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SPRING/SUMMER 2016

The University of Tennessee Medical Center & the University of Tennessee Graduate School of Medicine

Brooks Bailey:

From Micro Preemie to Busy Two-Year Old

Plus The Medical Center’s 60th Anniversary: A Look Back For Alumni and Friends

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Read More About Brooks Story on Page 15

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IF WE HAD NO WINTER THE SPRING WOULD NOT BE SO PLEASANT —ANNE BRADSTREET

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6

The University of Tennessee Medical Center and the UT Graduate School of Medicine Frontiers

Healing

Spring/Summer Issue 2016 Editor

Becky Thompson

Publishers

Joseph Landsman James Neutens, PhD

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Contributors

Kandi Hodges Bonnie Horner James McMillen, PharmD Christine Seaworth, MD Kelley Walters

Design/Creative

14

Dean Baker

Photography

Cover photo and images of Brooks Bailey courtesy of Christy Foreman Photography Jennie Andrews Dean Baker/UTMC Kandi Hodges/UTGSM Frontiers is a magazine produced by The University of Tennessee Medical Center and the University of Tennessee Graduate School of Medicine. It is designed to showcase the unique benefits of having an academic medical center in East Tennessee. Copyright Š 2016 The University of Tennessee Medical Center All Rights Reserved EEO/TITLE VI/TITLE IX Sec. 504/ADA

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23

28

22 Palliative Care: Answering a Calling Daughter: When the Physician 23 Doctor Becomes the Caregiver More Physicians to 24 Educating Care for the Community 26 Ethics in Medical Care Discovery

What You Forget When You Lose Sleep

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Visit us online for more information about Frontiers: bit.ly/UTFrontiers Links are case sensitive.

the Expert: Foot and 5 Ask Ankle Health 6 Celebrating 60 Years: A Look Back 10 The Lacey Legacy Journey to Excellence: Standardizing 12 ACare Produces Better Outcomes Brooks Bailey: From Micro-Preemie 14 to Busy Two-Year Old The Aortic Center Sets the Regional 17 Standard for Care Medicine: Therapies for 20 Integrative Treating or Coping With Disease Education

Contact us at Frontiers

2121 Medical Center Way, Ste. 300 Knoxville, Tennessee 37920-3257 Telephone: 865-305-6845 Fax: 865-305-6959 Email: frontiers@utmck.edu utmedicalcenter.org or gsm.utmck.edu

CONTENTS

28 Medicine Through New 30 Advancing Research Collaborations Research Links Hormones 32 Vascular to Surgical Outcomes Minutes With a Pharmacist: Care 34 5Wound Spring/Summer 2016 - 3

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&Friends,

Dear Alumni

The University of Tennessee Medical Center started its journey 60 years ago. On August 9, 1956, James Daughtery, the medical center’s first patient, was admitted for assistance with a facial laceration. Today, the medical center has grown into a two-million-square-foot hospital with 609 beds, six Centers of Excellence and more than 5,000 team members. Although the medical center’s campus has grown, one constant has remained the same: our mission is to serve the region through healing, education and discovery. We hope you enjoy reading about how the medical center has evolved in the 60th anniversary article and our stories that inspire hope and pioneer patient care. Educational programs have been part of the medical center since it opened in 1956, when it offered a fully accredited Internship Program. Since that time, graduate medical and dental education programs have grown significantly into what is now known as the UT Graduate School of Medicine. Today, the UT Graduate School of Medicine offers 22 residency and fellowship programs to more than 200 physicians and dentists each year. Discovery, or research, is an important part of the foundation of the medical center and the Graduate School of Medicine’s shared mission. And the Graduate School of Medicine continues its research mission today. Through innovative programs and partnerships, faculty continue to conduct basic science and case study research in collaboration with residents and fellows, as well as in collaboration with UT Knoxville and Oak Ridge National Laboratories. In 2015, the medical center participated in more than 102 active clinical trials, impacting patients using novel therapies in brain and spine disorders, oncologic disorders, cystic fibrosis and high risk obstetrics. As you’ll read about in this issue, we are at the forefront of research and treatment for illnesses like breast cancer and Alzheimer’s Disease. As the region’s only academic medical center, our residency and fellowship programs continue to expand and educate a greater number of healthcare professionals. Together our partnership embodies this philosophy and a spirit of exploration, a passion for education and a compassion that restores. We thank our team members, physicians, researchers, donors and the community who have pioneered the medical center forward with their high aspirations, dreams and a relentless dedication to advancing patient care, education and research. We look forward to being part of the East Tennessee community for 60 more years … and beyond.

Joseph R. Landsman, Jr. President and Chief Executive Officer University Health System, Inc.

Our Mission

To serve through healing, education and discovery

We Value

Integrity • Excellence • Compassion Innovation • Collaboration • Dedication

James J. Neutens, PhD Dean UT Graduate School of Medicine

Our Vision

To be nationally recognized for excellence in patient care, medical education and biomedical research

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ASK THE

EXPERT FOOT AND ANKLE HEALTH

It’s easy to overlook the importance of your feet. Contrary to what many may think, foot pain is not a normal part of life and can affect your overall health. If pain in your feet or other issues are keeping you from exercising or simply moving around as much as you’d like, it’s time to schedule an appointment with a doctor. Q: When is it more than just an ankle sprain? A: Statistics show that nearly 27,000 people sprain their ankle each day in the United States. Most will recover completely, while 5-10 percent will need surgery. It is important to see your foot and ankle specialist after an ankle sprain to prevent a repeat injury, as well as ankle looseness and pain. Bracing and physical therapy can be prescribed to help strengthen the injured ankle. If you have had injuries in the past with an ankle that frequently gives out on you, this can also be treated with an exercise program to improve balance and strength. However, the injury may require further treatment if exercises fail. Q: When should I have surgery to treat my bunion? A: Typically if your bunion does not cause pain or sores you can treat it by wearing shoes made with a large toe box or from soft, stretchy material. People also find that using a toe spacer, which can be found at the drugstore, can help. When your bunion begins to make wearing shoes difficult or painful, it may be time to consider surgery. Also if your second toe begins to be affected you should speak to a doctor regarding the condition.

Did You Know? • It’s not normal for your feet to hurt. • On average, a healthy person should take 8,000 to 10,000 steps a day. Q: How is ankle arthritis treated? A: The most common cause of ankle arthritis is damage to the joint caused by a prior injury. Other causes include general wear and tear, rheumatoid arthritis, gout or hemophilia. Treatment will start with medication, bracing and steroid injections. When these options fail you can consider an ankle replacement or ankle fusion. An ankle replacement is still a new technology but is rapidly gaining popularity. Some patients are best suited to the traditional ankle fusion where the bones around the ankle are joined together to relieve pain and improve function. This decision should be made after discussion with your orthopaedic surgeon. Q: Why do I have heel pain? A: Two very common causes of heel pain include plantar fasciitis (pain on

Christine Seaworth, MD, orthopaedic surgeon, is fellowship-trained in both foot and ankle surgery. She specializes in many conditions of the foot and ankle.

the bottom of the heel) and insertional Achilles tendonitis (pain on the back of the heel). They both cause severe pain when getting out of bed or after sitting for a long period of time. The pain can increase as the day goes on, especially when climbing stairs or standing, and eventually the pain may become constant. Beginning treatment starts with appropriate footwear, calf stretching, physical therapy and night splints. Both problems can usually be treated without surgery. Q: Why should I choose an orthopaedic surgeon for foot and ankle problems? A: A provider should have years of experience and extensive specialized training in the treatment of the foot and ankle. After completing medical school an orthopaedic surgeon spends an additional five years in an orthopaedic residency gaining experience treating illnesses and injuries of the entire musculoskeletal system. During residency, they perform hundreds of surgeries on knees, hips, shoulders and spines, as well as treating hundreds of fractures. This training is followed by one additional intensive year in foot and ankle treatment and surgery. A foot and ankle specialist will then go on to focus primarily on the foot and ankle in their medical practice.

