United States

Background: Spanish-speaking patients face persistent barriers to health information due to limited availability and poor readability of online Spanish-language educational resources. Generative artificial intelligence (AI) presents a promising solution to address this gap. This study modeled a practical, scalable AI intervention to generate accessible Spanish-language orthopedic educational materials that institutions can readily adopt to address language disparities.

Methods: We conducted a cross-sectional analysis of the 203 U.S. academic orthopedic institutions listed on the 2024 ERAS directory to assess the availability of Spanish-language patient resources on each institution’s website. We then modeled an AI intervention using 30 articles from [Institution]’s orthopedic patient library using ChatGPT-4o, as currently no Spanish resources are available, with the goal of improving readability and translation quality. Prompt development was performed using proven prompt engineering strategies including context/persona building, few-shot prompting, structured chain prompting, and iterative testing until satisfactory outputs were achieved. Readability was assessed using validated readability tests in both languages. A modified DISCERN tool scored by two Spanish-speaking orthopedic surgeons assessed content and translation quality. Scores before and after ChatGPT intervention were compared with paired t-tests while correlation between changes in reading grade level and quality was assessed with Pearson’s correlation (p&lt;0.05).

Results: Of the 203 institutions included in our search, 142 (70%) provided patient educational resources in English on their websites. Of these 142 institutions, only 17 (12%) provided Spanish-language resources. The cumulative average reading grade level of our model’s original articles was 10.7±2.3 in English and 10.1±1.7 in Spanish (“original” Spanish articles were approximated with Google Translate). ChatGPT significantly reduced the reading level in both languages, achieving an average of 6.9±1.5 in English (p&lt;0.01) and 6.8±1.2 in Spanish (p&lt;0.01). ChatGPT-generated Spanish articles demonstrated improvement in DISCERN content quality scores according to Grader 1 (p&lt;0.05), and noninferiority according to Grader 2 (p=0.37). The quality of translation was scored significantly higher by both graders for ChatGPT content (p&lt;0.05). No significant negative correlation was observed between improvements in readability and content quality scores for either grader (Grader 1: r=0.34, p=0.23; Grader 2: r=0.12, p=0.67).

Conclusion: Our model demonstrates the effectiveness of AI for enhancing the accessibility, readability, and quality of online Spanish-language education materials, representing a cost-effective and practical approach institutions may implement in real-time to address language barriers and promote equity in patient education. 


2025 AMA Research Challenge – Member Premier Access

Prompt engineering for health equity: A modeled AI intervention to improve online Spanish-language orthopedic patient resources

Background: Spanish-speaking patients face persistent barriers to health information due to limited availability and poor readability of online Spanish-language educational resources. Generative artificial intelligence (AI) presents a promising solution to address this gap. This study modeled a practical, scalable AI intervention to generate accessible Spanish-language orthopedic educational materials that institutions can readily adopt to address language disparities.

Methods: We conducted a cross-sectional analysis of the 203 U.S. academic orthopedic institutions listed on the 2024 ERAS directory to assess the availability of Spanish-language patient resources on each institution’s website. We then modeled an AI intervention using 30 articles from [Institution]’s orthopedic patient library using ChatGPT-4o, as currently no Spanish resources are available, with the goal of improving readability and translation quality. Prompt development was performed using proven prompt engineering strategies including context/persona building, few-shot prompting, structured chain prompting, and iterative testing until satisfactory outputs were achieved. Readability was assessed using validated readability tests in both languages. A modified DISCERN tool scored by two Spanish-speaking orthopedic surgeons assessed content and translation quality. Scores before and after ChatGPT intervention were compared with paired t-tests while correlation between changes in reading grade level and quality was assessed with Pearson’s correlation (p<0.05).

