Internal Medicine Commons^™

Complexities In Alcoholic Necrotizing Pancreatitis: A Case Report Of Severe Vascular And Infectious Complications, Dawood Tahir, Md, Shravya Ginnaram, Md, Jacob Lipkin, Md

The Medicine Forum

Acute pancreatitis (AP) incidence has been increasing, with an annual incidence of approximately 5 to 40 cases per 100,000.¹ Several complications occur with AP, including splanchnic vein thrombosis (SVT), pseudocyst, and pseudoaneurysm (PSA). Moreover, 15-20% of patients develop necrotizing pancreatitis (NP) following an episode of AP with a mortality rate of up to 32%,² which can be further complicated by infected necrosis in up to one-third of patients.² Hemorrhage is estimated to occur in less than 6% of patients with NP by pseudoaneurysm.³ The endoscopic step-up approach is the standard treatment for walled-off necrosis, whereas alternative …

Use Of Novel Agent Purastat® For Post-Sphincterotomy Bleeding, Ananya Venkatesh, Md, Bertilia Tavarez, Md, Ms, Pedra Palacios Argueta, Md, Donna Leet, Md, Afshin Khan, Md, Abdul Kouanda, Md, Anand Kumar, Md, Alana Persaud, Md, Yasi Xiao, Md, Alexander Schlachterman, Md, Thomas Kowalski, Md, Faisal Kamal, Md

The Medicine Forum

Endoscopic sphincterotomy is commonly performed during endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic sphincterotomy (ES) is associated with adverse events such as bleeding.¹ PuraStat® is a new synthetic hemostatic gel being used for treatment of gastrointestinal bleeding. We aim to report and outcomes of PuraStat® for post-sphincterotomy bleeding.

Use Of Novel Agent Purastat® For Post-Ampullectomy Bleeding, Bertilia Tavarez, Md, Ms, Ananya Venkatesh, Md, Pedra Palacios Argueta, Md, Anand Kumar, Md, Alana Persaud, Md, Yasi Xiao, Md, Alexander Schlachterman, Md, Faisal Kamal, Md, Thomas Kowalski, Md

The Medicine Forum

Endoscopic ampullectomy is the first line treatment modality for major papilla neoplasms that have not invaded the muscularis propria.¹ Complications of endoscopic ampullectomy include bleeding, pancreatitis, perforation, papillary stenosis, and cholangitis with the incidence of post-ampullectomy bleeding reported to be as high as 30%.^1,2 PuraStat® is a new synthetic hemostatic gel being used for the prophylaxis and treatment of gastrointestinal bleeding.^3-5 To date, there are no reports on the use of PuraStat® for post-ampullectomy bleeding. We hope to investigate the use and outcomes of PuraStat® for post-ampullectomy bleeding.

Racial Disparities In Response To Ibd Directed Therapy In Crohn’S Disease And Ulcerative Colitis: A Single Center Experience, Ananya Venkatesh, Md, Justin Robbins, Md, Zach Breslin, Md, Cuckoo Choudhary, Md

The Medicine Forum

Crohn’s disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) associated with significant morbidity and mortality. Current clinical guidelines recommend a range of therapies, including tumor necrosis factor alpha (TNFα) antagonists, anti-integrins, interleukin-12/23 (IL12/23) inhibitors, Janus kinase (JAK) inhibitors, and/or corticosteroids for both induction and maintenance of remission. Determining the optimal medication for individual patients can be challenging due to the complexity of treatment options and the need to consider numerous phenotypic factors. While treatment guidelines do not address racial differences explicitly, prior research has highlighted significant phenotypic disparities based on race. This study aims to explore …

Williams Syndrome Presenting With Pericardial Effusion And Left Ventricular Apical Aneurysm: A Case Report, Zachary Pang, Md, M. D. Kilpatrick, Md, Sairamya Bodempudi, Md, Darius Farzad, Md, Daniel L. Fischman, Gregary D. Marhefka, Md

