InTouch Newsletter, Vol 13, Issue 1

Advancing Research at UTGSM

The University of Tennessee Graduate School of Medicine, in collaboration with the University Health System, strives to foster an environment which promotes research to advance our collective medical knowledge. Dr. Jonathan Wall, Professor of Medicine, founded and continues to lead the Amyloidosis and Cancer Theranostics Program (ACTP), the goal of which is to “develop novel biological therapeutic and diagnostic agents for amyloidosis or cancer to impact patient outcomes”. Dr. Manasi Balachandran and Dr. Joseph Jackson are the newest members to join the ACTP. Dr. Balachandran joined the research group in January 2021 after completing her post-doctoral studies at Oak Ridge National Laboratory. An immunologist by training, she focuses on developing tissue culture workflows, in vitro and in vivo bioassays, and aiding clinical trials. She was drawn to Dr. Wall’s group because “this research has a direct impact on patient’s lives, thus making the work extremely valuable and satisfying”. She

Rajiv Dhand, MD, Chair

Points of View AN ODE TO TEXTBOOKS

Many of us grew up reading textbooks to gain knowledge. During my school years, each subject, be it English, Mathematics, Chemistry, Physics, Social Sciences, or Biology, had a recommended textbook that served as the primary resource for learning. After entering medical school in India, the desire to learn more led to supplementing the required (and beloved) Grey’s Anatomy, Wright’s Physiology, Boyd’s Textbook of Pathology, Love and Bailey’s Textbook of Surgery, Davidson’s

currently works to develop novel CARMacrophages as a potential mechanism for amyloid clearance. Furthermore, Dr. Balachandran works to engage the next generation of medical researchers by mentoring undergraduate students from the University of Tennessee. Dr. Jackson began working within the ACTP in June 2021; after completing a fellowship in cancer immunology at the University of Pittsburg School of Medicine. Dr. Jackson was recruited by Dr. Wall to aid in the development of amyloidosis imaging agents and to establish his cancer research program. Dr. Jackson works to develop methods that enhance amyloid removal within the body, and his cancer research focuses on engineering oncolytic viruses to combat glioblastoma with the impetus on arming these viruses with immunotherapeutic payloads designed to induce antitumor immunity. Dr. Jackson seeks to “translate what they do in the laboratory into the clinical setting” and hopes that the imaging agents developed to aid amyloidosis diagnosis will be “readily available to all who want them”. As a group the ACTP has worked on four clinical trials in the last five years, two of which have been successfully completed. Apart from their research, the ACTP works closely with the Amyloidosis Foundation to conduct support group meetings for patients and caregivers. The University of Tennessee Graduate School of Medicine is excited to see the direction this research takes and would like to congratulate this amazing team on their groundbreaking discoveries and accomplishments.

Principles of Medicine, and Shaw’s textbook of Gynecology among others, with more extensive coverage of each subject from a variety of other books. These books were indispensable companions during my undergraduate years. They were read from cover to cover, annotated, and quoted chapter and verse. The list of textbooks grew exponentially during postgraduate training with many long and satisfying hours spent in the library poring over various texts. Personally, I continue to find it a lot easier to assimilate and remember printed material compared to reading it in digital form. Other features make textbooks attractive, their covers, the feel of the paper, their texture and smell, and, of course, the satisfaction and excitement of learning from the most acclaimed authorities in the field. There is an inescapable and long-lasting bond between the reader and a textbook that can’t be

continued on page 2

Trials Research

“Differentiating the Effects of Long-acting Bronchodilators

Administered by Nebulizer versus Dry Powder Inhaler in Symptomatic Patients with Chronic Obstructive Pulmonary Disease”

The Department of Medicine is currently working on a prospective, randomized 13-week clinical trial with Viatris looking at outcomes between long-acting anti-muscarinic agents (LAMA) and long-acting beta agonist agents (LABA) delivered by a dry powder inhaler (DPI) vs LAMA/LABA combination nebulizers among symptomatic patients with stable COPD. The study team is led by Dr. Rajiv Dhand as the principal investigator and Drs. Isaac Biney, Samuel Treat, and Paul Terry as Co-investigators with additional help from many other research supporters, respiratory therapists, data analysts, pharmacists, and physicians.

