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^UF UNIVERSITY of
College of Medicine
NEWS AND NOTES^^^
On behalf of the Department of Medicine at the University of
Florida College of Medicine-Jacksonville I would like to wish
you a happy new year. I hope you all had a wonderful holi-
day season with family and friends.
With the inauguration of the 2010 we will be in our fourth \
year of launching the Academic Physician Quarterly (APC)
newsletter. The previously published issues of the APC are
on our website at http://hscj.ufl.edu/im/archives.asp.
I am proud to assure you that the state of the Department is strong. We have main-
tained a strong core residency program and we have now completed the devel-
opment of all subspecialties and have established training programs in each one.
The last subspecialty training program to be added in July 1st, 2010 will be in
Rheumatology and Immunology. If all goes as planned, this training program will
be launched as a joint effort with the Mayo Clinics in Jacksonville. This collabo-
rative accomplishment is an extension of our efforts to reach out to all the teach-
ing and patient care institutions in our community.
I hope you enjoy reading through the pages of this issue. As always if you have
any suggestions on how to improve our services please feel free to contact me per-
Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine
Juan C. Munoz, M.D.
Assistant Professor of Medicine
Division of Gastroenterology
Endoscopic Mucosal Resection (EMR)
Endoscopic Mucosal Resection (EMR) is a new minimally
invasive endoscopic technique used to locally excise lesions
confined to the superficial mucosa avoiding the need for
open surgery. Its main role is in the treatment of advanced
dysplasia and early gastrointestinal cancers. The EMR was
originally described as a therapy for early gastric cancer.
Japanese physicians have used EMR for almost two decades.
In the Western world, the predominant indication for EMR
in the upper gastrointestinal tract is the staging and treat-
ment of advanced dysplasia and early neoplasia in Barrett's
esophagus (Case #1).
47 yo BM
Ampulla, biopsy: Tubulovillous adenoma with focal high grade dyspla-
sia, consists of a 1.6 x 1.6 x 0.9 cm rubbery firm tan-brown sessile polyp.
Splenic flexure, polypectomy: Moderately differentiated adenocarcinoma
arising in an adenomatous polyp.
Continued on Page 3
Squamocolumnar with intestinal (goblet cell) metaplasia consistent wi
Barrett's esophagus and fibrinopurulent inflammatory exudate. No dys
Recently its use has expanded as a therapeutic option for
ampullary adenomas (Case #2), small/localized colorectal
cancer (Case #3-4), and large colorectal polyps (Case #5-6).
Focus continued from Page 2
EUS: A mass was found in the rectum. There was
Case #6 sonographic evidence suggesting invasion into
Rectum the superficial rectal tissues only.
51 BF Rectum, biopsy: Superficial fragments of
FINAL DIAGNOSIS rectum, biopsies: Multifocal intramucosal adeno-
carcinoma with focal invasion of the muscularis mucosa and superficial
portion of submucosa arising in a tubulovillous adenoma. The cauter-
ized base of the stalk appears free.
S20 mm sessile polyp withfocal high grade dysplasia at the hepatic flexure I
I Ascending/cecum, mass: Tubulovillous adenoma.
The EMR technique consists of the suction(using transparent
cap) or injection of a solution into the submucosa of the gas-
trointestinal wall to raise a lesion and separate it from the
deep muscular layer allowing removal of tissue for further
In contrast to surgical resection, EMR allows lesions to be
removed with a minimum of cost, morbidity and mortality.
EMR advantages include:
* Advanced dysplasia and most early neoplastic lesions can
be treated with curative intent simply by local resection.
* Provides tissue specimen for histology and staging.
* EMR is a valuable adjunct to EUS to accurately determine
intramucosal from submucosal tumor invasion (Case #6).
* Minimally invasive and carries lower morbidity and mor-
tality compared to traditionally surgical approaches.
* Surgery can be performed after EMR if advance neoplasia
or incomplete resection is detected on histology evaluation.
EMR disadvantages are:
* Is a labor intense, time consuming and requires advanced
* Large lesions (> 2 cm) can only be excised in piecemeal
fashion which precludes evaluation for completeness of the
resection at the lateral margins.