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Healing

Celebrating

60

years: A Look Back

Today, the 609-bed medical center totals more than two million square feet. It houses six Centers of Excellence, the UT Graduate School of Medicine and UT Pharmacy.

In November 1953, construction began on the new 306,000-square-foot facility.

At eight o’clock in the morning on a hot August day in 1956, 12 ambulances pulled up in front of the Knoxville General Hospital to begin the task of moving its patients to healthcare professionals awaiting their arrival at the University of Tennessee Memorial Research Center and Hospital. Men, sporting neckties and white, long-sleeved shirts, lined up stretchers on which patients were transported to ambulances parked outside. Dressed in crisp, white uniforms, smiling nurses walked gingerly down the stairway, carrying their luggage and other belongings from the old hospital for the last time. So marked opening day of what was then called, alternately, the atomic or isotopic hospital but what was, in fact, the rudimentary beginnings of The University of Tennessee Medical Center.

Opens August 9, 1956 as UT Memorial Research Center and Hospital

The Medical Center’s first patient, James Daughtery, August 9, 1956. Photo courtesy of Knoxville News Sentinel.

1956

1957

UT Memorial Hospital School of Nursing graduates six nurses from the new program

$1 million research center addition opens

Oral and Maxillofacial Surgery Residency begins; National March of Dimes awards grant to research center to study birth defects

1965

1966

Establishes residencies in Anesthesiology, Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pathology, Radiology and Surgery

Family Physicians Center opens; Henry Christian, MD, and Tom Lester, MD, start Neonatal Intensive Care Nursery

1968

1970

Research center tests L-Dopa to control Parkinson’s disease symptoms (one of only 15 sites nationwide)

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Early physicians attending to an infant. In 1984, a specially equipped ambulance began transporting the most critically ill babies in the region to the medical center’s NICU.

In 2007, the NICU completed a $4 million renovation and brought with it state-ofthe-art equipment, specialized services and a designation as the region’s first and only Level III private room NICU and conducts cutting-edge research.

Healing

Through our three-fold mission of patient care, education and discovery, we touch many lives in the region. But in this complex maze of medicine, we also want to provide a human touch—one filled with caring and compassion. — Joe Landsman, CEO and President of University Health System, Inc.

Patient care, education and discovery are built into The University of Tennessee Medical Center’s DNA. This regional research hospital opened in 1956 as a result of a partnership with some of the valley’s most powerful institutions to replace the aging Knoxville General Hospital. Its goal? To provide the most comprehensive medical care for the people of Tennessee. By comparison to the old, wooden-floored hospital, the cutting-edge medical center had 14 laboratories and modern tile floors. Instead of the large, open wards filled with patients, it boasted four-bed wards – a premium of privacy for the day. Parking for 1,000 and a 300-seat teaching auditorium were among the hospital’s unique features. It was a dream come true, a state-of-the-art medical complex. Today the bustling campus is home to more than 5,000 team members. The University of Tennessee Medical Center has evolved into a major healthcare facility with six Centers of Excellence. It is the region’s only academic medical center, LIFESTAR unveiled on September 1, 1984. Opening of the $44 million, 12-story East Pavilion

Cole Neuroscience Center introduces PET technology to detect Alzheimer’s and Parkinson’s diseases

1978

1980

Establishes General Dentistry Residency and region’s first Tumor Registry

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1982

Transitional Year Residency begins

1984

Magnet-recognized hospital and Level I Trauma Center. It is East Tennessee’s only dedicated Heart Hospital; adult and pediatric transplant center; and Joint Commission/American Heart Association-recognized Comprehensive Stroke Center. It houses the region’s only Level III private-room neonatal intensive care unit and serves as a regional perinatal center. The medical center attributes its rich history and wellrespected standing within the community to the exceptional people who dedicate themselves to excellence in patient care every day.

State designates medical center as Level I Trauma Center

1985

1988

Mitchell Goldman, MD, performs first kidney transplant in Knoxville at the medical center

American Cancer Society recognizes Alan Solomon, MD, for integrating research on multiple myeloma with patient care; establishes Vascular Surgery Fellowship

1991

Researchers send an experiment to study peripheral blood leukocytes and spleen lymphocytes on the 9-day NASA Columbia shuttle mission

1992

Board creates University Health Systems, Inc., to manage the medical center, the Health Network and other partnerships

1993

1999

George Kabalka, PhD, is recognized as the South’s most distinguished chemist for developing imaging agents for MRI and PET scans; establishes Surgical Critical Care Fellowship

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Healing

Education

Physician training programs have been part of the medical center since it opened in 1956, when it offered a fully accredited Internship Program. A shortage of doctors became a concern for Tennesseans in the 1960s, especially in rural communities. The state responded to that need by founding the Clinical Education Center in Knoxville, the predecessor to today’s UT Graduate School of Medicine. The center’s purpose was to help keep physicians in the state and to educate senior medical students in internships or residencies. Today, the UT Graduate School of Medicine, established in 1991, educates physicians and dentists in 22 residency and fellowship programs as well as UT Health Science Center medical students in their third and fourth years. It continues to add accredited programs to meet the healthcare needs of the region.

The accredited UT Center for Advanced Medical Simulation offers medical teams opportunities to improve quality of patient care through education, practice and assessment using patient and procedural simulations and skills-building models.

George Shacklett, MD, former chair of Family Medicine, teaches residents in the Family Practice Clinic in 1973.

Establishes Heart Lung Vascular Institute and Emergency Medicine Fellowship

2000

Establishes Center for Women and Infant Health

2001

Establishes Cancer Institute

2003

Albert Biggs, MD, instructing students. He later became vice chancellor and CEO of the medical center.

Preston Medical Library provides reference, research and instruction for faculty, residents, students and physicians and outreach to the community.

The UT Center for Advanced Medical Simulation opens; Oral/Head and Neck Oncologic Surgery Fellowship begins

Establishes Brain and Spine Institute

2004

Starts Urology Fellowship

2005

2007 Builds Private Neonatal Intensive Care rooms; establishes Cardiovascular Disease Fellowship

2008

2009

Vascular Research Team identifies the effect of hormone replacement therapy on female vasculature response

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A vault stored radioactive isotopes to use for cancer research. It took nearly 40 years of research before radioactive tracers became a standard in patient imaging.

Alan Solomon, MD, held the longest running grant from National Institutes of Health to study amyloidosis and neurodegenerative diseases.

George Kabalka, PhD, was recognized as the South’s most distinguished chemist for developing imaging agents for MRI and PET scans.

Discovery When The University of Tennessee Medical Center opened in 1956, there was a strong focus on medical research, and the facility included 14 laboratories. With its proximity to Oak Ridge, for many years research focused on birth defects, blood disorders and cancer. The medical center was making national and international headlines, attracting prestigious researchers with its intellectual and academic environment. Today, discovery is still at the foundation of the medical center’s mission. Its focus is to make discoveries in the lab that have clinical application while also taking clinical observations and studying their validity in the lab. Through a unique partnership with Siemens, the medical center has access to the world’s most advanced imaging technology for research and clinical applications. In this era, translational research and partnerships within the University of Tennessee, Oak Ridge National Laboratories and beyond, set the standard for modern medicine.

David Townsend, PhD, (left) established the Cancer Imaging and Tracer Development Research Program, setting the foundation for translational research. Working with Eric Carlson, DMD, MD, chair of Oral and Maxillofacial Surgery, they studied the use of PET/CT imaging in staging oral and head-and-neck cancers.

