Scholar Commons @ Tower Health

Shivangi, FNU

Gondal, Muhammad Umer Riaz

Paudel, Rubina

Jaleel, Syed

Introduction: Isolated vestibular syndrome from dorsal medullary infarcts typically presents 
with dizziness/vertigo, tinnitus, and ocular motor abnormalities. The dorsal medulla contains 
structures responsible for transmitting vestibular and ocular signals. It is imperative to 
distinguish isolated dorsal medullary infarcts from peripheral vestibulopathy to avoid devastating 
consequences, as the diagnosis can be challenging. We describe a case of a patient with vascular 
risk factors presenting with refractory vomiting before being diagnosed with an acute dorsal 
medullary stroke.  
 
Case description: 
A 41-year-old male with a past medical history of hypertension and uncontrolled diabetes 
presented to the emergency department with a severe occipital headache and persistent nausea 
and vomiting lasting for one day. He had at least a dozen episodes of vomiting. The headache 
improved, but the vomiting persisted. In the emergency, the patient was hypertensive with a 
blood pressure of 170/100 mm Hg. Due to significant vomiting, a complete neurological 
examination was deferred. A stat CT scan brain did not show hemorrhage, mass, or acute infarct. 
Blood work revealed unremarkable cell counts, serum lipase, and liver function tests. 
Hemoglobin A1c was elevated at 10.9 %. Murphy’s sign was negative. Initially, his presentation 
was thought to be due to viral gastroenteritis. CT scan abdomen and pelvis were negative for any 
acute intra-abdominal pathology. The urine drug screen was clear. Intravenous ondansetron and 
prochlorperazine were ordered for nausea, and meclizine for mild dizziness. The vomiting 
resolved, but the next day, he started having severe dizziness and vertigo. Detailed examination 
revealed right eye horizontal diplopia, decreased right-sided facial sensation, rightward swaying 
on Romberg test, but negative HINTS exam, intact hearing, intact finger nose testing, and 
bilateral heel-to-shin testing with no dysmetria, concerning for a right-sided stroke. MRI Brain 
was ordered that showed restricted diffusion along the right dorsal medulla suggestive of an 
acute/subacute right dorsal medullary infarct. CTA brain showed normal right posterior inferior 
cerebellar artery with no acute stenosis or large vessel occlusion. Transthoracic echocardiogram 
showed normal ejection fraction and valvular function. He was started on a high-intensity statin 
and aspirin and counseled on aggressive risk factor modification. His neurological deficits 
improved over the next few days, and he was discharged to rehab. 
 
Discussion:  
Bedside neurological evaluation is crucial for early recognition of isolated acute vestibular 
syndromes as patients can progress to cranial or sensorimotor impairments. The diagnosis is 
challenging as very few patients with vertigo and dizziness have additional focal neurologic 
abnormalities. Physicians must be aware of the atypical presentation of these syndromes. 
 


English

Refractory vomiting as the initial presentation of a dorsal medullary infarct

Segal, Jared

Lemoine, John

Kiyani, Zainab

Jyothi Ramachandran Nair, Devi Parvathy

McCauley, Brian

Title: Cardiotoxicity Induced by Capecitabine and Oxaliplatin in Gastric Cancer 
Treatment: A Rare Case of Cardiac Arrest and Cardiogenic Shock. 
  
Introduction: Combination-based adjuvant chemotherapy utilizing Capecitabine and Oxaliplatin 
has become a standard approach in gastric cancer treatment. Rare but severe cardiac events such 
as prolonged QT, cardiac arrest, and cardiogenic shock can result from their use.  
  
