Internal Medicine 2020 Projects

Project Title: Pulmonary Arterial Hypertension in Anti-synthetase Syndromes

Faculty Mentor: Raju Reddy 
Email: raju.reddy@medicine.ufl.edu 

Student: Jaimie Bryan and Abheek Raviprasad 
Email: jbryan1@ufl.edu raviprasada@ufl.edu 

Research Project Description:

Pulmonary arterial hypertension (PAH) is defined as an increased mean pulmonary artery pressure > 20 mmHg at rest with normal pulmonary artery occlusion pressures and pulmonary vascular resistance > 3 Woods units(1). Amongst various etiologies of PAH, the second most common cause of PAH is due to chronic hypoxic lung disorders such as interstitial lung diseases (ILDs). The prevalence of PAH in ILD is approximately 15%(2). However, ILDs are a broad group of heterogenous lung disorders that includes exposure (environment, drugs) related lung diseases, connective tissue disease lung diseases, sarcoidosis and so on. In each of these ILDs, the prevalence of PAH varies. For example, up to 10% of patients with scleroderma develop PAH whereas < 5% of patients with sarcoidosis develop PAH(3,4). Therefore, the risk factors and prevalence of PAH varies according to the ILD. One form of ILD is anti-synthetase syndrome related ILD (ASS-ILD. To date, there is only study that has examined the prevalence of PAH in ASS-ILD(5). The presence of PAH in this cohort increased mortality substantially (hazard ratio 5.1, 95% confidence interval 1.1–24.9; p=0.042) compared to those without PAH. However, the major limitations to this study are 1) single center data and 2) no external validation. Furthermore, the only other evidence of PAH in ASS-ILD is limited to isolated case reports. Therefore, we would like to examine our center’s cohort of patients with ASS-PAH and assess the prevalence of PAH and identify risk factors associated with the presence of PAH.

Project Title: Evaluation of Choosing Wisely Recommendations on Preoperative Cardiovascular Testing

Faculty Mentor:David Winchester 
Email: david.winchester@medicine.ufl.edu 

Student: Keval Patel
Email: kpatel347@ufl.edu 

Research Project Description:

Preoperative cardiovascular testing is often performed despite minimal evidence for patient benefit. The Choosing Wisely campaign is an effort by professional medical societies to create lists of low value health care strategies and encourage physicians and patients to minimize use of these strategies. Multiple Choosing Wisely lists identify preoperative cardiovascular (CV) testing as low value. We will evaluate patterns of care at UF Health related to preoperative CV testing. We hypothesize that preoperative CV testing will decrease after the publication of Choosing Wisely recommendations. The Choosing Wisely initiative has received substantial media attention in both the lay and medical press. Limited evidence from other areas of care have suggested reductions in low value care.

Project Title: Patients Opinions of Colorectal Cancer Screening

Faculty Mentor: Maryam Sattari 
Email: maryam.sattari@medicine.ufl.edu 

Student: Alexander Gitin 
Email: agitin@ufl.edu  

Research Project Description:

Colorectal cancer (CRC) is the third-leading cause of cancer death among adult men and women in the United States. (1) Currently, the United States Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer for adults aged 50-75 years old. (2) Despite consensus recommendations for screening, only 59% of eligible adults have undergone screening. (3) There is evidence that CRC screening adherence differs depending on which test is recommended by providers. In a 2012 study, 997 subjects at average risk of developing CRC were randomly assigned to receive recommendations for screening by either fecal occult blood test (FOBT), colonoscopy, or a choice of either FOBT or colonoscopy. The results showed that those assigned to FOBT or a choice of colonoscopy or FOBT, were more likely to undergo screening, compared to those who were recommended to undergo screening by colonoscopy. (4) At present, there is insufficient evidence for the USPSTF to establish a universal recommendation of use of one screening test over the others.(2,5) Furthermore, there is a multitude of other available screening tests, including flexible sigmoidoscopy, computed tomography colonography, the fecal immunochemical test, the multitargeted stool DNA test, and the methylated SEPT9 DNA test, for patients and providers to choose from.

