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Hypertrophic Cardiomyopathy Illustrated On A Transthoracic Echocardiogram And Cardiac Mri, Youssef Elfatatry, Md, Marina Gonzalez, Md

The Medicine Forum

A 46-year-old woman presented to the hospital with subacute dyspnea on exertion and syncope. She had three syncopal episodes in the months prior, all of which occurred after standing from seated position and were associated with complete loss of consciousness. Echocardiogram showed severe concentric left ventricular hypertrophy (LVH) with preserved systolic function (Panels A and B). Cardiac magnetic resonance (CMR) imaging was performed which confirmed asymmetric septal hypertrophy measuring 28-mm in thickness (Panel C, arrow). Patchy, late gadolinium enhancement was also seen within the myocardium (Panel D, arrows). A diagnosis of hypertrophic cardiomyopathy (HCM) was made. The patient had no …

Wellens' Syndrome On Electrocardiogram, A Highly Specific Indicator Of Critical Stenosis Of The Left Anterior Descending Coronary Artery, Youssef Elfatatry, Md, Ryan Gardner, Md

The Medicine Forum

An 85-year-old male with a past medical history of hyperlipidemia presented to his primary care physician with chest pain. The patient had experienced an acute episode of substernal chest pain that resolved spontaneously three days prior to presentation. An electrocardiogram (ECG) was obtained in the office which showed inverted and biphasic T-waves throughout the precordial chest leads (Panel A, arrows). The patient was sent to the emergency department and underwent an emergent cardiac catheterization which revealed a 99% proximal left anterior descending (LAD) artery occlusion (Panel B, arrow). A drug-eluting stent was placed with successful revascularization (Panel C, arrow). Wellens …

Investigating The Etiology Of Non-Ischemic Cardiomyopathy; A Case Report Of Cardiac Amyloidosis, Zachary Pang, Md, Joshua M. Riley, Md, Yair Lev, Md

The Medicine Forum

Amyloidosis is the result of misfolded protein deposition in organs and tissues, including the heart also known as cardiac amyloidosis. We describe a case of a patient presenting with decompensated heart failure, which highlights the importance of identifying the etiology of the patient’s cardiomyopathy through a thorough history and physical. This led to a diagnosis of cardiac amyloidosis. The patient was subsequently initiated on tafamidis, a medication that is associated with reductions in all-cause mortality and cardiovascular-related hospitalizations, reduced decline in functional capacity, and improved quality of life of the patient.

Laao Device Mass: A Classic Condition Involving A Not - So - Classic Device, Ryan Gardner, Md, Rabia Naheed, Md, Youssef Elfatatry, Md, Irfan Ahsan, Md, Alyson N. Owen, Md

The Medicine Forum

Current evidence suggests Class 2a recommendation for a left atrial appendage occlusion with a closure device in patients with atrial fibrillation who have moderate to high risk of stroke (CHA2DS2-VASc score ≥2) and a contraindication to long-term oral anticoagulation due to a nonreversible cause.¹ Watchman device (WD) related infection is infrequent due to complete endothelialization of the device in a few weeks.² We report a highly challenging case of possible WD-related infection that involved complex decision-making.

Dissecting The Literature: A Systematic Review Of Conservative Therapy Versus Revascularization In Spontaneous Coronary Artery Dissection, Avinash Saraiya, Ms, Brian Schonewald, Md

The Medicine Forum

Spontaneous coronary artery dissection (SCAD) is a rare, but increasingly recognized cause of acute coronary syndrome (ACS). While previously only described in case series, the advent of advanced imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) has increased its prevalence dramatically. Anatomically, SCAD results from the formation of an intramural hematoma with or without intimal tear in a coronary artery, potentially leading to occlusion and ischemia. This phenomenon is especially common in women, accounting for 35% of ACS in women under the age of 50, and representing the leading cause of peripartum myocardial infarct.¹ There …

From The Chief Residents, Michael Dong, Md, Chantel Venkataraman, Md, Tamar Wolinsky Md, Benjamin Claxton, Md

The Medicine Forum

As we introduce the latest edition of The Medicine Forum, the journal of our Internal Medicine residency program, we're thrilled to showcase the diverse talents and perspectives of our resident physicians. Evolving alongside our program, this publication serves as both a platform for scientific inquiry and a canvas for creativity, reflecting the dynamic interests of each resident cohort.

