D epartment
of
M edicine
Con ne c ti ng T e c h n o lo g y , Ed uca t i o n a n d D i s cove ry w ith H um anis m in Me dicine
Vol. 6, Issue 1: Jan. 2017
Amyloidosis Research
connections with clinical staff in the Medical Center and undergraduates who come from UTK to work with them. Their amyloid research investigates agents that have diagnostic and therapeutic potential as well as those that serve both functions (“theranostics”). Their findings have had implications for diagnosis and treating amyloid-related disorders such as light chain (AL) amyloidosis, type 2 diabetes, and potentially, Alzheimer’s disease. Success breeds success; the team’s gains in knowledge have led to successful bids for funding additional research. In 2008, the team received a $1.5 million NIH grant to develop an imaging agent to detect systemic amyloid deposits in amyloidosis patients. The grant was renewed in 2012 to the tune of $1.3 million. The proposal for re-renewal, submitted this year, scored very well; the team is hopeful the grant will be renewed again. In addition to this NIH grant, the team is expected to obtain a second NIH-funded award. The Amyloidosis Foundation continued on page 2 recently awarded Dr. Emily Martin,
Academic medical centers play a major role in medical education and patient care. They also have a unique contribution to make in research. Poised at the intersection of basic science and bedside care, “translational medicine” is especially important when it comes to rare diseases. Rare conditions are often under-studied by industry because they are usually not profitable to treat. The people affected by rare diseases often suffer more than those with common disorders because their condition often takes years to diagnose correctly, and they have fewer resources to effectively manage their disease. In many ways, UT Medical Center is the perfect setting to study amyloidosis, a serious, uncommon group of diseases in which amyloid proteins form deposits in the tissues and interfere with organ function. Dr. Alan Solomon began work on this disease here in the mid-1960s. Today, the UT Amyloidosis and Cancer Theranostics Program (ACTP) boasts eight worldrenowned researchers with more than 100 years of experience in amyloid research between them. The team also has strong
Points of View
Rajiv Dhand, MD, Chair
in these years. The quarterly In Touch Newsletter was started in July 2012 as a means of disseminating information and also to share the humanistic aspects of the department. On the educational front, we expanded the number of categorical residents from 9 to 12 each year, started fellowships in critical care and interventional cardiology, and clerkships in neurology, psychiatry and pediatrics. A new conference room, enhanced simulation center training, dedicated lectures, use of electronic educational resources, and electronic medical records have provided greater opportunities for our learners and helped us to stay in good standing with the ACGME. The house staff teams have been restructured to ensure long-term sustainability and the schedule revised continued on page 4
In the midst of the holidays, it is natural to reflect on the activities and achievements of the past year(s). Unbelievably, it is now 5 years since I had the privilege of becoming chairman of the department. Let me take this opportunity to share with you, especially the residents, fellows, faculty and staff who have recently joined the department, and alumni some of the signature developments 1
Central Line Tamper Device Discharging a patient with a central venous line with ongoing or history of intravenous (IV) drug abuse presents a potentially high risk situation for intentional misuse of lines. However, the risk of line manipulation does not begin at discharge. Drs. Mark Rasnake and Brandon Sammons (third year resident) noticed a trend in the types of Central LineAssociated Bloodstream Infections (CLABSI) in patients suspected of manipulating central lines and self-injecting during inpatient stays. Central lines pose a risk of infection to anyone who has one inserted, but Drs. Rasnake and Sammons noticed a difference in the types of organisms isolated. In the group not suspected of IV drug abuse (IVDA), blood cultures grew the typical organisms. In the group suspected of IVDA, blood cultures grew atypical organisms, particularly yeast. Patients with suspected IVDA had a 12-fold higher risk of developing CLABSI compared to those with no suspicion of IVDA. Unfortunately, a direct link is difficult to prove as no one was directly observed tampering with the IV lines. Self-injection is nearly impossible to prevent, and no commercial device currently exists to prevent central line tampering. This discovery prompted Dr. Rasnake to work with the University of Tennessee College of Engineering to develop a device to “lock” on to central lines. Once basic functionality has been assessed, a future clinical trial in a larger population will be conducted to assess the functionality of this device in detecting unauthorized access or tampering with several types of central venous lines.
