From the Chief Residents

As we introduce the latest edition of The Medicine Forum, the journal of our Internal Medicine residency program, we\u27re thrilled to showcase the diverse talents and perspectives of our resident physicians. Evolving alongside our program, this publication serves as both a platform for scientific inquiry and a canvas for creativity, reflecting the dynamic interests of each resident cohort. We must extend our heartfelt gratitude to our current editors, Amman Bhasin, Suraj Nyalakonda, Mez Kamanu, and Alex Grivas, for their unwavering dedication and tireless efforts in shepherding this journal to new heights. Their commitment to excellence and their vision for the future of The Medicine Forum have been instrumental in its continued success. Furthermore, we would be remiss not to acknowledge Dr. Coppock, our faculty mentor, whose guidance and support have been invaluable in nurturing the growth of this publication. With his expertise and passion for education, we are confident that The Medicine Forum will continue to flourish. We would also like to extend our heartfelt appreciation to Debbie Bizup and Joanne Gotto and Tim Flanagan for their invaluable contributions behind the scenes, ensuring the success of The Medicine Forum. As we turn the pages of this latest edition, let us celebrate the passion, talent, and community that define our residency program. Each article and illustration is a testament to the enduring legacy of Jefferson Internal Medicine and the bright future that lies ahead. As Chiefs, one of the most rewarding aspects of our role has been witnessing the remarkable growth of our residents. We are consistently impressed by the scholarly endeavors of our residents, spanning diverse areas of inquiry and innovation. Your dedication to academic excellence underscores the depth of talent within our residency community. Throughout our tenure, we\u27ve had the privilege of observing you all evolve as clinicians, researchers, educators, and advocates. As you prepare to embark on your future careers, we sincerely hope you carry with you the lessons learned and the experiences gained during your time in our residency program. May you continue to embrace the values of lifelong learning, compassionate patient care, and advocacy for positive change, making a lasting impact in your respective fields and communities

Shadows and Echoes of Understanding: A Physician\u27s Reflection on Plato\u27s Allegory of the Cave and Medicine

Plato\u27s Allegory of the Cave offers a lens through which one can contemplate the complexities of medicine, where the shadows and echoes of illness obscure the true forms of disease. As physicians, we seek to illuminate the shadows that shroud our patients’ understanding of their illnesses and provide clarity to help patients navigate the labyrinth of diagnoses and treatments

Nodular AL Amyloidosis — An Unusual Etiology of a Solitary Pulmonary Nodule

Solitary pulmonary nodules (SPN) are defined as single intraparenchymal opacities less than 3 centimeters. The differential diagnosis of the SPN is broad. AL amyloidosis is a protein conformational disease which occurs when certain monoclonal light chains develop an unstable tertiary structure with resultant polymerization of insoluble amyloid fibrils that deposit in the extracellular space of sundry tissues. In the lung, diffuse interstitial amyloid deposition is the most common form of the disease

Employer Health Benefits 2008 Annual Survey

Presents annual survey data on the health plans employers offer, including plan types, providers, premiums, coverage, eligibility, enrollment patterns, employee cost-sharing, prescription drug benefits, retiree benefits, and employer opinions

Acute Esophageal Necrosis Secondary to a Paraesophageal Hernia.

Acute esophageal necrosis (AEN) or black esophagus is a rare clinical entity caused by necrosis of distal esophageal mucosa stemming from esophageal ischemia. Possible etiologies are broad but most commonly include possible triggers of low-flow vascular states in the esophagus, including infections, broad-spectrum antibiotic use, and gastric volvulus, among others. Patients most commonly present clinically with acute onset hematemesis and melena. Here, we describe a patient who initially presented with multiple nonspecific gastrointestinal symptoms, including abdominal pain and nausea, that progressed over a 10-day period, culminating in multiple episodes of hematemesis prior to presentation. Endoscopic evaluation confirmed the diagnosis of AEN and unveiled a possible paraesophageal hernia (PEH) as the causative factor. A subsequent videofluoroscopic barium swallow was utilized to better characterize the upper gastrointestinal anatomy and confirmed the PEH as a likely etiology. Esophagogastroduodenoscopy (EGD) can often identify PEH independently, but in patients with AEN secondary to a possible, but unclear, PEH on EGD, a videofluoroscopic barium swallow is an appropriate and useful next step in confirming the diagnosis. While treatment of AEN traditionally involves fluid resuscitation, intravenous protein pump inhibitors, and total parenteral nutrition, surgical intervention is often indicated in patients who have a contributing and symptomatic PEH

Efficacy and safety of indacaterol 150 μg once-daily in COPD: a double-blind, randomised, 12-week study

