UPMC Physician Resources

Model to Improve Diabetes Management Well-Received by Primary Care Physicians

 PITTSBURGH, Sept. 11, 2014 – Nurses certified in diabetes education can be integrated successfully into primary care physician offices in an effort to improve the health of people with diabetes, according to a University of Pittsburgh Graduate School of Public Health evaluation funded by the American Diabetes Association

The determination was made following enrollment and initiation of the REdesigning MEDication Intensification Effectiveness Study for Diabetes (REMEDIES 4D), an ongoing trial to assess the effectiveness of certified diabetes educators in managing diabetes. The research is published in the September issue of the journal Contemporary Clinical Trials

“The vast majority of people with diabetes are seen by primary care physicians who have increasingly limited time to address the complexities of each patient’s care,” said Janice Zgibor, Ph.D., R.Ph., associate professor of epidemiology at Pitt Public Health. “A new model of care is necessary to best treat the growing number of people with diabetes.” 

The REMEDIES 4D trial includes 240 participants from 15 UPMC primary care practices, consisting of 57 physicians and two physician assistants. Eight of the practices are randomly assigned to receive a certified diabetes educator who provides treatment for glucose, blood pressure and cholesterol control; diabetes education; and follow-up to patients. The remaining practices serve as a control group and are proceeding with their usual care. 

A certified diabetes educator is a trained nurse who meets with diabetic patients, reviews their test results and medications, as well as their efforts to control diabetes through lifestyle changes. This nurse is certified to make therapeutic adjustments, such as changing medications when needed.  She also can educate the patient about managing diabetes and help with emotional issues, such as fear of needles or diabetes-related depression. 

“The certified diabetes educator’s main focus is staying on top of managing patients’ diabetes,” said Dr. Zgibor. “This could help prevent long-term diabetes complications, such as blindness and amputation, because the certified diabetes educator may be able to address care issues faster than the physician.”

Although the clinical trial pays for the cost of the certified diabetes educator provided to participating practices, Dr. Zgibor said there are ways to make the cost less of a burden to other practices interested in implementing the model, such as sharing a certified diabetes educator or completing requirements for insurance reimbursement. 

The REMEDIES 4D trial will include an economic evaluation to determine the cost-effectiveness of certified diabetes educators, both to primary care providers and society. 

“In addition to helping patients, we’re finding that the presence of the certified diabetes educator in primary care practices also is a resource to physicians and office staff with diabetes-related questions,” said Dr. Zgibor. “So far, it seems like this model of diabetes care is well-received in primary care physicians’ offices. It will be interesting to see whether it proves to be a cost-effective way to manage the diabetes epidemic that is becoming an increasing burden on the U.S. health system.”

Additional researchers on this study are Shihchen Kuo, Ph.D., R.Ph., Patricia Gittinger, R.N., Debra Tilves, B.S., and Maura Maloney, M.S., all of Pitt; Sharlene Emerson, C.R.N.P., and Francis X. Solano, M.D., both of UPMC; and Mayer B. Davidson, M.D., of the Charles R. Drew University in Los Angeles.

 This study was funded by the American Diabetes Association grant 1-12-SAN-31.

UPMC Residency Programs Rank Nationally

Physician network Doximity, along with U.S. News & World Report, announced the first comprehensive national evaluation of residency programs. In these results, 11 UPMC programs ranked in the top 10.

To determine the rankings, 3,691 residency training programs were evaluated by combining over 50,000 peer nominations from board-certified US physicians. U.S. News & World Report, nationally known for their education and health care rankings, consulted on the methodology.

Here is a listing of UPMC programs in the top 10:

  • Anesthesiology: No. 10
  • Obstetrics and gynecology: No. 3
  • Plastic surgery (integrated): No. 3
  • Otolaryngology: No. 4
  • Emergency medicine: No. 7
  • Physical medicine and rehabilitation: No. 7
  • Psychiatry: No. 7
  • Orthopaedic surgery: No. 8
  • Pediatrics: No. 8
  • Neurological surgery: No. 9
  • Surgery: No. 10

The results are used in a free tool from Doximity called Residency Navigator. The tool is designed for third- and fourth-year medical students.

