Internal Medicine Commons^™

Luspatercept Diminishes The Need For Red Blood Cell Replacement In Transfusion-Dependent Β-Thalassemia Patients, Joudeh B. Freij

Clinical Research in Practice: The Journal of Team Hippocrates

A clinical decision report appraising:

Cappellini MD, Viprakasit V, Taher AT, et al. A phase 3 trial of luspatercept in patients with transfusion-dependent β-thalassemia. N Engl J Med. 2020;382(13):1219-1231. https://doi.org/10.1056/NEJMoa1910182

for a patient with transfusion-dependent beta-thalassemia.

Acuity Level Of Care As A Predictor Of Case Fatality And Prolonged Hospital Stay In Patients With Covid-19: A Hospital-Based Observational Follow-Up Study From Pakistan, Aysha Almas, Zain Mushtaq, Jette Moller

Section of Internal Medicine

Objectives: To determine if there is an association between acuity level of care (ALC), case fatality and length of stay in patients admitted to hospital due to COVID-19.
Design: A hospital-based observational follow-up study.
Setting: Internal Medicine Service of the Aga Khan University Hospital, Pakistan, from 26 February 2020 to 30 June 2020.
Participants: Adult patients with confirmed COVID-19, aged ≥18 years.
Methods: ALC was categorised into low, intermediate and high level and patients were triaged using the standard emergency severity illness score. All patients were followed until the end of hospital admission for the outcome of case fatality and …

Improving Time To Defibrillation At Thomas Jefferson University Hospital, Sairamya Bodempudi, Md, Lisa Wus, Dnp, Rn, Crnp, Pccn-Cmc, Juergen Kloo, Md, Patrick Zeniecki, Ma, Frances Mae West, Md, Yair Lev, Md

Health Equity and Quality Improvement (HEQI) Summit

Aims for Improvement

• Increase in timely defibrillation by 30% over 1 year
• Decrease in the amount of Vfib/VTach cardiac arrests that are not defibrillated to <1% within a 1 year time frame

Preventing Iatrogenic Pneumothorax “Just-In-Time”, Jason Ho, Md, Ammar Saati, Md, Ryan Commins, Md, Justin Henneman, Md, Frances Mae West, Md

Health Equity and Quality Improvement (HEQI) Summit

• In 2020 a high incidence of iatrogenic pneumothorax was noticed at TJUH after internal jugular central line insertion - Accepted rate is 0.1%
• With long periods of time between ICU rotations, residents suffer from significant procedural skill decay
• The COVID-19 pandemic brought with it an increase in the number of central lines placed
• During the COVID-19 pandemic, there has been a lack of large group training opportunities due to social distancing constraints

By December 31st 2021, our intervention will improve rates of iatrogenic pneumothorax after US-guided internal jugular central line insertion by 50% of baseline, as measured by chart review …

The “Ok” Guideline: Implementing An Electronic Electrolyte Repletion Guideline For Improving Rates Of Oral Potassium And Magnesium Delivery, Joshua M. Riley, Jeffrey M. Riggio, Md, Alan A. Kubey, Md

Health Equity and Quality Improvement (HEQI) Summit

Nearly 500,000 doses of potassium (K) and magnesium (Mg) are given at Thomas Jefferson University Hospital (TJUH) each year. More than 80% of these doses are given intravenously.

Guidelines that encourage both intravenous and oral (PO) repletion options increase rates of PO dosing and more successfully attain goal levels than standard care.

Our goal was to increase the percent of K and Mg doses delivered by oral route to >50% of total doses distributed at TJUH within one year of implementation of an Epic-based electronic order set.

Improving Advanced Care Planning Discussion And Documentation, Justin Robbins, Md, Bharaniabirami Rajaram, Md, Patrick Kukulich, Md, Danielle Verghese, Md, Dianna Cheney-Peters, Md

Health Equity and Quality Improvement (HEQI) Summit

Our goal is to improve ACP discussion and documentation in patients above the age of 65 in our Jefferson Hospital Ambulatory Practice (JHAP) resident clinic. By instituting procedural changes within the EMR and the clinic, as well as improving provider education, we hope that residents can carry out a comprehensive and streamlined discussion regarding advanced care planning. We will institute these changes over the next 3 months, and we predict that there will be an increase in ACP discussion and uploading of appropriate documentation to 50% and 25%, respectively.