The significance of this study is that if the team’s hypothesis that nebulizers are more effective than inhalers in reducing symptoms and improving quality of life is correct, then there is potential to improve the lives of COPD patients. There will be three primary outcomes measured including the difference between the values of area under the response curve for inspiratory capacity (IC) from baseline through six hours after inhalation of LAMA/LABA combination with nebulizer vs DPI, proportion of participants achieving improvement of >2 points in their CAT score compared to baseline, or proportion of participants achieving reduction of 4 points in the SGRQ score compared to baseline. Additionally, there will be multiple secondary outcomes assessed.

The Department of Medicine is proud of the hard work and dedication that many individuals are placing on research to improve the lives of the patients that we serve.

Sharing Research Far & Wide

Research activity continues to grow at UT’s Graduate School of Medicine. The Pulmonary Critical Care (PCC) Department made a strong appearance at the annual CHEST conference in Honolulu, Hawaii in October 2023. Fellows listed as first authors include Drs. Akesh Thomas, Nishant Sharma, Elman Urbina, Raghu Tiperneni, and Shawnt Tosonian. Two attendings in the department presented their research; Dr. Rajiv Dhand presented on nebulized long-acting vs short-acting bronchodilators and Dr. Soto presented a cross sectional review on pulmonary hypertension. Drs. Soto, Gardner, and Urbina were also invited speakers at CHEST.

Other notable presentations and publications were completed both nationally and internationally. Dr. Dhand presented at The International Society of Aerosols in Medicine in Germany and published “The 2023 GOLD Report: Updated guidelines for inhaled pharmacological therapy in patients with stable COPD” in Pulmonary Therapy. Dr. Nishant Sharma presented at the American Association for Bronchology and Interventional Pulmonology with attendings Dr. Bevill, Branca, Callison, and Josan listed as authors. Dr. Josan was a second author on a quality improvement project published in the BMJ. The Cardiology Department published a case report in Cureus in August 2023 by fellow Dr. John Taylor as a second author and attending Dr. Benjamin Shepple on Cutibacterium. Drs. Wall, Martin, Lands, Ramchandren, and Kennel had a recent publication in November 2023 in JACC Cardiovascular Imaging on Cardiac Amyloid. Overall, 2023 proved to be a strong year for research in the Department of Medicine and we look forward to continued growth and development in 2024.

Points of View

continued from page 1

substituted by other materials. I feel nostalgic when I see the textbooks of yore in the library, such as my personal favorite, the book on Respiratory Diseases by Sir John Crofton. My bond with that book was so strong that it served as a foundation for my interest in pursuing a career in pulmonary medicine.

In recent years, there has been a transformation in how courses are taught. The emphasis has shifted to digital learning and there are no prescribed textbooks. Digital content is readily available and accessible from many places, it can be shared by many readers, and storage is much easier than printed books. With the speed at which new medical knowledge is being generated, the ability to update digital content is much simpler and clearly superior to printed material. It is easier and less expensive to incorporate color, figures, and multimedia in digital materials. The ability to search for specific topics in online materials is another distinct advantage. However, in my view, textbooks provide more comprehensive coverage of a subject compared to digital content. This allows the reader to gain a broader understanding of the subject with fewer distractions compared to digital content. As residents in Medicine, it was expected that we would gain basic knowledge from a textbook. I would encourage current residents to continue that practice and supplement their knowledge with digital or online content.

Textbooks and digital content should be considered as not competing but rather complementary resources. There are strengths in both formats and some learners find one medium preferable to the other. Let us not make textbooks obsolete, there is so much more to learn from them.