Heart Hospital opens; Mitchell Goldman, MD, named first assistant dean of Research

2010

Daniel Kestler, PhD, discovers a protein known as ODAM may have application to breast cancer and melanoma

2012

Emily Martin, PhD, has initiated new studies to develop novel ways of diagnosing and treating patients with rare diseases like myeloma and amyloidosis.

Launches Center for Advanced Orthopaedics; launches Health Information Center and expands Preston Medical Library; establishes Forensic Dentistry Fellowship and Advanced GI Minimally Invasive Surgery Fellowship

Receives Magnet designation

2011

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Jonathan Wall, PhD, and his research team were the first in the world to image people with amyloid using antibodies developed at the medical center. A clinical trial is currently underway, ultimately seeking FDA approval for their imaging agent. Photo courtesy of Shawn Millsaps/Knoxville News Sentinel.

2013 Creates Academy of Scholars to strengthen faculty development

2014

Begins Interventional Cardiology, Pulmonary Disease and Critical Care Fellowships

2015

Stacy Stephenson, MD, receives a Business Innovation Grant for a study to improve the tracking of cells used in regenerative medicine, a relatively new field of research

2016

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Healing John (Jack) W. Lacey, III, MD, Chief Medical Officer and Senior Vice President at The University of Tennessee Medical Center, retires after 39 years in March 2016.

The

Lacey

Legacy Chief Medical Officer and beloved community doctor retires after 40 years

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When Jack Lacey, MD, Chief Medical Officer of The University of Tennessee Medical Center, began his internal medicine practice in 1977, Apple II computers were just hitting the market and doctors were performing the first MRI scan on a human. While technology has given us increasingly more high-tech tools over the years, the heart of health care remains a doctor’s desire to heal. Lacey, who is retiring this year from his position after 40 years with the medical center, is beloved by the community precisely because of this dedication to healing. Although he earned a degree in nuclear engineering from the University of Tennessee Knoxville in 1970, and enrolled in medical school to focus on research, “I became completely enamored of medicine in the sense of caring for people,” he said. “I felt I was better suited for the physician piece than the research piece. I decided that was a more appropriate way for me to spend my life.” Lacey, who has served in his current position with the medical center since 1998, credits his partners in healthcare — his patients — for the success he has enjoyed. “I respect each person as an individual, and what I learned from my mentors early on is that if you listen carefully to what the patient is telling you, you will have your diagnosis and your plan,” he says. One of Lacey’s patients is worldrenowned singer and actress Mary Costa. “It is a God-given gift to be a patient of Dr. John Lacey,” said the Knoxville native. “Since our families had been friends for many years, it was my good fortune to have Dr. Lacey agree to become my doctor when I returned to Knoxville in 1994.” According to Costa, the good fortune she benefited from through her relationship with Lacey included a life-saving experience.

Jack Lacey, MD, with his family at his retirement celebration in February 2016.

“I really have been blessed to be a physician, to work with the people I’ve had a chance to work with and with a wonderful family that has supported my career and other activities. I’m just very thankful for the doors that God has opened to me and I just have to keep striving to be worthy.” “In 2007, I was diagnosed with a viral infection and was hospitalized at The University of Tennessee Medical Center for three weeks,” Costa said. “Dr. Lacey treated me, as he does all of his patients, with supreme medical knowledge. He guided me to a miraculous total recovery. When I thanked him for his help, his care and his dedication to the highest professional standards, he replied, ‘Thank you, Mary, but God is number one. He did it… and I was happy to help.’” Lacey’s commitment to healing extended beyond his own practice. He helped spearhead the Knoxville Area Project Access (KAPA) in 2006, and since its inception has served as its medical director. The program has coordinated more than $175 million in donated healthcare for Knoxville-area patients without insurance. Lacey was also Chair of the United Way of Greater Knoxville’s 2015 campaign. In 2011, he was presented the TMA Outstanding Physician Award for his work toward a healthier Tennessee. He acts as state chairman of the Governor’s Health and Wellness Task Force and was appointed chairman of a Governor’s task force focused on raising Tennessee from its current 39th-

place health ranking. Lacey also helped organize and serves as co-chair of the East Tennessee Quality Alliance. “When I’m asked any day how I’m doing, I usually respond, ‘Much better than I deserve,’” he said. “I really have been blessed to be a physician, to work with the people I’ve had a chance to work with and with a wonderful family that has supported my career and other activities. I’m just very thankful for the doors that God has opened to me and I just have to keep striving to be worthy.” Or, as Mary Costa says, “Throughout his life and his long and brilliant career, Jack Lacey’s faith has been enriched and deepened. This is now a new beginning of service in directions that will be rewarding and exciting to all involved. Serving others is what Dr. Lacey cherishes most, and what he most faithfully achieves.” The University of Tennessee Medical Center has benefited greatly from Jack Lacey’s commitment to healing, and is excited to see what new ways he will find to serve in the healthcare community in Knoxville and beyond.

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Healing

A Journey to Excellence Zero instances th c a re h e al

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tie

150 pathways target 80 % of the most common disease states

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D e crea se p a

Risk of infection due to unnecessary procedures has been reduced by standardization

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94% of all inpatients are covered by both a general and disease specific pathway

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Over the past few years at The University of Tennessee Medical Center, infection rates have dropped, communication on hospital teams has improved, and patient and family satisfaction has increased. What’s made all these changes possible? A focus on performance improvement, using Lean methodology and Patient Care Pathways.

of CL

Standardizing Care Produces e NICU in 20 in th 14 I Better Outcomes S B A

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A Patient Care Pathway is a patient-centered, evidencebased care plan developed through a multi-disciplinary collabortive process, containing milestones that communicate and standardize the care of the patient across the entire healthcare continuum.

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we


multi-disciplinary teams, we’ve seen an improvement in the standardization of care and documentation and evaluation tools. We’ve decreased the patient’s cost and length of stay, and increased patient and family satisfaction.”

we

ys

ev

ery

3 y e a rs

It took 17 years to adopt evidence-based medicine

’r e

u p d a ti n g p

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According to Joe Landsman, the medical center’s President and CEO, the pathways, and their positive impact on patient outcomes, have radically changed the medical center’s patientcare approach, from admission to discharge. “The medical center is committed to quality, safety, service, efficiency and effectiveness. This program embodies those core values and it has revolutionized our approach to patient care.” The medical center has invested time and resources into building a culture of trust, transparency and partnerships with its physicians and clinicians. As a result, multi-disciplinary teams were empowered to create patient pathways. “We’re seeing the benefits of the pathways from admission to discharge,” Landsman said. “Not only has communication improved across

Inga Himelright, MD, MPH, MBA, Senior Vice President and Chief Quality Officer, explains that 150 pathways are able to cover approximately 80 percent of all patients. “The successes are already significant, and as the medical center continues to develop additional pathways, we hope to see even more improvements,” said Himelright. According to Himelright, Patient Care Pathways have reduced or eliminated acute-care and critical-care infections by exceeding the National Healthcare Safety Network benchmarks. Acuteand critical-care infections include wellknown infections like pneumonia and MRSA. Two of the most common such infections are less well-known to the general public: Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI). Reducing the rates of all acute- and critical-care infections allows the medical center to fulfill its first priority: providing ongoing quality care to the patients of East Tennessee, said Himelright. Patient Care Pathways began its focus on decreasing these infection rates by standardizing practices around CLABSI and CAUTI. “As a result of Patient Care Pathways and our other performance improvement efforts, the medical center had zero instances of CLABSI in the NICU in 2014. The development of pathways has also led to reduction in the rate of CAUTIs. Acute- and critical-care CAUTIs have been reduced by 68 percent and 75 percent, respectively, from 2011 to 2014.”

