United States

Background:
Obstructive sleep apnea (OSA) is increasingly recognized as a risk factor for cognitive decline and dementia, but treatment adherence and efficacy in real-world settings may influence long-term outcomes. While continuous positive airway pressure (CPAP) is the standard of care, surgical options provide an alternative path for managing OSA. In this retrospective cohort study, we utilized the TriNetX database to examine whether surgical interventions for OSA were associated with a reduced incidence of dementia diagnoses and dementia-related pharmacotherapy compared to CPAP therapy.

Methods:
We identified adult patients (ages 45–80) with OSA using ICD-10-CM codes and divided them into two cohorts based on CPT codes indicating either CPAP initiation or surgical intervention (palatopharyngoplasty or inferior turbinate resection). Patients with cancer or cranial nerve stimulators were excluded. Propensity score matching was performed (1:1) on key demographic and clinical variables, including age, sex, race, BMI, and comorbidities. Patients were followed up from 6 months up to 10 years post-intervention for new diagnoses of Alzheimer’s disease, vascular dementia, unspecified dementia, and prescriptions for memantine or acetylcholinesterase inhibitors (AChEIs).

Results:
After propensity score matching, 9,739 patients remained in each group. Compared to surgical patients, CPAP patients had significantly higher risks of vascular dementia (RR 3.01, P=0.002), unspecified dementia (RR 5.12, P&lt;0.001), memantine use (RR 2.92, P=0.001), and AChEIs use (RR 1.91, P=0.017). Alzheimer’s disease incidence was higher in the CPAP group (RR 2.00, P=0.054), though not statistically significant. 

Conclusion:
Surgical interventions for OSA were associated with significantly reduced long-term incidence of dementia and the need for dementia-related medications compared to CPAP in this real-world cohort. These findings suggest that in practice, where CPAP adherence is variable, surgical treatment may offer superior cognitive protection. Further prospective studies are needed to confirm causality and explore underlying mechanisms.


AMA Research Challenge 2025 

Dementia Outcomes in Obstructive Sleep Apnea: Surgical vs. CPAP Intervention

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AMA Research Challenge 2022

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Background:
Obstructive sleep apnea (OSA) is increasingly recognized as a risk factor for cognitive decline and dementia, but treatment adherence and efficacy in real-world settings may influence long-term outcomes. While continuous positive airway pressure (CPAP) is the standard of care, surgical options provide an alternative path for managing OSA. In this retrospective cohort study, we utilized the TriNetX database to examine whether surgical interventions for OSA were associated with a reduced incidence of dementia diagnoses and dementia-related pharmacotherapy compared to CPAP therapy.

Methods:
We identified adult patients (ages 45–80) with OSA using ICD-10-CM codes and divided them into two cohorts based on CPT codes indicating either CPAP initiation or surgical intervention (palatopharyngoplasty or inferior turbinate resection). Patients with cancer or cranial nerve stimulators were excluded. Propensity score matching was performed (1:1) on key demographic and clinical variables, including age, sex, race, BMI, and comorbidities. Patients were followed up from 6 months up to 10 years post-intervention for new diagnoses of Alzheimer’s disease, vascular dementia, unspecified dementia, and prescriptions for memantine or acetylcholinesterase inhibitors (AChEIs).

Results:
After propensity score matching, 9,739 patients remained in each group. Compared to surgical patients, CPAP patients had significantly higher risks of vascular dementia (RR 3.01, P=0.002), unspecified dementia (RR 5.12, P<0.001), memantine use (RR 2.92, P=0.001), and AChEIs use (RR 1.91, P=0.017). Alzheimer’s disease incidence was higher in the CPAP group (RR 2.00, P=0.054), though not statistically significant. 

Conclusion:
Surgical interventions for OSA were associated with significantly reduced long-term incidence of dementia and the need for dementia-related medications compared to CPAP in this real-world cohort. These findings suggest that in practice, where CPAP adherence is variable, surgical treatment may offer superior cognitive protection. Further prospective studies are needed to confirm causality and explore underlying mechanisms.


