United States

Abstract Title: Unmasking Tuberculosis: A Case of Pericardial Effusion in a Young Adult with Recurrent Pneumonia
Background
Tuberculosis (TB) remains a major global health concern. While pulmonary TB is the most common manifestation, extrapulmonary tuberculosis (EPTB), particularly involving the pericardium, can lead to life-threatening complications such as cardiac tamponade. TB pericarditis accounts for 1–2% of TB cases and is a leading cause of large pericardial effusions and constrictive pericarditis in developing countries. Diagnosis can be challenging in immunocompetent patients without classic TB symptoms.
Case Presentation
A 25-year-old Indian male with no significant past medical history presented to the emergency department (ED) with a two-week history of productive cough and pleuritic chest pain. He had previously presented to the ED five days prior and was discharged against medical advice with azithromycin, which offered minimal relief. On readmission, he was diagnosed with multifocal pneumonia and started on intravenous antibiotics before being discharged on oral therapy. He returned one month later with worsening respiratory symptoms. Imaging revealed a left-sided pleural effusion and a large pericardial effusion. Echocardiogram confirmed tamponade physiology. A CT chest also demonstrated cavitary lesions in the left upper lobe. Pericardial window was performed, yielding 1 liter of clear pericardial fluid. Sputum acid-fast bacilli (AFB) smear was strongly positive, confirming Mycobacterium tuberculosis infection. The patient was started on RIPE therapy and TB control authorities were notified.
Discussion
This case illustrates a rare but critical presentation of extrapulmonary tuberculosis as pericardial effusion with tamponade physiology in a young, immunocompetent adult without classic constitutional symptoms. Initial misdiagnosis as community-acquired pneumonia delayed TB-specific testing and treatment. This highlights the need to maintain high clinical suspicion for TB in patients with recurrent pneumonia, pleural or pericardial effusions, especially those with epidemiologic risk factors such as prior travel to endemic areas. Early chest CT and echocardiography were key in identifying extrapulmonary involvement, prompting timely intervention. Pericardial TB, though rare, carries significant morbidity if undiagnosed and should be considered in patients with unexplained pericardial effusions. Comprehensive evaluation including imaging and microbiological studies is crucial for timely diagnosis and management to prevent complications and reduce disease transmission.

AMA Research Challenge 2025 

Unmasking Tuberculosis: A Case of Pericardial Effusion in a Young Adult With Recurrent Pneumonia

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A mild traumatic brain injury (mTBI) is defined as an injury to the brain due to sudden changes in velocity or blunt force trauma to the head, such as during a motor vehicle accident (MVA). Common sequelae include headaches, cognitive deficits, fatigue, and behavioral changes. The temperature of brain tissue during the time of injury has shown to affect outcomes of mTBI. Prior studies have found that the thalamus, hippocampus, cerebellum, and amygdala are particularly susceptible to heat damage. We investigated possible relationships between average temperature and humidity in relation to size values of the amygdala, hippocampus, cerebellum, and thalamus of patients with a history of mTBI. NeuroQuant software was used to analyze MRIs from 430 participants who experienced an mTBI from an MVA in the Las Vegas area. Historic temperature and humidity data was then sourced from the NCDC online database and the Visual Crossing weather database. Data was then compared across categorized temperature and humidity levels for the hippocampus, amygdala, thalamus, and cerebellum using Mood’s median test. Significant differences in total percent of ICV between temperature ranges were not observed for the brain regions of interest. Moderate statistical evidence for an effect was found between the hippocampus and humidity levels (Ꭓ2 = 7.06, p-value = 0.07). The results of our analysis suggests that temperature and humidity at the time of injury may not have a significant impact on post mTBI brain region size.