Results: Of the 203 institutions included in our search, 142 (70%) provided patient educational resources in English on their websites. Of these 142 institutions, only 17 (12%) provided Spanish-language resources. The cumulative average reading grade level of our model’s original articles was 10.7±2.3 in English and 10.1±1.7 in Spanish (“original” Spanish articles were approximated with Google Translate). ChatGPT significantly reduced the reading level in both languages, achieving an average of 6.9±1.5 in English (p<0.01) and 6.8±1.2 in Spanish (p<0.01). ChatGPT-generated Spanish articles demonstrated improvement in DISCERN content quality scores according to Grader 1 (p<0.05), and noninferiority according to Grader 2 (p=0.37). The quality of translation was scored significantly higher by both graders for ChatGPT content (p<0.05). No significant negative correlation was observed between improvements in readability and content quality scores for either grader (Grader 1: r=0.34, p=0.23; Grader 2: r=0.12, p=0.67).

Conclusion: Our model demonstrates the effectiveness of AI for enhancing the accessibility, readability, and quality of online Spanish-language education materials, representing a cost-effective and practical approach institutions may implement in real-time to address language barriers and promote equity in patient education. 


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Background
Sudden cardiac death (SCD) remains a leading cause of death in the United States. Although implantable cardioverter defibrillators (ICDs) reduce mortality, appropriate therapies are delivered in only 3-5% of sudden cardiac arrests (SCAs) annually, highlighting the need for improved risk identification for SCD and sustained ventricular tachycardia (VT). Cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) is prognostic for ischemic cardiomyopathy (ICM) and SCD; however, the recent PROFID trial found that gross scar parameters lacked predictive value. Radiomics enables granular scar characterization from LGE images. Additionally, a deep-learning artificial intelligence electrocardiogram (AI-ECG) risk estimator (AIRE) trained on millions of ECGs predicts cardiac events. In smaller cohorts, functional principal component decomposition (FPCD) produces more interpretable scalar features from ECG waveforms. This study aimed to develop and validate machine learning models to improve VT/SCD risk stratification and guide ICD selection.
Methods
Left ventricular LGE images from 455 patients with ICM and LVEF 4-49% were analyzed using Pyradiomics to extract ~2,000 scar and myocardial features. Principal component analysis (PCA) was used for dimensionality reduction, and LASSO logistic regression identified PCA components most associated with the primary outcome of sustained VT or SCD. 12-lead ECGs were processed using FPCD to extract scalar parameters characterizing the voltage-time curves, and predictive features were selected via LASSO. Identified predictors were combined with clinical data (LV ejection fraction [LVEF] and LGE) in a model and evaluated using area under the receiver operating characteristic (AUROC) curves with bootstrapping.
Results
Among 455 patients with ICM, 59 experienced either SCD or sustained VT; 115 received ICD implants. The combined model demonstrated high predictive accuracy with an AUROC of 0.83 (95% CI: 0.78-0.88). The radiomics-based principal component most associated with VT/SCD was “Contrast,” and higher values were linked to highly heterogeneous LGE signal intensity and increased arrhythmic risk. In parallel, the FPCD analysis of ECGs demonstrated that parameters based on leads aVF and V3 had the best association with VT/SCD. A positive R wave in V3 was associated with the primary outcome. Notably, in the subgroup with LVEF 36-49%, using a model of LVEF, AI-ECG, and CMR radiomics to predict the primary outcome had an AUROC of 0.94 (95% CI: 0.90-0.97). 
Conclusion
Integrating radiomics from LGE images and 12-lead ECG features with LVEF in this model enhances risk stratification in VT/SCD and may fill a critical gap for patients with ICM and LVEF 36-49% who lack established primary prevention ICD indications.


Machine Learning Predicts Ventricular Tachycardia and Sudden Cardiac Death in Ischemic Heart Disease

Background
Pediatric atopic dermatitis (AD) has been linked to later metabolic dysfunction, including obesity, dyslipidemia, etc. Systemic type-2-cytokine blockade with dupilumab may confer long-term protective metabolic effects in AD patients, but longitudinal studies in children receiving modern biologic therapy compared to topicals remain scarce. We compare short and long-term incidences of 23 metabolic disorders in pediatric AD managed with dupilumab, high-potency corticosteroids (HPCS), low/medium-potency corticosteroids (LMCS), topical calcineurin inhibitors (TCI), targeted non-steroidal topicals (crisaborole or ruxolitinib), or no therapy.

