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Prescriptions For Excellence In Health Care Spring 2012 Download Full Pdf

Prescriptions for Excellence in Health Care Newsletter Supplement

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A Step Backward For Italy's Meritocracy., Ignazio Roberto Marino

Department of Surgery Faculty Papers

Italian scientists have long lamented the lack of resources, political attention, and meritocracy in assigning taxpayers’ money.

How Will Comparative Effectiveness Research Influence Clinical Decision Making?, Nicholas Zaorsky, Md, Timothy Showalter, Md

The Medicine Forum

Most health care recommendations in the United States have come from trials designed to measure efficacy of medical interventions, with randomized controlled trials considered the gold standard for evidence-based medicine. Comparative effectiveness research has become an essential component of research to help define the benefits, risks, and effectiveness of different interventions for a particular illness. Comparative effectiveness research is informally defined as an assessment of all available options for a specific medical condition, with intent to estimate effectiveness in specific subpopulations. In this article, we contrast efficacy-based healthcare research and recommendations in the United States, under the model of evidencebased …

An American On Rotation In Switzerland, Jennifer Alloo Hong, Md

The Medicine Forum

It wasn’t easy getting to Switzerland. My husband started work at CERN at the end of 2009 when I was a 3rd year medical student and I was there helping him find an apartment during my winter break. In the back of my mind, I wondered if I could do an away rotation at les Hopitaux Universitaires de Genève (HUG) the following year. So I walked into the front entrance of the medical school associated with HUG. Bonjour! Do you have a program for students like me? Is it allowed for foreigners? Would I have to take a test in …

Quality Improvement Of Diabetic Care At A Resident Clinic, Carmi Santos Punzalan, Md, Sarah Rutherford, Md, Andrew Lerner, Md, Tasha Kouvatsos, Md, Sneha Thakkar, Md, Melissa Klein, Md, David Manoff, Md, Cecilia Kelly, Md, Dina Halegoua, Md, Gregory Kane, Md

The Medicine Forum

Our objective was to develop a quality improvement project on diabetes mellitus at our internal medicine residency clinic. Residents developed projects aimed at improving an aspect of diabetic care. Continuity of care, achievement of clinical targets, no-show rates, patient knowledge of diabetes, and preventive care were evaluated. Our data was obtained with a questionnaire and a retrospective review of medical records. A different provider was scheduled about every 1.78 visit. The no-show rate was 25.4%. About half of patients identified goal hgbA1c and BPs, and 35% and 60% achieved their hgbA1c and SBP goals respectively. Nearly all of the charts …

Persistent Severe Hyperkalemia In A Patient With Normal Renal Function, Michael L. Tobin, Md

The Medicine Forum

Case Report

A 75-year-old female with a past medical history significant for hypertension, hyperlipidemia, and colon cancer, status post colectomy with ileostomy, presented to the Methodist Hospital emergency room with muscular low back pain, which began a few hours prior, after abruptly bending over. Upon arrival to the hospital, she had no other complaints and noted that the back pain was starting to resolve without intervention.

In triage, her heart rate was measured at 38 beats per minute (BPM) with her other vital signs within normal limits. Her electrocardiogram (EKG) was read as a junctional rhythm with a rate of …

Sarcomatoid Mesothelioma In A Patient With Asbestos Exposure, Abhik Roy, Md, Merritt Brown, Md

The Medicine Forum

Case

A 76-year-old man with no significant past medical history presented with a two month history of progressive shortness of breath, 25-pound weight loss, and sharp right-sided chest, abdomen, and pelvic pain without radiation. The patient noted his dyspnea became more pronounced in recent weeks, notably worse with climbing stairs or performing work around the house. He described the pain as having a positional component, and exacerbated with deep-inspiration. On further questioning, the patient reported a 50-pack-year history of smoking and past exposure to asbestos while working with heating insulation. Physical examination revealed an age-appropriate, but cachectic appearing male with …

A 45-Year-Old Male With Hiv, Kaposi’S Sarcoma, And Squamous Cell Carcinoma Of The Skin, Jascha Rubin, Md, Hasan Bayat, Md

The Medicine Forum

Case

A 45-year-old male with a history of human immunodeficiency virus, (HIV), on highly active antiretroviral therapy (HAART), Kaposi’s sarcoma, and squamous cell carcinoma (SCC) of the right lower extremity complicated by chronic wound formation presented with worsening right leg pain and increasing wound drainage.

