Internal Medicine Commons^™

Lost In Stratification: The Underutilization Of Fib-4-Guided Masld Screening In The Primary Care Setting, Sanjna Shelukar, Md, Ananya Venkatesh, Md, Breanne Mcdermott, Bs, Julietta Gervase, Ba, Maria Winte, Md, Rebecca Loh, Md, Dina Halegoua-De Marzio, Md

The Medicine Forum

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a leading contributor to chronic liver disease worldwide. Early identification of MASLD and hepatic fibrosis in the primary care setting is essential for timely and effective management. The Fibrosis-4 (FIB-4) index is recommended as a first-line, non-invasive tool to screen at-risk patients for advanced fibrosis. This study aims to determine FIB-4 screening rates in at-risk patients in an urban resident-led primary care clinic.

A retrospective chart review was conducted in a single Internal Medicine resident-led primary care clinic. Patients aged 36 to 65 years were included, and FIB-4 scores were calculated. Patients were …

A Clinical Assessment: Counseling Families On Timing Of Colorectal Cancer Screening, Bertilia Tavarez, Md, Hamzah Shariff, Md, Breanne Mcdermott, Bs, Sanjna Shelukar, Md, Limi Jamma, Md, Sonali Shah, Md, Akash Patel, Do, Christopher Henry, Md, Aaron Martin, Md

The Medicine Forum

Colorectal cancer (CRC) remains the second most common cause of cancer mortality in the United States. Current recommendations advise initiating colonoscopy at age 40, or 10 years earlier than the youngest affected first-degree relative (FDR), in individuals with a family history of CRC or advanced polyps (AP). Despite these guidelines, their translation into routine clinical counseling is not well defined. This study examines how often patients with CRC or AP receive guidance about early screening for FDRs.

A retrospective review was performed using electronic health records from an urban academic center. Patients diagnosed with CRC or AP between January 2019 …

Commentary On The Withdrawal-Af Trial And Its Applicability In Select Patient Populations, David Zhang, Md

The Medicine Forum

Segan et al. report that 90% of patients with atrial fibrillation- mediated cardiomyopathy (AFCM) maintained left ventricular ejection fraction (LVEF) ≥50% af ter withdrawing heart failure therapy following successful rhythm control.¹ While these results challenge the current practice of indefinite guideline-directed medical therapy (GDMT) in patients with improved ejection fraction, two important questions remain before these findings can be applied more broadly: which patients are appropriate candidates for withdrawal, and how should they be monitored?

The trial excluded patients with coronary disease, structural heart disease, and AF duration exceeding one year. This approach reveals a fundamental challenge, distinguishing pure …

Sudden Syncope Due To Intra Hisian Block With Severely Prolonged His–Ventricular Interval Diagnosed On Electrophysiology Study, Sheraz Qamar, Md, Meiqi Luo, Md

The Medicine Forum

Syncope is a common cause of emergency department evaluation in older adults, when sudden loss of consciousness without prodromal symptoms raises concern for cardiac etiology. We present this case of an 80 year old woman with a prior history of vasovagal syncope who presented after a collapse. Initial evaluation, including electrocardiogram, telemetry, echocardiogram, and ambulatory monitoring, was unrevealing. Given the high risk clinical features such as lack of prodromal symptoms and sudden collapse, an inpatient electrophysiology (EP) study was pursued and demonstrated severe intra Hisian conduction disease with split His bundle electrograms and a markedly prolonged His–ventricular interval. A permanent …

A Strain On The Heart: The Hidden Threat Of Ventricular Tachycardia, Sheraz Qamar, Md, Meiqi Luo, Md, Naila Ijaz, Md, Behzad Pavri, Md, Facc, Praveen Mehrotra, Md, Facc