We must extend our heartfelt gratitude to our current editors, Amman Bhasin, Suraj Nyalakonda, Mez Kamanu, and Alex Grivas, for their unwavering dedication and tireless efforts in shepherding this journal to new heights. Their commitment to excellence and their vision for …

From The Editors, Amman Bhasin, Md, Suraj Nyalakonda, Md, Chukwuemezie Kamanu, Md, Alexandros Grivas, Md

The Medicine Forum

We are honored to present the 25th Annual edition of The Medicine Forum, carrying forth a quarter-century tradition of scholarly work produced by faculty, residents, and students -- proudly shared with the Jefferson community and beyond. The Medicine Forum embodies the collective voice and spirit of our residency, serving as a vibrant platform for scholarly and artistic expression, and showcasing the remarkable talents and diverse perspectives of our program’s faculty, residents, and students.

Throughout the years, The Medicine Forum has evolved alongside our program, adapting to the changing interests and passions of each new cohort of residents. It serves …

Foreword From Faculty Advisor, Dagan Coppock, Md, Msce

The Medicine Forum

The latest edition of The Medicine Forum celebrates our community’s efforts toward scholarly inquiry and creativity. Our current editors have approached this project with a true passion. Throughout the academic year, it has been my pleasure to work with Amman, Suraj, Mez, and Alex, not only on this project, but also on the medical wards. They have applied the same thoughtfulness and joy to editing this journal that they do to the care of patients. I am in awe of their efforts.

As a department, we are a productive group of writers, thinkers, scientists, and artists. So much of our …

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

The Medicine Forum

As we celebrate the silver jubilee of our beloved Jefferson Forum, it is with great pride and admiration that I extend a warm welcome to each of you. For a quarter-century, this annual publication has stood as a testament to the dedication, passion, and scholarly pursuits of our internal medicine residents.

Within the pages of the Jefferson Forum, you will find the embodiment of our residents' commitment to excellence in patient care, education, and research. As the Program Director, I have had the privilege of witnessing firsthand the remarkable growth and development of our residents. Their journey from eager learners …

Table Of Contents: The Medicine Forum, Volume 25, 2023-2024

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 25, 2023-2024

The Medicine Forum: Volume 25

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 25, 2023-2024

TABLE OF CONTENTS

• Case Reports
• Clinical Images
• Humanities & Reflections

Ephrin-B2 Promotes Nociceptive Plasticity And Hyperalgesic Priming Through Ephb2-Mnk-Eif4e Signaling In Both Mice And Humans, Eric David, Muhammad Saad Yousuf, Hao-Ruei Mei, Ashita Jain, Sharada Krishnagiri, Hajira Elahi, Rupali Venkatesan, Kolluru Srikanth, Gregory Dussor, Matthew Dalva, Theodore Price

Department of Neuroscience Faculty Papers

Ephrin-B-EphB signaling can promote pain through ligand-receptor interactions between peripheral cells, like immune cells expressing ephrin-Bs, and EphB receptors expressed by DRG neurons. Previous studies have shown increased ephrin-B2 expression in peripheral tissues like synovium of rheumatoid and osteoarthritis patients, indicating the clinical significance of this signaling. The primary goal of this study was to understand how ephrin-B2 acts on mouse and human DRG neurons, which express EphB receptors, to promote pain and nociceptor plasticity. We hypothesized that ephrin-B2 would promote nociceptor plasticity and hyperalgesic priming through MNK-eIF4E signaling, a critical mechanism for nociceptive plasticity induced by growth factors, cytokines …

The Attainment Of A Patient Acceptable Symptom State In Patients Undergoing Revision Spine Fusion, Tariq Z. Issa, Omar H. Tarawneh, Teeto Ezeonu, Ameer A. Haider, Rajkishen Narayanan, Jose A. Canseco, Alan S. Hilibrand, Alexander R. Vaccaro, Gregory D. Schroeder, Christopher K. Kepler

Rothman Institute Papers

INTRODUCTION: Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision.

