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Interim Governor's Notes

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July 2011 Michael F. Rein, MD, FACP, Interim Governor

Dr. Rein

Dear Colleagues:
It is with great sadness that I report that our Governor, Paul Florentino, MD, FACP, tragically died on June 19. Paul was an outstanding physician, a great friend, an honored colleague, and a long-term contributor to the Chapter and the College. He served on our Council for many years and brought considerable enthusiasm and wisdom to the task. He had interest and expertise in strategic planning, and, indeed, presented on our Chapter's (his) approach at the last national meeting of the College's Board of Governors. He had excellent and innovative plans for the Chapter, which we will do our best to carry out. Paul would have been an absolutely outstanding Governor, and we will feel his loss personally and professionally. Paul's obituary appeared in the Washington Post:
Paul Florentino, MD, FACP, Deputy Commander of Medical Services at National Naval Medical Center, died June 19th in Alexandria, Virginia. He was 56.

He was born in Brooklyn, NY and received his undergraduate degree magna cum laude from Colgate University and his medical degree cum laude from St. Louis University School of Medicine. He completed his training in Internal Medicine at Cornell Cooperating Hospitals-Memorial Sloan Kettering and North Shore University Hospitals. He served as a US Air Force Flight Surgeon following residency. He later joined the faculty at the Uniformed Services University of Health Sciences as a civilian pulmonary/internal medicine specialist. His dedication and interest in making a leadership difference eventually brought him to the Board of Directors where, in the words of RADM Nathan, "he had been a true shaker and mover as the Director". More recently he assumed the position of Deputy Commander of Medical Services, the only civilian to have ever held this position. There he made vital contributions to the Board, using his corporate experience and knowledge to assist in the major transitions involved in the merger of Walter Reed Army Medical Center and NNMC Bethesda. He had a lifelong pursuit of clinical excellence and dedication to Internal Medicine. In addition to his full time work at NNMC, he also served as Governor, Virginia Chapter of the American College of Physicians.

He is survived by his life partner Chris Pedersen of Alexandria, Virginia; his mother Rose Florentino of Spring Hill, FL; his brothers Michael Florentino of Manalapan, NJ; and Gene Florentino of Buffalo, NY, in addition to many beloved aunts, uncles, nieces, nephews, cousins, and an extensive network of dear friends.

Although flowers are appreciated, Paul would have been grateful for contributions in his name to the Whitman Walker Clinic, 1701 14th Street, NW Washington D.C., DC 20009, (202) 745-7000.

The College sent the following statement to be read at a memorial celebration on June 28.

June 27, 2011

To: Admiral Matthew L. Nathan Rear Admiral, Medical Corps, U. S. Navy Commander, Navy Medicine National Capital Area National Naval Medical Center Chief, Navy Medical Corps

On behalf of the American College of Physicians (ACP), its members, staff, and leadership, it is with great sorrow that we send this statement of condolence regarding the passing of Dr. Paul Florentino. Along with many others, we were grateful and honored to have had the opportunity to know and work with a gifted physician, natural leader and man of high character.

As stated so well in his obituary, "he had a lifelong pursuit of clinical excellence and dedication to internal medicine," which served him well in all of his endeavors. In his short time as Governor of ACP's Virginia Chapter, he was a productive and enthusiastic representative for our organization and we hope that his involvement with ACP brought him professional and personal fulfillment. We offer our heartfelt condolences to Paul's family, friends, colleagues, and patients and we appreciate the opportunity to send this statement in honor of his life. He will be missed.

Virginia L. Hood, MBSS, MPH, FACP, President, American College of Physicians
Yul D. Ejnes, MD, FACP, Chair, Board of Regents, American College of Physicians
David A. Fleming, MD, MA, FACP, Chair, Board of Governors, American College of Physicians
Steven E. Weinberger, MD, FACP, EVP/CEO, American College of Physicians

It has been both a particular privilege and a great pleasure to serve as your Governor for the past four years. The privilege results from being able to work in an organization in which I strongly believe, and to do so at a time during which we have had to consider major changes in the profession, which affect each of the purposes of the College. In accordance with the Bylaws of the Virginia Chapter and the practice of the College, I have been asked to serve as Interim Governor until a successor for Dr. Florentino has been duly elected. We will keep you informed about this procedure.


Nominations Sought for Virginia Chapter Awards

The Virginia Chapter bestows certain awards on its members annually. We are actively seeking nominations for the 2012 awards. If you are considering a nomination, please contact James Long, MD, FACP, Chair, Awards Committee at for information regarding the protocol for nominations. Completed nominations packets must be received by October 15, 2011.

Faculty Teaching Awards

The Virginia Chapter of the American College of Physicians now offers two teaching awards. One award will be presented to a full-time faculty member, and one to a community-based clinical faculty member or preceptor. We are now accepting nominations for the 2012 awards. The ACP Virginia Chapter Faculty Teaching Awards recognizes dedication to teaching and skill and accomplishment in the education of medical students, residents, or other physicians. Educational endeavors could take place in the clinic, on the wards, or in a practice setting. Particular emphasis is placed on a record of continued educational activity. The award will be presented at our Annual Associates' Day meeting on January 21, 2012.