Methods
We queried the TriNetX Global Network for patients <18 years carrying ICD-10 code L20 for AD. The index date was the first prescription or AD-related encounter, and baseline was the 12 months prior. Cohort sizes were: dupilumab 12,871; untreated 144,655; HPCS 45,992; LMCS 514,970; TCI 40,814; targeted topicals 9,408; any topical 634,356. Each comparator was 1:1 propensity-score matched to the dupilumab cohort on age, sex, race/ethnicity, and baseline metabolic diagnoses. All standardized mean differences were <0.01.

Outcomes were assessed at 6 months, 1, 3, and 5 years, and any time after index. Logistic regression provided odds ratios (OR) with 95% confidence intervals (CI); Kaplan-Meier curves, log-rank tests, and proportional-hazards diagnostics provided time-to-event differences. Two-sided p<.05 signified significance. Analyses were conducted in R 4.3 and TriNetX; de-identified data rendered our study IRB-exempt.

Results
Within 1 year of treatment-onset, dupilumab showed numerically higher—but frequently non-significant odds for metabolic dysfunction compared with topicals (e.g., overweight/obesity OR 1.225, 95% CI 0.857-1.751 at 6 months vs TCI). 

However, ~30 months post-index, Kaplan-Meier curves diverged; dupilumab seemed to confer a protective metabolic effect versus all comparators. By 5 years, dupilumab exhibited lower risk for nearly all metabolic outcomes. Versus the aggregated topical cohort, for example, 5-year ORs were 0.417 for overweight/obesity, 0.435 for dyslipidemia, 0.605 for elevated glucose, and 0.554 for acanthosis nigricans (all p<.001). This protective association continued beyond 5 years.

Protective associations were similar against HPCS, LMCS, and TCI, and modestly attenuated against targeted non-steroidal topicals. No comparator showed excess late metabolic risk relative to dupilumab.

Conclusion
Our analysis with this large real-world pediatric cohort suggests dupilumab may increase early metabolic dysfunction (frequently without statistical significance), while conferring pronounced long-term protective metabolic effects compared with topical-only management or no therapy, supporting the hypothesis that sustained interleukin-4/13 inhibition may favorably alter metabolic risk trajectories in pediatric AD. Prospective studies adjusting for disease severity and further mechanistic studies may help confirm this causality and elucidate the underlying mechanisms.

Metabolic Outcomes in Pediatric Atopic Dermatitis Treated with Dupilumab versus Topical Agents: a Retrospective Cohort Study

