Medicine and Health Sciences Commons^™

Sickle Cell Pain: A Critical Reappraisal., Samir K. Ballas, Kalpna Gupta, Patricia Adams-Graves

Department of Medicine Faculty Papers

Sickle cell pain includes 3 types: acute recurrent painful crises, chronic pain syndromes, and neuropathic pain. The acute painful crisis is the hallmark of the disease and the most common cause of hospitalization and treatment in the emergency department. It evolves through 4 phases: prodromal, initial, established, and resolving. Each acute painful episode is associated with inflammation that worsens with recurrent episodes, often culminating in serious complications and organ damage, such as acute chest syndrome, multiorgan failure, and sudden death. Three pathophysiologic events operate in unison during the prodromal phase of the crisis: vaso-occlusion, inflammation, and nociception. Aborting the acute …

A Kidney For Christmas, Stephen Scholand

The Medicine Forum

When Asmar Lawrence first walked into the small examining room in the Jefferson Hospital Ambulatory Practice (JHAP) Clinic, we both had no idea what the future would hold. It was July, 1998 and I was fresh from medical school. Each week, I looked forward to the JHAP experience to develop my clinical skills and follow patients longitudinally. No longer was my learning prescribed from a textbook, this was the 'real world' of medicine where anything could happen and I was supposed to be in control of it. The long white coat probably helped perpetuate some of that illusion. Fortunately our …

A Pilot Study Of Diabetes Management In The Managed Care Setting, Rachel Wagman

The Medicine Forum

Diabetes mellitus represents a disease entity that primary care providers commonly encounter in the outpatient setting. Patient visits encompass a broad range of concerns, from optimizing management of hyperglycemia to the sequelae of chronic disease. The third National Health and Nutrition Exam Survey, (NHANES III) 1988-1994 has reported the prevalence of diabetes mellitus type 2 in the U.S. adult population at 12.3%. The cost of diabetes in 1998, estimated at $77 billion, is a formidable challenge to the health care community and third-party payers. Historically, Health Maintenance Organizations (HMOs) have encouraged more preventative tests, procedures, and exams to curtail the …

Brachytherapy: A New Weapon Against Coronary Restenosis, Rob Silver

The Medicine Forum

Since its introduction in the late 1970's, coronary angioplasty has become a common procedure for treating coronary atherosclerotic disease. It offers significant improvement in symptoms of coronary artery disease through a less invasive procedure than coronary artery bypass grafting (CABG). Each year, over 500,000 percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in North America alone. In larger epicardial vessels that are 3 millimeters or greater in diameter, a metal stent can be placed during angioplasty to reduce the incidence of restenosis. In fact, stents are now deployed in approximately 80 percent of PTCA procedures. The success rate of PTCA …

Melena With Fever, Monica Patel, Jennifer Wilhelm

The Medicine Forum

The patient is a 62 year old Indian male with a past medical history significant for myasthenia gravis, hypertension, and diabetes mellitus, who presented to an outside hospital with fever, fecal incontinence, and melena. Work up at that hospital was remarkable for elevated liver function tests, heme-positive brown stool and a CT of the abdomen showing a thick ascending colon suggesting possible mass. The patient had an episode of desaturation and fever to 105 degrees Fahrenheit prior to transfer to Thomas Jefferson University Hospital for further evaluation. Upon arrival, the patient was in respiratory distress with oxygen saturation of 70% …

Severe Dyspnea And Cough, Traci Mellinger Kohl, Elizabeth Cartwright

The Medicine Forum

A 43 year-old white male with a history of hypertension and a smoking history of 30 pack-years presented to the emergency room coplaining of cough, severe dyspnea, nausea, and vomiting. Ten days prior to presentation, he experienced flu-like symptoms with a low-grade fever, myalgias, and malaise that lasted approximately four days but resolved spontaneously. He had a cough productive of white sputum and blood-tinged nasal drainage for one week. Three days prior to presentation he began to experience right upper quadrant abdominal pain and bilious vomiting. The patient worked as a bar inspector and had a routine PPD check 9 …

A Case Of Hypercalcemia, Daniel Lin

The Medicine Forum

A 79-year-old man with a past medical history of diet-controlled type 2 diabetes mellitus, hypertension, and chronic lower extremity venous stasis ulcers requiring two skin grafts was admitted to the hospital due to dehydration. He was in his usual state of health intermittently being wheelchair bound due to leg ulcers until four days earlier, when he accidentally spilled hot tea on his left arm while in the kitchen. In his attempt to maneuver the wheelchair away from the spill, the wheelchair turned over, pinning him on the floor and against the cabinets. He remained in that position for four days …

Hematuria Status Post Renal Biopsy, Bill Mcelhaugh

The Medicine Forum

This is a case of a 66 year old Caucasian woman admitted to the hospital following a ureteroscopic biopsy of the left renal pelvis. The biopsy was performed for asymptomatic hematuria, with a retrograde intravenous pyelogram revealing a mass in the left renal pelvis. The patient developed lightheadedness and left flank pain 12-24 hours following the procedure and was found to have a 3 gram drop in hemoglobin compared to blood work performed during the previous week.

