Residents and Fellows Symposia

2007-2010
The Annual Internal Medicine Resident Symposium
Peter White Award for Excellence in Scholastics
Peter White Symposium Award, April 28, 2010

Dr. White obtained his college degree from Yale, M.D degree from the University of Pennsylvania, also completed his residency in medicine and fellowship in hematology/oncology. In 1969 joined MCO as an associate professor of medicine, then he was one of the founders of internal medicine department. Dr. White has numerous contributions to the literature and to the community. Dr. White still active in teaching our residents and students.

1st Place: Dr Nizam Torok –POEMS Syndrome
2st Place: Dr Navpreet Josh-TTP associated with Sjogren Syndrome
3st Place: Dr Ehsan Rafiq-Overt obscure GI bleeding secondary to pancreatic transplant.

The 5th Annual University of Toledo Internal Medicine
Research and Clinical Resident Symposium

In association with
ST. VINCENT MERCY MEDICAL CENTER
INTERNAL MEDICINE RESIDENCY

Wednesday, April 28, 2010
9:00 A.M. – 1:00 P.M.
Mulford Library Café, Ground Floor

Peter White Award for Excellence in Scholarly Activity
Speakers:
9:00 am – 9:15 am
Welcome and Opening Remarks
Dr. Ragheb Assaly – University of Toledo Internal Medicine Residency Program Director

9:15 am – 9:30 am
Overt obscure gastrointestinal bleed secondary to pancreatic transplant diagnosed by Capsule Endoscopy
Dr. Ehsan Rafiq – University of Toledo PGY 1

9:30 am – 9:45 am
Thoracic Vertebral osteomyelitis as a complication of IBD.
Dr. Mohammad Taleb– University of Toledo PGY 1.

9:45 am to 10:00 am
An Uncommon Case of Peripheral Eosinophilia
Dr. Abhimanyu Ghose – University of Toledo PGY1

10:00 am to 10:15 am
Melanoma and the Lung
Dr. Hala Aboulkahair – University of Toledo PGY1

10:15 am to 10:30 am
BREAK

10:30 am to 10:45 am
FB Aspiration
Dr. Fadi Safi – University of Toledo PGY2

10:45 am to 11:00 am
POEMS Syndrome
Dr. Nezam Torok – University of Toledo PGY2

11:00 am to 11:15 am
Calcineurin mediates enhanced high-voltage-activated calcium currents in rat primary cortical neurons after acute hypoxia
Dr. Kun Xiang – University of Toledo PGY1

11:15 am to 11:30 pm
Pancreatic Cyst
Dr.Tariq Zeeshan – University of Toledo PGY1

11:30 am to 11:45 am
TTP associated with Sjogrens Syndrome.
Dr. Navpreet Josh– St Vincent Mercy Hospital - PGY1

11:45 am to 12:00 pm
Closing Remarks and Presentation of Awards
Dr. Peter White - Professor Emeritis Medicine, Division of Hematology/Oncology

Thomas Walsh Fellow Award in Teaching Excellence

Dr. Thomas Walsh

Dr. Walsh, had his undergraduate training in chemistry at Youngstown and Cincinnati Universities. Graduated as
an M.D from Medical College of Ohio in 1978. Completed his residency, cardiology fellowship training at MCO.
Joined MCO faculty in 1983 until 2006 when he died after a tragic accident. Dr. Walsh was a distinguished teacher,
scientist and a human being. His devotion to his fellows and to his patients was exemplary.

2nd Place: Steve Bruhl – Cardiology Fellow
Post Reperfusion Syndrome in Renal Transplantation.

