Expertise Sets Division of Endocrinology, Diabetes and Metabolism Apart

This is the first in a series of profiles on the Department of Medicine’s divisions

To be recognized among the best academic health systems nationwide requires excellence in education, research and patient care. So it was no surprise when Dean Pascal J. Goldschmidt, M.D., took the helm of the Miller School in 2006, the highly regarded cardiologist began to search for distinctive faculty to join him, people who were brilliant in their fields, who could lead and, in turn, build their own teams of similarly dedicated faculty to boost research and offer the kind of advanced care that would attract patients across the region, the country and the world.

One such hire was Marc Lippman, M.D., who, when he became chair of the Department of Medicine, recruited Antonio Bianco, M.D., Ph.D., to leave Harvard Medical School and build the Miller School’s Division of Endocrinology, Diabetes and Metabolism into one of the nation’s best.

A world authority on thyroid disease, Bianco’s latest recognition is his appointment to the Board of Scientific Counselors of the National Institute of Diabetes and Digestive and Kidney Diseases Intramural Research Program. The physician-scientist, who likes to recount how he moved from his tenured position at the University of São Paulo in Brazil for Harvard many years ago with not much more than his briefcase, is always up for a challenge. His decision to come to Miami turned out to be a good one.

Since his August 2008 arrival at the Miller School to lead the division, Bianco, a professor of medicine, has assembled an impressive faculty of cutting-edge scientists working in the labs, and physicians extending the most advanced patient care in multiple UHealth hospitals and clinics. Once focused primarily on diabetes and lipid disorders, the division has expanded way beyond its original scope, with a plethora of experts treating the full spectrum of endocrine and metabolic diseases, including thyroid diseases and cancer, pituitary and adrenal diseases, bone metabolic disease, reproductive endocrinology and nearly every variation of the category.

Renowned for his outstanding research contributions to understanding the molecular process that can activate or inactivate thyroid hormone, Bianco defined the importance of local control of thyroid hormone action via deiodination – the removal of iodine – that is mediated by the deiodinases. In other words, he established that cells are not passive bystanders as far as thyroid hormone action is concerned. By modulating the deiodinases, most cells customize how they respond to thyroid hormone, which can vary dramatically during development, in response to caloric intake or in disease states. For example, due to ischemia and hypoxia that follow a stroke or a myocardial infarction, there is localized hypothyroidism caused by expression of the deiodinase that inactivates thyroid hormone. On the other hand, a hypercaloric diet accelerates thyroid hormone activation, specifically in the brown adipose tissue, which then enhances energy expenditure without elevating systemic levels of thyroid hormone.

This new way of looking at thyroid hormone action has very significant clinical implications, primarily because serum hormone levels may not be predictive of the cell events that are driving clinical symptoms.

At the Miller School, Bianco continues to explore the molecular and cellular biology of the enzymes that mediate these pathways to better understand their physiological and pathophysiological roles, as well as to develop therapeutic approaches to regulate thyroid hormone action. A current focus of his attention is how the deiodinases in the brain affect the response of hypothyroid patients to replacement with thyroxine alone or combined therapy of thyroxine and the hormone T3, an issue that affects millions of patients worldwide.

Aside from his scientific contributions, Bianco understands that his division’s achievements are a team effort. “A patient coming here for treatment now can see any one of a number of experts who are extremely well qualified and in some cases among the best in their field,” said Bianco, the former chief of the thyroid section at Harvard. “I am really proud of our growth here at UM. The expanded faculty has been experiencing tremendous success and we have much more to come.”

His team includes newly recruited innovative physicians and scientists such as Brian Kim, M.D., assistant professor of medicine and co-leader of the thyroid cancer site disease group at Sylvester Comprehensive Cancer Center, whom Bianco mentored when he was a fellow at Harvard; Gianluca Iacobellis, M.D., Ph.D., associate professor of medicine and a pioneering specialist in obesity and metabolic diseases; and Sanford Baim, M.D., associate professor of medicine and a renowned expert in clinical bone densitometry.

Along with a list of experienced lipid and diabetes experts who were already here, including the associate directors of the Diabetes Research Institute, Ronald Goldberg, M.D., professor of medicine, and Jay Skyler, M.D., professor of medicine, pediatrics and psychology; Luigi F. Meneghini, M.D., M.B.A., associate professor of clinical medicine and director of the Kosow Diabetes Treatment Center; and Jennifer Marks, M.D., professor of medicine and medical director of the Diabetes Management Program at the Miami VA Medical Center, the entire division, Bianco says, emphasizes teamwork and more medical school-wide collaboration “to provide greater benefit for the patient.”

