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 Table of Contents  
CONFERENCE ABSTRACTS AND REPORTS
Year : 2022  |  Volume : 8  |  Issue : 3  |  Page : 151-188

The 2022 St. Luke's University health network annual research symposium: Event highlights and scientific abstracts


1 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
2 Department of Anesthesiology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

Date of Submission05-Sep-2022
Date of Acceptance18-Sep-2022
Date of Web Publication28-Sep-2022

Correspondence Address:
Dr. Anna Ng-Pellegrino
Department of Research and Innovation, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijam.ijam_87_22

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How to cite this article:
Michaud A, Ng-Pellegrino A, Birk R, Stawicki SP. The 2022 St. Luke's University health network annual research symposium: Event highlights and scientific abstracts. Int J Acad Med 2022;8:151-88

How to cite this URL:
Michaud A, Ng-Pellegrino A, Birk R, Stawicki SP. The 2022 St. Luke's University health network annual research symposium: Event highlights and scientific abstracts. Int J Acad Med [serial online] 2022 [cited 2023 Feb 1];8:151-88. Available from: https://www.ijam-web.org/text.asp?2022/8/3/151/357235



The annual St. Luke's University Health Network (SLUHN) Research Symposium was established in 1992 to highlight the various research and quality improvement projects completed by residents, fellows, and other trainees within the network. It allows trainees to discuss and reflect on current healthcare issues, hone their research skills and receive valuable feedback. The event is organized by a multi-departmental planning committee, with collaboration and consultation provided by Graduate Medical Education (GME) leadership, medical school leadership, as well as residency and fellowship faculty. Residents, fellows, and students submit their application either for the podium (8-min) or quick shot (5-min) presentation along with an accompanying abstract describing their project or case report.

This year's event featured one of the largest numbers of podium and quick-shot presentations in SLUHN's 30-year Research Symposium history. Several of the research projects presented during this year's symposium were published in journals of their respective fields. Before the event, each submitted project was assessed by at least two independent academics who judged its' overall scientific quality (60% of the score). This was followed by a live audience vote for the best presentation (40% of the score). Based on the above methodology, prizes were presented to the top three podium presenters and the best quick-shot presenter. Since 2018, students from the Temple/St. Luke's Medical School were invited to participate in the Research Symposium, where they competed for the scientific competition prize of “Best Presentation by a Medical Student.” Several of the research projects presented during the symposium were published in journals of their respective fields.

The 2022 Research Symposium winners were as follows:

  1. Podium presentations


    1. First place – Dr. John Hayes – Family Medicine Residency, St. Luke' Richard A. Anderson Campus, Easton “”Farmacy”: Food as Medicine for Chronic Diseases”
    2. Second place – Dr. Daniel Franey – General Surgery Residency, University Hospital Campus, Bethlehem: Innovation or Tried and True? Retrospective Cost Analysis of Robotic and Laparoscopic Paraesophageal Hernia Repair
    3. Third place – Dr. Timothy Daly – Internal Medicine Residency, University Hospital Campus, Bethlehem: Premorbid Echocardiography and Risk of Severe COVID-19


  2. Quick shot presentation


    1. First place - Steven Tessier – Lewis Katz School of Medicine (LKSOM): A Novel Mutation Causing Prolidase Deficiency: Genetic Testing as the Candle in the Dark


  3. Medical student presentation


    1. First place – Katherine Peake- Lewis Katz School of Medicine (LKSOM): Effects of the COVID-19 Pandemic on Depressive Symptoms in Adolescents


As in the previous 6 years, the 2022 Research Symposium included a Keynote Speaker. This year's invitee is Dr. Lisa Moreno-Walton, MD, MS, MSCR, FAAEM, FACEP. Dr. Moreno-Walton is the Associate Dean of Diversity and Inclusion and a Tenured Professor of Emergency Medicine at the Brody School of Medicine of East Carolina University, Greenville, NC. The Keynote presentation discussed disparities in research and the associated relationships to healthcare outcomes. During her presentation, Dr. Moreno-Walton discussed key historical aspects of medical research, both in the United States and around the world. She then highlighted the need for greater diversification, equity, and inclusion, based on statistical data on who conducts research, on whom the research is conducted, and how this affects response to therapy — examining whether equitable treatment (and thus access to research opportunities) is available to all patients and how these factors may affect outcomes at both individual and societal levels. Keynote Address concluded the morning session of the Research Symposium.

The afternoon session of the event included presentations from various departments that directly and indirectly support research and scholarly activity at SLUHN. This highly informative session featured content from the following areas: Clinical Trials, the Institutional Review Board, Graduate Medical Education Data Management and Outcomes Assessment, Temple/St. Luke's Medical School, Information Technology (IT)/St. Luke's Technology Ventures, Knowledge Management, Nursing/Evidence-Based Practice, Physical Therapy, Quality and Safety, Narrative Medicine, as well as several other specialties, departments, and topics. The 2022 Research Symposium took place on a virtual platform, in accordance with established Network / hospital guidelines applicable to the ongoing COVID-19 pandemic. The event was among the most highly attended virtual meetings at SLUHN this year.

This document contains a total of 13 original research / podium presentation abstracts as well as 15 case or case series presentations. Abstracts published and/or presented at other fora were not included herein. In addition, primary authors' consent was required prior to inclusion of Research Symposium abstracts in this published collection.

The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge, Patient care and procedural skills, Professionalism, and Systems-based practice.



G. Herbst1, P. Kaur2, H. Levin2,3, S. Makary2,3, D. Nunez2,3

1Temple Lewis Katz School of Medicine, Philadelphia, PA, USA; Departments of 2Graduate Medical Education, St. Luke's Richard A. Anderson Campus, Easton, 3Psychiatry Department University Hospital Campus, Bethlehem, PA, USA

Introduction: Mental illness is a pervasive issue in America, afflicting nearly 20% of U.S. adults. In serious mental illness (SMI) cases, the functional impairments of the disease warrant intensive treatment programs. One such program is the partial hospitalization program (PHP), in which patients attend outpatient group therapy for approximately 30 hours per week for an average of 10 treatment days. Depression, on its own and co-morbidly, is one of the most common reasons patients present to a PHP. Depression is a mood disorder characterized by feelings of persistent sadness, loss of interest in one's normal activities, fatigue, and changes in appetite.[3] Depression is often treated with psychotherapy and/or medication; however, the efficacy of these treatments is often variable, substantiating the need for alternative/additional therapies.[4] Due to the COVID-19 pandemic, mental health programs such as St. Luke's PHP had to adapt to the safety needs of our patient population and initiated a virtual option for patients. Research comparing the efficacy of virtual vs in-person therapy has been mixed. Some data point to online therapy as a means of providing easier access to treatment than in-person therapy, thus increasing patient adherence and satisfaction,[1],[5] while other data show online therapy to be less efficacious than in-person therapy due to issues with emotional connectivity between therapist and patient.[2],[5] The primary aim of our study was to compare the depression and quality of life scores of patients who attended therapy at the online St. Luke's PHP campus to those who attended therapy at the in-person St. Luke's PHP campus. Journaling is an intervention that has shown some promise as an adjunct to therapy for a variety of mental health disorders.[7] Our secondary aim was to compare the depression and quality of life scores between those who engaged in journaling over the course of their PHP treatment and those who did not.

Methods: Patients undergoing PHP at St. Luke's from June 2021- August 2021 were included in the study. St. Luke's has 2 PHP campuses, the Bowmanstown campus (group 1) and the Sacred Heart Campus (group 2). Both sites conduct similar treatment protocols; however, patients enrolled at Bowmanstown meet virtually for their treatment, while those at Sacred Heart meet in person. Inclusion criteria were being at least 18 yrs. and fluent and literate in English. Exclusion criteria were having a primary psychotic disorder- schizophrenia/schizoaffective disorder/psychotic disorder NOS. All participants in the study were asked to engage in pre, post, and 1-month follow-up survey evaluations. The outcomes measured were severity of depressive symptoms using the PHQ-9*, quality of life (QoL) measure using a single-item visual analogue scale (0–100), journaling frequency, as well as engagement in health behaviors as measured by the survey. * A PHQ-9 score of 0-4 points equals “normal” or minimal depression. Scoring between 5-9 points indicates mild depression, 10-14 points moderate depression, 15-19 points moderately severe depression, and 20 or more points severe depression.

Results: We used SPSS version 28 to analyze the data (Armonk, NY: IBM Corp.). Since continuous variables like PHQ-9 and QOL had a skewed distribution, we ran a non-parametric test. Due to multiple comparisons, Bonferroni corrections were used in interpreting the p-values. A p-value of <0.006 was considered statistically significant. 49 patients underwent PHP. Virtual group (N=24) had median age of 39.5 years (min=20, max=85) with 75% females while in-person group (n=25) was 34 years (min=19, max= 70) with 72% females. 17 patients journaled in virtual groups, while 13 patients journaled in the in-person group. When analyzing both PHP campuses together, PHQ-9 scores decreased by 5 points (p=.006), and QoL increased by 8 points (p=.003). However, when analyzing the outcomes for the 2 campuses separately, in-person therapy outperformed virtual therapy. The median PHQ-9 for the in-person group decreased from 16 (2-23) before therapy to 5.50 (0-14), while in the virtual group, the median PHQ-9 was 18 (3-27) before therapy and decreased to 14 (2-27) [Figure 1]. QOL scores improved for the in-person group from 40 (2-87) to 73.50 (50-100) (p=0.004), but no improvement in QOL was seen in the virtual group [Figure 2]. Changes in exercise and sleep for either group were not statistically significant [Table 1]. There were 13 patients who did journaling at the start of the study and did at least half of the days during the program. No statistical improvement was seen for QoL or PHQ-9 in journalers [Table 2].



Conclusion: Previous research suggests that online therapy can be less efficacious than in-person therapy for a variety of reasons,[2],[5],[6] which we found to be the case at St. Luke's PHP. However, online therapy has been successful for many populations.[7],[8] and is often more accessible than in-person therapy.[1] Future studies could investigate ways to enhance online therapy, including education about online therapy for patients [2] and reserving online therapy for older and more experienced therapists, who tend to be less affected by the drawbacks of online therapy.[6] Though journaling was not correlated with enhanced outcomes in PHP, many reported that they found it helpful, a trend also found in the literature.[9] Future studies could investigate what aspects of journaling the participants found helpful and use that information to design a directed journaling intervention. Additional studies could look for ways to enhance survey delivery, as we had a low response rate after one month.

Keywords: Depression, in-person therapy, partial hospitalization program, virtual therapy





  1. Lippke S, Gao L, Keller FM, Becker P, Dahmen A. Adherence with online therapy versus face-to-face therapy and with online therapy versus care as usual: Secondary analysis of two randomized controlled trials. J Med Internet Res 2021;23:e31274.
  2. Mateescu VM. Distance and boundaries issues in the transition from face-to-face talking therapy to online therapy in the time of covid-19. Studia Univ Babes-Bolyai Sociol 2021;66:113-23.
  3. Torres F. What is Depression? October 2020. Available from: https://www.psychiatry.org/patients-families/depression/what-is-depression American psychiatric association. [Last retrieved on 2020 Dec 29].
  4. Blackburn IM, Bishop S, Glen AI, Whalley LJ, Christie JE. The efficacy of cognitive therapy in depression: A treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br J Psychiatry 1981;139:181-9.
  5. Knechtel LM, Erickson CA. Who's logging on? Differing attitudes about online therapy. J Technol Hum Serv 2020;39:24-42.
  6. Békés V, Aafjes-van Doorn K, Luo X, Prout TA, Hoffman L. Psychotherapists' challenges with online therapy during COVID-19: Concerns about connectedness predict therapists' negative view of online therapy and its perceived efficacy over time. Front Psychol 2021;12:705699.
  7. Al-Alawi M, McCall RK, Sultan A, Al Balushi N, Al-Mahrouqi T, Al Ghailani A, et al. Efficacy of a six-week-long therapist-guided online therapy versus self-help internet-based therapy for COVID-19-induced anxiety and depression: Open-label, pragmatic, randomized controlled trial. JMIR Ment Health 2021;8:e26683.
  8. Novella JK, Ng KM, Samuolis J. A comparison of online and in-person counseling outcomes using solution-focused brief therapy for college students with anxiety. J Am Coll Health 2022;70:1161-8.
  9. Mims R. Military veteran use of visual journaling during recovery. J Poet Ther 2015;28:99-111.



  Abstract Number 2: Sleep Recorded on Fitbit Devices Compared to Sleep Journals amongst Emergency Medicine Residents by Shift Times Top


J. Hafycz, K. Morley1, S. Melanson, H. Stankewicz

Emergency Medicine Department, St. Luke's University Hospital Campus, 1Department of Graduate Medical Education, St. Luke's University Hospital Campus, Bethlehem, PA, USA

Introduction: Wellness of physicians continues to be a major focus for administrators and residency programs. Even with the advances of the ACGME (Accreditation Council for Graduate Medical Education) in terms of duty hours and other improvements, the demands of residency programs are well known. Residency affects the emotional and physical well-being of junior physicians. Shift work, in particular, results in many negative health effects, poorer sleep quality, and quantity. The goal of this study was to gather data by shift on how much emergency medicine residents sleep and compare it to how much they believe they are sleeping.

Methods: This was an IRB-approved, prospective, observational study in which Emergency Medicine (EM) residents had sleep characteristics (sleep time, light, deep, and REM sleep) recorded by a Fitbit™ Charge 3 device (FBD Fitbit/Google LLC, San Francisco, California, USA). Thirty-three EM residents consented and had their sleep data sent to a secure database, Fitabase ©. While wearing the FBDs, residents were instructed to fill out a sleep diary recording their sleep and other information. Data was recorded from December 2019 to May 2020 for six months total, although some residents opted out of the study early due to the Covid-19 pandemic. Emergency Department shifts were 8-10 hours long and coded as either day (starting between 6a-10a), evening (starting between 11a-4p), night shift (starting between 9p-12a), post-night (day after night shift), or off. T tests were used to compare the sleep recorded by Fitbit and by residents in sleep journals.

Results: There were statistically significant differences between sleep times in every shift between resident recorded sleep and FBD recorded sleep. There was less sleep recorded on FBDs (M=465), than sleep journals (M=408) for shifts off t (1669) =11.42 p=1.98*10^-29. Likewise, this was similar for post-nights (t (149) =2.06, p=0.02), day (t (570) =3.63, p=0.00016), evening (t (1178) =11.32, p=1.44*10^-28), and night shifts (385) =7.46, p=2.84*10^-13 [Figure 1]. Night shifts also resulted in statistically significant lowest amount of sleep recorded for both the sleep journals and FBDs.

Conclusion: Fitbit devices show that residents sleep significantly less than they believe they are sleeping for all shifts. This difference is roughly an hour less sleep. Thus, residents and residency programs need to be aware of this sleep deficit, specifically in evening and night shifts. As sleep quality and quantity are linked to the development of both emotional and physical diseases, it is important for residency programs to support its residents in improving their sleep patterns. Emergency medicine physicians need to do a better job of protecting their night shift workers. Advancements in wellness could lower burnout rates and ultimately lengthen the careers of emergency physicians.

