Group Title: Academic physician quarterly
Title: Academic physician quarterly. Vol. 2. Issue 3.
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 Material Information
Title: Academic physician quarterly. Vol. 2. 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: July 2008
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Bibliographic ID: UF00088871
Volume ID: VID00006
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.

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UF LORIDA
College of Medicine
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FOCUS
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GME CORNER
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NEWS AND NOTES^^


CHAIRMAN'S MESSAGE

Dear colleagues:
As you all know July 1st marks the start of a new academic
year. The Department has made substantial strides at ex-
panding and evolving. The productivity is at an all time
high and the operational efficiencies that were introduced
have started to show the benefits. Undoubtedly there will
be some obstacles as we move forward in upgrading our
clinic operations. Nevertheless, with perseverance and co- \
operation of all involved it will be a gratifying experience.
I am pleased to announce that the Department of Medicine
had an exceptionally successful presence at the Research Day on May 15th,
2008.
One third of platform and poster presentations from fellows and residents were
made by members of the Department. Four of our residents received the top
awards for their research presentations. The first prize for the Platform presen-
tations went to Dr. Andrew Darlington (Internal Medicine), the second prize
was awarded to Dr. Stuart A. Smalheiser (Cardiology) and the third prize went
to Dr. Ivan E. Rascon-Aguilar (Gastroenterology). In addition Dr. Joe E. Khoury
(Gastroenterology) was the First Prize winner in Poster presentations. To top it
off, Dr. Dominick Angiolillo (Cardiology) received the 2008 Researcher/Scholar
of the Year award. Please join me in congratulating the prize winners and the
participants of research day.
I am proud to report that 16 faculty members of the Department were recog-
nized for their exceptional contributions to the teaching mission of the Univer-
sity of Florida. The Department of Medicine at both campuses (Gainesville and
Jacksonville) was awarded the Golden Apple award for the second year in a
row. The award is in recognition by the medical students of the teaching excel-
lence of the Department.
It has been a wonderful spring season to finish off a very successful and pro-
ductive academic year.
Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine







FOCUS 1


Linda R. Edwards, M.D.

Associate Professor of Medicine
and Chief

Division of General
Internal Medicine






General Internal Medicine:
Who Are We and How Do We Stay Alive?

The discipline of General Internal Medicine has been
challenged from multiple directions in the past two
decades. These challenges have lead to a decline in the
number of primary care physicians available to provide
comprehensive primary care for our aging population.
Challenges include: 1) Compensation for the physicians
who are expected to coordinate the care of extremely com-
plex patients with multiple chronic diseases; 2) Internal
Medicine resident pursuit of procedure oriented fellow-
ships; 3) The hospitalist movement, while still a part of
General Internal Medicine (although there is discussion
of certification in Hospital Medicine), is drawing signifi-
cant numbers of graduating residents into its growing
ranks; and 4) The lack of exceptional role models. There
are efforts underway from the groups that represent In-
ternal Medicine, including the American College Physi-
cians and the Association of Program Directors in Internal
Medicine, to address the challenges facing Internal Med-
icine and particularly General Internal Medicine.

Here at home, the Division of General Internal Medi-
cine is focusing on exceptional role models in the hope of
increasing student and resident interest in Internal Med-
icine. The Division is comprised of 14 individuals, rang-
ing from the recent Chief Medical Resident to the more
seasoned clinician. While the interests and expertise of
the members of the Division vary, they share a common
goal of being excellent clinician educators of students, res-
idents and colleagues. Not only do they desire to excel in
being superb clinician educators, they also strive to pro-


vide comprehensive quality care, and possess the desire to
advance medical knowledge.

Our practice ranges from outpatient management of pa-
tients with complex medical illnesses, acute care of the
hospitalized patient to the longitudinal care of those who
require short term rehabilitation, and long term care. In
all of these settings the faculty serve as role models, men-
toring students and residents.

Our most decorated faculty member is Dr. Malcolm
Foster. He has been recognized as "The Doctor's Doctor"
and his opinion regarding difficult cases is sought out
across the country from prior trainees and colleagues. He
is currently the Governor of the Florida Chapter of the
American College of Physicians and is an advocate for in-
ternists and the role they play in the provision of care to
patients. He is a previous recipient of the Excellence in
Teaching Award presented annually to a faculty member
by the medical students. He continues to be recognized
by the medical students and residents as an excellent
teacher.
Several faculty members, including Drs. Palacio, Masri,
Sottile, Alexandraki, Ketty and Petrucelli have completed,
or are currently enrolled in, the Master Educators in Med-
ical Education Program offered by the University of
Florida College of Medicine. This 18 month course pre-
pares these individuals to be better clinician educators.