  1. Henley SJ, Ward EM, Scott S, Ma J, Anderson RN, Firth AU, et al. Annual Report to the Nation on the Status of Cancer, part I: National cancer statistics. Cancer. 2020 Mar 12. doi: 10.1002/cncr.32802. [Epub ahead of print]
  2. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr, García FAR, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2016 Jun 21;315(23):2564-2575.
  3. Brown ML, Klabunde CN, Cronin KA, White MC, Richardson LC, McNeel TS. Challenges in meeting Healthy People 2020 objectives for cancer-related preventive services, National Health Interview Survey, 2008 and 2010. Prev Chronic Dis. 2014 Feb 27;11:E29.
  4. Inadomi JM, Vijan S, Janz NK, Fagerlin A, Thomas JP, Lin YV, et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012 Apr 9;172(7):575-82.
  5. Quintero E, Castells A, Bujanda L, Cubiella J, Salas D, Lanas Á, Andreu M, et al. Colonoscopy versus fecal immunochemical testing in colorectal-cancer screening. N Engl J Med. 2012 Feb 23;366(8):697-706.
  6. Lieberman D, Ladabaum U, Cruz-Correa M, Ginsburg C, Inadomi JM, Kim LS, et al. Screening for Colorectal Cancer and Evolving Issues for Physicians and Patients: A Review. JAMA. 2016 Nov 22;316(20):2135-2145.
  7. Janz NK, Wren PA, Schottenfeld D, Guire KE. Colorectal cancer screening attitudes and behavior: a population-based study. Prev Med. 2003 Dec;37(6 Pt 1):627-34.

Project Title: Efficacy of Reminders on Increasing Colorectal Cancer Screening

Faculty Mentor: Maryam Sattari 
Email: maryam.sattari@medicine.ufl.edu 

Student: Michael Bacchus and Abdillahi Ahmed 
Email: michaelbacchus@ufl.edu abdiahmed@ufl.edu 

Research Project Description:

Colorectal cancer (CRC) is the third leading cause of cancer death in both men and women in the United States, and the second leading cause when men and women are combined. CRC screening has been shown to reduce/decrease both CRC incidence, via removal of pre-cancerous polyps, and mortality by identifying the cancer at an early stage where treatment is more effective (1,5). The utility of screening has been recognized by many, leading to large increases in the percentage of Americans over the age of 50 being screened since the early 2000s (3). According to the U.S. Preventive Services Task Force, it is recommended that individuals aged 50 to 75 undergo CRC screening. Despite a trending increase in recommended individuals completing screening, screening compliance was only 66% in 2018 (3). Of note, disparities in both incidence and mortality related to CRC remain and, due to the effectiveness of screening on both variables, may be addressed by identifying predictors of screening compliance.

There are many CRC screening methods available, including stool-based tests such as guaiac-based fecal occult blood tests (gFOBT), fecal immunochemical tests (FIT), or multitargeted stool DNA tests (FIT-DNA). There are also direct visualization tests, including colonoscopy, CT colonography, flexible sigmoidoscopy, or flexible sigmoidoscopy with FIT (4). Despite distinct advantages and disadvantages of each screening method, it has been shown that all common screening methods decrease CRC mortality. Furthermore, screening is associated with significant healthcare cost savings ($10,000 to $25,000) compared to no screening (2). The multifaceted benefits of CRC screening including mortality decrease and financial savings highlights the value of research targeted to improving screening compliance.