Additionally, Landsman explains that the medical center has shown improvements in five key areas: higher compliance, lower mortality and complications, decreased inefficiencies and readmissions have dropped dramatically.

As a result of our quality improvement efforts, the hospital has been nationally recognized by: • The Leapfrog Group — “2015 Top Hospital Award” — National Distinction for Patient Care (only hospital in Tennessee named as a “Top Urban Hospital”) • Becker’s Hospital Review — “2015 Top 100 Hospitals & Health Systems with Great Oncology Programs” • The Joint Commission — Top Performer on Key Quality Measures in the 2015 annual report, “America’s Hospitals: Improving Quality and Safety” • Tennessee Center for Performance Excellence — 2012 and 2014 Level 3 Award • Blue Distinction Center + — The Distinction Center + award recognizes facilities with the most efficient, highquality care, and received this award for the following: • Bariatric Surgery • Cardiac Care • Knee and Hip Replacements • Maternity Care • Spine Surgery • U.S. News & World Report — 2015-16 “Best Hospital” — Nationally ranked in Pulmonology and No. 2 in Tennessee — “Best Regional Hospital in Eastern Tennessee” • Knoxville News Sentinel — 2015 Best of Knoxville — “Best Place to Work”

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Healing Matt and Allison Bailey celebrating their son Brooks’ second birthday in November 2015. Photography by Christy Foreman.

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Brooks Bailey:

From Micro-Preemie to Busy Two-Year Old Allison and Matt Bailey tried for two years to get pregnant, so they were ecstatic when they found out in March 2013 that they had conceived their first child. The first half of the pregnancy progressed normally, but at 20 weeks, their obstetrician noticed on a routine ultrasound that their baby — whom they’d already named Brooks — had stopped growing. “At that point,” said Allison, “He had only fallen behind by about a week, but it was enough to be a concern.” So they were referred to High Risk Obstetrical Consultants (Hi-ROC) at The University of Tennessee Medical Center. Delivering a Micro-Preemie Brooks’ initial diagnosis was grim. The doctors weren’t sure if he would live, and it was touch-and-go every week as Brooks’ growth continued to fall behind. The doctors knew, to have any hope of survival, Brooks would have to be delivered early. They determined that the best option was to wait until Brooks measured over one pound in weight before delivering. Premature babies face medical issues because their systems haven’t developed enough to support them once they’re outside the womb. Micro-preemies, or babies weighing under two pounds and/ or who are under 28 weeks at birth, are even farther back on the development timeline, and thus are at an even higher risk.

At 33 weeks, Allison was hospitalized so she and Brooks could be more closely monitored. “We hadn’t been in the hospital 24 hours when they noticed his heart rate was dropping,” said Allison. “They decided to go ahead and deliver.” The one-pound, three-ounce Brooks entered the world on November 10, 2013, two months early. “Even though his breathing was our biggest concern, he took his first breath himself,” Allison said. Life in the NICU Life in the Tom and Katherine Black Neonatal Intensive Care Unit (NICU) took on a routine. Allison and Matt would spend a few hours with Brooks in the morning, go home and then come back to tuck him in. “The staff became our best friends. When people asked how we could stand to leave our baby, I told them it was like leaving him with family.” After a few days in the NICU, Brooks was stable enough for Allison to change his diaper. “I’ll never forget how hard it was to change a diaper the first time through all of the wires and monitors,” Allison said. “For the first month, all we did was learn. The nurses are amazing teachers. They’ll take time to show you how to do everything, to explain every beep, every number on every machine. They’ll teach you about blood gas, hematocrit levels, the pressure and flow of oxygen. It’s a whole new world.” Story continues next page Spring/Summer 2016 - 15

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continuous feedings through a feeding pump before being able to compress the feedings to a typical baby schedule. Even though it was one step forward and three steps back, Allison said, “The staff was incredible, as always.”

The stay in NICU was much longer and more stressful than Allison and Matt expected. Getting enough oxygen was Brooks’ biggest struggle. His lungs weren’t developed enough, and the doctors were concerned about their capacity. Brooks was put on a ventilator after surgery and had to be manually resuscitated many times following the operation. While in NICU, he was transitioned from different types of oxygen support like CPAP, high flow cannulas and the ventilator. When Brooks was four months old, he had a feeding tube surgically implanted, and was on painkillers to keep him calm enough to breathe and heal. But he couldn’t handle the large infusions of food through the tube, so he started on

Eventually, the nurses joked that Matt and Allison had NICU-itis, a syndrome parents get after seeing their babies go through such hard times for so long. They just wanted to take Brooks home. On the Brooks Nation Facebook page, Allison wrote, “This journey has been exhausting, especially the last week. Seeing Brooks having to go through a new obstacle time and time again makes us wonder if he is ever going to catch a break. We hope and pray that this last week was Brooks’ last big hurdle in the NICU and we can begin focusing on weaning his oxygen and increasing his feedings so he is home with us soon.” Taking Brooks Home Finally, Brooks made steady improvements, and doctors began

talking with the family about taking him home. He had been in the NICU 136 days when Allison and Matt got the news. “We were shocked,” Allison said. “We prayed and hoped for it for so long, and when the day came, we were thrilled and terrified.” Because Brooks still needed help breathing and eating, they went home with oxygen, a heart monitor and a feeding pump. “When we got home, we looked at each other and realized we missed the hospital. It was so great to be home — but we missed our friends and the security of the NICU.” Every Year is Easier Brooks turned two in November 2015, and like any two-year-old, his parents can’t keep him still. He’s now off of all oxygen, but still uses a G-tube to assist with feedings. “Another NICU family said the first year would be incredibly hard,” said Allison. “But that the next would be easier and so on. We’ve seen this proved true. In just the last six months, Brooks has come such a long way with his gross motor skills. And we always remind ourselves that every day is a blessing with Brooks, even the tough ones.” These Knoxville natives plan to raise Brooks here, surrounded by friends and family. They also stay in touch with their friends at the NICU. “They’re just wonderful,” said Allison. “They’re the best. If not for our doctors and staff in the NICU, and Hi-ROC, Brooks wouldn’t be here.

From one-pound, three-ounces at birth, to a now-happy two-year-old, Brooks continues to defy odds and conquer hurdles. His mom described Brooks’ personality as “always happy and always looking up.” Photography by Christy Foreman.

“He’s the happiest kid. He really is a blessing to everyone who knows him.”

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Healing

The

Aortic Center Sets the Regional

Standard for Care What do John Ritter, Lucille Ball and Albert Einstein have in common? They all died from aortic emergencies. Each year this silent killer takes more than 17,000 lives. Specifically, abdominal aortic aneurysms are the third leading cause of sudden death in men over age 60. Because many do not experience symptoms, it’s estimated that more than one million people are living with an undiagnosed abdominal aortic aneurysm and many more are living with other undiagnosed aortic abnormalities. Story continues next page

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Emergent aortic events can feel and present like heart attacks. If you feel a sudden pain that radiates to the back or chest along with feeling faint, dizzy or lightheaded call 911. A Dedicated Aortic Center As part of the Heart Lung Vascular Institute at The University of Tennessee Medical Center, the Aortic Center has taken treatment of aortic disease to heart. The Aortic Center offers a multidisciplinary team of experts, established protocols, ease of access

for transferring patients, quick diagnosis and surgery – all of which improve survival rates for people with this deadly disease. Our unique team approach makes the center a regional and national leader, sought after by medical companies offering national clinical trials on the latest aortic repair technology.

