InTouch Newsletter - October 2021

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D epartment

of

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. 10 Issue 4 Oct. 2021

Bone Marrow Transplantation at UTMCK An exciting addition to the medical center is the Transplant and Cellular Therapy Program! While new hematology/oncology faculty, Drs. Kelly McCaul and Renju Raj, are building the program, the hospital is busy putting the finishing touches on the new transplant and cellular therapy unit which will be located on the 5th floor of the heart hospital, with plans to open the program in the next several weeks. There will be two arms of the program to offer a wide range of innovative therapies to our patients: the transplant side and the cellular therapy side. The transplant branch of the program will feature both autologous and allogeneic transplantation. The allogeneic program will provide a wide variety of resources to our patients, allowing sibling, matched and mismatched allogeneic, and haploidentical donors to patients who may otherwise have no other available stem cells. Autologous transplantation can even be used to treat some solid tumors, such as germ cell tumors and Ewings sarcoma. There are plans to expand the transplant program further into the unrelated donor realm after the official introduction of the program, including cord blood transplantation. The cellular therapy segment of the program will include therapies such as chimeric antigen receptor cells (CAR-T) therapy. The program is developing relationships with all commercial CAR-T companies to allow patients access to all available FDA-approved CAR-T products. These products include treatments for aggressive lymphomas, multiple myeloma, and acute lymphocytic leukemia. “In addition, we are trying to approach this with somewhat of a modular approach,” says Dr. McCaul, “whereby we will be able to ‘plug in’ any other cell therapy product that comes active in the future with FDA approval.” The Cellular Therapy space will also feature research into the latest technologies and developments in cellular therapies, starting with Tumor Infiltrating Lymphocytes (TILs) in a research collaboration with Iovance Biotherapeutics. This new technology will expand cellular therapy treatments beyond hematologic malignancy into the solid tumor

realm, such as non-small cell lung cancer, melanoma, cervical, and squamous cell cancer of both the head and neck as well as the lung. The UT Medical Center Transplant and Cellular Therapy program will bring a much-needed resource to our local and regional communities, as currently there is no transplant program within a 100-mile radius of our institution. Through this program, our patients will have the opportunity for the best clinical outcomes available to them without the additional stress required for travel and lodging. Finally, we would like to offer Dr. McCaul and Dr. Raj the warmest welcome and our heartfelt support in their leadership of this program.

Points of View

The threat that these viruses would lead to a prolonged pandemic was not given serious consideration. The advent of the pandemic was swift. Gone were the conferences, parties, and dining at restaurants. Travel came to a standstill. Most people were working from home and children had to rely on computers for their education. There was a stillness that created a void in people’s social lives. It was like the end of the show after the audience had departed. What had been a hectic and busy place, full of laughter and good cheer, was replaced by a feeling of emptiness and loneliness! There was no escape from the onslaught of this deadly virus. The aging and vulnerable population were most affected by this “lockdown”. They were deprived of interaction with their family and friends for extended periods. The social isolation took an enormous emotional toll, with increased feelings of uncertainty, anxiety and depression. Suicide rates, alcoholism and continued on page 2

Social Isolation …

Like many killers, this one came in stealthily and picked off its victims at random. It did not, however, come without forewarning. Scientific experts had long predicted that a pandemic was overdue. Most were worried about another flu variant, and laboratories across the globe were monitoring for Rajiv Dhand, MD, Chair new strains of the influenza virus. Coronavirus was low on the radar of most public health agencies as the cause for a global pandemic. Previous exposures to coronaviruses causing serious respiratory illnesses were for a brief duration and seemed to subside for no conceivable reason. 1


One Year Anniversary of ECMO at UTMCK The current pandemic has brought about a plethora of unexpected challenges. It has resulted in hospitals constantly adapting to the latest guidelines and recommendations set forth by local, state, and national leaders. Rules, protocols, and contingencies unlike any ever seen before. These are set in place for the safety and well-being of hospital employees and improvement of patient care. Despite the turmoil, UTMC followed its vision to establish an ECMO Center, and the first patient was accepted for ECMO cannulation in 2020. Extra-corporeal membrane oxygenation, or ECMO, is an advanced form of mechanical life support used for patients with severe but potentially reversible respiratory or cardiac failure when conventional management has failed. Implementing ECMO at UTMC over the last year has been very rewarding. Dr. Ben Bevill, medical director of the ECMO program says, “With the unique challenges we have faced with COVID, ECMO has allowed us to support patients who otherwise would not have been able to survive their illness.” It has allowed UTMC to grow as an academic institution and provide a lifesaving service to people in East Tennessee and across the Southeast region. ECMO patients are complex and require a multidisciplinary approach to medicine. A typical team consists of physicians, ECMO specialists, respiratory therapists, nutritionists, and specialized nurses working together to meet the needs of the patients and their families and better serve them. ECMO has become an important tool in our toolbox as we continue to strive for excellence in patient care.