<p>Abstract</p> <p>Background</p> <p>Indacaterol is a novel, once-daily (o.d.) inhaled, long-acting <it>β</it>₂-agonist in development for chronic obstructive pulmonary disease (COPD). This 12-week, double-blind study compared the efficacy, safety, and tolerability of indacaterol to that of placebo in patients with moderate-to-severe COPD.</p> <p>Methods</p> <p>Efficacy variables included 24-h trough FEV₁(mean of 23 h 10 min and 23 h 45 min post-dose) at Week 12 (primary endpoint) and after Day 1, and the percentage of COPD days with poor control (i.e., worsening symptoms). Safety was assessed by adverse events (AEs), mean serum potassium and blood glucose, QTc (Fridericia), and vital signs.</p> <p>Results</p> <p>Patients were randomised (n = 416, mean age 63 years) to receive either indacaterol 150 <it>μ</it>g o.d. (n = 211) or placebo (n = 205) via a single-dose dry-powder inhaler; 87.5% completed the study. Trough FEV₁(LSM ± SEM) at Week 12 was 1.48 ± 0.018 L for indacaterol and 1.35 ± 0.019 L for placebo, a clinically relevant difference of 130 ± 24 mL (p < 0.001). Trough FEV₁after one dose was significantly higher with indacaterol than placebo (p < 0.001). Indacaterol demonstrated significantly higher peak FEV₁than placebo, both on Day 1 and at Week 12, with indacaterol-placebo differences (LSM ± SEM) of 190 ± 28 (p < 0.001) and 160 ± 28 mL (p < 0.001), respectively. Standardised AUC measurements for FEV₁(between 5 min and 4 h, 5 min and 1 h, and 1 and 4 h post-dose) at Week 12 were all significantly greater with indacaterol than placebo (p < 0.001), with LSM (± SEM) differences of 170 ± 24, 180 ± 24, and 170 ± 24 mL, respectively. Indacaterol significantly reduced the percentage of days of poor control versus placebo by 22.5% (p < 0.001) and was also associated with significantly reduced use of rescue medication (p < 0.001). The overall rates of AEs were comparable between the groups (indacaterol 49.3%, placebo 46.8%), with the most common AEs being COPD worsening (indacaterol 8.5%, placebo 12.2%) and cough (indacaterol 6.2%, placebo 7.3%). One patient died in the placebo group. Serum potassium and blood glucose levels did not differ significantly between the two groups, and no patient had QTc >500 ms.</p> <p>Conclusions</p> <p>Indacaterol 150 <it>μ</it>g o.d. provided clinically significant and sustained bronchodilation, reduced rescue medication use, and had a safety and tolerability profile similar to placebo.</p> <p>Trial registration</p> <p>NCT00624286</p

Reinventing grounded theory: some questions about theory, ground and discovery

Grounded theory’s popularity persists after three decades of broad-ranging critique. In this article three problematic notions are discussed—‘theory,’ ‘ground’ and ‘discovery’—which linger in the continuing use and development of grounded theory procedures. It is argued that far from providing the epistemic security promised by grounded theory, these notions—embodied in continuing reinventions of grounded theory—constrain and distort qualitative inquiry, and that what is contrived is not in fact theory in any meaningful sense, that ‘ground’ is a misnomer when talking about interpretation and that what ultimately materializes following grounded theory procedures is less like discovery and more akin to invention. The procedures admittedly provide signposts for qualitative inquirers, but educational researchers should be wary, for the significance of interpretation, narrative and reflection can be undermined in the procedures of grounded theory

Technology and the dis-placing of learning in educational futures

Common visions of online education entail radically re-configuring the experience of learning: a technological displacement from the spatial order of classrooms into the more diffuse arena of digital networks. One assumption seems to be that the very spatial order of classrooms creates an undesirably rigid sense of place for schooling, one that is depressingly impervious to change; and that the attendant solution is to escape the realm of the ‘physical’ altogether – into an online realm more supportive of collaboration and free of face-the-front conventions. In the present paper we seek to challenge this oppositional view. We consider several ways in which digital technology can restructure the traditional spaces of educational practice, and identify design dynamics that may be neglected in the wake of ‘virtualisation’. Discussion first highlights two theoretical perspectives that will inform many such designs: namely, situativity and sociality in learning. Three examples are then provided of how digital technology can intersect with learning space design to create novel interpersonal frameworks for learning and to destabilise conventional senses of ‘place’ in those settings. The examples concern, respectively, the organisation of collaborative, expository, and community-based social structures for learning. Those examples represent an illustrative counterpoint to models of online schooling and illustrate a potentially productive synergy between the opportunities afforded by digital technologies, the desires of those who wish to dis-place learning online, and a well-established interest in learning space design

Non-canonical Wnt signalling modulates the endothelial shear stress flow sensor in vascular remodelling

Endothelial cells respond to molecular and physical forces in development and vascular homeostasis. Deregulation of endothelial responses to flow-induced shear is believed to contribute to many aspects of cardiovascular diseases including atherosclerosis. However, how molecular signals and shear-mediated physical forces integrate to regulate vascular patterning is poorly understood. Here we show that endothelial non-canonical Wnt signalling regulates endothelial sensitivity to shear forces. Loss of Wnt5a/Wnt11 renders endothelial cells more sensitive to shear, resulting in axial polarization and migration against flow at lower shear levels. Integration of flow modelling and polarity analysis in entire vascular networks demonstrates that polarization against flow is achieved differentially in artery, vein, capillaries and the primitive sprouting front. Collectively our data suggest that non-canonical Wnt signalling stabilizes forming vascular networks by reducing endothelial shear sensitivity, thus keeping vessels open under low flow conditions that prevail in the primitive plexus