United States

Background
Proton pump inhibitors (PPIs) are one of the most commonly prescribed medications, primarily used for treatment of peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), and dyspepsia. By irreversibly inhibiting the hydrogen potassium ATPase pump in gastric parietal cells, PPIs help reduce gastric acid secretion, providing effective relief from symptoms such as acid reflux, epigastric pain, and heartburn. Although PPIs are generally considered safe for short-term use, emerging literature has suggested a variable, yet up-trending association between PPI use and an increased risk of acute kidney injury (AKI), especially within inpatient hospital settings. However, a clear quantification of this increased risk remains unclear. This meta-analysis aims to further evaluate and quantify the risk of postoperative AKI associated with perioperative prophylactic PPI usage.

Methods
To identify relevant studies, we conducted a focused database search using Google Scholar, ScienceDirect, and PubMed, particularly focusing on articles published within the last decade. Criteria for study inclusion and exclusion along with search methods deployed were conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. The analysis included 8 studies (N=632,226), comprising retrospective, cohort, and observational studies across diverse surgical populations.

Results
Using a fixed-effect based model, the pooled odds ratio (OR) for AKI events associated with prophylactic PPI use was 1.58 (95% CI: 1.56–1.61), indicating a significant increased risk. In highlight, subgroup analyses demonstrated variability with cardiac surgery populations (OR: 1.21, 95% CI: 1.03–1.42; OR: 2.238, 95% CI: 1.387–3.61) and cancer-related procedures (OR: 1.73, 95% CI: 1.08–2.75) showing pronounced risk.

Conclusion
The findings of this meta-analysis demonstrated a clinically significant increase of AKI incidences with the involvement of prophylactic PPI across various perioperative surgical inpatient settings. Given the strength of the pooled results, clinicians should carefully take into consideration the anticipated risk and benefits of prescribing PPIs within the course of patients undergoing major surgeries or operations, especially regarding renal harm and outcome. Future studies should further evaluate the underlying mechanisms behind this delicate relationship alongside exploring insights in optimal strategies in minimizing AKI damage from PPI usage.


AMA Research Challenge 2025 

Proton Pump Inhibitor Effects on Postoperative Acute Kidney Injury: A Meta-Analysis

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Background
FOXG1 syndrome (OMIM 613454) is a rare disease that is classified as a high-confidence syndromic cause of autism spectrum disorder (ASD). The predicted incidence of FOXG1 syndrome is 2.8-3.5 per 100,000 live births, and approximately 1200 individuals have been identified with FOXG1 syndrome. The symptoms of FOXG1 syndrome encompass many organ systems and include examples such as developmental delay, intellectual disability, microcephaly, epilepsy, movement disorders, hypotonia, and feeding and gastrointestinal difficulties. Missense, nonsense, deletion, frameshift, and duplication variants in the FOXG1 gene have been classified as pathogenic, and most of those variants are de novo. Our understanding of how genetic variants in FOXG1 lead to the diverse range of clinical symptoms observed in affected individuals remains limited, and there are currently no targeted treatments available for FOXG1 syndrome. Therefore, this study aims to uncover genotype-phenotype relationships, identify plasma biomarkers, and determine whether patient-specific variant mouse model phenotypes are reflective of patient phenotypes.

Methods
Using the innovative Citizen Health platform and the FOXG1 Research Foundation Patient Registry, we have collected medical records and caregiver-reported patient data. Additionally, we have conducted plasma proteomics studies for 12 patients with FOXG1 syndrome and 126 age-matched control samples to identify possible biomarkers. We have also developed and characterized four patient-specific variant mouse models, Foxg1 c.250dupC (p.Q84Pfs*31), c.483del (p.G161Gfs*23), c.646G>A (p.G216S), and c.900G>A (p.W300X). 

