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A D TMET ICIE BULLI
A DEPARTMENT OF MEDICINE BULLETIN
UF UNIVERSITY of
College of Medicine
INSIDE THIS ISSUE
The publication of the second issue of the Academic
Physician Quarterly (APQ), the official newsletter of the
Department of Medicine at the University of Florida-College
of Medicine in Jacksonville, coincides with the graduation of
our senior residents, subspecialty fellows and the arrival of
a new crop of talented young physicians to join our training
program. In addition to these anticipated annual changes,
the Department will be joined by several new faculty members in various
subspecialties. We will be introducing the new colleagues in the future issues
of the APQ.
I am proud to report that faculty members of the Department continue to be
recognized for their exceptional contributions to the teaching mission of the
University of Florida. In particular I want to recognize Dr. Carlos Palacio and Dr.
Manish Relan, both of the Division of General Internal Medicine, for receiving
the 2006 Exemplary Teachers Award. In addition, Dr. Irene Alexandraki,
also of the Division of General Internal Medicine, was a 2007 finalist of the
College's Excellence in Student Education Award. The award is given annually
to the faculty member identified as the most outstanding teacher by medical
In our effort of introducing the community of physicians in Northeast Florida
to the services offered at UF & Shands Hospital, we will be highlighting the
advanced technologies we currently offer for the management of patients with
complex problems. In this issue, Dr. Louis Lambiase, the Chief of the Division of
Gastroenterology, describes a powerful diagnostic tool, endoscopic ultrasound,
that is utilized by the faculty members in the Division of Gastroenterology.
As we close the chapter on a successful academic year, I am looking forward to
a new and productive season.
Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine
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Endoscopic ultrasound: A
powerful diagnostic tool
Louis Lambiase, M.D.
Chief, Division of Gastroenterology
of lung cancer is
on the stage of
the illness at the
time of diagnosis.
The presence of
within mediastinal lymph nodes
alters both prognosis and therapeutic
Endoscopic ultrasound (EUS), a
procedure in which a tiny endoscopic
transducer is attached to a therapeutic
endoscope, allows detailed visualization
of central chest structures from within
the esophagus. Placing the transducer in
the esophagus allows for highly detailed
images that are not subject to interference
from other organs that might be "in the
way" of traditional imaging modalities
such as computed tomography (CT).
EUS can detect lymph nodes that are
so small that they are missed on CT
scanning. In a recent study published in
the journal Lung Cancer, EUS detected
mediastinal spread of lung cancer in
twenty-one percent of patients who had
a normal CT scan.
In addition, EUS adds the ability to
biopsy lymph nodes in the chest in a
suspicious lymph nodes had to be
biopsied through a much more invasive
procedure called mediastinoscopy
where a surgeon inserts a rigid "scope"
into the center of the chest through a slit
at the base of the patient's neck. EUS
allows for the passage of a needle, under
FIGURE: Lymph Node Fine Needle
Aspiration Biopsy: This figure shows a
mediastinal lymph node (center) being
biopsied by a needle (diagonal white
line) under endoscopic ultrasound
guidance, through the wall of the
esophagus into the chest lymph nodes.
The small needle causes minimal trauma
and the patient usually experiences less
pain and risk then mediastinoscopy.
Furthermore, EUS may reach lymph
nodes positioned between the aorta
and the pulmonary arteries that
mediastinoscopy traditionally cannot
At the University of Florida/Shands
Hospital -Jacksonville, EUS is performed
in the Gastrointestinal Endoscopy Unit
by a team of specially trained physicians
and nurses. A multi-disciplinary
approach, with endoscopists and
cytopathologists working together at
the patient's bedside, is taken in order
to provide optimal care. In our hands
EUS for lung cancer is a low risk, high
yield procedure often yielding crucial
information for the treating physician.
The procedure is performed several
afternoons a week. Interested referring
physicians or patients may contact the
Gastroenterology service at (904) 244-
N. Stanley Nahman, Jr., M.D.
Professor of Medicine
Chief, Division of Nephrology and
antagonists: a new therapy for
The syndrome inappropriate anti-diuretic
hormone (SIADH) is the most common
cause of euvolemic hyponatremia and is
mediated by non-physiologic vasopressin
release under a wide variety of clinical
conditions. Hypervolemic hyponatremia
is associated with a decreased effective
circulating blood volume and may result
from congestive heart failure, nephrotic
syndrome or cirrhosis.