Keywords: Emergency medicine, Fitbit device, residents, shift, sleep




  Abstract Number 3: Fulfillment and Burnout at St Luke's Family Warren Residency Training amongst COVID-19 Pandemic Top


A. Yamada2, N. Zambas1, H. Nwazuruokeh2, K. Kumar1, A. Remde1

1Family Medicine Department, St. Luke's Hospital, Warren Campus, 2Family Medicine Department St. Luke's University Hospital, Bethlehem, PA, USA

Introduction: Physician burnout is a significant problem within the community of family physicians, with burnout rates as high as 46%. One of the most common sources of stressors in an outpatient clinic setting is finishing/catching up with work from job at home, documenting patients into the electronic health record (EHR), completing nonclinical activities, and completing external regulatory requirements while staying current on medical knowledge. Studies have shown that family physicians spend on average 86 minutes doing administrative work after hours or at home. Clerical and administrative tasks such as documentation, order entry, billing and coding, and system security accounted for 44% of the total EHR usage time. Physician wellness will not only benefit the individual physician, but it will also be vital to the delivery of high-quality health care. Among things to consider when considering emotional exhaustion and sense of fulfillment include work stress related to administrative tasks, the mean number of healthy habits, and resiliency. Organizational interventions, as well as individual changes, are needed to address the well-being of family physicians. The COVID-19 pandemic has brought upon additional new challenges that have strained primary care practices, with the need to rapidly adapt telehealth visits to account for reduced in-patient visits, as well as physicians and other health care personnel possibly leaving the practice threatening the sustainability of one's practice. The emotional, financial, and physical health burdens by volatile COVID-19 surges have led to worsening physician burnout. This study's goal is to answer the question: are residents feeling fulfilled at St Luke's Warren amongst COVID-19 pandemic? We will calculate the means of results per PGY class for every question and compare results per class.



Methods: This study uses a validated fulfillment survey with 3 sections and 16 questions that uses a Likert scale, asking participating residents to grade their response to questions concerning fulfillment, burnout, and the impact of COVID-19 on their emotional well-being [Table 1]. The research was performed 2 separate times, three (3) months apart, to compare the changes or stability in the responses over time. The Kruskal Wallis test was used to determine any statistical significance between any differences in response among the 3 different PGY classes.

Results: Overall, the graded responses to the questions showed no significant changes amongst the classes except for this question in the initial survey: I feel happy at work (The mean value for each class for this response were as follows: 2.38 (somewhat true) for PGY1;3.5 (very true) for PGY2; & 2.5 (somewhat-moderately true) for PGY3). The average response to the fulfillment questions were leaning towards fulfilling with a score >2.5. However, the average response to the first 4 out of 9 questions leans toward burnout with a score >2.5. The 3rd section related to COVID-19 questions remained relatively stable between the 2 surveys except for the response to how the COVID-19 pandemic has affected their survey responses, which has gone from a mean score of 2.25 (Somewhat true) to 2.13 (not at all true-somewhat true). Mean score to the question, “less connected with my colleagues,” residents scored a mean value of 1.94 (somewhat true) initially and then 2.44 (median response is still “under somewhat true”) on the subsequent survey.

Conclusion: Burnout is a pervasive problem in the medical profession, and its effect has been felt as early in one's professional life as in residency training. According to the response to the survey by St Luke's Warren Family residency program, residents, on average, have endorsed symptoms of burnout but have sustained a level of empathy towards fellow patients and co-workers as well as a sense of fulfillment. The average resident reports being less affected by COVID-19 in the 2nd survey, which may reflect the specific pandemic situation at the time. Future considerations include incorporating an intervention to help lessen burnout and assess how residents' response to the survey changes before and after the intervention. Such interventions may include a protected half-day admin time to acknowledge the additional administrative tasks demanded by residents outside of clinic visits involving patient care. A cohort study following the responses of upcoming interns from orientation may be informative.

Keywords: Burnout, COVID-19, family, residency


  Abstract Number 4: Exploration of Relationship between Adverse Childhood Experiences and Hospital Admissions Top


S. Ha1, K. Kumar2, A. Remde1, K. Viotto1, B. Susskind1

1Family Medicine Department, St. Luke's Hospital, Warren Campus, St. Luke's University Hospital, Bethlehem, PA, USA; 2Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

Introduction: Adverse childhood experiences have been known to contribute to both short and long-term chronic health problems, including mental illness and substance abuse in adulthood. In 1998, a groundbreaking study by Dr. Felitti et al. exposed the relationship between how childhood abuse and household dysfunction are related leading causes of death in adults.[1] From this study, the Adverse Childhood Experiences (ACE) questionnaire was created to collect information on child abuse and neglect, household challenges, and other socio-behavioral factors. It is estimated that approximately 61 % of adults (surveyed across 25 states) reported that they experienced at least one type of adverse childhood experience, with one out of six of those individuals reporting that they had experienced more than four types.[2] A high ACE Score has also been associated with increased social and economic costs for the individual, which can further complicate their health and may lead to increased clinical care costs. Hospital readmission continues to be a daunting problem at St. Luke's Warren Hospital. In this study, we aim to explore the relationship between a patient's ACE Score, a patient's chronic illnesses (calculated by their frequency of hospital admissions), and a patient's HOSPITAL Readmissions Score. It is our hypothesis that we will see a direct correlation between a patient's ACE Score, HOSPITAL Readmission Score, and the number of times they are admitted to St. Luke's Warren Hospital. It is our hope that we can identify the patients in need of targeted medical care and provide them with the right resources to help reduce their hospital readmission rates as well as clinical costs.

Methods: Adults who consent to be part of the study will be asked to fill out the ACE questionnaire, from which their ACE Score will be calculated. Then, at their discharge, their HOSPITAL Readmission Score will be calculated, and the number of times they have visited the ER in the past year will also be recorded. We will determine if there is a correlation between the subject's ACE Score and their HOSPITAL Readmission Score.

Results: There was no correlation between ACE score and HOSPITAL Score in this study [Figure 1].

Conclusion: This study did not find a correlation between patients' ACE scores and admission rates. There were many areas of this study that can be changed and improved. First, the sample size was too small for a complete data analysis. Many barriers inhibited admitted patients from filling out the ACE survey during their admission. The most significant barrier was patients' unwillingness to take the survey because of the acuity of their illnesses or discharges. It would be our suggestion to a new research group to have the survey filled out during a patient's follow-up Transition of Care Management visit at the Coventry Family Practice outpatient clinic. We believe patients may be more willing to participate when they are out of the hospital.



Keywords: Adverse, chronic, Hospital, Illness, readmission



  1. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) study. Am J Prev Med 1998;14:245-58.
  2. Center for Disease Control and Prevention (CDC). Adverse Childhood Experience 2022. Available from: https://www.cdc.gov/violenceprevention/aces.Accessed 1 May. 2022




  Abstract Number 5: Effect of Insurance Type on Outcomes after Minimally Invasive Hysterectomy by Gynecologic Oncologists Top


J. Pisan1, J. Ritchie1, I. Zighelboim1, N. Taylor1, A. Graul1

1Obstetrics and Gynecology Department St. Luke's University Hospital Campus, Gynecology Oncology Physicians Group, University Hospital Campus, Bethlehem, PA, USA

Introduction: Insurance status can reflect social determinants of health, such as income, education level, occupation, or access to care. Patients without insurance or who are underinsured have been shown to be less likely to have regular care, use prescriptions, and have all medical needs met. In gynecological malignancies, insurance status has previously been suggested to have a correlation with morbidity, mortality, treatment, and clinical outcomes. Gynecologic oncologists operate on patients with known gynecological malignancy but also on patients with concern for malignancy or a surgicallycomplex or difficult case. In 2016, 4.3% of Pennsylvania patients were uninsured, and 34% had public insurance (Medicare or Medicaid). Insurance status can be a proxy for social determinants of health and has been shown to correlate with poorer postoperative and oncologic outcomes. We sought to evaluate the relationship between insurance status and clinical outcomes among patients undergoing minimally invasive hysterectomy (MIS-H) by gynecologic oncologists at a single institution.

Methods: We conducted an IRB-approved retrospective chart review of patients who underwent MIS-H by a gynecologic oncologist for benign or malignant pathology from January 2015 to December 2017. Insurance status (private or public), demographics, co-morbidity information, surgical outcomes and 3-year overall survival (OS) were collected and analyzed. Non-parametric tests and multivariate logistic regression were used to evaluate associations.

Results: MIS-H was performed in 202 women, with 125 (61.9%) having private insurance and 77 (38.1%) having only public insurance (Medicare, Medicaid, or self-pay). Demographic characteristics are summarized in [Table 1]. Publicly insured patients were older (median 67 vs. 52, p=<0.001), predominantly menopausal (79.2% vs. 45.6%, p=<0.001), multiparous (3.9% nulliparous vs 17.7%, p=0.004), less likely to be White (85.7% vs 93.6%, p=0.009), and less likely to be married (46.8% vs 71.0%, p<0.001). Publicly insured patients also had significantly more comorbidities. They were more likely to have diabetes (32.5% vs. 14.4%, p=0.004), COPD or asthma (19.5% vs. 8.8%, p=0.032), hypertension (72.7% vs. 38.2%, p=<0.001), hyperlipidemia (64.9% vs. 25.0%, p=<0.001), and coronary artery disease (11.7% vs. 2.4%, p=0.011). Surgical pathology was more likely to be benign in privately insured patients (57.3% vs. 36.4%, p=0.006). Peri-operative outcomes were evaluated with no significant difference in intraoperative complications (p=0.19), readmissions (p=0.81), or subsequent surgeries related to the initial operation (including hernia surgeries or other elective procedures) (private 14.4%, public 5.2%, p=0.061). On univariate analysis of oncologic patients only (n=104), privately insured patients had significantly more future operations (22% private vs. 6% public, p=0.027). Further, among those with an oncologic diagnosis, there was no difference in OS (p=0.30).

Conclusion: Publicly insured patients, as expected, were older and had increased comorbidities. Despite this, readmission rates, operative times, and complications were not significantly different between populations. After controlling for confounders, insurance status was noted to be independently associated with subsequent surgical intervention, more frequent among the publicly insured. Further research may explore the possible differences that lead to increased reoperations among these patients.

Keywords: Gynecological malignancies, insurance, outcome


  Abstract Number 6: The Montreal Cognitive Assessment and the NeuroTrax Test in Cognitive Impairment Top


K. Nguyen1, R. Anmolsingh1, P. Pham1, E. Coyne1, A. Mandalapu1, P. Kaur2

Departments of 1Internal Medicine and 2Graduate Medical Education, St. Luke's Richard A. Anderson Campus, Easton, PA, USA

Introduction: Cognitive impairment is a common concern for older patients and their families. Furthermore, the population of older adults continues to rise. In 2019 there were an estimated 54.1 million US adults above the age of 65, which represents 16% of the total population. This number is expected to rise to 94.7 million in 2060, making up 25% of the US population.[1] Clinicians will be increasingly tasked to identify and assess cognitive symptoms. The initial evaluation for cognitive symptoms is aided by history, examination and several screening tools. The Montreal Cognitive Assessment (MoCA) is a widely validated screening tool used for mild cognitive impairment (MCI).[2] The MoCA test has a total of 30 points and assesses multiple cognitive domains, including short-term memory, visuospatial ability, executive function, attention/concentration, language and orientation to time and place. A score of 26 or above is considered normal while scores below 26 indicate varying levels of cognitive dysfunction.[3] The NeuroTrax (NT) system is a computerized series of tests used for the detection of cognitive impairment. A Global Score (GS) is computed as a weighted average of every cognitive domain index and summary scores with a score of 100 or greater (out of 130) being considered the norm. The purpose of this project was to analyze the relationship between the MoCA and the NT score equivalency.

Methods: Patients referred to St. Luke's Senior Care Associates for memory concerns were recruited to undergo a comprehensive geriatric assessment. Testing included both the Montreal Cognitive Assessment (MoCA) and the NT computerized cognitive assessment system. IBM SPSS version 26 was used to analyze data. Continuous variables were presented as mean +// standard deviation (SD) and median, P25 and P75 were also calculated.

Results: There was a total of 176 patients, with a median age of 78 (SD 7.7) years and 63.1% females. MoCA scores were significantly correlated with age (r = -0.14, p = 0.05) and educational years (r = 0.29, p <0.001) in the whole sample. NT Global Cognitive Score (GCS) did not show any correlation with age (p = 0.6), however it did show significant correlation with educational years (r = 0.23, p = 0.002). There was also a significant difference between gender in the scores (91.6 SD 10.5 versus 88.2 SD 9.9 p-value 0.04). The NT GCS had an area under the curve (AUC) of 0.816, p=0.05 when using MoCA as a gold standard [Figure 1].

Conclusion: When using the well-established MoCA as a gold standard screening test, NT was good for discrimination between normal cognition and MCI with an AUC of 0.816. NeuroTrax is a reliable diagnostic measure for neurocognitive assessments. However, no single test has high discriminatory ability and the pattern of performance in various domains must be interpreted in conjunction with the history, neuroimaging studies, and other testing to make a diagnosis. Participants attending a single center have caused a spectrum bias which may reduce the external validity.

Keywords: Cognitive screening, Montreal cognitive assessment, NeuroTrax




  References Top


  1. Promoting Health for Older Adults. Centers for Disease Control and Prevention. 6 June 2022. Available from: www.cdc.gov/chronicdisease/resources/publications/factsheets/promoting-health-for-older-adults.htm. Accessed 6 June 2022
  2. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The montreal cognitive assessment, MoCA: A brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695-9.
  3. McLennan SN, Mathias JL, Brennan LC, Stewart S. Validity of the montreal cognitive assessment (MoCA) as a screening test for Mild Cognitive Impairment (MCI) in a cardiovascular population. J Geriatr Psychiatry Neurol 2011;24:33-8.



  Abstract Number 7: Effects of the COVID-19 Pandemic on Depressive Symptoms in Adolescents Top


K. Peake1, D. Jacobetz2, J. Lee-Park2, P. Kaur3, H. Levin1, D. Wong1, R. Bates1

1Temple Lewis Katz School of Medicine, Philadelphia, 2Department of Pediatrics, St. Luke's University Health Network, Bethlehem, Departments of 3Graduate Medical Education, St. Luke's Richard A. Anderson Campus, Easton, PA, USA

Introduction: At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, the Center for Disease Control and Prevention (CDC) mandated that the American population develop measures to control the effects of the virus. This included social distancing, quarantine, lockdown restrictions, and wearing face masks to avoid human-to-human transmission. Thus, adolescents solely interact with their peers, teachers, and others through a virtual world. According to the American Academy of Pediatrics and the Children's Hospital Association, in the United States (U.S.) children currently represent approximately 16% of all COVID-19 cases. Although COVID-19 has had physical impacts on the adolescent population, the precautions and guidelines used to control the recent pandemic have also fostered a psychological impact as well. Over the first academic year of the pandemic, essentially all schools closed. Learning was either interrupted, or the predominant modality of learning became virtual. From March 2020-June 2020, significant emphasis was placed on social distancing, quarantining, and minimizing social relationships with people outside the home. During the second academic year of the pandemic, September 2020-June 2021, most schools utilized a hybrid learning format. This format included a mix of in-person and virtual learning but continued to have strict social isolation protocols and limited extracurricular activities. During the third academic year of the pandemic, September 2021-present day, schools have returned to fully in-person learning, with many students falling behind academically due to difficulties learning in virtual format. Within the third academic year, restrictions on extracurricular activities were lifted, but this was dependent on the community, as well as reported COVID-19 case levels. Additionally, most schools continued to require masks for most of the current academic year and had significant social distancing guidelines.

