Internal Medicine Commons^™

Looking For The Unseen: Application Of Wood’S Lamp In The Ambulatory Clinic, Alexandros Grivas, Md, John Caruso, Md

The Medicine Forum

A 56-year-old female patient with a personal medical history of class III obesity and uncontrolled DM presented to the ambulatory clinic with a pruritic rash behind her knees. The rash was of 4 weeks duration and did not improve with topical application of nystatin powder. Examination revealed an erythematous patch in the intertriginous area behind the knees bilaterally, associated with mild desquamation and clear demarcation from the normal skin. No satellite lesions were noticed. (figure 1A) The patient was evaluated for an intertriginous skin rash. The differential diagnosis included intertrigo, fungal infection, psoriasis, and lichen planus. Wood’s lamp examination was …

Minocycline-Induced Hyperpigmentation In A Patient With Multiple Causes Of Skin Discoloration, Jeffrey White, Md, Amman Bhasin, Md, Gregary Marhefka, Md

The Medicine Forum

Minocycline-induced hyperpigmentation is a well-documented but poorly understood adverse effect of the popular tetracycline antibiotic minocycline, mainly affecting patients who use it for a prolonged duration. When patients develop dark skin lesions, the etiology may be clouded if a patient on minocycline has other risk factors. We describe a patient on suppressive minocycline therapy as well as anticoagulation and a history of chronic venous stasis who developed ecchymosis after an invasive procedure.

Statin-Induced Necrotizing Autoimmune Myopathy: A Case Report, Eric M. Teichner, Ms, Arjun B. Ashok, Ms

The Medicine Forum

In the landscape of contemporary medicine, statins stand out as a cornerstone in the prevention and management of atherosclerotic cardiovascular diseases. By inhibiting the 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase enzyme, statins effectively lower cholesterol levels, thus mitigating the risk of heart attacks and strokes.¹ Despite their widespread adoption and generally well-tolerated nature, the clinical panorama of statin therapy is occasionally marred by side effects, including muscle-related adverse events. These range from relatively common and benign myalgias to the rare and severe statin-induced necrotizing autoimmune myopathy (SINAM), a condition marked by muscle weakness and profoundly elevated levels of creatine kinase (CK) …

A Case Report Of Acute Idiopathic Hepatitis Requiring Liver Transplant, Nathan Rim, Nevin Varghese, Md, Zachary Pang, Md

The Medicine Forum

Acute liver injury may be very difficult to treat, especially when the etiology is unknown. We describe a case of a patient who presented with signs and symptoms of acute liver injury and went through an extensive work-up that did not reveal a definitive cause. The lack of diagnosis can be distressing for the patient, so it is important to regularly communicate the current plan and potential future necessary steps (such as a transplant surgery) to facilitate smooth, informed decision-making throughout the whole process.

A Rare Case Of Upper Gastrointestinal Bleeding And Esophageal Candidiasis In Severe Achalasia, Nevin Varghese, Md, Bertilia Tavárez, Md, Justin Robbins, Md

The Medicine Forum

Achalasia is an esophageal dysmotility disorder characterized by failure of relaxation of the lower esophageal sphincter (LES), accompanied by aperistalsis of the distal esophagus. Recent data show that the prevalence of achalasia in the United States is 10 per 100,000 individuals.¹ Complications of achalasia include esophagitis, esophageal ulcer, esophagealtracheal fistula, esophageal rupture, aspiration pneumonia, and squamous cell carcinoma. We report a rare case of upper gastrointestinal bleeding associated with esophageal ulcer and candidiasis in a patient with severe achalasia requiring multiple endoscopic interventions.

Bicuspid Aortic Valve With Right Coronary Cusp And Noncoronary Cusp Fusion On Transesophageal Echocardiogram, Kashka Mallari, Md

The Medicine Forum

A 39 year old male with a bicuspid aortic valve (BAV) developed progression of aortic valve regurgitation and enlargement of the ascending aorta, despite showing no symptoms. BAV, affecting approximately 2% of the population, poses risks such as aortic stenosis, aortic regurgitation, endocarditis, and aortic dilation, which can lead to aortic aneurysm and potential rupture. Due to the risk of further progression, he underwent a trans-esophageal echocardiogram (TEE) to facilitate aortic valve repair. While majority of patients with BAV exhibit fusion between the right coronary cusp (RCC) and left coronary cusp (LCC), this patient displayed fusion between the RCC and …

