In symptomatic patients, 80% will develop worsening dyspnea, 15% will develop severe illness, & 5% will develop critical illness. Common risk factors include age >55 years, pre-existing conditions (including, but not limited to diabetes mellitus, cardiovascular disease, hypertension, immuno-suppression, ESRD, chronic liver disease, & obesity).

Oxygenation: Patients should be oxygenated with a goal oxygen saturation of 90 to96%. The mode of oxygenation should be determined by a stepwise fashion going from room air to nasal cannula or Venturi mask. High flow nasal

cannula may be used to help prevent intubation. Noninvasive positive pressure ventilation (NIPPV) such as bilevel positive airway pressure (BPAP) support is primarily

used for patients with respiratory insufficiency due to COPD, cardiogenic pulmonary edema & obstructive sleep apnea but has proven beneficial in COVID-19- induced ARDS as well, to halt intubation.

Proning continues to remain an effective way of improving oxygenation in patients with severe ARDS.

Update continued page 6

The medical society around the world is racing against the clock to produce an effective vaccine to tackle the ongoing COVID-19 pandemic. Manufacturing vaccines is no easy task. Tremendous amounts of research & testing is required before a vaccine is produced in bulk, which can span years. Scien-tists around the world have produced different vaccines that are being tested in clinical trials. Currently no vaccine has been approved by the U.S. Food & Drug administration. Moderna, Inc., a Massachusetts-based biotechnology company currently has an mRNA vaccine in its phase 3 trial that began last July. Results of this trial are still pending. However, the U.S. government did award the company $1.5 billion

PatronsNancy Hollingsworth, CEO

W. Eugene Egerton, MD, CMOMehdi Hakimipour, MD, DIO

Faculty AdvisorsHemant Dhingra, MD

Program DirectorJasleen Kaur, MDAmritpal Nat, MD

Bisharah Rizvi, MD

Editor-in-chiefSarbjot Grewal, MD

Co-editorsManpreet Singh, MDHannah Knox, MD

Mark Henry R. Cedeño, MD

Case of the MonthShankar Nair, MD

Vaccine! Vaccine!•

COVID-19 Treatment Update

•Case of the Month

•Meet Our Residents

•Scholarly Activities

dollar contract to mass produce the vaccine if proven safe & effective.

AstraZeneca, a British pharmaceutical & biotechnology company affiliat-ed with Oxford University is currently in a phase 3 trial with a vaccine based on a chimpanzee adenovirus called ChAdOx1. Study on monkeys proved immunity towards COVID-19.

Vaccine! continued page 6

Summer 2021 • Saint Agnes Scholarly Activity Articles submitted December 2020

SAIN

TAGNES MEDICAL CENTER

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RADUATE MEDICAL EDUCATIO

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Internal MedicineResidency News

Vaccine! Vaccine!Come get your vaccine!

A COVID-19 Treatment Update

Contributors

In this issue

CaseA 51-year-old male with a past medical history of IBS, GERD, asthma, and hypertension presented to the emergency room with abdominal pain for 1 week. Pain was deep, dull, and located in the upper abdomen with radiation to the back. Pain was relieved with pressure applied to the abdomen. He had recently stopped his antihyperten-sive medication. He denied a history of tobacco or illicit drug use. He presented with a blood pressure of 160/109 Labs were grossly unremarkable, except for an elevated CRP. CT abdomen with contrast showed an apparent dissection flap in the celiac artery near its proximal branch. IR & vascular surgery were consulted, who recommended medical management due to mild nature of presenting symptoms, no evidence of end-organ ischemia, & dissection being non-flow limiting on CT. He was started on dual antiplatelet therapy (aspirin, clopidogrel) and analgesia for abdominal pain. He was also restarted on anti-hypertensive medication. Follow up CT was recommended in 1 month to monitor for pro-gression of the dissection.

DiscussionSpontaneous isolated celiac artery dissection (SCID) is an extremely rare condition. As advancements in imaging modalities progress,the incidence of SCID will likely rise. Currently, the incidence of SCID is unknown, making each

case important to highlight. Some causes of SCID are thought to be due to athero-sclerotic disease, connective tissue disorders, fibro-muscular dysplasia, abdominal surgery, trauma, vasculitis, infectious disease, congenital disorders of the vascular wall, & pregnancy. Risk factors

include male sex, 40-60 years of age, hyperten-sion, & smoking. Most patients with SCID are often asymptomatic or present with abdominal pain. SCID may be found incidentally on imaging. Complications may include splenic infarction, intraperitoneal hemorrhage & intestinal ischemia as the artery itself provides significant blood supply to the liver, spleen, & stomach. Treatment & management primarily relies on medical management, which often leads to resolution of symptoms in most cases. Endovascular & surgical intervention should only be sought after in individuals with severe flow impairment. SICD should be kept in the differential for patients presenting with abdominal pain since it can have grave outcomes if missed.