Pitt, UPMC Researchers Create New Vestibular Test to Add to Comprehensive Concussion Evaluation

PITTSBURGH, Sept. 10, 2014 – Researchers at UPMC and the University of Pittsburgh have created a new, 5- to 10-minute test that could be added to a clinician’s concussion evaluation toolkit for a more comprehensive assessment of the injury. 

In a recent study published online first by the American Journal of Sports Medicine, researchers from the UPMC Sports Medicine Concussion Program demonstrated that clinicians could use their novel Vestibular/Ocular Motor Screening (VOMS) examination to be 90 percent accurate in identifying patients with concussion. The VOMS, which requires such minimal equipment as a tape measure and a metronome, was shown to be a valid and consistent tool to enhance the current multi-disciplinary approaches to concussion assessment that include clinical examination, symptom evaluation and computerized neurocognitive testing. 

Previous research conducted at UPMC identified the vestibular ocular system — responsible for integrating vision, balance and movement — as being the most predictive of longer outcomes from sports-related concussions. However, the researchers reported, most current evaluation and management tools for vestibular issues focus on balance, potentially missing important pieces of the concussion puzzle. In fact, the Sideline Assessment of Concussion (SAC), Sport Concussion Assessment Tool-3 (SCAT-3), Balance Error Scoring System (BESS), and similar tests fail to both comprehensively evaluate the vestibular system and measure ocular-motor dysfunction, they added.

“We were afraid that important findings were being missed in many patients following their concussion because we just didn’t have the right tool to measure this part of the injury,” said Anne Mucha, D.P.T., Concussion Program clinical coordinator for vestibular therapy and principal investigator in this research. “Current assessments clearly weren’t sufficient in identifying most of the dizziness and visual problems that we commonly see in our patients.”

“The VOMS is another tool in our toolkit,” said Michael “Micky” Collins, Ph.D., Concussion Program executive and clinical director who took part in this study. “For the past five to 10 years, our research has revealed that vision issues, fogginess and dizziness are symptoms associated with the worst outcomes in our patients. So we set out to create an evidence-based examination to assess these areas.”

The researchers studied 64 concussed patients approximately five days post-injury and 78 healthy control-group patients who were administered VOMS by trained clinicians. The VOMS, which was developed in conjunction with a multi-disciplinary team of UPMC experts, assesses five areas of the vestibular ocular system: smooth pursuits, saccades (rapid eye movement), horizontal vestibular ocular reflex, visual motion sensitivity, and near-point-of-convergence distance. Standardized screening instructions are attached as appendices with the journal paper.

“The results from the current study indicated that more than 60 percent of patients experienced symptoms following the VOMS — and these are patients whose impairments might have been missed without a tool like it,” said Anthony Kontos, Ph.D., Concussion Program assistant research director and senior investigator.

“Current assessment tools are not looking at these issues, which concerns us greatly,” Dr. Collins said. “We are seeing many young athletes who, in addition to neurocognitive deficiencies, are coming to us with vestibular ocular impairment. The VOMS provides a more specific evaluation that can help us better treat these patients using targeted treatment pathways. By integrating the VOMS with current tools, clinicians could very well foster a paradigm shift in concussion diagnosis and management.”

Other co-authors were: Joseph Furman, M.D., Ph.D., Pitt departments of Otolaryngology, Neurology, Bioengineering and Physical Therapy as well as Director, UPMC Division of Balance Disorders; Greg Marchetti, Ph.D., of Duquesne University; former Pitt researcher R.J. Elbin, Ph.D., University of Arkansas; and Cara Troutman-Enseki, D.P.T., and Ryan DeWolf, M.S., UPMC Concussion Program. The study was supported in part by a grant from the National Institute on Deafness and Other Communication Disorders, No. 1K01DC012332-01A1.

Internationally Acclaimed Scientist Named Co-Leader of UPCI Lung Cancer Program

PITTSBURGH, September 9, 2014 – An international leader in the field of epigenetics whose work has led to important discoveries into how cancer develops and progresses has been named the co-leader of the Lung Cancer Program at the University of Pittsburgh Cancer Institute (UPCI), partner with UPMC CancerCenter. James Herman, M.D., comes to Pittsburgh from Johns Hopkins School of Medicine, where he joined the faculty in 1996. 

