Title: Academic physician quarterly
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00088871/00008
 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, University of Florida
Place of Publication: Jacksonville, Fla.
Publication Date: January 2009
 Record Information
Bibliographic ID: UF00088871
Volume ID: VID00008
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:

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 2009.

We are in our third year of launching the Academic Physi-
cian Quarterly (APC) newsletter. I would like to invite you to
look up our previously published issues of the APC on our
website at http://hscj.ufl.edu/im/archives.asp. These
archival issues give the reader a glimpse of the evolution of the Department over
the last three years.

We have now completed the development of all subspecialties and have estab-
lished training programs in each one. The last Division to come on board as a well
rounded academic unit is the Division of Rheumatology. I am delighted that this
deficiency is being rectified with the arrival of additional outstanding Rheuma-
tologists. One of the new members of the Department is highlighted in the section
on Meet your Colleagues.

The Focus section of the current issue of the APC is dedicated to the echocardio-
graphic laboratory at Shands-Jacksonville. This is a state of the art facility that has
thrived under the leadership of Dr. Steven Lavine.

As is traditional with the beginning of each new year the Department's pledge
for this year is to make our training and educational programs patient centered,
hypothesis driven, outcome focused and evidence based.

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


Professor of Medicine

Program Director, Cardiology
Director, Noninvasive Lab

Division of Cardiology

The Echocadriographic Laboratory at

The Echocardiographic Laboratory at Shands-Jack-
sonville offers a variety of imaging studies that evaluate
cardiac anatomy, cardiac function, and intracardiac flow.
Although, echocardiography has not yet excelled in the
area of evaluating myocardial perfusion, this aspect of
cardiac evaluation may be imminently available. Echocar-
diography involves the use of high frequency ultrasound
that is able to discern cardiac structures within a resolu-
tion of 1 mm. Furthermore, ultrasound may be emitted in
pulses that may detect red blood cell movement and be
able to characterize intracardiac flow. This has been
termed the Doppler principle and serves as the basis for
imaging intracardiac blood flood, detection of regurgita-
tion, and characterization of the pressure gradients across
valves. The Doppler principle has also been applied to the
velocity of myocardial wall motion and has been useful
in characterizing the timing of myocardial wall movement
and increasing our understanding regarding myocardial
mechanics. More recently, we have added the 3 dimen-
sional imaging that will provide the busy clinician with a
3 dimension depiction of cardiac structure and function
and will more accurately calculate ejection fraction, de-
termine in severe mitral regurgitation which part of a mi-
tral leaflet may need repair, and whether intracardiac
shunts (atrial septal defects and the closely related patent
foramen ovale) are repairable using closure devices de-
ployed in the cardiac catheterization laboratory.
There are literally hundreds of indications for echocar-
diographic imaging of the heart. The growth of indica-
tions has been escalating to the point where the American
Society of Echocardiography has now issued "appropri-
ateness indications" in a recent publication. The use of
digital acquisition utilized in echocardiographic imaging
has shortened study time acquisition and allowed more
sophisticated evaluation of cardiac function off-line.
Presently, studies consist of 45-65 different imaging clips

that are acquired by a cardiac sonographer who has
passed a registry examination on cardiac anatomy, phys-
iology, ultrasound physics, and knowledge of cardiac dis-
ease. Imaging begins from 4 separate ultrasound
windows: parasternal, apical, subcostal, and suprasternal.
Digital clips of anatomy and intracardiac blood flow using
the Doppler principle are obtained from each cardiac
chamber, each valve, and from the aorta, pulmonary ar-
tery, and great veins. More advanced imaging techniques
are utilized to produce myocardial tissue velocity maps
acquired from the 3 apical views.

Left: Apical 4 chamber view, Center: Continuous wave Doppler of pa-
tient with Mitral Stenosis, Right: Color flow jet of patient with moder-
ate mitral regurgitation.

