BluePrint 2019

Anesthesiologist Historically | 8 Elected ASE President

Faculty Spotlight: | 36 Dr. Evan Kharasch

Innovative Research: The MARBLE Study

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10 Volume 2019

On the Cutting Edge of Regenerative Pain Therapies

BluePrint 2019

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What We Do Changes The World

MISSION: Extraordinary care through a unique culture of innovation, education, research, and professional growth.

2| DUKE ANESTHESIOLOGY

Contents

Volume 10 | 2019

DEPARTMENTAL 04 Message from the Chair

10 Volume

06 Full Frame: Run for the Warriors 14 Highlights 66 Departmental Listing 68 ASA Highlights 70 Closing Shots: Doing Good in the Neighborhood

DREAM CAMPAIGN 43 Donor Honor Roll 44 About DIG 45 2019 DREAM Innovation Grant Recipients

INNOVATIVE RESEARCH 52 Enhanced Neutrophil SUMOylation as a key to Anti-Inflammatory Effects of Hypothermia 54 Single Nucleus Expression

On the Cover 8 30

FEATURE Anesthesiologist Historically Elected ASE President.

The First of Firsts COVER STORY The New Becomes Reality.

On the Cutting Edge of Regenerative Pain Therapies

36

FACULTY SPOTLIGHT Dr. Evan Kharasch

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INNOVATIVE RESEARCH The MARBLE Study: Modulating ApoE signaling to Reduce Brain inflammation, deLirium and postopErative cognitive dysfunction

function

Nerve After Traumatic Amputation

GLOBAL HEALTH 56 Duke Collaboration Fosters a Safety Culture in Guatemala 58 Escape Room Challenge

RESIDENCY CORNER 60 Residency Program Ranks Top 5 in the Nation 63 Welcome Match Class of 2023

ALUMNI NOTES 64 Dr. Laura Niklason

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BluePrint BluePrintisispublished publishedonce oncea ayear yearbybyDuke Duke Anesthesiology.

Anesthesiology.This Thisissue issuewas waspublished publishedinin January January2020.

2020.Your Yourcomments, comments,ideas ideasand andletters letters February are arewelcome. welcome.

Message Messagefrom fromthe theChair Chair

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View Viewthis thisissue issueand andpast pastissues issuesonline: online: BluePrint.DUHS.Duke.edu BluePrint.DUHS.Duke.edu

nn2009, 2009,BluePrint BluePrintwas waslaunched launched with withthe theintent intentofofhighlighting highlightingthe the “collaboration “collaborationbetween betweenDuke Duke Anesthesiology’s Anesthesiology’sindividuality individualityand and innovation innovationthat thatintertwine intertwinetotobuild buildthe the future futureofofpatient patientcare.” care.”InInthat thatspirit, spirit,I I am ampleased pleasedtotopresent presentthe the10th 10th anniversary anniversaryissue issueofofBluePrint.

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Please Pleasecontact contactususat:at: Duke DukeAnesthesiology Anesthesiology BluePrint BluePrintMagazine Magazine DUMC DUMC3094 3094 Durham, Durham,NCNC27710 27710 blueprint@duke.edu blueprint@duke.edu Editor EditorininChief Chief Stacey StaceyHilton Hilton Senior SeniorWriter Writer Stacey StaceyHilton Hilton Contributing ContributingWriters Writers Ratna RatnaSwaminathan Swaminathan Duke DukeUniversity UniversitySchool SchoolofofMedicine Medicine Art ArtDirector Director&&Designer Designer Jaylynn JaylynnNash Nash Contributing ContributingPhotographers Photographers John John“Jack” “Jack”Newman Newman Jaylynn JaylynnNash Nash Website WebsiteAdministrator Administrator Christopher ChristopherKeith Keith Connect Connectwith withDuke DukeAnesthesiology: Anesthesiology: WEBSITE: WEBSITE:Anesthesiology.Duke.edu Anesthesiology.Duke.edu

Over Overthe theyears, years,we wehave havepresented presentedaavariety varietyofofhighlights highlightsranging rangingfrom fromthe the40th 40th anniversary anniversaryofofthe thedepartment departmenttotoour ourextraordinary extraordinaryfaculty facultyand andtheir theirinnovations innovationsinin education, education,clinical clinicalcare careand andresearch. research.This Thisissue issueisisnonoexception, exception,and andI hope I hopeyou you will willenjoy enjoyreading readingabout aboutsosomany manyofofour ouramazing amazingpeople. people.Putting Puttingtogether togethersuch suchaa take takeaamoment momenttotorecognize recognizeour ourcommunications communicationsteam team––Stacey StaceyHilton, Hilton,Jaylynn Jaylynn Nash Nashand andJack JackNewman, Newman,who whohave havecommitted committedcountless countlesshours hourstotothis thisproject. project.

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President PresidentTheodore TheodoreRoosevelt Rooseveltsaid saidthat that“the “thecredit creditbelongs belongstotothe theman manwho whoisis actually actuallyininthe thearena, arena,whose whoseface faceisismarred marredbybydust dustand andsweat sweatand andblood; blood;……who who atatthe thebest bestknows knowsininthe theend endthe thetriumph triumphofofhigh highachievement, achievement,and andwho whoatatthe the worst, worst,ififhehefails, fails,atatleast leastfails failswhile whiledaring daringgreatly, greatly,sosothat thathis hisplace placeshall shallnever never bebewith withthose thosecold coldand andtimid timidsouls soulswho whoneither neitherknow knowvictory victorynor nordefeat.” defeat.”Duke Duke Anesthesiology Anesthesiologyisisononaadaring daringjourney journeytotochange changethe theface faceofofanesthesiology. anesthesiology.AsAsyou you ..

FACEBOOK: FACEBOOK:@DukeAnes @DukeAnes TWITTER: TWITTER:@Duke_Anesthesia @Duke_Anesthesia INSTAGRAM: INSTAGRAM:@DukeAnes @DukeAnes Duke DukeAnesthesiology Anesthesiology 44|| DUKE DUKEANESTHESIOLOGY ANESTHESIOLOGY

Sincerely, Sincerely,

Joseph JosephP.P.Mathew, Mathew,MD, MD,MHSc, MHSc,MBA, MBA,FASE FASE

AtAtDuke, Duke,we webelieve believethat thatcontinued continuedengagement engagementwith withour ouralumni alumniisisthe thekey keytotoour ourfuture future success. success.We Wetake takegreat greatpride prideininthese thesetalented talentedmen menand andwomen womenwho whoplay playan anintegral integralrole role ininstrengthening strengtheningour ourdepartment departmentand andmaking makingititan anideal idealenvironment environmentininwhich whichfuture future generations generationsofoftrainees traineescan canlearn, learn,work workand andachieve achieveexcellence. excellence.

As Asaagraduate graduateofofDuke DukeAnesthesiology, Anesthesiology,you youare areautomatically automaticallyenrolled enrolledas asaamember memberofofthe the AlumniAssociation!

Association!Help Helpus usgrow growour ourdepartment’s department’salumni alumnioutreach outreach Duke DukeAnesthesiology AnesthesiologyAlumni by bystaying stayingconnected connectedtotoyour yourpeers, peers,fellow fellowalumni alumniand andfaculty. faculty.

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DURHAM VS ALL Y’ALL The Duke Anesthesiology racing team proved victorious at the 2018 ASASponsored Run For The Warriors race in San Francisco, securing first place for fundraising ($5,025) for the eighth consecutive year and earning the Team Award; Dr. Richard Moon took home the Top Fundraiser Award; teammate Reed Kamyszek won the overall race. Proceeds benefit the men and women wounded during service, their families, and families of the fallen through the many Hope For The WarriorsŽ programs.

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The First of Firsts

By Stacey Hilton

Dr. Madhav Swaminathan takes the helm as president of the American Society of Echocardiography (ASE), marking the ďŹ rst time that an anesthesiologist has been elected to head the ASE in its 44-year history.

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Photo Courtesy: ASE

June 25, 2019 marked a monumental day for the field of anesthesia as Duke Anesthesiology’s Dr. Madhav Swaminathan officially took his seat as the president of the American Society of Echocardiography (ASE) – the first anesthesiologist elected to serve in this role.

“I’m absolutely honored and privileged. It’s an exciting opportunity and a fantastic feeling to be recognized by your peers,” says Swaminathan, a cardiovascular anesthesiologist, who adds that this leadership role is especially significant because it is outside of his primary specialty. “That is the most heartwarming and gratifying part – that ASE members chose to elect an anesthesiologist to lead the entire organization. This is not only a win for our specialty, but a strong statement on diversity.”

Echocardiography (echo) has traditionally been represented almost exclusively by cardiology since cardiologists are the primary users of echo.

According to Swaminathan, anesthesiologists came into the picture much later on, but they have added enough value to echocardiography for cardiologists to feel that this is a good partner to “shake hands with.” He believes that ASE is leading the field in recognizing that diversity has value and is the key to further the growth of the organization.

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S

“Diversity to ASE means diversity of thought.

This society values those who value echocardiography and welcomes those with diverse backgrounds who can think outside of the box like no one else can,” says Swaminathan. The value that he brings to the society is his perspective of perioperative and critical care echo and his ability to attract non-traditional users of echo, whether it’s ER physicians or critical care intensivists, essentially providing the ASE perspective that the field is growing beyond the confines of the echo lab or even the operating room.

Cardiovascular anesthesiologists have long regarded their application in advanced intraoperative echo with transesophageal echocardiography (TEE) as a core skill within their subspecialty. “This skill being recognized outside of the domain of cardiac anesthesia, by cardiologists, in the form of selecting a cardiothoracic anesthesiologist as a president, gives us a lot of visibility and speaks volumes to the younger generation of cardiovascular anesthesiologists who have traditionally seen themselves in supporting roles in cardiac surgery. We are not just an opinion in the operating room. We add value to the community of cardiovascular sciences and people are taking notice.”

Jonathan B. Mark, MD

Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE

Joseph P. Mathew, MD, MHSc, MBA, FASE

Three Helpful Powerhouses Duke Anesthesiology is a leader in the field of perioperative echocardiography, with early pioneers such as Drs. Solomon Aronson, Jonathan Mark and Joseph Mathew. Aronson is credited for the creation and expansion of the National Board of Echocardiography and was influential in the development of ASE’s Council on Perioperative Echocardiography, which he once led. In June, ASE named him the 2019 Outstanding Achievement in Perioperative Echocardiography Award recipient.

“Without him, I would not be here today,” adds Swaminathan. Mark

was the 2018 recipient of that prestigious award and was the first chair of the exam committee in perioperative TEE; instrumental in ensuring that there was an exam process for anesthesiologists to be certified in echo by a national board, which helped validate their skills in perioperative echo. Mathew was also one of the early chairs of the Council on Perioperative Echocardiography and is the editor of the leading textbook on perioperative TEE. He, Aronson and Swaminathan have also co-authored several national guidelines on the practice of echo.

Swaminathan believes that his ASE presidency represents a golden moment in the recognition of the department’s pioneering efforts and vast contributions.

“It puts another feather in the cap.”

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1st Female President of ASE -Pam Douglas-

1st Phased Array 2D Echo -Developed by Joseph Kisslo and Olaf von Ramm-

1st to Introduce TEE in the OR + 1st Book on Periop TEE -Fiona Clements1st 3D Echo was Developed at Duke 1st Digital Reporting of Periop Echo Since 2000

4th President of ASE -Joseph Kisslo-

4 Faculty as ASE President 4th Duke President of ASE -Madhav Swaminathan-

4 Chairs of Council on Periop Echo

Solomon Aronson Joseph Mathew

Madhav Swaminathan 12| DUKE ANESTHESIOLOGY

Alina Nicoara

Duke University has a rich tradition of institutional history in echocardiography.

According to Swaminathan, 2D echo was first developed at Duke in the 1970s by a team of echocardiographers and bioengineers. 3D echo also first came to being here at Duke.

Prominent experts like anesthesiologist Dr. Fiona Clements introduced the use of TEE in the operating room at Duke. While Swaminathan is the first ever anesthesiologist to become president of ASE, he is the fourth Duke faculty member to serve in this role, following Drs. Joseph Kisslo, Pamela Douglas and Thomas Ryan. Kisslo helped develop the phased array transducer, is a founding member of ASE, and was largely responsible for the creation of the ASE headquarters in Durham. Douglas was the first woman to serve as an ASE president; she was also the second female to serve as president of the American College of Cardiology.

“The term, ‘first ever anesthesiologist,’ may seem phenomenal, but it comes with a lot of support behind it, so I’m not the only person who should be recognized for this achievement,” says Swaminathan. “I may be the ‘first ever,’ but I did not enable the ‘first ever,’ a lot of other people before me did that. There is absolutely no question that in this election to lead the ASE, there have been a lot of helping hands along the way. I cannot forget that this is the result of that support.”

Swaminathan’s eventual rise to the ASE presidency began back in 1994 when he first touched an echo probe. “It was extremely exciting to see a moving heart in real time. Taking a direct look at the heart through echo was just fascinating. I decided at that time, that this is something that gets my creative juices flowing.”

Swaminathan joined Duke Anesthesiology in 2000. His passion for echo, shown through clinical application, teaching, research, and writing, was quickly recognized by his mentors, Mathew and Dr. Mark Newman, who encouraged him to follow this path. Swaminathan has dedicated nearly the past 20 years of his career contributing to ASE, serving on its Board of Directors, the Industry Relations Committee, Education Committee, Advocacy Committee and the Scientific Sessions Committee. Notably, he was the first anesthesiologist selected to deliver the prestigious Feigenbaum Lecture at ASE’s Scientific Sessions in 2015.

He also served as chairman of both the Membership Committee and the Council on Perioperative Echocardiography – all volunteer efforts.

