Group Title: Academic physician quarterly
Title: Academic physician quarterly. Vol. 2. Issue 1.
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Permanent Link: http://ufdc.ufl.edu/UF00088871/00004
 Material Information
Title: Academic physician quarterly. Vol. 2. Issue 1.
Series Title: Academic physician quarterly
Physical Description: Serial
Creator: University of Florida College of Medicine
Publisher: College of Medicine, University of Florida
Publication Date: January 2008
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Bibliographic ID: UF00088871
Volume ID: VID00004
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.

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A DEPARTMENT OF MEDICINE BULLETIN


UF UNIVERSITY of
UF FLORIDA
College of Medicine
Jacksonville


FOCUS










*X UPDAEYS1U~f]EA6U
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NEWS AND NOTES















^Page 6'




MEET YOUR COLLEAGUES
^^Page 7

UF & SHANDS BRAND


^^^^^^Page 7'


CHAIRMAN'S MESSAGE

Dear Colleagues:

On behalf of the Department of Medicine at the University
of Florida, College of Medicine Jacksonville, I would like to
wish you a happy and prosperous 2008.

We are excited to be in our second year of publishing the
Academic Physician Quarterly (APQ) newsletter. Although
this vehicle of communication is still in its infancy, I am
proud to say that the newsletter has been an invaluable tool
to keep the physicians in our community abreast of the new ; ;
services developed at the University of Florida and Shands
Jacksonville.

We have made significant strides in developing our clinical units. We recently
welcomed three new diabetologists and endocrinologists. These new members of
the Division of Endocrinology, Diabetes and Metabolism are highlighted in the
Meet your Colleagues section.

The Focus section gives a glimpse of the breadth of patient care offered by the
faculty and staff of UF and Shands. The spectrum of this care spans from highly
intensive critical care to more rehabilitative transitional care and everything in
between. In the current issue, we highlight the activities of the Medical Intensive
Care Unit. In the next issue, we will focus on the Transitional Care Unit.

We would like to see the APQ become a vehicle of dialogue with the commu-
nity physicians. If you have any comments, interesting cases or observations to
share with colleagues please e-mail them to me and I will be happy to include
them in our future issues. My e-mail address is Arshag.mooradian@jax.ufl.edu.

Happy New Year to you all.
Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine







FOCUS


Kathryn Koch, M.D.
Associate Professor of Medicine
Division of Pulmonary and
Critical Care Medicine


Critical Care Unit


The medical intensive care unit (MICU) is a very busy
and dynamic service with high acuity. On the average, 10
patients are either admitted a day or require MICU con-
sults. Through the heroic efforts of the staff, many
patients in MICU survive despite the severity of their
acute illness. A great example of a good outcome is the
following case history.
In May, a 46-year-old man was found in his work van,
in urine and vomit. He was flown to Shands Jacksonville
where he was intubated for airway protection because of
a Glasgow Coma Scale of 6. The patient was pink,
diaphoretic, had a brisk capillary refill, blood pressure
of 110/70 mm Hg, pulse of 130/minute, a sinus rhythm
but there was no urine output. The arterial blood gas
analysis on 100 percent oxygen showed pH 7.23, pO2 302,
pCO245, measured 02 saturation of 81.5 percent, calcu-
lated bicarbonate of 18.8 meq/1 and carboxyhemoglobin
was 17.9.
It turned out that the generator in his work van was
three years old with no carbon monoxide monitor. He
said that he, "felt funny" working in the back of the van,
got out to see if he would feel better but found he could
not walk well and went back inside the van to sit down.
He was found about 2 hours later in the condition de-
scribed above.
Carboxyhemoglobin was down to 8.4 after four hours
on 100 percent oxygen, two hours later weaning off the
ventilator was started and when carboxyhemoglobin was
decreased to 1.6, he was extubated. The patient was dis-