METHODS: We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a …

A Comparison Of Icare And Goldmann Applanation Tonometry Measurements During The Covid-19 Pandemic: A Retrospective Study, Shreya Swaminathan, Amber M. Kisielewski, M. Hossein Nowroozzadeh, Shahin Hallaj, Daniel Lee, Natasha N. Kolomeyer, Jonathan S. Myers, Reza Razeghinejad

Wills Eye Hospital Papers

PURPOSE: To evaluate factors associated with differences in intraocular pressure (IOP) readings between iCare and Goldmann applanation tonometry (GAT) in established glaucoma patients.

METHODS: This retrospective comparative study included clinical data of 350 eyes from 350 established glaucoma patients who had iCare and GAT IOP measured by an ophthalmic technician and a glaucoma specialist, respectively. The main outcome measure was the difference in IOP measurements of the right eyes with iCare and GAT.

RESULTS: The intraclass correlation coefficient (ICC) between GAT and iCare was 0.90. The mean IOP difference between tonometers was - 0.18 ± 2.89 mmHg. Bland-Altman plots indicated …

A Case Of Severe Anaphylactic Reaction After Administration Of Diagnostic-Dose Ferumoxytol In A Pediatric Patient, Fam Ekladious, David Saul

Jefferson Hospital Staff Papers and Presentations

We describe a case of anaphylaxis during administration of intravenous (IV) ferumoxytol as a magnetic resonance imaging (MRI) contrast agent in a 4-year-old patient with complicated past medical history including YARS genetic mutation with resultant liver failure and deceased donor liver transplantation, stage IV chronic kidney disease (CKD), and hypertension. The patient was noted to have labored breathing 4 min after initiation of ferumoxytol infusion and was subsequently rapidly intubated and returned to the intensive care unit (ICU) for monitoring. Anaphylactic reactions to therapeutic doses of ferumoxytol led to issuance of a black box warning by the FDA in 2015. …

Development Of An Educational Brochure About Treatment Options For Pregnant Women With Opioid Use Disorders, Ruth Jeminiwa, Sohyeon Park, Caroline Popielaski, Meghan Gannon, Ronald Myers, Diane J. Abatemarco

College of Pharmacy Faculty Papers

The goal of this study was to describe the development of an educational brochure for pregnant women with opioid use disorders (OUDs) about treatment options. Based on findings from a preliminary review of the literature, we drafted a brochure that addressed the following questions: (1) What are your options (Medication-Assisted Treatment (MAT) versus no treatment)? (2) What are the benefits of MAT? (3) What are the risks of MAT? (4) Can I take buprenorphine or methadone while breastfeeding? (5) Which medication should I choose? Clinicians and doulas (n = 19) who provide care to pregnant women with OUDs were recruited. …

Association Of C-Reactive Protein/Albumin Ratio With Mortality In Patients With Traumatic Brain Injury: A Systematic Review And Meta-Analysis, Yuyang Liu, Yaheng Tan, Jun Wan, Qiwen Chen, Yuxin Zheng, Wenhao Xu, Peng Wang, Weelic Chong, Xueying Yu, Yu Zhang

Department of Medical Oncology Faculty Papers

Objective: This study examines the C-reactive protein (CRP)/albumin ratio (CAR) as an inflammation-based prognostic score for predicting mortality in patients with Traumatic Brain Injury (TBI). Methods: We systematically searched the electronic databases PubMed, Embase, and Cochrane up to February 2024. Our inclusion criteria encompassed studies investigating CAR-predicted mor- tality in patients with TBI. We calculated the Odds Ratio (OR) and associated 95 % confidence intervals (95 % CI) using a random-effects model. Quality assessment of the included studies was appraised using a Newcastle–Ottawa scale. Results: A total of five studies comprising 1040 patients were included in this meta-analysis. The pooled …