The following is a summary of the Practice Based
Learning Projects and improvement (PBLI) conducted
by the residents during the period July 2009-June 2010 .
Project 1
Anticoagulation management in an
Internal Medicine outpatient clinic.
Mahvish Muzaffar MD PGY 2
Leonard White, MD PGY 3
The purpose of the study is to evaluate coumadin management
in internal medicine resident clinic. The following end points
were looked at 1) complications 2) efficacy of monitoring, 3)
implementation of guidelines and 4) patient education.
PATIENTS
Forty five patients were identified as being on coumadin
monitoring list of internal medicine outpatient clinic. The
average age of patients was 60.1 years, male : 19/45 (42.2%),
females : 26/45 (57.8%), two patents had longest documented
intake of Coumadin for 8 years
The most common indications were: DVT and PE combination
in 20/45(45%) patients. A fib/A flutter in 9/45 (20%), DVT
only in 7/45 patients (15.5%) PE only in 9/45 (20%), 9/45
patients also had some form of hypercoagulable state.
Progress notes, hospitalization records discharge summaries
were evaluated for Coumadin related complication and
hospitalization.
Results : 10/45 patients had hospitalization related to
Coumadin complication (3/10 GI bleed, 2/10 subtherapeutic
INR and new thrombus, 5/10 supratherapeutic INR)
HOW CAN WE IMPROVE/Recommendations
Follow evidence based guideline
Use coumadin flowsheet
Improve documentation of patient flow sheets
Review indication, plan and goals periodically
Patient education, education and education
Evaluate for complication
Project 2
Residents involvement in the curriculum
development
Dr. Kiranmayee Lanka, PGY 3
Dr. Amjad shidyak, PGY 3
Sources
Pub Med, MKSAP 15, Up to date, ACCP, AHA, NEJM
Objectives
Provide direction and motivation for future learning, including
knowledge, skills and professionalism.
Protect the public by upholding high professional standards and
screening out trainees and physicians who are incompetent.
Meet public expectations of self- regulation
Choose among applicants for advanced training.
From above the need for fundamental redesign of medical
training is clear and in some instances the road is also clear,
but it is not a easy task. The challenge is not only defining the
appropriate content but also incorporating it into the curriculum
in a manner that emphasizes its importance relative to traditional
biomedical content and then finding and preparing faculty to
teach this revised curriculum.
Project 3
Frequent Readmissions to UTMC
Usman Ahmad, MD PGY 3
Hemlata Bhaskar, MD PGY 2
A study from Medicare data for beneficiaries
discharged in 2003-2004 revealed:
One of Five patients were readmitted.
Estimated cost:17.4 billion
Potentially Preventable Readmissions are defined as return
hospitalizations that may result from deficiencies in the process
of care and treatment or lack of post discharge follow-up 76% of
re-hospitalizations were preventable. 14 ‐ 46 % were assessed as
“potentially avoidable” in retrospective clinician reviews
Research and quality improvement initiatives have demonstrated
reduction of 30‐day readmission rate Clear indication that there
is room for improvement
Retrospective Study Design
Review the number of patients readmitted 2 or more times
within 30 days of discharge between the defined window. The
30 Day readmission window for discharges beginning August
1, 2009 and ending November 1, 2009. All Internal Medicine
Services were included in the study.
Data retrieved from billing information at UTMC for the
defined period of time.
Objectives
Fadi Safi, PGY 2
Objective
Rate of self extubation in our MICU
and compare it with the national average.
Method
Retrospectively over 6 months period between August-January
2009/2010 charts reviewed of MICU admission for patients
with Self Extubation/ Accidental Extubation
Define the size of the problem at UTMC
Identify the most common diagnosis at UTMC for readmission
Identify the patient demographic (age, gender, form of
insurance)
Analyze the cost burden of the problem at UTMC
Propose recommendations adapted to the UTMC health system
to address the problem
174 Medicine service patients were readmitted within the study
period
Total cost $ 16,724,991 , Totaling 2,496 days. The longest
readmission was 24 days
Average length of stay on readmission was 2 days.
Strategies to Reduce Rehospitalizations
Medication reconciliation , Personal health record, Physician
appointment scheduled within 7 days of discharge (visit within
2 weeks) , Patient emergency plan, Transition coaching.
Project 4
ANALYSIS OF QUALITY OF
RESIDENT DICTATIONS
Analysis of discharge summary dictations
and compare to standard.
Objectives
List common mistakes done by majority of residents.
Suggestions to improve the quality of dictations by recognizing
the common mistakes.
We analyzed randomly 100 dictations done by 9 interns.
The second year residents and third year residents were not
included in the study.
The softmedia software was used to analyze the dictations with
the help of IT department.
The first principal diagnosis was used as the primary diagnosis
and the other principal diagnoses were not included.
Results
Primary diagnosis: 100 percent
Secondary diagnosis: 100 percent
Procedures : 46 Percent
Hospital Course: 100 percent
Discharge Medications: 100 percent
Condition at Discharge: 90 percent
Disharge Disposition: 90 percent
Discharge Instructions: 90 percent
Out of 10 patients with CHF only one dictation mentioned the
ejection fraction in the list of principal diagnosis and in other six
dictations it was mentioned in the hospital course.
Two out of 10 patients had diastolic heart failure and it was only
listed as CHF without mentioning its diastolic nature. One out
of eight systolic heart failure patients did not have ACE inhibitor
in the discharge medication list where the patients EF was 10
percent.
None of the pneumonia listed in the diagnosis was categorized
as community acquired or hospital acquired . It was observed
that the residents dictation improved with time. It was more
organized, and did not miss things in the subsequent dictations.
Project 5
IMAGING STUDIES FOR
VENOUS THROMBOEMBOLIC DISEASE –
is there any other safer method ?
Dr Jacob PGY 3
Dr Rkaine PGY 2
REASERCH QUESTION….When used by our residents, Well’s
criteria is a very good tool for risk stratification for PE .
Retrospective study
55 records with D-dimer positive test results were reviewed
All these patients had either CTA, V/Q or
Doppler positive results
Risk stratification thru wells criteria was done by the
investigators, by chart review.
RESIDENT DIAGNOSIS
It was observed that thou indicated in 10%of patients who had
high probability for PE , anticoagulation therapy was not started.
It was also observed that increasing D- Dimer value correlates
very well with new incidence of thrombembolism.
Residents are hesitant to use CTPA in renal disease patients.
Screening, Management and Adult Vaccinations –
How are we doing?
Asma Taj PGY 2
Jagannath Saikumar PGY 3
Objectives
- Management of Hypertension
Screening for Cancer
-Vaccination of adult population
“How much are we doing and how well are we doing?”

