%.\ DA II 1 iL,, I ul MiLD1LL\L BLLL I.\
UF UNIVERSITY of
College of Medicine
MEET YOUR COLLEAGUES
Once again spring season is upon us. This year after an un-
seasonably cold winter in Jacksonville, we are all looking for-
ward to warmer days. This is the season of renewed life and
Despite the economic challenges facing the world economies
and despite shrinking resources to support research and edu-
cation, we are determined to forge ahead with innovative pro- .
grams, creative research and delivery of first rate training to
our students and residents.
Clinically, we have started a new musculoskeletal ultrasound unit under the direc-
torship of Dr. Gurjit Kaeley. In this issue he describes the scope of the clinical ap-
plications of this technology. This is the first such unit in Northeast Florida and we
expect it will generate interest among referring physicians.
Educationally, in January the Department sponsored an exceptionally successful
three day conference on new innovations in Internal Medicine. During the pro-
ceedings of this conference a special dinner was organized to honor Dr. Malcolm
Foster. Many of his past trainees who are currently prominent physicians and schol-
ars in their own right attended this dinner. An education fund in Dr. Foster's name
was established to help promote the involvement of young physicians in organized
Research continues to thrive on our campus and our faculty are successful in at-
tracting research funds and publishing their research findings in high profile jour-
I hope you will find this issue of Academic Quarterly meeting your expectations. If
you have any suggestions for improvement please do not hesitate to contact me.
Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman. Department of Medicine
Gurjit Kaeley, M.D.
Assistant Professor of Medicine
Director of Musculoskeletal
Division of Rheumatology
Musculoskeletal Ultrasound: The scope of its clinical applications
The use of Musculoskeletal ultrasound has been rapidly expanding among Rheumatologists in the USA. Its appeal
stems from the immediate bedside application of this technique after a thorough history and physical has been under-
taken. It can be effective in determining the source of a regional pain disorder, detection of an underlying inflamma-
tory disorder as well as injection guidance. 1,2
One of the common regional pain disorders seen in the Rheumatology clinic is shoulder pain. Sonography can as-
sist in depicting abnormalities such as supraspinatus tears (fig 1) and subacromial subdeltoid bursitis( fig 2). When
compared to MRI, Sonography is reliable in detecting erosions, complete supraspinatus tears as well as detecting syn-
Fig. 1.: B-Mode Longitudinal View And Schematic Of Depicting Complete Tear Of The Supraspinatus Tendon.
Fig. 2. (Left): Lateral Longitudinal View Revealing Disten-
sion of the Subacromial Subdeltoid Bursa
Entrapment neuropathies such as that at the
carpal and cubital tunnels may also be readily
evaluated The characteristic pre and post stenotic
dilation of the nerve can be demonstrated. (fig 3
Fig 3. (Below) B-Mode Transverse view of the carpal tunnel
and schematic of corresponding superficial structures. Arrow
points to the dilated edematous median nerve (MN).
Continued on Page 3
Focus continued from Page 2
Median Nerve Fig 4. B-Mode
view of the
Flexor Tendons carpal tunnel
Arrow points to
the dilated me-
cyno~ dian nerve.
With the advent of highly effective disease modifying agents, it has become important to detect inflammatory
arthropathies early. Several studies have demonstrated that clinical exam underestimates the presence of inflamma-
tion. Sonography is more sensitive than radiography in detecting erosions, and has the added bonus of detecting syn-
ovial hypertrophy. The activity of the synovial tissue can be inferred by detecting increased blood flow by Power
Doppler and does not require administration of contrast unlike MRI. These parameters can be followed longitudinally
to determine response to therapy. Recent literature also suggests that tenosynovitis may precede synovitis. Ultrasound
has excellent resolution in evaluating tendinous structures. (fig 5)
Fig. 5. B-Mode And Doppler Transverse Im-
ages Of The Right 3rd Proximal Tendon
Sheath Revealing Synovial Hypertrophy
Within The Sheath With Associated Increase
Sonography can also be valuable in
the evaluation and diagnosis of crys-
talline arthropathy. In acute arthopa-
thy, sonographic guidance can assist in
aspirating small joints such as the 1st
MTP. (fig 6)
Fig. 6. 1st MTP Aspiration In A Patient With Acute Poda-
gra Found To Have Classic Intracellular CPPD Crystals.
Urate crystals deposit on the surface of
cartilage whereas CPPD deposits within car-
tilage. The characteristic deposition of these
crystals can be depicted by sonography. In ad-
dition, subclinical tophaceous deposits can be
demonstrated intra- and extra- particularly. 4, 5
Fig. 7. B-Mode Longitudinal Plantar View and schematic of Urate Deposit on the surface of cartilage depicting the "double contour" sign.
