SPRING 2019

CURATING CARE [Machine Learning's Deep Dive into Big Data] Duke Surgery

Chair Chief of Staff Allan D. Kirk, MD, PhD Cynthia K. Shortell, MD

Vice Chairs Gregory S. Georgiade, MD Clinical Practice Ranjan Sudan, MD Education E. Shelley Hwang, MD, MPH Research 4 Chief of the Clinic Chief Administrator 4 Michael E. Lipkin, MD Katherine Stanley, MBA

Division Chiefs

Abdominal Transplant Surgery Plastic, Maxillofacial, Debra L. Sudan, MD and Oral Surgery Jeffrey R. Marcus, MD AT A GLANCE Cardiovascular and Thoracic Surgery Surgical Oncology Peter K. Smith, MD Peter J. Allen, MD Emergency Medicine Surgical Sciences Curating Care Charles J. Gerardo, MD Kent J. Weinhold, PhD 4 Machine Learning's Head and Neck Surgery & Trauma and Critical Communication Sciences Care Surgery Deep Dive into Big Data Howard W. Francis, MD, MBA Suresh K. Agarwal, Jr, MD Metabolic and Weight Urology Loss Surgery Glenn M. Preminger, MD Resilience in Surgery Dana D. Portenier, MD Vascular and 8 Pediatric General Surgery Endovascular Surgery Improving Provider Henry E. Rice, MD Cynthia K. Shortell, MD Well-Being

EDITORIAL STAFF Transplant Firsts in NC Editor in Chief Honorary Director 10 Looking to the Future, Brooke Walker Jill White Together Writers Designer Scott Behm Scott Behm Renee Dubois Brooke Walker Medical Illustrators Duke Surgery Pilots Lauren Halligan Editor Megan Llewellyn, CMI 14 National Curriculum Ashley Morgan for Medical Students Administrative Assistant Wendy Dixon 16 Training Follow us on Social Media in Immunobiology @DukeSurgery

On the cover: In the operating room and emergency room, Copyright © 2019 Duke Surgery data can serve to make sense of the chaos. Illustration by Lauren Halligan and Megan Llewellyn, CMI. 2 Duke Surgery 10 16

MESSAGE FROM THE CHAIR

urgeons have a direct, personal improving the experience of our care students in the surgery clerkship. This new relationship with their patients, providers. By focusing on the well-being curriculum bolsters our surgical program combined with a truly tactile of our faculty and trainees, we aspire for medical students to foster their success Sexperience with their patients’ illnesses. to cultivate an atmosphere of trust and in medical school while establishing a This unique access to both the patient support. The department now offers peer clear pathway for their future careers as experience and associated biological support groups for faculty and trainees to surgeons. processes puts our department in a promote resilience. Prioritizing the health position to define the entire spectrum of our faculty and staff is vital to providing By working to improve the experience of of health, disease/injury, and recovery— high-quality care to our patients. our patients, providers, and trainees, the access so compelling, it demands that we Department of Surgery strives to blend do so, “for all patients.” In this issue of Duke Surgery has been at the vanguard excellence into all aspects of our mission. the Duke Surgery newsletter, we examine of scientific discovery as demonstrated the means by which we are curating the by this year’s number 1 ranking in NIH experiences of our patients, providers, funding among departments of surgery. Sincerely, and trainees to build a foundation for Two recent advances in transplantation clinical excellence, innovative research, highlight our translational discovery work. Allan D. Kirk, MD, PhD, FACS In fall 2018, Duke surgeons were the first and formative education for the future of David C. Sabiston, Jr. Distinguished in the state of to perform surgery. Professor and Chair an abdominal wall transplant (done with Department of Surgery Duke surgeons are actively engaged in a a simultaneous small bowel transplant!), School of Medicine university-wide “+DS” drive to harness the and our hand transplant team performed -in-Chief power of data science, wielding big data the first bilateral hand transplant in the Duke University Health System to augment provider decision-making and state: remarkable technical achievements enhance the quality and value of clinical made all the more impactful by their care. In collaboration with the Duke School association with cutting-edge immune of Engineering, our faculty are gathering investigational protocols. These novel clinical and mechanistic data for use surgical procedures offer new options to as ground truth in artificial intelligence patients while providing insight into the and machine learning algorithms. These safe and efficacious application of these new approaches to data analysis aim to transplants in future patients. optimize the delivery of care and reduce surgical complications, length of hospital Finally, a significant part of our mission is stay, and wait times in the Emergency to develop the next generation of leaders Department. in surgery. We are working with the American College of Surgeons to enhance Importantly, improving our patient the trainee experience by implementing experience goes hand in hand with a standard curriculum for medical Contents 3 1 1 1 0 0 1 1 0 0 1 1 1 1 0 1 1 0 1 0 0 0 1 1 1 1 1 0 1 1 1 1 0 0 0 0 1 1 0 1 1 1 0 0 1 1 0 0 1 1 1 0 0 1 1 10 0 1 1 1 0 0 0 1 1 0 0 0 0 1 0 0 0 0 11 1 1 1 1 0 0 1 1 1 0 0 0 1 1 1 0 1 0 1 0 1 01 1 1 1 1 1 1 1 1 11 1 11 0 1 1 10 1 1 0 1 1 1 0 1 1 1 0 1 0 1 0 0 0 1 1 1 10 1 1 1 1 1 0 0 1 0 0 1 0 0 1 0 1 0 10 0 0 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0 1 0 0 0 1 0 1 1 0 1 0 0 1 0 1 0 1 1 0 1 1 0 0 1 01 1 1 1 00 1 1 0 1 0 1 1 1 1 1 0 1 1 1 1 1 1 0 1 10 11 1 0 1 0 1 0 0 0 0 1 1 1 0 1 0 10 1 1 0 0 1 0 0 1 1 0 1 11 0 1 0 1 1 0 1 0 1 1 0 1 0 1 1 0 1 0 0 0 1 0 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 10 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 1 1 1 1 0 0 1 0 1 0 0 1 1 1 0 0 CURATING1 1 0 1 1 0 00 0 CARE0 1 0 0 1 0 1 1 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 00 1 0 1 1 0 0 0 1 [Machine0 0 Learning's1 1 1 0Deep10 Dive0 into0 Big Data]1 0 0 1 1 1 1 1 0 0 1 0 0 1 0 0 0 1 0 0 0 10 1 1 0 0 0 1 1 0 1 0 1 0 0 1 1 1 0 0 0 1 1 0 0 1 1 1 1 0 1 1 11 0By1 Scott 1Behm 1 1 1 0 1 0 1 1 1 1 1 0 0 0 1 0 1 0 1 0 0 0 0 0 00 0 0 1 0 0