“We specialize in the treatment of complex aortic aneurysms,” said Michael McNally, MD, in Vascular Surgery. “Our cutting-edge techniques, like fenestrated aortic endovascular repair are tailored to each patient.”

Advanced Treatment Options An aneurysm is a bubble-like bulge in an artery, which stretches the artery walls and puts it at risk of tearing or bursting. Because the aorta runs

from the back of the heart down the spine, an aneurysm can occur in the thoracic cavity (chest area) or abdomen (stomach area). Fenestrated aortic endovascular repair, also called endografting, is a new procedure in which doctors insert a tube, called a stent, directly into the aneurysm. The stent has reinforced openings that allow doctors to attach arteries from other organs directly to the stent, the way they would naturally attach to the aorta. “The University of Tennessee Medical Center performed the first abdominal and thoracic aortic endografts in East Tennessee,” said McNally. “We teach our resident and fellow physicians these surgery techniques every day.” The team members at the Aortic Center are leaders in endovascular treatments for these complex aortic pathologies, and because of their partnership with companies that are performing clinical trials, they have access to new technology that sets the center apart. “This cutting-edge technology is not limited to surgical techniques,” said McNally. “The surgeons also have access to state-of-the-art surgical operating rooms and equipment.” For example, a hybrid room is where surgeons can perform combined simultaneous endovascular and aortic surgery. This allows them to handle complex cases during a single operation and can reduce the number of surgeries a patient needs. “Using a hybrid room improves patient safety and allows us to provide the highest quality of care to our patients,” said McNally.

The endovascular surgical suites combine conventional open surgical and endovascular techniques to treat a wide variety of vascular diseases. It is staffed 24/7 with board-certified vascular surgeons, vascular fellows, registered nurses, registered radiological technologists, certified surgical technologist and surgical scrub technologist.

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How It Works Abdominal aortic aneurysms were traditionally repaired with open abdominal surgery. In the 1990s, technology advancements led to a minimally invasive procedure called endovascular aortic aneurysm repair (EVAR), which involves placing a large aortic stent graft below the renal arteries. This stent redirects blood flow and relieves pressure from the aneurysm, preventing the aneurysm sac from rupturing. EVAR repair was limited to aortic aneurysms below the renal arteries until 2012, when the FDA approved a new technology. This new technology, called fenestrated endovascular aortic repair (FEVAR), can be used to repair complex aortic aneurysms involving vital blood vessels to both the kidneys and intestines. The stents used in FEVAR are customized to fit the patient’s anatomy, cut to precisely match the location of the vessels branching from the aorta. During surgery, two small incisions are made in the patient’s groin. The vascular surgeon places wires and the custom stent through the femoral arteries into the aorta. The stent is then oriented and deployed, precisely matching the graft holes to both renal arteries. Additional stents are then placed into the aortic branches, like the renal arteries, to assure blood flow to vital organs (see figure above). Fenestrated endovascular aortic repair procedures are highly intricate, and they involve years of specialized vascular surgery training. The University of Tennessee Medical Center’s vascular surgeons are successfully treating complex aortic aneurysms with this newest minimally invasive technology.

Common Conditions Treated In addition to specializing in multiple types of aortic aneurysms the center also treats: • • • • •

Acute Aortic Injuries Aortic Dissection Aortic Transection Thoracic Aortic Aneurysm Traumatic Aortic Injuries

Aortic Screening Diagnosis can be difficult, and screening tests are limited for aortic disease. Doctors diagnose diseases of the aorta by assessing for risk factors like family history and smoking as well as symptoms such as back or chest pain.

Based on a patient’s risk factors, an aortic ultrasound test could be used to diagnose an abdominal aortic aneurysm. “Medicare Part B covers a one-time test, an abdominal aortic ultrasound, if you have a family history of aortic aneurysms, or you’re a man age 65 to 75 who has ever smoked,” said McNally. “We perform those ultrasounds at the Heart Lung Vascular Institute and recommend them for those who meet the criteria.”

“We are the region’s only academic Aortic Center,” said McNally. “The systems approach with the team, including our specialists, allows us to offer unsurpassed leadership in the care of our patients every day.” Finding and treating aortic disease before it becomes an emergency is the best treatment. If you have a family history of aortic disease or want to learn more about the Aortic Center call 865-305-8040.

Giving patients the best medical care is the heartbeat of The University of Tennessee Medical Center. The Aortic Center embodies this mission for the patients they treat.

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Healing

Integrative Medicine

Therapies for Treating or Coping With Disease Why do we get sick? How do we get well? Thomas Edison once said, “The physician of the future will give no medicine, but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.” Although doctors today will continue to give medicine and provide treatment using high-tech care, there is an increasing trend toward incorporating integrative medicine into the traditional medical practice. With the use of integrative medicine, we can both prevent illness and promote healing.

state-of-the-art medical treatments with other therapies that are carefully selected and shown to be effective and safe. These integrated therapies are derived from cultures and ideas both old and new.

Many Americans have never used integrative medicine, but it is grounded in the definition of health and wellbeing. The World Health Organization defines health as, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Integrative medicine not only treats the disease but also the whole person.

Tools of Integrative Medicine • Mind and body practice — Includes a variety of practices such as yoga, meditation, massage therapy, acupuncture, chiropractic, nutrition, psychotherapy and relaxation techniques • Natural products — Includes a variety of products, such as herbs (also known as botanicals), vitamins and minerals, and probiotics

Doctors and patients are bringing integrative therapies into traditional medical practice to not just treat the disease but also support the patient’s overall wellness. The goal is to combine

For example, therapies such as acupuncture, yoga, meditation, herbs and massage therapy are increasingly integrated into today’s conventional treatment of heart disease, cancer and other serious illnesses — and scientific evidence supports this approach to health and healing.

Where to Find Complementary Health Coordinating all facets of a patient’s care is a cornerstone of the integrative medicine approach — mind, body and

In 2007, 3.1 million people tried acupuncture to relieve discomfort caused by fibromyalgia, chemotherapy-induced nausea and vomiting, low back pain, and other ailments

inc “im 43

s disease. Your primary care physician or specialist should work in tandem with your integrative medicine providers (physician, integrative health coach, nutritionist, massage therapist or acupuncturist). The University of Tennessee Medical Center offers integrative medicine in several primary care practices and within the Cancer Institute. Always inform your healthcare provider about any integrative/ complementary therapies and medicine that you are using to ensure coordinated and safe care. To find an integrative healthcare provider near you, call our Healthcare Coordinators at 865-305-6970.

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Why Integrative Health? Twelve minutes of daily yogic meditation for eight weeks increased telomerase, the “immortality enzyme,� by 43%, slowing the cellular aging process and suggesting an improvement in stress-induced aging

In 2012, 33.2% of U.S. adults used complementary health approaches

91% percent of Americans agree that massage can be effective in reducing pain

In 2012, as in 2007 and 2002, the most commonly used complementary approach was natural products (dietary supplements other than vitamins and minerals). 17.7% of adults used natural products

Integrative Medicine A practice of medicine that addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health.

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Education

Palliative Care Answering a Calling

In October 2015, The University of Tennessee Medical Center began offering palliative care services to cancer patients through University Palliative Care (UPC). This specialized type of care helps patients and families dealing with serious or life-threatening illness live and cope better with their disease. At the UPC, Palliative Care team members call their services an “extra layer of support” for patients and families. “We strive to be patient centered and family oriented for patients with serious disease,” said Joseph Simpson, MD, anesthesiologist and assistant professor at the UT Graduate School of Medicine. This program provides a specially trained support team that focuses on how an illness is affecting the patient and family and what is most important to the patient.

