of Medicine Curriculum Committee. The Curriculum Committee determines the direction, general content, assessment and policies for the medical student curriculum. It supports the implementation, ongoing review and renewal of the educational program.

The committee is composed of faculty, staff and students of the School of Medicine. The Curriculum Committee is advisory to the Vice Dean for Education.

GVT

Timothy E. Miller, MB, ChB, FRCA

Dr. Miller was recently appointed as the Interim Division Chief for General, Vascular, and Transplant and Critical Care Medicine (GVT). He is also the Clinical Director of Abdominal Transplant Anesthesiology.

Dr. Miller completed his residency in anesthesiology at the Nottingham and East Midlands School of Anesthesia, U.K. He went on to obtain a cardiothoracic anesthesia fellowship at Glenfield Hospital, Leicester, U.K. and is a fellow of the Royal College of Anesthetists.

Dr. Miller’s research interests include enhanced recovery and perioperative optimization of the high-risk, non-cardiac surgery patient. He has written more than 40 manuscripts, editorials and book chapters. Dr. Miller founded the Duke Enhanced Recovery After Surgery (ERAS) Program in partnership with the Department of Surgery in 2010, one of the first such programs established in the nation.

Under his leadership, colorectal patients at Duke benefit from faster recovery times than the national average. He is a founding member and Vice President of the American Society for Enhanced Recovery (ASER).

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NEUROA NES THESIOLOG Y

Dhanesh K. Gupta, MD

After an extensive search process, Dr. Gupta was appointed as the new Chief of the Division of Neuroanesthesiology this year. He received his B.S. in Biomedical Engineering and his M.D. from Northwestern University. He then completed his anesthesiology residency and fellowship in neuroanesthesiology at the University of California at San Francisco. Dr. Gupta went on to help build the Huntsman Cancer Center’s Brain Tumor Program during his time as Chief of Neuroanesthesia at the University of Utah. For the last nine years, he has been the Director of Neuroanesthesia Research and Co-Director of the Neuroanesthesia Fellowship Program at Northwestern University. He is currently on the Board of Directors for the Society for Neuroscience in Anesthesiology and Critical Care (SNACC).

NEUROA NES THESIOLOG Y

Michael “Luke” James, MD

Dr. James was appointed as Fellowship Director for the Division of Neuroanesthesiology. He completed his undergraduate degree at Vanderbilt University followed by medical school at Louisiana State University.

His postgraduate training was entirely at Duke. Dr. James is board certified in neurology, anesthesiology and neurocritical care. He is currently on the Board of Directors of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), and was recently appointed to the Board of Directors of the United Council of Neurologic Subspecialties (UCNS). Dr. James is a critical part of the division’s academic mission and has effectively mentored many of the junior faculty.

PEDI ATR IC A NES THESI A

Edmund H. Jooste, MB, ChB

Dr. Jooste was announced as the new Director of CARE (Anesthesiology Clinical Research Unit).

Dr. Jooste received his Bachelor of Medicine and Surgery degree from Pretoria University Medical School in South Africa. After earning his diploma in anesthesiology at Edendale Hospital in South Africa, he went on to do his residency in anesthesiology at Columbia University and completed a pediatric anesthesiology fellowship there as well.

He was a faculty member at Columbia University’s Children’s Hospital of New York and at the University of Pittsburgh’s Children’s Hospital before joining Duke in 2011 as Clinical Director of Pediatric Cardiac Anesthesiology.

WOMEN ’ S A NES THESI A

Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA

Dr. Habib has been appointed as the Division Chief for Women’s Anesthesia, after serving as Interim Division Chief since August of 2013.

Dr. Habib received his medical degree at Ain Shams University in Cairo, Egypt, and completed his training in anesthesiology at the University Hospitals of Leicester, U.K. In 2001, he finished his fellowship in obstetric anesthesiology at Duke University Medical Center and joined the faculty at Duke in the Division of Women’s Anesthesia.

After completing the Clinical Research Training Program at Duke, Dr. Habib obtained a Master’s in Health Science (MHSc).

He has published more than 100 manuscripts, book chapters and editorials, and has received research support from the Anesthesia Patient Safety Foundation and the Society for Ambulatory Anesthesia.

