Internal Medicine Commons^™

Etomidate Vs Ketamine In Rapid Sequence Intubation: A Comparative Review Of Clinical Efficacy And Safety, Abelardo Rodriguez, Cesar Ortega, Jessica Daza

Research Colloquium

Background: Rapid Sequence Intubation (RSI) is a critical procedure in emergency and critical care settings, and the choice of induction agent can significantly affect patient outcomes. Etomidate and Ketamine are two widely used agents with distinct pharmacologic profiles. Understanding their comparative efficacy and safety across clinical contexts is essential for optimizing care in high-acuity environments.

Objective: To compare Etomidate and Ketamine as induction agents for RSI, focusing on their mechanisms of action, hemodynamic effects, and clinical outcomes in various patient populations.

Methods: A literature-based review was conducted using key databases including PubMed, Cochrane, and clinical guidelines. Studies examining the use …

Refractory Neutropenic Fevers In Aml: Unmasking Voriconazole-Resistant Invasive Aspergillosis, Abdel Martinez Borrego, Sahir Bhatti, Cesar Gutierrez

Research Colloquium

Background: Persistent fever in neutropenic patients with acute myeloid leukemia (AML) often raises concern for invasive fungal infections (IFIs), especially when unresponsive to broad-spectrum antibiotics and first-line antifungal agents like voriconazole. Invasive aspergillosis (IA), primarily caused by Aspergillus fumigatus, is a major cause of morbidity and mortality in this population, with mortality rates exceeding 50% in refractory cases. The emergence of azole-resistant Aspergillus, now reported in up to 10–15% of isolates in some regions, has complicated management. Patients may present with nonspecific symptoms such as persistent fevers, as well as concerning findings like cutaneous lesions—a clue to hematogenous spread—and …

Predictors Of All-Cause In-Hospital Mortality In Patients With Malignant Well-Differentiated Gastroenteropancreatic Neuroendocrine Tumors, Elvis Obomanu, Tarfa Verinumbe, Tinsae Anebo, Colton Jones, Claudia Dourado

Einstein Health Papers

BACKGROUND: Factors influencing in-hospital mortality in patients with well-differentiated gastroenteropancreatic neuroendocrine tumors (GEP-NETs) remain understudied, highlighting gaps in optimizing acute clinical outcomes. This study aimed to identify sociodemographic and clinical predictors of all-cause in-hospital mortality in this population.

METHODS: Using 2016 - 2020 data from the National Inpatient Sample (NIS), patients with malignant well-differentiated GEP-NETs were identified via the International Classification of Diseases, 10th Revision (ICD-10) codes. The primary outcome was in-hospital mortality. Sociodemographic and clinical variables (heart failure (HF), malnutrition, Charlson Comorbidity Index (CCI), and tumor site) were analyzed using multivariable logistic regression.

RESULTS: Among 5,642 patients (mean age …

Fluid Resuscitation Choice And Its Effect On Plasma Chloride And Acute Kidney Injury In Severe Acute Pancreatitis: A Randomized Study Of Normal Saline Vs. Balanced Crystalloids (Physiomax), Mandip Singh Bhatia, Ritu Attri, Ashok Kumar Pannu, Atul Saroch, Saurabh C Sharda, Neeraj Singla, Sakshi Mehta

Journal of Community Hospital Internal Medicine Perspectives

Background: Acute pancreatitis (AP) is a potentially fatal gastrointestinal condition, often associated with organ failure and acute kidney injury (AKI). Early fluid resuscitation with Normal saline (NS) may lead to hyperchloremia and AKI, which prompted interest in using balanced crystalloids. However, the optimal choice of crystalloid fluid remains uncertain. This study aimed to compare the effects of NS versus Physiomax on plasma chloride levels and AKI incidence during early resuscitation in patients with predicted severe AP (pSAP).

