Digital Commons Network^™

Comprehensive Review Of Cardiovascular Disease Risk In Nonalcoholic Fatty Liver Disease, Kevan Josloff, Jacob Beiriger, Adnan Khan, Richard J. Gawel, Richard S. Kirby, Aaron Kendrick, Abhinav K. Rao, Roy Wang, Michelle Schafer, Margaret Pearce, Kashyap Chauhan, Yash B. Shah, Gregary D. Marhefka, Dina Halegoua-De Marzio

Department of Medicine Faculty Papers

Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising …

Cardiogenic Shock Due To Atrial Arrhythmia As The Initial Presentation Of Transthyretin Cardiac Amyloidosis, Svenja M. Schneider, Kirpal Kochar, Max Ruge, Stefanie Marek-Iannucci, Tanuka Datta, Alexander Hajduczok, Waqas Ullah, Indranee Rajapreyar, Yevgeniy Brailovsky

Jefferson Hospital Staff Papers and Presentations

Atrial arrhythmias are common in transthyretin cardiac amyloidosis (ATTR-CA), with a prevalence of ≤80%. They are often not well tolerated. We describe 3 patients with decompensated heart failure and cardiogenic shock precipitated by atrial arrhythmias who ultimately received diagnoses of ATTR-CA. (Level of Difficulty: Intermediate.)

Cannabidiol, ∆9 -Tetrahydrocannabinol, And Metabolites In Human Blood By Volumetric Absorptive Microsampling And Lc-Ms/Ms Following Controlled Administration In Epilepsy Patients, Federica Pigliasco, Sara Malaca, Alfredo Fabrizio Lo Faro, Anastasio Tini, Giuliana Cangemi, Alessia Cafaro, Sebastiano Barco, Antonella Riva, Angelica Pisati, Elisabetta Amadori, Pasquale Striano, Adriano Tagliabracci, Marilyn A. Huestis, Francesco Paolo Busardò

Institute of Emerging Health Professions Faculty Papers

Cannabidiol (CBD) exhibits anti-inflammatory, anxiolytic, antiseizure, and neuroprotective proprieties without addictive or psychotropic side effects, as opposed to Δ9-tetrahydrocannabinol (THC). While recreational cannabis contains higher THC and lower CBD concentrations, medical cannabis contains THC and CBD in different ratios, along with minor phytocannabinoids, terpenes, flavonoids and other chemicals. A volumetric absorptive microsampling (VAMS) method combined with ultra-high-performance liquid chromatography coupled with mass spectrometry in tandem for quantification of CBD, THC and their respective metabolites: cannabidiol-7-oic acid (7-COOH-CBD); 7-hydroxy-cannabidiol (7-OH-CBD); 6-alpha-hydroxy-cannabidiol (6-α-OH-CBD); and 6-beta-hydroxycannabidiol (6-β-OH-CBD); 11- Hydroxy-Δ9-tetrahydrocannabinol (11-OH-THC) and 11-Nor-9-carboxy-Δ9-tetrahydrocannabinol (THCCOOH). After overnight enzymatic glucuronide hydrolysis at 37°C, samples underwent acidic …

Risk Prevention And Health Promotion For Non-Alcoholic Fatty Liver Diseases (Nafld), Adnan Khan, Do, Heather Ross, Natali Salinas, Sarah Chen, Kashyap Chauhan, Makala Wang, Brian Yan, Ba, John Magagna, Jacob Beiriger, Yash Shah, Taha Shahzad, Dina Halegoua-De Marzio, Md

Division of Internal Medicine Faculty Papers & Presentations

Non-alcoholic fatty liver disease (NAFLD) is a serious clinicopathological condition that is recognized as the most frequent chronic liver disease, affecting 14%-30% of the world’s population. The prevalence of NAFLD has rapidly grown and is correlated with the growth in obesity and type 2 diabetes, among other factors. NAFLD often results in long-term complications including cardiovascular disease, liver cirrhosis, and liver fibrosis. This paper provides an updated overview of NAFLD with a focus on epidemiology, etiology, pathophysiology, screening, complications, and pharmacological therapies to identify effective risk prevention and health promotion.

