United States

BACKGROUND: 
Delirium is categorized by acute changes in attention, cognition, and awareness that are not explained by pre-existing medical conditions. Its etiology remains poorly understood. Delirium occurs in around 21-25% of older patients after elective surgery. Delirium is associated with increased risk for post-discharge mortality, dementia, long-term cognitive decline, and other poor outcomes. This study focuses on a previously identified neurodegenerative marker that is associated with delirium. APOe4 has been found to increase the risk for delirium, but not all patients with the APOe4 allele experienced delirium. This suggests that mechanisms underlying delirium are multifactorial. Recent literature has suggested that chronic conditions are associated with the onset and progression of neurodegenerative diseases. It is not known whether the combination of chronic conditions and APOe4 infers a greater risk for delirium than either variable alone.
OBJECTIVE: 
Question: What is the association between APOe4 and postoperative delirium after considering presence of chronic conditions?
Hypothesis: Both chronic conditions and APOe4 will be associated with postoperative delirium.
METHODS: 
This is a secondary analysis of data from 2001-2014 at the University of California, San Francisco. The inclusion criteria are:
- &gt;= 65 year old
- Major elective noncardiac surgery requiring anesthesia
- Expected to remain in the hospital postoperatively for more than 48 hrs.
- None were delirious at admission
The study included 351 elective surgery patients. Each patient is interviewed by the same research assistant preoperatively and postoperatively. Data collected from each patient include:
- APOe4 allele status
- Medical history
- The measured outcome, delirium status (Confusion Assessment Method)
148 of the patients analyzed in this study were also included in a prior study (Leung et al., 2007) investigating the risk of postoperative delirium in older patients undergoing noncardiac elective surgery.
RESULTS: 
30.2% of patients in this sample were over the age of 75. 15.4% of patients had at least one APOe4 allele, while 84.6% did not. 28.5% of patients had a Charlson Comorbidity Index (CCI) &gt; 1, while 71.5% had a CCI of 0 or 1. 32.8% of patients had postoperative delirium. There is an association between higher number of comorbidities and postoperative delirium (OR = 1.70, CI = 1.03 - 2.82). After controlling for confounding variables (comorbidities and age), the association between APOe4 and postoperative delirium (OR = 0.50, CI = 0.21 - 1.23) was not statistically significant. This indicates that increased comorbidities and increased age have a greater impact on postoperative delirium than APOe4 in this cohort.
DISCUSSION: 
Increased comorbidities are associated with postoperative delirium in non-cardiac elective surgery patients over age 65. This relationship can be used to inform clinical recommendations and aid in determining preventable risk.

AMA Research Challenge 2025 

The Combined Impact of Chronic Illness and Presence of Genetic Disposition for
Dementia on Incident Postoperative Delirium among Older Elective Surgery Patients

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AMA Research Challenge 2024 

Join the AMA Research Challenge poster symposium and semifinals to explore top research posters and score posters in the semifinals (an AMA member exclusive opportunity).