Internal Medicine & OB/GYN Resident Clinic Renovations The University of Tennessee Internal Medicine and OB/GYN Center recently underwent renovations to enhance both provider workflow and improve the overall patient experience within the clinic. To begin with, the waiting area for patients was expanded to include more square footage which will serve useful if further social distancing protocols are put in place during the ongoing pandemic. In addition to lighting and cosmetic changes, the extra space also allows improved access to front desk staff which is very important when helping patients with communication barriers. After their visit, patients often proceed to the on-site lab for blood draws which also recently had the addition of a dedicated lab waiting area as well. This is not only more comfortable for patients but is also more efficient for staff as exam rooms can be cleaned and prepared quickly for subsequent patient encounters. Another improvement was the separation of nursing and front desk staff workspaces. The dedicated nursing workspace has been relocated to optimize access to exam rooms for nurses, residents, and faculty working within the clinic. Additionally, separate check-out stations for internal medicine and OB/GYN have been created, which streamlines the scheduling process. In discussions with current residents and clinic director Dr. Juli Williams, these renovations seem to represent a refreshing change of environment that is both more functional for staff and enjoyable for patients.

Points of View

BEFORE

AFTER

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drug abuse increased at an alarming rate. The worst-hit were the patients admitted to the hospital. They were placed in “isolation”, and some of them died while struggling to breathe from the lack of oxygen without the comfort of their loved ones by their side. Among the ones who recovered, many had to fight depression, fatigue, weakness, breathlessness and a variety of other issues. The pandemic has been a humbling lesson for humanity at large. It exposed the vulnerability of our systems to counter new and emerging threats from infectious diseases. It also brought to light people’s varying responses to a worldwide threat and disparities in health care. We have a lot to learn from this historic event. I’m proud of the way frontline health care workers put their safety concerns at bay and rose to the occasion to take care of the sick and dying. Our own health care workers were no exception and are continuing to perform at an exceptional level. Society owes these health care workers an enormous debt of gratitude. They are the real heroes, and we salute them for their dedication and sacrifice!

CME OPPORTUNITIES

Currently hybrid attendance: half joining via Zoom or Microsoft Teams • • • •

Cardiology Conferences, held weekly on Wednesdays in the Medicine Conference Room for .75 hour CME credit. Medicine Grand Rounds, held on the 2nd and 4th Tuesdays of each month in the Medicine Conference Room for 1.00 hour CME credit. Ethics Case Rounds, held on the 4th Thursday of the month at noon in Wood Auditorium and are available for 1.00 hour CME credit. Pulm/HTN Conferences, held on the 2nd Monday of the month at noon in different locations and are available for 1.00 hour CME credit. 2


Resident Spotlight – Drs. Abdallah, Muaz, & Sohiub Assaf Sohiub, Muaz, and Abdallah Assaf are three of our newest interns who happen to be brothers. These brothers grew up in Jordan, attended college in Chicago together, and even decided to pursue a medical degree at the same school. Abdallah, the youngest brother says, “We have always been close to each other and wanted a residency program that was open to the idea of keeping us together.” The Assaf brothers did not decide on UT on a whim. Shortly after starting medical school in the Caribbean, a hurricane wiped out their school’s campus, causing them to relocate. A semester later, they found themselves in Knoxville where they would spend the next year and a half continuing their medical school training, exploring the city, and absorbing the culture. Abdallah and his brothers are all interested in pursuing a career in cardiology, and the thought of splitting up has not crossed their minds. They are enthusiastic for the next adventure that comes their way.