Dr. Jason Theiling, right, discusses recent Emergency Medicine data output with Strategic Services Associate Elizabeth Stacks, Division Chief Dr. Charles Gerardo, and Associate Professor Dr. Lauren Siewny (left to right). Photo by Colin Huth/Photo C4.

4 Duke Surgery onsider the sheer volume of data sources has the potential to inform your brain processes in making one decisions in monumental ways—creating a decision. Something as simple as detailed roadmap to improve quality and Cyour choice of breakfast is the culmination efficiency of care and to minimize potential of data analysis—decades of zeroing in on complications. personal taste, allergic reactions, nutrition, health considerations, and other factors. Curating Existing Data

The use of data to make decisions, then, For a system as large as Duke Health, is not profound—it is an innate aspect of curating EHR datasets to creating the human condition. In the surgical field, meaningful, useful data can take years. historically this data processing took place Kristin Corey, a medical student at Duke through the lens of personal experience. and scholar at the Duke Institute for Consider why a senior surgeon is typically Health Innovation (DIHI), has spent 2 years more trusted than an intern. More time working as part of the DIHI team to build in practice constructs a robust dataset to PYTHIA, a data pipeline that has wide make sound surgical decisions. application potential across Duke Health and beyond. For today’s surgeons, however, the dataset has expanded exponentially. To As part of the Perioperative Risk start, electronic health records (EHRs) Optimization with Machine Learning for an create massive datasets—a resource often Improved Surgical Experience (PROMISE) untapped due to the lack of processing program, Corey’s original focus was power needed to leverage terabytes of predicting outcomes for geriatric patients. data in a way that human brains can comprehend and make practical. “Because DIHI IS is an innovations group, As the capabilities of machine learning is really creat ive,” Corey says. “They gave expand, big data from EHR and other us the free range and flexibility to think

Patient Contents Care 5 big. When we got into the data, we started procedures and spanning 4 years,” trained with data asking questions. What if we did this for all Corey says. “Patient features include all at other centers, such as Duke Regional surgical patients, and not just geriatric?” inpatient and outpatient encounters, med Hospital, Duke Raleigh Hospital, and in the administrations, vitals, diagnosis codes, future, those outside the Duke University Corey, along with fellow students Sehj demographics, orders, labs, and more.” Health System. Kashyap and Elizabeth Lorenzi, spent their research year with DIHI mining and As the repository expands, so does its Creating New Data curating EHR data to create an initial variety of application, far beyond the initial repository of 99,755 procedures from models used to predict postoperative EHR data capture several important 66,370 patients. When the project received complications. Currently, the team is snapshots of the patient experience, but are far from complete and mostly attention at the Machine Learning in building a model to predict 30-day administrative. Intentional and systematic Healthcare Conference, the group decided readmission rates. Over time, training data collection is needed to broaden to commit to another year of research with computer models with data increases the strokes and create a fuller picture. Allan D. Kirk, MD, PhD, David C. Sabiston, their usefulness in making decisions and Collaborations between the Department Jr. Professor of Surgery and Chair of Duke predicting outcomes. of Surgery and experts in data science at Surgery, as the clinical primary investigator. The broadest application of the repository Duke are foundational to this approach. “The DIHI team has built out our EHR could come from generalizability. The team A valuable partner in this initiative is Erich data pipeline, now covering 550,000 is currently testing the success of models Huang, MD, PhD, Assistant Professor of Surgery and in Biostatistics and Bioinformatics, as well as Co-Director of Forge, Duke’s Center for Actionable Health Data Science. Dr. Huang is the founding 2018 DUKE SURGERY advisor of KelaHealth, a company that DATA SNAPSHOT originated from Duke Surgery around a machine learning platform that uses In just one year, millions of patients touch the Duke Health system, including algorithms from data points to reduce hundreds of thousands in Duke Surgery. These patient encounters provide surgical complications and objectively valuable data for care improvements and the future treatment of disease, inform decision-making. and inform decisions for all members of the department. “When a human makes a judgment, do they have formal confidence intervals, or is it subjective?” Huang asks. “The main reason we want to use machine 191,538 learning is that it will help us measure our performance. If we can objectively outpatient visits measure, then we can also improve.”