At Pitt’s School of Medicine, Dr. Herman will be a visiting professor of medicine in the Division of Hematology/Oncology. His appointment is effective Nov. 1. 

“Jim is a senior scientist who brings extensive experience to UPCI. He will assume leadership of the UPCI Lung Cancer SPORE grant and work closely with Dr. Mark Socinski in our Lung Cancer Program, strengthening an already impressive team,” said Nancy E. Davidson, M.D., director of UPCI and the UPMC CancerCenter. The National Cancer Institute’s prestigious SPORE, or Specialized Program of Research Excellence, is one of four such specialized research grants held at UPCI.

In addition to his work as a researcher, Dr. Herman is expected to have an appointment at the Veterans Affairs Hospital in Pittsburgh, where he will work to promote clinical care, education and clinical trials in thoracic malignancies. He will also serve as a co-director of the medical oncology fellowship program to promote training in basic and translational research.

“Our fellows are very lucky to have the opportunity to work with and learn from Dr. Herman. He has a vast knowledge of cancer research, and we can all benefit from having someone of his caliber on our team,” said Edward Chu, M.D., deputy director of UPCI and chief of the Division of Hematology-Oncology.

The author of more than 250 papers, chapters and editorials, Dr. Herman and his team are especially well-known for their development of the methylation-specific PCR assay (MSP), which is widely used to characterize DNA methylation patterns. His work has been supported by a variety of sources, including a V Scholar Award, multiple grants from the National Institutes of Health (including service as a project co-leader on the Hopkins Lung Cancer SPORE), and most recently a Department of Defense grant, all in the general area of epigenetics of cancer. He has served as a member of the editorial board for a number of journals, including Clinical Cancer Research and Journal of Clinical Oncology.

Dr. Herman received his medical degree from Johns Hopkins in 1989, where he was elected to Alpha Omega Alpha.  After completing a residency in internal medicine at Duke, he returned to Hopkins to undertake a fellowship in medical oncology. He joined the Hopkins faculty in 1996, and rose through the ranks to serve as professor of oncology starting in 2009.

Race and Ethnicity Important When Evaluating Risk of Fat Around the Heart

PITTSBURGH, Sept. 9, 2014 – A man’s likelihood of accumulating fat around his heart – an important indicator of heart disease risk – may be better determined if doctors consider his race and ethnicity, as well as where on his body he’s building up excess fat, reveals an international evaluation led by the University of Pittsburgh Graduate School of Public Health

The findings, published online today in the International Journal of Obesity, indicate that it may be useful to take racial and ethnic differences into account when designing programs to reduce obesity because what works for one man might not be as beneficial for another.  This analysis was funded in part by the National Institutes of Health (NIH).

“If you are an African American man and carry excess weight mainly around the mid-section, then you have a higher likelihood of more fat around the heart than if you gain weight fairly evenly throughout your body,” said lead author Samar R. El Khoudary, Ph.D., M.P.H., assistant professor in Pitt Public Health’s Department of Epidemiology. “But the reverse is true for Koreans – their heart disease risk is greater with overall weight gain. Knowing this can help doctors specify the right physical training for each racial ethnic group to reduce their heart disease risk.”

Dr. El Khoudary’s analysis relied on data from the “Electron-Beam Tomography, Risk Factor Assessment Among Japanese and U.S. Men in the Post-World War II Birth Cohort Study,” also known as the ERA JUMP study. It is a population-based study of men enrolled between 2002 and 2006 who were ages 40 to 49 and free of cardiovascular disease, type-1 diabetes and other severe diseases at the time of enrollment.

The recent analysis took a closer look at 1,199 men in the study who were white or black from Allegheny County, Japanese-American from Hawaii, Japanese or Korean.

The study looked at the amount of fat around the heart called ectopic cardiovascular fat. Higher volumes of this fat are associated with greater risk of heart disease.

For white men, an increase in body mass index, or BMI, which is a measure of overall body fat, and abdominal fat are equally likely to indicate an increase in fat around the heart.

Compared to white men:

  • Black men who carry disproportionally more weight around their mid-section are at similar risk of having more fat around their hearts. Increases in BMI have lower impact.
  • Japanese and Japanese American men are also at similar risk of having more fat around their hearts if they have more fat in their abdomens, with BMI having less of an impact.
  • Korean men with higher BMIs have a higher likelihood of fat around the heart, whereas abdominal fat matters less.