Faculty Announcements: New Faculty We are elated to welcome Dr. Luis Zayas Rodriquez for appointment to the rank of Clinical Assistant Professor in the division of neurology. Dr. Zayas completed medical school at UNIBE School of Medicine in Santo Domingo, Dominican Republic. He completed a residency in internal medicine at St. Barnabas Hospital in Bronx, NY, and a residency in neurology at Cooper University Hospital in Camden, NJ. Dr. Zayas completed a fellowship in neuro-critical care at Cleveland Clinic in Cleveland, OH, followed by a fellowship in movement disorders at the University of Nebraska Medical Center in Omaha, NE. Dr. Zayas has had several awards including an Honor certificate from the University of Puerto Rico, a Certificate of Merit for Academic Excellence from the University of Puerto Rico, and a Resident of the Year award during his time at St. Barnabas Hospital. We are pleased to welcome Dr. Katie Gardner for appointment to the rank of Clinical Assistant Professor in the division of pulmonary disease and critical care. Dr. Gardner completed medical school at Lincoln Memorial University DeBusk College of Osteopathic Medicine in Harrogate, TN. She completed a residency in internal medicine at McLauren Macomb Hospital in Mount Clemens, MI. She also completed a fellowship in pulmonary and critical care medicine at Henry Ford Hospital in Detroit, MI. Dr. Gardner’s academic history confirms her dedication to the eastern Tennessee area because she chose to attend Lincoln Memorial Debusk College of Osteopathic Medicine and also did her core clinical rotations at Indian Medical Center in Kingsport, TN along with electives throughout the Tri Cities area. We are delighted to welcome Dr. Shadi Barbu for the appointment to the rank of Clinical Assistant Professor in the department of neurology. Dr. Barbu completed medical school at Medical College of Georgia at Augusta University in Augusta, GA. She completed a residency in neurology and fellowship in movement disorders at the Barrow Neurological Institute at St. Joseph’s Hospital in Phoenix, AZ. Dr. Barbu has worked as a sub-investigator on several clinical trials and has an in-depth understanding of clinical trial research. She has also written and presented several papers and abstracts.

Faculty Promotions We are elated to announce the promotion of Dr. Paul Terry to Professor as of July 1, 2021. Dr. Terry has held the rank of Associate Professor in the University of Tennessee, Department of Medicine since December 1, 2014. He is an epidemiologist and an experienced researcher. Dr. Terry received his PhD in epidemiology from the Columbia University School of Public Health in New York, NY, and another doctorate in medical epidemiology and biostatistics from the Karolinska Institute in Stockholm, Sweden. He received his Masters of Public Health from the University of Connecticut Health Center in Farmington, CT followed by a fellowship in epidemiology at the American College of Epidemiology in Raleigh, NC. In 2012, he won the University of Tennessee Community Engagement and Outreach Award. Dr. Terry has been involved in the design and conduct of case-control, cohort, cross-sectional, experimental, and methodological studies of chronic diseases, including cancer, diabetes and metabolic syndrome, and various causes of mortality. He has published over 100 peer-reviewed articles related to chronic disease epidemiology.

Special Announcement: Hematology / Oncology Fellowship Program The Department of Medicine is excited to announce that the ACGME has accepted our application to start a fellowship program in hematology/oncology. Dr. Timothy Panella, as the fellowship director, will initiate the program in July 2022 with the recruitment of 2 fellows.. The program will provide 3 years of training and we plan to recruit 2 fellows per year for a total of 6 fellows as our maximum capacity. The program will provide a full range of facilities and educational experiences for the fellows, including Bone Marrow Transplantation and Cellular Therapy programs. Currently in the Department of Medicine, we have fellowship programs in cardiovascular diseases, pulmonary/critical care medicine, and interventional cardiology. A hematology/oncology fellowship program will be an important addition to our institution because it is a great need in our area that will promote advanced cancer therapy to the East Tennessee region. 3


Advanced Pregnancy and Decompensated Mental Illness: Promoting Safety and Dignity for All