Hypertrophic Cardiomyopathy Illustrated On A Transthoracic Echocardiogram And Cardiac Mri, Youssef Elfatatry, Md, Marina Gonzalez, Md

The Medicine Forum

A 46-year-old woman presented to the hospital with subacute dyspnea on exertion and syncope. She had three syncopal episodes in the months prior, all of which occurred after standing from seated position and were associated with complete loss of consciousness. Echocardiogram showed severe concentric left ventricular hypertrophy (LVH) with preserved systolic function (Panels A and B). Cardiac magnetic resonance (CMR) imaging was performed which confirmed asymmetric septal hypertrophy measuring 28-mm in thickness (Panel C, arrow). Patchy, late gadolinium enhancement was also seen within the myocardium (Panel D, arrows). A diagnosis of hypertrophic cardiomyopathy (HCM) was made. The patient had no …

Wellens' Syndrome On Electrocardiogram, A Highly Specific Indicator Of Critical Stenosis Of The Left Anterior Descending Coronary Artery, Youssef Elfatatry, Md, Ryan Gardner, Md

The Medicine Forum

An 85-year-old male with a past medical history of hyperlipidemia presented to his primary care physician with chest pain. The patient had experienced an acute episode of substernal chest pain that resolved spontaneously three days prior to presentation. An electrocardiogram (ECG) was obtained in the office which showed inverted and biphasic T-waves throughout the precordial chest leads (Panel A, arrows). The patient was sent to the emergency department and underwent an emergent cardiac catheterization which revealed a 99% proximal left anterior descending (LAD) artery occlusion (Panel B, arrow). A drug-eluting stent was placed with successful revascularization (Panel C, arrow). Wellens …

Investigating The Etiology Of Non-Ischemic Cardiomyopathy; A Case Report Of Cardiac Amyloidosis, Zachary Pang, Md, Joshua M. Riley, Md, Yair Lev, Md

The Medicine Forum

Amyloidosis is the result of misfolded protein deposition in organs and tissues, including the heart also known as cardiac amyloidosis. We describe a case of a patient presenting with decompensated heart failure, which highlights the importance of identifying the etiology of the patient’s cardiomyopathy through a thorough history and physical. This led to a diagnosis of cardiac amyloidosis. The patient was subsequently initiated on tafamidis, a medication that is associated with reductions in all-cause mortality and cardiovascular-related hospitalizations, reduced decline in functional capacity, and improved quality of life of the patient.

Laao Device Mass: A Classic Condition Involving A Not - So - Classic Device, Ryan Gardner, Md, Rabia Naheed, Md, Youssef Elfatatry, Md, Irfan Ahsan, Md, Alyson N. Owen, Md

The Medicine Forum

Current evidence suggests Class 2a recommendation for a left atrial appendage occlusion with a closure device in patients with atrial fibrillation who have moderate to high risk of stroke (CHA2DS2-VASc score ≥2) and a contraindication to long-term oral anticoagulation due to a nonreversible cause.¹ Watchman device (WD) related infection is infrequent due to complete endothelialization of the device in a few weeks.² We report a highly challenging case of possible WD-related infection that involved complex decision-making.

Dissecting The Literature: A Systematic Review Of Conservative Therapy Versus Revascularization In Spontaneous Coronary Artery Dissection, Avinash Saraiya, Ms, Brian Schonewald, Md

The Medicine Forum

Spontaneous coronary artery dissection (SCAD) is a rare, but increasingly recognized cause of acute coronary syndrome (ACS). While previously only described in case series, the advent of advanced imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) has increased its prevalence dramatically. Anatomically, SCAD results from the formation of an intramural hematoma with or without intimal tear in a coronary artery, potentially leading to occlusion and ischemia. This phenomenon is especially common in women, accounting for 35% of ACS in women under the age of 50, and representing the leading cause of peripartum myocardial infarct.¹ There …

From The Chief Residents, Michael Dong, Md, Chantel Venkataraman, Md, Tamar Wolinsky Md, Benjamin Claxton, Md

The Medicine Forum

As we introduce the latest edition of The Medicine Forum, the journal of our Internal Medicine residency program, we're thrilled to showcase the diverse talents and perspectives of our resident physicians. Evolving alongside our program, this publication serves as both a platform for scientific inquiry and a canvas for creativity, reflecting the dynamic interests of each resident cohort.