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HONOR SOCIET Y Awards • Grants • Honors BA SIC SCIENCES

Ru Rong Ji, PhD

NIH Research Grant (R01) Dr. Ru-Rong Ji of the Sensory Plasticity and Pain Research Group received a five year, $1,739,065 research grant from the National Institute of Neurological Disorders and Stroke (NIHDS) for his research project titled “Resolution Pathway of Pain.” More than 30 million Americans suffer from unrelieved chronic pain and it remains unclear how acute pain naturally resolves. Dr. Ji hypothesizes that disruption of local, active pro-resolving processing will result in chronic pain. The overall goal is to investigate how βarr2, a scaffold protein that is classically involved in desensitization of GPCRs, arrests pain and whether PRLMs resolve pain via βarr2. Dr. Ji’s approach combines genetic manipulation (transgenic mice, conditional knockout mice, gene therapy), electrophysiology, and behavioral testing for evoked pain and spontaneous pain (CPP). The study aims to identify a pro-resolution pathway for “pain arrest” and lead to the development of novel pain therapeutics.

BA SIC SCIENCES

Boyi Liu, PhD

Spring Core Facility Voucher Award Dr. Boyi Liu has been awarded a one year, $9,200 voucher for his proposal titled “Transcriptome Profiling of Poison Ivy-Induced Allergic Contact Dermatitis

by Microarray.” The Core Facility Voucher Program is a joint program with the School of Medicine (SOM), the Duke Translational Research Institute (DTRI) Pilot Program and the Office of the Provost. Allergic contact dermatitis (ACD) is a common skin condition triggered by environmental or occupational allergens.

The most common ACD in the United States is caused by contact with poison ivy. The objective of this proposal is to perform a genome-wide transcriptome profiling of the skin from healthy, poison ivy and the well-established oxazolone

ACD model by microarray in the two most popular mouse strains for ACD studies (C57BL/6 and BALB/c). This project will be important for the understanding of the mechanisms of the immune, inflammation and pruritus responses in poison ivy-induced ACD. BA SIC SCIENCES

Noa Segall, PhD

AHRQ Health Services Research Project (R01) Dr. Noa Segall received a five year, $1,246,724, project titled “Effect of Monitoring System Design on Response Time to Cardiac Arrhythmias.” To increase the potential for timely detection and treatment of cardiac events, hospitals have implemented a number of different cardio-respiratory monitoring systems for patients who meet at-risk criteria. However, decisions regarding how to structure and staff monitoring systems, have historically been made with little supporting evidence. She proposes to use simulation to identify and test determinants of effective cardiac monitoring. The knowledge to be gained will inform the development of evidence-based monitoring standards. The application of such standards is expected to improve survival after in-hospital cardiac arrest.

BA SIC SCIENCES

David S. Warner, MD

2015 Recipient of the FAER Mentoring Excellence in Research Award This award was created to ensure recognition of outstanding people who have sustained career commitment to mentoring and demonstrated a positive impact on the careers of mentees. The award will be presented at this year’s American Society of Anesthesiologists annual meeting in San Diego.

Duke School of Medicine 2015 Research Mentoring Award for Translational Research Dr. Warner has impacted the careers of trainees and faculty at Duke for nearly

21 years.In his first year as faculty, he successfully competed for the first Duke Anesthesiology NIH T32 Training Grant which has been consistently funded ever since. All but one trainee supported by these grants has remained in academic practice with substantial publication and extramural funding histories.Serving as our departmental Vice Chair for Research since 2001, Dr. Warner has set a strong pattern for success in transitioning faculty to independent investigator status.Dr. Warner also directs the Multidisciplinary Neuroprotection Laboratories where he has served as mentor to more than 80 undergraduates and post-doctoral fellows. Many of his mentees have become independent researchers and/or progressed to leadership levels as division chiefs or departmental chairs.

NIHDS Exploratory/Development Research Grant (R21) Dr. Warner received a two year, $793,750 research grant from the National Institute of Neurological Disorders and Stroke (NIHDS) titled “Xenon as a Therapeutic Experimental Intracerebral Hemorrhage.”

