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Meet An Ipe Faculty Champion From Thomas Jefferson University: Richard Hass, Phd, Assistant Professor Of Psychology, Richard Hass, Phd

Collaborative Healthcare: Interprofessional Practice, Education and Evaluation (JCIPE)

Meet an IPE Faculty Champion from Thomas Jefferson University: Richard Hass, PhD, Assistant Professor of Psychology

Advancing Senior Care And Aging In Place Through Collaborative In-Home Visits: A Novel Community-University Partnership, Michael J. Oldani, Phd, Ms, Sharon Chappy, Phd, Rn, Cnor, Lois Harrison, Pt, Dpt, Ms, Stacey L. Kukor, Mot, Otr/L, Travis Suss, Pharmd, Bcgp, Nancy A. Stoehr, Pharmd, Faca, Fiacp

Collaborative Healthcare: Interprofessional Practice, Education and Evaluation (JCIPE)

"Aging in place" (i.e., living independently in one's home) has become part of the national conversation as the U.S. demographically shifts towards an older population. What is interesting about aging in place is how seniors may end up in this particular situation. For some seniors, it may be their choice to age safely in their home with or without a partner and possibly other family members. For others, aging in place can occur out of necessity as a result of financial burden, lack of family support, or even isolation due to mental health or cognitive issues like dementia (see Brody, …

From The Editors

Collaborative Healthcare: Interprofessional Practice, Education and Evaluation (JCIPE)

From the Editors

Structural Basis For The Homotypic Fusion Of Chlamydial Inclusions By The Snare-Like Protein Inca., Gino Cingolani, Michael Mccauley, Anna Lobley, Alexander J Bryer, Jordan Wesolowski, Deanna L Greco, Ravi K Lokareddy, Erik Ronzone, Juan R Perilla, Fabienne Paumet

Department of Biochemistry and Molecular Biology Faculty Papers

Many intracellular bacteria, including Chlamydia, establish a parasitic membrane-bound organelle inside the host cell that is essential for the bacteria's survival. Chlamydia trachomatis forms inclusions that are decorated with poorly characterized membrane proteins known as Incs. The prototypical Inc, called IncA, enhances Chlamydia pathogenicity by promoting the homotypic fusion of inclusions and shares structural and functional similarity to eukaryotic SNAREs. Here, we present the atomic structure of the cytoplasmic domain of IncA, which reveals a non-canonical four-helix bundle. Structure-based mutagenesis, molecular dynamics simulation, and functional cellular assays identify an intramolecular clamp that is essential for IncA-mediated homotypic membrane fusion during …

Risk Factors For The Elevation Of Psychosocial Barriers In The Recovery Of Lumbar Pathology, Christopher Keating, Cameron Hui, Gerard Smith, Tingting Zhan

Department of Physical Therapy Faculty Papers

Background/Purpose: The prevalence of low back pain (LBP) continues to rise and an appreciation for a biopsychosocial approach, which takes in multiple facets of a patient presentation, may significantly impact this increase. To the best our knowledge, there are no studies evaluating the relationship between the STarTBack Screening Tool (SBT) and the access point the patient enters the health system. Our hypothesis is that patients that access care through the medical model will exhibit greater psychosocial risk.

Methods: A retrospective analysis of 1404 cases of LBP utilizing past medical history, demographic information, and SBT data. A linear regression model to …

Gpvi Inhibitor As Antitumor Gateway Drug., Lawrence E. Goldfinger

Department of Medicine Faculty Papers

In this issue ofBlood, Volz et al establish a potential antitumor strategy byexploiting the selective requirement for platelets to maintain vascular in-tegrity within the tumor microenvironment.1Their work demonstrates, forthefirst time, that functional inhibition of platelet-specific surface receptorglycoprotein (GP) VI, using F(ab9)2fragments to avoid platelet clearance,increases intratumoral hemorrhage and concomitant tumor cell apoptosis, aswell as enhanced accumulation of chemotherapeutic drugs. These effectswork additively to inhibit tumor growth, achieving results similar to thoseachieved by platelet depletion.

Stat3 Genotypic Variant Rs744166 And Increased Tyrosine Phosphorylation Of Stat3 In Il-23 Responsive Innate Lymphoid Cells During Pathogenesis Of Crohn's Disease, Ying Tang, Sanda A. Tan, Atif Iqbal, Jian Li, Sarah C. Glover

Department of Neurology Faculty Papers

Crohn's disease (CD) results from dysregulated immune responses to gut microbiota in genetically susceptible individuals, affecting multiple areas of the gastrointestinal tract. Innate lymphoid cells (ILCs) are tissue-resident innate effector lymphocytes which play crucial roles in mucosal immune defense, tissue repair, and maintenance of homeostasis. The accumulation of IFN-γ-producing ILC1s and increased level of proinflammatory cytokines produced by ILCs has been observed in the inflamed terminal ileum of CD patients. To date, the precise mechanisms of ILC plasticity and gene regulatory pathways in ILCs remain unclear. Signal transducer and activator of transcription 3 (STAT3) regulates gene expression in …

No Hard Feelings, Colin Thomas, Md

The Medicine Forum

No abstract provided.

