Internal Medicine Annual Report, Fiscal Years 2015-2016

Division of Internal Medicine

Annual Report 2015 and 2016 Onco-Medicine: Medical Care of the Cancer Patient

Table of Contents

Message from Division Head David J. Tweardy, M.D.......................... 4 Departments, Sections and Administration Reports............................ 7 Cardiology....................................................................................... 8 Dermatology..................................................................................13 Emergency Medicine.....................................................................17 Nephrology............................................................................... 22 Endocrine Neoplasia and Hormonal Disorders.............................. 25 Gastroenterology, Hepatology and Nutrition................................. 30 General Internal Medicine............................................................. 37 Rheumatology and Clinical Immunology.................................. 42 Infectious Diseases, Infection Control and Employee Health Services............................................................ 45 Psychiatry .................................................................................... 53 Pulmonary Medicine..................................................................... 56 Benign Hematology.................................................................. 61 Symptom Research...................................................................... 64 By the Numbers............................................................................ 72 Administration................................................................................74 A Focus on Collaborations.................................................................. 77 Clinical........................................................................................... 78 Research....................................................................................... 80 Residency..................................................................................... 83 Quality Improvement.................................................................... 86 Faculty and Division Administration.................................................... 91

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Message from Division Head DAVID J. TWEARDY, M.D.

I

have had the honor and privilege of leading Internal Medicine for more than two years now, and I can tell you that I am as joyful and excited after two years as I was after my first two months at MD Anderson.

Without a doubt, I’ve experienced joy in getting to learn more about the remarkable work of our people and their clinical, research and educational accomplishments. I’m continuously excited to see how both faculty and classified employees exploit the numerous opportunities available to us at the institution and throughout the UT System.

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Key among the opportunities in the past two years is the establishment of the Baylor College of Medicine/MD Anderson Internal Medicine Residency Program. Five inaugural residents began the program in June 2015. Five additional residents came on board in June 2016, and five more came on board in June 2017, making a total of 15 residents rotating here per month. I am invigorated by the intelligence, energy and enthusiasm that each of them has brought to the services here.

New to the second year curriculum has been the addition of Chief Resident Tony Pastor, M.D., who enthusiastically oversaw the MD Anderson

residents from June through December 2016.

He and Site Director Amit Lahoti, M.D., deserve commendation for the successful implementation of morning reports that increasingly grow in popularity among our faculty. We will continue to nurture the program as it grows to its full complement of 15 residents in June 2017.

I am also proud of the resiliency of our people who encountered the OneConnect transition. In the recent past I have referred to this as us overcoming

Endocrine Neoplasia and Hormonal Disorders already command a presence at a number of the HALs. Screening Endoscopy, Cardiopulmonary Testing and Dialysis are being considered for future expansion. Several of our faculty have shared their expertise with our partners at Banner and Cooper to help ensure we have best practices in place at all MD Anderson locations.

As we approach the end of our second decade as a division, my goal is that we will soon have a

“ I have had the honor and privilege of leading Internal Medicine for more than two years now, and I can tell you that I am as joyful and excited after two years as I was after my first two months at MD Anderson.”

David J. Tweardy, M.D. a battle, knowing full well that we had to deal with future skirmishes. A notable skirmish in the early weeks of the launch was the need to rebuild the system in the Cardiopulmonary Center. There were many heroes from this battle and others, far too many to acknowledge, which proved our people collectively banded together to ensure our patients received the quality care they expect from us. The lines are still in the sand, so to speak, to fine-tune our systems and those who use them on a daily basis. I am fully confident that we will continue to lead the way to overcome any obstacles.

Goals I fervently believe that we will continue to bear witness to the need for Onco-Medicine, my coined term for the Internal Medicine care of the cancer patient, not only at the Main Campus, but throughout the Houston Area Locations (HALS), MD Anderson Cancer Network and the Global Business Development system. Dermatology and

full cadre of full-time chairs to replace those who have left the institution or stepped down from their leadership positions. Recruitments are under way for chairs in Gastroenterology, Hepatology and Nutrition; and Symptom Research, and will start soon for Cardiology.

With the recent recruitment of key researchers and the heightened level of research activity among our seasoned faculty, the Division of Internal Medicine is leaving its IMprint through participation in initiatives such as the Cancer Moon Shots and CPRIT-funded grants that will either treat or cure cancer or curb its imposing side effects.

These are exciting times for MD Anderson and for the Division of Internal Medicine. As a physicianscientist and the head of the Division of Internal Medicine, I am excited to watch our people continue to reap the rewards of focused and collaborative work as we collectively aim to achieve our mission of Making Cancer History®. • 5

Departments, Sections and Administration REPORTS

Cardiology MD Anderson cardiologists are world-

Clinical

renowned for their Onco-Cardiology

The department has two inpatient services covered by separate teams that see 45-50 patients per day. The majority of Cardiology’s clinical work occurs in the Cardiopulmonary Center. This includes outpatient consults, follow up visits, and a wide spectrum of cardiac testing, procedures and interventions.

care of the cancer patient. They earned this recognition by using innovative approaches to prolong and improve the lives of our cancer patients.

Many patients enter MD Anderson with heart disease that is managed alongside their cancer treatment. Still others face heart complications as a result of their cancer care.

“Chemotherapy is known to cause cardiac damage that can be long-lasting,” says Edward T.H. Yeh, M.D., named the first Cardiology chair in 2000.

“There are many other areas of cardiovascular complications that can happen, too. Our patients have peculiar issues that need to be taken into consideration.”

Overview Since the department’s inception, and with the support of former Division Head Robert F. Gagel, M.D., Yeh built the department from two to 12 clinical faculty members who are part of a structure that includes all subspecialties of cardiology. The department also includes four research faculty.

“It’s a full-fledged cardiology department that includes interventional and invasive cardiology, imaging and the entire collection of cardiology expertise,” says Yeh, who recently left MD Anderson to pursue a leadership role at the University of Missouri Medical School. According to Yeh, “We were the first to start this movement, and it is now being emulated throughout the world.”

Division Head David J. Tweardy, M.D., is serving as ad interim chair until a search is completed for a permanent chair.

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“We manage complex comorbidities of cancer patients, including urgent pericardiocentesis, myocardial biopsies for new onset chemotherapy or other etiologies,” says Medical Director Elie Mouhayar, M.D., associate professor.

The Echo laboratories are among the busiest in the Texas Medical Center performing more than 60-70 Echos per day. Jose Banchs, M.D., associate professor, and director of the Echo Lab, says the lab has achieved the Integrational Societal Accreditation Commission’s highest level with accreditation in three areas – adult standard of resting studies, transesophageal Echo and stress Echo.

“We are doing things in our lab unmatched by any lab in the world,” Banchs says. “We have committed to cardiac function quantification, or what we call full volumetric analysis of the ejection fraction on every study.”

The Echo team can perform a volumetric analysis by taking an image and converting it into threedimensional frames. The process is time-consuming but accurate, Banchs says. Technicians also have incorporated myocardial mechanics measures into their workflows, which have proven to be helpful in identifying cardiotoxicity.

Banchs says the volume of studies has increased steadily over the past eight years.

“We performed more than 17,000 studies last year and this year we are on pace to increase that. It really is extraordinary to have one site perform this volume of studies when the majority of them are

Edward Yeh, M.D., founding Chair, Cardiology, is now Department of Medicine Chair at the University of Missouri. Division Head David J. Tweardy, M.D., is Cardiology Chair ad interim.

being read by physicians with the highest level of qualification in the field of echocardiography.”

Also in the Cardiopulmonary Center is the Electrophysiology service, under the direction of Jean-Bernard Durand, M.D., associate professor, which has developed Web-based technology practice to manage rhythm disturbances in our cancer patients.

In a separate location in the Main Building is the Cardiac Catheterization Lab (CCL), the first in a comprehensive cancer center. In 2016, MD Anderson Cardiology was selected to play a leading role in the development of the CCL guidelines because its clinicians perform the largest volume of interventional procedures among cancer patients.

Medical Director Cezar Iliescu, M.D., associate professor, was first author of a white paper published in early 2016 that focuses on CCL best practices. The information was shared in the Society for Cardiology Angiography and Interventions (SCAI) Expert Consensus Statement

for cardiac catheterization of cancer patients with specific diagnostic and interventional considerations for their treatment. It speaks to the unique multidisciplinary care offered here.

“This is a powerful document,” says Iliescu, “because it includes an international group commissioned by the SCAI.” New faculty have brought additional expertise over the past year and a half. Kaveh Karimzad, M.D., assistant professor, is an electrophysiologist who runs a Cardiac Device Clinic dedicated to pacemaker and defibrillator management in patients undergoing surgical procedures, radiation therapy and Magnetic Resonance Imaging (MRI). Susan Gilchrist, M.D., associate professor and exercise physiologist, initiated the Heart Health Clinic and sees cancer patients in the Cancer Prevention Center.

Research A leader in adult stem cell research, Yeh used human CD34+ cells isolated from peripheral blood to 9

repair the heart following myocardial infarction, and molecular imaging to determine the long-term fate of the injected cells. The results of the studies were published in high impact publications, Circulation and Circulation Research.

In 2014, Yeh recruited Professor Jun-ichi Abe, M.D., Ph.D., a vascular biologist from the University of Rochester. Abe and his research team have already made their mark since joining the department.

Abe, principal investigator (PI), received an R01 in February 2016 for his study, “Disturbed flow-induced TERF2IP post-translational modifications and atherosclerosis.”

Nhat Tu Le, Ph.D., assistant professor, recently received R01 funding for her work, “A novel role for

“ We manage complex comorbidities of cancer patients, including urgent pericardiocentesis, myocardial biopsies for new onset chemotherapy or other etiologies.”

Elie Mouhayar, M.D. MAGI1 in regulating non-canonical LATS signaling and atherosclerotic plaque formation.” In addition, she was awarded an Institutional Research Grant (IRG) for her research on “Identifying molecular mechanism of Ponatinib in cardiovascular diseases.”

In Fiscal Year 2016, Abe spearheaded an effort that resulted in an Institutional Research Capital Equipment (IRG) grant in the amount of $499,855 to purchase a confocal-two photon microscope.

Abe and his team have also made numerous literary contributions, including a paper in Journal of Clinical Investigation (2015) in which they reported the role of p90RSK and SENP2 in regulating endothelial dysfunction and subsequent development of atherosclerosis.

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Abe also co-authored a viewpoint article in Circulation Research (2016) with Yeh, “The future of Onco-Cardiology: We are not just ‘side effect hunters,’” which outlined the future direction of Onco-Cardiology research. In addition, the group published, or will publish, eight papers (editorials, reviews, and original articles) in Circulation Research, Arteriosclerosis, Thrombosis, and Vascular Biology, Antioxidants and Redox Signaling, and Proceedings of the National Academy of Sciences.

Outside the lab, Abe played a key role in organizing the inaugural Gulf Coast Vascular Research Consortium (GCVRC), which currently consists of 72 faculty from 11 different institutions throughout Texas and Louisiana. The GCVRC was established to leverage the strength of cardiovascular leaders and cardiovascular research in the region to build collaborations. The first consortium was held at the Center for Cardiovascular Diseases and Sciences at the Louisiana State University Health Sciences Center in Shreveport. Abe was one of the keynote speakers.

Clinical faculty are also involved in active, on-going studies. These include a National Institutes of Health (NIH) “Take a Heart” study in collaboration with Behavioral Science. The prospective trial assesses exercise intervention for chemotherapyrelated heart failure in cancer patients.

In collaboration with the Department of Infectious Diseases, Mouhayar is PI on a Phase I/II study to evaluate the safety and effectiveness of novel non-antibiotic, non-heparin nitroglycerin-based catheter lock solution used for the prevention of intraluminal central venous catheter infections in cancer patients.

Mouhayar published results of an additional study on how to manage a cancer patient who develops pericardial effusion in the American Journal of Cardiology. Yeh says this was a unique opportunity for a clinical faculty member to describe one of the treatments conducted here.

Peter Kim, M.D., associate professor, is PI of a study of Ibrutinib-related atrial fibrillation in patients with mantle cell lymphoma that was published in the April edition of Leukemia and Lymphoma.

The heart of the matter Resiliency and faith serve as cornerstones Garon Bates’ cancer journey began in 1995, but the damage to his body began long before that. A veteran of the Vietnam Conflict, Bates was exposed to Agent Orange which was later linked to a diagnosis of testicular cancer and nonHodgkin’s lymphoma.

that caused him to lose hearing in his left ear. He also experienced drop foot, a gait abnormality, on his left side which required that he wear a brace. Bates endured all this while he received chemotherapy and strong steroids to combat the latest diagnosis.

“Also at that time, I was scheduled for an Ommaya Reservoir placement in my head to drain fluid buildup,” Bates recalls. “But before I received it, I had a major seizure at home and was Lifeflighted to Herman Hospital and then transferred to MD Anderson.”

Facing death head on

Bates’ cancer treatment included chemotherapy through IV and spinal tap as well as six rounds of radiation.

As a result, the numerous toxins and radiation that killed the cancer adversely affected his heart and heart chambers.

Beginning in 2005, Jean-Bernard Durand, M.D., associate professor, Cardiology, treated him for left ventricular systolic dysfunction, atrial fibrillation and atrial flutter.

Continued bumps in the road Two years later, Bates’ oncologist discovered an inoperable brain tumor

During his hospitalization, Bates developed a Methicillinresistant Staphylococcus aureus (MRSA) infection and contracted pneumonia, which resulted in a seven-week hospital stay. Doctors did not give him much hope for survival, but Bates overcame this challenge. After being discharged, he made frequent visits to a rehabilitation facility where he learned to walk and lift his legs again. Today, only his drop foot gives him problems.

Facing continuous cardiotoxicity from his cancer treatment, Bates is currently on a SENECA trial of stem cell therapy for Adriamycin cardiomyopathy. He continues to maintain a peaceful acceptance of his situation.

“MD Anderson saved my life, and still does to this day. I am very grateful for the exceptional care, family support and my wife Mim, who never left my side. All this reinforced my belief in the power of prayer that helped my family and me cope with this roller coaster ride.”

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Banchs is the recipient of $225,000 in a study of 300 patients to invent a new stress test using heart quantification technology. He hopes the technology will lead to the development of a stress test that is 50% cheaper than the current one and which offers entire data in minutes rather than four hours.

Durand has received funding on three trials in collaboration with Amanda Olson, M.D., assistant professor, Stem Cell Transplantation. These studies involve invasive and peripheral infusion of stem cells for treatment of Anthracycline-based cardiomyopathy. The studies include SENECA (a National Heart Lung and Blood Institute-funded study) and infusion which is actively enrolling at our institution.

Education As leaders in Onco-Cardiology, the faculty each contributed to a book, MD Anderson Practices in Onco-Cardiology or MAPS, which includes algorithms for managing cardiac complications in the cancer patient.

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understand complex cardiac events in a setting of severe morbidities like cancer.

For the past four years, Banchs has conducted a non-invasive imaging boot camp in which several courses are offered throughout the year. Individuals who have completed the course have a 100% pass rate on their imaging boards.

Durand says the department also offers an annual professional boot camp for the Texas Medical Center cardiovascular fellows. The intent is to prepare them for life after fellowship.

“They focused on their career development and then they transition into a career where their income increases significantly,” says Durand. “We teach them how to establish a practice and to market and brand themselves.”

The team has increased its scope to include a boot camp for the Department of Pathology and plans to conduct one throughout the institution in the future.

Quality Improvement

With the United States approaching 15 million cancer survivors, Cardiology saw the need to establish the Onco-Cardiology Fellowship in summer 2016. Durand, who leads the program, says the department was also responding to the institution’s survivorship initiative.

Durand, the department’s quality officer, says a large effort has been placed on managing procedures with thrombocytopenia or deficiency of platelets. A study of the number of techniques and laboratory work has been conducted to determine the risk for bleeding or thrombosis.

Rohit Moudgil, M.D., Ph.D., is a trained cardiologist who has completed a clinical cardiology fellowship and two years in Yeh’s basic research lab. Durand says the intent of the training is to prepare Moudgil to manage cardiotoxicities in cancer survivors.

“This required that we look at blood work for platelet function rather than the absolute platelet number. We have learned there is little correlation between platelet number and platelet function. It’s all about the function,” Durand says.

“Rohit is focusing his efforts in non-invasive imaging of the heart, inpatient and outpatient consults, and cardiovascular procedures related to cardiac toxicities. He is also learning about quality improvement (QI) and pathways to improve patient care and safety,” Durand says.

The department is also introducing fellows to quality improvement (QI) to teach them the fundamentals of QI directives. This is necessary to meet Accreditation Council for Graduate Medical Education (ACGME) requirements and a division initiative to encourage a QI track.

In addition to the Onco-Cardiology Fellowship, the department has an active training program with Texas Heart Institute and The University of Texas Health Science Center at Houston. The fellows are exposed to the unique patient population and to

An electrocardiogram (EKG) project is underway to study different measures of EKG patterns.

The purpose is to identify risk for new cancer therapeutics that may affect the heart. It is also intended to improve drug safety in cancer patients. •

Ronald Rapini, M.D., Chair

Dermatology Department of Dermatology faculty are frontline caretakers for skin cancer and cancer prevention, and they play a

Transplantation Clinic to diagnose and treat rashes associated with Graft-versus-Host Disease.

supportive role to oncologists whose

Clinical

patients develop skin complications

Rapini oversees a staff that includes 25 full time faculty (16 based at MD Anderson), two part-time faculty, 10 volunteer faculty at UT Medical School, two advanced practice providers, 21 dermatology residents, three clinical and postdoctoral fellows and a strong ancillary staff that is an integral part of the team.

from targeted therapies and chemotherapies.

“People get rashes from all sorts of chemotherapies,” says Ronald Rapini, M.D., professor and chair in collaboration with MD Anderson and The University of Texas Health Science Center Houston Medical School (UT Medical School).

“A lot of the drug reactions are manageable, so patients can continue their treatment if the rash is under control.” For example, Sharon Hymes, M.D., professor, works closely with the Stem Cell

The team’s web of clinical expertise, which permeates the Texas Medical Center (TMC) and beyond includes: • Melanoma and Skin Center • Cancer Prevention Center • Houston Area Location Clinics (HALS) in The Woodlands, Sugar Land, Memorial City, and Katy 13

Dermatology patient “Mohs” his cancer

by Dick Perkins I ignored warnings of skin cancer from both my wife of 50 years and my dermatologist. That ended in 2015 when my dermatologist confirmed I had basal cell carcinoma (BCC) on my upper lip.

As an engineering alumnus of The University of Texas at Austin, I had learned of the quality of MD Anderson Cancer Center, which is also part of the UT System.

The lip is a ticklish place to remove cancer, but Mohs surgeon Dr. Deborah MacFarlane was a God send. Dr. MacFarlane, is a most business-like physician who made multiple removals of tissue to be sure to remove all the cancer.

At one point in the surgery, when she told me more tissue needed to be removed, I said to her, “I could argue with you about it.” In a moment that I clearly remember, Dr. MacFarlane quickly, and very politely, shot back saying, “It’s the cancer. What’s there to argue about?” Slam dunk and thank you, Dr. Mac. Soon afterward, a rash developed on my upper chest that was found to be incurable Mycosis Fungoides, a cutaneous T-cell lymphoma. That meant a trip back to MD Anderson where I saw Dr. Madeleine Duvic, an expert in the field and another spectacularly professional physician. By the time of the visit, the Mycosis had

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subsided, and so far, I remain lesion free but have regular checkups with Dr. Duvic.

My third, and hopefully last, bout with skin cancer came in July 2016 when another BCC was found on the side of my head. Dr. MacFarlane performed another Mohs surgery, removing the BCC in my hairline.

I’ve received fantastic treatment from Dr. MacFarlane, Dr. Duvic and the other physicians and nurses at MD Anderson.

I’m reminded of Dr. MacFarlane’s skill and diligence every time I shave since I see her masterful artwork of sewing up my upper lip after the cancer removal.

I am happy to personally attest to the commitment to excellence by MD Anderson and the entire UT System. We are all extremely privileged to have such great caregivers, physicians, and surgeons.

• The University of Texas McGovern Medical School HMC Clinic • Memorial Hermann Hospital • LBJ County Hospital and the Harris Health System • Mohs and Dermasurgery Unit “Dermatology lends itself to being in the community, because we are more than a consult business.

We also are ‘upstream’ and feed patients into the system,” Rapini explains.

The Melanoma and Skin Center is a multidisciplinary effort that includes faculty from Medical Melanoma, Surgical Melanoma and Radiation Oncology, along with faculty from Dermatology. Patients with more complex cases are seen in this center.

One of the clinical programs in the Melanoma and Skin Center is for Mycosis Fungoides and other skin lymphomas. Operated by Madeleine Duvic, M.D., professor, and Auris Huen M.D., assistant professor, the program is one of the largest in the world.

Anisha Patel, M.D., assistant professor, and Saira George, M.D., assistant professor, have established a data base to study patients with drug reactions.

“Dr. Patel expects to publish a number of articles based on the data collection, because she is on the cutting edge of some of the new reactions caused by the drugs,” Rapini says.

Patients with less complex cases are screened in the Cancer Prevention Center and in the (HALs) in The Woodlands, Sugar Land, Memorial City, and Katy.

Carol Drucker, M.D., was the first Internal Medicine Division physician to see patients outside the walls of the TMC when she opened a dermatology clinic in The Woodlands in 2008. She now spends 80% of her clinical time at MD Anderson in The Woodlands.

“Patients love the close proximity to their homes,” says Drucker, professor, who lives near the facility.

Dermatology faculty have expanded their clinics to other HALs. Saira George, M.D., sees patients at the Sugar Land facility, while Kudakwashe Maloney, M.D., assistant professor, sees patients in the Katy and Memorial City facilities.

Maloney, Rapini and Valencia Thomas, M.D., associate professor, diagnose and treat the indigent

patient population in the Harris County Hospital system. Thomas visits LBJ Hospital, while Maloney treats patients in the Thomas Street HIV Clinic.

“Many of the patients she sees are diagnosed with Kaposi’s sarcoma, which is one of the skin cancers you can get with HIV,” Rapini says.

Thomas recently was named director of The Mohs and Dermasurgery Unit, which has close collaborations with Plastic Surgery, Head and Neck Surgery, Ophthalmology and other surgical subspecialties.

Mohs micrographic surgery is most often used to treat primary or recurrent basal and squamous cell carcinomas on areas of the body where tissue conservation is important, such as the face, eyelids, lips, ears, hands, feet and external genitalia. This minimally-invasive procedure allows physicians to preserve the good tissue and remove only the cancer.

“Mohs-assisted excisions combine delicate surgery with precise pathology,” Thomas says. She and her colleagues Deborah MacFarlane, M.D., professor, and Michael Migden, M.D., associate professor, serve as both the surgeon and the pathologist during the Mohs-assisted excisions.

Skin Cancer Screenings Draw Awareness Using a clinical and educational approach, Susan Chon, M.D., associate professor, and Betty Spears, program coordinator, have developed a formidable community affairs program in which they conduct skin cancer screenings and awareness throughout the city.

They conduct a free annual city-wide screening with the American Academy of Dermatology, and they pay annual visits to two local universities. Students at the University of Houston and University of St. Thomas get to see firsthand how the sun has already affected their skin under the lens of the Derma Skin machine.

“When the students see they already have skin damage they say, ‘Oh, my, gosh, it’s already happening,’” Chon says.

For the fourth year in a row, Chon and Spears also voluntarily saw patients at the Brookwood Community, located near Katy, Texas. The 15

community offers a non-profit residential facility and vocational program for adults with disabilities.

“It’s really been rewarding for Betty and me to go there, plus it’s so much better for the patients.

We can relieve the stress some of them have experienced in a trip to the Main Campus. Plus, we can see more patients in a shorter amount of time.”

Skin care awareness has also spilled out to the Professional Golfers Association tour through interactive opportunities, e.g., handing out sunscreen samples and placing them in key locations like bathrooms or pavilions.

“ When the students see they already have skin damage they say, ‘Oh, my, gosh, it’s already happening.’”

Susan Chon, M.D. “We started with the players and caddies and more recently included the general public, since they’re out in the sun for long periods, too,” Spears says.

Research Madeleine Duvic, M.D., has been principal investigator of numerous clinical trials and translational research studies of T-cell mediated diseases and malignancies, including T-cell lymphomas, melanoma, and skin cancer. Her work focuses on developing and improving therapies for cutaneous T-cell lymphoma (CTCL). Within the past year, Auris Huen, M.D., was recruited and has become an important investigator in the skin lymphoma area.

Michael Migden, M.D., associate professor, is an expert in the study of Hedgehog signaling inhibitors. In recent years, he has participated in multiple protocols in search of treatment that could effectively treat advanced basal cell carcinoma.

The development of the drug Vismodegib showed promising results and provided hope to patients with advanced basal cell carcinoma. Migden was 16

among researchers in a multi-center study in which patients received the drug or a placebo in order to determine its efficacy. He has recently launched a study of an immunomodulatory drug for treatment of advanced skin cancer.

Ana Ciurea, M.D., associate professor, and Saira George, M.D., have been working with the Prevention Center on a study of the value of skin cancer screening in an underserved population.

Education The Dermatology Residency Program, primarily based at the University of Texas Medical School at Houston, is among the 10 largest in the nation with 21 residents.