Although adolescents who have tested positive for COVID-19 are more often asymptomatic, their age predisposes them to be a more impressionable and vulnerable population. This, in turn, may allow the fear of contracting COVID-19 to have a larger negative impact on the mental health of adolescents than that of older populations. Major depressive disorder (depression) was reported among the mental health outcomes in adolescents throughout the pandemic. Thus, it is pertinent to continue examining adolescents' mental health over the course of COVID-19 in hopes of providing prompt, robust relief and better preparedness for future pandemics that may lead to similar social isolation in the future. The primary aim of the current study is to investigate the psychological impact over different periods during the pandemic of depressive symptoms in adolescents.

Methods: The authors implemented a retrospective chart review to determine the effect of different time periods over the course of the pandemic on depressive symptoms in adolescents. The Patient Health Questionnaire adapted for Adolescents (PHQ-A) scores were the primary method of measuring depressive symptoms in adolescents. A score of greater than 10 was indicative of a positive depression screening. The time periods were defined as the following: 1st Surge (March 2020-August 2020), 2nd Surge (September 2020-August 2021), and 3rd Surge (September 2021-March 2022). The sample adolescent population, 11-17 years, was taken from St. Luke's University Health Network (SLUHN) pediatric population in primary care and specialty care settings. The authors utilized the SlicerDicer application within the Epic Electronic Medical Record system to examine the adolescent population within the SLUHN system that met the criteria of having a PHQ-A completed over the period of the study. The authors examined the COVID-19 infection status of the patient population as well as associated demographic factors to look for trends in the data. PHQ-A scores were the primary way of measuring depression in adolescence. The authors described results for four cohorts of adolescent patients: PHQ+/COVID+, PHQ+/COVID-, PHQ-/COVID+, and PHQ-/COVID-.The retrospective chart review obtained age, gender, and PHQ-A scores over the course of the pandemic. All data were collected in a HIPAA-protected data collection software app.

Results: A total of 3043 adolescents were screened for depression using PHQ-A from July 2019 to March 2022. 58% of these were females. There was an overall increase in PHQ-A screening in all patient groups; PHQ+/COVID+, PHQ+/COVID-, PHQ-/COVID+, PHQ-/COVID- during this time [Figure 1]. The authors compared monthly pre-pandemic PHQ+ prevalence of depression with post-pandemic and saw an upward trend during post-pandemic surges. There was a significant upward trend in PHQ-positive scores in the second and third surges of the pandemic [Figure 2]. The authors used SPSS version 28 to see the distribution of depression among Covid positive and negative adolescents during COVID-19 surges starting from March 2020 to March 2022. Due to multiple comparisons, Bonferroni corrections were used in interpreting the p-values. A p-value of <0.01 was considered statistically significant after Bonferroni correction. The authors did not see any statistical difference in the distribution of depression among COVID-19 positive and negative adolescents when all surges were collectively analyzed. The authors also compared gender differences in the distribution of depression during this time and saw a significant difference between males and females as well as a significant difference between surges [Table 1].



Conclusion: This study provides empirical data on depressive symptoms in adolescents between the ages of 11 and 17 throughout the different stages of the COVID-19 pandemic. The current study demonstrates that there was an increase in PHQ-A assessments over the course of the COVID-19 pandemic and an increase in positive PHQ-A assessments. Females were more likely to experience depressive symptoms. The increase in depressive symptoms, regardless of SARS-CoV-2 infection status, is hypothesized to be due to the social toll of the COVID-19 pandemic. This included social distancing, mask wearing, quarantine, and lockdown that may have increased the burden of the pandemic on adolescents by causing fear of infection, an uncertain timetable, family conflict, isolation, and disruption of daily routines. It is vital that primary care providers recognize the increased burden of depressive disorders that arise from the COVID-19 pandemic in this vulnerable population.

Keywords: Adolescent, COVID-19, depression, PHQ-9




  Abstract Number 8: Augmentation of Peripheral Venous Diameter for Ultrasound-Guided Peripheral Intravenous Line Insertion Top


B. Ciccarelli, V. Balakrishnan, H. Stankewicz, A. Reiss

Emergency Medicine Department, St. Luke's Hospital, Miners Campus, Coaldale, PA, USA

Introduction: Ultrasound-guided intravenous line placement is often used in the emergency department for venous access in patients whose veins are difficult to cannulate by traditional methods. This study aims to evaluate the performance of various interventions in augmenting venous cross-sectional areas using ultrasound imaging.

Methods: This is a prospective, single-emergency department study involving 41 volunteers. Each had their basilic vein identified on ultrasound with no intervention, and measurements of the area proximal to its branching point at the antecubital fossa were taken with the arm positioned parallel to the floor and approximately 30-60 degrees below the level of the bed. These two positions were repeated with the following interventions: one rubber tourniquet applied approximately 5 cm proximal to vein measurement, an additional rubber tourniquet applied 5 cm proximal to first tourniquet, blood pressure cuff inflated to between 160 to 200 mmHg, CAT tourniquet application, and soaked warm towel applied to brachium for up to one minute.

Results: All interventions were statistically significant in increasing venous cross-sectional area as compared to no intervention, with the most significant being CAT tourniquet (p < 0.001, mean change +7.32 mm2, 95% CI +5.73 to + 8.91 mm2). The addition of change in position of the arm was not statistically significant for any intervention except for the CAT tourniquet (p = 0.0056, mean change -1.74 mm2, 95% CI –0.54 to – mm2). Notably, there was no significant difference between the application of two tourniquets and the blood pressure cuff (p = 0.496, mean change +0.58 mm2, 95% CI –1.13 to +2.29 mm2), but there was a significant increase in cross-sectional area with CAT tourniquet use compared to blood pressure cuff (p = 0.018, mean change +1.62 mm2, 95% CI +0.29 to +2.95 mm2). Lastly, two tourniquets significantly increased cross-sectional area compared to one tourniquet (p < 0.001, mean change +2.20 mm2, 95% CI +1.14 to +3.26 mm2). The primary outcome of this study was an increase in venous cross-sectional area from baseline measurement.

Conclusion: This study identified several potential interventions for maximizing venous cross-sectional area on ultrasound. All the tested interventions resulted in a statistically significant increase in cross-sectional area. The addition of arm positioning did not show significant changes in most interventions except the CAT tourniquet. The devices used in this study are readily accessible in most emergency departments, allowing the results to be broadly applicable to practicing emergency physicians. Further study should be conducted to assess how these interventions affect overall success when used in ultrasound-guided intravenous line placement.

Keywords: Emergency department, tourniquet, venous


  Abstract Number 9: The Effect of COVID-19 on Pregnant Patients at SLUHN Top


A. Ohnona1, K. Glassburn1, M. Martinez-Baladejo2, A. Pellegrino3

1Obstetrics and Gynecology Department, St. Luke's University Hospital, Departments of 2Research and Innovation and 3Anesthesiology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

Introduction: Since the pandemic started over two years ago, COVID-19 has been shown to impact individuals who are already at high risk for respiratory, cardiac, and thromboembolic conditions. The parturient population is no exception. Recent studies published around the world at the end of 2020 have consistently identified an association between COVID-19 and preterm labor. In the US, the preterm labor incidence is around 10-15% with a COVID-19 diagnosis. In addition, the pregnant state may have a higher risk of needing mechanical ventilation, ICU admission, extracorporeal membrane oxygenation (ECMO) use, and death than the non-parturient state.[1],[2],[3] As vaccines were created and rolled out near the end of 2020, parturients were also left to decide whether inoculation was appropriate.[4] Additionally, the effects of COVID-19 on the babies of mothers who were infected during pregnancy are still unknown and warrant further analysis.

Methods: After IRB approval, we conducted a retrospective chart review from Jan 2020-Dec 2020 on parturients and their newborns from Allentown and Anderson Campuses. We reviewed 100 patients diagnosed with COVID 19 during their pregnancy and 100 patients who did not have COVID-19 while pregnant. In addition, we reviewed growth data on the newborns of both study groups. The groups were matched based on demographics, peripartum diagnoses, and comorbidities. Our primary outcome determined 1) Cesarean section rate and pre-eclampsia. Secondary outcomes include 1) newborn growth measures and 2) placental outcomes.

Results: The cesarean section rate was found to be 38% for COVID-19 patients, compared with 22% for non-COVID-19 patients. Cesarean section rates are known to vary widely due to the array of reasons to perform one; however, we found that 11% of COVID-19 patients required a cesarean section due to category II tracing, compared to 8% for non-COVID-19 patients. A major difference between both groups is the prevalence of pre-eclampsia, with COVID-19 patients being affected at a rate of 17% compared to 7% with non-COVID19 patients [Table 1]. The average birth length and weight for newborns exposed to COVID-19 during pregnancy were 19.56 and 3274, respectively. For the non-COVID19 group, the average birth length and weight were 19.55 and 3367, respectively. The placental complications in the non-COVID1-9 group were 39% compared to the COVID-19 group at 28%. Finally, only 3% of the COVID-19 babies needed positive pressure ventilation (PPV) compared to 5% in the non-COVID-19 group. The average age, BMI, and social status were unequivocal between the two groups. However, the mothers exposed to COVID-19 while pregnant were more likely to be Hispanics and with Spanish as their primary language [Table 2]. The COVID-19 mothers were more likely to acquire COVID-19 in the second trimester and be vaccinated against the disease [Table 3]. The COVID-19 mothers were also more likely to show mild symptoms of COVID-19 [Table 3].

Conclusion: COVID has been known to affect coagulation amongst patients, which can have a drastic impact on placental function. This could be an explanation as to why COVID patients had a more than two-time rate for preeclampsia. Similarly, this thought process helps explain why there could be fetal growth restriction in pregnancy as the placenta cannot function to its full ability. However, we did not find any evidence of fetal growth restriction as the standard growth metrics between the two groups were unequivocal. Furthermore, there were more placental complications in the non-COVI19 group compared to the COVID19 group. The array of placental complications in both groups is a subject of interest for future study. Lastly, the number of Hispanics and Spanish speakers in the COVID19 group was remarkably higher than in the non-COVID19 group. This correlated to the national metrics where we have seen that minority groups, and especially Hispanics, are at increased risk of exposure and infection.



Keywords: COVID-19, labor, pregnancy


  References Top


  1. Zambrano LD, Ellington S, Strid P, et al. Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status - United States, January 22-October 3, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(44):1641-1647.
  2. CDC. Characteristics and Maternal and Birth Outcomes of Hospitalized Pregnant Women with Laboratory-Confirmed COVID-19-COVID-NET, 13 States, March 1-August 22, 2020. Morbidity and Mortality Weekly Report: Centers for Disease Control and Prevention; 2020.
  3. Karimi L, Makvandi S, Vahedian-Azimi A, Sathyapalan T, Sahebkar A. Effect of COVID-19 on Mortality of Pregnant and Postpartum Women: A Systematic Review and Meta-Analysis. J Pregnancy. 2021;2021:8870129
  4. Lokken EM, Huebner EM, Taylor GG, et al. Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State. Am J Obstet Gynecol. 2021;225(1):77 e71-77 e14.



  Abstract Number 10: The Efficacy of Liposomal Bupivacaine in Regional Nerve Blocks for Below Knee Amputations: A Retrospective Case-Controlled Study Top


A. Allsbrook, A. Pellegrino1, C. Tran2, A. Gotsch

General Surgery Department, St. Luke's University Hospital Campus, 1Department of Anesthesiology, St. Luke's University Health Network, 2Department of Analytics, Senior Clinical Analytics Analyst, St. Luke's University Hospital Campus, Bethlehem, PA, USA

Introduction: Postamputation pain is highly prevalent, with an incidence of up to 95%. The pathophysiology of amputation pain is multifactorial therefore, the emphasis on a multimodal pain regimen is essential. Opioids are utilized in the postoperative course; however, their side effect profile can prolong a patient's hospital stay. The field of regional anesthesia has grown in the past two decades to provide new techniques for amputations, such as adductor canal and popliteal nerve blocks, for pain control after surgery. In addition, liposomal bupivacaine (LB) was introduced to extend a nerve block from hours into days. Regional nerve blocks with liposomal bupivacaine for below-knee amputation procedures can potentially reduce opioid use after surgery.

Methods: A retrospective, case-controlled chart review was conducted for patients who had received liposomal bupivacaine in regional nerve blocks vs. patients that did not receive a regional nerve block for post-operative pain control in below knee amputations. Charts were reviewed for the years 2019-2021 at the Bethlehem and Allentown Campuses. The primary outcome was postoperative opioid requirements in oral morphine equivalents (OME). The secondary outcome was hospital length of stay. Daily average opioid consumption was evaluated from the time in PACU (postoperative acute care unit) until day of discharge. The PO/IV opioids used per patient during this time period was converted to OME equivalents to standardize opioid use across both study groups. 0-40 OME implies minimal opioid use after surgery, 41-60 is moderate opioid consumption, 61-90 OME is severe opioid use, and >90 OME is excessive average daily opioid consumption.

Results: A total of 69 patients who had undergone below knee amputations (32 LB vs. 37 control) were reviewed between 2019-2021. Mean oral morphine equivalents were lower in the LB group compared to the control group (331.5 vs. 859.5 OME, respectively; p=0.002). A higher percentage of patients in the study group were categorized in the 0-40 OME range (minimal opioid use after surgery) when compared to the control group [Figure 1]. More patients in the control group had OME use > 61, which falls under severe or excessive opioid usage. No differences were detected for the average length of stay between the two groups.

Conclusion: Liposomal Bupivacaine regional nerve blocks for the BKA population are considered a relatively novel approach in pain control. There have been few studies/case reports detailing its usage so far. Our exploratory study at SLUHN shows that patients who had received LB nerve blocks had significantly lower opioid consumption compared to patients who did not receive LB. The use of LB in regional nerve blocks may reduce opioid consumption for below knee amputation procedures. Our study team aims to continue to follow BKA patients that receive this type of method for pain control, in hopes that broadening the power of the study may provide further validation and statistical significance.

Keywords: Bupivacaine, nerve block, oral morphine equivalents




  Abstract Number 11: Injury Prevention Program for the Distance Runner Top


J. Hamati-Attieh, E. Ballard, S. Kareha1

Department of Physical Therapy, St. Luke's University Health Network, 1Orthopaedic Physical Therapy Department, St. Luke's University Health Network, Bethlehem, PA, USA

Introduction: In an average day, about 1% of Americans will run. In a systematic review, injury rates in a year for novice runners were 27%, 32% in long-distance runners, and 52% in marathon runners1. The incidence proportion of running related injuries (RRIs) in long-distance runners ranged from 5.6-14.8%, while the prevalence of RRIs was 29.2-43.5%2. The main risk factor for RRIs reported was a history of injury in the past 12 months3. Preventative measures can be implemented when risk factors are tied to an individual runner. Risk factors can be extrinsic and/or intrinsic causes that contribute to RRIs, including ground stiffness, footwear, flexibility, training time, intensity, training frequency, foot posture, muscle weakness, previous injuries, biomechanical abnormalities, sex and body mass index4. The goal of this study was to investigate the effectiveness of a screening tool for distance runners and to determine injury risk prior to participation.

Methods: A convenience sample of NCAA Division III cross country runners were evaluated using a pre-participation screen, which included past medical history, foot posture index, and running analysis. The athletes were followed over the course of a season to determine injuries sustained. The athletic training staff documented if an injury was sustained and what type. After data was collected, chi-square or Fisher's exact tests were performed for categorical variables, t-tests were used for normally distributed continuous variables, and Mann-Whitney was used to rank sums tests for skewed continuous variables.