Continued on Page 4
Focus continued from Page 3
Fig. 8. B-Mode Longitudinal Dorsal View and schematic of Tophaceous Deposit within 1st MTP joint capsule..
Songraphically guided injections may improve outcomes compared to blind injections. 6-8 It also offers better patient
tolerance, and can be used to place medication with precision in small spaces such as synovial sheaths.
In conclusion, Musculoskeletal Ultrasound offers a powerful extension to the clinical evaluation of a patient. It is
helpful in deciding the cause of a regional pain disorder, detecting signs of inflammatory arthropathies and assisting
in injection guidance.
1. Grassi W, Filippucci E. Ultrasonography and the rheumatologist. Current opinion in rheumatology 2007;19(1):55-60.
2. Kane D, Grassi W, Sturrock R, Balint PV. Musculoskeletal ultrasound-a state of the art review in rheumatology. Part 2: Clinical indications for muscu-
loskeletal ultrasound in rheumatology. Rheumatology (Oxford) 2004;43(7):829-38.
3. Bruyn GA, Naredo E, Moller I, et al. Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis. Annals of the rheu-
matic diseases 2008:ard.2008.089243.
4. Grassi W, Meenagh G, Pascual E, Filippucci E. "Crystal Clear"--Sonographic Assessment of Gout and Calcium Pyrophosphate Deposition Disease. Semi-
nars in Arthritis and Rheumatism 2006;36(3):197-202.
5. Fodor D, Albu A, Gherman C. Crystal-associated synovitis- ultrasonographic feature and clinical correlation. Ortop Traumatol Rehabil 2008;10(2):90-102.
6. Chen MJ, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006;85(1):31-5.
7. d'Agostino M-A, Xavier Ayral Gabriel Baron Philippe Ravaud Maxime Breban Maxime Dougados. Impact of ultrasound imaging on local corticosteroid in-
jections of symptomatic ankle, hind-, and mid-foot in chronic inflammatory diseases. Arthritis Care & Research 2005;53(2):284-92.
8. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local
corticosteroids in patients with painful shoulder. The Journal of rheumatology 2004;31(2):308-14.
Senthil Meenrajan, M.D., M.B.A.
Assistant Professor of
Medicine, General Internal
Associate Program Director,
Internal Medicine Residency
A clinical educator might ask himself or herself how and
why I am here. This question might elicit a different response
from each of us. All the same we all have chosen to be in the
academic setting, being teachers and role models for a num-
ber of young doctors who are still looking for their mold.
Being physicians in and of itself puts us in a position that
requires, at the very least, knowledge, compassion, good
communication skills and beyond everything else profes-
sionalism. Think about the other role that we have to don, a
teacher, and what attributes we need for this. The list is
thankfully not very different from the one we are required to
possess already. Only in this role we influence not a few lives,
but score of them separated in time and distance, by influ-
encing the doctors that treat them. Think about the opportu-
nity at hand and the responsibility that comes with it.
It is said "The mediocre teacher tells, the good teacher ex-
plains, the superior teacher demonstrates, and the great
teacher inspires." In this seemingly simplistic statement lies
the truth about everything we strive to be in our careers as
academic physicians. Just being here makes us mediocre
teachers, telling residents what they should and should not
do and giving lectures. Some of us actually get to the level of
a good teacher, at least explaining to them 'why' things
should and should not be done a certain way. Rarely do we
find teachers who can live by what they preach and actually
teach by example, all the things they want their students to
learn. The level that is above all this is when you have stu-
dents not just following but who want to emulate what you
do and be everything that you are and more. This may not be
as easy as it sounds. This year I have had plenty of opportu-
nity to hear first hand from a number of medical school grad-
uates during interviews. It is not uncommon to hear they
Continued on Page 5
GME Corner continued from Page 4
chose medicine because their medicine attending was so
great they wanted to be like him/her as well. It is also not
uncommon for students to choose medicine because the at-
tendings in other rotations were terrible! In our own resi-
dency we have people choose their subspecialty solely based
on their experience with the attending physicians and how
they were either positively or negatively impacted by them.
The word 'Guru' brings a number of thoughts to mind.
Generally speaking a guru is thought to possess great wis-
dom, knowledge and authority in a certain field and uses it
to inspire others. In Eastern traditions the guru is seen as a
conduit for sacred wisdom and guidance, and finding a true
guru is often held to be a prerequisite for attaining self-real-
ization. The gurudev is the concept of one's highest con-
sciousness as an inner teacher or intuition within the student.