“It means a great deal to reach the presidency, but it comes after many years of hard work. And, it reflects the fact that contributions are valued in this society regardless of where you come from,” says Swaminathan. “You also have to be given that start. I think my start was given because I demonstrated passion and a willingness to continue learning. You cannot climb this type of ladder unless you really are passionate about the field that you love.”

On June 22, Swaminathan delivered his ASE presidential address. Three days later, he initiated the central theme of his one-year presidency, the ASE Cares campaign (#ASECares) – creating a caring society among the 17,000 cardiovascular professionals, focusing on the issues of wellness, resilience and burnout. Second, with his platform of diversity, he wants to ensure that the society adapts an outreach program that reaches even the non-traditional echo users throughout the world, including anesthesiologists, critical care physicians, ER doctors, and any other practitioner of cardiovascular ultrasound that isn’t already represented.

“Achieving this presidency is a responsibility. It’s not the end, it’s sort of the beginning because just like I have been able to ‘stand on the shoulders of giants,’ I’ve got to make sure to pay it forward. The same effort from my mentors that helped me rise to this position must be carried forward to help someone else. I view my new position as a big responsibility to identify talent and promote that talent as best as possible. It’s good to be the first, but the goal is not to be the last anesthesiologist in this role.”

Follow Dr. Madhav Swaminathan on Twitter @mswami001 #ASECares Campaign ASE.org/Presidents-blog

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Highlights

DIVISIONAL NEWS

AMBUL ATORY ANESTHESIA

CARDIOTHOR ACIC ANESTHESIA

Faculty Receive 1 Duke Periop Awards

A Historic First

On May 15, Drs. Karen Nielsen and Steve Melton received the Perioperative Culture Most Valuable Person Awards at the Duke Ambulatory Surgery Center (ASC). The awards were presented by the ASC management team at an anniversary celebration of the 1 Duke Periop initiative; it was launched on July 1, 2017 to officially bring together the perioperative environments at Duke Raleigh, Duke Regional and Duke University Hospitals under one umbrella. This new, system-wide structure supports global perioperative decision making and guides operations and resource utilization in the surgical environments across the Duke University Health System.

This division is also expanding its scope of operations, providing anesthesia services at the Duke GI Endoscopy Clinic at Brier Creek. A future state-of-the-art site of Duke Health’s Arringdon Medical Office Building will provide 35,000-square-feet, offering four operating rooms and four procedure rooms. There will be an adjoining 200,000-square-foot building that will house physicians and ancillary Duke services. The ASC will experience case re-allocations that come with outlying growth – an excellent opportunity for this division, which has experienced 20 successful years.

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Drs. J. Mauricio Del Rio and Ian Welsby represented Duke Anesthesiology during a first-of-its-kind joint meeting of cardiac anesthesiologists from Cuba and the United States, held November 16 – 17, 2018 at the Hermanos Ameijeiras Hospital in Havana. They were among eight physicians from the United States – the largest delegation of US anesthesiologists to visit Cuba in its history – in attendance at the Cuban Society of Anesthesiology’s third Cardiothoracic Anesthesiologists meeting.

The two-day academic program centered around cardiovascular and thoracic anesthesia; speakers focused on topics such as structural heart interventions and mechanical support in heart failure.

Del Rio delivered two presentations, titled “A History and Development of Mechanical Circulatory Support: Overview” and “Temporary Mechanical Circulatory Support.” Welsby delivered a presentation, titled “Right Ventricular Failure and Pulmonary Hypertension.”

Highlights

DIVISIONAL NEWS

COMMUNIT Y DIVISION

Davis Ambulatory Surgery Center Duke Fertility Center Duke Raleigh Duke Regional Holly Springs Surgery Center Johnston Health MedCenter Mebane NC Specialty Hospital Triangle Orthopaedics Surgery Center

6,707 261 21,406 12,125

2,009 2,774 2,528

9,934 8,911

66,655 TOTAL CASES PERFORMED

BY DIVISION

CRITICAL CARE MEDICINE

Dr. Wischmeyer Earns Prestigious FASPEN Designation The American Society for Parenteral and Enteral Nutrition (ASPEN) has elected Duke Anesthesiology’s Paul Wischmeyer, MD, an honorary fellow. The FASPEN award is one of ASPEN’s highest honors as a society. It recognizes Wischmeyer’s exceptional achievement in practice and his research contributions to the clinical nutrition field, as well as his commitments and contributions to the society.

“I am truly honored to receive the FASPEN designation as it reflects the fruition of many years of research work and clinical program development to improve the nutrition care of our perioperative and ICU patients,” says Wischmeyer, professor of anesthesiology. “The opportunity to grow this work and develop truly novel and innovative nutrition and metabolism clinical pathways and research initiatives at Duke is a significant reason why I joined Duke Anesthesiology.”

He adds that the FASPEN award demonstrates the recognition of the vision of Duke University and Duke Anesthesiology’s leadership in creating cutting-edge programs that can lead the way into the future and transform patient care. “We dream of a day when no malnourished patient will ever have surgery again without nutrition screening and nutrition intervention to train and optimize them for the ‘marathon’ of their life!”

The FASPEN honor was awarded March 23 – 26 at the ASPEN 2019 Nutrition Science & Practice Conference in Phoenix. Wischmeyer currently serves as the associate vice chair for clinical research within Duke Anesthesiology and the director of the TPN/Nutrition Support Team at Duke University Hospital.

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Highlights

DIVISIONAL NEWS

GENER AL, VASCUL AR AND TR ANSPL ANT ANESTHESIA

NEUROANESTHESIOLOGY

Perioperative Exercise Testing and Training at Duke

Singapore, US Researchers Studying Drug to Treat Hemorrhagic Stroke

“Fitness for surgery” is a commonly used term, which can be taken quite literally. Aerobic

Assistant Professor Nicolas Kon from the National Neuroscience Institute and Associate Professor Michael Lucas James from Duke University School of Medicine are testing a protein-based compound that reduces inflammation in the brain after injury. It would complement existing treatment for the affliction, which makes up about one-fifth of all stroke cases [in Singapore] but caused 44 percent of all stroke-related deaths in 2016.

fitness is one of the most powerful predictors of outcomes after surgery. With

the assistance of Duke Anesthesiology’s Human Pharmacology and Physiology Lab, Dr. John Whittle is leading research focused on prehabilitation and cardiopulmonary exercise testing (CPET). The overall goal is to make exercise training an essential part of surgical preparation for their patients - an aging population that is increasingly multimorbid and inactive. With careful assessment and intervention, patients can be trained before surgery in the same way that an athlete would be trained for their big event. Whittle and his colleagues have established a CPET facility where they have performed in excess of 100 exercise tests, as well as measured muscle health and metabolism in high-risk surgical patients amongst others; several projects related to the assessment of patient fitness are ongoing. These studies are designed to better understand the effects of surgery on fitness, as well as the effects of targeted exercise training on health in the perioperative period as part of preventative rehabilitation or “prehabilitation.”

"The clinical trials that have been run and finished to date don't show improvement in neurological recovery after having surgery for hemorrhagic stroke, although there are ongoing trials looking at newer technology that may or may not have benefits. So you have an opportunity to provide an effective treatment through the compound for a larger group of patients that may or may not respond to surgery," says James. “If it works, it would be the

first therapeutic drug for hemorrhagic stroke and it would be the first trial that's run congruently in Singapore and the US." Researchers at Duke University took 20 years to develop the compound, which is made from a protein produced in the brain.

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Photo Credit: National Neuroscience Institute Source: The Straits Times, Felicia Choo

Highlights

DIVISIONAL NEWS

ORTHOPAEDICS, PL ASTICS AND REGIONAL ANESTHESIOLOGY

Duke Health Team Performs First Bilateral Hand Transplant In another first for the state and the region, a Duke Health team of more than 40 hand surgeons, anesthesiologists, operating room staff, residents, fellows, lab technicians, and other key staff performed a bilateral hand transplant on Thanksgiving Day.

surgery a new milestone.

The surgery, [led by hand transplant surgeon Linda Cendales, MD] took 14 hours, with teams rotating in and out to perform the hand transplants simultaneously. In a previous first for the state and region, the Duke Health team performed a single hand transplant, but the added complexity of the bilateral procedure made the

Duke has now performed two of five hand transplants approved as part of a clinical research trial designed to lessen the risk of immunosuppression, which will benefit more than one patient.

“We came together across departments and disciplines to accomplish something few have done before, and we opened a new world of possibility to our patient population in need,” Cendales said. “And we can all be proud of that.”

Source: Duke Health News, Sarah Avery “Taking care of the patient has not only been a pleasure, but has inspired me to always have a positive outlook and be thankful for what I have and the people around me.”

Dr. Kevin Vorenkamp began his role as medical Duke Anesthesiology’s Dr. Joshua Dooley PAIN MEDICINE

Duke Anesthesiology Pain Management in Raleigh Duke Pain Medicine significantly increased its presence in Raleigh following the expanded collaboration with the Department of Neurosurgery in 2017 and the opening of the Department of Anesthesiology’s Duke Raleigh Hospital Pain Clinic in 2018.

Dr. Scott Runyon serves as the medical director of the Duke Raleigh Spine and Pain Clinic, where he has had a presence since 2015. Integrated with Neurosurgery, this clinic serves vital diagnostic and interventional needs for spine patients throughout the Raleigh area. Runyon, Jude Carr, PA, and their team perform more than 6,500 encounters per year, offering a full spectrum of fluoroscopic and ultrasound-guided procedures, including spinal injections, radiofrequency rhizotomy, spinal cord stimulation, dorsal root ganglion stimulation, botox injection for chronic pain conditions, kyphoplasty, and medication management.

director of the Duke Raleigh Hospital (DRaH) Pain Clinic in 2018 after leaving his role as Pain Medicine Fellowship director at Virginia Mason Medical Center (Seattle). The DRaH Pain Clinic offers comprehensive spine and pain management and is staffed with pain medicine (anesthesiology) physicians, including the recent addition of Dr. Brian Starr, and nurse practitioners, Emily Davis, Natalie Miller and Sarah Baxt. The clinic provides comprehensive evaluation, treatment and procedural care and is now providing access within 72 hours for all new patient visits. The clinic additionally offers perioperative pain management to the Duke Raleigh medical campus.

In July, Duke Anesthesiology’s Padma Gulur, MD, was named the director of pain management strategy and opioid surveillance in which she will provide direction, coordination and leadership for associated programs across the Duke University Health System.

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Highlights

DIVISIONAL NEWS

PEDIATRIC ANESTHESIA

Duke Anesthesiology Resident Wins Top Award at National Meeting The Society for Pediatric Anesthesia and the American Academy of Pediatrics presented Duke Anesthesiology then CA-3 resident, Dr. Jon Andrews, with the John J. Downes Resident Research Award at this year’s annual meeting for his project, titled “Perioperative Chest X-Rays After Placement of Central Venous Catheters in Children, a Quality Improvement Project.”

Andrews’ project aimed to obtain surgical chest radiographs (CXR) sign-out for 100 percent of stable patients within 30 minutes of arrival at the Post-Anesthesia Care Unit (PACU). Results revealed that

implementation of the new CXR protocol produced a significant process shift, improving perioperative efficiency in terms of surgical CXR sign-out time. “I think the American Academy of Pediatrics recognized the multidisciplinary nature of this project and found it noteworthy that a team of anesthesiologists, surgeons, OR nurses, PACU nurses, and radiology technicians came together and collaborated with a unified goal to improve patient care,” says Andrews. “Patients and their families are no longer getting interrupted in the PACU for radiology exams after their central venous catheters are placed, and the overall process has become more efficient as a result.”

VETER ANS AFFAIRS ANESTHESIOLOGY SERVICE

Study Shows Safety Initiative Decreases Opioid Use with Little Impact on Pain Scores New research published in the Online First edition of Anesthesiology, the peer-reviewed medical journal of the American Society of Anesthesiologists (ASA), reports that after an Opioid Safety Initiative (OSI) was implemented at the Veterans Health Administration (VHA), patients undergoing knee replacement surgery were prescribed significantly less opioids with minimal impact on patients’ reported pain scores.

The OSI uses VA/DoD guidelines to help health care providers evaluate and manage the individual needs and preferences of veterans with chronic pain. In addition, the OSI provided a computerized dashboard that tracks opioid prescriptions at national, regional, facility and provider levels, so that the leadership at each facility can audit the data and provide feedback to staff. The OSI was rolled out nationwide in 2013, and high-dose opioid prescriptions were substantially decreased after that.

The current study was based on group-level data from more than 60,000 patients (700 to 850 patients per month) between 2010 and 2015, all undergoing total knee replacement surgery. Researchers analyzed trends in patient reported pain scores, and in chronic opioid and nonopioid prescriptions, Source: American Society of Anesthesiologists news release (Chicago, IL – May 30, 2019) before versus after the implementation of the OSI. 18| DUKE ANESTHESIOLOGY

Highlights

DIVISIONAL NEWS

WOMEN’S ANESTHESIA

Duke University Designated SOAP Center of Excellence The Society for Obstetric Anesthesia and Perinatology (SOAP) has awarded Duke University (the Women’s Anesthesia Division) a 2018 SOAP Center of Excellence designation. It recognizes institutions and programs that demonstrate excellent obstetric anesthesia care. Duke is one of only 40

institutions to receive this designation that signifies a high-level of patient care and utilization of patient safety processes.

In order to provide a center of excellence designation, the SOAP committee conducted a comprehensive assessment of staffing, leadership, dedicated coverage, presence of protocols complying with national guidelines, institution of safety bundles, multidisciplinary collaborations, use of simulation and provision of evidence-based care with a process for continuous quality improvement.