charged to the floor for a short period of recuperation and
returned to work.
Despite the excellent outcome of patients in the MICU
given the nature of injuries and organ damage the
mortality rates are high. In 2006, there were 1,205 patients
admitted to the MICU, of whom 237 subsequently died
while still in the unit. This represents a mortality rate of
20 percent which is below the national average mortality
rate of 30 percent for MICU patients. These statistics
highlight the heroic work carried out by the UF Physi-
cians and the Shands Jacksonville MICU staff.
Every death in the MICU is tragic for a family. Occa-
sionally this tragedy may contribute to the miracle of life
for another patient suffering from a fatal disease. This
happens through the organ donation program.
Institutional policy mandates the referral of brain dead
individuals or individuals with a Glasgow Coma Scale of
5 or less who are not expected to survive, to an organ do-
nation program (Life Quest). Life Quest then evaluates
these individuals and if deemed appropriate, approaches
the family for consent. In 2006, there were 25 donors
whose organs were retrieved. A patient who progresses
to brain death is actually looked upon like eight patients.
The donor patient and the seven people who would ben-
efit from receiving transplanted organs.







SA CLINICAL CASE


Jesus Diaz, M.D.
Assistant Professor of Medicine,
Division of Pulmonary and Critical Care Medicine
Mayo Clinic Jacksonville


Kathryn Koch, M.D.
Associate Professor of Medicine,
Division of Pulmonary and Critical Care Medicine


Pulmonary Hypertension In Preg-
nancy


CASE PRESENTATION
A 26-year-old African American woman, who had four
normal pregnancies and deliveries, was admitted four-
weeks after the last normal vaginal delivery complaining
of shortness of breath which started two days post-par-
tum. Her SOB had progressed to the point where it was
persistent at rest. Chest pain had occurred for about a
week post-partum but had subsided. There has been in-
termittent nausea and vomiting, particularly whenever
she had to get up in the middle of the night, when cough-
ing fits would stimulate emesis. Past medical, surgical
and social history is otherwise negative.
Remarkable findings on initial evaluation were: Pulse
129/minute regular; respiratory rate of 32/minute; blood
pressure of 113/72 mm Hg; 02 saturation of 86% on
room area and 93% on 10 liters via face mask. She was
alert and oriented, no lymphadenopathy, neck veins were
flat and a right ventricular heave was present. The breath
sounds were decreased throughout all lung fields and a
holosystolic murmur was heard on cardiac examination.
Extremities were dry with good capillary refill, no club-
bing cyanosis or edema but pedal and radial pulses were
only 1+ and lower extremities were cool to touch.
Arterial blood gases on the second hospital day on
100% NRB revealed pH = 7.47, pCO2 =22 and pO2 =94.
Electrolytes were normal, BUN =28, creatinine =1.7
mg/dl, Hb =16 gm/dl, Hct =46.4%, WBC =8.2K and
platelets =353K. Chest X ray was clear with mild car-
diomegaly. EKG showed sinus rhythm. Other tests in-
cluded PT = 13.6, INR = 1.2, PTT =23.9, D-dimer =1.8.


Urinalysis showed 4+ protein and large blood. CT scan
of chest revealed no clots but changes consistent with
pulmonary arterial hypertension were present.
2D-ECHO revealed PA pressures estimated 107 mmHg
with EF55-60%. Differential diagnosis included pul-
monary vasculitis, pulmonary arterial embolism and pul-
monary veno-occlusive disease. Open lung biopsy was
planned on the third hospital day but upon intubation,
her condition deteriorated and aggressive resuscitation
including nitric oxide and vasopressin treatment failed.

DISCUSSION

This previously healthy young woman presented with
dyspnea that developed two days after delivering a
full-term healthy baby, which was followed by chest pain
four weeks later. The differential diagnosis of a young
woman with severe pulmonary hypertension in the
absence of evidence of left-sided cardiac disease, con-
genital heart disease or diffuse pulmonary parenchymal
disease is not broad. The current WHO classification of
pulmonary hypertension lists five different groups.
(Table):

TABLE : WHO classification of Pulmonary Hypertension.

