Group Title: Academic physician quarterly
Title: Academic physician quarterly. Vol. 1. Issue 3.
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 Material Information
Title: Academic physician quarterly. Vol. 1. Issue 3.
Series Title: Academic physician quarterly
Physical Description: Serial
Creator: University of Florida College of Medicine
Publisher: College of Medicine, University of Florida
Publication Date: October 2007
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Bibliographic ID: UF00088871
Volume ID: VID00003
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A DEPARTMENT OF MEDICINE BULLETIN


UF UNIVERSITY of
UFFLORIDA
College of Medicine
iiiick--i''n 'tile


-EU















E^^^^^i^wPIage
GME CORNER -
^^^^^^^^^^ Page 3^










A CLINICAL CASE
^^^^^^^^^ Page 4


CHAIRMAN'S MESSAGE

Dear Colleagues:

I hope you had an enjoyable summer and are now looking
forward to the cooler weather of the fall.
I am pleased to report that the publication of the Academic
Physician Quarterly (APC), the official newsletter of the
Department of Medicine at the University of Florida-College
of Medicine Jacksonville, has been well received by many
of our readers. I would like to encourage you all to send me
your thoughts, comments and articles you would like see I -
published in this venue.
The Department of Medicine and UF & Shands in general, are experiencing an
unprecedented growth of faculty membership. As in the past we will be
introducing some of our colleagues by highlighting their biography and areas of
expertise in the current and future issues of the APC.
The Department of Medicine had an exceptional year of growth and productivity
in FY 07. I am proud to report that faculty members of the Department have
expanded the clinical productivity by 36% and were recognized for their
exceptional contributions to the teaching mission of the University of Florida. In
addition, the faculty members were engaged in high quality biomedical research
that resulted in 77 publications in peer review journals along with numerous
presentations in National and International conferences.
In this issue we highlight the Division of Infectious Diseases. This Division has
a unique position, having a partnership with the Duval County Department of
Health. It is a model for public health with an academic link to better serve the
community and provide an educational resource to the UFCOM.
Also in this issue you will see the recent initiatives in enhancing cancer care
resources at UF & Shands. The central piece of these initiatives is the proton beam
facility that has put Jacksonville on the map of premier centers of excellence in
cancer therapy.

Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine







FOCUS


Michael Sands, M.D.
Associate Professor of Medicine
Chief, Division of Infectious Diseases


UF Infectious Diseases Division, a
model for public health-academic
linkage and service to the community

The Division of Infectious Diseases of the Department of
Medicine occupies a unique position in the Duval County
community as a partnership between an academic division
of infectious communicable diseases and the department of
public health. At the Shands Hospital Jacksonville, the
Division is primarily visible as a consultative and teaching
service. In this capacity the Division provides Shands Hos-
pital with infectious diseases consultative expertise in all
areas of adult patient care. Consultations are done on
request on both the teaching and non-teaching services.
Consultations benefit not only patient care and potentially
decrease patient length of stay but also provide a teaching
benefit to the students, residents and fellows on both the con-
sultative and the requesting services. A specialized area of
infectious diseases consultation for transplant patients is also
provided. Behind the scenes, the Division provides direc-
tion to the infection control activities of Shands Hospital.
Ten years ago, the Division Infectious Diseases and Duval
County Health Department (DCHD) Communicable Dis-
eases Division existed as two separate functionally disparate
groups. Drs. Michael Sands, Robert Nuss, Ted Bass (then
interim Chief of Medicine) and Jeffrey Goldhagen recog-
nized the need to revamp the DCHD's Communicable Dis-
eases Division into a professional group that could enhance
the patient care and development needs of the Division. It
was envisioned that collaboration between the University of
Florida (UF) and DCHD would foster the recruitment and
retention of highly qualified professionals, encourage the de-
velopment of an academic linkage between the two divisions
and create a growth environment that would benefit both
parties and the community. Over the ensuing 10 years, the
joint Infectious Diseases and Communicable Diseases
Division has grown to 7 faculty members, 3 adjunct faculty,
2 fellows, 3 Physican Assistants, 1 travel medicine specialty
nurse and 1 nurse research coordinator. The division con-
tinues to provide 24/7 consulting at Shands hospital, direc-
tion of hospital infection control, and outpatient travel
medicine clinics. Members of the division have developed
the administrative and area expertise to direct and/or pro-


*1~i
I.


