InTouch Newsletter - January 2020

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. 9 Issue 1 Jan. 2020

The Growth of a Division: Infectious Diseases The Division of Infectious Diseases at University of Tennessee Medical Center has seen tremendous growth over the last few years. In 2016, Dr. Mahmoud Shorman joined the University Infectious Diseases physicians group, and in 2019 he was promoted to Division Chief of Infectious Diseases for the UT Graduate School of Medicine. Since then Dr. Shorman has had a clear vision for transforming the infectious disease rotation, creating opportunities for residents and students to get involved in research in addition to learning about common clinical infections and their management. This has created great resident interest, with Dr. Henry Shiflett (class of 2019) having gone on to an infectious disease fellowship and several current residents considering pursuing an ID fellowship. Dr. Shorman has mentored several residents through writing journal articles and presenting at local and national meetings. He also coauthored an upcoming publication with Dr. Clayton Humphrey (class of 2019) on ototoxicity and the use of vancomycin.

“There are currently eight resident projects ongoing, including research projects and quality improvement projects [in infectious disease], with a strong focus on poster presentations and publications,” Dr. Shorman says. The current areas of interest include antibiotic stewardship and infections related to intravenous drug use. For example, because bone cultures are often non-diagnostic due to patients having received antibiotics prior to the culture, one study examines cases of vertebral osteomyelitis and use of a polymerase chain reaction to identify pathogen DNA rather than relying on cultures alone. This will hopefully lead to more targeted antibiotic therapy.

As a faculty mentor, Dr. Shorman feels he is “bridging a gap” between infectious disease and other subspecialties of medicine. For example, Dr. William Lorson (class of 2019, now a cardiovascular disease fellow at the University of South Carolina at Columbia) presented a poster at National Infectious Diseases Week 2018 on the epidemiology of infective endocarditis in intravenous drug users. Through infectious disease Dr. Lorson was able to present and subsequently publish work in his field of interest, cardiology. Dr. Shorman encourages other residents to overlap infectious disease with other specialties for their research projects.

He invites any residents interested in such projects to reach out to him for further assistance.

In an effort to curb the spread of infectious disease, employees at the medical center are now enrolled in a hand hygiene reminder system. A small device is worn by each employee which alerts its owner whenever he or she comes in close contact with a patient without using hand sanitizer. The hope is to increase personal hygiene in the hospital and decrease the spread of infections. We reached out to Jennifer Radtke, Manager of Infection Prevention, for feedback on results since implementing this system. She reported approximately 90% compliance rates for the hospital thus far, higher than the initial target of 80%. She added, “We know that team members respond to emergencies and in those moments responding to the emergency at hand is the priority. We know no one purposely skips an opportunity for hand hygiene. We are all busy and sometimes we forget because we are just thinking about the next thing that we need to do.” Overall, the infection prevention committee is pleased and would encourage everyone to keep up the good work! Questions regarding the hand hygiene reminder system can be directed to handhygiene@utmck.edu.

Points of View

be structured when they are grouped under headings (Background, Methods, Results, Conclusion) or unstructured when they follow the same order but without headings. In the Background section, the first sentence usually introduces the topic of interest and what is known about it. The next sentence describes what is not known and explains the question that the study wishes to address.

The Methods section starts with a description of the study design and population; followed by a statement about informed consent and IRB approval. In clinical trials, one sentence is devoted to the inclusion and major exclusion criteria. The next sentence describes the interventions and primary outcome measure which is based on the question that the study is designed to answer. One sentence should be devoted to the primary statistical analysis employed.

The first sentence in the Results section specifies the study population demographics and reports on the

HOW TO WRITE AN ABSTRACT Writing a good scientific abstract takes skill and is an art learnt over time. Arguably, the abstract is the most important part of a paper because (let’s be honest) most readers peruse it to determine if it is worthwhile to read the full manuscript. Abstracts generally have a low word limit (~150 - 300 words). Therefore, one has to compress vital information and Rajiv Dhand, MD, Chair attract the readers’ attention and interest.