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Background: Oropouche virus (OROV), an arbovirus transmitted by Culex and
Culicoides mosquitoes, was first identified in Trinidad in 1955. While commonly reported in South America, it had not been seen in the continental United States until 2024. We report the first two confirmed pediatric cases of OROV in South Florida, both with travel history to Cuba amid a regional outbreak in May 2024. These cases underscore the need for increased awareness, diagnostic
capability, and vector control. The first case is of a 16-year-old male on immunosuppressive therapy that presented with recurrent fever, headaches, fatigue, and decreased appetite following travel to Cienfuegos, Cuba. Initial tests for Dengue were negative and OROV antibodies returned positive (1:20). He recovered fully with outpatient supportive care. The second case we present was of a 15-year-old male who developed fever, vomiting, diarrhea, headaches, and fatigue after returning from Cuba. Multiple ED visits led to the findings of elevated monocytes and negative Dengue titers, and was ultimately admitted for supportive care. OROV antibody testing returned positive (1:160). These cases highlight OROV as an emerging arboviral illness with potential for geographic spread. Both patients exhibited biphasic illness, with symptoms including fever, headaches, and gastrointestinal upset. Laboratory findings consistently revealed monocytosis and atypical lymphocytes. Neither patient developed complications such as aseptic meningitis, although both exhibited headaches—an important consideration given the virus’s reported neuroinvasive potential. Current testing protocols rely on Dengue exclusion before pursuing OROV diagnostics, risking delayed or missed diagnoses. Broader multiplex PCR testing may improve timely detection. These cases emphasize the need for enhanced surveillance and preparedness, especially in Dengue-endemic regions. Public health measures, including vector control, travel advisories, and expanded testing access, will be essential in mitigating the impact of this emerging virus.

First Two Cases of Oropouche Virus detected at a Pediatric Hospital in South Florida

Background
Infective endocarditis (IE) typically presents with fever, malaise, and embolic phenomena. Risk factors include structural heart disease, prosthetic valves, IV drug use, and invasive procedures (1,2). Persistent hiccups (singultus), lasting over 48 hours, are rarely associated with IE and more often linked to gastrointestinal, neurologic, or metabolic disturbances (3,4). Limited reports suggest that IE may cause hiccups via phrenic or vagus nerve irritation or septic emboli to the brainstem (5–8). Group B Streptococcus (GBS) is a rare cause of adult IE but is associated with aggressive infection, especially in patients with uncontrolled diabetes (10). We describe a rare case of bivalvular GBS IE presenting with persistent hiccups.
Case Presentation
A 58-year-old man with no significant medical history presented with four days of persistent hiccups, fever, chills, diaphoresis, polydipsia, polyuria, and right upper extremity pain. Exam revealed a 3/6 holosystolic murmur and right hand swelling with limited range of motion. Labs showed WBC 17,000/µL, glucose 400 mg/dL, HbA1c 11.0%, CRP 296 mg/L, and hyponatremia. Urinalysis showed glucosuria and ketonuria. Chest X-ray revealed multifocal infiltrates. Initial management targeted presumed pneumonia. Blood cultures grew Streptococcus agalactiae (GBS). Echocardiography revealed a large mitral valve vegetation with severe regurgitation and posterior leaflet perforation, as well as a smaller tricuspid vegetation with moderate regurgitation. Diagnosis of bivalvular IE was made per Duke criteria. Antibiotics were escalated to IV ampicillin and gentamicin. The patient was transferred for surgical evaluation.
Discussion
IE remains diagnostically challenging due to its diverse presentations (1,2). Persistent hiccups are an unusual symptom, but may indicate serious underlying pathology when accompanied by systemic signs (3,4,9). In this case, persistent hiccups were linked to bivalvular GBS IE, possibly due to autonomic nerve irritation or central embolization (5–8,11). The patient’s uncontrolled diabetes likely predisposed him to severe infection, as hyperglycemia impairs neutrophil function and increases the risk of invasive disease (10,12). This case reinforces the importance of considering IE in patients with persistent hiccups and fever, even in the absence of classic risk factors, and highlights the value of early echocardiography in guiding diagnosis and management.


