Internal Medicine Commons^™

A Pedunculated Skin Lesion In A Case Of Clear Cell Renal Carcinoma, Meghana Kesireddy, Amit Correa, Raoul Correa, Rohit Venkatesan

Faculty & Staff Scholarship

Clear cell type renal carcinoma accounts for about 80% of all renal cell carcinomas. We present a 39-year-old male with clear cell renal carcinoma of the right kidney, stage I: T1 b (5 cm) N0 M0, who developed cutaneous metastases in the right submandibular region 28 months after nephrectomy. Our case is unique as i) the patient with stage I cancer (at the time of nephrectomy) presented with an isolated cutaneous nodule in a location distant from the primary site; ii) cutaneous nodule developed while being treated with pazopanib for metastatic lesions in the lung and adrenal; and iii) nivolumab …

Trial Sequential Analysis Comparing Bleeding And Major Adverse Cardiovascular Events In Patients With Atrial Fibrillation And Acute Coronary Syndrome On Dual Versus Triple Therapy, Muhamad B. Munir, Khansa Osman, Maryam Saleem, Kinjan Patel, Sudarshan Balla

Faculty & Staff Scholarship

Objective To assess efficacy and safety of dual therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI) and evaluate the quality of evidence with respect to said outcomes based on contemporary randomized trials (RCTs). The efficacy outcome taken was major adverse cardiovascular events (MACE) while safety outcome was major bleeding events. Introduction Appropriate anti-thrombotic therapy is still controversial in patients with AF and concomitant ACS or PCI. We conducted a conventional meta-analysis pooling data from major RCTs to assess the efficacy and safety of DT …

Story Of An Unfortunate Fall: Cardiac Contusion Presenting With An Atrioventricular Block, Maryam Saleem, Fatima Ahmed, Kinjan Patel, Muhamad B. Munir, Mary Warden

Faculty & Staff Scholarship

Blunt cardiac injury (BCI), also referred to in the literature as a cardiac contusion, is a known cause of myocardial injury. It is often challenging to diagnose this condition in the absence of clear diagnostic criteria. Furthermore, its clinical presentation is highly variable depending on the severity, type, and duration of the trauma, as well as the timing from the initial insult. The clinical manifestation of BCI ranges from none to fatal arrhythmias to cardiac wall rupture seen on post-mortem examination. Cardiac biomarkers and electrocardiograms (EKG) are usually helpful in identifying cardiac trauma but are not necessarily abnormal in all …

Adaptive Design Of A Clinical Decision Support Tool: What The Impact On Utilization Rates Means For Future Cds Research, D. Mann, R. Hess, T. Mcginn, R. Mishuris, S. Chokshi, L. Mccullagh, P. D. Smith, J. Palmisano, S. Richardson, D. A. Feldstein

Journal Articles

© The Author(s) 2019. OBJECTIVE: We employed an agile, user-centered approach to the design of a clinical decision support tool in our prior integrated clinical prediction rule study, which achieved high adoption rates. To understand if applying this user-centered process to adapt clinical decision support tools is effective in improving the use of clinical prediction rules, we examined utilization rates of a clinical decision support tool adapted from the original integrated clinical prediction rule study tool to determine if applying this user-centered process to design yields enhanced utilization rates similar to the integrated clinical prediction rule study. MATERIALS & METHODS: …

Improving Provider Adoption With Adaptive Clinical Decision Support Surveillance: An Observational Study, S. Khan, S. Richardson, A. Liu, V. Mechery, L. Mccullagh, A. Schachter, S. Pardo, T. Mcginn

Journal Articles

© Sundas Khan, Safiya Richardson, Andrew Liu, Vinodh Mechery, Lauren McCullagh, Andy Schachter, Salvatore Pardo, Thomas McGinn. Background: Successful clinical decision support (CDS) tools can help use evidence-based medicine to effectively improve patient outcomes. However, the impact of these tools has been limited by low provider adoption due to overtriggering, leading to alert fatigue. We developed a tracking mechanism for monitoring trigger (percent of total visits for which the tool triggers) and adoption (percent of completed tools) rates of a complex CDS tool based on the Wells criteria for pulmonary embolism (PE). Objective: We aimed to monitor and evaluate the …

Small Septal Branch Artery Thrombus Inducing Ventricular Fibrillation: To Intervene Or Not To Intervene, V. Agarwal, P. C. Olson, J. Mroue, Y. Olkovsky, S. Bekheit, J. Lafferty

Journal Articles

© The Author(s) 2019. A 64-year-old woman presented for chest pain and was diagnosed with anteroseptal ST segment elevation myocardial infarction (STEMI). Emergent angiography showed 95% stenosis at the ostium of the second septal branch, consistent with thrombus, and no other significant lesions. The lesion was not amenable to intervention due to small caliber. Post angiography, the patient’s electrical rhythm deteriorated into ventricular fibrillation. Following resuscitation, repeat angiography confirmed same findings. Electrophysiology study at 3 months was positive for inducing fibrillation. Due to patient risk factors, she had placement of a dual chamber defibrillator. A 5-month follow-up echocardiogram showed a …

Anti-N-Methyl-D-Aspartate Receptor Encephalitis Triggered By Emotional Stress, C. A. Obi, E. Thompson, L. Mordukhaev, I. Khan, N. J. Zhang

Journal Articles

© 2019, Copyright © 2019 Baylor University Medical Center. A 22-year-old woman presented with disorganized behaviors, restlessness, and subacute decline in mental status in the setting of stress. Extensive workup for autoimmune diseases disclosed positive anti-N-methyl-d-aspartate (NMDA) receptor antibodies. We recommend that fertility preservation should be discussed and stress management should be considered in patients with a history of anti-NMDA autoimmune encephalitis because this can help in preventing relapse.

