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MEET YOUR COLLEAGUE
I am pleased to share with you the spring 2008 issue of Aca-
demic Physician Quarterly (APQ) newsletter.
Traditionally this season is viewed as a time for rejuvenation,
rebirth and happiness in sharp contrast to the challenges of
winter. This is exemplified in a quote by the American poet
Anne Bradstreet "If we had no winter, the spring would not
be so pleasant: if we did not sometimes taste adversity, pros-
perity would not be so welcome" (Meditations Divine and -
Moral, 1655). Of course, having enjoyed a mild and beautiful
Florida winter season, it is hard for us to appreciate the simile in the quote. Per-
haps this will lead us to infer that the upcoming spring season would be even
As promised in the last issue of the APQ, we describe our Transitional Care Unit
in the Focus section. The dedicated team of health care providers in this unit
brings hope for rehabilitation and recuperation to a group of patients who have
suffered substantial loss of functionality and independence; a chance for "spring
season" after a long and brutal "winter" of health setbacks.
In an effort to keep our community physicians abreast of the new services devel-
oped at the University of Florida Jacksonville & Shands, two new members of the
Department are highlighted in the section on Meet Your Colleagues. Dr. Khan
and Dr. Bajwa bring a unique set of skills that are invaluable in patient care de-
livery to the Division of Pulmonary, Critical Care and Sleep Medicine.
As always, if you have any comments, interesting cases or observations to share
with colleagues, please e-mail them to me and I will be happy to include them in
our future issues. My e-mail address is email@example.com.
Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine
Senthil Meenrajan, M.D.,
Assistant Professor of Medicine
Division of General
Transitional Care Unit
Over the last few years the Transitional Care Unit (TCU)
has come to fill an important position in the care of pa-
tients at Shands and the University of Florida, Jack-
sonville. While the hospital is the best place to identify
and initiate treatment of acute and severe medical condi-
tions, many patients recover to the point that they no
longer need the intensive monitoring and intervention of
the hospital. However, these patients might still be con-
valescing and need ongoing care before they can be safely
discharged. The TCU has created a niche in this area and
has consistently delivered quality care.
Target Population: patients requiring rehabilita-
tion or other skilled nursing needs
Speech and Swallow therapy
Prolonged intravenous antibiotics
Extensive wound care
Management and education of complex
ostomy and tubes
We serve the above needs of patients that come from
different specialties including, general surgery, or-
thopedic surgery, neurosurgery, cardiothoracic sur-
gery, trauma surgery and medical specialties
including neurology, cardiology, pulmonary,
nephrology and oncology.
The Unit: The unit consists of 40 beds in 3 subunits
that are designed to provide each patient with a pri-
vate room during their stay here. The unit also has a
rehabilitation area that has equipment, a conference
room in each subunit meant for the staff and the fam-
ilies, and an activities area that patients can use to so-
cialize and participate in different activities. We are
equipped to handle many complex needs of our pa-
tients and have ready access to the same services
available in the hospital. Overall, the TCU is designed
to be as patient friendly and relaxed as possible while
providing optimal care.
* The Team: The team that makes visions turn into
reality at the TCU includes an Administrator, Med-
ical Director, Nursing Director, Admissions Coordi-
nator, MDS Coordinator, Activities Director, dietitian,
pharmacist, therapists (physical, occupational,
speech), social workers, respiratory and wound care
specialists and the compassionate and efficient nurses
and their aides.
A group photo of the TCU team
Over the years we feel privileged and honored to have
been instrumental in making significant changes in the
lives of people we have cared for. Our biggest success and
satisfaction comes from the compliments that our patients
give us while they are here and after they have left.
Added to this is the recognition from national and state
accreditation agencies that have evaluated and continue
to certify us with good distinction. Going forward we look
to continue delivering the excellent care for each patient,
each and every time.
A CLINICAL CASE 1
Gina Chacon, M.D.
David Wolfson, M.D.
Carlos Palacio, M.D., M.P.H.
Animesh A Sinha, M.D., Ph.D.
Darier's disease: a commonly misdiag-
nosed cutaneous disorder.
A 48 year old Caucasian woman presented to the
emergency department complaining of a two week his-
tory of severe burning pain and pruritus in her chest,
back, scalp, and lower extremities. She was taking diphen-
hydramine and using steroid creams applied to the af-
fected areas without any improvement.