Intracerebral hemorrhage (ICH) is a form of stroke and there are little treatment options other than supportive care. Xenon (Xe) is an inert gas which has undergone intensive preclinical investigation in models of brain injury and is currently being investigated as an adjunct to hypothermia for treatment of anoxic/asphyxia brain injury in humans. Dr. Warner explored the effect of Xe in two different mouse ICH models and found that Xe repeatedly improved both histologic and functional ICH outcome and decreased brain water content and microglial activation. The goal of the project is to subject Xe to a sequence of rigorous preclinical studies specifically designed to advance Xe to human ICH trials.

BA SIC SCIENCES

Zhen-Zhong Xu, PhD

NIHDS Exploratory/Developmental Research Grant Award (R21) Dr. Zhen-Zhong Xu, of the Sensory Plasticity and Pain Research Group received a two year, $436,628 grant from the National Institute of Neurological Disorders and Stroke (NINDS) for his research project BluePrint 2015

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HONOR SOCIET Y Awards • Grants • Honors titled “Treating Chemotherapy-Induced Neuropathic Pain by Targeted Silencing of A-Fibers.” Chemotherapy-induced peripheral neuropathy and neuropathic pain are the dose-limiting toxicity for many commonly used classes of anti-cancer agents. Studies have shown that mechanosensitive A-fibers contribute to neuropathic pain and targeted silencing of A-fibers could be an effective treatment for neuropathic pain induced by chemotherapy. In this project, Dr. ZhenZhong Xu proposes to address how to treat chemotherapy-induced neuropathic pain by targeted silencing of A-fibers. He believes this research will help develop new therapy for treating neuropathic pain in patients with CIPN. BA SIC SCIENCES

Wei Yang, PhD

Spring Core Facility Voucher Award Dr. Wei Yang received a one year, $7,000 award from the Core Facility Voucher Program for an application titled “Genome-Wide Analysis of Chromatin Modification by SUMO in Mouse Brain.” Dr. Yang has generated several unique SUMO transgenic and knockout mice models and found that a functional SUMO conjugation pathway is essential for emotionality and cognition. He also characterized the SUMO-modified proteome in the post-ischemic brains. The voucher will be used to identify the genomic loci occupied by SUMOylated proteins using chromatin immunoprecipitation coupled to next generation sequencing (ChIP-Seq). This pilot project is expected to establish a platform for future studies to uncover the mechanisms linking SUMO conjugation to neuronal functions in vivo.

C A R DIOTHOR ACIC A NES THESIOLOG Y

J. Mauricio Del Rio, MD

John W. Kirklin CT Resident & Fellow Research Award Duke Anesthesiology Assistant Professor, J. Mauricio Del Rio, MD, and Duke Surgery Resident, Jeffrey Javidfar, MD, have won this award for their abstract, “Standardized Handover Process in Adult Cardiothoracic Critical Care: Staff Satisfaction, Efficiency and Workflow.”

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The doctors explored how the development of a standardized handover process impacts CTICU staff satisfaction, involvement and perception of workflow and patient safety. They will present their research at FACTS-Care’s Cardiovascular-Thoracic Critical Care Conference this year in Washington, D.C. C A R DIOTHOR ACIC A NES THESIOLOG Y

Joern A. Karhausen, MD

AHA Scientist Development Grant Dr. Joern Karhausen received a three-year, $231,000 Mid-Atlantic Affiliate Winter 2015 Scientist Development Grant from the American Heart Association (AHA) entitled, “Platelets as regulators of inflammation and tissue injury after cardiac surgery.” The hypothesis is that platelets and mast cells work together to propagate inflammation and tissue injury, and that modifying this interaction provides a unique opportunity to improve organ protection during cardiac surgery.

way to allow new interventions to prevent POAF and improve patient outcomes.

C A R DIOTHOR ACIC A NES THESIOLOG Y

Madhav Swaminathan, MD, FASE, FAHA 2015 Feigenbaum Lecturer — First Anesthesiologist to Receive This Honor Dr. Madhav Swaminathan was selected as the Feigenbaum Lecturer for the 2015 Scientific Sessions of the American Society of Echocardiography in Boston. This prestigious honor is given to a young investigator who has provided a significant contribution to research in the field of echocardiography, with great potential to continue at a high level of achievement. It is named in honor of Dr. Harvey Feigenbaum, hailed as the “Father of Echocardiography,” who in 1963 took an unused echoencephalography machine and recorded the first cardiac images. Twelve years later, he founded the American Society of Echocardiography. While the biggest names in echocardiography have delivered this lecture since 2000, this is the first time it goes to a cardiac anesthesiologist.