Dr. Huang is a collaborator on the Department of Surgery's 1000 Patient Project, which collects biosamples from 29,612 consenting patients before, during, and after surgery. This data collection is unique, surgeries and therefore requires something the EHR cannot provide. performed “We are using surgery as a perturbation event to collect information from the patients before and after surgery,” Huang says. “We need a lot of structured 920 information about the patients, and it doesn’t live natively in the EHR. We are members of the collecting microbiome data and next- department, including generation sequencing data. We need to have a separate data system to store that all faculty, staff, information.”

residents, & fellows The genomic information collected in the 1000 Patient Project can be used to help answer several questions, including who 6 Duke Surgery With data, you can identify the necessary pinpoints—it helps us to have valuable conversations, to look at “what we are doing and to collaborate and work together for the betterment of our patient population." Neel Kapadia, MD Assistant Professor of Surgery

should have surgery and how they will Neel Kapadia, MD, and Brent Jason Machine learning can be used to expedite respond to it. Lawrence Carin, Professor Theiling, MD, work with a team to analyze care and stratify a variety of risks. A of Electrical and Computer Engineering at incoming data, streamline processes, and Sepsis Watch tool uses historical and Duke, has worked with Duke Surgery in its improve care. real-time data, including medical history, data collection and analysis. medications, vitals, and lab and radiology “Our goal is that we want to see and take results, to predict sepsis probability. “Artificial intelligence (AI), machine care of every patient that presents to the learning, and data science affects the hospital for care, and we want to do so “What is interesting is not only does the entire process, from beginning to end efficiently and to make sure that the care mode generate a single probability, but it of the surgical process,” Carin says. “All is high-quality,” Theiling says. “Once we generates multiple iterations adjusting as sources of data that we have—from started with that core, it is just a matter time and new data goes along,” Theiling radiology, pathology, genomics, the of breaking it down. What are the patient says. “In fact, if you look at the time when clinical record itself—how can we pull in demographics and other data that can the probability jumps, say from 15% to all of this information to better understand inform operational decisions and impact 90%, in many patients it is not tied to who should go into surgery and then for the better the quality and efficiency of any discrete data point. This just shows understand how the body will go through the care that is provided?” the power of a machine learning the healing process after?” model and how it differs from a purely “When we originally looked at the data, it The AI created by machine learning algorithmic program.” was more an executive summary,” Kapadia and data training has the potential says. “Performance services is continually This tool is being piloted in the Emergency to work collaboratively with "natural updating it. It has since evolved to our Medicine division, and if successful, will roll intelligence"—that of the clinicians utilization per hour of the day, and now and surgeons making decisions. This out across the hospital. subsequently we can get into the data collaboratiion of intelligences combine the patient by patient, how long they stayed, Data as a Tool, Not a Takeover subjective and well-rounded experience of why did they stay that long. We can break the clinician, with the objective and well- Machine learning possibilities are vast, it down by bed utilization, and all these defined trends of data sets. individual pieces can be put together.” though not limitless. Deeper analysis of data, analyzing algorithms, and training Collaborating on Real-Time Data Theiling and Kapadia add that because predictive models will offer insight, but There's no better test case for the benefits the emergency division collaborates with are not a substitute for the knowledge of real-time use of machine learning than many outside entities, including labs, and intuition of a master clinician. Pairing in the Division of Emergency Medicine, radiology, consultants, and transport, the two intelligences—both natural and where data can be used to analyze trends real-time data allows the division to artificial—offers both subjective and from the often unpredictable ebb and flow objectively pinpoint weaknesses and direct objective means of improving care for of the ER. Assistant Professors of Surgery improvement strategies accordingly. all patients. Patient Care 7 RESILIENCE in Surgery Improving Provider Well-Being By Brooke Walker

2008 survey from the American “Burnout has very far-reaching implications burnout among faculty and trainees by College of Surgeons found so it’s really important that we address promoting resilience, or the ability to that 40% of surgeons reported this,” says Cynthia Shortell, MD, Professor bounce back quickly from adversity. These Aburnout1. Burnout manifests as emotional programs teach resilience by encouraging of Surgery and Chief of Staff for the exhaustion, depersonalization, and a low Department. “I think in surgery we have the development of mindfulness and sense of personal achievement due to this culture that really values hard work coping skills. The department plans to chronic occupational stress. This highly and dedication and that’s necessary and incorporate this message into ongoing stressful state affects surgeons at all points important, but there is a line, that once training for providers. in their careers. In a 2016 survey of general passed is not helpful to anyone anymore. 2 “I think that part of promoting resilience surgery residents, 70% reported burnout . Teaching surgeons how to take care of and preventing burnout will also come in their patients and loved ones by taking The effects of burnout are widespread. our efforts with continuing education,” care of themselves is a hard one, but it’s Studies have shown that burnout is says Peter Smith, Ed.D, a clinical something that we’re going to have to associated with poor patient outcomes, psychologist affiliated with the Department figure out.” increased risk of medical errors, and of Surgery. “We’re developing training increased risk of surgeon injury. The A Culture of Support modules now for different work groups evidence is clear: Providers who take around our department that will be highly care of themselves take better care of The Duke Department of Surgery recently interactive in topics that they help shape. their patients. introduced several programs to prevent This will provide a deliberate committed

Led by Dr. Linda Cendales, the transplant team performs the first bilateral hand transplant in North Carolina. Extended procedures like this 14-hour event present unique challenges for maintaining focus and resilience.

