Publications

Giant Hepatocellular Carcinoma in a Young Adult Without Cirrhosis: A Case Report

Shamas Rafique, Iqra Rafiq, Saad A. Janjuah

Researchers' Journal of Internal Medicine.

Background: Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and typically arises in patients with chronic liver disease and cirrhosis. The occurrence of HCC in young adults without underlying liver disease is uncommon and presents distinct diagnostic and therapeutic challenges. Case Presentation: A 23-year-old male with no significant past medical history presented with persistent right upper quadrant abdominal pain and anorexia. Laboratory investigations revealed mildly elevated liver enzymes and a significantly elevated alpha-fetoprotein (AFP) level of 817.9 ng/mL. Viral serology for hepatitis B and C was negative. Additional etiologic evaluation revealed no clinical evidence of metabolic syndrome, obesity, significant alcohol use, or family history of liver disease. Iron studies, ceruloplasmin testing, and alpha-1 antitrypsin deficiency evaluation were not available at the treating facility. Ultrasound and triphasic contrast-enhanced computed tomography demonstrated a large heterogeneous hepatic mass measuring approximately 20 cm involving segments IV, V, and VIII, with compression of adjacent hepatic vasculature but without definite vascular invasion or tumor thrombus. Imaging characteristics were categorized as LI-RADS 5. An ultrasound-guided liver biopsy confirmed well-differentiated hepatocellular carcinoma with positive CD34 and HepPar-1 immunostaining. Histopathology did not demonstrate lamellar fibrosis or morphologic features suggestive of fibrolamellar carcinoma. The tumor was deemed unresectable due to its size, bilobar involvement, and vascular compression. Following multidisciplinary tumor board evaluation, a combined treatment plan with transarterial chemoembolization (TACE) and systemic therapy with sorafenib was recommended. Immunotherapy-based combinations were not selected because treatment planning occurred in a setting where these regimens were not routinely available. Short-term follow-up is planned to assess the response. Conclusion: Although rare, hepatocellular carcinoma can occur in young individuals without cirrhosis or viral hepatitis. This case highlights the importance of maintaining clinical suspicion for HCC when evaluating large hepatic masses in young patients and emphasizes the importance of differentiating conventional HCC from fibrolamellar carcinoma in atypical presentations. Multidisciplinary evaluation remains critical in determining appropriate management strategies for advanced unresectable disease.

Resistant Hypertension and Severe Hypokalemia Revealing Bilateral Adrenal Adenomas in Primary Aldosteronism: A Case Report

Shamas Rafique, Iqra Rafiq, Saad A. Janjuah

Researchers' Journal of Internal Medicine.

Introduction: Resistant hypertension, defined as uncontrolled blood pressure despite multiple antihypertensive agents, necessitates evaluation for secondary causes. Primary aldosteronism (PA) is a common but underdiagnosed endocrine etiology, characterized by autonomous aldosterone production leading to hypertension, hypokalemia, and suppressed renin. Case Presentation: A 60-year-old male presented with hypertension refractory to a five-drug regimen. Persistent hypokalemia (K as low as 2.4 mmol/L) and hypernatremia prompted biochemical testing, which revealed a markedly elevated aldosterone-to-renin ratio of 287.5 (aldosterone 23 ng/dL, renin 0.08 ng/mL/h). CT imaging confirmed bilateral lipid-rich adrenal adenomas. An electrocardiogram during severe hypokalemia showed significant QT prolongation (QTc 514 ms). Treatment and Outcome: The patient was started on spironolactone. Follow-up at 14 days showed improved blood pressure (137/95 mmHg), sustained and normalized at three months (127/76 mmHg). Serial ECGs demonstrated correction of the QT interval following potassium repletion. Conclusion: This case highlights that primary aldosteronism is a reversible cause of resistant hypertension, frequently associated with bilateral disease. It underscores the critical importance of screening with the aldosterone-to-renin ratio in all patients with resistant hypertension, particularly when hypokalemia is present, as targeted therapy leads to rapid clinical improvement.

The Incidental Diagnosis: Familial Adenomatous Polyposis Unmasked by CT in a Young Male Presenting with Chronic, Refractory Anemia

Shamas Rafique, Iqra Rafiq, Saad A. Janjuah

Researchers' Journal of Internal Medicine.