Physical examination revealed extensive hyperkera-
totic plaques on the chest, back, scalp, forehead, arms, and
legs (Fig. 1A). Flat-topped brown papules were present
on the dorsum of the hands. Other cutaneous signs in-
cluded keratotic papules with a central pit on the palms
and distal V-shaped notching with red longitudinal
streaking in the nails (Fig.lB). She also had white, flat-
topped papules in the oral mucosa (Fig. 1C). She noted
periodic exacerbations during summer months. Family
history revealed that her grandfather, father, and two sis-
ters had similar skin lesions.
Histological examination of a biopsy of skin taken
from a greasy papule from the patient's back showed a
vesiculobullous pattern described as acantholytic dysker-
atosis. A diagnosis of Darier's disease was established.
Figure 1: (A) Keratotic papules coalescing into crusted plaques;
(B) Ciii L. t i -tic nail changes. V-shaped notches in the thumb
nails, associated with longitudinal red bands; (C) White papules
in the oral mucosa
A. B C
Darier-White disease, also known as Darier's disease,
or keratosis follicularis, was described independently by
Darier and White in 1889. It is a rare autosomal dominant
disorder of abnormal keratinization and acantholysis with
involvement of the tonofilament-desmosome complex.
Most affected individuals will either give a family his-
tory of affected members or, in the absence of a positive
history, will be found to have relatives who are affected
with mild disease when they are carefully examined (1-
4). Although exact figures of prevalence are unknown,
there are estimates of 1 in 30,000 to 1 in 100,000 persons.
There is an equal incidence of the disease in men and
women. Almost all patients have worse symptoms dur-
ing the summer due to heat and humidity.
A mutation in the ATP2A2 gene on chromosome
12q23-24.1, which encodes the sarco/endoplasmic reticu-
lum calcium adenosine triphosphatase (ATPase) type 2
isoform pump (SERCA 2), is the causative mutation for
Darier's disease. Calcium is known to have a role in reg-
ulating cell differentiation and in initiating assembly of
desmosomes. Thus, acantholysis may result from loss of
adhesion as a result of desmosome breakdown.
Patients with Darier's disease typically present in
childhood or adolescence with hyperkeratotic, primarily
follicular papules with a predilection for seborrheic areas
of the body such as the scalp, face, chest, back, and flex-
ures. Palmar pitting and hyperkeratotic papules on the
hand dorsa and oral mucosal lesions may be seen. The
pathognomonic nail sign is the combination of red and
white streaks associated with a V-shaped notch.
Oral involvement, usually palatal, may be observed
ranging from a fine granular to a coarse 'pebbly' appear-
ance, or with cobblestone appearance of the palate. In-
volvement of the external ear, rhinoreactivity, and ocular
affliction has also been reported. Itch is the most common
complaint with Darier's disease, occurring in 88% of pa-
tients in one series. Patients complain of odor, especially
in flexural sites where secondary infections are frequent.
Heat, sweating, sunlight, lithium, steroid therapy, and
Continued on Page 4
A Clinical Case continued from page 3
stress may exacerbate the lesions. Darier's disease may be
associated with an excess of neuropsychiatric disorders
such as bipolar affective disorder, mental retardation,
schizophrenia and epilepsy.
The diagnosis of Darier's disease can be made with
history of familiar involvement, clinical appearance and
histopathology. The evolving lesions of Darier's disease
may be confused with acne, seborrheic dermatitis and
Grover's disease. Phemphigus and other suprabasilar blis-
tering disorders should be excluded.
The primary aim of treatment in Darier's disease is
controlling irritation (the most frequent symptom) with
emollients, soap substitutes, and keeping the skin cool by
wearing comfortable cotton clothing. Sunblock is recom-
mended for those with a history of photoaggravation.
Topical retinoids such as tazarotene or adaptalene applied
on alternating days in combination with topical corticos-
teroid antibiotic may be sufficient for patients with mild
generalized or linear disease. Steroid application may re-
duce erythema and pruritus. Oral retinoids such as
isotretinoin or acitretin have been shown to be effective
in more extensive disease, but have adverse effects.
This case of Darier's disease shows the importance of
recognizing patterns of dermatologic findings to arrive at
the correct diagnosis. We also point out the need for re-
evaluation of chronic cutaneous disorders that are not
ameliorated by conservative therapy, particularly blister-
1. Cooper SM and Burge SM. Darier's Disease. Epidemiology, pathophysi-
ology and management. Am J Clin Dermatol 2003; 4: 97-105.
2. Onozuka T, Sawamura D, Yokota K and Shimizu H. Mutational analysis
of the ATP2A2 gene in two Darier disease families with intrafamilial vari-
ability. Br J Dermatol 2004; 150: 652-7.