In addition to resting studies of cardiac function and
intracardiac flow, patients may be stressed using either
exercise or pharmacologic stress. Exercise modalities in-
clude treadmill exercise or bicycle. We favor supine bicy-
cle as it lends itself to better imaging and the ability to
obtain peak exercise images. Ischemia is better detected
at peak exercise. To assist in the quality of imaging, we
use an intravenous echo contrast agent that outlines the
cavity producing images with detail comparable to MR
imaging. Both endocardial wall motion assessment and
wall thickening can be obtained. Sensitivities for detect-
ing coronary disease by abnormal wall motion and thick-
ening are nearly as robust as perfusion imaging. The
greater strength of this technique lies in its specificity, as
false positives are infrequent. Pharmacologic stress can be
performed using dobutamine infusion to increase heart
rate and myocardial contractility. Not only is the pre-
dictability for coronary disease strong but also both these
testing modalities are exceptionally useful for preopera-
tive noninvasive risk assessment of the pre-operative pa-
tient. Images are analyzed using a side-by-side format
prior to and with peak stress.

Apical 4 chamber at rest and
post exercise (treadmill)
demonstrating apical akinesis
immediate post exercise sug-
gesting a significant stenosis
in the left anterior descending

Continued on Page 3

Focus continued from Page 2

An application of dobutamine stress echocardiography
is the assessment of myocardial viability. Patients with
heart failure most often have coronary disease as their eti-
ology. Areas of the myocardium may be transmurally in-
farcted and akinetic or dyskinetic with others areas being
hypokinetic and akinetic but capable of contracting with
revascularization. Patients with viable myocardium are at
increased risk for adverse events but at the same time have
potential reversibility of heart failure and other serious ad-
verse events including myocardial infarction and death.
Low dose dobutamine increases blood flow to the my-
ocardium resulting in hypokinetic and akinetic viable
areas contracting. With greater stimulation by dobuta-
mine, the myocardial wall may stop contracting demon-
strating it is severely ischemic. Patients who respond to
dobutamine in this fashion (biphasic response) have both
the highest risk and greatest potential with revasculariza-
tion to improving symptoms and survival.
Transesophageal echocardiography (TEE) adds a
unique window to imaging cardiac structure, function,
and intracardiac flow. TEE requires conscious sedation in
which the patient is attended by a team of health profes-
sionals including a cardiologist, nurse and sonographer to
ensure safety. By placing a transducer on the end of a gas-
troscope and inserting the TEE probe into the upper, mid,
lower esophagus, and the stomach, posterior views of the
heart are available with high resolution unimpeded by the
chest wall and the lung. Diagnosis of atrial clot, aortic dis-
section, prosthetic valve function, and delineation of en-
docarditis complications are only a few of the reasons why
TEE is often performed.

AWihdran Posterior Lef

F LLe M '- ".
Righ Riight Anterior
Transesophageal probe controls on the left and probe positions on
the right

TEE apical 4
chamber view of
anterior mitral
leaflet perforation
on the left and the
severe mitral
regurgitation on
the right.

There are several recent developments in echocardio-
graphic imaging. The first development was the applica-
tion of myocardial tissue Doppler to the description of
cardiac disease. Tissue Doppler is simply a refinement of
the existing Doppler principle applied to myocardium. By
altering the filters to show spectral traces of low velocity
and high amplitude signals, myocardial Doppler can be

SApical 3 chamber view
with sample volumes
placed in both walls on
Sthe left with tissue
Doppler signal from
the posterior wall on
.IIA-EW P-Aw the right (Ew=early
LA peak lengthening ve-
locity; Aw=late peak
lengthening velocity).

The sample volume can be placed in the mitral annu-
lus and the peak rapid lengthening velocity can be ob-
tained. The ratio of the mitral peak rapid filling velocity
and the mitral annular peak rapid lengthening velocity can
be used to predict LV filling pressures.

Transmitral velocity is shown on top and tissue
Doppler (DTI) mitral annular velocities are shown on
the bottom. The ratio of E/Ea can be used to estimate
LV filling pressures by a simple formula (LV filling
pressures=1.24*E/Ea+1.9 mm Hg).

