Internal Medicine Commons^™

Case Report: Uncontrolled Anasarca: Capillary Leak Syndrome, Ankita Mehta, Md, Mansi Shah, Md

The Medicine Forum

INTRODUCTION

Capillary leak syndrome (CLS) is a rare clinical disease that causes edema, hypoproteinemia, episodic hypotension, dyspnea, hyponatremia, and weight gain that can be life threatening1. Although the underlying pathology is currently unknown, CLS is thought to be secondary to a systemic process associated with hyperpermeability of the body's microcirculation, resulting from a diffuse and severe disruption of the endothelium and causing generalized edema and often acute respiratory distress2.

Limitations Of The Perioperative Cardiovascular Evaluation For Assessing Coronary Artery Disease: A Case Report, Rady Ho, Md, Mitul Kanzaria, Md, Paul Walinsky, Md

The Medicine Forum

INTRODUCTION

The American College of Cardiology (ACC) and the American Heart Association (AHA) publ ished pre-operative risk stratification guidelines in 2014. These guidelines have routinely been used by physicians to pre-operatively risk stratify patients. In this case report, a patient was found to have multi-vessel coronary artery disease post-operatively in the setting of unremarkable cardiac work-up preoperatively. This case highlights a limitation of the 2014 ACC/AHA guidelines.

Case Report: Diagnosis Of Dual-Biopsy Negative Severe Cardiac Amyloidosis, Kristin Lohr, Md, Eric Kasprowicz, Md

The Medicine Forum

INTRODUCTION

Amyloidosis is a rare disorder that involves the deposition of misfolded protein in extracellular tissue. Disease manifestations vary depending on the affected organs. Areas most often involved include the kidneys, gastrointestinal tract, heart, nervous system, and musculoskeletal system. The most common type is AL amyloidosis, in which plasma cells produce an abundance of a monoclonal proteins that affect numerous organ systems. A second variety, AA amyloidosis, is associated with inflammatory diseases such as rheumatoid arthritis and inflammatory bowel disease. Finally, a heritable version of amyloidosis mediated by mutations in the transthyretin protein (TTR) has a predilection for deposition in …

Coronary Subclavian Steal Syndrome, Rady Ho, Md, Jonathan A. Dunn, Md

The Medicine Forum

INTRODUCTION

Coronary subclavian steal (CSS) syndrome is a rare complication of coronary artery bypass graft surgery (CABG) involving the left internal mammary artery (LIMA) graft to the left anterior descending (LAD) artery. It results from stenosis of the left subclavian artery proximal to the LIMA, which compromises myocardial blood flow. The incidence of CSS syndrome is between 0.1-3.4% in the United States.1 Most cases occur as a result of long-standing subclavian stenosis due to progres-sion of the stenosis following CABG. We report a case of CSS syndrome, which presented as a non-ST elevation myocardial infarction (NSTEMI).

Allergic Inflammatory Mediated Coronary Artery Vasospasm: A Case Report Of Kounis Syndrome, Jonathan Hullman, Ms4, Jaehee Kim, Md, Gregary D. Marhefka, Md, Facc, Facp

The Medicine Forum

INTRODUCTION

Kounis syndrome is an acute coronary syndrome occurring secondary to an anaphylactic reaction. A wide variety of triggers such as drugs and environmental exposures have been described for the so-called allergic myocardial infarction. The pathophysiology of Kounis syndrome is thought to be due to the release of inflammatory mediators such as histamine and cytokines by mast cells and eosinophils resulting in either coronary vasospasm, myocardial infarction or stent thrombosis.

