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College of Medicine
^^^^^^^^^^^^ Page 6^
As I was compiling this issue of the Academic Physician
Quarterly and thinking how lucky we are to have had a
pleasant winter season, I couldn't help but remember a quo-
tation from a great and arguably the first American poet,
Ann Bradstreet, who in 1655, had this to say about winter:
"If we had no winter, the spring would not be so pleasant: if A\
we did not sometimes taste of adversity, prosperity would
not be so welcome". It is likely that Ms. Bradstreet did not I
spend any of her winters in Jacksonville. In this town we are
blessed with pleasant spring and winter seasons.
I am delighted to report to you that the Department of Medicine is doing excep-
tionally well. We have had a series of unprecedented successes including estab-
lishing of training programs in every subspecialty, increasing research
productivity, inaugurating a state of the art inpatient research unit and main-
taining black bottom-line. Nevertheless for the first time, I have to report the loss
of an important resource for the Department. It is with sadness that I announce the
resignation of Dr. N. Stanley Nahman, Jr., effective April 30th, 2010.
Dr. Nahman has been a pillar of the Department for the last 6 years and a per-
sonal friend of mine. He led the Division of Nephrology and the Core residency
program into nationally recognized levels. His departure is indeed a major set-
back. On behalf of the Department, I would like to express my sincere gratitude
for all his contribution and wish him and his wife, Dr. Beverly Nahman, happiness
and success in their newly adopted home of Augusta, Georgia.
Thank you for your interest and continued support of our programs.
Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine
I FOCUS 1
Rachana Palnitkar, M.D.
Fellow in Infectious Disease
University of Florida, COM Jacksonville
Nosocomial infections, pay for perform-
ance and role of the Infectious Disease
Nosocomial infection or healthcare associated infection
(HAI) is defined by the Centers for Disease Control (CDC)
as a localized or systemic condition resulting from an ad-
verse reaction to the presence of an infectious agents) or its
toxin(s) and a condition which is not present or incubating at
the time of admission. These infections are easily preventa-
ble and can result in improved patient outcomes. In addition
beginning October 1, 2008 Medicare does not pay hospitals
for infections such as catheter associated urinary tract infec-
tions, vascular catheter associated infections and medias-
tinits after coronary artery bypass graft surgery.
In this brief review, urinary tract infections (UTIs), vas-
cular catheter associated infections and ventilator associated
pneumonia are discussed.
Urinary tract infection (UTI):
UTIs comprise about 40% of the nosocomial infections
in the United States. Incidence of acquiring an UTI increases
at about 5% per day of catheterization. Each episode of UTI
is estimated to cost from about 675$ for an UTI alone to 2800$
for UTI complicated with bacteremia. UTIs can be divided
broadly into 2 types: Asymptomatic and symptomatic UTI.
Asymptomatic UTI includes positive urine culture (>100,000
colonies /ml) in the absence of symptoms. Symptomatic UTI
includes positive urinalysis and urine culture in the presence
of symptoms such as fever, urgency, suprapubic tenderness
and dysuria. In addition to E.coli, the causative organisms
also include other bacteria such as Enterococcus, Candida,
Klebsiella, Pseudomonas and Proteus spp. Important risk
factors include urinary catheterization, diabetes, female sex,
absence of use of a urinometer and improper catheter care.
UTI can be complicated with bacteremia, renal failure,
chronic renal insufficiency, urinary stones and in certain
cases death. The cornerstone of UTI prevention is removal
of catheters whenever feasible. Instituting catheter reminders
has been demonstrated to be of benefit. Other methods are
using condom catheters, suprapubic catheters, intermittent
catheterization and use of silver coated catheters. All have
demonstrated reduced rates of infection and more patient
comfort as compared to indwelling catheter in small studies.