Results: Participants (n=81, 38 fall athletes, 23 winter athletes, and 20 spring athletes, average age=20) were included in this study. Thirty-two participants sustained an injury resulting in a significant association between average miles per week and sustained injury (p=.04, uninjured= 45.1 mi and injured= 38.9 mi). Past medical history (p=.50), foot posture index (p=.20), orthotic use (p=.14), right rearfoot position (p=.06), and left rearfoot position (p=.09) yielded non-significant associations between results and future injury [Table 1].

Conclusion: Athletes who ran a lower mileage per week in pre-season were correlated with higher risk for injury. There is a possibility that participants who ran lower mileage could have been injured at the start of the season and progressed back to full mileage when the season started. No other variables demonstrated a significant correlation with injury. Future research should include a larger sample size to allocate for more injury and determine the correlation of risk factors prior to participation in competitive distance running.



Keywords: Distance, distance runner, injury prevention, running


  Abstract Number 12: “Farmacy”: Food as Medicine for Chronic Diseases Top


J. Hayes, K. Kumar1, I. Perez-Figueroa, M. Dorcus, E. Bilyk, I. Akusoba, A. Maziuk2, P. Kaur1, M. Grega, A. Goodbred

Family Medicine Department, St. Luke's Richard A. Anderson Campus, 1Department of Graduate Medical Education, St. Luke's Richard A. Anderson Campus, 2???, Business Development and Strategy, St. Luke's Richard A. Anderson Campus, Easton, PA, USA

Introduction: According to the CDC, 51.8% of all adults in the US have at least one chronic condition, and 27.2% have multiple conditions.[1] Adults with chronic diseases experience worse quality of life, increased healthcare costs, and higher risk of death.[1] Lifestyle interventions (healthy diet, physical activity, social engagement, and stress management) assist patients in controlling chronic conditions, including hypertension and diabetes, and decrease development of dangerous complications.[2] Community supported agriculture (CSA) is a food production and distribution system that directly connects farmers with communities, supporting increased fruit and vegetable consumption to improve patients' health status. As part of SLUHN-Anderson's ongoing commitment to the practice of Lifestyle Medicine, we engaged in our community-focused “Food as Medicine” collaboration with a local organic vegetable farm to promote healthier lifestyle practices for patients with chronic diseases.



Study Aims: We set out to pursue the following three primary aims: [a] To improve patient lifestyle practices by enhancing patient health education and health engagement in at least 50% of patients by the end of the 20-week intervention; [b] To decrease systolic/diastolic blood pressures in hypertensive patients by 5 mmHg/2 mmHg, respectively, and HbA1C by 0.5% in diabetic patients after our 20-week “Farmacy” intervention; and [c] To identify and measure community outreach gaps for CSA program to encourage patient diversity, equity and inclusion through demographic data and open-ended questions.

Method: Project was IRB approved, and SLUHN patients were recruited with poorly controlled diabetes (HbA1>8), high blood pressure (BP ≥140/90), or both, and consented for the study. Community Shared Agriculture (CSA) boxes from Rodale Organic Farm were provided to patients weekly for 20 weeks FM Residents prepared a 'Patient Education Series' that was implemented to educate patients about lifestyle practices. Vegetable identification flyers and recipe ideas, video links to nutrition sources to use as guides to learn about food and nutrition information were prepared and shared weekly with patients. Walk-with-a-Doc sessions were held monthly to encourage patients towards more physical activity and social engagement. Lastly, patients were invited to tour the Rodale farm to learn about how organic food is grown, sustainability, healthy eating, and nutrition.

To measure the impact of the study, pre-intervention, post-intervention, and long-term impact of intervention (3 months post) were recorded and compared:

  • Patient-engagement and behavior/lifestyle changes were measured through HIPAA protected REDCap surveys;
  • Biometrics (BP, HbA1C, weight, number of emergency room visits to hospital) were recorded through EPIC;
  • Demographic information was collected (age, gender, race/ethnicity, zip-codes, and education level).


Results: 63 patients initially qualified for the study; 54 enrolled at the beginning and 32 completed at least 50% of the 20-week study. Of the patients that completed the study at 20 weeks, pre- and post-intervention results were compared:

Patient-engagement and behavior/lifestyle changes: Consumption of fruits, vegetables, unprocessed foods and home-cooked foods increased; consumption of sugar sweetened beverages, fast foods/processed foods decreased; and physical activity increased [Graph 1], [Graph 2], [Graph 3].



  • Biometrics: Systolic BP decreased by 10 mmHg; HbA1C and weight did not show improvement. Statistical analysis was performed using the nonparametric Wilcoxon Signed Rank Tests which showed no statistical significance in p-values in the biometrics (all p-values >0.5), which could be attributed to the sample size. There was a 50% decrease in ER visits by participants [Table 1].
  • Demographics: Median age was 61, majority identified as females, Whites/Caucasians, completed High School/GED as their highest level of education, and lived in the zip code “18045” [Table 2].


Conclusion: The Community Supported Agriculture (CSA) program increases patient engagement in their own health, by increasing consumption of healthy foods and beverages, decreasing consumption of processed foods, and increasing physical activity. Our study showed a 10-mmHg improvement in systolic blood pressure at the end of the 20-week intervention, despite numerous limitations and challenges. Although the biometrics measured were not statistically significant (due to the sample size of participants who completed the study), our study provides evidence that patient engagement towards healthy lifestyle changes can have a clinical impact on the prevalence of chronic diseases. There were several limitations throughout this study; patient enrollment and engagement for the program were challenging due to COVID-19 and travel-to-and-from pick-up sites. To improve enrollment numbers, we contacted many unities health staff and leadership to recruit patients from multiple neighborhoods and offered multiple pick-up sites and times throughout the week. To improve engagement, we added additional supplementary programs, like 'Walk-with-a-Doc”. Attendance at Walk-with-a-Doc sessions was challenging at times due to inclement weather and timing – future interventions will need to offer multiple times for more people to join due to scheduling challenges.

Keywords: Community supported agriculture, food, patient engagement


  References Top


  1. Boersma P, Black LI, Ward BW. Prevalence of multiple chronic conditions among US adults, 2018. Prev Chronic Dis 2020;17:E106.
  2. National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). Center for Disease Control (CDC). Available from: https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm. [Last reviewed on 2022 May 06], [Last accessed on 2022 Aug 22].



  Abstract Number 13: The Efficacy of an Enhanced Recovery after Surgery Protocol for Robotic Prostatectomy and Nephrectomy Top


J. Turovsky1, A. Pellegrino2, Z. Goldsmith3, P. Verges3

1Temple Katz School of Medicine, Philadelphia, PA; 2Department of Anesthesiology, St. Luke's University Health Network, Bethlehem, 3 Urology Physician Group, St. Luke's Richard A. Anderson Campus, Easton, PA, USA

Introduction: Enhanced Recovery After Surgery (ERAS) protocols have been around since 2001, with the goal of mitigating the physiological and psychological stress of surgery. Recently there has been a rising interest in implementing an ERAS protocol for urological surgery. Multiple elements included in an ERAS protocol, which covers preoperative, intraoperative, and postoperative measures, have been previously described in studies examining outcomes in patients undergoing nephrectomy and prostatectomy procedures. These procedures are usually performed among surgical oncology patients. Such patients can have complex pathologies and comorbidities; hence recovery from surgery can be challenging. Numerous studies examining outcomes in patients undergoing these surgeries found that those receiving ERAS care had a significantly shorter length of stay (LOS), time to flatus, and lower overall complication rate than patients receiving standard care. Although the components of previously implemented ERAS protocols vary depending on the type of surgery and approach (e.g., open, laparoscopic, robotic), some common elements include preoperative education, intraoperative goal-directed fluid therapy, and early postoperative ambulation. Despite the compelling evidence supporting the use of ERAS protocols in major urological surgeries, to our knowledge, no studies have implemented a standardized ERAS protocol for all cancer patients undergoing robotic nephrectomy or prostatectomy. This study aims to apply an ERAS protocol tailored to patients undergoing robotic nephrectomy or prostatectomy and compare their postoperative outcomes to patients receiving standard care. The primary outcome of this study is postoperative opioid use, while the secondary outcomes include protocol compliance, readmissions, and LOS. Based on prior evidence, we hypothesize that patients undergoing robotic nephrectomy or prostatectomy procedures under an ERAS protocol will utilize fewer opioid analgesics, have a shorter LOS, lower readmissions, and lower hospital costs per person compared to patients receiving standard care for those surgeries.

Methods: A retrospective case-controlled study was performed. Patients from two urology surgeons that supported ERAS from 2020-2022 were compared to patients of three urology surgeons that did not participate in ERAS. The ERAS protocol consists of the following elements:

Preoperative:

  • Carbohydrate drink
  • Chlorhexidine gluconate (CHG) wash
  • VTE prophylaxis
  • Non-opioid pain medications (e.g., acetaminophen, gabapentin).


Intraoperative:

  • Antibiotics given 1 hour prior to surgery
  • Postoperative nausea/vomiting prophylaxis
  • Non-opioid pain medication (e.g., ketamine, dexmedetomidine).


Postoperative:

  • Non-opioid pain medications (e.g., acetaminophen, gabapentin)
  • Blood glucose <200 mg/dl
  • VTE prophylaxis
  • Early mobilization
  • Early diet advancement.


The patient lists were provided by the QI liaison within the Urology Service. Patients that underwent robotic nephrectomy or prostatectomy were selected (n=51) from 2020-2022. Chart review was performed on both groups within the EMR EPIC. Patients in the study arm (n=26) were compared to patients in the control arm (n=25). Daily average opioid use after surgery was calculated for primary outcome by conversion to oral morphine equivalents (OMEs) from PACU phase to time of discharge. The percentage of patients receiving 0-40, 41-60, 61-90, and >90 and OMEs were compared. QI/IT personnel helped to acquire data to assess readmissions, LOS, and hospital costs per person. Manual chart review was performed to determine compliance with ERAS protocol by comparing the number of patients in the study and control arms who received each ERAS measure.

Results: Patients in each arm of the study were of similar age- ERAS and non-ERAS group (62 vs. 63 years old). The ERAS group had more female patients compared to the non-ERAS group (31% vs 20%) and fewer males (69% vs 80%). Of those in the ERAS group, 73% fell into the least opioid usage range (0-40 OME), vs. 61% in the non-ERAS group. There was a greater distribution of patients in the moderate-severe opioid usage range amongst the non-ERAS group. No patients in either group required more than 90 OMEs [Figure 1]. The average LOS in the ERAS group was 2.1 days, compared to 3.1 days in the non-ERAS group. Patients in the ERAS group also had a lower LOS index (.72) compared to those in the non-ERAS group (.96) [Figure 2]. More patients in the ERAS group received a preoperative carbohydrate drink (35% vs. 0%), preoperative acetaminophen (88% vs. 12%), preoperative gabapentin (69% vs. 4%), intraoperative non-opioid pain medications (69% vs. 24%), postoperative acetaminophen (100% vs. 32%), and postoperative gabapentin (42% vs. 8%) [Table 1]. Patients in the ERAS group had a lower average total cost ($16,033.62) compared to patients in the non-ERAS group ($16,455.32), saving an average of $421.70. Those in the ERAS group had a lower readmission index (0.00) than those in the non-ERAS group (.71). A higher percentage of patients in the ERAS group returned home to self-care (88%) compared to those in the non-ERAS group (72%).



Conclusion: The results of our study support our hypothesis that patients in the ERAS group who underwent a robotic nephrectomy or prostatectomy will require fewer opioid analgesics, have a shorter LOS, lower readmissions, and lower hospital costs per patient compared to patients receiving standard care for those surgeries. We hope these outcomes will provide more urology surgeons to consider the utilization of an ERAS protocol. We aim to continue to follow the trend amongst patients enrolled in Urology ERAS to improve the power of this study and evaluate statistical significance.

Keywords: Enhanced recovery after surgery, nephrectomy, prostatectomy, robotics, urology




  Case Report Number 1: Acute Severe Aortic Regurgitation Secondary to a Spontaneous Rupture of Leaflet Commissure: A Minor Tear Results in a Major Leak Top


C. Dobrovolschi, E. Thwe1, P. Sudnik1, M. Krinock2, M. Durkin2

Internal Medicine Department, St. Luke's Richard A. Anderson Campus, 1Internal Medicine Department, St. Luke's Easton Campus, Easton, 2Department of Cardiology, St. Luke's University Health Network, Bethlehem, PA, USA

Introduction: Aortic regurgitation (AR) is defined regurgitation of blood from the aorta into the left ventricle during diastole.[1] In the setting of an acute severe aortic regurgitation, the volume of regurgitant flow is large and develops on an un-remodeled, normal-sized left ventricle, leading to a sudden increase in the left ventricular end-diastolic pressure (LVEDP). The steep rise in the LVEDP exceeds left atrial pressure, prematurely closing the mitral valve before the onset of the next systole. This premature mitral valve closure prevents LVEDP from being transmitted to the left atrium and pulmonary venous bed. However, this mechanism will soon be exceeded if the severe acute aortic regurgitation persists, leading to pulmonary congestion.[2],[3] Additionally, the left ventricle cannot acutely increase total stroke volume (SV), resulting in SV decline and decreased cardiac output. The decline is then exacerbated by the shortening of diastolic filling time secondary to tachycardia and early mitral valve closure, with the upshot being cardiogenic shock.[2] The most common cause of acute, severe aortic regurgitation is infective endocarditis. Other causes are flail aortic valve leaflet in the setting of acute aortic dissection, traumatic rupture, nontraumatic spontaneous rupture of the valve, rupture of a fenestrated aortic cusp, and postoperative acute AR after aortic commissurotomy.[2],[3] Acute, severe aortic regurgitation secondary to nontraumatic spontaneous rupture of the commissure is a rarely reported medical emergency that requires a high level of suspicion and immediate definite surgical treatment.[4]

Case Rationale: Acute, severe aortic regurgitation due to a spontaneous rupture of the aortic leaflet commissure is exceedingly rare. We report a case of an acute flail aortic valve secondary to a spontaneous tear in the absence of endocarditis causing severe aortic regurgitation.

Case Report: An 81-year-old female with a medical history of hypertension presented with a one-day history of shortness of breath, chest pain and fatigue. She was found to be hypoxic and tachycardic on admission. ECG showed sinus tachycardia with ST-segment depression in the inferior and anterolateral leads. Laboratory data showed troponin I at 1.9 ng/ml, NT proBNP > 25,000, D dimer 1.21 ug/ml, and a creatine of 1.04 mg/dL. CTA of the chest showed cardiomegaly, pulmonary hypertension, and vascular congestion, with no evidence of pulmonary embolism. Echocardiography on day 1 showed a normal Left Ventricular Ejection Fraction of 55–60% with mild anterior and apical septal hypokinesis, moderate mitral regurgitation, mild aortic regurgitation, moderate to severe pulmonary hypertension, and dilated inferior vena cava. The patient was initially admitted with acute congestive heart failure and treated with diuresis. On day 4, a widened pulse pressure (BP 150/50 mmHg) and a 4/6 diastolic murmur were noted for the first time. She subsequently decompensated, developing cardiogenic shock and multiorgan failure. Repeat TTE showed severe AR [Figure 1] with prolapse of the non-coronary cusp. No evidence to suggest endocarditis. TEE showed a tri-leaflet aortic valve with a flail aortic non-coronary cusp causing severe insufficiency, a normal aortic root, and an ascending aorta without dissection. The patient underwent emergent aortic valve replacement. During surgery, a tear was noted at the right noncoronary commissure, resulting in partial detachment of both the right and noncoronary leaflets with prolapse of both leaflets. Pathology report described a tri-leaflet aortic valve with myxomatous degeneration but no inflammation or infection suggestive of rheumatic valve disease or infective endocarditis. She had an uncomplicated post-op course and was discharged home with a cardiology follow-up.