An Incidentally Found Mass On The Remnant Stomach After A Roux-En-Y Gastric Bypass, Jennifer E. Geller, Santosh Swaminathan, Kristin Noonan

Abington Jefferson Health Papers

BACKGROUND: Incidentally found masses are a widely discussed area of medicine, and there are conflicting opinions as to how to deal with these findings, particularly in the stomach-which has limited documentation in the literature. Here we present a middle-aged female who was found to have an incidentally found mass on her remnant stomach 10 years after a Roux-en-Y gastric bypass (RYGB) surgery.

CASE PRESENTATION: We present the case of a 66-year-old female who is 10 years post-op from a RYGB. After a bout of self-resolving diarrheal illness prompted a computed tomography (CT) scan in the emergency department, she was diagnosed …

Metformin In Systemic Lupus Erythematosus: Investigating Cardiovascular Impact And Nephroprotective Effects In Lupus Nephritis, Yurilu A. Gonzalez Moret, Kevin Bryan Lo, Irene J. Tan

Einstein Health Papers

OBJECTIVE: Systemic lupus erythematosus (SLE) is characterized by widespread organ inflammation. Metformin, commonly used for diabetes mellitus type 2, has been explored for its anti-inflammatory potential in SLE. This study investigates the association of metformin use on renal and cardiovascular outcomes in patients with SLE.

METHODS: This is a retrospective study. We used the multicenter research network (TriNetX) database from 88 health care organizations globally. Patients with SLE aged 18 and above, admitted between January 1, 2014, and April 21, 2024, were included. Propensity score matching compared patients with SLE on metformin with those not on metformin, considering demographics, laboratory …

Altered Extracellular Matrix Correlates With An Immunosuppressive Tumor Microenvironment And Disease Progression In Younger Adults With Oral Cavity Squamous Cell Carcinoma, Leonard Estephan, Gaurav Kumar, Matthew Stewart, Raphael Banoub, Alban Linnenbach, Larry Harshyne, Ubaldo Martinez-Outshoorn, My Mahoney, Joseph Curry, Jennifer Johnson, Andrew South, Adam Luginbuhl

Kimmel Cancer Center Faculty Papers

INTRODUCTION: Oral cavity squamous cell carcinoma (OSCC) occurs most frequently in patients >60 years old with a history of tobacco and alcohol use. Epidemiological studies describe increased incidence of OSCC in younger adults (years). Despite its poor prognosis, knowledge of OSCC tumor microenvironment (TME) characteristics in younger adults is scarce and could help inform possible resistance to emerging treatment options.

METHODS: Patients with OSCC were evaluated using TCGA-HNSC (n=121) and a stage and subsite-matched institutional cohort (n=8) to identify differential gene expression focusing on the extracellular matrix (ECM) and epithelial-mesenchymal transition (EMT) processes in younger (≤45 years) vs. older adults …

Association Of Mildly Elevated Pulmonary Vascular Resistance With Major Cardiovascular Events In Pulmonary Hypertension And Chronic Kidney Disease: A Retrospective Cohort Analysis, Jose M. Martinez Manzano, Alexander Prendergast, Tara John, Raul Leguizamon, Ian Mclaren, Rasha Khan, Andrew Geller, Phuuwadith Wattanachayakul, John Malin, Simone A. Jarrett, Kevin Bryan Lo, Sadia Benzaquen, Christian Witzke

Einstein Health Papers

Pulmonary hypertension (PH) is associated with adverse outcomes in chronic kidney disease (CKD) patients. Our study suggests mildly elevated pulmonary vascular resistance ( > 2 to ≤ 3) is independently associated with major adverse cardiovascular events at 1-year follow-up. Early diagnosis of precapillary PH in CKD patients can potentially improve clinical outcomes.