BACKGROUND: 
Delirium is categorized by acute changes in attention, cognition, and awareness that are not explained by pre-existing medical conditions. Its etiology remains poorly understood. Delirium occurs in around 21-25% of older patients after elective surgery. Delirium is associated with increased risk for post-discharge mortality, dementia, long-term cognitive decline, and other poor outcomes. This study focuses on a previously identified neurodegenerative marker that is associated with delirium. APOe4 has been found to increase the risk for delirium, but not all patients with the APOe4 allele experienced delirium. This suggests that mechanisms underlying delirium are multifactorial. Recent literature has suggested that chronic conditions are associated with the onset and progression of neurodegenerative diseases. It is not known whether the combination of chronic conditions and APOe4 infers a greater risk for delirium than either variable alone.
OBJECTIVE: 
Question: What is the association between APOe4 and postoperative delirium after considering presence of chronic conditions?
Hypothesis: Both chronic conditions and APOe4 will be associated with postoperative delirium.
METHODS: 
This is a secondary analysis of data from 2001-2014 at the University of California, San Francisco. The inclusion criteria are:
- >= 65 year old
- Major elective noncardiac surgery requiring anesthesia
- Expected to remain in the hospital postoperatively for more than 48 hrs.
- None were delirious at admission
The study included 351 elective surgery patients. Each patient is interviewed by the same research assistant preoperatively and postoperatively. Data collected from each patient include:
- APOe4 allele status
- Medical history
- The measured outcome, delirium status (Confusion Assessment Method)
148 of the patients analyzed in this study were also included in a prior study (Leung et al., 2007) investigating the risk of postoperative delirium in older patients undergoing noncardiac elective surgery.
RESULTS: 
30.2% of patients in this sample were over the age of 75. 15.4% of patients had at least one APOe4 allele, while 84.6% did not. 28.5% of patients had a Charlson Comorbidity Index (CCI) > 1, while 71.5% had a CCI of 0 or 1. 32.8% of patients had postoperative delirium. There is an association between higher number of comorbidities and postoperative delirium (OR = 1.70, CI = 1.03 - 2.82). After controlling for confounding variables (comorbidities and age), the association between APOe4 and postoperative delirium (OR = 0.50, CI = 0.21 - 1.23) was not statistically significant. This indicates that increased comorbidities and increased age have a greater impact on postoperative delirium than APOe4 in this cohort.
DISCUSSION: 
Increased comorbidities are associated with postoperative delirium in non-cardiac elective surgery patients over age 65. This relationship can be used to inform clinical recommendations and aid in determining preventable risk.

poster

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Abstract Title: Psychiatric Care in the Pediatric Emergency Department 
Authors: Priyanka Kaushal, Lisa Gorham, Cedric Bruges, James Rudloff, Viani Dickey, Cynthia Rogers, & George Hoganson

Background: Due to surging demand for pediatric psychiatric services, emergency departments (EDs) are increasingly utilized by parents and community physicians to address psychiatric concerns. Further research is needed to understand the expectations of families seeking ED care for their children and barriers to community psychiatric services. We hypothesized that most families seek services in the ED due to unmet needs in the community and that there would be a mismatch of expectations between care sought and care received. 

Methods: Parents of children presenting with psychiatric complaints at the St. Louis Children’s Hospital ED completed a survey about their child. We extracted patient demographics, diagnoses, length of stay (LOS), and disposition from the medical record. Our primary outcomes were parent-reported goals for treatment and barriers to care outside of the ED as well as risk factors for being admitted. 

Results: We included 151 children in the final cohort (52% female, mean age 13.3 years, 66% White, 23% Black). The most common diagnoses were suicidal ideation/attempt (54.3%), depression (27.8%), ADHD (19.2%), aggression (17.9%), anxiety (11.9%), and self-harm (9.3%). Parent-reported reason(s) for ED visits included seeking overnight hospitalization (59%), medication changes (42%), a diagnosis (42%), counseling (36%), and intensive outpatient therapy (36%). Commonly reported barrier(s) to treatment outside of the ED included long wait lists for providers (36%), providers not accepting new patients (24%), and insurance issues (14%). The median LOS in the ED was 18.33 hours (range: 2.7 to 167.7 hours). Males, on average, had a longer LOS (t=-2.05, df=103, p=0.04). 28% of children got admitted, 15% were transferred to another psychiatric facility, and 57% were discharged. Of those families who sought inpatient care, only 61% were admitted/transferred. Across all subjects, having a diagnosis of depression (X2=31.99, df=1, p<0.001) and being older (OR 1.45, 95% CI 1.25-1.71, p<0.001) made children more likely to be admitted. 

Conclusion: The gap between families seeking inpatient care and actual admissions underscores the need for better outpatient access. By identifying barriers to care and mismatched expectations, this study helps inform policies to better support families in need.

