United States

Background
Early-onset psychosis (EOP), defined by the presence of psychotic symptoms before the age of 18, is associated with poorer clinical outcomes (cognitive impairment, hospitalizations, psychosocial function) as compared to individuals with adult-onset psychosis. Previous research found that EOP patients frequently report distressing pain and somatosensory symptoms, and that the severity of these symptoms is associated with the degree of psychopathology. This study expands upon those findings by exploring the prevalence and timing of pain and sensory symptoms in EOP patients.

Methods
A retrospective review of 77 patients (45 male, 32 female) with a DSM-5 diagnosis of psychotic disorder before age 18 and no comorbid autism spectrum disorder was conducted. Patients were grouped by age at psychosis onset: &lt;8 years, 8–13 years, and 14–18 years. All available clinical notes in the electronic health record were reviewed. Data on frequent and severe pain symptoms (musculoskeletal, headache, chest, gastrointestinal) without an identifiable cause and aversive sensory symptoms (auditory/visual, tactile, taste/smell) based on the Short Sensory Profile were abstracted. Patients were categorized into four groups: pain only, sensory sensitivities only, both symptoms, and neither. The timing of pain and sensory symptoms relative to psychosis onset (before/same-time or after) was also recorded. All cases were reviewed and confirmed by an expert clinician.

Results
Of the 77 patients with EOP, 95% (n=73) reported pain, sensory symptoms or both. The majority experienced pain and sensory symptoms; onset &lt;8 (n=21): 67%, onset 8-13 (n=41): 51%, and aged 14-18 (n=15): 80%.

Regarding symptom timing, among the 66 patients reporting pain, 73% (n=48) experienced symptoms before or at the time psychosis was first identified. Of the 40 patients with sensory symptoms, 98% (n=39) experienced symptoms by the time psychosis was recognized. Headache, frequent or severe enough to be reported to a clinician, was the most common pain symptom (76% with pain), and aversive auditory/visual sensitivities were the most common sensory symptom (62% with sensory symptoms).

Conclusion
This study expands upon prior findings by providing evidence that these somatosensory symptoms are typically present by the time the psychosis is recognized. The high prevalence of pain or sensory symptoms causing sufficient distress to prompt medical attention suggests that targeted treatment of these symptoms should be considered in the care of EOP patients.

AMA Research Challenge 2025 

Pain and Sensory Symptoms as Early Clinical Features of Early Onset Psychosis

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AMA Research Challenge 2024 

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

Background
Early-onset psychosis (EOP), defined by the presence of psychotic symptoms before the age of 18, is associated with poorer clinical outcomes (cognitive impairment, hospitalizations, psychosocial function) as compared to individuals with adult-onset psychosis. Previous research found that EOP patients frequently report distressing pain and somatosensory symptoms, and that the severity of these symptoms is associated with the degree of psychopathology. This study expands upon those findings by exploring the prevalence and timing of pain and sensory symptoms in EOP patients.

Methods
A retrospective review of 77 patients (45 male, 32 female) with a DSM-5 diagnosis of psychotic disorder before age 18 and no comorbid autism spectrum disorder was conducted. Patients were grouped by age at psychosis onset: <8 years, 8–13 years, and 14–18 years. All available clinical notes in the electronic health record were reviewed. Data on frequent and severe pain symptoms (musculoskeletal, headache, chest, gastrointestinal) without an identifiable cause and aversive sensory symptoms (auditory/visual, tactile, taste/smell) based on the Short Sensory Profile were abstracted. Patients were categorized into four groups: pain only, sensory sensitivities only, both symptoms, and neither. The timing of pain and sensory symptoms relative to psychosis onset (before/same-time or after) was also recorded. All cases were reviewed and confirmed by an expert clinician.

Results
Of the 77 patients with EOP, 95% (n=73) reported pain, sensory symptoms or both. The majority experienced pain and sensory symptoms; onset <8 (n=21): 67%, onset 8-13 (n=41): 51%, and aged 14-18 (n=15): 80%.