“What we now need to determine is whether concentrating efforts to reduce overall body fat or fat in the abdomen will actually decrease fat around the heart more in people of certain racial or ethnic groups,” said Dr. El Khoudary. “Such a long-term evaluation could help in designing race-specific heart disease prevention strategies.”

The senior author and principal investigator on this study is Akira Sekikawa, M.D., Ph.D., Pitt. Additional authors on this study are Emma Berinas-Mitchell, Ph.D., Aiman El-Saed, M.D., Ph.D., Rhobert W. Evans, Ph.D., and Lewis H. Kuller, M.D., Dr.P.H., all of Pitt; Chol Shin, M.D., Ph.D., of Korea University; Kamal Masaki, M.D., and Bradley J. Willcox, M.D., both of the University of Hawaii; Katsuyuki Miura, M.D., Ph.D., Sakaya Kadowaki, M.D., Ph.D., Akira Fujiyoshi, M.D., M.P.H., Ph.D., Takashi Hisamatsu, M.D., Ph.D., and Hirotsugu Ueshima, M.D., Ph.D., all of Shiga University of Medical Science in Japan; Matthew Budoff, M.D., of Los Angeles Biomedical Research Institute; Daniel Edmundowicz, M.D., of Temple University School of Medicine; and Takayoshi Ohkubo, M.D., Ph.D., of Teikyo University School of Medicine in Japan.

This work was supported by NIH grants HL068200 and HL071561, Korea Center for Disease Control and Prevention government budget codes 2004-E71001-00 and 205-E71001-00, Japanese Ministry of Education, Culture Sports, Science and Technology grants B 16790335, A 13307016, 17209023, 21249043, A 25253046 and B 23390174.

2014 Marshall S. Levy, MD, Memorial Lecture

UPMC and the University of Pittsburgh Division of Rheumatology and Clinical Immunology are pleased to host Iain McInnes, PhD, as the guest lecturer for the 2014 Marshall S. Levy, MD, Memorial Lecture.

Professor McInnes currently serves as the Muirhead Chair of Medicine and Director of Institute of Infection, Immunity and Inflammation at the University of Glasgow.

He has a major interest in the biology of inflammatory synovitis in rheumatoid arthritis, psoriatic arthritis, and septic arthritis. He operates a translational science program in which state of the art cellular and molecular biology techniques are applied to elucidate the mechanisms underlying the perpetuation of synovial inflammation. In parallel they have an extensive clinical trials facility in which they perform studies of novel biologic agents in inflammatory arthritis.

Dr. McInnes has an established leadership role in translational medicine reflected in academic participation in the United Kingdom as the chair of the newly created Arthritis Research UK New Agents Committee, as the vice chair of the Medical Research Council Panel for Training and Fellowships, and the UK Clinical Research Network Specialty Groups Scottish Lead for Inflammation Medicine.

He has also served as chief or principal investigator at the global and national level for numerous phase I, II, and III drug development programs. As such he provides knowledge and experience in the conduct and translation of a variety of investigative modalities in the field of inflammation medicine.

Dr. McInnes’ lecture, Micro Molecules with Macro Effects in Rheumatology, will be presented on Friday, October 10, 2014.

Marshall S. Levy, MD, was a nephrologist at UPMC for nearly 40 years. During this time he served as the president of UPMC St. Margaret Hospital staff. He used his position to advocate for patients’ rights and concerns.

For more information on the lecture contact Hilary Peterson at HJP4@pitt.edu or 412-383-8100.

Unusual Immune Cell Needed to Prevent Oral Thrush, Pitt Researchers Find

PITTSBURGH, Sept. 8 – An unusual kind of immune cell in the tongue appears to play a pivotal role in the prevention of thrush, according to the researchers at the University of Pittsburgh School of Medicine who discovered them. The findings, published online today in the Journal of Experimental Medicine, might shed light on why people infected with HIV or who have other immune system impairments  are more susceptible to the oral yeast infection. 