Cardiovascular Diseases / Interventional Cardiology Publications

• Moodie TR, Taylor J, Shepple B. A case of Cutibacterium acnes pericardial effusion after coronary artery bypass surgery. Cureus. 2023 Aug 7;15(8):e43095. doi: 10.7759/cureus.43095. PMID: 37680428; PMCID: PMC10482544

• Fogelson B, Baljepally R, Heidel E, Ferlita S, Moodie T, Coombes T, Goodwin RP, Livesay J. Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the Heart Team. Cardiovasc Revasc Med. 2023 Dec 16:S1553-8389(23)00936-3. doi: 10.1016/j.carrev.2023.12.005. Epub ahead of print. PMID: 38135570.

• King SA, Jenkins JD, Livesay J, Yune JM, Mannino E, Webb JM, Hill HC, Baljepally R, Daley BJ, Smith LM. Coronary Artery Calcification and Risk of Cardiac Complication in Geriatric Trauma Population. J Am Coll Surg. 2024 Jan 9. doi: 10.1097/XCS.0000000000000945. Epub ahead of print. PMID: 38193566.

Pulmonary Critical Care Publications

• Terry PD, Dhand R. The 2023 GOLD Report: Updated guidelines for inhaled pharmacological therapy in patients with stable COPD. Pulmonary Therapy. 09/01/2023; 9 (3) : 345-357. PMID: 37470971

• Cloyes RR, Josan E, Pastis N, Ma J, Palettas M, Peng J, Vasko-Wood S, Mohrman C, Ghattas C, Presley C, Revelo A, Pannu J. Reducing hospital admissions in patients with malignant pleural effusion: a quality improvement study. BMJ open quality. 09/01/2023; 12 (3) : 0-0. PMID: 37751941

• Flandes J, Martinez-Muñiz FB, Cruz-Rueda JJ, Soto FJ, Majid A, Tuta-Quintero E, Giraldo-Cadavid LF. The effect of combining different sampling tools on the performance of electromagnetic navigational bronchoscopy for the evaluation of peripheral lung lesions and factors associated with its diagnostic yield. BMC Pulmonary Medicine. 11/08/2023; 23 (1) : 432. PMID 37940942

• Biney I, Ari A, Barjaktarevic IZ, Carlin B, Christiani DC, Cochran L, Drummond MB, Johnson K, Kealing D, Kuehl PJ, Li J, Mahler DA, Martinez S, Ohar J, Radonovich L, Sood A, Suggett J, Tal-Singer R, Tashkin D, Yates J, Cambridge L, Dailey PA, Mannino DM, Dhand R. Guidance on mitigating the risk of transmitting respiratory infections during nebulization by the COPD Foundation Nebulizer Consortium. Chest. 11/15/2023. PMID 37977263

Amyloidosis Publications

• Wall JS, Martin EB, Lands R, Ramchandren R, Stuckey A, Heidel RE, Whittle B, Powell D, Richey T, Williams AD, Foster JS, Guthrie S, Kennel SJ. Cardiac Amyloid Detection by PET/CT Imaging of Iodine (124I) Evuzamitide (124I-p5+14): A Phase 1/2 Study. JACC Cardiovasc Imaging. 2023 Nov;16(11):1433-1448. doi: 10.1016/j.jcmg.2023.08.009. PMID: 37940323.

With each edition of the InTouch Newsletter, we like to highlight select members of the UT Medical Center family and learn more about their heritage. This month, I had the opportunity to talk with Dr. Elman Urbina, a pulmonary disease/critical care medicine fellow and soon-tobe attending here at UT, about his Nicaraguan heritage and traditions. He is originally from Juigalpa, Nicaragua, which he says is a medium-sized city located in the center of the county and around a two-hour drive from the country’s capital – Managua. He completed medical school at the Universidad Americana Facultad de Medicina in Managua. As a whole, Nicaragua is known as the “Land of Lakes and Volcanoes” with 19 active volcanoes along just the Pacific side of the country!