This designation therefore recognizes the outstanding state-of-the-art care that the Women’s Anesthesia Division provides for the parturient.

The Women’s Anesthesia Division is responsible for obstetric, gynecologic, oncologic, ophthalmologic, and urologic anesthesia at Duke. It was one of the first in the nation to offer patient-controlled epidural analgesia and programmed intermittent epidural boluses for maintenance of labor analgesia. The division was also one of the first units in the nation to introduce the use of an electronic medical record on the labor and delivery suite, allowing faculty to consistently audit and improve practice.

CENTER FOR PERIOPER ATIVE ORGAN PROTEC TION (CPOP)

CENTERS AND PROGRAMS

CENTER FOR PERIOPER ATIVE ORGAN PROTECTION (CPOP)

Dr. Ulloa Appointed Director of CPOP

Luis Ulloa, PhD, MS, was appointed director of the department’s Center for Perioperative Organ Protection (CPOP) in September, bringing 23 years of experience to his new role. He aims to advance the CPOP as an integrative center for basic, translational and clinical research, focused on the development of novel strategies for perioperative organ protection. The mission of this center is to improve the standard of perioperative care. His goals to achieve this mission and advance the center include 1) developing the Laboratory of Neuro-immunomodulation, 2) developing "common scientific backgrounds" to connect and consolidate research within the CPOP, 3) developing reagents and tools to advance research within the CPOP, 4) mentorship and development of junior faculty members for article publication and grant submission, and 5) creating an internal infrastructure for research and funding.

Ulloa's research centers on studying how the nervous system controls the immune system and organ function at the cellular and molecular levels. From a translational perspective, he focuses on how to stimulate specific neuronal networks both for experimental and clinical research to control organ and immune dysfunction.

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Highlights

CENTERS AND PROGRAMS

CENTER FOR TR ANSL ATIONAL PAIN MEDICINE

Dr. Jordt Receives Leading Edge in Basic Science Award To recognize the importance to pharmacology and toxicology of his contributions to basic science, Dr. Sven-Eric Jordt has been awarded the 2019

Society of Toxicology Leading Edge in Basic Science Award.

Jordt’s work has largely involved TRP channel biology, a cutting-edge area of toxicology within which he is a leader. His extensive investigation of sensory TRP ion channels and their role in responding to physical and chemical signals resulted in the identification of the sensory ion channel TRPA1 as the major receptor for reactive environmental toxicants and inflammatory agents in sensory neurons innervating the airways. Jordt also focuses on the means by which basic research findings can be translated to applied research in medicine, including asthma research, the discovery of countermeasures against chemical threats, and the health effects of smoking and electronic cigarettes.

Jordt has been recognized many times within the field of toxicology. He earned an American Asthma Foundation Early Excellence Award because of his work with TRPA1-deficient mice that showed TRPA1’s role in allergic airway inflammation and airway hyperreactivity and bronchoconstriction seen in asthma. He also is a past recipient of the National Institute of Environmental Health Sciences Outstanding New Environmental Scientist Award and the Presidential Early Career Award for Scientists and Engineers. Source: Society of Toxicology This award recognizes a scientist who, based on his/her research, has made a recent (within the last five years), seminal scientific contribution/advance to understanding fundamental mechanisms of toxicity.

20| DUKE ANESTHESIOLOGY

The Alzheimer’s Association International Society to Advance Alzheimer’s Research and Treatment (ISTAART) has named Duke Anesthesiology’s Niccolò Terrando, PhD, as its 2019 New Investigator

M f p t a e a n b

Research in the Terrando laboratory focuses on

P m c

Dr. Terrando Receives New Investigator Award

Award recipient.

surgery-induced neuroinflammation and perioperative neurocognitive disorders. He is

the director of the Neuroinflammation and Cognitive Outcomes Laboratory within Duke Anesthesiology, which centers on the pathophysiology of postoperative delirium, particularly how neuroinflammation impacts memory and behavior.

Terrando received the New Investigator Award at the 2019 Alzheimer’s Association International Conference in Los Angeles in July.

ISTAART is a professional society of the Alzheimer’s Association, representing scientists, physicians and other dementia professionals active in researching and understanding the causes and treatments of Alzheimer’s disease and other dementias.

“Thank you to ISTAART and the Perioperative PIA for this recognition,” says Terrando. “It is a great privilege to receive this award that highlights some of our contributions to this exciting field of perioperative medicine.”

“

s n D D T

"

F e b p n w t N m n u W r a

Highlights

CENTERS AND PROGRAMS

PERIOPER ATIVE ENHANCEMENT TEAM (POET ) At the clinic, the patient typically talks by phone or meets with Villalta to have their nutrition screening about three weeks to one month before surgery. A big part of the meetings are focused on nutritional education. The dietitian will recommend high-protein foods to eat before and after their surgery. Protein supplements are also administered. Once it has been determined the patient is healthy enough to undergo surgery, the procedure can proceed. Villalta Wischmeyer has teamed up with Elizabeth says the pathway they use is a simple, Preparing for surgery is no different. For straight forward one. Currently, Duke is Villalta, a registered dietician, with long many patients, a major operation for expertise in preoperative nutrition care to also performing a grant-funded quality cancer or heart disease is the improvement project that allows the high “marathon of their lives.” And a start the Duke POET Nutrition Clinic protein nutrition drinks to be shipped to Program, working with Dr. Solomon surgical patient’s preparation should be patients’ homes. They receive enough to no different, states Duke Anesthesiology’s Aronson, who leads the Duke POET clinic take them daily for two weeks – one month teams.

Dr. Paul Wischmeyer, who directs the before surgery and for one month after Duke University Hospital TPN/Nutrition surgery. Villalta follows all of the patients on This is what the Duke Anesthesiology team the POET nutrition pathway, weekly, to Team. hopes will be part of a growing movement check on compliance and answer any to diagnose and treat the “silent epidemic” questions.

"Why are we doing this?" he asks. of malnutrition for surgical patients.

After patients are awake from surgery, they For starters, habit. Telling patients to forgo Perioperative malnutrition is truly an are again given another protein unrecognized “silent epidemic” in health eating or drinking before surgery has supplement. A patient usually isn't hungry care today. It is well-known that become commonplace and it is a hard shortly after surgery, but it's important to preoperative malnutrition is a strong pattern to break. The other issue is that encourage patients to have nutrients in nutrition just isn't top of mind for doctors independent predictor of poor their body to improve their likelihood of a when their patients go into surgery. More postoperative outcomes. Malnourished speedy recovery, says Wischmeyer. Villalta than 75 percent of medical schools teach surgical patients have significantly higher will also call the patient weekly for one postoperative mortality, morbidity, length month after their surgery to ask about their NO required classes on nutrition in of stay, readmission rates, and increased medical school - so the importance of eating habits and if they have lost or gained hospital costs. nutrition is often not emphasized or weight since the procedure. understood by physicians, according to “So far, physicians at Duke have been Wischmeyer. But he says it's closely receptive to the program,” says related to how a patient will recover after Wischmeyer. “But we still want to ensure a procedure. we are reaching everyone at Duke, and hopefully soon nationwide, as programs like this are already being implemented using the Duke POET nutrition model across the country.”

FIGURE 1 Wischmeyer’s ultimate goal is that “no Marathon runners know they have to train for many weeks and often months to prepare for a marathon. Everyone knows to carbo-load the night before a big run and the importance of replenishing electrolytes as they tick off miles. Further, any athlete knows you need high protein nutrition to prepare and recover your body after any sport.

Studies show that a well-nourished individual is more likely to survive and is quicker to recover from many kinds of surgery, especially abdominal and cardiovascular procedures. Unfortunately, an estimated 30 – 50 percent of patients are malnourished before surgery, and less than one in 10 of these patients are ever recognized (FIGURE 1).

malnourished patient will ever have elective surgery again without nutrition screening and optimization.” This is how he

hopes the Duke POET Nutrition Clinic can best prepare patients as they face an operation to “win the marathon of

their lives.”

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Duke Anesthesiology B Y TH E N UM B ERS JULY 1, 2018 - JUNE 30, 2019

TOTAL CASES

CARDIOTHOR ACIC ANESTHESIA*

66,655

COMMUNIT Y

18,278

14,744

2,509

9,265

4,788

7,708

5,645

7,910

AMBUL ATORY ANESTHESIA*

9,654

ORTHOPAEDICS, PL ASTICS AND REGIONAL ANESTHESIOLOGY*

162,019

PAIN MEDICINE

27,654

Clinic Visits

16,341

PEDIATRIC ANESTHESIA*

CRITICAL CARE*~

VETERANS AFFAIRS ANESTHESIOLOGY SERVICE*

GENER AL, VASCUL AR AND TR ANSPL ANT ANESTHESIA*

WOMEN’S ANESTHESIA*

5,532

NEUROANESTHESIOLOGY*

*At Duke University Hospital ~At Duke Regional and Duke Raleigh Hospitals

Inpatient Pain Service Visits

CARDIOTHOR ACIC ANESTHESIA 144

AUTHORS

CENTER FOR TR ANSL ATIONAL PAIN MEDICINE

53

OTHER

52

GENER AL, VASCUL AR AND TR ANSPL ANT ANESTHESIA

51

CRITICAL CARE MEDICINE 40 NEUROANESTHESIOLOGY ORTHOPAEDICS, PL ASTICS & REGIONAL ANESTHESIOLOGY

542 22| DUKE ANESTHESIOLOGY

-

37

35

WOMEN’S ANESTHESIA

31

PEDIATRIC ANESTHESIA

30

PAIN MEDICINE

25

VA ANESTHESIOLOGY SERVICE

19

CENTER FOR PERIOPER ATIVE ORGAN PROTECTION

16

AMBUL ATORY ANESTHESIA

9

PUBLICATIONS

40 NEW GR ANTS

BY THE NUMBERS

TOTALING MORE THAN

$9

million

NEUROANESTHESIOLOGY

4 | $2,306,550

CARDIOTHORACIC ANESTHESIA 5 | $1,516,189 VA ANESTHESIOLOGY SERVICE 2 | $1,505,634 PAIN MEDICINE 3 | $1,295,063 BASIC SCIENCES GENERAL, VASCULAR AND TRANSPLANT ANESTHESIA

4 | $869,383 5 | $579,185

CRITICAL CARE MEDICINE 3 | $421,155 WOMEN’S ANESTHESIA 1 | $347,379 ORTHOPAEDICS, PLASTICS AND REGIONAL ANESTHESIOLOGY

4 | $310,631

PEDIATRIC ANESTHESIA

2 | $189,804

HYPERBARIC MEDICINE 1 | $148,689

$3.6 million 167

TOTAL OF 17 NON-COMPETING CONTINUING GR ANTS

CURRENT OPEN GR ANTS

15 RESEARCH LABORATORIES Chemical Sensing, Pain and Inflammation Research Laboratory Sven-Eric Jordt, PhD Duke Multi-Disciplinary Metabolic and Body Composition Assessment Team (MCAT) Laboratory Paul Wischmeyer, MD FG Hall Environmental Laboratory Richard Moon, MD, CM, MSc, FRCP, FACP, FCCP Human Affect and Pain Neuroscience Laboratory Katherine Martucci, PhD

Human Pharmacology and Physiology Laboratory David MacLeod, MB BS Laboratory of Mechanistic and Clinical Pharmacology Evan Kharasch, MD, PhD Laboratory of Neuromodulation Luis Ulloa, PhD, MS Molecular Neurobiology Laboratory Wei Yang, PhD

Nerve Injury and Pain Mechanism Laboratory Thomas Van de Ven, MD, PhD Neuroinflammation and Cognitive Outcomes Laboratory Niccolò Terrando, PhD Sensory Plasticity and Pain Research Laboratory Ru-Rong Ji, PhD

Molecular Pharmacology Laboratory Madan Kwatra, PhD

Systems Modeling of Perioperative Cardiovascular Injury & Adaptation Laboratory Mihai Podgoreanu, MD, FASE

Multidisciplinary Neuroprotection Laboratory David Warner, MD

Andrea Nackley, PhD

Translational Pain Research Laboratory

DEPARTMENTAL GRANTS $100,000+ JULY 1, 2018 - JUNE 30, 2019 SORTED BY OWNING DEPARTMENT

:CPOP/CTPM

Ru-Rong Ji, PhD

Neuroimmune Mechanisms Governing Neuropathic Cancer Pain Pathologies Funding Agency: International Association for the Study of Pain Grant Amount: $100,000 Resolution Pathway of Pain Funding Agency: National Institutes of Health Grant Amount: $347,813

Sven-Eric Jordt, PhD

Biomarkers of Lung Injury in Methyl Isocyanate Exposed Rodents and Pigs Funding Agency: University of Colorado - Denver Grant Amount: $105,838 Anesthetic and Synthetic Cooling Flavors in E-cigarettes: Chemistry and Respiratory Effects Modulating Nicotine Intake Funding Agency: National Institutes of Health Grant Amount: $1,456,395 Project 1: Effects of Flavors on Nicotine Choice and Central Reward Me Funding Agency: Yale University Grant Amount: $291,695

William Maixner, DDS, PhD

Niccolò Terrando, PhD

Neurovascular Dysfunction in Delirium Superimposed on Dementia Funding Agency: National Institutes of Health Grant Amount: $1,667,292 Bioelectronic Rescue of Cognitive Impairment After Surgery Funding Agency: National Institutes of Health Grant Amount: $197,980

David Warner, MD

Integrated Training in Anesthesiology Research Funding Agency: National Institutes of Health Grant Amount: $644,790 Translating Endogenous Vascular Protective Cascades into Therapy for Aneurysmal Subarachnoid Hemorrhage Funding Agency: Washington University in St. Louis Grant Amount: $114,685