* Recurrence of neoplastic disease after EMR is a potential
* There is uncertainty regarding the long term outcome (lack
of randomized trials directly comparing EMR vs. surgery).
* EMR is poorly reimbursed in the US.
Senthil Meenrajan, M.D.
Assistant Professor of Medicine,
General Internal Medicine
Associate Program Director,
Internal Medicine Residency
The GME corner provides me the unique opportunity to
reach everyone in a number of ways sometimes just as a re-
porting corner to update everyone of progress made, some-
times as a tool to query readers and sometimes as a comer to
reflect on a topic. This time I would like to do all three! In-
terspaced in this entire column are favorite phrases from dif-
ferent prominent leaders in our institution. If you know the
answers feel free to e-mail them to me or Jaime.
Practice based learning (PBL) this has become a key
phrase in everything we do. Hopefully no one reading this
right now is asking 'what's that'? As learners, educators and
administrators we should have heard the phrase in many dif-
ferent situations. From how we learn to how we teach to how
we practice medicine PBL has become an integral part of
everything we do. Learning more from how our residents
prepare and perform in the past has helped us improve our 3
year rolling average board pass rate from 70%, not too long
ago to 88% at the end of this year. PBL is not a new concept
nor is it unique to medical practice. I would have loved to say
here" Yogi Berra once said.....", but then I would be doing
what someone else loves to do (guess who?). The cornerstone
of PBL is reflective learning. In the Kolb's learning cycle we
go through 4 phases:
Abstract Conceptualization 4 Active Experimentation
4 Concrete Experience 4 Reflective learning
and then based on the reflective learning process we return
to new abstract conceptualization and the process and
We are particularly adept at the first 3 phases of the learn-
ing process but are certainly lacking in the last reflective part.
Reflective learning however really helps us "close the loop"
(according to who?) Reflecting on how we screen applications
and interview each season has helped us get stronger candi-
dates each year. The results are tangible...more applications
each year (>3600 this year), interns stronger in academics and
in clinical medicine and intense competition at regional and
national meetings. The residents have done well in all areas
of scholarly pursuits as typified by our winning the poster
presentation competition at the Florida ACP meeting at St.
Pete Beach. The jeopardy team finished second in the state.
Not bad for a place from whose title "the term asylum was
dropped rather prematurely" (says who?)
PBL comes to us from many different sources evaluations
in GME, PQRI (physician quality reporting initiative). At this
time PBL is also required for ABIM recertification in the form
of practice improvement modules. So if you know all about
PBL great...if not, get onboard and learn it now!! There is
no running away from it whether in academics or not.....wel-
come to the new world order of constant self evaluation and
[A CLINICAL CASE I
Karishma Ramsubeik, M.D.
Harry J. Griffiths, M.D.
Ghaith Mitri, M.D.
Arthritis in a patient with severe pso-
riasis: Narrowing the differential
An 84-year-old woman presented with a 1-week history of pain
and swelling in her knees and hands. She had a past medical history
significant for severe psoriasis and osteoarthritis (OA). The patient
reported morning stiffness and swelling lasting more than 60 min-
utes. On examination, there was swelling, warmth, and tenderness
at the proximal interphalangeal joints, metacarpophalangeal (MCP)
joints, wrists, and knees. Heberden and Bouchard nodes were pres-
ent. Skin findings included diffuse scaly, erythematous plaques
consistent with severe psoriasis.
Therapy with prednisone, 60 mg/d, had been started by the hos-
pital team 3 days before they consulted rheumatology, and the pa-
tient was already experiencing some relief. She did not have
"sausage digits" or nail pitting, but her arthritis was symmetrical.
She was taking only topical creams for her psoriasis, for which the
diagnosis had been made more than 20 years earlier.