Nagueh et al. JACC 1997;30:1527

Tissue Doppler can also be obtained as velocity maps
superimposed on structural images of the left ventricle.
Digital information can be extracted at a later time to eval-
uate the timing of contraction of the wall. This ability has
been used to time the contraction of the base and mid-por-
tion of all 6 walls of the heart. When the timing is not uni-
form, dyssnychrony is said to exist. Dyssnychrony occurs
with LV dysfunction and heart failure and can be corrected
by employing a biventricular pacemaker, which synchro-
nizes LV contraction, and coordinates LV contraction with
RV contraction and atrial systole. Echocardiography may
be used to select patients more likely to respond to this
therapy, and it also being used to determine changes in LV
size and function, an important correlate of response and
a predictor of survival.

Tissue Doppler color maps and
derived spectral tracings demon-
strating superimposition of sys-
tolic and diastolic peaks. All
portions of the septal wall are
synchronous in shortening and

Myocardial dyssynchrony is
demonstrated as the time from
the R wave to peak shortening ve-
locity occurs later on the lateral
wall (red and green arrows) as
compared to the septum (yellow
and blue arrows). This delay was
>65 milliseconds.

Continued on Page 4

Focus continued from Page 3

Myocardial tissue velocity images can be mathemati-
cally manipulated to demonstrate myocardial strain in all
segments of the heart. Myocardial strain refers to the de-
formation of tissue that occurs during active contraction
and during diastolic lengthening. It is unaffected by car-
diac motion which makes it more robust than velocity
measurements which may be affected both by myocardial
contraction and cardiac motion. Strain may be measured
in the longitudinal and radial directions using tissue
Doppler imaging.
Strain Imaging
Anterior Myocardial Infarction
Apical 2 chamber
view with tissue
Doppler image on the
upper right and my-
ocardial displace-
ment on the bottom
right. Strain curves
are shown demon-
strating reduced lon-
gitudinal systolic
strain (negative) in
the anterior wall.

Myocardial velocity and strain measurements can also
be derived directly from the two dimensional images
using a process called speckle tracking. The computer
tracks various amplitude signals called speckles of the
various myocardial walls. The change in the position of
the speckles at each frame of studied can be calculated.
Myocardial velocity and strain can be assessed as with tis-
sue Doppler. However, with this technique, myocardial
strain can be assessed longitudinally, radially, and cir-
cumferentially. This technique allows us to note circum-
ferential strain at the apex, which is in the opposite
direction to the base. This difference is called twist or tor-
sion and represents the "wringing" motion of the heart.
Abnormalities in pump function can be accentuated by
reduced apical rotation. Diastolic dysfunction may be ev-
ident when the rate of untwisting is reduced. Normally,
marked untwisting allows suction to fill the heart at lower

Left ventricular rotation at apical and basal levels during systole from
speckle tracking images. End-systolic speckle tracking imaging ac-
quisitions are overlaid on the end-diastolic image with corresponding
local trajectories. Normally, at apical level, the left ventricle rotates
counterclockwise as viewed from apex, whereas the base rotates
clockwise. This gradient of LV rotation between the two levels creates
a "wringing" motion of the left ventricle.

Finally, the most recent addition to advanced echocar-
diographic imaging is 3 dimensional echocardiography.
Images are most often acquired from the apical and
parasternal windows. A single apical and parasternal
view are acquired as a composite of 4 beats. Images are
acquired volumetrically and can be displayed with any
degree of rotation or as any view. Images may be viewed
en face as a surgeon might visualize in the operating
room. Three-dimensional imaging has found use in cal-
culating ventricular volumes and ejection fraction with an
accuracy comparable to MR imaging. It has utility in char-
acterizing masses, valve disease, and how much the aor-
tic or mitral valve regurgitates. It may have use in
identifying prosthetic valve abnormalities possibly sav-
ing a patient the need for TEE. Recently, using 3 dimen-
sional echocardiography, we were able to differentiate
prosthetic valve infection from a torn bioprosthetic leaflet.
The time of 3D imaging has now arrived bringing
echocardiography closer to other volumetric imaging
techniques especially MRI and CT angiography.