The Medicine Forum

Williams syndrome (WS) is a genetic disorder caused by a gene deletion involving the protein elastin on chromosome 7q11.23. WS is associated with intellectual disability and characteristic facial features, including a short nose with a flat nasal bridge, medial eyebrow flare, and long philtrum.^1-2 WS is also associated with cardiovascular manifestations, most commonly supravalvular aortic stenosis. Patients with WS have an estimated risk of sudden cardiac death that is 25 to 100 times greater than the healthy age-matched population.³ This case highlights the importance of keeping acute coronary syndrome on one’s differential when caring for patients with Williams …

A Shock To The Heart? A Case Of Phantom Shocks In A Patient With Brugada Syndrome, Virginia Gonzalez, Md, Rebecca Goldfinger-Chanin, Md, Behzad B. Pavri, Md

The Medicine Forum

Brugada syndrome is an inherited condition characterized by an increased risk of sudden cardiac death (SCD) secondary to lethal ventricular arrhythmias occurring most often in the fourth decade of life. Implantable cardioverter-defibrillators (ICDs) are recommended in patients who have documented ventricular tachycardia (VT) or ventricular fibrillation (VF) and in patients presenting with a spontaneous type 1 Brugada pattern on electrocardiogram (ECG) and a history of arrhythmic-sounding syncope.¹ However, patients with ICDs are at risk of developing “phantom shocks” which occur when a patient reports the sensation of receiving a shock that is not confirmed upon subsequent device interrogation.^{2 …}

Protamine Sulfate-Induced Coronary Vasospasm Resulting In Takotsubo Cardiomyopathy, Matthew J. Bierowski, Md, Andre Cunningham, Do, Jordan Feingold, Md

The Medicine Forum

Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, is characterized by new left ventricular (LV) dysfunction out of proportion to any known coronary artery disease that usually follows an emotional or physical stress. The disease process mimics acute coronary syndrome (ACS), with acute chest pain, moderate elevations in serum troponins, and electrocardiographic changes. While spontaneous return to normal left ventricular function is typical, the morbidity and mortality of TTS is significant, with increased risk for major adverse cardiac events and disease recurrence.¹

The understanding of the pathogenesis of TTS is incomplete, although recent work has identified that several processes …

Power Outage: Acute Subtotal Occlusion Of The Left Circumflex Artery With Minimal Ecg Changes, Daniel Moylan, Md, Brady Houtz, Md

The Medicine Forum

Acute coronary syndrome (ACS) represents one of the most recognizable causes of death in the United States. Despite significant advances in cardiovascular preventative health, an American will have a myocardial infarction approximately every 40 seconds.¹ Fortunately, rapid diagnosis and treatment of ACS have allowed for significant reductions in both morbidity and mortality of myocardial infarctions.² Thus, prompt identification of ACS is crucial, and nonetheless, it can still present a noteworthy challenge to physicians. In this case, we present a near-electrically silent acute thrombotic coronary subtotal occlusion. It constitutes a stark reminder that diagnosis of an acute myocardial infarction …

Mitral Annular Disjunction As A Cause Of Cardiac Arrest In Young Patient: A Case Report, Sheraz Qamar, Md

The Medicine Forum

Mitral annular disjunction is a structural abnormality where there is a separation of the mitral valve annulus and left atrial wall. We present a case of cardiac arrest in a young patient with known mitral valve prolapse that was now found to have mitral annular disjunction due to myxomatous mitral valve disease. This case highlights the importance of finding the etiology of cardiac arrest, which in this case, is myxomatous mitral valve disease causing mitral annular disjunction. It also highlights the importance of secondary prevention of sudden cardiac death with defibrillator placement in these patients.

Hot Coffee-Induced Takotsubo Cardiomyopathy: A Case Report, Zachary Pang, Md, M. D. Kilpatrick, Md, Jasmine Lee, Md, Gregary D. Marhefka, Md

The Medicine Forum

Takotsubo cardiomyopathy is a well-known phenomenon due to physical or emotional stress, causing a catecholamine surge leading to myocardial wall motion abnormalities, most commonly apical ballooning of the left ventricle.1-3 The diagnosis of Takotsubo cardiomyopathy can be challenging as its presentation often mimics acute coronary syndrome. This case highlights the classic presentation of the apical ballooning variant of Takotsubo cardiomyopathy and appropriate workup and diagnosis.