  1. Sparks JA, Barbhaiya M, Karlson EW, et al. Investigating methotrexate toxicity within a randomized double-blinded, placebo-controlled trial: rationale and design of the Cardiovascular Inflammation Reduction Trial-Adverse Events (CIRT-AE) Study. Semin Arthritis and Rheum. 2017;47:133-42. [PMID:28284844] doi:10.1016/j.semarthrit.2017.02.003
  2. Solomon DH, Glynn RJ, Karlson EW, et al. Adverse effects of low-dose methotrexate. Ann Intern Med. 2020;172:369. doi:10.7326/m19-3369.
  3. Alarcon GS, Tracy IC, Blackburn WD Jr. Methotrexate in rheumatoid arthritis. Toxic effects as the major factor in limiting long-term treatment. Arthritis Rheum. 1989;32:671-6. [PMID: 2735960]
  4. Hanrahan PS, Scrivens GA, Russell AS. Prospective long term follow-up of methotrexate therapy in rheumatoid arthritis: toxicity, efficacy and radiological progression. Br J Rheumatol. 1989;28:147-153. [PMID:2706419]
  5. Weinblatt ME. Toxicity of low dose methotrexate in rheumatoid arthritis. J Rheumatol Suppl. 1985;12 Suppl 12:35-9. [PMID:3913775]
  6. Ridker PM, Everett BM, Pradhan A, et al. Low-dose methotrexate for the prevention of atherosclerotic events. N Engl J Med. 2019; 380:752–762. doi: 10.1056/NEJMoa1809798

Project Title: Towards Prediction of CRC in Population Under 50 Years Old Using EHR-based Machine Learning

Faculty Mentor: Thomas George 
Email: thom.george@medicine.ufl.edu 

Student: Max Parker 
Email: max.parker@ufl.edu 

Research Project Description:

Colorectal cancer (CRC) is the 3rd most common cancer worldwide, and approximately 4.2% of both men and women will be diagnosed during their lifetime. Of all cancer deaths, CRC represents 8% of deaths worldwide. Despite the declining overall death rates attributed to screening programs over the past three decades, the overall 5 year survival rate for patients with CRC was only 64% from 2009-2015. There were an estimated 145,600 new cases and a total of 51,020 deaths in the US in 2019 from CRC. More concerning, there has been an increase in incidence of CRC in patients under 50 and these malignancies in the younger population have been shown to be more aggressive in comparison to ages over 50.
With the introduction of CRC screening programs, national guidelines currently recommend screening assessment (via endoscopy or fecal-based assays) beginning at the age of 50 for those without CRC risk factors. This allows early detection of cancer and pre-cancerous (i.e. hyperplasia, tubular adenoma) pathology leading to improved chances for survival. For those with a known CRC risk factor (i.e., a genetic predisposition/family history or inflammatory bowel disease [IBD]), the age to begin CRC screening should be significantly lower to also allow for early cancer detection and optimal survival. Given the increasing incidence rates of young patients with CRC without concomitant increases in IBD or genetic predisposition, it is critical to accurately identify previously unrecognized risk factors for CRC for public health, patient care and policy recommendations.
The ability to access and analyze data from large registries offers an opportunity to identify previously unrecognized risk factors or combinations of factors in young CRC patients that may be associated with this unfortunate trend in oncology. Currently, there is no model that is sufficient to cover the full range of risk factors across variable demographics. Most models use a non-genetic approach with typical multivariable linear regression techniques to correlate relationships between risk factors and colorectal cancers; however, these models have limitations in focusing on details of specific risk factors.

Project Title: Does the removal of use of thromboelastography (TEG) in guiding antiplatelet therapy for patients supported with left ventricular assist devices (LVAD) reduce the incidence of bleeding complications without predisposing patients towards thromboembolic complications?

Faculty Mentor: Mustafa Ahmed 
Email: Mustafa.Ahmed@medicine.ufl.edu 

Student: Sophia Fanelli 
Email: sfanelli@ufl.edu 

Research Project Description:

LVADs such as the commonly used HeartMate II (Abbott) and the more HeartWare HVAD (Medtronic) contemporary HeartMate III have broadened the horizon for intermediate and long-term circulatory support in patients with end stage heart failure and a poor prognosis despite optimal medical therapy (1). LVADs are utilized as a bridge to transplant or as destination therapy (1). With the immense technological advances that have been made over time, focus has shifted more toward minimizing long-term complications, improving quality of life, and decreasing cost-associated with device implantation rather than just addressing survival2.