As most countries in Central America, the official language of Nicaragua is Spanish although there are a number of different languages spoken throughout the country. These multitude of languages have been passed down for many generations, having originally come from the indigenous populations of the country. One such language is Miskito, which is spoken primarily by the group descending from the Misumalpan people who settled in the northeastern part of the country as well as parts of neighboring Honduras. According to Dr. Urbina, there are several terrific local foods which are derived from Nicaragua such as nacatamal (Nicaraguan version of tamale, see Picture 2), Nicaraguan beef-corn stew, and many excellent grilled meat dishes. Of course, one could not discuss Nicaraguan food and beverages without discussing its world-renowned coffee, a pride of the country!

If you find yourself traveling to Nicaragua, there are undoubtedly many historical sites to visit but the country is also home to the second largest rainforest in the western hemisphere, the Bosawás, which covers over 15% of the nation’s land area (see Picture 3)! The national rainforest reserve is a great place to escape everyday life as well as sightsee, camp, hike, and birdwatch. Regarding Nicaraguan culture, its people are family-centered with many of its citizens staying close to home the majority of their lives and participating in local festivals and events. The vast majority of citizens of Nicaragua are also avid church-goers, usually attending service every Sunday. When asked an interesting fact, Dr. Urbina states that the name of his home city Juigalpa comes from the native tongue and means “land abundant of black snails.” From his description of Nicaragua and its people, Nicaragua would be a wonderful place to visit and experience its history as well as become enriched in its culture!

Faculty Awards

Several faculty and staff awards were presented at this year’s Annual Faculty Recognition Dinner held on Wednesday – December 13th, 2023 at The Gettysvue Country Club – Ballroom / Westland Room.

• The Beasley Pylon Award for extraordinary leadership and service to the Department of Medicine was presented to Dr. Gary Klipple.

• The R.A. Obenour, MD, Distinguished Alumnus Award in Recognition of Outstanding Career Achievement in the Field of Medicine was presented to Dr. Michael Henderson.

• Dr. Anne Kassira received the R.A. Obenour, Jr., Excellence in Teaching Award for steadfast dedication and excellence in teaching.

• Dr. Benjamin Helms received the London Award, which is presented to a teacher who exhibits a dedication to excellence. The recipients of this award are chosen by our residents.

• Mr. Joe R. Landsman received the Chairman’s Outstanding Service Award for his extraordinary dedication and service to the Department of Medicine.

All of these award recipients have provided superb service to the Department of Medicine. We are delighted to recognize them for their many contributions.

Special Announcements:

We are delighted to announce that Guillermo “Andres” Quiceno, M.D., has accepted the position of Vice Chair of Education and the categorical Internal Medicine Program Director. He is currently an Associate Professor in the Department of Internal Medicine and Director of the Rheumatology Fellowship Program at the University of Texas Southwestern Medical Center in Dallas, TX. He specializes in rheumatology, with a particular interest in rheumatoid arthritis.

Dr. Quiceno earned his medical degree at CES University in Medellin, Colombia. He completed a residency in internal medicine at the University of Miami and then received advanced training in rheumatology through a fellowship at UT Southwestern. Dr. Quiceno joined the UT Southwestern faculty in 2009. He is board-certified in internal medicine and rheumatology.

Dr. Quiceno is a member of the American College of Rheumatology, the Dallas County

Medical Society, and the Texas Medical Association.

Dr. Quiceno will join the Department of Medicine at UT Graduate School of Medicine on March 11, 2024.

We are pleased to announce that Denia Ramirez, MD will serve at the Program Director of the Neurology Residency Program. Dr. Ramirez completed medical school at Universidad de Ciencias Medicas in San Jose, Costa Rica where she also completed a pediatrics residency. She obtained her Master’s in Public Health as well as a PhD in Genetics at the University of Rochester in Rochester, NY, where she also completed a residency in Pediatric Neurology and Epilepsy.