Conclusion: Acute severe aortic regurgitation (AR) is an uncommon and catastrophic disease, with a poor prognosis. Very few reports exist in the literature regarding acute AR secondary to spontaneous rupture of the aortic leaflet commissure.[4] While rare, this case highlights the need for broad differentials to include spontaneous rupture in the presence of cardiogenic shock as acute severe aortic regurgitation, without surgical intervention leads inevitably to heart failure and death.

Keywords: Aortic regurgitation, leaflet, rupture, valve


  References Top


  1. Bekeredjian R, Grayburn PA. Valvular heart disease: Aortic regurgitation. Circulation 2005;112:125-34.
  2. Morganroth J, Perloff JK, Zeldis SM, Dunkman WB. Acute severe aortic regurgitation. Pathophysiology, clinical recognition, and management. Ann Intern Med 1977;87:223-32.
  3. Hamirani YS, Dietl CA, Voyles W, Peralta M, Begay D, Raizada V. Acute aortic regurgitation. Circulation 2012;126:1121-6.
  4. Dehiscence of Aortic Valve Commissure Complicated by Aortic Regurgitation. Available from: https://www.jtcvs.org/article/S0022-5223(08)00130-X/fulltext. Accessed 5 May.2022



  Case Report Number 2: Break the Mold – Fresh Look on Subacute Aspergillosis Top


P. Sudnik, P. Ender1, M. Krishnamurthy2

Internal Medicine Department, St. Luke's Hospital, Easton, 1Department of Infectious Disease, St. Luke's University Hospital, Bethlehem, 2Department of Internal Medicine, St. Luke's Hospital, Monroe Campus, Stroudsburg, PA, USA

Introduction: Aspergillosis is a fungal infection caused by the genus Aspergillus, a ubiquitous mold. Only 20 out of 200 Aspergillus species are pathogenic to humans. The most common among them are A. fumigatus, A. flavus, A. terreus, and A. niger. Depending on the host immune response and interaction with the fungus, Aspergillus can cause allergic bronchopulmonary aspergillosis, aspergilloma, chronic cavitary pulmonary aspergillosis, and invasive aspergillosis. These entities have very distinct features and different prognoses. Invasive pulmonary aspergillosis has a high mortality rate and is one of the most common undiagnosed infections in sick patients such as patients in the ICU. Invasive lung disease due to Aspergillus is challenging to diagnose due to nonspecific clinical features and imaging findings. Etiologic laboratory testing is limited to insensitive culture techniques, nonspecific and not readily available PCR and galactomannan, and tissue biopsies, which are often difficult to obtain due to the clinical fragility of patients. Clear-cut diagnostic criteria do not exist, and a high level of concern in certain patient populations is important. There is a common misconception that invasive aspergillosis may only be seen in severely immunocompromised people. However, subacute invasive aspergillosis affects people with normal or slightly suppressed immune systems with underlying chronic lung diseases. Risk factors, therefore, include cystic fibrosis, pulmonary fibrosis, emphysema, previous radiation treatment, chronic corticoid use, connective tissue disease, diabetes mellitus, and malnourishment, to name a few. This condition has a dramatic course with progressive shortness of breath, cough, hemoptysis, fever, chills, and weight loss. Pathologically hyphae of the fungus grow with central invasion, developing necrotizing pneumonia and forming cavitations. Radiological findings in early disease are represented by upper lobe pulmonary opacities. Eventually, the central necrotic area separates away from the surrounding lung and thus forms an air crescent sign. This occurs after weeks to months, eventually resulting in a cavity with or without a central mycetoma. Prognosis of subacute invasive pulmonary aspergillosis is largely dictated by underlying lung disease and co-morbidities. Mortality ranges from < 10% to 39% depending on criteria for diagnosis and treatment administered.

Case Rationale: Subacute invasive pulmonary aspergillosis has similar course to invasive aspergillosis but in immunocompetent patients. It requires aggressive treatment, has a high mortality rate and constitutes a diagnostic challenge. A high level of suspicion in patients with underlying pulmonary disease is important to improve outcomes.

Case Scenario: An 87-year-old man presented to ED for dyspnea on exertion, productive cough, fatigue, and generalized weakness, over the past month. He was complaining of the copious amount of dark brown sputum production; he could barely walk and needed 1-2L of oxygen supplement. He was hospitalized earlier in the month for community-acquired pneumonia and received a 10-day course of a third-generation cephalosporin with some improvement. The patient had a background history of pulmonary fibrosis with bullous emphysema [Figure 1], atrial fibrillation on anticoagulation with warfarin, and rheumatoid arthritis on Plaquenil with long-term use of steroids. On the physical exam, he was malnourished, tachypneic, and had bilateral rales primarily in the middle and upper lobes. Laboratory findings were remarkable for WBC of 22 and procalcitonin of 1.71. The CT scan of the chest demonstrated a large cavity in the upper right lobe with intraluminal ball-like opacity along the medial aspect [Figure 2]. There was consolidation with thick wall cavitations seen in the middle lobe of the right lung. Blood cultures were negative, MRSA screen was negative, Strep pneumonia and Legionella antigens were negative. The acid-fast culture was negative. Bronchoscopy showed thick purulent tan-colored secretions. Bronchoalveolar lavage culture taken from the right upper bronchus grew colonies of Aspergillus niger. Serum galactomannan was negative. The patient was started on Voriconazole however he opted for hospice care on day 8 of admission and expired shortly [Figure 2].

Conclusion: Invasive pulmonary Aspergillosis should be suspected in ill patients with necrotizing pneumonia with underlying lung disease even if they are not immunocompromised.

Keywords: Aspergillosis, fungus, immune, pulmonary




  Case Report Number 3: Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis (PFAPA) Syndrome in a Young Adult Male Top


M. Thu Tun, E. Thwe1, M. Aung2, M. Kender3

Internal Medicine Department, St Luke's Hospital Richard A. Anderson Campus, 1Internal Medicine Department, St Luke's Hospital Easton Campus, 2Neurology Department, St Luke's Hospital Richard A. Anderson Campus, Easton, 3Internal Medicine Department, St. Luke's Hospital, Allentown, PA, USA

Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is one of the common causes of pediatric periodic fever. Due to its rare occurrence in adults, PFAPA syndrome might be difficult to diagnose even when adult patients present with the typical PFAPA constellation of symptoms such as recurrent fever, painless oral ulcers, pharyngitis, and adenitis. Clinicians must be aware of the symptom constellation of the disease to be able to reach the correct diagnosis and initiate appropriate therapy without delay to improve the quality of life of adult patients with PFAPA syndrome. As an observational case report, here, we discuss a 21-year-old male college student who was diagnosed with PFAPA syndrome after one year of typical clinical symptoms.

Introduction: The most common clinical symptoms of PFAPA syndrome are high fever (usually 40.0 °C to 40.6 °C) recurring at fixed intervals of every 2 to 8 weeks, lasting about 3-6 days, then resolve spontaneously.[1],[2],[3],[4] The diagnosis of PFAPA is currently made mainly on clinical criteria.[3] Its pathogenesis is still unknown.[2],[3] Glucocorticoids such as prednisone (1 to 2 mg/kg orally) relieve the fever usually within a few hours.[2],[5] The common preventive treatment is colchicine (0.5 to 1 mg/day) or cimetidine (20 to 40 mg/kg/day).[2],[5] Further investigations are needed to confirm the response rate to an optimal dose of prednisone, colchicine, and cimetidine in adult-onset PFAPA syndrome.[4],[5]

Case Scenario: A 21-year-old biological male patient with no significant past medical history presented with recurrent fevers associated with fatigue, malaise, chills, night sweats, unintentional weight loss of 20 pounds in 6 months, watery diarrhea, skin rash, and painless oral ulcers for 1 year. His febrile episodes lasted about 1-2 weeks, with temperature ranges between 102-104°F, and was temporarily relieved with ibuprofen and Tylenol. Patients did not report significant childhood illnesses. Previous workups have been unremarkable. He is bisexual and was sexually active with multiple sexual partners in the past 3 months. On physical examination, the patient was ill, and cachectic, but not in acute distress. Pertinent positive findings were tachycardia, skin rash [Figure 1], and a painless oral ulcer/bump [Figure 2]. He tested negative for HIV, syphilis, chlamydia, and chronic hepatitis on screening. Work up revealed mild leukocytosis on CBC, microscopic hematuria, elevated CRP at 18.9, and ESR at 31. CMP, TSH, thyroid antibody profiles, QuantiFERON TB gold test, chronic hepatitis panel, GC/chlamydia, fecal calprotectin, ANA screen, rheumatoid factor, anti-CCP antibody, flow cytometry for leukemia/lymphoma and blood cultures have been unremarkable. CT chest/abdomen/pelvis with contrast did not reveal any significant pathology. Genetic screening revealed that he was positive for HLA-B51, which is a known genetic marker for Bechet's disease [6] However, his clinical picture does not meet the criteria for Behcet's disease. After being evaluated by a hematology-oncologist, a gastroenterologist, and an infectious disease specialist, he came back to our clinic for a follow-up appointment and continued to complain of chronic fatigue, lack of appetite, and persistent unintentional weight loss. Thus, 0.6 mg of Colchicine was initiated daily for the past three months. Currently his symptoms are well controlled with Colchicine therapy. The plan is to follow up after the summer vacation.

Discussion: Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome, also known as Marshall's Syndrome, is one of the common causes of periodic fever in pediatric populations. It was first described by Marshall et al. and was named in 1989 later.[1] Disease onset usually begins between one and four years of age and the periodic fever episodes stop by 10 years of age in most patients.[1] A small proportion of patients might have an onset as adults or continue to have febrile episodes into adulthood.[2],[3],[4] It is part of the multifactorial autoinflammatory disorders (AIDs) spectrum, and it is characterized by spontaneous flares of systemic inflammation with fever and other clinical symptoms, particularly the cardinal signs as defined by the PFAPA acronym.[2],[3] Recent research suggests that it is caused by a dysregulation of the immune system, with continual pro-inflammatory cytokine activity and a diminished anti-inflammatory response both during and between febrile bouts.[2] The diagnosis of PFAPA is currently made mainly on clinical criteria.[2],[3] Several differential diagnoses, including viral disorders, juvenile idiopathic arthritis, Behcet's disease, familial  Mediterranean fever More Details, familial Hibernian fever, Tumor necrosis factor receptor-associated periodic syndrome (TRAPS), cryopyrin-associated periodic syndromes (CAPS) and hyperimmunoglobulinemia D syndrome should be considered before confirming a diagnosis of PFAPA syndrome.[2],[3],[7],[8] Symptomatic management with antipyretics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), abortive therapy during episodes with glucocorticoids, prophylactic therapy with cimetidine or colchicine, and surgical therapy with tonsillectomy are the four treatment arms included in consensus treatment plans (CTPs) for the management of PFAPA syndrome.[5],[10] Although there is growing evidence that PFAPA syndrome can persist into adulthood and manifest itself in adults with a broader range of clinical symptoms, in most cases, it usually fades away around puberty.[3],[4],[10]

Conclusion: Diagnosing PFAPA in adults, as in this example, can be challenging. For diagnosis of adult-onset PFAPA syndrome, a physician must consider several other diseases in the differential diagnosis. A correct and timely diagnosis will provide symptomatic relief and might prevent future episodes.

Keywords: PFAPA syndrome, periodic fever, aphthous stomatitis, pharyngitis, and adenitis




  References Top


  1. Marshall GS, Edwards KM, Lawton AR. PFAPA syndrome. Pediatr Infect Dis J 1989;8:658-9.
  2. Costagliola G, Maiorino G, Consolini R. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA): A clinical challenge for primary care physicians and rheumatologists. Front Pediatr 2019;7:277.
  3. Cantarini L, Vitale A, Sicignano LL, Emmi G, Verrecchia E, Patisso I, et al. Diagnostic criteria for adult-onset periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. Front Immunol 2017;8:1018.
  4. Abdurrahman K, Sibel Y, Mutlu K, Mustafa A, Yusuf E. The rare cause of recurrent fever in adults: PFAPA syndrome. Clin Case Studie Rep 2018;1:1-4.
  5. Berlucchi M, Meini A, Plebani A, Bonvini MG, Lombardi D, Nicolai P. Update on treatment of Marshall's syndrome (PFAPA syndrome): Report of five cases with review of the literature. Ann Otol Rhinol Laryngol 2003;112:365-9.
  6. Manthiram K, Preite S, Dedeoglu F, Demir S, Ozen S, Edwards KM, et al. Common genetic susceptibility loci link PFAPA syndrome, Behçet's disease, and recurrent aphthous stomatitis. Proc Natl Acad Sci U S A 2020;117:14405-11.
  7. Légeret C, Furlano R. Oral ulcers in children – A clinical narrative overview. Ital J Pediatr 2021;47:144.
  8. Unger M, Karanikas G, Kerschbaumer A, Winkler S, Aletaha D. Fever of unknown origin (FUO) revised. Wien Klin Wochenschr 2016;128:796-801.
  9. Vanoni F, Theodoropoulou K, Hofer M. PFAPA syndrome: A review on treatment and outcome. Pediatr Rheumatol Online J 2016;14:38.
  10. Yasuura S, Harada Y. A case of adult-onset periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome in Japan. J Gen Fam Med 2017;18:261-4.



  Case Report Number 4: The Safety of Using Warfarin and Torsemide Concomitantly Top


K. Ragarupa, N. Hindosh

Internal Medicine Department, St. Luke's Richard Anderson Campus, Easton, PA, USA

Introduction: Congestive Heart Failure (CHF) and Atrial Fibrillation (AF) are very common chronic medical conditions in the elderly and are associated with major morbidity. Both conditions coexist due to their similar risk factors and mechanisms. Multiple studies showed an increased prevalence of AF in patients with CHF. Even though safer alternatives are available, warfarin remains a widely used anticoagulant because of its affordability. Due to the higher bioavailability of torsemide, it is used more frequently than other diuretics in managing heart failure. Therefore, it is common to see patients on warfarin and torsemide simultaneously. Some concerns were raised regarding a possible interaction between these two medications. We present a case of a patient with a recently increased torsemide dose, found to have a significantly elevated international normalized ratio (INR).

Case Rationale: Torsemide is a pyridine sulfonyl urea loop diuretic. It is mostly metabolized in the liver mainly by cytochromeP450, specifically CYP2C9. Warfarin is also metabolized primarily by CYP2C9. Both medications are highly bound to albumin. Some cases showed that both medications compete for CYP2C9, thus reducing warfarin clearance. Another possibility is the competitive effect of torsemide on displacing warfarin from albumin, hence increasing the level of the unbound (active) form of warfarin. Both mechanisms contribute to potentiating the anticoagulation effect of warfarin. Patients carrying CYP2C9*2 and CYP2C9*3 alleles might require warfarin dosage adjustment. The addition of a drug with high protein binding capacity may displace other circulating protein-bound drugs. Therefore, the addition of torsemide may potentiate the anticoagulant effect of warfarin. An objective causality assessment revealed that the interaction was probable.