Methods: A single-center, prospective, randomized study was conducted between November 2022 and December 2023 at PGIMER, Chandigarh, India. 112 patients with pSAP were …

Role Of Addiction Medicine Consultation Service In A Community Hospital: Evaluation Of The Novel Service, Srikrishna Varun Malayala, Wesley Cervantes Perez, Rukshar Thapa, Archie Madan, Kushagar Singla, Pragyat Singh, Pelash Kumar, Akshay Thaper

Journal of Community Hospital Internal Medicine Perspectives

Objectives: Fewer than 2,500 physicians nationwide are certified in addiction medicine. Inpatient addiction hospitalist services have been shown to improve patient outcomes, but their capabilities and impact are underexplored in community hospitals. This study evaluates the role of an addiction medicine hospitalist service in enhancing patient outcomes in two community-based hospitals.

Methods: A retrospective chart review was conducted on patients who received care from addiction medicine service in two hospitals. The data were collected within the first 120 days of the establishment of service. The reason for consultation, substances used, types of management, impact on transition of care, readmissions and …

Left Atrial Thrombus In Rheumatic Mitral Stenosis: A Case Of Therapeutic International Normalized Ratio Failure, Muhammad Salman Sabri, Carly Weber, Yanis Belkadi, Donald C. Haas, Yasotha Rajeswaran

Division of Internal Medicine Faculty Papers & Presentations

BACKGROUND: Atrial fibrillation or flutter in rheumatic mitral stenosis (MS) increases left atrial appendage (LAA) thrombus risk despite therapeutic anticoagulation.

CASE SUMMARY: A 72-year-old woman on warfarin with moderate MS and atrial flutter presented with dyspnea. Transesophageal echocardiogram (TEE) showed a large LAA thrombus despite an international normalized ratio >2.5. Cardioversion was deferred, and the international normalized ratio target was raised to a range of 2.5 to 3.5.

TAKE-HOME MESSAGES: While cardioversion can be considered in patients with uninterrupted anticoagulation without TEE, those with rheumatic MS are at high risk of LAA and LA thrombus and should undergo TEE before …

International Accreditation For Acute Stroke Care: Lessons Learnt From A Kenyan Stroke Centre, Dilraj Sokhi

Internal Medicine, East Africa

Background: The prevalence of stroke is increasing in Africa, yet resources remain limited in managing the disease. Whilst there are international guidelines on how to set up and manage stroke services, even in resource-limited settings, the uptake remains low. We describe here the opportunities and challenges we faced whilst setting up a stroke care pathway of international standards in a regional referral hospital in East Africa.

Methods: We describe how we adapted international stroke care guidelines for acute primary stroke (including both ischemic and hemorrhagic stroke), and used these to inform our stroke care pathway. We highlight opportunities of leveraging …

Malignancy-Associated Renal Infarction: A Case Of Prostate Cancer Presenting With Flank Pain And Hematuria., Connor J Stinson, Alec Pupo, Patrick Laird

Internal Medicine Resident Research

Renal infarction is an uncommon but critical diagnosis that is frequently overlooked due to its nonspecific presentation and overlap with more common causes of abdominal or flank pain. Patients with malignancy, including metastatic prostate cancer, are at increased risk of thromboembolic events due to the intrinsic hypercoagulable state promoted by cancer, yet arterial events, such as renal infarction, remain underrecognized. We present the case of a 74-year-old male with metastatic castrate-sensitive prostate cancer who developed acute abdominal pain, nausea, and vomiting. Evaluation revealed elevated blood pressure, microscopic hematuria, and increased lactate dehydrogenase (LDH). CT scan of the abdomen and pelvis …

Time-Frequency Fingerprint Analysis In Seeg Source-Space To Identify The Epileptogenic Zone, Yash Shashank Vakilna, Deniz Atilgan, Johnson Hampson, Chinmay Chinara, Takfarinas Medani, Richard M Leahy, Nuria Lacuey, Samden D Lhatoo, Sandipan Pati, John C Mosher, Jay R Gavvala