We must extend our heartfelt gratitude to our current editors, Amman Bhasin, Suraj Nyalakonda, Mez Kamanu, and Alex Grivas, for their unwavering dedication and tireless efforts in shepherding this journal to new heights. Their commitment to excellence and their vision for …

From The Editors, Amman Bhasin, Md, Suraj Nyalakonda, Md, Chukwuemezie Kamanu, Md, Alexandros Grivas, Md

The Medicine Forum

We are honored to present the 25th Annual edition of The Medicine Forum, carrying forth a quarter-century tradition of scholarly work produced by faculty, residents, and students -- proudly shared with the Jefferson community and beyond. The Medicine Forum embodies the collective voice and spirit of our residency, serving as a vibrant platform for scholarly and artistic expression, and showcasing the remarkable talents and diverse perspectives of our program’s faculty, residents, and students.

Throughout the years, The Medicine Forum has evolved alongside our program, adapting to the changing interests and passions of each new cohort of residents. It serves …

Foreword From Faculty Advisor, Dagan Coppock, Md, Msce

The Medicine Forum

The latest edition of The Medicine Forum celebrates our community’s efforts toward scholarly inquiry and creativity. Our current editors have approached this project with a true passion. Throughout the academic year, it has been my pleasure to work with Amman, Suraj, Mez, and Alex, not only on this project, but also on the medical wards. They have applied the same thoughtfulness and joy to editing this journal that they do to the care of patients. I am in awe of their efforts.

As a department, we are a productive group of writers, thinkers, scientists, and artists. So much of our …

From The Desk Of The Residency Program Director, Christopher Henry, Md, Facp

The Medicine Forum

As we celebrate the silver jubilee of our beloved Jefferson Forum, it is with great pride and admiration that I extend a warm welcome to each of you. For a quarter-century, this annual publication has stood as a testament to the dedication, passion, and scholarly pursuits of our internal medicine residents.

Within the pages of the Jefferson Forum, you will find the embodiment of our residents' commitment to excellence in patient care, education, and research. As the Program Director, I have had the privilege of witnessing firsthand the remarkable growth and development of our residents. Their journey from eager learners …

Table Of Contents: The Medicine Forum, Volume 25, 2023-2024

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 25, 2023-2024

The Medicine Forum: Volume 25

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 25, 2023-2024

TABLE OF CONTENTS

• Case Reports
• Clinical Images
• Humanities & Reflections

What Questions Do Patients Ask About Biologic Therapies For Chronic Sinusitis With Nasal Polyps?, Samuel E Razmi, Lexi Goehring, Aatin K Dhanda, Jason Shenoi, Faizaan Khan, Keyvon Rashidi, Daniel Gorelik, Kenneth R Sims, Meha G Fox, Masayoshi Takashima, Omar G Ahmed

Faculty, Staff and Students Publications

Objective: The objective of this study is to explore the questions commonly asked online about biologic therapies for use in treatment of chronic sinusitis with nasal polyps (CRSwNP) and the quality of the available content.

Methods: Most common search terms were identified via Google Trends. People Also Ask (PAA) questions were identified and extracted with their associated website using an online data-scraping program [Search Engine Optimization (SEO) Minion, Keywords Everywhere]. Sources were evaluated using Flesch Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE, higher number = better) score for readability; Journal of American Medical Association (JAMA) Benchmark …

Clinical And Genomic Profile Of Primary Cranial Neurolymphomatosis, Emily B Wolf, Robin Imperial, Liuyan Jiang, Amit K Agarwal, Han W Tun

Faculty, Staff and Student Publications

Primary cranial neurolymphomatosis (PCNL) is a rare subtype of primary CNS lymphoma (PCNSL) in which infiltrative lymphomatous involvement is confined to cranial nerves. Here, we report a case of PCNL with successful genomic profiling. A 57-year-old male had a lengthy prediagnostic phase spanning approximately 30 months, characterized by multiple episodes of cranial neuropathies managed by steroids. At the time of diagnosis, the patient had right-sided cranial neuropathies involving cranial nerves (CN) V, VI, and VII. Pathological findings of the right cavernous lesion biopsy were consistent with large B-cell lymphoma-infiltrating nerve fibers. The clinical course was aggressive and refractory, characterized by …

Understanding Enterprise Data Warehouses To Support Clinical And Translational Research: Impact, Sustainability, Demand Management, And Accessibility, Thomas R Campion, Catherine K Craven, David A Dorr, Elmer V Bernstam, Boyd M Knosp

Faculty, Staff and Student Publications

OBJECTIVES: Healthcare organizations, including Clinical and Translational Science Awards (CTSA) hubs funded by the National Institutes of Health, seek to enable secondary use of electronic health record (EHR) data through an enterprise data warehouse for research (EDW4R), but optimal approaches are unknown. In this qualitative study, our goal was to understand EDW4R impact, sustainability, demand management, and accessibility.