Study Methodology
Chart review of patients in GIM clinic
The patient seen by the same resident for at least 3 consecutive
visits in 1 yr
2-3 patients per resident
HTN
The measures taken according to the BP recordings noted by
going through the dictations and the progress notes in the chart
– Screening for complications in poorly controlled HTN
– Increasing or decreasing the dose of anti-hypertensive meds
– Adding 2nd or 3rd medication to the hypertensive regimen
– Are all patients with DM on ACE- inhibitors or ARBs; if
not, why (documentation in chart/dictation)?
Cancer Screening
– screening done or started on time at appropriate age
– follow-up and discussion of results
– documentation if not done
Females: Mammogram, Pap smear, Sigmoidoscopy/Colonoscopy
Males: PSA, Sigmoidoscopy/Colonoscopy
Immunization
– Tetanus
– Influenza
– Pneumonia
– Appropriate age and population offered and given
– Complications from vaccinations noted?
– Documentation if refused/not given
No of patients per yr of training
Compliance with JNC 7 guidelines for
HTN + Diabetes
Drugs for different stages
Documentation of stages during initial diagnosis
Cancer screening and adult vaccination –
Appropriate age of screening
Regular follow-up with patient
Vaccination guidelines for target population
Project 6
Unplanned Extubation in the Intensive Care Unit.
Abd Alkarim abu Malouh PGY 3
Fadi Safi, PGY 2
Objective
Rate of self extubation in our MICU and compare it with the
national average.
Method
Retrospectively over 6 months period between August-January
2009/2010 charts reviewed of MICU admission for patients
with Self Extubation/ Accidental Extubation
Express the rate as number of extubations per 100 intubation
days
Focus on risk factors mainly Admitting Diagnosis, Agitation/
Sedation, Number of patients and staff, Nursing overtime within
unit, Breathing trial, Timing and Event and Restraints
• Agitation is one of the well-documented risk factors and
several study reported that self extubation occurred more in
patients who where less sedated
• Conflicting results in the literature regarding the use of
restraints to prevent unplanned extubation
• Tominaga et al found more self extubation when the use of
restrains was limited to meet ( JCAHO) Standards
• Patient Characteristics with self extubation.
Project 7
Standarizing Vasopressor doses in Shock
Rifat Hassan PGY 3
Rehana Qadir PGY 3
• The aim of this study was to determine how frequently the safe
dosing (mcg/kg/min) of the Vasoactive medications are being
utilized in various hospitals. This was a prospective study in
which information collected was from various institutions
about the methods of adminstration of vasoactive medications.
A search was performed and the top ranking hospitals of the
US were identified.
Next the ICU staff and/or the pharmacists of these hospitals
were contacted either by a telephone or by an email. The
information about the protocols of their ICUs (if any),
medications adminstration methods and dose titration was
collected from each hospital which agreed to provide the
required information. Some of the hospitals had the ICU
protocols available on their websites.
A search about these protocols and any available literature was
also performed with the help of our pharmacist and a librarian.
Results
Out of 35 hospitals contacted only 19 hospitals responded either
by email (N=10), or via telephone call (N=5). Eleven hospitals
were using the dose calculated as mcg/kg/min for epinephrine,
norepinephrine and phenylepinephrine. Seven hospitals reported
use of the dose calculated from mcg/min for epinenephrine ,
norepinephrine and phenylepinephrine.
One center reported dosing varied from patient to patient.
Eighteen hospital were using vasopressin in Units/min and
dopamine as mcg/kg/min. Most of the hospitals do not follow