Results
Genetic analysis of the FOXG1 Research Foundation Patient Registry and Citizen Health data demonstrated a diverse spectrum of genetic variants and phenotypes among the affected individuals with confirmed pathogenic variants in FOXG1. Moreover, we have discovered numerous differentially expressed proteins from our proteomics analysis, with several key pathways and processes being disrupted in FOXG1 syndrome patients, including chromatin remodeling and neuroimmune activation. In our patient-specific variant mouse models, we have identified anatomical brain deficits, motor deficits, impaired communication, impaired hippocampal-dependent learning, and social cognition deficits; thus, these models exhibit overlap with FOXG1 syndrome patient phenotypes.

Conclusion
We assembled a large FOXG1 syndrome patient cohort to perform molecular characterization of FOXG1 variants and assess phenotypic impacts. We also identified potential plasma biomarkers using proteomics and developed patient-specific mouse models that recapitulate patient phenotypes. Together, these efforts advance our understanding of the pathophysiology of FOXG1 syndrome and support the future development of targeted therapeutic strategies.

Genotype-Phenotype Mapping, Biomarker Discovery, and Modeling of FOXG1 Syndrome

Background
Pediatric patients with autonomic disorders often experience disabling symptoms such as fatigue, dizziness, abdominal pain, and syncope that limit daily functioning. The Functional Disability Inventory (FDI) is commonly used to assess disability in children and adolescents, with both self- and parent-report forms available. While prior studies show that children often report higher disability levels than their parents, little is known about the concordance of FDI scores in the context of autonomic disorders and symptom subtypes.

Methods
This study assessed FDI scores from both pediatric patients and their caregivers at a autonomic disorder clinic. Additional symptom-based surveys were administered, including fatigue assessments, orthostatic intolerance profiles, and gastrointestinal symptom checklists, to explore correlations between symptom domains and disability perception. FDI sum scores from child and parent surveys were calculated and compared using paired t-tests. Pearson correlation coefficients were used to evaluate agreement between parent- and child-reported FDI scores. Subgroup analyses assessed whether specific symptoms were associated with greater parent-child scoring discrepancies.

Results
A strong positive correlation was observed between child and parent FDI scores, suggesting that caregiver reports can serve as reliable proxies when child self-report is unavailable. Fatigue emerged as the strongest predictor of perceived disability across both respondent groups. On average, parents reported slightly higher levels of disability than their children, though the mean difference in FDI scores (–1.49) was not statistically significant (p = 0.1353). No substantial variation in FDI concordance was found across different autonomic diagnoses.

Conclusion
Caregiver-reported FDI scores are closely aligned with child self-reports in pediatric patients with autonomic disorders, particularly when fatigue is a prominent symptom. These findings support the clinical use of parent reports as a valid substitute for self-reports in the functional assessment of pediatric autonomic patients. Future research should investigate longitudinal changes in FDI scores to track evolving perceptions of disability and treatment response.

Concordance in FDI Scores Between Pediatric Autonomic Patients and Their Caregivers

Background
Breastfeeding (BF) is widely encouraged for maternal and infant health. Early cessation is frequently associated with postpartum depression (PPD). Difficulty with BF and low self-efficacy may contribute to depressive symptoms, creating a bidirectional relationship between BF challenges and PPD. International Board Certified Lactation Consultants (IBCLCs) have been shown to improve BF duration and maternal mental health through support and education. We hypothesized that postpartum patients with elevated depressive symptoms (PHQ-9 ≥5) would experience a significant reduction in depressive symptoms following consultation with an IBCLC. This study aimed to evaluate the relationship between IBCLC consultation and changes in PHQ-9 scores in this population.
Methods
Retrospective cohort analysis was conducted with 34 patients. Paired t-tests assessed pre- and post-consultation PHQ-9 score changes among patients with baseline scores ≥5.
Results
Among 34 patients with PHQ-9 ≥5, mean scores decreased significantly from 7.71 ± 2.50 to 4.18 ± 3.07 after IBCLC intervention (t(33) = 4.88, p < 0.0001).
Conclusion
Postpartum patients with elevated depressive symptoms experienced a significant reduction in PHQ-9 scores following IBCLC consultation. These findings support the potential role of lactation support as a non-pharmacologic intervention for improving emotional wellbeing in at-risk postpartum individuals. Further studies with larger sample sizes and standardized timing are warranted to validate these results.

