> Winter/Spring 2014


Message from the Chairman – Dr. Robert Hromas

      Robert Hromas Sometimes we as physicians take our own advice and sometimes we don’t. Take the case of smoking – In 1974, the fraction of physicians smoking was about the same as the general population, more than 20 percent. By 2004, the fraction of physicians smoking was 5 percent, less than half the general population, and those that did smoke were doing it less frequently. Conversely, we physicians have been far more intractable about taking our own advice when it comes to hand washing. Semmelweis first proposed hand washing in chlorinated lime solution in 1847 to prevent infection. For that major advance he was subjected to intense ridicule and was fired from his job. Becoming more and more embittered and irrational, he was placed in an insane asylum in 1865, where he was beaten to death by guards two weeks after confinement. After the practice was championed by Pasteur a decade later, hand washing before procedures became standard. However, physician hand washing before entering and after leaving patient rooms has been stuck at around 40 percent for the last half-century. So we believe our own data for smoking, but not for hand washing. Multiple awareness programs have failed to budge the hand washing rates. I have to hope that this is not because smoking causes us harm personally, and poor hand washing rates does not, rather it affects our patients. Well, given the advent of totally drug-resistant acinetobacter and klebsiella in hospitals, not to mention the spike in resistant C. difficile, we as physicians have a new reason to wash our hands, because those organisms can be as lethal to us as to our patients. Sometimes the oldest advances are the most difficult to implement, as the novelty has gone, yet in the long run they can make the most difference. In this issue of The SCOPE, we celebrate integrative medicine, one of the oldest medical disciplines, and yet under-utilized today, explore the latest advance in the treatment of achalasia, introduce you to our newest research center and more. 

UF Health Integrative Medicine Program

Integrative medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals and disciplines to achieve optimal health and healing (Consortium for Academic Health Centers in Integrative Medicine).

Dr. Irene Estores, medical director for the UF Health Integrative Medicine Program, completed her integrative medicine fellowship at the University of Arizona Center for Integrative Medicine, under the nationally recognized program of Dr. Andrew Weil, as a Bravewell Fellow. She is also a specialist in physical medicine and rehabilitation (PM&R) and completed her residency training at the Sinai Hospital-Johns Hopkins Hospital inter-institutional program in PM&R. In addition, she received her initial acupuncture training at the University of Miami Center for Complementary and Integrative Medicine and has applied this to the management of both musculoskeletal and neuropathic pain.

Dr. Estores has assembled a growing team of highly experienced practitioners, which includes yoga, martial arts and mindfulness practitioners, as well as massage and dance/ movement therapists. The collaborative team seeks to partner with the conventional medical community and offer patients the full-range of integrative medicine modalities to complement traditional methods of care.Integrative Medicine Program

During an integrative medicine physician consultation, Dr. Estores will perform a comprehensive medical evaluation from a holistic perspective. She and the patient then develop an individualized health plan based on this evaluation. In addition to conventional methods, this may include use of dietary supplements and botanicals, ways to optimize nutrition and physical activity, medical acupuncture, massage, and the use of mind-body practices such as meditation, yoga and Tai Chi.

An integrative medicine consultation can be requested for a wide variety of patient needs, including:

• Patients seeking an integrative approach for health promotion and disease prevention.

• Patients with acute and chronic pain of musculoskeletal or neurologic origin, anxiety or depression, or digestive complaints, who have not received full relief of symptoms with conventional medicine.

• Patients with chronic medical conditions who are interested in lifestyle modification in addition to their conventional medications.

• Patients with symptoms related to cancer or its treatment seeking complementary modalities for symptom management.

• Women seeking complementary modalities to manage symptoms related to hormonal imbalance.



New UF Center Focuses on Inflammation and Disease

Center for Inflammation & Mucosal ImmunologyRecognizing growing evidence that inflammation influences many diseases — including diabetes, certain cancers and even Alzheimer’s — UF has established the Center for Inflammation and Mucosal Immunology to foster collaboration among members of the UF biomedical research community with shared interest in inflammation and disease.

“Though the center is very new, our members already number more than 75 UF scientists whose interdisciplinary research efforts explore the whole gamut of complex biological responses of inflammation and immunology,” said center director Mansour Mohamadzadeh, PhD, a faculty member in the UF Department of Medicinedivision of gastroenterology, hepatology and nutrition, and professor in the UF College of Veterinary Medicine department of infectious diseases and pathology. “The center’s primary goal is to foster research collaborations among these multidisciplinary scientists, leading to new discoveries that alleviate human sickness and death caused by immune-mediated auto-inflammatory diseases.”

