> Summer 2013

Message from the Chairman – Dr. Robert Hromas

Robert HromasBesides caring for our patients, the highest calling we have as physicians is to reproduce ourselves. We need to pass on the art and science of medicine to the next generation of physicians in order to ensure that the ill have medical care long after we are gone. One of the greatest aspects of medicine is that it is constantly seeking improvement – it is one of the last bastions of meritocracy, where life or death is still pretty much an absolute definition of success or failure. Since much of medical knowledge is now available as a smart phone app, one of the most important things we teach medical students and residents is where to find things. But this pre-supposes that they already have the motivation to look. Thus, the concept of investigation is at the foundation of medical education, not so much in the sense of laboratory research, but of continuously investigating how to take better care of each patient. The best way for a medical student to learn this is by watching us – we too can and should always be continuous learners, where we are eagerly seeking new ways to better the lives of our patients. This is harder than it sounds, given the pressures of declining fee for service reimbursement, the increase in documentation requirements, and the ever-expanding regulatory environment. We have so many demands for our time that continuous learning is difficult. This is one reason for The SCOPE – it briefly summarizes the latest advances in medicine in an easy to read format, to help make continuous learning just a bit easier.

UF Head and Neck Cancer Program

The UF Head and Neck Cancer Program takes a multidisciplinary care approach to treating head and neck tumors through various innovative techniques. The comprehensive treatment team brings together expert physicians, nurses and staff from numerous specialties, including three medical oncologists dedicated to the program – Dr. Frederic Kaye, Dr. David Reisman and Dr. Priya Gopalan.

TheHead Neck Cancer Team team works together with the common goal of improving the survival and quality of life for patients and provides personalized treatment for cancers of the mouth, throat, voice box, salivary glands and thyroid, and skin cancers of the head and neck region.

Several specialists first examine each patient and then their unique case is presented at a weekly Multidisciplinary Head and Neck Tumor Conference where a treatment plan is recommended. Before treatment begins, the patient and family are fully informed of the recommended treatment, the reasons it is recommended, the procedures to be carried out, the expected or possible side effects or complications, and the expected benefits. This nationally recognized integrated approach to patient care allows for treatment options even in the most difficult cases.

The program is also building a portfolio of clinical trials for patients with head and neck cancers. Highlights of this clinical research include: participation in the Eastern Cooperative Oncology Group clinical trial for patients with recurrent and metastatic disease, which is studying the anti-angiogenic antibody bevacizumab (Avastin) in combination with chemotherapy; and a multi-institutional clinical trial exploring the role of reduced intensity radiation with low-dose chemotherapy in patients with HPV-associated head and neck cancer. The program is currently poised to launch additional trials targeting specific molecularly defined subpopulations, bringing personalized medicine to the field of head and neck cancer.


Obesity Update: Good and Bad News on the Horizon

Obesity is perhaps the greatest public health problem of this century. We receive daily news ranging from good to bad. First, the bad. Currently two out of three adult Americans are overweight or obese. More worrisome, one out of three children ages 9-17 are overweight or obese, raising concerns about the health of future generations. The rise in obesity has led to an unprecedented rate of type 2 diabetes mellitus (T2DM), with traditional comorbidities such as cardiovascular disease, Endo_Scopeas well as more novel but equally worrisome complications such as nonalcoholic fatty liver disease (NAFLD). A fatty liver is now the most common chronic liver condition in adult Americans and will soon be the leading cause of end-stage liver disease in patients that are obese or have T2DM.

Now, the good news. Reversing the metabolic harm of obesity doesn’t require returning to an “ideal” weight, but significant benefits may be achieved with even modest reductions (about 5-7% of body weight). It’s been know for some time that lifestyle changes leading to this degree of weight loss can prevent the progression from prediabetes to T2DM in about two-thirds of patients (Diabetes Prevention Program, NEJM 2002). More importantly, the FDA has recognized the need for pharmacological agents to assist lifestyle intervention. In 2012, two new weight-loss agents (lorcaserin [Belviq] and phentermine-topiramate [Qsymia]) were approved for use in patients as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial BMI of 30 kg/m2 or more (obese) or 27 kg/m2 or more (overweight) in the presence of at least one weight related comorbid condition. There is also an increased awareness among clinicians about the importance of fatty liver (NAFLD) in obesity and T2DM.