Based on what matters most to you – from emotional and spiritual support to symptom management – palliative care helps patients and their families make the most out of their resources. Palliative care does not replace or duplicate your primary treatment. Instead, it works with and supplements ongoing care at every stage of the illness.

“To work in palliative care, you don’t answer a job posting, you answer a calling,” Osterlund said. “Each and every team member is a compassionate individual who works tirelessly not only to be the patient’s best advocate, but to alleviate suffering and walk alongside patients and families at some of their most difficult moments in dealing with an illness,” said Lynnette Osterlund, MD.

How Can University Palliative Care Help? Whether you’ve just been diagnosed, have already begun treatment or are in a late stage of disease, you can benefit from palliative care. In consultation with your cancer physician, UPC team members can help you and your family better understand your medical options and the possible outcomes. Palliative care encourages you to provide input into your treatment decisions, and our team will guide you through difficult and complex choices. A patient’s physician is the best person to know whether or not UPC can help. Patients and families should talk with their physicians about whether they can benefit from a UPC consultation.

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“Doctor Daughter” When the Physician Becomes the Caregiver In the medical profession, grief is seldom discussed — especially among physicians. Except, perhaps, when the physician is the one coping with a personal loss. Health care professionals are trained to support grieving families. But what happens when those roles are reversed? For Jennifer Winbigler, MD, Internal Medicine resident at the University of Tennessee Graduate School of Medicine, her role changed from that of physician to caregiver, and the one in need of support. Jennifer wrote an essay titled “Doctor Daughter,” which chronicled her thoughts, both as a physician and as daughter, during her father’s final battle with squamous cell carcinoma. She describes, from a physician’s point of view, the medical details of her father’s case. As a daughter, she describes a single parent “Mr. Mom” who was CEO of an electric company, an SEC football official and “the BEST dad a girl could ask for.” Her father, Jim Allison, was first diagnosed with head and neck cancer in 2013, and he passed away September 8, 2015.

In 2013, Jennifer Winbigler, MD, celebrates her acceptance to the UT Graduate School of Medicine Internal Medicine Residency Program with her dad, husband and son.

When the initial biopsy results were returned, Jennifer said, “I asked my dad and step-mom if they wanted to know what I thought it was, and they said yes.” Her father’s liver biopsy tested positive for squamous cell carcinoma that spread from cancer in his head and neck. “I do this regularly in my profession but no amount of training could prepare me for this,” said Jennifer. Jennifer Winbigler, MD, hugs her father after On September 12, reading her residency acceptance letter. Jennifer and SEC football officials across the country wore black wristbands in memory of her father. Jennifer said “As a physician, I help people every day, but I couldn’t do anything to help my own father other than love and support him until the very end.” Her strength and willingness to share her story were recognized in the Tennessee Medicine’s eJournal.

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Education

Educating More Physicians According to the Association of American Medical Colleges, a shortage of 90,000 doctors is predicted by 2025. With an aging population that is increasing in size and has greater access to health benefits, addressing physician shortages continues to be a critical need.

to Care for the Community

To help address these patient care needs, the University of Tennessee Graduate School of Medicine, the educational foundation of The University of Tennessee Medical Center, has expanded several of its residency programs, now training more physicians in anesthesiology, internal medicine, general surgery, urology and vascular surgery. Expanding residency programs is difficult. The two main factors that determine residency program size are funding and approval by the

national accrediting organization, the Accreditation Council for Graduate Medical Education (ACGME). In general, funding for residency positions comes through Medicare reimbursements. In 1996, the Centers for Medicare and Medicaid Services established funding caps for graduate medical education programs, awarding permanent caps to teaching hospitals based on their current sizes. William Metheny, PhD, assistant dean for Graduate Medical and Dental

Anesthesiology:

Most recently, the ACGME has approved program expansion in five programs. By 2021, the UT Graduate School of Medicine will have trained an additional four anesthesiologists, nine internists, 10 surgeons, two urologists and one sub-specialized vascular surgeon.

In 2013, the Anesthesiology Residency program, led by Robert Craft, MD, transitioned from three years to four. As a threeyear program, residents were required to complete a transitional year residency. Now, residents complete all four years of training within one program, creating the opportunity for stronger recruitment. Anesthesiology also added four resident positions, training one additional anesthesiologist each year.

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This year, the UT Graduate School of Medicine will graduate its largest class of Internal Medicine residents through the addition of three additional residency positions per year. (From left) Nathan Smith, MD, Neena Agrawal, MD, and T. J. Mitchell, MD, will be among the physicians graduating.

Education, said, “In 1996, when the caps were set, our well-established residency programs helped leverage an excellent Medicare reimbursement level.” Unless Congress addresses resident caps, for residency programs to grow at the medical center, alternative funding must be identified. Once funding is identified, the ACGME must approve the additional residency positions to ensure the programs continue to be accredited.

Internal Medicine:

In 2013, the Internal Medicine Residency, led by Mark Rasnake, MD, added nine positions to its program and, for the first time this year, is training 36 residents. As a three-year program, the first expanded class will graduate in June.

“The ACGME wants to ensure that new positions will not diminish the educational opportunities of the current residents. This means ensuring we have adequate faculty, caseloads and other resources necessary for their training,” said Metheny. “When a program is able to create new positions, the growth is additive. If a three-year program previously had a maximum of 27 residents and creates six new positions, that means two new residents will be added to the entering residency class each year for the next three years.”

General Surgery:

Since 2013, the General Surgery Residency, led by Brian Daley, MD, has been approved for 10 additional categorical positions. As a five-year program, this provides two additional surgery candidates per year.

The medical center and UT Graduate School of Medicine, in the shared mission to provide excellence in healing, education and discovery, have combined financial resources to expand several programs. This helps the medical center better meet the needs of its patient and physician communities by attracting talented physicians who have a passion for teaching and by providing more, better-trained physicians to care for patients.

Urology:

Beginning in July 2016, the Urology Residency, directed by W. Bedford Waters, MD, is approved for a total of eight residents in this four-year program. Previously Urology alternated one to two new residents per year. With this expansion, the program can now admit two new residents per year.

Vascular Surgery:

Beginning July 2017, the Vascular Surgery Fellowship, directed by Michael Freeman, MD, is approved for four fellows, with a net increase of one position each year.

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Education

Annette Mendola, PhD, chief of the Division of Clinical Ethics, and Mark Rasnake, MD, Internal Medicine Residency Program director, confer on a case involving an ethically difficult situation.

When Healing Means Doing What Is Right: Ethics in Medical Care

Integrity plays an important role in healing, but sometimes what is “right� is unclear. Annette Mendola, PhD, chief of the Division of Clinical Ethics and assistant professor of Medicine, initiated a program at The University of Tennessee Medical Center known as Ethics Case Rounds to help guide clinical staff through ethically difficult situations.