Feasibility And Safety Of Peroral Endoscopic Myotomy With Fundoplication In Patients With Achalasia: A Systematic Review And Meta-Analysis, Faisal Kamal, Muhammad Ali Khan, Wade Lee-Smith, Sachit Sharma, Ashu Acharya, Umer Farooq, Zahid Ejaz, Muhammad Aziz, Manesh Kumar Gangwani, Umar Hayat, Anand Kumar, Alexander Schlachterman, David E. Loren, Thomas E. Kowalski

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND: Achalasia can cause disabling symptoms that may substantially impair the quality of life. Peroral endoscopic myotomy (POEM) has shown promising results in the management of achalasia. In this meta-analysis we have evaluated the feasibility and safety of single-session POEM with fundoplication (POEM+F) in patients with achalasia.

METHODS: We reviewed several databases from inception to July 08, 2022, to identify studies evaluating the feasibility and/or safety of single-session POEM+F for patients with achalasia. Our outcomes of interest included the technical success of POEM+F, adverse events, esophagitis and wrap integrity on follow-up upper endoscopy, total procedure time, and fundoplication time. Pooled …

The Mapk Homolog, Smk1, Promotes Assembly Of The Glucan Layer Of The Spore Wall In S. Cerevisiae, Julia Y. Lee-Soety, Gwendolyn Resch, Abhimannyu Rimal, Erica S. Johnson, Jonathan Benway, Edward Winter

Department of Biochemistry and Molecular Biology Faculty Papers

Smk1 is a MAPK homolog in the yeast Saccharomyces cerevisiae that controls the postmeiotic program of spore wall assembly. During this program, haploid cells are surrounded by a layer of mannan and then a layer of glucan. These inner layers of the spore wall resemble the vegetative cell wall. Next, the outer layers consisting of chitin/chitosan and then dityrosine are assembled. The outer layers are spore-specific and provide protection against environmental stressors. Smk1 is required for the proper assembly of spore walls. However, the protective properties of the outer layers have limited our understanding of how Smk1 controls this morphogenetic …

Males With Patellofemoral Pain Have Altered Movements During Step-Down And Single-Leg Squatting Tasks Compared To Asymptomatic Males: A Cross-Sectional Study, Lisa T. Hoglund, Amy H. Amabile, Thomas Alexander Hulcher

Department of Physical Therapy Faculty Papers

Background and Aims

Patellofemoral pain (PFP) is common in males, causing reduced physical activity and chronic pain. One proposed cause of PFP is aberrant biomechanics during tasks loading the patellofemoral joint. Consistent evidence exists for females with PFP, but it is uncertain if males with PFP have altered biomechanics. This study investigated the kinematics of males with PFP compared to pain-free males during forward step-down (StDn) and single-leg squat (SLSq).

Methods

A cross-sectional study including 40 males aged 20–39 years (28.28 ± 5.46) was conducted (20 PFP, 20 pain-free). Participants performed StDn and SLSq while motion was captured with a …

Differences In Neural Activation Between Actual Tool Use And Pantomime: Evidence For Two Different Streams?, Simon Thibault, Raphaël Py

Moss-Magee Rehabilitation Papers

No abstract provided.

Association Between Preoperative Patient Resilience And Patient-Reported Outcomes After Rotator Cuff Repair, Ryan W. Paul, Sydney Streicher, Matthew Wallingford, Michael P. Campbell, Adeeb J. Hanna, Sean Bryan, Fotios Tjoumakaris, Kevin Freedman

Rothman Institute Papers

Background: Mental and emotional health can affect outcomes after orthopaedic surgery, and patient resilience has been found to be significantly related to postoperative functional outcomes. Purpose: To evaluate the relationship between preoperative patient resilience and 2-year postoperative patient-reported outcomes after rotator cuff repair (RCR). It was hypothesized that patients with low preoperative resilience will have worse patient-reported outcomes at 2 years after RCR versus those with high resilience. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent primary arthroscopic RCR in 2020 at a single institution and completed the Brief Resilience Scale (BRS) preoperatively were identified. Other …

