Internal Medicine Commons^™

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 …

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 …

Assessing The Risk Of Venous Thromboembolism In Patients With Hereditary Hemorrhagic Telangiectasia: A National Inpatient Sample Study, Himal Kharel, Samikchhya Keshary Bhandari, Zeni Kharel, Chengu Niu, Aditya Sanjeevi, Devam Maity, Zauraiz Anjum

Advances in Clinical Medical Research and Healthcare Delivery

Background: Hereditary hemorrhagic telangiectasia is an underrecognized entity which increases the risk of mucosal as well as visceral bleeding. The thromboembolic risk of this condition is unknown.

Methods: We used the national inpatient sample database from 2016 to 2020 and performed a retrospective cohort study using multivariate logistic regression.

Results: In this retrospective cohort study of the national inpatient sample database from 2016 to 2020 using multivariate logistic regression, we found that hereditary hemorrhagic telangiectasia did not significantly increase the risk of deep vein thrombosis and pulmonary embolism.

A 65-Year-Old Man With Cough, Hypercalcemia, And Diffuse Opacities, Philip K Angelides, Oriana Salamo, Sujith V Cherian, Eduardo Yepez Guevara, Carlos A Jimenez, Saadia A Faiz

Faculty, Staff and Student Publications

Respiratory infections in patients with cancer are common. A low threshold for bronchoscopy with bronchoalveolar lavage (BAL) should be maintained in immunocompromised patients with pulmonary opacities on chest imaging to evaluate for opportunistic infections. In those with unresolving symptoms, transbronchial biopsies may add significant diagnostic value. Concomitant hypercalcemia in patients with cancer is typically related to underlying malignant disease. However, in those with persistent respiratory symptoms or atypical infiltrates then granulomatous inflammatory diseases should be considered. Diagnosing histoplasmosis in immunocompromised patients can be difficult. Antigen testing is often more sensitive, but tissue biopsy or culture may be needed. We describe …

Diagnostic Accuracy Of The Stopbang Questionnaire Against Polysomnography For The Screening Of Obstructive Sleep Apnea In A Tertiary Hospital In Kenya., Sandra Obaje Maseno

Master of Medicine in Internal Medicine

BACKGROUND: Obstructive sleep apnea is a syndrome of upper airway and neuromuscular dysfunction during sleep that subsequently causes interruption of normal breathing. Polysomnography is the reference test for the diagnosis of obstructive sleep apnea. Obstructive sleep apnea can be categorised as mild, moderate or severe based on an apnea-hypopnea index (AHI) on polysomnography. The recommended treatment using Continuous Positive Airway Pressure lowers morbidity and mortality rates. The STOPBANG questionnaire has been used as a screening tool for obstructive sleep apnea due to its easy and concise approach. However, even with the increasing prevalence of obstructive sleep apnea and its risk …

Outcomes And Microbiological Patterns Of Bacteremia In Chemotherapy-Related Febrile Neutropenia At A Tertiary Facility In Kenya, Abhijit Ghose, Jasmit Shah, Anne Mwirigi, Charles Makasa, Felix Riunga

Internal Medicine, East Africa

Introduction: Febrile neutropenia (FN) is a major cause of mortality and morbidity in patients with malignancy post-chmotherapy. Current guidelines for managing FN recommend starting empiric antibiotic therapy (EAT) promptly. The choice of antibiotic is based on the patient’s condition, local data on common microorganisms isolated, and their resistance patterns. Of note, there is a growing trend of isolating multi-drug–resistant gram-negative bacteria in these patients. In sub-Saharan Africa, there are insufficient data on the mortality rates of FN. There is also a lack of local epidemiologic data on the frequently isolated microorganisms and their antibiotic resistance patterns. This makes it challenging …

Congestion And Sinonasal Illness In Outer Space: A Study On The International Space Station, Faizaan Khan, Koyal Ansingkar, Roshan Dongre, Zain Mehdi, Aatin K Dhanda, Kayla Powell, Tariq Syed, Samuel E Razmi, Isuru Somawardana, Jeffrey T Vrabec, David Hilmers, Omar G Ahmed, Masayoshi Takashima

Faculty, Staff and Students Publications

Objectives: This study aims to characterize quantitative data pertaining to sinonasal symptoms and their related medication use aboard the International Space Station (ISS). A secondary focus involves correlating these findings with mission parameters such as extravehicular activity (EVA) participation and mission duration.

Methods: This retrospective cohort study was conducted utilizing data requested from the National Aeronautics and Space Administration (NASA) Lifetime Surveillance of Astronaut Health (LSAH) program.

Results: Of 71 de-identified ISS astronauts beginning with Expedition 1 in the year 2000 through 62 in 2019, there were 754 logged medical events; 60 astronauts reported any type of sinonasal medical event …

An Electronic Trigger To Detect Telemedicine-Related Diagnostic Errors, Daniel R Murphy, Himabindu Kadiyala, Li Wei, Hardeep Singh

Faculty, Staff and Students Publications

Introduction

Methods

Uncharted Territory: The First Case Of Cardiac Myxoma In A Patient With Nf2, Muhammad Sabri, Zinya Talukder, Naila Ijaz, Joseph Neri

Rothman Institute Papers

BACKGROUND: Cardiac myxoma is a benign tumor, typically originating in the left atrium, and is often linked to Carney complex. In our literature review, there are no case reports of cardiac myxoma in patients with neurofibromatosis type 2 (NF2).

