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D epartment


M edicine

Con ne c ti ng T e c h n o lo g y , Ed uca t i o n a n d D i s cove ry w ith H um anis m in Me dicine

Vol. 6 Issue 5 Dec 2017

Nebulizer Contamination

UTMC. It confirmed that nebulizers, artificial airways, and suction catheters are at risk for contamination after a single use in inpatient settings. An additional finding involved the method used to collect the contaminating bacteria. “We had been swabbing devices to extract cells for testing,” said Dr. Dewald. “Then Kristen found that vortexing was more effective for cell extraction.” The study was submitted for publication, and an abstract was submitted for presentation at the American Thoracic Society meeting next spring.

Many factors contribute to chronic respiratory complaints, including medication overuse and exposure to antibiotic resistant microorganisms. In Cystic Fibrosis patients, one known risk factor is self-contamination of personal respiratory equipment. However, there is a critical gap in evidence regarding patient contamination of such devices and risk of infection outside of Cystic Fibrosis studies. To address this gap, Department of Medicine chairman, Dr. Rajiv Dhand, third-year Medicine resident, Dr. Jonathan Dewald, clinical trials coordinator Jennifer Ferris, and, respiratory therapists, Scott Elder and Daniel Church have teamed up with Dr. Qiang He and his doctoral student, Kristen Wyckoff, from the University of Tennessee’s Department of Civil and Environmental Engineering.* Their study, “Bacterial contamination of disposable nebulizers following their first use,” was conducted on a diverse patient population here at

The interdisciplinary research team has turned its attention to determining the specific organisms responsible for contamination. They have received funding from the Physicians’ Medical Education Research Fund (PMERF) for this next study, titled “Characterization of the microbiome on respiratory devices after short-term use by patients and determination of serial changes with prolonged use.” The continued on page 3

Points of View

inevitable part of doing research, and dealing with rejection can be painful. After spending several months working on a manuscript, having it rejected is heartbreaking, especially if the reviewers do not agree with the findings. Indeed, nowadays it is the norm for papers to be rejected when they are first submitted. Likewise, it is not unusual for grants to get triaged. After putting in so much effort, the realization that your work does not measure up and is not worthy of funding can be depressing. Recently, I participated in a NIH Study Section and had firsthand experience of the grant process. I was surprised by the level of agreement between the comments of the various reviewers. There were also sharp differences, but those were much less frequent. The science behind the grants was novel and interesting. Where many investigators fell short was in the explanation and implementation of the planned experiments and other logistical issues. As we attempt to enhance scientific publications and grant funding in our department, we must be prepared to deal with the heartbreak that accompanies rejection. Persistence is the key to a successful research program.

The mission of the UT Medical Center is to promote Healing, Education and Discovery. In the Department of Medicine, we have recognized strengths in the clinical and educational areas, and the strategic plan of the institution stresses the need to enhance Discovery through original research. Research requires a passion for scientific enquiry and the desire to find answers for unresolved Rajiv Dhand, MD, Chair questions, especially those that impact patient care. Researchers are keenly aware of the painstaking and convoluted nature of the research process without any guarantee of success. Many researchers are unprepared to deal with rejection, which is another intrinsic part of the research process. Whether it is an abstract, paper, or grant, rejection is an 1

A Collaborative Effort Translational research is a kind of applied study that translates basic biomedical research into clinical application. UTMC’s Amyloidosis and Cancer Theranostics Program (ACTP) is preparing an Investigational New Drug (IND) application to the FDA to perform a clinical trial of a new radiolabeled agent (124I-p5+14) for imaging systemic amyloidosis, with the support of the National Heart, Lung, and Blood Institute’s (NHLBI) SMARTT Program (Science Moving towArds Research Translation and Therapy). Patients in the trial will receive the radiotracer and undergo PET imaging to assess the binding of the reagent to known amyloid deposits in their bodies. The trial, to be performed at UTMC, will be the first test of an imaging agent for systemic amyloidosis in the US. While tissue biopsies assessed by pathologists are currently used to detect amyloid deposits in targeted areas of the body, at this time there are no FDA-approved methods in the US to image the whole-body burden of amyloid. There are more than 30 clinically recognized amyloid-related disorders, including light chain-associated (AL) amyloidosis and transthyretin-associated (ATTR) amyloidosis. “This trial will be a first in-man, investigator-initiated clinical trial of the radioactive peptide that we think – is capable of imaging many forms of amyloid in patients,” said ACTP Program Director, Dr. Jonathan Wall. “We hope to begin the trial in the first quarter of 2018.” This truly collaborative effort includes the Cancer Institute, the Department of Radiology, and Dr. Ronald Lands, Clinical Professor of Medicine, as the trial clinician. It is being supported by the ACTP Gift Fund and from donations from Gerdau Knoxville, a local steel company.