“Our department is different from the others in the division, because we have only one mid-level provider at MD Anderson and one at the medical school. We engage our residents in the capacity for which some departments use mid-levels. That’s the model that works for us,” Rapini says.

Dermatology also has a one-year procedural dermatology fellowship accredited by the American Council on Graduate Medical Education (ACGME). The fellowship provides training on cutaneous oncology, Mohs micrographic surgery, reconstructive surgery and cosmetic surgery within ACGME guidelines.

Rapini has put his years of experience into play as the author of a single-author book, Practical Dermatopathology, which includes 30 chapters. The third edition of the book will be published in 2017.

According to Rapini, “A lot of residents and practicing physicians can cut to the core and immediately find what they’re looking for. I’m not a new discovery person, but I’m a consolidator of discovery and I am able to put it together into a meaningful format.”

Quality Improvement Chon has been at MD Anderson for 10 years and has been a member of the division’s Quality Council for most of that time. In the past two years, she identified needle sticks as an important safety issue, particularly for trainees and fellows. She

presented her findings at two consecutive Quality Improvement Grand Rounds.

the process. She plans for it to be placed on the department’s Website as an educational video.

“This is an on-going project in which we are trying to educate and teach our trainees – medical students and fellows – in needle safety. Awareness is so important because they will be doing these procedures throughout their careers,” Chon says.

Two other important projects are specimen labeling, an important patient safety area, and cost – disposal versus auto clavicle. Regarding the latter project Chon says, “We’ve looked at different aspects of the care we deliver, whether it’s for patient safety or the safety of the staff, in order to improve the care we deliver.” •

In order to be as effective as possible, Chon produced a short video to educate the target audience about the importance of improving

Emergency Medicine annually in one of the highest acuity areas of the cancer center.

According to founding Chair Knox Todd, M.D., “Oncologic emergency medicine focuses on the discovery and application of time-critical diagnostics, decision-making, and treatments to save lives, reduce disability, and restore health among persons with cancer.”

Todd launched the academic department in 2010.

He retired in fall 2015, but before he left, he strategically built an oncologic emergency care team that is nationally and internationally recognized for its extensive knowledge of the emergent care of the cancer patient.

Clinical Kumar Alagappan, M.D., Chair

Expect the unexpected and never let your guard down.

That’s the mantra of any emergency department physician, but particularly in the Emergency Center (EC) at MD Anderson where Emergency Medicine physicians and staff see more than 26,000 patients

One of his key recruits is newly-appointed Chair Kumar Alagappan, M.D., professor, who points to his faculty’s broad clinical know-how to treat a variety of acute oncologic emergencies.

“For instance, our doctors are managing pulmonary embolism patients in the outpatient setting, which is unheard of in the emergency medicine world,” says Alagappan, who served as chair ad interim since December 1, 2015. “This is all being done routinely here.”

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This unique expertise will soon be shared with the general emergency care population. Over the past year, the department received funding from the Bristol-Myers Squib ARISTA program to conduct a retrospective review of incidental pulmonary embolism in the EC. “Because MD Anderson performs so many CT scans for cancer staging purposes, quite a number of these patients are discovered here,” says Sai-ching “Jim” Yeung, M.D., Ph.D., professor. “Our experience is that the majority of them can be safely sent home on an outpatient basis.”

Yeung says many clinicians in non-cancer ECs opt for a conservative approach and admit these patients.

With the Bristol-Myers grant, researchers hope to develop a more rigorously controlled expanded sample size that will demonstrate how safe it is to treat these patients on an outpatient basis.

“ There is a lot of interest globally to learn about cancer emergencies. Fellows will be able to go back to their countries and run their emergency departments in their respective cancer hospitals.”

Kumar Alagappan, M.D. Alagappan also points to an important equipment purchase that has improved patient care. The physicians now have an ultrasound machine in their clinical management of patients.

“We use the ultrasound for procedures, such as paracentesis, and for diagnostic purposes - in sepsis, pericardial effusions, pleural effusions, fluid status, DVTS and some use it for placement of IVs,” says Deputy Chair Patricia Brock, M.D., assistant professor. “We also look at masses to see if there are fluid collections. If we find anything of clinical significance, we will obtain an official study.”

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In addition, Jerry Henderson, M.D., associate professor, who created the Zero-G database for the EC, was pivotal in the OneConnect launch.

Henderson was the first MD Anderson faculty member to earn the Epic Physician Builder certification. On launch day, March 4, 2016, he helped troubleshoot problems in the OneConnect Central Command.

Research Department faculty have a broad range of research interests. In addition to the pulmonary embolism study conducted over the past year, researchers have developed projects centered on delirium, sepsis and pain.

• Ahmed Elsayem, M.D., associate professor, and his colleagues conducted a single center study that determined that emergency medicine physicians frequently overlook delirium as a symptom among their patients despite prior education. Researchers screened 1,832 patients and 624 met study criteria. Of these patients, 243 gave consent and 241 were assessed for delirium. Results of the study, published in Cancer, highlighted the need for systematic screening for advanced cancer patients visiting the EC in cancer care settings.

• Yeung is conducting a prospective observational study along with George Calin, M.D., Ph.D., professor, Experimental Therapeutics, to examine blood samples from EC patients to analyze for cytokines, procalcitonin and non-coding microRNA. The study is supported by an Institutional Research Grant (IRG).

• The Program in Oncologic Emergency Medicine (POEM), led by founding Director Cielito Reyes-Gibby, Dr.PH., was established in 2015 to improve patient outcomes by providing an interdisciplinary research hub. The intent of POEM is to serve as a framework for developing emergency care research and implement research-driven practice in caring for cancer patients who present in the EC. POEM is participating in a prospective observational study of oncologic emergencies

with the Comprehensive Oncologic Research Network (Concern). Funded by the National Cancer Institute, members share patient information in this study.

• Reyes-Gibby is principal investigator on a National Institutes of Health R01 dedicated to studying “Molecular epidemiology of neuropathic pain in head and neck cancer.”

• She is also part of an NIH R21 grant that involves a multidisciplinary working group from MD Anderson aiming to improve clinical care of patients with mucositis through collaborative translational research. This multidisciplinary pilot study will evaluate the association between baseline microbial composition and incidence and time to onset of oral mucositis in patients with head and neck cancer and develop prediction models for incidence and time to onset of oral mucositis.

Education Emergency Medicine physicians globally share their unique knowledge of emergent care.

Another of POEM’s aims is to develop and train physician scientists and graduate students in oncologic emergency research. Reyes-Gibby mentored four faculty in FY16 who have co-authored manuscripts, presented posters at conferences and submitted grants within the past year. She received the Provost’s 2016 Distinguished Faculty Mentor Award in recognition of her efforts.

The department also has an Emergency Medicine Oncology Fellowship, which Todd and Brock established in 2012. The program was originally a oneyear program, but expanded to include a second year option for individuals interested in pursuing research. Alagappan says the program has cast a wide net of interested candidates, including those from India, Lebanon and Saudi Arabia.

Baylor Emergency Medicine residents rotate through the EC for one month at a time to gain experience in the still-new subspecialty of OncoEmergency Medicine.

back to their countries and run their emergency departments in their respective cancer hospitals,” he says.

The department also has an Emergency Medicine Oncology Fellowship, which Todd and Brock established in 2012. The program was originally a one-year program, but expanded to include a second year option for individuals interested in pursuing research. Alagappan says the program has cast a wide net of interested candidates, including those from India, Lebanon and Saudi Arabia.

Because of the high level of interest, the faculty is considering expanding the Emergency Medicine Oncology Conference Management Education (CME) program. Alagappan says he has spoken with Senior Vice President for Academic Affairs Oliver Bogler, Ph.D., about taking the program to other continents.

The “road show,” as Brock calls it, will be offered abroad two-to-four weeks at a time.

“There is a lot of interest globally to learn about cancer emergencies. Fellows will be able to go

Emergency Medicine physicians have already had a taste of traveling. Within the past fiscal 19

Acute Care Team (ACT): Addressing quality of life for late-stage cancer patients The MD Anderson Emergency Center (EC) is the gateway to the institution for many patients, particularly those with advanced cancer who are likely to be very ill and have a short life expectancy.

Although about half of admitted patients come through the EC, the majority (71%) of patients who ultimately died in the hospital came through the EC. “Because of innovations in cancer therapy and an aging Ahmed Elsayem, M.D. population, our patients are receiving treatment until the last few days of their lives,” provide psychosocial and emotional says Ahmed Elsayem, M.D., associate support to terminal patients and their professor, Emergency Medicine. caregivers. This coordinated approach “They are presenting to the EC with will include EC physicians and nurses, altered mental status, dyspnea and poor social workers, chaplains, case managers, performance status and are likely to face patient advocates, and members of negative outcomes, including referral to the Integrative Medicine. intensive care unit (ICU) or hospital death.”

“Training for EC nurses is a key component Elsayem says many times EC physicians of the program with a goal to empower are the bearer of bad news to these them in their day-to-day interactions with individuals, who have not addressed goals patients and caregivers,” Elsayem says. of care with their loved ones. Because of “They also will have access to monthly this, he believes all members of the EC staff educational trainings in which they will must be prepared to conduct complex and learn how to counsel and support upset delicate conversations with both patients patients and caregivers, become aware and their caregivers. of the various kinds of psychological “The need for a coordinated approach support available at MD Anderson, and to have difficult conversations in the EC learn how to maintain a professional and has been evident for several years,” says caring demeanor when faced with a highly Elsayem, formerly a physician in Palliative emotional response.”

Care. “Patients with advanced cancer and The team believes this harmonized their families experience high levels of approach will provide the necessary emotional distress and frustration.” support that patients and their family To respond to this challenge, Elsayem is members deserve as they struggle with leading an effort to build the Acute Care emotional distress and complications Team. With funds from the institution’s related to their disease and treatment.

Holiday Giving Program, the team will 20

year, several members were invited to present a half-day course on Oncologic Emergencies at the Mediterranean Emergency Medicine Annual Conference in Rome.

Closer to home, faculty members shared their unique body of knowledge at a day and a half Oncologic Emergency Medicine Conference in November 2015. The second conference was held in January 2017. Brock says she hopes this will be an annual event to “share some real ‘how to’ with community emergency physicians.”

Quality Improvement As the division’s Quality Council Chair Carmen Gonzalez, M.D., associate professor, has her pulse on all quality improvement (QI) projects. In her own department, recent projects relate to enhancing the quality of care for terminally ill patients at the endof-life. One of them is the building of the Acute Care Team in the EC. (See adjoining story) “It’s a project that’s been going on for five years, but what is important is that we continue to evolve it.

Currently, we are sending physicians to be educated in end-of-life issues of patients who come to the Emergency Center.”

Ahmed Elsayem, M.D., a former Palliative Care physician, leads the multi-disciplinary team that includes Nursing, Case Management, Social Work, Chaplaincy and Integrative Medicine. Elsayem received a grant to educate nurses on how to have conversations with patients and caregivers about their choices of care as they approach the end-of-life.

Additional QI projects undertaken during FY15 and FY16 include:

• An annual review of pathways and protocols that are frequently in use in the EC for pneumonia and neutropenic fever, • A multidisciplinary team of neuro-radiologists, radiation oncologists, EC physicians and neurosurgeons who have developed an algorithm and protocol for the evaluation and treatment of patients with acute cord compression, • The development of a Comprehensive Unitbased Safety Program which includes clinical team members of EC physicians, EC Nursing, Department of Emergency Medicine leaders, and supportive and administrative staff, who meet monthly (since October 2015) to address all patient safety issues by combining best clinical practices and the science of safety, • Zero Errors in Medication Reconciliation, a combined effort which involves multiple stakeholders to include the EC patients, patient safety coordinators (PSCs), nurses, pharmacists and physicians, to promoting a safe patient transition through the patients continuum of care, • A collaboration between Terry Rice, M.D., associate professor, and EC medical director, and Bruno Granwehr, M.D., associate professor, Infectious Diseases, in which they conducted a quality improvement initiative aimed at improving HIV testing in the EC and changing practices at the institutional level, and • Safe and timely patient handoffs. Fellow Srinivas Reddy Banala, M.D., received the 2016 Conquer Cancer Foundation of ASCO Merit Award for the work done in the quality initiative of standardization of handoffs in the EC. •

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Section of Nephrology educational and supportive care for patients who experience these challenges.

“Dialysis is a life-saving procedure that is very important for many hospitalized patients with cancer,” says Farhad Danesh, M.D., professor and section chief.

“Unfortunately, some chemotherapy drugs cause severe kidney damage, especially the newer targeted therapies. We use the dialysis machine to get through the acute phase of kidney injury.”

The clinicians see patients with both acute and chronic kidney disease. They perform about 3,000 inpatient dialysis procedures per year, including hemodialysis, peritoneal dialysis, and continuous renal replacement therapy.

Farhad Danesh, M.D., Section Chief

The kidneys are essentially the body’s trash collectors. Their major function is to remove waste products and excess fluid from the body, which are removed through the urine. The production of urine involves highly complex steps of excretion and re-absorption.

Cancer patients frequently face chronic kidney disease before their cancer diagnosis. But they may also experience kidney failure or decreased kidney function when their bodies are exposed to chemotherapy, particularly the newer targeted therapies. For some of these patients, their only option is to undergo dialysis when their own kidneys cannot clean the blood.

Overview The Section of Nephrology was established in 2006 to give birth to a new subspecialty – Onco-Nephrology – in order to provide clinical, 22

Currently, the section includes five nephrologists and four research faculty. The section also supports two postdoctoral fellows and a Ph.D. student.

Clinical Danesh says plans are underway to expand the dialysis procedures in the near future by providing dialysis to outpatients.

“Once our patients are sent home, we refer them to private dialysis clinics so they can continue their procedures.” Dr. Danesh says. But he states that is not necessarily the patient’s preference.

“Patients develop a relationship with us and they want to continue dialysis at MD Anderson. That has not been possible so far.”

In fall 2015, Biruh Workeneh, M.D., associate professor, joined the section to help establish an outpatient dialysis center. The goal is to eventually have dialysis centers at the Main Campus and at the Houston Area Locations.

“That would be fantastic for the Nephrology section since it allows us the flexibility to see patients with chronic kidney disease. It’s also good for our patients who prefer us, because of our

Compassionate care draws attention of Lufkin patient On a trip with his wife to Yellowstone in July 2014, Ted Lankford experienced a severe rash, swelling in both of his feet, fatigue, and weight loss.

Upon his return home to Lufkin, Lankford’s primary care physician prescribed Lasix to decrease the swelling. Because of his other symptoms, Lankford also underwent a CT scan that revealed he had a large mass, so his physician referred him to MD Anderson where he underwent a kidney mass ablation in the Urology Clinic.

After this treatment, Lankford continued to be wheelchair bound, fatigued and in kidney failure. He was then referred to see Ala Abudayyeh, M.D., assistant professor in Nephology, who diligently performed multiple blood tests to help find a reason for Lankford’s kidney injury. Abudayyah said a kidney biopsy provided key information about Lankford’s condition.

“The kidney biopsy indicated vasculitis and autoimmune disease that was causing inflammation in the kidney,” Abudayyah says. “He immediately underwent steroid treatment and Rituximab that placed him in remission.”

knowledge of cancer and cancer therapy and all the potential problems we have encountered with kidney disease.”

Research The section conducts a robust research program.

Danesh has two National Institutes of Health (NIH) R01 grants. His lab is interested in the role of mitochondria, which was the centerpiece of an article in Nature Communications in June 2016.

He also received recognition for the article as the

Lankford’s rash and swelling in his legs improved and he started to regain his strength and walk again.

With more than a year of treatment behind him, Lankford is happy to say that he won’t need to visit with Abudayyeh until fall 2017.

As he reflects on his time at MD Anderson, Lankford fondly recalls Abudayyeh’s great bedside manner and open communication.

“Even when I wasn’t scheduled for a nephrology visit, she would visit me in the waiting room before another appointment just to check on me,” he says.

Lankford says he particularly appreciated Abudayyeh going out of her way to see him when he faced so much uncertainty early on in his treatment.

recipient of the division’s Distinguished Paper Award for Basic Research for January through June 2016.

Workeneh’s research is dedicated to muscle weakness associated with cancer and kidney disease.

Presently he is participating in an NIH-sponsored study evaluating the effectiveness of a new exercise gaming (Exergaming) technology to enhance balance in cancer patients suffering from chemotherapy induced neuropathy. Other research interests include motor and cognitive impairment associated with hyponatremia, which is a common condition in cancer patients.

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Ala Abudayyeh, M.D., assistant professor, has conducted one of the first and largest retrospective studies evaluating the role of symptomatic BKV in post-SCT kidney function decline. Her study showed for the first time that symptomatic BKV independently contributes to kidney function decline and increased mortality rates.

“I am currently expanding on this work with a prospective study that looks at specific BKV T-cell responses post-SCT and creating a grading scale to guide intervention and treatment,” Abudayyeh says.

“I also further widened this project by collaborating with Pathology to stain for BKV in autopsy cases from our study population.”

Abudayyeh says the evidence from this study supported the need for better BKV screening protocols. She is also creating a grading system to assess risk for symptomatic BKV post SCT, and will be able to help intervene early in preventing the morbidity associated by introducing novel cellular therapies to treat BKV. Sheldon Chen, M.D., associate professor, is studying the patterns of how the kidney function changes during acute kidney injury and renal recovery.

“Classifying these patterns can help doctors diagnose and, hopefully, treat patients with kidney disease,” Chen says. “I am trying to make the computation of these changing kidney functions widely available, starting with an online calculator.”

Chen is also working on a more rational and quantitative way to treat the sodium disorders, both hyponatremia and hypernatremia. The work also lends itself to an online calculator.

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Education Amit Lahoti, M.D., associate professor, is one of the first nephrologists hired at MD Anderson. Lahoti oversees the educational activity in the section, and in fall 2014, he took on an additional role for the division as site director of the Baylor College of Medicine/MD Anderson Residency Program track. The goal of this partnership is to train future hospitalists to address the unique care of the acutely ill cancer patients. Some of the residents rotate through the Section of Nephrology.

Lahoti will also train future onco-nephrologists via the Onco-Nephrology fellowship. Established in 2015, the fellowship has graduated two successful people who have moved on to academic positions outside the institution. He is also in charge of fellows from the University of Texas Health Science Center at Houston who also see patients with a variety of kidney diseases at MD Anderson.

Outside of MD Anderson, members of the section delivered four oral presentations at the 2016 annual meeting of the American Society of Nephrology (ASN) meeting in Chicago. In addition, Danesh is a member of the ASN program committee, and the section hosted its first Onco-Nephrology Symposium in fall 2016.

Quality Improvement During FY16, the section started a dialysis steering committee which includes the nephrologists and others in Dialysis Patient Care to determine optimum quality parameters to put into place.

“Until now, there was nothing in terms of ensuring patients are getting adequate and effective dialysis,” Danesh says. •

Endocrine Neoplasia and Hormonal Disorders

Steven I. Sherman, M.D., Chair

At MD Anderson, Endocrine faculty perform both oncologic and traditional endocrine activities, and are trained and experienced to cover a broad spectrum of responsibilities: • Research-driven treatment of patients with malignant or benign tumors of endocrine glands, such as thyroid, adrenal, parathyroid, or pituitary glands, • Evaluation of novel therapeutics for advanced endocrine cancers, such as targeted therapies and immunotherapies, and

• Traditional endocrine consultative care focused on patients with cancer, emphasizing management of diabetes mellitus, bone health, and other common endocrine disorders.

“About half of what we do is to provide traditional endocrine consultative care focused on patients with cancer,” Chair Steven I. Sherman, M.D., professor and chair, says. “That includes the care of patients with diabetes, who are undergoing cancer therapy or who develop diabetes as a consequence of cancer therapy.”

Patients can also develop skeletal problems, Sherman says, which are complicated by their 25

cancer or cancer therapy. For instance, breast cancer patients can develop accelerated postmenopausal osteoporosis because of hormone deprivation in early menopause or because of the use of medications that block any endogenous female hormone.

With the rapid development of immunotherapy across oncology, some unique and increasingly frequent endocrine complications can occur with immunotherapies as they activate endocrine autoimmune diseases that affect the thyroid and the pituitary. Some also cause Type 1 diabetes, which is typically thought of as a childhood disease.

“That is only part of who we are, says Sherman, who is also the institution’s associate vice provost for Clinical Research. “That would be enough in any other institution to cover the spectrum.”

Clinical Thyroid Cancer Management The largest component from both the clinical and research standpoints are thyroid cancers.

“We have emerged as leaders in our field by managing our patients’ systemic therapy and their chemotherapy – something that is rarely done by endocrinologists elsewhere,” Sherman says.

The team uses a multidisciplinary approach with various groups throughout the institution, e.g., Surgery, Diagnostic Imaging, Radiation Oncology, and Medical Oncology. The primary oncologic care model includes the initial diagnosis, management of early stage to advanced stage metastatic disease and end-of-life care. This has been replicated with other endocrine malignancies as well, particularly those involving the adrenal glands and the group of tumors called Pheochromocytoma and Paraganglioma.

The pre-diagnostic Thyroid Nodule Clinic focuses on the undiagnosed patient who has a thyroid mass.

Fortunately, most of the patients seen at MD Anderson have a benign disease and do not require treatment. But by providing state of the art, multi-disciplinary diagnostic management, the patient can quickly move through the process and receive a definitive answer.

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New drugs for metastatic disease Sherman says the biggest clinical accomplishments have been the considerable expansion of the treatment paradigm for patients with metastatic disease, which goes hand in hand with the department’s research.

“We are the primary drivers behind two of the four new drugs for thyroid cancer (Cabozantinib and Lenvatinib) and a major contributor for the other two (Sorafenib and Vandetanib).”

Ramona Dadu, M.D., assistant professor, and Maria Cabanillas, M.D., associate professor, are leading several different ongoing projects that study the potential use of immunotherapy in patients with thyroid cancer. Collectively, the faculty treat hundreds of metastatic thyroid cancer patients using both approved and investigational agents in a very sophisticated clinical practice model.

“This has required that not only the faculty develop and acquire skill sets outside the normal realm, but that our advanced practice providers, research team, and clinical nurses do so as well,” Sherman says.

Diabetes Management An emerging problem is the management of diabetic patients whose care is complicated by high dose steroid therapy. Steroids exacerbate diabetes and make blood sugar levels higher. A huge population of patients in Leukemia, Stem Cell Transplantation, and other areas are on very high doses of steroids and medications for long periods of time. Faculty and nurse practitioners work to minimize their hyperglycemia and diabetic complications, and make life easier for the oncologists who are managing the patients’ leukemia or transplants.

The diabetes management team also: • Collaborates with staff in the Critical Care and Pre-Operative areas to optimize the complications of diabetics in intensive care units and undergoing surgery, • Manages patients who use continuous insulin pumps, and • Treats patients with feeding tubes or enteral feeding.

Sherman says the team also has established collaborations with other cancer institutes to develop standards of care for the cancer patient.

Victor Lavis, M.D., professor, Sonali Thosani, M.D., clinical assistant professor, and Conor Best, M.D., assistant professor, are working to create a larger, more uniform standard of care based largely on the experiences of our patients.

Other major attractions Camilo Jimenez, M.D., associate professor, has expertise in the treatment of malignant Pheochromocytoma and Paraganglioma. Considered a global expert in the disease, Jimenez is the lead investigator on multi-institutional clinical trials, including one for a drug that will be submitted for FDA for approval for treating the disease within the next year.

Sherman expects another programmatic expansion in the treatment of adrenal cancer. Mouhammed Habra, M.D., associate professor, is developing clinical trials based on collaborative translational studies that he has performed with other MD Anderson investigators to identify new mechanisms to target for therapy.

Research Research efforts have largely been synergistic with the department’s clinical research. Two of the department’s basic science laboratories are engaged in relevant translational research.

Marie-Claude Hofmann, Ph.D., professor, and her team have studied why certain thyroid cancers develop resistance to targeted therapy with BRAF inhibitors. Her lab has identified a unique mechanism that may explain, at least in part, why some patients, successfully treated with BRAF inhibitors for thyroid cancer for many months or years, develop progression or resistance to the drug.

Another important area of research focuses on the development of new biomarkers that will allow researchers to provide more accurate prognosis, and potentially predict, defense responses to therapy in patients with different thyroid cancers.

This work, funded by the department’s Thyroid Cancer SPORE that it shares with Ohio State, has

been particularly of interest in the lab of Gil Cote, Ph.D., professor. Cote’s team has developed a test that is based on detecting mutant DNA from medullary thyroid cancer in patients’ blood. The Molecular Testing Evaluation Committee (MTEC) recently approved the test, and it has moved to the institutional clinical lab for routine use.

According to Sherman, “His studies indicate that the presence and the amount of mutated DNA is highly prognostic for how long patients survive.

It’s potentially much more useful than the standard biochemical test.”

The next step will be to develop the tests so they provide early prediction of how the patient will respond to a therapy.

“If we know a patient is not going to respond to therapy after a week or two, we can then stop an ineffective therapy and move the patient on to something else, rather than waste two-to-four months to find out the therapy didn’t work,” Cote says.

And, in the lab of Robert Gagel, M.D., professor, Rosita Yarmand, Ph.D., assistant professor, has worked to find new mechanisms contributing to the growth and behavior of medullary thyroid cancer that could be targeted for therapy.

“We have this complementary research effort in our laboratories that is going on in our clinics that makes sense when we take care of our patients,” Sherman says.

Education Several years ago, members of the Endocrine department launched the Advanced Oncologic Endocrinology Fellowship Program in order to share their unique expertise with others.