Many learners are unaware of the sequence to follow while writing a scientific abstract. Abstracts may

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With Discovery in MIND Dr. J. Chris Ellis, PhD in microbiology, holds the first joint appointment between Oak Ridge National Laboratories (ORNL) and the UT Department of Medicine.

Dr. Ellis first came to ORNL two years ago, when he became interested in the connection between oxidative stress, infection, and neurodegenerative disorders. He wanted to use supercomputing to investigate the connection between the microbiome and neurodegenerative disease. Since ORNL has the world’s fastest supercomputer, it was the natural destination for him. Once here, he began collaborating with UTMC Department of Medicine neurologists: Dr. Randall Trudell, Dr. Christopher Tolleson, and Dr. Roberto Fernandez. Together, they are embarking on a project that will look at the relationship between the human microbiome and Alzheimer’s Disease, Parkinson’s Disease, and Amyotrophic Lateral Sclerosis (ALS). The study, called MIND (for Microbiome of Idiopathic Neurodegenerative Disease), will include 15 experimental subjects from each neurodegenerative disease and 15 controls. “Using deep sequencing, machine learning, and the world’s fastest supercomputer, we will be able to look at this in a way no one has ever been able to before,” Dr. Ellis says.

As a non-clinician scientist, Dr. Ellis is very excited to be working with clinicians. “Drs. Trudell, Fernandez, and Tolleson are great researchers and clinicians, but even more importantly they are great collaborators,” says Dr. Ellis. He believes that collaboration across disciplines profoundly accelerates discovery. “We are so very fortunate to be able to ask the right questions at the right time of the right people, and with the right computational infrastructure for support.”

Resident Research Committee: Progression Over The Years

In January 2019, InTouch introduced the Department of Medicine’s Resident Research Committee. Since its creation in July of 2017, the committee has been in high demand and has helped steward scholarly scientific research. For instance, the committee had 12 submissions—nearly a third of the residency program—for the 2019 Tennessee American College of Physicians (ACP) meeting in Nashville. The committee has also seen an increasing variety in submissions over the past year, including case reports, quality improvement projects, and research manuscripts. Because the interest in research participation and demand for the committee’s services has grown so much among residents, the committee added a new member, Dr. Elizabeth Ergen, who has been a phenomenal addition to the team. The committee also helped create a research elective in which internal medicine residents work with a mentor on their individual research projects. Additionally, the committee has compiled references for residents new to research: explanations of common pitfalls to avoid when conducting research, advice for writing abstracts, and templates for structuring research papers and abstracts. The committee plans to highlight their advancements and adjustments during the 2020 evidencebased medicine course in order to spread awareness of their services to incoming interns. Overall, since its establishment, the research committee has continued to grow and aid in facilitating research opportunities for our residents here at UT.

Resident Spotlight: Heidi Worth This edition’s feature resident is Dr. Heidi Worth. Dr. Worth’s journey into medicine and research began at the University of North Florida, where she completed her undergraduate degree while actively participating in breast cancer research at Pennington Biomedical Research Center. She went on to attend medical school at the American University of the Caribbean with her husband Kasey. They both matched at the UT Graduate School of Medicine for residency, Dr. Worth in internal medicine and her husband in radiology. Here, Dr. Worth has continued her passion for research, particularly in regards to breast cancer. This fall she presented two case reports at the Tennessee ACP meeting: one examining leukemia cutis as the presenting symptom of acute myeloid leukemia and another on follicular lymphoma presenting as hyperleukocytosis. After residency, she plans to pursue a fellowship in hematology/oncology.

Points of View

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statistical analysis of the primary outcome measure. This sentence is followed by a description of secondary outcomes, and any other important findings (including adverse effects).

The first sentence of the Conclusion relates to the major finding of the study. It is the message that you would like to convey to the reader.

