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  Severe Hypophosphatemia in a Patient with a Relapsing Lymphoma

  Xiaoying Deng, MD, PhD; Edgar Guzman-Suarez, MD; Anju Yadav, MD; and Rakesh Gulati, MD

  Hypophosphatemia in cancer patients is commonly ascribed to chemotherapy, renal wasting or malnutrition from anorexia and poor PO intake. We report a case caused by rapid cancer cell proliferation. 61-year-old woman with history of marginal zone lymphoma diagnosed in 2017 who presented with fatigue, poor oral intake and undetectable phosphate levels (Phos) for 5 days. Her outpatient medications included Acyclovir 400 mg by mouth daily, Allopurinol 100 mg PO daily and Enoxaparin 60 mg under the skin every 12 hours. Blood work revealed phosphate levels less than1 mg/dl (normal 2.4-4.5mg/dl). Her intact PTH level was normal. Her phosphate level further dropped to

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  Trust the Process: A Templated, Centralized, and Protocolized Patient Safety Pilot Project to Improve Outside Admissions

  Alan A. Kubey, MD and Jeffrey M. Riggio, MD

  Transfers are high-risk. Intra-hospital transfer processes research has improved protocols used nationally.1 Outside-hospital admissions remain without standards ensuring the transfer of the right information to the right clinician at the right time; presently, patients can arrive at a new hospital with limited-to-no information.2We trialed a novel process for outside (hospital, provider, or skilled nursing facility) admissions to a single academic medical center’s resident and- hospital-medicine-attending-based (“teaching”) medicine services.

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  Resident Experience Discussion (RED): Resident-led Discussion Groups to Promote Resilience

  Timothy Kuchera, Colin J. Thomas, Candace L. Haddox, Hannah C. Nordhues, Deanne T. Kashiwagi, and Alan Kubey

  We sought to promote resident wellness through a resident-initiated-and-run discussion forum outside the formal residency structure

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  POEM Perceptions: A Survey of Gastroenterologists and the Treatment of Achalasia in the Philadelphia Region

  Rebecca Loh, MD and Alexander Schlachterman, MD

  Introduction

  Peroral endoscopic myotomy (POEM) is a relatively new innovate technique that has been shown to be an effective treatment for achalasia. Despite studies demonstrating its effectiveness as a less invasive therapy, POEM is still not as widely implemented as the traditional Heller myotomy for the treatment of achalasia. We aimed to explore the barriers that may impact implementation of POEM and to assess the regional perception of POEM amongst gastroenterologists in an urban setting.

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  The Sensitivity of Cross-Sectional Imaging for Identifying Periampullary Diverticula

  Austin Chiang, MD, MPH; Jetmir Vojnika, MD; Alexander Schlachterman, MD; David E. Loren, MD; and Thomas E. Kowalski

  Our aim was to determine the sensitivity of imaging in identifying duodenal diverticula as seen during ERCP.

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  Improving Bedside Procedural Safety through Optimizing Timeout Documentation and a Pre-procedure Checklist

  Jennifer Harris, MD; R. Benson Jones, MD; Kristin Lohr, MD; Grant Turner, MD; Drew Kotler, MD; Justine Blum, MD; Megan Margiotta, MD; Matthew Bokhari, MD; Erica Li, MD; Riti Kanesa-thasan, MD; Bracken Babula, MD; and Rebecca Jaffe, MD

  Aim

  GOAL: Improve the safety of patients undergoing bedside procedures while maintaining the full spectrum of graduated autonomy in procedure training for residents.

  SMART Aim: Increase the rate of timeouts documented for bedside procedures from 29% to 50% by June 2018.

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  A Rare Case of Diffuse Alveolar Hemorrhage Secondary to Dabigatran Successfully Treated with Extracorporeal Membrane Oxygenation

  C. Hutchinson, F. M. West, and H. Hirose

  Introduction

  Dabigatran, a direct thrombin inhibitor, is used for stroke risk reduction in non-valvular atrial fibrillation and for treatment and prevention of venous thromboembolism. Minor side effects include indigestion and stomach pain. Major life threatening bleeding occurs in up to 2% of patients and is largely attributed to gastrointestinal hemorrhage. Here, we describe a case of a dabigatran related diffuse alveolar hemorrhage (DAH) treated successfully with extracorporeal membrane oxygenation.

