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 Di s c ove ry w ith H um anis m in Me dicine
Vol. 8 Issue 1 Jan 2019
Physical Activity and Weakness Score (PAWS) and Assessment of Muscle Weakness in Hospitalized Patients Experienced clinicians commonly observe that patients admitted to the hospital develop muscle weakness, and such patients are more prone to falls and injury. Muscle weakness also limits exercise ability, leads to frequent readmission to the hospital, and predisposes patients to other adverse clinical outcomes. Simplified assessment tools are needed to identify and track muscle weakness. For that reason, Drs. Rajiv Dhand and Jeffrey Hecht, along with third-year resident Asha Pathak and statistician Eric Heidel, developed a questionnaire in 2015 to assess major content areas related to muscle weakness. The Physical Activity and Weakness Score, or PAWS, is a self-reported questionnaire to screen and track patients’ level of weakness before, during, and after inpatient hospitalizations. Questions assess patients’ perception of their fitness in five areas: physical activity, shortness of breath, functional capacity, muscle strength, and fatigability. Each question has a total score value of 1-5 with a total questionnaire score ranging from 5-25. A score of 15-25 indicates the highest amount of possible weakness, 6-14 indicates some weakness, and a score of 5 indicates no weakness. In patients who were admitted to the hospital for more than 3 days and had no known reasons to have reduced muscle strength, PAWS was able to detect muscle weakness in approximately 40% of patients. This study included objective assessments of muscle strength and assessments of endurance. In 2018, clinical trials coordinator Jennifer Ferris and pulmonary fellows Drs. Bimaje Akpa and Swati Baveja noticed a close agreement between PAWS results and objective assessments of muscle strength and endurance. PAWS is able to use patients’ perception of their own fitness to capture a realistic picture of their muscle strength and physical ability. Dr. Hecht notes that the PAWS is faster and easier to administer
Jennifer Ferris and Dr. Bimaje Akpa measure a patient’s hand grip as one test to assess muscle strength.
than the FIM (Functional Independence Measure), which is widely used in rehabilitation medicine. Since participation in rehabilitation after hospitalization is extremely important for good long-term results, PAWS may be able to help guide treatment and predict health outcomes even in patients who are in rehabilitation facilities after discharge from the hospital. “While the PAWS won’t replace the other tests, these data remind us that we should listen to patients,” observed Dr. Hecht. “Often they can reliably tell us how they are doing.”
Points of View
functions and operations of Institutional Review Boards (IRBs), rules for obtaining informed consent from human subjects, and protections for vulnerable research subjects such as children, pregnant women, and prisoners. In 2017, these regulations were revised to meet the changing and growing demands of human research. After several delays, the date of implementation of these regulations (called the “Revised Common Rule”) has been set for January 21, 2019. The Revised Common Rule seeks to further enhance the protections for research participants, facilitate research that carries minimal risk, and reduce regulatory burdens for low-risk studies. It also addresses evolving research areas (such as collection of biospecimens for research) and further harmonizes research policies across several federal departments and agencies. After the Revised Common Rule goes into effect, all new studies submitted to the IRB must meet the new requirements. According to the policy of the UT Health Science Center, studies approved by the IRB before January 21, 2019 will continue continued on page 2
The Belmont Report by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research* declared human research should be governed by the ethical principles of respect for persons, beneficence, and justice. Based on this report, the first regulations protecting human subjects in research studies were issued in 1981. In 1991, these Rajiv Dhand, MD, Chair regulations were adopted by several federal departments and agencies and came to be called the “Common Rule.” These guidelines incorporated standards for obtaining informed consent, performing systematic assessments of risks and benefits, and appropriately selecting subjects for research. The Common Rule formed the regulatory framework for assuring compliance by research institutions. It provided guidance for the 1
“A True UTMC Effort” Twenty years of dedicated research on systemic amyloid is coming to a juncture where “we can make a difference for the patients,” said Dr. Jonathan Wall, head of the University of Tennessee Amyloidosis and Cancer Theranostics Program. Dr. Wall’s research team, consisting of eight world-renowned researchers and collaborating with Dr. Ronald Lands, Dr. Eric Heidel, and members of the UT chemistry department, published their newest breakthrough, a peptope to treat amyloidosis, in the Proceedings of the National Academy of the Sciences of the United States of America in October 2018. Amyloidosis is a rare and devastating disease characterized by pathologic protein deposition throughout the body, resulting in organ dysfunction. In the late 1990s, the amyloid research group at UTMC developed an antibody, 11-1F4, that binds to light chain amyloid (AL) and facilitates removal of deposits. This antibody is currently being studied in a Phase I clinical trial at Columbia University. However, Dr. Wall and his team have continued to pursue new approaches. In recent years, they have developed a peptide-conjugated epitope or “peptope,” which binds to many forms of amyloid, including AL. The team designed the peptope to have a binding site unique to their 11-1F4 antibody. In a mouse model, they were able to remove amyloid deposits with their antibody more effectively following peptope pre-treatment. This technology has been patented with hopes that industrial support will help move peptope-assisted immunotherapy into the clinic, as the researchers believe that this approach can enhance the benefit of therapeutic antibodies such as 11-1F4. The peptide used to develop this technology has also brought a Phase I clinical trial here to UTMC. To date, there is no FDA-approved agent for imaging systemic amyloid in patients. After years of support from the NIH and the NHLBI, the group has obtained FDA approval to test a peptide designated p5+14 as a new amyloid imaging agent. Using p5+14 they were able to image systemic amyloid deposits in animal models using small animal PET/CT and SPECT/CT imaging. Dr. Wall hopes to enroll 43 patients in the initial study of safety and efficacy. Participants will receive an injection of the study drug and then undergo two whole-body PET/CT imaging sessions to establish efficacy of the imaging peptide. The trial is entirely supported by the Department of Medicine and donations to a gift fund. Moreover, the support of Dr. John Bell, director of the Cancer Institute; the involvement of Dr. Yitong Fu, Bryan Whittle, and Robin Geldrich of Nuclear Medicine; and the involvement of Dr. Timothy Panella, Dr. Ronald Lands, and Barbara Marine of University Oncology make the trial “a true UTMC effort.” Dr. Wall’s dream of developing novel and effective diagnostic and therapeutic agents to benefit patients with amyloidosis is one step closer to fruition.
