Digital Commons Network^™

An Unusual Complication Of Metastatic Colorectal Cancer: Port-Site Hematoma As The First Sign Of Bone Marrow Involvement And Disseminated Intravascular Coagulation, Michael Predi, Do, Julia Palecki, Md, Jordan M. Isaacs, Ba, Ruben Rhoades, Md

The Medicine Forum

Disseminated intravascular coagulation (DIC) is a life-threatening condition marked by a spectrum of thrombosis due to activation of procoagulant factors and bleeding due to eventual consumption of these factors. DIC invariably occurs secondary to an underlying condition, including infection, inflammatory conditions, trauma, and malignancies. Treatment of DIC primarily involves treatment of the underlying cause.¹

Bone marrow invasion occurs when tumor cells infiltrate the hematopoietic marrow space, displacing progenitor cells and causing cytopenias. This process is distinct from bone metastases, where malignant cells spread to the cortical or trabecular bone, typically causing bone pain, pathologic fractures, or hypercalcemia. Disseminated carcinomatosis …

Immune Thrombocytopenic Purpura In The Setting Of Newly Diagnosed Colorectal Cancer: A Case Report, Beatriz Torre, Md, Karlie Brasch, Md, Christopher Henry, Md

The Medicine Forum

Immune thrombocytopenic purpura (ITP) is an acquired thrombocytopenia caused by autoantibodies against platelet antigens. ITP is most often associated with infection or autoimmune disease, but it has also been linked to malignancy.¹ In this case, we discuss the relationship between ITP and colon cancer.

Case Report Of Gastritis As A Complication Of Immunotherapy Treatment Of Metastatic Endometrial Cancer With Lenvatinib And Pembrolizumab, Bret Mccarty, Md, Nia Johnson, Bs, Suchit Bhutani, Md

The Medicine Forum

Immune checkpoint inhibitors (ICIs), such as pembrolizumab (a PD-1 inhibitor), have been shown to be effective in the treatment of a variety of malignancies, including progressive endometrial cancer. ICIs help to activate the patient’s immune system to attack neoplastic cells. However, this immune activation can trigger autoimmune side effects throughout the body, known as immune-related adverse events (irAEs). Immunotherapyassociated hepatitis, colitis and diarrhea have been well documented as irAEs, but gastritis is much less common.1 In this case report of immunotherapy-related gastritis, we attempted to better characterize this more rare condition to assist with early recognition and initiation of appropriate …

Investigating The Link Between Ulcerative Colitis And Papillary Thyroid Carcinoma: A Case Report, Sonali Shah, Md, Emily Chiacchiaro, Md, Priya Sehgal, Md

The Medicine Forum

Inflammatory bowel diseases (IBD) are chronic inflammatory conditions that primarily involve the gastrointestinal tract, but also cause widespread systemic inflammation. There have been multiple studies investigating the link between ulcerative colitis (UC) and crohn’s disease (CD) and thyroid diseases, as the incidence is greater than the general population.¹ In addition, patients with IBD have been found to be at increased risk of developing both intestinal malignancies and extra-intestinal malignancies.² Literature review suggests a possible connection between ulcerative colitis and papillary thyroid cancer, with most studies concluding there is a higher risk of PTC in patients with UC, but …

Complexities In Alcoholic Necrotizing Pancreatitis: A Case Report Of Severe Vascular And Infectious Complications, Dawood Tahir, Md, Shravya Ginnaram, Md, Jacob Lipkin, Md

The Medicine Forum

Acute pancreatitis (AP) incidence has been increasing, with an annual incidence of approximately 5 to 40 cases per 100,000.¹ Several complications occur with AP, including splanchnic vein thrombosis (SVT), pseudocyst, and pseudoaneurysm (PSA). Moreover, 15-20% of patients develop necrotizing pancreatitis (NP) following an episode of AP with a mortality rate of up to 32%,² which can be further complicated by infected necrosis in up to one-third of patients.² Hemorrhage is estimated to occur in less than 6% of patients with NP by pseudoaneurysm.³ The endoscopic step-up approach is the standard treatment for walled-off necrosis, whereas alternative …