The Laws Of The Dead, Gillian Naro, Md, Med, Marie-Laure Flamer, Md

The Medicine Forum

George Washington suddenly fell ill with a sore throat and labored breathing at his estate in 1799. Initial management consisted of a "mixture of molasses, vinegar and butter," that was followed by “sage, tea and vinegar.” With no signs of clinical improvement, his doctors were called to his bedside. As was standard medical care at the time and thought to be beneficial in various afflictions, he was “bleed” more than 2L of blood in an attempt to restore his good health. The three doctors overseeing the bleeding process noticed the General become weaker despite their best efforts. His breathing became …

Internal Medicine Residents’ Experience With Using Handheld Ultrasound Machines In Point-Of-Care Ultrasonography, Michael Dong, Md, Tudor Sturzoiu, Md, Fred Karaisz, Max Ruge, Md

The Medicine Forum

Point-of-care ultrasonography (POCUS) is defined as the acquisition and interpretation of ultrasonographic images generated by the clinician at the bedside. The advent of handheld machines has increased access and practical application of ultrasound technology in internal medicine training and medical education. The most common system involves a single portable ultrasound probe that connects to a smartphone or tablet, and storage of images are stored via cloud-based technology. We discuss our experience with POCUS using handheld ultrasound machines in the Thomas Jefferson University Hospital academic setting.

Pulmonary Metastases Of Basal Cell Adenocarcinoma Presenting As Hemoptysis, Matthew Dimeglio, Do, Mba, Mark Mallozzi, Md, Prarthna Kulandaisamy, Md, Julie Barta, Md, Jennifer Johnson, Md

The Medicine Forum

Basal Cell Adenocarcinoma (BCAC) is a rare malignancy, only accounting for approximately 2% of all salivary neoplasms. Considered the malignant counterpart of basal cell adenoma, it most commonly presents at 60 years of age without gender predilection. Sites of involvement frequently includes the parotid gland, but sites in the minor salivary glands, nasopharynx, buccal mucosa, and tongue have also been reported. Often regarded as an indolent malignancy, BCAC can occasionally cause invasive disease and infrequently, metastatic disease. Among all solid tumors, endobronchial metastases is quite a rare occurrence, contributing to approximately 4% of endobronchial biopsies4. Most common sites of metastases …

Spontaneous Tumor Lysis Syndrome In Undifferentiated Pelvic Solid Tumor With Associated New Onset Atrial Flutter: A Case Report, Sameep Thapa, Md, Max Ruge, Md, Tamar Wolinsky Md

The Medicine Forum

Tumor lysis syndrome (TLS) is an oncologic emergency that is caused by electrolyte derangements from the lysis of malignant tumor cells. The syndrome consists of several laboratory abnormalities including hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia1,2. When these lab findings are associated with end-organ damage such as acute renal failure, seizures, or cardiac dysrhythmias amongst others, it is known as clinical TLS3. TLS is more commonly associated with hematological malignancies given their tendency of rapid cellular turnover. The most common culprits include acute lymphocytic leukemia and Burkitt’s lymphoma. It is, however, quite rare for TLS to occur secondary to a solid malignancy4. …

A Case Report Of Methemoglobinemia And Hemolytic Anemia In The Setting Of Covid-19 Pneumonia And G6pd Deficiency, Grant W. Jirka, Md, Travis Hunt, Md, Sushil Ghimire, Md, Rakhshanda Akram, Md, Urvashi Vaid, Md, Ms

The Medicine Forum

It is well known that hereditary or acquired methemoglobinemia can cause hypoxia due to the oxidation of heme, which impairs its ability to offload oxygen (Figures 1 & 2), and that acquired methemoglobinemia is most often caused by exposure to drugs and toxins that oxidize hemoglobin to methemoglobin, directly or indirectly1. Recently, a few case reports have highlighted methemoglobinemia in patients with COVID-19 pneumonia. Some of these reports were due to treatment with hydroxychloroquine and others from unidentifiable causes2-4. We present a case in which a patient with COVID-19 pneumonia was diagnosed with methemoglobinemia and acute hemolysis from G6PD deficiency …