The patient described the pain as excruciating, with 10/10 intensity and exacerbated by movement. His wounds began draining purulent material and blood about two weeks prior to presentation. He has had several similar, though milder episodes in the past requiring hospitalization. When the wounds began to have a foul odor, he presented to the hospital. …

Thrombotic Thrombocytopenic Purpura Revisited: Upshaw Schulman Syndrome In A 20-Year-Old Male, Judy Wang, Md, Niluk Peiris, Md

The Medicine Forum

Case Report

A 20-year-old male with no significant past medical history presented to an outside hospital with a two-week history of progressive fatigue, malaise and decreased appetite. Prior to these events, he had been in his usual state of health with normal exercise tolerance and energy level. Upon development of his symptoms, the patient felt as though he had developed an upper respiratory infection (URI). The URI symptoms eventually resolved; however complaints of fatigue and malaise still remained. He then developed progressive dyspnea on exertion and tea-colored urine. The patient reported a singular febrile episode to 38.9˚C associated with nonbilious …

A Case Of Pyoderma Gangrenosum, Christopher T. Miller, Md

The Medicine Forum

Case Report

A 60-year-old man with past medical history of hypertension, post-traumatic stress disorder, major depression, hepatic steatosis, chronic kidney disease, and untreated hepatitis C virus (genotype 1b) initially presented to the outpatient primary care clinic with a chief complaint of an extremely painful right lower extremity ulcer that had developed and grown progressively larger after mild trauma against a metal corner 4 months prior to the appointment. He admitted to picking at the granulation tissue that would develop over the ulcer. He was treating the ulcer with antibiotic ointment. On initial exam, the ulcer was about 2x2 cm, located …

Two Cases Of Co-Infection With Babesiosis And Lyme Disease, Anthony Decicco, Md, B. Niluk Peiris, Md, Cecilia Kelly, Md, Michael Latreille, Md, Donald Jungkind, Phd

The Medicine Forum

Case 1

The patient is a 71-year-old female with past medical history significant for hypothyroidism and hyperlipidemia who presented to Thomas Jefferson University Hospital (TJUH) with complaints of myalgias for 6 weeks duration. The patient stated that she had begun an exercise program to lose weight and had subsequently noticed body aches and increased fatigue. She had presented to an outside hospital with these complaints, was told that the etiology was musculoskeletal, and was prescribed naproxen for pain relief. The pain did improve slightly with the naproxen but she noticed a rash and hives after starting the medication and stopped …

A Case Of A 32-Year-Old Female With Right-Sided Facial Droop And Numbness, Jason Schoenfeld, Msiii, Efstathia Andrikopoulou, Md

The Medicine Forum

Case Presentation

A 32-year-old Hispanic female with a past medical history of asthma, depression and insomnia presented to the emergency room with complaints of right-sided facial droop associated with ipsilateral facial numbness and diminished taste for the past three days. In addition, she reported a moderate to severe pulsatile headache for the past day. This headache was initially right-sided and frontal, but then became right-sided and occipital in location. She had a history of a similar headache episode four years ago. Additionally, she noted moderately severe intermittent chest pain described as sharp then dull occurring over the past day. On …

Mycobacterium Fortuitum Device Infection With Subsequent Endocarditis, Paurush Shah, Md, Alec Vishnevsky, Md

The Medicine Forum

Case

A 78-year-old female with a past medical history of mild dementia, hypertension, diabetes, coronary artery disease status post automatic implantable cardioverter defibrillator (AICD) for congestive heart failure presented with suspected bacterial endocarditis and AICD lead infection from an outside hospital (OSH). The patient initially presented to the OSH with chest wall tenderness, fevers up to 101° F, chills, decreased appetite, weakness and weight loss. She was diagnosed with a non-ST segment myocardial infarction based on elevated troponin levels without electrocardiogram changes. At the OSH, blood acid fast bacillus (AFB) cultures were checked after routine blood cultures and fungal cultures …

A 55-Year-Old Man With Rapid Onset Rectosigmoid Mass And Hepatic Metastases With An Afp Of > 3 Million Ng/Ml, Francis Kim, Md