C A R DIOTHOR ACIC A NES THESIOLOG Y

Michael Manning, MD, PhD

International Anesthesia Research Society Mentored Research Award Dr. Michael Manning received a two year, $150,000 award for his project titled “Mechanisms in the Development of Post Operative Atrial Fibrillation.”

Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery and there are currently no prevention strategies.

A key factor in POAF development may be inflammation. The exact mechanism by which inflammation influences POAF is unknown, however, one potential mediator is angiotensin II (AngII). Using both animal and human studies, Dr. Manning will determine whether AngII functions as a primary modulator or secondary regulator in the inflammatory cascade leading to POAF. The objective is to identify pharmacologically modifiable points in the path-

C A R DIOTHOR ACIC A NES THESIOLOG Y

Quintin Quinones, MD, PhD

Society of Cardiovascular Anesthesiologists/IARS Starter Grant Dr. Quintin Quiñones has been awarded a two year, $50,000 grant titled “Innate Immune Adaptations of Hibernation as a New Approach to Protection Against Acute Organ Injury.” Investigators developed a cardiopulmonary bypass-based model of ischemia/reperfusion and applied it to rats and a hibernating mammal, the arctic ground squirrel. Dr. Quiñones hypothesizes that hibernator resistance to ischemia/reperfusion is secondary to reversible modulation of innate immunity.

The rationale for the proposed research is that by understanding natural mammalian regulation of innate immunity, Dr. Quiñones will identify targets for therapeutic strategies that will provide organ protection in

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HONOR SOCIET Y Awards • Grants • Honors patients who suffer severe ischemia/ reperfusion injury in cardiac surgery, transplant and intensive care settings.

decreasing POAF after cardiac surgery.

2014 Young Investigator Award Dr. Quiñones received the 2014 Vivien Thomas Young Investigator Award from the American Heart Association for his project entitled, “Differences in Electron Transport Chain Proteins in the Hearts of Hibernating Arctic Ground Squirrels Compared with Rats after Surgical Ischemia and Reperfusion: A Convergence of Mammalian Cardioprotective Strategies.”The research study focused on the link between natural metabolic depression, as seen during hibernation, and organ protection for cardiac surgery, an unmet clinical need. The Vivien Thomas Young Investigator Award acknowledges the accomplishments of early career investigator members of the Cardiovascular Surgery and Anesthesia Council who are focusing on fundamental and applied cardiac surgical research.

Ian J. Welsby, MB BS

C A R DIOTHOR ACIC A NES THESIOLOG Y

Nathan Waldron, MD

FAER Research Fellowship Grant Dr. Nathan Waldron, CA-3 Resident received a one-year, $75,000 Research Fellowship Grant from the Foundation for Anesthesia Education and Research (FAER) for their proposal titled, “Temporary autonomic blockade to prevent atrial fibrillation after cardiac surgery.” Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, and is associated with increased morbidity, mortality, and hospital length of stay (LOS), resulting in greater healthcare costs. Despite intensive study, the incidence of POAF is essentially unchanged (»40%) over the last twenty years, suggesting that new therapeutic approaches are urgently needed. While the autonomic nervous system is implicated in the pathogenesis of atrial fibrillation, there are few strategies to prevent POAF targeted at autonomic modulation. In this study, the investigators intend to determine whether autonomic modulation via botulinum toxin injected in the epicardial fat pads is efficacious and safe for

C A R DIOTHOR ACIC A NES THESIOLOG Y

NIH Research Grant (R01) Dr. Ian Welsby, Associate Professor in the Cardiac Division, received a new, five year $1,227,568 grant as a Co-PI on a Multiple PI application through Mayo Clinic and Dr. Daryl J. Kor from the National Heart, Lung, and Blood Institute (NHLBI) for his research project titled “Point of Care Red Blood Cell (RBC) Washing to Prevent Transfusion-Related Pulmonary Complications.” Currently, there are no effective strategies to prevent complications following red blood cell (RBC) transfusion, but soluble biological response modifiers (BRMs) residing within the RBC storage solution are believed to play an important role.