Improving Colon Cancer Screening Rates In An Ambulatory Resident Clinic, Ashima Oza, Md, Tina Boortalary, Md, Elizabeth Chin, Md, Tudor Sturzoiu, Md, John Wallis, Md, Sonia Bharel, Md

Health Equity and Quality Improvement (HEQI) Summit

In the US, colorectal cancer (CRC) is the third leading cause of cancer-related deaths. According to the 2018 CDC Behavioral Risk Factor Surveillance System survey, 68.8% of US adults between 50 and 75 were up to date on colorectal screening (CRCS) across all screening modalities. In light of the COVID-19 pandemic, screening has dropped even further and is still 50% below pre-pandemic levels. At Jefferson, our CRCS rate is below the national average at 55.4%. Given the importance of regular screening for CRC prevention, this is clearly inadequate. There are several barriers to completing an invasive screening modality like a …

Improving Rates Of Nephrology Referral For Patients With Chronic Kidney Disease In Resident Clinic, Akanksha Arya, Md, Rabia Iqbal, Md, Rahed Mohammed, Md, Neveda Murugesan, Md, Jillian Zavodnick, Md

Health Equity and Quality Improvement (HEQI) Summit

• According to the KDIGO (Kidney Disease Improving Global Outcomes), evaluation by a nephrologist is recommended for patients with CKD stage 4 or higher (corresponding to a GFR of 30 or lower).
• Studies have shown that patients who are not referred to a nephrologist or referred later suffer from increased complications of renal disease, accelerated progression to ESRD, and have an increased overall mortality rate.
• At Jefferson Hospital Ambulatory Practice (JHAP), we noted decreased rates of nephrology follow-up in our patients with chronic kidney disease stage 4 and 5.
• We identified that the most prevalent reason for the decreased referral rates …

Sepsis In Two Hospitals In Rwanda: A Retrospective Cohort Study Of Presentation, Management, Outcomes, And Predictors Of Mortality., Dennis A Hopkinson, Jean Paul Mvukiyehe, Sudha P Jayaraman, Aamer A Syed, Myles Dworkin, Willy Mucyo, Thierry Cyuzuzo, Anne Tuyizere, Christian Mukwesi, Gaston Nyirigira, Paulin R Banguti, Elisabeth D Riviello

Student Papers, Posters & Projects

PURPOSE: Few studies have assessed the presentation, management, and outcomes of sepsis in low-income countries (LICs). We sought to characterize these aspects of sepsis and to assess mortality predictors in sepsis in two referral hospitals in Rwanda.

MATERIALS AND METHODS: This was a retrospective cohort study in two public academic referral hospitals in Rwanda. Data was abstracted from paper medical records of adult patients who met our criteria for sepsis.

RESULTS: Of the 181 subjects who met eligibility criteria, 111 (61.3%) met our criteria for sepsis without shock and 70 (38.7%) met our criteria for septic shock. Thirty-five subjects (19.3%) …

Get America Talking: Implementing Advanced Care Planning In Primary Care, Sasha Recht

Doctor of Nursing Practice Final Manuscripts

Advanced Care Planning (ACP) is an essential part of providing adequate care in the primary care setting. Discussing end of life with patients can be a tedious and uncomfortable conversation for many providers, however, its continued avoidance contributes to the stigma of end of life care and may also result in significant healthcare cost expenditure with the use of unwanted invasive treatments. All providers should engage in consistent advanced care planning in order to improve patient and provider communication, improve patient satisfaction, increase advanced directives on file, reduce the stigma of the topic, and improve quality of life.

Anal Cancer Screening At Truman Health Services, Peter D. Tran, Harshdeep Babbar

Quality Improvement/Patient Safety Symposium

Anal Papanicoloau Screening at Truman Clinic

Anal cancer is a squamous cell cancer associated with human papillomavirus (HPV), the same virus that is associated with cervical cancer. Although vaccination against HPV has been shown to be effective in reducing overall rates of infection, the number of new anal cancer cases has been rising for many years. In HIV-infected men and women, the incidence is even higher of anal cancer than in the general population. Current rates in an HIV-infected MSM population have been estimated to be as high as 70-144 per 100,000, with some studies of HIV-infected individuals showing that …

