United States

Background: Atrial fibrillation affects 38 million individuals worldwide, with dofetilide representing a cornerstone class III antiarrhythmic therapy. Current safety protocols mandate three-day inpatient monitoring for torsades de pointes (TdP) during drug initiation. Traditional risk stratification relies on static baseline QTc measurements, which inadequately predict proarrhythmic susceptibility during incremental dosing. Critically, 24% of TdP cases occur after the initial three-day period, indicating that current approaches fail to identify risk beyond discharge. Improved risk stratification methods are needed for delayed proarrhythmic events. We hypothesized that dynamic QTc changes during dofetilide loading would demonstrate significant predictive accuracy for identifying patients at risk for adverse events.
Methods: We conducted a retrospective cohort study of 101 consecutive atrial fibrillation patients admitted for dofetilide initiation(July 2022-August 2023). The primary composite endpoint included drug discontinuation or adverse ECG parameters (QTc &gt;500ms and/or ventricular arrhythmia). Receiver operating characteristic curve analysis determined optimal QTc change thresholds. Multivariable logistic regression models, adjusted for gender, heart failure status, baseline creatinine clearance, and baseline QTc, assessed predictive value of QTc changes after sequential doses. Study limitations include single-center design and retrospective methodology potentially limiting generalizability.
Results: The cohort demonstrated median age 71.0 years (IQR 63.0-75.0), with 30.7% female participants and mean baseline QTc 440.9±32.6 ms. Forty-six patients (45.5%) experienced the composite endpoint. First-dose absolute QTc increases &gt;48.0ms demonstrated exceptional predictive performance (aOR 17.24, 95% CI 4.34-68.53, p&lt;0.001) with high specificity (83.6%) and overall accuracy (73.3%). First-dose percentage increases &gt;10.54% showed equivalent discriminatory capability (aOR 18.66, 95% CI 4.66-74.75, p&lt;0.001). Cumulative QTc changes from baseline to second dose &gt;50.0ms (aOR 11.01, 95% CI 3.32-36.47, p&lt;0.001) and &gt;11.24% (aOR 10.74, 95% CI 3.23-35.68, p&lt;0.001) maintained robust predictive associations.
Conclusion: Dynamic QTc changes demonstrate superior predictive capability compared to static baseline measurements for identifying high-risk patients, with adjusted odds ratios exceeding 10.0 for clinically actionable thresholds. These threshold-based biomarkers enable precision risk stratification that could facilitate targeted continuous mobile ECG monitoring during the vulnerable post-discharge period. Since nearly one-quarter of TdP cases occur after standard monitoring ends, dynamic QTc-guided algorithms with continuous surveillance may substantially improve patient safety outcomes while optimizing resource allocation. Prospective validation studies are warranted to establish clinical implementation protocols for this precision-based monitoring approach.

AMA Research Challenge 2025 

ECG QTc Biomarkers Predict Adverse Events During Inpatient Dofetilide Drug Loading

Welcome to the **largest national, multi-specialty research** event featuring research from more than 750 medical students, residents, fellows, and international medical graduates.

Use the buttons below or navigation menu to access the event.
<br><br><br>

[![](https://assets.underline.io/markdown_image/1/image/20e1e77aa954efeac7a15d84c85eb383.jpg)](https://underline.io/events/468/sessions?searchGroup=all)
<br>
[![](https://assets.underline.io/markdown_image/1/image/068522d81aca0b68a369787c7dfccd1b.jpg)](https://underline.io/events/468/posters?searchGroup=all)
<br>
[![](https://assets.underline.io/markdown_image/1/image/d3971ece79d5e5575b178bdc2c8bbfae.jpg)](https://underline.io/events/468/help-desk)
<br><br>

#### Event Details

The 2024 American Medical Association Research Challenge includes a poster symposium hall and a semifinals hall with the top scored research. **Log in at any time throughout the event to:**

* **View posters and presentations** on a variety of topics and specialties
* **Score posters in the semifinals** to help decide the top five finalists (AMA member exclusive opportunity)
* **Connect with participants** and provide feedback to help advance their research

At the conclusion of this event, the AMA will announce the top five finalists who will advance to the AMA Research Challenge finals, present their research to an elite panel of judges, and compete to win a $10,000 grand prize presented by Laurel Road.<br><br>

### Grand Prize Sponsor

AMA would like to thank Laurel Road for sponsoring a $10,000 grand prize for the winner of the AMA Research Challenge. Laurel Road is not involved in winner selection process. The winner will be announced on February 20, 2025 during the AMA Research Challenge finals. Payment of the grand prize will be directly from Laurel Road. See the AMA Research Challenge Official Rules for terms and conditions.