Vascular catheter associated infections:
About 3 million Central venous catheters (CVCs) are
used annually in the US. Incidence of CVC infections range
from 0.5 catheter related bloodstream infections/ 1000
catheter days for peripheral lines to 2.7 for short term CVCs
[Edgeworth J, Intravascular catheter infections, J Hosp Infect
(2009)]. Infection can occur from defective containers, mal-
functioning inlet filter, infection at set-catheter junction or at
the time of catheter insertion. Most common organisms are
coagulase negative staphylococci, Staphylococcus aureus fol-
lowed by others such as gram negative rods, Candida and
Enterococcus. Formation of biofilms is an important mecha-
nism of pathogenesis. Biofilms reduce antibiotic penetration
resulting in reduced activity, development of resistance, im-
pair host defenses by diminishing activity of the neutrophils
and macrophages [Hall-Stoodley L.et al; Evolving concepts
in biofilm infections. Cell Microbiol. 2009;11:1034]. Catheter
infection is suspected if there is fever, exit site erythema,
derness or mal-
the catheter. In
such cases blood
culture must be
removed and tip
sent for culture.
A positive tip
tive blood cul-
ture confirms the diagnosis. Use of aseptic technique at the
time of insertion is essential to preventing these infections.
Chlorhexidine is more favorable than povidone iodine as a
method of skin preparation. Other modalities such as an-
tibiotic impregnated catheters may be considered in high risk
settings such as intensive care units, burn units. Antibiotic
lock prophylaxis (vancomycin/heparin or
vancomycin/ciprofloxacin/heparin) is not recommended by
Infectious Diseases Society of America (IDSA) due to con-
cerns regarding emergence of resistance. IDSA guidelines
recommend changing peripheral intravenous lines at 72-96
hours and disposable transducers in arterial lines at 96 hours.
These guidelines do not recommend routine changing of
long term accesses such as PICC lines or HD catheters un-
less infection is suspected.
Continued on Page 3
Focus continued from Page 2
Ventilator associated pneumonia (VAP):
VAP is defined as pneumonia developing in a ventilated
patient after 48-72 hours and is divided into 2 types: early
onset (<5 days), and late onset daysays. Risk of acquiring
VAP is highest in the first few days after intubation. Usual
microorganisms are Pseudomonas aeruginosa, E.coli, Kleb-
siella pneumoniae, Acinetbacter spp, Stenotrophomonas mal-
tophilia, Staphylococcus aureus and oropharyngeal flora.
Patients at higher risk of acquiring this disease are those liv-
ing in a healthcare facility like a nursing home, having re-
ceived antibiotics in the preceding 30 days, chronic dialysis
and home infusions. Diagnosis is established by presence of
clinical signs of pneumonia such as color and consistency of
endotracheal secretions, chest radiography, positive cultures
from the endotracheal aspirate, BAL or protected brush spec-
imen. Useful strategies to prevent VAP are head elevation to
more than 30 degrees, oral decontamination with chlorhexi-
dine, reduction of gastric acidity with agents such as sucral-
fate and subglottic aspiration of secretions.
from the Infectious Diseases Society of America; CID 2009:48
(1 January)]. Antibiotic stewardship programs (ASP) can play
a significant role in reducing the drug resistance in the hos-
pital by direct feedback to the physicians writing the antimi-
crobial orders, formulary restriction, preauthorization,
education, de-escalation of therapy and optimizing doses
among others. ASP team typically consists of an ID physician,
ID pharmacist, infection control personnel, clinical microbi-
ologist, hospital epidemiologist and information technology.
However, it is worth emphasizing hand washing remains an
easy and effective way of decreasing spread of nosocomial
infections. ID consultation has been demonstrated to reduce
mortality associated with Staphylococcus aureus associated
bacteremia. Adherence to ID recommendations is improved
if the recommendations are specific providing a defined end
point such as resolution of fever, leucocytosis and steriliza-
tion of blood cultures to list a few.
In summary, nosocomial infections are expensive, are
easily preventable and improve patient morbidity and mor-
tality. ASP can play a vital role, so can the ID consultant.
Increasing drug resistance amongst microbes is discon-
certing since the available drugs to treat drug resistant infec-
tions are few [Bad Bugs, No Drugs: No ESKAPE! An Update
Jeffrey House, D.O.
Assistant Professor of Medicine,
General Internal Medicine
Associate Program Director,
Internal Medicine Residency
As the 2009-2010 academic calendar matures, there are sev-
eral updates in the internal medicine training program. First
off, we have recently received the resident's inservice exam
scores and are very proud of their marks. This is the first time
in recent history that the program has ranked in the 50th per-
centile compared to the national composite scores. This is in-
deed a remarkable achievement and a testament to how hard
the trainees are studying. In the arena of scholarly activity,
special recognition goes to Drs. Salahuddin and Zhou for
their recent poster presentations at the Southern AFMR. The
Florida ACP convention is also nearing and several residents
will be representing UF Jacksonville there as well. Drs.