– Shankar Nair, MD, Bisharah Rizvi, MD

Case of the Month

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Jasmeet Dhaliwal, MD Hometown: Modesto, CA Medical School: Government Medical College Hobbies: my puppy, Kona

Keerat Dhatt, MD (Chief Resident) Hometown: Stockton, CA Medical School: St. George’s University Hobbies: losing valuable items in foreign countries, designer bag birthday cakes, reading

Parisa Rezapoor, MD Medical School: Rafsanjan University of Medical Science & Health Services Hobbies: “A friend failed his medical exam when he x-rayed his lower torso. He didn’t put his heart into it.”

Hannah Knox, MD Hometown: Sacramento, CA Medical School: American University of the Caribbean Hobbies: computer games, Japanese culture, anime, chainmail, long distance cycling

Mehrab Devani, MD Medical School: American University of Antigua College of Medicine Hobbies: “Did you head about the guy who had his whole left side was cut off? He’s all right now”

Neilinder Behniwhal, MD Hometown: Sacramento, CA Medical School: St. George’s University Hobbies: reading medical journal articles & doing MKSAP board review questions

Inderbir Baadh, MD Hometown: Bakersfield, CA Medical School: St. George’s University Hobbies: “I once heard a joke about amnesia, but I forgot how it goes.”

Alejandro Torres, MD (Chief Resident) Hometown: Seattle, WA Medical School: Universidad Autonoma de Guadalajara Hobbies: playing golf, film production

Not pictured:Gagandeep Rajpal, MD Medical School: University of California, Davis

Meet Our Residents

Class of 2021 First graduating class for Saint Agnes

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Meet Our Residents

Third-year Residents Class of 2022Manpreet Singh, MD (Chief Resident) Hometown: Reedley, CA Medical School: Ross School of Medicine Hobbies: traveling, basketball, music, techie

Shankar Nair, MD Hometown: Bakersfield, CA Medical School: Dr. Somervell Memorial CSI Medical College Hobbies: tennis, basketball, YouTube, guitars, cars

Mark Henry R. Cedeño, MD (Chief Resident) Hometown: Morgan Hill, CA Medical School: American University of the Caribbean Hobbies: Lakers, Bass Lake, getting by

Shelley Dhillon, MD Hometown: Lancaster, CA Medical School: University of Queensland-Ochsner Clinical School Hobbies: plant-based nutrition, spirituality, Sikhism

Adam Danielson, MD Hometown: Fresno, CA Medical School: Wayne State University School of Medicine Hobbies: everything ‘80s

Sarbjot “Jot” Grewal, MD Hometown: Fresno, CA Medical School: Dayanand Medical College Hobbies: cooking, kickboxing, Netflix & Chill

Nancy Dang, MD (Chief Resident) Hometown: Fountain Valley, CA Medical School: St. George’s University Hobbies: board games, baking, eating food that Kevin cooks

Benjamin Hambro, MD Hometown: Toledo, OH Medical School: University of Toledo College of Medicine Hobbies: reading, snowboarding, drag racing MP

Kevin Orita, MD Hometown: Laguna Hills, CA Medical School: St. George’s University Hobbies: camping, gaming

Namitha Malakkla, MD Hometown: Fresno, CA Medical School: American University of the Caribbean Hobbies: cooking, traveling, hiking, exploring new restaurants & coffee shops

Phison “Sonny” Pham, MD Hometown: Westminster, CA Medical School: Chicago Medical School Hobbies: board games, tennis, burger connoisseur

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Meet Our Residents

Second-yearResidents Class of 2023Nhia “Rocky” Yang, MD Medical School: St. George’s University Hobbies: competitive eating

Harjot Bath, MD Hometown: Bay Area, CA Medical School: Royal College of Surgeons in Ireland Hobbies: traveling, working out (pre-pandemic), yoga, new restaurants, baking, anything dog related, & skin care/makeup

Maryam Moradi, MD Hometown: Dallas, TX & Tehran Medical School: Texas Tech University Health Sciences Hobbies: sketching, & I’m a crazy cat lady!

Imrin Sidhu, MD Hometown: Fresno, CA Medical School: St. George’s University Hobbies: traveling, reading, baking

Anand Shivaprasad, DO Hometown: Fresno, CA Medical School: Kansas City University Hobbies: travel, hiking, LA Lakers, SF 49ers, served in the Peace Corps in Ukraine from 2010-2012

Harkirat “Harry” Singh, MD Hometown: Reedley, CA Medical School: American University of the Caribbean Hobbies: exercising, basketball

Brian Peng, MD Hometown: Orange County, CA Medical School: UC San Diego Hobbies: puzzles, board games, new tech, sleep

Thotsophon Taechariyukal, MD Hometown: Torrance/Redondo Beach, CA Medical School: Oregon Health & Science University Hobbies: singing, tennis, traveling, trying new street food, exploring new coffee shops, cooking, watching anime & Netflix, videogamesJuan Carlos “JC” De La Cruz Mayhua, MD Hometown: Cusco/Los Angeles, CA Medical School: Ross University Hobbies: hiking, traveling, soccer (especially the national team of Peru)

Akash Lohia, DO Hometown: San Jose, CA Medical School: Kansas City University Hobbies: football, Kansas City Chiefs!