Impact of Lactation Consultation on PHQ-9 Scores Among Postpartum Individuals with Elevated Baseline Depressive Symptoms: A Retrospective Cohort Analysis from a Midwestern Health System

Abstract Title
Isolating abductor hallucis and tibialis posterior activation for targeted foot arch strengthening
Jadah Eshenaur D.O.’28, Jackson Watson D.O.’28, Shane McClinton P.T., D.P.T., Ph.D. OCS, FAAOMPT, CSCS
Background
The abductor hallucis (AbdH) and tibialis posterior (TP) contribute to foot arch strength(1,3) and are often the target of foot strengthening programs.(2,4,5) However, strategies to isolate AbdH and TP while minimizing activation of compensatory muscles such as the flexor hallucis longus, flexor digitorum longus, and tibialis anterior have not been identified. This preliminary study aims to provide clinical guidance for isolating and strengthening the AbdH and TP.
Methods
Surface and fine-wire electromyography (EMG) measured muscle activity in 10 subjects during different foot strengthening exercises. EMG data was normalized to each muscle’s peak dynamic activity across all exercise conditions. Radar plots were constructed to identify exercises with optimal TP and AbdH activation.
Results
AbdH demonstrated its highest activation during the unilateral heel raise while TP had its highest activation with the plantar flexion inversion exercise. Exercises that yielded the highest activation for both AbdH and TP with minimal compensatory muscle activation included the plantar flexion inversion towel sweep (PITS), short foot (SF) in sitting, and walking. Exercises with the highest overall activation of both AbdH and TP, regardless of compensation, included the unilateral heel raise, SF hop, and unilateral stance SF.
Conclusion
When initiating foot training, seated PITS and SF exercises, and walking will optimize AbdH and TP recruitment while minimizing compensatory muscle activation. The next logical progression would be the unilateral stance SF before progressing to the unilateral heel raise and hopping exercises which demonstrated the highest activation, but with more compensatory muscle recruitment.
References
1. Fiolkowski, P., Brunt, D., Bishop, M., Woo, R., & Horodyski, M. (2003). Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. The Journal of Foot and Ankle Surgery, 42(6), 327–333. https://doi.org/10.1053/j.jfas.2003.10.003
2. Osborne, J., Menz, H. B., Whittaker, G. A., & Landorf, K. B. (2023). Development of a foot and ankle strengthening program for the treatment of plantar heel pain: a Delphi consensus study. Journal of Foot and Ankle Research, 16(1). https://doi.org/10.1186/s13047-023-00668-2
3. Jung, D.-Y., Koh, E.-K., & Kwon, O.-Y. (2011). Effect of foot orthoses and short-foot exercise on the cross-sectional area of the abductor hallucis muscle in subjects with pes planus: A randomized controlled trial1. Journal of Back and Musculoskeletal Rehabilitation, 24(4), 225–231. https://doi.org/10.3233/bmr-2011-0299
Ridge, S. T., Myrer, J. W., Olsen, M. T., Jurgensmeier, K., & Johnson, A. W. (2017).
Reliability of doming and toe flexion testing to quantify foot muscle strength. Journal of Foot and Ankle Research, 10(1). https://doi.org/10.1186/s13047-017-0237-y
4. Ridge, S. T., Olsen, M. T., Bruening, D. A., Jurgensmeier, K., Griffin, D., Davis, I. S., &
Wayne Johnson, A. (2018). Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles. Medicine & Science in Sports & Exercise, 51(1), 1.
https://doi.org/10.1249/mss.0000000000001751


Isolating abductor hallucis and tibialis posterior activation for targeted foot arch strengthening