Oral thrush is caused by an overgrowth of a normally present fungus called Candida albicans, which leads to painful white lesions in the mouth, said senior investigator Sarah L. Gaffen, Ph.D., professor, Division of Rheumatology and Clinical Immunology, Pitt School of Medicine. The infection is treatable, but is a common complication for people with HIV, transplant recipients who take drugs to suppress the immune system, chemotherapy patients and babies with immature immune systems. 

“In previous work, we found the cytokine interleukin-17 (IL-17), a protein involved in immune regulation, must be present to prevent the development of thrush,” Dr. Gaffen said. “But until now, we didn’t know where the IL-17 was coming from.” 

Typically, IL-17 is produced by immune T-cells that learn to recognize and remove a foreign organism after an initial exposure, known as adaptive immunity. But unlike humans, mice do not normally acquire Candida during birth and are considered immunologically naïve to it. When the researchers exposed the lab animals to Candida, their IL-17 levels rose within 24 hours despite the lack of a T-cell response. This suggested the immune activity was innate, rather than acquired. 

To find the cell responsible for IL-17 secretion, lead investigator Heather R. Conti, Ph.D., devised a way of applying a scientific technique called flow cytometry to sort for the first time cells gathered from the oral tissues. In the tongue, she identified unusual ones known as natural TH17 cells that looked very much like T-cells but didn’t behave like them. Subsequent tests showed that the novel cells did, indeed, make IL-17 when exposed to Candida. 

“These cells are part of a natural host defense system that is present at birth and does not require a first exposure to be activated,” Dr. Gaffen explained. “This study demonstrates for the first time that natural TH17 cells protect against infection.” 

The researchers speculate that the similarities natural TH17 cells share with T-cells make them vulnerable to HIV, chemotherapy and other agents as well, which could explain why certain people are more susceptible to oral thrush. Also, new drugs that block IL-17 soon will be on the market for treatment of rheumatologic conditions, so it’s possible that thrush could be a side effect. 

The team plans to examine the factors that influence thrush development within the high-risk groups.

 Co-authors of the paper include other researchers from the University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, the University of Pennsylvania, Genentech Inc., and the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH). 

The project was funded by NIH grants DE022550, AI107825, DE023815, AI095466, AI097333, AI106697, AI1110822, DE023293, AI098243 and T32-DK063922; Children’s Hospital of Pittsburgh of UPMC; the Pediatric Infectious Disease Society; the Edmond J. Safra Foundation/Cancer Research Institute; and the NIAID.

Children’s Brain Care Institute Experts Publish Paper that Supports Newborn Screening for Hurler Syndrome

PITTSBURGH, August 28, 2014 — Members of the Program for the Study of Neurodevelopment in Rare Disorders (NDRD) at Children’s Hospital of Pittsburgh of UPMC will have an article published in an upcoming issue of Annals of Neurology. The article, “Early Treatment is Associated With Improved Cognition in Hurler Syndrome,” was authored by Michele Poe, PhD, Sarah Chagnon, MD, and Maria Escolar, MD, of the Brain Care Institute.

Hurler syndrome is the most clinically severe form of an autosomal recessive lysosomal disorder characterized by the deficiency of α-L-iduronidase and is often fatal during childhood. Umbilical cord blood transplantation from unrelated donors has been shown to improve neurological outcomes of children younger than 2 years old, and extend the lives of these patients.

The authors followed 31 patients with Hurler syndrome who underwent umbilical cord blood transplantation between June 1997 and February 2013. Patients were evaluated at baseline and every six to 12 months thereafter. All 31 patients underwent complete neurodevelopmental evaluation and a median of seven evaluations. The authors found that younger age at transplantation was associated with improved cognitive function, receptive and expressive language, and adaptive behavior. Children younger than 9 months at the time of transplant showed normal cognitive development. These findings demonstrate that early diagnosis may be necessary for optimal outcomes and — because most patients are not identified at a young age — support the need for newborn screening.

Xiangya Hospital Partners with UPMC to Create World-Class Medical Center in China

PITTSBURGH, Aug. 25, 2014 Xiangya Hospital, Central South University, located in the Hunan Province of China, is partnering with UPMC to establish an international medical center that will improve access to high-quality care for patients within the region. Through this visionary relationship, Xiangya and UPMC expect to engage in a long-term collaboration.