Group 1: Pulmonary arterial hypertension, in which
there is proliferative obstruction of small, muscular
arterioles. Causes include collagen vascular diseases
(CVD), drugs (anorexigens), congenital heart disease
(CHD) with left-to-right shunts and idiopathic form
(formerly known as primary) which can be sporadic
or familial.
Group 2: Secondary to increased left-sided cardiac
pressures.
Group 3: Associated with bronchopulmonary disorders
with hypoxemia (interstitial lung disease, COPD, hy-
poventilation syndromes).
Group 4: Due to chronic pulmonary thromboembolic
disease (CPTED)
Group 5: Other causes, including fibrosing mediastinitis
or sarcoidosis with extrinsic vascular compression.
Pulmonary hypertension of this severity could not have
developed acutely. Therefore, it is admirable that this
woman managed to bring a pregnancy to full term while
dealing with her underlying cardiovascular illness. Case

Continued on Page 4





A Clinical Case continued from page 3


series of women with known pulmonary hypertension
idiopathicc, due to CHD, CVD or CPTED) have shown
that less than 25 percent are capable of carrying a preg-
nancy to term, with a neonatal mortality of 12 percent and
a maternal mortality of between 30 and 56 percent, de-
pending on the cause.1,2
Based on the data obtained pre-mortem, we can say that
she did not have CHD, CVD, diffuse pulmonary
parenchymal disease, left-sided cardiac disease or fibros-
ing mediastinits to explain her pulmonary hypertension. A
CT angiogram did not reveal thromboembolic disease.
However, this study may lack sensitivity in detecting seg-
mental, well-endothelialized thrombi. Therefore, we sus-
pect the cause of her pulmonary hypertension to have
been either idiopathic PAH (WHO Group 1), but cannot
rule out chronic thromboembolic disease.


congestion. There were intra-acinar arteries with
concentric laminar intimal thickening, medial hypertro-
phy, plexiform lesions and dilatation lesions. There was a
hypertrophic right ventricle with a transmural infarction
of the posterior wall of approximately 10 days of age. The
cause of death was determined to be primary
pulmonary hypertension with right ventricular myocar-
dial infarction.

REFERENCES

1. Smedstad KG, Cramb R, Morison DH. Pulmonary hypertension and
pregnancy: a series of 8 cases. Can J Anaesth. 1994;41:502.
2. Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of pulmonary vascular
disease in pregnancy: a systematic overview from 1978 through 1996.
J Am Coll Cardiol. 1998;31:1650.


Autopsy revealed features of primary pulmonary
hypertension with plexiform lesions and marked




GME CORNER


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







The annual identification and
recruitment of strong PGY-1 (intern) trainees is a cru-
cial facet of every successful residency training pro-
gram. The residency program leadership,
Departmental leadership, and all members of the fac-
ulty recognize this fact and each year work as a cohe-
sive team to attract the strongest candidates to the
program.
The eight-month process begins in August of each
year when the Electronic Residency Application
Service (ERAS) begins accepting applications from over
20,000 prospective interns. ERAS provides a vital serv-
ice by offering a standardized, online application plat-


form. The ERAS database contains a file on each appli-
cant and allows training programs to screen for
desirable candidates. From this pool, candidates are
invited for an interview. After all interviews are con-
ducted (late January) candidates rank their programs in
order of preference and programs rank their applicants
in the same manner. In mid-March, the National Resi-
dency Match Program (NRMP) uses a computer
algorithm to match applicants and training programs
according to the highest ranked preferences by each
party. The result of this computation is termed "the
match" and is one of the most important days of the year
for the program.
It is highly desirable to fill all open slots with candi-
dates from the rank list submitted by the program.
Unfilled positions result in a "scramble" for applicants.
The scramble is a gamble for both applicants and
programs a professional blind date, if you will and
most programs (including the University of Florida at
Jacksonville) prefer to avoid scrambling.
A key strategy to a successful match is to submit a
rank list with a sufficient number of candidates.