Atman Shah and Sudha Koduru will both be giving oral pre-
sentations, while our Jeopardy team is looking to continue
their winning ways. Resident scholarly endeavors such as
these continue to give other institutions a great impression of
On the recruiting front, we have recently concluded the
interview process for the upcoming resident class of 2010.
The applicant pool was at a record high this year; exceeding
3,600! After reviewing numerous strong candidates we were
able to interview roughly 200 students for 17 positions, which
was no easy task. We have had several responses from the
applicants following their visits and have found them quite
complementary about the residents, faculty, and overall
teaching environment. We would like to thank those of you
who were able to participate and we sincerely appreciate the
good light that you put us in. Our rank list was recently com-
pleted and we anxiously await our match results later this
Continued on Page 4
GME Corner continued from Page 3
Finally; to many people, March signifies the beginning of
spring, college basketball, or children's breaks from school.
To us in the GME office, March is marked by our annual Eval-
uation of Educational Effectiveness meeting. Here we review
inservice exam results as well as the numerous surveys that
residents and faculty have completed. This data is used to
evaluate not only successful areas of the program but most
importantly areas of opportunity. Your observations noted in
these surveys shape programmatic changes for the upcom-
ing academic years.
On a sad note, as was previously noted by Dr. Mooradian
in the "Chairman's Message", we will be losing a great leader
from the Department of Medicine and in Graduate Medical
Education. Dr. Nahman, who will be moving to Augusta
Georgia, has been more than instrumental in helping this pro-
gram reach its current lofty heights. A good leader is one
who is able to motivate people into advancing agenda be-
cause they want to, not because they are told to. As our di-
rector, Dr. Nahman has used these charismatic leadership
qualities to advance this program through trying times and
put trainees in a position to excel both clinically and aca-
demically. As we move forward, I will be transitioning to the
new role as Program Director and Christina Bailey, M.D. will
be joining us as Associate PD. We, along with Senthil Meen-
rajan, M.D., look forward to continuing the current academic
mission as well as facing the new challenges that will surely
come. What Dr. Nahman and his staff have done over the
last 6 years has been nothing short of remarkable and we plan
to build upon the strong foundation that he has laid down.
A CLINICAL CASE ]
Karishma Ramsubeik, MD Resident, Internal Medicine
Ravindra Maharaj, MD Resident, Internal Medicine
Ghaith M. Mitri, MD Chief, Rheumatology
(Adapted from Musculoskel Med. 2009;26:11-14)
When diagnosis of rheumatologic dis-
ease does not "follow the book"
Not all patients with symptoms suggestive of a rheuma-
tologic disease leave their doctor's office with a firm diagno-
sis in hand. Although disease classification and diagnosis
guidelines are available to help physicians evaluate their pa-
tients, a rheumatologic disorder can present atypically, or the
patient might not have all of the criteria needed to unequiv-
ocally support a given diagnosis. Also, the clinical picture
may change as the disease progresses from early to middle
and late stages. Consider, too, that many physicians practice
in areas where specialists are not available to consult on cases
that are especially challenging or questionable.
Thus, the process of arriving at an accurate diagnosis
often is an imprecise art. The physician may revisit evidence,
assess the patient at intervals, test response to treatment, con-
sult with colleagues, and rely on past experiences rather than
primarily on a published list of diagnostic criteria to confirm
his or her clinical suspicions.
Scleroderma (systemic sclerosis) is a rheumatologic dis-
order that can be mistaken for rheumatoid arthritis (RA) or
mixed connective tissue disease. Accurate diagnosis influ-
ences assessment of the patient's prognosis as well as the
choice of management. In this article, we use a scleroderma
case study to highlight the potential for misdiagnosis of a
rheumatologic condition and demonstrate potential pitfalls
the physician might encounter when evaluating patients.
MJ is a 62-year-old man with pulmonary fibrosis. In
2006, he was referred by his primary care physician to the
rheumatology clinic with a provisional diagnosis of mixed
connective tissue disease and RA. The patient had a 30-year
history of the following rheumatologic symptoms: diffuse
skin tightness; general fatigue; sicca syndrome; Raynaud
phenomenon; and constant, moderately severe bilateral
hand pain. The hand pain worsens in the mornings, when
MJ's hands are also stiff for about an hour.