Background: Familial adenomatous polyposis (FAP) is an autosomal dominant disorder characterized by early-onset colorectal adenomatosis and a near-absolute risk of malignancy. Young patients often present with nonspecific symptoms like chronic anemia, leading to diagnostic delays. Case Presentation: We report a 32-year-old male with no significant family history who presented with a 12-month history of severe, symptomatic iron-deficiency anemia (Hb nadir 4.9 g/dL), temporarily responsive to intravenous iron. Associated symptoms included fatigue, hematochezia, weight loss, and palpable abdominal masses. A contrast-enhanced computed tomography (CT) scan, obtained during the evaluation of severe anemia, revealed highly suggestive findings of innumerable colonic polyps. Subsequent colonoscopy revealed the classic phenotype of extensive polyposis, and biopsy confirmed tubular adenomas with low-grade dysplasia. Genetic testing identified a pathogenic APC variant (c.4391_4394del). He underwent total prophylactic colectomy with ileal pouch-anal anastomosis (IPAA). Management and Outcome: Postoperatively, high-output diarrhea was managed with loperamide and cholestyramine. At 6-month follow-up, his anemia had completely resolved (Hb 14.8 g/dL). Conclusion: This case underscores CT's role in suggesting FAP in cases of refractory anemia, prompting definitive endoscopic and genetic diagnosis and life-saving surgical intervention. Unexplained iron-deficiency anemia in young adults warrants thorough investigation to identify underlying polyposis syndromes.

A Resident-Led Group Approach for Collecting and Delivering Faculty Feedback: Targeting Evaluation Quality and Completion Rates

Jamie L. Geringer, Matthew Soderstrom, James K. Aden, Patrick G. O'Malley, Brian Neubauer

Researchers' Journal of Internal Medicine.

Background: Effective faculty teaching relies on receiving authentic and actionable feedback from learners. Numerous challenges in collecting feedback result in nonspecific assessments that limit their utility, as evidenced by our institution’s 2021-2022 faculty evaluations. Objective: To address this, our program implemented resident-led group feedback sessions. Methods: Residents provided group feedback to faculty through three Plan-Do-Study-Act (PDSA) cycles. PDSA cycle 1: Ten PGY-3 Medicine residents were trained to facilitate and transcribe group feedback for 20 ambulatory faculty. Ten cohorts of nine PGY1-3 residents met triannually to provide faculty feedback in a group setting without faculty present. PDSA cycle 2: The quality of faculty feedback from residents was evaluated using a modified narrative evaluation quality instrument (scale 0-10, higher is better). A subsequent round of resident-led feedback sessions occurred to collect longitudinal feedback on faculty, incorporating feedback from cycle 1. PDSA cycle 3: Replicated the procedures of previous cycles. Results: The primary outcome was feedback quality (using scales that quantified competencies addressed, specificity, and usefulness). The quality of feedback from residents to faculty significantly improved over three PDSA cycles. Total narrative quality scores increased from 4.9 to 8.1, with notable improvements in each subcomponent (higher is better): competencies addressed (0-4; 1.7 vs 3.3), specificity (0-3; 1.3 vs 2.2), and usefulness (0-3; 1.8 vs 2.7) (all p values < 0.001 pre- vs. post-intervention). The percentage of faculty evaluations completed by residents increased from 53% pre-intervention to 100% (N=127/240 vs. N=60/60). Discussion: Comprehensive facilitator training, dedicated time for feedback sessions, and feedback on the feedback process were implemented and perceived as key to overcoming these challenges. This approach ensured 100% of faculty received feedback throughout the year, covering multiple competencies with more specific and useful feedback. Conclusion: This innovation demonstrated that resident-led feedback sessions are feasible, valuable, and can be implemented without dedicated funding or additional resources.

A Rare Presentation of Porphyria Cutanea Tarda in a Patient With Treated Hepatitis C: A Case Report and Review of Management Constraints

Shamas Rafique, Iqra Rafiq

Researchers' Journal of Internal Medicine.

Introduction: Porphyria cutanea tarda (PCT) is the most common disorder of porphyrin metabolism, resulting from a deficiency of uroporphyrinogen decarboxylase (UROD). It manifests with blistering cutaneous lesions on sun-exposed skin and is strongly associated with hepatitis C virus (HCV) infection. Case Presentation: A 70-year-old Asian male with a history of successfully treated Hepatitis C presented with a several-month history of severe pruritus, skin fragility, blistering, and hyperpigmentation on sun-exposed areas. Diagnosis was supported by urinary porphyrin fractionation showing a classic pattern alongside elevated porphobilinogen (10.6 mg/24h) and delta-aminolevulinic acid (17.8 mg/24h) in the context of unequivocal clinical findings. Treatment and Outcome: The patient was initiated on low-dose hydroxychloroquine (125 mg orally twice weekly). At six-week and three-month follow-ups, he reported a marked reduction in pruritus, complete cessation of new blister formation, and significant improvement in skin integrity. Conclusion: This case underscores that PCT can manifest years after successful HCV treatment and highlights a pragmatic, cost-conscious diagnostic approach. Low-dose hydroxychloroquine proved to be a safe and highly effective therapy, leading to rapid and sustained clinical improvement.