Successful Management Of Bleeding Complications In Patients Supported With Extracorporeal Membrane Oxygenation With Primary Respiratory Failure., K Lamb, Sw Cowan, N Evans, H Pitcher, T Moritz, M Lazar, H Hirose, Nc Cavarocchi

Department of Cancer Biology Faculty Papers

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure in patients with severe respiratory insufficiency failing conventional support. Bleeding complications are common due to the necessity for anticoagulation and circuit-related factors. METHODS: A retrospective review was conducted in patients requiring ECMO for respiratory failure from 7/2010 to 6/2011 to identify episodes of major bleeding, bleeding management and outcomes. RESULTS: Twenty-one patients were supported with ECMO during the study although five experienced massive bleeding related to chest tube insertion, jejunal arterio-venous malformations, distal perfusion cannula dislodgement and ventricular rupture. Patients required aggressive resuscitation or endoscopic or operative intervention, totaling 28 procedures. …

Histology Slide, John Farber

The Medicine Forum

A 45 year old Black female without significant past medical history was admitted with insidious cough, dyspnea, nausea, vomiting, and progressive weight loss. She suddenly went into respiratory distress and succumbed to death. Autopsy subsequently showed widespread granulomatous disease. This slide of one of the lung lesions shows a noncaseating granulocyte with a fibrotic center surrounded by palisading histiocytes, consistent with a diagnosis of nodular sarcoma.

Candidal Retinitis, Carl D. Mele

The Medicine Forum

Mr. R.T. was a 49 year old male with recurrent Hepatitis C infection after orthotopic liver transplant, who presented with complications related to hemorrhagic pancreatitis. While on long term total parenteral nutrition, he developed blurry vision and Candida albicans fungemia. A fundus photograph revealed fungal endopthalmitis with focal areas of chorioretinitis. His vision improved significantly with serial intravitreal antifungal injections.

Validation Of A Novel, Non-Invasive System For Autonomic Profiling In Healthy Volunteers, Agostino Ingraldi, Behzad B. Pavri, Himanshu Patel, Sammy Zakaria, Reginald T. Ho, Arnold J. Greenspon

The Medicine Forum

Noninvasive profiling of the autonomic nervous system has been shown to have prognostic value in patients with myocardial infarction, CHF and diabetes. The ANSAR system (ANX 3.0, Philadelphia, PA) is a new commercially available system that utilizes respiratory rate, HR and BP to assess on-going sympathovagal modulation during various maneuvers known to evoke autonomic perturbations. Instead of using conventional Fast Fourier Transform for frequency domain analysis, a Continuous Wavelet Transform (CWT) is used to generate numerical and graphical data. The system calculates Low Frequency Area (LFA, analogous to LF Power) and Respiratory Frequency Area (RFA, analogous to High Frequency Power.) …

A Case Of Invasive Thymoma, Jon Geddes

The Medicine Forum

A 52 year-old man with a past medical history of an isolated seizure presented to the Veterans Affairs hospital complaining of weakness which was most prominent in the face and upper extremities. About 6 months prior to this admission he developed intermittent episodes of weakness when chewing and swallowing. He would often have to use his hands to close his jaw when eating or talking. He noticed that his voice had developed a nasal quality but he did not have slurred speech. He denied drooling, ptosis, cramping or muscle twitches. He was seen 6 months ago at another VA hospital …

Cord Compression By Extramedullary Hematopoiesis In Polycythemia Vera, Lisa Reale, Steve Zrada, Jose Martinez

The Medicine Forum

A 73-year-old male with polycythemia vera and a history of prostate cancer presents to an outside hospital complaining of back pain of two months duration. He denied fevers, chills, night sweats, weight loss, lower extremity weakness and decreased sensation. Other than chronic constipation and urinary hesitancy, his review of systems was unremarkable. A spinal x-ray revealed a T12 vertebral fracture and the patient was transferred to Thomas Jefferson University Hospital for further management.