[![](https://assets.underline.io/uploads/markdown_image/1/image/611e331d4a0eba0920f240cfc04b4d77.png)](https://www.laurelroad.com/)

<br><br>

You need to log in with the email address you registered with. Access credentials have been sent to your email. 

Please be sure to check your spam and other email folders if you do not see an email confirmation right away.

Please log in to explore this event.

**There is no registration fee for this event! **

If you have used the AMA Research Challenge platform previously, please click the ‘Log-in’ button below. If you do not remember your password, please click “forgot password” and follow prompts to reset your password. After resetting your password, please refresh your webpage to access the platform.

Register to explore research in a variety of topics. AMA members get exclusive access to score posters in the semifinals. 

**Please use this link [here](https://www.ama-assn.org/member-benefits/events/ama-research-challenge) to register for free.**

Registration Is Required

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: Atrial fibrillation affects 38 million individuals worldwide, with dofetilide representing a cornerstone class III antiarrhythmic therapy. Current safety protocols mandate three-day inpatient monitoring for torsades de pointes (TdP) during drug initiation. Traditional risk stratification relies on static baseline QTc measurements, which inadequately predict proarrhythmic susceptibility during incremental dosing. Critically, 24% of TdP cases occur after the initial three-day period, indicating that current approaches fail to identify risk beyond discharge. Improved risk stratification methods are needed for delayed proarrhythmic events. We hypothesized that dynamic QTc changes during dofetilide loading would demonstrate significant predictive accuracy for identifying patients at risk for adverse events.
Methods: We conducted a retrospective cohort study of 101 consecutive atrial fibrillation patients admitted for dofetilide initiation(July 2022-August 2023). The primary composite endpoint included drug discontinuation or adverse ECG parameters (QTc >500ms and/or ventricular arrhythmia). Receiver operating characteristic curve analysis determined optimal QTc change thresholds. Multivariable logistic regression models, adjusted for gender, heart failure status, baseline creatinine clearance, and baseline QTc, assessed predictive value of QTc changes after sequential doses. Study limitations include single-center design and retrospective methodology potentially limiting generalizability.
Results: The cohort demonstrated median age 71.0 years (IQR 63.0-75.0), with 30.7% female participants and mean baseline QTc 440.9±32.6 ms. Forty-six patients (45.5%) experienced the composite endpoint. First-dose absolute QTc increases >48.0ms demonstrated exceptional predictive performance (aOR 17.24, 95% CI 4.34-68.53, p<0.001) with high specificity (83.6%) and overall accuracy (73.3%). First-dose percentage increases >10.54% showed equivalent discriminatory capability (aOR 18.66, 95% CI 4.66-74.75, p<0.001). Cumulative QTc changes from baseline to second dose >50.0ms (aOR 11.01, 95% CI 3.32-36.47, p<0.001) and >11.24% (aOR 10.74, 95% CI 3.23-35.68, p<0.001) maintained robust predictive associations.
Conclusion: Dynamic QTc changes demonstrate superior predictive capability compared to static baseline measurements for identifying high-risk patients, with adjusted odds ratios exceeding 10.0 for clinically actionable thresholds. These threshold-based biomarkers enable precision risk stratification that could facilitate targeted continuous mobile ECG monitoring during the vulnerable post-discharge period. Since nearly one-quarter of TdP cases occur after standard monitoring ends, dynamic QTc-guided algorithms with continuous surveillance may substantially improve patient safety outcomes while optimizing resource allocation. Prospective validation studies are warranted to establish clinical implementation protocols for this precision-based monitoring approach.

poster

Congratulations to all the researchers who have qualified for the AMA Research Challenge virtual poster symposium and semifinals!

Welcome to the **largest national, multi-specialty research event** featuring research from nearly 1,000 medical students, residents, fellows, and international medical graduates across six topic areas - basic science, clinical and translational research, clinical vignettes, health systems science, medical education, and public health and health policy.

#### Access the Event
Use the buttons below or navigation menu to access the event. 

[![](https://assets.underline.io/markdown_image/1/image/d4076f2146939317a29eb9f69c53ad41.png)](https://underline.io/events/506/sessions?searchGroup=all)
[![](https://assets.underline.io/markdown_image/1/image/6bcee0b523a4874c4292ca0415d88dde.png)](https://underline.io/events/506/posters?searchGroup=all)

#### Event Details
The 2025 AMA Research Challenge includes the following symposium halls:
* **Semifinals hall:** Features research from 54 medical students, residents and international medical graduates that received top scores during first round scoring. 
* **Poster symposium hall:** Features research from nearly 1,000 medical students, residents and international medical graduates categorized by topics and subtopics.