Wei Yang, PhD

The Unfolded Protein Response and Neuroprotection in Stroke Funding Agency: National Institutes of Health Grant Amount: $695,626 C A R DIOTHOR ACIC A NES THESI A

Joseph Mathew, MD, MHSc, MBA, FASE

Role of Preoperative Baroreflex Sensitivity on Postoperative and Persistent Pain After Thoracic Surgery Funding Agency: National Institutes of Health Grant Amount: $442,750

Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Funding Agency: National Institutes of Health Grant Amount: $1,435,464

Katherine Martucci, PhD

Enhanced Neutrophil SUMOylation as a key to Anti-Inflammatory Effects of Hypothermia Funding Agency: American Heart Association Grant Amount: $200,000

The Impact of Opioids on Chronic Pain: Clinical Research and Career Training in Spinal Cord fMRI and Brain Reward Systems Funding Agency: National Institutes of Health Grant Amount: $746,654

Jorn Karhausen, MD

Mihai Podgoreanu, MD, FASE

Allergan Botox II Vestibulodynia: Understanding Pathophysiology Funding Agency: Allergan, Inc. Grant Amount: $816,649 and Determining Appropriate Treatments Madhav Swaminathan, MD, (Vestibulodynia: UPDATe) FASE, FAHA Funding Agency: National Institutes of Health Quark 309 Grant Amount: $6,887,590 Funding Agency: Quark Pharmaceuticals, Inc Grant Amount: $237,285

Andrea Nackley, PhD

Noa Segall, PhD

Effect of Monitoring System Design on Response Time to Cardiac Arrhythmias Funding Agency: Agency for Healthcare Research and Quality Grant Amount: $749,997 24| DUKE ANESTHESIOLOGY

Ian Welsby, MBBS

CytoSorbents REFRESH II Funding Agency: CytoSorbents Corporation Grant Amount: $187,255 Point-of-Care RBC Washing to Prevent Transfusion-Related Pulmonary Complications Funding Agency: Mayo Clinic Grant Amount: $246,385

CR ITIC A L C A R E MEDICINE

Jamie Privratsky, MD, PhD

The Role of the IL-1 Receptor in the AKI to CKD Transition Funding Agency: National Institutes of Health Grant Amount: $939,324

Paul Wischmeyer, MD, EDIC Abbott Nutritional Project Funding Agency: Abbott Nutrition Grant Amount: $224,247

GENER A L , VA SCUL A R A ND TR A NSPL A NT A NES THESI A

Timothy Miller, MB ChB

Assisted Fluid Management (AFM) Funding Agency: Edwards Lifesciences Corporation Grant Amount: $105,564

Richard Moon, MD, CM, MSc, FRCP(C), FACP, FCCP

PulseOx Study Funding Agency: Naval Sea Systems Command Grant Amount: $153,457 Altitude Study Funding Agency: Naval Sea Systems Command Grant Amount: $320,976 Advanced Technologies for Reducing Decompression Obligation and Risk Funding Agency: Creare, Inc. Grant Amount: $198,000 Sildenafil for Prevention of Immersion Pulmonary Edema Funding Agency: Naval Sea Systems Command Grant Amount: $150,259 HYPERBARIC MEDICINE

John Freiberger, MD, MPH

Does Heart Rate Variability Predict Impairment of Operational Performance in Divers?

Funding Agency: Naval Sea Systems Command Grant Amount: $148,689 NEUROA NES THESIOLOG Y, OTOL A RY NGOLOG Y A ND OFFS ITE ANESTHESIA

Miles Berger, MD, PhD

Ulrike Hoffmann, MD, PHD

High Resolution Awake Cortical Recordings to Analyze the Role of Spreading Depolarizations During Dynamic Stroke Evolution Funding Agency: National Institutes of Health Grant Amount: $426,854

Michael James, MD, FAHA, FNCS

HOBIT Trial Funding Agency: Minneapolis Medical Research Foundation Grant Amount: $113,499 CN105 to Improve Long-term Recovery in Models of Intracerebral Hemorrhage Funding Agency: AegisCN LLC Grant Amount: $135,000

PAIN MEDICINE

Padma Gulur, MD

Opioid Sparing Potential of Light-Induced Analgesia: A Pilot Trial of a Novel, Non-Pharmacological Treatment for Pain Funding Agency: National Institutes of Health Grant Amount: $160,875 PEDIATRIC ANESTHESIA

Brad Taicher, DO, MBA

Peds Pacira Exparel 402-C-319 PLAY Funding Agency: Pacira Pharmaceuticals Grant Amount: $109,483 REGIONAL ANESTHESIA

Amanda Kumar, MD

Pacira QL Block vs Thoracic Epidural in Laparoscopic Colectomy Funding Agency: Pacira Pharmaceuticals Grant Amount: $125,000

David MacLeod, MBBS

Medtronic NG INVOS JB4 NI Funding Agency: Medtronic, Inc. Grant Amount: $135,947 WOMEN’S ANESTHESIA

Ashraf Habib, MB BCh

402-C-414 Exparel Versus SOC in CS Neuro-Inflammation in Postoperative Funding Agency: Pacira Pharmaceuticals Cognitive Dysfunction: CSF and fMRI Grant Amount: $347,479 Studies Funding Agency: National Institutes of Health V E TER A NS A FFA IR S Grant Amount: $711,675 A NES THESIOLOG Y SERV ICE A Phase II Study of an ApoE Mimetic Thomas Van de Ven, MD, PhD Peptide to Reduce Postoperative Delirium, VIPER: Chronic Pain After Amputation Cognitive Dysfunction After Non-Cardiac Funding Agency: Department of Defense Surgery in Older Adults Grant Amount: $1,498,634 Funding Agency: Alzheimer's Drug Discovery Foundation Grant Amount: $1,631,197

Macalino Nominated for Prestigious Duke Leadership Award

Business Office

Macalino, who says she is “very honored to be nominated,” currently serves as the special assistant to Duke Anesthesiology’s chairman, Dr. Joseph Mathew. In addition to providing executive-level support to the chair, she coordinates the work and related coverage of all staff support roles in the department. Macalino first began at Duke in 2004 as a staff assistant for Dr. Mathew during his time as chief of the Cardiothoracic Anesthesia Division.

December marked her 15th year with not only this institution, but with the department.

n

Chancellor A. Eugene Washington and Melinda Macalino

Duke Anesthesiology’s Melinda Macalino is one of the four Duke staff members

nominated for the Susan B. Clark Administrative Leadership Award in

recognition of her dedication to the institution, service to others, personal strength of character, and acting as a role model.

This award was founded in 2007 to acknowledge administrative professionals at Duke who demonstrate the qualities exemplified by the late Susan Clark who spent a 33-year career at the institution, rising through the ranks from an entry-level position to strategic services associate in the Office of the Chancellor, and became a role model for all staff.

Macalino was nominated by Drs. Mathew and Padma Gulur, and John Borrelli, who believe that she “exemplifies all that is great in Duke and the Department of Anesthesiology.” They cite her attributes as being hard-working, proactive, efficient and personable – routinely going beyond the call of duty, happily engaging in new tasks, and helping whenever and wherever is needed.

Nominations for this annual award can be made by any Duke Health employee.

Honorees were invited to the 12th annual awards luncheon on April 23 at the Doris Duke Center at Sarah P. Duke Gardens to celebrate the excellence exemplified by the nominees and this year’s winner, Trena Martelon of Duke Pharmacology and Cancer Biology. Chancellor A. Eugene Washington presented each honoree with a bound version of their nomination packets.

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CELEBRATING 27 YEARS OF ACADEMIC EVENING FOR THE 27TH CONSECUTIVE YEAR, DUKE ANESTHESIOLOGY GATHERED TO SHARE THE RESULTS OF THEIR RESEARCH PURSUITS AND CELEBRATE SCIENTIFIC EXCELLENCE AT ITS ANNUAL ACADEMIC EVENING, HELD ON MAY 14 AT THE MILLENNIUM HOTEL DURHAM. A RECORD NUMBER OF 92 POSTER ABSTRACTS WERE PRESENTED THIS YEAR BY THE DEPARTMENT’S JUNIOR-LEVEL INVESTIGATORS AND FACULTY, RANGING FROM BASIC SCIENCE, CLINICAL TRIALS, CASE REPORTS, AND QI PROJECTS.

THIS YEAR’S GUEST JUDGE WAS DR. BEVERLEY ORSER, CHAIR OF THE DEPARTMENT OF ANESTHESIA AT THE UNIVERSITY OF TORONTO AND DIRECTOR OF RESEARCH AT SUNNYBROOK HEALTH SCIENCE CENTRE. “ALWAYS BE READY TO PIVOT OR COMPLETELY TURN AROUND IF THE SCIENCE DEMANDS IT,” SAID ORSER TO A CROWD OF ABOUT 150 FACULTY, TRAINEES, STUDENTS AND STAFF AT THE EVENT. SHE APPLAUDED THE DEPARTMENT FOR ITS RICH DIVERSITY AMONG TEAMS – INCORPORATING STATISTICIANS AND EPIDEMIOLOGISTS TO ACHIEVE THE BEST SCIENTIFIC OUTCOME, NOTING THAT “WE ALL WORK BETTER IN DIVERSE ENVIRONMENTS.” ACADEMIC EVENING AIMS TO ADVANCE ANESTHESIA, CRITICAL CARE AND PAIN MANAGEMENT. ONE OF THE ANTICIPATED HIGHLIGHTS OF THE ANNUAL EVENT IS THE PRESENTATION OF THE BILL WHITE RESIDENT RESEARCH AWARD. WHITE WAS INVOLVED IN THE DESIGN, DATA CONTROL AND EXAMINATION, AND STATISTICAL ANALYSIS OF BIOMEDICAL STUDIES IN BOTH OBSERVATIONAL AND CLINICAL TRIALS WITHIN DUKE ANESTHESIOLOGY FOR MORE THAN 20 YEARS. DR. STEPHEN ELLISON, CA-3 RESIDENT, RECEIVED FIRST PLACE IN THIS CATEGORY FOR HIS PROJECT, TITLED “NOVEL CIRCULATING METABOLIC MARKERS IMPROVE DISCRIMINATION OF METABOLIC HEALTH INDEPENDENT OF WEIGHT.” DR. MILLY RAMBHIA RECEIVED THE DICK SMITH AWARD; SMITH WAS A STATISTICIAN WHO, FOR NEARLY 15 YEARS WITH DUKE ANESTHESIOLOGY, PROVED INSTRUMENTAL IN HELPING INVESTIGATORS CONDUCT HIGH-LEVEL SCIENCE AT AN ETHICAL AND MORAL STANDARD THAT IS SECOND TO NONE. MEDICAL STUDENT: Trevor Weis, BS NON-MEDICAL STUDENT: Nicole Martin, DNP, CRNA CASE REPORT: Del Lamb, MD QUALITY IMPROVEMENT PROJECT: R. Christopher Call, MD 26| DUKE ANESTHESIOLOGY

POST-DOC BASIC SCIENCE RESEARCH: Sangsu Bang, PhD POST-DOC CLINICAL RESEARCH (DICK SMITH AWARD): Milly Rambhia, MD RESIDENT RESEARCH (BILL WHITE AWARD): Stephen Ellison, MD, PhD

ABLE ACADEMY FOR BUILDING LEADERSHIP EXCELLENCE

Translational Research

Katherine Martucci PhD

Clinical Research

W. Michael Bullock MD, PhD

Education

Marie-Louise Meng MD

Clinical Operations The ABLE Program is designed to

Nazish Hashmi MD

Grace McCarthy MD

Aurelio Alonso DDS, MS, PhD

Brian Starr MD

accelerate career development for junior faculty in their chosen pathway by pairing them in a one-year program with a personal coach. The program involves training in aspects of career development that include strategies to build resilience, enhance professional skills, and learn the infrastructure that supports their chosen domain.

Duke Anesthesiology Launches the CAPER Unit Through a foundation built on the rigorous methodologic principles of epidemiology and health services research, the Critical Care and Perioperative Epidemiologic Research (CAPER) Unit aims to fill the gap between basic science research and clinical trials, by conducting high-quality, observational research to advance knowledge in the care of perioperative and critically ill patients. It is comprised of a methods core (methodologists, analysts and data sources), subject-matter experts and a diverse membership who are all dedicated to advancing outcomes research in the fields of critical care and perioperative medicine. The unit’s goal is to improve health outcomes in perioperative and critically ill populations, both locally and globally. The CAPER Unit is a part of the Critical Care Medicine Division and led by directors, Drs. Vijay Krishnamoorthy and Karthik Raghunathan.

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Duke University School of Medicine Dean: Mary E. Klotman, MD Address: Office of the Dean, DUMC 2927, Durham, NC 27710 School Web Address: medschool.duke.edu @DukeMedSchool @MaryEKlotman linkedin.com/school/duke-med-school

“I anticipate [2020] will be one of the most exciting years in our school’s history. There is a palpable momentum on campus—a feeling of renewal and progress and commitment to action that will accelerate our work to live out our core values of excellence in education, research, and patient care.”

The youngest of the nation’s leading medical schools, Duke University School of Medicine is one of the nation’s premier schools for medical education, clinical care and biomedical research. Planning for the school began in 1925, when businessman James Buchanan Duke, benefactor of Duke University and The Duke Endowment, bequeathed $4 million to establish the Duke School of Medicine, the Duke School of Nursing and Duke Hospital. Less than five years after the school opened in 1930, the Association of American Medical Colleges ranked Duke in the top quarter of medical schools in the country. Now, more than 80 years later, the Duke University School of Medicine is still ranked among the leading medical schools in the nation. The School of Medicine employs more than 2,500 regular rank faculty physicians and researchers.