Case Scenario: 77-year-old female patient with a medical history of CHF, chronic kidney disease stage V and AF adequately anticoagulated on warfarin 2 mg daily, for over 10 years, with a target INR of 2-3. She was admitted to the hospital secondary to volume overload in the setting of worsening kidney disease. Patient is noted to have an INR above 15 on admission. Her only recent medication change was an increase of torsemide dosage from 20 mg daily to 40 mg daily one month prior to this admission. She has no known history of liver disease or bleeding disorders and denies dietary changes or recent antibiotic use. Warfarin and torsemide were held and her INR improved eventually to goal during the hospitalization. After resuming the home dose of torsemide and warfarin, INR continued to rise above the target range despite achieving euvolemia, requiring adjusting warfarin dose to 1mg daily to achieve a therapeutic INR range.

Conclusion: There is no contraindication in using warfarin and torsemide concomitantly, however more frequent INR monitoring is recommended when initiating or adjusting torsemide dose.

Keywords: Congestive heart failure, cytochromep450, international normalized ratio, warfarin


  Case Report Number 5: Penile Calciphylaxis: A Rare Manifestation of Uremic Calciphylaxis in a Patient with End Stage Renal Disease Top


N. Hindosh, B. Dada

Internal Medicine Department, St. Luke's Richard Anderson Campus, Easton, PA, USA

Introduction: Penile calciphylaxis, also known as calcific uremic arteriopathy of the penile arteries, is an extremely rare condition occurring in patients with end-stage renal disease (ESRD) with secondary hyperparathyroidism and diabetes mellitus.[1] It is characterized by medial calcification with intimal hypertrophy, fibrosis, and thrombosis of small vessels.[2] This condition carries an extremely high mortality rate which is reported as high as 60%, with a mean time to death of 3-6 months.[2],[3] There remains controversy regarding medical versus surgical treatment for penile calciphylaxis.[1] Surgical options include wound debridement or penile amputation, while principal aspects of medical treatment include pain control, wound care, and limiting inciting factors. Medications used for this condition include sodium thiosulfate, calcimimetics and bisphosphonates, although their efficacy remains undetermined.[1],[2],[3],[4] We present a case of penile calciphylaxis in a patient with ESRD, Type 2 Diabetes, and secondary hyperparathyroidism.

Case Report: A 77-year-old male with past medical history significant for systolic congestive heart failure, type 2 diabetes mellitus, ESRD on hemodialysis, presented with a one-week history of painful necrotic penile ulcers. Physical exam showed a dry, tender, necrotic ulcer over the anterior aspect of the penile shaft, with two additional small ulcers noted medially as shown in [Figure 1]. History and workup were negative for sexually transmitted infections. Laboratory work up was notable for Calcium 9.3 mg/dL, Phosphate 5.9 mg/dL, PTH 550.8 pg/mL. Biopsy of the ulcers showed vascular calcifications typical of calciphylaxis present in the deep reticular dermis and subcutis. He subsequently underwent partial penectomy after failing conservative measures with wound care, pain control and antibiotics.

Conclusion: The management in our patient consisted initially of analgesia, antibiotics, calcimimetics, non-calcium-containing phosphate binders, and local wound care. He subsequently underwent a partial penectomy which unfortunately did not show a major benefit as his symptoms persisted. He was ultimately transitioned to hospice care due to persistent symptomatology from the penile calciphylaxis in addition to his multiple medical comorbidities. There is a continued need for further research regarding other potential treatment modalities for patients presenting with penile calciphylaxis. Pentoxifylline and hyperbaric oxygen have utilized in some patients that resisted the above regimens, however they remain experimental and deficient in supporting data.[5] Considering the poor prognosis of penile calciphylaxis,[2] the objective of treatment should focus on improving life quality until more data is available to establish a management guideline for this condition. A multidisciplinary team including urologists, surgeons, nephrologists, and palliative care teams should be involved to organize and coordinate health and care services to achieve this goal.

Keywords: End stage renal disease, penile calciphylaxis, uremic calciphylaxis




  References Top


  1. Campbell RA, Alzweri LM, Sopko NA, Macura KJ, Burnett AL. Penile calciphylaxis: The use of radiological investigations in the management of a rare and challenging condition. Urol Case Rep 2017;13:113-6.
  2. Nigwekar SU, Thadhani R, Brandenburg VM. Calciphylaxis. N Engl J Med 2018;378:1704-14.
  3. Yang TY, Wang TY, Chen M, Sun FJ, Chiu AW, Chen YH. Penile calciphylaxis in a patient with end-stage renal disease: A case report and review of the literature. Open Med (Wars) 2018;13:158-63.
  4. Baldwin C, Farah M, Leung M, Taylor P, Werb R, Kiaii M, et al. Multi-intervention management of calciphylaxis: A report of 7 cases. Am J Kidney Dis 2011;58:988-91.
  5. Smilnak G, Jiang M, Jain B. Calciphylaxis of the penis and distal digits: A case report. J Med Case Rep 2022;16:18.



  CASE REPORT 6: A Case Report of Herpes Zoster Following Pneumococcal Vaccine Top


Y. Benavie, C. Donnelly

Emergency Medicine Department, St. Luke's Richard Anderson Campus, Easton, PA, USA

Introduction: Shingles, aka Herpes Zoster (HZ), is a condition caused by reactivation of latent varicella zoster virus (VZV).[1] According to the CDC, approximately 1.2 million people are diagnosed with HZ in the United States per year.[2] HZ is characterized by symptoms of peripheral neuritis, including burning or throbbing pain or numbness.[3] Patients subsequently develop a rash characterized as clusters of clear vesicles or bullae on an erythematous base. Once the rash dissipates, approximately 10-15 percent of patients will develop post-herpetic neuralgia (PHN), characterized as neuralgic pain that can last weeks to months. Pathognomonic of HZ is that all stages of this condition will present in a dermatomal distribution that does not cross the midline. Although rarer, HZ neuritis can have a wide array of symptoms depending on the dermatome affected, including sight-threatening ophthalmitis, ear pain, cholecystitis, and others. VZV can lie dormant within the dorsal root ganglia for years or even decades. During this time, it can effectively evade the host body's immune response while slowly replicating in very low numbers. VZV reactivation classically occurs opportunistically after an unrelated trigger causes immunosuppression. Known triggers include corticosteroid administration, taking immunomodulating medications after an organ transplant, HIV infection, psychological stress, or infection from an unrelated disease.[4]

Case Rationale: While not typically cited as a common trigger, there are a few case reports of HZ following administration of a vaccine. Vaccines cause inflammatory responses, which promote immune system activation and production of memory B cells. This inflammatory response is similar to what would be produced by a natural infection. Therefore, it is highly plausible that the inflammatory response created by vaccination could allow for opportunistic reactivation of HZ.

Case Scenario: A 78-year-old male presented to the Emergency Room for “welts” that started after receiving the 23-valent pneumococcal vaccine. His medical history consisted of transient ischemic attacks, restless leg syndrome, gastroesophageal reflux, and Barrett's esophagus. His medications included baby aspirin, clopidogrel, famotidine, sildenafil, diclofenac gel, gabapentin, rosuvastatin, and Flomax. He had chickenpox as a child and had not received a shingles vaccine. 50 years prior, he had a reaction to the Tdap (tetanus-diphtheria and pertussis) vaccine, which consisted of “welts” all over his body. He did not have other symptoms at that time and had not ever had reactions to other vaccines. Given how long ago this episode was, we were unable to obtain documentation of this reaction. Two days prior to presenting to the Emergency Room, the patient received the Pneumovax-23 vaccine via intramuscular injection to his right deltoid. That evening, he developed subjective fever and chills. He felt fine the next morning, though later developed a burning sensation over his upper right body. The patient reported that he felt like “the hair on his head was on fire.” The next morning, he developed “welts” on his right shoulder, which prompted him to present to the ER [Figure 1].

On physical examination, the patient had a rash consistent with HZ, namely clusters of clear vesicles on an erythematous base in a dermatomal distribution that did not cross the midline. This classic rash, along with the type of pain described by the patient, led to the diagnosis of Herpes Zoster. The patient was prescribed valacyclovir and was discharged from the ER after administration of the first dose. One month after presentation to the ER, the patient was still having PHN and occasional pruritis in the affected area. His primary care physician instructed him to increase his gabapentin dose. The rash itself was much improved, with only some residual marks and no active vesicles.

Conclusion: As with any adverse reaction, it is difficult to say whether HZ was caused by the vaccine or whether the timing was a coincidence. Though this association certainly has biologic plausibility. Another challenge to establishing a link between vaccination and HZ is the lack of lab evidence of HZ. Although cultures can be used to diagnosis HZ, it is usually a clinical diagnosis based on the classic rash.[5] Given this lack of objective data, it is possible that cases could be under or over recognized. Based on the scarcity of case reports discussing this link,[6] even if this were shown to be a true possible adverse reaction of vaccination, the incidence would be low, and people should not avoid vaccination for this reason. Furthermore, as VZV vaccine efforts increase, the incidence of primary VZV infection and subsequent HZ development will steadily decline. Further research should be done to establish whether there is a causal link between vaccine administration and reactivation of VZV.

Keywords: Herpes, pneumococcal vaccine, rash, zoster




  References Top


  1. Albrecht MA, Levin MJ, Hirsch M, Mitty J. Epidemiology, Clinical Manifestations, and Diagnosis of Herpes Zoster. UpToDate.Waltham, MA: UpToDate; 2020.
  2. Yawn BP, Saddier P, Wollan PC, St Sauver JL, Kurland MJ, Sy LS. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc 2007;82:1341-9.
  3. Schmader K. Herpes zoster in older adults. Clin Infect Dis 2001;32:1481-6.
  4. Aksu SB, Öztürk GZ. A rare case of shingles after COVID-19 vaccine: Is it a possible adverse effect? Clin Exp Vaccine Res 2021;10:198-201.
  5. Harbecke R, Oxman MN, Arnold BA, Ip C, Johnson GR, Levin MJ, et al. A real-time PCR assay to identify and discriminate among wild-type and vaccine strains of varicella-zoster virus and herpes simplex virus in clinical specimens, and comparison with the clinical diagnoses. J Med Virol 2009;81:1310-22.
  6. Walter R, Hartmann K, Fleisch F, Reinhart WH, Kuhn M. Reactivation of herpesvirus infections after vaccinations? Lancet 1999;353:810.



  Case Report Number 7: A Rare Case of a Small Bowel Obstruction Secondary to Hydrosalpinx Top


R. Alexander, J. To, S. DuBois

General Surgery Department, St. Luke's University Hospital, Bethlehem, PA, USA

Introduction: Small bowel obstructions account for 2-4 percent of emergency department visits and 15 percent of hospital admissions, with up to 90 percent secondary to adhesions from prior abdominal surgery, complex hernias, or neoplasms. Less frequent causes include underlying inflammatory bowel disease, gallstones, volvulus, and intussusception. Obstruction secondary to a gynecologic process is extremely rare.

Case Report: A 32-year-old female without significant past medical or surgical history presented to the emergency department (ED) with a three-day history of severe epigastric abdominal pain accompanied by nausea, vomiting, and constipation. Clinical examination revealed a hemodynamically stable patient with a soft, distended abdomen and epigastric tenderness without signs of peritonitis. Bloodwork, including white blood cell count (WBC), electrolytes, and lactic acid, was unremarkable. A computed tomography (CT) of the abdomen and pelvis demonstrated a small bowel obstruction (SBO) with a transition point in the right lower quadrant, mesenteric edema, and free fluid. She was taken to the operating room for a diagnostic laparoscopy, which was ultimately converted to exploratory laparotomy. Intraoperatively, dense adhesions involving the terminal ileum, appendix, sigmoid colon, and right ovary were encountered. Gynecology was consulted intraoperatively, and it was determined that these adhesions were secondary to pelvic inflammatory disease (PID). Lysis of adhesions, appendectomy, and right para tubal cyst excision was performed. The PID was treated medically with antibiotics, and the patient was ultimately discharged home without complications.

Conclusion: Small bowel obstruction caused by unusually extensive adhesions from chronic  Fallopian tube More Details hydrosalpinx and a para-tubal cyst in the setting of prior pelvic inflammatory disease is a rare entity with only a few cases reported in the literature. As such, it is important to keep this in mind when evaluating similar patients, young adult females with a virgin abdomen, presenting with symptoms concerning for obstruction.

Keywords: Adhesion, obstruction, pain


  Case Report Number 8: Mentoring to Improve Therapeutic Alliance and Patient Outcomes: A Case Series Top


M. Hager

Department of Facility Director, Outpatient Rehabilitation, St. Luke's Hospital, Monro Campus, Stroudsburg, PA, USA

Introduction: FOTO (Focus on Therapeutic Outcomes) Patient Outcomes is a widely used proprietary patient-reported outcome tool that measures and risk-adjusts the physical functional ability of patients and their satisfaction with care. It can be used to acquire data about risk-adjusted treatment effectiveness, utilization of services, and patient satisfaction scores and can be compared to other users worldwide. However, it has been found that patient satisfaction scores do not always correlate with treatment effectiveness scores. Furthermore, an increasing volume of research demonstrates the importance of therapeutic alliance and its correlation with better patient outcomes and satisfaction. Communication, including understanding the patient's main concerns and goals and establishing patient-provider expectations can affect overall outcomes and satisfaction. Thus, if providers could be trained to improve their communication and therapeutic alliance with patients, it has been suggested that outcomes may improve and may correlate better with patient satisfaction scores. Unfortunately, there is no specific protocol suggesting provider scripting prior to having a patient complete a FOTOô assessment and there are no studies demonstrating the effect mentoring a provider with deficient effectiveness outcome scores has on patient outcomes.

Case Rationale: This retrospective case analysis aimed to describe a mentoring intervention involving provider education in the importance of scripting to enhance therapeutic alliance and its results on overall treatment effectiveness outcome scores.

Case Scenario: This case series describes the two providers at a single physical therapy office with low effectiveness scores for greater than 12 consecutive months. A 1-hour mentoring session was provided at the initial period of the 12-month study and another 1-hour session was provided 6 months afterward. The mentoring sessions were conducted to help the providers better communicate with their patients and enhance therapeutic alliance. The sessions included review of the FOTO assessment tool and education on the meaning of scores. Suggestions on scripting were also discussed including how to present the tool to the patients and explaining the meaning of the patient's scores. It was advised that the provider review the scores with the patient during the initial examination period to ensure proper set-up; and use the patient's responses as a foundation for further questions to better understand the patient's perspective and assist in educating the patient, setting goals, and establishing a plan of care to reach the patient's desired outcome. The providers were also instructed to consistently ask questions about the patient's perceived progress toward these desired outcomes at each visit to further strengthen therapeutic alliance. The comparative FOTO effectiveness change scores were collected over a 12-month period. Effectiveness in care fluctuated during the 12-month period. However, the scores of both providers improved significantly from the initial score prior to the intervention compared to the 12-month score. Satisfaction scores remained unchanged.

Conclusion: In this retrospective case study, 2 providers struggled for a prolonged period with low patient effectiveness scores but had acceptable patient satisfaction scores. They were provided (2) 1-hour mentoring sessions to improve communication and therapeutic alliance. Scripting, as a component of generating therapeutic alliance, prior to issuing a self-report assessment can provide the patient with a clearer understanding about the meaning of the assessment tool and how it relates to the episode of care and therefore, may enhance effectiveness outcome scores. The results demonstrate the importance of mentoring in improving providers' ability to develop therapeutic alliance and how it can positively affect outcome measures.