**Here’s how to participate:**
* **View posters and presentations** on a variety of topics and specialties
* **Score posters in the semifinals** to help decide the top five finalists (AMA member exclusive opportunity)
* **Connect with presenters** and provide feedback to help advance their research
* **New this year: Watch live poster presentations** by topic area and engage directly with researchers

At the conclusion of this event, the AMA announced the top five finalists who advanced to the AMA Research Challenge final round, presented their research to an elite panel of judges, and competed to win a $10,000 grand prize presented by Laurel Road.

**Addison Shenk, a fourth-year medical student from Edward Via Virginia College of Osteopathic Medicine, was the winner of the 2025 AMA Research Challenge and was awarded the grand prize of $10,000, presented by Laurel Road.**

#### A message from Dr. Bobby Mukkamala, AMA President
<div style="position: relative; width: 100%; padding-bottom: 56.25%; height: 0; overflow: hidden;">
  <iframe 
    src="https://underline.io/embed/136894-ama-video?t=0"
    title="AMA Welcome Video"
    allowfullscreen
    style="position: absolute; top: 0; left: 0; width: 100%; height: 100%; border: 0;">
  </iframe>
</div>


#### Recognized Institutions
In 2025, 1,400 abstracts were submitted across six topic areas representing 174 medical schools and more than 150 residency and health care institutions. [See if your institution is represented this year!](https://drive.google.com/file/d/1eFrTqCmCeobx9pr5drJK2hllvsIpFNOY/view?usp=drive_link)

#### Grand Prize Sponsor
AMA would like to thank Laurel Road, a brand of KeyBank, for sponsoring a $10,000 grand prize for the winner of the AMA Research Challenge. Laurel Road and KeyBank are not involved in winner selection process. The winner will be announced during the AMA Research Challenge final round. Payment of the grand prize will be directly from Laurel Road/KeyBank. See the [AMA Research Challenge Official Rules for terms and conditions](https://www.ama-assn.org/system/files/research-challenge-official-rules.pdf).

[![](https://assets.underline.io/uploads/markdown_image/1/image/611e331d4a0eba0920f240cfc04b4d77.png)](https://www.laurelroad.com/)

#### Code of Conduct
<html>
AMA has a code of conduct for its meetings – we ask all attendees to adhere to this code to participate in this year’s meeting. Please read and <a href="https://www.ama-assn.org/about/code-conduct" target="_blank">learn more here</a> about your conduct requirements.
<br><br>
	</html>
	

#### Semifinals Judges

You need to log in with the email address you registered with. Access credentials have been sent to your email. 

Please be sure to check your spam and other email folders if you do not see an email confirmation right away.

Need help? Contact us at <support@underline.io>.

If you have used the AMA Research Challenge platform previously, please click the ‘Log-in’ button below. If you do not remember your password, please click “forgot password” and follow prompts to reset your password. After resetting your password, please refresh your webpage to access the platform. 

Register to explore research in a variety of topics. AMA members get exclusive access to score posters in the semifinals. 

**Please use [this link here](https://www.ama-assn.org/member-benefits/events/ama-research-challenge) to register for free. **

Background: Seborrheic keratoses (SKs) are common benign epidermal tumors that can cause significant cosmetic concerns or irritation. Although non-malignant, their appearance often leads patients to seek removal.

Purpose of Study: The purpose of this study is to provide an updated review of current and emerging treatments for seborrheic keratosis, evaluating their effectiveness, safety profiles, and impact on patient satisfaction to guide personalized, evidence-based management.

Methods: We performed a comprehensive literature review of SK treatments published from 2000 to 2025 using PubMed and major dermatology journals. Key outcomes assessed included treatment effectiveness, recurrence rates, adverse effects, and patient-reported satisfaction.

Results: Traditional treatments—such as cryotherapy, shave excision, and curettage—remain effective but are associated with risks of pigmentary changes or scarring. Recently, non-invasive therapies like topical hydrogen peroxide 40% solution have shown promise in randomized trials, offering comparable clearance rates with minimal downtime. Laser treatments, including Er:YAG and CO₂ lasers, are effective but cost-prohibitive for some patients. Patient satisfaction is highest with treatments that minimize pain, downtime, and post-treatment pigmentation changes.

Discussion: Choice of SK treatment should consider patient skin type, lesion location, cost, and cosmetic goals. Emerging therapies provide effective alternatives to traditional destructive methods, particularly for patients concerned about scarring or dyspigmentation.