Bidirectional Needs Assessment Of Otolaryngology-Head And Neck Surgery Short-Term Surgical Trips In Zimbabwe, Katerina J. Green, Naboth Matinhira, Amiti Jain, Priya Arya, Dontre' M. Douse, Titus Dzongodza, Clemence Chidziva, Joshua P. Wiedermann

Student Papers, Posters & Projects

OBJECTIVES: To describe findings from an otolaryngology-specific needs assessment tool in Zimbabwe.

METHODS: Surveys were developed and shared with Low-Middle Income Country (LMIC) hosting institutions in Zimbabwe and to High-Income Country surgical trip participants (HIC). Respondents were otolaryngologists identified online and through professional networks who had participated in a surgical trip.

RESULTS: The most common procedures Zimbabwe otolaryngologists reported treating were adenotonsillectomy (85.7%), chronic rhinosinusitis (71.4%), chronic otitis (57.1%), and head and neck tumor intervention (57.1%). The most common untreatable conditions that host physicians wanted to treat were skull base surgery (71.4%), flap reconstructions (57.1%), and laryngotracheal reconstruction (57.1%). The …

A Trna Modification Pattern That Facilitates Interpretation Of The Genetic Code, Isao Masuda, Ya-Ming Hou

Department of Biochemistry and Molecular Biology Faculty Papers

Interpretation of the genetic code from triplets of nucleotides to amino acids is fundamental to life. This interpretation is achieved by cellular tRNAs, each reading a triplet codon through its complementary anticodon (positions 34–36) while delivering the amino acid charged to its 3′-end. This amino acid is then incorporated into the growing polypeptide chain during protein synthesis on the ribosome. The quality and versatility of the interpretation is ensured not only by the codon-anticodon pairing, but also by the post-transcriptional modifications at positions 34 and 37 of each tRNA, corresponding to the wobble nucleotide at the first position of the …

Frontotemporal Dementia-Like Disease Progression Elicited By Seeded Aggregation And Spread Of Fus, Sonia Vazquez-Sanchez, Britt Tilkin, Fatima Gasset-Rosa, Sitao Zhang, Diana Piol, Melissa Mcalonis-Downes, Jonathan Artates, Noe Govea-Perez, Yana Verresen, Lin Guo, Don Cleveland, James Shorter, Sandrine Da Cruz

Department of Biochemistry and Molecular Biology Faculty Papers

RNA binding proteins have emerged as central players in the mechanisms of many neurodegenerative diseases. In particular, a proteinopathy of fused in sarcoma (FUS) is present in some instances of familial Amyotrophic lateral sclerosis (ALS) and about 10% of sporadic Frontotemporal lobar degeneration (FTLD). Here we establish that focal injection of sonicated human FUS fibrils into brains of mice in which ALS-linked mutant or wild-type human FUS replaces endogenous mouse FUS is sufficient to induce focal cytoplasmic mislocalization and aggregation of mutant and wild-type FUS which with time spreads to distal regions of the brain. Human FUS fibril-induced FUS aggregation …

Neuroimaging Evaluation Of The Long Term Impact Of A Novel Paired Meditation Practice On Brain Function, Andrew B. Newberg, Nancy Wintering, Chloe Hriso, Faezeh Vedaei, Sara Gottfried, Reneita Ross

Marcus Institute of Integrative Health Faculty Papers

BACKGROUND: A growing number of advanced neuroimaging studies have compared brain structure and function in long term meditators to non-meditators. The goal is to determine if there may be long term effects on the brain from practicing meditation. In this paper, we present new data on the long term effects of a novel meditation practice in which the focus is on clitoral stimulation. The findings from such a study have implications for potential therapeutic uses with regard to various neurological or psychiatric conditions.

METHODS: We evaluated the cerebral glucose metabolism in 40 subjects with an extended history (>1 year …