Internal Medicine Commons^™

Primary Billiary Cirrhosis (Antimitochondrial Antibody Negative) Leading To Secondary Amyloidosis, Om Parkash, Aysha Almas

Department of Medicine

A 49 years old lady presented with low-grade fever (99-100°F) for 2 years. During this time she was extensively worked-up for pyrexia of unknown origin but no diagnosis could be established. Her Initial blood work-up was all negative except high alkaline phosphatase and gamma GT (374 IU and 195 IU respectively). She later presented to our tertiary care centre with facial swelling, flushing and bilateral pedal swelling for 3 months. Along with generalized body swelling she had frothy urine. She was diagnosed as nephrotic syndrome on the basis of nephrotic range proteinuria. Her Renal biopsy done for workup of nephrotic …

Primary Billiary Cirrhosis (Antimitochondrial Antibody Negative) Leading To Secondary Amyloidosis, Om Parkash, Aysha Almas

Section of Gastroenterology

A 49 years old lady presented with low-grade fever (99-100degreesF) for 2 years. During this time she was extensively worked-up for pyrexia of unknown origin but no diagnosis could be established. Her Initial blood work-up was all negative except high alkaline phosphatase and gamma GT (374 IU and 195 IU respectively). She later presented to our tertiary care centre with facial swelling, flushing and bilateral pedal swelling for 3 months. Along with generalized body swelling she had frothy urine. She was diagnosed as nephrotic syndrome on the basis of nephrotic range proteinuria. Her Renal biopsy done for workup of nephrotic …

Primary Care Providers’ Perspectives On Online Weight-Loss Programs: A Big Wish List, Kevin O Hwang, Heather L Stuckey, Monica C Chen, Jennifer L Kraschnewski, Samuel N Forjuoh, Jennifer M Poger, Kathleen M Mctigue, Christopher N Sciamanna

Faculty, Staff and Student Publications

BACKGROUND: Integrating online weight-loss programs into the primary care setting could yield substantial public health benefit. Little is known about primary care providers' perspectives on online weight-loss programs.

OBJECTIVE: To assess primary care providers' perspectives on online weight-loss programs.

METHODS: We conducted focus group discussions with providers in family medicine, internal medicine, and combined internal medicine/pediatrics in Texas and Pennsylvania, USA. Open-ended questions addressed their experience with and attitudes toward online weight-loss programs; useful characteristics of existing online weight-loss programs; barriers to referring patients to online weight-loss programs; and preferred characteristics of an ideal online weight-loss program. Transcripts were analyzed …

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

BACKGROUND: Acute coronary syndromes (ACS; myocardial infarction or unstable angina) can induce posttraumatic stress disorder (PTSD), and ACS-induced PTSD may increase patients' risk for subsequent cardiac events and mortality.

OBJECTIVE: To determine the prevalence of PTSD induced by ACS and to quantify the association between ACS-induced PTSD and adverse clinical outcomes using systematic review and meta-analysis.

DATA SOURCES: Articles were identified by searching Ovid MEDLINE, PsycINFO, and Scopus, and through manual search of reference lists.

METHODOLOGY/PRINCIPAL FINDINGS: Observational cohort studies that assessed PTSD with specific reference to an ACS event at least 1 month prior. We extracted estimates of the …

An Incidentally Discovered Asymptomatic Para-Aortic Paraganglioma With Peutz-Jeghers Syndrome, Nazish Butt, Mohammad Salih, Mohammad Rizwan Khan, Rashida Ahmed, Zishan Haider, Syed Hasnain Ali Shah

Section of Internal Medicine

Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder characterized by mucocutaneous melanin pigmentation and gastrointestinal (GI) tract hamartomatous polyps and an increased risk of malignancy. In addition to polyposis, previous studies have reported increased risk of GI and extraGI malignancies in PJS patients, compared with that of the general population. The most common extraintestinal malignancies reported in previous studies are pancreatic, breast, ovarian and testicular cancers.We report the case of a 17-year-old boy who presented with generalized weakness, recurrent sharp abdominal pain and melena, had exploratory laparotomy and ileal resection for ileo-ileal intussusception. Pigmentation of the buccal mucosa was …

Intracranial Pressure Is A Better Predictor Of Mortalitythan Cerebral Perfusion Pressure, Ronald J. Markert, Jonathan M. Saxe, Cathryn L. Chadwick

Internal Medicine Faculty Publications

Objective: To evaluate whether elevated intracranial pressure (ICP) or depressed cerebral perfusion pressure (CPP) is a better predictor of intracranial compartment syndrome and long-term functional outcomes in blunt traumatic brain injury.