Regarding symptom timing, among the 66 patients reporting pain, 73% (n=48) experienced symptoms before or at the time psychosis was first identified. Of the 40 patients with sensory symptoms, 98% (n=39) experienced symptoms by the time psychosis was recognized. Headache, frequent or severe enough to be reported to a clinician, was the most common pain symptom (76% with pain), and aversive auditory/visual sensitivities were the most common sensory symptom (62% with sensory symptoms).

Conclusion
This study expands upon prior findings by providing evidence that these somatosensory symptoms are typically present by the time the psychosis is recognized. The high prevalence of pain or sensory symptoms causing sufficient distress to prompt medical attention suggests that targeted treatment of these symptoms should be considered in the care of EOP patients.

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Background

Salmonella enterica is an uncommon cause of urinary tract infections (UTIs), particularly in the absence of gastrointestinal symptoms. When present in urine cultures, non-typhoidal Salmonella should prompt investigation for extra-urinary reservoirs. The gallbladder can act as a chronic reservoir in patients with cholelithiasis, even without active cholecystitis, and may serve as a source of intermittent bacterial seeding. Recognition of this rare presentation is critical, as it poses diagnostic and management challenges and may require public health notification.

Case Presentation

An 86-year-old male with a history of bilateral nephrolithiasis, suprapubic catheterization, and cholelithiasis presented with recurrent UTIs over a three-month period. In February 2025, urine cultures repeatedly grew non-typhoidal Salmonella enterica (>100,000 CFU/mL), confirmed via MALDI-TOF. Despite appropriate IV antibiotic therapy with ceftriaxone, the patient’s symptoms persisted. Stool cultures were also positive for Salmonella enterica, supporting chronic gastrointestinal carriage despite the absence of diarrhea, recent travel, or sick contacts.

CT imaging revealed cholelithiasis with biliary sludge but no acute cholecystitis. Importantly, imaging also ruled out a colovesical fistula, eliminating a direct anatomical connection between the gastrointestinal and urinary tracts. With negative blood cultures and no signs of systemic bacteremia, these findings supported an ascending route of urinary tract infection. His clinical course was marked by persistent leukocytosis, sterile pyuria, and suprapubic discomfort.

Infectious disease consultation identified chronic gallbladder carriage as the most likely source of recurrent urinary Salmonella. Given the patient’s elevated surgical risk, cholecystectomy was deferred, and he was managed with long-term suppressive antibiotics. The case was reported to hospital infection control and the state health department for public health surveillance and serotyping.

Discussion

This case illustrates a rare but clinically significant presentation of recurrent UTIs due to chronic gallbladder Salmonella enterica carriage. The diagnosis was supported by microbiologic confirmation from urine and stool cultures and ruled-out anatomic causes of direct contamination. In patients with biliary pathology and persistent infection with uncommon urinary pathogens, hepatobiliary colonization should be considered. Early infectious disease involvement, careful imaging, and public health coordination were essential for diagnosis and management. Recognition of this atypical infection pathway emphasizes the importance of pathogen-specific investigation in persistent or recurrent UTIs.

Recurrent Urinary Tract Infections from Chronic Gallbladder Salmonella enterica Carriage

Background:
Mitral valve aneurysm (MVA) is an uncommon condition that may occur in association with aortic valve (AV) infective endocarditis. While the exact pathophysiology is unknown, it is possible that AV endocarditis and regurgitation can lead to a regurgitant jet that strikes the mitral valve (MV), leading to a secondary site of infection and the formation of an MVA.

Case Presentation:
A 68-year-old male patient underwent a transthoracic echocardiogram (TEE) revealing a large AV vegetation measuring 2.0×1.0cm with severe aortic regurgitation (AR). The left ventricular size and systolic function were normal (EF 60%), and the MV appeared normal without regurgitation. The patient underwent bioprosthetic AVR which revealed endocarditis of all three aortic cusps. Also noted intra-operatively was the absence of the AV vegetation seen on the baseline TTE, which suggests embolization. Tissue studies demonstrated Bartonella quintana AV endocarditis. Peri-operative transesophageal echocardiogram (TEE) showed normal left ventricular size and function, no vegetations, trace aortic paravalvular leak, and a normal MV. 