Case report: A 45-year-old female with stage II B gastric adenocarcinoma was started on 
capecitabine-oxaliplatin chemotherapy one week before presenting to the emergency department 
with weakness. Her vitals were blood pressure 78/56 mm Hg, heart rate 140 bpm, and oxygen 
saturation 85%. Within minutes of the presentation, she became unresponsive with pulseless 
ventricular fibrillation. CPR was initiated for cardiac arrest, and she required immediate 
intubation. She received two shocks, epinephrine, and amiodarone administration with return of 
spontaneous circulation. Labs revealed serum potassium of 3.1 mmol/L, magnesium of 1.1 
mg/dl, troponin 0.46 ng/ml, creatinine 1.74 mg/ml, AST/ALT 2990/1567 IU/L and lactic acid 12 
meq/L. An EKG revealed sinus tachycardia with a prolonged QT interval of 556 ms. The 
combined effects of capecitabine, oxaliplatin, and severe electrolyte abnormalities likely 
contributed to the QT prolongation. An echocardiogram demonstrated an ejection fraction of 10-
15% with extensive wall motion abnormalities. An emergent right heart catheterization showed 
right atrial pressure of 10 mm Hg and pulmonary artery pressure of 30/18 mm Hg however, 
cardiac output and index were not recorded. An intra-aortic balloon pump (IABP) was placed. 
She was admitted to the ICU for treatment of cardiogenic shock requiring norepinephrine, 
vasopressin, and dobutamine, which were gradually weaned off with the removal of the IABP. A 
repeat echocardiogram one week later showed a significantly improved ejection fraction of 65%, 
and she was discharged home.  
  
Discussion:   
Capecitabine and Oxaliplatin cardiotoxicity is an exceedingly rare occurrence. Although 
infrequent, both drugs have been reported to cause QT prolongation. Healthcare providers must 
recognize the potential QT interval prolongation effects of Capecitabine and Oxaliplatin, leading 
to potentially life-threatening cardiac arrhythmias.  
  
 


Cardiotoxicity Induced by Capecitabine and Oxaliplatin in Gastric Cancer Treatment: A Rare Case of Cardiac Arrest and Cardiogenic Shock.

Liao, Andy

Perez, Alanis D.

Cushwa, Ann

Vader, Daniel T.

Wilson, Jordan S.

Vega, Hope

Schmitz, Kristine H.

Spengler, Emily A

Title  
Behavioral Health Preferences Among Foster and Biological Families in a Primary Care Clinic for Families 
With Social Complexity 
Authors 
Liao, Andy. Perez, Alanis D. Cushwa, Ann. Vader, Daniel T. Wilson, Jordan S. Vega, Hope. Schmitz, 
Kristine H. Spengler, Emily A. 
Introduction: Children with a history of welfare involvement are more likely to have behavioral health 
needs. Foster parents desire behavioral health support and there is concern about overusing 
psychotropic medications for children in foster care. Less is known about what behavior support is 
desired by families in primary care. This article studies 1) behavioral health preferences of families in a 
primary care clinic specializing in children facing social complexity, and 2) whether preferences vary by 
guardian type. Methods: We investigated family preferences for behavioral health support in a primary 
care clinic for social complexity via surveys and focus groups. Participants were recruited based on 
convenience sampling and outreach to a random sample of patients. Focus groups and surveys were 
anonymous and guardians were compensated with gift cards. We tested differences in preferences by 
guardian type using Pearson’s Chi-squared test. Thematic analysis was applied to the qualitative data to 
identify themes from guardians’ responses. Results: Of 101 families surveyed, 63 were biological parents 
and 34 were foster parents (21 kinship; 13 non-relative). Six focus groups of foster, biological, and 
Spanish-speaking parents were completed to further explore preferences (24 parents: 12 biological and 
12 foster). All guardian types were interested in support for behavioral health needs. Foster parents had 
no greater interest in psychotropic medications than biological parents. Biological parents had desire for 
direct parenting support (76% vs 44%, p <0.01) (Table 1). Kinship foster parents had greater interest in 
behavioral health support (67% vs 23%, p = 0.01) and direct parenting support (57% vs 17%, p = 0.02) 
than non-relative foster parents (Table 1). Focus groups revealed 1) the importance of trust and 
relationships between patients and clinicians when addressing behavioral health, and 2) appreciation for 
when care teams addressed guardians’ stress and needs. Conclusion: These findings suggest that 
families, particularly biological and kinship parents, want behavioral health support in the primary care 
clinic, including direct parenting support. All desire a trusting relationship with clinicians who 
acknowledge family stress as part of behavioral health treatment. Inclusion of primary care-based 
behavioral support may help promote optimal wellbeing among children with social complexity. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 1. Behavioral Health Preferences by Guardian Type and Foster Parent Type 
 