Can An Amino Acid Mixture Alleviate Gastrointestinal Symptoms In Neuroendocrine Tumor Patients?, Aman Chauhan, Satya Das, Rachel Miller, Laura Luque, Samuel N. Cheuvront, James Cloud, Zach Tarter, Fariha Siddiqui, Robert A. Ramirez, Lowell B. Anthony

Internal Medicine Faculty Publications

Background: Neuroendocrine tumors, although relatively rare in incidence, are now the second most prevalent gastrointestinal neoplasm owing to indolent disease biology. A small but significant sub-group of neuroendocrine tumor patients suffer from diarrhea. This is usually secondary to carcinoid syndrome but can also be a result of short gut syndrome, bile acid excess or iatrogenic etiologies. Recently, an amino acid based oral rehydration solution (enterade® Advanced Oncology Formula) was found to have anti-diarrheal properties in preclinical models.

Methods: A retrospective chart review of all NET patients treated with enterade® AO was performed after IRB approval.

Results: Ninety-eight NET patients who …

Pi3k/Mtor Dual Inhibitor Pf-04691502 Is A Schedule-Dependent Radiosensitizer For Gastroenteropancreatic Neuroendocrine Tumors, Zeta Chow, Jeremy Johnson, Aman Chauhan, Tadahide Izumi, Michael Cavnar, Heidi L. Weiss, Courtney M. Townsend Jr., Lowell B. Anthony, Carrigan Wasilchenko, Matthew L. Melton, Jörg Schrader, B. Mark Evers, Piotr G. Rychahou

Markey Cancer Center Faculty Publications

Patients with advanced-stage gastroenteropancreatic neuroendocrine tumors (GEP-NETs) have a poor overall prognosis despite chemotherapy and radiotherapy (e.g., peptide receptor radionuclide therapy (PRRT)). Better treatment options are needed to improve disease regression and patient survival. The purpose of this study was to examine a new treatment strategy by combining PI3K/mTOR dual inhibition and radiotherapy. First, we assessed the efficacy of two PI3K/mTOR dual inhibitors, PF-04691502 and PKI-402, to inhibit pAkt and increase apoptosis in NET cell lines (BON and QGP-1) and patient-derived tumor spheroids as single agents or combined with radiotherapy (XRT). Treatment with PF-04691502 decreased pAkt (Ser473) expression for up …

A Metabolomic Endotype Of Bioenergetic Dysfunction Predicts Mortality In Critically Ill Patients With Acute Respiratory Failure, Raymond J. Langley, Marie E. Migaud, Lori Flores, J. Will Thompson, Elizabeth A. Kean, Murphy M. Mostellar, Matthew Mowry, Patrick Luckett, Lina D. Purcell, James Lovato, Sheetal Gandotra, Ryan Benton, D. Clark Files, Kevin S. Harrod, Mark N. Gillespie, Peter E. Morris

Internal Medicine Faculty Publications

Acute respiratory failure (ARF) requiring mechanical ventilation, a complicating factor in sepsis and other disorders, is associated with high morbidity and mortality. Despite its severity and prevalence, treatment options are limited. In light of accumulating evidence that mitochondrial abnormalities are common in ARF, here we applied broad spectrum quantitative and semiquantitative metabolomic analyses of serum from ARF patients to detect bioenergetic dysfunction and determine its association with survival. Plasma samples from surviving and non-surviving patients (N = 15/group) were taken at day 1 and day 3 after admission to the medical intensive care unit and, in survivors, at hospital discharge. …

Efficacy Of Half-Day Workshops For Internal Medicine Interns In Educating Breaking-Bad-News Discussions, Colin Thomas, Christine Kurian, Sarah Houtmann, Neil D. Palmisiano

Division of Internal Medicine Faculty Papers & Presentations

Background: Adequate end-of-life (EOL) care/breaking-bad-news (BBN) discussions with patients are becoming increasingly essential to adequate patient care. Purpose: Whether a half-day workshop would lead to improved confidence in EOL/BBN care discussions for internal medicine interns. Methods: Internal medicine interns (n = 43) were assigned to participate in a half-day workshop at Thomas Jefferson University Hospital. The workshop involved two standardized patient (SP) interactions involving delivering news of a terminal illness/initiating goals of care discussion with the intervention of SP feedback, a didactic and lecture on proper EOL/BBN discussion. Voluntary anonymous surveys before and after the workshop were utilized to …