Psychiatric Care in the Pediatric Emergency Department

Background: Androgen deprivation therapy (ADT) is a key treatment for patients with advanced prostate cancer. With longer durations of ADT, patients face an increased risk of cardiometabolic side effects. This study aimed to assess body composition, cardiometabolic risk, and overall survival in patients with advanced prostate cancer on long-term ADT. 
Methods: We performed a retrospective analysis of body composition, cardiometabolic risk, and outcomes in patients with locally advanced or metastatic prostate cancer treated with at least 6 months of intensified ADT at the UVA Comprehensive Cancer Center between 2015 and 2023. Patients included had baseline imaging within 9 months prior to ADT initiation and follow-up imaging around 1 year. Body composition was assessed at the L3 vertebral level using automated CT analysis (Comp2Comp). Cardiovascular risk was estimated using the American Heart Association PREVENT™ calculator. Overall survival was analyzed using the Kaplan-Meier method. 
Results: A total of 56 men were included, with a median age of 72 years (IQR 64.3 72.0). Fourteen (25%) had stage IVA disease and 42 (75%) had stage IVB disease. Twelve (21.4%) were classified as having castrate-resistant disease. At baseline, many had independent cardiovascular risk factors including hypertension (73.2%), hyperlipidemia (30.6%), and diabetes (21.4%). Nineteen of 49 (38.8%) had a predicted 10-year cardiovascular disease risk >20%. Fifteen of 55 (27.3%) had sarcopenic obesity, defined as a skeletal muscle index two standard deviations below a healthy U.S. reference, with expansion of subcutaneous and visceral fat. After a median of 13 months on ADT, most patients (32/39, 82%) showed selective loss of muscle mass without significant fat loss. The median skeletal muscle area (SMA) decrease was 10.52 cm² (P < 0.0001). Lower muscle mass correlated with increased cardiovascular risk score (R = -0.32, P = 0.026). A higher cardiovascular risk estimate was associated with lower overall survival (median OS 21.2 months for high risk vs. 49.9 months for intermediate risk, P = 0.0164). 
Conclusions: This study highlights elevated baseline cardiovascular risk and a body composition profile consistent with sarcopenic obesity in elderly men with prostate cancer. Long-term ADT-induced muscle loss may worsen cardiometabolic health and is associated with reduced overall survival.

Effect of long-term androgen deprivation therapy on body composition, cardiometabolic risk and overall survival in patients with advanced prostate cancer

Abstract Title
Adverse Childhood Experiences and Temporal Discounting in Older Adults

Background
Traumatic events experienced in the first 18 years of life, known as adverse childhood experiences (ACEs), are associated with an increased burden of chronic disease. ACEs have been shown to impact brain regions associated with impulsivity and may play an important role in an individual’s ability to delay reward. Temporal discounting is the tendency to prefer more immediate rewards over delayed gratification, and higher discounting has been implicated in poor chronic disease management. To better understand how adversity early in life could complicate chronic disease management, we examined the association between ACEs and temporal discounting in older adults. We hypothesized that a higher total number of ACEs will have a greater effect on future temporal discounting.

Methods
We conducted a cross-sectional analysis of self-reported ACEs and temporal discounting using previous cohort data in the Rush Alzheimer’s Disease Center on 834 participants 65 years and older (mean age 80, 86% white, 12.4% African American, 76% female). ACEs were measured with a 16-item trauma questionnaire and summed into a total ACE score (composite measure z- score) and five categories (principal component analysis): family separation/problems, emotional neglect, financial need, parental violence, and parental intimidation. Small scale (α) and large scale (A) temporal discounting was measured at baseline and assessed via a standard preference elicitation protocol of a 7-question binary choice task between smaller immediate versus larger delayed rewards. Cross-sectional analysis was conducted using R Statistical Software, ANOVA, and Poisson regression.

Results 
Higher total ACE scores were significantly associated with steeper temporal discounting: A (β = 0.077, SE = 0.028, p = 0.006) and α (β = 0.0022, SE = 0.0010, p < 0.001). Among ACE categories, parental violence showed the strongest effects on both A (β = 0.090, SE = 0.027, p = 0.001) and α (β = 0.0022, SE = 0.00070, p = 0.002) and was dose-dependent with a 14.8% (A; p-value < 0.001) and 15.4% (α; p-value = 0.001) increase in discounting per unit of parental violence. Race was also associated with discounting, while years of higher education, male sex, and high global cognition had protective effects.