To Those Who Don The White Coat, Cuckoo Choudhary, Md

The Medicine Forum

No abstract provided.

Heart Failure With Preserved Ejection Fraction: A Review Of The Acc/Aha Guidelines And Evidence-Based Management Strategy, Vikas Sunder, Md

The Medicine Forum

Introduction

Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome in which a patient has signs and symptoms of heart failure including dyspnea, fatigue, pulmonary rales, peripheral edema and an ejection fraction greater than 50%.1-4 Approximately half of patients with heart failure have a preserved ejection fraction.2-5 HFpEF is considered a distinct clinical entity from other causes of heart failure with a preserved ejection fraction such as valvular heart disease, pericardial disease, and infiltrative cardiomyopathy. HFpEF carries a poor prognosis, with an annual mortality of 29% in patients discharged after an acute decompensated heart failure admission.5 5-year survival …

A Gram-Negative False-Negative: Normal Procalcitonin Level In A Patient With Multiple Klebsiella Pneumoniae Intra-Abdominal Abscesses: A Case Report And Literature Review, Mario Caldararo, Md

The Medicine Forum

Introduction

Despite over 3,000 peer-reviewed articles on procalcitonin (PCT) since 2004, guidance on its usage is sparse.1 An analysis of more than 500 United States hospitals in the Premier Healthcare Database found large differences in utilization exist across regions (115 PCT encounters per 10,000 patients in the Northeast vs. 408 to 576 in other regions) and teaching vs. non-teaching hospitals (345 vs. 530 PCT encounters per 10,000 patients, respectively).2 The purpose of this work is to describe a case that exemplifies the caveats in PCT interpretation and to summarize the current knowledge of the clinical utilization of PCT.

Can Our Hearts Take The New Guidelines?, Eitan Frankel, Md

The Medicine Forum

No abstract provided.

Resident Experiences With Journaling, Tara Sunder, Md, Gretchen Diemer, Md, Vikas Sunder, Md

The Medicine Forum

Background

Each year, medical school graduates don their long white coat for the first time and begin their residency. While residency promises the excitement of learning and increased autonomy, it also brings long duty hours and stressful situations worsened by inexperience. Due to these stressors, burnout affects many residents each year. Studies have been done to see if wellness curricula help decrease resident burnout, and since journaling is a known way to relieve stress and enhance reflection, journaling has become a common intervention in these curricula.1,2 While there are studies evaluating the impact of journaling on mental health and stress …

Pneumatosis Intestinalis In A Patient With Systemic Lupus Erythematosus, Sean Dikdan, Md, Michael Lake, Md

The Medicine Forum

Introduction

Pneumatosis intestinalis (PI) refers to the radiographic finding of gas within the small or large bowel wall. It can be seen in association with gas in the portal venous system. The clinical significance of these findings is variable and depends on the patient's etiology and initial presentation. PI can be seen anywhere in the gastrointestinal tract distal to the stomach and is caused by a myriad of conditions.1 We present a case of a patient admitted to the intensive care unit with PI and portal vein gas.

Hemothorax And Hemorrhagic Ascites: A Rare Presentation Of Endometriosis, Harry Wang, Md

The Medicine Forum

Introduction

Endometriosis is a common diagnosis in reproductive age women characterized by the presence of endometrial tissue outside the uterine cavity.1 Although it is typically confined to the pelvis, rare manifestations involving the thorax, abdomen or pericardium have been documented.2-5 Even more rare is the concurrent presence of endometriosis- associated hemorrhagic pleural effusion and ascites, which can prove a diagnostic challenge. We describe a case of hemothorax and hemorrhagic ascites in a woman with shortness of breath and abdominal pain.

Subacute Onset Hand Clumsiness In A Renal Transplant Patient With A Recent Icu Stay, William Bradford, Md

The Medicine Forum

Introduction

Solid organ transplant recipients carry a high burden of disease and are susceptible to opportunistic infections not seen in other patient subgroups. Signs and symptoms that would not necessarily warrant timely attention in other patient groups may call for an aggressive workup in this subset of patients. Here, we present one case in which a seemingly trivial complaint denoted serious underlying pathology, and timely attention to this minor but unusual concern led to early intervention with appropriate treatment of an uncommon disorder.