Usually, it describes whether the study was successful in meeting the primary outcome measure. The second sentence of the conclusion goes beyond the outcome of a study. It describes the overall significance and scope of the study, as well as the key implications of the study in a broader context. Finally, if part of a clinical trial, it must be registered (https://clinicaltrials.gov) and the registry’s URL and trial registration number are stated.

Hopefully, this knowledge will help you in writing more informed abstracts and your keen eyes will pick up on the abstract structure while reading scientific papers.

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Faculty Announcements New Faculty

We are delighted to welcome Dr. Michael Slattery as a Clinical Assistant Professor in the Division of Sleep Medicine. Dr. Slattery graduated with his Bachelor of Science degree in neurobiology and behavior with honors and distinction from Cornell University in Ithaca, New York.

He received his Doctor of Medicine from Tufts University School of Medicine in Boston, Massachusetts. He completed a psychiatry and a neurology residency at Tufts New England Medical Center in Boston, Massachusetts. He completed fellowship training in EEG/Epilepsy and Sleep Disorders/Polysomnography at the Beth Israel Hospital/Harvard Medical School in Boston, Massachusetts. Dr. Slattery joined UTMC Sleep Disorder Center in August 2019.

We are pleased to welcome Dr. Christopher Ellis as an Assistant Professor. Dr. Ellis earned his Bachelor of Science and Doctor of Philosophy in microbiology from North Carolina State University in Raleigh, North Carolina. His postgraduate training consisted of a biotechnology graduate student fellowship at the National Institutes of Health from 2001 to 2003 and a National Institute of Environmental Health Sciences Intramural Research Training Award Postdoctoral Fellowship from 2006 to 2009.

He is a senior staff scientist at Oak Ridge National Laboratory. He has established numerous new methodologies in microbiome research.

We are thrilled to welcome Dr. Stephen Teague as a Clinical Associate Professor.

Dr. Teague earned his Bachelor of Science in electrical engineering from Purdue University in Lafayette, Indiana. He received his Doctor of Medicine from the University of Illinois in Chicago, Illinois. He completed an internal medicine residency and a fellowship in adult cardiology at Duke University in Durham, North Carolina.

Guest Speakers

Resident Research Awards

We were honored to have Larry Sthreshley, MPH, DrPH, give a presentation titled “Ebola in the Democratic Republic of the Congo” on October 16th, 2019. Dr. Sthreshley is a recognized global public health expert in a number of technical areas including MNCH, malaria, nutrition, health systems strengthening, disease control and prevention, water and sanitation, gender-based violence (GBV) and livelihood activities. He and his wife, Inge Sthreshley, live in Kinshasa and serve both the Presbyterian Community of Congo (CPC) as well as the Presbyterian Community of Kinshasa (CPK). They have worked to improve health care conditions and build up the local infrastructure in the Congo since 1987.

We are delighted to announce that one of our recent research projects, “Diagnostic Utility of Technetium-Labeled Red Cell Scans in the Diagnosis and Treatment of Acute Lower Gastrointestinal Bleeds at an Academic Medical Center”, won 3rd place prize for poster presentations at the annual Southern Hospital Medicine Conference; held October 3-5, 2019 in New Orleans, LA. Kristin O’Connor MD, a PGY-2 Medicine Resident and Sam Purkey DO, a PGY-1 Medicine Resident worked together on this project. Dr. Purkey presented the poster. Both residents were assisted by their mentor and attending physician, Daphne Norwood, MD. The Southern Hospital Medicine Conference showcases updates in the newest advances in clinical disease management, practice management, quality improvement, pharmacology, medical technology, evidence-based standards of care, and practice guidelines for all visiting physicians.

Awards and Honors

Several faculty awards were presented at this year’s Annual Faculty Recognition Dinner held on Wednesday, December 11th 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. Daphne Norwood.

• Dr. Steven Rider received the R.A. Obenour, Jr., Excellence in Teaching Award for steadfast dedication and excellence in teaching.

• Dr. Wahid Hanna received a 40-Year Service Award.