A photograph of the faculty in the Division of Infectious Diseases.
Christina Bailey, James Toomey, Nilmarie Guzman, Michael
Sands, Levonne Mitchell-Sammon, Jeffrey Lauer

vide consultative expertise in the areas of infection in
transplantation, bioterrorism, tuberculosis, sexually trans-
mitted diseases, HIV/AIDS, prison/institutional ID and
communicable diseases epidemiology. The Division is cur-
rently supported through the UF Department of Medicine
and consultative revenues. Communicable Diseases DCHD
activities are supported through a contractual agreement
with the UF Department of Medicine for services. The divi-
sion has developed a research section that oversees research
grants totaling approximately $250,000 and includes an NIH
- CPCRA site grant for conduct of the SMART study, interim
results of which have recently been published in the New
England Journal of Medicine. A large component of the
research conducted by the unit involves clinical trials in
HIV/AIDS patients. These trials provide availability of in-
vestigational medications to the HIV/AIDS population of
Jacksonville, advance the knowledge of efficacy, safety and
utility of medication regimens, while also advancing the
academic mission of the Division. The Division is also re-
sponsible for performance of components of federal and
state categorical grants awarded to the DCHD for TB, HIV,
refugee and STD care and epidemiologic services. These
grants are in excess of $6.5 million. Additionally, the Divi-
sion has been instrumental in acquiring and directing a fed-
eral Ryan White Title 3 grant of $300,000 annually for
improved community based access to care, that provides
HIV/AIDS care to 250 indigent patients not otherwise
brought into care or previously known to health care or who
had lost to follow up care.
A review of the number of patients clinically served by the
Division gives some insight into the impact of this division
on infectious and communicable diseases morbidity in the


Continued on Page 3





Focus continued from page 2

community. In the 4 month period July 1 Oct 31, 06, our ID
specialists over saw the care for 3,546 HIV/AIDS clinical vis-
its, 1,214 STD visits, 141 refugee visits and 653 TB visits at
DCHD specialty clinics. During the 2005-2006 academic year
the Division performed over 750 inpatient infectious diseases
consultations at Shands Hospital.
The Division takes pride in its teaching and fellowship
training program. Recently re-approved by the RRC for an
additional 3 years, the Infectious Diseases fellowship
program provides a 2 year clinical training program leading
to board eligibility in adult infectious diseases as an internal
medicine sub specialty. This program, in addition to provid-
ing extensive and diverse inpatient consultative experience
at Shands Hospital, also provides outpatient experiences in


HIV/AIDS, TB and STD management from a clinical and
public health perspective through the DCHD communicable
diseases specialty clinics, in clinical microbiology at Baptist
Hospital and the State of Florida Laboratories, pediatric
infectious diseases at Wolfson Children's Hospital and
transplant infectious diseases at the Mayo Clinic and St.
Lukes Hospital. Fellows leaving this program have gone on
to diverse careers in academic ID, public health and
community based infectious diseases consultation.
The Division has made remarkable strides in the past 10
years and hopes to continue its growth under the supportive
leadership of UF administration and Dr. Robert Harmon, Di-
rector of Duval County Health Department.


GME CORNER


N. Stanley Nahman, Jr., M.D
Program Director, Internal Medicine
Residency Program

Contemporary residency training includes more than just
learning clinical medicine it now mandates effective time
management skills, a high dependence on teamwork, and free
and open communication between trainees and
program leadership. The core medicine residency program of
the Department aspires to address each of these crucial train-
ing facets through a highly integrated and pragmatic training
platform.
Time management skills are taught and reinforced by
careful monitoring of duty hours on any rotation where the
resident has primary patient care responsibility. These expe-
riences include rotations through inpatient general medicine,
nephrology, MICU, cardiology, and night float. All residents
use a computerized card swipe system to clock in and out of
each work day (or night). In this way, the program is assured
that the 80 hour work week is never violated, that residents
have at least 10 hours off between shifts, and that each resi-
dent receives one day off in 7. Violations of the policy are al-
ways inadvertent and usually due to over zealous residents
starting too early in the morning or staying too late at night.
As much as we appreciate this dedication, equally important
is the development of effective time management skills to
meet the stated duty hour restrictions. Duty hour monitoring
with feedback is provided to each resident and if problems
arise, appropriate steps are taken to improve time manage-
ment skills.
Efficient time management ties directly to solid teamwork
within the residency. Effective patient hand-offs are the most
important way to assure quality patient care from day workers
to night workers, or to cross covering colleagues on
weekends and holidays. To facilitate quality hand-offs, the