The most common adverse event post implant is LVAD-associated gastrointestinal bleeding (GIB), with an incidence of up to 39% (3,4). GIB places a significant toll on the health care system. It is the second leading cause for 30-day readmissions after LVAD implantation, and the most frequent cause for any post-implant hospitalization (5,6). The pathophysiology of LVAD associated GIB is multifactorial, with AV malformations, acquired von Willebrand’s deficiency and dysregulation of angiogenic factors due to increased shear stress and mucosal ischemia all contributing(7-10). The degree of anticoagulation and anti-platelet therapy exacerbates this predisposition to bleeding and therefore may be a target to improve this adverse event.

Much research has been done on ventricular assist devices in an effort to identify the different factors related to these complications, but results across different studies have been relatively unpredictable and can vary, especially with respect to antiplatelet therapy (1). The role of TEG in optimizing anti-platelet therapies in LVAD recipients is unclear.

  1. Karimi A, Beaver TM, Hess PJ, et al. Close antiplatelet therapy monitoring and adjustment based upon thrombelastography may reduce late-onset bleeding in HeartMate II recipients. Interact Cardiovasc Thorac Surg. 2014;18(4):457-465.
  2. M.E. Stone, A. Pawale, H. Ramakrishna, et al. Implantable left ventricular assist device therapy-recent advances and outcomes. J Cardiothorac Vasc Anesth, 32 (2018), pp. 2019-2028.
  3. Jabbar HR, Abbas A, Ahmed M, Klodell CT Jr, Chang M, Dai Y, Draganov PV. The incidence, predictors and outcomes of gastrointestinal bleeding in patients with left ventricular assist device (LVAD). Dig Dis Sci. 2015;60:3697–3706.
  4. Mehra MR, Goldstein DJ, Uriel N, et al. Two-year outcomes with a magnetically levitated cardiac pump in heart failure. N Engl J Med. 2018;378(15):1386-1395.
  5. Akhter SA, Badami A, Murray M, et al. Hospital readmissions after continuous-flow left ventricular assist device implantation: Incidence, causes, and cost analysis. Ann Thorac Surg. 2015;100(3):884-889.
  6. Koliopoulou A, Selzman CH. Stop the LVAD bleeding. J Thorac Dis. 2017;9(5):E437-E439).
  7. K.D. Aaronson, M.S. Slaughter, L.W. Miller, et al. Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart transplantation. Circulation, 125 (2012), pp. 3191-3200.
  8. G.V. Letsou, N. Shah, I.D. Gregoric, et al. Gastrointestinal bleeding from arteriovenous malformations in patients supported by the Jarvik 2000 axial-flow left ventricular assist device. J Heart Lung Transplant, 24 (2005), pp. 105-109.
  9. N. Uriel, S.W. Pak, U.P. Jorde, et al. Acquired von Willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation. Journal of American College of Cardiology, 56 (2010), pp. 1207-1213.
  10. Tabit CE, Chen P, Kim GH, et al. Elevated angiopoietin-2 level in patients with continuous-flow left ventricular assist devices leads to altered angiogenesis and is associated with higher nonsurgical bleeding. Circulation. 2016;134(2):141-152).

Project Title: Incidence of methotrexate-induced bone marrow toxicity in US Veterans with rheumatoid arthritis

Faculty Mentor: Michael Bubb
Email: michael.bubb@medicine.ufl.edu 

Student: Sylvia Arce 
Email: stsangs@ufl.edu 

Research Project Description:

The purpose of this study is to evaluate the incidence of methotrexate-induced bone marrow toxicity in US Veterans with rheumatoid arthritis. Methotrexate is a first-line medication used in the treatment of rheumatoid arthritis (RA) and is used by millions of people worldwide (1). Methotrexate has been shown to reduce the symptoms of RA, decrease joint damage, and possibly improve mortality (2). Methotrexate, however, is not without its side-effects. Low-dose methotrexate has been associated with cytopenias, including leukopenia, anemia, and thrombocytopenia (3, 4, 5). Currently, the incidence of this effect is unclear and rarely requires dose adjustment.