Faculty, Staff and Student Publications

This case study highlights the application of seizure fingerprint analysis in the source-space of stereo-EEG (SEEG) data to accurately localize the epileptogenic zone (EZ) in patients with complex cortical malformations. A 25-year-old female with extensive bilateral perisylvian polymicrogyria (PMG) presented with intractable focal seizures. The source-level analysis performed in Brainstorm using the sLORETA imaging algorithm subsequently showed EZ fingerprint analysis. The patient underwent MR-guided laser interstitial thermal therapy (LITT), targeting the identified EZ, resulting in postoperative seizure freedom with minimal complications. Extending the analysis from the sensor-space to the source-space could further enhance surgical planning and improve outcomes in complex …

Left Bundle Area Pacing Outcomes Among Patients With Very Wide Qrs – Insights From An African Registry, Willy Mucyo, Mzee Ngunga, Miriam Msunza, Jeilan Mohamed, Marcus Ngantcha, Brian Vezi

Internal Medicine, East Africa

Background: Left Bundle Area Pacing (LBAP) is a promising alternative to conventional cardiac resynchronization therapy. There is a high prevalence of dilated cardiomyopathy in Africa, which is often associated with very wide QRS. However, data on LBAP outcomes in Africa are limited. Objective To evaluate the procedural and clinical outcomes of LBAP among African patients with very wide QRS durations.

Methods: The Multicenter African Cardiac Outcomes in Pacing (MACOP) registry enrolled 311 patients in Kenya and South Africa who underwent LBAP between 2021 and 2024. We evaluated procedural and clinical outcomes. Patients were stratified by baseline QRSd (normal …

Cardiogenic Shock With Acute Myocardial Infarction Among Older Adults In The United States, Taha Mansoor, Ali Bin Jabbar, Mahmoud Ismayl, Dylan Yu, Kartik Gupta, Sachin Parikh, Austin Brubaker, Abdul Minhas, Dmitry Abramov, Salim S. Virani

Population Health, East Africa

Background: Characteristics and outcomes associated with cardiogenic shock (CS) with acute myocardial infarction (AMI) in older patients have not been well characterized.

Objectives: The purpose of this study was to investigate characteristics and outcomes of older patients admitted with CS with AMI.

Methods: We used the National Inpatient Sample database to evaluate clinical characteristics of hospitalizations, clinical outcomes, and health care utilization of hospitalizations of older patients ≥80 years with CS and AMI from 2003 to 2021. We also compared data from older patients with a reference relatively younger patient population (18-79 years).

Results: During the study period, …

A Multi-Institutional Multi-Methods Analysis Of Jeopardy Systems In Academic Hospital Medicine, Kirsten N Kangelaris, Angela Keniston, Andrew D Auerbach, Gregory Bowling, Marisha Burden, Shradha A Kulkarni, Luci K Leykum, Anne S Linker, Matthew Sakumoto, Jeffrey Schnipper, Gopi Astik

Faculty, Staff and Students Publications

Background: Hospital medicine programs use backup ("jeopardy") systems to cover unexpected staffing gaps, but little is known about their structures or optimal practices.

Objectives: To describe jeopardy structures, assess clinician perceptions, and identify potential approaches across a broad sample of hospital medicine groups.

Methods: This multi-methods study, conducted within a national hospitalist consortium, used virtual focus groups and an email survey to (1) describe the presence and structure of jeopardy systems and (2) explore features perceived as fair, equitable, and tolerable. Rapid qualitative analysis identified major themes, while descriptive methods analyzed survey data.

Results: Twenty-five individuals participated in focus groups, …

Routine Antenatal Ultrasound By Nurse-Midwives In Rural Kenya: A Pragmatic Trial Assessing Feasibility And Effects Of The Mimba Yangu (My Pregnancy) Project, Claudia Hanson, Lucy Nyaga, Nidhi Leekha, Michaela Mantel, Sarah Kedenge, Caroline Gitonga, Violet Naanyu, Jasmit Shah, Marleen Temmerman

Centre of Excellence in Women and Child Health

Introduction: Task-sharing of obstetric ultrasound between nurse-midwives and doctors has the potential to operationalize the World Health Organization’s recommendation of at least one ultrasound before 24 weeks of gestational age for every pregnant woman. Here, we report on the feasibility, acceptability, and effects of the Mimba Yangu (My Pregnancy) task-sharing approach in rural Kenya.