Young Internist of the Year Award

This award recognizes outstanding achievement by a physician member within 16 years of graduating from medical school and who is not an ACP Medical Student Member or Associate. Areas of achievement may include leadership and advocacy; academics, including publishing, teaching, and mentoring; volunteerism; and service to the College.

Volunteerism Award

The Virginia Chapter presents a Volunteerism Award to a person who has demonstrated excellence in volunteer programs or has provided exceptional volunteer service post-training. The service must have been performed on a completely voluntary basis and not for the completion of training or for position requirements. Volunteer work must have been done as a physician or medical trainee and must be medically related.

Laureate Award

The Virginia Chapter presents a single Laureate Award annually. The award honors a Fellow or Master of the College who has demonstrated by example and conduct an abiding commitment to excellence in medical care, education, or research and in service to their community, their Chapter, and the American College of Physicians. The recipient of this award shall bear the title Laureate of the Virginia Chapter. This award is presented at the Annual Meeting and Clinical Update. The awardee should be a senior physician and Fellow or Master of long-standing, with acknowledged excellence and peer approval in the field of Internal Medicine. In addition, the awardee should have served the Chapter with distinction.


Governor's Notes

Dr. Florentino

At my first Board of Governors meeting this spring, the College reviewed its FY2011-12 Strategic Plan. While this plan reflects current ACP operations, it also highlights the four priorities in which the ACP will strategically focus its resources and direct its initiatives. Our task as a chapter is to align our strategic objectives to these following four goals.

The first and foremost strategic goal is to be the premier synthesizer and distributor of education and information for the internal medicine community. In addition to those products that we readily associate with the ACP, such as the MKSAP, the college seeks to develop an adaptable, electronic infrastructure to facilitate the delivery of new programs and services; provide educational products that meet accreditation, certification and licensure requirements; revitalize PIER; and develop products about high-value, cost-conscious care.

The second goal is to be the professional home for all internists. In order to achieve this goal, we will need to develop products that appeal to key member segments including hospitalists, subspecialists, and large group practices.

Given the declining interest in primary care, the third goal is to define and communicate the unique value of the internal medicine physician as a provider of patient-centered, complex, high quality, and evidence-based care. It has never been more important. We must improve the attitude of medical students and residents, as well as the general public, towards internal medicine.

Finally, we must support changes in the U. S. healthcare system that improve patient care, improve health, and promote cost conscious care. Whatever your position on the Affordable Care Act may be, we must, as a group, continue to advocate for its improvement and funding, as we model new paradigms for reimbursement. A first step is immediately to seek more than just a temporary fix to the SGR.

As I begin my four-year term as Governor, I have reflected on what my personal goals for the Chapter should be, in view of the College's priorities. After a careful Chapter assessment, I see the following immediate challenges:
1. The Chapter needs a short and long term strategic plan.
2. The Governor's Council does not reflect the diversity of our membership
3. Chapter expenses have exceeded revenues over the past few years
4. Social networking sites have not been used to their full potential as a means of communicating with our membership
5. Only 42% of the state's internists are members. We need a formal marketing plan to increase our market share
6. Student membership in the Chapter ranks 36th among all chapters with only 24% participation.
7. The Chapter does not sponsor any volunteer or community service activities
8. Although active nationally, the chapter needs to expand its local involvement in political advocacy activities, particularly in conjunction with other professional organizations.

Given the constraints of time and resources, I think it will be important for us to determine our strategic priorities for the immediate future. The Governor's Council will come together on the weekend of September 16-17 in Richmond to fine-tune our short and long-term goals. I invite you to write me with your thoughts on what the priorities of our Chapter should be. Hopefully we can achieve much more with your participation and encouragement. In the meantime, I would like to go on record as stating the following objectives I hope to achieve during my term as Governor:

1. The development and implementation of a financial and investment strategy to preserve our capital and fund our activities with a goal of return on investment > 1% over the rise in the consumer price index.
2. An increase in membership share in the state to >50%; increase medical student membership by 25%.
3. An improvement in our Clinical Update attendance by 10% each year, by surveying the membership and creating a program to meet their CME needs.
4. Expanded participation of membership in College, Chapter and Council Activities especially with regard to political advocacy.
5. Increase in communications, through email and social networking sites.

As I begin my term as Governor of your Chapter, I am humbled by my predecessors' accomplishments, and the Chapter's legacy of extraordinary achievement. There is a great deal of work to be done, however, for the profession of internal medicine. I hope to make the Virginia Chapter of the American College of Physicians your professional home of choice. I embrace the challenge and enlist your participation to make it happen. Please contact Dr. Rein,


Council Membership

The Governor's Council includes three representatives from each region of the state, whom you have elected to represent you on issues at the local and national level. Each year, one of the three rotates off council, and a successor is elected by you, our membership. These representatives, elected in 2011, will remain on our Council until the first Governor's Council meeting following Internal Medicine 2014. They are:

Region 1, Northern Virginia: Brad Pontz, MD, FACP; Region 2, Richmond Area: Lisa Ellis, MD, FACP; Region 3 Tidewater: Dean Gianakos, MD, FACP; Region 4 Charlottesville/Shenandoah Valley Area: Douglas Keim, MD, FACP;