Exploratory Analysis of Environmental Factors and NeuroQuant MRI Data in Patients With History of mTBI From MVAs


Background: Although thousands of clinical trials are underway in cell and gene therapy (CGT), clinical adoption remains limited due to insufficient cell tracking data. Here, we are developing a novel genetically encoded (GE) reporter system that uses hyperpolarized (HP) magnetic resonance spectroscopic imaging (MRSI) to image metabolically active CGT. HP-MRSI allows for a 10^6-fold increase in signal intensity over traditional MR, while also enabling longitudinal detection of viable cells.
Methods: We engineered a system that includes a MR-compatible, highly specific enzyme-substrate pairing incorporating porcine liver esterase (PLE) and a 1-methyl-cyclopropyl protecting group on an ester. PLE cleaves these substrates without background hydrolysis by endogenous esterases. We genetically modified three hepatocellular carcinoma (HCC) cell lines (SNU-398, SNU-449, Huh7) and HEK293t controls to constitutively express PLE with dTomato. A PLE-flank tumor model of HCC was established using subcutaneous implantations of the GE cells. Toxicity was assessed with chemiluminescent viability assays, and in vitro enzyme kinetics were evaluated using UV-Visible spectroscopy, mass spectrometry, and HP-NMR for several PLE substrates. Natural abundance HP-NMR was used to determine which carbons are suitable for isotopic labeling based on polarizability with dynamic nuclear polarization MRSI, long T1 relaxation times, and sufficient metabolism.
Results: GE HCC and control cell lines tolerated substrate concentrations up to 10mM in cellulo without cytotoxic effects. The cell lines grew phenotypically normal flank tumors, and IVIS imaging confirmed dTomato expression. Michaelis-Menten analysis indicated sufficient PLE hydrolysis of all four substrates. Natural abundance HP-NMR revealed that substrate #4 had the fastest hydrolysis by PLE and is amenable to isotopic labeling, with sufficient T1 relaxation times and metabolism at both the carbonyl and quaternary cyclopropyl carbon. Substrate #4 also demonstrated in vivo compatibility with mouse plasma, as plasma solutes did not interfere with the compound’s T1 relaxation time.
Conclusion: Using kinetic evaluation and natural abundance HP-NMR, the proof of concept was validated that small cyclopropane ester molecules can serve as metabolic HP reporters in a system with PLE. The in vivo functionality of the system will be determined in the murine flank tumor model to demonstrate the potential of using this HP reporter system as a means of monitoring CGT. We plan to employ a functional HP reporter system to monitor delivery efficacy and therapeutic impact of an electroporation-based suicide gene delivery to HCC tumors. When administered as a prodrug, the HP reporter will facilitate tracking of enzymatic activity by the suicide gene and approximation of levels of intra-tumoral cell death.

Hyperpolarized MRI reporter for improved tracking of hepatocellular carcinoma gene therapy

Background: The combination of xanomeline, a central/peripheral muscarinic agonist, and trospium chloride, a peripheral muscarinic antagonist, (X/T) was FDA approved in September 2024 for schizophrenia in adults. X/T is the first medication indicated for schizophrenia psychosis that is not classified an “antipsychotic” by FDA as it reduces presynaptic dopamine without blocking or partially blocking postsynaptic dopamine receptors. FDA trial subjects with schizophrenia and no comorbidities experiencing an exacerbation or relapse of psychosis, who were neither treatment-resistant nor had taken clozapine, were tapered off previous antipsychotics, or were treatment-naive, prior to a rapid X/T titration in the hospital as monotherapy. Xanomeline is an intestinal CYP3A4 inhibitor that can transiently elevate 3A4 substrates, and CYP2D6 inhibitors can raise xanomeline levels and duration. However, for outpatient practitioners, the generalizability of the studied population and the treatment protocol is limited, leaving many real-world clinical questions about how to use X/T when comorbidities with schizophrenia are the rule, polypharmacy is commonplace, and discontinuing antipsychotics prior to X/T initiation is often infeasible due to safety concerns, such as psychotic relapse with potential risks to self or to others, in less supervised community settings.
Case Presentation: Based upon our early experience treating 40 adult outpatients with schizophrenia and comorbidities using X/T to date, we present 3 representative cases that are reflective of this cohort to illustrate clinical pearls we have uncovered through applying extant pharmacokinetic and pharmacodynamic preclinical and clinical data. Case 1 is an 18-year-old male with autism spectrum disorder and recent onset of schizophrenia, refractory to risperidone and aripiprazole plus benztropine for akathisia. Case 2 is a 45-year-old female with treatment-resistant schizophrenia on olanzapine with cardiometabolic side effects, gastroparesis, and tardive dyskinesia. Case 3 is a 75-year old female with clozapine-resistant schizophrenia, Alzheimer’s dementia, and obsessive compulsive disorder (OCD) on fluoxetine.
Discussion: To maximize efficacy while ensuring tolerability, it is important to track cholinergic (e.g. nausea, vomiting, diarrhea) versus anticholinergic (e.g. gastroesophageal reflux, constipation, urinary retention) side effects, and to adjust X/T dose, titration, administration, and concomitant medications accordingly. In addition to addressing positive, negative, and cognitive symptoms of schizophrenia, X/T holds potential to improve cognitive deficits in comorbid autism or dementia, OCD, tics, addictions, and ameliorate cardiometabolic side effects, gastroparesis and tardive dyskinesia symptoms associated with antipsychotic medications.