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  Review of the Safety and Efficacy of Echocardiographically Guided Pericardiocentesis: A Retrospective Single-Center Analysis, 2009 – 2016

  Robert Park, MD; Michael Valentino, MD, PhD; Rajiv Kabadi, MD; Matthew Decaro, MD; and Gregary Marhefka, MD

  Aims

  • To investigate the safety and efficacy of EGP given the relatively limited data of this modality’s safety profile in American healthcare centers over the past decade
  • To evaluate the characteristics of and risk factors of those needing EGP

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  Drug Abuse Manifesting as Persistent Hypoglycemia: A Case Report of Hidden Sulfonylurea Poisoning

  Frederick B. Peng and Sharon Li, MD

  Background

  • Prescription drug abuse is on the rise. According to the Philadelphia Department of Health data in 2017, up to 26% of adults may be using benzodiazepines and/or opioids (Table 1).
  • 12% or 1/8 Philadelphians are estimated to be current benzodiazepine users and have taken one in the last 7 days. Benzodiazepine use is most common among people with household incomes below $25,000 and among the 45-54 years old age group (17.7%) [1].
  • Most current users (84%) obtain benzodiazepines from health care providers [1]. However, with new policies to closely monitor controlled substances, those with dependence on benzodiazepines may turn to alternative sources (such as black market vendors) to obtain the drug.
  • Street-obtained versions may be substituted or mixed with alternative products to maximize profits for vendors. Unsuspecting users can be subject to life-threatening side effects.
  • •To clinicians caring for these patients, the composition of benzodiazepines obtained outside of a pharmacy may not easily be identifiable, making treating intoxications a challenge.

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  Book Club at Intern Orientation to Help Frame Professional Identity

  Gretchen A. Diemer, MD and Emily Stewart, MD

  Background

  Orientation is a whirlwind of regulations, reminders, rules and usually some social outlets. Very little of it helps new interns foster and celebrate their blossoming professional identity. The book club combats the hidden curriculum emphasizing regulations and policies by nurturing the growing sense of whom they are as physicians, actively placing value on the idea that they are developing a professional identity.

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  Reduction of Central line Associated Bloodstream Infections in an Urban 40 bed, Level III Neonatal Intensive Care Unit when new practices were implemented

  Roberta Glenn, BSMT (ASCP) CIC

  BACKGROUND

  • Central line-associated bloodstream infection (CLABSI) in the neonatal population is a major source of morbidity and mortality.
  • The disruption of skin and mucus membranes by the use of invasive devices contributes to the susceptibility of this population.
  • In our Neonatal Intensive Care Unit (NICU), the CLABSI rate was continually increasing.
  • It became evident that new practice guidelines were necessary to reduce the CLABSI rate in this vulnerable population.

  Poster presented at: APIC 2017 in Portland Oregon, United States.

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  ST elevation myocardial infarction in a young adult: Expect the unexpected

  Shashank Jain, MD; Priya Rajagopalan, MD; Mitul Kanzaria, MD; and Meir Mazuz, MD

  Background

  • Acute myocardial infarction (MI) in young adults can present a diagnostic and therapeutic challenge
  • Kawasaki disease (KD) is a vasculitis of unknown etiology that occurs in infancy and childhood
  • Coronary artery aneurysms (CAA) are the most serious complication of untreated KD seen in upto 25% of patients
  • Thrombosis of these CAA or coronary stenosis can present as MI in less than 2% of cases which mainly occur in the 1^st year of disease onset
  • Late presentations in adult life is extremely rare

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  The Use of Palliative Performance Score in Patients with End-Stage Liver Disease

  Drew Kotler, MD; Mital Shah, MD; Sheela S. Reddy, MD; Jonathan M. Fenkel, MD; John Liantonio, MD; and Dina Halegoua-De Marzio, MD

  ● Palliative Care services are often underutilized in patients with End-Stage Liver Disease (ESLD) and often only initiated at the end of life

  ● The Palliative Performance Score (PPS) is an important tool used in Palliative Care to assess functional status

  ● PPS has five functional dimensions: ambulation, activity level and evidence of disease, self-care, oral intake, and level of consciousness

  ● The aim of this study is to determine if there is a correlation between Model for End-Stage Liver Disease (MELD) score and PPS in ESLD patients

  ● MELD is used to predict mortality and to prioritize liver transplant allocation in ESLD patients

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  Strategic approach of an urban 900-bed academic medical center to combat Clostridium difficile infection transmission using staff engagement

  Courtney Mitchell, MPH and Kelly Zabriskie, CIC

  BACKGROUND

  • Clostridium difficile infection (CDI) caused nearly 500,000 illnesses with 29,000 deaths in the United States
  • Preventing hospital-associated Clostridium difficile infection (HA-CDI) is crucial to modern healthcare systems for reducing mortality, healthcare costs and length of stay
  • There are multiple risk factors for CDI transmission in healthcare settings:
    • Failure to comply with hand hygiene
    • Ineffective equipment and surface cleaning
    • Diagnosis delays

  Poster presented at: APIC 2017 in Portland Oregon, United States.