The Medicine Forum

Mitral valve prolapse (MVP) is increasingly recognized to have an arrhythmic phenotype associated with ventricular arrhythmias and sudden cardiac death independent of mitral regurgitation severity. Mitral annular disjunction (MAD) is a key structural abnormality implicated in abnormal myocardial mechanics and myocardial fibrosis. We describe a patient with MVP and MAD who developed recurrent non-sustained ventricular tachycardia in association with markedly abnormal basal lateral wall longitudinal strain and progressive myocardial fibrosis on cardiac magnetic resonance imaging. Surgical mitral valve repair performed for MAD resulted in resolution of annular disjunction, improvement in regional myocardial strain, and elimination of ventricular arrhythmias. This case …

Lvad Patient With Delayed Family Involvement Due To Incarceration, J. Marco Cipriaso, Md, Kathleen Mechler, Md

The Medicine Forum

Left ventricular assist device (LVAD) placement requires an extensive support system for success. Patients who are incarcerated face unique challenges in achieving this due to prison rules. We describe a case in which an LVAD patient suffered a massive intracranial hemorrhage, leaving him unable to make his own decisions. Medical teams did not involve his family in admissions for his slow chronic decline, but family were asked to make decisions for him at this acute change causing them significant distress. We advocate that families of incarcerated patients be more routinely involved in provider communications and education related to their chronic …

Isolated Left Ventricle Apical Non-Compaction- A Diagnostic Conundrum, Trisha Sindhu, Md, Ranjita Sengupta, Md

The Medicine Forum

Left ventricular non-compaction (LVNC) cardiomyopathy is a rare myocardial disorder characterized by abnormal morphogenesis of the left ventricle (LV). It is typically associated with additional cardiac abnormalities and is most often diagnosed in childhood.¹ We present a unique case of isolated LVNC in a 42-year-old, physically active African American police officer. This case highlights an uncommon presentation of LVNC and underscores the variable specificity of current diagnostic criteria across diverse patient populations.³

A Dose Of Trouble: A Case Of Furosemide Exacerbating Amiodarone-Induced Hypothyroidism, Muneeba Ali, Md, Enad Haddad, Md, Warda Naqvi, Md, Ayesha Afzal, Md, Eddy Mizrahi, Md

The Medicine Forum

Heart failure with reduced ejection fraction is a clinical condition that often requires the concurrent use of multiple medications. Unfortunately, cross reactivity between multiple drugs occurs frequently. Today, we present the case of a 79-year-old male with heart failure and atrial fibrillation on long term amiodarone therapy. His furosemide dose was increased from 40 milligrams (mg) to 80 mg after he developed bilateral lower extremity swelling. The patient eventually developed generalized joint pains, weakness, difficulty maintaining balance, and frequent falls. He reported to the Emergency Department (ED), where he was noted to be suffering from severe acute kidney injury (AKI), …

Ascending Aortic Thrombus With Systemic Embolization: Implications For Risk Stratification And Management, Warda Naqvi, Md, Moses Morgan, Md, Muneeba Ali, Md, Enad Haddad, Md, Zaineb Alhassani, Md

The Medicine Forum

Ascending aortic thrombus is an uncommon clinical finding, particularly in the absence of significant underlying aortic disease, yet it poses a substantial risk for systemic embolization. We describe a 53-year-old woman with a history of cocaine use who presented with acute neurologic deficits and was found to have a left middle cerebral artery occlusion requiring mechanical thrombectomy. Cross-sectional imaging incidentally identified a 1.8 cm thrombus within the ascending aorta. Anticoagulation with intravenous heparin was initiated, however, her clinical course was complicated by recurrent embolic phenomena, including renal infarction and bowel perforation consistent with mesenteric ischemia. Ongoing deterioration with multiorgan failure …

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-seventh year serving as an outlet for our medical community’s scholarly and creative efforts. This year, it has been my pleasure to work with Nehar, Jasmine, Hamzah, and Allison on this project. It has been impressive to see them balance their efforts on this scholarly work with their efforts on the wards.

