Taking Free Flap Surgery Abroad: A Collaborative Approach to a Complex Surgical Problem.

Accessibility to health care, especially complex surgical care, represents one of the major health care disparities in developing countries. While surgical teams may be willing to travel to these areas to help address these needs, there are many logistical and ethical dilemmas inherent in this pursuit. We reviewed our approach to the establishment of the team-based surgical outreach program, wherein we perform head and neck free tissue transfer surgery in Haiti. We describe the challenges encountered in the delivery of surgical care as well as ethical dilemmas relevant to surgical outreach trips, highlighting an approach reliant on strong local cooperation. Despite the obstacles in place, our experience shows that free flap surgery can be successfully and ethically performed in these areas of great need

From the Desk of the Residency Program Director

It has been a historic year for the Nation, City of Philadelphia and teh Jefferson Internal Medicine Residency Program. We have eperienced many health care crises starting with the closure of the historic Philadelphia hospital, Hahnemann. We welcomed residents form this program as part of the Jefferson Family and integrated many patients into our practices

Nephrotic Syndrome: Is HIV Associated Nephropathy on Your Differential?

Case Description A 30-year old African American female with no significant past medical history initially presented to our emergency department with three days of sore throat, dysphagia, fever, fatigue, nausea and vomiting. She denied ear pain, rhinorrhea, shortness of breath or any sick contacts. Her social history was negative for tobacco, alcohol and illicit drug use. She works as a security officer, lives with her family and is sexually active only with her husband. On initial examination she was febrile to 101.9° F, with a heart rate of 100 beats per minute, blood pressure of 143/99 mmHg, respiratory rate of 18 breaths per minute and an oxygen saturation of 99% on room air. Her only pertinent physical examination findings were a mildly erythematous oropharynx without exudates, mildly swollen uvula and right tonsil, bilateral tender swollen sub-mandibular lymph nodes and reduced breath sounds on auscultation of the right lower lung base.She was routinely tested for HIV, ruled out for group A strep, and discharged home with the diagnosis of viral pharyngitis on supportive care. Following the identification of a presumptive positive rapid HIV screening test with evidence of HIV-1 p24 antigen and a reactive HIV-1 antibody on the multispot HIV 1 / 2 antibody test she was called to return to the ED for counseling regarding a positive HIV test. She reported continuation of her prior symptoms with worsening dysphagia, as well as new complaints of bilateral lower extremity edema to the knees. Initial laboratory testing revealed an elevated serum creatinine (Cr) of 2.2mg/dL (0.7-1.3 mg/dL) up from \u3c1.0mg/dL one-year prior, with an estimated Creatinine clearance (CrCl) of 43.4 ml/min using the modified Cockcroft-Gault equation. She was admitted for further workup. A trial of IV fluid hydration overnight worsened her symptoms and additional labs demonstrated hypoalbuminemia, 4+ proteinuria with 1+ blood, and a urine protein/creatinine ratio of 17mg/ mg (\u3c0.2 mg/mg), consistent with nephrotic syndrome. Her CD4 count was 115 cells/mm3 (500-1500 cells/ mm3) with an HIV viral load of 117,148 copies/ml. Based off negative labs for syphilis, hepatitis panel, ANA, complement C3/C4, and diabetes, findings were felt to be consistent with HIV Associated Nephropathy (HIVAN). The patient underwent renal biopsy to confirm the diagnosis and was started on abacavir, darunavir, dolutegravir, lamivudine and ritonavir. Pathology results were consistent with HIVAN with tubulointerstitial nephritis and collapsing glomerulonephropathy and electron microscopy showed diffuse epithelial cell injury with effacement of foot processes and segmental collapse of glomerular capillary loops. Her serum Cr peaked at 2.78 on day 7 of her admission. Her serum Cr and urea-nitrogen steadily improved after just one week of HAART therapy leading to a 42% reduction in serum Cr (Figure 1). Additionally, due to her un-resolving dysphagia the patient underwent esophagogastroduodenoscopy, which was unremarkable. However, she subsequently had esophageal manometry, which was consistent with diffuse esophageal spasm for which she was started on diltiazem