On examination, the patient had no skin tightness. How-
ever, Velcro rales were audible at the lung bases. MJ exhib-
ited contractures of his fingers, primarily at the level of the
proximal interphalangeal (PIP) and distal interphalangeal
(DIP) joints. His fingertips had pitting scars, and his distal
finger pads lacked substance.
Laboratory test results completed at this visit were as fol-
lows: antiscleroderma (Scl) 70 antibody, 684 U/mL (normal
range, 0 to 99 U/mL); white blood cell count, 5000/pL; ery-
Continued on Page 5
A Clinical Case continued from Page 4
throcyte sedimentation rate, 110 mm/h; C-reactive protein
level, 38 mg/L (normal range, less than 5 mg/L); blood urea
nitrogen level, 14 mg/dL; creatinine level, 1 mg/dL; rheuma-
toid factor (RF), positive; and antiribonucleoprotein (RNP)
Figure 1 A radiograph of the
right hand of a 67-year-old man
with possible scleroderma shows
erosive osteoarthritis with degen-
erative changes in the distal inter-
phalangeal joints and resorption
of distal phalangeal tufts, which
is highly suggestive of sclero-
derma and typically not seen in
rheumatoid arthritis without an
Figure 2 A CT scan of the
patient's chest shows alveo-
lar opacities within the lung
bases on both sides, which is
not specific for scleroderma
or any other rheumatologic
disease that could affect the
Chest radiographs showed a diffuse interstitial pattern pre-
dominantly involving the lung bases. Radiographs of the
hands showed erosive osteoarthritis; degenerative changes
were seen in the DIP joints along with resorption of distal
phalangeal tufts, which is highly suggestive of scleroderma.
There were no erosive changes to suggest RA (Figure 1). CT
of the chest revealed bibasilar parenchymal opacities (Figure
2). It is important to note that the neither the x-ray film nor the
CT scan findings are specific for scleroderma. Results of re-
peat RF testing performed on the day of evaluation were neg-
The patient's physician made a diagnosis of scleroderma
with positive anti-Scl 70 antibody based on the following
findings from the history and physical examination: the pres-
ence of diffuse cutaneous scleroderma in the early stages;
nonerosive arthritis with tendinopathy and contractures; se-
vere Raynaud phenomenon, with fingertip ulcerations, pit-
ting scars, and substance atrophy in the distal finger pads;
sicca syndrome; and pulmonary fibrosis. The patient was tak-
ing prednisone, 20 mg/d, and oral methotrexate (MTX), 10
mg/wk, a regimen he had followed for the past 5 years. Be-
cause the arthritis appeared to be degenerative and MJ's pul-
monary fibrosis was stable, medications were discontinued
according to standard protocol (e.g, MTX was stopped and
prednisone was tapered).
It is possible that MJ had an active alveolitis or inflam-
matory nonerosive arthritis in the earlier stages of his disease
and fulfilled, at least partially, the diagnostic criteria for RA
or mixed connective tissue disease. He also might have ben-
efited clinically from the previously prescribed therapies.
However, an overlap syndrome-when a patient has a diag-
nosis of more than 1 rheumatologic disease at the same
time -is considered rare.
As this case exemplifies, diagnosis of rheumatologic dis-
orders is not always accurate. These conditions can present a
confusing picture-especially to physicians who might be
practicing in a community setting and lack access to rheuma-
tologists, rheumatology clinics, or other specialized resources.