Photomicrograph showing peptide binding to human amyloid which stains brown by immunohistochemistry

Fluorescent photomicrograph of subcutaneous human amyloid that is used to study the action of novel therapeutic peptides

Resident and Fellow Presentations at ACCP and TNACP Back Row (L to R): Drs. Jonathan Dewald, Spencer Pugh, Matthew Boulos, Front Row (L to R): Drs. Rishi Seghal, J. Francis Turner

The Department of Medicine was well-represented by our residents and fellows at the annual meetings of The American College of Chest Physicians (CHEST) in Toronto, Canada, and the Tennessee American College of Physicians (TN ACP) in Franklin, TN. At CHEST, Dr. Matthew Boulos featured a case of Post Transplant Proliferative Disorder (PTLD) masquerading as cardiogenic shock from a pericardial effusion. Dr. Spencer Pugh’s poster revealed a case of submassive hemoptysis as the initial presenting symptom of Pulmonary Langerhans Cell Histiocytosis. Our former pulmonary fellow, Dr. Rishi Seghal, and current pulmonary critical care fellow, Dr. Naveed Sheikh, collaborated on an unusual complication using a convex probe endobronchial ultrasound. Dr. Jonathan Dewald highlighted a patient with pulmonary fibrosis. While most cases of pulmonary fibrosis are idiopathic, this patient’s condition resulted from telomere disease. Dr. Dewald urged physicians to evaluate patients with pulmonary fibrosis for underlying telomere disease, as treatments differ from other forms of pulmonary fibrosis. Dr. Dewald’s outstanding presentation was honored with one of only three blue ribbons awarded amongst the 900 posters presented. At TN ACP, Dr. Christina Kitsos was chosen for an oral presentation on a patient with refractory cellulitis of the cartilages of both ears and lower extremities. After several rounds of broad spectrum antibiotics, the correct diagnosis of relapsing polychondritis was made. Dr. Kitsos also presented a poster that exposed a case of renal amyloidosis presenting as nephrotic syndrome in an intravenous drug abuser. Dr. Lesley Jackson demonstrated a case of an intravenous drug abuser with tricuspid valve endocarditis complicated by adrenal abscesses growing Nocardia. Since the patient did not have classic risk factors for Nocardiosis, she hypothesized his prior splenectomy increased his risk. Our budding future infectious disease specialist, Dr. Henry Shiflett, ran into a case of Clostridium perfringens bacteremia. Mortality is high due to rapid disease progression, but his patient had a positive outcome due to early, appropriate antibiotic therapy. Dr. Christina Kozlovski (“Sister Teresa Mary”) presented L to R: Lesley Jackson, Henry Shiflett, a poster highlighting the importance of knowing the location of autotransplanted parathyroid tissue Sister Teresa Mary, Christina Kitsos following parathyroidectomies. During routine, postoperative surveillance for parathyroid hormone levels, the labs were drawn from the arm on the side where the autotransplanted parathyroid tissue was located, resulting in erroneously high parathyroid hormone levels. Next time you see these residents and fellows, please congratulate them on their accomplishments!


Resident Highlight – Dr. Avi Das Dr. Avi Das was born in Dhaka, the capital of Bangladesh. When he was thirteen years old, he and his family immigrated to Nashville, Tennessee. Dr. Das majored in Biomedical Engineering at UT and attended medical school at St. George’s University. During his housestaff rotations, Dr. Das observed the tendency to admit young, low risk patients with chest pain. It prompted him to investigate the utility of such practices. He studied 120 young patients with low Thrombolysis In Myocardial Infarction (TIMI) scores, of which 105 underwent Myocardial Perfusion Study (MPS). Four patients underwent cardiac catheterization, but only one revealed disease in the coronary arteries that was managed medically. Dr. Das concluded that MPS and diagnostic catheterization in this group is low yield diagnostically and significantly increases cost of care. He presented his research at the Society of Hospital Medicine’s annual meeting in Las Vegas and won first place at the Department of Medicine’s Research Day in May 2017. In his free time he lifts weights, but enjoys bulking with Cruze Dairy Farm ice cream even more. You can often find Dr. Das amidst a heated political debate with his co-resident, Dr. Bill Lorson. Following residency, Dr. Das will be a hospitalist with a private practice group in town.

