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

● Palliative Care services are often underutilized in patients with End-Stage Liver Disease (ESLD) and often only initiated at the end of life ● The Palliative Performance Score (PPS) is an important tool used in Palliative Care to assess functional status ● PPS has five functional dimensions: ambulation, activity level and evidence of disease, self-care, oral intake, and level of consciousness ● The aim of this study is to determine if there is a correlation between Model for End-Stage Liver Disease (MELD) score and PPS in ESLD patients ● MELD is used to predict mortality and to prioritize liver transplant allocation in ESLD patientshttps://jdc.jefferson.edu/medposters/1011/thumbnail.jp

Intestinal infection with Mycobacterium avium in acquired immune deficiency syndrome (AIDS)

At endoscopy, a 30-year-old man with acquired immune deficiency syndrome (AIDS), Kaposi's sarcoma, diarrhea, and unexplained malabsorption showed erythematous macular duodenal lesions consistent with Whipple's disease by histology and electron microscopy. Symptoms did not respond to tetracycline. Subsequent cultures revealed systemic Mycobacterium avium (M. avium) infection. Tissue from this patient, from patients with Whipple's disease and from a macaque with M. avium were compared. All contained PAS-positive macrophages but M. avium could be distinguished by positive acid-fast stains and a difference in pattern of indirect immunofluorescence staining with bacterial typing antisera. PAS-positive macrophages in the intestinal lamina propria are no longer pathognomonic of Whipple's disease. Ultrastructural and histological similarities between Whipple's disease and M. avium infection suggest that both are manifestations of immune deficits limiting macrophage destruction of particular bacteria after phagocytosis. M. avium must be considered in the differential diagnosis of diarrhea in patients with AIDS and other immunosuppressed conditions.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/44396/1/10620_2005_Article_BF01318186.pd

Subcutaneous Emphysema: A Case Report of an Atypical Manifestation of PCP in an HIV Patient

Introduction: Pneumocystis pneumonia (PCP), caused by Pneumocystis jirovecii (P. jirovecii), is a fungal opportunistic infection seen in poorly controlled Human Immunodeficiency Virus (HIV) and is considered an Acquired Immune Deficiency Syndrome (AIDS) defining illness. It is also found in other immunocompromised states, such as hyper IgM syndrome and in patients on immunosuppressive therapy. In the HIV+ population, a CD4+ T-lymphocyte count (CD4 count) less than 200 cells/mm3 is associated with an increased risk of PCP. Combination antiretroviral therapy in conjunction with PCP prophylaxis has significantly decreased the prevalence of this opportunistic infection. In the United States HIV-infected population, PCP prevalence has decreased from 29.9 per 1000 person years between 1994 to 1997 to 3.9 per 1000 person years between 2003 to 2007.1 At the onset of the HIV/AIDS epidemic, PCP occurred in 70% to 80% of patients with AIDS.2 PCP should be highly suspected in HIV+ patients with bilateral symmetrical interstitial infiltrates on chest radiography, hypoxemia, and a CD4 count less than 200 cells/mm3 in addition to infectious respiratory symptoms such as cough, fever, and dyspnea. For definitive diagnosis, histopathologic or cytopathologic organism identification is required, most commonly via bronchoalveolar lavage or tissue biopsy. In addition to pneumonia, P. jirovecii can invade the liver, spleen, and kidneys. It has also been associated with pneumothorax. Less commonly, it has been associated with pneumomediastinum without pneumothorax. Case Presentation: This is a 39-year-old man with a twenty-year history of HIV who presented with one month of worsening shortness of breath, dry cough, and dysphagia. At admission, the patient had a CD4 count of 52 cells/mm3, a viral load of 456,074 copies/mL, and a history of non-adherence to HIV treatment. Prior to admission, the patient was not taking his prescribed antiretroviral therapy or PCP prophylaxis. These were re-initiated at the time of admission. In the hospital, the patient had progressive hypoxia that eventually required high flow oxygen supplementation at 35 L/minute and 100% FiO2. Initial chest x-ray showed diffuse bilateral infiltrates

Neurosarcoidosis: Granulomatous Disease Presenting with Confusion and Gait Disturbance