The Medicine Forum

Case

A 55-year-old male with a past medical history of ulcerative colitis diagnosed in 1999, Barrett’s esophagus, hyperlipidemia, and diabetes mellitus presented with a 2-week duration of daily constant abdominal pain. He described the pain as a sharp, epigastric pain not worsened with food intake or bowel movements. He was unable to tolerate any oral intake for a week prior to admission secondary to increased epigastric pain. He stated an increase in bowel movements to 1 per day that was softer and less formed than usual. He also stated he had a near syncopal episode on the day of admission …

Not Your Typical Case Of Ascites: Pancreatic Ascites In A Patient With Cirrhosis And Pancreatic Duct Leak, Philip Montemuro, Md, Abhik Roy, Md

The Medicine Forum

Case

A 55-year-old male with a history of hepatic cirrhosis secondary to Hepatitis C and alcohol abuse presented to an outside hospital with progressive abdominal pain and distension. The patient initially complained of “punching” right upper quadrant and epigastric abdominal pain that was 10/10 in intensity and non-radiating. Although the pain had started one to two days prior to presentation, the patient had been experiencing several weeks of increasing abdominal distension. He reported drinking eight 40oz beers daily for over 40 years, and he felt that the abdominal pain improved slightly with cessation of alcohol use. The patient complained of …

Strongyloides Stercoralis Infection In A Patient With Aids, Abhik Roy, Md, Gregory Young, Md, Geoffrey Koff, Md, Tasha Kouvatsos, Md

The Medicine Forum

Case

A 46-year-old male with a past medical history significant for acquired immune deficiency syndrome (AIDS) presented with constant, non-radiating epigastric pain, nausea, non-bloody emesis, weakness, and lethargy. He had emigrated from Honduras twenty years prior. The patient denied fever, chills, recent travel, animal exposures, or sick contacts. His medications included efavirenz/emtricitabine/tenofovir, valganciclovir, trimethoprim/sulfamethoxazole, fluconazole, and iron.

Large, Solitary, High-Grade Duodenal Tubular Adenoma In A Patient Presenting With Gi Bleed, Paurush Shah, Md

The Medicine Forum

Case

A 71-year-old male with past medical history of hypertension, hyperlipidemia, aortic stenosis, and atrial flutter on warfarin presented to his primary care physician (PCP) a few days prior to admission with complaints of lethargy, lightheadedness, and mild shortness of breath (SOB) for about five days prior to admission. He stated that he had also been experiencing dark stools for one week while therapeutic on warfarin. His blood pressure in the office was slightly low, and he was told drink extra fluids as his symptoms were likely due to dehydration. The patient returned to his PCP a few days later …

An Indonesian Male With Abdominal Pain And Weight Loss: Abdominal Tuberculosis Presenting With Cervical Lymph Node Enlargement, Leah Duke Kaye, Md, Jayne Littlejohn, Md

The Medicine Forum

Case

A 21-year-old Indonesian male presented with a 6-month history of abdominal pain. The pain was described as a diffuse cramping that was worse with movement and after meals. He reported early satiety, and the pain was improved at rest. Associated with the pain, he reported a seventy pound weight loss, chills, decreased energy, and fatigue over the same time period. He denied nausea, vomiting, fevers, cough, dyspnea, or chest pain.

The patient emigrated from Indonesia to the United States in 2007 and has since had no travel or foreign visitors. He denied incarceration or military duty for both himself …

Hematemesis, A Distended Abdomen, And Pulseless Electrical Activity – An Unusual Presentation Of Boerhaave’S Syndrome, Andrew Garrett, Md, Marie Nguyen, Md, Lindsay Wilde, Md, Andrew Toscano, Md, Philip Pancari, Md, Andrew Lerner, Md

The Medicine Forum

Case Presentation

An 82-year-old male with a past medical history significant for coronary artery disease with three stents placed over the last 15 months, diastolic heart failure with preserved EF, atrial fibrillation on warfarin, colon cancer status-post sigmoid resection and prostate cancer status-post prostatectomy who presented with three episodes of melena, hematemesis, and weakness. The patient was in his usual state of health prior to these symptoms. He had no history of gastrointestinal (GI) bleeding or other GI pathology and was a non-drinker and non-smoker. He denied frequent use of non-steroidal anti-inflammatory medications.