One month following AVR, the patient was evaluated with TEE for fungemia with an unknown source. It showed no aortic root abscess, a stable and well-seated AV prosthesis, and a normal MV. Roughly three months after AVR, a new systolic murmur was noted, prompting evaluation with another TEE. This three-month post-operative TEE demonstrated a perforation of the anterior MV leaflet secondary to a MVA with moderate MR. Retrospective review of the one-month post-operative TEE imaging showed evidence of the early formation of an MVA at the location where the AR jet struck the MV leaflet. Given the patient’s poor clinical and functional status, further procedural intervention was deemed too risky. The patient was eventually lost to follow-up and current clinical status is unknown.

Discussion:
MVA is a rare but serious complication of AV endocarditis. Most reported MVA cases have developed shortly after the diagnosis of infective endocarditis. This case is unique because of the insidious formation of the MVA with perforation and MR three months after initial presentation, despite appropriate operative and medical management of AV endocarditis.

The formation of the aneurysm likely involved a combination of mechanical stress from the AR jet and inflammatory stress from the AV endocarditis. Interestingly, AVR did not seem to prevent the formation of the MVA despite the resolution of the underlying infection and regurgitation. Early detection and close monitoring of MVA is crucial as untreated MVA can lead to serious complications including rupture, embolism, and infective endocarditis.

Mitral Valve Aneurysm Complicated by Perforation Secondary to Aortic Valve Endocarditis

Abstract Title: Kyrle Disease: A Clue to Systemic Disease

Poster Author(s): Jung Sung, MS. Curt Samlaska, MD

Author Affiliation(s): Touro University Nevada COM. Academic Dermatology of Nevada

Author Financial and Relationship Disclosures: none

Author Contact Information: Jung Sung annesung1@gmail.com 

Background: Kyrle disease (KD), aka Kyrle’s disease is a systemic manifestation of chronic medical disease, so medical education about this disease is vital. KD is a perforating skin disorder that is common in diabetic and renal failure patients (10% of dialysis patients). KD can also occur in liver disease and heart disease. Other reported associations include HIV, sclerosing cholangitis, hypothyroidism, hyperparathyroidism, Hodgkin disease, herpes zoster, and biologic drugs. Differential diagnoses include prurigo nodularis, perforating folliculitis, reactive perforating collagenosis, and multiple keratoacanthomas. 

The lesions appear as hypertrophic or umbilicated papules with a central keratin plug that can form plaques. They commonly occur on the lower legs, but can occur elsewhere on the body and head. They are usually pruritic (50% of patients), and the pathophysiology is thought to be due to scratching or rubbing. KD affects both males and females with no racial predominance, and usually presents around 30 years old (range of 3rd to 5th decade). Medical treatments can include keratolytics, anti-pruritics, antibiotics, corticosteroids, and isotretinoin. Treatment procedures can include UV light therapy, electrocautery, cryotherapy and CO2 lasers.

Case Presentation: A 54 yo female presented to our dermatology clinic with itchy bumps on her lower legs and elbow for 3 weeks. Medical history was pertinent for diabetes, kidney disease on dialysis, hypertension, hypercholesterolemia, and triple coronary artery bypass graft surgery in 2022. On physical examination, she had multiple hyperkeratotic papules and plaques on her lower legs with central hyperkeratotic cones, consistent with KD. A shave biopsy was done to confirm the diagnosis.

Histopathology confirmed Kyrle disease with significant parakeratosis. The epidermis was edematous with an absent granular layer (which is consistent with KD). The patient had some improvement with topical clobetasol and oral doxycycline, but optimal treatment required treating her underlying medical conditions (diabetes, chronic renal disease, and heart disease).

Discussion: It is important for clinicians to recognize Kyrle disease since it is often a skin manifestation of systemic disease. Although topical and oral medications may help improve the skin lesions, treating KD effectively requires managing the underlying medical disease, for example diabetes or chronic renal disease. Also, patients with no known systemic disease should be worked up for diabetes, renal disease, liver disease and endocrine disorders by ordering labs such as comprehensive metabolic panel, hemoglobin A1C, thyroid function tests, and serum uric acid. Due to the possible pathophysiology of itching and superficial trauma causing KD, biologic drugs that target Interleukin receptors and JAK pathways may be a promising treatment in the future.