8 Duke Surgery Dr. Debra Sudan (above) and Dr. Detlev Erdmann, and Dr. Suhail Mithani (below, with transplant team) perform the first abdominal wall transplant in North Carolina. opportunity to talk about things in the workplace, including how to keep oneself strong that we often just take for granted.”

With the recent introduction of peer support groups for faculty and trainees, the department is poised to foster a culture of openness and trust. The group meetings provide an open forum to discuss topics that contribute to burnout. This year, the support groups will focus on harassment training. So far, Drs. Shortell and Smith believe these meetings have been tremendously successful with much participation from faculty.

“We’re working with the Diversity and Inclusion Committee to develop focus groups to introduce discussions around workplace well-being and burnout,” says Dr. Shortell. “People can share stories and listen to a speaker discussing a brief topic. Those groups would continue to get together to have this trusting group where people could share with each other.”

Expressions of Gratitude

The department recently introduced a new initiative to provide thank you cards to all work groups to encourage employees to recognize and appreciate their coworkers. Whether acknowledging a coworker’s quick-thinking decision to save a patient’s life or appreciating someone who went above and beyond at work, the simple act of expressing thanks helps to cultivate a supportive environment.

“My hope is that this will provide a reminder that gratitude and recognition are foundational qualities of respect, and respect is at the core of all successful cultures,” says Dr. Allan D. Kirk, David C. Sabiston, Jr. Professor of Surgery and Chair, Department of Surgery.

References

1. Shanafelt TD, et al. Burnout and career satisfaction among American surgeons. Ann als of Surgery 2009;250(3):463-471.

2. Elmore LC, et al. National survey of burnout among US general surgery residents. Journal of the American College of Surgeons. 2016;223(3):440-451.

Patient Care 9 Friends and family of Debra Kelly, the first bilateral hand transplant recipient in North Carolina, gather at a reception on February 26, 2019. Photo by Shawn Rocco.

TRANSPLANT FIRSTS IN NC Looking to the to perform different procedures at the of the most difficult types of allograft same time. Procedures of this complexity transplants. Duke is one of fewer than 15 Future, Together require not only a cohesive team of skilled centers nationwide that have an active By Renee Dubois medical professionals, but also dedicated intestinal transplant program. administrators, transplant coordinators, and partnerships outside the hospital with In the press conference held on ince its inception, Duke Surgery donor services organizations. November 15, 2018, Dr. Erdmann said has always placed a high emphasis procedures such as these “require a major on better patient care through The abdominal wall transplant was led by infrastructure – a team of 25 or more Sinnovation. David Sabiston, Jr, MD, FACS, Detlev Erdmann, MD, PhD, MHS, Professor people working in the operating room and who was the Chairman of the Department of Surgery, Division of Plastic, Maxillofacial, really everything has to come together.” of Surgery for 32 years, pioneered and Oral Surgery, and Kadiyala Venkata Dr. Sudan chimed in, “It takes a multitude coronary bypass graft surgery and pushed Ravindra, MBBS, Director, Abdominal of people to care for patients through for clinical excellence in all things. Duke Transplant Surgical Fellowship, Associate organ donation and transplantation.” Dr. continues to be at the forefront of new Professor of Surgery. The small bowel Erdmann spent 15 years preparing for surgical techniques, most recently with transplant, performed at the same time as abdominal wall transplantation, practicing the first abdominal wall transplant and the the abdominal wall transplant, was led by the procedure in the fresh tissue lab, where first bilateral hand transplant performed in Debra L. Sudan, MD, Chief of the Division he and his team discovered an innovative North Carolina. of Abdominal Transplant Surgery. way to create a vascular loop at the thigh Both of these procedures are unique Intestine transplants are incredibly rare, level to reconnect the blood supply to because two teams of surgeons needed to and due to the high risk of rejection and the abdominal wall, allowing surgeons to work together in the same operating room infection, are often considered to be one perform both transplantation procedures