Persistent Hiccups as an Unusual Presentation of Group B Streptococcal Infective Endocarditis with Bivalvular Involvement

Background

Blastomycosis is a fungal infection endemic to regions of North America, including Ohio and the Mississippi River Valleys. While pulmonary disease is the most common manifestation of blastomycosis, extrapulmonary dissemination can occur, with the skin being a frequent site of involvement. Cutaneous blastomycosis often presents as verrucous or ulcerated lesions. It can also present as pustular nodules, mimicking bacterial folliculitis, and lead to a delay in diagnosis and treatment.


Case Presentation

A male in his mid-60s with no history of immunosuppression presented with 6 weeks of tender, violaceous dermal nodules on his thigh, heel, back, abdomen, and chin. The patient initially believed the nodules were spider bites. These nodules burned, developed rapidly, and eventually formed tense blisters that drained a serosanguinous exudate. He had been treated unsuccessfully with multiple courses of antibiotics for presumed bacterial folliculitis. He then developed systemic symptoms, including fevers, malaise, and prostatitis.


Examination revealed multiple crusted, annular, violaceous nodules on his calf, arm, thigh, back, and jaw. Some lesions contained a collarette of scale with heme crust. The right heel was found to have a tense bulla with mild red inflammation. A punch biopsy and fungal cultures identified broad-based budding yeast, confirming blastomycosis. Blood tests were positive for Blastomyces antigen and antibody. A chest CT showed cavitary pulmonary nodules. A urine culture confirmed genitourinary involvement.


Treatment was initiated with an itraconazole loading dose of 200mg three times a day for three days followed by 200mg twice daily with a plan for 6-12 months of therapy. Despite adherence and attempts to optimize absorption, his serum itraconazole level was subtherapeutic. To achieve appropriate levels, the dose was increased to 300mg twice daily.


Discussion

This case highlights the diagnostic challenge of atypical cutaneous blastomycosis in immunocompetent patients. While classic lesions are verrucous or ulcerated, non-specific lesions of cutaneous blastomycosis can closely resemble bacterial folliculitis, especially if it manifests as pustular or nodular lesions. Ultimately, this misdiagnosis led to an incorrect use of antibiotics and the worsening of his clinical condition.


Clinicians must maintain a high index of suspicion for deep fungal infections in lesions that are persistent, atypical, or unresponsive to antibiotics. In endemic areas, immunocompetent patients without clear risk factors/behaviors can develop blastomycosis. Early biopsy and fungal-specific testing are crucial for timely diagnosis and treatment. Optimal management of blastomycosis requires awareness of itraconazole pharmacokinetics, including the need for acid-mediated absorption and therapeutic drug monitoring.

Cutaneous Blastomycosis Masquerading as Bacterial Folliculitis: A Diagnostic Challenge

Background
Invasive ductal carcinoma (IDC) is the most common type of breast cancer in women, and metastasizes most commonly to bone, lung, liver, and central nervous system. Breast cancer metastasis to the gallbladder is exceptionally rare and seen mostly in cases of invasive lobular carcinoma or mixed lobular and ductal origin; gallbladder metastasis is even more rarely reported from breast cancer with ductal origin.

Case Presentation
A 43 year old female with depression was diagnosed with IDC of the right breast, receptors ER+/PR+/HER-2+. She underwent six cycles of neoadjuvant chemotherapy, which was delayed significantly due to lapses in insurance. She underwent right lumpectomy, completed adjuvant breast radiation, and initiated a partial course of adjuvant biologic therapy and hormone therapy which was halted early due to suicidal ideation. Subsequently, the patient did not present for her follow-up appointments or surveillance mammograms.
Three years and nine months after her lumpectomy, she presented with two days of right upper quadrant abdominal pain. Physical exam, labs, and imaging workup were consistent with early acute cholecystitis, and she underwent laparoscopic cholecystectomy. Gallbladder pathology was compatible with metastatic carcinoma of breast origin, likely invasive mammary ductal carcinoma. Before the patient was able to follow-up with outpatient oncology, she presented to the emergency department 18 days after cholecystectomy with epigastric pain, vomiting, and shortness of breath. CT scan showed pelvic ascites, liver metastasis, bony metastasis, and bilateral lung metastasis. She was admitted inpatient and started on goserelin injections every 28 days as well as Herceptin and Perjeta. However, patient began to have worsening mentation and respiratory distress, was placed on comfort care, and died three years and ten months after her lumpectomy.