For many patients, Iacobellis’ work is especially significant as it involves measuring fat around the heart to help determine the risk of diabetes, cardiovascular diseases and other obesity-related diseases. His initial discovery, made at the University of Rome, that fat around the heart directly correlated to abdominal fat is now widely cited around the world.

“Now we know that we can try to give medication to decrease the fat around the heart and improve the heart’s performance,” said Iacobellis, whose Ph.D. thesis focused on endocrinology, metabolic and cardiovascular disorders. “This kind of work has strong clinical applications. If we can perform something as simple as an ultrasound for the heart, we can provide patients a metabolic profile that can be useful to their doctors. It’s one more step toward more personalized, accurate health care.”

Iacobellis also has been collaborating with Nestor F. de la Cruz-Muñoz, M.D., chief of the Division of Laparoendoscopic and Bariatric Surgery and co-director of the Center of Excellence for Laparoendoscopic and Minimally Invasive Surgery, to treat bariatric surgery patients.

Although UHealth already was known for treating osteoporosis through the work of Silvina Levis, M.D., professor of medicine and director of the Osteoporosis Center, the addition of Baim to the team has brought increased focus on parathyroid disease and the prevention and treatment of osteoporotic fractures. The team leader of a comprehensive, multidisciplinary osteoporosis and metabolic bone disease program built on system-wide collaboration, Baim is designing a system that will be fully integrated into and implemented by UChart, UHealth’s electronic medical record system, for the purpose of identifying all patients at risk for osteoporotic fractures when seen by any UM physician.

In addition, Baim is collaborating with orthopaedic surgery, neurological surgery, hospitalists, emergency room physicians and private physicians at University of Miami Hospital to develop a fracture liaison service for evaluating and treating all osteoporosis fracture patients admitted to UMH.

“We are in the process of developing diagnostic and treatment subcommittees that will utilize evidence-based medicine and guidelines from professional societies to develop the necessary protocols that will be seamlessly integrated into UChart,” explained Baim. “This system-wide initiative will utilize the information in our medical records system—patient demographics, diseases, medical conditions, and medications to identify at-risk patients, then program UChart to alert the evaluating physician of the patient’s likelihood to suffer an osteoporotic fracture prior to an event.”

Under Baim’s vision, departments such as orthopaedics and neurological surgery, UM physicians and community doctors will work together in a coordinated, multidisciplinary fashion to prevent osteoporosis as well as to serve as a successful template for the identification and prevention of other diseases.

Kim, who is also program director of the J. Maxwell McKenzie Fellowship in Endocrinology, was attracted to the Miller School and UHealth in part by the opportunity to start his own lab. “It was clear that the University had grown rapidly and was making a major commitment to investing in research,” said Kim. “It is exciting to be part of this new venture in South Florida.”

Like most of the other recently hired faculty members, Kim, who received his M.D. at Columbia University, is prolific at the bench and the bedside. His lab focuses on how thyroid hormones control metabolism and it is among a few on campus investigating new drugs that target thyroid cancer cells.

The division’s highly selective fellowship program is also adding to its renown. For example, Jennifer Glueck, M.D., finished the program three years ago and remained at UHealth where, as an assistant professor of medicine, she specializes in reproductive endocrinology and collaborates with George Attia, M.D., associate professor of clinical obstetrics and gynecology and director of the UHealth Reproductive and Fertility Center.

Bianco notes that other stars in the division contribute to its success, including Alejandro Ayala, M.D., associate professor of medicine, who trained at the NIH and Johns Hopkins and specializes in diseases of the adrenal gland and gonads, and Atil Kargi, M.D., assistant professor of medicine, who trained at the University of Washington and focuses on pituitary disease.

Basic research also has been a priority for Bianco, as illustrated by the recruitment of research associate professors of medicine Alejandro Caicedo, Ph.D., who is well known in the diabetes field and has jointly published in Nature Medicine with colleagues from the Diabetes Research Institute, and Barry Hudson, Ph.D., a Columbia University transplant who investigates the endocrine mechanisms that regulate cell adhesion in vascular and tumor biology.

“Today, if a patient in South Florida has an endocrine problem we have a full spectrum of experts to call on,” said Bianco. “Our expertise is what sets us apart.”

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