Point-of-care washing of allogeneic RBCs prior to transfusion may remove these BRMs, thereby mitigating their impact on post-operative respiratory complications. The objective of this project is to evaluate the feasibility, safety, efficacy, and clinical impact of point-of-care washing for allogeneic leukocyte-reduced (LR) RBCs using the FDA-approved Continuous AutoTransfusion System (CATS).

G V T & CCM

Nancy W. Knudsen, MD

Clinical Faculty Golden Apple Award This prestigious award allows Duke medical students to nominate and vote for faculty and teachers who have impacted their medical education. Three categories of the award include: Preclinical Faculty, Clinical Faculty and House Staff. Dr. Nancy Knudsen, Professor of Anesthesiology, is awarded for her extreme dedication to medical education as made evident by the many votes and kind comments in her favor.

GVT

Timothy Miller, MB, ChB, FRCA

Edwards Lifesciences Grant Dr. Miller received a grant from Edwards Lifesciences for $159,968.16 for the project entitled “Effectiveness of an enhanced recovery protocol on length of stay and complications in elective radical cystectomy.” The purpose of this study is to evaluate the effectiveness of an Enhanced Recovery After Surgery (ERAS) protocol for elective radical cystectomy. Radical cystectomy represents a significant surgical challenge to patients.

Despite the standardization of surgical technique, and improved anesthesia and perioperative care protocols, the morbidity after radical cystectomy is significant, even in high-volume centers. Cystectomy patients are mostly elderly and comorbid (many with smoking-related cardiovascular and pulmonary diseases). ERAS pathways can improve patient care, reduce morbidity, and shorten LOS. Several small studies evaluating elements of the ERAS care pathways in radical cystectomy have found benefits in postoperative morbidity, return to bowel function, or LOS. However, none have applied a full ERAS protocol to radical cystectomy patients.

GVT

Richard E. Moon, MD, CM, M.Sc., FRCPC, FACP, FCCP

Creare Inc. Subaward Dr. Richard Moon, Medical Director of the Center for Hyperbaric Medicine and Environmental Physiology, received a two year, $199,949 award for his application titled “Advanced Technologies for Reducing Decompression Obligation in Extreme Dives.” The objective of this research project is to develop advanced technologies for management of decompression sickness (DCS) during extreme military dives. DCS is a physical manifestation of decompression stress (DS), defined as the physiologic response to dissolved gas coming out of solution into the venous circulation as a body moves BluePrint 2015

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HONOR SOCIET Y Awards • Grants • Honors from a high pressure to low pressure environment, such as surfacing from a dive. At present, the only measure of DS is the direct manifestation of symptoms (DCS). Duke will serve as the primary animal testing facility for the Phase II project using the swine model.

NEUROA NES THESIOLOG Y

Miles Berger, MD, PhD

International Anesthesia Research Society Mentored Research Award Dr. Miles Berger received a two year, $150,000 research award titled “The Trajectory and Significance of Perioperative Changes in AD Biomarkers.” It is still unclear whether surgery and/or anesthesia promote Alzheimer’s disease pathology in patients, and whether such effects might explain part of the post-operative delirium and/or cognitive impairments seen in some patients. Preliminary results show that cerebrospinal fluid (CSF) tau levels increase significantly within the first day after surgery and anesthesia in a subset of patients. In this research study, Dr. Berger proposes to assess the long term trajectory of these CSF tau increases, and to determine whether these tau increases are associated with post-operative delirium and/or cognitive trajectory.

NIH Research Grant Dr. Berger and his colleagues in the Anesthesiology Department have been awarded a National Institutes of Health (NIH) grant from the National Institute of Aging for the project entitled, “The Significance of Perioperative Changes in CSF Tau Levels in the Elderly.” This twoyear grant will provide $75,000 per year for enrolling an arm of non-surgical control individuals matched for age, education and gender to the surgical patients already being enrolled in the MADCO-PC trial (Markers of Alzheimer’s Disease and Neurocognitive Outcomes After Perioperative Care). This GEMSSTAR (Grants for Early Medical/Surgical Specialists’ Transition to Aging Research) grant will also be accompanied by additional professional development funding for Dr. Berger from FAER (the Foundation for Anesthesia Education and Research).