There is a saying that compares teacher and parents to God,
since they both 'give life' in a certain way. It is indeed a great
privilege to be the life giver for someone who will positively
affect so many other lives.
All this privilege brings tremendous responsibility with
it and we need to periodically ask ourselves if we are living
up to it. In this capacity it is not enough to be mediocre or
good or even superior teachers. We have to be absolutely
'GREAT TEACHERS'. We have to be able to inspire our res-
idents, each and every one of them, all the time. Inspiring
and getting results has more to do with us than the students
and residents themselves. If we can only inspire and moti-
vate 'some' residents, 'some' times and in 'some' settings,
then that speaks more to the quality of the resident than our
own abilities as a teacher. The GREAT TEACHER can teach,
guide and motivate the weakest in the class to be the best
they can be. For this to happen the team (residents, students
and other learners) looks for four elements from the teacher
- Hope, Trust, Opportunity and Enjoyment. The team needs
to know from the teacher that there is hope for them, for their
continued improvement and for the progress of the entire
team. They need to know they can trust their teacher to be
'available' to them, to 'back' them and know that they will
not be 'let down' at the drop of a hat. Trust is always bidi-
rectional. There has to be opportunity an environment that
is conducive to learning, doing new things, asking questions.
Finally all of this has to be an enjoyable experience. Residents
and students should realize that learning can be an enjoy-
able experience as well. It does not have to be under situa-
tions where they are ridiculed and chastised. High pressure
and high stakes do not have to make the experience miser-
able for the participants. A closely fought football game that
goes 'down to the wire' might be stressful for the team and
the coach but does not have to be miserable for either. The re-
sult is also immaterial in so long as everyone knows that the
team did its best and had hope and trust instilled in it by the
In the high stakes environment in which we operate we
cannot expect anything less from each one of us. We have
the opportunity to affect lives, make them better and create
'GREAT TEACHERS' for future generations.
Ronald Mars, M.D.
Associate Professor of Medicine
Division of Nephrology and
Treatment of Secondary
The kidney is a remarkably versatile organ. When dis-
eased the kidney undergoes functional adaptation to main-
tain the internal milieu within a narrow physiologic range,
but often at the expense of maladaptive results elsewhere in
Secondary hyperparathyroidism (s-HPTH) represents
just such a circumstance whereby patients with progressive
chronic kidney disease (CKD) develop the simultaneous
events of hyperphosphatemia, hypocalcemia, vitamin D de-
ficiency, elevated [calcium] x [phosphorous] product (Ca x
P) which together and independently may result in excess
production and secretion of parathormone (PTH), or the con-
dition known as s-HPTH. The consequences of s-HPTH may
include metabolic bone disease (osteodystrophy), metastatic
calcification or calciphylaxis, cardiovascular disease, stimu-
lation of the renin-angiotensin system with difficult to con-
trol hypertension, or impaired erythropoesis and resistant
anemia. Successful strategy designed to treat s-HPTH re-
quires an understanding of the pathophysiologic events of
When patients develop Stage-3 CKD (GFR = 30 59
cc/min) or lower, they have reduced secretion of phosphate.
The resulting hyperphosphatemia binds ionized calcium,
taking it out of solution, causing transient hypocalcemia.
Hyperphosphatemia and hypocalcemia independently and
together have the ability to stimulate post transcriptional
PTH production by increasing and stabilizing PTH mRNA.
Notably, the effects of calcium on parathyroid cells is medi-
ated by a cell membrane bound calcium-sensing receptor
(CaSR) a recent discovery on which the use of calcimimet-
ics, CaSR agonists, have been recently introduced.
Simultaneous to developing hyperphosphatemia and
hypocalcemia is the impaired renal production of calcitriol
[1,25(OH)2D3], the metabolically active form of vitamin D.
Continued on Page 6
RX Update continued from Page 5
The physiologic effects of 1,25(OH)2D3 are to normally re-
duce PTH mRNA levels (and gene transcription) via an in-
tracellular vitamin D receptor (VDR). But, when vitamin D
deficiency develops, as in stages 3 5 CKD, parathyroid cell
proliferation occurs along with increased PTH synthesis.
The additional effects of hypocalcemia, resulting from im-
paired vitamin D intestinal calcium absorption, further en-
hance PTH production.
It is through an understanding of these pathophysiologic
events that has allowed the development of multifactioral
strategies to treat s-HPTH.
The treatment of s-HPTH in CKD is, therefore, directed
at normalizing phosphorous, calcium and PTH levels. Clin-
ical practice guidelines established by the National Kidney
Foundation Kidney Dialysis Outcome Quality Initiative
(K/DOQI) are clearly defined for stage 5 CKD (GFR < 15
cc/min, on or off dialysis). At this level of reduced kidney
function dietary phosphorous should be restricted to 800 -
1000 mg/day with the goal for phosphorous no > 5.5 mg/dl.