The School of Medicine, Duke University Health System, School of Nursing, and the Private Diagnostic Clinic (PDC) comprise Duke Health.

Dean’s Guiding Principles: One Duke: leveraging the rich environment that spans all aspects of Duke (SoM, University, DUHS, PDC) to maximize our effectiveness and impact.

Service: facilitating the success of our world-class faculty, staff, trainees, and students through strategic and effective support.

28| DUKE ANESTHESIOLOGY

US News Ranks DUKE

Best Medical Schools for Anesthesiology

“FORBES Recognizes DUKE as a 'BEST EMPLOYER' in 2019” BluePrint 2019

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30| DUKE ANESTHESIOLOGY

On the Cutting Edge of Regenerative Pain Therapies

By Ratna Swaminathan

“Collectively, medical institutions around the globe have had the philosophy that ‘if it hurts, put steroid on it.’ While that often improves symptoms, it does not promote healing,” says Thomas Buchheit, MD, director of the recently-inaugurated Regenerative Pain Therapies Program (RPTP) at the Duke Innovative Pain Therapies (DIPT) clinic in Brier Creek. “I think the interest in this program has been the ability to promote healing and longer-term outcomes.”

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The opioid crisis has precipitated a serious re-examination of regenerative therapies because there are no good solutions for chronic pain. The Health and Human Services (HHS) statistics shed light on the magnitude of these opioid and pain crises in the US. Approximately 11.4 million people have misused prescription opioids, 2.1 million have opioid use disorder and over 130 people die every day from opioid-related drug overdose. Chronic pain affects 50 million people in the country, including almost 20 million who suffer high impact debilitating pain.¹ With the HHS now investing at least a $1 billion effort towards new solutions to the opioid crisis, the urgency to resolve this issue cannot be overemphasized.²

-William Maixner, DDS, PhD

Tennis Elbow: Prior to Treatment

Tennis Elbow: Two Months After Treatment

32| DUKE ANESTHESIOLOGY

Regenerative medicine—therapies that promote the body’s natural healing mechanisms, is one of the important tools in reducing the burden of chronic pain. Duke Anesthesiology’s foray into this field has placed it at the cutting edge of interventional pain therapies, based on the basic and translational research taking place within the department’s Center for Translational Pain Medicine (CTPM), according to its founder, William Maixner, DDS, PhD, vice chair for research, and also the driving force behind the development of DIPT. Along with co-director and eminent basic science researcher, Ru-Rong Ji, PhD, he has developed the CTPM at Duke to be a nexus where both research activities and clinical management meet. “Within a short period of time, we have brought this facility to international recognition as one of the leading pain and drug discovery units in the country,” adds Maixner. “We focus on taking basic observations and clinical observations and turning those into new ways of diagnosing and treating pain patients,” he informs, adding that their portfolio has expanded to include many federal grants and potential partnerships.

“We are on the cusp of developing an NIH-sponsored center for excellence at the CTPM that will focus on alternative medicines for the treatment of pain,” says Maixner confidently.

Although there are multiple clinics offering various regenerative therapies, Duke Anesthesiology’s Regenerative Pain Therapies Program is unique in its rigorous, translational scientific approach.

The therapies are grounded on the research by Ji (pictured right), who has elucidated novel methods to resolve inflammation after injury. Ji believes that regenerative medicine has the potential to replace opioid treatment. He works alongside Buchheit and Maixner to determine the mechanisms underlying the actions of some effective pain treatments and taking them from bench to bedside and vice versa. Ji’s ground-breaking research explores the role of cellular therapies in mitigating chronic pain. His research on the molecular and cellular mechanisms of pain in animal models has shown that a single treatment could produce chronic pain relief that lasts from a few weeks to several months. He is also collaborating with Duke Neurosurgery and Duke Biomedical Engineering to develop and optimize an injection that can deliver cells to specific locations, such as the dorsal root ganglia, in humans.

“The Duke Autologous Serum (DAS) is the cornerstone of the Regenerative Pain Therapies Program that we’ve spent the past two years developing,” informs Buchheit proudly. This treatment for arthritis pain and musculoskeletal conditions is based on the extensive research by eminent pain medicine clinician, Peter Wehling, MD, PhD, a consultant and an internationally-renowned expert in molecular orthopedics in Dusseldorf, Germany. Wehling has honed the proper techniques to maximize the generation of anti-inflammatory growth factors - some of the same factors that Ji has been studying. Wehling’s decades of work have defined the optimal conditions to generate an acellular, safe serum product using the patient’s own blood and an on-site, state-of-the-art laboratory.

This product, under sterile conditions, is reinjected into the patient under live-image ultrasound guidance to the affected joint. “I think the unique part of the DAS is our rigorous approach to quality control,” adds Buchheit.

Patients with chronic pain symptoms related to mild to moderate osteoarthritis and other musculoskeletal conditions, including degenerative conditions of joints, muscles and tendons, and temporomandibular disorders, can now avail themselves of several biologic and non-biologic-based pain therapies offered at the DIPT clinic. The multidisciplinary approach, comprising anesthesiology, orofacial pain, neurology, psychology, acupuncture, massage therapy and physical therapy is working to shift the traditional paradigm of the pervasive use of pain relief medications, such as opioids, and changing the patient’s mindset in a holistic manner. The approach is to modify lifestyle and accelerate recovery in patients. “I really think it’s more about that mindset of looking at longer-term functional improvements,” adds Buchheit.

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Procedure-Based Regenerative Therapies

In-Situ Biologic Therapies:

Platelet Rich Plasma Autologous Conditioned Serum (ACS)

Figure: Phases of Inflammation Resolution. Adapted from “Autotherapies: Enhancing Endogenous Healing and Regeneration,”

by N. Lumelsky (2018). Trends in Molecular Medicine, 24 (11), 919-930.

HHS investment towards new solutions to the opioid crisis In addition to DAS (a customized autologous conditioned serum), the Regenerative Pain Therapies Program offers a spectrum of treatments for musculoskeletal conditions to make the therapies accessible to a wide audience. “We have tried very purposely to build a spectrum of therapies, so for patients who don’t have the means to pay for the costly biologic options, they can still have access to treatment,” says Buchheit. These treatment options include platelet rich plasma (concentrated platelets and white blood cells) and non-steroid treatments, all of which focus on various methods to induce an immune response and to concentrate growth factors at the site of arthritis, tendon or ligament injury and are tailored to the needs of the patient.

34| DUKE ANESTHESIOLOGY

This evidence-based program is built upon well-rounded clinical and translational research. “Our belief is that if we let the science and clinical outcomes lead, it maximizes both the safety and effectiveness for the patient. Every therapy that we offer has been researched for years before we deploy it,” adds Buchheit.

As Duke Anesthesiology finds itself on the frontlines to stem both the opioid and chronic pain crises, it is guided by a goal to develop novel, safe, and effective alternatives to opioid medications. The hope is that chronic pain will become a thing of the past for patients.

¹Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016.

MMWR Morb Mortal Wkly Rep 2018;67:1001–1006. ²US Department of Health and Human Services news release (September 19, 2018)

Thomas Buchheit, MD

William Maixner, DDS, PhD

Ru-Rong Ji, PhD

Peter Wehling, MD, PhD

Key Takeaways: Regenerative medicine should be conceptualized as a spectrum of therapies Treatments should be customized, and based on anatomy and symptoms with image-guided interventions Biologic therapies such as DAS/ACS will play a growing role in the treatment of injuries and degenerative conditions

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36| DUKE ANESTHESIOLOGY

It is evident that the vice chair for innovation at Duke Anesthesiology, Evan Kharasch, MD, PhD, is a curious anesthesiologist who approaches patient care with a mindset of a problem solver and a scientist. In 1979, it was this inquisitiveness that prompted him to pursue a PhD in pharmacology while still in medical school at Northwestern University in Illinois. Later, during his clerkship in surgery, he was captivated by the role anesthesiologists play in the operating room to help patients navigate the complexities of surgery. Kharasch feels that anesthesiology is the perfect place for a pharmacologist to practice medicine.

“The practice of anesthesia is the practice of clinical pharmacology,” he says.

Anesthesiologists should be in the forefront not only in the operating room, but in all spheres of medicine, emphasizes Kharasch, adding that curious people should not be limited by a label. He uses his pharmacology background with every patient each time he is in the operating room.

Elected to the prestigious National Academy of Medicine in 2013, Kharasch was also honored with the Lifetime Achievement Award by the International Society for Anesthetic Pharmacology in 2017. At Duke, he recently became the distinguished Merel H. Harmel Professor of Anesthesiology. With 280 research publications and numerous book chapters and two textbooks to his credit, this internationally-known academic anesthesiologist focuses on translational research, especially on advancing the understanding and practice of clinical pharmacology. While astute intellectual discipline and rigor define Kharasch’s approach in clinical medicine to rationally combine different drugs to create the ideal cocktail for every patient, his unquenching thirst for research also originates in the operating theater.

“We are looking for more and better ways to treat pain - acute pain, postoperative pain and chronic pain,” says Kharasch, a NIH-funded physician-scientist who leads a robust research program in basic, translational and clinical pharmacology at Duke.

In addition to anesthetic and analgesic drugs, his research interests include addiction therapies, aimed at optimizing drug disposition, drug safety, clinical effectiveness and patient satisfaction. He has done impressive work in areas of drug metabolism and transport (hepatic, renal, intestinal, and the blood-brain barrier), pharmacokinetics (time course of drugs in the body), pharmacodynamics (what drugs do to the body), pharmacogenetics (the genetic basis of individual responses to different drugs), toxicity, and drug interactions.

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Several of his studies have looked at genetic factors that influence the pharmacokinetics of drugs, including opioids and anti-depressants. Explains Kharasch: “One of the great problems in anesthesia in the 1960s and ‘70s was the toxicity of inhaled anesthetic drugs, mainly kidney and liver toxicity. My labs in Seattle and St. Louis have had a seminal role in identifying the mechanisms by which toxicity occurred. We changed some very fundamental, longstanding concepts about how anesthetics caused toxicity. Because we changed those concepts, we also changed the ways in which new anesthetics were developed.”

More than one billion patients globally have benefitted from Kharasch’s research on the mechanistic pathways on anesthetic toxicity, and the lack of toxicity of the anesthetic drug, sevoflurane. This volatile anesthetic agent is most frequently used to induce and maintain anesthesia with a rapid onset of action and rapid elimination. “My lab did a lot of the very fundamental research - clinical and laboratory - on sevoflurane.

And it was that research which in part

enabled the drug to be approved by the FDA and other regulatory agencies worldwide.”

His research today has a focus on the clinical pharmacology of opioids, and their rational and optimal use. As an opioid pharmacologist, he is well-qualified to inform on and help improve opioid use at Duke, and more broadly. That is now more important than ever, as the United States struggles with how best to treat pain while coping with the crisis of opioid misuse, and in a rational and thoughtful way.

As editor-in-chief of the eminent journal Anesthesiology, Kharasch is on the frontlines of cutting-edge research. He feels that the next frontier would be to identify new families of more effective drugs with fewer side effects and also to understand how anesthesiologists can mitigate both short-term and long-term consequences of surgery.

“We still today do not entirely understand how inhaled anesthetics work. These are one of the few drugs in clinical medicine today whose mechanism of action we don't understand. We still do not understand what is consciousness and how do anesthetics interrupt consciousness.” For this far-sighted physician researcher, it is not merely about the next breakthrough, but all the ones after that.

And for that, he is willing to go wherever science takes him. While it may not necessarily be directly related to anesthesiology, he says, it is important to medicine. Kharasch’s work expanded into the area of cancer in 2008 when his curiosity rendezvoused with chance during a routine nephrectomy surgery in a patient with advanced-stage kidney cancer . It led him to ask the question, “Why was the patient’s cancer detected so late?” Coincidentally, his research focus at Washington University at the time was to study the effects of drugs on kidneys. Returning to his lab and brainstorming with the research team set the wheels in motion and led to the discovery of two early

biomarkers of kidney cancer. The team found two proteins - aquaporin-1 and adipophilin - that were shed into the urine by kidney cancers and not by other kidney or urinary tract diseases.

Fast forward to today, Kharasch holds three US

patents for non-invasive biomarkers for population screening and differential diagnosis of kidney cancer.

Along with his collaborator at Washington University, he is

developing nanotechnology-based diagnostics for non-invasive screening for kidney cancer. The biomarkers, which are more than 90 percent sensitive and specific, are awaiting commercialization. He also has six other patents on nanotechnology for biomarker detection pending approval.

“I am evidence that it can be done. Because “I am evidence that it can be done. Because it’s really through commercialization that it’s really through commercialization science has the greatest impact.”that science has the greatest impact.”

Billion patients impacted

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Kharasch is an entrepreneur role model. He is a co-founder of Auragent Bioscience, a company focused on developing novel technologies for transforming biodetection that increase sensitivity, lower limits of detection, and increase the dynamic range of existing fluorescence-based analytical techniques.

For him, moving to Duke brings opportunities to ask new and different research questions, with new collaborators, and in new and different ways. “Duke itself has several programs for innovation and entrepreneurship in research, such as the Duke-Coulter Translational Medicine Partnership and Duke MEDx program, and it sits in a rich entrepreneurial ecosystem with several major research universities and faculty interested in entrepreneurial endeavors, and with start-up and established companies and entrepreneurs,” informs Kharasch.

As the director of academic entrepreneurship for the Duke University School of Medicine, he is keen to help researchers understand that scientific discoveries should not be looked at solely for publication, but for applicability. He wants to expand the culture of the moving of ideas from academia to industry. Taking innovation to fruition by going commercial, he feels, increases reach for greater patient benefit.

“My lab and collaborators are just one example that it can be done. Because it’s really through commercialization that science has the greatest impact.”