program adopted Dr. Robert Sullivan's (graduate of the
residency and currently a 1st year fellow in Nephrology at UF-
Jacksonville), unique computerized hands off system in the
spring of 2005. As an intern Dr. Sullivan recognized the need
for a computerized system for daily check-in and check-out.
Using his unique skills in software development, he created
the highly efficient system in use today by the program. A
recent visiting professor from UF Gainesville remarked that he
wished such a system was used in their program.
The dynamic nature of today's training environment

necessitates free and open communication with the program
leadership. The residency has two fourth-year chief medical
residents (CMR) who are the primary liaisons between the res-
idents and the program directors. The CMR are chosen by the
program leadership 18-20 months in advance and selection is
based on demonstrable quality leadership, outstanding clini-
cal skills, and the strongest of scholastic abilities. The CMR
provide the program director group with open feedback on
what is working and what is not, and frequently
devise solutions to recognized operational problems.
Free communication with the program leadership is also en-
couraged through the House staff council for education a
twelve member elected body of residents (4 per class) who
meet on a regular basis with the program leadership to
review the functional quality of the training platform. The
House staff council (HSC) has played a crucial role in helping
to make good ideas workable ideas. For example, our highly
successful night float system was converted from a 4 week to
a 2 week rotation in 2006. The leadership conversion plan
proved unrealistic, and was successfully reformatted by the
HSC into a workable plan. The positive relationship
between the HSC and the program leadership allows the lead-
ership to vent new ideas with an engaged resident group and
provides an effective means for residents to bring issues to the

Continued on Page 4





GME Corner continued from page 3


Annual Chief Medical Resident Dinner, June 2007

leadership in a formal and non-confrontational way. The
HSC is a key component to our recent and ongoing
successes in keeping our program educationally relevant and
effective.
Taken together, the successful training program in
medicine today emphasizes strong training in clinical medi-


cine that is integrated into a balanced work environment of
teamwork and free communication, with an open eye to
steady improvement. We believe our residency program
aspires to meet these needs and through this process will
continue to offer the highest quality educational experiences
for our residents.


A CLINICAL CASE


Carlos Palacio, M.D. (Adapted from South Med J. 2005
Jan; 98(1):129-30).


Hypercalcemia Complicating Infection

with Mycobacterium Avium-lntracellulare

Complex

CASE REPORT:
A 35 year-old woman with the diagnosis of AIDS of one
month duration and a CD4 count of 25, presented to the
emergency department with nausea and vomiting for two
days, a constant sharp pain under her diaphragm that was
pleuritic in nature. It radiated to her back and decreased with
lying on her right side. She reported constipation and a feel-
ing of fullness in her abdomen for two days with fevers of
102.9-oF.
She denied any drugs of abuse or alcohol. She acquired
HIV from unprotected heterosexual activity. She denied
exposure to tuberculosis, and had started trimethoprim/sul-
famethoxazole, azithromycin and HAART (lamivudine,
zidovudine and nelfinavir) in the preceding month.


She was thin and appeared her stated age. She was tachy-
cardic with clinical signs of dehydration. Abdominal exam
showed bowel sounds, diffuse tenderness without peritoneal
signs or organomegaly.
Admission labs included: BUN-29 mg/dl, creatinine-1.7
mg/dl, and calcium-15.2 mg/dl. Calcium corrected to 16.2
mg/dl when albumin of 2.7 gm/dl was taken into account.
Ionized calcium was 1.91 (1.09 1.31). Fractional excretion of
sodium was consistent with pre-renal insufficiency. White
blood count was 3,900 /mm3, hemoglobin was 7.3 gm/ d, and
platelet count was 97,000/mm3. Reticulocyte count was 1.2%.
Alkaline phosphatase was 183 U/L with a normal AST, ALT
and gamma-GT. Lipase was 1047 U/L. Triglycerides were
354 mg/dl and the chest x-ray was normal.
The patient was admitted with a diagnosis of pancreatitis
secondary to hypercalcemia, severe dehydration, and pancy-
topenia. Her hypercalcemia resolved with IV saline. After
fluids, creatinine was 0.6 mg/dl. An ultrasound of her
abdomen showed mild to moderately enlarged liver and
spleen that were homogenous in appearance, sludge in
the gallbladder and a normal pancreas. A bone marrow
biopsy showed a hypercellular bone marrow with trilinear