Conivaptan and tolvaptan are inhibitors
of the V2 vasopressin receptor of the
distal nephron, and increase the excretion
of free water by the kidney. Conivaptan
(intravenous) and tolvaptan (oral) have
been shown to correct the hyponatremia
of SIADH. Conivaptan is approved by the
FDA for short term treatment of SIADH
in hospitalized patients. Tolvaptan
was recently shown to be effective in
both euvolemic and hypervolemic
hyponatremia and continues to undergo
clinical testing. Both drugs may be
associated with increased thirst and
polyuria, but otherwise have favorable
side effect profiles. Vasopressin
receptor blockers may be of use in the
therapy of inpatients with euvolemic or
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N. Stanley Nahman, Jr., M.D.
Program Director, Internal Medicine Residency Program
"In the old days", residents had overnight in-house call obligations on every rotation. In today's learning
environment, in-house call has for the most part been replaced by a night float system, in which residents
work only the night shift for prescribed periods of time.
An important challenge for all night float experiences is maintaining the educational integrity of the
S rotation as well as keeping the residents connected with their daytime colleagues and the rest of the training
The UF Jacksonville residency program addresses these issues through a carefully crafted night float
rounding system that interfaces with daily morning report. Our night float shift concludes with morning
report from 7 8 am on Monday morning, and attending-led night float rounds Tuesday through Friday from 7:15 to 8 am.
Each night float team and attending leader work together for a two week block. Rounds commonly focus on one new patient
admitted by the night float team the previous night. The attending picks the patient for discussion, and the resident who performed
the evaluation presents the patient to the attending. The entire group then moves to the bedside, where the attending may
examine the patient and review relevant clinical findings. At the conclusion of the bedside evaluation, the case is summarized
and the salient teaching points emphasized by the faculty facilitator.
A CLINICAL CASE
Arshag D. Mooradian, M.D.
"Asymptomatic Hyperthyroidism": Is it a distinctive clinical and laboratory entity?
Hyperthyroidism is generally the result of increased serum free thyroid hormone levels and is
associated with a set of clinical signs and symptoms. In rare cases of congenital thyroid hormone
resistance syndromes, symptoms of hyperthyroidism are absent despite the elevated thyroid
hormone levels. Older patients who develop hyperthyroidism have a paucity of classical
signs and symptoms of hyperadrenergic state. Nevertheless they may have increased incidence
of weight loss, cardiac arrhythmias and occasionally have apathetic mood. We describe a case
of an acquired asymptomatic hyperthyroidism in an older woman who had elevated serum
free thyroid hormone levels, suppressed serum TSH level and yet lacked any clinical signs or
symptoms of hyperthyroidism
A 78 year old woman was seen in March 2007 for management of hypertension. She had
been feeling well over the last year and had not sought any medical attention since August
2006. In the last few days she developed upper respiratory tract signs with some hoarseness
of the voice and mild sore throat. She had been diagnosed with hyperthyroidism and started
on propylthiouracil in June of 2004 that was subsequently switched to methimazole. She had taken antithyroid medicines
intermittently until November 2005 when the endocrinology consultant discontinued methimazole. On March 2006 she was
seen in the clinic off antithyroid medicines and did not have any specific complaints.
Her past medical history is significant for coronary bypass surgery in 2001, transient ischemic cardiomypopathy and
The current medications included carvedilol 6.25mg twice a day, and a daily treatment of the following; aspirin 325mg,
felodipine 10mg, furosemide 40mg, potassium chloride 20 meq, lisinopril 40mg and pravastatin 20 mg.
Review of systems revealed stable body weight for the last one year, no palpitations, no shortness of breath, no tremors, no
heat intolerance, no change in bowel habits nor changes in cognition or mood.
Physical examination revealed a blood pressure of 129/59 mm Hg, heart rate of 71 beats per minute, body mass index of 28.4
Continued on page 4
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Kg/m2. The thyroid gland was enlarged (2 times normal) and thickened, and there was a systolic ejection murmur 3/6 at left
sternal border. Otherwise the examination was remarkable for the absence of any signs of hyperthyroidism or Graves' disease.
