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  Gastric Polyps Leading to Occult Blood Loss

  Nishant Aggarwal, Rabin Neupane, and Ketan Rana

  Publication Date: 10-2022

  Introduction

  In patients presenting with iron deficiency anemia, blood loss must be considered as an etiology. This is especially important in patients who are planned to undergo invasive procedure or need to be on antiplatelets or anticoagulation.

  Discussion

  Gastric polyps are noted to be present in 6% of EGDs, and are mostly incidentally detected. Many gastric polyps have similar endoscopic appearances and some of them have malignant potential, hence histolopathology is important. Gastric hyperplastic polyps are strongly associated with inflammatory disorders such as chronic gastritis, H. pylori gastritis, and pernicious anemia.1 Other gastric polyps: – Fundic gland polyps – Adenomatous polyps: High malignant potential – Gastric neuroendocrine tumors – Inflammatory fibroid polyps

  Conclusion

  Occult blood loss must be considered in differential diagnosis for new onset iron deficiency anemia. Even though gastric polyps may be incidentally detected, histopathology is important to rule out malignancy.

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  Paradoxical Embolism: Renal Infarct Presenting as Abdominal Pain

  Nishant Aggarwal, Dana Rector, Nicholas J. Lazar, Ali Khreisat, and Florian Bukovec

  Publication Date: 10-2022

  Introduction

  Paradoxical thromboembolism refers to thromboembolism originating in venous circulation which traverses directly into systemic circulation in the presence of an intracardiac (such as patent foramen ovale) or pulmonary shunt. Can have variable clinical presentation depending on site of embolization – Embolic stroke: neurological deficits – Intestinal ischemia: abdominal pain – Peripheral arterial embolization: acute limb pain – Renal infarct: flank pain and hematuria.

  Conclusion

  Simultaneous arterial and venous thrombosis requires hypercoagulable workup, including investigation for malignancy, infection, or thrombophilia. Rarely, venous thromboembolism can directly cause arterial thrombosis by paradoxical embolization. Renal infarction is rare. Usually presents as acute abdominal pain and AKI in patients with risk factors for thrombosis. High index of suspicion is crucial for timely diagnosis given patients may benefit from percutaneous endovascular therapy, if indicated.

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  Improving Appropriate Utilization of Echocardiography in the Workup of Syncope

  Sam Alsabti, Alexander Schick, Jacob Morton, Inna Sta. Maria, Devika Aggarwal, Matthew Sullivan, Pradeep Kaminoulu, Nicholas Maddens, Justine Nasr, and Alexandra Halalau

  Publication Date: 10-2022

  Introduction

  20-50% of all medical imaging is of low value or inappropriate. Echocardiography (echo) is a safe and diagnostic test that provides reliable information about the heart but comes at a cost. Current ACC/AHA guidelines only recommend use of echocardiography in syncope when there is suspected structural heart disease based on cardiac history, physical exam, or electrocardiogram.

  Objectives

  To identify appropriate utilization rates of echocardiography in the workup of syncope. • To improve appropriate resource utilization by implementing a guideline-based, PDSA (Plan-Do-Study-Act) Quality Improvement protocol (Figure 1) using informational material placed in and around commonly used resident working areas (Figure 2).

  Conclusion

  Echo has a low diagnostic yield when evaluating patients with syncope. • An increase in the appropriate utilization of this resource may increase its accessibility to clinical settings where it is more urgently needed, reduce hospital costs and length of stay, and lower the financial burden incurred by the patient

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  Death Exposure Influence on Medical Students’ Attitudes Toward End-of-Life Care

  Sara J. Barlow, Nelia Alfonso, and Jason A. Wasserman

  Publication Date: 5-5-2022

  INTRODUCTION
  Advance directives help guide individuals and their families in making end-of-life decisions that physicians must respect and carry out on behalf of patients to provide optimal care that aligns with their wishes. The facilitation of end-of-life care and the application of advance directives are impacted by physicians’ attitudes and knowledge regarding this topic. Current studies focus on the perspective that practicing physicians have toward advance directives. Our goal is to examine the end-of-life preferences of medical students at Oakland University William Beaumont (OUWB) School of Medicine before and after clinical exposure to better appreciate how and when opinions regarding end-of-life care develop during physician’s education.