3 dimensional imaging of the mi-
tral valve providing a surgical like

The Echocardiography Laboratory also performs and
supports a number of clinical investigations. Echocar-
diographic imaging of the left ventricle is performed fol-
lowing bone marrow stem cell instillation into the
myocardium by catheter techniques to determine the con-
tractile status of the myocardium at regular intervals fol-
lowing the experimental procedure. Our
electrophysiology section is investigating whether earlier
use of cardiac resynchronization therapy is helpful in pa-
tients with heart failure using tissue Doppler indices of
systolic dyssynchrony for both selection and optimization
of biventricular pacing. The echocardiography laboratory
has also developed a registry for patients with various
heart diseases to determine the importance of myocardial
dyssynchrony. Of interest, patients with diastolic dys-
function and aortic regurgitation are being evaluated. Fi-
nally, using tissue Doppler optimization parameters
following resynchronization therapy as selection criteria
prior to CRT is also being investigated.

The Echocardiography laboratory cardiologists in-
clude Steven J. Lavine, M.D. (Medical Director and Car-
diovascular Fellowship Director), Donald A. Conetta,
M.D., and Robert F. Percy, M.D.


Senthil Meenrajan, M.D.,

Assistant Professor of
Medicine, General Internal

Associate Program Director,
Internal Medicine Residency

"Either write something worth reading or do
something worth writing" Benjamin Franklin

This fall the residents & the GME office has a lot worth
writing and hopefully I will make it worth reading too! The
Internal Medicine Residency continues to march forward,
building on the successes from the end of the last academic
year. The excitement of the 'new' interns, fellowship match
are all behind us now and a new set of familiar and some un-
familiar issues are at our forefront.
First, ABIM results- at this year's Internal Medicine Board
exams our residents secured a 92% pass rate. This is almost
identical to the good showing from last year and we now can-
not wait for next year, so our 3 year rolling average will be
one of the best in the state. Kudos to all residents, faculty and
staff who worked so hard to make this happen. Our Board
Review course and quizzes help ensure all residents stay fo-
cused toward this goal.

Second, success breeds success. Our awesome perform-
ance in the fellowship match and the Boards seems to weave
it's magic on the interviewees. The interviews could not be
going better. The whole routine starting with a dinner with
residents the previous night, tour of facilities, morning report
and the interviews seem to hit a perfect vibe with all the can-
didates. All indicators point to a very positive experience for
everyone involved and we are interviewing truly desirable
candidates for the program.
Third, its everything else! Dr. Petrucelli made the very
difficult (and saddening) decision to leave the GME program
and we wish her the very best in everything she pursues. The
silver lining to that though is the fact that Dr. House will be
joining as the Associate Program Director. If there is an emo-
tion that is 'sad-happy', that's what I feel now!! The program
never seems to run out of motivated and talented residents
who want to serve it's ranks, as exemplified by Drs. Tauseef
Qureshi and Naveen Seecharan who will be the Chief Med-
ical Residents in 2010.
Finally, the big one SITE VISIT. The core program with
a number of the subspecialties will have it's site visit in Jan-
uary of 2009. This has become the singular focus of the GME
at this point in time and hopefully the next time we have the
GME update our site visit success will be the first, biggest and
proudest item on the list. Until then...........keep your fin-
gers crossed and stay tuned.


By Lauren Stafford, Pharm.D.

FDA Proposes Eliminating Pregnancy
Letter Categories for Safety of Drugs
In 1979, the FDA established the current "letter category
system" for rating the risks of drug use during pregnancy.
This system was initially praised as being easy for providers
to understand and for encouraging drug prescribing; when
necessary, in pregnant women. 1,2 Over the past ten years,
criticism of this system has increased because the current sys-
tem does not provide practitioners with enough information
to make informed decisions about appropriate therapy in
this vulnerable population.
The current lettering system (Table 1) does not take into
account variations in safety in different trimesters of preg-
nancy or provide information regarding the data from which
the letter category is derived. The A through X system also
indicates a gradient of safety rather than indicating the true
benefit to risk ratio, which may be patient specific. It also