Background Chronic idiopathic constipation (CIC) is one of the most common, debilitating digestive conditions that affects 0.7%-29.7% of children worldwide.1 Gold standard treatment for CIC is a structured bowel management program (BMP) which contains a clean out followed by a laxative or enema trial to find individualized dosages resulting in daily bowel movements and no fecal accidents. Proper management is essential to prevent further sequelae like the formation of a megarectosigmoid and social and/or psychological impact. This study aimed to evaluate the success rate of the BMP for patients with CIC at our institution and to identify factors that contribute to these outcomes.
Methods A retrospective review of 51 patients presenting for BMP to WVU Children’s Hospital was conducted. Patients were divided into groups based on their diagnosis: CIC, neurogenic bowel, Hirschsprung disease, and anorectal malformation. Patient’s demographics, treatment course, number of missed appointments and socioeconomic circumstances were collected. Failure was defined as occurrence of fecal accidents, fecal impaction, noncompliance, or loss to follow up. Statistical analysis was performed using JMP Student Edition 18. 
Results Among the 51 patients, 63% had CIC, 24% had neurogenic bowel, 10% had anorectal malformation, and 4% had Hirschsprung disease. In the group with CIC, 81% participated in a BMP. Failure rate was 31% due to loss to follow up (3), noncompliance (4), and in only one case fecal accidents. In the remaining, who did not participate, inability to comply was the primary reason. The majority of those who failed BMP were covered by public insurance (p=0.04). Among those who failed due to loss to follow up or noncompliance, 86% were covered by public insurance and lived in areas with 0 grocery stores within a 10-minute walk and an average of 1.5 stores in a 10-minute drive.
Conclusion The difference in insurance types between groups indicates a potential socioeconomic disparity between outcome populations. Beyond these disparities, compliance-related issues were overwhelmingly responsible for failure and inability to participate in BMP, indicating a critical role in the initiation and continuation of a successful BMP. Given that CIC requires a high level of support and attention from caregivers and retains stigmas surrounding treatment, a prospective study to identify contributing factors leading to noncompliance has been initiated. The future goal is to improve adherence to the BMP and mitigate the noncompliance-related barriers that contribute to the treatment outcome.


The effect of socioeconomic factors on the outcomes of pediatric patients treated at our institution for colorectal problems.

Background:
Kambo, a traditional Amazonian frog secretion ritual, has gained international popularity as an alternative intervention for psychological and physical complaints, but systematic evidence regarding its effects and the predictors of positive outcomes is lacking.

Methods:
In a prospective, observational study, 50 Kambo-naive adults underwent three supervised Kambo sessions within 30 days. Validated self-report scales measured change in depressive symptoms (IDSSR), fatigue (MFI), mindfulness (MAAS), subjective happiness (SHS), and psychological well-being (Ryff, binary responder definition) from baseline to 3-month follow-up. Predictors included demographic, health history, and session-level variables (e.g., ritual elements, acute reactions). Missing predictor data were imputed by Multivariate Imputation by Chained Equations (MICE). Lasso regression and Random Forests were used for prediction, with validation via bootstrapping and cross-validation.

Results:
Across 3 months, Kambo was associated with a group-level decrease in depressive symptoms (IDSSR) and increases in mindfulness (MAAS), subjective happiness (SHS), psychological well-being (Ryff), and fatigue (MFI) scores. Lasso regression models achieved moderate-to-high predictive performance (mean bootstrapped R²: IDSSR=0.78; MFI=0.63; MAAS=0.70; SHS=0.75), and Random Forests performed similarly (mean R² 0.93–0.94). For binary well-being response, both logistic regression and Random Forest achieved near-perfect discrimination (AUROC ≥0.99). Baseline symptom severity was the most consistent predictor of z-score change. Session-level features, such as fainting, vomiting, and Sananga or Rapeh use, contributed modestly for some outcomes, especially depression and fatigue, while demographic and health history variables showed inconsistent effects.

Conclusions:
In this exploratory analysis, both baseline psychometric scores and select session features predicted change in psychological outcomes after Kambo, with the largest effect seen for baseline symptom severity. Group-level z–score changes indicated improvement across most scales, but increased fatigue was observed. These findings are hypothesis-generating and limited by the lack of a control group, possible regression to the mean, and unmeasured confounding. Future controlled studies are needed to confirm these results and clarify which factors most influence response to Kambo.


