Medical Specialties Commons^™

Increasing Patient Confidence In Managing Asthma Using Asthma Action Plans, Pankhuri Jha, Jessica F. Most, Md

The Medicine Forum

Asthma is a common illness affecting 8% of the US population and costing $81.9 billion per year.^1,2 Due to its chronic and variable nature, asthmatics need frequent medication adjustments, making management challenging for both physicians and patients. Studies show that patients can control their asthma using an asthma action plan (AAP), which includes directions for daily self-assessment, baseline medications and steps to facilitate detection and treatment of an exacerbation. Self-management education using AAPs is associated with a reduction in hospital admissions and ED visits by 40% and 20%, respectively.³ Despite evidence that AAPs are efficacious, the underlying reason …

Stemi In A Young Patient With Covid-19; Too Great A Burden?, Naman Upadhyay, Md, Gillian Naro, Md, Med, Gregary Marhefka, Md

The Medicine Forum

Myocardial infarcts (MIs) can be especially devastating when their pathogenesis stems from a coronary artery occlusion by an intracoronary thrombus (ICT). ICTs are most frequently a result of an underlying atherosclerotic plaque rupture, however, can also be a result of emboli, vasospasm, hypercoagulable states, among other etiologies. Patients suffering from the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appear to be in both a hypercoagulable and proinflammatory state resulting in an increased risk of clot formation, endothelial damage, and plaque destabilization, thus increasing the ICT burden in infected patients.1 The literature does reflect an increase in ICT ST-segment elevation …

Pancreatic Plasmacytoma: A Rare Extramedullary Manifestation Of Multiple Myeloma, Justin Robbins, Md, Gregory Habig, Md

The Medicine Forum

Multiple myeloma is a plasma cell dyscrasia in which neoplastic plasma cells pathologically produce monoclonal immunoglobulin and infiltrate bone marrow throughout the skeletal system. The disease is classically characterized by bone pain caused by lytic bone lesions, marked increases in monoclonal antibodies in blood or urine, hypercalcemia, and other systemic signs and symptoms of malignancy including weight loss and night sweats. A rare variant of multiple myeloma presents with extramedullary plasmacytomas, or plasma cell tumors, which arise in organs outside of the bone marrow¹. The case presented here exhibits this disease variant, with a woman with severe multiple …

Idiopathic Retroperitoneal Fibrosis, Candace Derenge, Md

The Medicine Forum

Idiopathic retroperitoneal fibrosis (IRF) is a rare and unusual etiology of abdominal pain that is becoming more frequently diagnosed with the use of CT imaging for abdominal pain. Retroperitoneal fibrosis is characterized by the development of extensive fibrosis throughout the retroperitoneum that can encircle the aorta, iliac arteries, and ureters. About two thirds of retroperitoneal fibrosis cases are idiopathic, thought to be due to an autoimmune process of antibodies stimulating desmoplastic reaction. One third of cases are secondary to drugs (methysergide, beta-blockers, hydralazine, ergotamine, LSD) or diseases the stimulate desmoplastic reaction (tumors, infections, radiation, and Erdheim-Chester disease). Histology of IRF …

A Case Of Refractory Gestational Trophoblastic Neoplasia Requiring Hysterectomy After Methotrexate, Ida Micaily, Md, Saveri Bhattacharya, Do, Russell J. Schilder, Md

The Medicine Forum

Gestational trophoblastic neoplasia (GTN) refers to a group of malignant conditions that develop due to abnormal fertilization causing abnormal proliferation of tissue. GTN is primarily treated with surgical evacuation of the underlying proliferative tissue. Approximately half of cases of GTN arise from molar pregnancy¹. GTN include invasive moles, choriocarcinomas, placentalsite trophoblastic tumors and epithelioid trophoblastic tumors. The most common risk factors associated with GTN are prior molar pregnancy, advanced maternal age (>40 years of age), and Asian and Native American ancestry^2-4. Following evaluation of a molar pregnancy, a post-molar GTN is diagnosed based on the …

A Rare Presentation Of A Clear Cell Variant Of Peritoneal Mesothelioma, Nivethietha Maniam, Md, Michael Lee, Md, Mihir M. Shah, Md, H. Richard Alexander, Md