Methods: This was a retrospective evaluation of data collected on 203 patients with blunt traumatic brain injury who were admitted to Miami Valley Hospital, a Level I trauma center, over a 2 years period, whose initial hospital management required an intracranial pressure monitor. Serial measurements of ICP and CPP were recorded during the patients’ hospital stay. These patients were then evaluated at 3,6,12 and 24 months post-injury to assess …

Effect Of A Physician Uncertainty Reduction Intervention On Blood Pressure In Uncontrolled Hypertensives-A Cluster Randomized Trial, David J. Hyman, Valory N. Pavik, Anthony J. Greisinger, Wenyaw Chan, Jose Bayona, Carol Mansyur, Victor Simjms, James Pool

Community & Environmental Health Faculty Publications

BACKGROUND: Clinical inertia, provider failure to appropriately intensify treatment, is a major contributor to uncontrolled blood pressure (BP). Some clinical inertia may result from physician uncertainty over the patient’s usual BP, adherence, or value of continuing efforts to control BP through lifestyle changes.

OBJECTIVE: To test the hypothesis that providing physicians with uncertainty reduction tools, including 24-h ambulatory BP monitoring, electronic bottle cap monitoring, and lifestyle assessment and counseling, will lead to improved BP control.

DESIGN: Cluster randomized trial with five intervention clinics (IC) and five usual care clinics (UCC).

SETTING: Six public and 4 private primary care clinics.

PARTICIPANTS: …

Physician Review Of Workers' Compensation Case Files: Can It Affect Decision Outcomes?, Mark E. Hammett, Christopher Jankosky, John Muller, Elizabeth Hughes, Francesca Litow

Community & Environmental Health Faculty Publications

Objective: To identify common attributes of Federal workers compensation cases referred to Navy physicians for medical opinions and to determine the impact of the review on the final case decision. Methods: Retrospective case study and descriptive analysis of 258 opinion letters written by physicians on referred cases from 2006 to 2010. Results: Navy physician opinions were considered in the outcome in some of the cases, and there was a statistically significant difference between the claim acceptance rate in the study population and the total population. Worker age was correlated with certain claim types. Conclusions: There is preliminary evidence that the …

Brain-Computer Interfaces In Medicine, Jerry J. Shih, Dean J. Krusienski, Johnathan R. Wolpaw

Electrical & Computer Engineering Faculty Publications

Brain-computer interfaces (BCIs) acquire brain signals, analyze them, and translate them into commands that are relayed to output devices that carry out desired actions. BCIs do not use normal neuromuscular output pathways. The main goal of BCI is to replace or restore useful function to people disabled by neuromuscular disorders such as amyotrophic lateral sclerosis, cerebral palsy, stroke, or spinal cord injury. From initial demonstrations of electroenceph-alography-based spelling and single-neuron-based device control, researchers have gone on to use electroenceph-alographic, intracortical, electrocorticographic, and other brain signals for increasingly complex control of cursors, robotic arms, prostheses, wheelchairs, and other devices. Brain-computer interfaces …

Theoretically-Driven Infrastructure For Supporting Health Care Teams Training At A Military Treatment Facility, T. Robert Turner Jr., V. Andrea Parodi

VMASC Publications

Designated a Department of Defense Team Resource Center (TRC) in 2008, Naval Medical Center Portsmouth (NMCP) currently hosts three tri-service health care teams training courses annually. Each consists of didactic learning coupled with simulation-based training exercises to provide an interactive educational experience for health care professionals. Simulated cases are developed to reinforce specific teamwork skills and behaviors, and to incorporate a variety of technologies including standardized patients, manikins, and virtual reality. The course is also the foundation of a research program designed to explore applications of modeling and simulation for enhanced team training in health care. The TRC has adopted …

Region 11 Meld Na Exception Prospective Study, Robert A. Fisher, Douglas M. Heuman, Ann M. Harper, Martha K. Behnke, Alastair D. Smith, Mark W. Russo, Steven Zacks, John W. Mcgillicuddy, James Eason, Michael K. Porayko, Patrick Northup, Michael R. Marvin, Johnathan Hundley, Satheesh Nair

Surgery Faculty Publications

Introduction. Hyponatremia complicates cirrhosis and predicts short term mortality, including adverse outcomes before and after liver transplantation.