Dr. Sottile spent a month at Stanford where she com-


47 7r-




i.TW 4


A group photo of the Division of General Internal Medicine


Continued on Page 3





Focus continued from Page 2


pleted the Stanford Faculty Development Course in Clin-
ical Teaching. She returned invigorated and excited to im-
part what she had learned. All members of the Division of
General Internal Medicine have now completed a 16 hour
faculty development seminar in Clinical Teaching under
the tutelage of Dr. Sottile. This seminar is now being of-
fered to all members of the Department and I would
strongly encourage everyone to take advantage of this op-
portunity and Dr. Sottile's expertise in this area.

Several faculty members, including Drs. Edwards, Fos-
ter, House, Palacio, Petrucelli and Relan have received the


Excellence in Teaching awards presented each spring by
the College of Medicine. In the past few years Drs. Foster,
Ketty, House and Meenrajan have been recognized by the
residents as the best teacher for the year. The faculty mem-
bers in the Division of General Internal Medicine are ex-
ceptionally bright and energetic people who are interested
in the welfare of their students and residents and are ded-
icated to enhancing the discipline of Internal Medicine.
While the challenges exist, the Division's hope is that
through mentoring and excellent role models, our train-
ing program will see a resurgence of interest in the disci-
pline of General Internal Medicine.


A CLINICAL CASE I


Ashwin Mehta, MD, PGY-3, Department of Medicine
Nilmarie Guzman, MD, Department of Medicine, Divi-
sion of Infectious Diseases
Rajesh Rangaswamy, MD, Department of Radiology
UF College of Medicine Jacksonville



A Central Nervous System Manifes-
tation of Immune Reconstitution In-
flammatory Syndrome

INTRODUCTION
The advent of combination antiretroviral therapy for
HIV has prolonged the lives of patients with AIDS. In
some cases, however, initiation of therapy can precipitate
a paradoxical neurological deterioration, despite im-
provements in HIV viral load and CD4+ T-cell counts.
This case describes a presentation of Immune Reconstitu-
tion Inflammatory Syndrome (IRIS) in a patient who re-
cently began antiretroviral therapy.

CASE REPORT
A 45 year old college-educated man with a history of
HIV/AIDS diagnosed in 2005 presented with worsening
confusion of one week duration. He complained of inter-
mittent nausea although denied any subjective fevers,
chills, vomiting, photophobia or headaches. Subtle
changes, including short-term memory loss and inatten-
tion, began one month prior but were insufficient to keep


him from working as a real estate agent. His mental state
progressively deteriorated, began to compromise his
work and interfere with his activities of daily living. He
had not been adherent to a combination antiretroviral reg-
imen including abacavir, lamivudine, lopinavir and ri-
tonavir until two months prior to admission. His
pre-treatment CD4 count was 66.

Upon presentation, vital signs were stable and phys-
ical examination revealed an alert, cooperative man with
only partial orientation to time and place. He demon-
strated good eye contact although slow speech, difficulty
word finding, poverty of thinking, two to three word an-
swers to questions sometimes irrelevant to what was
asked. His recall was impaired 0/3 and he was unable to
spell world backwards. No focal sensory or motor deficits
were elicited. No overt meningeal signs were noted. A
lumbar puncture was performed and he was started on
empiric coverage for meningitis with vancomycin, ceftri-
axone, and acyclovir. Laboratory values including CBC,
BMP, urine toxicology screen and LFTs were within nor-
mal limits. Upon hospital admission, his CD4 count was
380 and viral load was 2000 copies per ml. CSF protein
was 69, glucose 51, gram stain and cultures were negative
as were serum cryptococcal antigen and toxoplasma anti-
body screens. MRI revealed multifocal bilateral leukoen-
cephalopathy with enhancement consistent with
inflammatory disease and immunocompromised state
(See attached figure). In spite of empiric treatment for
meningitis, his mental state continued to decline during
his hospitalization. He was started on a course of dex-
Continued on Page 4





A Clinical Case continued from Page 3


amethasone. CSF PCR studies were negative for HSV,
CMV, EBV, and positive for JC virus.