Recently, the Cardiovascular Inflammation Reduction Trial (CIRT), applied low-dose methotrexate or a placebo to patients with a history of myocardial infarction or multivessel coronary disease in order to determine if methotrexate resulted in a lower rate of cardiovascular events compared to the placebo. The trial lasted four years in duration. The CIRT trial found that low-dose methotrexate did not result in fewer cardiovascular events than placebo. In addition, one of the prominent findings was a low incidence of bone marrow suppression among patients who received the methotrexate (6). The data from the CIRT trial presents researchers an opportunity to evaluate the adverse effects of methotrexate therapy.

  1. Sparks JA, Barbhaiya M, Karlson EW, et al. Investigating methotrexate toxicity within a randomized double-blinded, placebo-controlled trial: rationale and design of the Cardiovascular Inflammation Reduction Trial-Adverse Events (CIRT-AE) Study. Semin Arthritis and Rheum. 2017;47:133-42. [PMID:28284844] doi:10.1016/j.semarthrit.2017.02.003
  2. Solomon DH, Glynn RJ, Karlson EW, et al. Adverse effects of low-dose methotrexate. Ann Intern Med. 2020;172:369. doi:10.7326/m19-3369.
  3. Alarcon GS, Tracy IC, Blackburn WD Jr. Methotrexate in rheumatoid arthritis. Toxic effects as the major factor in limiting long-term treatment. Arthritis Rheum. 1989;32:671-6. [PMID: 2735960]
  4. Hanrahan PS, Scrivens GA, Russell AS. Prospective long term follow-up of methotrexate therapy in rheumatoid arthritis: toxicity, efficacy and radiological progression. Br J Rheumatol. 1989;28:147-153. [PMID:2706419]
  5. Weinblatt ME. Toxicity of low dose methotrexate in rheumatoid arthritis. J Rheumatol Suppl. 1985;12 Suppl 12:35-9. [PMID:3913775]
  6. Ridker PM, Everett BM, Pradhan A, et al. Low-dose methotrexate for the prevention of atherosclerotic events. N Engl J Med. 2019; 380:752–762. doi: 10.1056/NEJMoa1809798

Project Title: College-aged IBD patients’ healthcare utilization trends and patient satisfaction with use of telemedicine approaches

Faculty Mentor: Ellen Zimmermann 
Email: ellen.zimmermann@medicine.ufl.edu 

Student: Ryanne Lehenaff 
Email: rlehenaff@ufl.edu

Research Project Description:

College-aged students with inflammatory bowel disease (Crohn’s disease and ulcerative colitis) are a unique population with different healthcare utilization patterns, and therefore, different healthcare needs than other populations with this disease (1). While attending college and transitioning to adulthood, these patients experience different life stressors associated with their disease than other groups. These include living in close quarters with unfamiliar people, lack of privacy in dormitory and campus bathrooms, challenges in making good nutritional decisions, and balancing disease management (i.e., appointments, coordinating medication deliveries, etc.) with academic obligations (2). Perhaps reflecting these additional stressors and challenges, IBD patients, particularly those with indicators of greater disease activity, have been shown to adjust more poorly to college than their peers without disease (3,4).

Previously reported data suggests that college-aged IBD patients have poorer disease outcomes than their older and younger counterparts. IBD patients age 17-25 years old have been found to have more bowel surgeries in the year after diagnosis, greater use of corticosteroids and biologics, and more emergency department (ED) visits and hospitalizations, but fewer outpatient visits, than other age groups (1). Many factors could contribute to this disparity, including lack of regular gastroenterology care, cost and insurance-related concerns, time constraints or something else entirely. Regardless, it appears that these students may be delaying care until their disease has become severe.