Material and methods. From April 1, 2008, through April 2, 2010, all adult candidates for primary liver transplantation with cirrhosis, listed in Region 11 with hyponatremia, were eligible for sodium (Na) exception.

Results. Patients with serum sodium (SNa) less than 130 mg/dL, measured two weeks apart and within 30 days of Model for End Stage Liver Disease (MELD) exception request, were given preapproved Na exception. MELD Na was calculated [MELD + 1.59 (135-SNa/30 days)]. MELD Na was capped at 22, and subject to …

Proliferating Tricholemmal Tumour: Clinicopathological Aspects Of A Case., Adeel Khoja, Yan B, Lee Sj, Cheong E. C, Tan K B

Department of Medicine

We report the case of a 49-year-old man who presented with an enlarging mass over his occipital scalp. The clinical impression was either a squamous cell carcinoma or an unusual adnexal tumour. A wide excision was performed with skin grafting. Gross examination revealed a large exophytic tumour mass measuring 10 cm. Histopathological examination showed a circumscribed, well-differentiated squamoproliferative lesion with a lobulated architecture. Clear cell features, pilar-type keratinisation, microcalcifications and the presence of mucinous degeneration were noted. A diagnosis of proliferating tricholemmal tumour was made. This entity incorporates a spectrum of lesions, ranging from the mostly benign proliferating tricholemmal cyst …

White Coat Hypertension Is Not A Benign Entity: A Cross-Sectional Study At A Tertiary Care Hospital In Pakistan, Saniya Siraj Godil, Halima Tabani, Aamir Hameed Khan, Aysha Almas

Department of Medicine

Objectives: To determine the frequency of White Coat Hypertension in patients undergoing ambulatory blood pressure monitoring at a tertiary care center and to compare ambulatory blood pressure profiles of normotensives, white coat hypertensives and hypertensives.
Methods: A descriptive cross-sectional study was conducted which included all adult patients undergoing ambulatory blood pressure monitoring over a 3-year period. Those patients with incomplete data, less than 85% successful BP readings and inadequate number of daytime and nighttime readings were excluded from the study. The data on ambulatory blood pressure monitoring comprised of demographics, blood pressure, pulse pressure and mean arterial pressure readings at …

Polycyclic Aromatic Hydrocarbons In Maternal And Umbilical Cord Blood From Pregnant Hispanic Women Living In Brownsville, Texas, Ken Sexton, Jennifer J Salinas, Thomas J Mcdonald, Rose M Z Gowen, Rebecca P Miller, Joseph B Mccormick, Susan P Fisher-Hoch

Faculty, Staff and Student Publications

Venous blood was drawn from 35 pregnant Hispanic women living in Brownsville, Texas, and matched cord blood was collected at birth. Gas chromatography/mass spectrometry was used to measure concentrations of 55 individual PAHs or groups of PAHs. Results indicate that these women and their fetuses were regularly exposed to multiple PAHs at comparatively low concentrations, with levels in cord blood generally exceeding levels in paired maternal blood. While the possibility of related adverse effects on the fetus is uncertain, these exposures in combination with socioeconomically-disadvantaged and environmentally-challenging living conditions raise legitimate public health concerns.

Preventable Lifestyle Risk Factors For Non-Communicable Diseases In The Pakistan Adolescents Schools Study 1 (Pass-1)., Ali Khan Khuwaja, Saleem Khawaja, Komal Motwani, Adeel Khoja, Iqbal Azam Syed, Zafar Fatmi, Badar Sabir Ali, Muhammad Masood Kadir

Department of Medicine

Objectives: The rising burden of preventable risk factors for non-communicable diseases (NCDs) among adolescents is a major public health challenge worldwide. We identified the preventable risk factors for NCDs in adolescents.

Methods: In a school-based study, pre-tested structured questionnaires were completed by 414 adolescents (14 to 17 years) at six schools in three cities in Pakistan. The chi-squared test and adjusted odds ratio (aOR) with 95% confidence interval (CI) were calculated in a multinomial logistic regression analysis.