Magnetic resonance imaging studies


Diffuse multifocal abnormalities primarily involving the
white matter of the cerebral hemispheres is suggestive of
inflammatory or infectious etiologies. This can be seen
with HIV encephalitis and progressive multifocal
leukoencephalopathy.

DISCusSIoN
Progressive multifocal leukoencephaopathy with abun-
dant JC virus is one known etiology of IRIS. Antiretrovi-
ral therapy is associated with dramatic reductions in
HIV-1 RNA and increases in CD4+ lymphocyte counts. It
can also be associated with paradoxical worsening of un-
derlying opportunistic infections. The clinical presenta-
tion of immune reconstitution syndromes varies
according to the pathogen. Not every patient who has im-


munologic improvement with antiretroviral therapy ex-
periences paradoxical worsening. The risk factors for the
development of these syndromes are not well understood,
however, it is most commonly presented in patients with
pre-treatment CD4 count < 100, after the first 2-6 weeks
of initiating antiretroviral therapy with evidence of im-
munologic response to the current regimen. Intra-
parenchymal and perivascular infiltration of T
lymphocytes, predominantly of the CD8 subtype, in re-
sponse to latent viral infection in AIDS patients can also
give rise to IRIS when combination antiretroviral therapy
is begun. IRIS should be suspected in patients who show
clinical or radiologic deterioration following initiation of
antiretroviral therapy accompanied by improvement in
CD4 cell count and viral load.

REFERENCES:
(1) Riedel DJ, et al. Therapy Insight: CNS manifestations of HIV-as-
sociated immune reconstitution inflammatory syndrome. Nat Clin
Pract Neurol. 2006 Oct;2(10):557-65.
(2) Venkataramana A, et al. Immune reconstitution inflammatory
syndrome in the CNS of HIV-infected patients. Neurology. 2006
Aug 8;67(3):383-8.
(3) Crum-Cianflone NF. Immune reconstitution inflammatory syn-
dromes: what's new?
AIDS Read. 2006 Apr;16(4):199-206.
(4) Lipman M, et al. Immune reconstitution inflammatory syn-
drome in HIV. Curr Opin. Infect Dis. 2006 Feb;19(1):20-5.


GME CORNER


N. Stanley Nahman, Jr., M.D.

Professor of Medicine

Associate Chairman

Program Director, Internal
Medicine Residency




The Medicine Residency Program honors its graduates
every June with a formal dinner. Sponsored by the GME
program, all residents are invited to help celebrate the
graduation of our senior residents and fellows, and the
preliminary interns. The event includes a dinner, the
recognition of the graduates, and the acknowledgment of


individual accomplishments through specific annual
awards.

The Malcolm Foster Outstanding Intern Award is
named for Dr. Malcolm Foster, Chairman of Medicine
from 1976-1979 and Associate Chairman from 1979-1994.
The Foster Intern is that individual who best personifies
the features of a physician comrade-in-arms. She/he is
peer selected, and, above all, places the health and well-
being of the patient first. In addition, this physician is that
person who is always ready to work, always willing to
help, and is the one you know you can call upon when a
"go-to" person is needed.

The Outstanding Senior Resident Award is reserved
for the graduating senior whose performance has been


Continued on Page 5





GME Corner continued from Page 4


characterized by a willingness to go beyond the call of
duty in the care of the sick, who is genuinely excited about
learning medicine, who willingly helps colleagues in a
jam, and someone whose name evokes a good feeling
when you see it next to yours on the on-call sheet. The
Senior of the year is peer selected.

The Housestaff Teaching Award identifies the faculty
Teacher of the Year and is designed to recognize the fac-
ulty member who best demonstrates exemplary effort and
teaching ability. The Teacher of the Year Award is the
most prestigious of annual awards, and is a clear reflec-
tion of an individual faculty member's dedication to the
educational development of physicians in training.

Finally, one of the most coveted "awards" is the Uni-
versity of Florida wooden rocker that is given to each


graduating senior resident. Made possible by a generous
endowment from Mrs. Anne Michael, wife of Dr. Max
Michael, the first Dean of
the Jacksonville campus,
each piece is a hand crafted
full-sized rocking chair af-
fixed with the University of
Florida seal. Mrs. Michael
wanted to foster pride in
both the institution and the
accomplishment symbol-
ized by successful comple-
tion of residency training.
She surely has succeeded, for of all the awards, this is the
one most bragged about by the graduates.