  
  
  

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  Multiple Endocrine Neoplasia Type 1 in a Young Man With Seizures

  Nitya Batra, Nishant Aggarwal, Shailesh Niroula, Daniel Misra, Peter Czako, and Daniel Shelden

  Publication Date: 10-2022

  Introduction

  Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder involving mutation of the MEN1 gene. Clinically it is defined by tumors of the pituitary, parathyroid, and the entero-pancreatic endocrine cells. Other tumors have been associated with MEN1. We present a case of a previously healthy young man presenting with seizures.

  Discussion

  We present a classic case of MEN1 in a patient with significant family history with the presence of primary hyperparathyroidism, pituitary microadenoma, and duodenopancreatic NETs. • Interestingly, rare presentation of MEN1 as refractory seizures have been reported secondary to hyperinsulinemic hypoglycemia, but our patient was euglycemic with appropriate levels of insulin and C-peptide. This suggests an alternative etiology that is not well documented in available literature. • Given the complex and highly specialized skills needed to diagnose and treat MEN1, involvement of a multidisciplinary team is vital.

  Conclusion When the clinical suspicion for MEN1 is high, endocrinology evaluation with appropriate laboratory workup and targeted imaging of the typical endocrine organs as described for this patient are advised with careful multidisciplinary management and follow-up.

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  A Novel Case of Babesiosis in a Gardener

  James Benke, Jay Shah, and David Lang

  Publication Date: 5-2022

  • Babesiosis serious health concern in Northern and Midwestern US • Transmitted through tick, Ixodes scapularis • Presents with fever and several non-specific complaints • Diagnosis - Blood smears, DNA by PCR, and anti-body titers • Can be fatal when left untreated • Treatment - IV antibiotics • This case discusses a severe presentation of babesiosis in a gardener, who survived with a prolonged course of antibiotics

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  Apical Hypertrophic Cardiomyopathy: A Rare Variant of Hypertrophic Cardiomyopathies

  Alexandra Corrado-Kittel, Diana DeAngelis, Katharine Glover, and Gregory Hazergian

  Publication Date: 5-2022

  Introduction • AHCM is a rare morphological variant of hypertrophic cardiomyopathies • The AHA/ACC defines hypertrophic cardiomyopathy as left ventricular hypertrophy in the absence of abnormal loading conditions, or other cardiac, systemic, or other metabolic disease capable of producing the magnitude of hypertrophy observed on echocardiogram • Regardless of the morphology, understanding workup, management and follow up are crucial

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  Cannabis and Acute Coronary Syndrome: A Case Report Exploring Potential Links

  Fawaz Habba, Michael Hoban, and Scott Searing

  Publication Date: 5-2022

  Introduction • Cannabis is a commonly abused drug in the United States. It is paramount that physicians understand the risks of its use that may impact patient safety, particularly its effects on the cardiovascular system. • There are two cannabinoid receptors which the active component of marijuana, delta-9- tetrahydrocannabinol (THC), acts on: Cannabinoid receptor type 1 (CB1 ) and cannabinoid receptor type 2 (CB2 ). • THC causes stimulation of the sympathetic nervous system while inhibiting the parasympathetic nervous system. • While the precise pathophysiology behind myocardial infarction in patients consuming marijuana is unknown, it is postulated that sudden coronary occlusion is likely due to plaque disruption caused by the hemodynamic alterations cannabis causes on the cardiovascular system.

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  Incidental Pathogenic Fibrin-Associated Diffuse Large B-Cell Lymphoma Found During Aorto-Biiliac Bypass

  Peter Habib, Thomas Serena, Caitlin Flynn, Aaron Hartkop, Elizabeth Wey, David Lang, and Eugene Laveroni Jr

  Publication Date: 5-2022

  Introduction • Fibrin-associated diffuse large B-cell lymphoma (FA-DLBCL) is an extremely rare form of Epstein-Barr virus positive (EBV+) non-Hodgkin’s lymphoma. • This case presents a rare and unique presentation of a pathological non-Hodgkin’s lymphoma

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  Exploring the Effects of Mindfulness Based Stress Reduction on Pre-Clinical Medical Students: A Qualitative Methods, Longitudinal Pilot Study

  Alyssa Heintschel, Scott Sabbagh, Patrick Herndon, Michael Moussa, and Ruth Lerman

  Publication Date: 5-2-2022

  INTRODUCTION
  Mindfulness Based Stress Reduction has become an increasingly popular practice in healthcare-affiliated populations. MBSR is a course designed to promote mindfulness and awareness within oneself through a combination of formal and informal practices. Studies suggest healthcare workers are at higher risk of experiencing stress and burnout; this is prevalent among pre-clinical medical students due to the rigorous nature of medical school coursework. The primary objective of this study is to evaluate the effectiveness and feasibility of implementing an MBSR program to facilitate improvements in key areas of mental health among medical students throughout their training.