The American College of Rheumatology (ACR) has estab-
lished criteria for classifying RA.1 Although these criteria
were developed to ensure that the diagnosis of RA is made
according to standardized guidelines in research participants
rather than in clinical patients, clinicians now use these crite-
ria widely to make a diagnosis in individual patients. Keep in
mind, however, that these criteria are empiric and are not
meant to include or exclude a particular diagnosis in any
The consequences of misdiagnosis can be profound for
patients. Although high-dose corticosteroid therapy has been
shown to be beneficial in the management of RA,2 its use in
patients with systemic scleroderma has been shown to be as-
sociated with the development of scleroderma renal crisis.3
Thus, we strongly discourage the use of high-dose corticos-
teroids in patients with early systemic scleroderma. MTX ad-
ministered weekly in low doses is a mainstay of RA
management.4 However, its efficacy for managing arthritis or
pulmonary fibrosis related to scleroderma is inconclusive.5
Diagnosis of rheumatological conditions can be confus-
ing for those who lack extensive experience in rheumatology
because there may be similarities in presentation among the
various conditions. Familiarity with distinct diagnostic crite-
ria for the diversified conditions is necessary, as this case
demonstrates. Failure to recognize a condition can lead to
misdiagnosis or a significant delay in diagnosis or initiation
of the inappropriate therapy, possibly resulting in complica-
tions. Disease-modifying antirheumatic drugs are not indi-
cated unless there is an active disease process with a
favorable risk/benefit ratio.
Continued on Page 6
Clinical Case continued from Page 5
1. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism As-
sociation 1987 revised criteria for the classification of rheumatoid arthritis.
Arthritis Rheum. 1988;31:315-324.
2. American College of Rheumatology Subcommittee on Rheumatoid Arthri-
tis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002
update. Arthritis Rheum. 2002;46:328-346.
3. Steen VD, Medsger TA Jr. Case-control study of corticosteroids and other
drugs that either precipitate or protect from the development of scleroderma
renal crisis. Arthritis Rheum. 1998;41:1613-1619.
4. Cronstein BN. Low-dose methotrexate: a mainstay in the treatment of
rheumatoid arthritis. Pharmacol Rev. 2005;57:163-172.
5. Pope JE, Bellamy N, Seibold JR, et al. A randomized, controlled trial of
methotrexate versus placebo in early diffuse scleroderma. Arthritis Rheum.
Preventing venous thromboembolism
in hospitalized patients
By Kurt Woldgang, Pharm.D.
Reprinted from Drug Update volume 26, issue number 6, 2009
Venous thromboembolism (VTE), a term which encom-
passes deep vein thrombosis (DVT) and pulmonary embolism
(PE), is the most common cause of preventable hospital death
in the U.S.(1). It is the 2nd most common complication experi-
enced in the post-operative patient and a contributor to pro-
longed hospitalization (1). Pulmonary embolism, a complication
of DVT, is often clinically undetected and can cause fatalities (2).
However, even in cases of DVT, which do not lead to fatal PE,
patients may suffer significant morbidity and may be predis-
posed to future thromboembolic events.
Thromboprophylaxis of hospitalized patients is both cost-
and clinically effective. As of 2009, the Centers for Medicare and
Medicaid Services (CMS) will not pay for occurrences of
DVT/PE in patients with total hip arthroplasty and total knee
arthroplasty (3). As a result, prevention of VTE is not only a pa-
tient safety concern, but also an economic issue for hospitals.
Two major guidelines have been established to assist
healthcare providers in recognizing VTE risks and appropri-
ately selecting prophylaxis. The 1992 Thromboembolic Risk
Factors Consensus Group (THRIFT) Guidelines detail patient
risk factors for developing VTE and also provide recommen-
dations for prophylaxis based on risk stratification. Addition-
ally, the 2008 American College of Chest Physician (ACCP)
Guidelines for Prevention of Venous Thromboembolism pro-
vide recommendations for the prevention of VTE. According
to the 2008 ACCP guidelines, the incidence of deep vein throm-
bosis (DVT) in hospitalized patients ranges from <10 to 80%
when patients do not receive prophylaxis (1). As a result, these
guidelines provide specific evidence-based recommendations
for VTE prophylaxis based on patient risk factors.
Several studies have suggested that inadequate prophylaxis
and lack of adherence to established guidelines is a large prob-
lem. There are many contributors to inadequate prophylaxis,
including lack of knowledge. Historically, a high percentage of
physicians fail to recognize VTE risk factors and adequately
provide prophylaxis against VTE (4). Educating prescribers on
disease characteristics, risk factors, and appropriate methods of
prophylaxis has improved adherence to ACCP guidelines ().
Studies have shown that using predefined order sets, staff ed-
ucation, or computer reminders increases the amount of phar-
macologic and physical prophylaxis ordered (-7).