The Medicine Forum

Primary malignant peritoneal mesothelioma with clear cell subtype is a rare malignancy with few previously reported cases. We present a 63-year-old female who presented with abdominal distention and was diagnosed with clear cell mesothelioma of the peritoneum with an isolated metastasis to the liver. The patient underwent surgical resection of a greater than 50 cm mass with en-bloc partial liver and gastric resection with an uneventful post-operative course. There are established prognostic and treatment recommendations for peritoneal mesothelioma based on histological subtype and patient-specific factors, although they do not explicitly incorporate clear cell subtype. This case report describes the presentation, …

A Slow Burning Diagnosis: A Case Report Of Hemophagocytic Lymphohistiocytosis Preceding The Diagnosis Of Subcutaneous Panniculitis-Like T-Cell Lymphoma, Steven Manobianco, Md, William Bradford, Md, Ida Micaily, Md, Adam Binder, Md

The Medicine Forum

HLH is a severe inflammatory syndrome characterized by primary or secondary immune dysregulation causing excess activation of macrophages and cytotoxic lymphocytes, leading to multi-system dysfunction. Diagnosing and managing HLH can be challenging for clinicians, with HLH-2004 criteria for diagnosis requiring a molecular diagnosis or the presence of at least five of the following: fever, splenomegaly, cytopenia involving two or more cell lineages, hypertriglyceridemia and/or hypofibrinogenemia, hemophagocytosis in the bone marrow, spleen or lymph nodes with no evidence of malignancy, low or no NK cell activity, elevated ferritin, or elevated soluble IL-2 receptor¹. These criteria have been utilized to …

Opioid-Induced Secondary Adrenal Insufficiency In A Young Patient With Chronic Pancreatitis, Amry Majeed, Nicholas Noverati, Md, Christine Kurian, Md, Shirin Jaggi, Do

The Medicine Forum

Opioid misuse is a national public health crisis that has contributed to a decrease in life expectancy in men and women in the US. From 1999-2017, the rate of drug overdose deaths tripled, largely due to the rise in opioid use¹. Despite widespread misuse, chronic opioid therapy still has a role in the clinical setting. Adverse effects include dizziness, nausea, vomiting, respiratory depression, and dependence². While these side effects are well- documented, other effects of opioids are less explored, including opioidinduced adrenal insufficiency^3,7. The typical presentation of adrenal insufficiency from any cause can include …

A Severe Case Of Hypertriglyceridemia In Alcoholic Hepatitis, Jillian Cooper

The Medicine Forum

A 53-year-old man with a past medical history of hypertension and alcohol abuse with prior episodes of alcoholic hepatitis presented to the hospital with generalized weakness. He was in his usual state of health until 4 days prior to admission when he began to develop generalized weakness, nausea, and vomiting. Notably, he had had multiple prior admissions with similar symptoms attributed to hyponatremia. He endorsed drinking a few beers daily but denied any other drug use. Review of systems was otherwise negative.

New-Onset Rheumatologic Disease In An Elderly Patient Initially Presenting As Worsening Sequelae Of Longstanding Peripheral Vascular Disease, Peri Levey, Lauren Lally, Md, Xuejun Alice Wang, Md, Vivek Batra, Md

The Medicine Forum

Systemic lupus erythematosus (SLE) is an autoimmune disease that is believed to activate and attack nuclear antigens in genetically susceptible individuals after exposure to environmental factors causing cell damage.^1,2 Although it is most common in females of child-bearing age, initial presentation is not strictly limited to this population, as onset over the age of 50 years is reported in 3-18% of cases.² The common manifestations of SLE affect nearly every system of the body and may include arthralgia, myalgia, fever, rash, hepatosplenomegaly, lymphadenopathy, pleuritis, glomerulonephritis, pericarditis and neuropsychiatric manifestations.^1-3 Common laboratory findings in SLE with varying degrees …

Carbamazepine Induced Bullous Pemphigoid In A 49 Year Old Male, Brendan Gleason, Lisa Matonti, Pharmd, Bcps, Xuejun Alice Wang, Md, Bahar Dasgeb, Md

The Medicine Forum

Bullous pemphigoid is an autoimmune blistering condition mediated by autoantibodies1. It is categorized as an uncommon disorder2-4, with an estimated incidence of 2.4-21.7 cases per million2-6 but carries significant morbidity and mortality, warranting clinical awareness and investigation7,8. A number of medications have been implicated in the development of bullous pemphigoid including loop diuretics, ace inhibitors, and anti-epileptic drugs.