A Case Of Acute Pancreatitis Associated With Empagliflozin, Tudor Sturzoiu, Md, Sameep Thapa, Md, Ellen Solomon, Suchit Bhutani, Md

The Medicine Forum

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are being prescribed increasingly more often for type 2 diabetes mellitus as well as heart failure. They have not typically been associated with acute pancreatitis, but there has been a steady flow of case reports implicating them in acute pancreatitis over the years since they were initially approved. Here, we present the case of an 82-year-old woman with a past medical history of T2DM, COPD, hyperlipidemia, a remote stroke, peripheral arterial disease, and remote breast cancer now with recurrent localized breast cancer on treatment with ademaciclib and letrozole who presented to the emergency department with …

A Confounding Case Of Acute Hepatitis A, Andrea Molin, Md, Michael Cheung, Md, Timothy Kuchera, Md

The Medicine Forum

Hepatitis A (HAV) is a picornavirus transmitted via fecal-oral route that disproportionately affects homeless persons, men who have sex with men, and individuals who use intravenous drugs. Acute HAV typically presents with nausea, vomiting, abdominal pain, and fever. It is most commonly self-limited but can progress to fulminant hepatic failure in less than 1% of cases. The following case is a unique presentation of acute HAV infection requiring diagnostic dexterity and critical thinking.

Shocked But Not Surprised: The Philly Cardioversion, Gillian Naro, Md, Med, Naman Upadhyay, Md, Emilie Thompson, Md, Tudor Sturzoiu, Md

The Medicine Forum

Neuromuscular incapacitating devices, colloquially known as ‘tasers’, are typically used by police and security personnel as a non-lethal way to subdue combative assailants. Unfortunately, there are times in the hospital when patients can become assailants, thus potentially necessitating the use of tasers to ensure the safety of staff and other patients. Tasers come in several varieties. However, those typically used by law enforcement have a 50,000-V capacity and deliver 0.36 - 1.76 Joules of energy per pulse, at a rate of ~20 pulses per second, via two barbed projections. This leads to incapacitation of the assailant via the induction of …

A Case Of Patent Foramen Ovale As A Cause Of Persistent Hypoxia, Jaya Janadhyala, Md, Jonathan Foster, Md

The Medicine Forum

Patent foramen ovale (PFO) is a congenital cardiac variant caused by failure of the closure of a passage in the atrial septum. It is quite common, occurring in as much as 27% of the population based on autopsy studies. Most cases of PFOs are incidentally discovered or found during work-up of cryptogenic strokes as a potential cause of the stroke.1 New research is being conducted on the role PFOs play in hypoxia from intracardiac right-to-left shunting, including in patients with co-existent cardiovascular and pulmonary disease

Cardiac Amyloidosis: A Known Disease With An Unknown Presentation, Svenja Schneider, Md, Tudor Sturzoiu, Md, Tanuka Datta, Md, Yevgeniy Brailovsky, Do, Facc, Sung-Hae Cho, Md, Facc, Paulina Gorodin-Kiliddar, Md

The Medicine Forum

Cardiac amyloidosis is an increasingly recognized entity that causes significant morbidity and mortality. Transthyretin amyloidosis (ATTR) is present in about 16% of patients with severe aortic stenosis and up to 17% of patients with heart failure with preserved ejection fraction9,10. Though the screening test of choice, echocardiography is not highly sensitive or specific, and it should not be relied upon to rule out cardiac amyloidosis, especially if clinical suspicion is high.

We present a case of a 58-year-old woman with a history of bilateral carpal tunnel syndrome who presented with paresthesia and syncope. Extensive workup for neurologic, infectious, and malignant …

Another Case Of Takotsubo Syndrome: Excluded By The Presence Of Significant Coronary Artery Disease, Or Caused By Significant Coronary Artery Disease?, Bharaniabirami Rajaram, Md, Neveda Murugesan, Md, Gregary D. Marhefka, Md

The Medicine Forum

Takotsubo syndrome (TTS) is a reversible condition of abnormal myocardial contraction that was first given this name in Japan by Dr. Sato in 1991. The name comes from the Japanese word for “octopus trap,” which has a similar shape to that of the left ventricle on ventriculography during Takotsubo syndrome. It is also known as broken heart syndrome, stress-induced cardiomyopathy, or apical ballooning syndrome. The first descriptions of this phenomenon date as far back as the 1960s.