MATERIALS AND METHODS: We engaged a convenience sample of informatics leaders from CTSA hubs (n = 21) for semi-structured interviews and completed a directed content analysis of interview transcripts.

RESULTS: EDW4R have created institutional capacity for single- and multi-center studies, democratized access …

Troponin: Think Before Testing, Shakirat Ganiyu, Fatimah Bello, Danielle Stone, Gregory Ruhnke, James Stone

School of Medicine Publications

This is a high-value care-based quality improvement project that was carried out to decrease inappropriate troponin testing in the emergency department (ED) of a tertiary health institution in the United States with the goal of promoting evidence-based practices, minimizing waste, and enhancing the quality of care.

Abdominal Aortic Aneurysm Screening And Surveillance – Can We Do Better? A Qi Project, Hassan Saeed, Hania Liaqat, Vidisha Master, Binita Neupane

Advances in Clinical Medical Research and Healthcare Delivery

Abstract

Background:

Abdominal aortic aneurysm (AAA) has a global prevalence of about 5% and its first presentation can be acute and fatal. USPSTF recommends one time screening for men aged 65 to 75 years who have ever smoked. We designed a study to evaluate the effect of resident education on AAA screening ordered in our outpatient primary care clinic.

Methods:

All men aged 65 to 75 years of age attending appointments in the resident run clinic were included in the study. Pre-intervention data was collected retrospectively for 5 weeks which included patient demographics and the rates of appropriate AAA screening …

Identification And Characterization Of Cannabichromene's Major Metabolite Following Incubation With Human Liver Microsomes, Alexandra M Ward, Touraj Shokati, Jost Klawitter, Jelena Klawitter, Vu Nguyen, Laura Kozell, Atheir I Abbas, David Jones, Uwe Christians

Faculty, Staff and Student Publications

Cannabichromene (CBC) is a minor cannabinoid within the array of over 120 cannabinoids identified in the Cannabis sativa plant. While CBC does not comprise a significant portion of whole plant material, it is available to the public in a purified and highly concentrated form. As minor cannabinoids become more popular due to their potential therapeutic properties, it becomes crucial to elucidate their metabolism in humans. Therefore, the goal of this was study to identify the major CBC phase I-oxidized metabolite generated in vitro following incubation with human liver microsomes. The novel metabolite structure was identified as 2′-hydroxycannabicitran using gas chromatography–mass …

A Rare Case Of Disseminated Extra-Nodal Natural Killer (Nk) Cell Lymphoma, Sowbharnika Arivazhagan, Guru Prasad Parthiban, Sukanthini Subbiah

School of Medicine Faculty Publications

Extranodal Natural Killer (NK)/T-cell lymphoma, nasal type, is rare and frequently found in Asia and South America. It is rarely found in the United States, mainly in the immigrant population. We present a 26-year-old male from Central America who was found to have disseminated NK/T-cell lymphoma. Through this article, we explain how we manage our patient and try to consolidate the treatment modalities for different stages of the disease.

Digital Twin Mathematical Models Suggest Individualized Hemorrhagic Shock Resuscitation Strategies, Jeremy W Cannon, Danielle S Gruen, Ruben Zamora, Noah Brostoff, Kelly Hurst, John H Harn, Fayten El-Dehaibi, Zhi Geng, Rami Namas, Jason L Sperry, John B Holcomb, Bryan A Cotton, Jason J Nam, Samantha Underwood, Martin A Schreiber, Kevin K Chung, Andriy I Batchinsky, Leopoldo C Cancio, Andrew J Benjamin, Erin E Fox, Steven C Chang, Andrew P Cap, Yoram Vodovotz

Faculty, Staff and Student Publications

BACKGROUND: Optimizing resuscitation to reduce inflammation and organ dysfunction following human trauma-associated hemorrhagic shock is a major clinical hurdle. This is limited by the short duration of pre-clinical studies and the sparsity of early data in the clinical setting.

METHODS: We sought to bridge this gap by linking preclinical data in a porcine model with clinical data from patients from the Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study via a three-compartment ordinary differential equation model of inflammation and coagulation.