This is a case report of carbamazepine-induced bullous pemphigoid in a 49-year-old male after taking the medication for almost 30 years. Diagnosis of bullous pemphigoid was based on biopsy histology and immunofluorescence, as well as the presence of BP 180 antibody. Clinical …

A Case Of Native Hip Pseudomonas Aeruginosa Septic Arthritis Caused By Vesico-Acetabular Fistula, Tudor Sturzoiu, Md

The Medicine Forum

A 61-year-old man with a past medical history significant for metastatic rectal cancer treated with local resection, chemotherapy, and radiation complicated by vesicocutaneous fistula presented with subacute ambulatory dysfunction secondary to right hip pain. Imaging studies were consistent with a right hip effusion, and fluoroscopyguided hip aspiration revealed septic arthritis caused by Pseudomonas aeruginosa. Resistance patterns identified this strain of Pseudomonas to be the same one that caused pyelonephritis that was treated during the same hospitalization. Although further diagnostic imaging was not pursued, the presentation was most consistent with vesico-acetabular fistula causing native hip septic arthritis. This is a very …

Severely Impaired Gastric Emptying In The Setting Of An Extensive Malignancy History: A Case Of Paraneoplastic Gastroparesis, Gregory Habig, Md, Justin Robbins, Md

The Medicine Forum

Gastroparesis is a disorder of the stomach involving a delay in the emptying of gastric contents that typically presents with nausea, vomiting, early satiety, and weight loss. Though commonly associated with diabetes or as a complication of surgical procedures, etiologies stemming from paraneoplastic processes are important to consider despite often being overlooked. The case presented here describes a patient with a significant malignancy history and evidence of severely impaired gastric emptying concerning for paraneoplastic gastroparesis and highlights the evaluation, diagnosis, and management of the condition.

Acute Mitral Regurgitation Presenting With Right Upper Lobe Opacification, John Wallis, Md, Mark Decaro, Md

The Medicine Forum

We describe a rare entity in which acute mitral regurgitation causes asymmetric findings on chest radiograph. The patient presented with rapid-onset respiratory failure from flash pulmonary edema. She had unilateral infiltrates on chest radiograph, which evoked infectious etiology. However, we identified a flail mitral valve leaflet, for which the patient received an emergent mitral valve replacement. Fortunately, she made a full recovery. We discuss the mechanism of the asymmetric chest radiograph findings, which we were able to confirm using a transesophageal echocardiogram.

Effusive-Constrictive Pericarditis Due To Poorly Differentiated Carcinoma Of The Mediastinum, John Wallis, Md, Naman Upadhyay, Md, Fred Karaisz, Md, Mark Decaro, Md, René Alvarez, Md

The Medicine Forum

A 33-year-old male developed subacute effusiveconstrictive pericarditis with recurrent pleural effusions and mediastinal lymphadenopathy. He was found to have poorly differentiated carcinoma of the mediastinum that led to constrictive physiology not amenable to medical or surgical management, ultimately requiring hospice. This case was remarkable for its rare etiology and presentation.

“Covid Nails”, Gillian Naro, Md, Med, Gregory Kane, Md, Macp

The Medicine Forum

A 73-year-old female presented to an outpatient clinic for management of her COPD. Two months prior, she had experienced a febrile illness with a cough and subsequently tested positive for the SARS-CoV-2 virus, requiring hospitalization and intubation in an intensive care unit. Physical examination revealed transverse white lines extending across the nail plate about 5mm from the base of the nail on multiple nails. These findings were consistent with Beau Lines, a sign of acute systemic inflammation resulting in the sudden interruption of nail keratin synthesis. The location of the line relative to the growth of the nail can reflect …

From The Editors, Xuejun Alice Wang, Md, Nivethietha Maniam, Md, Hillary Landon, Md, Jillian Cooper, Md, Joseph Grogg, Md, Akanksha Arya, Md

The Medicine Forum

It is our honor to present the product of 22 years of resident-run tradition – the 2020-2021 annual edition of The Medicine Forum. In the world of Jefferson traditions, ours is a small one. There is no regalia, pomp and circumstance, or any such fanfare in this marking of the year’s close. Rather than the celebratory release of those other springtime occasions, this publication is a representation of the yearlong dedication and hard work of our residents and fellows in their academic pursuits.