Methods: We conducted a pragmatic trial including 28 primary care facilities between April 2021 and March 2022, selected based on feasibility criteria. Fourteen facilities received the ultrasound intervention composed of (i) task-sharing with nurse-midwives, (ii) the use of portable ultrasound devices (Lumify™) connected to a tablet, …

Silent Damage, Early Signals: A Narrative Review Of The Evolving Role Of Cardiac Biomarkers In Oncology-Driven Cardiotoxicity, Aura Calderon, Luis Salcedo, Jose Loayza, Catherine Matos, Ivan Mogollon, Francisco Arias, Everardo Cobos

School of Medicine Publications

Advancements in cancer therapy have led to improved patient survival but have also introduced an increasing risk of cardiotoxicity, particularly with agents such as anthracyclines, trastuzumab, and various targeted treatments. Cardiotoxic effects may present as myocardial injury, systolic or diastolic dysfunction, or heart failure (HF), often developing insidiously before clinical symptoms become evident. Early detection is therefore crucial to preserve cardiovascular health in oncology patients. This narrative review examines the expanding role of cardiac biomarkers; including high-sensitivity troponins, natriuretic peptides, Galectin-3, soluble ST2, and novel molecular markers like microRNAs, in identifying and monitoring chemotherapy-induced cardiac injury. It also highlights how …

Longitudinal Meta-Cohort Study Protocol Using Systems Biology To Identify Vaccine Safety Biomarkers, Joann Diray-Arce, Ana C Chang, Sara Moradipoor, Donato Amodio, Bruce Carleton, Wan-Chun Chang, Nigel W Crawford, Meagan Karoly, Annmarie Hoch, Kerry Mcenaney, Tahir S Kafil, Mahitha Donthireddy, Sarah K Steltz, Simon D Van Haren, Asimenia Angelidou, Kinga K Smolen, Hanno Steen, Jessica Lasky-Su, Huyen Tran, Peter Liu, C Buddy Creech, Clare L Cutland, Helen Petousis-Harris, Ishac Nazy, Rae S M Yeung, Sonali Kochhar, Steve Black, Nicholas Wood, Dale Nordenberg, Paolo Palma, Inna G Ovsyannikova, Richard B Kennedy, Gregory A Poland, Al Ozonoff, Robert T Chen, Ofer Levy, Karina A Top, International Network Of Special Immunization Services (Insis) Members

Faculty, Staff and Students Publications

The International Network of Special Immunization Services (INSIS) was established to investigate the causes and risk factors of rare adverse events following immunizations (AEFIs) and develop immunization strategies for mitigating or preventing risk for individuals with prior AEFIs or at risk of AEFIs. INSIS integrates clinical data with multi-omic technologies (e.g., transcriptomics, proteomics, metabolomics) through a global consortium of clinical networks, leading immunology, pharmacogenomics teams to uncover the molecular mechanisms behind AEFIs. The network ensures accurate and standardized data collection and analysis through rigorous data management and quality assurance processes. INSIS also implements harmonized case definitions and protocols for collecting …

Nondominant Right Coronary Artery Occlusion Leading To An Anterior St-Segment Elevation Myocardial Infarction, Taha Ahmed, Taylor Wood, Austin Harris, Rajan Desai, Garima Handa, Naoki Misumida, Amartya Kundu

HCA Healthcare Journal of Medicine

Background

A nondominant right coronary artery supplies a small portion of the myocardium. Albeit rare, an acute occlusion of a nondominant right coronary artery is believed to be inconsequential with minimal clinical relevance.

