February 2015 Newsletter

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Department of Medicine eNewsletter
February 2015
:: Interview
:: Department News
:: Department Events
:: Leadership Council Minutes
Leadership Council
February 2015
Chair:
Richard Walsh
Present:

B. Arafah

K. Armitage

A. Askari

R. Bonomo

R. Chandra

F. Cominelli

F. Creighton

S. Gravenstein

D. Hricik

M. Jain

N. Meropol

R. Salata

R. Schilz

D. Simon

R. Walsh

J. Wright

 

Guests:

Catherine Koppelman, Chief Nursing & Patient Experience Officer

Robin Rowell, Vice President, Institute and Medical-Surgical Clinical Operations and Vice President, UH Harrington Heart & Vascular Institute

 

Recorded by:
A. Staruch
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department interview
Albert Waldo, MD, Associate Chief of Cardiovascular Medicine for Academic Affairs at University Hospitals Case Medical Center and University Hospitals Harrington Heart & Vascular Institute, shares his proudest accomplishments that led him to become an international authority on atrial fibrillation, evaluates the effectiveness of recently introduced anticoagulants and discusses the future of atrial fibrillation.

You have published over 400 scientific articles in the field of cardiovascular medicine. What do you believe to be your most significant achievement?

 

Having been active academically for more than four decades, it is hard to pick out one thing. First, I want to say that am proud of all the cardiac electrophysiology fellows we have trained who are now superb physicians and academicians.

 

I became interested in cardiac electrophysiology early on in my career, and before it was a subspecialty. I was fortunate to train in a basic science laboratory in the Department of Pharmacology at Columbia-Presbyterian Medical Center in New York with Brian Hoffman, MD, who was the father of contemporary cardiac electrophysiology. As a result, I was able to break new ground in many aspects of clinical cardiac electrophysiology, and have been able to make many contributions.

 

One of the things I am most known for is the concept of entrainment of cardiac arrhythmias. This is a method for identifying and characterizing reentrant cardiac arrhythmias, and has become a seminal part of everyday procedures in clinical cardiac electrophysiology laboratories around the world. Of note, the key paper we published on entrainment was selected by the American College of Cardiology (ACC), as part of the ACC's 50th Anniversary Commemoration, as one of 14 historical (influential) articles previously published in ACC journals, and was the only article on cardiac electrophysiology. Additionally, we also showed that atrial flutter was a reentrant rhythm, despite a large school of thought stating that it was due to a single focus firing rapidly. This discovery subsequently led to ablation of the atrial flutter, which is now a curative procedure.

 

Some other contributions include the cardiac pacing interruption of tachyarrhythmias, which ultimately led to the incorporation of antitachycardia pacing algorithms in implantable pacemakers and defibrillators; the use of temporary epicardial wire electrodes in the diagnosis and treatment of arrhythmias in the immediate period following open heart surgery; mapping the course and extent of the specialized atrioventricular conduction system in complex congenital heart disease patients during open heart surgery, thereby helping to reduce the incidence of complete heart block at the time of surgical repair; and the development of an animal model for the study of atrial fibrillation and atrial flutter. Finally, I have been meaningfully involved in over 70 clinical trials, many of which made major contributions, including the Atrial Fibrillation Follow-Up Investigation on Rhythm Management (AFFIRM) trial, Cardiac Arrhythmia Suppression Trial (CAST), and Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial.

 

What are the key concepts that have influenced the field of electrophysiology and shaped it into a subspecialty of its own?

 

Originally the only tool of electrophysiology was the electrocardiogram, discovered at the turn of the 20th century. As good as the electrocardiogram was, it still had its limitations. When we started recording with catheter electrodes from inside the heart, this changed things greatly, as this approach gave us a more accurate and detailed perspective on cardiac rhythms of all sorts. The next big influence was the trials with new anti-arrhythmic drugs as well as the development and implementation of cardiac pacemakers and defibrillators.

 

You were able to transfer a lot of your research findings from the laboratory to the bedside, and have been caring for patients for many years. What clinical advice would you like to pass on to future cardiologists?

 

A key component of good care is to listen to the patient, as history still accounts for a significant percentage of the diagnosis (even though for rhythm disorders, one needs an electrocardiogram and a few other things). It is critical to establish a bond with your patient. It starts with establishing eye contact and listening to the patient, preferably without taking notes. You can write your notes afterward. If you happen to forget something, you can always go back and ask the patient. In our current time, doctors can get carried away with technology, computers and the paperless records, and never even look at a patient while taking the history.