“The idea is to take this expertise that we have acquired over years with endocrine complications of cancer and this primary oncologic care and train other endocrinologists to do this as well,” Sherman says.

The one year, multi-disciplinary training through Endocrine Neoplasia, Surgery, Medical Oncology, Pathology and Diagnostic Imaging is targeted for individuals who have completed basic training in 27

Endocrinology or Medical Oncology. Now in its third year, the program’s first two graduates have moved into academic positions. Steven Weitzman, M.D., assistant professor, accepted a position with the department, and Sarika Rao, M.D., was recently

appointed to the faculty at the Washington Hospital Center in Washington, D.C.

Weighing the odds

Keene traveled from Fort Worth to MD Anderson where she saw Mimi Hu, M.D., associate professor in Endocrine Neoplasia and Hormonal Disorders, who confirmed the diagnosis. By the end of January 2012, surgeons removed the tumor along with more than 50 lymph nodes.

Patient focuses on giving life Twenty-eight-year-old Natalee Keene didn’t let a cancer diagnosis get in the way of giving birth to the joy of her life, three-yearold daughter Hailee. In November 2011, Keene noticed a small lump in her neck.

During an appointment with her primary doctor, she learned it was medullary thyroid cancer (MTC).

“This has been extremely popular. Dr. Mimi Hu, who oversees the program, now has a large cohort of applicants each year for the program. We have had

“Surgery and lymph node dissection are the standards of care for MTC patients,” says Hu, “but these options alone won’t necessarily cure the disease, which was the case with Natalee whose disease had progressed to other areas of her body.”

In addition, “There is no criteria to tell a patient whether the disease will be slowgrowing or quickly progressive,” Hu says.

Thankfully for Keene, the Food and Drug Administration had just approved the drug Vandetinib, which was the first glimmer of hope for MTC patients to control cancer growth.

Exercise in patience Despite this good news of having an available drug, Keene chose to postpone taking it even after Hu informed her that she had disease progression. During this visit, she also learned that taking Vandetinib would be long-term and pregnancy was not recommended while taking it. Empowered with this information, Keene took a chance, delayed treatment and set her sights on becoming a mom.

Hu said she was concerned for Keene’s prognosis under observation, but she felt her role as Keene’s doctor became more meaningful as she worked to support the young woman’s personal priority.

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a real pleasure of being able to be highly selective who we take into the program,” Sherman says.

Quality Improvement The department’s major quality initiative is Facilitating Anaplastic Thyroid Cancer Specialized

“As we tend to focus on cancer management, it was definitely an exercise in patience. However, I feel there is a need to balance a patient’s happiness and personal goals with the oncologic care.

Thankfully, in this case, Natalee’s decision was the right one because she is so much happier after having her baby.”

Rather than receiving treatment, Keene underwent ultrasounds and bloodwork so Hu could closely watch for further disease progression. Eighteen months later, she gave birth to Hailee who just celebrated her third birthday. As she reflects on her choice Keene says, “I have no regrets. My life is so much more with my daughter.”

The power of choice Shortly after her Hailee’s birth, Keene learned the disease had further progressed, so she began taking Vandetinib in pill form.

“I had a rough period at the start, but now I have acne and rashes on my face, chest and back. Aloe Vera helps with that.”

She also makes it a habit to nap with her daughter to ward off fatigue.

“I have several friends with children close in age to my daughter. Having a threeyear-old can be stressful for anyone,” she laughs, taking her destiny all in stride.

As Hu looks back on this experience, she says, “Natalee’s joy at having Hailee reinforced my belief that delaying treatment was worth it. I respect her strength and ability to shoulder the burden of this diagnosis and focus on motherhood.”

Treatment (FAST). Cabanillas, who spearheads the effort, presented the FAST program metrics at the division’s Quality Improvement presentations during Grand Rounds in fall 2015 and received high marks for her work.

The program, in combination with surgeons, radiologists and pathologists, is a multidisciplinary effort focused on moving patients with the most lethal form of thyroid cancer quickly through the system.

“The idea is to get a patient into the institution as quickly as possible. If you can’t get the patient in within a week or two of first contact, they may not survive before they get here,” Cabanillas says.

“We have been able to trim the time from first contact to first appointment to less than a day. Most importantly, 35-40% of these patients have been able to go on a clinical trial.”

Sherman says the department now has the capability to perform single institution clinical trials in anaplastic thyroid cancer, something that has not been done before at MD Anderson.

“With the growth of the cancer population, it’s put a strain on the system because these are very sick patients. We also now have clinical trials available for this group,” he says.

Future Plans A priority for Fiscal Year 2017 will be the expansion of placing anaplastic thyroid cancer patients into new clinical trials specific to their cancer. Cabanillas leads the anaplastic thyroid cancer planning group that meets weekly to discuss and study therapies to determine whether they are evolving successfully to increase patient throughput and provide quality patient care.

Combining targeted therapies with immunotherapies will be the focus of an investigator-initiated study led by Cabanillas and supported by the Genentech Rare Tumor Alliance. This Strategic Alliance Agreement includes studies of 12 rare cancers. Cabanillas’ study on anaplastic and poorly differentiated carcinomas will be one of four trials contained in this novel program. •

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Gastroenterology, Hepatology and Nutrition Overview The patient population served by GHN consists of numerous special programs including: • Advanced therapeutic endoscopy, • Ablation of Barrett’s esophagus for individuals diagnosis at increased risk for cancer of the esophagus, • Hereditary predisposition for cancers, • Diagnosis of primary tumors of unknown origin, • Complications of cancer therapy including graft vs. host disease and colitis that may result from many forms of therapy and • A variety of forms of hepatopathy, including those at increased risk for reactivation of hepatitis as a sequelae to cancer therapy.

John Stroehlein, M.D., Chair ad interim

The Department of Gastroenterology, Hepatology and Nutrition (GHN) is a dynamic, strong, forwardthinking department of clinical gastroenterologists and laboratorybased scientists. Each seeks to provide the highest level of care for patients with a wide variety of gastrointestinal disorders, including pre-neoplastic and malignant conditions, complications of cancer and cancer therapy.

“Each of our faculty apply new skills, and evaluate new devices or new techniques that result in providing exemplary patient care,” said John R. Stroehlein, M.D., chair ad interim. He noted that “each member of the department has as individual area of expertise.”

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Endoscopic procedures are available for screening, diagnostic, therapeutic and research uses and include endoscopic ultrasound, endoscopic removal of large polyps, and dilation of complex strictures. Chemoprevention studies, paraneoplastic syndromes that affect motility, biomarker studies and mechanism of tumor development, progression and metastasis are major research interests of the department.

Clinical Over the past fiscal year, more than 24,000 units of service were performed by GHN clinicians who treat patients in the Gastrointestinal (GI) Center and the Endoscopy Center. The GI Center recorded the highest patient volume at the institution with 20% of the business performed by GHN physicians.

During Fiscal Year 2016, the Endoscopy Center, which at the time was led by Marta Davila, M.D., professor, became part of the Division of Internal Medicine. This provided a reporting structure that more closely paralleled the activities of the department. The relocation of Palliative Care from

an area adjacent to Endoscopy has led to plans for expansion of the waiting area, pre-procedure reception and recovery.

In recent years the volume and complexity of endoscopic procedures have dramatically increased.

For instance, endoscopists performed 5,800 procedures in 2002, compared to 15,165 during the past year.

Some of the major issues driving the growth: • Increased aging population and clinical acuity and severity of patients’ illnesses, • Emphasis on preventative care and surveillance and • New technologies for both diagnostic and interventional procedures.

Not only has the complexity of endoscopic cases increased, but similarly there has been an increase in the complexity of the 2,841 established outpatient visits, 1,588 new patients and 1,821 outpatient consults. Inpatient services continue to grow at a high pace and included 3,073 patients seen during the past year. The endoscopy and clinical services are intense and frequently involve working into the evening hours.

Two medical assistants and two advanced practice providers (APPs) hired two years ago provided important contributions to the operations. The medical assistants routinely meet with patients in the pre-procedure area to initiate consent for procedures and they have significantly reduced the percentage of no-shows by calling patients ahead of time to let them know about upcoming procedures.

The APP program, supervised by Tonya Whitlow, manager, Advanced Practice Providers, is vibrant and vital to many aspects of the operations.

For instance, the team assists faculty in clinic operations, provides services in Cancer Prevention, and is pursuing an APP clinic. In addition, an APP is trained to assist faculty in the performance of percutaneous gastrostomy placement, and is skilled to see prospective gastrostomy patients three days a week.

It is through this diversity that all aspects of clinical care can be provided. Consider the diverse expertise of the clinical faculty:

The APP program, supervised

by Tonya Whitlow, is vibrant and vital to many aspects of our operations. For instance, the team assists faculty in clinic operations, provides services in Cancer Prevention, and is pursuing an APP clinic.

Manoop Bhutani, M.D., has extended the diagnostic capability of Endoscopic Ultrasound to include the first endoscopic microscopy and biopsy of a pancreatic cyst that has resulted in definitive diagnosis. He is also involved with therapeutic aspects of endosonography, including intralesional therapy of tumors involving the pancreas.

Boris Blechacz, M.D., has accurately diagnosed unusual causes of liver disease and identified errors in the OneConnect go-live transition that impact surveillance of those at risk for liver disease.

Robert Bresalier, M.D., brings expertise in the laboratory to clinical operations.

Marta Davila, M.D., provides a leading role in the study of Barrett’s esophagus and the ablation of Barrett’s mucosa and maintains a registry of patients seen with this condition.

Raquel Davila, M.D., is a member of the Barrett’s ablation team and is experienced in Endoscopic 31

Ultrasound and Endoscopic Retrograde CholangioPancreatography (ERCP) procedures.

in the high risk genetic predisposition of colon cancer clinic.

Jeffery H. Lee, M.D., has received training and has pursued animal model experience with endoscopic submucosal resection of large lesions in the upper gastrointestinal tract. This has averted surgery in the majority of these patients.

Mimi Wang, M.D., the newest faculty member, brings expertise in the evaluation and management of Inflammatory Bowel Disease and the utility of fecal transplantation in the management of a variety of conditions seen in a cancer patient population including recurrent C. Difficile.

Patrick Lynch, J.D., M.D., plays a lead role in the identification of individuals at increased risk for colon cancer predicated on genetic factors.

Ethan Miller, M.D., provides expertise in the care of patients with liver disease and has played an important role in the electronic health record implementation.

G. S. Raju, M.D., newly appointed medical director in the Endoscopy Center, is recognized for his ability to endoscopically remove large polyps which has obviated the need to surgery in the majority of these patients. A cost-effectiveness study of this technique is underway, and Raju has received extra training in endoscopic submucosal resection.

Andrew Rhim, M.D., who leads an important research activity, is an active contributor to our clinical service. He will be correlating his clinical care of patients at increased risk for pancreatic cancer with his research.

William Ross, M.D., specializes in Endoscopic Ultrasound and ERCP procedures and has brought the importance of quality improvement to the forefront. As the top reviewer for Gastrointestinal Endoscopy, he keeps abreast of developments on a national level.

Mehnaz Shafi, M.D., has received additional training in the identification of motility disorders which can occur as paraneoplastic syndromes. She is principal investigator (PI) of a compassionate need study of Domperidone for gastrointestinal dysmotility.

John Stroehlein, M.D., is co-PI for the compassionate need Domperidone study. He is also a primary collaborator on a multi-departmental study related to the effect of malnutrition in the elderly.

Selvi Thirumurthi, M.D., is completing a course of training provided by the City of Hope that will position her to more effectively assist Patrick Lynch 32

Brian Weston, M.D., is skilled at Endoscopic Ultrasound and ERCP. His wealth of experience is now extended to developing procedures including endoscopic gastroenterostomy.

Research GHN researchers are at the forefront of discoveries and processes are in place to bridge communication between clinical service and research endeavors.

Andrew Rhim, M.D., assistant professor, nationally recognized in the study of pancreatic cancer, joined the department in summer 2016. Rhim received a $4 million CPRIT Rising Star grant as part of his recruitment package.

His laboratory is focused on the biology of precancerous lesions of epithelial organs and the molecular and cellular events that occur during their transition to cancer and metastatic disease.

Three themes underscore this work: 1. Elucidation of the key molecular (genomic and transcriptional) events that drive the progression of precancerous lesions to invasive carcinoma, including careful studies of how driver mutations and other required genetic events, such as codon 12 Kras mutations, arise in the setting of pancreas inflammation; 2. Dissecting the role of endogenous deaminase enzymes in cancer initiation, progression and development of intra-tumoral heterogeneity in vivo, including APOBEC3 and ADAR1 enzymes; and 3. Understanding the clinical implications of blood-borne dissemination and distant organ seeding of pancreatic epithelial cells, an

A race to survivorship Patient credits care team for successful treatment, recovery Long distance cyclist Howard Miller’s body has endured relentless, dry heat and triple digit temperatures that typically accompany the Hotter than Hell 100 held each August in Wichita Falls.

However, the esophageal cancer diagnosis he received in July 2011 proved to be the

more extreme test for the 65-year-old’s body as well as his psyche. Five years later, Miller has cleared that finish line, too, and gives credit to his care team.

“By the grace of God, I’m cancer free,” Miller says. “I know I wouldn’t be alive today without the care I received at MD Anderson.”

Miller’s multidisciplinary team included Jaffer Ajani, M.D., professor, Gastrointestinal Medical Oncology; Ritsuko Komaki Cox, M.D., professor, Radiation Oncology; David Rice, M.D., professor, Gastrointestinal Medical Oncology; and Brian Weston, M.D., associate professor, Gastroenterology, Hepatology and Nutrition.

“I have had the privilege of following Mr. Miller for surveillance since his successful treatment and surgery of esophageal cancer back in 2011 by Dr. Ajani, Dr. Komaki and Dr. Rice respectively,” Weston says.

“His positive outlook on life and continued pursuit of living life to its fullest is humbling and truly inspirational.”

Miller also attributes his successful recovery to the Fast Track nurses on Floor 7 in Alkek Hospital.

“They see us at our worst after coming out of surgery,” Miller says.

As an inpatient, he showed his appreciation to them with a bouquet of roses.

“I received roses while I was in the hospital and I gave them all out to my girls. My wife said, ‘Howard, you never even gave me one.’”

Miller plans to give her something even more special – continued survivorship to celebrate their Golden Anniversary.

“All I ever asked for was to make it to our 50th wedding anniversary, and now this will be possible, hopefully, in March 2018.”

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for 12 months is safe and resources the expression of CDX2 MRNA. 2. Recipient of a CPRIT Early Translational Research Award for his work on blood-based markers for screening and early detection of colorectal cancer which may result in the commercialization of biomarker panels for early detection of colorectal neoplasia.

Lynch’s work, in many respects, is an extension of the pivotal medical history observations of his father, Henry Lynch, M.D.

unexpectedly early event during the transition from pre-cancer to cancer in multiple organs.

It is this type of research that is positioned to identify circulating tumor cells in patients and mice through the use microfluidic devices.

Robert Bresalier, M.D., professor, is a wellfunded researcher whose laboratory research program focuses on the role of glycoproteins and carbohydrate binding proteins in tumor progression and metastasis as well as their role as diagnostic and prognostic biomarkers. His research group has been instrumental in establishing the roles of mucin-associated glycoproteins and the ß-galactoside binding protein galectin-3 in colon cancer progression.

As a member of the Steering Committee of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) and the National Institutes of Health (NIH)-funded Polyp Prevention Study Group, Bresalier has been an active contributor to the Early Detection Research Network (EDRN). Some of his research accomplishments include: 1. Lead investigator on a randomized, double blind placebo-controlled Phase II chemoprevention trial investigating whether supplementation with aspirin 325 mg/day 34

3. Work that involves inter-institutional collaboration between MD Anderson and the University of Puerto Rico designed to explore new markers for cancer prevention in Hispanics.

4. Center PI of an R01, “Colorectal chemoprevention with calcium and vitamin D.” The major role of the trial is to clarify the synergistic and independent chemopreventive effects of both vitamin D and calcium on large bowel cancer.

Patrick Lynch, J.D., M.D., professor, and Mala Pande, Ph.D., associate professor, are developing a Web registry that will identify families and patients with hereditary colorectal syndromes. The registry will allow people to visit the registry, report their colon cancer diagnosis, and list names of family members who should be aware of the diagnosis.

Lynch’s work, in many respects, is an extension of the pivotal medical history observations of his father, Henry Lynch, M.D. The senior Lynch conducted groundbreaking research in the 1960s that is now known as the Lynch Syndrome, an inherited condition that has historically been known as hereditary nonpolyposis colorectal cancer (HNPCC).

Patrick Lynch’s other work includes a multi-center study being conducted at 10-to-12 sites with established Familial Adenomatous Polyposis (FAP) registries in North America and Europe. The primary objective of the clinical trial is to determine if a combination drug treatment is superior to treatment with only one of two drugs, either Sulindac or CPP1X, in preventing the disease from worsening.

Lynch has brought the importance of genetic predisposition to colon cancer and has resulted in more effective and efficient use of resources that can be used to selectively screen individuals at risk for colon cancer and its precursors.

Keping Xie, M.D., Ph.D., professor, has five active R01 grants and earned two of them in Fiscal Year 2016. Xie and his research team have a long-standing interest in the process of tumor progression and metastasis, and the molecules and signaling pathways that contribute to progression and spread of cancer including tumor invasion and angiogenesis. The types of molecules that have received the most attention in the Xie lab over the past 20 years are transcription factors, including KLF4, FOXM1, Vitamin D receptor and Sp1.

Regarding work on FOXM1, the team found it directly bound to ß-catenin and is a key component in mediating ß-catenin nuclear accumulation and downstream target genes expression. However, the molecule mechanism underlying FOXM1 dysregulation and its impact on gastrointestinal cancers pathogenesis remain unclear.

Using genetic mouse models, state-of-art cell and molecular biology technology, and human specimens Xie and his team are pursuing a long-term goal to translate their laboratory findings to benefit patients. Some of the major recent findings include: 1. KLF4-mediated suppression of CD44 signaling negatively impacts pancreatic cancer stemness and metastasis. (Yan Y, et al., Cancer Res. 2016), and that KLF4 is essential for induction of cellular identity change and acinar-to-ductal reprogramming during early pancreatic carcinogenesis (Wei D, et al., Cancer Cell. 2016).

2. FOXM, which is overexpressed in many cancers, is a transcription factor and a key regulator of cell cycle and essentially regulates multiple aspects of tumor cell biology including recent studies that suggest it plays a critical role in pancreatic cancer growth, angiogenesis, invasion and metastasis.

3. Activation of Vitamin D receptor signaling downregulates the expression of nuclear FOXM1 protein and suppresses pancreatic cancer cell stemness (Li Z, et al., Clin Can Res. 2015).

Boris Blechacz, M.D., Ph.D., a tenure track assistant professor, is becoming nationally recognized for his knowledge and research related to hepatology.

Skilled in the clinical management of patients with liver disease, tumor and molecular biology of hepatobiliary malignancies, Blechacz’s research has focused on studies of viral and non-viral gene delivery systems for hepatocellular carcinoma (HCC).

He has provided specialized clinical expertise in the management of patients with advanced stage HCC and cholangiocarcinoma (CCA), and was actively involved in clinical trials evaluating novel therapeutic strategies for CCA. Blechacz is actively involved in the field of hepatobiliary malignancies on the national level as a member of ASCO GI and AASLD planning committees and special interest groups. He has built a collaborative HCC network, including transplant hepatologists and surgical oncologists from John’s Hopkins, Mayo Clinic, The University of Texas and Baylor College of Medicine who actively support him in the proposed studies.

His laboratory has identified a novel molecular interaction between the TGF-ß and c-KIT signaling pathways; the resulting manuscript was recently published in Neoplasia. His research is aimed at moving the treatment of HCC, and particularly cholangiocarcinoma, towards the preclinical evaluation of newer therapeutic implications.

Education The approved Advanced Endoscopy Fellowship Program, under the direction of Jeffrey H. Lee, M.D., professor, provides training in therapeutic endoscopies, including endoscopic retrograde cholangiopancreatoscopy (ERCP), endoscopic ultrasound (EUS), endoscopic ultrasound guided fine-needle aspiration (EUS/FNA), enteral stenting, endoscopic mucosal resection (EMR), among others.

The goal of the one-year curriculum is to provide advanced clinical and endoscopic training in the diagnosis, treatment and management of gastrointestinal disorders. Fellows are also provided research time and learn how to initiate clinical research, analyze research data and publish in peer35

reviewed gastroenterology journals. All trainees have succeeded in developing innovative research that moves the field of therapeutic endoscopy forward.

The department, which co-founded the joint GI Fellowship program more than forty years ago, provides training on a rotation basis for 10 fellows from The University of Texas at Houston Gastroenterology Fellowship. The program is now under the leadership of site director, Selvi Thirumurthi, M.D. The department began the GHN Clinical Education Lecture Series in 2011, which occurs the fourth Wednesday of each month. This lecture is attended

by The University of Texas Health Science Center at Houston (UTHSC) faculty, fellows, MD Anderson faculty, fellows and mid-levels. In addition, MD Anderson faculty are invited to present Grand Rounds at UTHSC on the third Thursday of each month.

Beginning in early 2017, MD Anderson will receive and provide clinical experience to GI Fellows from the Houston-Methodist GI Fellowship.

The Department has been highly regarded for the excellent clinical experience provided to our Internal Medicine Residents in training with the joint Baylor College of Medicine/MD Anderson Internal Medicine Residency Program.

Additional educational opportunities include: • A weekly Pathology conference conducted by faculty members, Patrick Lynch, Selvi Thirumurthi, and Ethan Miller.

• Jeffrey H. Lee and Manoop Bhutani co-chaired the Sawyer Biliary Pancreatic Symposium in fall 2016. Funding for the international conference was provided by the family of a grateful patient.

• G.S. Raju is founding co-editor-in chief of a new journal, Video GI Endoscopy, an open access video journal of the American Society of Gastrointestinal Endoscopy (ASGE). Raju has produced more than 500 videos UTube that have more than 470,000 views.

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• Selvi Thirumurthi, who is new site director for Education, has taken an active role in all aspects of the education program and has established a Journal Club that meets monthly.

She will assisted by Drs. Brian Weston and Boris Blechacz.

• Boris Blechacz has arranged a monthly educational conference for all mid-level providers.

Quality Improvement The department continues to center its quality improvement initiatives with a monthly Morbidity and Mortality conference that is designed to upgrade quality measures and to report any issues that involve complications of care regardless of severity.

The department’s quality officer William Ross, M.D., and Ethan Miller, M.D., who took a leading role in the OneConnect launch, have developed a partnership with the Department of Anesthesiology with the intent to establish a quality assurance project that bridges our departments.

The Quality Council of the Division of Internal Medicine has approved an ambitious project that is designed to capture any and all complications of therapy and builds upon a previous quality assurance project that focused on start time for procedures.

Summary All GHN practitioners are committed to provide the best possible care by effectively communicating between our clinical service and our research aspects of our operation to eliminate cancer once and for all. •

diseases, allergy and immunology disorders, and other metabolic disorders.

In order to treat these highly complex issues, Carmen Escalante, M.D., professor and chair, leads a department that has four sections, including: • Hospital Medicine • Consultative Medicine • Rheumatology (information presented in a separate report) • Research and Education Unit

Clinical Hospital Medicine Hospital Medicine is one of the most rapidly growing sections at MD Anderson because of the increasing complexities of medical problems in our cancer patients and survivors.

“Hospitalists are physicians with expertise in acute issues of hospitalized patients and are well-versed about the functioning and workflow of the hospital,” Section Chief Josiah Halm, M.D., says.

“We see the extremely ill solid tumor cancer patients in the inpatient setting to allow our oncologist colleagues to focus on their outpatients.”

Carmen Escalante, M.D., Chair

General Internal Medicine General Internal Medicine providers are dedicated to improving the quality of life of our cancer patients through integrated medical care.

Physicians care for patients with a wide range of acute non-cancer related medical problems, including diabetes mellitus, heart disease, hypertension, thyroid dysfunction, rheumatic

The hospitalists are joined by a team of advanced practice nurses and pharmacists who coordinate and provide care in a multidisciplinary approach.

Hospitalist Jaya Amaram-Davila, M.D., assistant professor, joined the team in late August 2016.

Initially, hospitalists treated Gastrointestinal Medical Oncology patients. In September 2015, the service expanded to include patients from Thoracic Head and Neck, Neuro-oncology and Surgery. Escalante, who launched the program 10 years ago with former faculty member Mary Merkle, M.D., says the hospitalists are leaders in Onco-Hospitalist care.

“We all do best in our areas of expertise.

Oncologists are trained to know about the latest drugs and the latest state-of-the-art treatments.

Internists are trained at managing highly complex medical patients in the inpatient environment.

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“You break down the silos and it’s much easier to be innovative and institute quality projects when all these patients are under one similar group that practices the same way,” Escalante says.

The section enhanced its service in July 2016 when Joanna Manzano, M.D., opened the Transition of Care Clinic. An advanced practice provider (APP) staffs the post discharge clinic which is meant to reduce readmission rates and improve patient outcomes.

“Patients who are on anti-coagulants, antibiotics or those with very highly complex conditions may need a visit or two before they reconnect with their routine clinic to be sure they are taking their medications and understand what they should be doing as an outpatient,” Escalante explains.