Xanomeline and trospium chloride for schizophrenia in adults: early outpatient experience

Background: Nailfold capillaroscopy (NFC) is an essential tool for evaluating microvascular abnormalities in patients with Raynaud’s phenomenon (RP), especially in United States (U.S.) Veterans. While dermatoscopy is an acceptable and cost-effective screening method for nailfold assessment in systemic sclerosis (SSc), published guidelines highlight the importance of clear image acquisition for appropriate interpretation. The objective of this project was assessment of NFC in patients with concern for connective tissue disease (CTD)-related RP to determine whether pigmentation of the skin impacts the interpretability of dermatoscopy screening.

Methods: Patients undergoing evaluation for CTD-related RP were consented for participation in Institutional Review Board approved research at the time of care at the Veterans Affairs (VA) Hospital (No. 1618579-17). Patients were prepared for NFC per published protocols. Images were obtained with two devices available at the VA Hospital, a dermatoscope attached to a smartphone (200X magnification, smart phone focus) and Smart G-Scope (250X magnification, USB automatic focus). Each image was classified for the clarity of image by two capillaroscopy experts. Microvascular findings for capillary density, apical enlargement, hemorrhages, and abnormal shapes were determined by the capillarscopy.io software application.

Results: A total of 38 U.S. Veterans were assessed for RP by NFC using clinically available two devices. Among these, 28% (n=11) of subjects were classified as African American. Dermatoscopy produced blurry images in 63.6% (7/11) of patients with Fitzpatrick skin type IV and V and 37% (10/31) in Fitzpatrick skin type I, II, and III. In 45.5% (5/11) of dermatoscopy exams in Fitzpatrick skin type IV and V skin were deemed uninterpretable compared to 37% (10/31) of Fitzpatrick skin type I, II, and III (kappa statistic >0.9). Smart G-Scope improved interpretability across the cohort of patients, especially in Fitzpatrick Skin Types IV and V. A scleroderma (SD)-pattern characteristic of scleroderma microangiopathy was detected by the Smart-G-scope in 3 of those 5 uninterpretable dermatoscope acquired images.

Conclusion:In patients with CTD-related RP, particularly among African American Veterans, a dermatoscopy device led to a high rate of uninterpretable examinations. The Smart-G USB device improved diagnosis of abnormal NFC. These results highlight that reliance on dermatoscopy alone as a screening tool may risk underdiagnosing microvascular involvement in SSc.

Dermatoscopy Limitation and the Critical Role of Capillaroscopy in Systemic Sclerosis and Raynaud’s Phenomenon among African American Veterans