Dr. Florentino used his Governor's prerogative and appointed Stuart Henochowicz, MD, FACP of Burke, VA ( to fill the seat vacated by Chalapathy Venkatesan, MD, FACP in Region 1. Dr. Rein has appointed Sami Tahhan, MD, FACP to fill the seat vacated by Glenn Jones, MD, FACP in Region 3. Your other representatives are as follows:

Region 1: James Long, MD, FACP (2012)
Region 2: Alan Dow, MD, FACP (2012); Ranjodh Gill, MD, FACP (2013)
Region 3: William Atchley, MD, FACP (2012)
Region 4: Jeri Lantz, MD, FACP (2012); William Fox, MD, FACP (2013)


Virginia Chapter Associates' Meeting

By Michael F. Rein, MD, FACP, Immediate Past Governor

Dr. Sweet
Jon Sweet, MD, FACP welcomes attendees to Associates Day (photo by Suehyb G. Alkhatib)

Our annual Associates' Day meeting was held on January 8, 2011, at the Virginia Tech Carilion School of Medicine under the stewardship of Jon Sweet, MD, FACP, Chair, Associates' Programs; Anke Hacker, MD, FACP, Chair-Elect, Associates' Programs; John Port, MD, ACP Member; and Salman Gohar, MD, Associate. This program is a very high priority for the Chapter, and it is a project supported by your Chapter dues. Associates' Day gives our young members a chance to present their research work in an open and, in fact, competitive forum. It stimulates interest in research and in evidence-based medicine, and it exposes Associates to the sorts of professional networking that is provided by membership in the College.

Wayne M. Sotile, PhD, presented the keynote address on the topic of The Resilient Physician. A nationally recognized expert in the fields of health psychology and work/family balance, Dr. Sotile effectively described skills and techniques for "transforming the medical workplace into a positive interpersonal culture." Over 140 research abstracts and clinical vignettes were received from our Virginia residents. The initial submissions were reviewed by a panel of volunteer judges from throughout the state: John McGurl, MD, ACP Member; Sidney Barritt III, MD, FACP; Michael Rein, MD, FACP; Bruce Johnson, MD, FACP; Ross Murchison, MD, ACP Member; Csaba Kovesdy, MD; Joel Schectman, MD, FACP; Amitabh Parashar, MD, ACP Member; Rhonda Whittie-Bradford, MD, FACP; and Richard Butler, DO, ACP Member. Forty excellent abstracts were chosen for oral presentation.

Abstracts selected for presentation were usually collaborative efforts and benefitted from mentorship, but only the ACP Associate presenter's name is shown below.