A Case Of Thrombosis And Thromboembolic Events, Daniel Lin

The Medicine Forum

A 65 year old black woman with hypertension (HTN), gastroesophageal reflux disease (GERD), and anxiety had complained to her primary care physician of vague abdominal pain. Initial empiric treatment as an outpatient for worsening GERD was unsuccessful. The patient had insidious development of generalized fatigue, early satiety, nausea, vomiting, and weight loss. An ultrasound of the abdomen revealed multiple liver lesions, with the largest lesion being 2.5 cm x 2.5 cm. She subsequently underwent a CT scan of the abdomen and pelvis, which confirmed multiple hyperdense liver lesions. The remainder of the scan was unremarkable. Esophagogastroduodenoscopy (EGD) as well as …

A Case Of A Male With Fever And Fatigue, Steve Ting

The Medicine Forum

This is a case of a 78 year old Caucasian gentleman who presented to the hospital in the early summer with complaints of high fevers and progressive fatigue. The patient lives near Philadelphia and enjoys doing yard work. He reported finding a tick attached to the skin near his groin approximately 3 weeks prior to admission. The tick was removed; however the patient was unsure of the duration of the tick attachment. He also denied developing any significant rash in that area. He had no recent sick contacts and no recent history of travel. He began developing fever spikes up …

Nevirapine Hepatotoxicity: Case Report And Discussion, Matt Baichi

The Medicine Forum

Nevirapine (viramune) is a nonnucleoside reverse transcriptase inhibitor commonly used in combination with other antiretroviral medicines in the treatment of HIV/AIDS. The safety profile of nevirapine, as determined by review of prospective clinical trials, reports rash with an incidence of 16% as the most common side effect. Clinical hepatitis is reported to occur with an incidence of 1%. A review of the literature shows many case reports of nevirapine-induced hepatotoxicity in patients receiving both treatment and prophylaxis for HIV. The purpose of this case report is to stress the importance of early recognition and withdrawal of the offending drug.

Nonspecific Interstitial Pneumonitis In Hiv-Infected Patients, Bobbak Vahid

The Medicine Forum

A 24 year old African-American male with a history of AIDS with a recent CD4 count of 57/uL, is admitted to the hospital with substernal chest pain and shortness of breath for the past two weeks. Dyspnea is mostly on exertion, and the patient denied productive cough or hemoptysis, fevers, chills, or night sweats. Three weeks prior to presentation, the patient underwent esophagogastroduodenoscopy, which revealed an esophageal ulcer. Biopsies did not show any specific pathology and cultures were negative. Outpatient medications include prednisone, rabeprazole, fluconazole, clarithromycin, and ethambutol, bactrim.

Vitals on admission were as follows: temperature 97.2, pulse 80/min, and …

A Case Of Facial Pain And Vesicular Rash, Matt Baichi

The Medicine Forum

The patient is an 81 year old male with a past medical history of non-insulin dependent diabetes mellitus, hypertension, and dyslipidemia who presents with a complaint of facial pain. The pain began 3-4 days before presentation to his primary care physician. It was constant and intense. There was no history of similar head or facial pain, visual changes, jaw claudication, rash, tearing, nasal discharge, photophobia, phonophobia, sinus congestion, tooth ache, nor neurologic complaints. There was no relief with over-the-counter analgesics. A rash subsequently developed over his left forehead and scalp. At presentation, vital signs were stable. Skin examination revealed an …

A Case Of Chronic Intestinal Pseudo-Obstruction, Matt Baichi

The Medicine Forum

Scleroderma is a systemic disease characterized by the deposition of excessive collagen and other matrix elements in the skin as well as in multiple internal organs. Scleroderma can be classified into diffuse cutaneous disease and limited cutaneous disease. Limited cutaneous disease is characterized by skin involvement limited to the hands, face, feet, and forearms; it includes the CREST variant (calcinosis, raynauds, esophageal dysmotility, sclerodactyly, and telangiectasia). Diffuse cutaneous disease is characterized by skin involvement as well as early and diffuse visceral involvement. Clinically significant gastrointestinal involvement occurs in approximately 50% of all patients with scleroderma. The esophagus is the most …

Sleep Disturbances And Hypnotic Medication Use In Relation To Risk Of Barrett’S Esophagus And Esophageal Adenocarcinoma, Anastasia Shnitser, Md, Abhik Roy, Md, Sidney Cohen, Md, Anthony J. Dimarino, Md