Inflammation has been found to influence many medical maladies. These include colon and other cancers, irritable bowel syndrome, eosinophilic esophagitis, chronic infectious diseases, systemic pulmonary fibrosis, type 1 diabetes, arthritis and Alzheimer’s. Facilitating interdisciplinary research of the inflammatory processes behind these conditions should accelerate scientific discoveries leading to improved prevention and treatment. Networking and collaboration opportunities among researchers are a key component of the center, which hosts a monthly seminar series where members share their research, as well as an annual retreat. However, one of the greatest benefits of center membership is access to core equipment and animal research platforms.

“In addition to providing access to advanced technologies that are perhaps too expensive for individual labs to purchase, such as flow cytometry, confocal microscopy and cell analysis, one of the very important membership benefits is access to the center’s germ-free mouse and zebrafish models,” Mohamadzadeh said. “These germfree animal platforms are free of contaminating microorganisms or disease, and can be deliberately modified with specific bacteria, making it possible to directly investigate the impact of colonization in a living organism. We believe these core resources will prove to be invaluable assets to UF scientists, giving them a competitive edge in the national research community.”


Cardiology Clinical Trials Recruiting Patients

The UF Division of Cardiovascular Medicine Clinical Trials Office is actively recruiting patients for clinical trials, many of which also involve the use of adult stem cells, focusing on the areas of: • Heart failure/transplant

• Refractory angina Science Alone Campaign 001(2)

• Peripheral arterial disease

• Post-myocardial infarction

Furthermore, stem cell clinical trials are being expanded this year to include nonsurgical candidate abdominal aortic aneurysm, acute myocardial infarction and left ventricular assist device (LVAD) patients.

The dedicated research team is currently conducting more than 15 clinical trials, each led by physician-scientists from the division, including Dr. Juan M. Aranda, professor of medicine and director of the UF Health heart failure and heart transplant programs.

Dr. Aranda has served as principle investigator for several heart failure, heart transplant and LVAD clinical trials during his tenure at UF and is currently conducting two trials for acute heart failure patients, both of which are accepting enrollment. The first, which involves using an approved bedside filtration system, seeks to assess the effects of vasopressin receptor antagonist (30 mg q.d. tolvaptan) in patients who are hospitalized for heart failure exacerbation. The second is a biomarker-guided heart failure therapy clinical trial for improved heart failure management after hospitalization to prevent re-hospitalization.

He is also actively recruiting heart transplant recipients to participate in a registry using clinically approved AlloMap® molecular expression testing in order to observe real-world, short- and long-term clinical outcomes in patients who receive regular AlloMap® testing as part of allograft rejection surveillance.

In addition, in the later part of 2014, Dr. Aranda will participate in an LVAD clinical trial evaluating a new version of the device, as well as participating in a new stem cell trial involving post-LVAD patients.



Per-Oral Endoscopic Myotomy (POEM) for the Treatment of Achalasia

Achalasia, a motility disorder of the esophagus, is characterized by aperistalsis of the esophagus and incomplete relaxation of the lower esophageal sphincter (LES). Treatment of achalasia is currently aimed at decreasing the resting pressure in the LES.

Traditionally, surgical myotomy and endoscopic pneumatic balloon dilation (PBD) have been considered the standard of care for the treatment of achalasia. However, there are certain limitations with both of these approaches. Surgical myotomy requires open or laparoscopic access to the intrathoracic and intraperitoneal cavity. Furthermore, this procedure mandates an adjunctive fundoplication for the management of post-operative reflux; thus, increasing the complexity of the operation and the risk for complications. On the other hand, PBD often needs to be performed serially in order to maintain symptomatic control, which inevitably exposes the patient to the risks of repeated endoscopic procedures and associated costs.

Per-oral endoscopic myotomy (POEM) is an emerging novel endoscopic procedure for the treatment of achalasia. This is a minimally invasive technique that allows complete myotomy of the esophageal circular muscle fibers and LES using a standard upper endoscopy. POEM is associated with a very quick post-procedural recovery (1-2 days) and does not require any additional surgeries for reflux prevention.

We have recently adopted this new technique at UF Health as part of our ongoing commitment to provide the best possible care to our patients. Our initial experience with POEM for the treatment of achalasia is that it has demonstrated a very good safety profile, excellent short-term symptom resolution, low incidence of reflux symptoms and high patient satisfaction. We are currently the only referral center in the state of Florida to offer this innovative procedure for the management of achalasia and we look forward to continuing this trend of excellence and sharing more information regarding POEM with all of those interested.