Continued on Page 5





GME Corner continued from page 4


According to the NRMP, programs that match success-
fully rank 9 candidates for every position. Programs
that scramble rank about half that number (- 4.8 candi-
dates per position).
In 2007, our program was seeking 13 categorical
trainees. This final number translated to a desired
active rank list of ~ 117 candidates (9 candidates per po-
sition). In fact, we ranked 100 candidates (~ 7.7 candi-
dates per position). The rank list was based upon
interviewing 118 applicants. To identify the 118 inter-
viewees, the program used ERAS to screen more than
1,600 applicants.
The interview days were conducted between No-


vember and January. The interview itinerary included
an ice-breaker with current residents the night before
the interview and a one night stay at the Hyatt (both at
the program's expense), followed the next day by a
morning of interviews with faculty and interaction with
the residents. By 1 p.m., the typical interview day had
concluded and preparation for the next group began.
The interview season is a scheduling nightmare
capped with frantic days of interviews but well worth
the effort for a successful match. We did match last
year, managing to recruit a delightful group of bright,
energetic professionals all derivative of the top end of
our rank list. No blind dates here, just another suc-


RX UPDATES


Luis Laos, M.D.
Associate Professor of Medicine
Division of Pulmonary and
Critical Care Medicine


Drotrecogin alfa (XIGRIS")


Drotrecogin alfa (activated) is a recombinant form of
human activated protein C, an endogenous protein that
promotes fibrinolysis and inhibits thrombosis and inflam-
mation. It appears to be an important modulator of the co-
agulation and inflammation associated with severe sepsis.
Drotrecogin alfa is approved by the FDA for adults with
severe sepsis who have a high risk of death as determine
by an APACHE II score greater than 25. This approval is
based on a large multicenter, randomized, placebo-con-
trolled trial (PROWESS) that showed that treatment with
drotrecogin alfa was associated with a 6.1% absolute
reduction in 28-day mortality in patients with severe
sepsis, compared with placebo (24.7% vs. 30.8%)1
Patients included in PROWESS had a known or
suspected infection, three or more signs of systemic
inflammation (temperature >100.4'F or <96.8F; heart rate
>90 beats/min; respiratory rate >20 breaths min, PaCO2


<32 mmHg, or need for mechanical ventilation; and white
blood count of >12,000/mm3, <4,000/mm3, or > 10% im-
mature neutrophils), and sepsis-induced dysfunction of at
least one organ system for less than 24 hours. Patients were
primarily excluded if they had any condition that
increased the risk of bleeding.
The mortality benefit of drotrecogin alfa was largest in
the sickest patients, such as those with an APACHE II
score of more than 25. In this group there was a 13 percent
absolute risk reduction in 28-day mortality compared with
placebo. This represents a 29 percent relative risk
reduction.
Since PROWESS, a follow-up study has confirmed a
large, sustained benefit in sicker patients with an im-


Continued on Page 6


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RX Updates continued from page 5



provement in survival that remains highly significant over
a follow-up period of more than two and half years.2
The ADDRESS trial was an FDA required study to eval-
uate the efficacy of drotrecogin alfa for adults who had se-
vere sepsis and a low risk of death3. Enrollment was
terminated early because of a low likelihood of meeting
the prospectively defined objective of demonstrating a sig-
nificant reduction in the 28-day mortality rate with the use
of drotrecogin alfa. The absence of a beneficial treatment
effect indicates that drotrecogin alfa should not be used in
patients with severe sepsis who are at low risk for death,
such as those with single-organ failure or an APACHE II
score less than 25.
Drotrecogin alfa does have anti-coagulant properties
and there was a trend to an increased incidence of serious
bleeding in the therapy arm in PROWESS (3.5% vs. 2.0%,
p=0.06). However, serious bleeding occurred primarily in
patients with an identifiable predisposition to bleeding,
and blood-transfusion requirements were similar
between groups after adjustment for duration of survival.
Several large uncontrolled series since PROWESS have re-
ported similar bleeding rates. The elimination half-life is 13
minutes, indicating a rapid inactivation of drotrecogin alfa
after stopping infusion. Approximately 80 percent of the
drug is eliminated in 30 minutes. The above-mentioned
pharmacokinetic data is based on healthy subjects. Plasma
clearance of drotrecogin alfa in patients with severe sepsis
is approximately 50 percent higher.