Achieving Symptom Control in Patients with Moderate Asthma

Disease severity in asthma can be classified as mild, moderate or severe based upon the frequency of symptoms or the severity of airflow obstruction. This review will focus on the treatment of youths greater than 12 years of age and adults with moderate persistent asthma. Moderate asthmatics may have daily symptoms that cause some limitation with normal daily activities and require use of a rescue inhaled short-acting beta(2)-agonist inhaler or experience nocturnal awakenings secondary to asthma that occur more than once per week. Furthermore, spirometry may reveal airflow obstruction with a reduction in FEV(1) to between 60% and 80% of predicted. Although inhaled corticosteroids (ICS) are the primary controller medication used to modify symptoms in moderate asthmatics, additional controller medications, such as inhaled long-acting beta(2)-agonists (LABA), leukotriene receptor antagonists (LTRA) or theophylline, are often needed to obtain optimal disease control. While the addition of an inhaled LABA to an ICS is very effective at improving disease control in moderate asthma, concerns have arisen over the safety of LABAs, in particular the risk of asthma-related death. Therefore, consideration may be given to initially adding a LTRA, rather than a LABA, to ICS when asthma symptoms are not adequately controlled by ICS alone. Furthermore, individualization of medication regimens, treatment of co-morbid conditions, and patient education are crucial to optimizing compliance with therapy, improving disease control, and reducing the risk of exacerbations. Lastly, the development of new asthma treatments, perhaps based upon personalized medicine, may revolutionize the future treatment of moderate asthma

The TJUH Hospital Medicine COVID19 Emergency Taskforce: A guiding light during the surge of spring 2020

What’s the Problem? In mid March 2020 a highly infectious and deadly disease appeared in Philadelphia that no American physician had ever treated before. The challenge of disseminating reliable and relevant information about a novel and dangerous pathogen across practice areas cannot be understated. Usual practices for communication and leadership are not designed to manage this kind of challenge

Paraneoplastic Acral Vascular Syndrome

Introduction Cases of rheumatologic phenomena coinciding with malignancy have been well-documented in the medical literature. These syndromes may be associated with common autoimmune markers, potentially masking the underlying diagnosis of malignancy. The association between malignancy and its coinciding rheumatologic manifestations is poorly understood. These paraneoplastic symptoms are more prevalent in high-stage adenocarcinomas of the lung, breast, and ovary. Possible mechanisms may include cytokine derangements, blood hyperviscosity, and circulatory disruption. While some evidence suggests that control of the primary tumor alleviates its associated paraneoplastic symptoms, other proposed therapies include heparin, prednisone, aspirin, and vasodilatory agents. Efficacy is limited due to association of these syndromes with high-grade malignancy. We describe the case of a patient presenting with para neoplastic acral vascular syndrome (PAVS) in association with primary ovarian carcimona.1.2 Case The patient is a 57-year-old female with a history ofHashimoto\u27s thyroiditis and migraines, who presents with an ulcerating rash of the fingertips and a tender discoloration of the plantar aspect of both feet. The rash began four weeks prior to presentation as a purple discoloration of the fingertips, progressing to a desquamating, palmar rash with distal phalangeal ulceration and necrosis of the fingertips. Almost simultaneously, the patient experienced purple discoloration of the soles of her feet bilaterally and described a sensation of standing on marbles. She denies similar episodes in the past as well as sick contacts. She reports experiencing excessive stress in preparing for her daughter\u27s wedding, exposure to a new type of dryer sheet, and a recent manicure/pedicure. The patient was recently treated with two medrol dose packs, minocydine, nitroglycerin paste (which had to be discontinued due to hypotension), and aspirin. Following treatment, the patient had no relief of symptoms