leads practitioners to believe that all drugs within one cate-
gory carry the same level of risk.
The FDA has proposed a rule, currently open for public
comment, to abolish the letter categories and provide more
comprehensive information in a standardized format (Table
2) within the drug's prescribing information, allowing prac-
titioners to make prescribing decisions based on a review of
all available data of the drug's use in pregnancy. This rule
will also give drug manufacturers incentives to develop
pregnancy registries and publish both positive and negative
data from these registries, adding to the knowledge base of
drug use in pregnancy, associated safety factors, and out-
Once the proposed rule is approved, all newly approved
drug labeling will be required to conform to the above for-
mat. The proposed rule for these changes is currently open
for comment to the FDA, but is expected to take effect before
the end of 2008.3

Continued on Page 6

RX Update continued from Page 5

Table 1: Review of Current FDA Pregnancy Categories1
Category Definition % of Drugs
A Well-controlled, adequate studies in pregnant women have failed to demonstrate risk to the fetus. 0.7%

B Either animal study shows risk, but human studies do not support the identified risk, or if no 19%
human studies have been performed, animal studies do not demonstrate risk
Human studies are absent or inadequate and animal studies either show fetal risk or are absent. 66%
Potential benefits may justify the risks

D Studies or post-marketing data demonstrates risk to the human fetus. Potential benefits to the pa- 7%
tient may still outweigh the known risks.

X Studies in humans or animals or post-marketing data show risk to the human fetus which clearly 7%
outweighs all possible benefits. Drug is contraindicated in pregnancy.

Table 2: Summary of Proposed Changes to Pregnancy Labeling in Prescribing Information (PI)

Eliminate all current pregnancy This change will affect all new drugs upon approval, and all existing drugs when-
1) category listings from PI ever changes to labeling are made
New Pregnancy Labeling
2.) Sections:
Fetal Risk Summary One sentence describing likelihood of abnormalities (i.e., structural, fetal and in-
fant mortality, impaired physiologic function, alterations to growth). This section
will also describe:
1) Incidence, seriousness, reversibility, & correct-ability of the abnormality
2) Effect of dose, duration of exposure, and gestational timing of exposure
3) Evidence (animal vs. human data)
Data Will provide information on:
1) Inadvertent exposure in pregnancy
2) Prescribing decisions in pregnant women
3) Drug effects on labor and delivery

Pregnancy registry exposures Will provide phone # and other information to enroll patients

General Statement of Background Will include a statement that all pregnancies have a background risk of birth de-
Risk fects, loss, or other adverse outcome regardless of drug exposure

3.) Lactation
Risk Summary If appropriate, include a statement that the use of the drug is compatible with
1.) Effects of the drug on milk production
2.) Whether the drug is present in human milk (and if so, how much)
3.) The effect of the drug on the breast-fed child
Clinical considerations 1.) Ways to minimize exposure to the breast-fed child, such as timing or
pumping and discarding milk.
2.) Potential drug effects in the child and recommendations for monitoring or
responding to these effects.
3.) Dosing adjustment during lactation.
Data Overview of data on which risk summary and clinical considerations are based.

1) Doering PL, Boothby LA, Cheok M. Review of pregnancy labeling of prescription drugs: Is the current system adequate to inform of risks. Am J Obstet Gy-
necol. 2002;187:333-9
2) Public Affairs Committee of the Teratology Society. Teratology public affairs committee position paper: Pregnancy labeling for prescription drugs: Ten years
later. Birth Defects Res A Clin Mol Teratol. 2007 79 (9):627-30
3) Food and Drug Administration (FDA)Center for Drug Evaluation and Research (CDER) homepage. Pregnancy and lactation labeling. Available at
http://www.fda.gov/cder/regulatory/pregnancylabeling/default.htm. Accessed June 8th 2008


Dr. Dominick Angiolillo receives "William
Harvey" award from the Italian Society of

This year, Dr. Dominick Angiolillo is the
recipient of the "William Harvey" award
from the Italian Society of Cardiology.
This award is in recognition of an Italian
investigator who has made contributions
to cardiovascular research over the past
3-5 years and representing "Italian Car-
diology" internationally.