10 Duke Surgery TRANSPLANT FIRSTS IN NC

without interfering with each other’s of a clinical trial designed to lessen the risk includes professionals from transplantation, work. This technique will benefit many of immunosuppression and evaluates the neuropsychology, histocompatibility, patients in the same situation as Johnathan patients’ ability to use the transplanted internal medicine, occupational therapy, Nauta, the transplant recipient. Mr. Nauta limb in daily activities (Clinicaltrials.gov and pathology, to name a few. And just needed an intestinal transplant, but had NCT02310867). as important are the administrative and too much scar tissue on his abdomen for research infrastructures that make large- proper coverage. Mr. Nauta is thriving Under the VCA program, Dr. Cendales scale innovative procedures such as these after the transplant and is now able to is collaborating with Dr. Erdmann and possible. The 14-hour procedure took eat unassisted. This procedure will benefit is co-principal investigator with Dr. place on Thanksgiving Day, when the team many other transplant candidates waiting Ravindra on a study of the efficacy of demonstrated their dedication by spending for kidney, liver, or intestine transplants abdominal wall transplants to restore a holiday taking care of the patient, Debra who might otherwise be rejected due to the function of the defective abdominal Kelly, instead of being at home with their the condition of their abdomens. wall (Clinicaltrials.gov NCT03310905). It is families. Ms. Kelly continues to do well. therefore fitting that Dr. Cendales was the A reception celebrating with her and her Much of this research was made possible surgeon to lead the team that performed friends and family was held on February 26 on by the Vascularized Composite Tissue the first bilateral hand transplant in the the Duke University Medical Center campus. Allotransplantation (VCA) program, state. The over 40-person team included founded by Linda Cendales, MD, the professionals from different department None of this would have been possible director of the program and the surgeon and disciplines, including hand surgeons, without the generous gift of the donor who lead the team that performed the anesthesiologists, nurses, operating room families, who chose to provide life and first hand transplant in North Carolina. staff, and lab technicians. In addition to the quality of life to the patients in the face Dr. Cendales is the principal investigator expertise in the operating room, the team of their grief.

Patient Care 11 PUBLICATIONS IN HIGH IMPACT FACTOR JOURNALS*

5-year outcomes of self-expanding transcatheter versus A phase II trial of the aurora kinase A inhibitor alisertib surgical aortic valve replacement in high-risk patients. for patients with castration-resistant and neuroendocrine Gleason TG, Reardon MJ, Popma JJ, et al. J Am Coll Cardiol. prostate cancer: efficacy and biomarkers. 2018;72(22):2687-2696. Beltran H, Oromendia C, Danila DC, et al. Clin Cancer Res. 2019; 25(1):43-51. Association of renin-angiotensin inhibitor treatment with mortality and heart failure readmission in patients One-year outcomes after MitraClip for functional mitral with transcatheter aortic valve replacement. regurgitation. Inohara T, Manandhar P, Kosinski AS, et al. JAMA. Ailawadi G, Lim DS, Mack MJ, et al. Circulation. 2019;139(1):37- 2018;320(21):2231-2241. 47.

Combination therapy with anti-HIV-1 antibodies ROBO4 variants predispose individuals to bicuspid aortic maintains viral suppression. valve and thoracic aortic aneurysm. Mendoza P, Gruell H, Nogueira L, et al. Nature. Gould RA, Aziz H, Woods CE, et al. Nat Genet. 2019;51(1):42-50. 2018;561(7724):479-484. Route of immunization defines multiple mechanisms of Evaluation of a mosaic HIV-1 vaccine in a multicentre, vaccine-mediated protection against SIV. randomised, double-blind, placebo-controlled, phase Ackerman ME, Das J, Pittala S, et al. Nat Med. 2018;24(10):1590- 1/2a clinical trial (APPROACH) and in rhesus monkeys 1598. (NHP 13-19). Barouch DH, Tomaka FL, Wegmann F, et al. Lancet. Simulation modeling of cancer clinical trials: application to 2018;392(10143):232-243. omitting radiotherapy in low-risk breast cancer. Jayasekera J, Li Y, Schechter CB, et al. J Natl Cancer Inst. Inference of the HIV-1 VRC01 antibody lineage 2018;110(12):1360-1369. unmutated common ancestor reveals alternative pathways to overcome a key glycan barrier. T-cell exhaustion signatures vary with tumor type and are Bonsignori M, Scott E, Wiehe K, et al. Immunity. severe in glioblastoma. 2018;49(6):1162-1174.e8. Woroniecka K, Chongsathidkiet P, Rhodin K, et al. Clin Cancer Res. 2018;24(17):4175-4186. LncRNA CamK-A regulates Ca2+-signaling-mediated tumor microenvironment remodeling. *Journals with an Impact Factor greater than 10.0 Sang LJ, Ju HQ, Liu GP, et al. Mol Cell. 2018;72(1):71-83.e7.

George C. Hughes IV, MD CLINICAL TRIALS Bolton Medical Relay Pro A37 Bolton Medical, Inc. ABDOMINAL TRANSPLANT SURGERY Sure-AVR LivaNova Stuart Knechtle, MD BMS Protocol # IM103-407 Peter K. Smith, MD Bristol-Myers Squibb Company Hybrid Coronary Revascularization Trial- DCC Evaluation of patient outcomes from the kidney allograft Icahn School of Medicine at Mount Sinai outcomes allosure registry (KOAR) agreement CareDx, Inc. EMERGENCY MEDICINE Bruce J. Derrick, MD Kadiyala V. Ravindra, MBBS Forest Devices - EDGAR Study Medeor Therapeutics MDR-103-L2K Forest Devices, Inc. Medeor Therapeutics, Inc. Alexander T. Limkakeng Jr., MD CARDIOVASCULAR AND THORACIC SURGERY Capsule Endoscopy for HEmorrhage in the ER (CHEER) The George Washington University Matthew G. Hartwig, MD CCC for NHLBI Prevention and early Treatment of OCS TOP Registry Acute Lung Injury PETAL Network – CLOVERS TransMedics Vanderbilt University Medical Center