Several studies have demonstrated that despite the
initial acquisition cost, drotrecogin alfa has a very
acceptable cost-effectiveness profile similar to, or better
than, many well-adopted healthcare interventions. 4-6

REFERENCES
1. Bernard GR et al. Efficacy and safety of recombinant human activated
protein C for severe sepsis. N Eng J Med. 2001;344:699-709
2. Angus DC et al. The effects of drotrecogin alfa (activated) on long-term
survival after severe sepsis. Crit Care Med 2004;32:2199-2206
3. Abraham E et al. Drotrecogin Alfa (Activated) for Adults with Severe
Sepsis and a Low Risk of Death. N Eng J Med. 2005;353:1332-1341
4. Angus DC et al. Cost effectiveness of drotrecogin alfa (activated) in the
treatment of severe sepsis. Crit Care Med. 2003;31:1-11
5. Manns BJ et al. An economic evaluation of activated protein C treatment
for severe sepsis. N Eng J Med. 2002;347:993-1000
6. Nelson AR et al. Cost-effectiveness od drotrecogin alfa (activated) for the
treatment of severe sepsis in Germany. J Crit Care 2003;18:217-227


NEWS & NOTES I


* During the last six months, several faculty members in
the Department of Medicine received prestigious
awards and grants. Four faculty members were the re-
cipients of 2007 Dean's Fund Faculty Research Awards.
The awardees were Dr. Arpitha Ketty (General Internal
Medicine), Dr. Fauzia Rana (Hematology and Oncol-
ogy), Dr. Kenneth Vega (Gastroenterology) and Dr.
Kent Wehmeier (Endocrinology).

These competitive awards provide seed money to enable
the faculty to develop a research idea into a publishable
manuscript and use the information generated as


preliminary data when seeking additional extramural
funding.

* Dr. Martin Zenni, Division of Cardiology, is the
recipient of the 2007 Rear Admiral Paul Kaufman
Award. The award is given annually by the Medical
Staff of Naval Hospital Jacksonville in appreciation of
a healthcare provider's selfless support of the Naval
Hospital staff and care of its patients. Congratulations
to Dr. Zenni for this honor.






MEET YOUR COLLEAGUES

Three Endocrinologists and Diabetologists Join the Department.







































Jacksonville
Ann Harwood-Nuss, M.D., and software in order to redesign, enhance and present the
Assistant Dean for Program Development. clinical services provided on our campus. The Web Team
has also purchased a Google server for searching the site.
SHANDS JACKSONVILLE DEBUTS REDESIGNED WEB SITE A template was developed so that information provided
Shands Jacksonville and the University of Florida College by the academic departments would be organized in an in-
of Medicine-Jacksonville have formed a collaborative Web formative, comprehensive manner to serve as a marketing
Development Team in order to grow our Internet presence. tool for the public, patients and referring physicians. All
The initial efforts were directed toward the development departments were asked to provide information about their
of a comprehensive clinical services Web site. This required
the acquisition of additional web developers, equipment Continued on Page 8
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the acquisition of additional web developers, equipment Continued on Page 8





UF & Shands Brand continued from page 7


clinical services and faculty. The ultimate goal is to have
an interactive Web site with online appointments, pod-
casts, featured faculty, on-line health surveys and other
patient-friendly features.
Thanks to the response of the University's departments
and divisions, the redesigned site was launched in
September.
Successful Web sites are dynamic, consistently updated
with new information. The great value of Web-based in-
formation is obvious; however, its success is dependent
upon the integrity of the information. There is a Web site
feedback link on the home page for the purpose of
obtaining customer impressions. This link can also be used
by you and your staff to send comments or suggestions to
the Web Team.
Take some time to review the new Web site at
jax.shands.org and click on the Healthcare Services link.


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You'll see there are now several ways for visitors to find
the information they're looking for: by centers and insti-
tutes, departments and divisions, and alphabetically by
topic. The pages for each department include more
detailed descriptions of medical conditions and the serv-
ices we provide something consumers have come to ex-
pect from an academic medical center.










































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