RX UPDATES


Patrick Aaronson, Pharm.D.
Ashley Schields, Pharm.D., BCPS

Ezetimibe and the ENHANCE Trial

There has been much press regarding the safety and
efficacy of eztimibe monotherapy (Zetia) and combina-
tion therapy ezetimibe/simvastatin (Vytorin). Vytorin
is not in the Shands Jacksonville Inpatient or Ambulatory
Formulary, but the ezetimibe and simvastatin individu-
ally are available. However, the utility of eztimibe has
been questioned by some.

ENHANCE was a prospective, randomized, double-
blind, multicenter trial comparing the effects of simvas-
tatin alone versus in combination with ezetimibe in 720
patients with familial hypercholesterolemia (FH). These
patients entered the study without regard of previous
lipid lowering agents, including stations, but with a
placebo washout period for 6 weeks. The duration of the
trial was 24 weeks. The primary endpoint was mean
change in carotid-artery intima-media thickness (IMT).
Results included a significant decrease in LDL (16%) with
Vytorin versus simvastatin alone; however, there was not
a significant difference regarding mean change in IMT.
Although this is not an outcomes trial, questions regard-
ing the efficacy of ezetimibe are raised due to the consid-


eration of IMT as a surrogate marker for cardiac events. A
comparison with a previous trial in FH patients, ASAP
(Atorvastatin 80 mg vs. Simvastatin 40 mg on Artheroscle-
rosis Progression) study, showed a significant difference
in the atorvastatin group with regards to decrease in IMT.
Conversely, the simvastatin group did not have a signifi-
cant decrease in IMT.

Editorialists suggest that the ASAP patients had a
thicker IMT at baseline compared to the ENHANCE pa-
tients, which raises the question of study design flaws
with extensive prior station use by patients. However, 19%
of patients in the ENHANCE trial that were not on a station
did not have a decrease in IMT thickness. Concerns re-
garding a relatively short evaluation period of 24 weeks
and relation to progression of IMT thickness have also
come into question.

Outcomes data are projected to be reported in 2011.
The American College of Cardiology (ACC) suggests con-
sidering decreasing lipid levels as much as possible with
agents that presently have favorable outcomes data in-
cluding the use of stations at optimized doses in combina-
tion if needed with other agents with proven outcomes
data such as nicotinic acid, fibrates, and bile acid seques-
trants. Ezetimibe may be best considered in patients who
are unable to tolerate alternative regimens.







NEWS & NOTES


Editor's note: The last quarter was exceptionally bountiful of good news for the Department of Medicine. Here are
some highlights of these successes.


Exemplary Teacher Awards


Annual Research Day Awards


Sixteen faculty members in the Department of Medicine
were chosen to receive the 2008 University of Florida Col-
lege of Medicine's Exemplary Teacher Award.

The awardees include (arranged alphabetically): Drs.
Irene Alexandraki, Theodore A. Bass, James D. Cury,
Linda R. Edwards, Malcolm T. Foster, Luis Guzman,
Steve S. Hsu, Arpitha K. Ketty, Ghania Masri, Senthil
R. Meenrajan, Alan B. Miller, N. Stanley Nahman Jr.,
Carlos Palacio, Olga M Petrucelli, Michael Sands and
Elisa M. Sottile.

This award is given in recognition of outstanding teaching
contributions of an individual faculty member. The
awardees will receive a plaque, lapel pin and a financial
award determined by the compensation plan incentive for
outstanding teaching.

Teaching Awards for Dr. Alexandraki

Dr. Irene Alexandraki was chosen
as the 2008 University of Florida-
College of Medicine's Excellence in
Student Education Award. The
award is given annually to the fac-
ulty member identified as the most
outstanding teacher by medical
students. Dr. Alexandraki received
the award during the graduation
ceremonies on June 18, 2008.

But wait... that's not all! Dr. Irene Alexandraki was cho-
sen as the Outstanding Clinical Year Instructor by the
Class of 2008 of the University of Florida Physician As-
sistant Program. Dr. Alexandraki was recognized for this
Award during the 2008 Honors and Convocation Cere-
mony on Saturday June 21, 2008. The award is given an-
nually to a faculty member in recognition of her or his
commitment to clinical education.