Christopher Wood, DO (VTC) - Varicella Zoster Virus Encephalitis in a Patient with AIDS and Seizures (Selected for poster presentation at state meeting)
Kristen Peichert, MD (UVA) - An Unforeseen Benefit to Gastric Bypass Surgery
Mayur Patel, MD (VTC) - Isolated Diplopia: An Atypical Presentation of Temporal Arteritis
Robert Cajes, MD (EVMS) - A Hot Dog Meal That Started It All (Selected for oral presentation at state meeting)
Krystal Larson, MD (VCU) - Unknown Pregnancy Presenting as Severe Preeclampsia
Laura Habelow, MD (NMCP) - Membranoproliferative Glomerulonephritis After a Premature Delivery for HELLP Syndrome
Christopher Clark, MD (VTC) - "Stink Bugs" and Permethrin Inhalation: A Stimulus for Apical Ballooning Cardiomyopathy
Allison Chan, MD (VCU) - Bilateral Ankle Arthritis
Jennifer Knips, MD (EVMS) - Superior Mesenteric Venous Thrombosis in Setting of Diverticulitis
Vlad Stanila, MD (NMCP) - Asymptomatic Neurosyphilis in a Newly Diagnosed HIV Positive Patient
Robert Becker, MD (UVA) - A Particularly Aggressive Course of Acute Myelomonocytic Leukemia Leading to Spontaneous Splenic Rupture and Cardiac Arrest
Christopher Partovi, MD (NMCP) - So You Think a Right Bundle Branch Block is Harmless?
Susan Szulc, MD (EVMS) - Anti-retroviral Agent Turned Anti-tubule Agent Tenofovir-Induced Fanconi's Syndrome (Selected for poster presentation at state meeting)
Vijai Bhola, MD (VTC) - Nafcillin Induced Hypokalemia Secondary to Electrolyte Redistribution and Kaliuresis (Selected for oral presentation at state meeting)
Salman Gohar, MD (VTC) - Fatal Left Coronary Artery Aneurysm Infection (Selected for poster presentation at state meeting)
Robert Brevetta, DO (VTC) - Refractory Hypoglycemia due to Prostate Cancer-Related NICTH (Sent to National; Selected for oral presentation at state meeting)
Imran Farooq, MD (VCU) - Uncontrolled Hypertension and Elevated Alkaline Phosphatase: Presenting Symptoms of Low Grade Metastatic Neuroendocrine Carcinoma
Chandana Bommireddy, MD (VTC) - Massive Hematemesis Due to a Hepatic Artery Pseudoaneurysm Complicating Pancreatitis
Richard Hedelius, MD (NMCP) - Nephrotic Syndrome and Unrecognized Plasmodium malariae Infection in a U.S. Navy Sailor Fourteen Years after Departing Nigeria (Selected for poster presentation at state meeting)
Jean Fiedler, MD (VCU) - Migratory Polyarthralgia in a Renal Transplant Patient
Margaret Williams, MD (EVMS) - There is a Fungus Among Us
Leia Ince-Mercer, MD (VTC) - A Case of Intramuscular Monosodium Urate Crystal "Abscesses" (Selected for poster presentation at state meeting)
Mary Caroniti, MD (NMCP) - Silent Herald: A Unique Case of Idiopathic Membranous Glomerulonephritis Presenting as a Pulmonary Embolism
Faizah Siddique, MD (VCU) - A Triple-Secreting Challenge
Alisha Young, MD (EVMS) - Massive Pulmonary Embolism Diagnosed by Bedside Ultrasound
Christopher Arnold, MD (UVA) - A Case of Grave's Disease Presenting as Vasospasm-Induced Myocardial Infarction
Marcus Carden, MD (VCU) - Acute Chest Syndrome: I-N-O Spells Relief
Sean Cowley, MD (NMCP) - Aggressive Refractory Cervical, Vaginal, and Vulvar Carcinoma In-Situ as a Manifestation of Idiopathic CD4 Lymphocytopenia (Selected for poster presentation at state meeting)
Om Samantray, MD (VTC) - "Broken Heart Syndrome": A Critical, Reversible Complication of Status Epilepticus
Tamika Khan, MD (VTC) - Chiari 1 Malformation Presenting as Unilateral Facial and Abducens Nerve Palsies
Michael Lucas Gambill, MD (VCU) - Enhanced Interleukin-1 Activity in Plasma of Patients with Acute Decompensated Heart Failure
Poonum Korpe, MD (UVA) - Degree of Peripheral Inflammation is Associated with Poor Outcomes in Hospitalized Patients with C. difficile Infection(Selected for poster presentation at state meeting)
Heidi Zapata, MD (UVA) - The Presence of the KPC Gene in Kluvyvera Intermedia: An Environmental Bystander
Rosemary Rengel, MD (VCU) - Circulating Cardiodepressant Factors in Patients with Sepsis (Sent to National; Selected for oral presentation at state meeting)
Ian Anderson, MD (UVA) - Dehydration Prevalence Among Elderly Patients Admitted to a Tertiary Care Hospital Using ICD-9 Coding Versus Laboratory Data
Haeseong Park, MD (VCU) - A Pilot Phase II Trial of Magnesium Supplements to Reduce Menopausal Hot Flashes in Breast Cancer Patients
Mary Caroniti, MD (NMCP) - Evaluation of Possible Association Between Statins and Abnormal Esophageal Motility (Selected for poster presentation at state meeting)
Robert Schutt, MD (UVA) - Evaluation of Clinical and Angiographic Factors Associated with the Presence of Coronary Collaterals in Patients with Coronary Artery Disease

The 40 selected oral presentations were judged by: Dean Gianakos, MD, FACP; Amitabh Parashar, MD, ACP Member; Dexter DeLeon, MD, ACP Member; John McGurl, MD, ACP Member; Michael Rein, MD, FACP; Cecilia Steans, MD, ACP Member; Ganesh Kini, MD, FACP; Shikha Vasudeva, MD, ACP Member; Donald Steinweg, MD, FACP, Ranjodh Gill, MD, FACP, John Cary, MD, FACP, and Sami Tahhan, MD, FACP

Top 4 Abstracts

A Triple-Secreting Challenge, Faizah Siddique, MD, ACP Associate, Virginia Commonwealth University (Selected for oral presentation at state meeting)
Refractory Hypoglycemia Due to Prostate Cancer-related Nicth, Robert Brevetta, DO, ACP Associate, Virginia Tech Carilion School of Medicine
Membranoproliferative Glomerulonenephritis After a Premature Delivery for Hellp Syndrome, Laura Habelow, MD, ACP Associate, Naval Medical Center Portsmouth (Selected for oral presentation at state meeting)
Circulating Cardiodepressant Factors in Patients with Sepsis, Rosemary Rengel, MD, ACP Associate, Virginia Commonwealth University (Sent to National; Selected for oral presentation at state meeting)

Teaching Award

The Virginia Chapter ACP annually presents a teaching award to physicians in Virginia. The award recognizes dedication to teaching and skill and accomplishment in the education of medical students, residents, or other physicians. Educational endeavors can take place in the clinic, on the wards, or in a practice setting. Particular emphasis is placed on a record of continued educational activity. This year the Virginia Chapter Teaching award was presented to Mitchell Rosner, M.D., FACP. The ACP Virginia Chapter's annual Teaching Award was presented at Associates' Day, January 8, 2011, in Roanoke, Virginia. Michael Rein, MD, FACP, Governor of the Virginia Chapter presented the award.

Dr. Rosner is currently an Associate Professor of Medicine at the University of Virginia School of Medicine as well as the Vice Chairman of the Department of Medicine. Dr. Rosner also serves as the director of the Nephrology Fellowship Training program. Dr. Rosner serves on the executive committee of training program directors for the American Society of Nephrology. His research interests include sodium and water metabolism and acute kidney injury. He is a Fellow of the American Society of Nephrology and a Fellow of the American College of Physicians. He has authored over 80 manuscripts and 3 textbooks. He is recognized as an outstanding teaching and has been awarded the University of Virginia All-University Teaching Award.