Background
Acupuncture has been practiced for thousands of years as a modality of Traditional Chinese Medicine. A greater emphasis on Complementary and Alternative Medicine (CAM) has led to enhanced adoption of acupuncture in Western medicine. While traditional acupuncture relies on surface landmarks and empirical knowledge, modern imaging techniques offer the opportunity to more precisely understand the proximity of critical neurovascular structures to needled sites. Peripheral nerves are particularly vulnerable to inadvertent injury at acupoints underlying nerves are superficial to dense osseo-ligamentous structures. Despite these risks, there is limited data quantifying the spatial relationships between acupuncture needles and adjacent nerves. Ultrasound imaging provides a non-invasive, real-time method for visualizing both acupuncture needle placement and underlying anatomical structures. Accordingly, this study aims to map the relative distance between inserted acupuncture needles and nearby peripheral nerves at selected acupoints, providing an evidence-based framework for safer clinical practice.
Methods
Ultrasonography was utilized in a physician-led acupuncture clinic to assess the distance of the acupuncture needle to nerves (NTN) at two specific acupoints (ACPs): Pericardium 6 (PC 6) and Kidney 3 (KI 3). These two points were selected because of their high clinical significance, relationship to underlying nervous structures, and ease of visualization via ultrasound. With informed consent from patients attending their scheduled acupuncture appointments, a physician, trained and board certified in medical acupuncture, located the selected ACP. Ultrasonography was performed to identify the underlying nerves. The site was then cleaned, and an acupuncture needle was inserted to achieve de qi by the physician. Ultrasonography was performed at the site again to identify the location of the needle. The NTN distance is measured and recorded. 
Results
The data collection and analysis are currently ongoing, and no results are yet available. 
Conclusion
This study demonstrates the value of ultrasound in visualizing anatomical structures relevant to acupuncture practice. By mapping the spatial relationships between acupuncture needles and underlying peripheral nerves, this work contributes to a growing body of evidence aimed at improving the safety and anatomical precision of acupuncture treatments. Although data collection and analysis are ongoing, preliminary findings are expected to inform clinical decision-making and guide safer needling practices, particularly in regions where nerves lie superficially. Limitations include the variability in individual anatomical presentations and the technical challenges of standardizing needle insertion depth and angle. Future work will benefit from larger sample sizes and functional outcome data to further refine anatomical risk mapping in acupuncture.

Anatomical Risk Mapping of Peripheral Nerves in Acupuncture via Ultrasound

Background
Idiopathic Intracranial Hypertension (IIH) is characterized by elevated intracranial pressure, papilledema, and often transverse sinus stenosis, in the absence of imaging or cerebrospinal fluid (CSF) abnormalities. Current treatments focus primarily on medical management, weight loss, and dural venous sinus stenting. However, inspired by arachnoid granulation function, a novel endovascular device may show significant potential in improving IIH management. The eShunt System is a transdural shunt deployed via the inferior petrosal sinus (IPS) to drain CSF from the cerebellopontine angle cistern (CPAC) into the internal jugular vein. Although it has shown promising results in patients with normal pressure hydrocephalus, the implant’s applicability in IIH remains undefined. This study aims to characterize the morphometrics of cisternal, venous, and skull base anatomy in adult patients with IIH-associated dural venous sinus stenosis and evaluate them against minimum required dimensions for safe deployment of the eShunt implant.

Methods
High-resolution T1-weighted Gadolinium-enhanced brain MRIs of IIH patients post-venous sinus stenting at Tufts Medical Center (Boston, MA) were retrospectively analyzed to measure CPAC depth, IPS diameter, IPS angle, and cerebellar tonsillar descent; pertinent history and demographics were also assessed.

Results
Sixty adult patients (ages 18-77, 50 females) were included. Median CPAC depth was 4.5 mm and 4.4 mm, while median IPS diameter was 4.1 mm and 3.8 mm, for right and left sides, respectively. CPAC depth trended higher in older (P=0.05) and male (P=0.07) patients, but not significantly. Transverse sinus stenting did not significantly affect cistern dimensions (P=0.8). Endovascular placement of the eShunt implant was possible with stringent (CPAC depth >5mm and IPS diameter >2mm), moderate (CPAC depth >4mm and IPS diameter >2mm), and permissive (CPAC depth >3mm and IPS diameter >2mm) feasibility criteria in 55%, 65%, and 78% of analyzed patients, respectively. Interestingly, CPAC depth was found to be inversely correlated with cerebellar tonsillar descent (P<0.01); patients with Chiari I diagnoses tended to have small CPA cisterns. On excluding 26 patients with tonsillar descent below the foramen magnum, eShunt eligibility rose to 62%, 76%, and 91%, under stringent, moderate, and permissive criteria, respectively. Thus, cerebellar tonsillar position emerges as another predictive factor for eShunt eligibility.

Conclusion
A significant proportion of patients with IIH currently treated with dural venous stenting may be suitable candidates for the eShunt implant. Its biomechanical potential for ICP reduction, minimally invasive endovascular deployment, and lack of anti-coagulant and anti-platelet requirements, warrant further clinical investigation of its role in IIH management.