Conclusion: Management of SKs is evolving beyond traditional modalities. Newer options, such as hydrogen peroxide 40%, provide effective, well-tolerated alternatives. A personalized approach based on patient preferences and lesion characteristics optimizes outcomes and satisfaction. Further studies comparing long-term efficacy and safety across treatment options are needed.

Advances in Seborrheic Keratosis Treatment Options

Abstract Title
A Cadaveric Study Indicates That Lower Intercostal Nerves (T11 and T12) Have Sufficient Lengths and Diameters for Pudendal Nerve Coaptation

Background
Pudendal nerve injury can cause debilitating bladder and fecal incontinence and sexual dysfunction. It is known that intercostal nerves can be transferred to S2-S3 roots for functional restoration. We sought to determine the feasibility of T11 and T12 intercostal-to-pudendal nerve transfer, using a posterior approach (deep to gluteus maximus). We hypothesized the intercostals would have sufficient tensionless length and diameter for coaptation to pudendal nerves.

Methods
Twenty-one fixed cadavers (9 female, 12 male) were included. With cadavers prone, lower ribs were palpated, and T11/T12 were dissected from deep to erector spinae muscles and followed laterally. After repositioning supine, nerves were followed ventrally, freed, and “transferred” to the ischial spine. Measurements included: distance from intercostal nerve exits from erector spinae to ischial spines and to terminus, and diameters at the same landmarks. Mixed-effects model statistics were used.

Results
Distances from the erector spinae to ischial spines were longer for T11 than for T12; total lengths exceeded the distance to ischial spines; and T11 was longer than T12 (p=0.01). Mean diameters of T11/T12 at ischial spines or termini did not differ. When data was stratified by sex, distances to ischial spines were longer in males, as was T12’s total length. Male T12 nerves were wider at terminus. In cases of multiple terminal branches, at least one branch reached the ischial spine.

Conclusion
Using a posterior access, both T11 and T12 showed sufficient length and diameter to serve as donor nerves for coaptation to pudendal nerves. The diameter of each intercostal nerve at the level of the pudendal was less than the known diameter of the pudendal nerve. We suggest that T11 and T12 could be combined post-transfer for optimal restoration of end-organ function.

A Cadaveric Study Indicates That Lower Intercostal Nerves (T11 and T12) Have Sufficient Lengths and Diameters for Pudendal Nerve Coaptation

Background
Tractional retinal detachment (TRD) is a severe complication of diabetic retinopathy, but its risk factors and impact on mortality in patients with Type I (T1DM) and Type II (T2DM) diabetes remain underexplored. Given the rising prevalence of diabetes, understanding the key contributors to TRD development is critical. This study aims to identify risk factors for TRD and evaluate its effect on survival in individuals with T1DM and T2DM.
Methods
A retrospective study was conducted using the US TriNetX Network database, identifying adults with T1DM and T2DM who were diagnosed with TRD between 2010-2024. Baseline characteristics, including demographics, comorbidities, renal and glycemic labs, and use of antidiabetic medications, were collected within 1 year of diagnosis. Propensity score matching (PSM) of these characteristics was performed to compare T2DM patients with and without TRD, and the same analysis was repeated for T1DM patients. Data were expressed as n (%) or mean (standard deviation). The primary outcome was all-cause mortality over 10 years, analyzed with Kaplan-Meier curves and log-rank tests.
Results
Among 14,701 adults with TRD, 9,820 (66.8%) had T2DM and 3,903 (26.5%) had T1DM. Compared to T2DM patients without TRD (n=3,897,132), the T2DM and TRD cohort had a higher prevalence of Black race (3,172 [32.3%]), HTN (4,624 [47.1%]), adverse SDOH (176 [1.8%)]), higher A1c (8.4 [2.3]%), lower eGFR (53.0 [36.7] mL/min), and higher CRP (42.4 [68.2] mg/L) (p<0.001 for all). Similarly, the T1DM and TRD cohort exhibited higher prevalence of Black race (1,288 [33.0%]), smoking (68 [1.8%]), HTN (2,277 [58.4%]), adverse SDOH (108 [2.8%]), higher A1c (8.6 [2.2]%), and lower eGFR (52.7 [37.7] mL/min) (p<0.001 for all) compared to those with T1DM but without TRD (n=738,984) After PSM, both T2DM and T1DM cohorts with TRD exhibited worse overall survival compared to their respective control groups (log-rank χ2=162.83, p<0.001; log-rank χ2=13.56, p<0.001).
Conclusion
Adults with T1DM and T2DM diagnosed with TRD face significantly higher mortality risk compared to those without TRD, despite adjusting for covariates. Key risk factors that may contribute to TRD development include Black race, hypertension, poor glycemic control, renal dysfunction, and lower socioeconomic status. These findings underscore the need for targeted management strategies to mitigate mortality risk in patients with diabetes and TRD. Future research should assess the effectiveness of interventions addressing TRD risk factors to improve survival outcomes in this high-risk population.