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“The University of Tennessee Medical Center’s Ethics Service is available to support people facing difficult health care decisions,” said Mendola. “For example, when patients do not have decision-making capacity for treatment, and family members disagree about what the patient would want done, the goals of care are not clear for the physician. Other common situations include when patients or family members are requesting treatment the physician believes would be harmful, or when patients may not fully understand their options. Discussing our different perspectives helps us understand one another and resolve potential conflict in a mutually respectful way.” Each month, Mendola presents a situation based on a real case from the Ethics Consult Service, with identifying information changed, and invites a panel of team members who were involved with the case to help lead discussions. Attendees often include physicians, nurses, residents, occupational therapists, physical therapists, respiratory therapists, dietitians, case managers, and chaplains, and the format is open discussion among all who attend. The goal of Ethics Case Rounds is to learn from each other and develop a shared understanding of how to handle similar situations. Doctors remember one case in particular that discussed whether removing life support should also include inactivating the patient’s pace maker. The patient’s family requested deactivation as part of end-of-life care, but none of the cardiologists would agree, saying that deactivation would be unethical. Mark Rasnake, MD, assistant professor and Internal Medicine Residency Program director, explained, “For a

cardiologist to inactivate the pacemaker, there would be a significant change. The patient would pass immediately. This case highlighted the somewhat gray zone between standard end-of-life/

residents. They seem to feel it is a safe space for them to discuss the emotional impact some cases have on them, and they get to see how others react under similar circumstances. Dr. Mendola

Each month, Mendola presents a situation based on a real case from the Ethics Consult Service, with identifying information changed, and invites a panel of team members who were involved with the case to help lead discussions ... The goal of Ethics Case Rounds is to learn from each other and develop a shared understanding of how to handle similar situations. comfort care versus euthanasia. Many in the room felt that deactivating artificial devices (pacemakers included) did not constitute euthanasia. The contrary opinion, that fully implanted devices were now a ‘part of the patient’ is one that has significant weight. Intentionally deactivating such devices would be essentially harming a patient under such a viewpoint. It is a very thorny issue.” While Ethics Case Rounds was initiated as a learning tool for physicians and nurses, Rasnake recognized the program as a valuable teaching tool for residents, and participation in Ethics Case Rounds has become a core part of the Internal Medicine Residency curriculum. Rasnake said, “The program has provided me a significant amount of benefit personally, and it has provided a wonderful educational venue for my

is to be commended for bringing this program to the medical center.” Resident Sachin Amin, MD, already sees the benefit Ethics Case Rounds will have on his career. “It is a course that not many other residency programs provide,” he said. “Once we finish residency, we will be seeing many more patients on a daily basis, and we will be surrounded by ethical conflicts. Having a good base of ethical principles will help us make decisions in the patient’s best interest.” Patients, families and healthcare teams who need to discuss an ethical issue related to patient care may contact the Ethics Committee for a consultation. Patients and their families should ask their nurse how to reach this valuable resource.

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Discovery

“If we don’t sleep, the information is lost. It will simply disappear.”

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Subimal Datta, PhD, conducts studies in the Anesthesiology Research Laboratory with his team to see how sleep affects brain functions.

fridge and canned goods in the cabinets, you can easily find whatever you need. This is like the brain sorting memories for long-term storage.”

Juggling work and busy families sometimes makes sleep deprivation the norm. But a new lab at The University of Tennessee Medical Center is proving that getting enough sleep is vital to good mental health. The Anesthesiology Neuroscience Research Program studies how consciousness works, particularly when patients are under anesthesia or sleeping naturally. Subimal Datta, PhD, professor of Anesthesiology, recently joined the team to continue his research into the link between sleep and neurological disorders. He is recognized as one of the world’s leading sleep experts, with studies on insomnia, addiction, depression and anxiety disorders, including PTSD — all done through the lens of sleep. Sleep is one of the best windows for studying the brain, and studies have shown that sleep carries with it a number of positive functions. Datta is focusing on how the brain regulates a certain sleep stage, called REM, or

dreaming sleep. Particularly of interest is how the brain processes different types of memory during this stage. “We encode information as we go through the day, and that information goes into short-term memory,” Datta said. “If we don’t sleep, the information is lost. It will simply disappear.” But, if we sleep long enough to achieve the dream state, our brain is able to place that information in long-term storage, Datta says. Datta compares it to putting away your groceries. “After you shop, you have two choices. You can put the bags in the kitchen, and if you need something later, go through all the bags to find it. “But if you have a system, where frozen foods go in the freezer, cold ones in the

In addition to the correlation between sleep and long-term memory, the research program is also looking deeper at the link between sleep and psychiatric disorders. Because the brain uses the same neurochemicals and processes in both experiences, if researchers can understand sleep, they may also isolate the source of stress, anxiety and other psychological issues. “A lack of sleep can trigger early onset of all sorts of psychological disorders,” said Datta. For example, if someone is genetically predisposed to Alzheimer’s, Huntington’s or Parkinson’s, a consistent lack of sleep (fewer than six hours a night for 20 years), can trigger the disease 10 years earlier. Diabetes, hypertension and heart disease can also be triggered by deficient sleep. Datta notes that, if you can’t sleep a full six hours at a time, taking a nap during the day helps. “If you sleep four hours at night and two during the day,” he said, “it’s not equal but it’s much better than just getting four.” Datta will continue his innovative research with the Neuroscience Research Program through a generous grant from the National Institutes of Health. “A lot of progress has been made in understanding sleep and the brain over the last 50 years,” he said. “While we may never know all there is to know about it, we continue to do what we can to understand it better.”

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Discovery

Advancing Medicine

Michael Karlstad, PhD, director of the UT Graduate School of Medicine Shock Trauma and Nutrition Laboratory, and Tim Sparer, PhD, microbiologist at UT Knoxville, investigate a pancreatic gene in the incidence of juvenile diabetes.

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What if juvenile diabetes could be prevented? What if women could do an at-home test to detect cervical cancer? Or, what if treating a common, suppressed virus led to reduced incidence of obesity? These are the types of questions researchers at The University of Tennessee Medical Center are hoping to answer through a new grant program that fosters collaborations with engineers and scientists from UT Knoxville (UTK) and the UT Institute of Agriculture (UTIA). With government resources for discovery continuing to shrink, research collaborations are more important than ever to advance medicine. The idea for the new grant opportunity grew from a hypothetical question Mitchell Goldman, MD, assistant dean for Research at the UT Graduate School of Medicine, asked to a group of medical scientists: “What would you do if you had some funding to support an entirely new collaborative research project?” Goldman’s question led to a new grant program that is sponsored and equally funded by the UT Graduate School of Medicine, UTK Office of Research and Engagement, and UTIA. The goal is for cross-campus teams to develop innovative research projects that have a strong potential of eventually attracting further external funding from the National Institutes of Health (NIH), medical device manufacturers or pharmaceutical companies. Now in its second year, the program recently awarded six, one-year grants of $10,000 each for research projects, including several that have the potential to impact the medical center’s healing mission through the possibility of a cervical cancer selftesting device; learning the effects of a virus on fat storage cells; improving outcomes for vascular surgery patients; and developing a robotic system for colonoscopic surgery. James McLoughlin, MD, associate professor of Surgery, is working with

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thickening following vascular surgical procedures. This thickening can sometimes lead to the need for a second surgical intervention. The researchers hope to create a drug delivery system to administer medicine directly to the vessel walls at the time of surgery that will stop this process and lead to improved patient outcomes.

Michael Karlstad, PhD, director of the UT Graduate School of Medicine Shock Trauma and Nutrition Laboratory, finds that a gene, CXCR2, may be connected to juvenile diabetes.

