Title: Academic physician quarterly
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00088871/00007
 Material Information
Title: Academic physician quarterly
Series Title: Academic physician quarterly
Physical Description: Serial
Language: English
Creator: College of Medicine, University of Florida
Publisher: College of Medicine
Place of Publication: Jacksonville, Fla.
Publication Date: October 2008
 Record Information
Bibliographic ID: UF00088871
Volume ID: VID00007
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.


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Dear colleagues:

I am pleased to share with you the Fall 2008 issue of Aca-
demic Physician Quarterly (APQ) newsletter.

As you all know we went through the first major hurri-
cane of the season with relatively minimal consequences.
Fortunately, The Institution and the Department had a
comprehensive hurricane preparedness plan in place that
was executed seamlessly. We hope that hurricanes in our
area would not detract us from the excitement of upcoming presidential elec-
tions. Indeed, these are exciting times to be part of making history when the
country for the first time will either have a woman vice president or an
African American president.

The Department of Medicine continues to make headway in delivering clini-
cal care, educating residents and students and developing research projects.
In this issue, we describe our Division of Hospital Medicine in the Focus sec-
tion. This is currently the largest division within the Department of Medicine
and is comprised of over 20 providers. Most recently 7 internists joined the
Division to make it one of the largest in the country. Other Divisions were
also successful in recruiting talented faculty some of whom are highlighted in
the section on Meet Your Colleagues.

As always, if you have any comments or observations to share with col-
leagues 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.

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


Jeff House, D.O.

Assistant Professor of Medicine
and Chief

Division of Hospital Medicine

Hospitalist and Patient Care:

Keeping with the Times

In 1996 Drs. Robert Wachter and Lee Goldman coined
the term "hospitalist" in a publication in the New Eng-
land Journal of Medicine, referring to physicians whose
practice emphasizes providing care for hospitalized pa-
tients. Since this review the hospitalist profession has ex-
perienced dynamic growth. In 2007 there were an
estimated 20,000 hospitalists practicing in the United
States, and this number is expected to exceed 30,000 by
2010. Today there are more jobs available in hospital
medicine than any other career in internal medicine.

Membership is not the only area where hospital medi-
cine has evolved. What began as a temporary job has now
become a career for many physicians. Today's hospitalist
activities not only include patient care, but teaching, re-
search, and leadership related to hospital medicine. In-
terest from medical students and residents has lead many
academic institutions to develop hospitalist residency and
fellowship programs. Hospitalist tracks offer additional
exposure to the broad range of issues confronting hospi-
tal-based physicians, such as end-of-life care, quality im-
provement, and medical consultation.

The University of Florida Division of Hospital Medicine
is not without its own growth and evolution. Since the
program's inception in 2000, it has grown from a one
physician, one physician assistant service to 18 full time
physicians and 2 physician extenders. The division now
has an established team of highly qualified, specially
trained, experienced providers, some who have been on

service here for over 6 years. They have grown from an
average daily census of approximately 20 patients in 2000
to 125 in 2008. The service routinely handles 20-30 new
admissions a day, and they are the exclusive health care
providers of all medical patients transferred from outside
facilities. Their service is not limited to ED admissions
and hospital-to-hospital transfers. They are also the re-
ceiving service for direct admissions from University of
Florida satellite offices. This service allows primary care
physicians to focus on their office patients.

Just as with the national trend in hospital medicine, this
division's growth can be measured by more than just the
number of employees or degree of clinical service de-
mands. The division has ventured into other areas out-
side of patient care including scholarly activity, education,
and quality improvement. This past year marks the divi-
sion's first successful elective in hospital medicine. This
one-on-one Hospital Medicine rotation, designed for 3rd
year residents, was complete with a written curriculum
and didactic sessions on advanced topics such as pallia-
tive care, insurance, and billing. Dr. Praveen Garg has
completed an 18 month course in the Master Educators in
Medical Education Program to further develop clinical ed-
ucator skills. Scholarly activity has been a new focus over
the last year, and this has resulted in 6 publications as well
as several abstracts.

The division also participates in a number of adminis-
trative activities that directly affect patient care. These in-

I #I eI

A group photo of the Division of Hospital Medicine

Continued on Page 3

Focus continued from Page 2

clude the Med Safety Committee, Throughput Committee,
Medical Performance Improvement Committee, and Fac-
ulty Council. Many of these programs directly impact the
quality of health care delivered in this hospital.
As the national picture of hospital medicine continues to
evolve, so too will this program. The division's primary
focus remains to provide high quality care for all hospi-

talized patients. Our team works in partnership with var-
ious entities within the hospital including specialists and
case management. Our mission is to support and promote
changes to the health care system that lead to higher qual-
ity and more efficient care for all hospitalized patients.