Discussion
Our literature review of eight cases reporting breast cancer metastasis to the gallbladder found no obvious trends in receptor status, time to gallbladder symptoms after breast cancer diagnosis, or survival after gallbladder removal. The only universal aspect within our literature review was that each symptomatic presentation was diagnosed as cholecystitis, and gallbladder metastasis was diagnosed on review of the pathology after cholecystectomy. Therefore, adequate suspicion should be maintained when evaluating patients with a history of breast cancer who present with symptoms of cholecystitis in order to promptly identify breast cancer metastasis to the gallbladder. 


Invasive ductal carcinoma of the breast with gallbladder metastasis: a rare case involving the natural course of invasive ductal carcinoma with incomplete adjuvant treatment

Background: This report details a rare case of fulminant babesiosis in a splenectomized patient, emphasizing key diagnostic and therapeutic dilemmas. Babesiosis is a globally emerging tick-borne disease caused by the protozoan Babesia, posing a significant public health burden with mortality reportedly greater than 20% in immunocompromised individuals and those with transfusion-acquired infections. Splenectomized individuals are especially vulnerable to life-threatening Babesia infections, often manifesting as a more hazardous course requiring aggressive treatment.

Case Presentation: A 62-year-old pre-diabetic male with a history of traumatic total splenectomy presented with three days of high-grade fever, chills, bodyache, weakness, and near-syncopal episodes. Laboratory evaluations indicated anemia, haptoglobinemia, thrombocytopenia, leukocytosis, elevated creatinine and blood urea nitrogen, hepatic transaminitis, hyperbilirubinemia, and hypoalbuminemia. A peripheral blood smear confirmed the diagnosis, revealing extra- and intra-corpuscular Babesia microti with prominent vacuoles and ring forms, with a high parasitemia level of 17.6%. The patient was diagnosed with severe babesiosis complicated by multi-organ failure - including acute kidney injury and liver failure. Antiparasitic therapy with atovaquone and azithromycin was instituted. Additionally, the patient required multiple red blood cell exchange (RCE) transfusions with 12 units of packed red blood cells (PRBCs), to reduce the parasitemia down to a safer level (4%) leading to gradual clinical stabilization over the next few days.

Discussion: This case emphasizes the importance of high clinical suspicion and prompt diagnosis of babesiosis in susceptible patient groups, such as asplenic patients, presenting with unexplained fever, especially with hemolytic anemia or multi-organ dysfunction. Diagnosis relies on blood smear microscopy or polymerase chain reaction (PCR) test. Standard treatment combines atovaquone and azithromycin, or clindamycin and quinine. Exchange transfusion is typically recommended for severe babesiosis, especially for parasitemia exceeding 10% or organ dysfunction, to reduce parasite burden and clear out harmful toxins. While high parasitemia strongly correlates with disease severity, the definitive clinical benefit of RCE, particularly when compared to antibiotic therapy alone, is a topic of ongoing debate in the literature. The optimal administration and precise indications for RCE are not well studied, with current guidelines based on weak evidence and vaguely-defined criteria. RCE predisposes to potentially serious complications including transient hypotension, dyselectrolytemia, transfusion reactions, transfusion-related infections, fluid overload, and acute respiratory distress syndrome (ARDS). As babesiosis cases continue to rise in endemic regions of the US, targeted research is urgently needed to determine definitive effectiveness of RCE and to develop clear, evidence-based guidelines for its use in severe cases, ensuring safe patient outcomes.