Acknowledgement(s): none
Funding Source: none

Kyrle Disease: A Clue to Systemic Disease

Abstract Title
Ischemic Colitis Induced by Amphetamine Use in a 72-Year-Old
Background
Ischemic colitis is the most common form of intestinal ischemia, typically affecting elderly individuals with underlying vascular risk factors. While drug-induced ischemic colitis is increasingly reported, it is largely associated with stimulant use in younger populations. Amphetamines, through their potent vasoconstrictive and sympathomimetic effects, can cause significant microvascular compromise. However, cases in elderly patients remain rare and under-recognized.
Case Presentation
A 72-year-old female with a history of hypertension, deep vein thrombosis, scoliosis, and polysubstance abuse presented with a 24-hour history of abdominal pain, diarrhea, and melena. She had a recent history of methamphetamine, fentanyl, and marijuana use following postoperative opioid use. On arrival, she was tachycardic, hypertensive, and altered, with localized abdominal pain. Laboratory studies revealed leukocytosis, hypokalemia, and elevated BUN, bilirubin, and troponin. Urine drug screen was positive for amphetamines. CT imaging showed severe colitis affecting the distal transverse, descending, and sigmoid colon. She met sepsis criteria and was treated with IV fluids, broad-spectrum antibiotics, and bowel rest.
Gastroenterology consultation confirmed the diagnosis of ischemic colitis, likely secondary to amphetamine use. Over the next 72 hours, her clinical condition significantly improved without the need for surgical intervention.
Discussion
Amphetamine-induced ischemic colitis is uncommon, particularly in elderly patients. The pathophysiology is thought to involve alpha-adrenergic receptor-mediated vasospasm, leading to transient or sustained ischemia, particularly in colonic watershed zones. While most cases occur in younger adults, recent pharmacovigilance data highlight increased incidence in older patients, especially females. Management is primarily supportive, including intravenous fluids, antibiotics, and cessation of the offending agent. Surgery is reserved for cases with signs of perforation or clinical deterioration. Early recognition is critical, as outcomes vary based on severity and comorbidities. This case highlights the importance of considering stimulant use, even in older adults, as a potential etiology of acute colitis.

Ischemic Colitis Induced by Amphetamine Use in a 72-Year-Old

Background
Patient experiences shared online provide a wealth of real-time insights into medication effects, highlighting concerns often missed by or underemphasized in clinical trials and literature. Existing social listening methods are often one-off, fixed workflows that do not scale to diverse therapeutic contexts and lack integration with medical literature. Autonomous AI agents powered by large language models (LLMs) offer a scalable, active approach to synthesize patient narratives with scientific evidence to support more empathetic and informed care.

Methods
We developed a novel multi-agent system that fully automates scraping and research from social media and PubMed, along with synthesis of the results into actionable clinical insights. The system takes a user’s topic input such as a medication name, and autonomously generates relevant search strings, retrieves Reddit discussions and biomedical literature, classifies posts by theme, extracts representative quotes, and synthesizes findings into clinical actionable insights and summaries. We validated the system using four medications: semaglutide, adalimumab, lamotrigine, and sertraline.

Results
Each query was completed autonomously in minutes. For semaglutide, Reddit users frequently mentioned gastrointestinal side effects, high cost, aesthetic motivations, and emotional strain. Fertility concerns and rebound weight gain appeared often in posts but were rarely discussed in PubMed articles. For adalimumab, themes included injection-site pain, diminishing response over time, and high out-of-pocket costs. These findings led to insights about early counseling on injection technique and financial navigation. Lamotrigine users discussed memory issues, anxiety around dose tracking, and the burden of long-term titration. These emotional impacts were not reflected in the literature, which focused on rash risk. For sertraline, patients described emotional blunting, sexual dysfunction, sleep issues, and significant weight gain. Users also shared strategies like dose timing adjustments and combining with other therapies.
Across all four drugs, Reddit surfaced consistent concerns around side effects, adherence, affordability, and emotional impact. Support strategies and patient-led workarounds added depth not captured in clinical studies.