The Resident Research Committee One of the Department of Medicine’s goals is to increase participation in research by internal medicine residents. While some residents have past research experience, many do not have that experience or know where to begin. In the fall of 2017, Dr. Dhand formed the Resident Research Committee, co-chaired by Dr. Emily Martin and Dr. Mark Rasnake. Other members of the committee include one resident, Dr. Blair Reynolds; one fellow, Dr. Jaime Holbert; Dr. Daphne Norwood; Dr. Paul Terry; Kristi Gregg; and Sissy Ensor. In addition to clinical content review, Dr. Martin and Dr. Terry offer much expertise from their own years of research and writing manuscripts. Residents can send their abstracts, posters, and manuscripts to the committee, who will blindly review each submission and offer valuable input. Dr. Martin hopes “to be there to guide residents through the process and foster collaboration for more research.” Interested residents can submit their work to Kristi Gregg, who will distribute it to the committee for review.
Resident Spotlight – Jason Frisbee Jason Frisbee, DO, PharmD, took home first place prize in last June’s Department of Medicine Research Awards for his work in antibiotic stewardship in heart failure exacerbations. Jason retrospectively analyzed patients admitted with a primary diagnosis of heart failure exacerbation to see whether or not antibiotic administration affected length of stay and readmission rates. He found that in patients with an admitting diagnosis of heart failure exacerbation without objective evidence of infection, the administration of antibiotics (particularly parenteral antibiotics) led to longer lengths of stay as well as higher readmission rates. He recently presented his research to Infectious Diseases Week in San Francisco. Jason hopes his research will help guide antibiotic stewardship for internists in the future. He plans to pursue a fellowship in pulmonary/critical care medicine after completing residency. He would like to thank Dr. Eric Heidel and Dr. Mark Rasnake for their assistance in his project.
Points of View
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under the previous Common Rule and will not need to update to the new informed consent template. If such studies were exempt, then there will be no change in the category under which the study was approved. I encourage all investigators at UTMC to familiarize themselves with the changes in the Revised Common Rule so that they are in compliance with the new regulations. *Full text of the Belmont Report: https://www.hhs.gov/ohrp/sites/default/files/the-belmont-report-508c_FINAL.pdf 2
Faculty and Staff Awards and Honors
Susan Burchfield
Dr. W. Corbet Curfman
Dr. Tina Dudney
Dr. Crystal Gue
Dr. Judith Kinzy
Dr. Mark Rasnake
Dr. Francisco Soto
Dr. Juli Williams
Several faculty and staff awards were presented at this year’s Annual Faculty Recognition Dinner held on Wednesday, December 12th 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 Dr. Mark Rasnake. • The R.A. Obenour, MD, Distinguished Alumnus Award in Recognition of Outstanding Career Achievement in the Field of Medicine was presented to Dr. Tina Dudney. • Dr. Dudney’s father, Dr. Elijah Dudney, was also recently named an Outstanding Alumnus of the College of Medicine. • Dr. Juli Williams received the R.A. Obenour, Jr., Excellence in Teaching Award for steadfast dedication and excellence in teaching. • Dr. Francisco Soto 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. W. Corbet Curfman received a 40-Year Service Award. • Dr. Crystal Gue, Dr. Judith Kinzy, and Dr. Tom Doty received their 25-year service awards. • Susan Burchfield received the Outstanding Service Award for her extraordinary dedication and service to the Department of Medicine. All of these award recipients have provided superb service to the Department of Medicine. We are delighted to recognize them for their many contributions.