Continued on Page 5





A Clinical Case continued from page 4

hematopoiesis and normal maturation with multifocal granu-
lomas that were positive for numerous acid-fast bacilli. Blood
cultures and bone marrow culture grew mycobacterium
avium-intracellulare complex. 1,25-dihydroxyvitamin D level
was 56.8 (normal range 15.9-55.6). PTH Intact (pg/ml) was
2.57 (normal range 16-65). 25-hydroxyvitamin D level was 28.5
(normal range 8.9- 46.7). PTH-related peptide was not
detectable.

DISCUSSION:
The association of hypervitaminosis D is documented in
many granulomatous diseases. These include sarcoidosis,
Wegener's disease, fungal infections, tuberculosis and, a typ-
ical mycobacteria[1-4]. The mechanism of hypercalcemia is
unregulated, constitutive production of dihydroxyvitamin D
by macrophages. Theoretically, any granulomatous disease
may lead to the constitutive production of 1, 25-vitamin D
through dysregulation by cytokines[5]. Vitamin D increases
the gut absorption of dietary calcium and this suppresses the
secretion of parathyroid hormone.
This patient's pancytopenia and hypercalcemia resulted
from MAC infiltrating her bone marrow. Hypercalcemia can
cause pancreatitis, and nephrogenic diabetes insipidis
manifesting as polyuria.
The initiation of HAART likely precipitated an immune
reconstitution syndrome. The increase in production of a


cytokine such as gamma-interferon led to constitutive vitamin
D production. We may well see more similar cases with initial
HAART in severely immunocompromised HIV disease.

REFERENCES:

1. Spindel SJ, et al: Case report: vitamin D-mediated hypercalcemia in fun-
gal infections. Am J Med Sci 1995; 310(2): pp 71-76
2. Playford EG, et al: Hypercalcaemia and elevated 1,25 (OH)(2)D(3) levels
associated with disseminated Mycobacterium avium infection in AIDS. J
Infect 2001; 42(2): pp 157-158
3. Newell A, Nelson MR: Hypercalcaemia in a patient with AIDS and My-
cobacterium avium intracellulare infection. Int J STD AIDS 1997; 8(6):405
4. Jenny-Avital ER, Abadi M: Immune reconstitution cryptococcosis after
initiation of successful highly active antiretroviral therapy. Clin Infect Dis
2002; 35(12): pp 128-133
5. Delahunt JW, Romeril KE: Hypercalcemia in a patient with the acquired
immunodeficiency syndrome and Mycobacterium avium intracellulare
infection. J Acquir Immune Defic Syndr 1994; 7(8): pp 871-872
6. Aly ES, et al: Hypercalcaemia: a clue to Mycobacterium avium intracellu-
lare infection in a patient with AIDS. Int J Clin Pract 1999; 53(3): pp 227-
228
7. Ali MY, et al: Hypercalcemia associated with infection by Cryptococcus
neoformans and Coccidioides immitis. Am J Med Sci 1999; 318(6): pp
419-423
8. Dusso AS, et al: gamma-Interferon-induced resistance to 1,25-(OH)2 D3
in human monocytes and macrophages: a mechanism for the hypercal-
cemia of various granulomatoses. J Clin Endocrinol Metab 1997; 82(7): pp
2222-2232


RX UPDATES


Patrick Aaronson, Pharm.D., PGY1 Pharmacy
resident, reviewed by Amy Rockwell, Pharm.D.