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  A Case of Severe Insulin Resistance in a Diabetic Patient Being Treated for Acute Promyelocytic Leukemia with Arsenic and Glucocorticoids

  Eric Shiffrin, MD; Intekhab Ahmed, MD; Serge Jabbour, MD, FACP, FACE; and Kevin Furlong, DO

  Objective:

  To present a case of severe insulin resistance in a patient with a new diagnosis of acute promyelocytic leukemia (APML) treated with all-trans retinoic acid (ATRA), arsenic, and high-dose glucocorticoids.

  Poster presented at Thomas Jefferson University House Staff Quality and Safety conference.

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  Finding the Right FIT to Improve Colorectal Cancer Screening

  Joseph Spataro; Richard Denicola; Drew Kotler, MD; and Albert Lee, MD

  Background

  • An estimated 28% of eligible US adults have never been screened for colorectal cancer (CRC) 2
  • Fecal Immunochemical Testing (FIT) offers an acceptable non-invasive screening option
  • An estimated 56% of patients at our internal medicine clinic have not had colorectal cancer screening and alternatives to colonoscopy were seldom promoted

  Poster presented at: Pennsylvania Society of Gastroenterology (PSG) Annual Scientific Meeting 2017 at Nemacolin Woodlands Resort, Farmington, Pennsylvania, United States of America.

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  Symptomatic Choledocholithiasis After Cholecystectomy

  Joseph Spataro, Mazen Tolaymat, Charles Kistler, Michael Jacobs, Jeffrey Fitch, and Monjur Ahmed

  Background

  • Clinical manifestations of choledocholithiasis include biliary colic, obstructive jaundice, pancreatitis, and acute cholangitis
  • Secondary common bile duct (CBD) stones are common when the gallbladder is intact or after recent cholecystectomy (CCY) whereas recurrent stones develop >3 years after surgery1,2
  • Patients with retained CBD stones after CCY may be asymptomatic for years and there is limited data on their pattern of presentation
  • Despite known predisposing conditions and risk factors for recurrent biliary disease, the role of intraoperative cholangiography (IOC) during CCY remains controversial

  Poster presented at: World Congress of Gastroenterology at ACG 2017 in Orlando Florida, United States.

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  Intrahepatic Cholangiocarcinoma Presenting as LI-RADS 5 "HCC"

  Raja K. Dhanekula, MD; Donald Mitchell, MD; John Farber, MD; Ashwin R. Sama, MD; and Jesse M. Civan, MD

  Background

  • Hepatocellular Carcinoma (HCC), if within Milan Criteria, is an indication for liver transplantation.

  • In contrast, intrahepatic cholangiocarcinoma (IHCC) is a contra-indication to liver transplantation due to high rates of recurrence.

  • LI-RADS 5 classification (synonymous with OPTN-5) carries a near 100% positive predictive value for HCC, allowing prioritization of patients for liver transplantation without histological confirmation.

  • The “LI-RADS M” classification indicates the presence of malignancy not meeting diagnostic criteria for HCC. In theory, IHCC lesions should be identified as LI-RADS M and not LI-RADS 5.

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  Who Helps Our Helpers? Rediscovering Joy in Medicine by Addressing Secondary Trauma

  Donald M. Friedman, MD and Vic Compher, MSS, LCSW

  Poster presented at International Conference of Physician Health in Boston Massachusetts.

  Supplementary handout with definitions and extensive bibliography available at bottom of page.

  Film is basis for poster: Portraits of Professional Caregivers-Their Passion. Their Pain (click on picture to view movie trailer)

  Quotes about movie from IMDB

  Learning objectives

  1. Become more aware of what secondary trauma is and its prevalence in health care professionals

  2. Recognize the importance of personal wellness and intentional self-care by physicians and other allied professionals

  3. Encourage the development of medical systems in the formation of effective peer support structures

  Context/background

  The documentary filmmaker, Vic Compher, a former administrator, supervisor and social worker in the Department of Human Services in Philadelphia, realized the presence of secondary trauma in professionals who rescue, assist and/or treat injured, traumatized or physically ill patients. His film, “Portraits of Professional Caregivers – Their Passion, Their Pain,” contains narrative interviews with a broad spectrum of professional empathetic caregivers who describe the stressful effects of their work and how those stresses affect them emotionally and functionally. The purpose of these stories is to promote awareness of secondary trauma/compassion fatigue and how it can be toxic and lead to burnout, promote provider self-care and emphasize the need for an organizational structure that provides support and healing for the medical staff.