12 Duke Surgery SURGERY RESEARCH GRANT ACTIVITY

EMERGENCY MEDICINE Joshua S. Broder, MD Identification of Abdominal/Pelvic Traumatic Shock Hemorrhage Sources, Active Bleeding, and Quantification of Hemorrhage by 3D Augmentation bf 2D Ultrasound: A Comparison Study with Computed Tomography Emergency Medicine Foundation

Bruce J. Derrick, MD Ketogenic Diet for Reduction of CNS Oxygen Toxicity Symptoms in Working Divers Naval Sea Systems Command

Alexander T. Limkakeng Jr., MD, and Jinny Ye, MD Prehospital Termination of Resuscitation in Out-of-Hospital Cardiac Arrest Society for Academic Emergency Medicine

Anjni P. Joiner, DO, MPH Healthcare Access Barriers and an Evidence Based Solution in a Low-Income Country Society for Academic Emergency Medicine

PLASTIC, MAXILLOFACIAL, AND ORAL SURGERY David A. Brown, MD, PhD A Point-of-care, Biomarker-based Test to Predict Non-healing in Chronic Wounds The Plastic Surgery Foundation

SURGICAL ONCOLOGY Shelley Hwang, MD, MPH HEAD AND NECK SURGERY AND Breast Pre-Cancer Atlas Center COMMUNICATION SCIENCES National Institutes of Health Walter T. Lee, MD Molecular and Radiologic Predictors of Invasion Clinical Evaluation of the OncAlertTM RAPID in Subjects in a DCIS Active Surveillance Cohort Presenting for Evaluation and/or Initial Biopsy Breast Cancer Research Foundation Vigilant Biosciences SURGICAL SCIENCES METABOLIC AND WEIGHT LOSS SURGERY Aravind Asokan, PhD Jin Yoo, MD Evolving High Potency AAV Vectors for Signia Stapling System Neuromuscular Genome Editing Medtronic National Institutes of Health

Dawn E. Bowles, PhD UROLOGY Cadaver Implant Studies of PABP Brant A. Inman, MD 3R Life Sciences Taiwan, Ltd. TAR-200 Study TARIS Biomedical, LLC VASCULAR AND ENDOVASCULAR SURGERY Ellen D. Dillavou, MD, and Ehsan Benrashid, MD VASCULAR AND ENDOVASCULAR SURGERY The Effect of Bundled Measures to Reduce Surgical Site Ellen Dillavou, MD Infection (SSI) in Vascular Surgery Patients Laminate - VasQ Study Acelity Laminate Medical Technologies, Inc. Research 13 or close to 100 years, Duke Surgery Co-chaired by Dr. Ranjan Sudan, Professor studying what was important,” says has trained surgeons from the ground of Surgery and Vice Chair of Education at Dr. Sudan. up, forging the path for medical Duke Surgery, and Dr. Marc A. de Moya, Fstudents to become future leaders in The first of its kind in the country, the Medical College of Wisconsin, the ASE ACS/ASE curriculum aims to provide surgery. Now the department will help Curriculum Committee decided a national an essential set of topics to ensure drive the way surgical education evolves curriculum was necessary for all medical on a national level. that all medical students have a core students regardless of whether they understanding of surgery and are In June 2018, the department implemented ultimately chose surgery for their adequately prepared for the NBME® a new pilot curriculum for medical career path. Surgery Shelf, a case-based exam that tests students in the surgery clerkship under students’ ability to diagnose and manage “The faculty in the clerkship were pretty the leadership of the clerkship director surgical patients. Dr. John Haney and with enthusiastic much trying to teach students to the exam support from the Duke University School as opposed to saying, ‘you know, this “What we wanted to do is figure out of Medicine. is what’s really important,’ so students those topics that every medical student were preparing for the exam, rather than should have read through and gained a In contrast to other medical specialties, surgery currently lacks a standard curriculum for medical students on their surgery rotation. The Association for Surgical Education (ASE) in partnership with the American College of Surgeons (ACS) convened a committee 7 years ago to address this need.

Duke Surgery Pilots

NATIONAL CURRICULUM

for Medical Students

By Brooke Walker

General surgery resident Dr. Whitney Lane (left) with second-year medical students Etienne Flamant, John Park, Timothy Beck, and Shane Killarney. Photo by Colin Huth/ 14 Duke Surgery PhotoC4. good understanding of in medical school,” For each topic, the students learn relevant relationships with the residents and explains Dr. Sudan. “We said let’s survey all hands-on skills in the surgery simulation faculty who are working with them.” the stakeholders to find out what they think lab, such as how to start intravenous Dr. Sudan will present the results of the is important. We surveyed medical students lines and insert a Foley catheter. At Duke, needs assessment survey at the ASE annual who had completed their surgery clerkship, this learning is supplemented by several conference in April. Duke plans to share residents, and interns. Once we got the different index cases to help the students student and faculty feedback with five or six topics together, we then started putting gain a broader understanding of common other institutions across the country before down some very well-described goals and operations. those institutions implement the national objectives.” curriculum. Following the multi-institutional “We changed the structure of our clerkship phase, the ACS plans to disseminate the The committee developed content specific around the curriculum in order to give our curriculum nationally to medical schools. to each topic to meet those goals and students more continuity,” says Dr. Sudan. objectives, which would be easily accessible “Rather than split the rotation into 3-week The Core Curriculum can be found online at on the ACS website by faculty and residents segments, we’ll give them 6 weeks on https://www.facs.org/education/program/ teaching in the clerkship as well as students. one rotation so that they can build some core-curriculum.