TTS typically presents with symptoms and clinical signs suggestive of acute coronary syndrome (ACS). It may include ST segment elevations on electrocardiogram (ECG) …

Challenges Of Managing Giant Cell Myocarditis: A Case Report On The Mechanical Support Perspective, Abdul W. Kazi, Md, Mba, Harsh Doshi, Md

The Medicine Forum

Giant cell myocarditis is a rare and fatal disease which may result in heart failure, complete heart block, or ventricular arrhythmias. We describe a patient who previously had been discharged from our institution with a left ventricular assist device and immunosuppressive therapy for management of his giant cell myocarditis. His subsequent course was complicated by further deterioration of heart function which required multiple mechanical circulatory support devices. He successfully received a heart transplant which later had recurrence of giant cell myocarditis. This case highlights the challenges of left and right sided mechanical assist devices in managing giant cell myocarditis.

AG …

From The Chief Residents, Cristina Angelo, Md, Katherine Duffey, Md, Evan Nardone, Md, Michelle Perkons, Md

The Medicine Forum

The four of us have had the unique opportunity to work alongside you and watch you grow throughout the last three years. During an extremely turbulent time at Jefferson, in the city of Philadelphia, and the larger healthcare landscape you all have been the constant presence that has kept the Jefferson IM residency culture alive. Jefferson residents are: Compassionate, intelligent, dedicated, fun, and resilient. But most of all, Jefferson residents look out for each other and have each other’s backs. This is the culture that brings people to our program and the culture that makes residency training which would otherwise …

From The Editors, Shuji Mitsuhashi, Md, Abdul W. Kazi, Md, Matthew Dimeglio, Do, Mba

The Medicine Forum

It is our honor to present the 23rd Annual edition of The Medicine Forum to the Jefferson community. With all the uncertainties and stressors that exist both inside and outside of the hospital walls, it is truly remarkable to see the quality of contributions by our authors. From the multitude of case reports to the collection of artworks, our residents have generated an array of unique and interesting work. We hope that this edition will continue to honor the tradition of The Medicine Forum, which is the celebration of scholarly activity among physicians in training at our institution.

Editorial …

From The Desk Of The Residency Program Director, Emily Stewart, Md, Facp

The Medicine Forum

Our program continues to train the best and brightest residents in the country. As we complete another challenging academic year marred by the ongoing fight against gun violence in Philadelphia and across the United States, the opioid pandemic and the ever present threat of another COVID-19 surge our residents have continued to rise to every challenge and thrive as physicians. During the three years we are fortunate to have them at our program, it is my distinct pleasure to watch them grow into confident, dedicated, compassionate clinicians. The residents are not just outstanding clinicians but excel in all aspects of …

Table Of Contents: The Medicine Forum Volume 23, 2021-2022

The Medicine Forum

Table of Contents: The Medicine Forum Volume 23, 2021-2022

Interobserver Variability Among Expert Readers Quantifying Plaque Volume And Plaque Characteristics On Coronary Ct Angiography: A Clarify Trial Sub-Study, Rebecca Jonas, Shaneke Weerakoon, Rebecca Fisher, William F Griffin, Vishak Kumar, Habib Rahban, Hugo Marques, Ronald P Karlsberg, Robert S Jennings, Tami R Crabtree, Andrew D Choi, James P Earls

Division of Internal Medicine Faculty Papers & Presentations

Background: The difference between expert level (L3) reader and artificial intelligence (AI) performance for quantifying coronary plaque and plaque components is unknown.

Objective: This study evaluates the interobserver variability among expert readers for quantifying the volume of coronary plaque and plaque components on coronary computed tomographic angiography (CCTA) using an artificial intelligence enabled quantitative CCTA analysis software as a reference (AI-QCT).