Squamous Cell Carcinoma Metastatic To The Heart Mimicking St-Elevation Myocardial Infarction, Jason Chen, Md, Colin Craft, Md, Andrew W. Panakos, Md, Gregary D. Marhefka, Md, Facc, Facp

The Medicine Forum

INTRODUCTION

Heart disease remains the leading cause of mortality in the United States, accounting for about one quarter of all deaths in 20131. Acute ischemic heart disease is a major subpopulation of this group, and typically presents with characteristic electrocardiographic (EKG) changes. The most concerning of these findings are ST-elevations, as ST Elevation Myocardial Infarction (STEMI) typically indicates the need for emergent reperfusion therapy because 30-day mortality of untreated STEMI is approximately 10-15% versus 5% in treated cases2. As a result, clinicians are taught to recognize the symptoms and signs of myocardial ischemia and STEMI in order to achieve timely …

Table Of Contents

The Medicine Forum

Table of Contents The Medicine Forum

The Journal of Thomas Jefferson University Hospital

Department of Internal Medicine

Volume 17, 2015-2016

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

The Medicine Forum

I am honored to be writing my first message for the Forum as the Residency Program Director. This journal, now in its 17th edition, continues to exemplify the dedication, inquisitiveness, passion and talent of our Internal Medicine residents.

It has been an exciting year of changes at Jefferson, which began with Dr. Gregory Kane being appointed Chair of the Department of Medicine. As a new Program Director I could not have asked for a leader who is more dedicated to the educational needs of the residents, and has such a keen understanding of the ever changing residency training environment. This …

The Carefirst Patient-Centered Medical Home Program: Cost And Utilization Effects In Its First Three Years, Alison Cuellar, Lorens A. Helmchen, Gilbert Gimm, Jay Want, Sriteja Burla, Bradley Kells, Iwona Kicinger, Len M. Nichols

Health Policy and Management Faculty Publications

Background

Enhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.

Objective

To test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.

Design

We compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized …

Epidemiology And Outcomes Of Out-Of-Hospital Cardiac Arrest In A Developing Country-A Multicenter Cohort Study., Minaz Mawani, Muhammad Masood Kadir, Iqbal Azam Syed, Amber Mehmood, Bryan Mcnally, Kent Stevens,, R. Nuruddin, Mohammad Ishaq, J. Razzak

Section of Cardiology

Background

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death and disability worldwide. Overall survival after an OHCA has been reported to be poor and limited studies have been conducted in developing countries. We aimed to investigate the rates of survival from OHCA and explore components of the chain of survival in a developing country.

Methods

We conducted a multicenter prospective cohort study in the emergency departments (ED) of five major public and private sector hospitals of Karachi, Pakistan from January 2013 to April 2013. Twenty-four hour data collection was performed by trained data collectors, using a …

Precision Medicine Informatics, Lewis J Frey, Elmer V Bernstam, Joshua C Denny

Faculty, Staff and Student Publications

No abstract provided.

Hiperimunoglobulin E, Atopi Dan Hiv, Evy Yunihastuti

Jurnal Penyakit Dalam Indonesia

No abstract provided.

Five-Year Survival In Patients With 3-Vessels Coronary Arterydisease And Diabetes Mellitus Undergoing Coronary Arterybypass Graft, Coronary Percutaneus Intervention, Or Receivingpharmacological Therapy In Cipto Mangunkusumo Hospital, Andreas Arie Setiawan, Marulam Panggabean, M Yamin, Siti Setiati

Jurnal Penyakit Dalam Indonesia

Introduction. Revascularization results in patients with diabetes mellitus (DM) and coronary artery disease involving 3 vessels (CAD 3VD) undergo coronary artery bypass surgery (CABG) are better compared with those undergo percutaneous coronary intervention (PCI) or medical therapy. However, CABG is not always done despite being recommended in accordance with Syntax Score because some patients unwilling to undergo CABG or PCI . This trial determined whether the choice of revascularization affect 5-years survival. Methods. This was a retrospective cohort study with survival analysis to examine the 5-years survival rate of CAD 3VD DM patients undergoing CABG, PCI, or medical therapy. The …

Comparison Of Chemotherapy Regiments Between Cisplatinetoposide And Cisplatin-Docetaxel On 2-Year And Progressionfree Survival In Late-Stage Non-Small Cell Lung Cancer Patients, Salman Paris Harahap, Noorwati Sutandyo, Cleopas Martin Rumende, Hamzah Shatri