 


Behavioral Health Preferences Among Foster and Biological Families in a Primary Care Clinic for Families With Social Complexity

Li, Vivian

Greenberg, Karen

Ross, Jennifer

Binning, Mandy

Emergent IV Dye Prep in Stroke Alert Patients

Parson, Jory P

Fitzgerald, Patrick

Grossweiler, Jack

Charlton, Alex

Fletcher, Daniel

Nick Pohl, Nick

Brush, Parker

Postoperative Trigger Finger Complications and Subsequent Treatments: An In-Depth 
Analysis 
Parson, Jory; Fitzgerald, Patrick; Charlton, Alex; Fletcher, Daniel; Grossweiler, Jack; Pohl, 
Nick; Brush, Parker 
Abstract: 
Introduction: Complications following trigger finger release (TFR) are well-documented, but 
there is limited understanding of the incidence of subsequent adjacent, contralateral or the same 
digit triggering requiring treatment. 
 
Methods: In this retrospective review conducted at a single tertiary care center between July 
2015 and December 2017, all patients who underwent operative treatment for trigger finger 
release were examined. The electronic medical records were scrutinized for prior TFR and 
subsequent TFR within the following 5 years. Univariate statistical analysis was conducted to 
determine the proportion of patients requiring further treatment, either through steroid injections 
or operative A1 pulley release. Bivariate analysis compared the frequency of subsequent 
treatment between patients with and without prior carpal tunnel release (CTR) in either wrist. 
 
Results: Among 1128 patients who underwent primary TFR, 220 had undergone prior or same-
day CTR. Right-hand releases were more common (58.4%), and a significant portion of patients 
had previously received a steroid injection before surgical release (58.9%). After the initial 
release, 341 patients (30.2%) received at least one subsequent steroid injection, with 28 (2.5%) 
of these involving the same finger. In addition, 227 patients (20.1%) underwent at least one 
subsequent A1 pulley release, with only 1 case (0.09%) involving the same finger as the initial 
release. A notable 12.6% of patients required three or more additional procedures, while one 
patient underwent 11 subsequent procedures. Postoperative wound complications, such as 
infection or dehiscence, occurred in 1.6% of patients after their primary release. Patients with a 
prior or concurrent CTR exhibited similar rates of subsequent injections (31.4% vs. 30.0%) and 
subsequent A1 pulley releases (22.3% vs. 19.6%). 
 
Discussion and Conclusion: Although TFR is relatively straightforward, a substantial number of 
patients require additional treatment in different digits and should be counseled accordingly. 
Notably, prior CTR does not seem to influence the likelihood of subsequent triggering. 
 
Keywords: Trigger finger release (TFR), Subsequent treatment, Digital triggering, Carpal tunnel 
release (CTR), Complications 
 
 


Postoperative Trigger Finger Complications and Subsequent Treatments: An In-Depth Analysis

Cho, Peter D

Viswanathan, Amba

Strand, Kathryn S

Friday, Chet

Hast, Michael, PhD

Dasika, Uday, MD

Sternal Single-Wire Closure: Biomechanical Analysis of Modified Sternal Closure Technique

Coe, Brielle

THE EFFECT OF THE GLUCOCORTICOID RECEPTOR MODULATOR,SAFIT, ON ACUTE 
STRESS REACTIVITY IN A RAT MODEL OF ABUSIVE HEAD TRUAMA