3. Porgpermdee S, Nakamura S, Takagi A et al. Expression of SERCA2
(Darier's disease gene product) in acantholytic dermatoses. J Dermatol Sci
2006; 43: 146-9.
Burge S. Management of Darier's disease. Clin Exp Dermatol 1999; 24: 53-6.
4. Norman R and Blanco P. Papulosquamous diseases in the elderly. Der-
matol Ther 2003; 16: 231-42
N. Stanley Nahman, Jr., M.D.
Professor of Medicine
Program Director, Internal
The Medicine residency program is lead by faculty
program directors, but the real "in the trenches" workers
are our 4th year chief medical residents (CMR).
The CMR are chosen 18 months in advance and repre-
sent our strongest resident leaders. The position is an
honor and for many, leads to fellowship training in sub-
sequent years. Today we introduce our CMR for July 2008,
Dr.'s Rosie Alcalde and Shilpa Reddy.
Dr. Rosie Alcalde
Dr. Alcalde hails from South Florida
and obtained her medical degree from
Ross. She is a quiet, determined leader
and was honored as an intern with the
best attendance for all noon confer-
ences. She is recognized for her men-
toring and teaching skills, both crucial
qualities for an effective chief. Rosie plans to pursue fel-
lowship training in Rheumatology.
Dr. Shilpa Reddy
Dr. Reddy is from Northwest Florida,
Panama City to be exact, where her fa-
ther is a gastroenterologist. Shilpa
graduated from The University of
Michigan and obtained her medical de-
Continued on Page 5
GME Corner continued from page 4
gree from Nova. She is a highly organized and assertive
leader who has excelled during her training. Her interest
in clinical research led to a funded Dean's grant, followed
by a presentation at a national meeting, and culminating
with the submission of a manuscript. Shilpa is currently
seeking a fellowship in gastroenterology for July follow-
ing her year as CMR.
professional development, the program will send both
CMR to the national meeting of the Association of Pro-
gram Directors in Internal Medicine where they will at-
tend a two day leadership seminar with the other 625 CMR
from around the country. Through this seminar, our CMR
share experiences with other national leaders in residency
training and will bring home ideas and systems that will
help raise our program to the next level of excellence.
Both Dr.'s Alcade and Reddy will bring strong profes-
sional qualities to the position of CMR but wait they do
not yet know all they need to know. To help foster their
Ashley Schields, Pharm.D., BCPS
Amy Rockwell, Pharm.D.
Drug Therapy for Pulmonary Arterial
Mainstays of pulmonary arterial hypertension (PAH)
therapy include supplemental oxygen, diuretics, antico-
agulation and calcium channel blockers. Prior to the in-
troduction of intravenous epoprostenol (prostacyclin or
prostaglandin I) the median survival of patients after di-
agnosis was 2.8 years. In subsequent years, there has been
an increase in options available for medical management
of PAH including the prostanoids, endothelin antago-
nists, and phosphodiesterase type 5 inhibitors. These
products are not stocked by retail pharmacies and are
available through special purchasing arrangements
shipped directly to the patient The Prostanoids are gen-
erally reserved for patients with more severe PAH symp-
toms (WHO Functional Class III-IV). These agents have a
very short half-life and are therefore associated with in-
convenient methods of administration.
Epoprostenol (Flolan) has been shown to im-
prove survival, functional class status, and quality of
life in Class III-IV PAH; however, patients must wear
a continuous ambulatory central intravenous infusion
pump. This increases the risk for catheter-related in-
fections, thrombosis, and/or potentially fatal re-
bound PAH symptoms, should the pump
malfunction. Adverse effects generally include jaw
pain, headache, flushing, and gastrointestinal distur-
bances (N/V). The drug must be refrigerated to
maintain stability. (1995 FDA Approval)
Treprostinil (Remodulin) has the advantage of
greater stability compared to epoprostenol and pos-
sible lower complication rate as it is delivered by con-
tinuous subcutaneous infusion. However, use is
limited due to painful injection site reactions and in-
duration and less survival data compared to
epoprostenol. (2002 FDA Approval)
Iloprost (Ventavis) shipped directly to the pa-
tient is administered via a handheld nebulizer, usu-
ally six to nine times daily. This drug has been
shown to improve quality of life and WHO functional
class in PAH patients; however, cost of the hand-held
nebulizer device is approximately $5,000. (2004 FDA
The Endothelin Receptor Antagonists are also useful
in treatment of PAH and are available for oral adminis-
tration. Endothelin-1 is considered a potent vasocon-
strictor, which may contribute to an increase in vascular
Continued on Page 6
RX Updates continued from page 5
tone and pulmonary hypertrophy that is observed in pa-
tients with PAH. These agents are more commonly rec-
ommended for less severe disease (WHO II to III). Two
drugs are currently available in this class:
Bosentan (Tracleer) is the most studied of the
two and is taken twice daily.. It is associated with
multiple drug interactions, severe hepatotoxicity, and
teratogenicity (Pregnancy Category X); therefore, it
requires patient registration in a limited access pro-
gram in order to ensure monitoring. (2001 FDA Ap-
Ambrisentan (Letairis) is available for once
daily dosing. This agent is also considered Pregnancy
Category X and carries a warning for hepatotoxicity
requiring distribution only through a limited access
program. This agent may have less reported drug in-
teractions, but experience has generally been limited
in vitro data. (2007 FDA Approval)
Finally, the phosphodiesterase-5 inhibitor sildenafil
(Revatio) was approved in 2005 for treatment of PAH.