Use Of Novel Agent Purastat® For Post-Sphincterotomy Bleeding, Ananya Venkatesh, Md, Bertilia Tavarez, Md, Ms, Pedra Palacios Argueta, Md, Donna Leet, Md, Afshin Khan, Md, Abdul Kouanda, Md, Anand Kumar, Md, Alana Persaud, Md, Yasi Xiao, Md, Alexander Schlachterman, Md, Thomas Kowalski, Md, Faisal Kamal, Md

The Medicine Forum

Endoscopic sphincterotomy is commonly performed during endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic sphincterotomy (ES) is associated with adverse events such as bleeding.¹ PuraStat® is a new synthetic hemostatic gel being used for treatment of gastrointestinal bleeding. We aim to report and outcomes of PuraStat® for post-sphincterotomy bleeding.

Use Of Novel Agent Purastat® For Post-Ampullectomy Bleeding, Bertilia Tavarez, Md, Ms, Ananya Venkatesh, Md, Pedra Palacios Argueta, Md, Anand Kumar, Md, Alana Persaud, Md, Yasi Xiao, Md, Alexander Schlachterman, Md, Faisal Kamal, Md, Thomas Kowalski, Md

The Medicine Forum

Endoscopic ampullectomy is the first line treatment modality for major papilla neoplasms that have not invaded the muscularis propria.¹ Complications of endoscopic ampullectomy include bleeding, pancreatitis, perforation, papillary stenosis, and cholangitis with the incidence of post-ampullectomy bleeding reported to be as high as 30%.^1,2 PuraStat® is a new synthetic hemostatic gel being used for the prophylaxis and treatment of gastrointestinal bleeding.^3-5 To date, there are no reports on the use of PuraStat® for post-ampullectomy bleeding. We hope to investigate the use and outcomes of PuraStat® for post-ampullectomy bleeding.

Racial Disparities In Response To Ibd Directed Therapy In Crohn’S Disease And Ulcerative Colitis: A Single Center Experience, Ananya Venkatesh, Md, Justin Robbins, Md, Zach Breslin, Md, Cuckoo Choudhary, Md

The Medicine Forum

Crohn’s disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) associated with significant morbidity and mortality. Current clinical guidelines recommend a range of therapies, including tumor necrosis factor alpha (TNFα) antagonists, anti-integrins, interleukin-12/23 (IL12/23) inhibitors, Janus kinase (JAK) inhibitors, and/or corticosteroids for both induction and maintenance of remission. Determining the optimal medication for individual patients can be challenging due to the complexity of treatment options and the need to consider numerous phenotypic factors. While treatment guidelines do not address racial differences explicitly, prior research has highlighted significant phenotypic disparities based on race. This study aims to explore …

Williams Syndrome Presenting With Pericardial Effusion And Left Ventricular Apical Aneurysm: A Case Report, Zachary Pang, Md, M. D. Kilpatrick, Md, Sairamya Bodempudi, Md, Darius Farzad, Md, Daniel L. Fischman, Gregary D. Marhefka, Md

The Medicine Forum

Williams syndrome (WS) is a genetic disorder caused by a gene deletion involving the protein elastin on chromosome 7q11.23. WS is associated with intellectual disability and characteristic facial features, including a short nose with a flat nasal bridge, medial eyebrow flare, and long philtrum.^1-2 WS is also associated with cardiovascular manifestations, most commonly supravalvular aortic stenosis. Patients with WS have an estimated risk of sudden cardiac death that is 25 to 100 times greater than the healthy age-matched population.³ This case highlights the importance of keeping acute coronary syndrome on one’s differential when caring for patients with Williams …

A Shock To The Heart? A Case Of Phantom Shocks In A Patient With Brugada Syndrome, Virginia Gonzalez, Md, Rebecca Goldfinger-Chanin, Md, Behzad B. Pavri, Md