Dr. Kenneth Cusi, Chief of the UF Division of Endocrinology, Diabetes and Metabolism, has found in screening studies that most obese patients with T2DM have a fatty liver (as many as four out of five). This poses considerable long-term health risks: dyslipidemia, cardiovascular disease and liver damage. He discovered in a pilot study that pioglitazone (Actos), a drug used in the treatment of T2DM, may reverse a fatty liver in patients with prediabetes or T2DM (Belfort et al, NEJM 2006). Very recently, Dr. Cusi’s laboratory completed the first long-term study (presented at the June 2013 American Diabetes Association annual meeting) that has confirmed and extended the original findings about the efficacy of pioglitazone in obese patients with T2DM and a fatty liver (Cusi et al, Diabetes, suppl 1, 2013). In summary, obesity and T2DM continue to be a major public health problem, but lifestyle intervention and proper pharmacological therapy can greatly assist a large number of our patients.


Organ Regeneration: Bioengineered Kidneys

Dr. Edward A. Ross, Professor of Medicine in the UF Division of Nephrology, Hypertension & Renal Transplantation, alongside Dr. Christopher D. Batich, Professor in the UF Department of Materials Science and Engineering, and their multidisciplinary team are continuing to forge ahead with their research into organ regeneration using biological scaffolds to address transplant organ shortages.

Ross_EdwardIn their prior investigations, rat kidneys were decellularized so as to produce whole-organ intact scaffolds. These were then seeded with precursor (stem) cells and there was evidence of appropriate differentiation. With partial funding by the Gatorade Foundation, the team is now transitioning from rat to pig kidneys. All cells are removed from the organs by a multi-day sequential protocol utilizing detergents, enzymes and mechanical rinsing. Different precursor cells are infused (antegrade) into the artery and (retrograde) up the ureter. The kidneys can then be incubated in special bioreactors using appropriate growth factors for the vasculature and renal collecting systems.

Ultimately, the goal is that the swine scaffolds might be suitable for regeneration using human cells, thereby becoming a source of organs for transplantation. This approach is currently under study and has had some limited clinical success for such other organs as the trachea, heart, liver, esophagus and bladder.


UF Interventional Endoscopy – Offering Comprehensive Advanced and Theapeutic Endoscopic Procedures

UF interventional endoscopists in the Division of Gastroenterology, Hepatology and Nutrition offer advanced and therapeutic endoscopic procedures for the treatment of pancreatobiliary diseases and other luminal GI disorders. They utilize the latest devices and technology available for the treatment of both benign and malignant gastrointestinal disorders. The UF interventional endoscopy service is multidisciplinary, with colleagues in surgery, oncology, radiology and other specialties working together to provide patients with the best in personalized care. The team performs cutting-edge scientific research to improve prevention, detection, treatment, and outcomes of gastrointestinal disorders. The newly opened GI endoscopy unit is equipped with the latest technology and spacious state-of-the-art interventional endoscopy rooms.

UF interventional endoscopists specialize in the following procedures:

  • Endoscopic Retrograde
  • Cholangiopancreatography (ERCP)
    • Biliary stones and strictures
    • Pancreatic endotherapy
    • Pancreatobiliary stent placement
    • Lithotripsy
    • Ampullectomy
    • Cholangioscopy and pancreatoscopy (Spyglass ERCP)
    • ERCP in post-surgical anatomy
    • Combined laparoscopic-endoscopic procedures
  • Endoscopic Ultrasonography (EUS)
    • EUS staging of gastrointestinal cancers
    • Fine Needle Aspiration (FNA)
    • Evaluation of subepithelial lesions
    • EUS guided fiducial placement for radiation therapy
    • EUS guided celiac plexus block/neurolysis
    • EUS guided pancreatic pseudocyst drainage
    • EUS guided rendezvous ERCP
  • Extracorporeal Shock Wave Lithotripsy (ESWL) for pancreatic stones
  • Endoscopic treatment of Zenker’s diverticulum
  • Complex stricture dilation
  • Esophageal, duodenal and colonic stenting
  • Deep small bowel enteroscopy
    • Spirus-overtube assisted Enteroscopy
    • Single-Balloon Enteroscopy
  • Endoscopic therapies for Barrett’s esophagus and early cancers
    • Endoscopic Mucosal Resection (EMR)
    • Radiofrequency Ablation (Barrx)
    • Cryotherapy
  • Endoscopic Submucosal Dissection (ESD)
  • Per-Oral Endoscopic Myotomy (POEM) for achalasia

UF Advanced and Therapeutic Endoscopists: Dr. Shailendra S. Chauhan, Dr. Dennis P. Collins, Dr. Peter V. Draganov, Dr. Christopher E. Forsmark, Dr. Anand R. Gupte and Dr. Mihir S. Wagh.