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  Investigating the Effectiveness of a Mindfulness Based Stress Reduction Course Within Healthcare: A Qualitative Methods Study

  Patrick Herndon, Michael Moussa, Alyssa Heintschel, Scott Sabbagh, and Ruth Lerman

  Publication Date: 5-2-2022

  INTRODUCTION
  Mindfulness practice has emerged as a promising means to address stress in healthcare workers (HCW). Virtually all HCW studies of the standardized, validated Mindfulness Based Stress Reduction (MBSR) curriculum have been conducted using homogeneous (HCW only) populations. This work examines the novel approach of comparing the effects of heterogeneous MBSR classes: HCW, oncology patients and family members (HCW-HE) as compared to homogeneous classes HCW and their family members only (HCW-HO)

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  Asymptomatic chronic sinusitis as an atypical presentation of meningitis

  David Hwang, Laura Azzouz, Zeshan Choudhry, and Benjamin Rossi

  Publication Date: 5-2022

  Introduction We present a unique case report of asymptomatic acute on chronic pansinusitis with parameningeal involvement as an atypical presentation of meningitis with associated pyrexia, nuchal rigidity, and headaches. Following initial admission, patient clinically deteriorated subsequently requiring emergent surgical debridement with ENT with cultures demonstrating fusobacterium nucleatum. This case presentation is of unique interest given long term neurological sequelae which can manifest as a result of delayed therapy, both medical and surgical, which includes but is not limited to permanent vision loss, ataxia, gait difficulty, and long standing sensorimotor deficits. We hope to provide additional educational resources given the lack of clear standard treatment protocols for meningitis secondary to sinusitis and rare clinical scenario

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  PEG Tube: Dealing With Transcolonic Misplacement

  Marko Kozyk, Kateryna Strubchevska, and Mihaela Batke

  Publication Date: 10-2022

  Introduction

  Percutaneous endoscopic gastrostomy (PEG) tube acts as the favorable route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition, generally beyond 4 weeks. As PEG tube provides direct percutaneous access to the stomach, another indication for PEG placement includes stomach decompression. PEG tube placement is a relatively safe procedure; however, complications sometimes occur.

  Discussion

  Complications of PEG: • Hemorrhage • Aspiration • Inflammation • Infections • Misplacement • Formation of fistulas Misplacement results from juxtaposition of the colon between the stomach and the skin during the PEG insertion, resulting in a feeding tube passing through the colon, usually the transverse colon, before being anchored in the stomach.

  Prevention of PEG-tube misplacement: • Adequate air insufflation of the stomach can help prevent this complication by displacing the colon away from the path of the PEG tube

  Management of PEG tube misplacement: • Surgical (in the presence of peritonitis) • Endoscopic (in the absence of peritonitis) • Percutaneous removal of the tube may result in stercoral peritonitis or colocutaneous fistula.

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  Investigating the Effects of a Mindfulness Based Stress Reduction Course on a Grouping of Oncology Patients, Health Care Workers and their Families on Measures of Stress and Burnout in Health Care Workers: A Randomized Control Trial

  Michael Moussa, Patrick Herndon, Alyssa Heintschel, Scott Sabbagh, and Ruth Lerman

  Publication Date: 5-2-2022

  INTRODUCTION
  Mindfulness Based Stress Reduction (MBSR) can improve the mental health of health care workers (HCW). How will the inclusion of oncology patients (OP) in MBSR classes for HCW affect the mental health of HCW?

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  Acquired Acrodermatitis Enteropathica Presenting as Confusion and Desquamating Maculopapular Rash

  Nazli Begum Ozturk, Ali Khreisat, Luai Madanat, and Lynda Misra

  Publication Date: 10-2022

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  Mindfulness-Based Stress Reduction for Pre-Clinical Medical Students: Exploring Efficacy and Benefit

  Scott Sabbagh, Alyssa Heintschel, Patrick Herndon, Michael Moussa, and Ruth Lerman

  Publication Date: 5-2-2022

  INTRODUCTION
  Studies suggest that healthcare-affiliated populations are at an increased risk of experiencing chronic stress and burnout. Mindfulness meditation has become an established method to address and alleviate their effects, though it has not been extensively studied in the medical student population. The primary goals of this study are to assess the feasibility and efficacy of an 8-week, 30 contact hour MBSR course for first and second year medical students, and to assess its impact on their reported levels of stress, burnout, fear of compassion, and mindfulness.