As a Department, we are a productive group of writers, thinkers, scientists, and artists, who send out our work for publication in the larger medical community. What makes The Medicine …

From The Chief Residents, Brian Schonewald, Md, Beatriz Torre, Md, Chukwuemezie Mamanu, Md, Julia Palecki, Md

The Medicine Forum

As the current Chief Residents, we beam with pride at the 27th edition of The Medicine Forum – a culmination of the passion, hard work, and talent of the residents of the Thomas Jefferson Internal Medicine Residency Program. We believe that The Medicine Forum stands as a testament to the fact that our residents are not only outstanding clinicians and medical educators, but also excel across all facets of medicine, including research, quality improvement, and the humanities.

We applaud our talented and driven Chief Editors, Nehar Damle, Hamzah Shariff, Allison Kayne, and Jasmine Lee, who worked diligently to ensure the …

From The Editors, Nehar Damle, Md, Pharmd, Hamzah Shariff, Md, Allison Kayne, Md, Jasmine Lee, Md

The Medicine Forum

As physicians in training, much of our work is shaped by immediacy – responding to evolving clinical situations, navigating diagnostic uncertainty, and making decisions with present information. In this environment, it can be easy to prioritize action over reflection. Yet it is through reflection, inquiry, and shared scholarship that we deepen our understanding of medicine and the patients we serve.

It is within this spirit that we present Volume 27 of The Medicine Forum. This publication represents not only scholarly achievement, but also the intellectual curiosity and dedication that define our community.

This year, we were particularly struck by …

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

The Medicine Forum

I am excited to once again share this year’s The Medicine Forum. It continues to open a window into the tireless commitment our residents bring to the bedside and to the field of medicine at large. As is uniquely our brand at Jefferson, the residents accomplish this with as much rigorous intellect as with their abundant enthusiasm and personality.

In an era where artificial intelligence has become an ever-burgeoning tool in the clinical landscape, the ingenuity displayed by our residents both in their artistic talents and their scholarly pursuits serves as a vital reminder. It reminds me that the …

Table Of Contents: The Medicine Forum, Volume 27, 2025-2026

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 27, 2025-2026

The Medicine Forum: Volume 27

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 27, 2025-2026

TABLE OF CONTENTS

• Case Reports
• Letter to the Editor
• Research Studies
• Humanities & Reflections

Hiding In Plain Sight: A Case Of Intestinal Tuberculosis Masquerading As Benign Lower Gi Bleeding, Lavender Otom, Priyanka Panwar, Gerald Odong, Fatma Kassim, Patricia Okiro, Christopher Opio, Saleem Abdulkarim

Internal Medicine, East Africa

Background Intestinal tuberculosis (TB) represents the most common form of abdominal TB, often affecting the ileocaecal region. Lower gastrointestinal bleeding is an uncommon presentation and may create significant diagnostic uncertainty, particularly in immunocompromised patients and in settings where inflammatory bowel disease is also encountered.

Case Presentation A woman in her sixties from Africa presented with recurrent diarrhoea and intermittent haematochezia over a 6-month period. Initial endoscopic evaluation was nondiagnostic. Cross-sectional imaging later demonstrated multifocal bowel involvement affecting both the small and large bowel, including ileocaecal and rectoanal disease, with associated abdominopelvic lymphadenopathy. Histopathology from repeat colonoscopy biopsy showed caseating granulomas …

May Measurement Month 2023: Results Of An Opportunistic Blood Pressure Screening Campaign In Kenya, Mzee Ngunga, Thomas Beaney, Gabriele Kerr, Bernard Samia, Lilian Mbau, Neil Poulter, Hellen Nguchu, Jeilan Mohamed, Elijah Ogola