Dr. Rein
Michael F. Rein, MD FACP, Governor, Presents the Teaching Award to Dr. Rosner (photo by Suehyb G. Alkhatib)

Dr. Rein's Comments:

It is a particular pleasure to present the Virginia Chapter's Teaching Award to Mitchell Rosner M.D., FACP. I have known Dr. Rosner since he was a resident and then a chief resident at the University of Virginia, but neither of us would like you to know how long ago that occurred. I have personally observed Dr. Rosner as a teacher in many different settings. As a resident, he was an excellent teacher of medical students. I was able to observe him, as junior faculty, on his rounds and in his performance of consultations. He was able to create an outstanding teaching environment, with a wonderful balance of being supportive and, at the same time, appropriately challenging. More recently, I have heard him lecture in many settings, including our Grand Rounds and, repeatedly, at ACP events. His lectures are characterized by exceptional clarity of thought, and he is able to communicate his ideas with great effectiveness. In addition to all of this, Mitch teaches professionalism by serving as an outstanding role model. He is also a really nice guy. His winning this award actually contributes to its stature.

Doctor's Dilemma

Dr. Port
Jon Port, MD, FACP explains the rules of Medical Jeopardy to the teams

Associates from the 5 Virginia residency programs competed in Doctor's Dilemma, the medical "Jeopardy" game. The program was designed and directed by John Port, MD, ACP Member. Buzzers and a game-show board similar to that of the television show were used for teams to choose categories and questions and to log in. In a hard-fought contest, teams vied for the championship of the Commonwealth and the coveted trophy! The winning team will keep the trophy in its possession until the 2012 competition. Teams that participated in the Medical Jeopardy competition were:

Virginia Tech Carilion: Bonny Moore, MD; Emily Thomas, DO; Kevin Loughry, DO Eastern Virginia Medical School: Jody Boggs, MD; Ellen Peterman, MD; Armin Rashidi, MD Naval Medical Center, Portsmouth: Jennifer Cunningham, MD; Mike Wagner, MD; Sarah Wied, MD. University of Virginia: Christopher Arnold, MD; Glenn Moulder, MD; Robert Schutt, MD Virginia Commonwealth University/Medical College of Virginia: Nayef Abouzaki, MD; Amit Bharara, MD; Krystal Larson, MD Virginia Commonwealth University/Medical College of Virginia won the competition, and the team was sent to compete at Internal Medicine 2011 in San Diego in April.

Jeopardy Team
Winning Medical Jeopardy Team from VCU/MCV: Amit Bharara, MD; Stephanie Call, MD, FACP, Program Director; Nayef Abouzaki, MD; Krystal Larson, MD


Annual Chapter Meeting and Clinical Update

This year's Clinical Update at the Hilton at Short Pump in March saw attendance increased to 226, for what proved to be an exciting and innovative program of interest to both ambulists and hospitalists. Chaired by Lisa Ellis, MD, FACP, Associate Professor, Obstetrics and Gynecology and Internal Medicine at VCU and Medical Director of Clinical Services at Stony Point Women's Health Center in Richmond, the update included a series of four talks that focused on facilitating the transition for patients and providers as they move from inpatient to outpatient care. The overwhelming majority (87%) of physicians in the initial post-conference survey sample reported that the 2-day continuing medical education meeting definitely improved their skills in areas where they felt their patient care needed improvement. Of note was the remarkable medical student program chaired by Thamiris Palacios, ACP Student Member, which attracted 47 medical students from around the state to the meeting.

At the Awards Luncheon on Saturday, March 5, the Chapter awarded its Laureate to the UVA Chair of Medicine, Robert M. Strieter, MD. PhD, MACP, for excellence in all areas of academic medicine and his contributions to the ACP. The Young Internist Ward for 2011 was presented to Leanne Yanni, MD, FACP, for the extraordinary magnitude of her contributions at the institutional, state, regional and national level in teaching, scholarship, clinical, and administrative services. With a long history of community service activities including renal screenings for medically underserved populations in Charlottesville and its Remote Area Medical Clinic, the Volunteerism Award was given to Rasheed A Balogun, MD, FACP, a popular and inspiring teacher at UVA.

Despite the overwhelmingly positive reviews of the meeting, income from tuition and exhibitors resulted in a net cost to the Chapter of approximately $14,000. We will continue to promote interest and attendance for 2012 with hopes making this year's meeting a more budget neutral event. Our Council of Young Physicians, chaired by John Port, MD, ACP Member, will serve as the Program Committee for the 2012 ACP Virginia Annual Meeting and Clinical Update 2012 to be held at the Omni Charlottesville Hotel, March 16-17, 2012. Already the program is shaping up to be an interesting, timely, and relevant event for all internists. At this time, plans are in progress to continue to provide 15 hours of CME credit, with updates on traumatic brain injuries in sports, tick-borne illnesses in Virginia, and many more of the topics you have requested in your post-meeting surveys. We will hopefully continue our medical student participation with a program led by our new medical student rep, Neha Chande, Student Member. We have purposely planned the meeting in a central part of the state for ease of travel and lower hotel costs. I hope we can count on your attendance! As always, we are interested in hearing from those of you who did not attend the meeting. Please let us know how we can make this meeting more attractive to you.