Be Afraid Of Severe Pulmonary Hypertension And Right Ventricular Failure In The Peri-Op Patient, Avish Patel, Md, Lily Ackermann, Md

The Medicine Forum

Heart failure (HF), particularly right ventricular (RV) failure, and pulmonary hypertension (PH) present significant risks during the perioperative period. Despite the fact that these comorbidities are not always considered in preoperative risk evaluation, they are very important when considering perioperative risk. Current risk assessment tools mainly include the Revised Cardiac Risk Index (RCRI); however, it does not effectively assess severity of HF or PH. This review aims to highlight the major points on peri-operative management in non-cardiac surgeries using a case of a patient with severe PH who experienced unexpected mortality from acute RV failure post-operatively.

A Case Of Type 4 Spontaneous Coronary Artery Dissection (Scad), Virginia Gonzalez, Md, Ms, Kashka Mallari, Md, Marina Gonzalez, Md, Svenja Schneider, Md, Sung-Hae Cho, Md, Paulina Gorodin-Kiliddar, Md

The Medicine Forum

A 52-year-old female presented to the emergency department ten minutes after the development of sudden-onset crushing chest pain radiating to both of her arms, associated with dyspnea on exertion. Notably, she reported a several-month history of significant stress caring for her elderly mother with Alzheimer’s disease. On admission, her vital signs revealed sinus bradycardia with a heart rate of 56 beats/min.

The patient reported a past medical history of hypothyroidism, breast cancer status post lumpectomy, nicotine dependence, and anxiety. She did not have a prior history of cardiovascular disease or stroke, nor a family history of premature coronary disease. She …

Evaluating Mortality And Bleeding Risk After Percutaneous Left Atrial Appendage Closure In Atrial Fibrillation: A Propensity-Matched Analysis Using A Multi-Institutional Database, Youssef Elfatatry, Md, Ryan Gardner, Md

The Medicine Forum

Percutaneous left atrial appendage closure (pLAAC) has emerged as an effective treatment strategy for stroke prevention in patients with atrial fibrillation (AF) who otherwise cannot tolerate anticoagulation (AC) therapy. The American College of Cardiology, American Heart Association, American College of Chest Physicians, and Heart Rhythm Society combined guidelines offer a class 2a recommendation to pursue pLAAC in patients with an elevated risk of stroke from AF and a contraindication to oral AC, and a class 2b recommendation for pLAAC in patients with elevated risk of stroke from AF and elevated risk of life-threatening bleeding from AC.¹ The predominant pLAAC …

3d-Printed Coronary Arteries: An Effective Tool In Medical Education, Zachary Pang, Md, Shreyas Chandragiri, Md, Shumpei Mori, Md, Phd, Alexander Hajduczok, Md, Cannon G. Hiranaka, Md, Jesse Ottaway, Md, Zachary Mace, Md, Michael Wong, Md, Tammy Yoshioka, Md, Noah Haroian, Md, Pharmd, Guiyan Zhang, Md, Phd

The Medicine Forum

Anatomy and physiology can be a challenging topic due to their inherent complexity. Anatomy is most effectively learned through a combination of memorization, comprehension, and visualization.¹ Lectures and textbooks provide efficient means for memorization and comprehension but can often be challenging for thee-dimensional (3D) visualization. Conceptualizing 3D structures from two-dimensional (2D) textbook figures poses difficulty for many students. Anatomical education can be accompanied by dissection of cadavers, which can aid in visualization, but can be time-consuming and expensive.² 3D printing technology, however, holds the potential to solve this problem and enhance the anatomical education experience.