Consultative Medicine Sunil Sahai, M.D., professor, assumed the role as section chief of Consultative Medicine (formerly General Internal Medicine) when Clinical Deputy Division Head Ellen Manzullo, M.D., stepped down to focus on her division responsibilities. Consultative Medicine includes subspecialty clinics, the Internal Medicine Perioperative Assessment Clinic (IMPAC) and the Mary Ann Weiser Suspension of Cancer Clinic, along with patient services dedicated to Nutrition and Geriatrics.

During the past year, Sahai, who is also medical director of IMPAC, integrated new processes with the Department of Anesthesia and the Department of Surgery to improve the patient experience, both before and after surgery.

Recent turnover left opportunities for him to replace faculty in the Mary Ann Weiser Suspicion of Cancer Clinic, Nutrition and Geriatrics.

Geriatrician Linda Pang, M.D., assistant professor, joined the GIM faculty in September 2016, while Ruth Falik, M.D., associate professor, joined the department in April 2017.

Research Maria Suarez-Almazor, deputy chair for research, says clinical research is the primary focus in the department.

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Angeles Lopez-Olivo, M.D., Ph.D., has expertise in pharmacology, epidemiology, and evidence-based medicine and its application to clinical decisionmaking evidence-based medicine, and translation of evidence into practice.

She has conducted several systematic reviews of drug therapies for the Cochrane Collaboration and two Health Technology Assessments. LopezOlivo also has experience in the methodologies for economic evaluations and has collaborated in the translation of evidence into educational tools to inform patients with chronic conditions and facilitate decision-making.

Jessica Hwang, M.D., associate professor, focuses on supportive care, specifically viral reactivation in patients undergoing chemotherapy or stem cell transplant.

She has published articles on management of patients with hepatitis B who require immunosuppressive therapy, human papillomavirus knowledge and awareness among Vietnamese mothers, and acute exacerbation and reactivation of chronic hepatitis C virus infection in cancer patients.

The latter study is in collaboration with faculty from Infectious Diseases.

Geriatrician Beatrice Edwards, M.D., associate professor, is interested in bone health issues and geriatric assessment in cancer patients.

Education A few years ago, Escalante appointed Jeong Oh, M.D., associate professor, to oversee the department’s educational component with the goal to bring the educational activities on par with those in the clinical and research arenas.

In 2014-15, the Clinical Education Group consisted of four faculty who oversaw 13 programs that included: • 24 fellows • 36 interns and residents • 17 MS III and IVs • 12 Observers • 12 Mid-level students

Trusting in the journeys Beaumont patient unfazed by multiple trips for treatment Nemo Lovelady has been a patient so long that he remembers when MD Anderson was one building with a gravel parking lot on Bertner Avenue.

“Every time we came here there would be a new wall going up,” he says.

During this time, Lovelady and his wife Diana decided that he needed to distance himself from exposure to the petrochemical plants in and around Beaumont. So he and one of his daughters moved to Dripping Springs to find other work, while his wife stayed behind to finish college.

“We were in the Austin area for two or three years, and I made a lot of trips back and forth to MD Anderson for different types of chemotherapy.”

In 1998, Lovelady learned that his bladder needed to be removed because chemotherapy was inflaming it. He received a Studer orthotropic bladder pouch, a neo-bladder, made from his own intestines. Post-surgery left him with other complications.

“Scar tissue developed in my bowels after the surgery to remove my intestines,” he says. “After several years I developed bowel obstructions causing severe pain resulting in hospitalization.”

As an inpatient, Lovelady was under the care of the General Internal Medicine inpatient hospitalist team on G19 in Alkek Hospital.

Lovelady was a construction supervisor in a piping and mechanical company when he was diagnosed with bladder cancer in the summer of 1985. A local physician removed a tumor and recommended several months of chemotherapy.

He also wanted to remove Lovelady’s bladder, but friends encouraged the Beaumont native to go to MD Anderson for a second opinion where he received a more favorable option.

“A team of urologists encouraged me when they said they would not remove the bladder, but save it, which they did for 15 years,” Lovelady recalls.

“You couldn’t ask for a better group of doctors. The young doctors who are with them (the hospitalists) are being trained really well.” One of Lovelady’s care providers is Maria-Claudia Campagna, M.D., who he says “is so good and so thorough.”

So far Lovelady hasn’t had to face another surgery. Despite the many years and miles he has traveled to MD Anderson over the years, Lovelady remains optimistic saying, “I am very happy. All the trips here have given my wife Diane and me the opportunity to express to other people the greatness and the good that they do at MD Anderson.”

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productivity, Oh guided her to develop a model, try it with a few residents, write a case report on it, and then present it at a workshop. “She can then become the expert,” he says.

Education efforts also include the training of residents in the combined Baylor College of Medicine/MD Anderson Internal Medicine Residency Program, which just completed its first year and initiated a second group of residents in June 2016.

Oh decided to take a “divide and conquer” approach.

First he redesigned the program and then engaged additional colleagues to share the workload.

The program now includes two directors, one for Ambulatory Education and the second for Inpatient Education, who each oversee six clerkship directors.

Oh decided to take a “divide and conquer” approach. First he redesigned the program and then engaged additional colleagues to share the workload. The program now includes two directors, one for Ambulatory Education and the second for Inpatient Education, who each oversee six clerkship directors.

This separation of duties allows Oh to validate the activities of the two directors and encourage and mentor the clerks and program directors. His mantra is name it and claim it.

“I first met with the clerks on the inpatient side to discuss their roles. I felt I needed to teach them how to be leaders – how to mentor and when to step back,” Oh explains.

For instance, when Santhosshi Narayanan, M.D., assistant professor, had an idea to improve 40

“The residents spend the majority of their time with hospitalists on the inpatient side,” Escalante says.

“There is real potential there for education, for clinical care and for quality improvement.”

During the summer of 2016, the Texas Medical Board approved the Oncologic-Hospitalists fellowship program. Maria-Claudia Campagna, M.D., associate professor, will head the program which will launch in summer 2017 with two fellows.

“Hopefully this will be a pipeline to select interested faculty who will become hospitalist oncology attendings at MD Anderson or elsewhere,” Halm says. “They will augment inpatient staffing and teach in our residency program, and they will have an optional second year to do research.”

Escalante is pleased with progress made in the educational field. “It’s really flowered. I give credit to Dr. Oh and the faculty. There’s a lot of energy and activity.”

Research and Education Two years ago Maria Suarez-Almazor, M.D., Ph.D., professor, and collaborators from MD Anderson, The University of Texas School of Public Health, and the American Society of Clinical Oncology (ASCO), received a five-year, $2.4 million R25 grant from the Agency for Healthcare Research and Quality (AHRQ).

The researchers proposed to develop a comprehensive educational program to increase the number of U.S. cancer researchers who conduct Comparative Effectiveness Research (CER) and Patient-centered Outcomes Research (PCOR).

“By receiving this grant, it recognized our ability to train others in comparative effectiveness methods, starting with cancer prevention all the way through

survivorship,” says Suarez-Almazor, principal investigator of the grant.

Since then, the project team has completed the first phase of the Comparative Effectiveness Research Training and Instruction (CERTaIN) program through the presentation of webinars and workshops.

Researchers are currently developing the online lectures for an EdX course being built by Program Managers Susan Parker and Cecilia Aguerre, Ph.D, who are managing the project. Online lectures became available at no cost to participants in early 2017.

“ We are vested in Making Cancer History® by improving patient outcomes through this multi-faceted research training approach.”

Maria Suarez-Almazor, M.D., Ph.D. Parker and Aguerre are also facilitating an experiential learning program that focuses on mentoring trainees through individual patientcentered outcomes and comparative effectiveness research projects.

“There is a need for quality training for healthcare professionals in comparative effectiveness research,” says Parker. “By offering free workshops, webinars and online courses by experts in the field, we are able to provide top-notch courses to anyone interested in patient-centered comparative effectiveness research.”

Suarez-Almazor is joined by co-investigators Barry Davis, M.D., Ph.D., professor of Biostatistics and Public Health, The University of Texas School of Public Health; Angeles Lopez-Olivo, M.D., Ph.D., assistant professor, General Internal Medicine; Sharon Giordano, M.D., chair, and Robert Volk, Ph.D., professor, Health Services Research. The team members will ultimately offer over 45 online lectures that will include four basic modules: • Pragmatic Clinical Trials and Health Care Delivery Evaluations (Suarez-Almazor and Davis) • Knowledge Synthesis (Lopez-Olivo) • Observational Studies and Registries (Giordano)

• Patient-Centered Outcomes Research (Volk) According to Suarez-Almazor, “What this means is that we will host physicians, students, fellows, junior faculty, and policy makers who will develop specific projects here at MD Anderson, ASCO or the School of Public Health. ”We are vested in Making Cancer History® by improving patient outcomes through this multifaceted research training approach.”

Quality Improvement Halm, the department’s quality officer, sees his role as a liaison between the institution with its quality of care expectations and his colleagues who need to meet institutional quality metrics and certification requirements such as the Focused Professional Practice Evaluation (FPPE).

“I try to think globally when I consider how to channel the patient care needs into our practices.

You ultimately provide quality patient care to everyone, not just the patients you see,” he says.

A number of inpatient programs have developed from General Internal Medicine’s quality improvement projects efforts, including the Transition of Care Clinic, which was mentioned earlier. Halm says the hospitalists also intend to partner with Thomas Feeley, M.D., who heads the institution’s Institute for Cancer Care Innovation (ICCI), on a project to demonstrate value-based outcomes and costs related to inpatient care.

Escalante says the department’s quality improvement efforts have also been enhanced with the recruitment of David Rubio, M.D., assistant professor. Rubio, who is one of the hospitalists, is working with Ellen Manzullo, M.D., clinical deputy division head, and Amit Lahoti, M.D., site director of the BCM/MD Anderson Internal Medicine Residency Program, on introducing quality projects to the housestaff and residents.

“Dr. Rubio is a star,” Escalante says. “He created the whole quality perspective for the house staff.

He’s very organized, focused, and conscientious. He has a lot of potential.”

The residents will deliver their first QI presentations in fall 2017. • 41

Maria Suarez-Almazor, M.D., Ph.D., is joined by rheumatologists Jean Tayar, M.D. and Huifang (Linda) Lu, M.D., Ph.D.

Section of Rheumatology and Clinical Immunology The MD Anderson Section of Rheumatology and Clinical Immunology has four full time clinical faculty, Maria Suarez-Almazor, M.D., Ph.D., Huifang (Linda) Lu, M.D., Ph.D., Jean Tayar, M.D., and Sang T. Kim, M.D., Ph.D., and one full-time researcher, Maria Angeles Lopez-Olivo, M.D., Ph.D. Noha Abdel-Wahab, M.D., Ph.D., is a post-doctoral fellow who will join the section as an instructor.

Clinical The rheumatology outpatient service is located in the Mays-ACB Internal Medicine Center 42

and is staffed daily by one or more physicians to accommodate the increasing numbers of consultations, with minimal to no wait referral time for the patients. The clinical faculty also provides 24/7 coverage for the inpatient service.

Section physicians treat cancer patients with musculoskeletal diseases and systemic autoimmune conditions commonly referred to as rheumatic diseases. Such diseases are either preexisting, or may be caused by cancer or its therapy. Many rheumatic and autoimmune conditions can be very disabling and greatly affect the quality of life of cancer patients and survivors. Diseases treated by our clinicians include: • Rheumatoid arthritis, lupus, scleroderma and other connective tissue diseases,

• Osteoarthritis and local soft tissue problems like rotator cuff tendinitis, carpal tunnel syndrome, • Osteoporosis and bone health issues, • Acute joint pain or swelling which can be secondary to infections or other inflammatory conditions such as gout or psudogout, • Paraneoplastic diseases such as dermatomyositis and • Immune-related adverse events from arising from cancer immunotherapy, such as immune checkpoint blockade.

In addition, one of the clinicians, Linda Lu, M.D., Ph.D., is also a board-certified allergist/immunologist who treats allergic and hypersensitivity reactions related to drugs, and primary and secondary immunodeficiencies. Jean Tayar, M.D. also runs a weekly musculoskeletal ultrasound clinic on Wednesdays to help diagnose and treat difficult local soft tissue problems, and performs ultrasoundguided joint aspirations and injections.

Research Much of the team’s research focuses on getting to the bottom of the development of paraneoplastic diseases in patients with cancer and the immune-related adverse events of immunotherapy in cancer patients.

Maria Suarez-Almazor, M.D., Ph.D., is section chief of Rheumatology and Clinical Immunology. SuarezAlmazor is a clinical epidemiologist interested in comparative effectiveness and patient-centered outcomes research. She has over 280 publications and has been Principal Investigator (PI) on many NIH and AHRQ awards.

Increasingly, she has become interested in the potential immune effects of therapies on cancer patients. Suarez-Almazor says inflammatory and immune-related adverse events can occur when cancer patients are treated with immune checkpoint inhibitors such as ipilimumab or nivolumab. These targeted drugs stimulate the patient’s own immune system so that it can identify and destroy tumoral cells.

“By enhancing the immune response, you’re hoping to suppress tumor progression,” Suarez-Almazor

says. “However, the problem is that by enhancing the immune system patients can also then develop an immune-related adverse event and even a de novo autoimmune disease.”

In addition to her clinical activities, Lu co-directs the multidisciplinary Bone Health Clinic at MD Anderson, where clinicians from several specialties provide clinical care, research and education for bone health to our cancer patients.

More than 50% of stem cell transplant patients develop some form of graft-versus-host disease which requires prolonged use of glucocorticoids and immunosuppressive agents. Lu and her team have conducted a controlled, prospective study using Ibandronate to prevent bone loss in stem cell transplants patients. They are currently looking at the prevalence of fractures in stem cell transplant patients.

Another area of interest is the musculoskeletal complications of breast cancer patients taking aromatase inhibitors.

“We found that patients who had baseline joint pain are at higher risk of developing joint pain after they started on aromatase inhibitors,” Lu says. “More work is planned on the translational research on the mechanism and potential treatment for joint pain associated with aromatase inhibitors.”

Mays Internal Medicine Clinic Director Jean Tayar, M.D., devotes most of his time to patient care and education. He also collaborates on various research initiatives within the section, including conducting systematic reviews and participating in studies to determine how to best manage cancer patients and survivors who present with musculoskeletal complaints or autoimmune disorders.

Maria Angeles Lopez-Olivo, M.D., Ph.D., is a clinical researcher with expertise in pharmacology, epidemiology and evidence-based medicine. Her research focus is on knowledge synthesis and translation of evidence into practice to improve clinical decision-making primarily in the field of rheumatic diseases. She has conducted several systematic reviews of drug therapies for the Cochrane Collaboration. Lopez-Olivo also has experience in the translation of evidence into educational tools to inform patients with chronic conditions and facilitate decision-making including 43

the development of multimedia platforms for health education purposes. In addition, she has collaborated in the implementation of innovative learning programs targeting health providers on comparative effectiveness research delivered through massive open online courses.

The newest member of the team, Sang Kim, M.D., Ph.D., who joined the section in June 2016, is a physician-scientist with research training in

immunology. His research interest is to elucidate mechanisms of immunotixicity associated with cancer immunotherapy and to find biomarkers to predict immunotoxicity with cancer immunotherapy agents. Kim has extensive research experiences in human immunology using patients’ tissues.

He is collaborating with oncologists to establish longitudinal cohort who developed immunotoxicity after immune checkpoint inhibitor treatment.

Blessed with longevity Couple overcomes adversity, looks forward to golden anniversary Thomas Davis knows a few things about longevity.

The 83-year-old retiree contributed more than 40 combined years in the Air Force and civil service. He spent 26 of those years in administrative positions at NASA at Johnson Space Center in Clear Lake City. Next summer he and his wife Dot will celebrate their 60th wedding anniversary.

knee injections, as needed. Davis has had two bouts of pneumonia, and now receives immune system infusions to prevent it in the future. More recently, he faced a bladder cancer diagnosis, which is being followed on a regular basis.

Throughout his cancer journey, Davis says he has appreciated MD Anderson’s multidisciplinary care approach. When his primary care physician informed him he had rheumatoid arthritis, she also told him that he could see one of MD Anderson’s team of rheumatologists. Now a patient of Rheumatology Section Chief Maria SuarezAlmazor, M.D., Ph.D., Davis has witnessed, first-hand, the onco-medicine care of the cancer patient.

“It means that not only am I going to the best place in the world for cancer, I get to see highly-skilled doctors for my other health challenges, too.”

Davis knows about overcoming adversity, too.

He had a cancerous colon polyp removed 11 years ago and received treatment for chronic lymphocytic leukemia (CLL), rheumatoid arthritis and temporal arteritis, all of which are in remission. He visits a pain management clinic for spinal stenosis and 44

With so many trips to the institution in the past 11 years, Davis’ wife Dot also occasionally sees Suarez-Almazor for osteoarthritis. She also likes the convenience of seeing a physician for hematologic issues.

“Even though we drive 40 miles to MD Anderson, both Dot and I feel the trips are well worth it to see the best specialized doctors,” Davis concludes.

Education The Section of Rheumatology and Clinical Immunology offers a rheumatology fellowship program, in conjunction with Baylor College of Medicine, with Tayar as site program director. The fellows obtain a significant part of their clinical training, including musculoskeletal ultrasound, at MD Anderson.

Tayar also organizes an annual musculoskeletal ultrasound course for the rheumatology fellows and faculty. Other regular educational activities include a monthly rheumatology fellowship half day didactic activity, including a radiology conference organized

by Lu, and weekly journal clubs organized by Kim. In their second year, many of the fellows have chosen to complete the required research component of the program at MD Anderson under the guidance of Suarez-Almazor.

In addition, the section also contributes to various other educational activities. Tayar is also the

Director of the Observership Program within the Department of General Internal Medicine. Faculty members support the training of residents of the Baylor College of Medicine/MD Anderson Internal Medicine Residency Program by regularly lecturing, and offering one-month rheumatology rotations in the outpatient clinics.

In addition, Suarez-Almazor is a PI in an AHRQ-funded R25 grant that provides methodological support and training to junior investigators and trainees interested in comparative effectiveness and patient-centered outcomes research (see pages 40-41).

Quality Improvement Suarez-Almazor and Tayar are graduates of the Clinical Safety and Effectiveness Education Program and have collaborated in various Quality Improvement (QI) initiatives. Tayar is a member of institutional committees closely associated with quality of care initiatives, including infection control and sedation procedures. •

Infectious Diseases, Infection Control and Employee Health Services During the past fiscal year, the multi-faceted Department of Infectious Diseases, Infection Control and Employee Health (ID) provided a wide variety of services throughout the institution. On its inpatient service alone, the ID providers saw one in seven inpatients admitted to MD Anderson.

The expert clinicians continue to provide surveillance and preventative, diagnostic and treatment strategies for fungal, viral and bacterial infections particularly in our high-risk patients, including those who have experienced a bone marrow or stem cell transplantation.

Clinical The department has four inpatient consult services that operate simultaneously:

• Stem Cell Transplant Lymphoma • Solid Tumor • Intensive Care Unit – in collaboration with Critical Care Issam Raad, M.D., professor and chair, says among the highlights over the past fiscal year is the expansion of the physician assistant (PA) team from seven to 10 members.

“We now have five concurrent teams, four of which are 24/7,” Raad says. “This is in addition to our same day and regular clinics where we daily see new consults and follow ups.”

Another highlight occurred when the Executive Council of the Medical Staff allowed for an expansion of the Antimicrobial Stewardship

• Leukemia 45

Program. Launched 10 years ago, the program promotes interventions that foster judicious use of antibiotics, according to Clinical Deputy Department Chair Victor Mulanovich, M.D., professor, who succeeded Roy Chemaly, M.D., professor.

“We make sure we are using the appropriate antibiotics, the right dose and the right duration to improve patient outcomes, and to prevent toxicities and bacteria resistance,” Mulanovich explains.

Clinical Pharmacy Specialists Frank Tverdek and Sam Aitkin oversee the program and email the Infectious Disease physicians names of patients who have received the most potent antibiotics for up to five days. They want to ensure two things in particular: that the provider has used the right antibiotic and that the patient is not over-medicated.

“You’re supposed to pick the rationale on why you have to use a particular antibiotic after a few days when there are cultures. It makes you stop and think,” says Mulanovich. This “stop and check” method is geared to prevent toxicities and improve patient outcomes.

The expansion also has allowed the clinical specialists to be more proactive. For instance, if a patient has a positive blood culture, the specialist will call the attending physician to be sure the patient is on the right antibiotic.

“It’s just to be sure people that have potentially lethal infections can be treated with the most appropriate antibiotic as soon as possible,” Mulanovich says.

Raad speaks highly of his team, who he says, responded remarkably well during the institution’s OneConnect implementation.

“It was crucial that we had a good system in place to care for our sickest patients (those on the inpatient services). The clinical faculty and midlevel providers were very successful during the OneConnect transition.”

The department had five super users during implementation – Roy Borchardt, Kathleen Smith, Candace White, Bruno Granwehr, M.D., and Ariel Szvalb, M.D., who supported colleagues on each of the inpatient services. Additional faculty were added to the rotations during the week and on 46

weekends. Raad says seven of the 10 advanced practice providers were on rotation at all times, vacations were postponed and frequent meetings were held to fine-tune the processes.

In the outpatient clinics, the Hepatitis Clinic, under the leadership of Harrys Torres, M.D., associate professor, is working to get more patients tested and treated for the disease. The clinic opened in 2009 and remains the only clinic of its kind at a comprehensive cancer center to address the unmet medical needs of patients with the hepatitis C virus (HCV).

“Our findings tell us that the association between hepatitis C and oropharyngeal and non-oropharyngeal cancers is as high as its link to non-Hodgkin’s lymphoma,” says Torres, who has recently been named medical director of the Internal Medicine Center Main Building.

In the last few years, new antiviral drugs have made it possible to cure more than 90% of the HVC population, Torres says. Once they are cured, they have a better chance of gaining access to necessary cancer therapy since an HCV infection could affect how patients respond to their therapy.

Infection Control Infection Control had a banner year with near zero infections in the Intensive Care Unit, particularly those related to line-related infections.

Joint Commission readiness also commanded the team’s attention. Infection Control Medical Director Roy Chemaly, M.D., is a member of the institution’s Quality Operations Team led by Charles Levenback, M.D. For the past year, the team has been preparing for the Joint Commission visit that occurred in August 2016.

“The Joint Commission’s focus changes from year to year,” Chemaly says. “Before they arrived, we knew they would focus on high level disinfection and processes, procedures and what we are doing to keep our patients safe during invasive procedures.”

Overseeing this charge is Manager Linda Graviss, who leads an eight-member team that includes six Infection Preventionists and two Program Coordinators.

Infection Preventionists made pre-Joint Commission visits to patient care areas throughout the Main Campus and the Houston Area Locations (HALS) to inspect for compliance of institutional policies. They also conducted face-to-face meetings, as needed, to discuss, plan and implement process improvements.

These efforts paid off as the Joint Commission cited one grievance related to tape residue.

In additional to Joint Commission readiness, other key projects included: 1. Institutional Standardization of High-level Disinfection (HLD) and Sterilization practices which involved: – A toolkit binder – HLD process flow charts (Scopes, Instruments and Probes) – Cleaning equipment and supplies – Facility signage – Monitoring process – Competency and checklist templates and – Measures 2. Computer-based training-education center for Hand Hygiene Observers – More than 23 areas participated

Issam Raad, M.D., Chair

– 975 observations in FY15; 6,950 observations in FY16 – Compliant and non-compliant electronic notification of each observation was made – Staff with more than two non-compliant reports were entered into the Safety for Intelligence for Leadership Review.

3. The use of a new Cerner Millennium Laboratory system which included the ordering of cultures and tests.

4. Reporting of HAI’s (CAUTI, CLABSI and SSI’s) in Safety Intelligence System – Infection Preventionist Amy Hawkins oversees this effort.

– Reported on institutional dashboards, including Executive Clinical Operations Team (ECOT) and Operations and Administration Team (OAT)

5. Build and implementation of new Infection Control module (ICON) in OneConnect that included: – Infection Control surveillance – Mandatory reporting to state and federal health authorities – Isolation monitoring 6. OneConnect electronic medical record – Institutional isolation processes were improved, including travel screening for MERS and Ebola 7. New mandatory reporting of NHSN C Difficile Lab ID and MRSA bacteremia events 8. Participation in Health Department review of Ebola processes in December 2015 and the

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UT System Pandemic Tabletop Exercise in August 2016 9. Opening of Alkek pavilion with Infection Control support for the new Interventional Radiology area with new processes and policies.

Employee Health Services Employee Health Services continued to successfully vaccinate the majority of the employee population in Fiscal Year 2015-2016 with a 97% vaccination rate. This more than doubled the average rate for employees working in high-risk areas a decade ago.

Back in 2006, the overall influenza vaccination rate among employees was 56%. The average rate for employees working in high-risk patient areas was 47%, while the average rate for those working in inpatient nursing units was 41%.

“ Our approach was, and still is, that as we protect our employees, we protect our patients from hospitalacquired influenza.”

Elizabeth Frenzel, M.D. Elizabeth Frenzel, M.D., says institution leaders knew the rates needed to improve, especially for those directly involved in patient care. So she led a strategic approach to increase the numbers through increased vaccination opportunities, communications efforts, and education.

Implementation of the Mandatory Participation Influenza Prevention Program in 2009 and the Vaccine Preventable Diseases Policy in 2012 led to sustained rates exceeding 95%.