Report from the Board of Governors Meeting

Thirty resolutions were considered by the Board of Governors (BOG) at this year's meeting held just prior to Internal Medicine 2011 in San Diego. After considerable discussion, eight of those were adopted by the BOG, referred to the Board of Regents, and are in various stages of implementation:

08-S11. Promoting the Leadership Role of Physicians in the Health Care Team
14-S11. Supporting Federal Legislation and/or Regulations that Require Clearly Labeling Food with Genetically Engineered Ingredients
16-S11. Allowing Members of ACP Military Chapters to Maintain Membership in Both Military and State ACP Chapters
17-S11. Notifying Governors when Fellowship Nominees are Approved
20-S11. Developing a Strategy to Market MKSAP and Other ACP Products through ACP Chapters
26-S11. Endorsing and Encouraging the Development of Preceptorship Programs throughout ACP Chapters
29-S11. Developing a Strategic Theme to Improve the Health of the Public by Promoting Health and Preventing Disease in Populations as well as Individuals
You can see the details of these resolutions here.

The resolutions deadline (May 23) for our Fall BOG conference has passed and the number of resolutions is significantly fewer. We have a total of 7 resolutions to be heard at the Fall BOG meeting. You can review these online at Please send any comments to Dr. Rein, Interim Governor, or your local Council Representative so we can bring your views to the meeting. The resolution process is a powerful way for our members to reaffirm or change College policy and to align it with the current needs of the membership. Your suggestions for future resolutions are always welcome by your council reps or Dr. Rein.

VA Chapter of the ACP Well Represented at IM 2011

By Michael F. Rein, MD, FACP, Immediate Past Governor

Members of our Chapter participated in many different ways at Internal Medicine 2011, the College's national meeting in San Diego, April 7-9, 2011. Our Virginia Reception was generously supported by the Departments of Medicine at Eastern Virginia Medical School, University of Virginia, Virginia College of Osteopathic Medicine, Virginia Commonwealth University-Medical College of Virginia, and Virginia Tech Carilion School of Medicine. Many thanks. It was great fun to introduce our new Governor, Paul Florentino MD, FACP, and once again to meet with current and former students and residents, academic colleagues, and practitioners from across the state.

Photo 5
Photo 6
Photo 7

Among the attendees enjoying the Virginia Reception at IM2010

Our Chapter leads the pack in the strength of its strategic planning program. Paul Florentino, MD, FACP, Governor, and Ann Tennett, Executive Director, were invited presenters at the Board of Governors Chapter Leader Networking Session, immediately preceding the national meeting. They discussed the Virginia Chapter's Strategic Plan and presented information on putting the plan into action.

Congratulations to our newest Fellows who marched at Convocation.

Abdullah M. Al-Osaimi, MBBS, FACP, FACG
Valentina L. Brashers, MD, FACP
Kristin M. Clontz-Bell, MD, FACP
Richard Y. Kim, MD, FACP
Ganesh D. Kini, MD, FACP
John W. Pendleton, MD, FACP
Sami G. Tahhan, MD, FACP
Phyllis K. Yeboah, MBChB, FACP

Dr. Port
Fellowship inductees at IM2010: Abdullah Al-Osaimi, Governor-elect Paul Florentino, Kristin Clontz-Bell, John Pendleton, Governor Michael Rein, Phyllis Yeboah, Ganesh Kini, Sami Tahhan, and Richard Kim (Photo by Ann Tennett)

Doctors' Dilemma Team Does Particularly Well

Our Virginia Championship "Jeopardy" Team, from Virginia Commonwealth University-Medical College of Virginia included:

Nayef Abouzaki, M.D., Associate
Amit Bharara, M.D., Associate
Krystal Larson, M.D., Associate

They fought knowledgably, brilliantly, and valiantly in Doctors' Dilemma. Tied for first place with a team from the University of Michigan at the end of the Regular Round, they underestimated their mastery of Ophthalmology, the category in Final Jeopardy Round. Of course, they knew the answer, but having failed to bet the boat, they did not end up with the highest final score. Congratulations, VCU-MCV Team, you are better than you thought you were! Vastly well done!

The team's attendance was co-sponsored by the Virginia Chapter and the Department of Medicine at Virginia Commonwealth University-Medical College of Virginia.

Virginia Associates' Presentations Receive High Acclaim

A good number of Virginia's Associates were selected to present papers and posters at the national Associates' Competition. Two received special recognition:


Leave No Stone Unturned: Atazanavir -Induced Nephrolithiasis

First Author: Susan V Szulc, MD, Associate, Second Author: David J Castaldo, MD, FACP