Hyperviscosity In Non-Igm Lymphoplasmacytic Lymphoma, Mario Fonseca-Paricio, Md, Sushil Chmire, Md, Adam Binder, Md

The Medicine Forum

The following is a case of how a non-IgM paraproteinemia can present with symptoms of hyperviscosity and coagulopathy, an uncommon occurrence.1-3 As this case demonstrates, this diagnosis must be considered even in patients with relatively normal coagulation laboratory results. Such pathology requires urgent treatment with plasmapheresis.

Worsening Autoimmune Neutropenia After Stopping Ibrutinib In A Patient With Chronic Lymphocytic Leukemia: Case Report And Review Of Literature, Natalie Rosen, Ba, Thomas Klumpp, Md, Sameh Gaballa, Md, Msc

The Medicine Forum

Introduction

Autoimmune cytopenia (AIC) is relatively common in patients with chronic lymphocytic leukemia occurring in 5-10% of patients during the course of their disease.1 Autoimmune hemolytic anemia (AIHA) constitutes the highest prevalence (5-10%) of CLL-associated AIC followed by idiopathic thrombocytopenic purpura (ITP) (2-5%), pure red cell aplasia (PRCA) (<1%), and autoimmune neutropenia (AIN) (<1%).2,3 The prevalence of AIN, however, may in fact be higher than reported due to a lack of awareness of the condition and difficulty in its diagnosis.4 Despite its rarity, autoimmune neutropenia can be a significant clinical challenge in patients with CLL and can increase the risk of infectious complications. Thus, the prompt diagnosis and resolution of CLL-associated AIN is essential to the management of these patients.

Ibrutinib is a selective inhibitor of Bruton tyrosine kinase and induces a durable response in patients with CLL.5 The activity of ibrutinib in CLL-associated AIC is largely unknown as pivotal clinical trials excluded patients with AIC. We report a case of a patient with CLL who experienced worsening of AIN after …

Bilateral Choroidal Metastases As Initial Presentation Of Widespread Follicular Thyroid Cancer, Jennifer Hong, Md

The Medicine Forum

Introduction

Follicular thyroid cancer (FTC) is the second most common malignancy of the thyroid gland and comprise 10-15% of all thyroid tumors; the usual mode of spread is via hematogenous dissemination with the most common sites of metastases being the lungs and bones.4 A case is presented to demonstrate the unusual presentation of follicular thyroid cancer as bilateral choroidal metastases. Although exceptional, a diagnosis of choroidal metastases should be considered in any decline in visual acuity in patients with thyroid cancer.

Complicated Persistent Peritonitis, Lindsey Roth, Ba, Kumar Sarkar, Md

The Medicine Forum

Introduction

Spontaneous bacterial peritonitis (SBP) is a common complication of end-stage liver disease. SBP can present with many symptoms such as abdominal pain, fever and altered mental status.1 The diagnosis of SBP is made when ascitic fluid from a paracentesis has an absolute neutrophil count (ANC) more than 250/uL, there is a positive ascitic fluid culture, and no secondary source of infection can be idenitifed.2 However, nearly 60% of patients with SBP have negative fluid cultures.3 These patients can still potentially have SBP and should be treated as such since in-hospital mortality ranges from 20-40%.1,4 Conventional treatment for SBP includes …

Sealing The Diagnosis Of Celiac Disease In Pregnancy, Ritu Nahar, Md, Avani Aman, Md

The Medicine Forum

Introduction

Celiac disease (CD) is an immune mediated condition that results from a reaction to dietary gluten and primarily affects the small intestine. Genetically predisposed individuals develop a chronic inflammatory state of the small intestine which leads to malabsorption. The disease is mediated by HLA DQ2 or DQ8 haplotypes, which bind the gliadin peptides of gluten, present the peptides to CD4+ T lymphocytes and trigger cytokine and B lymphocyte responses.1

The prevalence of CD in the United States is approximately 1% and can reach up to 4-5% in at-risk groups.2 Serologic study of asymptomatic elderly patients in the United Kingdom …

Thyrotoxic Periodic Paralysis – A Case Report Of A Rare Cause Of Paralysis In A 39-Year-Old Asian Man, R. Benson Jones, Md, James Uricheck, Md

The Medicine Forum

Introduction

Uncontrolled hyper thyroidism has a myriad of presentations. Classically, symptoms include weight loss, tremor, palpitations, shortness of breath, diarrhea, anxiety, and heat intolerance. A rare manifestation of hyperthyroidism is thyrotoxic periodic paralysis (TPP). Periodic paralysis is a musculoskeletal channelopathy manifested by episodes of painless muscle weakness often precipitated by heavy exercise, fasting, or high carbohydrate meals. Although classically associated with painless weakness; cramping, myalgias, and stiffness can also occur prior to the episodes as prodromal symptoms. Neurologic examination during an attack typically demonstrates proximal more than distal muscle weakness, and the upper extremities are more commonly affected than the …

A Case Report Of Pseudohypoglycemia In A Patient With Leukocytosis, Michael Weintraub, Md, Deepika Nandiraju, Md, Monika Shirodkar, Md

The Medicine Forum

Introduction

Hypoglycemia is most convincingly documented by Whipple’s triad: low plasma glucose, symptoms of hypoglycemia and relief of symptoms after treatment.1 Pseudohypoglycemia is a condition where there is an artifactually low glucose concentration and an absence of hypoglycemic symptoms. We present a case of pseudohypoglycemia where leukocytosis played a role in lowering venous glucose.