Severe Babesiosis in an Asplenic Patient Treated with Red Cell Exchange: Highlighting the Critical Need for Evidence-Based Guidelines – A Case Report and Literature Review

Background:
The posterior femoral cutaneous nerve (PFCN) is a purely sensory nerve arising from the sacral plexus that supplies sensation to the posterior thigh, gluteal fold, and upper medial thigh. Isolated PFCN mononeuropathies are rare, underrecognized, and present with neuropathic pain without motor deficits; very few cases are documented as of 2025. Posterior thigh pain is often misattributed to sciatic or pudendal nerve involvement or musculoskeletal strain, leading to misdiagnosis and ineffective treatment and the deep anatomical location further complicates identification. While peripheral nerve blocks are increasingly used in pain management, selective ultrasound-guided blockade of the PFCN is seldomly reported.

Case Presentation:
A 20-year-old collegiate track athlete presented with persistent right posterior thigh, hip, and gluteal pain following a hamstring strain during sprint training. Despite physical therapy and MRI ruling out musculoskeletal or sciatic nerve pathology, she reported sharp, stabbing pain with numbness radiating to the posterior thigh and gluteal fold. The pain impaired daily activities and prevented her from competing in her track meets. Examination revealed sensory changes along the PFCN distribution without motor weakness. Given the pure sensory distribution, an ultrasound-guided PFCN block was performed using 0.25% Bupivacaine with epinephrine and betamethasone. The patient experienced immediate, near-complete pain relief with no motor deficit, allowing ambulation and return to activity the same day. Within two weeks, she returned to full competition, reaching the state finals. At four-week follow-up, she remained over 90% symptom-free.

Discussion:
This case highlights the therapeutic potential of selectively targeting the PFCN in isolated posterior thigh neuropathic pain. While nerve blocks are well-established for mixed motor-sensory nerves such as the sciatic nerve, there is minimal literature on ultrasound-guided sensory-only blocks for the PFCN. Anatomically, the PFCN lies within the gluteal deep investing fascia (GDIF), medial to the inferior gluteal artery and superficial to the sciatic nerve, which lies deeper and lateral. Accurate identification of this fascial plane is critical. Hydrodissection separates the gluteus maximus from the fascia to safely visualize the PFCN. Advancing too deep risks spread into the sciatic compartment, potentially causing motor blockade. This precise approach enabled the patient to receive a purely sensory blockade without motor compromise to allow her to return to competition. This rare but effective intervention for isolated posterior thigh neuropathic pain emphasizes the need to include PFCN mononeuropathy in the differential for athletes with refractory thigh pain and highlights the role of targeted nerve blocks in restoring function while preserving motor integrity.

Cutting the pain, not the power: Posterior Femoral Cutaneous Nerve Block Restores Competitive Drive

Abstract Title
Delayed Flap Reconstruction of Bilateral Stage IV Pressure Ulcers in a Pediatric Spinal Cord Injury Patient
Background
Pressure ulcers (PUs) are common and severe complications in patients with spinal cord injury (SCI), particularly among those who are non-ambulatory. Pediatric SCI patients present unique reconstructive challenges, as preserving core muscle function is essential for long-term posture, respiratory support, and mobility. While musculocutaneous flaps are the gold standard for treating advanced PUs, they may result in functional compromise. The use of delayed fasciocutaneous flaps offers a muscle-sparing alternative by enhancing vascularity and increasing flap reliability. This report describes the use of a delayed flap in a pediatric patient with bilateral stage IV PUs following SCI.
Case Presentation
A seven-year-old girl developed paraplegia after sustaining multiple gunshot wounds, resulting in a complete T3 SCI. Over the following year, she developed chronic bilateral stage IV PUs over the anterolateral hips. Despite aggressive wound care, debridement, and prior surgical attempts at an outside hospital, the ulcers failed to heal. Imaging revealed extensive soft tissue loss, anterior compartment necrosis, and osteomyelitis of the right femur. A delayed superficial inferior epigastric artery (SIEA) fasciocutaneous flap was selected for the right hip to preserve muscle function and avoid anterior thigh donor site morbidity. The flap was delayed with a distal skin bridge for four days prior to inset. The left hip was reconstructed using a rectus femoris muscle flap with subsequent skin grafting. Postoperatively, the delayed flap maintained strong Doppler signals and demonstrated healthy granulation and successful graft take. Complications on the left included delayed healing and drainage, requiring further intervention.
Discussion
This case illustrates the utility of delayed flap techniques in complex pediatric PU reconstruction. By enhancing vascularity through the delay phenomenon, the SIEA flap achieved robust perfusion despite the patient’s compromised circulation and prior tissue damage. The muscle-sparing approach preserved essential core function in a growing child with SCI. Traditional muscle flaps were avoided to prevent long-term deficits in posture and mobility. This flap strategy was particularly beneficial given the patient’s anatomical limitations, previous flap exhaustion, and high risk of perfusion compromise with hip flexion. While complications occurred on the contralateral side, the delayed flap healed well, supporting its use as a viable alternative to muscle sacrifice in pediatric SCI patients.