We at The Medicine Forum know that producing scholarly work even during what would constitute a …

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

The Medicine Forum

The past year has been the most trying many of us have faced as physicians. Despite the challenges, I leave this academic year with hope and gratitude for the future of medicine. The exceptional altruism and dedication portrayed by our colleagues both within and outside the Department of Medicine made this year possible. I've been overwhelmed by the collegiality and dedication of all our colleagues, but specifically our residents. Despite the challenges, they have risen to every encounter with grace and poise working alongside faculty to support the Jefferson mission: We Improve Lives. In the midst of the chaos, our …

Table Of Contents: The Medicine Forum Volume 22, 2020-2021

The Medicine Forum

Table of Contents: The Medicine Forum Volume 22, 2020-2021

The Medicine Forum: Volume 22

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 22, 2020-2021

TABLE OF CONTENTS

Clinical Images

Case Reports

• Cardiology
• Gastroenterology and Hepatology
• General Medicine
• Hematology and Oncology
• Pulmonary Medicine

Resident Reflection

A Randomized Phase 2 Study Of Vt-1161 For The Treatment Of Acute Vulvovaginal Candidiasis, Stephen R Brand, Jack D Sobel, Paul Nyirjesy, Mahmoud A Ghannoum, Robert J Schotzinger, Thorsten P Degenhardt

Department of Obstetrics and Gynecology Faculty Papers

Background: Acute vulvovaginal candidiasis (VVC) is common among women, but current azole antifungal treatments are often associated with safety and resistance issues. VT-1161 (oteseconazole) is an oral agent with increased selectivity for fungal CYP51. In this phase 2 clinical study, we evaluated the efficacy and safety of VT-1161 vs fluconazole in participants with moderate to severe acute VVC.

Methods: Participants presenting with an acute episode of VVC (n = 55) were randomized to receive VT-1161 300 mg once daily (q.d.) for 3 days, 600 mg q.d. for 3 days, or 600 mg twice daily (b.i.d.) for 3 days or to …

Medical Outcomes, Quality Of Life, And Family Perceptions For Outpatient Vs Inpatient Neutropenia Management After Chemotherapy For Pediatric Acute Myeloid Leukemia, Kelly D Getz, Julia E Szymczak, Yimei Li, Rachel Madding, Yuan-Shung V Huang, Catherine Aftandilian, Staci D Arnold, Kira O Bona, Emi Caywood, Anderson B Collier, M Monica Gramatges, Meret Henry, Craig Lotterman, Kelly Maloney, Amir Mian, Rajen Mody, Elaine Morgan, Elizabeth A Raetz, Jeffrey Rubnitz, Anupam Verma, Naomi Winick, Jennifer J Wilkes, Jennifer C Yu, Brian T Fisher, Richard Aplenc

Department of Medicine Faculty Papers

Importance: Pediatric acute myeloid leukemia (AML) requires multiple courses of intensive chemotherapy that result in neutropenia, with significant risk for infectious complications. Supportive care guidelines recommend hospitalization until neutrophil recovery. However, there are little data to support inpatient over outpatient management.

Objective: To evaluate outpatient vs inpatient neutropenia management for pediatric AML.