Conclusion
Our multi-agent AI system rapidly generated nuanced, clinically relevant insights across diverse drug classes by integrating real-world patient narratives with evidence-based literature. The system surfaced underrecognized themes, such as fertility concerns with semaglutide and affordability with adalimumab, while capturing emotional burdens and treatment courses from patients. This demonstrates the system’s value as a scalable, generalizable tool for pharmacovigilance, shared decision-making, and more empathetic, anticipatory clinical care.


From Forum to Clinic: Transforming Patient Narratives into Clinical Insights Using Autonomous AI

Background:
Falls are the leading cause of injury-related deaths among older adults in the U.S., with mortality rising by 35% in the past decade. Concurrently, loneliness remains a silent epidemic, especially in rapidly aging rural communities like Southern Utah. Despite the availability of effective fall prevention strategies, access and adherence remain low. Intergenerational interventions combining novel technology and medical education offer a dual-benefit solution. This project integrates virtual reality (VR)-based balance training with osteopathic medical student engagement to simultaneously target senior fall risk reduction, social isolation, and improved geriatric care competency among future physicians.
Methods:
This pilot study employs a pre/post mixed-method design to evaluate a novel intergenerational VR intervention. We will recruit 25 community-dwelling older adults (aged 65–85) who demonstrate moderate fall risk based on STEADI criteria. Concurrently, five first-year medical students will be engaged as facilitators. Participants will be recruited via convenience sampling through partnerships with local senior centers and healthcare systems, with clear inclusion and exclusion criteria applied.
Over a 12-month period, seniors will participate in 24 VR-based balance training sessions (two sessions per month), utilizing Meta Quest headsets and UprightVR software. Each session will be approximately 45 minutes in duration and will be structured and closely supervised by medical students trained in elder care and VR technology.
Primary outcomes include changes in fall risk, measured quarterly using validated tools such as the FRAT, Berg Balance Scale, Timed Up and Go (TUG) test, and BOOMER tools. Social isolation will be assessed using the UCLA Loneliness Scale. For medical students, secondary outcomes will include changes in geriatric attitudes (Kogan’s Scale) and empathy (Jefferson Empathy Scale), measured via validated pre/post surveys and analyzed alongside reflective assignments integrated into their curriculum.
Results:
Preliminary qualitative data indicates high feasibility and acceptance, with improved senior engagement and student empathy noted during structured reflections. Quantitative data collection remains ongoing with final analysis anticipated in 2026. Early trends suggest reductions in loneliness scores and improvements in senior balance confidence.

Addressing Fall Risk and Social Isolation in Older Adults Through a Medical Student-Led VR Intervention

Background 
Patients frequently prefer to avoid certain ingredients in their food and medications. Healthcare providers, especially physicians, have an ethical obligation to develop the ability to cater to these preferences and be transparent about the contents of prescribed medications. For example, the American Medical Association Policy H-100.947 encourages transparency regarding the presence of animal-derived ingredients in medications. However, research shows that 70% of physicians are entirely unaware of the presence of animal-derived ingredients in medications despite a strong majority of medications containing ingredients commonly sourced from animal components. To address this knowledge gap, a pilot teaching session in pharmacotherapy ethics was developed. This study assessed the impact of this teaching session on perceived medical student knowledge and competence in medication ingredient ethics. 

Methods
Medical students at Central Michigan University College of Medicine attended a teaching session on pharmacotherapy ethics as part of their coursework. This session was composed of a 15-minute pre-recorded lecture followed by in-person instruction. Upon conclusion of the session, students were administered a voluntary survey assessing the impact of the session on their perceived knowledge and competence in medication ingredient ethics. The survey was composed of identical pre- and post-session questions, with 16 questions in each category. Responses were collected on Likert scales ranging from 1 to 5, and higher scores indicated higher perceived knowledge or competence of the content. Question scores were added to generate a total score, and the Wilcoxon signed-rank test was used to compare pre- vs. post-session total scores. IRB approval for the survey was waived. 

Results
The session delivered instruction on common controversial medication ingredients, drug information resources to assess for medication ingredients, and a standardized algorithm to safely alter pharmacotherapy in this setting. 59 subjects chose to take part in the survey. The mean pre-session total score was 34.66 (SD = 11.9) vs. 66.31 post-session (SD = 8.0, p <0.001). 