Considering the patient's symmetrical arthritis involving small
and large joints with severe psoriasis, our top 2 considerations in
the differential diagnosis were psoriasis and RA. Rheumatoid fac-
Continued on Page 5
A Clinical Case continued from Page 4
tor (RF) and cyclic citrullinated peptide IgG antibody test results
were negative. X-ray films of the patient's hands revealed chondro-
calcinosis in the triangular fibrocartilage, as well as in many of the
MCP joints (Figure 1). In addition, there were severe degenerative
changes throughout the carpus with marked scapholunate disasso-
ciation and narrowing of the triscaphe joint (between the scaphoid,
trapezium, and trapezoid). On the basis of the imaging findings, a
diagnosis of calcium pyrophosphate dihydrate (CPPD) deposition
disease was made.
Figure 1: A radiograph of
our patient's hand shows
chondrocalcinosis in the tri-
angular fibrocartilage as well
as in many of the intercarpal
joints. Severe degenerative
changes have occurred
throughout the carpus, with
marked scapholunate disas-
X-ray films of the knees revealed chondrocalcinosis in the fibrocar-
tilage (menisci) and in the hyaline cartilage outlining the femoral
condyles and tibial plateaus (Figure 2). This finding is unique to
CPPD deposition disease, but the patient also had secondary de-
generative joint disease.
Figure 2: A knee radiograph
shows chondrocalcinosis in
both the fibrocartilage
(menisci) and hyaline carti-
lage outlining the femoral
condyles and tibial plateaus.
Severe secondary degenera-
tive joint disease also is pres-
ent in our patient.
Further testing showed a white blood cell count of 8.5 x 103/pL
(normal range, 4.5 to 11 x 103/pL); hemoglobin level, 10.7 g/dL (nor-
mal, 12 to 16 g/dL); hematocrit level, 37.7% (normal, 37% to 47%);
platelet count, 240,000/pL (normal, 140,000 to 440,000/pL); calcium
level, 8.3 mg/dL (normal, 8.6 to 10 mg/dL); phosphate level, 2.9
mg/dL (normal, 2.5 to 4.5 mg/dL); magnesium level, 1.8 mEq/L
(normal, 1.8 to 2.6 mEq/L); C-reactive protein level, 89 mg/L (nor-
mal, lower than 5); erythrocyte sedimentation rate, 127 mm/h (nor-
mal, 0 to 20 mm/h); uric acid level, 7.4 mg/dL (normal, 3 to 8.2
mg/dL); vitamin D level, 8.8 ng/mL (normal, 15.9 to 55.6 ng/mL);
and parathyroid hormone (PTH) level, 154 pg/mL (normal, 16 to 65
pg/mL). Because the PTH level remained elevated on repeated test-
ing, an endocrinology consultation was requested; the endocrinolo-
gist made an additional diagnosis of vitamin D deficiency.
The patient had symmetrical polyarthritis with a long history of
psoriasis and severe arthritis. The presence of psoriatic dermal signs
is not pathognomic for PsA, which may have several manifesta-
PsA is a type of arthritic inflammation that occurs in about 30% of
patients with psoriasis.2 Symmetrical PsA accounts for about 15% of
cases of PsA. Wilson and associates3 observed that nail dystrophy,
scalp lesions, and intergluteal and perianal psoriasis are psoriatic
features associated with a higher probability of PsA.
In 2005, the ClASsification of Psoriatic ARthritis (CASPAR) study
group put forth a set of criteria for the diagnosis of PsA.4 To meet the
CASPAR criteria, a patient must have inflammatory articular dis-
ease (joint, spine, or entheseal) with 3 or more points from 5 cate-
Current psoriasis is assigned a score of 2; all other features have a
score of 1. The CASPAR criteria have a specificity of 98.7% and a
sensitivity of 91.4%.4 Our patient had a score of 3 points, making a
diagnosis of PsA a possibility.
Regardless of the criteria, many patients may have PsA without
skin disease; isolated nail psoriasis is observed in 3% of the patients
with psoriasis.5 Note that most criteria were intended as clinical re-
search inclusion criteria and not diagnostic criteria.
RA would be a possibility in the differential of symmetrical PsA.
However, the American College of Rheumatology (ACR) criteria, in
which at least 4 of 7 findings must be met, should be considered 6.
Our patient met 3 of the 7 ACR criteria. Therefore, she did not qual-
ify for a diagnosis of RA. The patient would have been character-
ized by this diagnosis if her RF had been positive, which is not
uncommon in her age-group.