Conclusion
These findings suggest that ACEs, particularly parental violence, are associated with diminished ability to delay gratification in later life. This supports the hypothesis that early adversity has a significant and dose-dependent effect on temporal discounting. Further studies are warranted to further explore these implications on health behaviors and chronic disease management and to inform interventions.

Adverse Childhood Experiences and Temporal Discounting in Older Adults


***This is an ongoing study. 31/40 patients have completed the protocol are included in this preliminary abstract.

Abstract Title
A Comparison of Push-off and Gait Strength following Open Haglund’s Resection vs. Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy

Background
The gold standard for surgical treatment of insertional Achilles tendinopathy (IAT) is the open midline Achilles tendon splitting Haglund’s resection (OH). However, the percutaneous Zadek osteotomy (ZO) is a safe and effective alternative intervention. Retrospective studies have compared patient-reported outcomes and radiographic findings between ZO and OH; however, data on post-operative strength remain limited. Accordingly, the current prospective study evaluated the postoperative push-off and gait strength following OH vs ZO for IAT.
Methods
Thirty-one patients >18 years of age who underwent unilateral OH (N=17) or ZO (N=14) for IAT with ≥1-year follow-up met the inclusion criteria; patients with prior midfoot/hindfoot surgery, recent lower extremity surgery, neuromuscular conditions were excluded. Static plantarflexion/dorsiflexion strength were assessed in seated and supine positions. Standing strength was evaluated by unilateral and bilateral calf raises performed on pressure plates. Single-leg balancing was timed. Finally, vertical and anterior ground reaction forces at toe off were captured during gait. The mean difference between operative/non-operative limbs was calculated for each measurement and reported as percentage of body weight (%BW).
Results
In patients who underwent OH, a significant decrease in lower anterior ground reaction force of the operative limb was observed (0.00950.013, p=0.007). Also, following OH, patients demonstrated a decrease in unilateral vertical ground reaction force when compared to the non-operative limb (0.0210.035, p=0.02). Interestingly, following OH patients balanced on their operative limb a mean 8.311.7 seconds longer in comparison to their non-operative limb (p=0.01). No significant differences were observed in the ZO cohort.
Conclusion
Statistically significant decreases in operative limb strength during unilateral calf raise and forward propulsion was observed following OH for IAT. Meanwhile, no such loss of strength was observed following ZO. While both procedures are safe and effective surgical options for managing IAT, these preliminary findings suggest ZO may allow for preserved post-operative strength relative to OH.

Strength Analysis of Open Haglund's Resection & Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy

Background: Aerobic exercise induces a range of complex molecular adaptations in skeletal muscle. However, a complete understanding of the specific transcriptional changes following exercise warrants further research. Methods: This study aimed to identify gene expression patterns following acute aerobic exercise by analyzing Gene Expression Omnibus (GEO) datasets. We performed a comparative analysis of transcriptional profiles of related genes in two independent studies, focusing on both established and novel genes involved in muscle physiology. Results: Our analysis revealed ten consistently upregulated and eight downregulated genes across both datasets. The upregulated genes were predominantly associated with mitochondrial function and cellular respiration, including MDH1, ATP5MC1, ATP5IB, and ATP5F1A. Conversely, downregulated genes such as YTHDC1, CDK5RAP2, and PALS2 were implicated in vascular structure and cellular organization. Importantly, our findings also revealed novel exercise-responsive genes not previously characterized in this context. Among these, MRPL41 and VEGF were significantly upregulated and are associated with p53-mediated apoptotic signaling and fatty acid metabolism, respectively. Novel downregulated genes included LIMCH1, CMYA5, and FOXJ3, which are putatively involved in cytoskeletal dynamics and muscle fiber type specification. Conclusions: These findings enhance our understanding of the transcriptional landscape of skeletal muscle following acute aerobic exercise and identify novel molecular targets for further investigation in the fields of exercise physiology and metabolic health.