An Endovascular Approach for Idiopathic Intracranial Hypertension: Assessing Feasibility of the eShunt Implant using Morphometric Analysis

Background:
Macular edema (ME) is an ocular condition resulting from the accumulation of fluid in the central, most visually important part of the retina, typically as a complication of a retinal or inflammatory disease. Traditionally, laser photocoagulation or intravitreal injections of corticosteroids or anti-vascular endothelial growth factor agents are used to treat ME. However, these treatment options may have a wide array of undesirable side effects or limitations in their usage. In ophthalmology, topical NSAIDs are already largely used for their potent inhibition of inflammatory processes and treatment of postoperative ME. The overall diversity of NSAID agents, their mechanism of action, and risk profile make them a viable alternative option for intravitreal administration. This study sought to present a narrative synthesis and meta-analysis on the efficacy and safety of intravitreal injections of NSAIDs for the treatment of macular edema. 
Methods
A systematic search was conducted in the PubMed, Embase, Springer, and Cochrane Library databases, with search terms such as ('cystoid macular edema' OR 'cme' OR 'macular edema' OR 'macula cystoid edema') AND ('intravitreal injection' OR 'intraocular injection' OR 'intra-ocular injection') AND ('non-steroid anti-inflammatory agent' OR 'nsaid' OR 'non-steroidal anti-inflammatory drug' OR 'diclofenac' OR 'ketorolac' OR 'bromfenac' OR 'nepafenac' OR 'flurbiprofen') in KEYWORDS and FULL-TEXT on April 4, 2025. Relevant randomized and non-randomized clinical trials and observational studies were included if they involved intravitreal NSAID administration. Risk of bias and certainty were assessed. Data was extracted and evaluated using either narrative synthesis or meta-analysis, depending on the available data. Studies missing data for average best-corrected visual acuity and central macular thickness (CMT) were excluded from the meta-analysis. 
Results
Eight total studies, including six randomized and two nonrandomized trials, reporting 313 subjects and 340 eyes were included. All eight studies validated the safety of intravitreal NSAID agents. Two studies indicated intraocular pressure (IOP) reduction following administration, while others reported no significant IOP changes. Meta-analysis of 110 eyes found nonsignificant functional visual recovery (p=0.07), while meta-analysis of 130 eyes revealed significant reductions in CMT and anatomical improvement (p=0.04). Risk of bias and certainty assessment suggested potential effects of publication bias in the results. 
Conclusion
Intravitreal NSAID treatments for ME were not associated with any adverse reactions. Comparatively, they show insignificant functional gain but significant structural improvement. Although there is uncertain evidence of their efficacy, intravitreal NSAIDs present a viable alternative to current treatment methods and require further investigation in ME management.

Intravitreal Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for the Treatment of Macular Edema: A Systematic Review and Meta-Analysis

Abstract Title: A Diagnostic Dead-End: Chronic Microcytic Anemia in a Medically Complex Patient

Background:
Anemia, defined as hemoglobin <13 g/dL in men, is a common condition with numerous etiologies, including nutritional deficiencies, chronic disease, blood loss, and hemolysis. While most cases have identifiable causes, the etiology of a few remains unknown. Such cases pose a diagnostic challenge, requiring a
multidisciplinary and longitudinal approach. This report presents a patient with chronic microcytic anemia unresponsive to conventional treatment despite an extensive workup.