Conclusion
Physicians’ knowledge gap in medication ingredients ethics owes to the lack of standardized instruction in this subject matter within medical curricula. This study demonstrated that instruction in medication ingredient ethics significantly improves perceived medical student knowledge and competence of this content. Given the increasing prevalence of patient vaccine hesitancy and overall mistrust in the healthcare system, medical schools are encouraged to incorporate medication ingredients ethics into their curricula, as physicians with enhanced knowledge and competence in this area would be better equipped to build patient trust in healthcare providers.

Medical Students’ Understanding and Attitudes Towards Medication Ingredient Ethics

Introduction: Microplastic exposure is an emerging global health concern, implicated in inflammation, oxidative stress, and endocrine disruption. As microplastics degrade, they release associated chemicals, including phthalates. Mono-n-butyl phthalate (MBP), is a human biomarker for phthalate and indirectly microplastic exposure. While MBP is a known endocrine disruptor linked to reproductive, metabolic, and neurodevelopmental issues, its specific impact on human hematopoiesis remains understudied. Broader phthalate research suggests potential disruption of bone marrow function and hematopoiesis, through altered antioxidant enzyme activity, increased hemoglobin oxidation, and reduced hematopoietic stem cell expansion. This study addresses a critical knowledge gap by investigating the association between environmental microplastic exposure, as indicated by urinary creatinine-normalized MBP (CnMBP) levels, and hematologic parameters in a nationally representative population. Our objective was to evaluate the relationship between urinary CnMBP levels, hemoglobin and platelet counts.
Methods: Participants from the National Health and Nutrition Examination Survey (1999-2018) were included. Blood hemoglobin levels and platelet counts were determined using Coulter HMX Hematology Analyzer. Urinary CnMBP levels were measured using HPLC separation and tandem mass spectrometry. Survey-weighted linear and logistic regression models were used without and with adjusting for age, gender, race, body mass index, hypertension, diabetes mellitus, CKD, and family income. To assess levels of anemia and thrombocytosis, parameters of hemoglobin level <12.0 g/dL in women and <13.0 g/dL in men and platelet count above 450 × 10⁹/L were utilized, respectively, in accordance with World Health Organization (WHO) parameters.
Results: Of 20,616 participants, Mean (SD) age was 35.2 (23.3) years, hemoglobin 14 (1.49) g/dL, platelet count 270 (71) 109/L. Participants in the highest CnMBP quartile, compared to the lowest, had 0.63 g/dL lower hemoglobin ( –0.63 g/dL, p<0.001). Other quartiles also revealed significantly lower hemoglobin levels (Q2: –0.09 g/dL, p=0.034; Q3: –0.33 g/dL, p<0.001). Participants in the highest exposure quartile also had a 43% higher odds of anemia (OR = 1.44, 95% CI: 1.12–1.84, p=0.004). Upon examining platelet counts, participants in higher CnMBP quartiles had progressive increases in their platelet counts (Q2: 7.5 ×10⁹/L, p<0.001; Q3: 16.5 ×10⁹/L, p<0.001; Q4: 18.3 ×10⁹/L, p<0.001). No significant increase in thrombocytosis was noted (Q2: OR 0.74, 95% CI: 0.38–1.45, p=0.38; Q3: OR 1.03, 95% CI: 0.63–1.68, p=0.92; Q4: OR1.32, 95% CI: 0.80–2.16, p=0.28). All significant results remained significant after adjustment for confounders.
Conclusion: Higher CnMBP levels, a microplastics biomarker, were significantly and independently associated with lower hemoglobin and higher platelet levels, translating into an increased probability of anemia, though not thrombocytosis. These observations align with evidence suggesting microplastics and associated chemicals disrupt biological systems, including inducing oxidative stress and altering blood cell function. Given microplastics' pervasive presence, these results highlight a novel and critical public health concern. Further mechanistic research is warranted to clarify how MBP influences hematopoiesis and assess clinical implications for populations with chronic microplastic exposure. This study enhances understanding of microplastics' systemic effects and emphasizes the urgent need for exposure mitigation and hematologic health protection.