During Dr. Ramirez’s training, she was quite active in teaching. She demonstrated her desire to teach and

Cheers for Fellow Matches

Congratulations to all of our outstanding residents for continuing the journey of subspecialty training and being matched with great fellowship programs. Not only here at the University of Tennessee Graduate School of Medicine but also around the country.

2024 Graduating Seniors: Shawna Stephens, DO –Cardiovascular Diseases Fellowship (UTMCK)

Warner Thomas, MD –Hematology/Oncology Fellowship (UTMCK)

mentor the next generation of providers and thorough commitment to develop a neurology program in Knoxville. She has many academic accomplishments, numerous peer-reviewed publications, committee memberships, invited lectures, honors and awards. She also served as Associate Editor of Child Neurology Open. She has particular interest in genetic epilepsies, neurodegenerative diseases of childhood, and loves working with parents, families and patients.

Congratulations to the Tennessee Chapter Governor-elect Designee (GED) for the American College of Physicians, Daniel S. Ely, MD, FACP. He will complete a year of training as a Governor-elect and then will start their fouryear term as Governor in the Spring of 2025. As Governor, Dr. Ely will serve as the official representative of the College for our Chapter, providing a link between members at the local level and leadership at the national level.

Abdallah Assaf, MD –Cardiovascular Diseases Fellowship (Baylor)

Martin Valdes, MD – Pulmonary/ Critical Care Medicine Fellowship (San Antonio)

2023 Graduated Seniors: Greg Desrosiers, MD –Cardiovascular Diseases Fellowship (UTMCK)

Saffet Guleryuz, MD –Hematology/Oncology Fellowship (Chicago)

CME OPPORTUNITIES—MARK YOUR CALENDARS!

currently hybrid attendance: half joining via Zoom or Microsoft Teams

• 10th Annual Primary Care CME Conference, approved for AMA PRA Category 1 Credit™ hours this year. The conference will be held in-person at the Bridgewater Place in Knoxville, TN on March 2nd, 2024. We hope you can join us for this informative event. View course information, agenda, and fees at: Primary Care CME Details

• Cardiology Conferences, held weekly on Wednesdays in the Medicine Conference Room for .75 hour CME credit.

• Medicine Grand Rounds, held on the 2nd and 4th Tuesdays of each month in the Medicine Conference Room for 1.00 hour CME credit.

• Ethics Case Rounds, held on the 4th Thursday of the month at noon in Wood Auditorium and are available for 1.00 hour CME credit.

• Pulm/HTN Conferences, held on the 2nd Monday of the month at noon in different locations and are available for 1.00 hour CME credit.

Left to Right: Dr. Klipple, Mr. Landsmen, Dr. Dhand, Dr. Kassira

Ethics Case Rounds: Disparities at End of Life: The Social Determinants of Comfort

Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.

Most people are familiar with the Social Determinants of Health: the structural conditions that influence health outcomes of individuals and populations, such as food security, the safety of the built environment, and allostatic load. Increasingly, clinicians are incorporating the Social Determinants of Health that impact their patients’ lives in care plans. Providers’ responsiveness to these factors can have a positive effect on their patients’ health outcomes.

In a similar vein, the Social Determinants of Comfort are the conditions that impact comfort for patients with severe symptoms, chronic illness, or at end of life. These are structural conditions that determine whether and in what forms comfort measures are available for, offered to, and understood by individuals with serious illness and their loved ones. Responsiveness to these differences can help eliminate health disparities for vulnerable people at critical moments in their lives.

Recognition of which barriers are interfering is the first step. Perhaps the easiest element of the Social Determinants of Comfort to recognize is the variability in what resources are available. Some resources for comfort measures are extremely limited or simply do not exist in some geographic areas, particularly rural areas and neighborhoods with high rates of crime. Resources can also be unavailable to patients due to insurance barriers, lack of financial resources, limitations of the home environment, or the inability of the family to provide care.