Introduction: There are over one million HIV+ individuals in the U.S.1 ART has become commonplace and management is no longer reserved for infectious disease specialists. However, do medicine practitioners see what's hidden beneath the stones of common therapy? Case Presentation: A 40-year-old male with HIV (CD4 404, undetectable viral load) presented with complaints of flank pain and "passing kidney stones". The patient had a history of indinavir-associated nephrolithiasis. He was switched from his original ART regimen (indinavir, lamivudine/zidovudine) to ritonavir-boosted atazanavir, tenofovir/emtricitabine in 2005. With this change, he reported no further episodes of nephrolithiasis. However, the patient presented four years later, with complaints of "passing kidney stones" again. He denied fevers, nausea or vomiting. On examination, the patient was afebrile and did not display CVA tenderness. Urinalysis revealed a pH of 5.5 and no red blood cells. Labwork was only significant for an elevated total bilirubin of 2.3, which was stable. The patient was advised to strain his urine. The stones were sent for analysis and found to be composed of atazanavir. Discussion: Atazanavir was FDA-approved in 2003 and was embraced for its once-daily dosing and its favorable side effect profile. Compared with other protease inhibitors (PI), atazanavir has less adverse effects of hyperlipidemia, diarrhea and lipodystrophy.1 Furthermore, the CASTLE study in 2008 demonstrated noninferiority of atazanavir/ritonavir to lopinavir/ritonavir, solidifying its place as cornerstone initial therapy. Currently, ritonavir-boosted atazanavir is a CDC-preferred regimen. Nephrolithiasis is a well-known complication of therapy with indinavir, another PI. However, this isn't a class effect and was not initially reported during the clinical trials for atazanavir. In fact, the first case wasn't reported until 2006. Since then, there have been only three cases described in the literature. Furthermore, from December 2002 through January 2007, there were only 30 cases reported to the USDA Adverse Event Reporting System. The mechanism of the development of the stones is unknown. However, atazanavir is primarily metabolized by the CYP3A isoenzyme and 7% is excreted unchanged in the urine. Drug solubility increases substantially with urine acidity. Thus, hepatic dysfunction and alkaline urine act as risk factors for crystal formation. However, as in our patient, atazanavir-stones may develop de novo. Physicians must maintain a high level of suspicion in patients on atazanavir with urinary complaints. Stones should be sent for composition analysis, to guide decisions on therapy changes. Currently, nephrolithiasis is not a strict indication for discontinuation. In fact, only 30% of the USDA-reported cases resulted in atazanavir discontinuation. In addition, clinicians should consider urinary acidification as possible treatment. Because this complication is associated with significant morbidity, including invasive procedures, hydronephrosis and renal failure, additional studies are needed to help prevent and treat this very important side effect of a commonly used medication.


When Cultures Fail, PCR Gets to the Heart of the Matter: The Use of PCR in the Diagnosis of Culture-Negative Endocarditis First Author: LT Michael S. Wagner, MD, Associate, Second Author: CDR Jeffrey Tjaden, MD, MPH, FACP

Introduction: In cases of endocarditis when cultures remain negative, there is increasing use of PCR of valvular tissue to identify an organism to tailor antibiotic therapy. The following is a case of an active duty male with culture-negative endocarditis (CNE) found to have Aggregatibacter aphrophilus. Case Presentation: The patient is a 53-year-old physician who developed progressive fatigue, fevers, night sweats, and headaches shortly after deploying to Iraq. Symptoms did not resolve after conservative treatment and continued despite treatment with 5 days of azithromycin for a presumed sinus infection. Weeks later he was found to have persistent fevers, thrombocytopenia, elevated liver associated enzymes, and 20lb weight loss requiring transfer to Naval Medical Center Portsmouth for further evaluation. Although febrile (103°F) and with markedly elevated C-reactive protein on presentation, initial blood cultures were negative despite extended incubation and terminal subculture. MRI of the brain obtained for persistent retro-orbital headaches and left inferior quadrant hemianopsia revealed multifocal regions of acute ischemia. He was found to have two vegetations on the posterior leaflet of the mitral valve by trans-esophageal echocardiogram. An extensive workup to obtain microbiologic diagnosis to include multiple cultures (bacterial, fungal, mycobacterial) from the blood, urine, CSF, and bone marrow as well as serologic testing for Coxiella burnetii, Brucella species, and Bartonella species were negative. The patient was treated for CNE (possible endocarditis by modified Duke Criteria) with 30 days of gentamicin and 42 days of vancomycin (PCN allergy) plus ciprofloxacin. Due to worsened symptomatic mitral regurgitation, the patient required a posterior leaflet resection and primary reconstruction. Special stains did not reveal any organisms, and bacterial, fungal, and mycobacterial cultures of the valve were finalized as negative. PCR testing on valvular tissue using 16S rDNA primers were positive for Aggregatibacter aphrophilus.

Internal Medicine 2011 Virginia Chapter Faculty:

Corbett, Eugene C. Jr., MD, FACP, Professor of Medicine, Department of Internal Medicine, University of Virginia, Charlottesville, VA Ophthalmoscopic Skills for the Internist

Crowe, Sheila E., MD, FACP, FRCPC, FACG, AGAF, Professor of Medicine, Department of Medicine, University of Virginia, Charlottesville, VA Multiple Small Feedings of the Mind: Gastroenterology, Psychiatry, and Rheumatology

Dallas, Apostolos P., MD, FACP, Assistant Professor of Medicine, Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA. News You Can Use: Current Clinical Guidelines

Ellis, Lisa, MD, FACP, Associate Professor, Departments of Obstetrics and Gynecology and Internal Medicine; Director of Clinical Services, Women's Health Center at Stony Point, Medical College of Virginia, Medical Commonwealth University, Richmond, VA Moderator: Multiple Small Feedings of the Mind: Oncology, Infectious Diseases, and Hematology