Sydney Iriana, MD Hometown: Palmdale, CA Medical School: Chicago Medical School Hobbies: basketball, cycling, cooking

Jasdave Mann, MD Hometown: Madera, CA Medical School: American University of Antigua Hobbies: traveling

Paul Kohanteb, MD Hometown: Los Angeles, CA Medical School: Chicago Medical School Hobbies: applications of AI in medical imaging, Salsa dancing, Chicago Cubs, LA Lakers

Peter Chao, MD Medical School: Saint Louis University

Ariel Leung, MD Hometown: Phoenix, AZ Medical School: George Washington University Hobbies: volleyball, scuba diving, gourmet cooking, vintage thrifting

Harkanwal Kaur, MD Hometown: Fresno, CA Medical School: Christian Medical College, Ludhiana Hobbies: cooking, nutrition, shopping, listening to music

Rameet Sidhu, MD Hometown: Scottsdale, AZ Medical School: Royal College of Surgeons in Ireland Hobbies: traveling, playing basketball

Yudhveer Brar, MD Hometown: Fresno, CA Medical School: American University of Antigua Hobbies: weightlifting while listening to Sidhu Moosewala

Derrick Martin, MD Medical School: Trinity School of Medicine

Argenis Curiel, MD Hometown: Yuma, AZ Medical School: Universidad Autónoma de Guadalajara Hobbies: playing Super Smash Brothers, sleeping, hanging out with my BFFs, Rameet & Yudhveer

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Once intubated, given the similarities to previous therapeutic trials for ARDS, our recommendation is to continue lung protective ventilation using the ARDSnet protocol. This includes a tidal volume of 6 to 8 mL/kg of ideal body weight, sedation for ventilator synchrony with a consideration for paralytics if the patient has refractory hypoxemia.

Steroids: Steroids have shown significant mortality benefit in severe COVID-19 pneumonia; with a prelim-inary report from a large randomized open-label trial in the United Kingdom showing a reduced 28-day mortality among hospitalized patients. Confidence in the finding of mortality benefit is low for those with supplemental oxygen & high for those on mechanical ventilation. However, methylprednisolone studies done in Brazil of only 393 patients did not show a 28-day mortality benefit.

Anticoagulation (AC): Therapeutic AC is recommendedin patients with Severe COVID-19 pneumonia. While the pathophysiology behind the hypercoagulable state in COVID-19 is still under investigation, multiple mech-anisms have been proposed. Disseminated intravascular coagulation properties of the virus itself, antiphospholipidsyndrome, activation of the complement cascade, & endothelial dysfunction induced by the virus, all ultimately leading to microvessel thrombosis causing hypoxemia. We recommend initiating therapeutic AC in hypoxicpatients.

Remdisivir: Remdisivir is recommended for all patients hospitalized with COVID-19 pneumonia requiring supplemental oxygen. However, Remdisivir trial showed no mortality benefit in patients requiring HHF/NIV/invasive mechanical ventilation or ECMO. In nonsevere COVID-19, Remdisivir may only have a modest benefit; however, clinical significance of the data is uncertain. Most common adverse reactions include nausea, vomiting, & elevated transaminases.

The company began phase 2/3 trials in England & India, along with a phase 3 trial in Brazil, South Africa & the United States. The European Union came to an agreement with AstraZeneca to deliver 400 million doses if the vaccine proved to be effective & safe. Unfortunately, in early September 2020, the company halted global trails due to one volunteer developing transverse myelitis, which led to a significant drop in the company’s stock value. Regarding finances, biotechnology companies stock prices have significantly increased since the pandemic started.

Novavax (NVAX), a Maryland based biotechnology company who has a protein-based vaccine in phase 2 trials in Africa has noticed a huge surge in stock value. The stock was trading at $4.49 on Jan 1, 2020 & noticed a surge with alltime high of $189.40 at the beginning of August 2020. The road ahead remains unclear. Few will succeed & the majority will fail but the efficacy & safety of these vaccines will be an important factor for mass adoption. But is this vaccine really the solution to the current pandemic?