Jurnal Penyakit Dalam Indonesia

Introduction. Chemotherapy is one of therapy choices for the advanced Non-Small Cell Lung Cancer (NSCLC). The success in therapy is measured with the 1-year survival, 2-year survival and the Progression Free Survival (PFS). The success is influenced by many factors: resistant to the citostatic, dosage, administer intensity, chemotherapy regiment, type histology, stage, performance status, comorbidity and social economic. In Indonesia, funding and chemotherapy regiment become the challenge for the success of therapy. Methods. The study used the Retrospective Cohort study with survival analysis. The Patients included in this study were the advanced NSC Lung Cancer (At least Stadium IIIa) who …

The Correlation Of Depression Level With Tumor Necrosis Factoralpha (Tnf-Α) Concentration In Uncontrolled Bronchial Asthmapatients, Muhammad Ali Apriansyah, Rudi Putranto, Eddy Mart Salim, Hamzah Shatri

Jurnal Penyakit Dalam Indonesia

Introduction. Depression occurs at high rates in people with chronic diseases, including bronchial asthma, with the prevalence of depression approaches 50% in tertiary care asthma clinic. Tumor necrosis factor alpha (TNF-α) is known to play a critical role in the pathogenic mechanism of a number of chronic inflammatory disease, including bronchial asthma and depression. There has not been any research data on the subject in Indonesia. The objective of this study was to investigate the correlation between depressive level and TNF-α level in uncontrolled bronchial asthma. Methods. This was a cross sectional study conducted in 40 patients with uncontrolled bronchial …

The Role Of Duke Treadmill Score As A Predictor Of Coronaryartery Disease In Patients With Positive Treadmill Test Results, Muhammad Ikhsan, Sally Aman Nasution, Ika Prasetya Wijaya, Cleopas Martin Rumende

Jurnal Penyakit Dalam Indonesia

Introduction. Coronary Artery Disease (CAD) is one of the disease entity that leading cause of morbidity and mortality in worldwide. Treadmill test is part of the diagnostic modality which readily available to assess possibility of narrowing coronary artery and guiding us whether we need for the further investigation. Despite of that, treadmill test has limitation in diagnostic accuracy. Duke Treadmill Score (DTS) was also tested as a diagnostic score, and shown to predict significant CAD better than the ST-segment response alone. Methods. This is a cross-sectional study performed in adult patients with stable CAD that underwent treadmill test and coronary …

Diagnostic Value And The Role Of Inferior Vena Cava Diametercollapsibility Index To Evaluate Dry Weight In Hemodialysispatients, Muhammad Artisto Adi Yussac, Dharmeizar Dharmeizar, Murdani Abdullah, Dono Antono, Muhadi Muhadi

Jurnal Penyakit Dalam Indonesia

Introduction. In daily clinical practice, fluid status in Hemodialysis (HD) patients is well correlated with dry weight calculation. Dry weight calculation is commonly practiced by clinical observation, which is not accurate. Because of these, few methods has been suggested to calculate the dry weight non-invasively. Bioelectrical Impedance Analysis (BIA) is widely available in overseas but not readily available in all dialysis center in Indonesia, while inferior vena cava diameter is a relatively inexpensive method, and readily available in all dialysis center because it can be performed with ultrasonography (USG) instrument. Methods. A cross-sectional study was performed in a group of …

Prevalence And Predictors Of Atopy In Hiv/Aids Patients, Jimmy Tesiman, Heru Sundaru, Teguh H. Karjadi, Siti Setiati

Jurnal Penyakit Dalam Indonesia

Introduction. HIV infection attacks the center of immune control system resulting opportunistic infection, malignancy and death. Immune system dysregulation plays the central role in the progression of the disease. Some studies reported that HIV-infected patient prone to have allergic disease such as sinusitis, asthma and atopic dermatitis. Elevated serum immunoglobulin E (IgE) and increased prevalence of atopy had also been reported in HIV-infected patient. Methods. A cross sectional study was performed in 92 HIV-infected persons and 90 non-HIV persons. Atopy diagnosis was based on immediate hypersensitivity to six common aeroallergen using skin prick test. CD4 cell count, total serum immunoglobulin …

Hiv In Geriatrics, Nur Ainun, Evy Yunihastuti, Arya Govinda Roosheroe

Jurnal Penyakit Dalam Indonesia

Through both prolonged survival and late acquisition of the disease, numbers of older adults with HIV are climbing. Along with ageing process is an accumulation of HIV-associated non-AIDS related comorbidities, creating a complex patient group affected by multi-morbidity along with polypharmacy, functional decline and social issues.