Case Presentation:
A 65-year-old African-American male with hypertension, stage 3a CKD, type 2 diabetes, rheumatoid arthritis(RA), monoclonal gammapathy of undetermined significance (MGUS), COPD, gout, and prior H. pylori infection presented with three years of progressive fatigue, lightheadedness, and poor appetite. Hemoglobin consistently oscillated between 7.4-11.5 g/dl over 2.5 years, with microcytic
indices. Iron studies showed low serum iron, transferrin saturation (9.6%), low UIBC, and elevated ferritin (>800 ng/mL), indicating anemia of chronic disease or iron sequestration. The patient received 26 intravenous iron infusions without significant hemoglobin improvement. Renal function declined in 2024 (eGFR 47.1) but improved in 2025 (>90), reducing CKD-related anemia likelihood. Other potential causes, such as vitamin deficiencies, LDH abnormality, thyroid dysfunction, and a
negative Coombs’ test, were ruled out. Upper GI endoscopy confirmed H. pylori, treated successfully; colonoscopy revealed benign polyps. CT chest and PET-CT showed mild mediastinal lymphadenopathy and splenomegaly; biopsy and bronchoalveolar washings were negative for malignancy. Bone marrow biopsy, the gold standard, revealed normocellular marrow with increased storage iron,
mild reticulin fibrosis, and non-diagnostic megakaryocytic atypia. Flow cytometry was unremarkable. Bronchoalveolar lavage showed hemosiderin-laden macrophages. Serum electrophoresis revealed two M-spikes without MGUS progression. Methotrexate was discontinued due to RA remission.
Despite epoetin alfa initiation, hemoglobin response remained minimal.

Discussion:
This case highlights the challenges of diagnosing chronic microcytic anemia in a patient with multiple comorbidities. Iron studies suggested functional iron deficiency in the context of inflammation from his chronic diseases. Despite successful H. pylori treatment, normalized renal function, and extensive hematologic and imaging workup, no unifying etiology was found. The presence of hemosiderin-laden macrophages and mild splenomegaly may reflect occult processes such as chronic pulmonary bleeding or altered iron handling. The patient’s limited response to IV iron and erythropoietin supports the role of inflammation-driven impaired iron
utilization and erythropoiesis. Close monitoring remains essential, as subtle or
evolving hematologic pathology cannot be fully excluded, and chronic methotrexate therapy may also contribute to anemia.

A Diagnostic Dead End: Chronic Microcytic Anemia in a Medically
Complex Patient

Abstract Title
Pyridostigmine for the Persistent Ileus
Background
Pyridostigmine is an acetylcholinesterase inhibitor. By inhibiting the enzyme, pyridostigmine will increase the amount of acetylcholine binding to synapses. This promotes muscular contraction of the gastrointestinal system and stimulates motility. Through this mechanism, pyridostigmine has been shown to reduce post-operative ileus after abdominal surgery and to treat pediatric chronic intestinal pseudo-obstruction.
Case Presentation
This is a case of a 72-year-old female with a past medical history of heart failure and hypothyroidism, presenting with palpitations and found to have multifocal atrial tachycardia (MAT). Patient was afebrile and heart rate ranged from 104-124 bpm. Physical exam was remarkable for tachycardia and a soft, distended, nontender abdomen. Lab work was notable for potassium 3.3, phosphorus 1.8, magnesium 0.8, creatinine 1.4, and lactic acid 4.6. Electrolytes were aggressively repleted. Overnight, the patient had significant abdominal distension and tenderness and could not pass flatus. A nasogastric tube (NGT) was placed for decompression. CT abdomen with PO contrast showed no evidence of obstruction, but dilated bowel loops in ascending and transverse colon, concerning for developing ileus. GI was consulted and recommended rectal tube for further decompression and aggressive bowel regimen. After 4 days, the NGT and rectal tube were removed. Patient had small daily bowel movements with slow advancement to a soft diet. However, her abdominal distension persisted, and serial abdominal X-rays were unchanged. On hospital day 15, her abdominal distension worsened so her diet was changed back to liquids. Given the persistence of ileus despite electrolyte repletion and discontinuation of any hypomotility medications, pyridostigmine 30mg BID was trialed for 3 days. Patient was able to tolerate a regular diet, had daily bowel movements, and noted improvement in distension. While receiving pyridostigmine, she was monitored on telemetry for cardiac side effects. 
Discussion
Based on prior studies, the recommended dose of pyridostigmine for reducing ileus is 60mg twice a day. The patient should be monitored for side effects, including bradycardia, atrioventricular block, and bronchoconstriction. Given that this patient presented with an arrythmia, pyridostigmine 30mg was trialed to monitor for adverse effects. After tolerating one dose of the medication, she was then started on 30mg twice a day. Her distension improved with this dose, so she was continued on 30mg twice a day. When ileus does not improve with an aggressive bowel regimen and after addressing the underlying cause, such as electrolyte abnormalities, pyridostigmine should be considered in management.