Psychological Outcomes of Human Participants in the Kambo ritual: Using Machine Learning to inform Predictors of Participant, Ritual, and Session-Level Factors in a Prospective Observational Study

Background
Myocardial infarction can lead to a host of complications; however, the occurrence of refractory ventricular tachycardia particularly comes with a poor prognosis. Managing refractory VT becomes significantly challenging in the absence of electrophysiology services. Use of Impella CP for cardiac support before ablation has the potential to be an effective bridge. We aim to document a unique instance of Impella CP-assisted hemodynamic stabilization of a patient suffering from delayed refractory ventricular tachycardia following a STEMI.

Case Presentation
A 70-year-old male patient with a history of hypertension, prediabetes, and GERD presented to a rural hospital with STEMI, where he received tPA before being transferred to a tertiary hospital. Angiography revealed 100% occlusion of the RCA and 99% stenosis of the proximal ramus intermedius. Percutaneous coronary intervention and transluminal coronary angioplasty were performed.
While in ICU, the patient developed atrial fibrillation with a rapid ventricular rate and was treated with an amiodarone drip, later converted to the oral form. He was readmitted to the ICU on day 4 in view of a non-sustained VT and hypotension, which progressed to cardiogenic shock. With multiple pressors and IV amiodarone, temporary rhythm control was established.
However, on day 9, the patient had a cardiac arrest secondary to ventricular fibrillation, requiring about 12 minutes of CPR. He received amiodarone and lidocaine during the code, followed by return of spontaneous circulation, but continued to have intermittent nonsustained VT with The patient experienced an increased frequency of arrhythmias and eventually developed pulseless ventricular tachycardia (VT), which required intermittent brief CPR and cardioversion, despite the ongoing administration of amiodarone and the addition of lidocaine. He had a brief response after starting procainamide but eventually worsened with more frequent nonsustained VT episodes along with hemodynamic decompensation and escalating pressor requirements.
In the absence of an electrophysiologist, an Impella CP device was inserted for mechanical circulatory support. This intervention stabilized the patient and provided a critical bridge to definitive care. The patient was successfully transferred to a higher level of care without any ventricular arrhythmia episodes during transport.

Discussion
This case showcases the utility of temporary mechanical support using Impella CP in stabilizing patients with refractory, unstable arrhythmias. This approach enables patients to achieve hemodynamic stability before definitive treatment can be provided, extending the window for intervention and improving the likelihood of a favorable outcome.

Delayed Refractory VT Storm Post Myocardial Ischemia and Use of Impella for Hemodynamic Stabilization—A Case Report

Ogilvie Syndrome in an HIV-Positive Young Male with Nutcracker Phenomenon: A Rare Dual Diagnosis
Background
Acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, is a rare condition characterized by massive colonic dilation without mechanical obstruction. It is typically associated with postoperative states, severe illnesses, or advanced age. We report a rare presentation of Ogilvie syndrome in a young, ambulatory male with well-controlled HIV, highlighting the importance of broadening diagnostic considerations beyond traditional risk profiles.
Case Presentation:
A 37-year-old African American male with well-controlled HIV (CD4 1414 cells/mm³; HIV-1 RNA 197 copies/mL) presented with three weeks of progressive abdominal distention, diffuse discomfort, intermittent nausea, and urinary retention. He denied fever, recent hospitalization, or surgery. Physical examination revealed a tense, tympanic abdomen. Laboratory values were within normal limits. CT imaging demonstrated marked colonic dilation without obstruction and incidentally revealed compression of the left renal vein between the aorta and superior mesenteric artery—consistent with the Nutcracker phenomenon. Flexible sigmoidoscopy confirmed the absence of mechanical obstruction. Conservative management—including bowel rest, decompression via a rectal tube, and supportive care—resulted in full resolution by hospital day 7, without the need for neostigmine or surgery.
Discussion:
This case illustrates an atypical presentation of Ogilvie syndrome in a young, HIV-positive individual without typical hospitalization factors. While his HIV was well-controlled, HIV-associated subclinical autonomic dysfunction may have contributed to colonic dysmotility. The coincidental presence of Nutcracker anatomy, although radiologically striking, was not clinically relevant due to absence of hematuria or renal impairment. This emphasizes the importance of correlating imaging findings with the clinical picture and avoiding diagnostic anchoring based on incidental findings. Clinicians should consider functional bowel obstruction in younger patients, including those with HIV, and recognize that conservative treatment can be highly effective when initiated promptly.