Please join me in congratulating Dr. Alexandraki for these
multiple honors.


Department of Medicine Residents received the top prizes
at the UF-COM JAX Annual Research Day on May 15th,
2008. Four of our residents received the top awards for
their research presentations. The first prize for the Plat-
form presentations went to Dr. Andrew Darlington (In-
ternal Medicine), the second prize was given to Dr. Stuart
A. Smalheiser (Cardiology) and the third prize went to
Dr. Ivan E. Rascon-Aguilar (Gastroenterology). In addi-
tion Dr. Joe E. Khoury (Gastroenterology) was the First
Prize winner in Poster presentations.

Congratulations to the prize winners and the participants
of research day presentations.

American Society of Gastroenterology
2008 Minority Award: Dr. Kenneth Vega


Dr. Kenneth Vega was selected
as the recipient of the 2008
ASGE Minority Award. The
award is granted to physicians
who submit an outstanding ab-
stract for Digestive Disease
Week promoting minority-re-
lated healthcare research.


Congratulations to Dr. Vega.



Outstanding Presentation at the Southern
Society for Clinical Investigation
Nephrology Fellows Research Forum

Bobby Sullivan (Nephrology Fellow) placed third out of
11 abstracts for his outstanding presentation at the South-
ern Society for Clinical Investigation Nephrology Fellows
Research Forum. He presented the Hep C work from the
USRDS which included the new data on cirrhosis.

Way to go Bobby...







MEET YOUR COLLEAGUES


Editor's note: Periodically the "Academic Physician Quarterly" will introduce our readership to new faculty mem-
bers who have exceptional clinical skills. In this issue we highlight the Chief of Rheumatology and Clinical Immunol-
ogy who joined UF-Shands Hospital in the last year.









cld huaodathii,,'rdramoii n ot


HANDS BRAND


New Magnet at Shands Jacksonville Creates 3-D Images of the Body in Just
6 Minutes Shands


Jacksonville Center for Advanced CT & MR Imaging Now Open
Written by Kelly Brockmeier

On Feb. 14, a 28,600-pound, high-powered imaging magnet was hoisted through the roof of a new imaging building
behind the Pavilion that was built exclusively for the Siemens 3T TIM Trio
and an accompanying state-of-the-art dual source 64-slice CT system. The
magnet is the core of Shands Jacksonville's advanced MRI system from
Siemens Medical Solutions.

The 3T is capable of rapidly creating 3-D images of different parts of the
S- body, including the moving heart. The 3T is so fast that it can scan the entire
body in just six minutes. It is also better suited than traditional MRI systems
at evaluating abnormalities in organ metabolisms and function before per-
manent damage has occurred.

With the 3T system, UF physicians and imaging scientists are able to see into
the most microscopic corners of the human body. In the heart for instance,
it enables them to observe mildly impaired blood flow to its muscle and early scarring.


Continued on Page 8





Shands Brand continued from Page 7


"3T MR technology allows us to better diagnose the most complex cardio-
vascular, neurological and oncologic conditions, and, thus, better support
the subspecialty care of patients," said Richard D. White, MD, chairman ..
of the UF Department of Radiology on the Shands Jacksonville campus.

In addition to the 3T magnet, the new Shands Jacksonville Center for Ad-
vanced CT & MR Imaging houses a dual-source 64-slice CT scanner. The
scanner, primarily used for imaging of cardiac patients, allows radiologists
to evaluate patients quicker than traditional CT technology. Previously,
patients having single-source CT scans had to take medication to slow their
heart rate for imaging purposes, but the speed of the dual source system
eliminates that need in most cases. In addition, the new imaging system provides substantially less radiation than a sin-
gle-source CT scan.

For more information or to refer patients, call the Shands Jacksonville Center for Advanced CT & MR Imaging at 244-
7232.


NON-PROFIT ORG.
U.S. POSTAGE
PAID
JACKSONVILLE, FL
PERMIT NO. P173


fUF UNIVERSITY of
UFFLORIDA
College of Medicine
Jacksonville
653-1 West Eighth St.
Department of Medicine
Jacksonville, FL 32209-6511
904-244-8846; fax: 904-244-8844

653-1 West 8th Street
Department of Medicine, L20
Jacksonville, FL 32209-6511
904-244-8846; fax: 904-244-8844




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