Keywords: Communication, focus, mentoring, outcomes, providers, therapeutic


  Case Report Number 9: My Feet Hurt, and I Can't Walk: An Unusual Presentation of Leptotrichia Bacteremia Top


L. Probasco1, M. Tun1, S. Manuel1, J. Mittal2

1Internal Medicine Department, St Luke's Hospital Anderson Campus, Easton, 2 Infectious Disease Department, St Luke's Health Network, Bethlehem, PA, USA

Introduction: Leptotrichia species are nonmotile, anaerobic, gram-negative rods.[1] Leptotrichia goodfellowii, is one of seven known species in the genus. These organisms can inhabit the oral cavity, intestinal tract, and genitalia as part of normal flora.[2],[3] Various human disease entities caused by Leptotrichia species are reported in the literature. There seems to be a proclivity for these organisms to cause disease in immunocompromised hosts, acting as an opportunistic pathogen.[2],[3],[4],[5],[6],[7] However, the few cases of of  Leptotrichia goodfellowii Scientific Name Search /i>bacteremia are seen more often in immunocompetent hosts, and there is a developing association with endocarditis.[2],[3],[5] Here we describe a case of Leptotrichia goodfellowii bacteremia in an immunocompetent host, with a clinically diagnosed endovascular infection without any prior valvulopathy, and an unexpected presenting complaint.

Case Rationale: Leptotrichia species are a rare cause of human disease. This is a case of a 57-yo immunocompetent female who developed Leptotrichia goodfellowii bacteremia. Leptotrichia goodfellowii bacteremia has been seen in immunocompetent hosts and has been associated with endovascular infections such as endocarditis. Diagnosis was confirmed with next-generation DNA sequencing. This case highlights the organism's capability to infect an immunocompetent host, as well as the indolent nature of infection from this organism.

Case Scenario: A 57-year-old female without any significant past medical or surgical history presented to the emergency department on January 9, 2022, with swelling in the soles of her feet and toes and spots developing on her toes. She noted the swelling in her feet began the evening prior to presentation, and then it was in the morning she saw spots developing on her toes. She developed pain with ambulation during this time which also prompted her to come in for evaluation. She expressed fears of falling at home. She denied fever, chills, shortness of breath, chest pain, palpitations, abdominal pain, hematuria, night sweats, or weight loss. She had no other localizing complaints. She reported a family history of hypertension and diabetes. She denied any history of significant drug, alcohol, or tobacco use. She denied risk factors for HIV or other sexually transmitted diseases like syphilis and hepatitis. She initially refused testing. She denied any personal or family history of malignancy. At baseline, she reported being independent and living alone. She was divorced and had one daughter who lived with her ex-husband. She denied extensive outdoor activities or tick exposures. She had no pets or exotic animals at home. She was not vaccinated for COVID and refused testing on presentation. She self-reported focusing on natural remedies and diet for her overall health. She did not follow up with a primary care doctor and was noted to have eccentric thoughts and habits in general on her evaluations by multiple providers.

On exam the patient was non-toxic appearing. Her vitals were unremarkable, and she was afebrile. She had tangential speech with eccentric thinking. Her lung, cardiac, and abdominal exams were benign. She had no cranial nerve deficits or focal motor or sensory deficits on neurologic exam. Her vision was grossly intact. On her lower extremities there was visible swelling of the digits with ecchymotic rounded lesions on the dorsal and plantar aspect of her toes [Figure 1]a, [Figure 1]b, [Figure 1]c. The feet and legs had mild non-pitting edema [Figure 1]d. There were no changes consistent with cellulitis.

The lesions were very tender to palpation and with attempted ambulation, the patient was unable to place any weight onto her toes. The patient was ultimately admitted for further work up. She did find initial relief with pain medications. She was seen by dermatology early on and the rash and history were concerning for perniosis, and differential for this finding included chilblain lupus, cryoglobulinemia, vasculitis or other cutaneous thrombosis. She refused biopsy at presentation. Therefore, as part of initial work up, chest x-ray was done which showed no acute cardiopulmonary disease. ESR, CRP, D-dimer, ANA, p-ANCA, c-ANCA, RF, MPO antibodies, anti-PR3 antibodies, serum cold agglutinins, cryoglobulins and urinalysis with urine protein to creatinine ratio were unremarkable. Transthoracic echo was done which showed an EF of 65% but no other valvular abnormalities. Blood cultures were also collected on admission. Bilateral lower extremity venous duplex was negative for deep vein thrombosis.

Over the next few days her pain was waxing and waning with mixed response to pain medications. She was noted over admission to have a Hemoglobin A1C of 6.3. She was also diagnosed with uncontrolled hypertension and had some episodes of headaches with particularly high pressures. She eventually agreed to start blood pressure medications. She continued to refuse any COVID testing. Three days into admission one of her three sets of blood cultures returned positive with gram-negative rods on gram stain. She had been off antibiotics since admission and remained afebrile and without leukocytosis. Infectious Diseases was consulted, and cultures were repeated, and the patient was started on Unasyn empirically.

On review of the gram stain and plates with the microbiology lab the organism was an anaerobe with poor growth. There was thought initially that this may be a contaminate with her benign appearance, but identification with matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) showed Leptotrichia species. After review of the literature, further history was obtained. Patient denied having regular cancer screenings including colonoscopy and last had a  Pap smear More Details over 10 years ago. She had questionable vaginal spotting post menopause and no history of black stools or abnormal bowel habits. She also reported a chronically loose tooth causing pain and intermittently bleeding. With positive blood cultures she was agreeable to further testing, oral surgery evaluation, dermatology re-evaluation with biopsy and images.

On the 4th day into admission, she noted new lesions showing up on her toes, and on exam there was evolution with purulence developing on a few of the older lesions. Overall, her clinical picture became concerning for a subacute bacterial endocarditis likely from an odontogenic source and the lesions were likely part of a thromboembolic phenomenon. CT of the head, chest, abdomen, and pelvis with contrast was unremarkable. Transesophageal echo was without any valvular disease. RPR, HIV, urine gonorrhoea and chlamydia and viral hepatitis testing were negative. Repeat cultures remained without growth. The isolate was sent out to a reference lab for formal identification and susceptibility testing. On review of records after discharge, formal identification was Leptotrichia goodfellowii. The reference lab ultimately required next generation sequencing as MALDI-TOF was unable to provide subspecies identification. Additionally, the lab was unable to obtain susceptibility as the organism had poor viability on growth media for testing.

CT of the face showed chronic large periodontal cavity of the left mandibular second molar. Oral surgery exam showed a grossly mobile tooth but did not warrant immediate intervention. The patient was provided follow up for eventual extraction. Skin punch biopsy from the right lateral foot and left dorsal great toe demonstrated thrombotic (occlusive) vasculopathy with small vessel thrombosis. No organisms were seen on staining, but this was collected on antibiotics. The findings were discussed with dermatology, and this was felt to be due an embolic phenomenon given the patient's bacteremia and the evolution of these lesions over her admission.

The patient remained in the hospital from January 9th till the 26th. In that time, she received 2 weeks of intravenous antibiotics. She stopped developing new toe lesions and the older lesions were regressing. Unfortunately, there was no standard of care in terms of treatment for infection with this organism. She was recommended for 4 weeks of intravenous Unasyn similar to the treatment of Streptococcal and HACEK group organism native valve endocarditis. She was seen in the office followup with infectious diseases on February 8th. She reported resolution of the lesions and was compliant with antibiotics. She was recommended for follow with various services and for surveillance blood cultures 2 weeks after treatment completion. On chart review, she unfortunately has now followed up with other providers. She presented in March for facial swelling and pain, uncertain if this was related to her teeth. She was provided a referral again and blood cultures collected there were negative. She has not had an encounter with our healthcare system since.

Discussion: Leptotrichia species are a rare cause of human infections, with the literature primarily consisting of case reports. A recent review article on this topic mentions about 54 cases in the literature.[1],[2] There is a proclivity for these organisms to affect immunocompromised hosts as cases are reported in patients with lupus, those receiving chemotherapy, leukemic and neutropenic patients, as well as bone marrow transplant recipients.[1],[3],[5],[7],[8] Human diseases caused by Leptotrichia species include animal bite wounds, bloodstream infections, intra-abdominal abscess, septic arthritis, chorioamnionitis, periodontal disease, and rarely endovascular infections such as endocarditis.[1],[2] Both identification and susceptibility testing are difficult for most clinical labs, even with MALDI-TOF and so next-generation sequencing of 16S rDNA amplicons is often utilised.[1],[2],[3]

As seen in our case, there is usually an indolent clinical presentation and a high level of suspicion as well as awareness of this organism is needed to guide further workup.[2],[6] Our case is particularly unique as the patient presented with thromboembolic phenomenon though she did not technically meet Duke's criteria for endocarditis especially with her negative cardiac imaging (IDSA endocarditis guideline citation). However, with the progression of her lesions on exam, biopsy findings and then regression with appropriate therapy clinically her case is most consistent with an endovascular infection. Additionally, the subspecies identification points to the same. The few cases of Leptotrichia goodfellowii bacteremia seem to be more often in immunocompetent hosts, and there is a developing association with endocarditis.[1],[2],[4] However, pre-existing valvular pathology and the presence of prosthetic material is a common thread amongst these cases but was not seen with our patient.[1],[2],[6]

We present our case here so that it may add to the growing literature on this organism and contribute to potential treatment knowledge. Our case stresses pathogenic potential in the immunocompetent host, indolent nature of infection with this organism, workup to be explored given where it exists in human flora, and the need for increased awareness by clinicians so as not to dismiss isolation in cultures as a contaminate.

Keywords: Edema, immunocompetent, leptotrichia, lesion




  References Top


  1. Eribe ER, Olsen I. Leptotrichia species in human infections. Anaerobe 2008;14:131-7.
  2. Lieberman JA, Kurosawa K, SenGupta D, Cookson BT, Salipante SJ, Busch D. Identification of Leptotrichia goodfellowii infective endocarditis by next-generation sequencing of 16S rDNA amplicons. Cold Spring Harb Mol Case Stud 2021;7:a005876.
  3. Hou H, Chen Z, Tian L, Sun Z.  Leptotrichia trevisanii Scientific Name Search teremia in a woman with systemic lupus erythematosus receiving high-dose chemotherapy. BMC Infect Dis 2018;18:661.
  4. Matias WR, Bourque DL, Niwano T, Onderdonk AB, Katz JT. Subacute bacterial endocarditis with Leptotrichia goodfellowii in a patient with a valvular allograft: A case report and review of the literature. Case Rep Infect Dis 2016;2016:3051212.
  5. Couturier MR, Slechta ES, Goulston C, Fisher MA, Hanson KE. Leptotrichia bacteremia in patients receiving high-dose chemotherapy. J Clin Microbiol 2012;50:1228-32.
  6. Lim YK, Kweon OJ, Kim HR, Lee MK. Leptotrichia goodfellowii infection: Case report and literature review. Ann Clin Lab Sci 2016;46:83-6.
  7. Schrimsher JM, McGuirk JP, Hinthorn DR. Leptotrichia trevisanii sepsis after bone marrow transplantation. Emerg Infect Dis 2013;19:1690-1.
  8. Sabater Cabrera C, Fernández Blázquez A, García Carús E. Bacteremia due to leptotrichia trevisanii after an allogeneic bone marrow transplant. Enferm Infecc Microbiol Clin 2017;35:389-90.



  Case Report Number 10: A 67-Year-Old Man with Acute-Onset Asterixis Induced by Pregabalin Top


B. Canlas, R. Mayeda1, C. Craven

Neurology Department, St. Luke's University Health Network Anderson Campus, Easton, 1???, Temple St. Luke's School of Medicine, Bethlehem, PA, USA

Introduction: Here we illustrate a case of acute, new onset Pregabalin (PGB) induced asterixis in a patient with lower extremity neuropathy. Asterixis is a form of negative myoclonus, whereby agonist muscles suddenly lose tone and antagonist muscles compensate with a jerk-like movement. Though asterixis is a hallmark of hepatic encephalopathy, medications including valproate, carbamazepine, and phenytoin have also been associated with bilateral asterixis but are not a common adverse effect of PGB. This case highlights the rare occurrence of asterixis after PGB initiation, outlining the steps of medical management and workup and its reversible effect.

Case Rationale: Pregabalin is commonly used for neuropathic pain (such as diabetic neuropathic pain and herpetic neuralgia). Yet, the most common side effects (reported in about >10% of adults) are CNS depression/respiratory depression, peripheral edema, blurred/decreased vision, and weight gain. Asterixis is a rarely reported adverse effect (AE). Symptoms were induced in our patient during rapid dose titration which may indicate a lesser-known titration effect in addition to the rarely reported adverse effect of asterixis This AE, should be highly considered if a patient has improvement and resolution of the asterixis as pregabalin is tapered down or withdrawn. Ultimately, the occurrence of asterixis in the setting of pregabalin usage should indicate to a clinician to consider decreasing the dosage/withdrawing the medication, in addition to other indicated metabolic workup, to stop this adverse effect while still managing the neuropathic pain.

Case Scenario: A 67-year-old man with a PMH of Birt-Hogg-Dubé Syndrome and stage 4 renal cell carcinoma with metastases to the bone and lungs (treated prior w/ radiation & chemotherapy) currently on Pembrolizumab infusion q3 weeks presented with left lower extremity (LLE) weakness for 1 day with increasing pain and numbness for a few days. Surgical history includes L hip arthroplasty due to bone metastasis 1 year ago, and CT hip showed a fluid collection around his L hip that was aspirated. The pain in his L hip has been severe for 5 months and has had no relief with gabapentin. Exam was significant for patchy sensory loss to pinprick on the dorsum of his L foot, LLE strength (plantar flexion 4/5, dorsiflexion 2/5, hip flexion 4/5), and absent L Achilles reflex. CT head and vascular ultrasound of the LLE were negative. Neurology was consulted and ordered MRIs of the lumbosacral plexus and L-spine showing a large collection of fluid surrounding the prosthesis w/ significant atrophy and edema of the muscles of the L pelvis, hip, and upper thigh. IR performed an aspiration of the fluid that was negative for infection or malignancy. His pain regimen was switched to pregabalin 150 mg BID from gabapentin. He also received hydromorphone 1 mg TID as needed until pregabalin started working more effectively. After 1 day, the pain did not improve, and pregabalin was doubled to 300 mg BID. The next day, the patient developed a flapping tremor in both arms consistent with bilateral asterixis and had visual hallucinations of familiar and unfamiliar faces. A petechial rash appeared on the patient's LLE. Pregabalin was immediately tapered back to the initial dose. The patient's visual hallucinations resolved after 1 day, and his bilateral asterixis was significantly reduced after 2 days w/ continued improvement until discharge. Metabolic testing was ordered and was normal. The patient continued to have L foot weakness and was discharged to rehabilitation and w/ a follow-up EMG.

Conclusion: Though PGB is not well known to cause asterixis, this case demonstrates it can be triggered by rapid initiation and titrated dosing of PGB. Pregabalin is typically started at 25 mg once daily or 50-150 mg daily in divided doses and increased at weekly intervals of 25-150 mg. Pregabalin should also be adjusted for renal dysfunction and is more likely to elicit side effects in this group. The first line management should include decreasing or stopping the offending agent. In addition, it is important to order metabolic tests to rule out hepatic encephalopathy, as this is the most common cause of bilateral asterixis. Though this patient did not have a history of cirrhosis or liver failure, he did have a history of renal cell carcinoma, which could increase his risk of developing metabolic encephalopathy. Asterixis and other movement disorders are not widely reported side effects of pregabalin, however, it is important to be aware that this risk exists.