Vu, Ho John MD (University of Florida (UF), Medicine)
Mannepalli, Supriya MD (UF, Infectious Disease)
Ahmad, Maria MD (UF, Pathology)
Laos, Luis MD, FCCP (UF, Pulmonary & Critical Care)

Non-Infectious Cause of Pneumonia
in an Immunocompromised Patient


A 24 year old man with untreated HIV/AIDS with a
CD4 count of 6 presented with progressive shortness of
breath, nausea and vomiting for more than 3 weeks.
Initial Chest X-ray demonstrated a reticulonodular pat-
tern bilaterally throughout the lung fields and he was
treated empirically for Pneumocystis jiroveci and hospital
acquired pneumonia. No clinical improvement was noted
even on broad spectrum antibiotics including anti-fun-
gals. Blood and sputum cultures were consistently nega-
tive. There were no suspicious skin lesions on physical
examination and brochoalveolar lavages performed on
two separate occasions were negative for organisms but
did show alveolar hemorrhage.

His condition worsened and he developed respiratory
distress, multi-organ failure and expired in the ICU. His
autopsy report showed widespread Kaposi's sarcoma in-
volving the lungs, liver, small and large bowel, mediasti-
nal and mesenteric lymph nodes (see included pathology


Pneumonia in the patient with HIV/AIDS can be at-
tributed to a number of different causes: most commonly
bacterial then Pneumocystis jiroveci and, depending on
the endemic region, fungal and viral. This case report

demonstrates a rare cause of pneumonia in a 24 year old
man: neoplasm.

In HIV disease, the development of Kaposi's sarcoma
(KS) is dependent on the interplay of a variety of factors
including HIV-1 itself, human herpes virus 8 (HHV-8),
immune activation, and cytokine secretion. KS is an
angio-proliferative disease with excessive proliferation of
spindle cells that are believed to be of vascular origin and
have features in common with endothelial and smooth-
muscle cells.

Pulmonary Kaposi's sarcoma is often associated with

Continued on Page 4

A Clinical Case continued from Page 3

dyspnea, nonproductive cough, fever, and hemoptysis.
Although Kaposi's sarcoma is typically a multicentric neo-
plasm with skin, gastrointestinal, and lymph node in-
volvement, many patients with pulmonary Kaposi's
sarcoma do not have the characteristic cutaneous viola-

ceous macules, papules, or nodules or clinical evidence of
disease in other organs. It is important to consider Ka-
posi's sarcoma when evaluating HIV/AIDS patients with
respiratory distress and alveolar hemorrhage even in the
absence of classical disease findings.


Senthil Meenrajan, M.D.,

Assistant Professor of
Medicine, General Internal

Associate Program Director,
Internal Medicine Residency

The start of the academic year could not have been bet-
ter for the Internal Medicine Residency. Every year we
think we have the best cohort of trainees and the very next
year we are proven wrong. We are delighted to be wrong
again this year!! The anxiety of having new interns and
some new residents went away when everyone seemed to
take to their duties like 'fish to water'. One of the keys for
ensuring that everyone does their part really well is hav-
ing exemplary role models. The Graduation Dinner was
held to celebrate our graduating residents and also to
honor those that were peer selected to be the best Dr.
Michael Hernandez (Senior Resident of the Year) & Dr.
Jasdip Matharu (Intern of the Year). Oh! By the way, Dr.
Cury won the 'Teacher of the Year' award. The number of
times he has won this award in the past 2 (I don't think
anyone knows the real number for sure but I think I might
have forgotten a zero after the 2!!). We are privileged that
he teaches our residents.

While we have many distinguished faculty on our
staff, we still miss Dr. Arpitha Ketty who had to move on
to pursue other goals. As a physician, colleague, teacher
and Associate Program Director, she was loved and re-
spected by all. She has left a pair of shoes that are impos-
sible to fill and she is dearly missed.