For patients receiving either three times weekly hemodialy-
sis, or daily peritoneal dialysis, dietary phosphate restriction
alone is generally inadequate to control the positive phos-
phate balance. Consequently phosphate binders are invari-
ably required. The available phosphate binders in the USA
may be either calcium-containing (e.g., calcium carbon-
ate/acetate) or non-calcium-containing (e.g., sevelamer hy-
drochloride or lanthanum carbonate). The use of aluminum
containing phosphate binders is not recommended for long
term use because of the risk of aluminum toxicity. The phos-
phate binders work best when taken with meals to maximize
binding of phosphorous in the gut. While calcium carbonate
(500 mg elemental calcium in a 1250 mg tablet) and calcium
acetate (169 mg elemental calcium in 667 mg tablet) are use-
ful phosphate binders, because of the increasing risk of vas-
cular calcification in stage 5 CKD, the total dose of calcium
based phosphate binders should be limited to 1500 mg/day
of elemental calcium with a total elemental calcium intake
(including diet) not to exceed 2000 mg/day.
The growing concern re: consequences of vascular calci-
fication have now lead to the more popular use of non-cal-
cium-containing sevelamer hydrochloride and lanthanum
carbonate. Sevelamer acts as an ion exchange polymer to
bind phosphorous in the gut and has the additional benefit
of lowering LDL and increasing HDL lipoproteins. These
combined effects may account for the fewer arterial calcifi-
cations when compared with calcium-containing phosphate
binders. Standard sevelamer dosing may range from 800 -
4000 mg TID with meals and/or snacks.
Lanthanum carbonate, like aluminum, is a trivalent com-
pound that chelates dietary phosphate, but has low systemic
absorption. It is approximately four times as effective as
sevelamer on a dose for dose basis with dosing ranging be-
tween 1000 1500 mg TID with meals. It is currently mar-
keted as a wafer sized tablet that must either be chewed or
crushed and sprinkled on food.
By K/DOQI guidelines, successful use of phosphate
binders will lower the (Ca x P) product to C 55.
Control of phosphorous and calcium is usually insuffi-
cient to lower PTH in stage 5 CKD to the K/DOQI recom-
mended range of 150 300 pg/ml. So treatment with cal-
citriol or a vitamin D analogue (paricalcitol or
doxercalciferol) will be required in the majority of dialysis
patients and will suppress PTH production by binding to the
VDR in parathyroid tissue. Vitamin D analogues, available
in oral or IV form, may be more advantageous than calcitriol
because of a greater PTH suppression and a lower risk for
hypercalcemia. While the desired range of PTH in dialysis
patients (150 300 pg/ml) exceeds by 2 3 fold the upper
limit of normal, the risk for adynamic bone disease is low
when PTH does not fall < 150 pg/ml. Not to be trivialized
are the other novel biologic activities of vitamin D that di-
rectly or indirectly may affect cardiovascular function,
blood pressure, immune and neurologic function. These
too are positively impacted by use of calcitriol/analogues
with data showing improved morbidity and mortality in
Calcimimetics are an emerging class of calcium receptor-
sensing agonists that modulate the activity of the calcium
sensing surface receptor (CaSR) by allosterically increasing
the sensitivity of the receptor to calcium. Available in the
USA as cinacalcet HC1, treatment is generally reserved for
stage 5 CKD and can profoundly lower PTH without elevat-
ing serum calcium or phosphorous. Although the cinacalcet
may provide an estimated 30 40% drop in PTH levels, its
greatest benefit is when used in combination with phosphate
binders and vitamin D/analogue therapy. Monitoring for
hypocalcemia (< 8.5 mg/dl) is critical and may require fur-
ther adjustment of either the calcimimetic and/or vitamin
While subtotal (7/8th) parathyroidectomy with auto-
transplant of 1/8th gland to the subcutaneous forearm is an
absolute strategy to reduce PTH levels, this is rarely indi-
cated for s-HPTH and generally reserved for patients with
tertiary hyperparathyroidism and symptoms of refractory
bone pain or pruritis. Post parathyroidectomy the risk for
symptomatic hypocalcemia is high for patients demonstrat-
ing the "hungry bone" syndrome. In this situation, phos-
phate binders are withheld, dietary calcium and
phosphorous are liberalized, large doses of IV calcium may
be required (especially if paresthesiae and neuromuscular
activity spontaneously increases) and calcitriol may be indi-
cated to enhance intestinal absorption of calcium.