ABSTRACT Background: Managing complex coronary artery disease in post-CABG patients remains challenging due to diffuse calcification, prior graft failure, and high surgical risk. Calcium modification with rotational atherectomy (RA) and intravascular lithotripsy (IVL) offers a novel hybrid approach to achieve optimal stent expansion and durable outcomes.
Case Summary: A 68-year-old male with prior CABG (LIMA–LAD patent, SVG–OM occluded) presented with CCS Class III angina. Coronary CTA demonstrated extensive multivessel calcific CAD (Agatston score 3120). Angiography revealed 80% distal LM stenosis extending into the ramus and LCx ostia, and an LCx ostial CTO (Syntax score 31). The patient underwent IVUS-guided PCI using a combination of RA (1.5 mm, 1.75 mm burrs) and IVL (3.5 × 12 mm balloon) to treat the LM bifurcation, followed by sequential DES implantation via the mini-crush technique. Post-PCI, TIMI 3 flow was achieved in all vessels with no procedural complications.
Outcome: The patient had an uneventful recovery and was discharged on dual antiplatelet and guideline-directed medical therapy. At one-month follow-up, he remained asymptomatic with preserved LV function.
Conclusion: This case highlights the efficacy of combined RA and IVL for calcium modification in complex LM bifurcation PCI and demonstrates that IVUS-guided multivessel PCI can be safely and effectively performed in post-CABG patients where surgical re-intervention carries prohibitive risk.
Keywords: Rotational Atherectomy, Intravascular Lithotripsy, Left Main PCI, Chronic Total Occlusion, Post-CABG, Intravascular Ultrasound

Triple Triumph-Multivessel PCI with RA and IVL for LM, Ramus & LCxCTO in Post-CABG Patient

INTRODUCTION: GLP-1 receptor agonists have gained widespread use in recent years due to their efficacy in managing type 2 diabetes and promoting weight loss. However, their association with acute pancreatitis remains a concern, particularly in patients with complex comorbidities. This case report describes a 74-year-old male with a significant medical history—including chronic lymphocytic leukemia, breast cancer, and multivessel coronary artery disease—who developed acute pancreatitis attributed to the GLP-1 agonist combination therapy, Soliqua (lixisenatide and insulin glargine).
CASE PRESENTATION: We followed this patient during his hospitalization at Medical City Fort Worth and subsequent follow-up visit. Informed consent was obtained, and relevant clinical data and imaging were collected from his medical chart. The patient initially presented to Medical City Weatherford with acute epigastric pain. CT imaging confirmed a diagnosis of acute pancreatitis, suspected to be induced by Soliqua. He was admitted for three days and treated supportively.
One week later, during a routine preoperative evaluation for coronary artery bypass grafting (CABG) at Medical City Fort Worth, the patient reported new-onset fatigue. Concern for gastrointestinal bleeding prompted an emergency department evaluation. Upper endoscopy revealed hemosuccus pancreaticus (HS), characterized by blood in the duodenum—a rare complication of pancreatitis. Although CTA did not show evidence of a pseudoaneurysm, active ampullary bleeding consistent with HS was observed.
RESULTS: Soliqua was discontinued following the pancreatitis diagnosis. At his post-discharge follow-up, the patient reported improved energy levels, a return of appetite, and resolution of gastrointestinal symptoms. His clinical course underscores the potential for serious gastrointestinal complications related to GLP-1 agonist therapy, particularly in medically complex individuals.
CONCLUSION: This case highlights the importance of careful risk-benefit assessment when prescribing GLP-1 agonists, especially in patients with significant comorbid conditions. Clinicians should remain vigilant for signs of pancreatitis and its rare but severe complications, such as hemosuccus pancreaticus. Early recognition and appropriate management are essential to preventing morbidity in this growing population of patients treated with incretin-based therapies.

Hemosuccus Pancreaticus: Acute Pancreatitis Caused by GLP-1 Agonism


Nepal continues to face problems with the migration of its medical graduates both abroad and into major urban centers like Kathmandu Valley, worsening the already uneven distribution of doctors across the country. Despite years of expanding medical education with the goal of improving rural healthcare access, many graduates choose opportunities overseas or in cities, leaving rural and remote areas underserved. Understanding where Nepali medical graduates are practicing, and why, is essential for developing effective strategies to retain them and strengthen
Nepal’s healthcare system. A descriptive cross-sectional survey was conducted from June 2023 to January 2025 among 1,208 Nepali medical graduates (both undergraduate and postgraduate levels) using a self-constructed electronic questionnaire. Participants were recruited through online platforms and alumni networks across all medical colleges in Nepal. Among the 1,208 respondents, 75.3% were male and 24.7% female, with a steady rise in female representation over
time from 8.1% before 2000 to 37.4% after 2020. The majority (67.8%) graduated from Tribhuvan University. Overall, 66.8% were practicing in Nepal, while 33.2% worked abroad, predominantly in the United States (74.31% of those abroad). Within Nepal, 62.3% of graduates were working in Kathmandu Valley, with Bagmati Province hosting the highest number of doctors. Male graduates were more likely than females to work outside Kathmandu Valley. A significant association was found between graduation year and current practice location (p <0.0001), with post-2020 graduates showing the highest retention in Nepal. Gender disparities, university affiliation, and graduation year significantly influenced practice location. Addressing these challenges will require targeted policies that improve rural incentives, expand postgraduate opportunities outside urban centers, and create supportive, gender-sensitive work environments.