As part of a five-year advisory services agreement with the 3,500-bed Chinese hospital, UPMC will help it to establish the Xiangya International Medical Center on the existing Changsha campus. The facility will offer world-class care to private-pay patients under a government-endorsed effort to relieve overcrowding in public hospitals by cooperating with private facilities. UPMC will serve as the exclusive advisor on the management of the International Medical Center and will participate in both medical and administrative oversight of all services.

“As one of the most respected medical centers in China, Xiangya Hospital is well positioned to expand its services and its reach throughout Asia. By partnering with one of the largest academic health care systems in the U.S. — and one that brings a wealth of international experience — we believe that the new Xiangya International Medical Center will quickly become a leader in providing the highest-quality medical care available in China,” said Sun Hong, M.D., Ph.D., president of Xiangya Hospital.

UPMC’s services will include training for medical and administrative staff both in China and in Pittsburgh, sharing of enhanced quality assurance and safety processes, recommendations on technology, equipment and staffing plans, and telemedicine links to UPMC’s clinical programs in Pittsburgh and Italy. A small number of UPMC staff also will be located at the hospital for consultative work.

“This clinical collaboration in China is UPMC’s most extensive effort yet in that country,” said Charles Bogosta, president of UPMC’s International and Commercial Services Division. “This effort will ensure that more patients receive the most advanced medical care close to home. At the same time, the financial and intellectual capital generated by this partnership will allow UPMC to advance its clinical and research missions in western Pennsylvania and beyond.”

UPMC’s informal relationship with Xiangya dates back nearly a decade, with physicians from both institutions and the University of Pittsburgh collaborating on patient care and research. “Xiangya has a long history of innovation in medical care and a reputation for advanced clinical programs, including organ transplantation,” noted Bruno Gridelli, M.D., medical and scientific director of UPMC’s International and Commercial Services Division. “We are excited about the potential to exchange knowledge and expertise with one of China’s best hospitals and to lay the groundwork for even greater collaboration in the future. Together, we are building a model for expanding access and raising the quality of health care throughout China.”

Established in 1906, the Xiangya Hospital is affiliated with the prestigious Central South University in Changsha, the capital of central China’s Hunan province. With more than 80 clinical departments, the hospital serves more than 100,000 inpatients and more than 2.1 million outpatients annually.

UPMC announced its first medical services agreement in China in 2011 with the provision of second-opinion pathology consultations to KingMed Diagnostics, the largest independent medical diagnostic laboratory in China. UPMC also has operations or offers services in Italy, Ireland, India, Canada, Singapore, Japan and Kazakhstan. Through its international growth and commercialization efforts with industry partners, UPMC is diversifying its revenue, fueling economic development in its communities, and strengthening its ability to recruit and retain the best and brightest clinicians who are working together to improve health care outcomes globally.

Children’s Physician Receives PCORI Funding for Study on Early Rehabilitation in Pediatric Patients with Acute Brain Injury

PITTSBURGH, August 19, 2014 – Led by a Children’s Hospital of Pittsburgh of UPMC physician, a multidisciplinary research project to improve outcomes for children with acute brain injury was recently approved for a $1.9 million funding award by the Patient-Centered Outcomes Research Institute (PCORI).

The study, “Early Rehabilitation Protocol (ERP) in the Pediatric ICU for Children with Acute Brain Injury (ABI),” led by Ericka Fink, MD, of the Department of Pediatric Critical Care Medicine, will perform a needs assessment to further characterize the current practices, barriers to care, and resources for physical, occupational, speech, and behavioral assessment and therapies needed for ERP implementation in pediatric intensive care units (ICUs). It will also evaluate ERP versus usual care to improve outcomes for children admitted to the ICU with ABI.

The two-center, randomized, controlled trial and resource survey is one of 33 proposals PCORI approved for funding to advance the field of patient-centered comparative effectiveness research and provide patients, health care providers, and other clinical decision makers with information that will help them make better-informed choices.

Dr. Fink and Craig Smith, MD, a former pediatric ICU fellow at Children’s and the principal investigator at Lurie Children’s Hospital, expect that participating sites will perceive an inadequate use of rehabilitation in pediatric ICU patients with ABI and predict that children with ABI will benefit from early ICU rehabilitation rather than usual care.

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