Fluoroquinolones are no longer recom-

mended for the treatment of gonococcal

infections


The Centers for Disease Control (CDC) recently
revised the treatment recommendations for gonococcal infec-
tions, due to a steady increase in reports of quinolone resist-
ant Neisseria gonorrhoeae (QRNG). Fluoroquinolones are no
longer recommended for the treatment of gonococcal infec-
tions caused by Neisseria gonorrhoeae.1 This recommendation
was based on analysis of data from the CDC's Gonococcal
Isolate Surveillance Project (GISP), system that monitors an-
timicrobial susceptibilities of strains of N. gonorrhoeae from
approximately 26 sexually transmitted diseases (STD) clinics
throughout the country.2 Intermediate and resistant isolates
have increased from less than 1% of clinical isolates in 1990 to
approximately 15% in 2006.


The CDC's most recent sexually transmitted disease treat-
ment guidelines recommend the following regimens3:
SUncomplicated Gonococcal Infections of the Cervix, Urethra, and
Rectum:
First line treatment includes: ceftriaxone 125 mg IM in a single

Continued on Page 6





RX updates continued from page 5


dose or cefixime 400 mg orally in a single dose plus treatment
for chlamydia if chlamydial infections are not ruled out.
Uncomplicated Gonococcal Infections of the Pharynx:
First line treatment includes: ceftriaxone 125 mg IM in a sin-
gle dose plus treatment for chlamydia if chlamydial infections
are not ruled out.
Disseminated Gonococcal Infection (DGI):
First line treatment includes: ceftriaxone* 125 mg IM or IV
every 24 hours. Alternative regimens includes: cefotaxime*
or ceftizoxime* 1 g IV every 8 hours (non-formulary at Shands
Jacksonville).
All of the preceding regimens should be continued for
24-48 hours after improvement begins, at which time ther-
apy may be switched to one of the following regimens to
complete at least 1 week of antimicrobial therapy, which in-
cludes: cefixime 400 mg, cefixime suspension 500 mg, or
cefpodoxime 400 mg orally twice daily.
Parenteral treatment of Pelvic Inflammatory Disease (PID):
Parenteral regimen A includes: cefotetan 2 g IV every 12
hours or cefoxitin 2 g IV every 6 hours (non-formulary at
Shands Jacksonville) plus doxycycline 100 mg orally or IV
every 12 hours. Parenteral regimen B includes clindamycin
900 mg IV every 8 hours plus gentamicin loading dose IV or
IM (2 mg/kg of body weight), followed by a maintenance
dose (1.5 mg/kg) every 8 hours. Single daily dosing of gen-
tamicin may be substituted. An alternative parenteral
regimen includes: ampicillin/ sulbactam 3 g IV every 6 hours
plus doxycycline 100 mg orally or IV every 12 hours.


* Oral Treatmentfor mild-to-moderately severe acute PID:
First line oral regimen includes: ceftriaxone 250 mg IM,
cefoxitin 2 g IM and probenecid, 1 g orally administered con-
currently in a single dose, or other parenteral third-genera-
tion cephalosporin (e.g., ceftizoxime or cefotaxime). The
preceding regimen also includes doxycycline 100 mg with or
without metronidazole 500 mg orally twice a day for 14 days.
Since there are limited data regarding alternative regimens
for treating gonorrhea among persons who have documented
severe cephalosporin allergy, infectious diseases consultation
is recommended. The best available treatment option is
cephalosporin treatment following desensitization. If desen-
sitization is not an option, azithromycin may be considered.
Azithromycin 2 grams orally is effective against uncompli-
cated gonococcal infection, but concerns with emerging
antimicrobial resistance to macrolides should limit its use.'

REFERENCES:
1. Centers for Disease Control. Update to CDC's sexually transmitted dis-
ease treatment guidelines, 2006: Fluoroquinolones no longer recommended
for the treatment of gonococcal infections. MMWR 2007; 56:332-36
2. Centers for Disease Control. Sexually transmitted disease surveillance 2005
supplement: Gonococcal Isolate Surveillance Project (GISP) annual report,
2005. Atlanta, GA: US Department of Health and Human Services, CDC;
2007. Available at http://www.cdc.gov/std/GISP2005/default.htm.
Accessed May 10, 2007
Centers for Disease Control. Updated recommended treatment regimens
for gonococcal infections and associated conditions United States, April
2007. Available at http:/ /www.cdc.gov/std/treatment/2006/GonUp-
dateA


Mark Schreiber, Pharm.D.
Clinical Toxicology Fellow
Florida Poison Information Center/Jacksonville