Non-St Elevation Mi As A Unique Presentation Of Angioimmunoblastic T-Cell Lymphoma, Paurush Shah, Md, Gunjan Shah, Md, Avinash Chandra, Md, Lawrence Lee, Msiv, Gregary Marhefka, Md

The Medicine Forum

Case

A 61-year-old Chinese female with a history of hypertension, hyperlipidemia, asthma, and gastroesophageal reflux disease presented with four days of chest pressure that radiated to her left arm and jaw. On exam, her vital signs were within normal limits and cardiac and pulmonary exams were unremarkable. Her initial electrocardiogram (ECG) demonstrated ischemic ST segment depressions in leads II, III, and aVF; her first troponin I was elevated at 2.3 ng/mL (normal <0.05 ng/mL) and peaked at 6.8 ng/mL. She was given sublingual nitroglycerin and metoprolol, which controlled her symptoms, and she was started on a heparin infusion to prevent further ischemia. The patient’s medications included: amlodipine was notable for the following daily medications: amlodipine 5 mg, olmesartan 20mg, atorvastatin 20mg, esomeprazole 20mg, montelukast 10mg, and mometasone 110mcg twice daily. Her family history was significant for a brother who had a coronary stent placed at age 57. She denied drug, tobacco, or alcohol use. She was non-English speaking, and immigrated to the United States from China five years ago.

A 47-Year-Old Female With Shortness Of Breath, Dana Marrero, Md, Kelly Wright, Md

The Medicine Forum

This patient is a 47-year-old female with a history of end-stage liver disease secondary to hepatitis C virus (HCV) complicated by hepatic encephalopathy, obstructive sleep apnea, asthma, and severe peripheral neuropathy who presents to the hospital with complaints of shortness of breath and cough. The patient was recently discharged from an outside hospital 2 days prior to this admission where she was treated for pneumonia and an asthma exacerbation but her symptoms have not improved. She complains of shortness of breath at rest and severely decreased exercise tolerance with dyspnea while walking across the room. Her cough is persistent and …

Table Of Contents, The Medicine Forum, Volume 13, 2011

The Medicine Forum

Table of Contents, The Medicine Forum, Volume 13, 2011

A Case Series Of Lyme Carditis With Complete Heart Block, Rina Shah, Md, Mitul Kanzaria, Md

The Medicine Forum

Case 1

A 25-year-old Caucasian male with a history of a benign functional heart murmur presented to the emergency department for evaluation of 10 days of dyspnea with minimal exertion, such as walking a few blocks or climbing a flight of steps. Dyspnea was accompanied by moderate, dull, left-sided chest pain, which had been progressively worsening over the previous 3-5 days. The symptoms initially occurred only with exertion, but progressed to last 30-45 minutes after discontinuation of activity. He also noticed palpitations during these episodes, but did not try any remedies for his symptoms. Of note, two weeks prior to …

From The Editors, Andrew Lerner, Md, Tasha Kouvatsos, Md, Andrea Fennelly, Md

The Medicine Forum

The editorial staff would like to acknowledge the support of Dr. Diemer and Dr. Kane in producing this year’s Jefferson Forum. We appreciate your guidance and thank you for all that you have done to help bring this issue to print. We would also like to thank our internal medicine resident colleagues for contributing interesting and unique case reports, review articles, original research, travel experiences, and poetry. This issue of the Jefferson Forum could not have been done without your hard work and enthusiasm.

From The Desk Of The Residency Program Director, Gretchen Diemer, Md, Facp

The Medicine Forum

To the Friends of the Department of Medicine:

I am honored to be given the opportunity to lead this talented group of residents as they travel down the path toward completion of their residency training. On September 1st, Dr. Gregory Kane took the reins as the Interim Chair of the Department of Medicine here at Jefferson. A new Program Director could not ask for a more staunch supporter of education to occupy that role than Dr. Kane.

This edition of The Forum showcases the broad variety of patients our residents and students encounter during their training. The submissions to this …

The Effect Of Required Ipads On Library Use, Gary Kaplan, Mslis, Dorothy Berenbrok, Mslis, Daniel G. Kipnis, Msi, Helena Washington, Mls

Academic Commons and Scott Memorial Library Staff Papers and Presentations

OBJECTIVES

Measure the impact on Library use of a new requirement by anaccelerated, one-year nursing program that all students haveiPads loaded with the required texts and determine whether theLibrary should continue offering these books in print.