Methods: This study uses CCTA imaging obtained from 232 patients enrolled in the CLARIFY (CT EvaLuation by ARtificial Intelligence For Atherosclerosis, Stenosis and Vascular MorphologY) study. Readers quantified overall plaque volume and the % breakdown of noncalcified plaque (NCP) …

The Medicine Forum: Volume 23

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 23, 2021-2022

TABLE OF CONTENTS

Case Reports

• Cardiology
• Gastroenterology and Hepatology
• Hematology and Oncology
• Pulmonary Medicine

Resident Reflection

Echocardiographic Predictors Of Symptomatic Cardiotoxicity Among Patients Undergoing Chemotherapy: A Systematic Review And Meta-Analysis, Muhammad Umer Siddiqui, Youssef Yaacoub, Heidi-Anne Hanson, Joey Junarta, Ahmed K Pasha, Mahek Shah

Division of Internal Medicine Faculty Papers & Presentations

BACKGROUND: Chemotherapeutic agents have been associated with cardiotoxicity; thus, they require close monitoring. Several echocardiographic variables have been investigated as early predictors of symptomatic cardiotoxicity in patients undergoing chemotherapy.

OBJECTIVE: To identify if global longitudinal strain (GLS) is a better predictor of symptomatic cardiotoxicity compared to left ventricular ejection fraction (LVEF) in patients receiving chemotherapy.

METHODS: MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were searched from inception through December 2020. Adults who developed symptomatic cardiotoxicity (New York Heart Association [NYHA] Class III-IV heart failure, cardiac arrest, or cardiac death) after undergoing chemotherapy with pre- and postchemotherapy echocardiographic measures …

Feasible Stenting Of A Large Septal Perforator Providing A Sizeable Coronary Collaterals, Hussam Al Hennawi, Mohammad F. Mathbout,, Abdulrahman Taftafa, Christopher D. Nielsen

Division of Internal Medicine Faculty Papers & Presentations

While coronary artery disease involving the septal perforator branches presents similar to diseases of major coronary arteries, management can present a challenge. Owing to their relatively small size, performing interventional procedures is often impractical in terms of selecting appropriate devices. Although larger septal perforator branches have been managed percutaneously, similar to major vessels, long-term sequelae and clinical effectiveness have been indeterminate. We present our experience in managing a patient with a stenosed septal perforator branch and challenging comorbidities.

The Overestimation Of Concentric Hypertrophy In Patients With Hfpef As Determined By 2d-Echocardiography, Mohammad F. Mathbout, Hussam Al Hennawi, Anwar Khedr, Gaurang N. Vaidya, Marcus Stoddard

Division of Internal Medicine Faculty Papers & Presentations

Background: Heart failure with preserved ejection fraction continues to pose multiple challenges in terms of accurate diagnosis, treatment, and associated morbidity. Accurate left ventricular (LV) mass calculation yields essential prognostic information relating to structural heart disease. Two-dimensional (2D) echocardiography-based calculations are solely limited to LV geometric assumptions of symmetry, whereas three-dimensional (3D) echocardiography could overcome these limitations. This study aims to compare the performance of 2D and 3D LV mass calculations. Methods: A prospective review of echocardiography findings at the University of Louisville, Kentucky, was conducted and assessed. Normal ejection fraction (EF) was defined as >=52% in males and >=54% …

Smartphone Apps For Diabetes Medication Adherence: Systematic Review, Sheikh Mohammed Shariful Islam, Vinaytosh Mishra, Muhammad U Siddiqui, Jeban Chandir Moses, Sasan Adibi, Lemai Nguyen, Nilmini Wickramasinghe

Division of Internal Medicine Faculty Papers & Presentations

Background: Diabetes is one of the leading noncommunicable chronic diseases globally. In people with diabetes, blood glucose levels need to be monitored regularly and managed adequately through healthy lifestyles and medications. However, various factors contribute to poor medication adherence. Smartphone apps can improve medication adherence in people with diabetes, but it is not clear which app features are most beneficial.

Objective: This study aims to systematically review and evaluate high-quality apps for diabetes medication adherence, which are freely available to the public in Android and Apple app stores and present the technical features of the apps.