A less-obvious element involves variations in whether or what comfort measures are offered to patients and families. Services that are available and appropriate may not be offered due to gaps in providers’ familiarity with available comfort measures. If we don’t know about it or don’t think about it, we can’t offer it! Another reason for gaps in what is offered concerns providers’ discomfort or misconceptions regarding comfort measures. Health professionals may feel that discussing palliative approaches to care is disloyal to the patient or taking hope away. Self-awareness can be a crucial part of providing patient-centered care.

Measures that are available and offered may be declined simply because patients and families genuinely don’t want or need them. However, comfort measures may also be rejected due to patients’/families’ lack of understanding. Misunderstandings about the patient’s prognosis, the effects of continued treatment, and the effects of comfort measures can lead to patients and families rejecting modalities they would otherwise want. Lack of trust can also interfere with acceptance of comfort measures; patients or families may feel that comfort measures are being offered because the care team does not value the patient, e.g., because of payor source, insurance issues, or patient attributes (race, socioeconomic status, substance use history, etc.)

Ultimately, the importance of the Social Determinants of Comfort involves closing the gaps. While we can’t magically make resources available where none exist, cultivating curiosity is a place to begin. Develop the habit of asking questions about patients’ and families’ past experiences that may be relevant to the current situation. It can be difficult to ascertain whether comfort measures are not accepted because they are genuinely not desired and when communication barriers are interfering with understanding and acceptance. Investing the time to build trust, assessing for assumptions (ours and others’), and communicating at the patient’s literacy level can make a big difference.

Many thanks to Dr. Adam Tyson for his contributions to this Ethics Case Rounds.

References

• Mendola A, Naumann WC, Mooney-Doyle K, Lindley LC. Social determinants of comfort: a new term for end-of-life care. J Palliat Med. 2021;24(8):1130–1131

• Mooney-Doyle K, Mendola A, Naumann WC, Svynarenko R, Lindley LC. Social Determinants of Comfort: A New Way of Conceptualizing Pediatric End-of-Life Care. J Hosp Palliat Nurs. 2022 Sep 9.

Presentations, Publications, Awards

Department of Medicine faculty, residents, and fellows share their knowledge and experience by publishing and presenting across the world. For a list of our most recent accomplishments, visit http://gsm.utmck.edu/internalmed/scholars.cfm.

Thank You For Your Support

For information about philanthropic giving to the UT Graduate School of Medicine, Department of Medicine, please contact the Development Office at 865-305-6611 or development@utmck.edu.

If you would like more information about any of the topics in this issue of In Touch, please contact the Department of Medicine at 865-305-9340 or visit http://gsm.utmck.edu/internalmed/main.cfm. We look forward to your input. Thank you.

Stay In Touch!

Alumni, please update your contact information by completing the simple form at http://gsm.utmck.edu/internalmed/alumni.cfm or by calling the Department of Medicine at 865-305-9340. Thank you!

In Touch

Vol. 13 Issue 1: January 2024

Publisher

Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs

Editor

Annette Mendola, PhD

Administrative Director

Jenny Roark

Contributors

Jenny Roark

Robin Underwood

Rajiv Dhand, MD

Annette Mendola, PhD

Cassandra Mosley

Shawna Stephens, DO

Ashley Gutierrez-Santana, MD

Erin Hamric, DO

Logan Shaver, DO

Design

J Squared Graphics

In Touch is produced by the University of Tennessee Graduate School of Medicine, Department of Medicine. The mission of the newsletter is to build pride in the Department of Medicine by communicating the accessible, collaborative and human aspects of the department while highlighting pertinent achievements and activities.

Contact Us

In Touch

University of Tennessee

Graduate School of Medicine

Department of Medicine 1924 Alcoa Highway, U-114 Knoxville, TN 37920

Telephone: 865-305-9340

E-mail:

InTouchNewsletter@utmck.edu

Web: http://gsm.utmck.edu/ internalmed/main.cfm

The University of Tennessee is an EEO/AA/Title VI/ Title IX/Section 504/ADA/ ADEA institution in the provision of its education and employment programs and services.

Disclaimer: quotes/ interviews are edited for length and clarity