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Social Entrepreneurship Accelerator at Duke Research Award An inter-professional team in the Human Simulation and Patient Safety Center (HSPSC) received a one year, $25,000 research award for a project titled “Postpartum Hemorrhage Education Via Simulation.”This pilot program aims to reduce the incidence of postpartum haemorrhage (PPH), and to serve as a broader model for using simulation to scale education and spread virtual learning through the developing world in resource-poor settings. The PPH simulation software will be used to address gaps in care at Mulago International Referral Hospital in Kampala, Uganda, and to decrease disparities in healthcare education. This team will host inter-professional, interactive, gamesbased simulation training sessions from Durham to Mulago, online. Key personnel include: Jeffrey Taekman, MD, who is the Principal Investigator, Megan Foureman, CRNA, MSN, Amy Mauritz, MD, Adeyemi Olufolabi, MBBS, DCH, FRCA, Michael Steele, BS and Genevieve DeMaria, BS. PEDI ATR IC A NES THESI A

Allison Kinder Ross, MD

Grünenthal Research Grant Dr. Allison K. Ross has received a two-year research grant sponsored by Grünenthal, titled “An Evaluation of the Efficacy and Safety of Tapentadol Oral Solution in the Treatment of Post-operative Acute Pain Requiring Opioid Treatment in Pediatric Subjects Aged From Birth to Less Than 18 Years Old.” The purpose of the study is to evaluate the efficacy of tapentadol oral solution, based on the total amount of supplemental opioid analgesic used over 12 hours or 24 hours after initiation of investigational medicinal product in children and adolescents who have undergone surgery that would produce moderate to severe pain during opioid treatment.

PEDI ATR IC A NES THESI A

Brad M. Taicher, DO, MBA

Society for Pediatric Anesthesia’s 2015 Young Investigator Award Dr. Brad Taicher was presented this award for his study titled “Caudal Anesthesia is Associated with Increased Risk of Postoperative Surgical Complications in Boys Undergoing Hypospadias Repair.” This project found that caudal anesthesia was independently associated with surgical wound dehiscence and fistula formation.

Collaborating with pediatric anesthesiologists, Dr. Allison Ross and Dr. John Eck, as well as pediatric urologists, Dr. Jon Routh and Dr. John Wiener, Taicher reviewed 13 years of data from one surgeon and identified local risk factors for postoperative complications. Hypospadias is one of the more common urological surgeries in children, and caudal anesthesia is often utilized as an adjunct. While serious anesthesia related complications from caudal anesthesia are very rare, the impact on surgical complications has not been formally investigated.

VA A NES THESIOLOG Y SERV ICE

Jonathan B. Mark, MD, and Amy K. Manchester, MD VA Patient-Centered Specialty Care Education Centers of Excellence Award Dr. Sandhya Lagoo-Deenadayalan, Associate Professor of Surgery, received a multi-year grant to introduce a novel training model for senior level residents in the departments of surgery, anesthesiology and geriatrics. The Durham VAMC Perioperative Optimization of Senior Health (POSH) Program aims to improve outcomes for frail, older adults undergoing elective surgical procedures. Dr. Jonathan Mark, Chief of the Division of VA Anesthesiology Service, and Dr. Amy Manchester, Assistant Professor of Anesthesiology, will

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HONOR SOCIET Y Awards • Grants • Honors participate in this novel program which fosters the transformation of clinical education and patient care.

V E TER A NS A FFA IR S

Karthik Raghunathan, MD, MPH

Patient Safety Center of Inquiry Grant Dr. Karthik Raghunathan was recently awarded a three year, $779,000 grant for his study titled “Reduction of Perioperative Opioid-Related Adverse Events and Prolonged Use of Opioids Following Surgery.” The project is focused on improving the safe prescription of opioids in the perioperative period and on preventing adverse drug events related to perioperative use of opioids.

The proposal will leverage the VA Corporate Data Warehouse (which contains millions of surgical cases) to identify and implement best practices at individual VA Medical Centers in collaboration with colleagues at the San Francisco and Palo Alto VA Medical Centers.