Results: Over 80% of the adolescents had unhealthy diets, and 54% were physically inactive. Most adolescents were exposed to passive smoking, and 14% …

Hepatitis B Vaccination Rate And Determining Factors Amongst Health Care Workers At Aga Khan University Hospital, Nairobi, Herman Ekea

Master of Medicine in Internal Medicine

Aim: To determine Hepatitis B vaccination rate and determining factors for health care workers (HCWs) at AKUHN. Design: Cross sectional analytical study Study subjects and setting: Aga Khan University Hospital-Nairobi, is a 254 bed tertiary hospital, with 815 HCWs with occupational risk of infection with hepatitis B virus (HBV). The hospital has a HCW vaccination policy and vaccine available to HCWs as part of medical scheme Methodology: Two hundred and sixty six (266) eligible HCWs of all cadres were stratified then randomly recruited after giving informed consent. A questionnaire was then administered to assess knowledge, attitude and practice towards HBV …

The Influence Of Depression On Adherence To Antiretroviral Therapy Among Hiv Infected Patients At Aga Khan University Hospital (Nairobi), Evelyn W. Karanja-Mbugua

Master of Medicine in Internal Medicine

Aim: To determine the influence of depression on adherence to antiretroviral (ARV) therapy among HIV-infected patients. Design: Cross-sectional survey Patients: One hundred and forty HIV-positive patients on treatment with Combination Antiretroviral Therapy selected from the out-patient department of Aga Khan University Hospital took part in the survey. Methodology: Every third patient who was eligible was assessed for adherence to antiretroviral therapy using The Adult AIDS Clinical Trial Group follow up adherence questionnaire followed by screening for depression using the Patient Health Questionnaire 9. Pharmacy data was then retrieved for the same patients and used to assess adherence by the medication …

Aua Guideline For The Diagnosis And Treatment Of Interstitial Cystitis/Bladder Pain Syndrome, Philip M Hanno, David Allen Burks, J Quentin Clemens, Roger R Dmochowski, Deborah Erickson, Mary Pat Fitzgerald, John B Forrest, Barbara Gordon, Mikel Gray, Robert Dale Mayer, Diane Newman, Leroy Nyberg, Christopher K Payne, Ursula Wesselmann, Martha M Faraday

Faculty, Staff and Student Publications

PURPOSE: To provide a clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome.

MATERIALS AND METHODS: A systematic review of the literature using the MEDLINE® database (search dates 1/1/83-7/22/09) was conducted to identify peer reviewed publications relevant to the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Insufficient evidence-based data were retrieved regarding diagnosis and, therefore, this portion of the Guideline is based on Clinical Principles and Expert Opinion statements. The review yielded an evidence base of 86 treatment articles after application of inclusion/exclusion criteria. These publications were used to create the majority of the treatment portion …

An Evaluation Of The Emerging Interventions Against Respiratory Syncytial Virus (Rsv)-Associated Acute Lower Respiratory Infections In Children, Harish Nair, Vasundhara R. Verma, Evropi Theodoratou, Lina Zgaga, Tanvir Huda, Eric Af Simoes, Peter F. Wright, Igor Rudan, Harry Campbell

Dartmouth Scholarship

Background: Respiratory Syncytial Virus (RSV) is the leading cause of acute lower respiratory infections (ALRI) in children. It is estimated to cause approximately 33.8 million new episodes of ALRI in children annually, 96% of these occurring in developing countries. It is also estimated to result in about 53,000 to 199,000 deaths annually in young children. Currently there are several vaccine and immunoprophylaxis candidates against RSV in the developmental phase targeting active and passive immunization.

Methods: We used a modified CHNRI methodology for setting priorities in health research investments. This was done in two stages. In Stage I, we systematically reviewed …

Multicentric Hepatic Ebv-Associated Smooth Muscle Tumors In An Aids Patient: A Case Report, Investigation Of Mtor Activation And Review Of The Literature, Qi Shen, Wei Feng, Michael S Long, Xiuzhen Duan, Siraya Jaijakul, Cesar A Arias, Robert E Brown, Bihong Zhao

Faculty, Staff and Student Publications

Epstein-Barr virus (EBV) - associated smooth muscle tumors (EBV-SMT) are a rare, recently recognized distinct group of mesenchymal tumors that develop exclusively in patients with immunosuppression. It is believed that tumorigenesis is, at least in part, through the activation of the Akt/mammalian target of rapamycin (mTOR) signal pathway. We describe the clinicopathologic and immunohistochemical features of a multifocal hepatic EBV-SMT in a 34-year-old acquired immunodeficiency syndrome (AIDS) patient and investigate the activation status of the mTOR signal pathway in this tumor. In addition, we provide a review of the literature on the clinicopathologic findings of hepatic EBV-SMT in adult AIDS …