Geographical distribution and career preferences of Nepali medical graduates - A cross sectional study

Objective: Health disparities in gynecology are understudied. Racial and ethnic minorities are less likely to receive minimally invasive hysterectomies and more likely to have surgical complications, and this gap is not fully explained by patient or health system factors. Socioeconomic status (SES) influences preventive care access and surgical outcomes, and may explain this gap. Higher Distressed Communities Index (DCI), a composite SES measure, is associated with worse outcomes in general surgery populations. We hypothesized that higher DCI scores would be associated with worse risk-adjusted outcomes and higher healthcare resource utilization after gynecologic surgery.

Design: This was a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Gynecology Collaborative database. Generalized linear mixed-effect models and linear mixed-effect models were used to evaluate the association between Distressed Community Index (DCI) scores and surgical outcomes, with institution treated as a random effect and models adjusted for the ACS-NSQIP predicted probability of morbidity score.

Six ACS-NSQIP Gynecology Collaborative sites in the United States, between January 1, 2018, and June 30, 2023. Adult patients undergoing gynecologic operations during the study period. Patient records including ZIP Code data were merged with DCI scores ranging from 0 (low distress) to 100 (high distress), with DCI >75 identifying distressed communities.

No therapeutic interventions were applied. Exposures of interest were community-level distress as measured by DCI. The primary outcome was a composite measure of postoperative morbidity. Secondary outcomes included markers of resource utilization (length of stay, discharge to nursing facility, and hospital readmission) and comparisons of outcomes between oncologic and benign procedures.

Results: Patients with DCI>75 had a higher mean BMI (32.5 vs 30.6, p<0.001) and greater burden of comorbidities, as represented by a larger number of patients with ASA classification >2 (42.6 vs 35.7%, p<0.001). In unadjusted analyses, the DCI>75 group exhibited a higher ACS-NSQIP predicted probability of morbidity (6.4 vs 5.7%, p<0.001), a greater composite outcome rate of postoperative complications (7.6 vs 6.3%, p=0.040), and a higher rate of cancer diagnosed during the operative procedures (35.7 vs 28.6% p<0.001). Patients with DCI>75 also experienced longer mean length of stay in the hospital (1.5 vs 1.3 days, p<0.001).

In generalized linear mixed-effect models and linear mixed-effect models, DCI, whether modeled continuously or dichotomized at > 75, was not independently associated with patients’ postoperative complications, discharge destination, need for unplanned surgical revision, need for unplanned hospital readmission, postoperative infection, hospital length of stay, or length of operative duration. When stratified by postoperative cancer status, DCI >75 was not associated with composite complications in univariable or adjusted analyses.

By contrast, each 1% increase in ACS-NSQIP predicted probability of morbidity maintained strong associations with higher composite postoperative complication odds (OR 1.12, 95% CI 1.11-1.14, p<0.001) and longer hospital stays (p<0.001). DCI showed a weak positive Spearman correlation with NSQIP-predicted morbidity (ρ = 0.090), indicating slightly higher estimated risk with higher DCI scores.

Conclusion: In our multicenter cohort, DCI showed no independent association with postoperative outcomes in multivariable analysis. Future research should include samples with higher proportions of participants from highly distressed communities, as well as more precise SES measures (income, education, neighborhood), since ZIP code-based indicators may lack granularity. Such efforts could enhance individual risk stratification and targeted interventions. Linking clinical and community data is promising, but success requires rigorous harmonization, quality control, and methodological refinement.