Transcriptional Signatures of Aerobic Exercise-Induced Muscle Adaptations in Healthy Young Humans

Background: Neonates with severe forms of congenital heart disease (CHD) such as hypoplastic left heart syndrome (HLHS) are at increased risk of delayed brain development and brain injury. Disorders of the placenta have been linked to brain abnormalities in this population, but mechanisms by which the placenta increases this risk are unknown. We hypothesize that placental pathologies impact the development of cerebral autoregulation (CAR), leading to higher risk of brain injury and delayed brain development. Placental vascular malperfusion lesions may be most likely to exert deleterious effects on cerebral hemodynamics. The purpose of this study was to compare the percentage of time spent with impaired CAR during the early postnatal period in neonates with HLHS and healthy placenta versus those with histopathologic lesions of the placenta. 

Methodology: In this single center observational cohort study, we analyzed time synchronized vital sign data in neonates with HLHS born at ≥35 weeks' gestation. CAR was determined in the early postnatal and pre-operative time period using the temporal relationship between mean arterial blood pressure (MAP) and regional cerebral oxygen saturation (rSO₂). To assess intact versus impaired CAR, we used a rolling calculation of the Cerebral Oximetry Index (COx), a dynamic correlation in which values >0.3 were considered impaired CAR in accordance with prior studies. Placental pathologic diagnoses were made using Amsterdam guidelines. We used a student's t-test to determine differences between mean time spent with impaired CAR in HLHS neonates with normal versus abnormal placentas. In subgroup analyses, we compared those with normal placentas to neonates with vascular malperfusion lesions of the placenta. 

Results: In our cohort of 26 neonates with HLHS, we analyzed an average of 86 hours of continuous monitoring (range 18-153). There was a total of 18 (69%) patients with evidence of placental pathology and 8 (31%) with normal placentas. COx showed a wide range in time spent with impaired CAR between subjects (range 0-35%, Fig 1). Mean time spent with impaired CAR in those with normal placentas was significantly less than those with placental histopathology (3.0 ± 1.8% vs. 8.4 ± 9.0%; p=0.02, Fig 2). In exploratory subgroup analyses, those with vascular malperfusion lesions of the placenta had similar time spent with impaired CAR (8.8 ± 6.5%; n=5) to those with normal placentas (p=0.12). 

Conclusion: In neonates with severe forms of CHD such as HLHS, placental histopathologies may increase the risk of brain injury through disrupted development of CAR.

Placental Effects on Early Postnatal Cerebral Autoregulation in Neonates with Hypoplastic Left Heart Syndrome

Background
Transfusion during cardiac surgery is independently associated with adverse outcomes, yet no tool currently provides a validated estimate of transfusion-free aortic repair. We developed and validated a point-based clinical tool to predict the likelihood of bloodless proximal thoracic aortic aneurysm (TAA) repair and support personalized surgical planning.

Methods
We retrospectively analyzed 1,074 patients who underwent open proximal TAA repair between 2012 and 2023 at a single academic center. Bloodless operation was defined as complete avoidance of allogeneic blood products throughout hospitalization. Predictive factors were identified via multivariable logistic regression with internal cross-validation. For risk score model development, the sample was randomly divided into 4/5 training and 1/5 validation cohorts. Model performance was assessed using area under the curve (AUC), Brier score, and F-score. A point system was derived from model coefficients. Observed and predicted probabilities in the validation cohort were compared to assess accuracy.

Results
Of 1,074 patients, 668 (62.2%) received transfusion, while 406 (37.8%) achieved bloodless repair. Eight independent predictors of bloodless surgery (p<0.05) were incorporated into the scoring system: body surface area (BSA) (OR=2.429), hypertension (OR=0.679), reoperation (OR=0.526), heart failure (OR=0.617), preoperative hemoglobin (OR=1.134), extent of repair (OR=0.729), concomitant procedure (OR=0.404), and hypothermic temperature (OR=1.095). The model demonstrated strong discrimination (AUC = 0.761), calibration (Brier = 0.192), and positive predictive value (F-score = 0.758). In the point system, BSA > 1.9 m² and hemoglobin > 13.1 g/dL (8 points each) conferred the greatest positive influence, while extensive repair involving both proximal and distal extension (-8 points) conferred the greatest negative influence. Possible point totals range from -34 to 16, while observed totals in our validation cohort range from -34 to 13. The point system accurately stratified patients into three probability tiers for bloodless repair, with strong alignment between predicted and observed rates; the “unlikely” group was the most congruent.