Crystal-induced arthritis usually is monarticular. However, pol-
yarticular acute flares are not uncommon and many joints may be in-
volved simultaneously or in rapid succession.
Our patient had an inflammatory arthritis. Therefore, crystal
arthritis- including gout was included in the differential diagno-
sis. According to the American Rheumatism Association, a patient
has gout if at least 7 of 13 criteria are present .7
An arthrocentesis would have been useful, because the diagnosis
of gout includes the presence of intracellular negatively birefringent
monosodium urate crystals, but was not performed for our patient.
However, the patient's x-ray films lacked the classic findings of gout
and the history was not suggestive of the condition.
In addition, although elevated serum uric acid levels are an im-
portant risk factor for gout, they neither confirm nor exclude the dis-
order. During acute attacks of gout, serum uric acid levels may be
normal; conversely, many persons with hyperuricemia do not have
gout. In fact, psoriasis with high tissue nucleic acid turnover also
Continued on Page 6
A Clinical Case continued from Page 5
may lead to mild to moderate hyperuricemia.8
Chondrocalcinosis -a pathological and radiographic term denot-
ing stippled calcification of cartilage within joints, including both
hyaline articular cartilage and fibrocartilage -usually affects mid-
dle-aged and older persons. A review of the literature suggests that
this nomenclature involves an area of confusion. Chondrocalcinosis
is not synonymous with CPPD crystals. The term also may refer to
dicalcium phosphate dihydrate crystals or calcium hydroxyapatite
crystal deposition disease (HADD). However, CPPD crystal depo-
sition accounts for about 95% of chondrocalcinosis cases.9
The occurrence of intra-articular chondrocalcinosis also may be
associated with OA.10 However, plain x-ray films are not very sen-
sitive for the diagnosis of chondrocalcinosis; in fact, Fisseler-Eckhoff
and Miuller" showed that a radiographic diagnosis of chondrocalci-
nosis is made in only about 40% of patients who have pathologically
proven CPPD crystal deposition.
CPPD disease is characterized radiologically by the presence of
chondrocalcinosis or involvement of an unusual joint or both. The
classical radiological features in the wrist include calcification of the
triangular fibrocartilage between the distal ulna and the carpal
bones. There also may be solitary narrowing of the radiocarpal joint,
which may progress to narrowing of the triscaphe joint. Chondro-
calcinosis also may progress and be seen in the ligaments between
the various carpal bones, particularly in the scapholunate and
lunotriquetral joints but also on the metacarpal heads and in the in-
In the knee, apart from the presence of chondrocalcinosis in both
the fibrocartilage and hyaline cartilage (a finding unique to CPPD),
the most characteristic finding is solitary narrowing of the
patellofemoral joint without visible narrowing of the lateral or me-
dial compartment. Chondrocalcinosis may be seen in other joints,
including the hips, shoulders, and symphysis pubis. Note that chon-
drocalcinosis is a radiographic diagnosis and a radiological entity
that may occur with or without clinical manifestations.
The most likely diagnosis in our patient, without our having per-
formed aspiration, was pseudogout. The presence of CPPD crystals
accounts for most cases of crystal-induced arthritis, apart from gout.
The clinical presentation of CPPD crystal deposition is highly vari-
able. Five clinical patterns have been described: asymptomatic,
pseudogout, pseudorheumatoid, pseudo-osteoarthritis, and pseudo-
neuropathic joint disease pattern; 50% of cases are idiopathic.
CPPD crystal deposition is thought to be associated with hypo-
magnesemia, hypophosphatasia, hyperparathyroidism, and he-
mochromatosis, but this possible association is controversial. A
proposed mechanism of secondary CPPD crystal deposition in hy-
perparathyroidism is the associated hypercalcemia. The cause of
CPPD crystal deposition is not known, but 2 mechanisms have been
proposed, overproduction or decreased removal of CPPD crystals
from cartilage and abnormality of the underlying cartilage collagen.