Shigetoshi Eda, PhD, a microbiologist at UTIA, and Jayne Wu, PhD, an electrical engineer at UTK, to determine whether a device developed at UT can detect cervical cancer or pre-cervical cancer genes in women. The device works by identifying specific genes and proteins with something as simple as saliva. Their goal is to develop a test that can be performed at home, similarl to a pregnancy test. Tom Masi, PhD, research associate, is collaborating on a project with Tim Sparer, PhD, a microbiologist at UTK to see if a common herpes virus, which normally does not make you sick, plays a role in obesity development and related diseases, such as diabetes. They are testing whether herpes viruses can infect and alter the development of fat cells. Their ultimate goal is to understand whether herpes viruses could be a target for diminishing health-related pathologies related to obesity. Deidra Mountain, PhD, assistant professor of Surgery and scientific director of the Vascular Research Laboratory, and Michael Best, PhD, a chemist at UTK, are trying to develop technology to inhibit vessel wall

Andrew Russ, MD, a colon and rectal surgeon and assistant professor of Surgery, is working with Daniel Caleb Rucker, PhD, a mechanical engineer with UTK, to develop a robotic system for colonoscopic surgery. They hope to develop a novel, flexible robotics tool to aid in advancing minimally invasive techniques for treating colorectal conditions endoscopically, thus limiting the need for invasive surgery and improving surgical outcomes. Already, the grant program is proving to be successful. Michael Karlstad, PhD, director of the Shock Trauma and Nutrition Laboratory, and Sparer won an initial grant to study the role of a specific pancreatic gene in the incidence of type 1 diabetes, commonly known as juvenile diabetes. Jason Collier, PhD, an islet biologist with faculty appointments at Louisiana State University and Pennington Biomedical, is a key collaborator on the inflammation aspects of these studies. Preliminary results of their testing are promising, and they are currently applying for NIH funding to continue their study. Collaborative and team science is felt by the scientific community to be the wave of the future for important medical discoveries. Goldman says the initial success of the program confirms this sense and has led the three institutions to commit to funding another round of proposals next year.

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Discovery

Vascular Research Links Hormones to Surgical Outcomes Vascular Research Laboratory codirectors Deidra Mountain, PhD, and Oscar Grandas, MD, study the effects of hormones on vascular interventions.

No two vascular surgery candidates are exactly alike, so it’s not always easy to predict surgical outcomes. However, surgeons in The University of Tennessee Medical Center’s Heart Lung Vascular Institute, a Center of Excellence, are trying to do just that. By collaborating with the UT Graduate School of Medicine’s Vascular Research Laboratory, discoveries are being made that may improve vascular patient outcomes through correlations to hormone levels.

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Oscar Grandas, MD, medical director of the Vascular Research Laboratory and professor of Vascular Surgery, and Deidra Mountain, PhD, scientific director of the laboratory and associate professor of Vascular Surgery, are combining their clinical and research expertise to better understand and hopefully prevent one of the most common causes of failure following vascular interventions: intimal hyperplasia, or scar tissue in blood vessels. Intimal hyperplasia occurs when the blood vessel’s inner layer of cells grows uncontrollably, causing the walls to thicken. This can result in abnormal narrowing, reduced blood flow and, sometimes, blockage. Vascular interventions — such as balloon angioplasty, stent placement or vascular grafting — while necessary to restore the vessel’s health, inherently injure vessels and cause inflammation. In most cases vessels heal normally. However, when they don’t, the resulting intimal hyperplasia can lead the patient back into the hospital for a second intervention. So Grandas and Mountain have directed their research at finding out why some people have worse outcomes (or more intimal hyperplasia) while others recover normally. “Several years ago,” said Grandas, “While I was a Vascular fellow-in-training, in collaboration with the vascular surgeons on faculty, we noted that women who were receiving hormone replacement therapy had more adverse outcomes after a vascular intervention than those women who weren’t.” By studying records of past cases at the medical center, researchers confirmed that receiving hormone replacement therapy (HRT) significantly correlated to more intimal hyperplasia. Once

Grandas and Mountain joined the Vascular Research Laboratory, the team then started an initiative to find out why, at the cellular level, synthetic female hormones led to increased thickening of blood vessels. They were able to define several mechanisms, and as a result, they are developing ways to decrease the chances of intimal hyperplasia forming in women on HRT.

Things can be discovered and solved in a laboratory, which are often left unanswered in clinical-type studies alone. “Similarly, if a study stays in the laboratory and never makes it back to the clinic, then what impact have we made? What is gratifying is the collaboration between

“These studies drew the interest of other clinical faculty within the Surgery department,” said Mountain. “Our urologists approached the lab with a similar question: Was there a relationship between intimal hyperplasia formation and decreased androgen (a male sex hormone) in older men?” So the Vascular Research team collaborated with vascular surgeons and urologists to determine the role of androgen deficiency in the formation of scar tissue. The team demonstrated that androgen replacement therapy could protect males against intimal hyperplasia, and they identified several potential therapeutic options to improve vascular disease progression. Mountain says this type of research — making discoveries in the lab that physicians can build upon — is the lab’s primary approach to improving patient outcomes at the medical center and beyond. “In this lab,” Mountain said, “basic science is just a stepping stone.

Oscar Grands, MD, sees patients in the clinical setting allowing him to apply discoveries in the lab to his clinical practice.

basic, translational and clinical science — all working together to impact and improve patient care.” As a surgical scientist, Grandas gets to see the true meaning of translational research in an academic medical center. He said, “Our goal is to develop an intervention that can someday go from the lab bench to the bedside.”

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minutes

with a pharmacist Expert advice from James McMillen, PharmD, BCPS

A wound occurs when a cut, blow or other impact damages the skin. There are many different types of wounds including tears, burns, ulcers, gangrene, post-operative infections, slow- or non-healing surgical cuts, and traumatic wounds. In the United States, chronic wounds affect approximately seven million patients, and collectively are a major contributor to overall healthcare costs. It is important to effectively treat these wounds and to ensure that appropriate measures are employed to prevent them from recurring.

James McMillen, PharmD, BCPS, is the clinical pharmacy specialist in Critical Care Trauma and practices within the Trauma Surgical ICU at The University of Tennessee Medical Center. He is also an assistant professor with the University of Tennessee College of Pharmacy.

Wound Care Q: What are some factors that negatively affect my wound healing? A: When providing wound care for patients in our trauma and surgery units, health care personnel may use the mnemonic, “DIDN’T HEAL,” for remembering factors that adversely affect wound healing. This represents Diabetes, Infection, Drugs, Nutritional problems, Tissue necrosis, Hypoxia (inadequate oxygen levels), Excessive tension on wound edges, Another wound, and Low temperature. These and other contributing factors should be discussed with your doctor and wound care specialist.

Q: Should I use antibiotics to treat my wound? A: Although all wounds have bacteria, this does not mean that all wounds are infected. Therefore, antibiotic therapy is not necessary for all wounds, and should be reserved for wounds that appear clinically infected or as determined appropriate by your doctor. Signs and symptoms of wound infection include swelling, increased pain and redness, local heat, and the presence of pus.

factors important for wound healing. PDGF promotes cell production, the development of new blood vessels and enhances new tissue formation on the surfaces of wounds. A PDGF gel product has been approved by the U.S. Food and Drug Administration for the treatment of certain types of lowerextremity diabetic ulcers. It is the only pharmacological agent approved for the treatment of chronic wounds. To find out if PDGF therapy is the best treatment for you, talk to your doctor.

Q: Can honey be used to manage my wound? A: Since ancient times, honey has been used for the management of wounds due to its acidity, high concentration and high levels of naturally occurring hydrogen peroxide. Thus, for some chronic wounds, medical-grade honey products such as gel or honey-saturated dressings may be used to promote healing.

Q: What other topical agents may be used to manage my wound? A: There are several topical agents that may be used to manage your wound and promote healing. A few common agents include collagenase, silver sulfadiazine and calmoseptine ointment. Collagenase is an ointment that is used to remove damaged tissue in skin ulcers and severe burns, allowing new skin to grow. Silver sulfadiazine may be used to prevent and treat infection in secondand third-degree burns. Calmoseptine ointment may be used to protect skin from moisture and drainage and is available over the counter.

Q: What is platelet-derived growth factor? A: Platelet-derived growth factor (PDGF) is one of the body’s growth

Because so much medical information is available through various sources, it’s important to differentiate fact from fiction. “5 Minutes With a Pharmacist” provides clear advice about medication to the people of East Tennessee. 34 - Frontiers

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