Design, setting, and participants: This cohort study used qualitative and quantitative methods to compare medical outcomes, patient health-related quality of life (HRQOL), and patient and family perceptions between outpatient and inpatient neutropenia management. The study included patients from 17 US pediatric hospitals with frontline chemotherapy start dates ranging …

Engaging Patients With Late-Stage Non-Small Cell Lung Cancer In Shared Decision Making About Treatment., Ronald E. Myers, Phd, Dsw, Shailesh M Advani, Pamela Myers, Preethi Selvan Mph Student, Gregory Garber, Msw, Lcsw, Brooke Worster, Md, Neal Flomenberg, Md, Andrew Chapman, Do, Ralph Zinner

Department of Medical Oncology Faculty Papers

Few treatment decision support interventions (DSIs) are available to engage patients diagnosed with late-stage non-small cell lung cancer (NSCLC) in treatment shared decision making (SDM). We designed a novel DSI that includes care plan cards and a companion patient preference clarification tool to assist in shared decision making. The cards answer common patient questions about treatment options (chemotherapy, chemotherapy plus immunotherapy, targeted therapy, immunotherapy, clinical trial participation, and supportive care). The form elicits patient treatment preference. We then conducted interviews with clinicians and patients to obtain feedback on the DSI. We also trained oncology nurse educators to implement the prototype. …

Prognostic Implications Of Epidermal And Platelet-Derived Growth Factor Receptor Alterations In 2 Cohorts Of Idh, Iyad Alnahhas, Appaji Rayi, Maria Del Pilar Guillermo Prieto Eibl, Shirley Ong, Pierre Giglio, Vinay Puduvalli

Department of Neurology Faculty Papers

Background: Glioblastoma remains a deadly brain cancer with dismal prognosis. Genetic alterations, including IDH mutations, 1p19q co-deletion status and MGMT promoter methylation have been proven to be prognostic and predictive to response to treatment in gliomas. In this manuscript, we aimed to correlate other mutations and genetic alterations with various clinical endpoints in patients with IDH-wild-type (IDHwt) glioblastoma.

Methods: We compiled a comprehensive clinically annotated database of IDHwt GBM patients treated at the Ohio State University Wexner Medical Center for whom we had mutational data through a CLIA-certified genomic laboratory. We then added data that is publicly available from Memorial …

Bassini Inguinal Hernia Repair: Obsolete Or Still A Viable Surgical Option? A Single Center Cohort Study, Wayne Tse, William Johns, James Maher, Jeannie Rivers, Thomas Miller

Department of Orthopaedic Surgery Faculty Papers

Background: Most inguinal hernias are presently repaired using some type of mesh technique. This mesh can be placed through an inguinal incision or positioned through a laparoscopic approach. Either way, results have been impressive including a low recurrence rate, minimal pain and a rapid return to work and normal activity compared to tissue based approaches. Notwithstanding these results, there is still a subset of patients who, for various reasons, are strongly opposed to having a mesh repair. This study summarizes our 13 year experience with such patients and why the Bassini hernia repair is a viable surgical option in these …

Conditional Analysis On New Tumor Formation With Solitary Unilateral Retinoblastoma In 482 Consecutive Patients, Carol L Shields, Philip W Dockery, Megan Ruben, Madalyne A Sunday, Martin Calotti, Antonio Yaghy

Wills Eye Hospital Papers

PURPOSE: The objective of the study was to understand dynamic risk (conditional analysis based on patient age) for new tumor development in patients with solitary unilateral retinoblastoma.

METHODS: This was a retrospective analysis.

RESULTS: Of 482 patients with solitary unilateral retinoblastoma, 55 new tumors developed in 20 patients (4%). Comparison (new tumor vs. no new tumor development) revealed those with new tumor demonstrated younger mean age at presentation (10 vs. 36 months,

CONCLUSION: Children (≤24 months) with solitary unilateral retinoblastoma showed decreasing risk for new tumors up to 24 months of life. Later onset of new tumor was more likely …

Real-World Assessment Of Asthma Specialist Visits Among U.S. Patients With Severe Asthma., Jessica F Most, Christopher S Ambrose, Yen Chung, James L Kreindler, Aimee Near, Stephen Brunton, Yao Cao, Huan Huang, Xiaohui Zhao

Division of Pulmonary, Allergy, and Critical Care Medicine Faculty Papers

BACKGROUND: U.S. guidelines recommend that patients with severe asthma be referred to specialists (allergists/immunologists or pulmonologists) for systematic assessment or comanagement; however, contemporary, real-world data on the frequency and impact of specialist care among U.S. severe asthma patients are lacking.

OBJECTIVES: To quantify the frequency of asthma specialist visits among U.S. patients with severe asthma, identify patient demographic and clinical characteristics associated with specialist visits and describe health outcomes following specialist care.