New Faculty We are delighted to welcome Dr. Elizabeth Ergen as an Assistant Professor in the Division of Dermatology. Dr. Ergen graduated with her Bachelor of Science from Brown University in Providence, Rhode Island. She received her Doctor of Medicine from the University of Tennessee College of Medicine in Memphis, Tennessee. She also completed an internal medicine residency and a dermatology residency from Vanderbilt University Medical Center in Nashville, Tennessee. She joined Dermatology Associates of Knoxville in November 2018.
We are excited to welcome Dr. Jason Green as a Clinical Assistant Professor in the Division of Pulmonary and Critical Care Medicine. Dr. Green received his Bachelor of Business Administration and his Bachelor of Science in Biology from East Tennessee State University in Johnson City, Tennessee. He received his Doctor of Medicine from Edward Via Virginia College of Osteopathic Medicine in Blacksburg, Virginia. He completed an internal medicine residency and a pulmonary and critical care medicine fellowship at East Tennessee State University in Johnson City, Tennessee. He joined University Pulmonary and Critical Care in July 2018.
We are eager to welcome Dr. Paul Hauptman as a Professor in the Division of Cardiology. Dr. Hauptman graduated with his Bachelor of Arts from Columbia University in New York, New York. He received his Doctor of Medicine from Cornell University Medical College in New York, New York. He completed an internal medicine residency at Brigham and Women’s Hospital in Boston, Massachusetts. Dr. Hauptman was a Clinical Fellow in Medicine at Harvard Medical School, a Clinical Fellow in Cardiology at Mount Sinai Hospital and a Research/Clinical Fellow in Medicine, Cardiovascular Division at Brigham and Women’s Hospital and a Research Fellow in Medicine at Harvard Medical School. He was named Dean of the Graduate School of Medicine in October of 2018.
CME Opportunities—Mark Your Calendars! • Cardiology Conferences, held weekly on Wednesdays for .75 hour CME credit. • Medicine Grand Rounds, held on the 2nd and 4th Tuesdays of each month for 1.00 hour CME credit. • Ethics Case Rounds, held on the 4th Thursday of the month at noon in Wood Auditorium, are available for 1.00 hour CME credit. 3
Ethics Case Rounds - Autonomy, Health, and Financial Capacity Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality. “Tom” was a 68-year-old gentleman admitted for COPD exacerbation. He had multiple admissions and ED visits over the last three years. His medical problems included COPD, CHF, CAD, atrial fibrillation, extreme obesity, cellulitis, obstructive sleep apnea, arthritis, and schizophrenia. For 30 years, he had been essentially homeless. Sometimes he lived in a vehicle, sometimes in a hotel or shelter, but often simply on the streets. Tom had been discharged to assisted living facilities before, but was not welcome back at most of them due to noncompliance and nonpayment. He stated he did not take his medications because he couldn’t afford them, though EMR noted that he refused assistance to get his prescriptions filled and bought snacks and ordered takeout food into his room frequently. He stated he had no family or close friends. He could not explain his medical problems, the effect his medications were intended to have, or what happened when he did not take them. He did say he had trouble breathing and walking, and that he felt “bad” most of the time. He said life on the streets had been hard, and he would like to live in a facility long-term “until I die.” Fortunately, he had insurance and received an SSI check. We talked with Tom about getting a representative payee so he can get into a facility. He was not interested, saying he could manage his finances: “It’s just that they just charge too much for rent. I want to be in charge of my money and my life.” Legally competent beneficiaries of public funds are presumed to be capable of managing their money independently unless evidence is available to the contrary. Limiting a person’s financial self-determination is a substantial intrusion on autonomy, and should not be considered without good reason. At the same time, poor management of funds can lead to homelessness, non-compliance, vulnerability to financial exploitation, and other threats to health and well-being. Therefore, the Social Security Administration relies on mental health and other professionals to assess beneficiaries’ capability to manage their money. Screening questions for inability to manage funds include whether the person: • routinely makes purchases that interfere with the ability to meet the need for food, clothing, medical care, or shelter • is worse-off when s/he receives the assistance check • does not appear to understand the consequences of his/her financial decisions • fails to pay bills, resulting in conflict with significant others, legal problems, or eviction Beneficiaries who have been determined by the Social Security Administration to be incapable of managing their own money are assigned a representative payee, which may be a family member, friend, lawyer, or organization. We submitted a letter for review for a payee, outlining Tom’s medical and mental health issues along with his goals and preferences. Over the next several months, Tom was readmitted once or twice a month, each time with few options for discharge. Ultimately Tom was assigned a payee and discharged to an assisted living facility, where he remained until his death. Comments on this case may be sent to amendola@utmck.edu. References Appelbaum PS, Birkenmaier J, Norman M. Improving social security’s financial capability assessments. Psychiatr Serv 2016;67(7): 704-706. Black AC, McMahon TJ, Rosenheck RA et al. Development of the clinician assessment of financial incapability (CAFI). Psychiatry Res 2014;215(3): 784-789.
In Touch Vol. 8, Issue 1: January 2019
Publisher 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 Kimberly Givens David Wilson, DO Elana Smith Sister Teresa Mary Kozlovski, MD 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
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.
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