 

There are a few rules that I have adopted through practicing medicine that I still apply today. Some rules go beyond just patient care, but help me get through many-a-day:

 

1. Thou canst always giveth, but thou canst not always taketh away.

2. Perfect is the enemy of good.

3. Don't just do something, stand there.

4. The tail does not wag the dog.

5. Slow and steady wins the race.

6. Good relationships make life easier, not more difficult.

7. A dog is a four-legged animal, but not every four-legged animal is a dog.

8. Things are never as good, nor as bad as they seem.

9. Don't assume.

10. Always give the benefit of the doubt.

11. Sometimes you just have to make your peace.

12. It has to be fun to come to work in the morning.

13. Knowledge comes, but wisdom lingers. (Tennyson)

14. Life is a compromise.

15. Good people can always work things out.

16. Always take the high road.

17. Get found out.

18. Success has 100 fathers; only failure is an orphan. (Santayana)

 

Recently four new anticoagulants have been introduced and approved by the FDA for use in patients with atrial fibrillation. What are your thoughts on the new drugs? Do you think they can address the needs of patients effectively?

 

There is a real need to protect patients with atrial fibrillation who are at risk of stroke, so we have to identify and provide them with appropriate medication. Though we have been using warfarin for over six decades now, its use has a lot of problems. It has a very narrow therapeutic range for efficacy. In addition, warfarin interacts with a large number of foods and drugs which influence its potency. For instance, patients may not be aware that by drinking cranberry juice or eating broccoli, they can increase or decrease the potency, and, thereby, the efficacy or safety of the drug. Then, too, warfarin has no predictable dose response. So it has been recognized for a long time that we need to have more and better anticoagulation options available for patients.

 

There are four new oral anticoagulant drugs that have now been approved for use by the FDA - rivaroxaban, apixaban, edoxaban, dabigatran, - three of them are factor Xa inhibitors, and the last is a direct thrombin inhibitor. They are all more effective and safer than warfarin in most respects. The new oral anticoagulants have a rapid onset of action, within two to four hours, unlike warfarin that takes weeks to get a patient adequately anticoagulated at a stable dose. New anticoagulants also have a significantly lower chance of intracranial bleeding and hemorrhagic strokes, and far fewer drug and food interactions. Essentially, they are safer, and their efficacy is equal to or even better than that of warfarin. The new drugs are not only good for preventing stokes, they have all been approved for preventing and treating deep vein thrombosis and pulmonary embolism. Finally, antidotes to these new drugs are currently undergoing testing, and we anticipate will soon be available for use as reversal agents.

 

How will atrial fibrillation be developing over the next few years? What are some of the promising theories and technologies?

 

We believe atrial fibrillation has more than one mechanism, as we have already shown in animal models. Atrial fibrillation can be due to one or more reentrant circuits, or to a focus or foci firing rapidly. In addition, we believe that the mechanism of atrial fibrillation can change over time in the same patient. Once we fully understand and define the mechanism of atrial fibrillation, we will be able to provide better treatment for our patients through new medications and ablation procedures. I believe we are at the brink of doing that. Ablation has been a wonderful tool for the treatment, in fact, it was able to cure most arrhythmias. But for atrial fibrillation ablation, the technology is way ahead of science. Currently ablation of atrial fibrillation is an important clinical treatment option, its efficacy will be greatly improved when we understand the mechanisms of atrial fibrillation more fully so that we can better identify targets for ablation.

 

Schedule a clinical appointment with Albert Waldo, MD

 

department news report

Division of Cardiovascular Medicine

Hiram Bezerra, MD, PhD, was appointed Director of Cardiac Catheterization Laboratory at UH Case Medical Center.



 

 

 

 

 

Sahil Parikh, MD, was appointed Director of the Center for Research & Innovation at UH Harrington Heart & Vascular Institute. The center is the focal point for the acquisition of new drug, device and regenerative medicine technologies and plays a key role in realizing the goal of UH Harrington Heart & Vascular Institute of advancing care through innovation.

 

 

 


Schedule a clinical appointment with Cardiovascular Medicine physicians

 

 

 

 

Division of Gastroenterology & Liver Disease

Fabio Cominelli, MD Fabio Cominelli, MD, PhD, was awarded a $6 million grant from the NIH to establish Cleveland Digestive Diseases Research Core Center. The center will be one of only 17 in the country and will concentrate on researching digestive inflammation, metabolic diseases, gastrointestinal cancer and liver through the collaboration of Cleveland Clinic and University Hospitals.

 





 

 


Division of General Internal Medicine

Attila Nemeth, MD, Charlie LoPresti, MD, and Todd Smith, MD, were awarded the Annual Scholarship in Teaching award from the School of Medicine for the project entitled "Bedside Procedure Simulation Training: Two Years of Increasing the Confidence of Acting Interns." Dr. Nemeth and his team will present their notable work at the 2015 Society of Hospital Medicine's Annual Meeting.

 

 

Mimi Singh, MD, was awarded a $3 million grant for the continuation of the Center of Excellence in Primary Care education. The funding will support further training of future health care professionals.