• Dr. Gary Klipple & Dr. Daniel • Dr. Mark Rasnake & Dr. David McCammon received their 25-year Aljadir received the London Award, service awards. which is presented to teachers who exhibits a dedication to excellence.

The recipients of this award are chosen by our residents.

All of these award recipients have provided superb service to the Department of Medicine. We are delighted to recognize them for their many contributions.

• The R.A. Obenour, MD, Distinguished Alumnus Award in Recognition of Outstanding Career Achievement in the Field of Medicine was presented to Dr. Kim Morris.

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.

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Ethics Case Rounds – If I Can’t Get a Liver … What Then?

Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.

“Rob”, a 37-year-old gentleman who lived with his brother and sister-in-law, was admitted with altered mental status, alcohol-related liver disease (ALD), severe malnutrition, COPD, anxiety, and depression.

Lab tests suggest that he has been drinking recently, though his brother, “Steve,” says he has been sober for 6 months. He was intubated and sedated at the time of the ethics consult. Steve had been advocating for aggressive interventions, in hopes that Rob could recover enough to receive a liver transplant. Without a transplant, his prognosis was very poor.

Rob rallied while in ICU and was able to be extubated. As he became stronger, he vacillated between saying he wanted to “just finally be comfortable and enjoy the time I have” and that he wanted to take the steps to be listed for a transplant. When the subject of his alcohol use was broached, he became tearful and did not want to talk further.

Ethical principles for transplant include urgency (likelihood of dying without a transplant) and utility (likelihood of surviving with a transplant). Once patients are on a transplant list, their priority on the list is based on objective criteria. However, criteria for getting on the list in the first place are more subjective. For example, some argue that ALD patients should have a lower priority for liver transplantation than non-ALD patients. Arguments for this position take two forms: medical arguments and moral arguments.

Medical arguments against transplantation for ALD patients are based on principles of stewardship of scarce resources, and the belief that ALD patients will have low survival rates compared to non-ALD patients.

However, ALD transplant recipients have similar survival rates as non-ALD recipients. Additionally, they have relatively low rates of relapse into heavy drinking, though when relapse into heavy drinking does occur, it is associated with increased mortality from ALD. Thus, it is important to thoroughly evaluate each patients’ psychological and social situation to determine individual risk of relapse. Insight about the role alcohol plays in their illness and their motivation to engage in substance abuse treatment are especially germane.

The moral argument against transplantation for ALD patients is based on the claim that they are responsible for their need for a liver, and thus, do not deserve the same chance as those who are not. However, many healthcare problems are partly attributable to individual behavior, including non-alcoholic fatty liver disease.

Healthcare providers are not in a position to judge a person’s worthiness to receive life sustaining measures.

While likelihood of survival is morally relevant, the etiology of liver disease is morally irrelevant.

Over time, Rob’s malnutrition worsened, and the likelihood that he would survive declined, even with a liver transplant. He became less and less responsive, and his pain became difficult to control. Rob was at a crossroads; Steve had to decide whether to continue aggressive care in the ICU, or transition to comfort care.

After much discussion with the team and with family, Steve decided to transition Rob to comfort measures.

He told the team he’d felt Rob had been given a fighting chance, and was now at peace.

Comments on this case may be sent to amendola@utmck.edu References • Douglas, C. “Addiction medicine ethics: relapse, no lapse and the struggle to treat addicts like everyone else” Internal Medicine Journal 47 (2017) 1121–1123 • Mellinger, JL and Volk, ML. “Transplantation for Alcohol-related Liver Disease: Is It Fair?” Alcohol and Alcoholism, Volume 53, Issue 2, March 2018, Pages 173-177

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!

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In Touch Vol. 9, Issue 1: January 2020

Publisher Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs Editor Annette Mendola, PhD Administrative Director Jenny Roark Contributors Jenny Roark Robin Underwood Kristin O’Conner, MD Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Kimberly Givens David Wilson, DO Elana Smith 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.