Given that adjustment to and success in college is critically important for future success, there is a great need for innovative solutions to the challenges that college-aged IBD patients face in achieving that success. One possible solution is the implementation of telemedicine strategies to improve access to care. To date, studies on the potential of telemedicine to impact disease outcomes in IBD have been promising (5,6); however, there is an ongoing need to determine which patient population will benefit most from these types of interventions (7). To this end, we have found no studies examining the impact of such technology specifically in a college-aged population, who are usually grouped with older adults (1). We believe that as this group has spent their entire lives engaged with ever-evolving technology, that they may be more interested in and see greater benefits from use of telemedicine approaches to their care than other groups. If it is possible to engage patients in telemedicine to provide disease education, provide preventive care, and address clinical symptoms, it could result in fewer emergency department visits, leading to fewer hospitalizations, less steroid use, and ultimately, better disease outcomes.

Project Title: Performance of systemic endothelial-derived and platelet-derived microparticles as prognostic biomarkers in COPD

Faculty Mentor: Jorge Lascano 
Email: jorge.lascano@medicine.ufl.edu 

Student: Jason Katz 
Email: jasonbkatz@ufl.edu 

Research Project Description:

COPD (Chronic Obstructive Pulmonary Disease) is a chronic, complex condition with significant morbidity, mortality, and cost associated with it (1). Recent research has focused on adopting novel methods of COPD prognostication to use alongside the widely used clinical parameters including pulmonary function tests, diffusion capacity of carbon monoxide and 6-minute walk test. Specifically, this research revolves around measuring circulating microparticles (MPs) both quantitively and qualitatively in patients’ serum.

Microparticles (MPs) are 0.1 to 1 µm membrane-bound vesicles present in circulating blood shed from cells during activation, injury or apoptosis (2,3). These particles can be measured via flow cytometry in which presence of specific transmembrane proteins characterize their cell of origin. Countless studies have shown a link between elevation of certain MPs and disease presence/progression of atherosclerosis, acute coronary disease, cerebrovascular accidents, uncontrolled arterial hypertension, diabetes, the metabolic syndrome, end-stage renal disease and pulmonary arterial hypertension (2, 4, 5-11). Furthermore, COPD is known to have a complex pathophysiology involving endothelial cell dysfunction, apoptosis, inflammation, and pro-thrombotic events. This explains the rationale for examining MPs in both COPD patients as well as patients at risk for COPD to see if similar valuable information can be obtained.

  1. Sullivan J, Pravosud V, Mannino DM, Siegel K, Choate R, Sullivan T. National and state estimates of COPD morbidity and mortality — United States, 2014-2015. Chronic Obstr Pulm Dis. 2018; 5(4): 324-333. doi: http://doi.org/10.15326/jcopdf.5.4.2018.0157
  2. Chironi GN, Boulanger CM, Simon A, Dignat-George F, Freyssinet JM, Tedgui A. Endothelial microparticles in diseases. Cell and tissue research 2009;335:143-151.
  3. Mackman N. On the trail of microparticles. Circulation research 2009;104:925-927.
  4. Amabile N, Guerin AP, Leroyer A, Mallat Z, Nguyen C, Boddaert J, London GM, Tedgui A, Boulanger CM. Circulating endothelial microparticles are associated with vascular dysfunction in patients with end-stage renal failure. Journal of the American Society of Nephrology : JASN 2005;16:3381-3388
  5. Amabile N, Guerin AP, Leroyer A, Mallat Z, Nguyen C, Boddaert J, London GM, Tedgui A, Boulanger CM. Circulating endothelial microparticles are associated with vascular dysfunction in patients with end-stage renal failure. Journal of the American Society of Nephrology : JASN 2005;16:3381-3388.
  6. Distler JH, Huber LC, Gay S, Distler O, Pisetsky DS. Microparticles as mediators of cellular cross-talk in inflammatory disease. Autoimmunity 2006;39:683-690.
  7. Owens AP, 3rd, Mackman N. Microparticles in hemostasis and thrombosis. Circulation research 2011;108:1284-1297.
  8. Arteaga RB, Chirinos JA, Soriano AO, Jy W, Horstman L, Jimenez JJ, Mendez A, Ferreira A, de Marchena E, Ahn YS. Endothelial microparticles and platelet and leukocyte activation in patients with the metabolic syndrome. The American journal of cardiology 2006;98:70-74.
  9. Amabile N, Guignabert C, Montani D, Yeghiazarians Y, Boulanger CM, Humbert M. Cellular microparticles in the pathogenesis of pulmonary hypertension. Eur Respir J 2013;42:272-279.
  10. Bernal-Mizrachi L, Jy W, Jimenez JJ, Pastor J, Mauro LM, Horstman LL, de Marchena E, Ahn YS. High levels of circulating endothelial microparticles in patients with acute coronary syndromes. American heart journal 2003;145:962-970.
  11. Bakouboula B, Morel O, Faure A, Zobairi F, Jesel L, Trinh A, Zupan M, Canuet M, Grunebaum L, Brunette A, Desprez D, Chabot F, Weitzenblum E, Freyssinet JM, Chaouat A, Toti F. Procoagulant membrane microparticles correlate with the severity of pulmonary arterial hypertension. Am J Respir Crit Care Med 2008;177:536-543
  12. Lertkiatmongkol, P., Liao, D., Mei, H., Hu, Y., & Newman, P. J. (2016). Endothelial functions of platelet/endothelial cell adhesion molecule-1 (CD31). Current opinion in hematology, 23(3), 253–259. https://doi.org/10.1097/MOH.0000000000000239
  13. Jimenez, J. J., Jy, W., Mauro, L. M., Soderland, C., Horstman, L. L., & Ahn, Y. S. (2003). Endothelial cells release phenotypically and quantitatively distinct microparticles in activation and apoptosis. Thrombosis Research, 109(4), 175–180. doi: 10.1016/s0049-3848(03)00064-1