“Our approach was, and still is, that as we protect our employees, we protect our patients from hospital-acquired influenza,” says Frenzel, professor.

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Frenzel is first author of an article published in the May 2016 edition of American Journal of Infection Control that detailed an eight-year study in which researchers evaluated the multi-faceted employee influenza vaccination program and its effect on nosocomial influenza infections in cancer patients.

The results were impressive with a significant increase from 56% in 2006-2007 to 94% in 2013-2014. During that time, the proportion of nosocomial flu infections significantly decreased, and was significantly associated with the increased vaccination rates among health care employees, including the nursing staff and those working in high risk areas.

Research In the 20 months since January 1, 2015, the Department of Infectious Diseases, Infection Control, and Employee Health has made significant advances in a broad array of scholarly activity.

The recruitment of Division Head David Tweardy, M.D., increased the bolus of the department’s research effort. The focus of the Tweardy Laboratory is understanding and modulating the host damage response to microbial and traumatic injury to treat disease. Tweardy’s clinical research interests include the role of apoptosis and inflammation in susceptibility to infection, especially following injuries.

His basic research interests over the past 20 years have centered on cytokines and cytokine signaling and currently focus on the second messenger— signal transducer and activator of transcription (STAT) 3—critical in the signal transduction pathway of over 40 cytokines, as well as the role of STAT3 in inflammation and cell survival.

Additional active research programs in the department include several key aspects of infectious diseases: • Viral hepatitis (Harrys Torres, M.D., associate professor) • Viral infections in immunocompromised patients (Roy Chemaly, M.D., professor)

• Device-related infections and biofilm research (Issam Raad, M.D., professor and chair) • Fungal infections (Dimitrios Kontoyiannis, M.D., Sc.D., professor and research deputy division head) • Bacterial pathogenesis (Sam Shelburne, M.D., Ph.D., associate professor) • Infectious diseases related quality improvement initiative (Javier Adachi, M.D., professor) Major publications over this time period from the department have included: 1. Mahale P, Sturgis EM, Tweardy DJ, ArizaHeredia EJ, Torres HA*. Association between Hepatitis C Virus and Head and Neck cancers.

Journal of the National Cancer Institute.

2016 108(8).

2. Maertens JA, Raad II, et al., Isavuconazole versus Voriconazole for primary treatment of invasive mould disease caused by Aspergillus and other filamentous fungi (SECURE): a phase 3, randomized-controlled, non-inferiority trial.

Lancet 2016:387(10020):760-9.

3. Zakhour R, Chaftari, AM, Raad II. Catheter-related infections in patients with haematological malignancies: novel preventive and therapeutic strategies.

Lancet Infectious Diseases. 2016 Nov: 16(11):e241-e250.

4. Jung DS, Farmakiotis D, Jiang Y, Tarrand JJ, Kontoyiannis DP. Uncommon Candida species Fungemia among cancer patients, Houston, Texas, USA. Emerging Infectious Diseases.

2015 Nov; 21(11):1942-50.

5. Aitken SL, et al., Chemaly RF. High rates of non-susceptibility to ceftazidime-avibactam and identification of New Delhi Metallo-ßlactamase production in Enterobacteriaceae bloodstream infections at a major cancer center. Clinical Infectious Diseases. 2016 Oct 1; 63 (7):954-8.

6. Frenzel E, Chemaly RF, Ariza-Heredia E, Jiang Y, Shah DP, Thomas G, Graviss L, Raad I. Association of increased influenza vaccination in health care workers with a reduction in

nosocomial influenza infections in cancer patients. American Journal of Infection Control. 2016 Sep 1; 44 (9):1016-21.

7. Galloway-Peña JR, et al., Kontoyiannis DP, Shelburne SA (2). The role of the gastrointestinal microbiome in infectious complications during induction chemotherapy for acute myeloid leukemia. Cancer.

122(14):2186-96 (2016).

Raad says faculty in the department continue to be leaders in infectious diseases as evidenced by membership on the planning committees of major national and international conferences such as the Infectious Diseases Society of America, International Congress of Antimicrobial Agents and Chemotherapy, and the European Confederation of Clinical Microbiology.

Education The department has combined training programs with the Division of Infectious Diseases at The University of Texas Health Science Center Houston (UT Health McGovern School of Medicine) and with the Section of Infectious Diseases at Baylor College of Medicine (BCM). In addition, the Gerald P. Bodey Visiting Fellowship Program has collaborative agreements with several institutions across the country and in Canada that allow senior fellows from other programs to rotate at MD Anderson.

Leading the fellowship program are Pablo Okhuysen, M.D., professor and UT Health site director, and Bruno Granwehr, M.D., associate professor and BCM site director. Because of these arrangements, Infectious Diseases (ID) participates in the training of over 20 fellows per year, making this one of the largest infectious diseases fellowship training sites in the nation.

When candidates apply to the combined programs, they choose to participate in either a general ID track or in a unique track that emphasizes the care and prevention of infectious diseases complications in immunocompromised and cancer patients.

As a part of the immunocompromised track, MD Anderson financially sponsors the training of two fellows per training year, with each one of our partnering institutions in Houston.

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Passing it on Cancer care leads patient to support others Second opinion leads to second chances Chirico Shiffman sought a second opinion in 2005 when a local physician informed her she had stage one endometrial cancer.

She decided to send her slides and scans to two other institutions – one of them was MD Anderson. She eventually flew to Houston and met with a multidisciplinary team who shared news that shocked her. Chirico Shiffman had stage four endometrial cancer that metastasized to the left adrenal gland.

“Coming to Houston and MD Anderson literally saved my life. No question about it. If had accepted the original diagnosis, I would have been dead in a year.”

Toni Chirico Shiffman is grateful for the high quality of care she received at MD Anderson. In fact she says if she lived in Houston, she would work or volunteer here. Instead the vibrant, 60-year-old New York State resident is a patient advocate and navigator on a pro-bono basis as a result of her own cancer experience.

“Not everyone is able to advocate for themselves,” says Chirico Shiffman, a retired nurse who holds a Master in Nursing and a Master in Counseling Psychology. “Every visit with a physician requires a second set of ears. A professional, like myself, who has been intricately involved with the process, can immediately help ease the overwhelming nature of a new cancer diagnosis.”

Chirico Shiffman quickly learned that MD Anderson offers, what she calls, “comprehensive patient care.” Because of the metastasis, she needed to have a frontal retroperitoneal adrenalectomy which led her to see Nancy Perrier, M.D., who performed the first laparoscopic procedure in the United States on Chirico Shiffman.

In addition, several of Chirico Shiffman’s family members died of colon cancer, so Karen Lu, M.D., her oncologist, ordered a genetic search which showed she has Lynch Syndrome. As a result, she continues to see Patrick Lynch, J.D., M.D., professor, Gastroenterology, Hepatology and Nutrition, on a yearly basis.

“What happened here has been very interesting. God gathered all the right people in just the right place and at just the right time. These are truly sacred grounds,” she says.

Chirico Shiffman says receives comprehensive care that comes with chronic issues inherently present for a cancer survivor. But she’s experienced other health challenges along the way.

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Encounter with a lethal infection In 2010, Chirico Shiffman fell at the home of a friend here in Texas. She decided to take a nap and woke up with a 105o temperature. Her friend drove her to MD Anderson’s Emergency Center where she learned that a virulent pseudomonas organism had encapsulated in her spinal cord and was eating away at her bone.

Osteomyelitis ensued with fractures of L3, L4 and L5 vertebrae. She faced emergency surgery and a year of rehabilitation and IV antibiotics, along with an extended stay in Texas, away from her family.

Enter George Viola, M.D., associate professor in Infectious Diseases, who came on board during this critical and challenging time.

“Dr. Viola ‘stewed up’ all types and combinations of antibiotics to treat the source of my infection,” she says.

“My neurologist at the time said the pseudomonas putida had the ability to degrade solvents, and is used to reverse gulf oil spills. If it weren’t for Dr. Viola, I would not have survived the sepsis.”

Since returning home, Shiffman has been hospitalized twice for septic shock. Each time, her local doctor consulted Viola, who she refers to as “the most endearing, thoughtful, brilliant and upbeat” physician.

Chirico Shiffman says she firmly believes MD Anderson is a spiritual place with many souls to touch.

“There is an adage that says, ‘It is in your moments of decision that your destiny is met.’ In those moments of decisions, I am grateful for the indomitable team everyone involved in every aspect of my care at MD Anderson who kept the spirit of hope alive, and gave my life back to me.”

During the two-year program, fellows spend half of the time in clinical rotations and half of the time conducting clinical or basic research. During their clinical rotations, the fellows rotate through four ID consult services, including Stem Cell Transplant ID, Leukemia ID, Solid Tumor ID, and Intensive Care Unit ID. This is complemented by rotations at hospitals and clinics affiliated with UT Health and BCM. The ID faculty work closely with faculty from UT Health and BCM to provide outstanding educational activities for the fellows. The MD Anderson faculty are responsible for 18 presentations per year in the well-attended weekly Infectious Diseases City-Wide Case Conference. They are also responsible for 15 presentations per year in the year-round City-Wide Infectious Diseases Core Curriculum Conference.

Evidence of the high-caliber of the fellows training at MD Anderson includes: Farida Malik, M.D., who graduated this summer and worked with Okhuysen, received the Best Trainee Abstract Award at the fall 2015 ID Week Conference in San Diego, CA, for her work on microbiome and fecal indole correlates in Stem Cell Transplant recipients.

Parag Mahale, M.D., received the 2015 Conquer Cancer Foundation of ASCO Merit Award for his study, “Hepatitis C virus seropositivity and head and neck cancers: A new trio,” which was published in Journal of the National Cancer Institute. It was highlighted in more than 100 Web sites, including Fox News, Reuters, and the Houston Chronicle.

Mahale, who was a postdoctoral fellow working with Harrys Torres, M.D., recently completed his Ph.D. on epidemiology and disease control at the University of Texas School of Public Health. He is now receiving additional training at the National Cancer Institute.

Jeff Hosry, MD., received the 2016 Conquer Cancer Foundation of ASCO Merit Award for his study, “Effect of antiviral therapy on overall survival in hepatitis c virus-infected patients with diffuse large b-cell lymphoma,” which was published in the International Journal of Cancer. Hosry, who also was a postdoctoral fellow working with Torres, recently joined the UT ID fellowship program.

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In addition, the department organized four symposia in Houston that were well-attended by clinicians in Infectious Diseases from the community and local academic centers. These half-day conferences presented by faculty focused on Fungal Infections in March 2015, Viral Infections in Immunocompromised Cancer Patients in April 2015, HIV/Hepatitis C in August 2015 and A Sepsis Week Symposium: Prevention and Management of Line Related Sepsis in September 2016.

The department recently hired its first, doubleboarded, pediatric and adult Infectious Diseases physician. Natalie Dailey-Garnes, M.D., assistant professor and a graduate from the combined ID program with BCM, will develop a Pediatric Infectious Diseases Section.

“In addition to building her clinical practice, a short term goal is to set in place agreements with UT Health that would enable pediatric residents and fellows from that institution an opportunity to rotate at the MD Anderson’s Children’s Cancer Hospital,” Okhuysen says.

As previously mentioned, a visiting fellowship program established in honor of Gerald P. Bodey, M.D., founding department head of Infectious Diseases, sponsors one-month rotations at our institution. This allows fellows from smaller, outside programs to participate in the care of patients with hematologic malignancies and Stem Cell Transplantation under the supervision of our faculty. This program hosted seven fellows in Fiscal Year 2016.

The department is also in the process of establishing a Faculty Development Program in collaboration with the Office of Graduate Medical Education. Okhuysen says the goal of the faculty development educator program is for both fellows and attending physicians to learn how to become better educators.

A number of ID faculty have been recognized as expert educators: • Issam Raad, M.D., earned the SHEA Mentor Award from the Society for Health Care Epidemiology of America, presented at ID Week 2015 in San Diego.

• Raad also received the UT Board of Regents Outstanding Teaching Award for 2016.

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• Pablo Okhuysen, M.D., earned the 2016 Best Teacher Award presented by the BCM Infectious Diseases fellows.

• Javier Adachi, M.D., received the UT Board of Regents Outstanding Teaching Award for 2015.

Finally, Chair Issam Raad, M.D., has appointed Samuel Shelburne, M.D., Ph.D., as Deputy Director of Scholarly Activities. In this role, Shelburne will enhance, expand and oversee scholarly activities in research, education/mentoring and quality improvement projects. He formerly served as ID’s Research Development Director.

“Dr. Shelburne was a catalyst for expanding our research scope while inspiring many junior faculty to venture into new innovative areas of research as it relates to infections in cancer,” Raad says. “He played an important role in enhancing educational and quality improvement projects involving many of our faculty and fellows.”

Quality Improvement Roy Chemaly oversees the quality efforts in the department, in addition to leading Infection Control.

“I make sure that whatever projects we do are aligned with our goals to provide safe and high quality care,” Chemaly says.

Over the past year, ID completed three quality improvement projects with two of them focused on blood stream infections. One study centered on labeling the source of the blood culture to improve the diagnosis of catheter-related infections. Anne Marie Chaftari, M.D., assistant professor, and her team studied data collected from the Emergency Center to see if reducing mislabeled blood cultures would help determine if a patient’s catheter was the source of infection or if it came from a secondary source.

Chemaly and two colleagues, Javier Adachi, M.D., and Bruno Granwehr, M.D., are Certified in Medical Quality (CMQ). The American Board of Medical Quality offers physicians and other eligible professional candidates a certification exam to test basic knowledge in medical quality management.

To date, more than 300 candidates have earned the CMQ designation. •

2015-16 FLU CAMPAIGN METRICS Total flu shots

19,228 Overall rate

97%

High Risk areas

96%

Clinical Operations

94%

Nursing

97%

Patient Care Facilities

93%

Psychiatry The Department of Psychiatry joined the Internal Medicine Division in September 2016.

“Our group is keenly focused on the psychiatry of cancer, with interests ranging from applications of novel psychotherapeutic interventions, to management of complex neuropsychiatric complications of disease and treatment,” says Alan Valentine, M.D., professor and chair.

“In addition, we treat complications arising from cancer care in patients with long standing mental health illness. We are also responsible for management of all psychiatric emergencies on the main campus.”

Clinical The clinical team currently includes seven psychiatrists and four psychiatric advanced practice

Alan Valentine, M.D., Chair

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Cancer’s psychological impact Sick of being sick.

This is the typical reason why patients schedule a visit with providers in the Psychiatric Oncology Center.

“The overwhelming majority of the diagnoses are adjustment disorders,” says Alan Valentine, M.D. “Because of their cancer diagnosis, patients’ coping mechanisms may break down. We try to work collaboratively with colleagues to shore these people up through the use of medications or with pure psychotherapy.”

Valentine says there is also an intuitive association between cancer pain and cancer depression, both of which are multidimensional. Cancer patients commonly experience depressive disorders and pain syndromes simultaneously.

“Research has suggested, but not conclusively proven, a cause-effect relationship,” Valentine says.

Suicidal ideation is also common in cancer patients with severe depression and pain.

Antidepressant therapy is a mainstay of management.

“Because antidepressants that are effective as coanalgesics may not be tolerated at doses effective for depression, the clinician must be familiar with newer classes of antidepressants and psychostimulants,” Valentine says. With or without the intervention of pain and mental health specialists, Valentine says it is essential that the primary clinician recommend ongoing supportive therapy.

He adds that delirium, in particular, poses a major health problem, and is a dangerous situation.

“If you’re going to be a palliative care doctor, you need to specialize in delirium.

Delirium predicts whether a patient should be admitted into the hospital or whether a patient should go to a skilled nursing facility rather than go home.” It can also predict the patient is near death, he says.

nurses (APNs). Two of the APNs are assigned to the inpatient consultation service while two others provide psychotherapy to outpatients in the Psychiatric Oncology Center. The consultation service is supported by psychiatry residents from the UT-Houston McGovern School of Medicine.

Daniel Tan, M.D. is the department’s child/ adolescent/young adult psychiatrist.

(Chemobrain), and anxiety disorders unique to the cancer experience.

The group often collaborates with colleagues in Supportive Care, Integrative Medicine, Behavioral Sciences and Pain Medicine to provide comprehensive psychosocial care.

Psychiatric services available to inpatients, outpatients and family members include:

While primarily focused on patients in active treatment, Valentine says the department sees some cancer survivors on a case-by-case basis, for problems such as persistent cognitive impairment

The overall goal is to eventually transition patients to community providers if/when feasible. Similarly, the group is often involved in the short term care of cancer patients in active treatment who have preexisting major psychiatric disorders, such as bipolar disorder or schizophrenia.

• Consult-specific psychiatric assessment and follow-up care for outpatients and inpatients, • Pharmacotherapy, • Individual psychotherapy, • Child/adolescent/young adult psychiatry, • Body image/sexual counseling and

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• Caregiver support group (limited) Caregivers are of particular interest to Valentine, who wants to expand the department’s care for them.

“There is definitely a case to be made for some aspects of caregiver distress to be in the portfolio of a psycho-oncologist,” says Valentine, who has been at MD Anderson for 25 years. “We’ve treated some caregivers, but it’s been done on a case-by-case basis. If it weren’t for cancer, caregivers would not be experiencing the particular distress that brings them to our attention.”

Research The predominantly clinical department is looking to raise its research profile.

Four years ago, Psychiatry received funding from the Pauline Lechenger Morgenstern Fund, which paid for the initial build of a clinical/research database.

Data on symptoms, including depression, anxiety and general emotional distress, is collected from all patients in the Psychiatric Oncology Center and used in real time to aid clinical decisions. A similar capability for inpatients is planned. To date, clinicians have collected evaluations from more than 2,000 patients with 18,000 plus visits.

The Hackett Family Foundation has also generously provided financial support which has facilitated continued development of the database, hiring of research staff and initial grant funding for collaborative psychosocial research in oncology.

“Having a database is important. Not having one crippled us,” Valentine says. “The Morgenstern funds, and then the Hackett Funds, opened many doors. The clinical data we are collecting on all our patients can concurrently be used for research.

“Our ability to present our observations and research at professional meetings and in publications is greatly enhanced. Going forward, among other things, we hope to leverage our data to determine the extent to which cancer type, psychiatric diagnosis, and psychosocial interventions affect not only quality of life and emotional distress, but also objective disease outcomes.”

Psychiatry faculty also collaborate with oncology colleagues on a wide variety of research protocols,

especially those involving treatment interventions with potential psychiatric side effects.

Margaret Bell, D.N.P., clinical administrator for the Psychiatry Oncology Clinic, is also going to bat for patients and caregivers.

“My hope is to build a business argument for the insurance companies. Insurance plans have limited-to-little coverage for psychiatric cancer care. Currently, insurance companies will do onespot agreements. I want to build a case for why it should be covered, both for patients and caregivers.

The first step in the process is to collect clinical information,” Bell says.

Education Aside from its clinical activity, the department is a teaching service. Psychiatry residents and child psychiatry fellows from the UT-Houston McGovern School of Medicine, and medical students from Baylor College of Medicine rotate on the inpatient consultation service.

The department’s four APNs teach students from the Texas Medical Center’s various graduate nursing programs. Fellows from various MD Anderson clinical departments rotate through, as do some observers from MD Anderson’s Global Academic Programs. Valentine says plans are under way for providers to get involved in core lectures with the Baylor College of Medicine/MD Anderson Internal Medicine Residency Program.

In addition, the department hosts a quarterly Psychosocial Grand Rounds, which Anis Rashid, M.D., associate professor, coordinates.

Quality Improvement Since joining the division, Valentine appointed Rachel Lynn, M.D., assistant professor, to serve as the department’s quality officer.

One of the major projects Margaret Bell is working on is to determine what constitutes quality in cancer care for patients receiving mental health services. She will do this by determining the value of psychiatric care at MD Anderson. Using a Harvard Business School model, Bell plans to include three other comprehensive cancer centers in 55

an effort to build an argument at a national level to change cancer care in the United States.

“I looked at our patients’ distress screening for two years. If we can define how patients benefited from intermittent psychiatric care, we know there is a business argument that we can work with insurance companies in trying to get an exemption for the four cancer centers involved in the study,” she explains.

Bell elaborates by describing the frustrations of cancer patients whose insurance companies deny payment of psychiatric care.

“I have had patients who literally have gone round and round. They can’t get care here, but their

community provider won’t see them because they have a cancer diagnosis. So I’m trying to figure out a way so we can offer them the care they need.”

Conclusion Psychosocial care is recognized as an essential component of comprehensive cancer care. The vision of the Department of Psychiatry is to be a recognized leader in clinical and research psychooncology, medical education, and advocacy. In doing so, the department believes it can effectively support the Division of Internal Medicine and the institution’s core missions. •

Pulmonary Medicine Pathogens stream into our bodies with every breath we take.

In normal hosts, lung infections are a rare event since healthy lungs will clear out everything we breathe in. But in cancer patients, many treatments suppress white cells, leaving patients with impaired immunity and susceptible to a number of pulmonary illnesses, such as pneumonia.

Enter the experts from the Department of Pulmonary Medicine who treat a full spectrum of pulmonary diseases; many of them are common like asthma or chronic obstructive pulmonary disease (COPD). Others are more complex in nature.

“The majority of what we do is take care of pulmonary complications of cancer and cancer treatment that affect our immunocompromised patients,” says Burton Dickey, M.D., professor and chair.

Clinical Dickey and his team of 12 full-time physicians are a procedure-driven unit. For instance: • More than 3,500 diagnostic bronchoscopies are performed each year.

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• Thoracentesis is a large part of the practice with more than 1,000 thoracenteses performed annually.

• Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of mediastinal lymph nodes is a reliable, well-established technique that the pulmonologists use to work up and stage new lung masses, with more than 1,000 performed annually.

“EBUS-TBNA is especially helpful when oncologists aren’t sure whether to treat with surgery, radiation or chemotherapy,” Dickey says.

The department includes three sections: Interventional Pulmonology, Sleep Medicine, and Pulmonary Rehabilitation, and one super section, Benign Hematology, which will be featured in a separate report.

George Eapen, M.D., professor, heads the Section of Interventional Pulmonology that includes five interventional pulmonologists who perform the most complex of procedural cases.

“We perform full service interventional pulmonology here with capabilities for rigid bronchoscopy,

medical bronchoscopy and pleural biopsies,” Eapen says. The endobronchial ultrasound program is the largest in the nation, with more than 1,000 bronchial ultrasounds performed annually.

Within the past year, Sleep Medicine, led by Dave Balachandran, M.D., professor, began performing home sleep studies which allowed for more patients to be diagnosed with sleep apnea, especially those requiring surgery.

He and his colleagues published the paper, “Length of stay in ambulatory surgical oncology patients at high risk for sleep apnea as predicted by STOPBANG questionnaire,” in Anesthesiology Research Practice, which examined if patients at high risk for sleep apnea experienced increased complications in our post-anesthesia units (PACUs).

Furthermore, Balachandran presented data on sleep disorders in breast cancer and multiple myeloma patients at the American College of Chest Physicians (CHEST) conference. He also presented the first-of-its kind, half-day workshop on sleep disruption and cancer-related fatigue at the Multinational Association of Supportive Care in Cancer (MASCC) Conference in Adelaide, Australia.

Pulmonary Rehabilitation, relatively new to the cancer care setting, is led by Vickie Shannon, M.D., professor. The multidisciplinary effort includes physical therapy, occupational therapy, nutrition, education, psychiatry, behavioral medicine (for tobacco cessation) and social work.

Initially, only lung cancer patients and those with COPD were enrolled in the program. Shannon says it is now available for patients with chronic symptoms of dyspnea caused by all types of cancer and/or its treatment as well as other forms of chronic lung disease.

“In addition, patients with marginal lung function may be enrolled in our pre-habilitation program in an effort to optimize their performance status prior to cancer therapy,” Shannon says.

A baseline assessment, which includes lung function analysis, cardiopulmonary exercise testing, and clinical, nutritional and psychosocial evaluations, is used to create an individualized exercise prescription and program for each patient.

Burton Dickey, M.D., Chair

Local patients are enrolled in our state-of-the-art rehabilitation facility on the Main Campus. Other patients are enrolled in rehabilitation facilities closer to home. All patients are reassessed after completing the program.

In the fall of 2015, Shannon conducted an investigation with Reza Mehran, M.D., professor, Thoracic and Cardiovascular Surgery, to determine if pulmonary rehabilitation could improve the surgical candidacy of patients with anatomically resectable lung cancers, but whose poor performance status precluded potentially curative surgery. Fifteen patients were enrolled in the study. After three weeks of pulmonary rehabilitation, 12 of them subsequently underwent successful surgery.

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Shannon says that for many patients who experience chronic dyspnea after undergoing cancer treatment, pulmonary rehabilitation provides the missing link that allows them to feel whole again.

For others, pulmonary rehabilitation may open doors to therapeutic options that had been closed due to poor performance status.

“It’s a good feeling to know that I am providing an important niche that had not been offered in a structured format before 2009,” Shannon says.

Research “Pneumonia is one of the biggest killers in immunocompromised patients,” Eapen says. A vigorous pneumonia diagnostic program is under way within the department. Dickey and Scott Evans, M.D., associate professor, are studying pneumonia therapeutics with some drugs.