Hydroxocobalamin for Cyanide Toxicity


Cyanide is an extremely lethal poison. As a concentrated
aerosol, it has the ability to cause death within seconds.
Concerns over terrorist activity and expanded use of
synthetic products which release cyanide in smoke when
burned have increased awareness of cyanide toxicity. Until
recently, the Taylor Cyanide Antidote Kit (previously the
Lilly Cyanide Antidote Kit) was the only cyanide antidote
available in the United States. However, the methemoglo-
bin produced by the nitrite portions of the kit can danger-
ously lower the oxygen carrying capacity in patients with an
elevated carboxyhemoglobin level. As a result, it is gener-
ally unsafe to administer these kits in a prehospital setting.
On December 15,2006, hydroxocobalamin was approved by
the Food and Drug Administration as a cyanide antidote.


Hydroxocobalamin is vitamin B12a, the precursor to
cyanocobalamin (vitamin B12), which had previously been
approved in a more dilute formulation in the United States
for the treatment of pernicious anemia. It has been approved
for cyanide toxicity in France since 1996. Hydroxocobalamin
functions as a cyanide antidote by binding cyanide in a
1 mol:l mol ratio. This reaction converts hydroxocobalamin
and cyanide to cyanocobalamin, which is then excreted
safely in the urine. It is now distributed by Dey, L.P. in the
United States as the Cyanokit which consists of two vials,
each containing 2.5 g hydroxocobalamin.2 Each vial must be
diluted with 100 mL normal saline and then individually
infused intravenously over 7.5 minutes.2 The starting dose is
5 g for adults and 70 mg/kg for pediatric patients.2
Depending on the severity and clinical response, a second
dose may be administered.2
An efficacy trial utilizing adult beagle dogs poisoned with
potassium cyanide compared mortality of those treated with
150 mg/kg hydroxocobalamin, 75 mg/kg, and placebo.1
Fifteen day survival rates of the three groups were 100%,
79%, and 18%, respectfully.' A safety trial for hydroxo-


Continued on Page 7





RX Updates continued from page 6

cobalamin compared the effects of 2.5 g, 5 g, 7.5 g, and 10 g
of hydroxocobalamin given to healthy volunteers.4 Due to
the red color of hydroxocobalamin, all patients should be
expected to develop chromaturia and skin redness which re-
quires several days to subside.4 Elevation of blood pressure
and a compensatory decrease in heart rate are also to be ex-
pected, both of which return to baseline within 4 hours of
treatment completion.4 Two of the 136 volunteers in the
study developed an allergic reaction, which responded to
antihistamine treatment and resolved within 2.5 hours of
onset.4
Due to the deep red color of hydroxocobalamin, interfer-
ence of colorimetric dependent laboratory tests is to be
expected.2 The extent and duration of laboratory interfer-
ence is dependent on several factors such as dose, analyte,
methodology, and analyzer.2 Therefore, it is imperative to
use caution when reporting and interpreting laboratory
results following the administration of hydroxocobalamin.
The Paris Fire Brigade has reported their experience with
hydroxocobalamin from 1995-2003.3 They reported treating
101 patients with a survival rate of 42%.3 Of the thirty-eight
patients found in cardiac arrest, 21 had a return of circula-
tion; however, 19 of those patients expired within 8 days.3
Hemodynamic instability was reported in 12 patients and
improvement was observed in 9.3


Until recently, the United States lacked a cyanide antidote
suitable for prehospital administration. Hydroxocobalamin
is now commercially available and potentially fills this need.
The availability of Cyanokit" better prepares the United
States and its health care providers with the best available
treatment for cyanide victims of potential terrorist attack or
smoke inhalation. The Cyanokit" was approved for addi-
tion to the Shands Jacksonville Formulary by the Pharmacy
and Therapeutics Committee in May. If you have any
further questions regarding hydroxocobalamin, its
administration, or cyanide toxicity in general, please contact
your local poison information center at 1-800-222-1222.