In Touch

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

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

“Tracy” is a 27 y/o lady who presented to UT Medical Center with acute mania. In ED she was agitated, yelling and throwing objects at staff. She had a history of bipolar disorder but was otherwise healthy. Tracy was also 36 weeks pregnant. Fortunately, fetal status was described as “reassuring” at the time of admission. She had received regular prenatal care and had not had any mental health problems during the pregnancy until a few weeks prior. Normally, acute mania would be stabilized in an inpatient psychiatric acute setting. However, placement was denied at several facilities due to Tracy’s advanced state of pregnancy and/or her level of physical aggression. Tracy’s behavior was disruptive and dangerous to herself and others. She paced in her room, attempted to hit and kick staff, stood on furniture and jumped off, threw herself against walls, sang, shrieked, and attempted to leave. Medications did little to ease her agitation. A 1:1 sitter was assigned to help calm her and monitor the situation. Out of concern for the safety of Tracy, her baby, and staff, Ethics was consulted to assist in developing a plan of care. An interdisciplinary team meeting was assembled. After much discussion, the team agreed that delivery in the near future would be safer for both mother and baby than to try to allow the pregnancy to progress to closer to term. The plan was to continue psychiatric medications and supportive care in hopes of attempting induction of labor and vaginal delivery. Urgent c-section would be performed if she became agitated to the point of becoming an acute danger to herself or the baby (e.g., if she were to escape her restraints twice in a short period of time). The obstetrician explained the plan to Tracy, but she would not engage with him. The team was aware that if a c-section became the safest option, she would require a surrogate decision maker as she would (almost certainly) lack decision making capacity. Her husband was willing and appropriate to assume that role. From the American College of Obstetricians and Gynecologists Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. It should be noted that disagreement with a physician’s recommendation is not, per se, evidence of decisional incapacity. Therefore, when pregnant patients present in a mental health crisis, their decision-making capacity should be assessed. If an incapacitated patient continues to refuse a recommended intervention despite respectful persuasion and attempts to accommodate her preferences, the harm of providing it over the refusal should be balanced against the benefit of the intervention itself. Tracy consistently demonstrated lack of decisional capacity during her hospitalization. Overnight, despite the use of medications Tracy was extremely agitated and combative and did indeed get out of restraints twice. In the morning, her husband gave consent for a c-section. The team attempted to discuss this with Tracy, but she was unable to participate in the discussion. After the delivery, Tracy’s mood continued to be labile, but gradually became somewhat more stable. She was discharged to an inpatient psych facility. Their daughter was doing well and went home with her dad. Comments may be sent to amendola@utmck.edu

References • Refusal of Medically Recommended Treatment During Pregnancy | ACOG • Singh N, Lepping P, Whitaker R, Masood B, Joshi S, Banfield P. Incapacity in childbirth - Rare or common? Eur J Obstet Gynecol Reprod Biol X. 2021 Jan 29;10:100122. doi: 10.1016/j.eurox.2021.100122. PMID: 33681757; PMCID: PMC7910498

Presentations, Publications, Awards

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

Thank You For Your Support

For information about philanthropic giving to the UT Graduate School of Medicine, Department of Medicine, please contact the Development Office at 865-305-6611 or development@utmck.edu. If you would like more information about any of the topics in this issue of In Touch, please contact the Department of Medicine at 865-305-9340 or visit http://gsm.utmck.edu/internalmed/main.cfm. We look forward to your input. Thank you.

Stay In Touch!

Alumni, please update your contact information by completing the simple form at http://gsm.utmck.edu/internalmed/alumni.cfm or by calling the Department of Medicine at 865-305-9340. Thank you! 4

Vol. 10, Issue 4: October 2021

Editor Annette Mendola, PhD Administrative Director Jenny Roark Contributors Jenny Roark Robin Underwood Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Cassandra Mosley James Drew, MD Marc Oropilla, DO Megan Sears-Smith, DO Design J Squared Graphics In Touch is produced by the University of Tennessee Graduate School of Medicine, Department of Medicine. The mission of the newsletter is to build pride in the Department of Medicine by communicating the accessible, collaborative and human aspects of the department while highlighting pertinent achievements and activities. Contact Us In Touch University of Tennessee Graduate School of Medicine Department of Medicine 1924 Alcoa Highway, U-114 Knoxville, TN 37920 Telephone: 865-305-9340 E-mail: InTouchNewsletter@utmck.edu Web: http://gsm.utmck.edu/ internalmed/main.cfm The University of Tennessee is an EEO/AA/Title VI/ Title IX/Section 504/ADA/ ADEA institution in the provision of its education and employment programs and services. Disclaimer: quotes/ interviews are edited for length and clarity