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  Urinary cytokines as potential biomarkers of mild cognitive impairment and Alzheimer’s disease: a pilot study

  Nazia Saiyed, Ali Yilmaz, Sangeetha Vishweswariah, Sarah Bartolone, Tammy Osentoski, Stacey Ruff, Amita Pai, Michael Maddens, Khaled Imam, and Stewart F. Graham

  Publication Date: 10-21-2022

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  HIV-associated nephropathy presenting as the first manifestation of HIV 2 infection

  Kamil Sardarli, Rania Daboul Daboul, Sumesh Khanal, and Sami Zarouk

  Publication Date: 4-2022

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  Dual Paraneoplastic Syndrome in Small Cell Lung Cancer

  Kamil Sardarli, Austin Morris, and Jamal AbuKhaled

  Publication Date: 11-2022

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  A Rare Case of Subcutaneous Panniculitis-Like T-cell Lymphoma

  Blake Seelbinder, Angela Kim, Marcos Rosado, Mohamed Musheinesh, Amanda Cimino, John Pui, Armen Korkigian, and Craig Gordon

  Publication Date: 5-2022

  Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare and typically slow growing variant of T-cell lymphoma. The clinical course usually mimics infectious panniculitis. It characteristically affects the subcutaneous adipose tissue of the trunk or extremities without resultant lymph node involvement. It comprises

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  Primary Carnitine Deficiency Induced Ventricular Fibrillation

  Andrew Sherman, Luai Madanat, Timothy Pow, and Akhil Gulati

  Publication Date: 5-13-2022

  Background: Children with primary carnitine deficiency (PCD) frequently develop cardiomyopathy; however it is not commonly seen in adults. Arrhythmias are less common and include forms of long QT-syndrome and ventricular fibrillation. ECG findings commonly involve peaked T-waves and short QT intervals that may resolve with supplementation of L-carnitine. Case presentation: An 18-year-old female with a family history of sudden cardiac death (SCD) presented to the emergency department following a witnessed out-of-hospital cardiac arrest. She was initially noted to be in ventricular fibrillation (VF) and was subsequently defibrillated twice on presentation. Her rhythm converted to supraventricular tachycardia at which time adenosine 6 mg IV was administered twice with reversion to sinus rhythm. ECG on presentation demonstrated peaked T waves and short QT interval. She was admitted to the cardiac intensive care unit for targeted temperature management. Carnitine level on admission was subtherapeutic at 1 nmol/mL (normal: 34-78 nmol/mL) due to suboptimal dosing at home. She was loaded with L-carnitine 12 g/day with repeat levels improving to 41 nmol/mL. Echocardiogram revealed an ejection fraction (EF) of 35% with a dilated right ventricle and global left ventricular hypokinesis. The patient later regained consciousness and was transferred out of the cardiac intensive care unit. Repeat echocardiogram two weeks later revealed no significant change in EF. Her hospital course was complicated by methicillinsensitive staphylococcus aureus pneumonia, for which ICD placement was delayed until completion of antibiotics. She was discharged home in stable condition with plans for 4 weeks of IV antibiotic therapy and close follow-up. Discussion: Primary carnitine deficiency can present as ventricular fibrillation with or without pre-existing cardiomyopathy in adults. Strategies for primary prevention of SCD should be considered in these patients, especially in those with a known family history of SCD.

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  Case of Leptospirosis in Urban Settings With Perplex Clinical Presentation

  Kateryna Strubchevska, Marko Kozyk, and Brian Nadeau

  Publication Date: 10-2022

  Introduction

  Leptospirosis is a zoonosis with variable clinical manifestations caused by pathogenic spirochetes of the genus Leptospira. It occurs in both temperate and tropical regions. A systematic review and modeling exercise estimated that there were 1.03 million cases worldwide annually with 58,900 deaths. Leptospirosis stays among the leading zoonotic causes of morbidity worldwide and accounts for numbers of deaths, which approach or exceed those for other causes of hemorrhagic fever.

