Internal Medicine Commons^™

A Review Of The Effectiveness, Feasibility, And Acceptability Of Art Therapy For Children And Adolescents During The Covid-19 Pandemic, Minh Ngoc Le Vu, Anh Linh Do, Laurent Boyer, Quy Chi Tran, Stefan Kohler, Syed Ishtiaque Ahmed, Andreea Molnar, Tung Son Vu, Nhan Trong Huynh Vo, Linh Mai Vu Nguyen, Linh Gia Vu, Vu Anh Trong Dam, Thomy Duong, Dan Linh Nguyen Do, Ngoc Minh Do, Roger S Mclntyre, Carl Latkin, Roger Chun Man Ho, Cyrus Su Hui Ho

Faculty, Staff and Student Publications

Art therapy has been widely offered to reduce symptoms of psychological disturbance. Pooled evidence about its effectiveness in epidemic contexts, particularly during the COVID-19 pandemic, has not been yet established. This study reviewed the effectiveness, feasibility, and acceptability of art therapy on children and adolescents during the COVID-19 pandemic and past epidemics. We searched PubMed/Medline, PsycINFO, CENTRAL (Cochrane Library), and CINAHL for articles on art therapy during COVID-19. Included studies reported improvements in measures of mental health, sleep quality, and psychological well-being in children with or without disabilities in the epidemic context. Results also showed that art therapy was highly …

A Case Report And Literature Review On Argatroban Refractory Heparin-Induced Thrombocytopenia, Imad Ud Deen, Swati Ajay Jha, Sadaf Mustafa

Journal of Community Hospital Internal Medicine Perspectives

Heparin-induced thrombocytopenia (HIT) is characterized by low platelets and thrombosis after exposure to Heparin products. It is classically characterized by a rapid and significant drop in platelets and life-threatening thrombosis. Thrombosis can occur up to 50% of the cases if left untreated. It requires immediate discontinuation of all heparin products and switching to a non-heparin anticoagulant to prevent further thrombosis. Here we present a case of a 56-year-old male who presented to the Emergency Department with sudden onset of severe left leg pain. Duplex study showed arterial thrombosis in the common iliac and distal iliac arteries. He received TPA at …

A Rare Case Of Pembrolizumab Associated Encephalopathy, Sijan Basnet, Rajanbir Singh, Biswaraj Tharu, Tushar Pawar, Garima Basnet

Journal of Community Hospital Internal Medicine Perspectives

We present a unique case of a 55-year-old man with confusion thought to be due to pembrolizumab which he was receiving for renal cell carcinoma. His workup for other possible etiologies for encephalopathy was negative. He was treated with high dose intravenous methylprednisolone followed by prednisone taper and intravenous immunoglobulin with gradual improvement in his mentation.

The Lawnmower And The Pediatric Lower Extremity: A Catastrophic Combination, Alvaro Tamayo-Gutierrez, Hassan N Ibrahim

Faculty, Staff and Student Publications

Heart failure can lead to renal impairment, an interaction now termed "cardiorenal syndrome." The prevalent physiological explanation for the renal impairment that accompanies heart failure centers around the forward failure hypothesis, which emphasizes the role of left ventricular dysfunction in causing edema, and the backward failure hypothesis, which singles out venous congestion as the dominant mechanism of edema and reduced glomerular filtration rate. In this review, we provide an appraisal on venous congestion, an extremely important contributor that has received little attention. We also summarize the pharmacology of loop diuretics, explain current understanding of diuretic resistance, and address controversies regarding …

Hypertension Management In Patients With Chronic Kidney Disease, Sean A Hebert, Hassan N Ibrahim

Faculty, Staff and Student Publications

Hypertension and chronic kidney disease are closely linked. Patients with chronic kidney disease have hypertension almost universally and uncontrolled hypertension accelerates the decline in kidney function. The pathophysiology of hypertension in chronic kidney disease is complex, but is largely related to reduced nephron mass, sympathetic nervous system overactivation, involvement of the renin-angiotensin-aldosterone system, and generalized endothelial dysfunction. Consensus guidelines for blood pressure targets have adopted a blood pressure <120/80 mm Hg in native chronic kidney disease and <130/80 mm Hg in kidney transplant recipients. Guidelines also strongly advocate for renin-angiotensin-aldosterone system blockade as the first-line therapy.