REFERENCES:
1. Borron SW, Stonerook M, Reid F. Efficacy of hydroxocobalamin for the
treatment of acute cyanide poisoning in adult beagle dogs. Clinical Toxi-
cology 2006;44:S5-15.
2. Cyanokiti [package insert]. EMD Pharmaceuticals Inc; Durham (NC):
December 2006.
3. Fortin JL, Giocanti JP, Ruttiman M, Kowalski JJ. Prehospital
administration of hydroxocobalamin for smoke inhalation-associated
cyanide poisoning: 8 years of experience in the Paris Fire Brigade. Clini-
cal Toxicology 2006;44:S37-44.
4. Uhl W, Nolting A, Color G, Rost KL, Kovar A. Safety of
hydroxocobalamin in healthy volunteers in a randomized,placebo-con-
trolled study. Clinical Toxicology 2006;44:S17-28.


UF & SHANDS BRAND


By Erin VanWey


Shands Jacksonville, UFPTI offer
world's most advanced forms of
radiation in one setting


*0000 UNIVERSITY OF FLORIDA

0llm PROTON THERAPY
*0000 INSTITUTE

Shands Jacksonville and the University of Florida Proton
Therapy Institute (UFTPI) began offering consolidated
radiation oncology services in August. With the latest con-
ventional radiation equipment and proton beam, the two or-
ganizations together offer patients the most advanced forms
of external beam radiation therapy in the world in one set-
ting.
This partnership gives patients access to more treatment
options. Every patient referred for radiation therapy will be


evaluated to identify whether they are a candidate for
conventional treatment, proton therapy or both.
Situated on the Shands Jacksonville campus, UFPTI is one
of only several proton therapy facilities operating in the
nation and the only proton therapy facility in the Southeast.
On average, 65 patients receive proton therapy in the
98,000-square-foot facility each day. With the addition of
conventional therapy services, the number of patients
receiving radiation treatment will grow to 150.
UFPTI has been treating adult patients with prostate, head
and neck, breast and brain cancer, as well as pediatric
patients, with proton therapy since August 2006. Proton
therapy is a precise radiation treatment that destroys cancer
cells and minimizes damage to healthy tissue. This results
in higher cure rates, a low incidence of side effects and fewer
long-term effects. UFPTI has future plans to expand proton
therapy treatment to cancers of the eye, lung and gastroin-
testinal tract.
Making this facility even more unique is the addition
Shands Jacksonville's conventional external beam equip-
ment: LINAC, IMRT, IGRT and stereotactic radiosurgery.


Continued on Page 8





UF & Shands Brand continued from page 7


The linear accelerator (LINAC) is the device most com-
monly used for external beam radiation treatments for cancer
patients. The LINAC can also be used in stereotactic radio-
surgery similar to that achieved using the gamma knife on
targets within the brain. Its delivery of a uniform dose of
high-energy x-ray to the region of the patient's tumor
destroys the cancer cells while sparing surrounding normal
tissue.
Intensity-modulated radiation therapy (IMRT) uses
computer-controlled x-ray accelerators to deliver precise
radiation doses to a malignant tumor or specific areas within
the tumor. The radiation dose is designed to conform to the
3D shape of the tumor by modulating the intensity of the ra-
diation beam to focus a higher radiation dose to the tumor.
Because the ratio of normal tissue dose to tumor dose is re-
duced to a minimum with IMRT, higher and more effective
radiation doses can safely be delivered to tumors with fewer
side effects.
Tumors can shift and move slightly between treatments,
and even during treatments, because of normal physiological
processes. Image-guided radiation therapy (IGRT) verifies
the tumor's exact location at the moment of treatment. The


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accuracy results in higher radiation doses to the tumor,
thereby increasing the likelihood of controlling or eliminating
the cancer. IGRT is well suited to treating tumors virtually
anywhere in the body, including those areas affected by
respiratory motion.
Stereotactic radiosurgery involves the delivery of a single
high-dose-or sometimes smaller, multiple doses-of radia-
tion beams that converge on the specific area of the brain
where the tumor or other abnormality resides. Stereotactic
radiosurgery is an important alternative to invasive surgery,
especially for tumors and blood vessel abnormalities located
deep within or close to vital areas of the brain. Radiosurgery
is also used to treat arteriovenous malformations.
In determining the most effective therapy, the
patient's treatment team conducts a simulation using CT,
MRI, PET/CT or a combination of the modalities to localize
the tumor and get the most accurate representation of treat-
ment volume.

For more information or to make a referral, call 244-7810.
Reference: Radiological Society of North America (rsna.org).


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