Foreword From Faculty Advisor, Dagan Coppock, Md, Msce

The Medicine Forum

We are honored to present this latest edition of The Medicine Forum. This platform is in its twenty-sixth year serving as an outlet for our medical community’s scholarly and creative efforts. This year, it has been my pleasure to work with Marc, Marina, Virginia, and Devin on this project. I have not only worked with them on the Forum, but also on the wards. It is impressive to see the same excellence they bring to patient care applied to this academic publication.

This journal serves as a showcase for the efforts of our Department. It is always exciting …

From The Chief Residents, Akash Patel, Do, Ashley Traczuk, Md, Mark Liotta, Md, Claire Zurlo, Md

The Medicine Forum

It is with great pride that we present this year’s edition of The Medicine Forum, a reflection of the passion, intellectual curiosity, and multidimensional talents that define our Internal Medicine residency program.

This journal continues to be more than a collection of case reports and research findings — it is a celebration of who we are as a community. It reflects our shared commitment to inquiry, creativity, and the art of medicine. From the rigor of original research to the introspection of narrative writing and the vibrancy of visual art, this edition captures the full spectrum of our residents’ …

From The Editors, Marina Gonzalez, Md, Virginia Gonzalez, Md, Devin Vasoya, Md, Marc Yorker, Md

The Medicine Forum

It is with great enthusiasm that we present to you the 26th edition of our internal medicine residency journal. As chief editors, we have the privilege of curating the latest insights, research, and reflections from the ever-evolving world of medicine, all to enrich our shared knowledge and foster meaningful discussions within our community.

Over the years, this journal has served as a platform for scholarly exploration, clinical advancements, and the voices of residents shaping the future of internal medicine. With each edition, we strive to uphold the highest standards of academic excellence while embracing the diversity of thought and expertise …

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

The Medicine Forum

The Jefferson Forum is a reflection of our residents' dedication to patient care, education, resilience, and research. Within these pages, you’ll find a unique combination of hard work, intellectual curiosity, and personality. As Program Director, I have the privilege of watching their transformation from learners to skilled clinicians and scholars, a journey marked by perseverance and a sense of purpose.

In a time of rapid political and societal change, this publication stands as a testament to our renewed commitment to science, well-being, and the pursuit of knowledge. As physicians and researchers, we remain steadfast in our mission to improve health …

Table Of Contents: The Medicine Forum, Volume 26, 2024-2025

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 26, 2024-2025

The Medicine Forum: Volume 26

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 26, 2024-2025

TABLE OF CONTENTS

• Research Studies
• Case Reports
• Humanities & Reflections

Cardiovascular Health In Cardiac Rehabilitation: Applying The American Heart Association Life's Simple 7 Framework In A Center-Based Cohort, Audry Chacin-Suarez, Tomoaki Hama, Matthew P. Johnson, Helayna Abraham, Thomas P. Olson, Laprincess C. Brewer

Einstein Health Papers

BACKGROUND: Cardiac rehabilitation (CR) is a comprehensive secondary cardiovascular disease program with structured lifestyle interventions to reduce morbidity and mortality. The American Heart Association cardiovascular health (CVH) framework measures health-promoting behaviors and clinical factors, but it has not been rigorously evaluated in the CR setting.

METHODS: This retrospective cohort study analyzed patients attending CR from January 2018 to September 2020. Patients were evaluated at baseline (pre-CR) and completion (post-CR) using 3 clinical factors (blood pressure, cholesterol, and hemoglobin A1c) and 4 health behaviors (smoking, body mass index, physical activity, and diet). CVH score was computed as a composite of each …

Slow-Growing Lung Mass In A Patient With Multiple Endocrine Neoplasia Type I: Consider Carcinoid Tumor, Ramin Talebi, Charalambos C. Solomides, Nathaniel R. Evans Iii, Gregory C. Kane