COE BRIELLE,BRISCOE TIFFANY,MARTIN CYDNEY, RAGHUPATHI RAMESH
Introduction:Traumatic brain injuries (TBI), particularly as a result of child abuse, are pervasive 
amongst infants and children and lead to psychosocial and cognitive deficits that persist 
throughout life. Importantly, as brain-injured infants and toddlers age into adolescence where 
they face stressful situations, they may not be able to adapt in an appropriate manner. Previous 
studies in Dr. Raghupathi’s lab have demonstrated that maternally separated neonatal rodents 
subjected to repeated mild TBIs (rmTBI) at post-natal day 11-13 exhibited increased stress-
related behaviors when tested in the elevated plus maze (EPM) than non-maternally separated 
animals subjected to rmTBIs. Separately, it has also been demonstrated that a dysfunction of 
the glucocorticoid receptor (GR) within the hippocampus may underlie this aberrant response 
to acute stress. Enhanced activity of FKBP5(a GR co-chaperone protein) has been associated 
with increased corticosterone effects and blunted negative feedback of the HPA axis. Thus, 
regulating the HPA axis by inhibiting the GR through inhibition of FKBP5, is thought to relieve 
some of the behavioral impairments associated with TBIs. One such modulator of the the GR 
receptor is SaFit, an inhibitor of FKBP5. Methods: In the present study, neonatal rats 
underwent maternal separation for 4 weeks and received a rmTBI on post-natal day 11-13. On 
post-natal day 41, rats were treated with SaFit 4 hours prior to testing in the EPM. Results: 
Elevated plus maze is a behavioral paradigm that has been shown to be a measure of anxiety 
in rodents. An increase in open arm activity reflects anti-anxiety behavior. We found 
confirmatory evidence that neonatal rats sustaining rmTBIs were spending prolonged time in 
the open arm with a reduction in closed arm time for both the Injured-Vehicle and Injured-SaFit 
cohorts compared to Sham groups. Administration of SaFit in post-rmTBI rats did not show 
significantly different behavioral patterns compared to post-rmTBI rats who received only 
vehicle although it did show a trend in behavior between SaFit injured vs. uninjured. Statistical 
significance data was revealed between the Sham-SaFit and Injured-Vehicle group, 
demonstrating that SaFit was significantly beneficial in un-injured rats when ran through the 
elevated plus maze. 



THE EFFECT OF THE GLUCOCORTICOID RECEPTOR MODULATOR, SAFIT, ON ACUTE STRESS REACTIVITY IN A RAT MODEL OF ABUSIVE HEAD TRAUMA

Evanson, Davin

Asghar, Arveen

York, Eugene

Weingarten, Michael S

Bohnenblust, Walter

Evanson Davin, Asghar Arveen, York Eugene, Weingarten Michael, Bohnenblust Walter 
 
Title: The Financial Impact of Correct Status Within Health Systems 
 
Introduction: For financial purposes, a healthcare setting began a quality improvement 
project aimed at optimizing the determination of patient status (Observation vs. Inpatient). 
The Centers for Medicare and Medicaid Services (CMS), through the "2 midnight rule," offers 
guidelines to distinguish observation and inpatient statuses. Nonetheless, achieving 
consistent and appropriate status determination is intricate, demanding comprehensive 
comprehension of clinical factors, medical necessity, and financial considerations.  
Methods: Data extracted from the financial records of patients was utilized, focusing on 
observation status cases that stayed in the hospital for at least two midnights. The primary 
objective was to reduce the rate of prolonged observation stays, defined as cases exceeding 
two midnights, from a baseline of 34.6% to below 10% within a one-year timeframe. The 
project involved educating utilization management nurses and attending physicians on the 
distinction between observation and inpatient care. Each month, re-evaluation and re-
education would occur as necessary to ensure there was a decrease in total unrealized 
cases. To evaluate success of the intervention total realized and total unrealized opportunity 
were compared to provide a percent realized.  
Results: The results showed a substantial decrease in the rate of prolonged observation 
stays to 7.3% by November 2022, leading to an increase in inpatient admissions and higher 
financial reimbursement. The average monthly realized cases were 41 (range: 21-67), 
amounting to a realized financial opportunity of $251,857 per month (range: $128,482 - 
$409,919). The Period to Date reports $3,407,823. Unrealized cases averaged 17 (range: 11-
29), with an unrealized financial opportunity of $106,045 per month (range: $67,300 - 
$177,428). The Period to Date reports $1,823,224.  
Conclusion: The project findings underscore the financial significance of accurate patient 
status determination, with potential positive impacts on healthcare institutions' revenue and 
indirectly on patient care quality. Major limitations include the single-center focus, and the 
short-term nature of the project. Future research should expand to multi-center studies, 
emphasize long-term monitoring, conduct cost-benefit analyses, and promote a culture of 
continuous quality improvement to enhance the effectiveness of educational interventions 
and maintain the balance between financial optimization and high-quality patient care. 
 