Poster presented at Medical Library Association Annual Conference, Seattle, WA 2012.

Genetic Ablation Of Cav1 Differentially Affects Melanoma Tumor Growth And Metastasis In Mice: Role Of Cav1 In Shh Heterotypic Signaling And Transendothelial Migration., Franco Capozza, Casey Trimmer, Remedios Castello-Cros, Sanjay Katiyar, Diana Whitaker-Menezes, Antonia Follenzi, Marco Crosariol, Gemma Llaverias, Federica Sotgia, Richard G Pestell, Michael P Lisanti

Department of Cancer Biology Faculty Papers

Both cell-autonomous and non-cell-autonomous factors contribute to tumor growth and metastasis of melanoma. The function of caveolin-1 (Cav1), a multifunctional scaffold protein known to modulate several biologic processes in both normal tissue and cancer, has been recently investigated in melanoma cancer cells, but its role in the melanoma microenvironment remains largely unexplored. Here, we show that orthotopic implantation of B16F10 melanoma cells in the skin of Cav1KO mice increases tumor growth, and co-injection of Cav1-deficient dermal fibroblasts with melanoma cells is sufficient to recapitulate the tumor phenotype observed in Cav1KO mice. Using indirect coculture experiments with fibroblasts and melanoma cells …

Prevention Of Stone Migration With The Accordion During Endoscopic Ureteral Lithotripsy., Christopher J Pagnani, Magdy El Akkad, Demetrius H Bagley

Department of Urology Faculty Papers

BACKGROUND AND PURPOSE: Endoscopic lithotripsy is often prolonged secondary to the retrograde migration of calculous fragments. Various balloons, baskets, and other devices have been used to prevent this migration. Our purpose is to analyze the effect of the Accordion(®) on stone migration and overall efficiency during lithotripsy.

PATIENTS AND METHODS: We prospectively evaluated 21 patients with a total of 23 distal ureteral stones. Patients underwent lithotripsy using an endoscopic impact lithotriptor. The Accordion was randomly used in 11 of these 21 patients. Data were collected regarding stone migration, stone size, stone ablation, ureteral clearing, and lengths of time for various …

Occupational Therapy And Sensory Integration For Children With Autism: A Feasibility, Safety, Acceptability And Fidelity Study., Roseann C Schaaf, Teal W. Benevides, Donna Kelly, Zoe Mailloux-Maggio

Department of Occupational Therapy Faculty Papers

Objective: To examine the feasibility, safety, and acceptability of a manualized protocol of occupational therapy using sensory integration principles for children with autism. Methods: Ten children diagnosed with autism spectrum disorder ages 4-8 years received intensive occupational therapy intervention using sensory integration principles following a manualized protocol. Measures of feasibility, acceptability and safety were collected from parents and interveners, and fidelity was measured using a valid and reliable fidelity instrument. Results: The intervention is safe and feasible to implement, acceptable to parents and therapist, and therapists were able to implement protocol with adequate fidelity. These data provide support for implementation …

Influence Of The Menstrual Cycle On The Incidence Of Nausea And Vomiting After Laparoscopic Gynecological Surgery: A Pilot Study., Tatjana Simurina, Boris Mraovic, Neven Skitarelić, Tatjana Andabaka, Zdenko Sonicki

Department of Anesthesiology Faculty Papers

STUDY OBJECTIVE: To investigate whether the phase of menstrual cycle influences the incidence of postoperative nausea and vomiting (PONV) in women undergoing general anesthesia for elective laparoscopic gynecological surgery.

DESIGN: Prospective, observational, blinded study.

SETTING: General hospital, Postanesthesia Care Unit, and gynecologic floor room.

PATIENTS: 111 ASA physical status 1 and 2 women, aged 18 to 53 years.

INTERVENTIONS: Patients were classified into three groups according to the phase of menstrual cycle at the time of anesthesia: Group F1: follicular phase (menstrual days 1-8; n = 34); Group O2: ovulatory phase (days 9-15; n = 40); and Group L3: luteal …