The thyroid function tests on March 2007 showed free thyroxin (T4) of 3.3 ng/dl (normal 0.8-1.7), free triiodothyronin (T3) of
8.0 pg/ml (normal 2.57-4.43) and thyrotropin (TSH) of 0.005 mU/L (0.27-4.2). Laboratory work-up seven months prior to this
visit showed free T4 of 3.5 ng/dl, free T3 of 11 pg/ml and TSH of 0.005 mU/L. The thyroid stimulating immunoglobin (TSI)
was 336% (NL < 130%) and 6 hour radioactive iodine uptake was 41% with 22 hour uptake of 79% (normal 10-35%). Thyroid
scan showed diffusely enlarged gland.
As the name implies, people with asymptomatic hyperthyroidism have all the laboratory features of hyperthyroidism
but do not have any obvious symptoms or signs of hyperthyroidism. Although this syndrome is a distinct entity it has
features that overlap with other well known disorders of thyroid physiology, namely subclinical hyperthyroidism, apathetic
hyperthyroidism and thyroid hormone resistance syndromes.
In subclinical hyperthyroidism, the serum free T4 and free T3 remain within the reference range. Asymptomatic
hyperthyroidism is also distinct from apathetic hyperthyroidism since the former does not exhibit neuropsychiatric features
of hyperthyroidism, including apathetic mood.
Asymptomatic hyperthyroidism may be a variant of tissue selective thyroid hormone resistance syndromes. People with
thyroid hormone resistance do not have suppressed serum TSH levels and the condition is congenital, while asymptomatic
hyperthyroidism, like subclinical hyperthyroidism and apathetic hyperthyroidism, are acquired conditions
Asymptomatic hyperthyroidism can be viewed as a variant of apathetic hyperthyroidism. In both entities there is acquired
insensitivity to thyroid hormones. Since apathetic hyperthyroidism is predominantly a disease found in older people, it is
tempting to speculate that the previously described age-related insensitivity to thyroid hormones may partly account for the
clinical manifestations of apathetic hyperthyroidism and the related entity of asymptomatic hyperthyroidism of the aged.
Age-related changes in thyroid hormone action are reflected in changes in specific gene products that are known to be
modulated by thyroid hormones. An age-related blunted responsiveness of biomarkers of thyroid hormone action has been
demonstrated in various tissues including the cerebral cortex. In addition, the thyroid hormone responsiveness of adrenergic
neurotransmission in synaptosomal membranes and in myocardial tissues is also reduced in aged rats.
Multiple biological changes may account for the altered thyroid hormone action with age. These include impaired transport
of thyroid hormones across plasma membrane, impaired tissue metabolism of thyroid hormone, and alterations in post-
receptor processes modulating gene expression.
Age-related thyroid hormone resistance (THR) differs from congenital THR in many ways. One of the biochemical hallmarks
of congenital THR is normal or mildly elevated serum TSH levels. The suppressed serum TSH levels in older adults with
THR can be explained by the tissue selectivity in age-related changes of thyroid hormone responsiveness such that the
hypothalamic-pituitary unit either retains or acquires enhanced thyroid hormone responsiveness in the face of reduced
responsiveness of peripheral target tissues. Indeed, data from experimental aging models suggest that the thyroid hormone
receptors in the pituitary may be increased with age along with an increase in the conversion of T4 to T3 through the increased
activity of 5' deiodinase type II enzyme.
Asymptomatic Subclinical Apathetic Generalized Pituitary
Hyperthyroidism Hyperthyroidism Hyperthyroidism Resistance to TH Resistance to TH
Symptoms None None/Minimal Apathy None or Hyperthyroid
Weight loss Hypothyroid
Goiter Variable Variable Variable Yes Yes
Free T4 Increased Normal Increased Increased Increased
Free T3 Increased Normal Increased Increased Increased
TSH Very Decreased Decreased Decreased Normal/ Increased/
Onset Acquired Acquired Acquired Congenital Congenital
Frequency Unknown Common Rare Very rare Very rare
Table 1: Comparative profile of patients with asymptomatic, apathetic, and subclinical r .... -' or thyroid hormone (TH) resistance syndromes.
Continued on page 5
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A CLINICAL CASE continued from page 4
Although an increase in serum thyroid hormone concentrations is expected in a syndrome characterized by resistance to
hormonal action, unchanged serum thyroid hormone levels in the euthyroid elderly person may be secondary to confounding
physiological changes with age, including increased suppressability of TSH, decreased conversion of T4 to T3, and decreased
thyroidal sensitivity to TSH.