He advises researchers to be curious, to explore, and to ask more questions. A passionate educator, Kharasch has given lectures in conferences around the world and is a sought-after speaker in the science of anesthetic pharmacology and biomarker discovery. Driven each day to pursue life-changing cures and to treat pain, this accomplished physician-scientist feels there are many questions yet to be answered; there are many clinicians yet to be educated; and, most importantly, there are many patients yet to be benefited.

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Active Research Within Dr. Kharasch’s Laboratory of Mechanistic and Clinical Pharmacology at Duke Optimizing Outpatient Anesthesia, Pain Relief, and Rational Opioid Use Anesthesiologists face the challenge of providing optimal and cost-effective anesthesia and pain relief, while minimizing opioid (and other) drug-related side effects. They want to set patients on an optimal trajectory for rapid and complete recovery, yet they only interact with them for a small amount of time and thus their window of opportunity is narrow. This is even more challenging in outpatient surgery settings.

Although the past three decades have seen increasing attention to treating postoperative pain, surveys have shown that patient satisfaction with postoperative pain relief has not improved. In addition, some patients will develop chronic postoperative pain, which can affect recovery, delay return to normal activities, and affect quality of life. Acute postoperative pain is the greatest risk factor for chronic postsurgical pain. Hence optimal postoperative pain relief is important.

Kharasch’s research group is investigating the paradigm-shifting concept of using long-duration opioids (rather than traditional short-duration opioids) for surgical anesthesia in outpatients. The idea is to better match the duration of drug effect to the duration of patient pain. The goal is to provide better pain relief, decrease postoperative pain, and decrease the need for postoperative opioid use and prescribing. More specifically, the group is evaluating this concept in patients undergoing same-day discharge and next-day discharge ambulatory (outpatient) surgery.

This research, supported by a grant from the National Institutes of Health, also addresses more broadly the national opioid crisis. “If we can reduce postoperative pain, surgeons may need to prescribe less take-home opioids. Reducing the national oversupply of opioids is a public health imperative,” says Kharasch.

“Implementing this clinical trial at Duke has been a wonderful way to ‘jump into’ the institution’s clinical research environment. The Duke University Health System is a living laboratory for asking and addressing important clinical questions. Implementing this clinical trial in the Duke University Hospital operating rooms was remarkably easy, and my surgical colleagues have been wonderfully collaborative and supportive. The perioperative research environment of Duke University Hospital is a particular strength of Duke University. And, as its health system continues to expand, to Duke Regional and Duke Raleigh Hospitals, we have the potential to grow perioperative research even more.”

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We empower great minds to turn dreams into reality By encouraging the entrepreneurial spirit, unfettered imagination, and unchecked ambition, the DREAM Campaign inspires Duke Anesthesiolog y faculty and provides them with the wherewithal to achieve the impossible. Together with our supporters, we are transforming the future of patient care.

Help us continue to train the leaders of tomorrow, develop the careers of our faculty, and protect quality of life for years to come.

DEVELOPING RESEARCH EXCELLENCE IN ANESTHESIA MANAGEMENT 38

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DUKE ANESTHESIOLOGY

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Thank you to our valued 2018-2019 donors ANDREW GARDNER LUTZ

MARTIN MARIET TA MATERIALS, INC.

ANDREW WIKSTEN

MCKIM WILLIAMS

ANGELO V. GAGLIANO

MICHAEL A. FIERRO

ANIL M. V YAS

MICHAEL D. SMITH

ANNEMARIE THOMPSON

MICHAEL J. PL AKKE

ASHR AF S. HABIB

MICHAEL L ASECKI

BRENDA S. GERHARDT

MICHAEL LUCAS JAMES

BRIAN J. TITUS

PAIN CENTER OF ORL ANDO, INC.

CHRISTINA REITER

PATRICIA CARROLL V YAS

CORY MICHAEL FURSE

PAUL MICHAEL JAKLITSCH

DAVID S. WARNER

PAUL R. SHOOK

DERYL HART WARNER

RICHARD LEE WOLMAN

DOUG AND K ATHRYN KING

ROBERT FREDERICK EVANS

EDWARD SANDERS

RU-RONG JI

EUGENE WILLIAM MORET TI

SOLOMON ARONSON

G. BURKHARD MACKENSEN

STANLEY RESEARCH FOUNDATION

HELEN MARIE PAVILONIS

STEPHEN B. PACKER

JAMES AND K ATHERINE GRICHNIK

SUR AJ MANJUNATHA YAL AMURI

JAMIE PRIVR ATSK Y

TEODULO REMANDABAN

JANICE EVANS

TIMOTHY MILLER

JOHN AND BONNIE WOLFE

TIMOTHY STANLEY

JOHN VERNON PARHAM, JR.

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KEITH NORRIS PHILLIPPI

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KIEU LUU

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DRE AMC AMPAIGN.DUHS.DUKE.EDU

BluePrint 2018 | 39 11 YEARS OF GIVING: DREAMCAMPAIGN.DUHS.DUKE.EDU BluePrint 2019

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DEVELOPING RESEARCH EXCELLENCE IN ANESTHESIA MANAGEMENT

11 years of the DREAM campaign

20

k

15

$

M

of extramural funding received from $842,378 in DIGs

2018's largest single donation (Martin Marietta Materials)

Campaign Goals 1.

2.

3.

Establish Endowed Professorships

Raise Funds

Establish Philanthropic Support

to invest in world-class faculty who would, in turn, secure extramural funding.

Interest dollars from these endowments are to be used to support investigator salaries and provide them with the time and resources necessary to develop research programs.

to support research through the DREAM Innovation Grant, known as DIG.

as a long-term mechanism of limiting the adverse consequences of cyclical federal funding.

Visit our DREAM web pages to read more about the campaign and make a gift online!

Dreamcampaign.duhs.duke.edu

What is a “DIG?” The DIG is an annual competition held among Duke Anesthesiology faculty members.

Recipients can receive up to $30,000 in seed money for their innovative pilot studies, which ultimately help them apply for and obtain extramural funding. This grant creates an avenue for healthy competition among faculty, inspires ingenuity, promotes the careers of young physician investigators, enhances donor communication, and furthers the department’s academic mission.

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DREAM INNOVATION GRANT 2019 RECIPIENT

Andrea Nackley PhD

B ackground

"A Molecular Exploration into Comorbid Chronic Pain and Obesity”

From: Roanoke, Virginia PhD: University of Georgia While the mechanisms underlying the overlap between chronic pain and obesity remain unclear, a hallmark feature of both conditions is increased systemic inflammation. Dr. Andrea Nackley’s preliminary data suggests that pain- and obesity-relevant inflammation is driven through adipocyte Adrb3 via miR-133-mediated increases in cytokines, which activate local immune cells.

The 2019 DIG is assisting Nackley in implementing an innovative set of studies that will identify, for the first time, molecular features of adipose tissue expansion that underlie comorbid chronic pain and obesity.

She will analyze biological samples (adipose tissue and blood plasma) and clinical data collected from 40 patients undergoing bariatric surgery. Her hypothesis is that compared to obese individuals without chronic pain, those with chronic pain will have increased levels of cytokines/adipokines in adipocytes and plasma and greater number of inflammatory immune cells in adipose alongside increased expression of Adrb3 and decreased expression of miR-133a in adipocytes. Further, local and systemic inflammation will be positively correlated with poorer physical and mental health.

Results from this study will allow better understanding of the mechanisms that drive comorbid chronic pain and obesity. Through recent NIH R01 follow-on funding (from the DIG), Nackley will also determine if treatments that normalize Adrb3 and miR-133 signaling are effective in resolving inflammation underlying chronic pain and obesity.

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DREAM INNOVATION GRANT 2019 RECIPIENT

"Effect of Neuronal Stimulation in Enhancing Injured Spinal Cord Repair"

Huaxin Sheng MD

B ackground

From: Jiangsu, China MD: Nantong Medical College (China)

Spinal cord injury can be catastrophic.

Dr. Huaxin Sheng seeks to understand the pathological process of injury and define novel therapeutic targets through multiple approaches. His team has established four mouse models of spinal cord injury, including ischemia, contusion, compression, and hemisection. His work has been critical in elucidation of the role of extracellular superoxide dismutase (SOD) in acute CNS injury.

This allowed him to then demonstrate efficacy of pharmacologic SOD mimetics in mouse spinal cord injury. SUMO conjugation, a post-translational protein modification, has been characterized

by Sheng and his colleagues in cerebral ischemia. The team extended this work to spinal cord injury. SUMO conjugation was dramatically increased in normal mice subjected to transient thoracic aorta clamping. Astrocyte activation was significantly inhibited in SUMO knock out mice, potentially leading to decreased production of growth factors mitigating tissue damage.

46| DUKE ANESTHESIOLOGY

Sheng’s work is centered around advancing discoveries of molecular mechanisms of injury, derived from basic neuroscience research, to animal models of human disease to enable therapeutic interventions to emerge that may be relevant to patient care. The 2019 DIG is assisting Sheng in applying novel molecular technology to promote recovery from spinal cord injury and obtain sufficient preliminary data to compete for federal funding.

p i c p a p n s

H a e t

l s s d , s n f e n .

John Whittle MBBS, MD, FHEA, FRCA, FFICM

DREAM INNOVATION GRANT 2019 RECIPIENT

"Can a Structured Exercise Intervention Modulate the Vagal Inflammatory Response in High-Risk Surgical Patients?"

From: United Kingdom MD: University College London

B ackground

Dr. John Whittle’s research focuses on modulating the autonomic nervous system to optimize immune and bioenergetic pathways with a view to preventing or blunting perioperative organ injury.

Whittle’s current research uses exercise training in the preoperative period to improve aerobic fitness, a clear correlate with perioperative outcome and function of the parasympathetic nervous system.

He aims to explore the impact of improving parasympathetic function on the ability of the body to use oxygen and defend itself from the trauma of surgery.

The 2019 DIG will assist Whittle in further examining the role of low exercise capacity and parasympathetic function in surgical outcome. Impaired preoperative aerobic exercise capacity is strongly associated with established inflammation, an increased inflammatory response to surgical trauma, mitochondrial dysfunction and the development of postoperative complications.

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Providing state-of-the-art methodology for clinical, basic science and translational research empowers Duke Anesthesiology to explore revolutionary clinical inquiries by using innovative investigation methods.

Through significant research in neuroscience, molecular biology, molecular and human pharmacology endeavors, our team is making crucial advancements for patients worldwide.

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The MARBLE Study: Modulating ApoE signaling to Reduce Brain inflammation, deLirium and postopErative cognitive dysfunction Up to 40 percent of the more than 16 million older Americans (over age 60) who undergo anesthesia and surgery each year will likely develop postoperative delirium or cognitive dysfunction (also referred to as neurocognitive disorder-postoperative). Two potential mechanisms that may contribute to these perioperative neurocognitive disorders are Alzheimer’s disease (AD) pathology and/or neuroinflammation. Thus, an ideal drug to prevent these disorders would ideally help prevent AD pathology and neuro-inflammation. One gene that modulates both AD pathology and neuro-inflammation is ApoE, for which the ApoE4 variant allele is the most common genetic contributor to late onset Alzheimer’s disease. As compared to those who do not have a copy of the ApoE4 allele, ApoE4 carriers have worse long-term cognitive trajectories after anesthesia and surgery. Dr. Danny Laskowitz and colleagues have shown that Alzheimer’s disease pathology and neuro-inflammation can be prevented in mouse models by modulating ApoE4 signaling with the small peptide drug CN-105. CN-105 is a 5 amino acid peptide from the C-terminal tail of ApoE, which is thought to work at least in part by interacting with the ApoE receptor, LRP1.

Funding Awarded: $1,631,197, three-year grant Funding Source: Alzheimer’s Drug Discovery Foundation, Program to Accelerate Clinical Trials (PACT) 50| DUKE ANESTHESIOLOGY

Based on this work, the investigators started the MARBLE study: Modulating ApoE signaling to Reduce Brain inflammation, deLirium and postopErative cognitive dysfunction. MARBLE is an FDA phase II dose escalation study designed to determine the safety of treating older surgical patients with CN-105 (the primary study objective). MARBLE patients (older adults age ≥ 60) are randomized to receive CN-105 or placebo every six hours starting just before surgery and continuing through postoperative day four (or up to 13 doses, whichever occurs first). All MARBLE study patients also undergo cognitive testing before and six weeks after surgery, postoperative delirium screening, intraoperative EEG recordings, and blood and CSF sampling before as well as 24 hours and six weeks after surgery. These samples allow determination of whether CN-105 treatment prevents postoperative increases in inflammatory cytokines or Alzheimer’s disease biomarkers within the CSF, thus providing important in vivo evidence on whether CN-105 actually blocks neuroinflammation and AD pathology in the human central nervous system. The cognitive and delirium testing data provide preliminary data on the extent to which CN-105 helps prevent perioperative neurocognitive disorders, while the EEG data will help provide information on the extent to which these disorders are associated with altered intraoperative brain activity patterns, and/or whether these patterns can be prevented by CN-105 treatment.

The MARBLE study will help clarify whether CN-105 should be further studied for its potential to prevent perioperative neurocognitive disorders. Yet, beyond this important goal in perioperative medicine, MARBLE will also help evaluate the safety of CN-105 and determine whether it may be useful for helping to prevent Alzheimer’s disease. Currently, there are no clinically available treatments designed to prevent AD. Most of the drugs that have been tested for AD prevention have been based on the amyloid cascade hypothesis, which holds that amyloid beta (Aß) plays a key role in causing AD. Yet, virtually all of these drugs targeting Aß have failed to prevent AD in clinical trials. CN-105 provides a potentially novel approach to preventing Alzheimer’s disease, an approach that is based on the genetic variant (i.e. ApoE4) that has been the most closely associated with the development of late onset AD. In this way, the MARBLE study has the potential to not only help lead to better cognitive outcomes for older adults after anesthesia and surgery, but also to lead to better treatments for the most common type of dementia, Alzheimer’s disease.