Education Research 15 Training Surgeons in Immunobiology

nderstanding the immune research training, leaving surgeons funding opportunities for candidates with system and its role in disease inadequately prepared to lead immune- PhD and Master’s level degrees and aims Uand wound healing has become related research as a surgeon–scientist. to develop surgeon–scientists who will increasingly relevant in surgical practice. lead areas of immunobiological research This past fall, the Department of Surgery Immunobiology influences a variety of relevant to surgical discovery. was awarded a T32 grant from the National surgical disciplines, including oncology, Institutes of Health to create a formal transplantation, inflammatory bowel training program specifically for surgical Interested applicants can email Dr. Kent disease, trauma, and critical care. However, residents interested in immunobiological Weinhold, Professor and Chief, Division of surgical training often lacks this critical research. The five-year award provides Surgical Sciences, at [email protected].

KURe Multidisciplinary Benign Fresh Cadaver Flap DUKE SURGERY Urology Research Day Dissection Course ADVANCED April 26, 2019, Durham, NC August 2–4, 2019, Durham, NC

2019 Duke Masters of Minimally EDUCATION Duke Tuesday in Urology Invasive Thoracic Surgery COURSES July 9, 2019, Durham, NC October 10–12, 2019, Orlando, FL

Craniomaxillofacial For a complete list of courses, 2019 Duke Solid Organ please visit http://innovation.surgery. Trauma Anatomy Course Transplant Summit duke.edu/courses. July 19–21, 2019, Durham, NC October 19, 2019, Durham, NC

16 Duke Surgery NEW FACULTY

SHARON L. GARY J. ANNETTE M. CLANCY, MD FAERBER, MD JACKSON, PhD Assistant Professor of Professor of Surgery, Associate Professor of Surgery, Division of Division of Urology Surgery, Division of Plastic, Maxillofacial, Abdominal Transplant and Oral Surgery Surgery Clinical interests include breast reconstruction, Clinical interests include urologic surgery. Research interests include transplantation corrective surgery, and complex reconstructive Research interests include urologic surgery and related immunology, including HLA surgery in women’s cancers, including clinical outcomes, medical and surgical desensitization and the down-regulation of B cell breast cancer, single-stage, and postablative management of urinary stone disease, and responses to organ and tissue transplantation. mammoplasty reconstruction. Research sleep deprivation and its effect on resident interests include outcomes research in breast performance. reconstruction, surgical education, and breast microenvironment cell signaling pathways.

GEORGE CAROLYN S. SHERRI KASOTAKIS, MD, MPH MENENDEZ, MD SMITH, PhD, AuD Assistant Professor of Assistant Professor of Associate Professor of Surgery, Division of Surgery, Division of Surgery, Division of Head Trauma and Critical Surgical Oncology and Neck Surgery & Care Surgery Communication Sciences Clinical interests include surgical critical illness, Clinical interests include breast surgical Clinical interests include advanced-practice acute respiratory distress syndrome, laparotomy oncology. Dr. Menendez is the hereditary cancer rehabilitative audiology, including auditory for trauma, hernia repair, complex abdominal clinic representative at the weekly molecular implants, individualized and group audiologic wall reconstruction, diverticulitis, gallbladder tumor board and the program leader for rehabilitation, amplification, and accessories disease, chest wall injury, appendicitis, and peptic hereditary cancer counseling in Wake county. for older adults with co-morbidities. Research ulcer disease/intestinal perforation. Research Research interests include cancer risk assessment interests include adult audiologic rehabilitation, interests include pulmonary inflammation in and clinical cancer genomics and genetics. outcome assessment, dual-sensory impairment, acute lung injury/acute respiratory distress speech perception, auditory working memory for syndrome, gallbladder disease, and more. speech, service-delivery models for amplification.

JEFFREY SCOTT T. FACULTY CHENG, MD HOLLENBECK, MD Promoted to Associate Promoted to Associate PROMOTIONS Professor of Surgery, Professor of Surgery Division of Head with tenure, Division of and Neck Surgery Plastic, Maxillofacial, & Communication and Oral Surgery Sciences

JOHN KRISTAL M. RISKA, MIGALY, MD PhD, AuD, CCC-A Promoted to Associate Promoted to Assistant Professor of Surgery Professor of Surgery, with tenure, Division of Division of Head Surgical Oncology and Neck Surgery & Communication Sciences

Faculty 17 NATIONAL RANKINGS ONYE E. AKWARI, MD Professor of Surgery, Division of Surgical Sciences in Blue Ridge National Received the Raymond Gavins Rankings of NIH Distinguished Faculty Award from the Funding for Surgery Samuel DuBois Cook Society.