Evidence-Based Eating The World Health Organization (WHO) first highlighted the obesity epidemic in 1997 yet it continues to affect over one third of U.S. adults. Obesity added an additional cost of $147 billion to the medical field in 2008 alone.1 Sadly, obesity is a preventable disease. Our second year Internal Medicine resident, Dr. Matthew Boulos, is passionate about nutrition and obesity. During exercise physiology, he noticed nearly 8 times the amount of energy is generated by the catabolism of one molecule of a fatty acid compared to one molecule of glucose. This observation inspired him to conduct further research, “The body prefers to use fatty acids for energy as it is more efficient. I want to challenge the current dietary guidelines, as they are not derived from an evidence-based approach and even have detrimental implications with regards to common disease processes such as obesity, diabetes, and heart disease.” Dr. Boulos investigated the effects of dietary composition on pancreatic islet cell destruction. He separated mice into two groups. One received a Western diet, the other a control diet over a course of 12 weeks. Diets were provided ad libitum. Blood glucose levels and amount of food consumed were monitored. Blood glucose levels and the amount of food consumed between Matthew Boulos, DO the two groups did not differ. However, the mice that were fed the Western diet consumed more calories and gained more weight. Dr. Boulos postulates there are changes in gene expression that occur while consuming a Western diet. Further investigation into pancreatic gene expression and differences in inflammatory markers is ongoing. Dr. Boulos’ response to the obesity epidemic? “Educate patients and practitioners alike to reduce carbohydrate consumption, allow fat consumption, and reassure them that it is based on scientific evidence.” Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Milwood). 2009 Sep-Oct;28(5):w822-31.doi: 10.1377/hlthaff.28.5.w822.
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Amyloidosis Research
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Assistant Professor in the Department of Medicine, a $50,000 grant to continue work on a diagnostic assay for identifying patients with multiple myeloma who are at risk for also developing amyloidosis, before amyloid-related organ failure occurs. The experience of living with a rare, devastating illness can make patients feel isolated, explains Dr. Jonathan Wall, Program Director and Professor of Medicine. To address this issue, a support group for amyloidosis patients and their families was developed through the joint efforts between Charlotte Heffner of the Amyloidosis Foundation, the ACTP, and Cancer Institute leaders Renee Hawk, VP of the Cancer Institute, and Dr. John Bell, Director of the Cancer Institute. The group includes patients, their families, and the amyloid research team. During meetings, speakers provide updates on clinical developments and promising research, and patients talk about their experiences with amyloidosis. Everyone benefits from getting together. “I think it’s hopeful for patients to hear what progress is being made, and it definitely helps us to hear about their experiences of living with these diseases,” said Dr. Wall. “Not only does it help us understand the disease, but it’s a real motivator to see the people affected by it. Ultimately, they are why we do what we do.” 2
Faculty and Resident Awards and Honors Dr. Daphne Norwood was presented with the Laureate Award by the Tennessee Chapter of the American College of Physicians during the annual scientific meeting held in Nashville. The Laureate Award honors senior physicians and fellows of long-standing service to the Chapter. The recipient is selected through a nomination process. Awardees demonstrate a commitment to excellence in medical care, education, or research, and in service to their community, their Chapter, and the American College of Physicians. We are delighted Dr. Norwood has been recognized with this prestigious award. Dr. Christopher Waggoner was presented with the Good Catch Award by the University of Tennessee Medical Center for September 2016. This award is given to a team member who identifies and properly reports a patient safety issue and improves care at the hospital. This recognition is part of the hospital’s ongoing efforts to enhance their patient safety culture.
Several faculty awards were presented at this year’s Annual Faculty Recognition Dinner held on Tuesday, December 6th at the Holiday Inn World’s Fair site.
• The Beasley Pylon Award for extraordinary leadership and service to the Department of Medicine was presented to Timothy J. Panella, MD.
• The RA Obenour, MD, Distinguished Alumnus Award in Recognition of Outstanding Career Achievement in the Field of Medicine was presented to Alfred Beasley, MD.
• William M. Law, Jr, MD, received the RA Obenour, Jr., Excellence in Teaching Award for steadfast dedication and excellence in teaching.
• Drs. Ross Nesbit (not pictured) and Bret Rogers received the London Award, which is presented to a teacher who exhibits a dedication to excellence. The recipients of this award are chosen by our residents.