A National Analysis of Community Level Socioeconomic Status and Surgical Outcomes in Gynecologic Surgery

Background
Social media plays a significant role in patient education as about 80% of US internet users obtain health information online. YouTube is a popular search engine amongst people looking for dermatologic advice. Our study assesses the content on homeopathic remedies for non-melanoma skin cancers available on YouTube.

Methods
We searched YouTube in a private browsing tab for “natural skin cancer remedies,” “alternative skin cancer treatment,” and “holistic skin cancer treatment” in separate searches. The top 40 videos meeting inclusion criteria in each search were analyzed. For data extraction, the video characteristics, engagement metrics and content themes were recorded. Duplicates were removed.

Results
61 videos were analyzed in total. 36.1% of the videos were created by homeopathic YouTube channels, 32.8% by laypeople and/or influencers, 18% by physicians and pharmacists, 6.7% by news channels and 6.7% by other personnel. The 10 most frequently mentioned remedies included green tea (19.7%), turmeric/curcumin (19.7%), coconut oil (14.8%), black salve (11.5%), apple cider vinegar (11.5%), baking soda (11.5%), garlic (11.5%), frankincense oil (9.8%), eggplant (9.8%) and milk thistle (9.8%).

Conclusion

Although most videos were created by homeopathic channels, they had the lowest engagement. Videos created by healthcare professionals achieved significantly higher engagement. Thus, even when seeking natural remedies on social media, viewers prefer content created by professionals. There is some existing literature on the role the recommended remedies play in preventing and/or treating skin cancers.

Dermatologists should be aware of the various at-home therapies patients may try for their skin cancer. They should consider creating their own reliable and accurate social media content to educate the public about the risks of these dangerous trends and emphasize the importance of seeking evaluation for suspicious skin lesions.


Alternative Treatments for Non-melanoma Skin Cancers on YouTube: A Cross-
Sectional Analysis

Trust and Transparency in Teaching: Medical Student Attitudes Toward Educator AI Use

Background:
Generative artificial intelligence (AI) is rapidly transforming medical education by offering teaching and learning tools. As AI becomes integrated into academia, it is often used by educators without clear guidelines or etiquette. Understanding how key shareholders, particularly students, perceive educator AI use is increasingly important to develop best practices that center the learner. We aimed to explore student perceptions of faculty AI use to understand learner concerns and use these insights to guide recommendations for responsible faculty AI use.

Methods:
We conducted a mixed-methods study at the University of Louisville School of Medicine using surveys and semi-structured interviews to investigate student perceptions of faculty AI use in medical education. Surveys were distributed to medical students and asked respondents to rate AI use for various educational activities that have been described/recommended in the medical education literature. These results were summarized with descriptive statistics. Online, semi-structured interviews with student and faculty participants were then completed to explore the topic more in-depth. We used thematic analysis with two coders as part of a grounded theory approach to analyze transcripts with the qualitative software Dedoose.

Results:
Sixty-nine students participated in the survey, with 83% reporting prior AI use themselves. Students expressed significant concern with faculty using AI to create exam questions (56%), write clerkship evaluations (63%), and compose letters of evaluation (61%). Fifteen interviewees (ten students, five faculty) expressed overall positive sentiments about potential AI uses in medical education, but we identified the following themes regarding concerns: 

1. AI as a Tool – respondents identified the potential of AI to enhance learning but stressed the importance of proper training and guidelines for faculty to ensure its effective use. 
2. Transparency & Trust – lack of disclosure about AI use from faculty undermined trust between educators and students, highlighting transparency about AI use in education as a key factor to maintain and restore trust. 
3. Human Touch – many feared a “loss of humanity,” especially in the realm of personalized feedback, and expressed concern that the lack of human oversight would diminish the accuracy and impact of AI-created materials.

Conclusion:
While most medical students recognized AI’s potential to enhance and personalize learning, many are also concerned that faculty may use AI in ways that they do not anticipate or agree with. Clear institutional guidelines specifying appropriate use, disclosure, and quality-control would help foster trust between educators and students. Including students in AI guideline development will be key.

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Exploratory Analysis of Environmental Factors and NeuroQuant MRI Data in Patients With History of mTBI From MVAs

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