Conclusion
This is the first validated, clinically applicable scoring tool to predict bloodless proximal TAA repair. It offers a novel, actionable framework for risk stratification in patients where transfusion avoidance is paramount, such as Jehovah’s Witnesses or those at high risk for transfusion-related complications, and may support surgical decision-making, resource allocation, and patient counseling in cardiac surgery.


Predicting Bloodless Aortic Aneurysm Repair: A Validated Scoring Tool


Background 
Coronary artery calcification, particularly in the form of calcified nodules (CN), presents a significant challenge in percutaneous coronary intervention (PCI), especially in patients with end-stage renal disease (ESRD) and acute coronary syndromes. We report a case of a 67-year-old woman with ESRD on hemodialysis, prior right coronary artery stent, and hypertension who presented with acute dyspnea and mild chest discomfort. She was hypoxic, requiring BiPAP support. Laboratory tests revealed a BNP of 1736.9 pg/mL and troponin of 580 ng/L. Chest X-ray showed pulmonary edema, and ECG demonstrated nonspecific ST changes. Initial management included IV heparin and urgent hemodialysis.

Case Presentation 
Cardiac catheterization revealed a chronic total occlusion of the proximal left circumflex artery with a prominent, heavily calcified nodule, along with a patent RCA stent. Elevated pulmonary capillary wedge pressure (28 mmHg, V wave 36 mmHg) and TEE confirmed secondary mitral regurgitation. Due to the presence of a calcified nodule—a known cause of stent underexpansion and poor outcomes—PCI was planned using advanced calcium modification strategies. Intravascular ultrasound (IVUS) was used to assess lesion morphology. Rotational atherectomy with a 1.5 mm burr debulked the lesion, followed by intravascular lithotripsy (IVL) using a 4 × 12 mm balloon (100 pulses) to fracture residual calcium. A 4 × 28 mm Megatron drug-eluting stent was deployed with optimal expansion. The patient was successfully weaned off BiPAP after dialysis and discharged on optimized heart failure therapy.

Discussion 
This case underscores the complexity of managing CNs in ESRD patients with NSTEMI and pulmonary edema. CNs are particularly resistant to conventional balloon angioplasty. A combination of IVUS-guided assessment, rotational atherectomy, and IVL enabled effective modification of both superficial and deep calcium, achieving optimal stent expansion. The strategy aligns with findings from the Disrupt CAD III trial, which demonstrated >92% success rates with IVL in severely calcified lesions. Such techniques are particularly valuable in ESRD, where vascular calcification is often severe and multifocal.


IVUS-Guided PCI Using Rotational Atherectomy and Lithotripsy for a Calcified Coronary Nodule in ESRD Presenting with NSTEMI and Pulmonary Edema

Background 
Percutaneous endoscopic gastrostomy (PEG) is frequently utilized to provide long-term enteral nutrition for patients with impaired swallowing ability. Most PEG-related complications are considered minor, such as peristomal wound infections, tube dislodgement, and leakage. Entero-colo-cutaneous fistulas are rare (0.5%-3%) but represent serious complications following PEG tube placement, particularly in patients with altered gastrointestinal anatomy. Here, we present the case of a 51-year-old female with the formation of an entero-colo-cutaneous fistula after PEG tube insertion post Roux-en-Y procedure. 

Case Presentation 
A 51-year-old woman with a medical history significant for resected anaplastic oligodendroglioma diagnosed approximately 12 years prior, refractory epilepsy, and tracheostomy dependence, previously underwent Roux-en-Y gastric bypass surgery for morbid obesity. Postoperatively, she developed chronic dysphagia, necessitating placement of a percutaneous endoscopic gastrostomy (PEG) tube for long-term enteral nutrition. Five months following PEG placement, the patient exhibited intolerance to enteral feeding. Abdominal computed tomography (CT) revealed malposition of the PEG tube, which had traversed the colon, leading to the development of an entero-colo-cutaneous fistula. The PEG was subsequently removed, and enteral nutrition was continued via a Dobhoff tube. Given her surgically altered anatomy and poor candidacy for re-intervention, PEG replacement was deferred. Although the cutaneous fistula opening closed externally, serial imaging demonstrated a persistent and progressively enlarging fistulous tract between the small intestine and colon. Medical management included acid suppression therapy to reduce gastric secretions and calorically restricted tube feeds to manage obesity-related comorbidities. 