Ogilvie Syndrome in an HIV-Positive Young Male with Nutcracker Phenomenon: A Rare Dual Diagnosis

Background: In traditional U.S. medical education, preclinical training offers limited exposure to community-based experiences during a critical formative period of career discernment. The absence of early experiential learning may result in missed opportunities to cultivate motivation and sustained enthusiasm to practicing medicine. 
Objective: This observational study aimed to understand the perspectives of preclinical students on their volunteer experiences with the Mobile Health Initiative (MHI), focusing on its perceived impact and role in enhancing their medical education.
Methods: A survey was disseminated to all MHI volunteers to assess the program’s impact on student engagement and future practice intentions. Seventy-six percent of volunteers (n=49) reported participating during their preclinical years. 
Results: Students defined meaningful experiences as providing healthcare to underserved populations, utilizing cultural understanding to bridge care gaps, and fostering community connections. There was a significant increase in the feeling of connectedness with their community, which helped students rediscover their purpose for pursuing a career in medicine. Some highlights from the survey responses centered on an increased sense of fulfillment and learning to communicate compassionately. In addition, many respondents detailed how MHI events improved their clinical skills through these hands-on experiences and enhanced their clinical judgment in resource-limited settings. 
Conclusion: We identified four main themes that defined meaningful experiences for medical student volunteers: 1) Community Engagement and Connection, 2) Hands-On Clinical Skills Development, 3) Health Equity and Access, and 4) Emotional Fulfillment. There is a strong need for community-based, service-learning programs, such as MHI, to enhance traditional medical education.

Enhancing early medical education through mobile health care: An observational survey of medical student volunteers

Background:
Self-directed learning (SDL) is increasingly emphasized in undergraduate medical education and is a requirement of LCME Standard 6.3 and AAMC Entrustable Professional Activity (EPA) 7. These standards expect students to develop competencies in identifying knowledge gaps, acquiring and appraising information, and implementing feedback. SDL is inherently active and student-driven, relying heavily on learners’ motivation, self-regulation, and engagement. While prior studies highlight generally positive attitudes toward SDL, mixed findings persist regarding student preparedness and motivation for lifelong learning. One area lacking in the literature is the concept of “buy-in”—students’ belief in the value and relevance of SDL to their development. Buy-in, as used in educational research, refers to commitment and acceptance of pedagogical approaches and is known to correlate with greater engagement and behavior change. This study investigates the extent of medical student buy-in toward SDL at the end of their pre-clinical training and whether exposure to SDL practices leads to meaningful implementation in clinical practice.
Methods:
A cross-sectional survey was administered to second-year medical students at Virginia Commonwealth University after completing their pre-clinical curriculum. The survey, adapted from validated instruments, measured SDL buy-in using the Exposure–Persuasion–Identification–Commitment (EPIC) framework across each SDL activity defined by EPA 7. We analyzed the percentage of students endorsing each EPIC stage, performed one-way ANOVAs to assess differences by gender, race, ethnicity, and age, and developed a serial mediation model to examine the pathway from exposure to implementation.
Results:
Students reported high exposure to tasks involving identifying knowledge gaps and appraising medical information, and lower exposure to reflection and incorporating feedback. Tasks requiring information acquisition and source evaluation showed greater progression through the EPIC model compared to those requiring metacognition. No significant differences in EPIC stages were observed across demographic variables. The serial mediation analysis revealed a significant pathway from exposure to implementation, mediated by persuasion, identification, and commitment (p<0.05).
Conclusion:
Buy-in to SDL varies across competencies, with lower engagement in reflection and feedback utilization—critical yet underemphasized aspects of SDL. These findings suggest a need to enhance exposure to these components in the pre-clinical curriculum. Moreover, the observed mediation effect supports the idea that structured exposure to SDL practices fosters deeper commitment and implementation, reinforcing the importance of intentional SDL design to prepare students for clinical learning and lifelong self-improvement.

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