RESULTS: The mathematical model accurately predicts physiologic, inflammatory, and laboratory measures in both the porcine model and patients, as well …

An Essential Gene Signature Of Breast Cancer Metastasis Reveals Targetable Pathways, Yiqun Zhang, Fengju Chen, Marija Balic, Chad J Creighton

Faculty, Staff and Students Publications

BACKGROUND: The differential gene expression profile of metastatic versus primary breast tumors represents an avenue for discovering new or underappreciated pathways underscoring processes of metastasis. However, as tumor biopsy samples are a mixture of cancer and non-cancer cells, most differentially expressed genes in metastases would represent confounders involving sample biopsy site rather than cancer cell biology.

METHODS: By paired analysis, we defined a top set of differentially expressed genes in breast cancer metastasis versus primary tumors using an RNA-sequencing dataset of 152 patients from The Breast International Group Aiming to Understand the Molecular Aberrations dataset (BIG-AURORA). To filter the genes …

Hemojuvelin-Mediated Hepcidin Induction Requires Both Bone Morphogenetic Protein Type I Receptors Alk2 And Alk3, Deniz Y Dogan, Eugen I Urzica, Isabelle Hornung, Philipp Kastl, David Oguama, Franca M Fette, Lien H Nguyen, Frank Rosenbauer, Kai Zacharowski, Ursula Klingmüller, Elise Gradhand, Andreas Von Knethen, Rüdiger Popp, Ingrid Fleming, Lisa Schrader, Andrea U Steinbicker

Faculty, Staff and Student Publications

Hemojuvelin (HJV) is a glycosylphosphatidylinositol-anchored protein of the repulsive guidance molecule family acting as a bone morphogenetic protein (BMP) coreceptor to induce the hepatic iron regulatory protein hepcidin. Hepcidin causes ubiquitination and degradation of the sole known iron exporter ferroportin, thereby limiting iron availability. The detailed signaling mechanism of HJV in vivo has yet to be investigated. In the current manuscript, we used an established model of adeno-associated virus (AAV)-mediated liver-specific overexpression of HJV in murine models of hepatocyte-specific deficiency of the BMP type I receptors Alk2 or Alk3. In control mice, HJV overexpression increased hepatic Hamp messenger RNA (mRNA) …

The Emerging Biomarkers In Chronic Obstructive Pulmonary Disease: A Narrative Review, Kaitlin M Phillips, Philip F Lavere, Nicola A Hanania, Muhammad Adrish

Faculty, Staff and Students Publications

The burden of chronic obstructive pulmonary disease (COPD) is increasing, especially for women in low-to-middle income countries. Biomarkers provide ever-increasing diagnostic precision for COPD and show promise for primary, secondary, and tertiary disease prevention. This review describes emerging applications for biomarkers in COPD, especially as they align with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) emphasis on prevention, early diagnosis, and response to therapy. These biomarkers include blood eosinophils; IgE; C-reactive protein; fibrinogen; procalcitonin; interleukins 6, 8, and 33; tumor necrosis factor alpha; and soluble receptor for advanced glycated products (sRAGE). They have been used in various ways …

Community-Acquired Pneumonia: The Importance Of The Early Detection Of Drug-Resistant Organisms, Sai Doppalapudi, Muhammad Adrish

Faculty, Staff and Students Publications

Pneumonia is a disease associated with significant healthcare burden with over 1.5 million hospitalizations annually and is the eighth leading cause of death in the United States. While community-acquired pneumonia (CAP) is generally considered an acute time-limited illness, it is associated with high long-term mortality, with nearly one-third of patients requiring hospitalization dying within one year. An increasing trend of detecting multidrug-resistant (MDR) organisms causing CAP has been observed, especially in the Western world. In this editorial, we discuss about a publication by Jatteppanavar

Driving Pressure Decoded: Precision Strategies In Adult Respiratory Distress Syndrome Management, Muhammad Adrish, Sai Doppalapudi, Dmitry Lvovsky

Faculty, Staff and Students Publications

Mechanical ventilation (MV) is an important strategy for improving the survival of patients with respiratory failure. However, MV is associated with aggravation of lung injury, with ventilator-induced lung injury (VILI) becoming a major concern. Thus, ventilation protection strategies have been developed to minimize complications from MV, with the goal of relieving excessive breathing workload, improving gas exchange, and minimizing VILI. By opting for lower tidal volumes, clinicians seek to strike a balance between providing adequate ventilation to support gas exchange and preventing overdistension of the alveoli, which can contribute to lung injury. Additionally, other factors play a role in optimizing …