Klein, Wendy Simons, MD, FACP, Associate Professor Emeritus of Internal Medicine and Obstetrics/Gynecology, VCU Institute for Women's Health, Virginia Commonwealth University School of Medicine, Richmond, VA. Moderator: Mars and Venus: Male and Female Sexual Health, Scientific Program Committee

Florentino, Paul, MD, FACP, Governor, Virginia Chapter, ACP, Director Of Medical Services, National Naval Medical Center, Bethesda, MD: Chapter Leader Networking Session, Strategic Execution

Macik, B. Gail, MD, Member, Professor of Internal Medicine and Pathology, Division of Hematology and Oncology, Department of Internal Medicine, University of Virginia Health System, Charlottesville, VA Multiple Small Feedings of the Mind: Oncology, Infectious Diseases, and Hematology

Nadkarni, Mohan M., MD, FACP, Associate Professor, Department of Internal Medicine, University of Virginia Health Systems, Charlottesville, VA Moderator: Multiple Small Feedings of the Mind: Gastroenterology, Psychiatry, and Rheumatology

Pendleton, John W., MD, FACP, Associate Professor of Internal Medicine, Virginia Tech Carilion School of Medicine, Assistant Professor of Clinical Internal Medicine, University of Virginia School of Medicine, Department of Medicine, Carilion Clinic, Roanoke,VA; Rheumatology Section, Medical Service, Salem Veterans Affairs Medical Center, Salem, VA Multiple Small Feedings of the Mind: Gastroenterology, Psychiatry, and Rheumatology

Ann Tennett, Executive Director, Virginia Chapter, ACP: Chapter Leader Networking Session, Strategic Execution

Yanni, Leanne M., MD, FACP, Assistant Professor, Department of Internal Medicine and Palliative Care, Virginia Commonwealth University Medical Center, Richmond, VA Managing Chronic Pain; Opioids for Chronic Pain: Maximizing Benefits and Minimizing Risks


Leadership Day Update 2011

By William Fox, MD, FACP

On May 24 and 25, I had the honor of leading an intrepid group of Virginia members to Washington, DC as part of ACP Leadership Day. Our delegation, comprised of Downs Little, MD, FACP, Sami Tahhan, MD, FACP, Joseph Aloi, MD, FACP, Joe Verdirame, MD, FACP, Preston Reynolds, MD, FACP, Patrick Baroco, MD, John Daniel, MD, FACP, Renee' Carter, MD, FACP, Governor Paul Florentino, MD, FACP, Sarah Corley, MD, FACP, Jeffrey Harris, MD, MACP, Stuart Henochowicz, MD FACP, Doug Summerfield, MD, Anthony Fam, MD, Ursula Kelly, MD, Jennifer Knips, MD, Morgan Obrian, MD, Rob Green, MD, and Furhan Qureshi, MS, received briefings on medical policy from members of congress and their staff, and then spread out across Capitol Hill to meet directly with our congressional offices.

In our discussions with congressional offices, we focused on the following concerns:

  • Eliminating the Medicare SGR and transitioning to better payment systems.
  • Preserving key Discretionary Workforce Programs including the National Health Service Corps, the National Health Care Workforce Commission, and Section 747 of Title VII funding for training in primary care.
  • Preserving key mandatory programs such as the Medicare Primary Care Incentive Program and the Medicaid Comparability Program.
  • Moving forward legislation on liability reform.

With regard to the SGR, Republican and Democratic Leadership have both stated their commitment to permanently fix the broken payment system. At their request, the ACP, along with several other major medical organizations, recently sent a letter to the House Energy and Commerce Committee outlining our view of how this should be done. ACP's proposal recommends eliminating the SGR and guaranteeing five years of stability that would ensure that no physician services would receive negative updates. During this five-year period, according to the ACP proposal, E/M services should receive updates of no less than 2%, regardless of the specialty of the physician that provides them, while non E/M services should receive updates of no less than zero percent. Also during this five year period, there should be robust testing of new payment models, including Patient Centered Medical Homes and Accountable Care Organizations among other innovative models. By 2019, the expectation would be that physicians would completely transition away from the traditional fee-for-service model. Read the full ACP letter

Our visit wasn't all business, however. At the awards dinner, our organization heard remarks from Senator Max Baucus, to whom we presented our Joseph F. Boyle Award for Distinguished Public Service, and political strategist and CNN analyst Alex Castellanos. In addition, our own Downs Little, MD, FACP received one of the Top Ten Key Contact of the Year Awards. Congratulations Downs!

We are always looking for members who wish to join us for Leadership Day. Our chapter will support one member from each congressional district, and one medical student and resident from each program in the Commonwealth. We are especially interested in members from Congressman Morgan Griffith's 9th congressional district. If you are interested, please contact me.

Leadership Day 2010
Leadership Day, 2010. Robert Green, ACP Member; The Honorable Robert Hurt (R-5th); William Fox, MD, FACP, Chair Virginia Chapter's Health and Public Policy Committe


Upcoming Events

Associates' Day
Norfolk, VA
January 21, 2012

Virginia Chapter ACP Annual Meeting and Clinical Update
Omni, Charlottesville, VA
March 16-17, 2012

Internal Medicine 2012
New Orleans, LA
April 19-21, 2012