 


The Financial Impact of Correct Status Within Health Systems

Lozano, Priscilla

Qutob, Maya, DO

Espiridion, Eduardo

A Case of “Neptune’s Fix Elixir” - The dangerous consequences of unregulated use of
Tianeptine in over-the-counter products
Priscilla Lozano; Maya Qutob, DO
Drexel University College of Medicine; Department fo Psychiatry Tower Health
Abstract
Tianeptine is an atypical tricyclic antidepressant approved for treatment of major depressive
disorder in some European, Asian, and Latin countries, however is not approved for use in the
US. Along with its serotonergic properties, tianeptine also acts as a full agonist at the mu-opioid
receptor, creating sensations of euphoric highs and significant risks of addiction and withdrawal.
For this reason, along with increased reports of adverse effects and fatalities, Tianeptine has not
been approved in the US. Despite this, tianeptine continues to be accessible through
unregulated online stores and small retailers under street names including “zaza”, “tia”, “tianna”,
and ‘gas-station dope”. In this report, we discuss a case of a 34 y.o. male who presented to the
ED via EMS after being found unresponsive secondary to the ingestion of “Neptune’s fix Elixir”,
the main ingredient of which is Tianeptine.
Key terms:
“Neptune’s fix elixir”, “tianeptine”, “tianeptine abuse”, “zaza drug”, “gas-station heroin”,


A Case of “Neptune’s Fix Elixir” - The dangerous consequences of unregulated use of Tianeptine in over-the-counter products

Mowery, John

Russell, Taylor

Sigal, Adam

Cassella, Courtney

 
Thrombus in Transit with Diagnosis and Treatment Guided by Bedside Ultrasound — A Case 
Report 
Introduction: 
Pulmonary embolism (PE) is always on the differential diagnosis when a patient presents with 
chest pain or dyspnea. This case report describes a clinical scenario in which bedside ultrasound 
(US) was instrumental in rapidly establishing the diagnosis of PE and guiding treatment in a 
situation where the gold-standard diagnostic imaging was relatively contraindicated. 
Case Description: 
A 77-year-old female with a past medical history of hypertension presented to the emergency 
department with weakness, dizziness, and shortness of breath for 5 days. She reported multiple 
recent syncopal episodes and left lower extremity swelling. Her initial evaluation revealed the 
following vital signs: HR 119, BP 73/64, RR 39, T 37.7 SpO2 81%. She was ill-appearing, 
tachycardic, with decreased breath sounds bilaterally. Bedside US was performed on this patient. 
The examining physician noted right ventricular dilation with bowing of the interventricular 
septum into the left ventricle, in addition to a thrombus in transit through the right side of the 
heart (Figure 1). US of the left lower extremity demonstrated a deep vein thrombosis.   
  
The patient was started on high-flow nasal cannula and intravenous fluids with improvement in 
her oxygenation and hypotension. Her laboratory values revealed a creatinine of 4.4. The bedside 
US findings were discussed with a pulmonary intensivist and an interventional radiologist, and a 
joint decision was made to forego a CT angiogram of the chest in the setting of acute renal 
failure and commence thrombolysis with tPA, which was then followed by anticoagulation with 
heparin. The patient was transferred to the intensive care unit. She was discharged on apixaban 
to acute rehab on hospital day 8 and followed up outpatient with hematology. 
   
Discussion:   
  
Bedside US is a powerful tool to aid the trained emergency physician in rapidly diagnosing PE. 
This case illustrates a situation in which bedside ultrasonographic and clinical findings consistent 
with a hemodynamically unstable PE were discussed with consulting physicians to help guide 
definitive treatment and prevent a potentially nephrotoxic CT angiogram in a patient with 
concomitant acute renal failure. 


Thrombus in Transit with Diagnosis and Treatment Guided by Bedside Ultrasound — A Case Report

Phoenixville Hospital

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