Risk Factors and Mortality Associated with Tractional Retinal Detachment in Type I and Type II Diabetes

Background
Latent autoimmune diabetes in adults (LADA) is an underrecognized slowly progressive form of autoimmune diabetes that presents in adulthood and is frequently misdiagnosed as type 2 diabetes mellitus (T2DM) due to its indolent progression and overlap features of metabolic syndrome. Patients may initially respond to oral hypoglycemic agents but eventually require insulin therapy due to progressive beta-cell failure. Misdiagnosis can lead to suboptimal glycemic control and increased risk of complications, including DKA.
Case Presentation
A 60-year-old woman with asthma, hyperlipidemia, and type 2 diabetes was initially admitted to the ICU for euglycemic DKA. This occurred three weeks after a hospitalization for influenza. A–related respiratory failure. Labs in the ED revealed a high anion gap metabolic acidosis (gap 25, pH 7.2), blood glucose of 140 mg/dL, and moderate ketones, confirming euglycemic DKA. She was compliant with her medications, including empagliflozin/metformin, but was not on
insulin. Her HbA1c was 8.5%. From 2023–2025, she had eight diabetes-focused visits with consistent medication adherence. A prior GLP-1 trial was discontinued due to GI side effects. Despite nutrition counseling and lifestyle changes, her HbA1c remained between 8.5–9.3%. LADA was suspected and confirmed with positive ZnT8 antibodies. She was started on Lantus 10 units nightly and referred to
endocrinology. At follow-up, fasting glucose averaged 150 mg/dL—an improvement from baseline.
Discussion
In 2019, the WHO reclassified LADA as slowly evolving, immune-mediated diabetes in adults. It resembles adult-onset type 1 diabetes but presents with metabolic syndrome features, a single autoantibody (often GAD), and preserved β-cell function. LADA typically affects adults misdiagnosed with T2DM who test positive for pancreatic autoantibodies (GAD, IA-2, or ZnT8).
These patients initially manage without insulin but progress to insulin dependence faster than typical T2DM. The Immunology of Diabetes Society defines LADA by age ≥30, at least one positive diabetes-related autoantibody, and no insulin requirement within six months of diagnosis. C-peptide helps guide therapy: levels ≥0.7 nmol/L may allow for T2DM management, while < 0.3 nmol/L warrants full insulin therapy. SGLT-2 inhibitors, though cardioprotective in T2DM, pose a risk in LADA due to their association with euglycemic DKA. This is believed to result from increased glucagon, hepatic ketogenesis, and impaired ketone clearance. As β-cell function declines, the risk of DKA rises, similar to T1DM. Misdiagnosis of LADA as T2DM often delays appropriate treatment, increasing the likelihood of poor glycemic control and complications like DKA.

Unmasking Latent Autoimmune Diabetes: A case that challenges Type 2 Diabetes

Immune Thrombocytopenia in Pregnancy: Recognition, Risk, Response
Background
Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia, which presents unique challenges in pregnancy due to potential bleeding risks and effects on the fetus. It occurs in 1 to 2 of every 1,000 pregnancies, which is a greater rate than in the general population. Thrombocytopenia in pregnancy can be connected to different etiologies, which can have very different consequences and are treated differently. ITP is a diagnosis of exclusion, so early recognition and close monitoring are essential to optimize maternal and neonatal outcomes.
Case Presentation
A 34-year-old G4P3 woman at 14 weeks gestation with a history of Hashimoto’s thyroiditis and gluten intolerance presented with mild fatigue and dyspnea on exertion. She was being evaluated for persistent thrombocytopenia during pregnancy, with laboratory studies revealing a platelet count of 104,000/μL with otherwise normal complete blood count and peripheral smear. She was also found to have iron deficiency without anemia. This was addressed with a trial of IV iron, resulting in improvement. Platelet counts during previous pregnancies, in chronological order, were 116k, 99k, and 92k. The patient denied any
bleeding issues and previous postpartum hemorrhages. Infectious and autoimmune panels were negative, and Von Willebrand disease was ruled out. There was no evidence of vitamin B12 or folate deficiency. A diagnosis of ITP was made based on exclusion and most likely given chronicity and personal medical history of other autoimmune disease processes. Besides closely watching the trend of her platelet count throughout her pregnancy, which stayed >100k and remained asymptomatic, no intervention was needed. Her platelet count was 125k 6 months postpartum.
Discussion
ITP in pregnancy requires careful distinction from gestational thrombocytopenia and more serious etiologies such as HELLP syndrome and preeclampsia. Treatment of ITP during pregnancy is generally the same as that outside of pregnancy and is focused on reducing the risk of bleeding rather than increasing platelet count. Platelet count should be checked at least every 4 weeks up until delivery. First-line therapy is indicated if the platelet count drops to <30k and includes corticosteroids with IVIG, with possible platelet transfusion. Decisions regarding delivery method and timing depend on platelet levels and maternal- fetal status. Platelet count requirements during delivery for the following procedures are: epidural >50-80k, c-section >50k, vaginal >30k. Neonate platelet count should be taken immediately after delivery to determine if therapy is needed. This case highlights the recognition and tailored therapy for ITP in pregnancy to ensure favorable outcomes.