This drug is commonly used for treatment of erectile dys-
function under the trade name Viagra. Dosing of silde-
nafil in PAH is 20 mg TID, which is significantly different
from dosing for erectile dysfunction. Sildenafil is usually
recommended for patients who have failed alternative
medical treatments; however, there has been increasing
evidence for the use of this agent earlier in treatment (i.e.,
Functional Class I-II). This agent may be found in most
pharmacies. At Shands Jacksonville, use of sildenafil (Re-
vatio) is restricted to the Divisions of Pulmonology and
Cardiology for treatment of PAH. An indication of PAH
must be documented on all outpatient prescriptions be-
fore they may be filled in the Shands Jacksonville Ambu-
latory Pharmacy. (2005 FDA Approval)
References available upon request
Drug Information Service
Department of Pharmacy
NEWS & NOTES
Dr. Supriya Maddirala, Assistant Professor of Medicine, Division of Nephrology and Hyperten-
sion, won the Young Faculty Research Award from the Southern Society for Clinical Investigation
and the southern section of the American Federation for Clinical Research. Dr. Maddirala will pres-
ent her work at the Plenary Session for the two organizations on Friday, February 22, 2008 in New
Orleans. The title of her work is "Bacteremia in patients with HIV and hepatitis C: analysis of the
DMMS study" and was chosen by the committee as the winning submission.
Congratulations to Supriya.
Continued on Page 7
News and Notes continued from page 6
Dr. Michael Hernandez, PGY3 in Internal Medicine, has been elected to Alpha Omega Alpha
Medical Honor Society through his alma mater Florida State University College of Medicine (FSU-
COM). Each year an AOA chapter can elect a house-staff member, an alumnus/alumna, and a
faculty member in addition to senior students.
Congratulations to Michael for this exceptional honor.
Dr. Kent Wehmeier, Associate Professor of Medicine and Chief of the Division of Endocrinology,
Diabetes and Metabolism, in collaboration with Dr. Michael Haas, Associate Research Professor,
published a seminal study in the prestigious journal Biochim Biophys Acta. The title of the man-
uscript is "Differential regulation of apolipoprotein A-I gene expression by vitamin D receptor
MEET YOUR COLLEAGUES
Two Pulmonologists Join the Department.
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DIABETES & ENDOCRINOLOGY UPDATE SYMPOSIUM
University of Florida College of Medicine Jacksonville
Division of F El,., i I1. ,. ., Diabetes & Metabolism
Date: Saturday, May 3, 2008
Time: 7:30 A.M. 4:00 P.M.
Location: Hyatt Regency Jacksonville Riverfront
Available Credits: 7.0 CME
Register now for a one-day symposium featuring seven expert clinicians who will present updates on the following top-
ics: insulin therapy, growth hormone replacement in adults, skeletal heath and osteoporosis, drug therapy for Type 2
diabetes, male hypogonadism, thyroid disorder, and diabetic dyslipidemia.
Join your colleagues for this interactive and enjoyable educational program with endocrinologists from UF Jacksonville,
Cleveland Clinic, and Case Western Reserve University.
Registration fees: Physicians $50; Non-Physicians $35; Residents/Fellows: No Charge with letter from department ver-
ifying status. A $25 late fee is added to registrations after April 29. Register on UF's online secure website,
For more information, please contact Barbara Jones at 904-244-2380 or firstname.lastname@example.org
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