If the syndrome is truly asymptomatic, then the question arises whether therapeutic interventions are necessary. Since
clinical features are an insensitive barometer of tissue effects of excess thyroid hormones, in view of lack of clinically useful
tissue biomarkers of thyroid hormone action, and since the natural history of this entity is not known, it is advisable to
normalize the thyroid hormone levels in these patients even though they are asymptomatic. Given the lack of clinical trials in
these patients the recommendation to treat with anti-thyroid medications is based on the studies in patients with apathetic
hyperthyroidism and subclinical hyperthyroidism.
Asymptomatic hyperthyroidism is an under diagnosed entity. It may be a variant of apathetic hyperthyroidism with complete
absence of symptoms and signs including apathetic mood. Unlike thyroid hormone resistance syndromes, it is an acquired
condition that is probably more common in the elderly and may well be an extreme manifestation of age-related thyroid
hormone insensitivity. Widespread screening of older people for thyroid disease is likely to uncover more people with this
1. American Association of Clinical Endocrinologists (2002) Medical guidelines for clinical practice for the evaluation and treatment of
hyperthyroidism and hypothyroidism. Endocrine Practice, 8, 457-467.
2. Oiknine RF, Mooradian AD. Thyroid disorders. In. Principles and Practice of Geriatric Medicine, 4th edition, MS John Pathy, AJ Sinclair,
JE Morley, John Wiley and Sons, Ltd. 4th edition; Vol 2;,2006; pp: 1405-1414.
3. CASE CC, Mooradian AD. (2000) Thyroid changes with aging. In: The Science of Geriatrics. Facts, Research and Intervention in
Geriatrics Series. J.E.Morley, H.J. Armbrecht, R.M. Coe, and B. Vellas (eds.), Serdi Publisher, Paris, vol.1, pp 273-281.
4. Mooradian AD, Wong NCW (1994) Age-related changes in thyroid hormone action. European Journal of Endocrinology, 131, 451-61.
5. Mooradian AD. (1995) Normal age-related changes in thyroid hormone economy. Clinics in Geriatric Medicine 11:159-169.
6. Friedman D, Reed RL, Mooradian AD. (1992) The prevalence of over medication with levothyroxine in ambulatory elderly patients.
Age, 15, 9-13.
7. Shah GN, Li JP, Schneiderjohn P, Mooradian AD. (1997) Cloning and characterization of a complementary DNA for a thyroid hormone
responsive protein in mature rat cerebral tissue. Biochemical J. 327:617-623.
8. Shah GN, Li J, Mooradian AD. (1999) Novel translational repressor (NAT-1) expression is modified by thyroid state and age in brain
and liver. Eu. J. Endocrinology 139:649-653.
9. Mooradian AD, Li J, Shah GN. (1998) Age-related changes in thyroid hormone responsiveness protein (THRP) expression in cerebral
tissue of rats. Brain Res. 793:302-304.
10. Haas MJ, Li J-P, Pun K, Mooradian AD. (2002) Partial characterization of a cerebral thyroid hormone responsive protein (THRP).
Archives of Biochemistry and Biophysics 399:6-11.
11. Haas MJ, Fishman M, Mreyoud A, Mooradian AD. (2004) Thyroid hormone responsive protein (THRP) mediates thyroid hormone-
induced cytotoxicity in primary neuronal cultures. Exp. Brain Res. (in press).
12. Mooradian AD, Scarpace PJ. (1993) 3,5,3'-L-triiodothyronine regulation of B-adrenergic receptor density and adenylyl cyclase activity in
synaptosomal membranes of aged rats. Neurosci. Lett. 161:101-104.
13. Mooradian AD. (1990) Blood-brain transport of triiodothyronine is reduced in aged rats. Mech. Age. Develop. 52:141-147.
14. Mooradian AD (1990) The hepatic transcellular transport of 3, 5, 3'- triiodothyronine is reduced in aged rats. Biochem Biophys Acta,
15. Mooradian AD, Fox-Robichaud A, Meijer ME, Wong NCW. (1994a) Relationship between transcription factors and S14 gene expression
in response to thyroid hormone and age. Proc. Soc. Exp. Biol. Med. 207:97-101.
16. Ladenson PW, Singer PA, Ain, KB, Bagchi N, Biogs SB, Levy EG, Smity SA, Daniels GH (2000) American Thyroid Association guidelines
for detection of thyroid dysfunction. Arch Intern Med, 160, 1573-75.
17. U.S. Preventive Services Task Force (2004) Scientific Review & Guidelines for Diagnosis & Management. JAMA, 291, 228-238.