Quantifying Patient Satisfaction With Process Metrics Using A Weighted Bundle Approach., N. B. Riebling, S. Norouzzadeh, G. Reeder, C. Mouradian, A. Hillier, R. Cowan, M. Doerfler

Journal Articles

Background:Current patient satisfaction assessment results are delayed and obtained from select patient surveys. As a result, these assessments may not represent the experience of the entire patient population. This study developed a method to measure and evaluate all patients' experiences while they are within the care episode and link it to processes within the organisation. Methods:Using the Six Sigma methodology, sites assembled diverse teams to categorise and analyse negative experience comments from patients to understand the drivers of dissatisfaction. These customer expectations lead to the development of the four components in the Patient Experience Bundle (PEB): communication, environment, basic needs/comfort …

Medical Education Using Minimal Technology: Achieving Professional Development, K. A. Friedman, S. W. Herman, A. Fornari

Journal Articles

No abstract provided.

A Novel Curriculum To Prepare Internal Medicine Residents For Fellowship Interviews., M. Sinclair, J. Raimo, K. Wong, M. Kline, K. Friedman

Journal Articles

Background:Applications to the Fellowship Match through the National Resident Matching Program (NRMP) Specialties Matching Service (SMS) are at an all-time high. Data regarding the preparedness of medical residents who go through the interview process is limited. Objective:To assess whether the implementation of an interview curriculum could improve medical resident preparedness for and performance during fellowship interviews. Methods:All third-year internal medicine residents (N = 18) at the Zucker School of Medicine at Hofstra/Northwell (Northwell) applying to subspecialty fellowship participated in an interview curriculum that comprised a didactic session and an Objective Structured Teaching Exercise (OSTE). Participants were surveyed on preparedness before …

Live Usability Testing Of Two Complex Clinical Decision Support Tools: Observational Study, S. Richardson, D. Feldstein, T. Mcginn, L. S. Park, S. Khan, R. Hess, P. D. Smith, R. G. Mishuris, L. Mccullagh, D. Mann

Journal Articles

© 2019 Journal of Medical Internet Research. All rights reserved. Background: Potential of the electronic health records (EHR) and clinical decision support (CDS) systems to improve the practice of medicine has been tempered by poor design and the resulting burden they place on providers. CDS is rarely tested in the real clinical environment. As a result, many tools are hard to use, placing strain on providers and resulting in low adoption rates. The existing CDS usability literature relies primarily on expert opinion and provider feedback via survey. This is the first study to evaluate CDS usability and the provider-computer-patient interaction …

Adult Onset Morgagni Hernia: Medical Vs. Surgical Management., A. Elfiky, D. Daneshvar, M. Krzyzak, I. Mukherjee

Journal Articles

Morgagni hernia is a type of diaphragmatic hernia where bowel content herniates through an irregular opening into the thoracic cavity. Herein, we present the case of an 84-year-old female patient with multiple hospital admissions for abdominal symptoms. Radiological studies confirmed Morgagni hernia. She underwent a laparoscopic intervention with mesh placement. She was discharged in stable condition and was doing well on follow-up.

Developmental Subtypes Assessed By Dna Methylation-Iplex Forecast The Natural History Of Chronic Lymphocytic Leukemia, B. Giacopelli, Q. Zhao, A. S. Ruppert, A. Agyeman, C. Weigel, Y. Z. Wu, M. M. Gerber, K. G. Rabe, K. R. Rai, C. C. Oakes, +16 Additional Authors

Journal Articles

© 2019 by The American Society of Hematology Alterations in global DNA methylation patterns are a major hallmark of cancer and represent attractive biomarkers for personalized risk stratification. Chronic lymphocytic leukemia (CLL) risk stratification studies typically focus on time to first treatment (TTFT), time to progression (TTP) after treatment, and overall survival (OS). Whereas TTFT risk stratification remains similar over time, TTP and OS have changed dramatically with the introduction of targeted therapies, such as the Bruton tyrosine kinase inhibitor ibrutinib. We have shown that genome-wide DNA methylation patterns in CLL are strongly associated with phenotypic differentiation and patient outcomes. …

Predictors Of Overtesting In Pulmonary Embolism Diagnosis, S. Richardson, E. Lucas, S. Cohen, M. Zhang, G. Qiu, S. Khan, T. Mcginn