Project Title: Assessment of Perioperative Neuroendocrine Evaluation of Pituitary Patients at the University of Florida

Faculty Mentor: Whitney Woodmansee
Email: whitney.woodmansee@medicine.ufl.edu  

Student: Austin White 
Email: a.white232@ufl.edu 

Research Project Description:

Patients with pituitary tumors can be treated medically or surgically (1). Patients with clinically or radiographically detected tumors undergo thorough work-up involving documentation of their complete medical history, performance of comprehensive neurological and physical examinations, characterization of their lesion and its behavior via magnetic resonance imaging (MRI), and evaluation of neuroendocrine (NE) hormonal laboratory results (2). Patients with visual field impairment, radiographic evidence of optic nerve compression, or hypersecreting tumors, aside from prolactinomas, typically require transsphenoidal surgical resection (TSS) of their tumor (3, 6). Among these patients, it is important that NE laboratory assessments are performed and evaluated both pre- and post-operatively in order to assess and monitor overall endocrine functional status. The results of preoperative laboratory results performed within three months prior to surgery will inform their treatment plan and can indicate the need for management of endocrine dysfunction, such as the initiation of perioperative hormone replacement, which may reduce the patient’s risk for complications (4).

A comprehensive work-up includes assessment of serum prolactin in addition to the adrenocortical, thyroid, reproductive, and growth hormone axes (3). It is particularly critical that clinicians know the adrenocortical and thyroid functional status among these patients prior to surgery due to concern for adrenal insufficiency (AI) (4) and to assess individual risk for cardiac dysfunction or hyponatremia related to concomitant hypothyroidism (5). The extent to which comprehensive NE hormonal assessments are being included in work-up and follow-up for surgical patients at the University of Florida is currently unknown. Given the importance of characterizing NE status and individual risk, it is beneficial to determine the frequency of comprehensive NE hormonal assessment completion perioperatively and to evaluate the impact of a standardized laboratory panel on completion rates following implementation.