Immune Thrombocytopenia in Pregnancy: Recognition, Risk, Response

Paget-Schroetter Syndrome is a form of upper extremity deep vein thrombosis that typically affects young, healthy individuals following repetitive arm movements or strenuous activity. It results from compression of the subclavian vein at the thoracic outlet, often due to anatomical abnormalities like a cervical rib or hypertrophied muscles. This compression can lead to vein injury and clot formation. Early diagnosis and treatment—including anticoagulation, possible thrombolysis, and surgical decompression—are important to prevent long-term complications.

A 39-year-old woman with a medical history of migraines and who uses a hormonal contraceptive vaginal ring presented to her physician with a swollen, discolored right arm. She reported right arm weakness for the past three months, and over the preceding week, she had noticed increased tightness in her sleeve along with numbness. Due to concern for deep vein thrombosis (DVT), point-of-care ultrasound (POCUS) was performed, revealing a thrombus in the subclavian and axillary veins. A formal ultrasound confirmed an occlusive thrombus in these veins, raising suspicion for Paget-Schroetter Syndrome. A CT scan of the chest was unremarkable. She started apixaban and referred to Interventional Radiology (IR). Venography performed by IR demonstrated high-grade stenosis of the distal subclavian vein at the level of the first rib, confirming the diagnosis. Successful angioplasty was performed. It was at that time that she was referred to vascular surgery. The patient ultimately underwent first rib resection and scalenus anticus resection to address a cervical rib contributing to the compression.

Tight Sleeves and Silent Stenosis: A Vascular Surprise

Clinical Implications of a Left Vertebral Artery Arising from the Aortic Arch
M. Culligan, D. Taneja, A. Charles, K. Thurmann, A. O’Neill, L. Suh, B. Wang, D. Taneja

Background: The left and right vertebral arteries typically originate as the first branches of the left and right subclavian arteries, respectively. Variations in their origin are fairly rare, with the left vertebral artery (LVA) arising as a fourth branch directly off the aortic arch in approximately 3.6-5.5% of the population. LVA abnormalities have the potential to complicate surgical and diagnostic procedures of the neck and surrounding vasculature. 

Case Presentation: During a cadaveric dissection of a 71-year-old female in the anatomy lab at Creighton University School of Medicine - Phoenix, the left vertebral artery was observed originating directly from the aortic arch, between the origins of the left common carotid artery and left subclavian artery. The LVA extended superiorly before entering the transverse foramen of the C5 vertebra. The LVA’s prevertebral length was 93.5mm, compared to 37.8mm for the right vertebral artery (RVA), which entered the spine at C6. The diameters at the base of the LVA and RVA were 2.7mm and 2.1mm, respectively. The brachiocephalic trunk and RVA branching from the right subclavian artery were anatomically unremarkable. Of note, an ependymal cyst in the left parietal lobe was discovered in a previous dissection of this cadaver, who was noted to have a history of epilepsy. 

Discussion: A LVA of aortic arch origin is classified as a Type III aortic arch abnormality. Type III LVAs tend to ascend medially and have a longer course prior to entering the transverse foramen of the vertebrae. This longer, and often more tortuous, prevertebral course can predispose patients to a greater risk of vertebral artery dissection, which presents with headaches and other neurological symptoms. The increased prevertebral, medially-running course also poses increased risk for complications such as hemorrhage, neurological deficits, and even death during anterior approach cervical spinal surgeries. Clinicians unaware of a LVA abnormality while attempting a carotid artery stent or aortic arch procedure could inadvertently occlude the LVA and cause cerebral ischemic effects. In catheterization and other diagnostic studies, a Type III LVA could be incorrectly considered occluded and subject to unnecessary treatment. Obtaining computed tomography angiography or magnetic resonance imaging studies to identify an abnormality prior to a procedure can prevent misdiagnosis and reduce the risk of vertebral artery damage and downstream complications. 