Treatment of patients with CPPD crystal deposition is geared
mainly toward symptomatic relief. Aspiration of large effusions,
NSAIDs, intra-articular corticosteroid injection or oral doses of cor-
ticosteroids, and low-dose colchicine may be used. There is no med-
ical treatment for calcium deposits or polyarticular and progressive
degenerative changes. Successful management of hyperparathy-
roidism or hemochromatosis has not been shown to reverse chon-
drocalcinosis, but managing the disease correctly prevents future
flares and worsening of the disease condition.
HADD is characterized by the deposition of calcium hydroxyap-
atite crystals in para-articular soft tissues, resulting in tendinitis and
bursitis; the cause is unknown. Hydroxyapatite crystals have a char-
acteristic amorphous paste-like appearance on x-ray films.
HADD was a possibility in our patient. However, it more typi-
cally affects middle-aged persons and men and has a different joint
distribution (ie, shoulders), although calcifications may be found in
every joint and multiple deposits are common." HADD has been
found to be associated with chronic renal failure, collagen vascular
disease, and trauma.'2
Our patient may qualify for systemic management of psoriasis,
which may include methotrexate or biologic agents. However, man-
aging her psoriasis may not help her arthritis. We lowered our pa-
tient's dosage of prednisone to 5 mg 3 times a day and then tapered
it. We started therapy with colchicine, 0.6 mg twice daily, and sup-
plemental vitamin D. The patient's symptoms have since improved.
Adapted from The Journal of Musculoskeletal Medicine. Vol. 26 No. 9
1. Landells I, MacCallum C, Khraishi M. The role of the dermatologist in identifi-
cation and treatment of the early stages of psoriatic arthritis. Skin Therapy Lett.
2. Zachariae H. Prevalence of joint disease in patients with psoriasis: implications
for therapy. Am J Clin Dermatol. 2003;4:441-447.
3. Wilson FC, Icen M, Crowson CS, et al. Incidence and clinical predictors of pso-
riatic arthritis in patients with psoriasis: a population-based study. Arthritis
4. Taylor W, Gladman D, Helliwell P, et al; CASPAR Study Group. Classification
criteria for psoriatic arthritis: development of new criteria from a large interna-
tional study. Arthritis Rheum. 2006;54:2665-2673.
5. Kaur I, Saraswat A, Kumar B. Nail changes in psoriasis: a study of 167 patients.
Int J Dermatol. 2001;40:601-603.
6. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Associ-
ation 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis
7. Wallace SL, Robinson H, Masi AT, et al. Preliminary criteria for the classifica-
tion of the acute arthritis of primary gout.Arthritis Rheum.1977;20:895-900.
8. Pittman JR, Bross MH. Diagnosis and management of gout. Am Fam Physician.
9. McCarty DJ r I .. ,, i I Gatter RA, Grossman M. Studies on pathological cal-
cifications in human cartilage, I: prevalence and types of crystal deposits in the
menisci of two hundred fifteen cadavers. J Bone Joint Surg. 1966;48A:309-325.
10. Reuge L, Van Linthoudt D, Gerster JC. Local deposition of calcium pyrophos-
phate crystals in evolution of knee osteoarthritis. Clin Rheumatol. 2001;20:428-
11. Fisseler-Eckhoff A, Muller KM. Arthroscopy and chondrocalcinosis.
12. Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radi-
Changes in the "Legible Prescription Law".
Reprinted with modifications from Drug Update, Volume 26
No. 4; May 2009.