The Medicine Forum

Brugada syndrome is an inherited condition characterized by an increased risk of sudden cardiac death (SCD) secondary to lethal ventricular arrhythmias occurring most often in the fourth decade of life. Implantable cardioverter-defibrillators (ICDs) are recommended in patients who have documented ventricular tachycardia (VT) or ventricular fibrillation (VF) and in patients presenting with a spontaneous type 1 Brugada pattern on electrocardiogram (ECG) and a history of arrhythmic-sounding syncope.¹ However, patients with ICDs are at risk of developing “phantom shocks” which occur when a patient reports the sensation of receiving a shock that is not confirmed upon subsequent device interrogation.^{2 …}

Protamine Sulfate-Induced Coronary Vasospasm Resulting In Takotsubo Cardiomyopathy, Matthew J. Bierowski, Md, Andre Cunningham, Do, Jordan Feingold, Md

The Medicine Forum

Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, is characterized by new left ventricular (LV) dysfunction out of proportion to any known coronary artery disease that usually follows an emotional or physical stress. The disease process mimics acute coronary syndrome (ACS), with acute chest pain, moderate elevations in serum troponins, and electrocardiographic changes. While spontaneous return to normal left ventricular function is typical, the morbidity and mortality of TTS is significant, with increased risk for major adverse cardiac events and disease recurrence.¹

The understanding of the pathogenesis of TTS is incomplete, although recent work has identified that several processes …

Power Outage: Acute Subtotal Occlusion Of The Left Circumflex Artery With Minimal Ecg Changes, Daniel Moylan, Md, Brady Houtz, Md

The Medicine Forum

Acute coronary syndrome (ACS) represents one of the most recognizable causes of death in the United States. Despite significant advances in cardiovascular preventative health, an American will have a myocardial infarction approximately every 40 seconds.¹ Fortunately, rapid diagnosis and treatment of ACS have allowed for significant reductions in both morbidity and mortality of myocardial infarctions.² Thus, prompt identification of ACS is crucial, and nonetheless, it can still present a noteworthy challenge to physicians. In this case, we present a near-electrically silent acute thrombotic coronary subtotal occlusion. It constitutes a stark reminder that diagnosis of an acute myocardial infarction …

Mitral Annular Disjunction As A Cause Of Cardiac Arrest In Young Patient: A Case Report, Sheraz Qamar, Md

The Medicine Forum

Mitral annular disjunction is a structural abnormality where there is a separation of the mitral valve annulus and left atrial wall. We present a case of cardiac arrest in a young patient with known mitral valve prolapse that was now found to have mitral annular disjunction due to myxomatous mitral valve disease. This case highlights the importance of finding the etiology of cardiac arrest, which in this case, is myxomatous mitral valve disease causing mitral annular disjunction. It also highlights the importance of secondary prevention of sudden cardiac death with defibrillator placement in these patients.

Hot Coffee-Induced Takotsubo Cardiomyopathy: A Case Report, Zachary Pang, Md, M. D. Kilpatrick, Md, Jasmine Lee, Md, Gregary D. Marhefka, Md

The Medicine Forum

Takotsubo cardiomyopathy is a well-known phenomenon due to physical or emotional stress, causing a catecholamine surge leading to myocardial wall motion abnormalities, most commonly apical ballooning of the left ventricle.1-3 The diagnosis of Takotsubo cardiomyopathy can be challenging as its presentation often mimics acute coronary syndrome. This case highlights the classic presentation of the apical ballooning variant of Takotsubo cardiomyopathy and appropriate workup and diagnosis.

Be Afraid Of Severe Pulmonary Hypertension And Right Ventricular Failure In The Peri-Op Patient, Avish Patel, Md, Lily Ackermann, Md

The Medicine Forum

Heart failure (HF), particularly right ventricular (RV) failure, and pulmonary hypertension (PH) present significant risks during the perioperative period. Despite the fact that these comorbidities are not always considered in preoperative risk evaluation, they are very important when considering perioperative risk. Current risk assessment tools mainly include the Revised Cardiac Risk Index (RCRI); however, it does not effectively assess severity of HF or PH. This review aims to highlight the major points on peri-operative management in non-cardiac surgeries using a case of a patient with severe PH who experienced unexpected mortality from acute RV failure post-operatively.