In January 2008, a hospital protocol, based on the current
ACCP and THRIFT guidelines, was devised at Shands Jack-
sonville by a multidisciplinary team of physicians and phar-
macists in order to increase the number of patients receiving
appropriate VTE prophylaxis. This form, available in Form-
Fast, was intended for use in both medical and surgical patients.
It recommends specific prophylactic regimens based on indi-
vidual patient risk factors for likelihood of VTE development.
Appropriate prophylaxis is a key step toward reducing
thromboembolic events, avoiding associated costs, and im-
proving patient outcomes.
1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous throm-
boembolism: American College of Chest Physicians evidence-based clinical
practice guidelines (8th edition). Chest. 2008; 133:381S-453S.
2. Haines ST, Witt DM, Nutescu EA. Venous thromboembolism. In: DiPiro
JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharma-
cotherapy: A Pathophysiologic Approach. 7th ed. New York, NY:McGraw-
3. Henderson KE, Recktenwald AJ, Reichley RM, et al. Clinical Validation of
the AHRQ Postoperative Venous Thromboembolism Patient Safety Indica-
tor. Jt Comm J Qual Saf 2009; 35: 370-376.
4. Zierler BK, Meissner MH, Cain K, Strandness DE Jr. A survey of physi-
cians' knowledge and management of venous thromboembolism. Vasc En-
dovasc Surg. 2002;36:367-375.
5. Cohn S, Adekile A, Mahabir V. Improved use of thromboprophylaxis for
deep vein thrombosis following an educational intervention. J Hosp Med.
6. Mosen D, Elliott CG, Egger MJ, et al. The effect of a computerized reminder
system on the prevention of postoperative venous thromboembolism. Chest.
7. O'Connor C, Adhikari NKJ, DeCaire K, Frie-drich JO. Medical admission
order sets toim-prove deep vein thrombosis prophylaxis rates and other out-
comes. J Hosp Med. 2009;4:81-89.
NEWS & NOTES
Dr. Malcolm Foster is elected as the DCMS President-Elect
Dr. Malcolm Foster has been elected President-Elect of the Duval County Medical Society (DCMS)
at its 157th Annual Meeting, Thursday, January 21, 2010.
Dr. Foster has been on the DCMS Board of Directors since 2007 and served as treasurer in 2008 and
2009. His experience and leadership in administrative medicine at the University of Florida has
been an asset for his DCMS leadership roles. In his role, Dr. Foster will work with DCMS presi-
dent, Dr. John W. Kilkenny III of the Department of Surgery, to promote the goals of the medical
Dr. Foster has received numerous honors over his career such as Outstanding Clinical Teacher and the Laureate Award
from the ACP-ASIM (Florida Chapter).
Please join me in congratulating Dr. Foster for this honor.
MEET YOUR COLLEAGUES
Adi .. aa, M.D., Assita, Prfeso ofM dcie-ivso oumnay riia Cr
Dr. J I' Shuj"a earne ihisT medca degre fro Kin Edar Meia College iono Pakista Heom
What makes for good PR?
How do we get the public to know what we do
and why it's important?
In some industries, the answer is clear cut. For example,
those in the entertainment industry want people to watch or
buy their products, so they hire PR agents or publicists. The
same thing can be said about nearly every area in which
there's competition to sell a product-banking, retail sales,
But what about the medical field?
Although we're not selling a product in the traditional
sense, public relations can be used to help boost image. It's
about letting the public know you have the expertise, tech-
nology and compassion they won't find anywhere else. It's
about letting potential patients believe you are who they
should trust with their care. And it's about letting current pa-
tients know they made the right choice.
How can this be accomplished in medicine?
By putting a face with the product. Physicians should take
advantage of opportunities to get in front of the public-
L 'ON II/nI:I3d
whether through television, print, radio or speaking engage-
ments- so that they become known as the expert on a partic-
ular subject (medical condition, treatment, public health issue
or research). Through these opportunities, they are able to ed-
ucate the public, create a positive impression and, potentially,
gain new patients.
And the only thing it costs is a little time.
If you have a topic you think might interest the media, contact
Dan Leveton, media relations manager for Shands Jacksonville, at
firstname.lastname@example.org. Dan came to Shands from WJXT Chan-
nel 4 and has more than 25 years of experience in public relations
and the news media. He directs all public/media relations for both
Shands Jacksonville and the University of Florida College of Med-
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