Moving on, the educational platform continues to be

stronger than ever. The expanding number of fellowships
and the accomplished fellows we attract also make us
proud. This year during the fellowship match our resi-
dents had an astounding showing:

* Tom Nguyen Nephrology, UF Jax
* Vinny Samuel Nephrology, UF Jax
* Siva Suryadevara Cardiology, UF Jax
* Ruchi Gupta Gastroenterology, University of Mis
souri Columbia
* Mohammad Asif Khan Oncology, UF Jax

Congratulations to all of them. Talking about congrat-
ulating and being strong also reminds me of a number of
residents (and faculty) that have 'graduated' to being par-
ents or being parents again and we offer them our best
wishes. The program is also making positive changes in
the way several educational activities are conducted in-
cluding Morning Report and Board Review. All of this has
been very well received by students, residents and faculty.

Like in everything else, the circle of life continues and
I am back to where I started i.e. recruiting the very best.
The interview season looms and we have made significant
changes to our process, partly guided by feedback from
those who have successfully interviewed and matched
with us. Standardization of the interview routine will elim-
inate some of the loose ends in the process. They will also
be given a 'view' that showcases the best the Institution
has to offer new look for the webpage, enthusiastic resi-
dents leading tours, outstanding conferences that inter-
viewees attend and a brief presentation on the history and
laurels of the program. So, in the next few months, if you
see some of these well dressed, young doctors in the hall-
way have your smiles and 'hellos' ready! Be part of the
team that continues to prove us wrong!!


Edward K. Partyka MD, Former Assistant Professor of
Medicine, Division of Gastroenterology

Lubiprostone (Amitiza), a novel drug
for chronic idiopathic constipation

The newest stimulant-type drug for chronic idiopathic
constipation is Lubiprostone (Amitiza,by Sucampo Pharma-
ceuticals). The FDA approved it January 31,2006. (1) Last
July, the company submitted a new drug application to the
FDA for lubiprostone to be used in Irritable Bowel Syn-
drome with constipation (IBS-C). Research is underway to
determine the efficacy of lubiprostone in post-operative and
opiod-induced bowel dysfunction.
Lubiprostone is a bicyclic fatty acid (prostaglandin El de-
rivative) that selectively stimulates the type 2 chloride chan-
nels, C1C-2, increasing intestinal chloride,sodium and water
secretion without altering sodium and potassium serum con-
centrations. Prostones have no significant pharmacologic ef-
fect on smooth muscle contractions. (1,2) The C1C-2 chloride
channels are on the apical(luminal) aspect of gastrointestinal
epithelial cells (along the villous surfaces). The CFTR (cystic
fibrosis transmembrane conductance regulator) chloride
channels are not affected by lubiprostone ( see Fig. 1). (3,4)
As a result of this stimulation the stool softens, motility
increases and spontaneous bowel movements (SBM"s)
occur. Minimal distribution of the drug occurs beyond the
immediate GI tissues. It is rapidly metabolized by reduc-
tion/oxidation,mediated by carbonyl reductase. There is no
metabolic involvement of the hepatic Cytochrome P450 Sys-
tem. Data indicate that metabolism of the drug occurs locally
in the stomach and jejunum. Excretion is renal (60%) and
fecal (30%). (1)
Approval by the FDA was based on data from two
placebo-controlled, randomized phase 2 clinical trials in 479
patients with a history of less than 3 SBM's per week for a
period of at least 6 months. Lubiprostone (24mcgs orally,
twice daily) yielded a SBM within 24 hours in (56.7%,first
study;62.9%,second study). In addition, the increase from
baseline in SBM frequency at one week was significantly
greater in those receiving lubiprostone compared with those
receiving placebo, an effect that was maintained through the
four week study period. Also, results of three long-term clin-
ical safety studies in 871 patients showed that lubiprostone
decreased constipation severity, abdominal bloating, and

discomfort for six to twelve months. Results were consistent
among sex and race subpopulations and in patients aged 65
years and older. (5)
In a double-blind, placebo-controlled, dose-ranging study
to evaluate efficacy and safety, 129 patients with chronic con-
stipation were randomized to receive lubiprostone (24,48 or
72 mcg/day) or placebo for three weeks. Results showed
more patients taking the 48 and 72 mcg/day doses experi-
enced a SBM on the first treatment day(P<_ 0.009).The most
common AEs were nausea, headache and diarrhea. In-
creased AE severity at 72 mcg/day did not provide a clear
risk-to-benefit advantage compared with the 48 mcg/day,
the dose chosen for subsequent Phase 3 studies. (6)
Other study data reveal that nausea, diarrhea, headache,
abdominal pain, and distention occur in 31.7%, 12%, 11.7%,
8%, and 6% respectively. Nausea was mild to moderate,
which resulted in treatment discontinuation in 5% of treated
patients. (4)
Lubiprostone does not show signs of tolerance, depend-
ency, or altered serum electrolyte concentrations. Upon with-
drawal, a graded return to pre-treatment bowel movement
frequency should be expected. Contraindications are in pa-
C( J-4 S i I it l P ,, '(