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND

The incidence of esophageal adenocarcinoma (EA) has increased more rapidly than any other cancer (with the exception of malignant melanoma) in the United States over the past 30 years. Gastroesophageal reflux disease (GERD) is the strongest risk factor for the development of Barrett’s esophagus, which in turn leads to the rise of most EA’s. In a large portion of persons with sleep disorders, perhaps as high as 30%, GERD is a major causal or contributing factor. It has been proposed that the use of hypnotics for the treatment of sleep disorders may exacerbate the damaging effects of refluxate on …

Creating A Custom E-Book For Your Course, Jennifer L. Bellot, Phd, Rn, Mhsa, Cne

Tech Talks

Dr. Bellot used AcademicPub to create a custom ebook for her course. Students were able to purchase the ebook edition for use on their iPads or chose to have a print copy made and mailed to them. AcademicPub makes it easy to incorporate your syllabus, presentations, a collection of content from different text books and journal articles into a single book for your course. Dr. Bellot will describe the process, compare it to past practices and report on student satisfaction with this new format for course materials.

12 PowerPoint slides

Severe Stress Switches Crf Action In The Nucleus Accumbens From Appetitive To Aversive., Julia C Lemos, Matthew J Wanat, Jeffrey S Smith, Beverly A S Reyes, Nick G Hollon, Elisabeth J Van Bockstaele, Charles Chavkin, Paul E M Phillips

Farber Institute for Neuroscience Faculty Papers

Stressors motivate an array of adaptive responses ranging from 'fight or flight' to an internal urgency signal facilitating long-term goals. However, traumatic or chronic uncontrollable stress promotes the onset of major depressive disorder, in which acute stressors lose their motivational properties and are perceived as insurmountable impediments. Consequently, stress-induced depression is a debilitating human condition characterized by an affective shift from engagement of the environment to withdrawal. An emerging neurobiological substrate of depression and associated pathology is the nucleus accumbens, a region with the capacity to mediate a diverse range of stress responses by interfacing limbic, cognitive and motor circuitry. …

Possible Steps Of Complete Disassembly Of Post-Termination Complex By Yeast Eef3 Deduced From Inhibition By Translocation Inhibitors., Shinya Kurata, Ben Shen, Jun O Liu, Nono Takeuchi, Akira Kaji, Hideko Kaji

Department of Biochemistry and Molecular Biology Faculty Papers

Ribosomes, after one round of translation, must be recycled so that the next round of translation can occur. Complete disassembly of post-termination ribosomal complex (PoTC) in yeast for the recycling consists of three reactions: release of tRNA, release of mRNA and splitting of ribosomes, catalyzed by eukaryotic elongation factor 3 (eEF3) and ATP. Here, we show that translocation inhibitors cycloheximide and lactimidomycin inhibited all three reactions. Cycloheximide is a non-competitive inhibitor of both eEF3 and ATP. The inhibition was observed regardless of the way PoTC was prepared with either release factors or puromycin. Paromomycin not only inhibited all three reactions …

Trends In Permanent Pacemaker Implantation In The United States From 1993 To 2009: Increasing Complexity Of Patients And Procedures., Arnold J Greenspon, Jasmine D Patel, Edmund Lau, Jorge A Ochoa, Daniel R Frisch, Reginald T Ho, Behzad B. Pavri, Steven M Kurtz

Division of Cardiology Faculty Papers

OBJECTIVES: This study sought to define contemporary trends in permanent pacemaker use by analyzing a large national database.

BACKGROUND: The Medicare National Coverage Determination for permanent pacemaker, which emphasized single-chamber pacing, has not changed significantly since 1985. We sought to define contemporary trends in permanent pacemaker use by analyzing a large national database.

METHODS: We queried the Nationwide Inpatient Sample to identify permanent pacemaker implants between 1993 and 2009 using the International Classification of Diseases-Ninth Revision-Clinical Modification procedure codes for dual-chamber (DDD), single-ventricular (VVI), single-atrial (AAI), or biventricular (BiV) devices. Annual permanent pacemaker implantation rates and patient demographics were analyzed. …

Treatment Of Cardiomyopathy With Pap Therapy In A Patient With Severe Obstructive Sleep Apnea., Ritu G. Grewal, Md

Department of Sleep Medicine Faculty Papers

Obstructive sleep apnea is common in patients with heart failure. This case illustrates that treatment with PAP therapy can improve cardiac function in patients with both conditions. CPAP-emergent central apnea, as seen in this patient, has multiple etiologies. It is commonly seen in patients with severe sleep apnea, usually resolves over time, and does not need treatment with adaptive servoventilation.