  1. Esposito D, Olsson DS, Ragnarsson O, Buchfelder M, Skoglund T, Johannsson G. Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management. Pituitary. 2019;22(4):422‐434. doi:10.1007/s11102-019-00960-0
  2. Freda PU, Beckers AM, Katznelson L, et al. Pituitary incidentaloma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2011;96(4):894‐904. doi:10.1210/jc.2010-1048
  3. Prete A, Corsello SM, Salvatori R. Current best practice in the management of patients after pituitary surgery. Ther Adv Endocrinol Metab. 2017;8(3):33‐48. doi:10.1177/2042018816687240 (34)
  4. Santhanam P, Saleem S, Saleem T. Diagnostic predicament of secondary adrenal insufficiency. Endocrine prac. 2010; 16(4): 686-691. doi: 10.4158/EP0011.RA
  5. Woodmansee W, Carmichael J, Kelly D, Katznelson L. American association of clinical endocrinologists and American college of endocrinology disease state clinical review: postoperative management following pituitary surgery. Endocrine prac. 2015; 21(7): 832-838. doi: 10.4158/EP14541.DSCR
  6. Orija IB, Weil RJ, Hamrahian AH. Pituitary incidentaloma. Best Pract Res Clin Endocrinol Metab. 2012; 26(1) 47-68. doi: 10.1016/j.beem.2011.07.003

Project Title: Pulmonary Arterial Hypertension in Anti-synthetase Syndromes

Faculty Mentor: Raju Reddy 
Email: raju.reddy@medicine.ufl.edu 

Student: Veronica Kuteyeva 
Email: vkuteyeva17@ufl.edu

Research Project Description:

Interstitial Lung Diseases (ILDs), a diverse group of diseases related to inflammation and scarring of lung interstitium, are often complicated by and are the second most common cause of pulmonary arterial hypertension (PAH). Pulmonary arterial hypertension can be severe and life threatening, and is characterized by mean pulmonary artery greater than 20 mmHg at rest with normal pulmonary artery occlusion pressures. Although 15% of patients with ILDs also develop PAH, it is difficult to assess the correlation because ILDs encompass a variety of pathology with different prevalence and risk factors of PAH in each. A few ILDs have been studied, including scleroderma and sarcoidosis, finding prevalence of 10% and <5% respectively, which shows that prevalence and risk of PAH with ILD will be different between different pathologies. However, a specific ILD, Anti-Synthetase Syndrome (ASS), has only had one study exploring the prevalence of PAH in patients with ASS-ILD. This study found that concurrent PAH increased mortality rates of the patients significantly (hazard ratio 5.1, 95% confidence interval 1.1–24.9; p=0.042). However, the topic needs more research and attention because the single study used single center data with no external validation. As a result, we would like to provide additional evidence to evaluate its conclusions and provide more data on this interaction. We aim to examine the prevalence of PAH and the risk factors associated in UF Health Pulmonology Center’s cohort of patients with ASS or ASS-ILD. The results of this study are important to improving patient outcomes and better understanding of pulmonary pathophysiology.

Our hypothesis is that the presence of PAH in patients with ASS or ASS-ILD increases all-cause mortality (deaths from any cause in a time period). This hypothesis is based on the rationale that a previous single study on PAH in ASS-ILD found a significant increase in mortality amid ASS-ILD patients with PAH versus without (hazard ratio 5.1, 95% confidence interval 1.1–24.9; p=0.042).

References:

  1. Frost A, Badesch D, Gibbs JSR, et al. Diagnosis of pulmonary hypertension. Eur Respir J. 2019;53(1):801904.
  2. Handa T, Nagai S, Miki S, et al. Pulmonary Hypertension and Its Clinical Relevance in Patients with Interstitial Pneumonias comparison between idiopathic and collagen vascular disease associated interstitial pneumonias. Intern Med. 2007;46(12):831-7.
  3. Morrisroe K, Huq M, Stevens W, Rabusa C, et al. Risk factors for development of pulmonary arterial hypertension in Australian systemic sclerosis patients: results from a large multicenter cohort study. BMC Pulm Med. 2016;16(1):134.
  4. Mayock RL, Bertrand P, Morrison CE, et al. Manifestations of sarcoidosis. Analysis of 145 patients, with a review of nine series selected from the literature. Am J Med. 1963;35:67.
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