Clinical Implications of a Left Vertebral Artery Arising from the Aortic Arch

Background
Terminal extubation, or palliative or compassionate extubation, is a legally and ethically accepted practice in the US where mechanical ventilation is withdrawn when ongoing life-sustaining treatment no longer aligns with a patient’s goals of care, with nearly 42% of ICU deaths involving withdrawal of such measures. Despite its legal acceptance, it remains a nuanced decision, particularly in patients with spinal cord injury (SCI). Approximately 18,000 new SCIs occur annually in the US, with respiratory failure being the leading cause of death. While extubation protocols exist, there are none specific to the SCI population. Discussions around goals of care and prognosis for patients with SCI may be complicated by quality of life (QOL) concerns and potential ableist bias when physical dependence is misinterpreted as incompatible with meaningful life. Here, we present a case of an older adult with cervical SCI who requested terminal extubation following prolonged hospitalization.

Case Presentation
An 88-year-old male with a history of hypertension and prostate cancer sustained a traumatic high cervical SCI with craniocervical subluxation and multiple associated injuries. He required mechanical ventilation and underwent tracheostomy after developing respiratory failure and pneumonia, and his hospital course was further complicated by pneumonia, pressure injuries, and persistent ventilator dependence. Psychiatric evaluation initially raised concerns for depression and adjustment disorder, though he expressed a consistent, clear expression of a wish not to live ventilator-dependent. Over weeks across multiple care settings, he reaffirmed this wish. After comprehensive interdisciplinary assessment confirming decision-making capacity, and with strong family support, he elected for hospice care. Supported by his family and palliative care team, he was extubated and passed 48 hours later. 

Discussion
This case illustrates the complex intersection of autonomy, capacity, and ethics in end-of-life decisions for patients with SCI. Withdrawal of nonbeneficial life-sustaining treatment is ethically distinct from physician-assisted dying and aligns with guidelines from the American Academy of Hospice and Palliative Medicine, and the patient’s final decision was expressed consistently over time and across settings with concerns about mood disorders impairing decision-making carefully evaluated. SCI presents unique challenges to autonomy, especially when provider bias may influence care framing. QOL judgements must be patient-centered, informed by lived experience rather than assumptions. Physiatry plays a crucial role, offering prognostic insight and advocating for patient-centered goals. As terminal extubation becomes more common in ICU care, cases like this highlight the need for ethical, patient-centered approaches to end-of-life decision making.

Respecting Patient Autonomy in the Context of Terminal Extubation: A Case Report and Ethical Analysis