“Nut” An Anatomical Malignancy! A Solid Tumor Characterized By A Genetic Translocation, Bana Antonios, Ruby Gupta, Nwabundo Anusim, Markie Zimmer, Emma Herrman, Ishmael Jaiyesimi

Conference Presentation Abstracts

NUT midline carcinomas are rare poorly differentiated tumors driven by t(15,19) rearrangements and clinically characterized by rapid progression and high mortality. A 49 year-old-male with no comorbidities, presented with acute worsening of chronic cough, new onset hemoptysis and left sided chest pain for 2 weeks. Workup revealed NUT midline carcinoma of the lung as confirmed by next-generation sequencing that revealed the presence of a NUTM1-BRD4 fusion. He was diagnosed with NUT midline lung cancer clinical stage IIIB. The tumor was not amenable to surgical resection, therefore, he was started on concurrent chemoradiation with weekly carboplatin and paclitaxel for 5 weeks. …

Type 1 Cryoglobulinemia Secondary To Primary Plasma Cell Leukemia, Antonio Faieta, Khatoon Tawhida

Conference Presentation Abstracts

Primary plasma cell leukemia (pPCL) is a rare and aggressive form of plasma cell dyscrasia that comprises 1% of the plasma cell dyscrasias. Even more rare is its association with type 1 cryoglobulinemia which management can be challenging. A 63-year-old African American male with no past medical history presented with severe burning pain in his legs, necrotizing rash, constitutional symptoms and severe acute kidney injury (AKI). HIV, hepatitis B and C were negative. Serum electrophoresis revealed an M-spike of 5.67, IgG of 7000, free lambda of 152.10 with a K/L of 0 and cryoglobulin of 81%. CT revealed extensive lytic …

Rare Case Of Recurrent Hyperhemolysis Syndrome (Hhs) And Methemoglobinemia In A Patient With Sickle Cell Anemia, Ashbina Pokharel, Pradeep Khanal, Dilip Khanal, Samikshya Pandey, Bipin Ghimire

Conference Presentation Abstracts

Hyperhemolysis syndrome (HHS) is a rare but serious and potentially life-threatening complication of red blood cell (RBC) transfusion and has been described in both sickle cell disease and non-sickle cell disease patients. It is characterized by destruction of both donor and host RBC. Methemoglobinemia is another rare condition leading to cyanosis, tissue hypoxia and potentially death. We present a middle-aged female with sickle cell anemia who developed methemoglobinemia and hyperhemolysis after a surgical procedure. 41 yo female with sickle cell anemia (SC type) was hospitalized for elective right total hip resection arthroplasty. Patient received 3 units blood transfusion during the …

Very Late Relapse Of Hodgkin Lymphoma 18 Years After Remission, Bana Antonios, Markie Zimmer, Emma Herrman, Shiva Shrotriya, Ishmael Jaiyesimi

Conference Presentation Abstracts

A 72-year-old male with a history of protein C and protein S deficiency, factor V Leiden mutation, DVT/PE, and stage IIIB nodular sclerosis Hodgkin lymphoma (diagnosed 18 years back) presented with shortness of breath. EKG showed complete heart block and a transvenous pacemaker was placed. Laboratory studies showed severe normocytic anemia with hemoglobin of 6.2 g/dL, WBC of 2.6 bil/L, platelets of 113 bil/L, and INR of 2.8. The direct antiglobulin test was positive for Anti-IgG and negative for Anti-C3D. LDH was normal and haptoglobin was elevated, contrary to hemolysis. Computed tomographic scan of the abdomen and pelvis showed extensive …

Potts Puffy Tumor: A Rare Complication Of Rhinosinusitis, Bipin Ghimire, Omar Jameel, Sumesh Khanal, Ryan Owen, Ashbina Pokharel, Samiksha Pandey

Conference Presentation Abstracts

Pott's puffy tumor is a sub-periosteal abscess of the frontal bone with associated osteomyelitis. It arises as a complication of untreated or partially treated frontal sinusitis. Overall prevalence has decreased due to timely treatment with antibiotics. It is largely limited to the pediatric population and is rare in adults. A 46-year-old Caucasian male with a history of chronic rhinosinusitis presented with one-week history of progressive painful swelling over the left forehead without any other systemic signs of infection. He was started on intravenous ampicillin-sulbactam and given one dose of dexamethasone due to concern for intracranial involvement. Facial CT showed 3 …