Another early detection effort is one in which Ajay Sheshadri, M.D., assistant professor, is addressing post stem cell transplantation airflow obstruction from bronchiolitis obliterans. Saadia Faiz, M.D., associate professor, is leading a study of difficult-totreat hypertension which can prevent patients from getting cancer therapy, or which occurs after it.

This is an interdepartmental effort with Cardiology physicians Cezar Iliescu, M.D., and Juan-Carlos Lopez-Mattei, M.D. Dickey says the addition of Roberto Casal, M.D., associate professor, and former chief of Interventional Pulmonology at the Houston Veteran Administration (VA) Hospital, will bring the department’s clinical research to a higher level. Casal and colleagues performed the first randomized trial of EBUS-TBNA under general anesthesia versus moderate sedation, which was published in a top pulmonary medicine journal.

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could not give rise to cancer. Jichao found it is capable of leaving its highly differentiated state and contributed to lung repair and possibly carcinogenesis.”

Peyman Moghaddam, M.D., assistant professor, has achieved breakthroughs in the promotion of lung carcinogenesis by inflammation, while Edwin Ostrin, M.D., Ph.D., assistant professor, had a breakthrough in terms of the role of the immune-proteasome in lung cancer progression. In Fiscal Year 2017, Ostrin accepted a position in General Internal Medicine and is working in the Suspicion of Cancer Clinic. In this role, he works closely with Pulmonary Medicine in the evaluation of lung nodules.

Evans’ lab has also discovered a drug currently named PUL-042, whose principle mechanism involves the generation of reactive oxygen species that are mitochondrial in nature. The drug was developed by Pulmotect.

“We knew the drug worked, but not how it worked until now,” Dickey says. Epithelial cells in the lungs generate reactivate oxygen that kill the organisms you breathe in,” Dickey explains.

Within the past year, Dickey personally has been awarded an R01. His research has identified molecular components of the machinery responsible for mucin secretion in the airways. A second company, Exotext, was founded to research this, which he is now working to translate into the clinic.

Education Pulmonary Medicine is a major training site for The University of Texas Health Science Center Pulmonary Critical Care Fellowship Program. The fellows spend about a third of their time here where they get 90% of their procedural experience performing bronchoscopies and inserting pleural catheters.

In the Pulmonary Medicine basic research labs, Jichao Chen, Ph.D., assistant professor, had a successful year in obtaining grants. Chen has multiple projects and has achieved major discoveries in the role of the alveolar epithelial cell.

The Interventional Pulmonary Fellowship Program, established in 2000, involves two fellows per year.

Eapen says it is the preeminent interventional pulmonology program in the country with the best faculty-to-training ratio.

“He determined that plasticity of type 1 alveolar epithelial cells was not recognized. It was a differentiated cell, it was thought, that

“It’s very competitive. We get on average about 30-40 applicants for the two spots. We have been very successful in graduating fellows. More than

Patient breathes easier Shortness of breath treated like asthma Bronchiolitis obliterans, a disease that results in obstruction of the smallest airways of the lungs due to inflammation and fibrosis, can sideline an elite athlete.

So it’s no surprise that 75-year-old Mary O’Malley continues to have breathing complications 17 years after her initial diagnosis of Myelodysplastic Syndrome (MDS).

About one-third of patients with MDS progress to acute myeloid leukemia, a rapidly growing cancer of bone marrow cells. As a result of her diagnosis, O’Malley underwent two allogeneic stem cell transplantations with bone marrow from one of her brothers.

Although she survived MDS, O’Malley immediately faced side effects from her cancer therapy. She developed graft-versus-host disease (GVHD), a common complication of allogeneic stem cell transplantation, and experienced pulmonary involvement that occurs in up to 10% of allogeneic stem cell transplant patients.

More than a decade later, O’Malley is susceptible to colds, which can last up to a month or two. She is grateful to pulmonologist Burton Dickey, M.D., who gave her a method to use at the first sign of cold symptoms.

“We found that treatment with high dose inhaled steroids inhalers for mild obstruction and systemic steroids for severe obstruction may improve lung function or prevent disease progression,” Dickey says.

He adds that O’Malley was deeply interested in intervening to prevent progression of her lung disease, and has conscientiously implemented the program that he and his collaborators put in place.

“Dr. Dickey treated it like asthma.” O’Malley says. “I immediately start my inhalers, and I do this before it becomes a fullfledged problem.”

“Her attentiveness to her health care and working in partnership with us has played a big part in successfully controlling her lung disease.”

This treatment evolved after Dickey, chair of Pulmonary Medicine, and a collaborative research team conducted a study to alleviate breathing challenges like those of O’Malley.

However, O’Malley has the last word saying, “I’m in excellent condition. Dr. Dickey’s treatment allows me to sometimes forget that I ever had a transplant.”

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90% of them have gone on to lead interventional pulmonology programs elsewhere in the nation and other countries.”

Two of the fellows, Horiana Grosu, M.D., and Casal, were recently recruited into the faculty.

The Pulmonary faculty conducts additional training programs: • They educate community pulmonologists in advanced diagnostic procedures, offering multiple EBUS and pleural courses throughout the year.

• Each February the faculty conducts hands-on interventional pulmonary training which is designed for those with an interest in minimally invasive advanced diagnostics or therapeutics.

• In partnership with the American Association of Oncology and Interventional Pulmonology, the faculty offers a boot camp for all interventional pulmonology (IP) fellows in the nation. Attendees receive a toolkit filled with useful information about career development, business plan, equipment list, contact information for vendors and other resources to help them establish their practices.

• Faiz leads a critical care fellowship boot camp.

The annual program is open to 16-18 fellows from The University of Texas Medical Branch in Galveston, Tulane, Baylor, UT Houston and the Army’s fellowship program at UT Southwestern in San Antonio.

Quality Improvement Members of the department conducted several quality improvement (QI) projects throughout the fiscal year.

• A team led by department quality officer Lara Bashoura, M.D., associate professor, conducted a project to improve pneumococcal vaccination. “Our patient population is at high risk of developing infections, either because they have pulmonary disease or they are immunocompromised from their cancer or

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the cancer treatment,” Bashoura says. The vaccination rate was barely 1% among these patients when the team started its project. As a result of the interventions, the screening rate is now at 75%, and the vaccination rate is 50%.

• Eapen, Faiz and one of the department’s interventional fellows, graduated from the Clinical Safety and Effectiveness (CSE) program in August 2016 with a project focused on decreasing wait times for patients needing an interventional service. In their initial findings, the team learned that some patients come into the system while they are undergoing testing.

This can cause a one or two month bottleneck, which can have a major effect on patients with lung cancer. The team expanded the service from one room per day to two rooms per day.

This intervention allowed the wait times to decrease. The service is also now offered on the inpatient side.

“ Our patient population is at high risk of developing infections, either because they have pulmonary disease or they are immunocompromised from their cancer or the cancer treatment.”

Lara Bashoura, M.D. Bashoura, who chairs the institution’s Quality Improvement Assessment Board, says the department also decided to dedicate time to smoking cessation as a specific quality indicator relevant to its practice.

“We collectively think this is relevant to MD Anderson and to a pulmonologist working in a cancer center. Everyone thought this was important,” Bashoura says. •

Section of Benign Hematology Clinical Activity Two key personnel joined the section in Fiscal Year 2016 – Assistant Professor Cristhiam RojasHernandez, M.D., and Advanced Practice Registered Nurse Marilyn Miller. Rojas-Hernandez became the fourth member of the clinical faculty, joining Kroll, Vahid Afshar-Kharghan, M.D., and Thein Oo, M.D., Afshar-Kharghan and Oo were promoted to full professorship within the past year.

The inpatient activity is 24/7 while the team sees outpatients six half-days a week. Before the OneConnect launch in March 2016, inpatient and outpatient activity had increased 10-20% annually during the past 5 years. Clinical revenue had grown as well. The section originally budgeted to generate $1 million annually, and it has almost doubled that amount by achieving $1.9 million annually.

Michael Kroll, M.D., Section Chief

Patient care providers in the Section of Benign Hematology are often the first point of contact for cancer patients entering MD Anderson.

Many of these patients have nonmalignant, complicated systemic diseases of the blood, such as porphyria, hemochromatosis, hemophagocytic syndromes and immune deficiency syndromes.

“We take care of patients with low blood counts, with high blood counts, with bleeding problems and with thrombotic problems,” says Michael Kroll, M.D., professor and section chief.

The team works collaboratively with members of its own division, and the Divisions of Cancer Medicine, Surgery and Radiation Oncology.

Patient access looks good, too.

“The time from contact to appointment and availability of clinic slots is exceptional. It’s rare that patients have to wait two or three days if immediate attention is necessary,” Kroll says.

Research In the past 18 months, Benign Hematology has been active in three key clinical research projects.

• Protocols are established to study whether direct oral anticoagulants are safe, effective and improve the quality of life for cancer patients.

• A clinical study is in motion to research the use of a thrombopoietic drug in chemotherapyinduced thrombocytopenia.

• A translational study aims at examining the role of complement in stem cell transplantassociated graft versus host disease (GVHD) and if complement inhibition can be used to treat refractory GVHD. Most patients with solid tumors and almost all patients with hematologic tendencies will suffer 61

Temporarily sidelined Louisianan endures rare blood disease Nora Nichols’ health issues started when her right foot swelled and bruised. Visits to a walk-in clinic and her local physician didn’t immediately pinpoint the problem.

“In the meantime, I got another huge bruise from my knee to my thigh,” she says.

Results of subsequent blood work indicated she has Acquired Hemophilia A (AHA), a rare bleeding disorder. The soft tissue bleeding disease can occur with or without a family history of it. Like an astute medical student, Nichols researched her condition.

“What caused it? We just don’t know.

It looks like my immune system looked out there and for some reason thought that factor 8 shouldn’t be there. It got an inhibitor,” she surmises.

After a short hospital stay in her small Central Louisiana community, Nichols’ local doctor referred her to MD Anderson under the care of Thein Oo, M.D., professor in Benign Hematology, where she could have cutting edge research and treatment at her fingertips.

“Dr. Oo went through a process to find the right medication for me. I was on Prednisone for a while, but then he added an oral 62

chemotherapy to my treatment plan.”

Nichols had several rounds of each medication, but side effects eventually sidelined the use of both drugs. The disease continued to take its toll as well.

“It was so bad that just resting my arm to drive to Houston would bruise me. I also developed fractures in my back for no reason at all.”

In July 2016, Oo prescribed Rituximab.

Nichols received four rounds of this medication. She is now on Azathioprine, an immunosuppress medication that is typically used for rheumatoid arthritis or Crohn’s disease.

The 66-year-old grandmother said she was working before she got sick, but she retired because the disorder debilitated her.

“I just could not work with this condition.

One of the worst things was losing my independence. I used to do everything for myself, including yard work.”

Nichols is in remission for five months now and credits Oo for working to get her well.

“Dr. Oo and others have been wonderful. I can’t imagine not having them here to help.”

from chemotherapy-induced thrombocytopenia, Kroll says, which is often associated with bleeding.

“Despite the discovery of thrombopoietin 25 years ago, we have not developed any drug to treat chemotherapy-induced thrombocytopenia, like neupogen for white blood cell production or epogen for red blood cell production.”

Among the patients seen by the Benign Hematology team, between 20-30% of them have venous thromboembolism in their history, or they are under active treatment.

“When a venous blood clot breaks loose and travels in the blood through the heart to the lungs, this is called pulmonary embolism and the disease process is designated venous thromboembolism (VTE).

“We spend a lot of time helping individual patients with VTE and we teach our peers how to provide standards of care and safety when using anticoagulation therapy.

We also participate in national and international organizations to optimize the management of cancer-associated VTE,” Kroll explains.

Specific areas of expertise Thein Oo, M.D., has emerged as an international expert on the use of venous thromboembolism prophylaxis in cancer patients receiving outpatient chemotherapy. His approach is to develop large randomized controlled trials in order to get an answer in a reliable and accurate fashion.

“Thein has contributed immensely to the notion that the use of prophylactic coagulation in most outpatients who are receiving chemotherapy is not a good idea,” Kroll says.

Vahid Afshar-Kharghan, M.D., was elected to the American Society of Clinical Investigation. He continues with active R01 funding and is making great inroads into determining previously poorly understood mechanisms by which platelets contribute to the development and spread of cancer.

He is also studying how aspirin provides primary and secondary protection against cancer and the complex role of the complement system in cancer, cancer-associated thrombotic microangiopathies and stem cell transplant-induced GVHD. “He is doing wonderful work trying to elucidate the importance of platelets in tumor cell growth and

the mechanism of that effect,” Kroll says. AfsharKharghan is collaborating with Anil Sood, M.D., professor, Gynecologic Oncology and Reproductive Medicine, on this project. Sood and Afshar-Kharghan are also working on projects that look at the role of complement proteins in tumor cell growth.

In collaboration with Amin Alousi, M.D., associate professor, Stem Cell Transplantation, and John Hansen, M.D., professor of Medicine at the University of Washington and the Fred Hutchinson Cancer Center, Afshar-Kharghan continues to work on the importance of complement regulatory proteins and other factors in the pathogenesis of stem cell transplant-related GVHD. Afshar-Kharghan is receiving DNA from 7,000 transplants through the National Merit Donor Registry in Milwaukee to study the genetics of GVHD. Cristhiam Rojas-Hernandez, M.D., is the site PI of a large randomized prospective clinical trial comparing a direct oral anticoagulant to low molecular weight heparin as treatment for cancer-associated VTE. According to Kroll, “His enrollment rate is better than anyone in the whole program, which is a testament to his hard work. Cris is well-organized, identifies patients, enrolls them on the protocol and keeps them there. His clinical research team is outstanding. They just get the job done.”

Kroll is working on a lab-based project looking at the role of platelets in innate immunity, specifically how platelets protect against pneumonia. His clinical research interest is principally aimed at determining how to use anticoagulation in patients with thrombocytopenia, with the goal of elucidating it through a prospective well-controlled randomized trial. He credits members of the Clinical Effectiveness and Leukemia Departments, especially Yvette Dejesus and Alessandra Ferrajoli, M.D. with providing exceptional collaborative support for this project.

Education The section has a robust education program in which they teach 60 residents from The University of Texas residents, six residents from Baylor College of Medicine residents and 20 fellows each year.

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“I want to bring more people into the academic arm of this business of ours,” Kroll says. “They don’t have to be bench researchers, but I want everybody to have the opportunity to improve the standard of care by whatever means they favor.”

Fellows voted him Teacher of the Year and the UT Internal Medicine Residents honored him as Faculty of the Year.

To see Kroll sharing his knowledge with trainees is to witness his sincerity in wanting to train those to whom he can pass the torch.

Kroll is an active member of the clinical effectiveness committee in which he has participated in many projects, including anticoagulation safety, VTE prophylaxis, management of heparin-induced thrombocytopenia, inferior vena cava filter retrieval, and management of leukemia-associated VTE.

“I’m trying to ‘vacuum clean’ as many young people into the field as I can, particularly benign hematology. None of the 100 graduating fellows in the past eight years have gone into this field. “ Kroll is among the leadership team of the Hematology/Oncology Fellowship Program.

As associate program director since 2011, his responsibility is to oversee the Hematology training.

Rojas-Hernandez has been at MD Anderson less than two years and has already earned coveted teaching awards. In FY16, the Hematology/Oncology

Quality Improvement

Rojas-Hernandez is evaluating the safety of direct oral coagulants in cancer patients and presented his finding at the American Society of Hematology and at the International Conference of Thrombosis and Hemostasis and Cancer in Italy.

“His data were really greatly received and he is working on a manuscript right now,” Kroll says. •

Symptom Research As the first department established to address the symptoms produced by cancer and its treatment as a strategic priority, the Department of Symptom Research is at the forefront of developing validated ways to characterize the symptoms induced by cancer and its treatment and discovering the mechanisms that underlie associated neurotoxicities.

The department employs an innovative two-pronged approach:

Annemieke Kavelaars, Ph.D, Chair ad interim 64

• Preclinical Research (the department’s Neuroimmunology Laboratory) conducts molecular, cellular, and behavioral studies on neurotoxicities associated with cancer and its treatment, with the long-term goal

of identifying mechanism-based therapeutic strategies for alleviating or preventing pain, neuropathy, cognitive impairment, and fatigue associated with cancer and its treatment; • Clinical Research develops symptomassessment methods based on patient-reported outcomes for use in clinical research and practice and designs, and conducts clinical trials to assess new and existing interventions that may reduce symptom severity or prevent symptom occurrence.

This configuration uniquely positions the department to combine results from preclinical, translational and clinical research into an integrated program that ranges from bedside to bench and from bench to bedside. Through this comprehensive structure, the Department of Symptom Research aims to increase the tolerability of cancer therapies for patients and to reduce the negative impact of treatment-related symptoms for cancer survivors.

Charles Cleeland, Ph.D., professor, is the founder and initial chair of the department. An internationally recognized expert on the assessment and treatment of pain medicine, Cleeland brought his Pain Research Group, which he established at the University of Wisconsin – Madison, to MD Anderson in 1996. The Pain Research Group became the Department of Symptom Research in March 2002.

Cleeland stepped down from his leadership role in September 2015, and Division Head David Tweardy, M.D., stepped in as chair ad interim. In September 2016, Annemieke Kavelaars, Ph.D., director of the Neuroimmunology Lab, was appointed chair ad interim. Kavelaars is principal investigator on preclinical studies focusing on the prevention and resolution of chemotherapy-induced neuropathy and other forms of pain.

Overview The department establishes animal models to study the molecular and cellular mechanisms of the neurotoxicities that occur within the context of cancer and its treatment. It also develops and validates symptom assessment tools for clinical and research use by health care professionals around the world.

Through interdisciplinary basic science and clinical research, the department strives to: • Discover the underlying mechanisms of neurotoxicities, including pain, fatigue, neuropathy, and cognitive impairment, that result from cancer and its treatment, • Enhance the identification of the prevalence, severity, and treatment of symptoms via patient-reported outcomes, and to promote this effort nationally and internationally, and to • Improve the management of pain, fatigue, and other symptoms in patients with cancer through evidence-based clinical trials.

Preclinical Research Neurobehavioral deficits resulting from cancer treatment greatly affect patient comfort and functioning, and may lead to lower doses of therapy, treatment holds, and even treatment termination, which potentially influences patient survival.

The Neuroimmunology Lab seeks to increase understanding of the pathophysiology of cancer therapy-induced neurobehavioral toxicities, including neuropathic pain, depressed mood, cognitive dysfunction, and fatigue. It then applies this newlyacquired knowledge to the rational design of novel interventions for alleviating symptom burden in patients with cancer.

The lab is developing preclinical and translational studies on regenerative medicine for treatment of neurotoxic symptoms, and is seeking to expand preclinical and translational efforts to develop, identify, and test novel drugs for neurotoxicities.

To achieve these goals, the group is actively collaborating with basic scientists, pharmacologists, clinicians, and imaging experts in the Departments of Pain Medicine, Neuro-oncology, and Radiation Oncology, and the Institute for Applied Cancer Science (IACS).

The three principal investigators (PIs) sharing the Neuroimmunology Lab, Professors Annemieke Kavelaars, Ph.D., Cobi J. Heijnen, Ph.D., and Robert Dantzer, D.V.M, Ph.D., joined MD Anderson in 2012 and have longstanding experience in the broad field of brain, behavior, and immunity.

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The MD Anderson Symptom Assessment Platform Building bridges between clinical development and patient-reported outcomes

By Jeanie Woodruff, program manager, Symptom Research

Charles Cleeland, Ph.D., was never one to let a hitch in federal funding slow him down.

His mission to reveal and reduce the symptomatic effects of cancer therapy is of interest to a number of stakeholders, including drug developers, regulatory entities, policymakers, payers, and advocacy groups. Given recent reductions in NIH grant funding, Cleeland and his colleagues in the Department of Symptom Research have been reaching out to pharmaceutical companies, who are increasingly interested in the patient experience in response to cancer therapies.

A joint effort between his department and MD Anderson’s Office of Strategic Industry Ventures has established the MD Anderson Symptom Assessment Platform, a framework for incorporating patient-reported outcomes (PROs) into the developmental trajectory of experimental therapies, to capture both symptom benefit and symptom burden of a given treatment and to position successful treatments for FDA approval and labeling.

“Working directly with pharmaceutical companies, our investigators engage patients participating in early-phase/ Phase I clinical trials to learn how certain investigational new drugs are affecting them,” says Cleeland. Early-phase clinical trials present an opportunity to capture signs of a new drug’s potential toxicity and/or symptom benefit (for example, reduction of disease related-symptoms, improved functioning) early in the drugdevelopment process.

“We create ‘fit-for-purpose’ questionnaires that are an invaluable resource for understanding how patients are being affected by new therapies, in terms 66

of symptoms, their severity, and their interference with daily activities and quality of life,” Cleeland says. “For patients and their physicians, knowing the probable effects of a treatment can help with decisions among treatment options when therapeutic outcomes are similar but symptomatic effects are not.”

Purposeful process of information gathering Fit-for-purpose questionnaires developed under the Platform begin with an existing multisymptom PRO questionnaire, MD Anderson Symptom Inventory (MDASI).

The MDASI is a simple, straight-forward instrument for assessing patient ratings of the severity and functional impact of common cancer-related symptoms. It is widely used in clinical trials and academic studies, both nationally and internationally.

“We augment the core MDASI with additional symptom items specific to the disease or treatment to form these fit-forpurpose questionnaires,” Cleeland says.

New items are derived through a structured process, led by Lori Williams, Ph.D., assistant professor. She and her team conduct detailed qualitative patient interviews to capture the emergence of treatment-related symptom burden or benefit and refine the item list.

The next step is psychometric validation of the final questionnaire. Tito Mendoza, Ph.D., associate professor, is the department’s psychometrician and leads the validation effort. “Validation is a statistical method for ensuring that a questionnaire truly and adequately measures what it intends to measure, yields consistent, reproducible results,

The Neuroimmunology Lab has established collaborative studies with the Departments of Neuro-oncology, Neurosurgery, and Radiation Oncology, and with IACS.

Preclinical Research Highlights Kavelaars’ main interest is in the molecular and cellular mechanisms leading to chronic pain and its resolution. She currently is PI on three multi-PI National Institutes of Health (NIH) R01 grants.

Kavelaars reports, “One of our most exciting recent findings is that we can reverse chemotherapyinduced peripheral neuropathy. In collaboration with the pharmaceutical company Acetylon, we have found that inhibitors of HDAC6, when applied to mice who have developed pain and numbness as a result of cisplatin treatment, completely reverse these signs of neuropathy.”

Charles Cleeland, Ph.D., Professor

She adds that the beneficial effect was maintained even when the researchers stopped dosing the inhibitor.

and is sensitive to change when change is expected,” explains Mendoza.

Kavelaars notes that one of the HDAC6 inhibitors is already in clinical trials to examine its potential to enhance the anticancer effects of chemotherapy, and that rapid clinical translation of the findings should therefore be possible.

The Platform’s careful questionnaire development plan is designed to satisfy FDA guidance on using PROs as valid evidence of the impact of a new treatment and should well position new agents for regulatory approval. Beyond the earlyphase trials, the questionnaires can be used to further evaluate the drug in larger numbers of patients, if it progresses to Phase II and III clinical trials.

“The ultimate goal [of the Platform] is to develop patient-centered questionnaires that will provide new understanding about the patient’s experience with experimental therapies,” said Ferran Prat, Ph.D., J.D., vice president for Strategic Industry Ventures.

“This venture is an exciting model for delivering previously uncaptured information that will directly benefit patients.”

Learn more about the MDASI and available fit-for-purpose modules at mdanderson.org/mdasi.

Heijnen was awarded tenure track in Fiscal Year 2016. Her more recent work centers on the cognitive deficits and impaired brain connectivity induced by chemotherapy and/or radiation, otherwise known as “chemobrain.”

Utilizing a mouse model of cisplatin-induced cognitive impairment, Heijnen has shown that cognitive impairment is associated with structural abnormalities in white matter and a reduction in dendritic spine density and dendritic branching.

She is investigating various interventions to prevent or ameliorate the development of chemobrain, including pifithrin-µ, which protects mitochondrial morphology; metformin, which has anti-inflammatory properties; and mesenchymal stem cells, which migrate to areas of damage or structural abnormality and stimulate repair mechanisms. The first results of one of these

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studies were recently published in Cancer Research (Chiu GS et al, 2016).

Heijnen says, “It is breathtaking when one observes the extent of the structural and functional damage to the brain caused by cancer and its treatment.

It is fascinating and promising to see how a few mesenchymal stem cells can reverse the cognitive impairment and structural defects in the brain.”

She continues, “With more cancer survivors every day, it is my mission to bring chemobrain to the forefront of the attention of clinicians and policymakers, so as to support cancer survivors in their search for a better quality of life.”

Dantzer has spent the last three decades studying the role of inflammatory cytokines in sickness,

“ We have been able to show that it’s possible to block inflammationinduced depression at the level of blood–brain barrier transporters. We’ve also been able to characterize the motivational alterations that are associated with fatigue, which is an important step in the effort to treat it.”

Robert Dantzer, D.V.M, Ph.D. depression, and fatigue. In addition to his collaborative work with Kavelaars and Heijnen on cancer-related symptoms, he is currently researching ways to block the symptoms of depression induced by inflammation and elucidating the mechanisms of cancer-related fatigue.

According to Dantzer, “We have been able to show that it’s possible to block inflammation-induced depression at the level of blood–brain barrier transporters. We’ve also been able to characterize 68

the motivational alterations that are associated with fatigue, which is an important step in the effort to treat it.”