Proposed Mechanisms of Perioperative Neurocognitive Disorders

Credit: Rupp, B., Peters-Libeu, C. (2001). Apolipoprotein E4 (ApoE4), 22K fragment.

Retrieved from rcsb.org/structure/1B68.

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Enhanced Neutrophil SUMOylation as a key to Anti-Inflammatory Effects of Hypothermia One of the few strategies shown to modulate inflammation resulting from ischemia and reperfusion is hypothermia, and therefore patients are often cooled (e.g. after cardiac arrest or during cardiac surgery). However, adverse effects on coagulation and host-defense systems, and inconsistent results in clinical trials, highlight persistent problems with this approach.

Investigators aim to elucidate the underlying mechanisms that link low temperature to inflammation control. Their ongoing work suggests that hypothermia activates endogenous stress response programs, such as the SUMOylation network.

Posttranslational modification with Small Ubiquitin-like MOdifiers (SUMO) is highly dynamic, and because transcription factors are key targets, significant changes in protein SUMOylation can achieve rapid reprograming of entire pathways. Importantly, they have shown, that enhanced global SUMOylation levels broadly alter inflammatory responses following I/R leading to reduced inflammatory cell infiltration and improved tissue preservation. Their current research will focus on neutrophils as a primary effector cell of ischemia/reperfusion injury and will use a broad spectrum of techniques, including cell-permeable inhibitory peptides and conditional genetic approaches, to define the specific SUMOylation effects in this cell population.

Funding Awarded: $200,000, two-year grant Funding Source: American Heart Association, Innovative Project Award Co-Investigator: Wei Yang, PhD 52| DUKE ANESTHESIOLOGY

Immunohistochemistry showing increased SUMOylation in cells infiltrating the submucosa in a mouse model of acute intestinal inflammation. A) control B) five days after induction of intestinal inflammation. SUMO2-positive cells are labeled red, the intestinal epithelium is outlined by green counterstain.

Rationale: A key target of hypothermia-mediated anti-inflammatory effects are neutrophils, which are central effector cells of I/R injury through release of neutrophil-derived reactive oxygen species, proteases and cytokines. In their ongoing work, they found primary evidence that hypothermia dynamically increases leukocyte SUMOylation in patients undergoing deep hypothermic circulatory arrest (unpublished data), which could dramatically alter the neutrophil ability to engage at sites of inflammation. However, due to a lack of specific genetic tools, there is an enormous gap in knowledge on how the critically important SUMOylation pathway defines neutrophil functions, and the main target pathways remain unknown.

Central Hypothesis: SUMOylation constitutes a key mechanism by which environmental factors, such as hypothermia, dynamically modulate neutrophil functions and as such a novel target to therapeutically modulate functions of this crucial inflammatory effector cell.

Experimental Aims: The investigators will take a comprehensive in vitro and in vivo approach to examine SUMO-mediated inflammatory regulation during low temperature states. To define basic mechanisms, they will test low temperature responses in isolated human neutrophils treated with cell-permeable decoy peptides that specifically inhibit the ability of SUMO peptides to interact with their target proteins. To then expand their knowledge into clinically relevant questions, the team will examine the therapeutic effect of enhanced SUMOylation in the murine cardiac arrest model as a clinically relevant model of whole-body ischemia/reperfusion injury. SUMOylation effects specifically in the neutrophils will be examined, through an approach that allows the targeting of lentiviral particles to this cell population.

Importantly, as a further step towards establishing the clinical relevance SUMO-mediated responses in hypothermia, the researchers will conduct a comparative analysis of gene expression responses from these genetically modified mice vs. neutrophils from patients undergoing deep hypothermic arrest.

“By specifically targeting the molecular mechanisms that modulate inflammation during cooling, we are providing an entirely new perspective on managing injury after ischemia/reperfusion events such as cardiac arrest or during cardiac surgery. The specific molecule that we are interested in, the small ubiquitin-like modifier (SUMO), modulates the action of critical response proteins and transcription factors and therefore, may have broad and rapid effects on the performance of entire pathways.”

-Jorn Karhausen, MD

Example of in vivo imaging of neutrophil activity in an intestinal inflammation model. Two mice on the right show significant inflammation.

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Single Nucleus Expression Profiling of Human Sciatic Nerve After Traumatic Amputation

“Our research group feels fortunate, honored, and obligated to study these unique tissue samples, generously donated by military service members during a period of intense physical and mental suffering,” says Dr. Van de Ven. “We believe this project will advance efforts to prevent chronic pain after trauma and surgery.”

Funding Awarded: $1,431,182, three-year grant Co-Investigators: Drs. Thomas Buchheit and Muhammad Yawar Qadri (Duke Anesthesiology), and Chester “Trip” Buckenmaier (Uniformed Services University and Duke Anesthesiology alum)

Funding Source: Department of Defense (DoD) Peer Reviewed Medical Research Program (PRMRP) Investigator-Initiated Research Award

54| DUKE ANESTHESIOLOGY

Summary: This research aims to use single-nuclei RNA sequencing and global unbiased proteomics on sciatic nerve samples collected from active duty military members suffering traumatic battlefield amputation to reveal the time course of inflammatory and regenerative events that occur after amputation. Investigators also aim to identify the differences in inflammation and regeneration that put soldiers at risk for chronic, disabling, post-amputation pain.

Abstract: A majority of service members who undergo traumatic amputation develop chronic phantom or chronic residual limb pain with 10 – 15 percent of these patients developing severe, disabling, long-term pain.

30 - 40 percent of traumatic amputees, however, have no clinically significant chronic pain. Investigators believe this dichotomy of outcome is the key to understanding the development of chronic neuropathic pain after nerve injury. Preclinical studies using rodent models have provided some insights into the pathological sequelae of nerve injury, but this knowledge has not resulted in successful translation to the clinic. Recent evidence suggests that interspecies differences are a major barrier to successful translation, since rodent sensory neurons diverge considerably from their human counterparts. Accordingly, in order to better understand the pathological processes that lead to neuropathic pain after nerve injury, it is necessary to comprehensively study injured human nerves. Colleagues at Walter Reed National Military Medical Center spent three years obtaining sciatic nerve samples from service members undergoing primary amputation revision surgery after suffering traumatic amputation on the battlefield.

These unique samples allow, for the first time, study of nerve regeneration and neuroinflammation in humans during the days following traumatic amputation.

Hypotheses, Aims and Objectives: Hypothesis 1: After traumatic amputation, there are distinct immune, neuronal, and glial RNA and protein signatures found in the peripheral injured nerve that will permit a detailed description of the neuronal and immune events occurring during the days following traumatic nerve injury.

Specific Aim 1: Utilizing bulk tissue and single nuclei RNA-sequencing and unbiased global proteomics of the distal portion of sciatic nerve, collected 1-14 days after initial traumatic amputation, investigators aim to establish the distinctive transcriptional, protein and glial/immune cell profile of injured sciatic nerve during injury and regeneration.

Hypothesis 2: A specific immune cell signature, RNA and protein expression profile present in the days following traumatic amputation is present in patients who have been successful at resolving inflammation and regenerating neuronal tissue without neuroma formation or chronic sensitization (pain).

Specific Aim 2: Complete a pain and functional outcome database describing each patient who donated sciatic nerve tissue and use those outcomes to identify immune cell populations, gene and protein expression changes around the time of amputation that correlate good function, and minimal residual limb or phantom pain.

Hypothesis 3: Anesthetic technique alters the immune cell population and the mRNA and protein expression profile in sciatic nerves collected at the time of definitive amputation surgery following trauma. Use of ketamine produces an immune cell signature and RNA expression profile that correlates with reduced chronic post-amputation pain.

Specific Aim 3: Compare anesthetic technique – specifically ketamine use– with immune cell population and gene and protein expression profile to determine whether the resulting cell and RNA/protein expression signature correlates with improved pain and functional outcomes.

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Duke Collaboration F Culture in

Guat

What originally began in 2012 as a trip to solely provide clinical care for children in a small hospital in the largest city in Guatemala, has gradually transitioned to a strategic initiative to improve quality and patient safety in this resource-constrained environment.

During the symposium, the Guatemalan pediatric nephrology team provided a real life example about a pilot program that they launched in their unit of the largest hospital in Guatemala. Utilizing Duke’s tools to measure a culture of safety, they reported vast improvements – functioning more as a team and enhancing quality of care and job satisfaction – without adding staff or increasing cost.

Duke collaborators include Dr. Henry Rice, a Duke pediatric surgeon, members of the Duke Global Health 56| DUKE ANESTHESIOLOGY Institute and Joe Doty, executive director of the Feagin Leadership Program.

n Fosters a Safety

atemala

For the first time, the Duke team traveled abroad to host the Executive Leadership and Patient Safety Symposium

people in attendance hospital directors participating experts

+ Ministry of Health

“Our focus is to develop stronger systems and apply the research on culture and safety, burnout, resiliency and teamwork at Duke into the Guatemalan health care system so they can make a big leap in their safety culture,” says Duke Anesthesiology’s Dr. Brad Taicher, a pediatric anesthesiologist and chair of the Anesthesia Patient Safety and Quality Committee. In October 2018, he and Duke collaborators embarked on a five-day trip to Guatemala City for the seventh consecutive year. Their long-term aspirations include assisting national governance and leadership in developing a cross-country structure to address training needs, and to not only expand the local clinicians’ experience and skill sets, but the number of safety experts and the tools that they can use to assess their progress.

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Residents

Faculty

$21,947 Raised

In a Clue-style room, each team had 60 minutes to follow the clues, determine the killer's identity and escape! The faculty team won the challenge by 34 seconds. The $4,520 raised directly supports departmental residents’ mission trips abroad, covering the cost of their travel, vaccinations and more. These annual events have raised a total of $21,947 since 2014.

THE DUKE

ANESTHESIOLOGY

CHALLENGE A GLOBAL HEALTH FUNDRAISER 58| DUKE ANESTHESIOLOGY

WHERE DO YOU WANT TO CHANGE LIVES? Duke Anesthesiology Global Health Program

“We have a role to play in global health to make the world a better place.” — Adeyemi J. Olufolabi, MB BS Associate Professor of Anesthesiology Program Director, Anesthesia Global Health Fellowship

Anesthesia plays a critical role in global health care, not only in times of crisis, but also in day-to-day events, such as childbirth. Things that we consider routine or trivial in the U.S. can be life threatening in third-world countries. In response, Duke Anesthesiology’s doctors and staff are committed to actively taking mission trips to countries that need help the most. Our goal is to achieve health equality worldwide by meeting the health challenges of today and tomorrow.

Ready to make a difference?

Visit tinyurl.com/DukeGlobal

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ResidencyRecap

“For medical students seeking world-class training i supportive environment, I cannot imagine a better place

RANK IN THE

BY DOX RESIDENCY PROGRAM RANKING

Keep in touch! Update your alumni profile by visiting: anesalumni.duhs.duke.edu/alumni

Keep in t 60| DUKE ANESTHESIOLOGY

g in a challenging but ace to begin your journey.”

— Annemarie Thompson, MD Residency Program Director

KED #5 E NATION OXIMITY

in touch! Update your alumni profile by visiting: anesalumni.duhs.duke.edu/alumni

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Duke Anesthesiology’s Residency Class of 2019 Robert Sladen Teacher of the Year Award Stuart Grant, MB ChB, FRCA

Jon Andrews, MD

Outstanding Graduate Award 62| DUKE ANESTHESIOLOGY

Welcome Match Class of 2023

Benjamin Andrew

Subasish Bhowmik

Duke University

Andrew Breglio

Dartmouth College

Nathaniel Erskine

Icahn SoM at Mount Sinai

Sara Feldman

University of Massachusetts

Alex Girden

University of North Carolina

Akshay Jagadeesh Drexel University

Thomas Jeerson University

Suhas Kochat

Dylan Matthews

University of Texas Medical Branch

Michael Paonessa

Tulane University

Katherine Sun

Kathryn Pearson

University of Miami

Hoang Tang

State University of NY Downstate

Johns Hopkins University

Wake Forest University

Reade Tillman

Ibtehaj Naqvi

University of Colorado

Duke University

CA-1 , Class of 2022

By the Numbers 2018-2019 Residents RANKED #5 in the nation board

States

9 Countries Represented

ranked TOP 10 by Conde Nast Traveler Best Places to Live in the U.S. BluePrint 2019

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AlumniNotes

Humacyte + Duke Alumni = Remodel Blood Vessels to Form Living Tissue

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The co-founders of Humacyte include Duke Anesthesiology faculty alumnus, Dr. Laura Niklason, Duke University alumnus, Dr. Shannon Dahl, and Dr. Juliana Blum

umacyte is an innovator in biotechnology and regenerative medicine. On March 28, 2019 they announced publication in the journal Science Translational Medicine of pivotal scientific work demonstrating Humacyte’s human acellular vessels (HAVs) repopulate with the patient’s own cells to form a living vascular tissue. The published study presents a comprehensive microscopic evaluation of HAV samples retrieved 16 weeks to four years after implantation in patients enrolled in the company’s Phase II clinical trials providing vascular access for hemodialysis. The results suggest that the HAV may be an innovative advance as a bioengineered vessel that develops characteristics of a living tissue over time.

A Look Back June 2013: In a first-of-its-kind operation in the US, doctors at Duke University Hospital helped create a bioengineered blood vessel and transplanted it into the arm of a patient with end-stage kidney disease. The procedure was the first US clinical trial to test the safety and effectiveness of the bioengineered blood vessel, marking a milestone in the field of tissue engineering.