Treating patients with stage 3 4 CKD, not yet on dialy-
sis, should focus on prevention of parathyroid gland hyper-
plasia by way of phosphate restriction, phosphate binder and
calcium supplementation as needed. When to start treat-
ment with calcimimetics or active vitamin D/analogues has
not been firmly established but should generally be used in
the later stages of their disease.
s-HPTH begins as early as stage 3 CKD. It is a progres-
sive condition and becomes full blown as patients reach
stage 5 CKD. Successful treatment outcomes rely on the
therapeutic combination of phosphate binders, calcitriol or
vitamin D analogues, and calcimimetics.
NEWS & NOTES
Establishment of a fund honoring Dr. Malcolm Foster
Dr. Malcolm T. Foster, Jr. was honored for his contributions to medicine at a dinner at Amelia Is-
lan d 'Plntation on Friday, January 23, 2009. The dinner was held in conjunction with the Uni-
vel-it\ if Florida College of Medicine's Department of Medicine annual Update in Internal
M-diciini Over 80 people came to celebrate Dr. Foster's contributions to medicine and in many
ca-, -- t, their professional and personal growth. Twelve of Dr. Foster's previous chief residents
d ii in. 1 is tenure as Chairman of the Department of Medicine at the University of Florida-Jack-
soni ill-. were in attendance and had the opportunity to renew old acquaintances and make new
onil_-.. B.I-ed on the wonderful turnout and the comments made, it is evident that Doctor Foster
has touched the lives of many individuals and continues to do so.
To recognize Doctor Foster's many contributions to medicine, a scholarship fund in his name has been established
through the University of Florida Foundation. Annually, a scholarship will be awarded to a deserving resident in In-
ternal Medicine to attend the annual meeting of the American College of Physicians or another scholarly endeavor. If
you would like to honor Doctor Foster by making a contribution to the fund, please contact the Office of Development
and Alumni Affairs of the College of Medicine-Jacksonville at 904-244-1062.
Diabetes & Endocrinology Update 2009
Presented by the Department of Medicine and Division of Endocrinology, Diabetes & Metabolism
Date: Saturday, May 2, 2009
Time: 7:30am 4:00pm
Location: Hyatt Regency Jacksonville Riverfront
This second annual event will showcase current and emerging trends in Endocrinology
with practical recommendations and guidelines from clinical experts. Target audience
includes primary care physicians and allied healthcare providers.
For more information, please contact Barbara Jones at 904-244-2380 or
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 a new member of the Division of Cardiology who
will also serve as Assistant Program Director of the Electrophysiology Fellowship Program.
Kat is bor cetiie in Inera Meicne Cadoasua Disas an ClinicalCardiac
Stroke Program Receives High Marks
The Shands Jacksonville Comprehensive Stroke Pro-
gram successfully completed its second recertification as a
Primary Stroke Center by the Joint Commission in No-
vember. Shands Jacksonville is also certified as a Compre-
hensive Stroke Center by the Florida Agency for Health
The hospital is one of only two Comprehensive Stroke
Centers in North Florida. The successful review noted that
there were no deficiencies or need for follow-up. The
stroke center exceeded the national average in 2008 with
100 percent compliance in eight out of 10 measures.
The Neuroscience Institute received positive com-
ments on its community and EMS educational initiatives.
UF physicians are involved in multiple research projects
to expand and improve care for stroke victims. Research is
also underway on the effectiveness of traditional stroke
education to post stroke patients who are likely to be cog-
nitively impaired during hospitalization.
Shands Jacksonville currently sees 50 to 80 new stroke
patients each month. With the help of TraumaOne flight
services, Shands has expanded the coverage area of the
stroke center to include rural areas surrounding
Jacksonville. Patients have successfully received the dis-
ability reducing treatment tPA after being transported
from as far away as 100 miles.
The window for IV tPA has expanded from three
fom fl -.-I Ind-a-
p enabling the
ti l_.I treat
p:1 t i aits
h, Ii did not
i d int i fy
ec i I\ or
who have come from farther distances. Additionally, the
measure for DVT prophylaxis will expand from DVT pro-
phylaxis considered, to DVT prophylaxis being consid-
ered, ordered and administered.
Call Scott Silliman, MD, UF associate professor of neu-
rology, or Nader Antonios, MD, UF associate professor of
neurology, at 244-3960 if you have questions about treat-
ments or education programs available to your patients.
UF UNIVERSITY of
College of Medicine
653-1 West Eighth St.
Department of Medicine
Jacksonville, FL 32209-6511
904-244-8846; fax: 904-244-8844
PERMIT NO. P173