Case Presentation

We present a case of a middle-aged man who presented with chest pain and an electrocardiogram demonstrating anterior ST-segment elevation. An emergent coronary angiogram revealed acute thrombotic occlusion of the proximal nondominant right coronary artery with no significant obstructive atherosclerotic disease in the dominant left coronary circulation. Balloon angioplasty of the occluded vessel followed by implantation of a drug-eluting stent resulted in the resolution of …

Recurrent, Acute Limb Ischemia Secondary To Arterial Thrombosis: A Devastating Complication In The Setting Of Severe Covid-19 Infection, Shaikh Afaq, Kyle S. Strouse, Sini Saju, Olugbenga Oyesanmi, Mohamad Eid, Salman Muddassir

HCA Healthcare Journal of Medicine

Background

COVID-19 infection, particularly with the Delta variant, has been associated with a heightened risk of thromboembolic events due to a profound hypercoagulable state. While venous thrombosis is more commonly reported, arterial thrombosis—including acute limb ischemia—has emerged as a serious complication with significant morbidity and mortality.

Case Presentation

We report the case of a 53-year-old man with severe COVID-19 pneumonia who developed recurrent acute limb ischemia secondary to an aortic mural thrombus. Despite therapeutic anticoagulation and multiple surgical interventions—including thrombectomy, angioplasty, and stenting—the patient experienced repeated episodes of arterial thrombosis. His clinical course was further complicated by pneumothorax and hemothorax, …

Retrieval Of An Embolized Left Atrial Appendage Occluder From The Aortic Arch Using A Transcatheter Retrieval Device, Juan Siordia, Hussam Al Hennawi, Muhammad Sabri, Daniel Ice, Ronald Ross, Sheena Rastogi, Chunguang Chen, Richard Kovach, Muhammad Raza

Abington Jefferson Health Papers

BACKGROUND: Device embolization is a recognized complication of left atrial appendage occlusion (LAAO) procedures, with outcomes depending on the location of the embolized device and patient management.

CASE SUMMARY: A 70-year-old male with atrial fibrillation underwent LAAO due to high bleeding risk. Postoperative surveillance revealed an Amplatzer Amulet device embolized in the transverse arch of the aorta. The patient remained asymptomatic, and transcatheter retrieval was planned. A percutaneous approach was used with the ONOCOR system and snare devices with successful retrieval. The patient recovered without complications and remained stable at follow-up.

DISCUSSION: Device embolization often presents challenges, with clinical outcomes …

Patterns And Implications Of Electronic Messaging Use In Clinical Communication: Insights From A Single-Center Survey., Basil George Verghese, Rupinder Buttar, Prakash Upreti, Kaiwen Zhu, Tamer Salhab Altamimi

Advances in Clinical Medical Research and Healthcare Delivery

Background: Efficient communication in healthcare is critical, significantly impacting patient outcomes. Electronic messaging tools, like Epic Secure Chat, are increasingly integrated into healthcare settings to enhance interactions among professionals. However, the practical implications of these tools on workflow and care quality are underexplored.

Methods: We conducted a comprehensive cross-sectional survey involving 309 healthcare professionals, including hospitalist physicians, advanced practice providers (APPs), and internal medicine residents, to evaluate Epic Secure Chat's usage patterns, satisfaction levels, and communication preferences.

Results: The survey yielded insightful data from 156 complete responses, revealing a notable issue with misdirected messages: 64.1% of hospitalists, 52.6% of residents, …

Appropriate Application Of Cardiac Telemetry Monitoring: A Quality Improvement Initiative, Muhammad H. Sharif, Abdullah A. Orakzai, Nauman Naeem, Omofolarin Babayale, Basil George Verghese

Advances in Clinical Medical Research and Healthcare Delivery

Background: Telemetry is an important clinical tool but it can be overutilized and leads to a higher cost of patient care and negative patient experience. We conducted this study to assess the effectiveness of our educational intervention in reducing inappropriate use of telemetry and to determine if there is any difference between the two types of educational interventions.

Methods: We conducted a retrospective in-patient study that included all non-ICU patients admitted on a randomly selected mid-week day at our hospital. A 2-step educational intervention was used separated by a 5-week period. The first, a PowerPoint presentation regarding the updated 2017 …