The preclinical research group has been quite successful in obtaining external grant funding this year.

• The NIH granted a competitive renewal in the amount of $1.1 million to Kavelaars, Dantzer, and Heijnen for the multi-PI project, “Neuroimmune mechanisms of recover from comorbid depression and chronic pain.”

• Heijnen and Kavelaars were awarded another multi-PI, NIH R01 grant in the amount of $1.2 million, entitled, “Mesenchymal stem cells to repair chemobrain.” The major goal of this study is to determine whether nasally administered mesenchymal stem cells can repair existing cisplatin-induced cognitive impairment and to identify mitochondrial damage as a key underlying mechanism.

• Dantzer received a $250,000 grant from Ajinomoto Innovation Alliance Program to study the mechanisms of the antidepressant properties of L-leucine. The major goals of this project are to determine whether the positive results obtained with leucine in a situation of depression-like behavior induced by acute systemic inflammation extend to chronic systemic inflammation.

• Heijnen is co-investigator on an NIH R01 Provocative Question award, “Synaptic basis of deficits in attention and executive function following cranial radiation” (PI: David Grosshans). The major goal of this $1.5 million project is to understand the synaptic mechanisms of RT-induced cognitive dysfunction, including deficits in attention and executive function, and introduce novel therapies to improve functional outcomes and quality of life for brain tumor survivors.

• Kavelaars is a co-investigator on a $275,000 NCI award, “Proton mini-beams: overcoming proton beams inability to spare superficial tissues” (PI: Sunil Krishnan). The major goal of the project is to compare the biological effects of proton mini-beams and solid beams in

transgenic mouse models sensitive to changes in cognition following radiotherapy.

Clinical Research Symptoms are subjectively experienced effects from disease, disease progression, and/or treatment, and as such are best understood through self-report from patients at specific stages of specific types of cancer. Such patient-reported outcomes (PROs) have been recognized by the US Food and Drug Administration (FDA) as legitimate primary outcome variables for clinical trials. Funding agencies, regulatory groups, pharmaceutical companies (of all sizes, with drugs in all stages of development), and clinical research departments within and outside MD Anderson are increasingly interested in methods for addressing the patient perspective on toxicities and potential symptomatic benefits of treatment—and in using PROs to do so.

The clinical research group is led by Charles Cleeland, Ph.D., director of Clinical Research.

Instrument Development The clinical research group designs and licenses fitfor-purpose PRO-based assessment questionnaires to measure the symptoms experienced by cancer patients, to determine their severity and how they affect quality of life (see related story). Symptom Research’s cache of questionnaires include the Brief Pain Inventory, the Brief Fatigue Inventory, the MD Anderson Symptom Inventory (MDASI) and its various disease-specific and treatmentspecific modules, the Therapy-Induced Neuropathy Assessment Scale, and the Alopecia Areata Symptom Impact Scale. Most of the current work on grants and clinical trials revolves around the MDASI. The MDASI is a brief but concise assessment tool in which patients rate the severity core common symptoms that anyone with cancer might experience—for example, pain, fatigue, neuropathy, nausea, and sleeplessness—on a 0–10 scale.

Cleeland says that the MDASI is not only a clinical assessment, but has a quality of life element to it, too. For instance, the MDASI picks up on how cancer and its treatment interfere with relationships

and work. And whereas other symptom scales show adverse effects only, the MDASI also records benefits.

“Even if the disease is worsening, if a patient feels better, that may give them an extra lease on life,” Cleeland explains.

Clinical Trials and Observational Studies The clinical research group designs and conducts clinical trials to assess new and existing interventions that may reduce symptom severity or prevent symptom occurrence. The clinical group has well-established collaborations and publications with many disease-specific clinical divisions (including Radiation, Surgery, and Cancer Medicine) and is bridging with other departments who are developing, or who wish to develop, their own science in this area, including Pain Medicine, Neurooncology, and Investigational Cancer Therapeutics.

The clinical research group is well-positioned to support the increasing demands of patient advocacy groups, regulators, and payers for more information about how patients feel and function during and after cancer therapy. It continues to support education for implementation of PROs in clinical trials worldwide.

Clinical Research Highlights Charles Cleeland, Ph.D., professor, has spearheaded a joint effort with MD Anderson’s Department of Strategic Industry Ventures to establish the MD Anderson Symptom Assessment Platform, a formal MDASI-based pathway for documenting both benefit and toxicities from new agents being tested in early-phase clinical trials and for achieving FDA approval based in part on symptom burden outcomes. A psychometrically valid tool like the MDASI is necessary for a pharmaceutical company to make a symptom-related claim about its drug, to prove that the symptom data on which the claim is based is reliable. Cleeland and other department staff are working with several pharmaceutical companies under the Platform to enable the use of PROs in drug development, from preclinical and Phase I studies to drug registration trials.

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talk about how they are feeling and what they are experiencing, symptom-wise.”

Part of the proposed study will see if patients can inform researchers early on if the new drugs are causing issues while they are still in the development phase.

Part of the proposed study will see if patients can inform researchers early on if the new drugs are causing issues while they are still in the development phase.

The development of the MD Anderson Symptom Assessment Platform has opened up new avenues of symptom research in early-phase clinical trials, including studies of patients who have rare diseases and those testing new cancer therapies.

Goldy George, Ph.D., instructor, transitioned to Symptom Research from the Phase I team in December 2015. George brings her unique experience to develop key projects targeted for grant submissions. One of her projects, in collaboration with David Hong, M.D., professor, Investigational Cancer Therapeutics, will address how to work with some of the PRO-based immunotherapy studies with a small patient sample.

“There are some who doubt you can ask patients who are very sick about their conditions and whether they can give a useful, reasonable response,” says Damian Walsh, department administrator. “We believe that our studies in the Phase I clinic will show that the opposite is true.

“We know from other studies we’ve done that patients very much want to tell their stories and to

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“What we’re trying to do, in essence, is to increase our knowledge of triaging these patients,” George says. “Are there warning signs in the early stages of the drug’s development? Is there a sub-set of patients who react in certain ways because they have different conditions?”

Clinical group researchers were awarded key grants in Fiscal Year 2016 to sustain their efforts.

Xin Shelly Wang, M.D., professor, was awarded an NIH R01 in the amount of $638,160 for her work, “Improving recovery after major cancer surgery using patient-reported outcomes.”

The goal is to develop tools to objectively quantify symptom burden and symptom control, as well as functional recovery indices, after major cancer surgery, comparing standard surgery procedures with Enhanced Recovery after Surgery (ERAS) methods. The study spans departments across the institution, including: • Gastrointestinal Project (colorectal, pancreatic, liver, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) • Gynecological Oncology and Reproductive Medicine Project • Genitourinary Project • Thoracic Project (lung, esophageal) Notes Wang, “This research is a good example of our department’s cross-institutional collaboration.

In this study, we’re working with clinicians using ERAS methods to measure the impact of this kind of surgery on patients, across several cancer sites.”

Wang also hopes to implement a common instrument to capture postoperative morbidity and to develop a common platform to prospectively capture data for all of the projects.

Three other faculty members, Tito Mendoza, Ph.D., associate professor, Qiuling Shi, Ph.D., assistant

professor, and Lori Williams, Ph.D., assistant professor, were awarded key funding.

• Mendoza is the psychometrician for a $6 million CPRIT multi-institutional award to UTMB (Program PI: James Goodwin, UTMB).

This award is similar to an NIH P01 in scope, with several subprojects and cores; Mendoza is funded as part of the Survey Core (PI: Susan Peterson). The project aims to improve methods for measuring individual patient characteristics and patient preferences, to help patients and their physicians make individualized decisions about the best cancer care options.

• Shi received a one-year, $75,000 Institutional Research (IRG) Grant, “Establishing a symptom monitoring tool for patients with esophageal cancer,” to develop and psychometrically validate a simple, easily administered PRO instrument for esophageal cancer patients. She is also a co-investigator and major participant in the Wang R01 described above.

• In addition, Shi is using big-data mining techniques to analyze data from the ECOG E2Z02 Symptom Outcomes and Practice Patterns study. “Our goal,” she notes, “is to develop clinically meaningful PRO parameters from this large dataset, to characterize cancer treatment-induced symptom burden and its impact on daily functioning.”

• Williams received a two-year, $50,000 Cancer Survivorship Research Seed Money Grant to study patient attitude, therapy compliance, and symptom effects of switching from Gleevec™ to generic Imatinib. She also has a grant from Genentech to validate the use of the MDASI in adolescents with cancer. As part of the MD Anderson Symptom Assessment Platform, she is working on the development of a MDASI

module for malignant pleural mesothelioma to be used as a secondary endpoint for labeling in a Phase III clinical trial.

Quality Improvement Williams, the department’s quality council representative, showcased Symptom Research’s collaborative efforts during the 2014 and 2015 Internal Medicine Grand Rounds quality improvement presentations. The two-part study used the MDASI to track patient-reported symptom burden after surgery, with and without enhanced recovery (ERAS) procedures.

Explains Williams, “In 2014, we collected baseline data on symptom burden from standard surgery in several departments that were planning to implement ERAS. In 2015, we collected symptom burden data from the same departments for both ERAS and standard surgeries, to compare outcomes against the baseline data.”

Results showed that ERAS produced lower symptom burden compared with standard perioperative techniques, and that the MDASI was able to empirically quantify the differences between the two approaches.

Williams points out that this latter finding is important, because the health care industry (e.g., private payers), regulatory bodies (e.g., the FDA and Medicare), and research funding organizations (e.g., NIH, PCORI) are placing emphasis on symptom and functional outcomes of treatment, as measured by PROs such as the MDASI. “There is growing interest in integrating PROs into electronic health record systems and patient portals as part of routine clinical care. The information PROs provide is just as valuable to clinicians as are lab tests, scans, and physical findings.” •

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By the Numbers

BREAKDOWN

FACULTY

Total Full-Time Faculty

181

Research Faculty

43

Clinical Faculty

138

Total Staff and Administration Trainees

51

Residents Internal Medicine Residency Program Numbers as of August 31, 2016.

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10

496

Professional Gross Patient Revenue

$127,881,951 Hospital Gross Patient Revenue

$153,549,456

RESEARCH

TOTAL Fund Group 90

$20.4m

FUNDING

Fund Group 80

$1.5m Fund Group 30

$1.7m

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Administration Our people: support staff, providers, leaders exhibit true grit

by Bill Atkinson

Internal Medicine became a clinical division at MD Anderson more than 17 years ago. It was a division built around medical care for the cancer patient, and then developed into a vision of medicine and oncology working hand in hand to provide the best treatment, not only of the cancer itself but the toxicities associated with its treatment.

Now almost two decades later, our vision is even clearer.

We provide not only internal medicine care, but specifically, Onco-Medicine care to our patient population. Our Division Head David J. Tweardy, M.D., coined the term two years ago to emphasize the uniqueness of our sub-specialty in a cancer care setting. The term Onco-Medicine takes the partnership to a new level to complete integration into the care team, which I believe, our division has fully realized. We are equal partners in care, with the key word “equal.”

Integration, teamwork, and exceptional care are the core of the culture here in Internal Medicine. Our success can be measured by the exponential growth since our inception. In addition to growth in the

“ I’ve often said it is appropriate for a red head to be in the position of division administrator in Internal Medicine, as we have always felt a bit like the proverbial ‘red-headed stepchild.’”

Bill Atkinson

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number of patients, during the past two fiscal years we have grown in actual structure. The Department of Psychiatry joined us at the beginning of Fiscal Year 2017, along with the Psychiatric Oncology Center, rounding out our division’s complete medical care of the patient from body to mind. We also added the Endoscopy Center to our division, where our internationally acclaimed gastroenterologists perform most of their clinical duties. These additions have brought us to a total of 10 academic departments and six clinical centers.

The hallmark of our success – teamwork – was tested this past year as we experienced the long awaited OneConnect launch. Scores of clinicians and staff members from each department put their noses to the grindstone to become adept at the new system. We were definitely tested early, especially our friends in the Cardiopulmonary Center, who were mired in the first days and weeks with tremendous operations issues, and flow and billing issues for months after that. As always, Internal Medicine rose to the challenge.

The tenacity and doggedness of our team, led by Medical Director Elie Mouhayar, M.D., Associate Medical Director Lara Bashoura, M.D., Department Administrator Christine Reid and Charge Capture and Documentation Manager Mona Williams, worked around the clock to get the center operational, safe and profitable. By early 2017, the Cardiopulmonary Center went from the lowest performing center immediately post Go-Live to the highest performing center at MD Anderson. Its success is a testament to what we can all do when we face an extraordinary challenge.

In the past two years, the institution has also taken notice of the trailblazers in Internal Medicine.

Providers from our division have earned the coveted Geneva and James Briscoe Physician Assistant Award for Excellence for the past two years.

William Atkinson IV, Division Administrator

Kathleen Smith, physician assistant, Infectious Diseases, Infection Control and Employee Health, won the award in 2015, while Myrshia Woods, physician assistant, Cardiology, took home the prize in 2016.

We also consistently have finalists in the prestigious Rogers Award including Ellen Manzullo, M.D., clinical deputy division head, who was a finalist in the Patient Care category in 2014; and Betty Spears, program coordinator, Dermatology; and Roy Chemaly, M.D., professor, Infectious Diseases, Infection Control and Employee Health; who were finalists in the Prevention category in 2016.

I’ve often said it is appropriate for a red head to be in the position of division administrator in Internal

Medicine, as we have always felt a bit like the proverbial “red-headed stepchild.”

That time is no more.

The institution has taken notice of the great work of our people and our faculty. Through tough financial times, we have posted our best financial performance in the history of Internal Medicine.

More importantly, we have maintained the innovation and fierce work ethic in a challenging time, while keeping the collegial and servant values instilled by our first Division Head Robert Gagel, M.D. It is a privilege to work alongside each of you. It is truly our time to shine. •

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A FOCUS ON

Collaborations

COLLABORATION: CLINICAL

Collaboration essential for high quality patient care

by Ellen Manzullo, M.D. As you read this annual report, you may have witnessed the very essence of collaboration which occurs on a daily basis between those of us in Internal Medicine and among our colleagues throughout MD Anderson. I hope you have already had an opportunity to read about the numerous examples where individuals collaborated on behalf of our patients across the continuum of their cancer care.

Through MD Anderson’s unique multidisciplinary approach, collaboration occurs from the moment a patient receives his/her diagnosis. Many of our own Internal Medicine clinicians in several clinics such as the Mary Ann Weiser Suspicion of Cancer Clinic, Endocrinology, Dermatology, Gastroenterology, and Pulmonary Medicine, are actively involved in making the initial cancer diagnosis.

A large majority of our patients will come to know us because of the Onco-Medicine care that we

provide them as a result of the side effects of their cancer treatment. Here are only a few examples: • Infectious diseases physicians treat infectious complications of cancer therapy, • Benign hematologists deal with episodes of bleeding or thrombosis, and • Internists assess and optimize patients for surgery in the Internal Medicine Perioperative Assessment Center (IMPAC).

As the number of cancer survivors continues to increase, the long-term management of the late effects of cancer and cancer therapy becomes of great importance. The division is wrought with experts in the fields of bone health, pulmonary rehabilitation, cardiotoxicity and renal complications of cancer therapy whose care will become of critical importance. Finally our hospitalist service, as well as Emergency Center physicians, play a vital role in the treatment of our acutely ill cancer patients.

A web of clinical care outside Main Campus It is equally exciting to witness collaboration as our footprint continues to grow at the Houston Area Locations (HALs) and throughout the Cancer Network worldwide. As MD Anderson leadership explores new partner relationships, Internal Medicine physicians are called upon to exchange knowledge, ignite new ideas and develop new relationships to allow a greater number of patients to receive their treatment closer to home.

In the fall of 2016, I attended, as well as participated, in the third annual MD Anderson Cancer Network Partners meeting. Representatives from all of our global partners attended the forum which provided everyone a great chance to reunite

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Ellen Manzullo, M.D., Clinical Deputy Division Head

with colleagues and learn of the many strides that have been made in our areas of expertise.

Of equal importance was the opportunity to meet leaders from some of MD Anderson’s newest partners, such as MD Anderson Cooper Cancer Center in New Jersey. As we shared information about our respective institutions, I was particularly excited to have the chance to highlight recent clinical developments within our own division.

As I showcased Internal Medicine’s many clinical accomplishments, the audience became excited when they realized how we can collectively

contribute to the emerging discipline focused on the internal medicine care of the cancer patient and survivor. As we learn from each other, we have the opportunity to continually strive to have an impact on a growing number of cancer patients and deliver an increasingly high quality of care.

Finally, with the creation and implementation of our Internal Medicine Residency Program, in partnership with Baylor College of Medicine, we are developing our future leaders who can carry on this mission for years to come. •

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COLLABORATION: RESEARCH

Team Science highlights research talent, capabilities

by Dimitrios Kontoyiannis, M.D., Annemieke Kavelaars, Ph.D., and Sam Shelburne, M.D., Ph.D. More than ever, investigation of cancerrelated complications, acute and chronic, has become a key item in the oncology research agenda. The era of the solo researcher attacking a problem is long gone, as quality research has many dimensions and requires a multidisciplinary approach.

With a rapidly expanding “critical mass” of investigators from different disciplines, the Division of Internal Medicine has made impactful contributions to the research mission and agenda of our institution. Indeed, team science research in the Division reflects the esprit de corps of our talented and diverse research force.

Taking advantage of the institution’s highly collaborative environment and robust resources, team science ventures within and outside the division have been formed, and it is my pleasure to highlight two of them.

• The Neuroimmunology Laboratory in the Department of Symptom Research works in diverse aspects of neurotoxicity and fatigue following cancer chemotherapy that has nurtured several active collaborations with related disciplines in the institution.

• The Microbiome Group in the Department of Infectious Diseases has already branched out by reaching to several other departments in the institution.

Neurotoxicity and Fatigue The Neuroimmunology Laboratory in the Department of Symptom Research houses the research teams of three principal investigators (PIs) – Annemieke Kavelaars, Ph.D., Robert Dantzer, D.V.M., Ph.D., and Cobi Heijnen, Ph.D. 80

Their research projects aim at understanding the mechanisms underlying the neurotoxic symptoms of cancer and its treatment, including pain, cognitive deficits, fatigue and depression. Their long-term goal is to identify novel mechanismbased interventions to prevent or reverse these neurotoxicities.

All three PIs were recruited to MD Anderson in 2012 to establish a preclinical laboratory within the department. Because they share research space, both in the lab as well as in the animal facility, along with all of their equipment, they have created a highly collaborative environment that strongly supports team science.

The Heijnen research team focuses on chemotherapy-related and radiation-induced cognitive impairment (chemobrain) and has made some truly exciting discoveries. When Heijnen began these studies, her working hypothesis was that neuro-inflammation and local production of cytokines in the brain play a major role in the development of chemobrain; however, her most recent results clearly demonstrate that this is not always the case. For example, the cognitive impairment found in mice treated with cisplatin is associated not with inflammatory activity in the brain, but with mitochondrial deficits.

We have discovered that a small compound that protects mitochondria from damage (pifithrin-μ) prevents both the behavioral signs of cognitive impairment and the associated structural abnormalities in the brain, (Chiu et al, Cancer Research 2016).

Other exciting recent results indicate that chemobrain or chemoradiation-induced brain damage and cognitive impairment can be reversed by nasal administration of mesenchymal stem cells. These studies are performed in a

collaborative effort with Kavelaars and Shelli Kesler, M.D., and other researchers from the Departments of Neuro-oncology, Neurosurgery, Radiation Oncology and Stem Cell Transplantation and Cellular Therapy. Positive results and successful completion of safety studies should soon lead to a clinical trial aimed at using mesenchymal stem cells to alleviate the cognitive deficits in patients treated for glioblastoma. These studies have led to awarding of a multi-PI RO1 NIH grant (HeijnenKavelaars) on the use of MSC for reversal of chemobrain.

Dimitrios Kontoyiannis, M.D., Research Deputy Division Head

The Kavelaars team focuses on cancer treatmentinduced pain and numbness. In a recently published article (Krukowski et al, Journal of Neuroscience 2016), the team showed that the resolution of chemotherapy-induced neuropathy after completion of treatment is an active process that requires CD8 T cells and IL-10 signaling. This novel finding shifts the paradigm when thinking about the transition into chronic neuropathic pain that happens in 25–30% of patients with chemotherapy-induced neuropathy, suggesting that patients may develop chronic pain when the normal active resolution pathways fail.

This exciting finding is one of several that formed the basis for the renewal of Kavelaars’ multi-PI R01 grant (with Heijnen and Dantzer as the other PIs) this year.

In this renewal, the aim will be to determine the role of this T-cell–dependent and IL-10–dependent resolution pathway in multiple models of pain and depression. Kavelaars will also explore the idea that T cells can be educated, either by vaccination or by ex vivo stimulation with specific cytokines, to reverse pain and depression.

Dantzer’s group has a strong interest in the pathways leading to fatigue, a very common complaint of patients with cancer. His team uses a mouse model of HPV-positive head and neck cancer treated with chemoradiation to assess the

contribution of inflammation, mitochondrial deficits, and tumor to brain signaling and to the development of fatigue.

This has necessitated the development of behavioral assays to identify fatigue in mice. For this purpose, Dantzer is using running wheels to measure changes in voluntary activity and sophisticated behavioral analysis to assess incentive motivation, by determining the mouse’s willingness to exert effort and its sensitivity to reward (Vichaya et al, Neuropsychopharmacology 2014). Parallel studies using computerized tasks are under way in cancer survivors to better characterize the motivational aspects of their fatigue.

Microbiome Group Project The efforts of the Samuel Shelburne laboratory in Microbiome Research begin in 2013 when it joined a tri-partite project led by Dimitrios Kontoyiannis, M.D., entitled, “Integrated project in toxicity genomic in patients with acute myelogenous leukemia.” The role of the Shelburne laboratory in this project was to perform longitudinal assessment of the microbiome in patients with acute myelogenous leukemia (AML) undergoing induction chemotherapy.

This project was coupled with efforts by the Department of Symptom Research to better 81

understand neurobehavioral toxicities during AML therapy and with the Department of Genomic Medicine which sought to elucidate genetic predispositions to toxicity during AML treatment.

immunotherapy to development of graft vs. host diseases to infectious toxicities. The data from the multiple projects are being prepared for publication and have already served as the nidus for external grant submissions.

“ This highly collaborative project seeks to broadly define how the microbiome influences key aspects of cancer-care ranging from response to immunotherapy to development of graft vs. host diseases to infectious toxicities. The data from the multiple projects are being prepared for publication and have already served as the nidus for external grant submissions.”

In addition to the projects outlined above, Shelburne has created and leads the MD Anderson Microbiome Working Group which now includes investigators from 10 different departments who are interested in microbiome-based cancer research. The Working Group helped recruit Robert Jenq, M.D., a world leader in microbiome-stem cell transplant related research, to the institution in fall 2016, which has helped galvanize microbiome research at MD Anderson. The demand for such research has resulted in plans for formation of a core facility for microbiome analyses at MD Anderson. Thus, the development of microbiome research at MD Anderson is truly an example of team science.

Samuel Shelburne, M.D., Ph.D. The success of the AML-microbiome project resulted in the formation of a group effort between the Departments of Stem Cell Transplantation, Surgical Oncology, and Infectious Diseases to form a multi-disciplinary team to examine how the microbiome affects an array of cancer-care related issues. The project is led by Drs. Elizabeth Shpall and Dimitrios Kontoyiannis and is entitled, “The role of the gastrointestinal microbiome in the care of the cancer patient.”

This highly collaborative project seeks to broadly define how the microbiome influences key aspects of cancer-care ranging from response to

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Kontoyiannis Closing Comments In my 20 years in clinical /translational research, I have found that the key elements in the team research concept and programs are: • Sharing common goals and resources as a team, • Caring less about who gets the credit; and • Building a nice mixture of researchers with complementary talents who are in different stages of career development. The latter allows the most seasoned and experienced researcher to contribute through sage advice and mentoring.

I am proud of the camaraderie, highly collaborative and multidisciplinary nature of the researchers in our Division. I am convinced that the Division of Internal Medicine will continue its impactful and sustained contributions to our institution’s research mission through a quality, team science approach. •

COLLABORATION: RESIDENCY

Program creates environment to build leaders in cancer care setting

The second round of Level One residents joined the program in June 2016. From left to right: Amit Lahoti, M.D., site director, Bhavitka Kaul, M.D., chief resident; Rafee Talukder, M.D., Sami Bashour, M.D., Noman Ali, M.D., Robert Hester, M.D., Neeraj Joshi, M.D., Charity Sembera, M.D., program coordinator, and Tony Pastor, M.D., chief resident.

Ellen Manzullo, M.D., and former Internal Medicine Division Head Robert Gagel, M.D., probed the feasibility of an Internal Medicine Residency Program in 2011. Four years later, Manzullo saw their efforts pay off when the first class of five residents matched with the program that was established in collaboration with Baylor College of Medicine (BCM).

“This is so exciting to have this unique training program in place,” says Manzullo, professor and clinical deputy division head. “Housestaff will become board certified in internal medicine, and they will acquire additional expertise in the internal medicine of the cancer patient and survivor.”

Ideal match energizes division, institution With the institution’s support, Manzullo and division administration staff then prepared a feasibility analysis and invited an outside consultant to assess the division’s clinical services which led to the partnership with Baylor College of Medicine (BCM).