Internal Medicine, East Africa

The May Measurement Month (MMM) is a global screening campaign launched in 2017 to raise awareness of raised blood pressure (BP). Kenya has participated in all previous MMM campaigns. Adults aged ≥18 years were recruited through convenience sampling in nine counties of Kenya. Three seated BP readings were taken on each participant, and a questionnaire collected information on demographics, lifestyle factors, and comorbidities. Hypertension was defined as a systolic BP ≥140mmHg or diastolic BP ≥90mmHg or being on BP-lowering medication. Controlled BP was defined as being on BP-lowering medication with a BP < 140/90mmHg. Multiple imputation was used to estimate missing BP readings. In total, 4,601 were screened, with a mean age of 41.7 years and 42.7% were female. Of all participants, 1,176 (25.6%) had hypertension, of whom 198 (16.8%) were aware, and 190 (16.2%) were on antihypertensive medication. Of those on antihypertensive medication, 65 (34.2%) had controlled BP, and of all participants with hypertension, 5.5% had controlled BP. The mean systolic and diastolic BPs of those on treatment was significantly higher than those without hypertension. Hypertensive disease in a previous pregnancy was associated with higher BP amongst female participants.

The MMM campaign in Kenya identified a substantial …

Hepatitis B In The Vaccine Era: Persistent Burden And Clinical Implications, Cherechi Nwabueze, Eunice Omeludike, Ridwan Ademola Lawal, Kedife Nwabueze

School of Medicine Publications

Hepatitis B virus (HBV) infection remains a leading global cause of advanced liver disease and imposes a substantial economic burden. Early prevention is critical, as perinatally acquired HBV carries a high risk of progression to cirrhosis or hepatocellular carcinoma (HCC). Hepatitis B vaccination has been proven effective in preventing cancer, yet coverage of the complete vaccine series remains suboptimal. This implementation gap perpetuates the clinical burden, manifesting decades later as hepatic decompensation and liver cancer. This narrative review synthesizes the current HBV landscape, highlighting how gaps in vaccination policy and delivery contribute to real-world gastrointestinal outcomes. By reframing HBV vaccination …

Two Years Of Ocrelizumab Treatment In Black And Hispanic People With Multiple Sclerosis In Chimes: A Single-Arm Clinical Trial, Lilyana Amezcua, Anthony Reder, Evanthia Bernitsas, Nancy Monson, Timothy Vartanian, Gregory Wu, Mansoor Saleh, Annette Okai, Ahmed Obeidat, Dilraj Sokhi

Haematology and Oncology, East Africa

Objective To evaluate the effectiveness and safety of ocrelizumab in self-identified black and Hispanic people with relapsing multiple sclerosis.

Methods The Characterization of Ocrelizumab in Minorities with Multiple Sclerosis (CHIMES) trial, a prospective, open-label, single-arm, phase 4 study, intentionally recruited underrepresented populations in the US, Puerto Rico, and Kenya. Black and Hispanic people with relapsing multiple sclerosis aged 18–65 years with Expanded Disability Status Scale score 0–5.5 received ocrelizumab for 2 years. The primary endpoint was the proportion of participants with no evidence of disease activity in 3 components at week 48: protocol-defined relapse, 24-week confirmed disability progression, and disease …

Health Systems Interventions For Prevention Of Maternal Peripartum Infection In Low And Middle-Income Countries: A Systematic Review, Roseline Abwao, Job Mapesa, Wanja Tenambergen, David Odada, Nasra Gathoni, Felix Riunga

Internal Medicine, East Africa

Background Globally, there is growing recognition that a functional health system is key to improving maternal health and reducing maternal mortality. Maternal peripartum infection remains a major cause of maternal morbidity and mortality, particularly in low- and middle-income countries. This infection is a multifaceted problem with many players. Adopting a health systems approach could help avert this preventable infection by addressing the gaps across all the components of care.

Objective The aim of this systematic review was to identify and evaluate interventions to prevent maternal peripartum infection in LMICs.

Methods A systematic search was conducted in Cochrane Library, CINAHL, MEDLINE …