A Case Of Left Ventricular Myocardial Calcification In A Patient With Severe Sepsis, Carly Sedlock, Md, Randi Zukas, Md, Hillary Landon, Md

The Medicine Forum

Introduction

Sepsis is an important source of morbidity and mortality among patients admitted to the Intensive Care Unit (ICU) and can cause critical damage to all organ systems. Regarding cardiac complications, sepsis can acutely result in cardiomyopathy characterized by ventricular dilatation and a depressed ejection fraction.1 Myocardial calcification is a more rare, delayed cardiac complication of severe sepsis that has been reported in literature.1-6 Herein we report a case of a patient with Acute Myeloid Leukemia (AML) admitted to the TJUH ICU requiring prolonged vasopressor support for severe sepsis whose clinical course was complicated by left ventricular myocardial calcification.

Fibrous Web In The Right Atrium: A Complication Of Fungal Endocarditis And Previous Lead Infections, Harry Wang, Md

The Medicine Forum

A 57-year-old woman with a past medical history of severe non-ischemic cardiomyopathy undergoing orthotopic heart transplant evaluation on milrinone, prior extraction of multiple pacemaker and implantable cardioverter defibrillator (ICD) leads due to Staphylococcus epidermidis endocarditis, and multiple central venous catheter infections presented with several days of worsening dyspnea on exertion, orthopnea and lower extremity edema, prompting admission for congestive heart failure exacerbation.

Table Of Contents: The Medicine Forum Volume 20, 2018-2019

The Medicine Forum

Clinical Images

Case Reports

• Cardiology
• Endocrinology
• Gastroenterology and Hepatology
• Hematology and Oncology
• Infectious Disease
• Pulmonary Medicine
• Rheumatology

Original Article

Editorial

Literature Review

Creative Writing

From The Editors, Colin Thomas, Md, Eitan Frankel, Md, Guy Katz, Md, Michael Weintraub, Md, Brianna Shinn, Md, Navdeep Sangha, Md, Rachel Redfield, Md, Mario Caldararo, Md

The Medicine Forum

We are delighted to present you with the 20th annual edition of The Medicine Forum. Here in the birthplace of our nation, we like to think of The Medicine Forum as being of the housestaff, by the housestaff and for the housestaff. Undeniably, this publication would not be possible without the countless hours dedicated by our residents, students, fellows and faculty.

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

The Medicine Forum

It has been another wonderful year in the Jefferson Internal Medicine Residency Program. Our program continues to train the best and brightest residents in the country. This publication is just one example of the passion, dedication and creativity our residents continue to provide to the Jefferson Community. The residents are not just outstanding clinicians but excel in all aspects of medicine including: research, humanities and medical education.

The Medicine Forum: Volume 20

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 20, 2018-2019

TABLE OF CONTENTS

Clinical Images

Case Reports

• Cardiology
• Endocrinology
• Gastroenterology and Hepatology
• Hematology and Oncology
• Infectious Disease
• Pulmonary Medicine
• Rheumatology

Original Article

Editorial

Literature Review

Creative Writing

Immunomodulatory And Neuroprotective Mechanisms Of Huangqi Glycoprotein Treatment In Experimental Autoimmune Encephalomyelitis., Yanxia Xing, Binyu Liu, Yijin Zhao, Lihong Zhang, Rodolfo Thome, Huiqing Xue, Peijun Zhang, Cungen Ma

Department of Neurology Faculty Papers

Previous studies have shown that Huangqi glycoprotein (HQGP) has an anti-inflammatory effect in vitro, and suppressed experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis; however, the mechanism underlying its effect is largely unknown. In this manuscript we investigated the mechanisms by which HQGP protect mice from EAE. HQGP was extracted from Astragalus membranaceus and purified by anion-exchange and gel filtration chromatography. HQGP delayed disease onset, reduced disease severity and alleviated inflammation and demyelination in the central nervous system (CNS). Moreover, HQGP reduced the infiltration of pathogenic immune cells and increased the expression of microtubule-associated protein 2 (MAP-2) and …