SHELLEY This is a noteworthy recognition befitting the talents HWANG, MD, MPH and accomplishments of Duke Surgery. I am particularly proud of the outstanding commitment of our faculty Vice Chair of Research and staff who work every day to drive innovation and and Professor of Surgery, discovery in surgical care. We are all in when it comes to Division of Surgical “improving outcomes for future surgical patients!” Oncology Shelley Hwang, MD, MPH Ranked 1st in 2018 NIH funding Vice Chair of Research according to the Blue Ridge Institute for Medical Research, with more than $10 million in funding.

PAUL J. MOSCA, MD, PhD, MBA Associate Professor of Surgery, Division of in U.S. News & World Surgical Oncology

Report's Graduate Surgical Inducted into the Southern Education Programs Surgical Association.

PETER K. We are very happy to see these rankings as it SMITH, MD represents the very high quality of the students with Mary and Deryl Hart whom we have the privilege of working everyday, the Professor of Surgery environment of discovery that exists at Duke, and the and Chief, Division of reputation that Duke Surgery is blessed to have among Cardiovascular and “educational leadership. It also emphasizes that we have Thoracic Surgery to keep working very hard to provide our students with an environment that will help them become competent Appointed chair of the American and compassionate physicians." Medical Association’s Specialty Society Relative Value Scale Update Ranjan Sudan, MD Committee. Received the American Vice Chair of Education Association of Nurse Practitioner's NC State Award for Excellence-Nurse 18 Duke Surgery Practitioner Advocate. FACULTY AWARDS

BRADLEY H. GUIDO SCOTT T. COLLINS, MD FERRARI, MD HOLLENBECK, MD Associate Professor of Associate Professor of Associate Professor of Surgery, Division of Surgery, Division of Surgery, Division of Abdominal Transplant Surgical Sciences Plastic, Maxillofacial, Surgery and Oral Surgery Listed among the most highly cited Inducted into the Southern Received the 2019 Leonard Palumbo researchers in 2018 according to Surgical Association. Jr., MD Faculty Achievement Award, Clarivate Analytics. which honors a faculty member who displays a dedication to patient care and excellence in teaching and mentoring young physicians.

GEORGE STUART DAVID C. KASOTAKIS, MD, MPH KNECHTLE, MD MONTEFIORI, PhD Assistant Professor of Mary and Deryl Hart Professor of Surgery, Surgery, Division of Professor of Surgery, Division of Surgical Trauma and Critical Care Division of Abdominal Sciences Surgery Transplant Surgery Among the most highly cited Received a 3-year scholarship to attend Inducted into the Association of researchers in 2018 according to the Eastern Association for the Surgery American Physicians. Ranked 7th Clarivate Analytics. of Trauma Leadership Development in NIH funding received in 2018 Workshop. according to the Blue Ridge Institute for Medical Research.

PAUL J. MOSCA, SREEJA M. GLENN M. JONATHAN C. MD, PhD, MBA NATESAN, MD PREMINGER, MD ROUTH, MD Assistant Professor of James F. Glenn, M.D. Paul H. Sherman, M.D. Surgery, Division of Professor of Urology Associate Professor of Emergency Medicine and Chief, Division of Surgery, Division of Urology Urology Named course director of the Received the Karl Storz Lifetime Named president-elect of the Pediatric Emergency Medicine Board Review Achievement Award from the Urologic Oncology Working Group. Redefined course. Endourological Society.

PETER K. RANJAN BRUCE GEORGIA SMITH, MD SUDAN, MD SULLENGER, PhD TOMARAS, PhD Vice Chair of Education Joseph W. and Dorothy Professor of Surgery, and Professor of Surgery, W. Beard Professor of Division of Surgical Division of Metabolic Experimental Surgery, Sciences and Weight Loss Surgery Division of Surgical Sciences Will serve as consultant to the Ranked 7th in NIH funding received American College of Surgeons Division Elected a Fellow of the National in 2018 according to the Blue Ridge of Education. Began his second year Academy of Inventors. Institute for Medical Research. Among serving on the Board of Trustees for the most highly cited researchers in the Society for the Surgery of the 2018 according to Clarivate Analytics. Alimentary Tract.

Faculty 19 Non-profit Org. U.S. Postage PAID Durham, NC Department of Surgery Permit No. 60 DUMC 3704 Durham, NC 27710

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MISSION VISION Through sustainable, multidisciplinary teams we: Duke Surgery: United, for All Patients

Provide insight regarding the Empower all patients, trainees, Provide safe and high-quality fundamental nature of patient and colleagues with knowledge care based on an advanced health and disease understanding of and respect for our patients’ needs and 1 2 3 guided by best practices

PARTNERS IN PHILANTHROPY DUKE SURGERY

A gift to the Duke Department If you would like to make a ALUMNI of Surgery is a gift of knowledge, philanthropic investment in Duke discovery, and life. Every dollar is Surgery, please contact Marcy Romary, Keeping in touch with our alumni is used to further our understanding Senior Major Gifts Officer, with Duke important to us. Please update your of surgical medicine, to develop Health Development and Alumni Duke Surgery alumni profile via new techniques, technology, and Affairs at [email protected] the online form below: treatments, and to train the surgeons or visit surgery.duke.edu/gift. surgery.duke.edu/alumni-update and researchers of the future.

In memory of Jill White, Duke Surgery Director of Communications Duke Surgery: United, for All Patients