VA A NES THESIOLOG Y SERV ICE

Thomas Van de Ven, MD, PhD

Department of Defense (DoD) Neurosensory Research Grant Dr. Thomas Van de Ven received a 3-year, $1.5 million research grant renewal for his VIPER (Veterans Integrated Pain Evaluation Research) study titled “Chronic Pain After Amputation: Inflammatory Mechanisms, Novel Analgesic Pathways and Improved Patient Safety.” This grant will fund Dr. Van de Ven and his staff for three years, and it will allow him to continue his work in chronic pain in amputation patients, specifically inflammatory mechanisms, novel analgesic pathways and improved patient safety. Other personnel involved in this study are LTC Dr. Chester Buckenmaier, Associate Professor at Uniformed Services University of the Health Sciences, and Dr. Andrew Shaw, former Duke faculty and now Division Chief of Cardiothoracic Anesthesiology at Vanderbilt University Medical Center.

Spring Core Facility Voucher Award Dr. Van de Ven has been awarded a one year, $9,036 voucher for his proposal titled “Transcriptional Profiling of Sciatic Nerve Samples from Traumatic Amputees.” Chronic neuropathic pain (NP) frequently occurs following nerve injury and treatment options are limited.

One significant etiology of NP is limb amputation. To better understand the pathological processes that lead to neuropathic pain after nerve injury, collaborators at the Walter Reed Army Medical Center have collected injured sciatic nerve segments from veterans who suffered lower limb amputation due to combat trauma. Analysis of these human samples will provide unprecedented insights into the molecular pathology of peripheral nerve injury, with wide ranging implications for the study of pain and neural regeneration. Dr. Van de Ven’s goal is to uncover differentially expressed genes and activated molecular pathways that contribute to NP.

WOMEN ’ S A NES THESI A

Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA Acacia Pharma Ltd Research Grant Dr. Ashraf Habib has received a three-year research grant sponsored by Acacis Pharma, titled “Randomised, Double-blind, Placebo-controlled Phase III Study of APD421 (Amisulpride for IV Injection) as Combination Prophylaxis Against Post-operative Nausea and Vomiting in High-risk Patients.” The purpose of this trial is to compare the efficacy of APD421 and placebo when combined with a standard anti-emetic in the prevention of PONV in patients at high risk of Post-operative Nausea and Vomiting (PONV).

DR E A M INNOVATION GR A NT (DIG)

WOMEN ’ S A NES THESI A

Terrence Allen, MD

Junior Faculty Receive Time, Training, and Mentorship through KL2 Awards Thanks to a Duke CTSA-sponsored KL2 award, Dr. Terrence Allen will be able to spend three quarters of his time as a junior faculty member over the next three years pursuing his research dream with his mentor, Dr. Amy Murtha.

Dr. Allen has seen first-hand the high costs, emotionally, physically and financially, of preterm births. He will use the KL2 award to improve the skills he needs to research the role of a novel progesterone receptor in preventing the premature rupture of membranes that leads to preterm births.Allen is one of three junior faculty in the most recent cohort of KL2 scholars, including Anthony Sung, MD and Kanecia Zimmerman, MD. READ MORE ON THE DUKE TR ANSLATIONAL MEDICINE INSTITUTE (DTMI) WEBSITE:

tinyurl.com/qdetskf

Congratulations 2015 DIG winners!

After careful consideration, the DREAM Innovation Grant (DIG) Application Review Committee, comprised of Dr. Manuel Fontes, Dr. Ru-Rong Ji, Dr. Jerrold Levy, Dr. Joseph Mathew, Dr. Richard Moon, Dr. Mihai Podgoreanu, Dr. Mark Stafford-Smith, and Dr. David Warner, selected four doctors to receive the grant: Dr. Terrence Allen, Dr. Atilio Barbeito, Dr. Jennifer Dominguez, and Dr. Boyi Liu. We are confident that their work will truly improve and advance the field of anesthesiology. We want to thank the review committee and all of our Duke DREAM Campaign supporters who make the DIG possible.

BluePrint 2015

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Duke Anesthesiology BluePrint Magazine DUMC 3094 Durham, NC 27710

Dream Big. Think Big. Apply Today!

DREAM Innovation Grant (DIG) The DREAM Innovation Grant (DIG) supports innovative high-risk, and potentially high-reward investigations to accelerate anesthesia and pain management research. The grant will provide investigators with one-year pilot funding, enabling them to develop their hypotheses and collect data that will be submitted for longterm funding from other prestigious agencies. Winners will be announced at this yearâ&#x20AC;&#x2122;s annual ASA Duke Anesthesiology Alumni Reception in San Diego, California.

DREAMCAMPAIGN.DUHS.DUKE.EDU

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