Hyper-Ige Syndrome With Bullous Pemphigoid And Esophagealstricture, Laras Budiyani, Adeputri Tanesha Idayu, Ika Prasetya Wijaya, Alvina Widhani

Jurnal Penyakit Dalam Indonesia

Laras

Expansion Of Myeloid-Derived Suppressor Cells Promotes Differentiation Of Regulatory T Cells In Hiv-1+ Individuals, Ling Wang, Juan Zhao, Junping P. Ren, Xiao Y. Wu, Zheng D. Morrison, Mohamed A. El Gazzar, Shunbin Ning, Jonathan P. Moorman, Zhi Q. Yao

ETSU Faculty Works

Objective: Regulatory T cells (Tregs) contribute to HIV-1 disease progression by impairing antiviral immunity; however, the precise mechanisms responsible for the development of Tregs in the setting of HIV-1 infection are incompletely understood.

Design: In this study, we provide evidence that HIV-induced expansion of monocytic myeloid-derived suppressor cells (M-MDSCs) promote the differentiation of Foxp3+ Tregs.

Methods: We measured MDSC induction and cytokine expression by flow cytometry and analyzed their functions by coculturing experiments.

Results: We observed a dramatic increase in M-MDSC frequencies in the peripheral blood of HIV-1 seropositive (HIV-1+) individuals, even in those on antiretroviral therapy with undetectable viremia, …

Severity Of Lower Urinary Tract Symptoms Among Middle Aged And Elderly Nigerian Men: Impact On Quality Of Life, Patrick Temi Adegun, Philip Adebayo, Peter Olufemi Areo

Internal Medicine, East Africa

Objectives. To compare the severity of LUTS among middle aged and elderly Nigerian men and determine the influence of LUTS severity on QoL.

Methods. This cross-sectional study was conducted among new patients presenting with LUTS attending Urology clinic between 2011 and 2015. Assessment of symptoms was based on IPSS and bother score completed by the eligible subjects on the same day of their clinic visits.

Results. Four hundred patients were studied comprising 229 middle aged and 171 elderly men. Interquartile range (IQR) of IPSS scores for men < 65 years and those ≥65 years was 14.0 (16.0) and 19 (15.0), respectively (p < 0.001). Mild LUTS was significantly associated with best, good, and poor quality of life while moderate LUTS was associated with poor QoL. Severe LUTS was significantly associated with all the categories of QoL (Best-Worst). Among the cohort of subjects with poor QoL, elderly patients had a significantly higher median IPSS score (p < 0.05).

Conclusions. There is no level of severity of LUTS in which patients’ QoL …

Increasing Hiv-1 Pretreatment Drug Resistance Among Antiretroviral-Naïve Adults Initiating Treatment Between 2006 And 2014 In Nairobi, Kenya, Michael Chung, Silverman Rachel, Beck Ingrid, Yatich Nelly, Dross Sandra, Jennifer Mckernan-Mullin, Stephen Bii, Kenneth Tapia, Joshua Stern, Chohan Bhavna, Samah R. Sakr, James N. Kiarie

Internal Medicine, East Africa

Antiretroviral-naïve adults initiating antiretroviral therapy in Nairobi, Kenya were tested for HIV-1 drug resistance at codons K103N, Y181C, G190A, M184V, and K65R using an oligonucleotide ligation assay. Prevalence of pretreatment drug resistance increased from 3.89% in 2006 to 10.93% in 2014 (P < 0.001), and 95% of those with resistance had at least one nonnucleoside reverse transcriptase inhibitor mutation. Resistance to tenofovir (K65R) was found in 2014 but not in 2006.