A Case Of Type 4 Spontaneous Coronary Artery Dissection (Scad), Virginia Gonzalez, Md, Ms, Kashka Mallari, Md, Marina Gonzalez, Md, Svenja Schneider, Md, Sung-Hae Cho, Md, Paulina Gorodin-Kiliddar, Md

The Medicine Forum

A 52-year-old female presented to the emergency department ten minutes after the development of sudden-onset crushing chest pain radiating to both of her arms, associated with dyspnea on exertion. Notably, she reported a several-month history of significant stress caring for her elderly mother with Alzheimer’s disease. On admission, her vital signs revealed sinus bradycardia with a heart rate of 56 beats/min.

The patient reported a past medical history of hypothyroidism, breast cancer status post lumpectomy, nicotine dependence, and anxiety. She did not have a prior history of cardiovascular disease or stroke, nor a family history of premature coronary disease. She …

Evaluating Mortality And Bleeding Risk After Percutaneous Left Atrial Appendage Closure In Atrial Fibrillation: A Propensity-Matched Analysis Using A Multi-Institutional Database, Youssef Elfatatry, Md, Ryan Gardner, Md

The Medicine Forum

Percutaneous left atrial appendage closure (pLAAC) has emerged as an effective treatment strategy for stroke prevention in patients with atrial fibrillation (AF) who otherwise cannot tolerate anticoagulation (AC) therapy. The American College of Cardiology, American Heart Association, American College of Chest Physicians, and Heart Rhythm Society combined guidelines offer a class 2a recommendation to pursue pLAAC in patients with an elevated risk of stroke from AF and a contraindication to oral AC, and a class 2b recommendation for pLAAC in patients with elevated risk of stroke from AF and elevated risk of life-threatening bleeding from AC.¹ The predominant pLAAC …

3d-Printed Coronary Arteries: An Effective Tool In Medical Education, Zachary Pang, Md, Shreyas Chandragiri, Md, Shumpei Mori, Md, Phd, Alexander Hajduczok, Md, Cannon G. Hiranaka, Md, Jesse Ottaway, Md, Zachary Mace, Md, Michael Wong, Md, Tammy Yoshioka, Md, Noah Haroian, Md, Pharmd, Guiyan Zhang, Md, Phd

The Medicine Forum

Anatomy and physiology can be a challenging topic due to their inherent complexity. Anatomy is most effectively learned through a combination of memorization, comprehension, and visualization.¹ Lectures and textbooks provide efficient means for memorization and comprehension but can often be challenging for thee-dimensional (3D) visualization. Conceptualizing 3D structures from two-dimensional (2D) textbook figures poses difficulty for many students. Anatomical education can be accompanied by dissection of cadavers, which can aid in visualization, but can be time-consuming and expensive.² 3D printing technology, however, holds the potential to solve this problem and enhance the anatomical education experience.

Foreword From Faculty Advisor, Dagan Coppock, Md, Msce

The Medicine Forum

We are honored to present this latest edition of The Medicine Forum. This platform is in its twenty-sixth year serving as an outlet for our medical community’s scholarly and creative efforts. This year, it has been my pleasure to work with Marc, Marina, Virginia, and Devin on this project. I have not only worked with them on the Forum, but also on the wards. It is impressive to see the same excellence they bring to patient care applied to this academic publication.

This journal serves as a showcase for the efforts of our Department. It is always exciting …

From The Chief Residents, Akash Patel, Do, Ashley Traczuk, Md, Mark Liotta, Md, Claire Zurlo, Md

The Medicine Forum

It is with great pride that we present this year’s edition of The Medicine Forum, a reflection of the passion, intellectual curiosity, and multidimensional talents that define our Internal Medicine residency program.

This journal continues to be more than a collection of case reports and research findings — it is a celebration of who we are as a community. It reflects our shared commitment to inquiry, creativity, and the art of medicine. From the rigor of original research to the introspection of narrative writing and the vibrancy of visual art, this edition captures the full spectrum of our residents’ …

From The Editors, Marina Gonzalez, Md, Virginia Gonzalez, Md, Devin Vasoya, Md, Marc Yorker, Md

The Medicine Forum

It is with great enthusiasm that we present to you the 26th edition of our internal medicine residency journal. As chief editors, we have the privilege of curating the latest insights, research, and reflections from the ever-evolving world of medicine, all to enrich our shared knowledge and foster meaningful discussions within our community.