Development and Validation of the New Helping Attitude Scale to Assess Propensity for Serving Others

Stephen Trzeciak, Anthony J. Mazzarelli, Michael B. Roberts, Brian W. Roberts

Researchers' Journal of Internal Medicine.

Objective: Employers in service industries (e.g., healthcare) seek employees whose values align with serving others. To facilitate evaluation of these values, our objective was to develop and provide validity evidence for a simple tool for assessing people’s propensity to serve others and how serving others makes them feel. Methods: We developed a 12-item tool, the New Helping Attitude Scale, and performed psychometric validity testing in two independent representative samples of the general adult U.S. population using a web-based platform. Results: In a sample of 975 adults studied in three phases, we found that the 12 items of the New Helping Attitude Scale load on a single factor with all factor loadings >0.6 and good fit indices (Comparative Fit Index = 0.95; Tucker-Lewis Index = 0.94; Standardized Root Mean Squared Residual = 0.04). Internal consistency was excellent (Cronbach’s alpha = 0.92). In this report, we present normative data to aid in the interpretation of results. Conclusion: The 12-item New Helping Attitude Scale is a simple, psychometrically sound, and reliable tool to assess people’s values related to serving others. Future research to determine its value in predicting job performance among employees in service industries such as healthcare is warranted.

Prospective Evaluation of the Systemic Coagulation–Inflammation Index as a Short-Term Prognostic Marker in Infective Endocarditis

Sahasyaa Adalarasan, Nithishkumar Ravichandran, Kapil R. Alex, Ritvik Arunaash, Preetha Selvan

Researchers' Journal of Internal Medicine.

Background: Infective endocarditis (IE) remains associated with high morbidity and mortality despite advances in diagnosis and therapy. Biomarkers that integrate inflammatory and coagulation pathways may assist in risk stratification. The Systemic Coagulation–Inflammation Index (SCII), calculated as (platelet count × fibrinogen / leukocyte count), reflects the interaction between systemic inflammation and coagulation activity. This study evaluated the utility of SCII as a short-term prognostic marker in patients with IE. Methods: In this prospective observational study, 26 consecutive adults diagnosed with IE at a tertiary care center in India were enrolled over a six-month period. SCII values were calculated from admission blood samples obtained prior to treatment initiation. Patients were followed throughout hospitalization, and mortality outcomes were recorded. Results: The mean age of the cohort was 50.08 years, and 53.85% were male. Overall mortality during follow-up was 50% (13/26). Mean SCII was significantly higher in non-survivors than in survivors (176.2 ± 26.1 vs. 89.4 ± 20.7; p < 0.001). A strong association was observed between SCII and mortality (r = 0.77, p < 0.001). Conclusion: Elevated SCII at admission was significantly associated with short-term mortality in patients with IE. These findings suggest that SCII may serve as a useful adjunct for early risk stratification in IE. Larger studies with multivariate analyses are warranted to determine its independent predictive value and clinical applicability.

Analysis of Utilization of Sodium-Glucose Cotransporter 2 Inhibitors in Patients with Diabetes and Chronic Kidney Disease within a Primary Care Setting

Sydney L. Robbins, Jodi M. Grandominico, Neeraj H. Tayal, Lauren A. Kirk, Cory P. Coffey

Researchers' Journal of Internal Medicine.

Background The 2022 KDIGO guidelines now recommend the initiation of sodium glucose-cotransporter 2 inhibitors (SGLT2i) in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) with an eGFR > 20 mL/min/1.73m2 to slow the progression of kidney dysfunction. Despite updated standard of care recommendations, the uptake of SGLT2is in eligible patients is suboptimal.   Objective This research aimed to observe the prescribing patterns of SGLT2is by primary care resident physicians in eligible patients with T2D and CKD G3a/3b.   Methods This study utilized a data analytics platform to identify adults with CKD G3a/G3b and T2D at two primary care clinics, comprised of more than 100 resident physicians between July 1st, 2023, and October 31st, 2023. The primary objective of this study was to identify the proportion of patients currently prescribed an SGLT2i. Secondary objectives included identifying the proportion of patients: (1) never prescribed an SGLT2i, (2) previously prescribed an SGLT2i but not currently on therapy, and (3) not currently on SGLT2i therapy but may qualify for initiation based on current clinical practice guidelines   Results A total of 240 patients were identified with CKD G3a/G3b and T2D. 111/240 (46.2%) were removed from the primary care resident cohort due to eGFR values falling outside the CKD G3a/G3b criteria at the time of review. 12/240 (5%) were not observed as they have not seen their primary care resident physician in more than 12 months. 46/240 (19.2%) were observed in the specialist cohort as they were managed by endocrinology or nephrology.  This left 71/240 (29.6%) patients observed in the primary care resident physician cohort for SGT2i use. Among these, 27/71 (38%) were currently prescribed an SGLT2i, while 44/71 (62%) were identified as potential candidates for therapy initiation.   Conclusion This analysis describes the underutilization of SGLT2is in eligible patients, despite updated standard of care recommendations and evidence to support its benefit.