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

A 23-year-old man with multiple endocrine neoplasia type 1 (MEN 1) with pancreatic tail masses and Cushing syndrome (status after transsphenoidal adenomectomy) presented with a slow-growing, asymptomatic right lower lung lobe mass confirmed to be an atypical carcinoid tumor by pathologic staging following successful basilar segmentectomy with mediastinal lymphadenectomy. Pulmonary carcinoid tumor (PCT) is a rare neoplasm in patients with MEN 1, but there is limited data on trends in atypical versus typical carcinoid tumors in these patients. This case emphasizes the need to characterize these trends given the implications for metastatic potential and 5-year survival, which can help guide …

A Tubo-Ovarian Abscess In Aplastic Anemia Presenting As Fever Of Unknown Origin, Rashi Mittal, Saurabh Kumar Gautam, Prasan Kumar Panda, Latika Chawla

Chulalongkorn Medical Journal

This report describes a complex case of a tubo-ovarian abscess (TOA) presenting atypically as fever of unknown origin (FUO) in a young woman initially diagnosed with severe aplastic anemia. The case involved protracted febrile illness, heavy menstrual bleeding, and pancytopenia. Identification of an Escherichia coli tubo-ovarian abscess, rather than tuberculosis, emphasized the need for a thorough evaluation in atypical presentations of TOA. Negative tuberculosis tests highlighted the variety of possible microbial etiologies. The resolution of fever following drainage and tailored antibiotic therapy, along with timely surgical intervention, demonstrated the importance of specific management strategies in such cases. Awareness of the …

Management And Optimization Of Chronic Renal Insufficiency In The Setting Of Kidney Cancer A Systematic Review, Jessica K. Cobb, Hiroko Miyagi, Jad Chahoud, Claude Bassil, Philippe E. Spiess

Division of Internal Medicine Faculty Papers & Presentations

PURPOSE: There is a bidirectional relationship between chronic kidney disease and the incidence of renal cell carcinoma. Despite the frequency of patients with both chronic kidney disease and renal cell carcinoma, there are limited systematic reviews detailing the nuanced treatment. This review provides comprehensive insights for clinicians for managing chronic kidney disease, and renal cell carcinoma. Methods and Methods: We reviewed published literature that examined either chronic kidney disease and renal cell carcinoma or an indirect contributor of both.

RESULTS: We compare and contrast renal cell carcinoma treatment with partial and radical nephrectomies, ablative techniques, and radiation and their impact …

Building Models, Building Capacity: A Review Of Participatory Machine Learning For Hiv Prevention, Mark Sendak, Meg Young, Jee Young Kim, Alifia Hasan, Clare Kelsey, Catherine O’Neal, Tonya Jagneaux, Wayne Wilbright, John Couk, Stephen Lim, Tamachia Davenport, Shirley Lolis, Jennifer Thomas, Shannon Widman, Suresh Balu, Meredith Clement, Lance Okeke

School of Medicine Faculty Publications

A growing number of researchers and practitioners are embracing a “participatory turn” in machine learning (ML) to improve model development, prevent harm, and provide communities more influence over systems that impact them. In this paper, we explore the intersection of participatory practices in healthcare and the emerging focus on responsible AI with a focus on human immunodeficiency virus (HIV) care. We review the historical context of participation in HIV treatment and prevention, emphasizing how patient activism has shaped practices in this field. We then review participatory ML in HIV prevention and present a brief case study of a project designed …

Disparities In Mortality Associated With Disseminated Intravascular Coagulation: A Nationwide Study, Manas Pustake, Atulya Khosla, Saif Syed, Avi Harisingani

Conference Presentation Abstracts

Background : Disseminated intravascular coagulation (DIC) is a serious and often life-threatening condition that can result in widespread morbidity and mortality. Despite its clinical significance, there remains a lack of comprehensive, national-level data analyzing trends in DIC-related mortality. Understanding these trends is crucial for identifying at-risk populations, informing public health strategies, and optimizing clinical interventions. Aims : This study aims to analyze DIC mortality trends from 2018 to 2023, focusing on key demographic and regional factors, to provide insights that can guide future healthcare policy and practice. Methods : An analysis of DIC mortality trends from 2018 to 2023 was …

Disparities In Pulmonary Embolism Mortality In Us-Mexico Border Regions: A Population-Based Study, Manas Pustake, Atulya Khosla