Longitudinal Effects Of Combination Antiretroviral Therapy On Cognition And Neuroimaging Biomarkers In Treatment-Naive People With Hiv, Miriam T Weber, Alan Finkelstein, Md Nasir Uddin, Elizabeth Asiago Reddy, Roberto C Arduino, Lu Wang, Madalina E Tivarus, Jianhui Zhong, Xing Qiu, Giovanni Schifitto

Faculty, Staff and Student Publications

BACKGROUND AND OBJECTIVES: While combination antiretroviral therapy (cART) has dramatically increased the life expectancy of people with HIV (PWH), nearly 50% develop HIV-associated neurocognitive disorders. This may be due to previously uncontrolled HIV viral replication, immune activation maintained by residual viral replication or activation from other sources, or cART-associated neurotoxicity. The aim of this study was to determine the effect of cART on cognition and neuroimaging biomarkers in PWH before and after initiation of cART compared with that in HIV-negative controls (HCs) and HIV elite controllers (ECs) who remain untreated.

METHODS: We recruited 3 groups of participants from the University …

Comparative Analysis Of Co-Cultured Amniotic Cell-Conditioned Media With Cell-Free Amniotic Fluid Reveals Differential Effects On Epithelial-Mesenchymal Transition And Myofibroblast Activation, Naiyou Liu, Charles M Bowen, Mohammadali M Shoja, Karen Larissa Castro De Pereira, Laxmi Priya Dongur, Antonio Saad, William K Russell, Thomas Christopher Broderick, Jeffrey H Fair, William Samuel Fagg

Faculty, Staff and Student Publications

Myofibroblast activation is a cellular response elicited by a variety of physiological or pathological insults whereby cells initiate a coordinated response intended to eradicate the insult and then revert back to a basal state. However, an underlying theme in various disease states is persistent myofibroblast activation that fails to resolve. Based on multiple observations, we hypothesized that the secreted factors harvested from co-culturing amniotic stem cells might mimic the anti-inflammatory state that cell-free amniotic fluid (AF) elicits. We optimized an amnion epithelial and amniotic fluid cell co-culture system, and tested this hypothesis in the context of myofibroblast activation. However, we …

Preoperative Inflammatory Markers As Prognostic Predictors After Hepatocellular Carcinoma Resection: Data From A Western Referral Center, João Paulo Maciel Silva, Fabricio Ferreira Coelho, Alex Jones Flores Cassenote, Vagner Birk Jeismann, Gilton Marques Fonseca, Jaime Arthur Pirola Kruger, José Donizeti De Meira Júnior, Sérgio Carlos Nahas, Paulo Herman

Faculty, Staff and Student Publications

BACKGROUND: Recent studies from eastern centers have demonstrate an association between inflammatory response and long-term outcomes after hepatocellular carcinoma (HCC) resection. However, the prognostic impact of inflammatory markers in western patients, with distinct tumor and epidemiologic features, is still unknown.

AIM: To evaluate the prognostic impact of preoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR), as well as their impact according to tumor size (< 5 cm, 5-10 cm, > 10 cm) in patients undergoing HCC resection with curative intent.

METHODS: Optimal cut-off values for NLR, PLR, and MLR were determined by plotting the receiver operator curves. Overall survival (OS) and disease-free …

Health Care Utilization And Costs Associated With Functional Status In Patients With Psoriatic Arthritis, Alexis Ogdie, Mark Hwang, Phani Veeranki, Alexandria Portelli, Steven Sison, Jason Shafrin, Sofia Pedro, Steven Hass, Peter Hur, Nina Kim, Esther Yi, Kaleb Michaud

Faculty, Staff and Student Publications

BACKGROUND: The Health Assessment Questionnaire Disability Index (HAQ-DI) has been validated and widely used in psoriatic arthritis (PsA) clinical trials for the assessment of patient functional status. Significant improvements in the HAQ-DI have been reported in response to therapeutic interventions; however, few US studies have evaluated the economic impact of functional disability in patients with PsA.

OBJECTIVE: To evaluate the association of functional status with health care resource utilization (HCRU) and total health care costs in US patients diagnosed with PsA.

METHODS: This retrospective study included adult patients with PsA enrolled in FORWARD between July 2009 and June 2019 who …

National Network Of Depression Centers' Recommendations On Harmonizing Clinical Documentation Of Electroconvulsive Therapy, Peter P Zandi, Michael Morreale, Irving M Reti, Daniel F Maixner, William M Mcdonald, Paresh D Patel, Eric Achtyes, Mahendra T Bhati, Brent R Carr, Susan K Conroy, Mario Cristancho, Marc J Dubin, Andrew Francis, Kara Glazer, Wendy Ingram, Khurshid Khurshid, Shawn M Mcclintock, Omar F Pinjari, Kevin Reeves, Nelson F Rodriguez, Shirlene Sampson, Stephen J Seiner, Salih Selek, Yvette Sheline, Roy W Smetana, Takahiro Soda, Nicholas T Trapp, Jesse H Wright, Mustafa Husain, Richard D Weiner

Faculty, Staff and Student Publications

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best …

Fatal Case Of Ebv-Negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis In An Adult Kidney Transplant Recipient, Sergio Mazzola Poli De Figueiredo, John C Johnson, Kirill A Lyapichev, Heather L Stevenson, Alfred Lea, Syed Hussain, Rupak D Kulkarni, Jeffrey H Fair, Muhammad Mujtaba, Mike L Kueht