Methods: We systematically searched …

Mortality After Transcatheter Aortic Valve Replacement For Aortic Stenosis Among Patients With Malignancy: A Systematic Review And Meta-Analysis, Muhammad U Siddiqui, Omar Yacob, Joey Junarta, Ahmed K Pasha, Farouk Mookadam, Mamas A Mamas, D L Fischman

Division of Internal Medicine Faculty Papers & Presentations

Background: With advancements in cancer treatment, the life expectancy of oncology patients has improved. Thus, transcatheter aortic valve replacement (TAVR) may be considered as a feasible option for oncology patients with severe symptomatic aortic stenosis (AS). We aim to evaluate the difference in short- and long-term all-cause mortality in cancer and non-cancer patients treated with TAVR for severe AS.

Methods: Medline, PubMed, and Cochrane Central Register of Controlled Trials were searched for relevant studies. Patients with cancer who underwent treatment with TAVR for severe AS were included and compared to an identical population without cancer. The primary endpoints were short- …

Left Ventricular Outflow Tract Thrombus In A Patient With Covid-19-A Ticking Time Bomb: A Case Report., Hamza Zahid Ullah Muhammadzai, Nathaniel Rosal, Muhammad Arslan Cheema, Donald Haas

COVID-19 Papers, Posters, and Presentations

Background: Coronavirus disease 2019 (COVID-19) is a manifestation of severe acute respiratory syndrome coronavirus 2, which results in many different complications including left ventricular (LV) thrombi.

Case summary: We present a 30-year-old female presenting with chest pain and shortness of breath. Patient had an extensive history including heart failure with an ejection fraction 15-20% and COVID-19 2 months ago. Echocardiogram revealed a 3.3 cm ×  1.7 cm LV thrombus which was not present 4 months ago before her diagnosis of COVID-19. The LV thrombus embolized resulting in an embolus extending from the distal infrarenal abdominal aorta to the common iliac …

Hyperdynamic Left Ventricular Ejection Fraction Is Associated With Higher Mortality In Covid-19 Patients, Annas Rahman, Max Ruge, Md, Alex Hlepas, Batha Nair, Joanne Gomez, Jeanne Du Fey De Lavallaz, Setri Fugar, Nusrat Jahan, Annabelle Santos Volgman, Kim A. Williams, Anupama Rao, Karolina Marinescu, Tisha Suboc

Division of Internal Medicine Faculty Papers & Presentations

Study objective: To compare the characteristics and outcomes of COVID-19 patients with a hyperdynamic LVEF (HDLVEF) to those with a normal or reduced LVEF.

Design: Retrospective study.

Setting: Rush University Medical Center.

Participants: Of the 1682 adult patients hospitalized with COVID-19, 419 had a transthoracic echocardiogram (TTE) during admission and met study inclusion criteria. Interventions: Participants were divided into reduced (LVEF < 50%), normal (≥50% and <70%), and hyper- dynamic (≥70%) LVEF groups.

Main outcome measures: LVEF was assessed as a predictor of 60-day mortality. Logistic regression was used to adjust for age and BMI.

Results: There was no difference in 60-day mortality between patients in the reduced LVEF and normal LVEF …

Safety And Efficacy Of Colchicine In Covid-19 Patients: A Systematic Review And Meta-Analysis Of Randomized Control Trials, Farah Yasmin, Hala Najeeb, Abdul Moeed, Wardah Hassan, Mahima Khatri, Muhammad Sohaib Asghar, Ahmed Kunwer Naveed, Waqas Ullah, Salim Surani

Department of Medicine Faculty Papers

Background: Colchicine has been used an effective anti-inflammatory drug to treat gout diseases. Owing to its pharmacodynamic of inhibiting interleukins, it has been repurposed to target the cytokine storm post-SARS-CoV-2 invasion. The goal of this meta-analysis was to evaluate the safety profile of colchicine in COVID-19 patients using the gold-standard randomised-control trials.

Methods: Electronic databases (Pubmed, Google Scholar, and Cochrane) were systematically searched until June 2021 and RCTs were extracted. Outcomes of interest included all-cause mortality, COVID-19 severity, mechanical ventilation, C-reactive protein and D-dimer levels. Using a random-effects model, dichotomous outcomes were pooled using odds ratios (OR) through the generic …