Dr. Avi Das pictured during a recent visit to Cruze Dairy Farm

Grand Rounds Guest Speaker,

Grand Rounds Guest Speaker,

November 28, 2017

December 12, 2017

Charles J. Duffy, MD, PhD,

David J. Lederer, MD, MS,

Professor of Neurology University of Rochester Medical Center “Cognitive Care in Primary Care: A Neurological Perspective”

Nebulizer Contamination

Associate Professor of Medicine Columbia University Medical Center, New York, NY “The Changing Landscape of Interstitial Lung Disease”

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study team will collect used respiratory devices such as nebulizers, artificial airways, and suction catheters from patients admitted to UTMC. A one-time collection will occur for artificial airways, which will be sent to the UTK study team. There, DNA sequencing and Polymerase Chain Reaction amplification of 16s ribosomal RNA will be used to identify the bacteria present. The team has received IRB approval and will begin data collection early next year. “A very large number of people in East Tennessee suffer from respiratory conditions like COPD and require the routine use of respiratory devices; however, there are no universally standardized cleaning guidelines for these types of devices. Many people fail to follow any type of cleaning process for their respiratory equipment, so the data generated from this study could lead to the standardization of infection prevention and control guidelines for respiratory devices and pave the way for further research relating to how recurrent contamination of respiratory devices can affect the health outcomes of patients,” said clinical trials coordinator, Jennifer Ferris. Identifying the contaminants present on patient respiratory devices may provide new insights into the relationship of device contamination and airway colonization with bacteria. Dr. Dhand, Dr. He, and their study teams seek to fill the evidence gaps relating to patient contamination of respiratory devices through this collaborative project. * Dr. Wyckoff completed her PhD in the fall of 2017. We extend our congratulations!


Faculty and Resident Awards and Honors Several faculty awards were presented at this year’s Annual Faculty Recognition Dinner held on Thursday, December 7th at the Holiday Inn World’s Fair site.

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

• Dr. Amy Barnett, received the RA Obenour, Jr., Excellence in Teaching Award for steadfast dedication and excellence in teaching.

• The RA Obenour, MD, Distinguished Alumnus Award in Recognition of Outstanding Career Achievement in the Field of Medicine was presented to Dr. Janet Purkey.

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

• Dr. Jack Lacey received a 40-Year Service Award. • 25-Year Service Awards were received by Drs. Stuart Bresee and Russell Smith. All of these award recipients have provided superb service to the Department of Medicine. We are delighted to recognize them for their many contributions.

New Faculty We are pleased to welcome Dr. Maya Raiman as a Clinical Assistant Professor in the Division of Dermatology. Dr. Raiman attended medical school at the University of Michigan Medical School in Ann Arbor, Michigan. She completed a transitional year at Oakwood Hospital and Medical Center in Dearborn, Michigan and completed a dermatology residency in the University of Michigan Health System in Ann Arbor, Michigan. Dr. Raiman joined Dermatology Associates of Knoxville in September 2017.

We are delighted to welcome Dr. Priya Gyani as a Clinical Assistant Professor in the Division of Pediatrics. Dr. Gyani attended medical school at Ross University in Dominica, West Indies. She completed a pediatrics residency at Penn State Hersey Medical Center in Hershey, Pennsylvania. Dr. Gyani has been a pediatric hospitalist at East Tennessee Children’s Hospital since July 2014.

CME Opportunities—Mark Your Calendars! • Weekly Cardiology Conferences, generally held on Wednesdays each week for .75 hour CME credit.

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

• Medicine Grand Rounds, which are generally held on the 2nd and 4th Tuesdays of each month for 1.00 hour CME credit.

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The 6th Annual Medicine CME Conference, The Rhythm and Blooms of Internal Medicine, offering 10.25 hours of CME credit, will be held April 6-7, 2018, at the Holiday Inn World’s Fair Site. We hope you can join us for this informative event.