Faculty, Staff and Student Publications

Renal transplantation usually requires the administration of lifelong immunosuppressive therapy to minimize rejection.1 However, while these immunosuppressants are vital to graft protection, they increase the risk of infection and malignancy. Posttransplant lymphoproliferative disorder (PTLD), a troublesome combination of both, covers a wide range of lymphomas, most commonly B-cell type and has been described in pediatric and adult patients.2 Risk factors for PTLD include Epstein-Barr virus (EBV) infection and immunosuppression and the prevalence of adult kidney transplant PTLD is estimated to be 0.5% to 4%, with the highest incidences occurring within the first year of transplant.2-5 …

Distinguishing Intrathyroid Parathyroid Adenoma From Colloid Nodules And Papillary Thyroid Carcinomas Using Multiphasic Multidetector Computed Tomography, J Matthew Debnam, T Linda Chi, Michael Kwon, Jia Sun, Dawid Schellingerhout, Brandon T Golant, Salmaan Ahmed, Nancy D Perrier, Thinh Vu

Faculty, Staff and Student Publications

OBJECTIVE: The aim of the study is to determine whether multiphase multidetector computed tomography (4D-MDCT) can differentiate between intrathyroid parathyroid adenomas (ITPAs), colloid nodules, and papillary thyroid carcinoma (PTC).

METHODS: We studied 22 ITPAs, 22 colloid nodules, and 11 PTCs in 55 patients. Hounsfield unit (HU) values of the nodules were measured on 4D-MDCT in the precontrast, arterial, venous, and delayed phases. Raw HU values, phase with peak enhancement, and washout percentages between the phases were evaluated.

RESULTS: Regardless of size, all ITPAs (22/22) showed peak enhancement in the arterial phase, which was significantly greater than both colloid nodules (15/22) …

Ugrc 2021 Recommendations On Gme Transition: Pros And Cons, Opportunities And Limitations, John R Gimpel, Jennifer L Swails, Jessica L Bienstock, Grant L Lin, Michelle A Roett, Juhee K Patel, Daniel W Giang

Faculty, Staff and Student Publications

The Coalition for Physician Accountability's Undergraduate Medical Education-Graduate Medical Education (UME-GME) Review Committee (UGRC): Recommendations for Comprehensive Improvement of the UME-GME Transition final report includes a total of 34 recommendations and outlines opportunities to transform the current processes of learner transition from a US-based MD- or DO-granting medical school or international medical education pathway into residency training in the United States. This review provides a reflection on the recommendations from the authors, all members of the UGRC, describing the pros and cons and the opportunities and limitations, in the hopes that they might inspire readers to dig deeper into the …

Hepatic Circadian And Differentiation Factors Control Liver Susceptibility For Fatty Liver Disease And Tumorigenesis, Baharan Fekry, Aleix Ribas-Latre, Rachel Van Drunen, Rafael Bravo Santos, Samay Shivshankar, Yulin Dai, Zhongming Zhao, Seung-Hee Yoo, Zheng Chen, Kai Sun, Frances M Sladek, Mamoun Younes, Kristin Eckel-Mahan

Faculty, Staff and Student Publications

Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths, and the most common primary liver malignancy to present in the clinic. With the exception of liver transplant, treatment options for advanced HCC are limited, but improved tumor stratification could open the door to new treatment options. Previously, we demonstrated that the circadian regulator Aryl Hydrocarbon-Like Receptor Like 1 (ARNTL, or Bmal1) and the liver-enriched nuclear factor 4 alpha (HNF4α) are robustly co-expressed in healthy liver but incompatible in the context of HCC. Faulty circadian expression of HNF4α- either by isoform switching, or loss of expression- results in an increased …

Covid-19 And Blood Clots: A Report Of Massive Pulmonary Embolism In Covid-19 Patient Supported On Veno-Venous Ecmo And The Utility Of Thrombolysis, Bindu Akkanti, Joseph Zwischenberger, Mark T Warner, Kha Dinh, Rahat Hussain, Farah Kazzaz, Pascal Kingah, Lisa M Janowiak, Biswajit Kar, Igor D Gregoric

Faculty, Staff and Student Publications

COVID-19 morbidity and mortality are not equivalent to other etiologies of acute respiratory distress syndrome (ARDS) as fulminant activation of coagulation can occur, thereby resulting in widespread microvascular thrombosis and consumption of coagulation factors. A 53-year-old female presented to an emergency center on two occasions with progressive gastrointestinal and respiratory symptoms. She was diagnosed with COVID-19 pneumonia and admitted to a satellite intensive care unit with hypoxemic respiratory failure. She was intubated and mechanically ventilated, but her ARDS progressed over the next 48 hours. The patient was emergently cannulated for veno-venous extracorporeal membrane oxygenation (V-V ECMO) and transferred to our …