  Discussion

  Leptospirosis has unusual symptoms which make the diagnosis challenging. There is a need for a comprehensive approach when the disease is suspected. • Liver and kidney involvement represent life-threatening manifestations of the disease. • Antibiotic treatment is usually recommended as it shortens the clinical course and prevents the spread of the disease.

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  Diabetic Ketoacidosis Precipitated by COVID-19 Induced Acute Pancreatitis

  Tamera Tennant and Bhavinkuma Dalal

  Publication Date: 5-13-2022

  Gastrointestinal manifestations of COVID-19 infection are increasingly being recognized, such as nausea, vomiting, and diarrhea. Research into the pathophysiology is ongoing. I present a case of a 52-year-old female without a history of diabetes who presented to the emergency room with progressive lethargy and altered mental status. Her tests results were consistent with diabetic ketoacidosis with glycemia 1440 mg/dL, venous pH 7.23, beta hydroxybutyrate of 7.53 mmol/L, bicarbonate 14 mmol/L, and anion gap 32. COVID-19 (SARSCoV- 2) testing by nucleic acid amplification was positive on admission. She was admitted to the intensive care unit and started on an insulin drip. Her severe abdominal pain led to the diagnosis of acute pancreatitis with lipase >1200 U/L and computed tomography of the abdomen showed inflammatory changes around the head of the pancreas and second portion of the duodenum. Workup for the cause of her pancreatitis was unrevealing. A right upper quadrant ultrasound negative for evidence of cholelithiasis, common bile duct dilation or liver abnormalities. She denied alcohol and drug use, which was confirmed with a negative blood alcohol level and urine drug screen on admission. Furthermore, she was not taking any medications prior to arrival, specifically those known to cause pancreatitis. She was diagnosed with diabetes mellitus during this admission and DKA was the presenting situation precipitated by COVID-19 pancreatitis. She was treated with intravenous fluids and supportive care. The remainder of her hospital stay was unremarkable. She was discharged home with an insulin regimen, and her HbA1C two months later was 8.3%. Follow-up CT of the abdomen one month after discharge showed no abnormalities. Literature review revealed a study in China reported an elevated incidence of pancreatic injury with few exhibiting hyperglycemia, and without a diagnosis of acute pancreatitis (1). There are few cases of acute pancreatitis that are classified as being caused by COVID-19 infection (2). However, none of these reported a complication of DKA. This case demonstrates pancreatitis and DKA as rare, yet possible, complications of COVID-19 and emphasizes the importance of thorough history-taking and diagnostic evaluation.

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  A Case of Pancreatic Squamous Cell Cancer

  Bijaya Thapa, Ujjwal Jung Karki, Bipin Ghimire, Ashbita Pokharel, Shailesh Niroula, and Mohammad Muhsin Chisti

  Publication Date: 10-2022

  Introduction

  Primary Squamous Cell Carcinoma of the pancreas is a rare entity that comprises 0.05% of all exocrine pancreatic carcinomas. The main differential diagnoses of primary SCC of the pancreas are adenosquamous carcinoma- another rare primary tumor of the pancreas and metastatic SCC from another primary site.

  Discussion

  Squamous cell carcinoma of the pancreas is a controversial entity of uncertain origin, as the pancreas is entirely devoid of squamous cells[1] • Adenosquamous carcinomas may be misdiagnosed in case of inadequate sampling of adenocarcinoma component. • Literature is limited to a few case reports, and has shown pancreatic SCC to be an aggressive cancer with a poor prognosis. • Isolated reports are available on the use of gemcitabine and newer taxane formulations, but the response to chemotherapy or radiotherapy is sub-optimal. • Similar to breast, ovarian, and endometrial cancers; pancreatic cancers can be genetically inherited. • As with all pancreatic cancers, surgical resection of the tumor has been the most effective modality, however treatment with targeted immunotherapy could be promising in unresectable tumors with targetable mutations.

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  Prediabetes as a risk factor for major adverse cardiovascular events

  Muhammad A. Waheed, Ramy Mando, Adrian Michel, and Alexandra Halalau

  Publication Date: 5-2-2022

  INTRODUCTION
  Major adverse cardiac events (MACE) have been shown to be associated with Type II diabetes mellitus (DM) as it is a proinflammatory process. Some DM inflammatory markers may be present in prediabetes (pDM). Yet, the clinical relationship between pDM and MACE has not been well studied. Thus, this study’s primary goal is to see if pDM increases one’s risk for MACE.