METHODS: Severe asthma patients aged 6 years or older were identified between January 1, 2015, and December 31, 2017, in the IQVIA PharMetrics® Plus database of commercially insured …

Multicenter, Double-Blind, Placebo-Controlled Trial Of Seviprotimut-L Polyvalent Melanoma Vaccine In Patients With Post-Resection Melanoma At High Risk Of Recurrence, Craig L Slingluff, Karl D Lewis, Robert Andtbacka, John Hyngstrom, Mohammed Milhem, Svetomir N Markovic, Tawnya Bowles, Omid Hamid, Leonel Hernandez-Aya, Joel Claveau, Sekwon Jang, Prejesh Philips, Shernan G Holtan, Montaser F Shaheen, Brendan Curti, William Schmidt, Marcus O Butler, Juan Paramo, Jose Lutzky, Arvinda Padmanabhan, Sajeve Thomas, Daniel Milton, Andrew Pecora, Takami Sato, Eddy Hsueh, Suprith Badarinath, John Keech, Sujith Kalmadi, Pallavi Kumar, Robert Weber, Edward Levine, Adam Berger, Anna Bar, J Thaddeus Beck, Jeffrey B Travers, Catalin Mihalcioiu, Brian Gastman, Peter Beitsch, Suthee Rapisuwon, John Glaspy, Edward C Mccarron, Vinay Gupta, Deepti Behl, Brent Blumenstein, Joanna J Peterkin

Department of Medical Oncology Faculty Papers

Background: Most patients with advanced melanomas relapse after checkpoint blockade therapy. Thus, immunotherapies are needed that can be applied safely early, in the adjuvant setting. Seviprotimut-L is a vaccine containing human melanoma antigens, plus alum. To assess the efficacy of seviprotimut-L, the Melanoma Antigen Vaccine Immunotherapy Study (MAVIS) was initiated as a three-part multicenter, double-blind, placebo-controlled phase III trial. Results from part B1 are reported here.

Methods: Patients with AJCC V.7 stage IIB-III cutaneous melanoma after resection were randomized 2:1, with stage stratification (IIB/C, IIIA, IIIB/C), to seviprotimut-L 40 mcg or placebo. Recurrence-free survival (RFS) was the primary endpoint. For …

Bone Mineral Density Changes Associated With Pregnancy, Lactation, And Medical Treatments In Premenopausal Women And Effects Later In Life., Nelson B Watts, Neil Binkley, Charlotte D Owens, Ayman Al-Hendy, Elizabeth E Puscheck, Mohamad Shebley, William Schlaff, Md, James A Simon

Department of Obstetrics and Gynecology Faculty Papers

Bone mineral density (BMD) changes during the life span, increasing rapidly during adolescence, plateauing in the third decade of life, and subsequently entering a phase of age-related decline. In women, menopause leads to accelerated bone loss and an increase in fracture risk. Between peak bone mass attainment and menopause, BMD is generally stable and the risk of fracture is typically low. This time period is marked by life events such as pregnancy and lactation, which transiently decrease BMD, yet their long-term effects on fracture risk are less certain. BMD may also be altered by exposure to medications that affect bone …

Anti-Sars-Cov-2 Monoclonal Antibodies For Early Covid-19: A Real-World Experience, Katherine Belden, Md, Bryan Hess, Md, Caroline Brugger, Crnp, Rachel Carr, Pa, Todd Braun, Md, Joseph Derose, Do, John Zurlo, Md

Division of Infectious Diseases and Environmental Medicine Posters

Higher rates of COVID-19 related hospitalization and death are reported in patients with underlying health conditions and advanced age as compared to the general population.While polyclonal immunity generated by vaccines has demonstrated protection against severe disease, vaccine response takes time and may be inadequate in some high-risk populations.1 Treatment with anti-SARS-CoV-2 neutralizing monoclonal antibodies affords prompt, passive humoral immunity and has been shown in randomized, controlled trials to reduce rates of hospitalization and death from COVID-19 in high-risk ambulatory patients treated early in the course of infection.2,3 The U.S. Food and Drug Administration (FDA) has issued Emergency Use Authorization for …