“The Baylor Program has an excellent reputation.

They were as excited as we were, so we felt it would be a good match,” Manzullo says.

Once the program was in place, Manzullo and Richard Hamill, M.D., BCM program director, discussed overall development of the training program, curriculum and schedules. The recruitment of David Tweardy, M.D., as new division head was also a plus, Manzullo says, because of his familiarity with the program as a member of the BCM faculty for more than 16 years, and his success in securing 83

funding for its expansion to MD Anderson as part of his recruitment package.

Other significant developments included the participation of more than 20 Internal Medicine faculty who participated in the first round of residency candidate interviews, and the appointment of Amit Lahoti, M.D., associate professor, Nephrology, as site director.

“The breadth of this training is unparalleled to most programs across the nation with residents receiving training in venues ranging from the county hospital to one of the top cancer centers in the country.”

Lahoti says.

Program Coordinator Charity Sembera is the residents’ “Mom away from home.” Lahoti says they universally love Sembera, who was recruited from a similar role at the University of Texas Health Science Center at Houston.

“From organizing our schedules and conferences to providing individual support to residents, Charity has worked to ensure that each resident that rotates at MD Anderson has the best possible experience,” says second year resident Victoria Serpas, M.D.

The growth continues Now in its second year, the program welcomed aboard its first chief resident, Tony Pastor, M.D., along with a class of five new first-year residents in June 2016.

Pastor, a native Houstonian, chose the MD Anderson track for the first six months of his chief residency, because he saw it as a clean slate.

“It’s really exciting to be part of molding a new program,” Pastor says.

Lahoti and Pastor chose to make the MD Anderson experience more like the others in the BCM program, which includes a morning report, now three days per week. Initially only residents attended the sessions, but once word spread, other faculty also attended them, including current Division Head David Tweardy, M.D., and former Division Head Robert Gagel, M.D. Lahoti says the morning report is only one example of having a chief resident on site. He credits Pastor 84

Amit Lahoti, M.D., Site Director, Baylor College of Medicine/MD Anderson Internal Medicine Residency Program

with the launch of a monthly Morbidity, Mortality and Improvement (MMI) Conference which has CME/RME credit.

Bhavika Kaul, M.D., assumed the chief resident role in January 2017 once Pastor continued his chief residency at Ben Taub Hospital.

Other contributors enhance program One of the residents’ key rotations is with the inpatient hospitalist team led by Section Chief Josiah Halm, M.D. “Over the past 10 years, I have learned a lot about what it takes to provide the best care for cancer patients and survivors,” says Halm, associate professor, General Internal Medicine.

“The combined Baylor/MD Anderson Residency Program is “icing on the cake” as we collectively teach and share our experiences with the next generation of onco-hospitalists. Nothing makes me prouder than to have this opportunity.”

Marina George, M.D., associate professor, General Internal Medicine, directs the inpatient education.

She says learning occurs for both attendings and the residents.

“Teaching always enriches the experience of the attendings because it brings out fresh knowledge and teaches us to query more. As we enhance our interpersonal communication, we are also helping the residents to remove the fear of dealing with a complicated oncology patient.”

George says the residents overcome this fear because they are dealing with real patients and not case studies printed in a textbook. This offers them opportunities to search for answers that exist in front of them on their rounds.

George’s colleague David Rubio, M.D., assistant professor, General Internal Medicine, oversees the quality improvement curriculum for the house staff.

He says the goal for the PGY-2 year is a longitudinal curriculum and group project.

“For the development, I attended the Society of Hospital Medicine’s Quality and Safety Educators Academy in May and gathered some ideas.

Then in the summer, I worked with the Office of Performance Improvement (OPI) to determine feasibility and their available resources.”

Rubio conducts four didactic, two-hour sessions every two months with a curriculum he developed using the MD Anderson Quality College Resources to teach the Model for Improvement. A group of nine, second-year residents met with staff on G19 of the Alkek Hospital to discuss problem areas before they selected a project.

“They decided to focus on communication and patient satisfaction. Due to attending physician rotation, schedule turnover and many consultants, patients have difficulty identifying their primary doctor.”

Rubio says the team submitted the project to the QIAB review board and conducted the work from December 2016 through March 2017. The residents are required to present their results at the BCM Housestaff Research Symposium or at the Baylor Quality Improvement Symposium. They will also deliver a presentation at an Internal Medicine and Cancer Survivorship Grand Rounds in fall 2017.

efforts. Residents presented three abstracts with Santhosshi Narayanan, M.D., assistant professor, General Internal Medicine, at the Texas Chapter of American College of Physicians meeting. Second year resident Victoria Serpas, M.D., presented research at the European Society of Medical Oncology (ESMO) 2016 Congress in Denmark where she won the Best Poster Award.

Other Internal Medicine physicians have embraced the residency program, too. Samuel Shelburne, M.D., Ph.D., associate professor, Infectious Diseases, has contributed a number of hours in interviewing candidates for the MD Anderson tract.

“I am very impressed with the caliber of the resident applicants,” says Shelburne, a former chief resident of the BCM program. “They are very mature and have amazing backgrounds. I think that MD Anderson will greatly benefit from providing a training environment for this talented group.”

Ajay Sheshadri, M.D., assistant professor, Pulmonary Medicine, also says, “I’ve had a great experience with our Baylor residents. They are enthusiastic about seeing our unique patient population, and it is a joy to be involved in their teaching.”

Future Directions Lahoti says the goal is to expand the Morning Report to four days per week. In June 2017, the MD Anderson track increased to its full complement of 15 housestaff rotating at the institution. He expects rotations to expand and include Cancer Prevention, Palliative Care, Emergency Medicine, and Psychiatry.

As Division Head Tweardy reflects on the past two years of the program, he commends Manzullo and Gagel for having the tenacity and leadership to accomplish this achievement.

“Its impact on the division, as well as the institution, will be extremely positive and long-lasting,” he says. • — Written by Judy Overton

In addition to the quality improvement project, the housestaff has been engaged in other scholarly

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COLLABORATION: QUALITY IMPROVEMENT

Quality Council leads change in quality improvement and safety

By Carmen Gonzalez, M.D., chair, Quality Council “The transition to a high-performance healthcare organization requires leaders to define a culture that has quality at its core and to establish clear and specific expectations for all involved in the quality journey.”

– The Healthcare Quality Book, 2nd Edition Internal Medicine faculty formed the Internal Medicine Quality Council in 2007 to get physician buy-in to initiate quality improvements projects and to reduce variation of practice care. Former MD Anderson cardiologist Joseph Swafford, M.D., led this charge, followed by Kenneth Rolston, M.D., who is the current deputy chair. Since then, the council has grown and expanded as we integrated pivotal members into the quality improvement team.

Everyone has a fundamental role that is necessary for the team to achieve success.

The Quality Council is composed of trained champions, subject matter experts and professionals highly respected by their peers.

The members include representatives from each of the division’s ten departments, three sections, five centers and the Baylor College of Medicine/ MD Anderson Internal Medicine Residency Program.

They include physicians, quality engineers, quality officers, clinical administrative directors (CADs), clinical medical directors (CMDs) and managers.

Each of them serve as models, mentors and motivators, and are key participants in quality improvement efforts.

With the help of this talented group, the council has been able to align with the Division of Internal Medicine and MD Anderson goals to create, implement, monitor and evaluate quality 86

improvement efforts. The intent is to improve the level of performance of major processes and outcomes and to build a culture of continuous quality, safety and excellence in patient care.

Our mission aligns with the Institute of Medicine’s six aims for quality improvement. They include providing evidence-based quality care practice; and offering care that is safe, efficient, effective, timely and patient-centered.

We share a vision of strategic commitment to that of the institution to seek improvement in healthcare quality. We plan to do this by creating a culture that promotes quality, patient safety, and patientcentered care through research, education and professional development.

One team – varied areas of focus The council has different and complimentary areas of interest: • Healthcare quality improvement process, • Patient safety, • Variation and measurement, • Methods and skills for making sustainable changes in the systems, and • Collaborative approaches to healthcare delivery and value-care delivery.

Data drives our scholarly initiatives in quality improvement, and our techniques are scientific in nature. Many of our members, if not all of them, are graduates of the institution’s Clinical Safety and Effectiveness program.

We were among the first divisions at MD Anderson to regularly work on quality improvement and value of care initiatives. The outcomes are presented annually at three Internal Medicine and Cancer Survivorship Grand Rounds. (The exception was fall

2016 because of the OneConnect launch.) Acquired knowledge is also disseminated at other lectures and poster presentations at the state, national and international levels.

Some of the historical projects have transcended time and have evolved into institutional quality improvement initiatives. The 2010 Emergency Medicine project on the Emergency Center (EC) observation unit, led by Patrick Chaftari, M.D., is one example.

Project members established a clinical observation unit (CDU) in order to provide safer care for EC patients who needed to remain in the hospital more than 16 hours before being discharged. Not only did the EC team improve the quality of care, but it also saw an increase in patient satisfaction, along with a financial benefit to the institution of approximately $650,000 in annual technical charges and of $428,000 in annual professional charges.

The CDU is currently serving as the observation unit for the institution.

The Department of Infectious Carmen Gonzalez, M.D., Chair, Quality Council Diseases pioneered the Antimicrobial Stewardship Program under the leadership we felt compelled to recognize academic of Kenneth Rolston, M.D., and scholarly activity. As a result, we established Javier Adachi, M.D. Launched ten years ago, the the Distinguished Paper Award in Quality intent is to monitor patients who have received Improvement which will annually recognize the most potent antibiotics for up to five days. an excellent article published in a quality Clinicians want to ensure that the providers have peer review publication. Competing papers used the right antibiotics and that the patients are are evaluated using the Standards for Quality not over-medicated. The institution allowed for Improvement Reporting Excellence (SQUIRE 2.0). expansion of the program in Fiscal Year 2016.

Gottumukkala S. Raju, M.D., and his team in Gastroenterology, Hepatology and Nutrition, Additional accomplishments were the inaugural recipients in summer 2016. during FY2016: The manuscript, “Natural language processing • Using quality as our niche, it is imperative as an alternative to manual reporting of that we disseminate our findings by publishing colonoscopy quality metrics,â€? was published in our work. And, in order to place quality at Gastrointestinal Endoscopy in September 2015. the highest level in an academic department,

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• We also made an effort to see that quality improvement work would be recognized as an academic career path for faculty promotion in the Clinical Faculty Appointment (CFA) track. Council representatives visited the Cincinnati Children’s Hospital Medical Center which is considered a benchmarking site in the science of quality because of its strong curriculum in quality scholar initiatives. We presented our learnings to MD Anderson leaders and they were incorporated into the newly-recommended Quality Improvement track guidelines.

• Projects conducted by departments during FY2015-2016: Department

Presenter(s)

Presentation Title

Cardiology

Caesar Iliescu, M.D.

Catheterization Laboratory Quality Improvement

Dermatology

Susan Chon, M.D.

Decreasing the Incidence of Needlesticks in Dermatology Procedures

Endocrine Neoplasia and Hormonal Disorders

Maria Cabanillas, M.D.

Facilitating Anaplastic Thyroid Cancer Specialized Treatment (FAST)

Emergency Medicine

Terry Rice, M.D., and Bruno Granwehr, M.D.

HIV Testing in the Emergency Center at a Comprehensive Cancer Center

Infectious Diseases, Infection Control and Employee Health

Ella Ariza-Heredia, M.D.

Improving Vaccination Compliance after Stem Cell Transplant

Gastroenterology, Hepatology and Nutrition

John Stroehlein, M.D.

Endoscopy Start Time

General Internal Medicine

Norman Brito-Dellan, M.D., and Srinivas Reddy Banala, M.D.

Strategic Plan: Handoff

Pulmonary Medicine

Lara Bashoura, M.D.

Vaccination Initiative

Symptom Research

Loretta Williams, Ph.D.

Level of Symptom Burden after Abdominal/Pelvic or Thoracic Surgery

I have tremendous personal satisfaction of achievement, and I’m very proud of the institution and my council because this involves team work. This Division of Internal Medicine has the holistic view and care of the patient in mind. I believe that by establishing the Quality Council, our leaders had a clear vision to provide the highest quality of care that is significant for the patients and their families. •

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Faculty and Division Administration

Division Leadership and Faculty Cardiology

David Tweardy, M.D.

Nicholas Palaskas, M.D. Assistant Professor

Kudakwashe Maloney, M.D. Assistant Professor

Kara Thompson, M.D. Assistant Professor

Michael Migden, M.D. Associate Professor

Syed Wamique Yusuf, M.D. Professor

Kelly Nelson, M.D. Clinical Associate Professor

Dermatology

Division Head

Omar Pacha, M.D. Assistant Professor Anisha Patel, M.D. Assistant Professor

Chair Ad Interim Dallas/Fort Worth Living Legend Chair for Cancer Research III

Valencia Thomas, M.D. Associate Professor

Professor of Infectious Diseases and Molecular Oncology

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Xiao Ni, M.D., Ph.D. Associate Professor

Jun-ichi Abe, M.D., Ph.D. Professor

Ronald Rapini, M.D.

Jose Banchs, M.D. Associate Professor

Distinguished Chernosky Professor at UT Health

Chair

Emergency Medicine

Jean-Bernard Durand, M.D. Associate Professor

Karen Chen, M.D. Clinical Specialist

Michael Ewer, M.D. Professor

Adrienne Choksi, M.D. Assistant Professor

Keigi Fujiwara, Ph.D. Professor

Susan Chon, M.D. Associate Professor

Kumar Alagappan, M.D.

Susan Clark Gilchrist, M.D. Associate Professor

Ana Mercedes Ciurea, M.D. Associate Professor

Saamir Hassan, M.D. Assistant Professor

Patricia Brock, M.D. Assistant Professor

Carol Drucker, M.D. Professor

Cezar Iliescu, M.D. Associate Professor

Kathryn Burk, M.D. Assistant Professor

Madeleine Duvic, M.D. Professor

Kaveh Karimzad, M.D. Assistant Professor

Patrick Chaftari, M.D. Assistant Professor

Blanche Bender Professorship in Cancer Research

Peter Kim, M.D. Associate Professor

Maria Teresa Cruz Carreras, M.D. Assistant Professor

Saira George, M.D. Assistant Professor

Nhat Tu Le, Ph.D. Assistant Professor

Ahmed Elsayem, M.D. Associate Professor

Auris Huen, PharmD., M.D. Assistant Professor

Juan Lopez-Mattei, M.D. Assistant Professor

Carmen Gonzalez, M.D. Associate Professor

Sharon Hymes, M.D. Professor

Elie Mouhayar, M.D. Associate Professor

Jerry Henderson, M.D. Associate Professor

Deborah MacFarlane, M.D. Professor

Chair

Guido Hita, M.D. Assistant Professor Kalen Jacobsen, M.D. Clinical Associate Professor

Endocrine Neoplasia and Hormal Disorders

Gastroenterology, Hepatology and Nutrition

Jianyin Long, Ph.D. Assistant Professor Adam Miller, M.D. Associate Professor Cielito Reyes-Gibby, Dr. PH. Associate Professor Terry Rice, M.D. Associate Professor

Steven I. Sherman, M.D.

Margaret Row, M.D. Professor

Naguib A. Samaan Distinguished Professorship in Endocrinology

Marcelo Sandoval, M.D. Assistant Professor

Conor Best, M.D. Assistant Professor

Jayne Viets-Upchurch, M.D. Assistant Professor

Naifa Busaidy, M.D. Associate Professor

Monica Wattana, M.D. Assistant Professor

Maria Cabanillas, M.D. Associate Professor

Sai-ching Jim Yeung, M.D., Ph.D. Professor

Gilbert Cote, Ph.D. Professor

Birdie J. and Lydia J. Resoft Distinguished Professorship in Gastrointestinal Oncology

Ramona Dadu, M.D. Assistant Professor

James Byrd, Ph.D. Associate Professor

Robert Gagel, M.D. Professor

Jian Chen, M.D., Ph.D. Assistant Professor

Mouhammed Habra, M.D. Associate Professor

Raquel Davila, M.D. Associate Professor

Marie-Claude Hofmann, Ph.D. Professor

Marta Davila, M.D. Professor

Mimi Hu, M.D. Associate Professor

Zhiliang Jia, Ph.D. Instructor

Farhad Danesh, M.D.

Camilo Jimenez, M.D. Associate Professor

Jeffrey H. Lee, M.D. Professor

Professor

Victor Lavis, M.D. Professor

Patrick Lynch, J.D., M.D. Professor

Sonali Thosani, M.D. Clinical Assistant Professor

Ethan Miller, M.D. Assistant Professor

Jeena Varghese, M.D. Assistant Professor

Mala Pande, Ph.D. Assistant Professor

Steven Waguespack, M.D. Professor

Gottumukkala Raju, M.D. Professor

Steven Weitzman, M.D. Assistant Professor

Dr. John R. Stroehlein Distinguished Professorship in Gastroenterology

Rozita Yarmand, Ph.D. Assistant Professor

Andrew Rhim, M.D. Assistant Professor

Anita Ying, M.D. Associate Professor

William Ross, M.D. Professor

Section of Nephrology

Section Chief

Ala Abudayyeh, M.D. Assistant Professor Sheldon Chen, M.D. Associate Professor Daniel Galvan, M.D. Instructor Amit Lahoti, M.D. Associate Professor Yin Wang, M.D., Ph.D. Instructor Biruh Workeneh, M.D. Associate Professor

Chair

John Stroehlein, M.D. Chair Ad Interim

Manoop Bhutani, M.B.B.S. Professor Boris Blechacz, M.D., Ph.D. Assistant Professor Robert Bresalier, M.D. Professor

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Mehnaz Shafi, M.D. Professor

Jessica Hwang, M.D. Associate Professor

Huifang Lu, M.D., Ph.D. Associate Professor

Selvi Thirumurthi, M.D. Associate Professor

Gloria Iliescu, M.D. Assistant Professor

Yinghong Wang, M.D., Ph.D. Assistant Professor

Joanna-Grace Mayo Manzano, M.D. Assistant Professor

Maria de los Angeles Lopez-Olivo, M.D., Ph.D. Assistant Professor

Brian Weston, M.D. Associate Professor

Ellen Manzullo, M.D. Professor

Daoyan Wei, Ph.D. Assistant Professor

Santhosshi Narayanan, M.B.B.S. Assistant Professor

Keping Xie, M.D., Ph.D. Professor

Khanh Nguyen, M.D. Associate Professor

General Internal Medicine

Jean Tayar, M.D. Associate Professor

Infectious Diseases, Infection Control and Employee Health

Jeong Oh, M.D. Associate Professor Edwin Ostrin, M.D., Ph.D. Assistant Professor Linda Pang, M.D. Assistant Professor David Rubio, M.D. Assistant Professor Sunil Sahai, M.D. Professor

Carmen Escalante, M.D. Chair

Jaya Amaram-Davila, M.D. Assistant Professor Etsuko Aoki, M.D., Ph.D. Assistant Professor Norman Brito-Dellan, M.D. Assistant Professor

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Kathleen Smalky, M.D. Associate Professor Jean Tayar, M.D. Associate Professor Khanh Vu, M.D. Associate Professor

Section of Rheumatology

Issam Raad, M.D. Chair

Gerald P. Bodey, Sr. Distinguished Professorship in Infectious Disease Javier Adachi, M.D. Professor Ella Ariza Heredia, M.D. Assistant Professor Uddalak Bharadwaj, Ph.D. Assistant Professor Anne-Marie Chaftari, M.D. Assistant Professor

Maria-Claudia Campagna, M.D. Associate Professor

Roy Chemaly, M.D. Professor

Kodwo Dickson, M.D. Assistant Professor

Natalie Dailey Garnes, M.D. Assistant Professor

Beatrice Edwards, M.D. Associate Professor

Elizabeth Frenzel, M.D. Professor

Ruth Falik, M.D. Associate Professor

Maria Suarez-Almazor, M.D., Ph.D.

Bruno Granwehr, M.D. Associate Professor

Shu-Wei Gao, M.D. Associate Professor

Section Chief Professor

Ray Hachem, M.D. Professor

Marina George, M.D. Associate Professor

Barnts Family Distinguished Professorship in Cancer Research

Moses Kasembeli, Ph.D. Assistant Professor

Josiah Halm, M.D. Associate Professor

Sang Kim, M.D., Ph.D. Instructor

Dimitrios Kontoyiannis, M.D. Professor

Texas 4000 Distinguished Endowed Professor for Cancer Research

Roberto Gonzalez, M.D. Assistant Professor

Saadia Faiz, M.D. Associate Professor

Victor Mulanovich, M.D. Professor

Jerry Ignatius, D.O. Assistant Professor

Horiana Grosu, M.D. Assistant Professor

Pablo Okhuysen, M.D. Professor

Sawsan Khan, M.D. Assistant Professor

Qianghua Hu, Ph.D. Instructor

Prema Robinson, Ph.D. Associate Professor

Rachel Lynn, M.D. Assistant Professor

Carlos Jimenez, M.D. Professor

Samuel Shelburne, M.D., Ph.D. Associate Professor

Anis Rashid, M.D. Clinical Associate Professor

Seyed Moghaddam, M.D. Assistant Professor

Ariel Szvalb, M.D. Assistant Professor

Daniel Tran, M.D. Clinical Specialist

David Ost, M.D. Professor

Mahnaz Taremi, M.D. Assistant Professor Georgia Thomas, M.D. Professor

Pulmonary Medicine

Harrys Torres, M.D. Associate Professor

George Viola, M.D. Associate Professor

Psychiatry

Ajay Sheshadri, M.D. Assistant Professor Michael Tuvim, M.D. Professor

David Tweardy, M.D. Professor Dallas/Fort Worth Living Legend Chair for Cancer Research III

Vickie Shannon, M.D. Professor

Burton Dickey, M.D.

Section of Benign Hematology

Chair

Clifton D. Howe Distinguished Professorship in Pulmonary Medicine Roberto Adachi, M.D. Associate Professor Diwakar Balachandran, M.D. Associate Professor Lara Bashoura, M.D. Associate Professor

Michael Kroll, M.D.

Section Chief of Nephrology and Professor

Roberto Casal, M.D. Associate Professor

Shuju Feng, Ph.D. Assistant Professor

Alan Valentine, M.D.

Jichao Chen, Ph.D. Assistant Professor

Vahid Afshar-Kharghan, M.D. Professor

Professor

Min Soon Cho, Ph.D. Assistant Professor

Thein Oo, M.D. Professor

George Eapen, M.D. Professor

Cristhiam Rojas Hernandez, M.D. Assistant Professor

Chair

Deepti Chopra, M.B.B.S. Assistant Professor Richard De La Garza II, Ph.D. Professor

Scott Evans, M.D. Associate Professor

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Symptom Research

Administration

Crystal Swalwell

Internal Medicine Center – Main and Mays Margaret Bell, D.N.P.

Psychiatric Oncology Center

Division Administration Resources Annemieke Kavelaars, Ph.D. Chair Ad Interim

William Atkinson IV Division Administrator

Professor Charles Cleeland, Ph.D. Professor McCullough Professorship for Cancer Research Robert Dantzer, D.V.M, Ph.D. Professor Goldy George, Ph.D. Instructor Cobi Heijnen, Ph.D. Professor Geoffroy Laumet, Ph.D. Instructor Tito Mendoza, Ph.D. Associate Professor Qiuling Shi, Ph.D. Assistant Professor Elisabeth Vichaya, Ph.D. Instructor Xin Shelley Wang, M.D. Professor Loretta Williams, Ph.D. Assistant Professor

Department Administrators Christine Reid Cardiology Debbie Chow Dermatology Denise Langabeer Emergency Medicine Carol Atwood Endocrine Neoplasia and Hormonal Disorders Felecia Hancock Gastroenterology, Hepatology and Nutrition Cheryl Faust General Internal Medicine Rachelle Mainard, J.D. Infectious Diseases, Infection Control and Employee Health Margaret Bell, D.N.P Psychiatry Denise Holcomb Pulmonary Medicine Damian Walsh Symptom Research

Clinical Administrator Directors Shu Ha Oberhelman Ad Interim Cardiopulmonary Center Crystal Swalwell Endocrine Center Marvetta Walker Endoscopy Center

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Erica Martinez Director, Internal Medicine Administration Betty Redd Senior Financial Analyst Kenny Lee Senior Financial Analyst Kate Lakhani Project Director, Office of the Division Head Penny Benzman Executive Assistant to David J. Tweardy, M.D. Cara McCutcheon Administrative Assistant to Dimitrios Kontoyiannis, M.D., Sc.D. and Ellen Manzullo, M.D. Charity Sembera Program Coordinator, Baylor College of Medicine/MD Anderson Internal Medicine Residency Program Sofia Wied Director, Division Research Development Roberto Reyes Manager, Information Services James Bramhall System Analyst II Susie Liu Data Base Coordinator Juniour Mbithi System Analyst II Khanh Nguyen System Analyst II Judy Overton Program Manager

DIVISION OF INTERNAL MEDICINE 1515 Holcombe Blvd.

Unit 1463 Houston, TX 77030 mdanderson.org/internal-medicine WRITER/EDITOR Judy Overton DESIGNER Jenny McGee PHOTOGRAPHY Creative Services Department The University of Texas MD Anderson Cancer Center, Judy Overton and featured patients

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Division of Internal Medicine 1515 Holcombe Blvd.

Unit 1463 Houston, TX 77030 mdanderson.org/internal-medicine