Introduction
Massive pulmonary embolism (PE) is a life-threatening condition that can present with cardiovascular collapse and cardiac arrest. Rapid recognition and timely intervention are crucial for improving patient outcomes. This case highlights a unique stepwise treatment approach, where systemic thrombolysis with tenecteplase (TNK) was initially administered, followed by catheter-directed thrombolysis (CDT) using the EkoSonic Endovascular System (EKOS), a strategy not commonly reported in the literature.
Case Presentation
A 69-year-old male with a history of class III obesity (BMI 43), untreated obstructive sleep apnea, non-insulin-dependent type II diabetes mellitus, and chronic lymphedema presented to the emergency department after a fall at a gas station. Emergency medical services (EMS) responded and found the patient severely short of breath. While being transported, he became unresponsive and was found to be in pulseless electrical activity (PEA) arrest, necessitating cardiopulmonary resuscitation (CPR). Return of spontaneous circulation (ROSC) was achieved before intubation, and the patient arrived at the emergency department with tachycardia, hypotension, and oxygen saturation of 96% on a non-rebreather mask.
Given the hemodynamic instability and history of sudden cardiovascular collapse, an emergent computed tomography (CT) angiogram of the chest was performed, revealing bilateral massive pulmonary emboli with right heart strain. Two rib fractures, likely secondary to CPR, were also noted. A transthoracic echocardiogram demonstrated a normal ejection fraction (55%) with a moderately enlarged right ventricle, McConnell’s sign, and moderate-to-severe tricuspid regurgitation consistent with right heart strain. A diagnosis of acute bilateral PE with cor pulmonale was made..
Given the patient’s unstable hemodynamics and contraindications to full-dose thrombolysis, cardiology was consulted for EKOS catheter-directed thrombolysis. However, at that time, he was deemed unsuitable for the procedure. Instead, he received half-dose systemic TNK (50 mg) due to concerns over his rib fractures. He was started on intravenous heparin and admitted to the intensive care unit for close monitoring.
Despite initial improvement in oxygenation, the patient developed worsening hypotension requiring increasing doses of norepinephrine. Due to persistent hemodynamic instability, the decision was made to proceed with EKOS catheter-directed thrombolysis. The catheter was placed for direct administration of tissue plasminogen activator (tPA) into both pulmonary arteries. The patient tolerated the procedure well, with subsequent hemodynamic stabilization and improved blood pressures. He was transitioned from heparin to apixaban and vasopressor support was weaned. Patient was discharged home shortly after in stable condition.
Discussion
This case underscores the effectiveness of EKOS catheter-directed thrombolysis in treating massive PE, particularly in patients with contraindications to full-dose systemic thrombolysis. While TNK served as an initial bridge to slow clot progression, hemodynamic deterioration necessitated escalation to EKOS, which successfully facilitated clot resolution. The use of ultrasound-assisted CDT offers the advantage of lower thrombolytic doses with enhanced clot penetration, reducing the risk of bleeding while achieving rapid hemodynamic stabilization. This case highlights the importance of considering EKOS as a definitive intervention in high-risk PE cases, particularly when systemic thrombolysis alone proves insufficient.
This case underscores a novel treatment approach combining systemic TNK followed by EKOS-directed CDT in a patient with massive PE. This strategy may offer a balanced approach in select patients, allowing for initial clot lysis with reduced bleeding risk while preserving the option for targeted intervention. Multidisciplinary collaboration remains essential in optimizing outcomes for this high-risk population.


Sequential Thrombolysis with Tenecteplase Followed by EKOS in Massive Pulmonary
Embolism

Abstract Title: A Cross-Rank Analysis of Gender Disparities in Promotional Salary Scaling in Academic Medicine

Background
Gender-based disparities remain persistent and widespread throughout academic medicine. Recent studies show that women are less likely to be promoted from assistant to associate professor, from associate to full professor, and to department chair. Women also receive unequal compensation in nearly all specialties, with differences primarily originating from lower starting salaries. Though the differences in advancement and salary have been examined prior, there is 
still more to learn about the differences in promotional salary scaling – that is, the relative increase in salary with advancement in academic rank – between genders. This study investigates that comparison.

Methods
We analyzed gender-based differences in salary increases using data from the AAMC 2023 Fiscal Year Report, which includes summary statistics (mean, SD, and count) on total compensation for MD or equivalent faculty. Salary data were analyzed across academic ranks from instructor to chair in both “Total Medicine” and “Total Surgery.” Z-statistics were used to compare differences in promotional salary increases between male and female faculty. To estimate average percent 
change differences and 95% confidence intervals, we conducted 10,000 parametric bootstrap simulations using the reported summary data at each promotion level. All z-tests were two-sided with significance set at p<0.05.

Results
After conducting the simulations in Total Medicine, between instructor to assistant professor (n=13,358) men received an average raise $30,952 higher than women (95% CI: $19,844–$42,060; p<0.001). There was also a mean difference of $10,160 (95% CI: $1,735–$18,585; p=0.018) from assistant to associate professor (n=17,410). Simulated percent change in salary from instructor to assistant professor showed a 10.5% advantage for men (95% CI: 4.95–16.49%). In Total Surgery, there were also higher raises on average for men compared to women. From assistant to associate professor (n=6,833), the difference was $29,332 (95% CI: $3,708–$54,957; p=0.025). From professor to chief (n=2,874), it was $89,462 (95% CI: $5,308–$173,616; p=0.038). However, when looking at the simulated percent changes in salary, there was no statistically significant change between genders at any promotional level. 

Conclusion
While no consistent disparities in promotional salary scaling were observed across all ranks or specialties, a significant gender-based difference in relative salary increase was identified at the instructor-to-assistant professor level in medical subspecialities. This early-career inequity may 
contribute to long-term salary divergence, which is well-documented. These findings also highlight the need to examine how initial promotion practices shape broader patterns of compensation inequality in academic medicine.

Premium content

Next from AMA Research Challenge 2025

Advances in Seborrheic Keratosis Treatment Options

Similar lecture

Long QT type 7 (Andersen Tawil Syndrome): Is the QTc prolongation associated with higher odds of developing life-threatening arrhythmias or cardiac arrest?