Quantifying The Cdk Inhibitor Vmy-1-103'S Activity And Tissue Levels In An In Vivo Tumor Model By Lc-Ms/Ms And By Mri., Paul Sirajuddin, Sudeep Das, Lymor Ringer, Olga C Rodriguez, Angiela Sivakumar, Yi-Chien Lee, Aykut Üren, Stanley T Fricke, Brian Rood, Alpay Ozcan, Sean S Wang, Sana Karam, Venkata Yenugonda, Patricia Salinas, Emanuel Petricoin, Michael Pishvaian, Michael P Lisanti, Yue Wang, Richard Schlegel, Bahram Moasser, Chris Albanese

Kimmel Cancer Center Faculty Papers

The development of new small molecule-based therapeutic drugs requires accurate quantification of drug bioavailability, biological activity and treatment efficacy. Rapidly measuring these endpoints is often hampered by the lack of efficient assay platforms with high sensitivity and specificity. Using an in vivo model system, we report a simple and sensitive liquid chromatography-tandem mass spectrometry assay to quantify the bioavailability of a recently developed novel cyclin-dependent kinase inhibitor VMY-1-103, a purvalanol B-based analog whose biological activity is enhanced via dansylation. We developed a rapid organic phase extraction technique and validated wide and functional VMY-1-103 distribution in various mouse tissues, consistent with …

Neurophysiological Impact And Modeling-Independent Elucidation Of Inactivation Pathways In A-Type K+ Channels, J.D. Fineberg, David Ritter, Manuel Covarrubias

Department of Molecular Physiology and Biophysics Faculty Papers

Poster presented at Society for Neuroscience

Abstract:

A-type voltage-gated K⁺ channels auto-regulate their function by undergoing fast inactivation. Independent of molecular mechanisms, this inactivation can proceed after channel opening (open-state inactivation, OSI) or from a closed state prior to opening (closed-state inactivation, CSI). We hypothesize that the specific neurophysiological roles of A-type Kv channels depend on whether they undergo OSI, CSI or both (CSI+OSI). To explore these possibilities, we introduced Markov kinetic schemes of the A-type Kv4 conductance into a computational model of the hippocamcal CA1 neuron assuming either CSI or CSI+OSI and compared the properties of the somatic …

Mk-0448, A Specific Kv1.5 Inhibitor: Safety, Pharmacokinetics And Pharmacodynamic Electrophysiology In Experimental Animal Models And In Humans., Behzad B. Pavri, Howard E Greenberg, Walter K. Kraft, Nicole Lazarus, Joseph J Lynch, Joseph J Salata, Mark T Bilodeau, Christopher P Regan, Gary Stump, Li Fan, Anish Mehta, John A Wagner, David E Gutstein, Daniel Bloomfield

Department of Pharmacology and Experimental Therapeutics Faculty Papers

BACKGROUND: -We evaluated the viability of I(Kur) as a target for maintenance of sinus rhythm in patients with a history of atrial fibrillation through the testing of MK-0448, a novel I(Kur) inhibitor. METHODS AND RESULTS: -In vitro MK-0448 studies demonstrated strong inhibition of I(Kur) with minimal off-target activity. In vivo MK-0448 studies in normal anesthetized dogs demonstrated significant prolongation of the atrial refractory period compared with vehicle controls without affecting the ventricular refractory period. In studies of a conscious dog heart failure model, sustained AF was terminated with bolus intravenous MK-0448 doses of 0.03 and 0.1 mg/kg. These data led …

Acute Heart Transplant Rejection In The Presence Of Apparently Weak, Non-Complement-Fixing Donor-Specific Antibodies Detected At The Time Of Transplant, Anthony Nizio, Paul J. Mather, Beth Colombe

Division of Cardiology Faculty Papers

Poster presented at: American Society for Histocompatibility and Immunogenetics (ASHI) conference.

AIM: A 66 year old female with an end-stage NYHA class IV inotrope-dependent, ischemic cardiomyopathy received a heart transplant on 9-12-09 from a doctor having antigens B13 and DR7. Pre-transplant antibody testing indicated only weakly positive, non-complement fixing donor-specific antibodies. The patient suffered a cardiac arrest on POD#6 and was resuscitated. She was in cardiogenic shock from allograft failure and subsequently expired on POD#9 of multiorgan failure due to "acute humoral rejection". These antibodies were investigated further.

METHODS: Antibodies were evaluated using Labscreen PRA (One Lambda), Labscreen Single Antigen …