Ethics Case Rounds - Plan Ahead -- and Stay Flexible Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality. Donnie is a 28-year old gentleman who was admitted to the ED with altered mental status and respiratory distress from the facility where he resides. He was unresponsive on arrival and was intubated before information about his wishes could be provided by EMS. His medical background includes Muscular Dystrophy, severe scoliosis, cardiomyopathy, and history of respiratory failure requiring intubation. He uses a wheelchair and other assistive devices. In such situations, physicians need guidance from written directives about the level of care patients wish to receive. POLST (Physician Orders for Life Sustaining Treatment) is the national paradigm for medical orders to clarify and communicate patients’ choices for end of life care. Different states have their own variations; Tennessee uses the POST (Physician Orders for Scope of Treatment.) It is appropriate only for people with terminal illness, advanced chronic illness, or frailty; intended to be a mechanism for translating patients’ wishes into actionable medical orders for all care providers, including EMS. Instructions stipulate it should be completed after a discussion about the patient’s wishes for end of life, and signed by a physician who has a bona fide relationship with the patient. In practice, however, POST forms are often completed in a perfunctory manner and signed by a physician who has only a superficial relationship with the patient. A POST form completed here and signed by Donnie six months earlier indicated he did not want to be resuscitated or intubated, comfort measures only, and do not re-hospitalize. Per chart, he has declined to appoint a surrogate decision maker, though his mother’s contact information is listed under “Patient Information.” Under the circumstances, the critical care team requested an Ethics Consult in the ED prior to accepting him for ICU care. We needed to learn more about Donnie. In a phone call, Director of Nursing at his facility said Donnie has lived with them for several years, that he had always enjoyed computer games and getting around in his wheelchair. However, his Muscular Dystrophy has progressed. He has been unhappy about the effort it now takes him to use his computer, and has been talking about being tired of the “merry-go-round” of being in and out of the hospital. They believe this POST form accurately reflects Donnie’s wishes. They also say Donnie has a “strained” relationship with his mother, his only known relative. At times she is involved in his life, but at other times he refuses her calls and visits. They said he feels “she treats me like a baby” and “doesn’t let me speak for myself.” They have been out of touch for over a month; he had stated one week earlier that his mother was not to be given any information under any circumstances. Based on our best understanding of Donnie’s wishes, the Ethics recommendation was to transition to comfort measures, including DNR and extubation without plan to re-intubate. It was also recommended not to contact his mother at that time. Donnie was placed on comfort measures and extubated in the ED. Once stable, he went up to the floor. Over the next 24 hours, his conditioned improved. He regained decision making capacity and asked for medical treatment. He also asked us to call his mother and ask her to come visit him. After a few days of treatment for pneumonia, he went back to his nursing home with a new POST that indicated DNR/I and limited interventions (OK to re-hospitalize, avoid ICU). Comments on this case may be sent to References 1. Mirarchi, FL, et al. “TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders” Journal of Emergency Medicine 2012 (42) 511-520 2. Elements of a POLST Paradigm Form. (n.d.). Retrieved September 27, 2017, from

Presentations, Publications, Awards

Department of Medicine faculty, residents, and fellows share their knowledge and experience by publishing and presenting across the world. For a list of our most recent accomplishments, visit

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In Touch Vol. 6, Issue 5: December 2017

Publishers James Neutens, PhD, Dean Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs Editor Annette Mendola, PhD Administrative Director Susan Burchfield, CAP-OM Contributors Susan Burchfield Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Azaria Ehlers, MD Kimberly Givens Design J Squared Graphics In Touch is produced by the University of Tennessee Graduate School of Medicine, Department of Medicine. The mission of the newsletter is to build pride in the Department of Medicine by communicating the accessible, collaborative and human aspects of the department while highlighting pertinent achievements and activities. Contact Us In Touch University of Tennessee Graduate School of Medicine Department of Medicine 1924 Alcoa Highway, U-114 Knoxville, TN 37920 Telephone: 865-305-9340 E-mail: Web: http://gsm.utmck. edu/internalmed/main.cfm The University of Tennessee is an EEO/AA/Title VI/ Title IX/Section 504/ADA/ ADEA institution in the provision of its education and employment programs and services.

In Touch January 2018  
In Touch January 2018  

In Touch is a newsletter for alumni and friends of the Department of Medicine at the University of Tennessee Graduate School of Medicine.