Exploring Hematologic Effects of Microplastics: Urinary Mono-n-butyl Phthalate and Blood Cell Counts

Background & Objective: Trofinetide (DAYBUE™) is the first FDA-approved disease-directed therapy for Rett syndrome (RTT), but its list price (~$615 000 / year for a 25 kg child) poses severe budgetary challenges. Since most pediatric RTT patients depend on Medicaid, state programs employ prior authorization (PA) to manage access. A January 2026 CMS rule (CMS-0057-F) will require seven-day electronic PA decisions and public reporting of denial rates, but will not alter PA content. We audited Medicaid fee-for-service policies in all 50 states to (1) catalogue trofinetide listing status; (2) characterize PA criteria; and (3) assess preparedness for the new federal standard.
Methods: In May 2025, two independent reviewers searched *.gov domains for “DAYBUE OR trofinetide”, abstracting five variables: listing status; PA requirement; renewal interval; prescriber-specialty restrictions; and source URL. Discrepant data (< 4% of entries) were resolved by consensus. Categorical results were tallied and visualized.
Results: Trofinetide appeared on 46 states’ formularies (92%); four states (ID, MS, WV, WY) had no listing, leading to automatic claim denials. Of listing states, 40 (87%) required PA -most mandating genetic confirmation of classic RTT (38/40; 95%), neurologist prescribing (35/40; 88%), and annual renewal (31/40; 78%) [3]. Six states (CA, MN, ND, VT, HI, AK) allowed point-of-sale coverage without PA. Lifetime therapy caps (36 months unless functional gains documented) appeared in GA, SC, and OK. The Southern region bore the highest PA burden (92% PA prevalence; 3/4 non-listing states).
Conclusions: Two years post-approval, trofinetide access remains highly uneven: nearly nine in ten states impose stringent PA hurdles, and four offer no pathway. The upcoming CMS seven-day rule will speed decisions but not alleviate restrictive clinical criteria. Harmonized, diagnosis-only PA standards-and multistate pooled-rebate agreements-are urgently needed to ensure equitable access.


Gatekeeping DAYBUE: A50-State Audit of Medicaid Prior Authorization For Rett Syndrome

Introduction:Breast cancer is the most common cancer among women worldwide and the leading cause of cancer-related death. Poverty, lack of resources and screening programs, shortage of services, and weak health systems have made developing countries more vulnerable to diseases and have significantly contributed to the delay of cancer diagnosis and management.This is a KAP study that aims to explore what is known about breast cancer (knowledge), what the beliefs (attitude) are, and what are the current adopted practices toward it (practices).

Methods: A cross-sectional hospital-based study targeting women attending outpatient clinics in Khartoum, Sudan (April - November 2022), with an objective to assess the level of awareness among Sudanese women regarding breast cancer signs, symptoms, and risk factors. Furthermore, the study aimed to evaluate women's attitudes toward breast cancer primary prevention methods and their practices concerning these measures and to investigate the underlying causes behind the lack of awareness. Data from 284 participants were collected using “Google Forms” and analyzed using SPSS program version 25.

Results: Most of the participants recognized a breast lump (26%) as a symptom of breast cancer, followed by (21%) of the participants who did not recognize any of the signs and symptoms of breast cancer. There was a delay in seeking medical advice among (36%) of the participants. Seventy-two percent of the participants reported that there was no breast cancer awareness activity in their area. The study concluded that around (22%) of the participants had excellent knowledge about breast cancer signs, symptoms, and risk factors, while the majority of the participants (57%) had good knowledge, and only (21%) had poor knowledge.

Conclusion: There was a positive attitude toward breast cancer awareness. The practice of breast examination was average. The main recommendations were for the federal and Khartoum state ministries of health to enhance the current health system and improve coverage and access to health services.

Keywords: Breast, Knowledge, Attitude, Practice, Developing countries, Primary prevention, Awareness, Women.



Knowledge, Attitude, and Practice About Breast Cancer Primary Prevention Among Women Attending 
Outpatient Clinics, Khartoum, Sudan: ACross-sectional Study.


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