Pyridostigmine for the Persistent Ileus

Background:
Thyrotoxic periodic paralysis (TPP) is a rare but reversible cause of acute flaccid paralysis, resulting from thyrotoxicosis-induced upregulation of the Na+/K+ ATPase in skeletal muscle, leading to a rapid intracellular shift of potassium. TPP affects approximately 0.1%–0.2% of hyperthyroid patients in the U.S., with a strong male and Asian predominance. Normokalemic TPP variants are exceedingly rare and frequently overlooked, particularly in non-Asian populations. We present an unusual case of normokalemic TPP in a young Caucasian woman with overlapping endocrine disorders whose presentation mimicked a spinal cord emergency.
Case Presentation:
A 30-year-old Caucasian woman presented with sudden-onset bilateral lower extremity flaccid paralysis, accompanied by perineal numbness and difficulty initiating urination, lasting approximately two minutes. Past medical history included Sheehan syndrome, hypothyroidism and adrenal insufficiency.
Initial concern was for cauda equina or conus medullaris syndrome. Further history revealed that she frequently self-adjusted her medications: levothyroxine (100–300 mcg/day) and hydrocortisone (80 mg/day, divided doses). She had withheld both medications for over 36 hours before arrival, which likely contributed to partial biochemical normalization by the time of evaluation.
On exam, she exhibited persistent perineal numbness, urinary hesitancy, and bradycardia; an unexpected finding in the context of thyrotoxicosis. MRI of the brain and entire spine was unremarkable effectively ruling out spinal cord emergencies, demyelinating processes, transverse myelitis and a spinal abscess. Laboratory testing revealed:
• TSH 0.008 uIU/mL
• Free T4 1.51 ng/dL
• Total T3 0.85 ng/mL
• Potassium 4.4 mmol/L
• Cortisol 68.86 mcg/dL
She reported multiple classic TPP triggers: intense physical activity, heat exposure, a high-carbohydrate meal, and acute emotional stress. Despite normal potassium and borderline thyroid labs, the overall presentation was consistent with normokalemic TPP.
Discussion:
TPP is a hormonally driven channelopathy in which excess thyroid hormone enhances Na+/K+ ATPase activity, shifting potassium intracellularly, hyperpolarizing the resting membrane potential, and rendering skeletal muscle fibers temporarily inexcitable. This hyperpolarization prevents adequate depolarization by inactivating voltage-gated sodium channels, resulting in transient flaccid paralysis.
In hyperthyroid states, elevated T3 and T4 can rapidly decline due to increased type 3 deiodinase activity, masking the biochemical severity. Normokalemia may also reflect post-event normalization of serum potassium.
This patient’s exogenous levothyroxine and hydrocortisone misuse magnified the intracellular shift: thyroxine directly increases ATPase expression, while cortisol enhances β-adrenergic sensitivity. Combined with physiologic triggers, this created a transient but dramatic neuroendocrine storm.
Recognizing TPP, particularly in atypical presentations, is essential to avoid unnecessary invasive workups, inappropriate steroid escalation, and iatrogenic harm.

The Paralysis Paradox: A Thyrotoxic Periodic Paralysis Masquerading As A Spinal Cord Emergency

Background: 
Dissecting aneurysms of the vertebral artery are life-threatening causes of subarachnoid hemorrhage, with higher rupture rates in the posterior circulation. Their pathogenesis is multifactorial, often involving structural vessel wall abnormalities and hemodynamic stress. While beta thalassemia minor is typically considered a benign carrier state, it can contribute to endothelial dysfunction and vascular injury. We present a case of a ruptured vertebral artery dissecting aneurysm in a patient with beta thalassemia and discuss whether her hematologic
condition could have played a contributing role. 