Conference Presentation Abstracts

Background : Health disparities in pulmonary embolism (PE) mortality are notably evident along the US-Mexico border, where limited healthcare access and socioeconomic challenges contribute to poorer outcomes. While PE is increasingly recognized as a major health concern, little research has been done to understand the specific difficulties faced by border communities in managing and preventing the condition. Identifying these disparities is essential to closing healthcare gaps and implementing targeted interventions to reduce PE mortality in these areas. Aims : To analyze and compare PE mortality rates between the US-Mexico border and non-border regions, while examining the influence of demographic factors. …

Implementation Mapping To Guide Adoption Of A Semi-Structured Intraoperative Anesthesia Handoff Tool, Aubrey Samost-Williams, Reed Richter, Naveen Vanga, Spandana Mandaloju, Adlai Arandela, Srikanth Sridhar, Eric J Thomas

Faculty, Staff and Student Publications

There frequently exists a gap between known best practices and real-world methods. Closing this gap involves thoughtful implementation, typically involving multiple implementation strategies. Implementation mapping is a technique that links the innovation being implemented with potential barriers to implementation and connects these barriers to the strategies that form the implementation plan. This study demonstrates the application of implementation mapping to guide the adoption of the Epic Health Systems Intraoperative Anesthesia Handoff Report. The objective is to create a comprehensive implementation plan tailored to the anticipated challenges of the local environment. There are five steps in implementation mapping: (1) performing a …

Pharmacogenetics Of Plasma Dolutegravir Exposure During 1-Month Rifapentine/Isoniazid Treatment Of Latent Tuberculosis, Nia Covington, Anne F Luetkemeyer, Marjorie Z Imperial, Rodney Dawson, Yoninah Cramer, Sue Rosenkranz, Susan Swindells, Irina Gelmanova, Anchalee Avihingsanon, Roberto C Arduino, Wadzanai Samaneka, Kelly E Dooley, Rada Savic, Anthony T Podany, David W Haas

Faculty, Staff and Student Publications

In Advancing Clinical Therapeutics Globally protocol A5372, a pharmacokinetic study of dolutegravir with 1-month of daily rifapentine/isoniazid, twice-daily dolutegravir offset the induction effects of rifapentine on plasma dolutegravir trough concentrations (C trough ). Here, we characterize the impact on dolutegravir C trough of UGT1A1 , AADAC , and NAT2 polymorphisms that affect dolutegravir, rifapentine, and isoniazid, respectively. People with HIV receiving dolutegravir-based antiretroviral therapy with an indication to treat latent tuberculosis underwent pharmacokinetic sampling during dolutegravir 50 mg once daily alone, and on day 28 of dolutegravir 50 mg twice daily with rifapentine/isoniazid. Multivariable linear regression models characterized genetic associations …

Impact Of Metabolically Healthy Obesity On Post Percutaneous Coronary Intervention Outcomes In Patients With Acute Myocardial Infarction: A Nationwide Propensity Matched Analysis, Rupak Desai, Adhvithi Pingili, Arankesh Mahadevan, Vishal Reddy Bejugam, Hafeezuddin Ahmed, Vamsikalayan Borra, Adil Sarvar Mohammed, Gayatri Bondi, Shobana Krishnamurthy, Nithya Borra

School of Medicine Publications

Background

Obesity paradox in post-percutaneous coronary intervention (PCI) outcomes among acute myocardial infarction (AMI) patients is a known controversy. However, these studies included patients who had diabetes, hypertension, or hyperlipidemia. We studied relationship between metabolically healthy obesity (MHO—without diabetes, hypertension, or hyperlipidemia) and in-hospital post-PCI outcomes among AMI patients.

Methods

We extracted data from National Inpatient Sample 2020 using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for admissions of AMI patients who underwent PCI. We then identified patients with diabetes, hypertension, and hyperlipidemia using Elixhauser comorbidity index and Clinical Classifications Software and excluded them. Then, using Elixhauser …