Introduction: Sarcoidosis is a multisystem disorder characterized by noncaseating granulomas that frequently presents with pulmonary infiltrates, hilar lymphadenopathy, and ocular and skin lesions. Sarcoidosis affects about 20 per 100,000 individuals in the US with a higher prevalence among African Americans than in Caucasians.1 The average age of presentation ranges from 33 to 41 years.1 Less than 10% of people with sarcoidosis have CNS involvement, with cranial neuropathy, aseptic meningitis, hydrocephalus, seizures, psychiatric symptoms, and cerebral lesions with endocrine manifestations included among the possible manifestations.2 This case report describes a woman with neurosarcoidosis presenting with confusion and gait disturbances. Case Presentation: A 59-year-old woman with a past medical history of hypertension and diabetes presented with one month of progressive confusion, lower extremity weakness, and gait instability. Prior to admission, she was treated at an outside hospital for presumed aseptic meningitis without improvement. The following diagnoses were present on admission: acute kidney injury with a creatinine of 2.1 mg/dL, a FeNa of 3.3%, and hypercalcemia to 14.5 mg/ dL. The physical exam was only notable for a persistent low grade fever averaging 100.3°F. She had no other symptoms. During the course of her admission, she developed polyuria which prompted a discussion of possible diabetes insipidus. A brain MRI without contrast ordered to evaluate this possibility showed mild dilatation of the lateral and third ventricles, suggestive of non-obstructive hydrocephalus. A subsequent lumbar puncture revealed an elevated opening pressure and elevated protein of 64 mg/dL. In the CSF, the ACE level was normal at 8U/L, the glucose level was 51 mg/dL, and oligoclonal bands were seen. No other cytological or pathological findings were noted

A Rare Infectious Cause of Optic Neuritis

Introduction: Optic neuritis (ON) is the most common type of inflammatory, demyelinating disorder of the optic nerve, most often caused by multiple sclerosis (MS). However, alternative diagnoses should be considered and investigated thoroughly in the setting of other systemic symptoms. Optic neuritis is a rare manifestation of Lyme disease that typically improves with antibiotics. Case Presentation: A 50 year-old woman with history of breast cancer treated with mastectomy and chemotherapy in remission for ten years presented with a right-sided headache and right eye vision changes. She was feeling well until three weeks prior to hospital admission in June when she developed fevers up to 103.1 °F, sweats, and a circular, slightly raised and pruritic rash on her neck, chest and on her right lower extremity. She was evaluated at an urgent care clinic where a rapid strep test was negative, and she was sent home without antibiotics. Over the next three days, fevers and rash resolved without treatment. Two weeks afterward, the patient developed a right-sided headache associated with right eye pain and intermittent blurry vision. She denied neck stiffness, joint pain, rash, or myalgias at that time. Outpatient ophthalmic evaluation revealed right optic disc edema and MRI of the brain showed enhancement along the right optic nerve. The patient had hiked in wooded areas in the Philadelphia region in the spring and summer months but was not aware of any mosquito or tick bites. Her allergies include an unknown allergy to oxytetracycline

Finding the Right FIT to Improve Colorectal Cancer Screening

Background An estimated 28% of eligible US adults have never been screened for colorectal cancer (CRC) 2 Fecal Immunochemical Testing (FIT) offers an acceptable non-invasive screening option An estimated 56% of patients at our internal medicine clinic have not had colorectal cancer screening and alternatives to colonoscopy were seldom promoted Poster presented at: Pennsylvania Society of Gastroenterology (PSG) Annual Scientific Meeting 2017 at Nemacolin Woodlands Resort, Farmington, Pennsylvania, United States of America.https://jdc.jefferson.edu/medposters/1010/thumbnail.jp

Dr. Seishu Hanaoka (1760-1835): surgeon, pharmacist, and anesthesiologist.

The notion of decreasing pain in surgery stretches back thousands of years with alcohol noted as one of the first anesthetics. Natural elements including coca and opium have been used by various civilizations in an attempt to mute the searing pain of surgery. By the 16th century, physicians around the world began to experiment with nitrous oxide and ether, providing the groundwork for the future of modern anesthesia. The successful application of general anesthesia in surgery was first documented in 1804 by Dr. Seishu Hanaoka (Fig. 1) in Wakayama, Japan, during a breast lumpectomy. During the case, Dr. Hanaoka served as the surgeon, anesthesiologist, and pharmacist. Although most of his worldwide contemporaries were unaware of his successes, this achievement stands as an emblematic and triumphant landmark in medicine