  Method/approach

  Our poster will provide a colorful chart with the statistics of physician burnout and a display of the statistics of secondary trauma in allied professions. The poster will also include definitions of secondary trauma/compassion fatigue, burnout and compassion satisfaction. There will be dramatic still shots from the film depicting professional narratives, self-care in action and group peer debriefing/support sessions. Handouts will include a bibliography of current research, definitions and symptoms of secondary trauma and burnout, illustrations of compassion satisfaction, and examples of organizational structures that provide emotional support and healing for medical staff.

  Findings/results

  Secondary trauma is prevalent among a wide variety of professional caregivers and can lead to poor performance, dissatisfaction with work and burnout. Provider self-care and institutional support of the caregiver are crucial for promoting compassion satisfaction and resiliency.

  Conclusions/discussion

  Secondary trauma is a recognized occupational hazard of professional caregivers but can be countered by self-awareness, self-care and institutional support.

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  Training EMR in Case-Based Curriculum

  Anthony J. Frisby, PhD; Steven Herrine, MD; and Deborah Ziring, MD

  Introduction:

  The Sidney Kimmel Medical College (SKMC) at Thomas Jefferson University (TJU) is creating a new medical curriculum (JeffMD), in which more learning will take place in small groups and individual activities.

  In their small groups, students will focus on core case studies that will become increasingly complex, each building on the prior phase of the curriculum.

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  Patient Perception of Telehealth Primary Care Video Visits

  Rhea E. Powell, MD, MPH; Jeffrey Henstenburg, BS; Grace Cooper, BA; Judd Hollander, MD; and Kristin L. Rising, MD, MS

  Introduction

  • Telehealth (TH) is an innovative model of care delivery with potential to provide more patient-centered healthcare, allowing patients to receive care when and where is most convenient.
  • To date, little is known about patient perceptions of receiving care with the use of TH video visits.

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  A Case of Arterioportal Fistula Leading to Non-cirrhotic Portal Hypertension

  Sheela S. Reddy; Raja K. Dhanekula, MD; Warren R. Maley, MD; Colette Shaw, MD; Jesse M. Civan, MD; David A. Sass, MD; Jonathan M. Fenkel, MD; Susan Shamini Noori, MD; and Dina Halegoua-De Marzio, MD

  Background

  • Arterioportal fistula (APF) is a rare cause of non-cirrhotic portal hypertension.

  • This is a case of a hepatic artery-portal vein fistula presenting with recurrent variceal hemorrhage and ascites in a patient with no known liver disease.

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  Follicular Bronchiolitis in an Adult Male with Common Variable Immune Deficiency

  Megan K. Ford, MD; Alana B. Kekevian, DO; Charalambos C. Solomides, MD; and John R. Cohn, MD, FACAAI

  BACKGROUND

  • Follicular bronchiolitis (FB) in patients with common variable immune deficiency (CVID) is rarely described and knowledge is based on case reports, case series, and studies on the individual disease entities.^1-5
  • FB is a granulomatous-lymphocytic interstitial lung disease (GLILD). GLILD is a group of non-infectious lung diseases which also includes lymphocytic interstitial pneumonia, granulomatous disease, and lymphoid hyperplasia.^6,7
  • FB is caused by an external stimulus or abnormal immune response that incites lymphoid hyperplasia.⁸
  • The etiology of FB is idiopathic or associated with collagen vascular disorders (e.g., Sjogrens, rheumatoid arthritis), hypersensitivity reactions, acquired immunodeficiencies (typically HIV), and less commonly, primary immunodeficiencies.^9,10 In case reports, FB has also been linked to primary ciliary dyskinesia, multicentric Castleman’s disease, primary tuberculosis, and eosinophilia with elevated IgE.^11-14
  • The differential diagnosis of FB includes other types of GLILD, low grade bronchus associated lymphoid tissue lymphoma, and sarcoidosis.¹

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  Detection of genetic and epigenetic DNA markers in urine for the early detection of primary and recurrent hepatocellular carcinoma

  Hie-Won Hann, Surbhi Jain, Ting-Tsung Chang, Chi-Tan Hu, Selena Lin, Wei Song, and Ying-Hsiu Su

  Poster presented at American Association of the Study of Liver Diseases (AASLD) meeting in San Francisco California.

  Objective:

  Develop a urine test using a panel of select genetic and epigenetic markers for the early detection of primary and recurrent HCC.

  Introduction:

  Hepatocellular carcinoma (HCC) or liver cancer is an aggressive disease and one of the fastest growing cancers by incidence in the United States. Early detection is the key for effective treatment of HCC as the 5-year survival rate is 26% in early stage HCC as compared to only 2% when found after spreading to distant organs. The current marker, alpha-feto protein (AFP) and its fucosylated glycoform, L3, are of limited value with only 40-60% sensitivity.