Apical Basolatoral

CFTR C.- c K ,- I

I -!C- N

'Ati A K
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have a negative pregnancy test prior to starting the drug.
(Category C),Also it has not been studied in pediatric pa-

Continued on Page 6

RX Update continued from Page 5

tients. (5) Takeda Pharmacy (on-line) lists 60 capsules for
$216.30, a month's supply.
It is the opinion of this author that lubiprostone has now
replaced tegaserod(zellnorm), as the premier "high-end"
stimulant laxative of choice, since tegaserod was asked to sus-
pend sales by the FDA on March 30, 2007, due to associated
cardiovascular events .(5) Time will tell if lubiprostone will
suffer any similar fate. In the meantime, I am hopeful that it
will pass scrutiny by the FDA for use in IBS-C, and especially
opiod-induced bowel dysfunction.
1. Ambizas EM Lubiprostone: A Chloride Channel Activator for Treatment

of Chronic Constipation The Annals of Pharmacotherapy 2007 June,V.41,957-
2. Attaluri A, Diagnostic and Therapeutic Approaches to Patients with Constipation,
Practical Gastroenterology Nov. 2006,V30, #11,30-44
3. Cuppoletti Jet al SPI-0211 activates T 84 cell chloride transport and recombinant
human C1C-2 chloride currents Am J Physiol Cellphysiol 287:C1173-C1183,2004
4. Johanson JF et al Multicenter, 4-week, Double-Blind, Randomized, Placebo-Con-
trolled Trial of Lubiprostone, a Locally-Acting Type-2 Chloride Channel Activator, in Pa-
tients with Chronic Constipation AmJGastroenterol 2008;103(1):170-177.
5. Johanson JF Review of the Treatment Options for Chronic Constipation Medscape
General medicine 2007;9(2):25.
6. Johanson JF Lubiprostone, a Locally Acting Chloride Channel Activator, in Adult
Patients with Chronic Constipation, a Double-Blind, Placebo-Controlled, Dose-Ranging
Study to Evaluate Efficacy and Safety. Aliment Pharmacol Ther 25,1351-1361,2007.


Dr. Kenneth Vega, Associate Professor of Medicine, Division of Gastroenterology, was
the recipient of the 2008 American College of Gastroenterology Award for excellence in research
regarding health disparities between genders. The award is granted to physicians who make
seminal contributions to research in health care.

As the recipient, Dr. Vega will be receiving an award in the amount of $1,000. He will be rec-
ognized at the 2008 American College of Gastroenterology meetings.

Please join me in congratulating Dr. Vega for this honor.


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 11 faculty members who have joined the Depart-
ment of Medicine this fall.

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Shands HealthCare Wins Sterling scored based on the following seven categories: leadership,
Award strategic planning, customer and market focus, informa-
tion and analysis, human resource focus, process manage-
Shands HealthCare is the proud recipient of the 2008 ment and business results. After reviewing the application,
Governor's Sterling Award the state's top honor for per- examiners interviewed more than 500 staff members over
formance excellence. a three-day period at all of the Shands facilities.
The award is given to organizations and O>O'S ST/-R In a press release announcement, the gov-
businesses in Florida that are role models ,-, ernor applauded the organization's abil-
for improving the way they do business. tf- ity to provide critical healthcare
Few healthcare systems have been recog- C-, j services to patients in Florida and
nized this way for quality, outcomes and around the country. He went on to
organizational excellence. say, "The use of technology and in-
Since its inception in 1992, only 57 or- novation is apparent in the organiza-
ganizations have received the honor. tion's endeavor to allocate all the
Shands is the largest organization thus far. *. resources needed to serve patients with
"To be in the company of the other great or- excellence."
ganizations that have received the award 5is EA In October, Shands Jacksonville will host
such an honor," Jim Burkhart, president and ad- the Sterling Showcase of Best Practices. This one-
ministrator of Shands Jacksonville, said. day event will offer other businesses and healthcare or-
To be considered for the award, Shands HealthCare ganizations the opportunity to learn the processes and
had to submit a 50-page application. The application was measurements that earned Shands Healthcare this award.

College of Medicine JACKSONVILLE, FL
Jacksonville PERMIT NO. P173
653-1 West Eighth St.
Department of Medicine
Jacksonville, FL 32209-6511
904-244-8846; fax: 904-244-8844

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