On July 1, 2003, the "Legible Prescription Law" went
into effect1. This law was created to reduce prescription er-
rors and keep Florida citizens and visitors safe. The specific
statute, "Written Prescriptions for Medicinal Drugs", is lo-
cated in Section 456.42 of the Florida statutes, a chapter that
addresses general provisions for health professions and oc-
When first enacted, the law required ALL prescriptions
to have the date written out (i.e., January 1, 2009) and the
quantity written in both textual and numerical formats [i.e.,
30 (thirty)]. In 2006, the law was amended to include a pro-
vision to exempt electronically generated and transmitted
prescriptions from the requirement to list the quantity in tex-
tual format2. Recently, on April 29, 2009, Bill 1868 was ap-
proved by both the Florida House and Senate amending the
law again3. The changes are to become law on July 1, 2009,
pending signing by the governor. Following approval, the re-
quirement for the date (as an abbreviate month [e.g., Jan]) and
quantity in textual format will apply only to controlled sub-
It is important to remember that this law only applies to
prescriptions and not for medication orders written for hos-
pitalized inpatients. Also, the law does not specifically pro-
hibit filling by a pharmacist if the requirements of this law
are not met; however, a separate statute (893.04 Pharmacist
and practitioner) is being updated to give direction to phar-
macists if the textual quantity is missing. The statute states:
"If a prescription includes a numerical notation of the quan-
tity of the controlled substance or date, but does not include
the quantity or date written out in textual format, the phar-
macist may dispense the controlled substance without verifi-
cation by the prescriber of the quantity or date if the
pharmacy previously dispensed another prescription for the
person to whom the prescription was written"3. If the pre-
scription is illegible the pharmacist should call the prescriber
1. Frequently Asked Questions: Legible Prescription Law [Internet].
Florida Board of Medicine [cited 2009 May 22]. Available from:
www.doh.state.fl.us/mqa/MEDICAL/infol. _.I-. -,. r,..... i..I '
2. 456.42 Written Prescriptions for Medicinal Drugs [Internet]. 2008 Florida
Statutes, Title XXXII: Chapter 456 [cited 2009 May 22]. Available from:
3. Enrolled Senate Bill 1868: Relating to the Practice of Pharmacy [Internet].
The Florida Senate 2009 Legislative Session [cited 2009 May 22]. Available
NEWS & NOTES
Dr. Santosh Kale, receives 2009 Shahin Award
for Medical Research
Dr. Santosh Kale is the recipient of the 2009 Shahin
Award for Medical Research, Review Category for his article
A Case and Literature Review of Complicated Gastrointestinal
Stromal Tumors, published in Gastroenterology and Hepatology.
The decision of the committee was unanimous.
The award is given annually by the Duval County Med-
ical Society (DCMS) to recognize young physicians for their
scholarly efforts. The award was presented to Dr. Kale at the
DCMS / Navy meeting on September 22, 2009.
Please join me in congratulating Dr. Kale for this honor.
Top prizes for our residents at the Florida Amer-
ican College of Physicians (ACP)
Drs. Mohsen and Dr. Zhou, two of our residents in the
core program have won joint first place in the poster pres-
entation competition. They were chosen among over 25 other
In addition, our medical resident jeopardy team did well
by finishing second in the state.
Congrats to the team.
Update in Nephrology:
Hyatt Riverfront Hotel, February 20, 2010
Save the Date A one-day program focusing on relevant
current and emerging diagnostic and management issues
for primary care providers pertaining to patients with kidney
disease and hypertension.
Diagnostic and Interventional Musculoskeletal
Ultrasound for Rheumatologists:
Ponde Vedra Inn, March 5 7, 2010
An intensive skills workshop to improve accuracy of di-
agnosis and treatment. This course, with didactic, demon-
stration, and cadaveric sessions, addresses anatomy and
imaging techniques of the upper and lower extremities and
hips for the practicing Rheumatologist.
Internal Medicine Update:
One Ocean, Atlantic Beach, March 12-14, 2010
This program is designed to provide general internists
and subspecialists, family medicine physicians, physician
assistants, nurse practitioners and allied health care profes-
sionals with a state-of-the-art update in Internal Medicine.
We look harder.
We feel softer.
At the Shands Jacksonville Ad\anced Breast Imaging
Center at Emerson Medical Plaza, ie'\ve combined the
soft comfort ot a ManmmoPadTM with the latest digital
eclumology. The ManunoPad'T is a soft foam pad that
creates a cushion between the breast and the
mammography machine. All this with 3-D ultrasound
technology for patients who need additional testing.
At the Shands Jacksonville Advanced Breast Imaging
Center, patients have access to the best there is to offer--
expert University of Florida physicians, state-of-the-art
equipment and compassionate care.
We also offer:
Monr Conrenient Hours Closer Location Caring Staff
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