Case Presentation:
A 50-year-old woman with history of beta thalassemia minor presented to the ED for altered mental status. On arrival, her GCS declined from 12 to 8, prompting intubation. CT head revealed acute subarachnoid hemorrhage within the basilar cisterns and sylvian fissures and EVD was placed. Diagnostic cerebral angiogram showed right vertebral artery V4 segment irregular fusiform dissecting aneurysm at the takeoff of the right PICA, with the aneurysm measuring 7.1mm in length and 3.7mm in width. Patient underwent deconstruction of the right vertebral artery proximal to the dissection. Despite intervention, the patient deteriorated and was
ultimately declared brain dead. 

Discussion:
Several mechanisms raise the question of whether beta thalassemia could have predisposed this patient to vascular pathology. Beta thalassemia is associated with ineffective erythropoiesis, leading to chronic anemia, which appeared in this patient with baseline hemoglobin of 8-9 g/dL. Anemia reduces oxygen carrying capacity of the blood, leading to tissue hypoxia and cerebral hypoperfusion. In response to
hypoxia, mitochondrial respiration is inefficient which leads to formation of reactive oxygen species. Reactive oxygen species causing oxidative stress and altered nitric oxide metabolism can promote endothelial injury. In response to cerebral hypoperfusion, autoregulatory mechanisms trigger compensatory dilation of cerebral blood vessels to increase cerebral blood flow. But because of the persistent anemia in beta thalassemia, the ability to fully normalize cerebral oxygenation is limited, which can promote vessel wall remodeling, leading to a vessel
that is structurally more vulnerable.

Vertebral Artery Aneurysm Rupture in a Patient with Beta Thalassemia Minor: A Case Report

Background: Asthma is one of the most common chronic diseases among children, afflicting around 8.1% of school-aged children in the U.S. and contributing significantly to school absenteeism. Effective asthma management requires consistent medication adherence and education, which can be challenging for young children. Because nearly all children attend school and spend much of their day there, schools represent an ideal setting for health interventions. This study evaluates New York City’s Asthma Case Management Program (ACMP), which placed trained case managers in K–8 community schools to support asthma control, medication adherence, and coordination between families and providers. ACMP began in 2015-16 in one school and was rolled out to 32 schools by 2018-19. Using a triple-differences identification strategy motivated by the staggered rollout of ACMP, we studied the effect of a program placing asthma case managers in schools to educate and support children with asthma on school processes and health outcomes. 

Methods: We used student-level data (n=291,813) from the NYC Office of School Health on NYC elementary and middle schools from 2011 to 2019. We developed a triple differences design to study the causal effect of the program by comparing: 1) students with asthma vs. without asthma, 2) schools with vs. without ACMP, and 3) before vs. after the program’s implementation. Outcomes include student absenteeism, school nurse visits, and the completion of Student Asthma Questionnaires (SAQs). We assume no other policies affected these outcomes simultaneously.

Results: After ACMP implementation, students who ever had asthma had one fewer absence per year, on average. There was also an increase of about two nurse visits for medication administration per year, on average. Further investigation suggests this increase was driven by more asthma controller (preventive) medication. Lastly, after implementation, there was about a 44% increase in completed SAQs returned by students with asthma. 

Conclusion: ACMP shows promise in improving both administrative and health-related outcomes for students with asthma. The program led to greater return of administrative forms, suggesting improved care coordination. The program also benefited student outcomes as seen through reduced absences and increased nurse visits for prophylactic asthma management, pointing to better asthma control. This study provides early causal evidence of the benefits of school-based asthma management programs and supports the broader role of schools in chronic disease care for children. 


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