• Dr. Paul Serrell received a 40-Year Service Award.
• 25-Year Service Awards were presented to Ilse Anderson, MD, (left); Inga Himelright, MD, (center); Janet Purkey, MD, (right), James Cox, MD, (not pictured), and John Stancher, MD (not pictured).
All of these award recipients have provided superb and longstanding service to the Department of Medicine. We are delighted to recognize them for their many contributions. 3
New Faculty It is with pleasure that we announce four new faculty appointments to the Department of Medicine: Lawrence Smith, DO, William P. Powers, MD, Arseniy Tsapenko, DO, and Jeffrey Bieber, MD. Dr. William Powers and Dr. Arseniy Tsapenko practice with University Pulmonary and Critical Care and will be working with our pulmonary and critical care fellowship. Dr. Powers completed his internal medicine residency and a fellowship in pulmonary and critical care medicine at the University of Tennessee Health Science Center, Memphis, TN. Dr. Tsapenko completed an internal medicine residency at Kyiv University Hospital #12 and an internal medicine residency at Albert Einstein College of Medicine at Beth Israel Medical Center. He also completed a critical care fellowship at Brown University, a pulmonary medicine fellowship at UT Medical Center and a sleep medicine fellowship at Dartmouth-Hitchcock Medical Center. Dr. Lawrence (Larry) Smith practices with UT Hospitalists and will work with the residents on our new Hospitalists Team. He completed his residency in internal medicine and a pulmonary critical care fellowship at Genesys Regional Medical Center, Lansing, MI. Dr. Smith is assistant medical director for UT Hospitalists and plays an active role in process improvement for the hospitalist program. Dr. Jeffrey Bieber joined our faculty in early January. He practices with University Rheumatology. Dr. Bieber completed medical school and internal medicine residency at East Tennessee State University James H. Quillen College of Medicine where he was presented the James Thompson Memorial Award. He completed his fellowship in rheymatology at the University of California San Diego.
CME Opportunities—Mark Your Calendars!
• Weekly Cardiology Conferences, generally held on Wednesdays each week for .75 hour CME credit. • Medicine Grand Rounds, which are generally held on the 2nd and 4th Tuesdays of each month for 1.00 hour CME credit. • Ethics Case Rounds, which are held on the 4th Thursday of the month at noon in Wood Auditorium, are available for 1.00 hour CME credit.
Annual Medicine Conference
• The 5th Annual Medicine CME Conference, Current Practices for Primary Care and Updates for Clinicians, offering 10.25 hours of CME credit, will be held March 24-25, 2017, at the Holiday Inn World’s Fair Site. We hope you can join us for this informative event.
Register Now
Points of View
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to provide more dedicated time for ambulatory training. The MICU experience has been streamlined and several new clinical programs have been added, including the REACT clinic. Faculty have been hired in neurology, cardiology, pulmonary disease, infectious disease, rheumatology, dermatology, hematology/oncology, and experimental medicine and new staff recruited to support the expansion of these services. The number of Grand Rounds and other activities providing CME credits increased several fold, and we are preparing to host the fifth annual CME conference of the department, Current Practices for Primary Care and Updates for Clinicians. We have also achieved notable successes in the research arena, especially in experimental research and achieved grant funding by NIH, foundations, pharmaceutical companies, and other sources. The number of presentations and publications continues to increase each year. Our board pass rates for our internal medicine residency program are among the highest in Tennessee and some of our divisions, notably the pulmonary and critical care medicine division, have consistently achieved national recognition. I am truly humbled to be a part of the incredible, dedicated team work that has led to the impressive progress in our vibrant department. I wish you all the best for the coming year. 4
Ethics Case Rounds
In Touch
Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.