Primary Sjögren's Syndrome Presenting As Cerebral Venous Thrombosis: A Rare Case, Mohan Sonu Chandra, Monisha G A, Ravi Kiran M

Faculty, Staff and Student Publications

Sjogren's syndrome is a late-onset, slowly progressing autoimmune disease characterized by the destruction of the exocrine glands by lymphocytic infiltration, resulting in dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca). Sjögren's syndrome may be associated with various autoimmune diseases, including systemic lupus erythematosus, rheumatoid arthritis, and systemic sclerosis. We report a case of a 34-year-old female who delivered a live baby 20 days ago. She presented in a postictal state after two episodes of tonic-clonic movements of limbs with altered sensorium with a history of headache for seven days. Further evaluation revealed that the subject had a history of multiple …

Post–Lung Transplantation Outcomes And Ex Vivo Histopathological Findings In Severe Post-Covid-19 Pulmonary Disease—A Single-Center Experience, Hana Javaid, Masayuki Nigo, Bihong Zhao, Daniel Ocazionez Trujillo, Rodrigo Hasbun, Luis Ostrosky-Zeichner, Manish Patel, Soma Jyothula

Faculty, Staff and Student Publications

BACKGROUND: A significant proportion of patients with severe and persistent coronavirus disease 2019 (COVID-19) require continuous ventilatory support and occasional extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS). Lung transplantation is a treatment option for patients who develop severe ARDS.

METHODS: Our lung transplant database was retrospectively reviewed for patients who underwent lung transplantation for COVID-19 pulmonary disease at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas, from January 2020 to March 2022. We evaluated outcomes of patients who were followed in our clinic at least 6 months post-transplant. Pretransplant patient characteristics, COVID-19-related treatment, histopathology results, and postdischarge …

Modulation Of The Association Between Age And Death By Risk Factor Burden In Critically Ill Patients With Covid-19, Ashwin Sunderraj, Chloe Cho, Xuan Cai, Shruti Gupta, Rupal Mehta, Tamara Isakova, David E Leaf, Anand Srivastava

Faculty, Staff and Student Publications

Older age is a key risk factor for adverse outcomes in critically ill patients with COVID-19. However, few studies have investigated whether preexisting comorbidities and acute physiologic ICU factors modify the association between age and death.

DESIGN: Multicenter cohort study.

SETTING: ICUs at 68 hospitals across the United States.

PATIENTS: A total of 5,037 critically ill adults with COVID-19 admitted to ICUs between March 1, 2020, and July 1, 2020.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: The primary exposure was age, modeled as a continuous variable. The primary outcome was 28-day inhospital mortality. Multivariable logistic regression tested the association between …

Minimal Impact Of The Covid-19 Pandemic On Disease Activity And Health-Related Quality Of Life In Patients With Ankylosing Spondylitis Receiving Bimekizumab: Exploratory Analyses From A Phase 2b Open-Label Extension Study, Philip C Robinson, Pedro M Machado, Nigil Haroon, Lianne S Gensler, John D Reveille, Vanessa Taieb, Thomas Vaux, Carmen Fleurinck, Marga Oortgiesen, Natasha De Peyrecave, Atul Deodhar

Faculty, Staff and Student Publications

OBJECTIVE: The impact of the COVID-19 pandemic on patients with inflammatory rheumatic diseases, such as ankylosing spondylitis (AS), has been variable. Here, we assess disease activity and health-related quality of life (HRQoL) through the pandemic in patients with AS.

METHODS: In the open-label extension (OLE) of the phase 2b BE AGILE study, patients with AS received 160 mg of subcutaneous bimekizumab every 4 weeks. We assessed Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Quality of Life (ASQoL) scores in the OLE immediately before and during the COVID-19 pandemic …

Coronary-To-Coronary Bypass Grafting In Aortoarteritis: A Case Report, Immaneni Sathyamurthy, Narra Lavanya, Kanthallu Narayanamoorthy Srinivasan, Maligail Ramkrishna Girinath

Faculty, Staff and Student Publications

Takayasu's arteritis (TA) is an idiopathic vasculitis affecting the aorta and its major branches. In TA, coronary artery involvement is rare and it mainly consists of stenosis or occlusion of the coronary ostia. In TA, as the arterial tree is diseased, often, arterial grafts are unsuitable for grafting so the saphenous vein grafts (SVG) are commonly used. We present a case of a young female with TA with an ostial left main stenosis who has undergone a right coronary-to-left anterior descending artery SVG and put on immunosuppression and steroids. She was asymptomatic with a patent graft during 7 years follow-up.