Photo Credit: Shawn Rocco, Duke Health News

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Alumna: Dr. Laura Niklason joined the faculty at Duke University in 1998, where she continued her work in cardiovascular tissue engineering, and co-founded Humacyte, a biotechnology company designed to bring tissue engineered cardiovascular products to the clinic. She moved to Yale in 2006.

Scanning electron microscopy shows that the HAV is composed of densely-packed and aligned extracellular matrix fibers.

Following implantation, histological evidence demonstrated recellularization of the HAVs over time, with multiple cell populations from the patient. Cell types identified include smooth muscle and endothelial progenitor cells that mature over time. The histological evidence also suggests that these cells may form distinct tissue layers in the HAV similar to that of native blood vessels. These layers include a surrounding neoadventitial layer containing microcapillaries and progenitor cells, a dense and circumferentially aligned medial smooth muscle layer, and the presence of a potentially functional endothelium on the lumen.

Regions of the HAV wall that were previously injured or disrupted by needle cannulation during dialysis showed evidence of restoration by host cell populations, which suggests a self-healing potential of recellularized HAVs.

No evidence of adverse inflammatory or immune reaction to the HAV was observed in the clinical tissue samples.

Source: Humacyte news release (Research Triangle Park, NC – March 2019)

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DepartmentChairman Joseph P. Mathew MD, MHSc, MBA

Jerry Reves, MD, Professor of Cardiac Anesthesiology

CHIEF

Stephen M. Klein, MD Medical Director, Ambulatory Surgery Center Associate Professor of Anesthesiology

AMBULATORY ANESTHESIOLOGY Michael Kent, MD Steve Melton, MD Karen C. Nielsen, MD

CHIEF

Mihai V. Podgoreanu, MD, FASE Associate Professor of Anesthesiology Director, Perioperative Genomics Program

SeniorCabinet (Pictured Left to Right)

John Borrelli, MBA Mark Stafford-Smith, MD, CM, FRCPC, MBA, FASE Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE Madhav Swaminathan, MD, FASE, FAHA

Joseph P. Mathew, MD, MHSc, MBA, FASE Evan Kharasch, MD, PhD Padma Gulur, MD William Maixner, DDS, PhD Gavin Martin, MB ChB, FRCA, MMCi

CARDIOTHORACIC ANESTHESIOLOGY Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE Brandi Bottiger, MD Anne Cherry, MD J. Mauricio Del Rio, MD Rasesh Desai, MD Kamrouz Ghadimi, MD Loreta Grecu, MD Nazish Hashmi, MBBS Mandisa Maia Jones-Haywood, MD Jorn A. Karhausen, MD Rebecca Klinger, MD, MS Jerrold Levy, MD, FAHA, FCCM Yasmin Maisonave, MD Negmeldeen Mamoun, MD, PhD Michael W. Manning, MD, PhD Joseph P. Mathew, MD, MHSc, MBA, FASE Sharon McCartney, MD Alina Nicoara, MD, FASE Angela Pollak, MD Quintin Quinones, MD, PhD Mark Stafford-Smith, MD, CM, FRCPC, FASE Madhav Swaminathan, MD, MMCi, FASE, FAHA Annemarie Thompson, MD Eleanor Vega, MD Ian J. Welsby, MBBS, BSc, FRCA Meredith Whitacre, MD

ExecutiveTeam (Pictured Left to Right) Dan Cantrell Melinda Macalino Annemarie Thompson, MD Evan Kharasch, MD, PhD Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE Raquel R. Bartz, MD, MMCi Adam Flowe, CRNA Madhav Swaminathan, MD, FASE, FAHA Joseph P. Mathew, MD, MHSc, MBA, FASE William Maixner, DDS, PhD Gavin Martin, MB ChB, FRCA, MMCi Timothy E. Miller, MB, ChB, FRCA Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA 66| DUKE ANESTHESIOLOGY

Padma Gulur, MD Stephen M. Klein, MD Jeffrey C. Gadsden, MD, FRCPC, FANZCA Allison K. Ross, MD Atilio Barbeito, MD, MPH John Borrelli, MBA Not Pictured: Dhanesh K. Gupta, MD Mihai V. Podgoreanu, MD, FASE Dana Rawls Edward G. Sanders, MD Mark Stafford-Smith, MD, CM, FRCPC, MBA, FASE Kevin Vorenkamp, MD

DIRECTOR

Richard E. Moon, MD, CM, MSc, FRCP(C), FACP, FCCP Professor of Anesthesiology Professor of Medicine

CENTER FOR HYPERBARIC MEDICINE AND ENVIRONMENTAL PHYSIOLOGY Bruce J. Derrick, MD John J. Freiberger, MD, MPH Claude A. Piantadosi, MD Hagir Suliman, DVM, PhD

DepartmentFaculty DIRECTOR

Luis Ulloa, PhD, MS Associate Professor of Anesthesiology

CENTER FOR PERIOPERATIVE ORGAN PROTECTION Satya Achanta, DVM, PhD Sven-Eric Jordt, PhD Madan Kwatra, PhD Qing Ma, MD Noa Segall, PhD Huaxin Sheng, MD Niccolo Terrando, PhD David S. Warner, MD Wei Yang, PhD Zhiquan Zhang, PhD

Scott V. McCulloch, MD Tyler McCulloch, MD Edward McKenzie Jr., MD Elizabeth Nichols, MD William P. Norcross, MD Shannon Page, MD Gary L. Pellom, MD Lisette Ramos, MD Earl S. Ransom Jr., MD Benjamin F. Redmon, MD Richard D. Runkle III, MD Siddharth Sata, DO Nicole E. Scouras, MD Theresa Seay, MD Kavitha Sharkady, MD Michael J. Stella, MD Megan Stiger, MD Zaneta Y. Strouch, MD, MPH Frank Sutton, MD Neel Thomas, MD Danai Udomtecha, MD

CHIEF

Dhanesh K. Gupta, MD Professor of Anesthesiology

William Maixner, DDS, PhD

Joannes H. Karis, MD, Professor of Anesthesiology Vice Chair, Research Director, Duke Innovative Pain Therapies

CENTER FOR TRANSLATIONAL PAIN MEDICINE Aurelio Alonso, DDS, MS, PhD Andrey Bortsov, MD Ru-Rong Ji, PhD (Co- Director of CTPM) Francis J. Keefe, PhD Wolfgang Liedtke, MD, PhD Katherine Martucci, PhD Andrea G. Nackley, PhD Jongbae Jay Park, PhD, LAc Shad B. Smith, PhD

Raquel R. Bartz, MD, MMCi

Co-Director, Surgical Intensive Care Unit (SICU) Assistant Professor of Anesthesiology Assistant Professor in Medicine

CRITICAL CARE MEDICINE Sandy An, MD, PhD Kathleen Claus, MD Taylor Herbert, MD, PhD Melanie Hollidge, MD, PhD Vijay Krishnamoorthy, MD, PhD Theresa Lo, MD Nitin Mehdiratta, MD Okoronkwo Ogan, MD Jamie Privratsky, MD, PhD Galen Royce-Nagel, MD Paul E. Wischmeyer, MD, EDIC

CHIEF

Edward G. Sanders, MD Assistant Clinical Professor of Anesthesiology

NEUROANESTHESIOLOGY, OTOLARYNGOLOGY AND OFFSITE ANESTHESIOLOGY Miles Berger, MD, PhD Nicole R. Guinn, MD Jennifer Hauck, MD Ulrike Hoffmann, MD, PhD Michael Luke James, MD, FAHA, FNCS Colleen Moran, MD Charles Andrew Peery, MD, MPH, MA Vijay K. Ramaiah, MBBS, MD Bryant W. Stolp, MD, PhD Jeffrey Taekman, MD

COMMUNITY Lu Adams, MD David S. Bacon, MD Rachel Beach, MD Ryan Bialas, MD John D. Buckwalter, MD Ajinder Chhabra, MD David Chyatte, MD Nathan Davis, MD Eric Ehieli, MD Matthew Glass, MD Christopher Gratian, MD Elsje Harker, MD Erica Heniser, MD Kristal Keys, MD Daniel Kovacs, MD Eugene R. Lee, MD Andrew Lloyd, MD Debabrata Maji, MD Jonathan Mathew, MD Cory D. Maxwell, MD Kristina Mayo, MD Andrea Mazzoni, MD

INTERIM CHIEF

Kevin Vorenkamp, MD

Associate Professor of Anesthesiology

PAIN MEDICINE Richard L. Boortz-Marx, MD Thomas Buchheit, MD Anne Marie Fras, MD Arun Ganesh, MD Padma Gulur, MD Thomas J. Hopkins, MD Steven Prakken, MD Muhammad Yawar J. Qadri, MD Neil Ray, MD Lance A. Roy, MD Scott Runyon, MD Brian M. Starr, MD

CHIEF

Timothy E. Miller, MB ChB, FRCA

Clinical Director, Abdominal Transplant Anesthesiology Director, Perioperative Medicine Fellowship Associate Professor of Anesthesiology

GENERAL, VASCULAR AND TRANSPLANT ANESTHESIOLOGY Jeanna D. Blitz, MD, FASA Yuriy Bronshteyn, MD Brian J. Colin, MD W. Jonathan Dunkman, MD Sarada Eleswarpu, MD Ehimemen Iboaya, MD Evan Kharasch, MD, PhD Nancy W. Knudsen, MD Catherine M. Kuhn, MD Richard E. Moon, MD, CM, MSc, FRCP(C), FACP, FCCP Eugene W. Moretti, MD, MHSc Aaron J. Sandler, MD, PhD Arturo Suarez, MD Ankeet Udani, MD Kerri M. Wahl, MD, FRCP(C) John Whittle, MBBS, FRCA David A. Williams, MD, MPH Christopher C. Young, MD

Jeffrey Gadsden, MD, FRCPC, FANZCA

Associate Professor of Anesthesiology Director, Regional Anesthesiology and Acute Pain Medicine Fellowship

CHIEF

DIRECTOR

CHIEF

ORTHOPAEDICS, PLASTICS AND REGIONAL ANESTHESIOLOGY W. Michael Bullock, MD, PhD Joshua Dooley, MD Amanda Kumar, MD David B. MacLeod, MBBS, FRCA Erin Manning, MD, PhD Gavin Martin, MB ChB, FRCA, MMCi Hector Martinez-Wilson, MD, PhD Brian Ohlendorf, MD Stephen J. Parrillo, MD

CHIEF

Atilio Barbeito, MD, MPH

Associate Professor of Anesthesiology

VETERANS AFFAIRS ANESTHESIOLOGY SERVICE Juliann C. Hobbs, MD, MPH Hung-Lun (John) Hsia, MD Eric A. JohnBull, MD, MPH John Lemm, MD David R. Lindsay, MD Amy K. Manchester, MD Jonathan B. Mark, MD Grace C. McCarthy, MD Srinivas Pyati, MD, MBBS Karthik Raghunathan, MD, MPH Rebecca A. Schroeder, MD, MMCI Timothy Stanley, MD Thomas Van de Ven, MD, PhD Dana N. Wiener, MD

CHIEF

Allison K. Ross, MD Professor of Anesthesiology Professor in Pediatrics

CHIEF

Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA Professor of Anesthesiology Professor in Obstetrics and Gynecology

PEDIATRIC ANESTHESIOLOGY Warwick Ames, MBBS, FRCA Guy de Lisle Dear, MA, MB, BChir, FRCA, FUHM John B. Eck, MD Lisa M. Einhorn, MD Hercilia Mayumi Homi, MD Edmund H. Jooste, MB ChB Kelly Machovec, MD, MPH Elizabeth Malinzak, MD Brad M. Taicher, DO, MBA Andrea Udani, MD

WOMEN’S ANESTHESIOLOGY Terrence Allen, MBBS, FRCA Matthew Buck, MD Jennifer E. Dominguez, MD, MHS Jennifer Mehdiratta, MD Abigail H. Melnick, MD Marie-Louise Meng, MD Adeyemi J. Olufolabi, MBBS Cameron Taylor, MD Mary Yurashevich, MD, MPH

Get to know our entire team: Anesthesiology.Duke.edu/MeetTheTeam.html

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30th ANNUAL Duke Anesthesiology marked its 30th Annual American Society of Anesthesiologists (ASA) Alumni Event at Cityscape Lounge, known for its 360-degree views of the city’s skyline and iconic Golden Gate Bridge, with several firsts.

John Borrelli emceed the live auction, featuring Duke sports memorabilia, which raised $5,225 for the department’s Global Health Program. Those donations directly support residents’ global health missions. The department also announced the inaugural scholars of its new Academy for Building Leadership Excellence (ABLE) Program; Drs. Jamie Privratsky, John Whittle, Mary Yurashevich, Amanda Kumar, Elizabeth Malinzak, Lisa Einhorn, and Timothy Stanley.

Another anticipated event of the evening was the annual announcement of the DREAM Innovation Grant (DIG) recipients; Andrea Nackley, Huaxin Sheng and John Whittle.

DIGs are part of the Duke DREAM Campaign, which was launched in 2007.

The evening’s guests (Duke Anesthesiology faculty, trainees, staff, alumni, donors and friends) also celebrated another successful ASA meeting; 47 faculty and trainees participated in the conference, which included 96 lectures, workshops, panel discussions, presentations, and more.

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CLOSING SHOTS

DOING GOOD IN THE NEIGHBORHOOD Duke Anesthesiology once again teamed with Habitat for Humanity of Durham – this year, to build a home for Liz Jordan (an EVS worker in the Duke Medicine Pavilion operating room) and her grandkids.

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