the standard protocols for the adminstration of vasopressors.
Project 8
Aijaz Sofi PGY 2
Khaled Abuhantash PGY 3
QTc interval changes during
Therapeutic Hypothermia
We attempted to investigate the effects of therapeutic hypothermia
(TH) on QT-interval and to investigate if this QT-prolongation
is clinically relevant with regards to the incidence of cardiac
arrhythmias directly resulting from TH.
Methods:
We reviewed all the patient charts who were admitted in
Intensive Care Unit (ICU) following a cardiac arrest between
03/12/2009 until 04/08/2010. We further divided this patient
population into 2 groups- those who received TH and those
who did not. We compared the QT-prolongation on admission
in the two groups. Then we measured the effects of hypothermia
on QT-interval in the TH-group. We further compared the
incidence of arrhythmias in the patient group who underwent
therapeutic hypothermia with those who did not. Some of the
variables taken into consideration were- medications which can
prolong QT-interval and previous h/o- prolonged QT-interval.
Pearson’s co-relation was used for the QT-interval and coretemperature.
Results:
A total of 37 patients (18 females and 19 males) were admitted
to ICU between 03/12/2009 until 04/08/2010 following a
cardiac arrest. Of these, 26 patients received TH and 12 patients
did not receive TH. In the TH group, 21 (70.2%) patients died
during the TH. Seven patients (29.2%) survived. Mean QTc
interval in TH group before the initiation of TH was 402.92
msec and in non-TH group was 443 msec. Mean QTc interval
during hypothermia was 538.37 msec. Paired t-test for QTinterval
between patients who survived and those who died was
not significant (p-0.09). Pearson’s correlation for QTc interval
with the core temperature was available for one patient and there
was negative co-relation between the two variables (fig-1).
Discussion:
TH has been found to be beneficial in preventing neurological
damage in patients who survive cardiac arrest. However,
hypothermia is associated with numerous arrhythmogenic and
electrophysiological effects on heart. These include: 1.Atrial
fibrillation with slow ventricular rate; 2. Bradycardias, including
junctional rhythm and asystole; 3. Prolongation of PR, QRS and
QTc intervals; 4. Osborn ( J)-waves; 5. Premature ventricular
complexes (PVC), VT and ventricular fibrillation (VF); 6.
Serum hypokalemia and hypomagnesaemia.
Mean QTc interval in both TH group and non-TH group was
similar prior to induction of hypothermia. QTc-interval during
TH was prolonged in TH group by 33.8 %. This is important
as there has been reported cases of Torsades de pointes3
and idioventricular rhythm 5 during prolongation of QTc
secondary to TH. Even though, TH is recommended both by
International Liaison Committee on Resuscitation (ILCOR)
2 and European Resuscitation Committee (ERC), there are no
guidelines on ECG monitoring during hypothermia. In addition,
treatment of VT or VF secondary to hypothermia might not
be straightforward. The commonly used anti-arrhythmic drug,
amiodarone can produce QTc-prolongation and can cause
torsades de pointes 6, therefore its use can potentiate QT
prolongation during hypothermia. More data is required to
determine the safety of various anti-arrhythmic for VT/VF
during TH.
The drawbacks with our study were:
i. there were no frequent EKG recordings;
ii. Time of re-warming was not always charted;
iii. some pts had support withdrawn per family.
There is a need to conduct a well designed, possibly multicentric,
prospective study to determine the incidence of various
types of arrhythmias during TH and its relationship with the
temperature and QTc. This would Further, the efficacy of antiarrhythmic
medications for VF/VT during TH needs to be
determined.