CASE SUMMARY: A 60-year-old man presented with dizziness and was found to have meningioma and vestibular schwannoma, consistent with NF2. Cardiac myxoma was incidentally diagnosed through echocardiography and confirmed by cardiac magnetic resonance imaging and tissue pathology. The mass was surgically resected. The patient was offered genetic testing; however, he decided to not undergo further testing.

DISCUSSION: NF2 is an inherited …

Patient Information Needs During Ambulatory Medication Changes: A Qualitative Study, Elaine Giletta, Vanessa B. Hurley, Yushi Yang, Jessica L. Schwartz, Rabia Jalalzai, Nicole L. Mollenkopf, Raquel Mayne, Samantha I. Pitts

Journal of Patient-Centered Research and Reviews

Purpose: We performed interviews with patients and caregivers to explore whole-person, whole-regimen information needs at times of routine outpatient medication changes. We categorized information needs in this relatively unstudied context and identified which needs were commonly recognized as insufficiently met.

Methods: We explored the content of the semi-structured interviews, which involved nine patients and two caregivers of pediatric patients, all of whom experienced a recent medication change in the outpatient setting of a large urban academic healthcare system. We used inductive thematic analysis to organize information needs into categories to identify key information gaps.

Results: We identified five categories of …

Flipping The Curriculum For Resident Didactics: In-Training And Certifying Examination Scores In An Internal Medicine Residency, Luke Mccoy, Ronald J. Markert, Elysha Thoms, Olivia Noall, Kathryn Burtson

Internal Medicine Faculty Publications

Purpose The flipped classroom (FC) model is increasingly used in undergraduate medical education, where it has been associated with improved knowledge acquisition. However, its impact on graduate medical education (GME) remains underexplored. We hypothesized that implementing a flipped didactics curriculum in our internal medicine residency program would improve performance on the Internal Medicine In-Training Examination (IM-ITE) and the American Board of Internal Medicine Certifying Examination (IM-CE). Methods In 2017, we transitioned from a traditional lecture-based (LB) curriculum to a flipped model. Noon conferences were replaced with problem-based learning (PBL) sessions three days per week, with additional active learning formats used …

Clinically Validated Graphical Approaches Identify Hepatosplenic Multimorbidity In Individuals At Risk Of Schistosomiasis, Yin-Cong Zhi, Simon Mpooya, Narcis Kabatereine, Betty Nabatte, Christopher Opio, Narcis Kabatereine, Goylette Chami

Internal Medicine, East Africa

The global burden of multimorbidity is increasing yet poorly understood, owing to insufficient methods for modelling complex systems of conditions. In particular, hepatosplenic multimorbidity has been inadequately investigated. From 17 January to 16 February 2023, we examined 3186 individuals aged 5–92 years from 52 villages across Uganda within the SchistoTrack Cohort. Point-of-care B-mode ultrasound was used to assess 45 hepatosplenic conditions within the context of schistosomiasis (Schistosoma mansoni). Three graph learning methods for representing hepatosplenic multimorbidity were compared. Thresholds for including graph edges were found using graph kernels and tested with graph neural networks to assess predictive utility for unobserved …

Clinico-Epidemiological Characteristics Of Cerebral Venous Sinus Thrombosis In Kenya: A Retrospective Case Series, Taby Siika, Jaskirat Sokhi, Juzar Hooker, Sheila Waa, Anne Mwirigi, Jasmit Shah, Dilraj Sokhi

Internal Medicine, East Africa

Background: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke that is more common in young, especially female, adults and can be challenging to diagnose due to its frequently non-specific presentation and diverse risk factors. Most cases are idiopathic, and international guidelines do not recommend routine investigations for underlying thrombophilia. Timely diagnosis, with prompt neuroimaging and guideline-based treatment, leads to good outcomes. However, in the literature on CVST from sub-Saharan Africa, the gap is substantial, with the few cases described as being related to systemic and/or brain infections. We describe here the largest cohort of CVST from the …

Vitamin D Status And Risk For Breast Cancer In Kenya, Ronald Wasike, Victor Mobegi, Esther Maina, Francis Makokha, Robert Armstrong, Annastacia Mbithi

General Surgery, East Africa

Background: Vitamin D plays a critical role in bone metabolism, calcium regulation, and various cellular processes, including those linked to cancer. The biologically active form, 1,25-dihydroxyvitamin D [1,25(OH)2D], works through the Vitamin D Receptor (VDR). Polymorphisms in VDR and related genes have been associated with cancer risk, including breast cancer. This case-control study aimed to investigate the relationship between serum vitamin D levels and breast cancer among Kenyan women.

Methods: Serum 25-hydroxyvitamin D [25(OH)D] levels were measured in 112 breast cancer patients and 106 controls using electrochemiluminescence.

Results: Results indicated that 81.2% of participants had deficient or insufficient vitamin D …

1d Thermoembolization Model Using Ct Imaging Data For Porcine Liver, Rohan Amare, Danielle Stolley, Steve Parrish, Megan Jacobsen, Rick R Layman, Chimamanda Santos, Beatrice Riviere, Natalie Fowlkes, David Fuentes, Erik Cressman

Faculty, Staff and Student Publications

Innovative therapies such as thermoembolization are expected to play an important role in improving care for patients with diseases such as hepatocellular carcinoma. Thermoembolization is a minimally invasive strategy that combines thermal ablation and embolization in a single procedure. This approach exploits an exothermic chemical reaction that occurs when an acid chloride is delivered via an endovascular route. However, comprehension of the complexities of the biophysics of thermoembolization is challenging. Mathematical models can aid in understanding such complex processes and assisting clinicians in making informed decisions. In this study, we used a Hagen-Poiseuille 1D blood flow model to predict the …