Over the years, this journal has served as a platform for scholarly exploration, clinical advancements, and the voices of residents shaping the future of internal medicine. With each edition, we strive to uphold the highest standards of academic excellence while embracing the diversity of thought and expertise …

From The Desk Of The Residency Program Director, Christopher Henry, Md. Facp

The Medicine Forum

The Jefferson Forum is a reflection of our residents' dedication to patient care, education, resilience, and research. Within these pages, you’ll find a unique combination of hard work, intellectual curiosity, and personality. As Program Director, I have the privilege of watching their transformation from learners to skilled clinicians and scholars, a journey marked by perseverance and a sense of purpose.

In a time of rapid political and societal change, this publication stands as a testament to our renewed commitment to science, well-being, and the pursuit of knowledge. As physicians and researchers, we remain steadfast in our mission to improve health …

Table Of Contents: The Medicine Forum, Volume 26, 2024-2025

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 26, 2024-2025

The Medicine Forum: Volume 26

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 26, 2024-2025

TABLE OF CONTENTS

• Research Studies
• Case Reports
• Humanities & Reflections

Early Recurrent Midgut Volvulus Post Ladd's Procedure In A Newborn: A Case Report, Nicole Clarke, Joanna Sajdlowska, John Paul Bustamante, Nishith Bhattacharyya

Rowan-Virtua School of Osteopathic Medicine Departmental Research

Ladd's procedure is the standard surgical intervention for intestinal malrotation. Although generally curative, rare cases of early postoperative complications, including adhesions or recurrent volvulus, can necessitate reoperation. We present the case of a full-term newborn girl who underwent emergent Ladd's procedure on Day 3 of life for malrotation with volvulus. She was discharged on postoperative Day 17 but returned the following day with recurrent bilious emesis. Imaging suggested partial obstruction. Exploratory laparotomy revealed recurrent volvulus with two twists at the duodenojejunal junction, which was successfully reduced. The patient recovered well and was discharged on postoperative Day 8. This case underscores …

The Effect Of Sars-Cov-2 Reinfection On Long-Term Symptoms In The Innovative Support For Patients With Sars-Cov-2 Infections Registry (Inspire), John J. Openshaw, Ji Chen, Robert Rodriguez, Michael Gottlieb, Kalyani Mccullough, Michelle Santangelo, Mandy J. Hill, Kristyn Gatling, Ahamed H. Idris, Samuel Mcdonald, Lauren E. Wisk, Jonathan Dyal, Ralph C. Wang, Kristin L. Rising, Efrat Kean, Kelli N. O'Laughlin, Kari A. Stephens, Caitlin Malicki, Zhenqiu Lin, Erica S. Spatz, Huihui Yu, Robert A. Weinstein, Joann Elmore

Department of Emergency Medicine Faculty Papers

BACKGROUND: The clinical consequences of repeated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are not clear, especially as they relate to long-term symptoms after infection. We analyzed data collected for the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE) to determine whether reinfection changes the likelihood of symptoms 3-6 months after reinfection compared with the likelihood in individuals experiencing a single infection.

METHODS: Individuals reporting a single SARS-CoV-2 infection or a single reinfection were included in this analysis. A positive SARS-CoV-2 test occurring ≥90 days after a first infection was considered a reinfection. Outcomes included severe fatigue (fatigue …

Potential Strategies For Reducing Mortality And Morbidity In Acute Ischemic Cardiogenic Shock, Richard Smalling, James Mccarthy, Tim Henry, Ali Denktas

Journal of Shock and Hemodynamics

Cardiogenic shock is predominantly caused by acute ischemic myocardial injury. Despite advancements in reperfusion strategies, outcomes remain poor, with the duration of ischemia before reperfusion playing a crucial role in the development of irreversible damage. This review synthesizes insights from animal models and human studies, highlighting the limited myocardial salvage beyond 90 minutes of ischemia. In light of the high mortality rates associated with cardiogenic shock, this review proposes re-evaluating pre-hospital fibrinolysis, exploring left ventricular unloading strategies before reperfusion, and assessing the potential role of endothelin antagonists. These approaches aim to improve outcomes in this high-risk population.