Delayed Flap Reconstruction of Bilateral Stage IV Pressure Ulcers in a Pediatric Spinal Cord Injury Patient

Posterior circulation strokes can present with a range of subtle or fluctuating symptoms, often delaying diagnosis and complicating treatment decisions. We present the case of a 59-year-old woman with a prior history of transient ischemic attack (TIA), ischemic stroke, and antiphospholipid syndrome who was brought to the emergency department with acute dysarthria, vertigo, tinnitus, and vomiting. Imaging was initially unrevealing, but brain MRI confirmed acute infarcts in the superior vermis and right cerebellar hemisphere. Further workup revealed a patent foramen ovale (PFO) and May-Thurner syndrome (MTS), which were suspected contributors to a paradoxical embolic stroke. She underwent successful PFO closure and stent placement for left iliac vein compression. This case highlights the diagnostic challenge of posterior strokes and underscores the importance of considering underlying embolic and structural contributors in cryptogenic stroke presentations.



Posterior Circulation Stroke in a Patient with May-Thurner Syndrome and Patent Foramen Ovale

Background

According to the AMA, the new Pass/Fail STEP 1 “reduc[es] the burden of exam preparation for medical students and creat[es] a more holistic residency-application selection process.” However, following the USMLE Step 1 transition to pass/fail in 2022, students began reporting pressure to accumulate research experience as a way of standing out among other applicants. This project seeks to evaluate the impact of research participation on medical student well-being
as well as student perceptions of the value and utility of their research.

Methods
Our team distributed a survey to medical students that included Likert-Scale questions on research participation, student well-being, perceived value of research, and if they feel pressure to participate in research. Response options included: Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree, Not Applicable (do not plan to do research). Inclusion criteria included currently enrolled medical students. We received 122 responses to our survey. Of these respondents, 26 were M-1 year, 63 were M-2 year, 14 were M-3 year, and 22
were M-4 year. The remaining 8 students marked “other” or left that choice blank. Although not every student answered every question, we included all data that we received.


Results
Our data showed that 60% (strongly agree or agree) of students say that research participation has a negative impact on their well-being, with 87% stating that the main reason they are doing research is to help their residency application. With regard to the potential of their research to decrease healthcare costs, 27% answered affirmatively (strongly agree or agree). However, 51% of students believe (strongly agree or agree) that their research can help improve outcomes. In
addition, 38% believe (strongly agree or agree) that it can change treatment guidelines. When asked if students would still participate in research if it had no impact on their ERAS application, 32% said that they would still do research, while 56% answered they would not participate in research, 11% students were unsure if they would still participate.


Conclusion
Results showed that students feel pressure to participate in research, which is adversely affecting the majority of students’ well-being. Further many students are not finding value or utility in the research they do. Our data shows that students are mainly driven to participate in research to strengthen their ERAS application and improve their chance of a successful residency match.

Evaluating the Value and Purpose of Medical Student Research

An Assessment of Service Awareness for the Unhoused Population in San Diego County

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