Barriers To Anticoagulation In Atrial Fibrillation Among Cardiologists, Internists And Family Physicians, Jad Al Danaf, Md, Mph, Mitul Kanzaria, Md, John U. Doherty, Md

House Staff Quality Improvement and Patient Safety Conference (2016-2019)

Current Performance:

The rates of AC in patients 18 years or older who visited general internists & family physicians not seen by cardiologists from 4/30/2013 to 4/30/2015, cardiologists from 11/29/2012 to 11/29/2014 and all 3 specialties from 1/30/2014 to 1/30/2016 were derived from the EHR.

A 12-question survey was shared using RedCap with these physicians to examine potential reasons for not prescribing AC.

Multiorgan Chronic Inflammatory Hepatobiliary Pancreatic Murine Model Deficient In Tumor Necrosis Factor Receptors 1 And 2, Helieh S. Oz

Physiology Faculty Publications

AIM: To provoke persistent/chronic multiorgan inflammatory response and to contribute to stones formation followed by fibrosis in hepatobiliary and pancreatic tissues.

METHODS: Tumor necrosis factor receptors 1 and 2 (TNFR1/R2) deficient mice reared in-house were given dibutyltin dichloride (DBTC) twice within 10 d by oral gavage delivery. Sham control animals received vehicle treatment and naïve animals remained untreated throughout the study. Animals were monitored daily for symptoms of pain and discomfort. The abdominal and hindpaw hypersensitivity were assessed with von Frey microfilaments. Exploratory behaviors were recorded at the baseline, after initiation of treatment, and before study termination. Histopathological …

Does Myocardial Necrosis Occur In Rhabdomyolysis?, Gabriel M Aisenberg, Herbert L Fred

Faculty, Staff and Student Publications

No abstract provided.

Carotid Ultrasound Is Not Helpful In Simple Syncope, Nicholus Yee M.D., Shilin Patel M.D., Raymond Gong

Clinical Research in Practice: The Journal of Team Hippocrates

A critical appraisal and clinical application of Scott JW, Schwartz AL, Gates JD, Gerhard-Herman M, Havens JM. Choosing wisely for syncope: low-value carotid ultrasound use. J Am Heart Assoc. 2014 Aug 13;3(4). pii: e001063. doi: 10.1161/JAHA.114.001063

Factors That Influence Advance Directives Completion Amongst Terminally Ill Patients At Akuhn, Stephen Omondi Otieno

Master of Medicine in Internal Medicine

Background: An advance directive is a written or verbal document that legally stipulates a person’s health care preference while they are competent to make decisions for themselves, and which is then used to guide decisions on life-sustaining treatment in the event that they become incapacitated. Advance directives can take one of four forms: a living will, a limitation of care document, a do-not-resuscitate order, and an appointment of a surrogate by durable power of attorney. The completion rate of advance directives varies from region to region, and it is influenced by different patient, caregiver, legal, institutional, cultural, and religious factors. …

Outcomes In Patients With Acute Coronary Syndromes At The Aga Khan University Hospital, Nairobi, Mohamed Hasham Varwani

Master of Medicine in Internal Medicine

Background: As the prevalence of cardiovascular diseases in Sub-Saharan Africa rises, coronary artery disease, with its acute presentations, is being increasingly recognized in Kenyans and treated at tertiary level hospitals. It is just over a decade since the introduction and wide availability of modern cardiology services, including interventional cardiology in Kenya. Following an acute coronary syndrome (ACS), patients remain at high risk of death and other adverse events such as heart failure, recurrent myocardial infarction, stroke, and bleeding. Local and regional data on long-term outcomes following ACS are lacking. These data are important to clinicians for prognostication and to health …

The Association Between Asymptomatic And Mild Neurocognitive Impairment And Adherence To Antiretroviral Therapy Amongst People Living With Hiv, Violet Maloba Awori

Master of Medicine in Internal Medicine

Background: HIV disease is associated with neurocognitive impairment which is one of the neurological complications of the viral infection. The spectrum of HIV Associated neurocognitive impairment has significantly changed since the advent of ART. The inclusion of the asymptomatic but cognitively impaired population of patients has changed the dynamics of this population, and requires further research to identify the impact it has on the progression of the disease as well as on any other aspects. Poor adherence to ART is one of the main causes of treatment failure and studies done previously point towards the milder forms of Neurocognitive Impairment …