Congratulations to Dr. Angiolillo for this exceptional honor.

Dr. Senthil Meenrajan receives Philip H.
Gilbert Young Physician Award

Dr. Senthil Meenrajan is the recipient of the 2008 Philip H.
Gilbert Young Physician Award. This
award is given annually by the Duval
County Medical Society (DCMS) to rec-
ognize young physicians with leadership
traits. The award will be presented to
Dr. Meenrajan at the 2009 DCMS Annual
Meeting on Thursday, January 15, 2009.

Congratulations to Dr. Meenrajan for this honor.

TaxHATS is recognized as one of seven pro-
grams in the country

The Maternal and Child Health Bureau (MCHB) Division of
Services for Children with Special Healthcare Needs (DSC-
SHN) is charged with achieving a community-based service
system for all children and youth with special health care
needs and their families. The MCHB has recognized only
seven programs addressing transition issues for children and
youth with special health needs (CYSHN). One of those
seven programs was the JaxHATS program under the lead-
ership of Dr. David Wood (Pediatrics) in collaboration with
Dr. Linda Edwards (Internal Medicine). JaxHATS was also
named one of Jacksonville Business Journal's Health Care
Heroes for 2008.

Congratulations to this unique program and the team that
makes is a success.

Dr. Malcolm Foster is recognized as a
Health Care Hero

I am proud to inform you that Dr. Mal-
colm Foster was selected as an honoree
by the Jacksonville Business Journal's
Health Care Heroes Program 2008. This
program honors top medical profession-
als in Northeast Florida who have im-
proved healthcare and saved lives,
especially in the past few years.

Congratulations to Dr. Foster.


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 a new member of the Division of Rheumatology
and Clinical Immunology who will also serve as Director of Musculoskelatal Ultrasound.

I 5 *, S S.*
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Shands Jacksonville Program Used as
System Model

In October 2007, Shands Jacksonville initiated patient
and family activation of the Rapid Response Team in
emergency situations. This program, called Partners in
Care, was used as the model for other hospitals in the
Shands HealthCare system.
The RRT responds to the patient's bedside at the first
sign of trouble or deterioration. The team is comprised of
critical-care trained respiratory therapists and registered
nurses who provide detailed assessments and resources to
the patients and nurses in the Med/Surg and Progressive
Care units. They also collaborate with the primary nurse,
physician team and other disciplines to stabilize the con-
dition or assist in transferring the patient to a higher level
of care.
The goal of the RRT is to decrease Code Blues that
occur outside of the Intensive Care setting. The team res-
cues or stabilizes the patient before the patient deteriorates
to the point of cardiopulmonary arrest. Additionally, RRT
nurses make rounds on patients during their first 24 hours
out of the ICU and respond to Code Blue calls.
So far, the team has helped decrease the number of
Med/Surg Code Blues by 27 percent and survival to dis-

charge after Code Blues has increased from 21.05 to 38.6
"By providing a dedicated RN 24 hours a day, we are
proactively assessing and intervening as opposed to re-
sponding only when there are signs of trouble," said Kelly
Miles, vice president and chief nursing officer. "By doing
so, we are giving our patients the best chances of survival
and the highest level of quality care possible."
Patients and their families are educated about the Part-
ners in Care program and RRT process at the time of ad-
mission. Signs have been posted in all patient rooms, and
patient phones are labeled with instructions for accessing
the 4-CARE hotline. There have been fourteen calls since
implementing the program and all but two were clinically
indicated as necessary. Two patients called because visi-
tors in their rooms became ill and one patient called be-
cause another patient in the room was exhibiting signs of
a stroke.
In addition to responding to patient emergencies, the
RRT also responds to employee and visitor medical emer-
gencies in the Clinical Center, LRC and ACC buildings. To
access the Rapid Response Team, call extension 4-2222. For
non-emergent ICU consults, page the team at 306-4049. For
the Pavilion, page 393-0178.

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


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