18. Surks MI, Ortiz E, Daniels GH, Sawin CT, Col NF, Cobin RH, Franklyn JA, Hershman JM, Burman KD, Denke MA, Gorman C,
Cooper RS, Weissman NJ (2004) Subclinical Thyroid Disease, U.S. Preventive Services Task Force (2004) Screening for thyroid disease:
Recommendation statement. Ann Intern Med, 140, 125-127.
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News & Notes
MEET YOUR COLLEAGUES
Editor's note: Periodically the "Academic Physician Quarterly" will introduce our readership to new faculty members who have
exceptional clinical skills. In this issue we highlight two outstanding academic surgeons who joined UF-Shands Hospital in the
Sadir J. Alrawi, MD, FRCS,
Assistant Professor, Surgery
Section Chief, Surgical Oncology
University of Florida College of Medicine-Jacksonville
Dr. Alrawi earned his medical degree from the University of Baghdad and completed his surgical
education in England, Scotland and the United States. He completed his fellowship training in head and
neck surgery and surgical oncology with both clinical and basic science research at Roswell Park Cancer
Institute, a National Cancer Institute designated center.
DR. ALRAWI'S SPECIALTIES
* Upper gastrointestinal oncological surgery with emphasis on esophageal, gastric, pancreas, liver and biliary tumors
* Sarcoma and melanoma tumors, including extremity and truncal tumors, with extensive experience in both sentinel
and radical lymph node dissection
* Intraperitoneal advanced cancer management with debulking surgery and intraperitoneal chemoperfusion
* Lower gastrointestinal oncological surgery (colonic malignancy) with pelvic exenteration for advanced tumors
* Head and neck malignancies, including thyroid, parathyroid, parotid with various tumors of digestive tract, both
primary and metastatic
* Breast tumors
Ziad T. Awad, MD
Assistant Professor, Surgery
Director, Minimally Invasive Surgery
University of Florida College of Medicine-Jacksonville
^ Dr. Awad earned his medical degree from the University of Baghdad and completed surgical residencies
at Creighton University in Omaha, Neb., and the University of Missouri in Columbia. Dr. Awad completed
9 1 his fellowship training in minimally invasive surgery at New York Presbyterian University Hospitals of
Columbia and Cornell.
DR. AWAD'S SPECIALTIES
* Minimally invasive (laparoscopic) gastrointestinal surgery with emphasis on:
* Esophageal cancer, gastroesophageal reflux disease, achalasia
* Colon cancer, diverticular disease
* Rectal prolapse repair
* Gastric cancer, peptic ulcer disease, motility disorder
* Cholecystitis, common bile duct stones, biliary stricture
* Solid organs: liver, spleen, adrenal, pancreas
* Inflammatory bowel disease
* Complications from gallbladder surgery
* Small bowel resection for benign and malignant lesions
* Hernia repair
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Shands Jacksonville's TraumaOne program is flying high
with a new air ambulance. The EC-145 will allow pilots to
fly faster and complete more missions due to the advanced
technology onboard. In fact, the EC-145 is said to be the most
technologically advanced air ambulance on the market.
The EC-145 is equipped with infrared color radar that allows
pilots to respond quickly to threatening weather situations.
The air ambulance also has an auto pilot feature like that of
major airlines, which will be used during every mission to
help keep the aircraft stable, particularly in rougher weather.
This helicopter flies faster (150 mph) than the previous
helicopter and is able to carry a heavier payload (7,716 lbs).
Ultimately that means it can carry more fuel and patient
weight. The EC-145 is also roomier, providing a larger work
space for TraumaOne crews to care for patients.
the regions first helicopter transport system for stroke
Shands Jacksonville is one of a few flight programs in the
country to fly the EC-145 and one of only two hospitals in the
Florida. The helicopter is manufactured by Eurocopter. The
Army recently began using these helicopters.
TraumaOne has two helicopters in service one located at
Shands Jacksonville and the other in Lake City. The program
serves 30 counties in Florida and Georgia and is responsible
for saving the lives of thousands of people in its near 22-year
Shands TraumaOne flight program started in 1985. Every
month, pilots fly between 75 and 100 missions and in 2006,
crews transported nearly 1,200 patients from the scenes of
medical emergencies including traumas, heart attacks and
strokes. In fact, UF Neurologist, Scott Silliman MD, Associate
Professor and Director of the Comprehensive Stroke Program
at the Shands Jacksonville Neuroscience Institute, pioneered
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