“A Family’s Request to Turn Off a Pacemaker” Betty was an 85 year-old lady who was admitted having sustained an extensive head bleed after a fall at home. Her prognosis was expected to be poor. Her family was at bedside over the next week as her condition continued to deteriorate. They all agreed she would not want her life prolonged in this situation and opted for comfort measures at that time. Though sad, they were at peace with their decision. During the discussion with Palliative Care, Betty’s daughter asked about having her pacemaker turned off. Cardiology was consulted to address their request. Dr. Steve Dolacky, then a fellow in the Cardiology program, explained their mother’s heart would stop when the effects of the brain bleed ran the natural course since her device had no defibrillator. The family said they understood, but they thought their mother would not want her dying process prolonged by the pacemaker, particularly as the vigil was taking a toll on their father, who had dementia and whose health was fragile. “We know she is not suffering, but he is,” her daughter explained, “and she wouldn’t want him to have to go through this.” Dr. Dolacky believed the family’s request was sincere, but he was not comfortable with it. Betty was pacer-dependent; if the pacemaker were deactivated, she could die immediately. Moreover, none of the cardiologists felt comfortable deactivating a pacemaker in a patient they did not know. An ethics consult was placed to help the team and the family develop a plan. In 2010 the Heart Rhythm Society issued a consensus statement on pacemaker de-activation. This statement contains three important points: 1. Informed patients with decision-making capacity or their surrogates acting according to the patient’s wishes have the ethical and legal right to refuse -- or request withdrawal of – any treatment or intervention, including the disabling of Cardiac Implantable Electronic Devices (CIEDs), 2. Cardiologists may not be compelled to deactivate a CIED if it conflicts with their own ethical commitments, and 3. Physicians have a duty not to “abandon” patients who are asking for something that is within the scope of ethical practice they are morally uncomfortable providing. Essentially, both the family’s request and the cardiologists’ moral commitments must be respected. After additional discussion, Betty’s family opted not to pursue deactivation of her pacemaker, as she was rapidly approaching end of life. She died peacefully a few days later. They told the team they were grateful to them for taking their request seriously. The case highlighted the need for a process to address requests like this, as well as Advance Care Plans that specifically address pacemakers. Dr. Jeremy Mahlow, Clinical Assistant Professor of Cardiology, and Dr. David Perkel, Cardiology Fellow, have begun work with the Ethics Committee to work on these issues. The Ethics Consult Service is available for help with ethically difficult situations. Any team member can request a consult by paging 1198. Comments on this case may be sent to amendola@utmck.edu. References • Bevins M. “The Ethics of Pacemaker Deactivation in Terminally Ill Patients” Journal of Pain and Symptom Management vol. 41 no. 6 June 2011 1106-1110 • Kramer DB, Mitchell SL, and Brock DW. “Deactivation of Pacemakers and Implantable Cardioverter Defibrillators” Progress in Cardiovascular Diseases 55 (3) 2012 290–299 • Lampert R, et al. “HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing the end of life or requesting the withdrawal of therapy” Heart Rhythm vol. 7 no. 7 July 2010 1008-1026
Presentations, Publications, Awards Department of Medicine faculty, residents, and fellows share their knowledge and experience by publishing and presenting across the world. For a list of our most recent accomplishments, visit http://gsm.utmck.edu/internalmed/scholars.cfm.
Thank You For Your Support For information about philanthropic giving to the UT Graduate School of Medicine, Department of Medicine, please contact the Development Office at 865-305-6611 or development@utmck.edu. If you would like more information about any of the topics in this issue of In Touch, please contact the Department of Medicine at 865-305-9340 or visit http://gsm.utmck.edu/internalmed/main.cfm. We look forward to your input. Thank you.
Stay In Touch! Alumni, please update your contact information by completing the simple form at http://gsm.utmck.edu/internalmed/alumni.cfm or by calling the Department of Medicine at 865-305-9340. Thank you! 5
Vol. 6, Issue 1: January 2017
Publishers James Neutens, PhD, Dean Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs Editor Annette Mendola, PhD Administrative Director Susan Burchfield, CAP-OM Contributors Susan Burchfield Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Azaria Ehlers, MD Kimberly Givens Design J Squared Graphics In Touch is produced by the University of Tennessee Graduate School of Medicine, Department of Medicine. The mission of the newsletter is to build pride in the Department of Medicine by communicating the accessible, collaborative and human aspects of the department while highlighting pertinent achievements and activities. Contact Us In Touch University of Tennessee Graduate School of Medicine Department of Medicine 1924 Alcoa Highway, U-114 Knoxville, TN 37920 Telephone: 865-305-9340 E-mail: InTouchNewsletter@utmck.edu Web: http://gsm.utmck. edu/internalmed/main.cfm The University of Tennessee is an EEO/AA/Title VI/ Title IX/Section 504/ADA/ ADEA institution in the provision of its education and employment programs and services.