Integrating Endocannabinoid Signaling, Cck Interneurons, And Hippocampal Circuit Dynamics In Behaving Animals, Shreya Malhotra, Florian Donneger, Jordan S Farrell, Barna Dudok, Attila Losonczy, Ivan Soltesz

Faculty, Staff and Students Publications

The brain's endocannabinoid signaling system modulates a diverse range of physiological phenomena and is also involved in various psychiatric and neurological disorders. The basic components of the molecular machinery underlying endocannabinoid-mediated synaptic signaling have been known for decades. However, limitations associated with the short-lived nature of endocannabinoid lipid signals had made it challenging to determine the spatiotemporal specificity and dynamics of endocannabinoid signaling in vivo. Here, we discuss how novel technologies have recently enabled unprecedented insights into endocannabinoid signaling taking place at specific synapses in behaving animals. In this review, we primarily focus on cannabinoid-sensitive inhibition in the hippocampus in …

The Multilayered Control Of Acetylation During Adenovirus-Based Immunotherapy Of Cancer, Akhila Parthasarathy, Maria Frost, Andrew G Gillard, Marta M Alonso, Candelaria Gomez-Manzano, Juan Fueyo

Faculty, Staff and Student Publications

Adenoviruses are highly immunogenic agents that have shown promise first as gene delivery vectors and later as oncolytic viruses. Currently, oncolytic adenoviruses are featured in over 30% of cancer virotherapy clinical trials. Due to their effective cellular uptake and hijack of cellular machinery, replication-competent adenoviruses are promising therapeutic agents for treating a wide range of tumors. Adenoviral influence on host cell acetylome regulation has regained attention, as these viruses redirect or suppress acetylation during replication, making them potentially desirable therapeutic agents for cancers driven by epigenetic modifications. In this review, we aim to cover the viral processes influencing the acetylome …

Therapy, Safety, And Logistics Of Preoperative Vs Postoperative Stereotactic Radiation Therapy: A Preliminary Analysis Of A Randomized Clinical Trial, Debra Nana Yeboa, Jing Li, Ruitao Lin, Sujit S Prabhu, Thomas H Beckham, Kristina Woodhouse, Todd Allen Swanson, Jeffrey S Weinberg, Xuemei Wang, Xiaohan Chi, Chinenye Lynette Ejezie, Dima Suki, Chenyang Wang, Chibawanye Ene, Ian E Mccutcheon, Susan Mcgovern, Mary Frances Mcaleer, Martin Tom, Amol Ghia, Subha Perni, Wen Jiang, Brian De, Caroline Chung, Betty Y S Kim, Barbara J O'Brien, Jason T Huse, Jeffrey S Wefel, Laurence Court, Hussein Tawbi, Filip Janku, Nandita Guha-Thakurta, J Matthew Debnam, Jason Johnson, Ceylan Altintas Taslicay, Christopher Alvarez-Breckenridge, Shaan M Raza, Amy B Heimberger, Franco Demonte, Robert North, Tina M Briere, John F De Groot, Raymond Sawaya, David Grosshans, Frederick F Lang, Ganesh Rao, Sherise D Ferguson

Faculty, Staff and Student Publications

Importance: Preoperative stereotactic radiation therapy (SRT) vs postoperative SRT logistics and toxic effects provides clinically significant data on management outcomes.

Objective: To determine preoperative SRT logistics and safety profile compared with postoperative in patients with brain metastases.

Design, setting, and participants: This single-institution phase 3 randomized clinical trial included patients 18 years and older and undergoing a planned surgical resection. Patients were required to have an Eastern Cooperative Oncology Group Performance Status score of 2 or greater and be candidates for SRT within 30 days of surgical resection. Patients with radiosensitive histologies (eg, small cell lung cancer and lymphoma), brain …