Discussion 
Entero-colo-cutaneous fistulas are rare following PEG tube placement but are more frequently observed in patients with prior Roux-en-Y gastric bypass, primarily due to intra-abdominal adhesions that increase colonic fixation and the risk of inadvertent colonic injury during tube insertion. Additionally, gradual internal migration of the PEG tube’s internal bumper toward the jejunal limb may contribute to the development and persistence of the fistulous tract over time. Diagnosis of such fistulas can be particularly challenging as many patients remain asymptomatic for an extended period, with symptoms typically emerging only after tube dislodgement or attempted replacement. In the present case, the patient exhibited intolerance to enteral feeds five months post-PEG placement, without classic signs such as feculent vomiting or diarrhea, underscoring the variability in clinical presentation. This case emphasizes the need for heightened clinical suspicion in patients with prior gastric surgery, especially Roux-en-Y gastric bypass. Conservative management, consisting of PEG tube removal and initiation of alternative enteral nutrition, is considered for clinically stable patients. However, surgical intervention is required in cases complicated by sepsis, peritonitis, or a high-output fistula.


Entero-Colo-Cutaneous Fistula Following PEG Placement in a Post-Gastric Bypass Patient: A Rare and Challenging Complication

Background: DiGeorge Syndrome is a relatively common genetic disorder, the cardinal features of which are often remembered by the acronym, ‘CATCH-22.’ While this acronym helps highlight the medical morbidities and genetic bases of the syndrome, it tends to ignore its profound psychiatric burden. The current literature posits that approximately 70% of affected individuals have a lifetime prevalence of at least one psychiatric condition, with over one-third developing psychosis by early adulthood, making DiGeorge Syndrome the most significant risk factor for developing schizophrenia, second only to having a monozygotic twin or both parents diagnosed with schizophrenia. 

Case Presentation: We present the case of a 21-year-old female with a known diagnosis of DiGeorge Syndrome who presented with marked conceptual disorganization, delusions of reference and grandeur, pronounced grandiosity, and auditory hallucinations. The patient appeared disheveled, with an inappropriate affect, significant distractibility, and agitation, which complicated the clinical assessment. She reported her mood to be 'very bad' and endorsed ongoing suicidal ideation with intent. The patient had a complex psychiatric history with multiple psychiatric hospitalizations dating back to early adolescence, frequently complicated by medication non-adherence. The most recent hospitalization occurred one month prior, following a psychotic episode with imminent concerns for suicidal and homicidal ideation. Following a thorough psychiatric evaluation and collateral information, a diagnosis of Schizoaffective Disorder, current episode Bipolar, was established. Due to the complex presentation, the patient was started on a regimen of Olanzapine/samidorphan 200 mg and Quetiapine 300 mg. Despite this aggressive pharmacologic approach, there was limited improvement after two weeks. Therefore, given the urgency, Paliperidone Palmitate 1.5 ml was added as an augmentation agent. Additionally, her Olanzapine/samidorphan dose was increased to twice daily, and her nighttime Quetiapine dose was doubled to address the imminent risk to herself and others. Clozapine was considered unsuitable due to concerns about medication adherence and current medical morbidities. 

Discussion: DiGeorge Syndrome is the most significant molecular risk factor for schizophrenia-spectrum disorders, believed to be linked to COMT gene mutations. Psychosis in DiGeorge tends to appear early, be complex, and resistant to treatment. Its comorbidities, like hypocalcemia, disabilities, and metabolic disturbances, 
complicate care. Research shows psychosis often develops gradually, with 20-60% showing sub-threshold symptoms, allowing early intervention. With this case report, the authors aim to highlight the complex psychiatric challenges of DiGeorge and recommend comprehensive screening for early sub-threshold symptoms to enable timely intervention.

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