– Manpreet Singh, MD

Vaccine! from page 1

Convalescent plasma: data is lacking; in a randomized clinical trial in China with only 1 infusion, showed improved nasopharyngeal viral RNA clearance at 72 hours, but no statistically significant difference in overall rates of clinical improvement, in critically ill patients. In non-critically ill patients, the rate of clinical improvement was greater; but the trial was stopped early due to poorenrollment. IL-6 inhibitors: results from trials (available from press release only) do not indicate a benefit of using these agent, but new studies do indicate a limited benefit.

Hydroxychloroquine/chloroquine: not recommended; no benefit & potential for toxicity.

Vaccine updates: A randomized, placebo-controlled phase 1-2 trial of 131 healthy adults, to evaluate safety & mmunogenicity of the rCOVID-19 vaccine showed elic-ited immune response that exceed-ed levels in COVID-19convalescent serum. There were no serious adverse events noted, reactogenicity was absent or mild with 1 patient having a mild fever that lasted 1 day. Use of an adjuvant resulted in enhanced immune response.

References available upon request.

– Hannah Knox, MD, Amritpal Nat, MD

COVID-19 update from page 1

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We would like to express our sincere gratitude and appreciation to the Saint

Agnes Medical Center Board of Directors for their support

of our Internal Medicine Program and the continued

education of our new generation of Saint Agnes

trained physicians in the Central Valley

Board of DirectorsJudge Robert Oliver, Chair

Nancy Hollingsworth, RN, MSN, President & CEO

Pilar De La Cruz Samoulian, RN, MSN, Vice-Chair

Michael R. Tolladay

Sister Mary Alice Bowler, CSC

Carolyn C. Drake, RN, MSN, EdD

Allen M. Evans, MD

A. Thomas Ferdinandi Jr.

Julie Maldonado, MBA

P. Terrence O’Rourke, MD

Dalpinder Sandhu, MD

Luis Santana

Sheri Shapiro

Dora Westerlund

Annual CHEST case report “Diagnostic challenge of Miliary Tuberculosis” N Malakkla, P Rezapoor, S Nair, S Grewal, M Kelley

CHEST CONGRESS, Italy “Don’t Poke Every Ball: A hilar mass of Coccidioidomycosis” S Grewal, A Nat, P Bharati, A Rad

ACG research abstracts “Is Ammonia the correct test for your patient?” S Grewal, N Behniwal, I Baadh, N Dang, P Ansari, R Mann

“All that confusion is not ammonia: a retrospective study on utility of ammonia in patients with hepatic encephalopathy in a community hospital” I Baadh, N Behniwal, N Dang, S Grewal, J Mueller, P Ansari, R Mann

“The utility of routine use of stress ulcer prophylaxis in hospitalized atients: a retrospective study in a community-based hospital” I Baadh, M Devani, K Dhatt, V Vishnoi, N Malakkla, J Kaur

American Medical AssociationResearch Symposium “Corticosteroids & Therapeutic Anticoagulation combination in treating COVID-19 hypoxia: A retrospective study” S Grewal, J Vimpelly, A Rad, A Nat, P Bharati

Society of Critical Care Medicine Abstract submission “A rare side effect of Phenytoin due to Phenobarbital discontinuation” S Grewal, M Cedeno, A Rad, P Bharati

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Welcome to the team

Thank You

Rupinder Mann, MDAssociate Program

Director

Mehdi Hakimipour, MDDesignated Institutional

Official

Alyssa GurneyInternal Medicine

Program Coordinator

A special shoutout!Scholarly Activities

Special Thanks

Early adoption of Covid-19 mitigation efforts allowed The Nephrology Group to keep their doors and services open as practices are shuttering in during spring/summer of 2020. They recognized that they treat the most vulnerable and at-risk population so staying ahead and implementing change is key. The practice partnered with the Fresno Nephrology Kidney Foundation to make home-made face masks and donated them to various local hospitals and dialysis centers early on in the pandemic when PPE was scarce. They began securing an independent supply chain for PPE and cleaning supplies, not relying solely on traditional wholesalers and supply vendors. The Nephrology Group incorporated Covid-19 rapid testing when most were still waiting in line for analyzers and test kits. During early announcements of Covid-19 vaccine development, the practice’s leadership decided to take an active role in procuring vaccines and was part of an early-stage vaccination program to help inoculate healthcare providers and high-risk patients in January 2020. When local health officials announced a call-to-action for local healthcare providers to help alleviate the strain of hospitals by offering monoclonal antibody for early on-set Covid-19 infections, The Nephrology Group was among the first few private practices to answer the call. As we approach the plateau of the Covid-19’s 4th wave, The Nephrology Group remains steadfast and hopeful that with the combined effort and collaboration within the community, we can make a meaningful impact by continuing to offer treatment for Covid-19 and aiding in the vaccination campaigns.

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Fresno Madera Medical Society

Message from the Program DirectorExperience of a Private Practice During Times of Covid