Outcomes in COVID-19 ARDS: A Cohort Study Comparing Patients Transferred to an ECMO Center and Patients at a Community Hospital

Sonja Knittel-Hliddal, Adam Green, Abhimanyu Chandel, Awab Khan, Hena Yagnik, Reena Patel, Joshua Levy, Derek Chen, Nishi Parikh, Sydnee Lim, Gregory Felock, Jean-Sebastien Rachoin, Michael Bonk

Researchers' Journal of Internal Medicine.

Introduction The transfer of patients with severe acute respiratory distress syndrome (ARDS) to extracorporeal membrane oxygenation (ECMO) capable centers is a prevalent practice, despite a paucity of data regarding the outcome of transferred patients and those remaining in a community setting with standardized care. Our aim was to compare outcomes in these two patient populations. Methods Adult patients admitted to a community health system with SARS-CoV-2 infection requiring invasive mechanical ventilation (IMV) from February 2020 to July 2022 were identified. We performed univariate and multivariable logistic regression (adjusting for demographics and severity of illness). Categorical data are presented as percentages, and continuous data as median [25-75% Interquartile range]. Results 397 patients were identified with COVID-19 requiring IMV, and 29 were transferred to the ECMO center. Non-transferred patients were older, 64 [56-73] vs. 48 [40-55] (p < 0.001), with a higher proportion of comorbid conditions. Both groups had similar initial P/F ratios, trending towards a lower P/F in the transferred group at 24 hours after IMV: 121 [88-167] vs. 105 [75-132] (p = 0.083). The organ-specific (renal, liver, coagulation) SOFA score was lower in transferred patients, 0 [0-1] vs. 1 [0-2] (p = 0.007). Two hundred eighty-two patients (71.2%) in the community health system died. Among those transferred, 21 (72.4%) were not supported with ECMO, and 9 (42.9%) died. Of the 8 patients supported with ECMO, 3 (37.5%) died. Transfer to a tertiary care center was associated with a reduced risk of death (OR 0.25; 95% CI 0.11-0.55, p = 0.001), which persisted when adjusted for age, P/F ratio, & organ-specific SOFA scores (OR 0.34; 95% CI 0.15-0.80, p = 0.013). Conclusions Patients with severe ARDS have a reduction in mortality when transferred to an ECMO-capable center despite providing similar care in both settings. An emphasis on appropriate patient selection is important, specifically focusing on ECMO-eligible patients. More research is needed to identify the variables impacting mortality in these patient populations.

Trends in Medical Student-Authored Publications, 2012-2022

Brian P. Elliott, Zachary Gottschall, Evan Suppa, J Bryan Carmody

Researchers' Journal of Internal Medicine.

Purpose To analyze trends in the quantity and quality of medical student-authored publications from 2012 to 2022. Methods We searched PubMed to identify all articles with an author affiliation listed as “medical student” from 2012 to 2022. We manually reviewed articles to determine study design and cross-referenced articles with Semantic Scholar and Scimagojr databases to determine citation count and journal rank data. As a secondary exploratory analysis, we then reviewed the websites for the 100 journals with the most medical student publications during the study period to determine whether they had mandatory fees associated with publishing. Results We identified 5,591 articles with medical student authors, of which 5,181 met the inclusion criteria. The number of articles increased by 1,329% from 2012 to 2022. The median Scimago Scientific Journal Ranking of medical student publications increased from 2012 to 2022 (0.470 to 0.630, p=0.0002). The proportion of articles published in a top quartile journal was 29% in 2012 and 41% in 2022 (p=0.09). Twenty-three percent of medical student-authored articles received zero citations. There was a relative increase in medical student-authored perspective articles (from 6% in 2012 to 23% in 2022; p=0.002) and a decrease in case reports (from 26% in 2012 to 14% in 2022; p=0.02). The proportion of papers published in journals with publication fees increased from 3.7% in 2012 to 14.8% in 2022 (p=0.02). Conclusions Between 2012 and 2022, the quantity of medical student research on PubMed increased more than tenfold. There was a relative increase in perspective papers and a decrease in case reports. Approximately one in four medical student papers were never cited, and approximately one in six were published in a journal with a publication fee.

The Researchers’ Journal of Internal Medicine: A New Way to Publish Research

Brian P. Elliott, Kathryn Burtson, Michael McMahon, Abhimanyu Chandel

Researchers' Journal of Internal Medicine.