 

 

 

 

Division of Geriatrics & Palliative Care


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Stefan Gravenstein, MD, MPH, published an article entitled "Are We Teaching Our Hospitalized Patients Self-Management Skills? Opportunities Lost" in the Journal of Hospital Administration. Dr. Gravenstein and his team argue that readmission risk can be reduced by teaching patients four basic self-management skills during routine clinical encounters.



 

 

Schedule a clinical appointment with Geriatrics & Palliative Care physicians

 

 

 

 

 

 

Division of Hematology & Oncology

Lisa Arfons, MD, was awarded $250,000 funding to continue the Specialty Care in Education Center of Excellence from the Office of Academic Affiliations. The center fosters the transformation of clinical education and patient care by preparing graduates of health professional schools and programs to work in and lead patient-centered interdisciplinary and interprofessional teams in providing specialty care in the setting of coordinated longitudinal primary care.
In addition, Phyllis Nsiah-Kumi, MD, Lisa Arfons, MD, and Brook Watts, MD, were awarded a $50,000 grant from VACO Women's Health Services through the 2015 Women's Health Grant RFP for the project entitled "Achieving Excellence in Breast Health Services for Women Veterans." The project focuses on testing an electronic tool for tracking breast care services program, developing a new Women Veterans Cancer Support Group, and offering formalized navigation services for breast care patients.

 

Richard Chang, MD, was appointed as Chair of the Cancer Committee at St. John Medical Center.

 

 

 

 

 

 

 

Department of Medicine Staff

Deena Segal became Chair-Elect of the Association of Program Directors in Internal Medicine (APDIM) Program Administrators Advisory Council for 2015 - 2016. Ms. Segal completed her Certification for Training Administrators of Graduate Medical Education Programs a few months ago.


department conferences & events

Team Science Challenge

The purpose of Team Science Challenge is advancing modern medical research. The awards from the Department of Medicine will provide support for developing a major research proposal to a multidisciplinary team.

Application Deadline: May 1, 2015
Submission: Send applications in PDF format to Martha Salata

 


Research Day 2015

When: Friday, May 15

When: 12:00 - 3:30 p.m.

Where: Wolstein Research Building Atrium and Lobby

Abstracts Deadline: Monday, May 4

Click here to register for the event

 

 


Grand Rounds

When: Tuesdays, 12:00 - 1:00 p.m.

Where: Kulas Auditorium, Lakeside, 5th Floor

 

March 3

"Streptococcus Pneumoniae: Prevention and Treatment" by Michael Jacobs, MD, PhD

 

March 10

"Update on Ophthalmology for the Internist" by Douglas Rhee, MD

 

March 17

"Interventional Pulmonology" by Jordan Kazakov, MD

 

March 24

"Improving Veteran Access to Lung Cancer Care" by Rami Monochakian, MD

 

March 31

"Mentoring: What Do We Need? How to Get It?" by Marjorie Greenfield, MD

department humanities journal

Lasting Impressions is an online medical humanities journal that serves as an avenue for artistic expression of the Cleveland medical community. It is an outlet for providers to share their reflections on anything from patient interactions to work/life balance. By sharing our lives through artwork and writing, our medical experience is elevated, and our medical community becomes stronger.

Submission Guidelines

What: Poetry, prose, photography or artwork from medical students, trainees, alumni, faculty and health care workers

Deadline: March 1, 2015

Contact: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Detailed Guidelines

 

department leadership council minutes

Leadership Council

Dr. Walsh introduced Cathy Koppelman and Robin Rowell who presented on LIP (Licensed Independent Practitioners) Workforce and Professional Development Task Force - System Assessment including: LIP Workforce and Professional Development Taskforce Members; UH - Current State; Drivers of need for LIPs and criteria for placement; and Priority areas for development. UH Case Medical Center currently has 350 LIPs.

 

Leadership Council

 

Dr. Chandra gave an update on the UH Primary Care Institute.

 

 

 

Leadership Council Dr. Armitage distributed data on overdue attending evaluations. He also gave an update on intern recruitment. Over 650 applicants were interviewed this year. Match results are released to the departments on March 19 and to the applicants on March 20.

 

Leadership Council Dr. Salata presented information on the Team Science Challenge grants. These awards, from the Department of Medicine, provide seed support for developing a major research proposal. Grants will have an initial annual budget not to exceed $25,000 direct costs each and be for up to one year in duration. The grant deadline is May 1, 2015, and more information will be forthcoming from Dr. Hostetter.

 

 

5 Dr. Walsh requested information from Division Chiefs by June 1 to be utilized for the planning of allocation of resources. A template for this data will be distributed.

 

Among the nation's leading academic medical centers, University Hospitals Case Medical Center is the primary affiliate of Case Western Reserve University School of Medicine, a nationally recognized leader in medical research and education.