Journal Articles

© 2019 Background: The benefits of computed tomography pulmonary angiography (CTPA) for pulmonary embolism (PE) diagnosis must be weighed against its risks, radiation-induced malignancy, and contrast-induced nephropathy. Appropriate use of CTPA can be assessed by monitoring yield, the percentage of tests positive for PE. We identify factors that are associated low CTPA yield, which may predict overtesting. Methods: This was a retrospective cohort study of six emergency departments between June 2014 and February 2017. The electronic health record was queried for CTPAs ordered for adult patients in the emergency department. We assessed the following patient factors: age, gender, body mass …

Long-Term Safety Of Single-Agent Ibrutinib In Patients With Chronic Lymphocytic Leukemia In 3 Pivotal Studies, S. E. Coutre, J. C. Byrd, P. Hillmen, J. C. Barrientos, P. M. Barr, S. Devereux, T. Robak, T. J. Kipps, A. Schuh, S. M. O’Brien, +9 Additional Authors

Journal Articles

© 2019 by The American Society of Hematology Ibrutinib, a first-in-class once-daily oral Bruton tyrosine kinase inhibitor indicated for chronic lymphocytic leukemia (CLL), is continued until progressive disease or unacceptable toxicity. We conducted an integrated safety analysis of single-agent ibrutinib from randomized phase 3 studies PCYC-1112 (RESONATE, n 5 195) and PCYC-1115/1116 (RESONATE-2, n 5 135), and examined longer-term safety separately in the phase 1b/2 PCYC-1102/1103 study (n 5 94, 420 mg/d). In the integrated analysis (ibrutinib treatment up to 43 months), the most common adverse events (AEs) were primarily grade 1/2; diarrhea (n 5 173, 52% any-grade; n 5 …

Which Clinical And Biochemical Predictors Should Be Used To Screen For Diabetes In Patients With Serious Mental Illness Receiving Antipsychotic Medication? A Large Observational Study, A. J. Mitchell, D. Vancampfort, P. Manu, C. U. Correll, M. Wampers, R. Van Winkel, W. Yu, M. De Hert

Journal Articles

© 2019 Mitchell et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Objective We aimed to investigate which clinical and metabolic tests offer optimal accuracy and acceptability to help diagnose diabetes among a large sample of people with serious mental illness in receipt of antipsychotic medication. Methods A prospective observational study design of biochemical and clinical factors was used. Biochemical measures were fasting glucose, insulin and lipids, oral glucose tolerance testing (OGTT), hemoglobin …

The High Cost Of Low Value Care, T. Mcginn, S. Cohen, S. Khan, S. Richardson, M. Oppenheim, J. Wang

Journal Articles

The main focus of this study is bridging the "evidence gap" between frontline decision-making in health care and the actual evidence, with the hope of reducing unnecessary diagnostic testing and treatments. From our work in pulmonary embolism (PE) and over ordering of computed tomography pulmonary angiography, we integrated the highly validated Wells' criteria into the electronic health record at two of our major academic tertiary hospitals. The Wells' clinical decision support tool triggered for patients being evaluated for PE and therefore determined a patients' pretest probability for having a PE. There were 12,759 patient visits representing 11,836 patients, 51% had …

Correction: Posttraumatic Stress Disorder Prevalence And Risk Of Recurrence In Acute Coronary Syndrome Patients: A Meta-Analytic Review., D. Edmondson, S. Richardson, L. Falzon, K. W. Davidson, M. A. Mills, Y. Neria

Journal Articles

© 2019 Edmondson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. There are a number of errors in the citations in Table 1. Please see the correct Table 1 here. (Table presented).

Recruitment Via Social Media: Advantages And Potential Biases, C. Benedict, A. L. Hahn, M. A. Diefenbach, J. S. Ford

Journal Articles

© The Author(s) 2019. Background: Adolescent and young adult (AYA) cancer survivors are under-represented in research. Social media is increasingly used for recruitment given its ability to reach large audiences. Differences in participant characteristics and potential biases due to recruitment source are not well understood. Purpose: This study aimed to: (a) compare recruitment strategies (hospital-based v. social media) in enrollment metrics, and (b) among enrolled participants, evaluate group differences in patient characteristics and patient reported outcomes (PROs). Methods: Preliminary data from a cancer and fertility study with female AYAs were evaluated. Hospital-based recruitment used electronic medical records (EMR) to identify …

Behavioral Economics Implementation: Regret Lottery Improves Mhealth Patient Study Adherence., S. A. Husain, K. Diaz, J. E. Schwartz, F. E. Parsons, M. M. Burg, K. W. Davidson, I. M. Kronish

Journal Articles

Background: Nonadherence to study protocols reduces the generalizability, validity, and statistical power of longitudinal studies.

Purpose: To determine whether an automated electronically-delivered regret lottery would improve adherence to an intensive mHealth self-monitoring protocol as part of a longitudinal observational study.

Methods: We enrolled 77 adults into a 52-week study requiring five daily ecologic momentary assessments (EMA) of stress and daily accelerometer use. We performed a pre/post single-arm study to evaluate the efficacy of a lottery intervention in improving adherence to this protocol. Midway through the study, participants were invited to enter a weekly regret lottery ($50 prize, expected value

Results: …