Keywords: Asterixis, encephalopathy, pregabalin


  Case Report Number 11: Delayed Presentation of Mycobacterium abscess Infection after Abdominoplasty Top


J. Petrochko, C. James

General Surgery Department, St. Luke's University Health Network, Bethlehem, PA, USA

Introduction: Mycobacterium abscessus infection after abdominoplasty has been described as an uncommon cause of postoperative surgical infection after abdominoplasty.[1],[2]



Case Report: Patient is a 32-year-old female who presented with a 20cm lower abdominal wall seroma [Figure 1] two months after undergoing abdominoplasty in the Dominican Republic. Our interventional radiology colleagues placed a percutaneous drain, and although the output was serious and culture-negative, she had a separate superficial abscess at the left lateral part of her extended pfannenstiel incision [Figure 2]. which grew Mycobacterium abscessus after bedside drainage. This initial incision and drainage (I&D) site improved with serial packing changes by the patient after discharge, but she developed a second superficial abdominal wall abscess distant from the initial abscess. This was managed with bedside I&D in the general surgery clinic, serial packing changes, and a seven-day course of clarithromycin.

Conclusion: Mycobacterium abscessus infection after abdominoplasty has been described as an uncommon cause of postoperative surgical infection after abdominoplasty. We discuss the epidemiology of this condition as well as best practice guidelines for management. Key takeaways include the need for high index of suspicion for Mycobacterial infection as an etiology for delayed surgical site infection.

Keywords: Abscess, Mycobacterium abscessus


  References Top


  1. Furuya EY et al. Outbreak of  Mycobacterium abscessus Scientific Name Search  infection among “Lipotourists” from the United States Who Underwent Abdominoplasty in the Dominican Republic, Clinical Infectious Disease 2008;46:1181-8
  2. Schnabel D, et al. Multistate US Outbreak of Rapidly Growing Mycobacterial Infections Associated with Medical Tourism to the Dominican Republic 2013 – 2014, Emerging Infectious Diseases 2016;22(8):1340-134




B. Canlas, J. Kerrigan1

Neurology Department, St. Luke's Richard A. Anderson Campus, Easton, 1Department of Neurology, St. Luke's University Health Network, Bethlehem, PA, USA

Introduction: We present a case of recurrent, progressive vertigo initially thought of as BPPV (Benign Paroxysmal Positional Vertigo), then vestibular migraine, and finally vestibular paroxysmia. Vestibular paroxysmia consists of brief episodes of vertigo lasting a few to several seconds, several times a day with attacks unprovoked or provoked by head movements. Diagnosis is based on at least ten attacks of spontaneous spinning or non-spinning vertigo, duration <1-minute, stereotyped phenomenology, response to treatment with carbamazepine/oxcarbazepine, and not better accounted for by another diagnosis.

Case Rationale: This study intends to educate and further inform neurologists and other clinicians who commonly address vertigo to consider vestibular paroxysmia in their differential. If other specialties are not as familiar with this diagnosis, then a low threshold to refer to neurology should be had as patients can have a prolonged course of this syndrome that causes unneeded suffering that can be addressed sooner rather than later. Education to PCPs and ENTs is also a possible application of this case report as it allows the community to be able to give possible treatment options, particularly in areas where there are scarce neurologists available.

Case Scenario: A 45-year-old female with a history of intermittent vertigo about 3-4 times previously presented for evaluation. Previous episodes of vertigo progressed from 2 weeks to 4 months. Episodes were sudden in onset of vertigo 3-4 times/day, lasting a few seconds, and triggered with upward and right gaze but not left gaze. There was associated bilateral tinnitus but absent hearing loss, auditory fullness, or migraine history. She was started on meclizine for probable BPPV but did not improve. Brain imaging, VNG, and ENT evaluation were negative for causes of vertigo. Exam showed counterclockwise torsional and upbeating nystagmus when laying flat and turning head to the left. Abnormal head impulse test with right rotation indicated a deficient right vestibular ocular reflex implying a right peripheral vestibular lesion. Referral to PT ordered for canalith repositioning with no improvement. A trial of carbamazepine was started, drastically decreasing episodes. On return visit, she denied any episodes of vertigo, and initial nystagmus and abnormal head impulse test were resolved. Based on the history and exclusion of other peripheral causes of vertigo, the patient was diagnosed with vestibular paroxysmia and continued on carbamazepine.

Conclusion: This case investigates the findings of vestibular paroxysmia, its work-up, and potential other diagnoses that need to be excluded (i.e., BPPV, Meniere's disease, Vestibular Neuritis, Labyrinthitis) as it's an uncommon cause of peripheral vertigo.

Keywords: Gaze, nystagmus, paroxysmia, vertigo


  Case Report Number 13: Minimally Invasive Removal of a Massive Ovarian Cyst in Teenage Patient Top


K. E. Ackert1, C. Roldan1, M. Wright1

1Obstetrics and Gynecology Department, University Hospital Campus, Bethlehem, PA, USA

Introduction: Pelvic pain is a common presenting symptom in female teenage patients, and ovarian torsion is at the top of the differential as it can be fertility-threatening. This case report is important because we were able to maintain a minimally invasive approach for a large ovarian cyst in a patient with Class 3 Obesity. Ovarian torsion does not often involve such a large cyst, as it is hard for the ovary to torse when there is pathology that fills up so much space. Typically, a cyst of this size would be removed via laparotomy due to concern for malignancy and spillage. After consulting with the patient and through shared decision-making, we opted for minimally invasive management.

Case Scenario: This patient is a 18 y/o G0 who presented to the ED (Emergency Department) with pelvic pain. She had a known history of a large simple appearing para-ovarian cyst that was first noted in 2018 when she presented to one of our institution's community hospitals for similar pain. At that time, the cyst was 17 cm in size on ultrasound. She states that at that time, her periods were very painful, and surgical management was deferred due to her age. Her pain since then had been well controlled until presentation to ED. On ultrasound, her right ovary was enlarged with few small, mostly peripheral follicles and sparse color Doppler flow with high resistance arterial waveforms. Findings were concerning for ovarian torsion or torsion/detorsion and a 23 cm right adnexal simple cyst, which appears separate from the right ovary. CT scan showed a massive 24 x 24 x 17 cm thin-walled cystic mass arising from the right adnexal region [Figure 1]. There are mild associated inflammatory changes and small fluid along its inferior aspect, likely due to rupture. Given this massive ovarian cyst, we proceeded to the operating room for a diagnostic laparoscopy, possible exploratory laparotomy, removal of cyst, possible oophorectomy, salpingectomy, and or hysterectomy. In the operating room, a Veress needle was inserted into Palmer's Point directly into the cyst, and the suction irrigator was hooked up to the Veress, and 5.5L of serous fluid was drained. We then proceeded with direct entry into Palmer's Point, and incidental insufflation of the ovarian cyst was noted. The abdomen was desufflated, and intraperitoneal entry was achieved through a Hassan technique infra-umbilically [Figure 2]. A large ovarian cyst wall was noted, left ovary and tube were noted to be dark purple and torsed x4 in the pelvis [Figure 3]. The uterus, right tube, and right ovary appeared normal. The majority of the cyst wall was removed with the Enseal, and the left ovary and tube were flipped out of the pelvis. Per ACOG recommendations, we waited to see if the ovary would regain its pink color, but it was noted to be non-viable, and LSO was performed [Figure 4]. The specimens were taken out in a bag via ini-laparotomy [Figure 5]. Good hemostasis was achieved. The patient met all post-op milestones on POD1 and was discharged home. During her follow up clinic visit, she noted to be doing well and was placed on OCPs to reduce the risk of recurrence. Healthy lifestyle choices were encouraged.

Conclusion: Consideration of minimally invasive surgical approach can result in optimization of patient healing, outcomes, and opioid reduction even in large pathology.

Keywords: Diagnostic laparoscopy, ovarian cyst, ovarian torsion, pelvic pain




  Case Report Number 14: A Double-Edged Sword: A Case of Infliximab Associated Vasculitis Top


N. Hindosh, J. Kamau, M. Scaccia

Internal Medicine Department, St. Luke's Richard Anderson Campus, Easton, PA, USA

Introduction: Tumor necrosis factor (TNF) is a proinflammatory cell signaling protein used in the induction of interleukin-1 and interleukin-6 as well as neutrophil activation. Infliximab (Remicade) is a monoclonal antibody that inactivates TNF alpha reducing its proinflammatory effects. This is beneficial in disease states with persistent inappropriate inflammation such as inflammatory bowel disease (IBD), rheumatoid arthritis (RA), and vasculitis. The paradox of immunosuppressive medications is the risk of significant immune-mediated side effects. Despite its beneficial properties for vasculitis, medications that inhibit TNF have been paradoxically implicated as a cause of vasculitis. This may be due to the development of antibodies against the anti-TNF that form immune complexes, which are deposited on the vessel walls, thus initiating the inflammatory cascade. We present a case of an Infliximab induced vasculitis.

Case Scenario: A 26-year-old male with a history of ulcerative colitis well controlled on infliximab for 5 years presented with a painful rash on his hands and neck of three days duration. On exam, he had an erythematous papular rash involving the whole face and posterior neck, a petechial rash involving the arms and legs, and tender erythematous nodules on both palms. There was no purulence or vesicular lesions noted. Vitals showed a temperature of 98.3 F. pulse of 108 per minute, blood pressure of 185/106 mm Hg and respiratory rate of 18 per minute. Initial labs, which included complete blood count and comprehensive metabolic panel, were only notable for white blood count of 12.38, potassium of 3.2, and creatinine of 0.96. Further workup included IgA/M/G levels, ANA, anti-double stranded DNA, ESR, CRP, cryoglobulins, ANCA, HIV, VZV PCR, Viral Culture, Varicella IgM antibody, and ASO titers. Apart from positive cryoglobulin and mildly elevated ESR and CRP, other blood workup was within normal limits. Punch biopsies of the skin lesions were obtained that showed a neutrophilic infiltrate with leukocytoclasia in the dermis, with many eosinophils, which supported an anti-TNF associated vasculitis and ruled out Sweet syndrome. Furthermore, tissue cultures showed no growth of organisms. Infliximab was held, and patients started on intravenous steroids with good response. He was discharged on an oral prednisone taper with subsequent resolution of the rash.

Conclusion: Anti-TNF induced vasculitis has been called into question because the conditions treated by anti-TNF are often associated with development of vasculitis. More studies are needed to look at the risk of vasculitis in patients with IBD treated with anti-TNF versus those treated with other agents. Until then, vasculitis associated with anti-TNF in IBD remains a rare but significant adverse effect that needs to be promptly recognized as about 50 percent of patients may develop systemic vasculitis with peripheral nerves and kidneys predominantly affected. This can be challenging as this form of vasculitis usually occurs 3-years after initiation of treatment which falls out of the scope of the “recent medication changes” window typically employed to screen for potential drug induced complications and can be easily mistaken for disease flare up with potentially grave consequences in the setting of continued treatment with the same agent.

Keywords: Inflammatory, rash, tumor necrosis factor


  Case Report Number 15: Does this Patient Have Familial Adenomatous Polyposis? Top


N. Hindosh, R. Hindosh, M. Tawadros, B. Dada

Internal Medicine Department, St. Luke's Richard Anderson Campus, Easton, PA, USA

Introduction: Familial adenomatous polyposis (FAP) is an autosomal dominant condition caused by adenomatous polyposis (APC) gene mutation with an incidence of 1-3/10000 births.[1],[2] Below, we report an interesting cascade of events that led to the diagnosis of FAP in a 33-year-old male patient.

Case Presentation: A 33-year-old male presented with a two-day history of intractable nausea and vomiting associated with abdominal pain. The patient has a significant surgical history of bowel perforation resulting in colectomy and subsequent ileal-rectal anastomosis several years ago. He does not have any other significant medical history; however, he has a significant family history of GI malignancies which were recognized late in the course after further investigation with the patient and his family; the patient was unable to provide further details regarding his family history. Vital signs were stable and on physical exam, the patient had periumbilical abdominal tenderness to palpation. CT scan of the abdomen and pelvis was significant for a distended third and fourth portion of the duodenum with small-bowel decompression as well as gastric decompression consistent with obstruction secondary to food bolus or intraluminal mass. The Gastroenterology service was consulted for emergent endoscopy. He underwent a push enteroscopy showing multiple large duodenal masses in the second and third portion of the duodenum. Additionally, more than 100 gastric polyps were visualized in the gastric body. Final pathology of the duodenal masses revealed tubulovillous adenomas with high-grade dysplasia; therefore, he underwent pancreatico-duodenectomy.

Given his significant family history, he underwent genetic testing and was found to have a pathologic variant identified in the APC gene. The patient's clinical presentation is consistent with classical familial adenomatous polyposis (FAP). Yearly surveillance for gastric polyps through upper endoscopy as well as thyroid examinations are recommended due to the associated malignancy potential of FAP.[3]

Conclusion: Gastroduodenal polyps are prevalent in patients with FAP patients.[4] Although the cancer incidence is not extremely high in these patients, it is still significant enough to develop surveillance guidelines to diagnose them as early as possible. Current guidelines recommend upper endoscopic screening at the onset of colonic polyposis or at the age of 25-30 years.[3],[5] Our patient demonstrated tubulovillous adenoma at the age of 33 years, raising the question of whether a more diligent surveillance should be implemented in patients with APC gene mutation. Moreover, the hindsight recognition of our patient's family history of GI malignancies played a role in late diagnosis. Patients ought to be encouraged to familiarize themselves with their family history.

Keywords: Adenomatous, familial, gastric, malignancies, polyp

Financial support and sponsorship

Nil.

Conflicts of interest:

Dr. Stawicki serves as Executive Director (USA) for The American College of Academic International Medicine - The sponsoring organization for the International Journal of Academic Medicine.

Research quality and ethics statement:

All research projects presented during the St. Luke's University Health Network Annual Research Symposium were verified to have either appropriate Institutional Review Board approvals or exemptions. For case reports, proof of appropriate patient consent documentation was required. In all instances, appropriate EQUATOR guidelines (see https://www.equator network.org/reporting guidelines/) for scientific reporting were followed.

Content inclusion:

Please note that due to subsequent knowledge dissemination plans, including content submission to other journal(s) and scientific meeting(s), not all abstracts presented during the 2022 St. Luke's University Health Network Research Symposium are included herein.


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  2. Hyer W, Cohen S, Attard T, Vila-Miravet V, Pienar C, Auth M, et al. Management of familial adenomatous polyposis in children and adolescents: Position paper from the ESPGHAN polyposis working group. J Pediatr Gastroenterol Nutr 2019;68:428-41.
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  4. Bertoni G, Sassatelli R, Nigrisoli E, Pennazio M, Tansini P, Arrigoni A, et al. Dysplastic changes in gastric fundic gland polyps of patients with familial adenomatous polyposis. Ital J Gastroenterol Hepatol 1999;31:192-7.
  5. Campos FG, Martinez CA, Sulbaran M, Bustamante-Lopez LA, Safatle-Ribeiro AV. Upper gastrointestinal neoplasia in familial adenomatous polyposis: Prevalence, endoscopic features and management. J Gastrointest Oncol 2019;10:734-44.







 

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