United States

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.


AMA Research Challenge 2025 

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

## Welcome to NAACL 2022!
The Annual Meeting of the North American Chapter of the Association for Computational Linguistics (NAACL) is taking place July 10-15, 2022 as a hybrid event, in Seattle, WA and online. We are happy to welcome all of you to conference!  
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NAACL 2022

2022 Annual Conference of the North American Chapter of the Association for Computational Linguistics

poster

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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
Delivery of messenger RNA (mRNA) offers potential to ameliorate numerous pathologies by translation of therapeutic proteins. Nevertheless, clinical translation of mRNA technologies has been limited due to a lack of delivery efficiency. Here we describe the development of a novel mRNA delivery system that overcomes barriers faced by existing systems.

Methods
We demonstrate that co-encapsulating gold nanoparticles (AuNPs) and mRNA within non-ionic surfactant vehicles (AuNSVs, termed “Aurniosoves”) improves tumor accumulation and vector uptake into cancer cells. This delivery system was validated through in vitro and in vivo studies with ovarian and hepatocellular carcinoma models utilizing reporter GFP-coding mRNA and therapeutic p53-coding mRNA. The mechanism of action was elucidated through fluorescence-based cellular uptake assays with relevant protein-AuNP interactions identified via pulldown assays.

Results
AuNSVs show improved tumor accumulation, protein expression, and therapeutic efficacy in delivery of p53 mRNA to p53-null cancer cells in comparison to NSV analogs (without AuNPs). Mechanistically, these effects are the result of a nanoengineered “iterative delivery” process in which AuNSVs enter the cell initially through clathrin-mediated endocytosis (CME) and release AuNPs into the cytoplasm. AuNPs subsequently adsorb and inactivate cellular trafficking regulators PP2A and Rab7, producing two primary effects: 1) rapid entry of additional AuNSVs through preferential activation of caveolin-mediated endocytosis (CvME), and 2) endosomal escape through inhibited endo-lysosomal fusion. These two mechanisms combine to drastically increase the delivery efficacy of therapeutic mRNA.

Conclusion
We have made two major advances: 1) nanoengineer a gold nanoparticle (AuNP)-mRNA hybrid therapeutic with translatable characteristics, and 2) improve the therapeutic efficacy of exogenous mRNA in cancer cells using an iterative delivery mechanism. We propose that this class of Aurniosoves and its associated mechanism of action may be exploited as next generation mRNA delivery systems for basic and translational biomedical applications.


Enhancing mRNA Therapy Through Iterative Delivery

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

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

Background: Eyeglasses may influence children’s self-image and social perceptions, and as animated films are widely consumed by children and caregivers, the way spectacle-wearing characters are portrayed may shape attitudes toward spectacle use. This study aimed to determine common character traits associated with spectacle-wearing characters in animated films across major studios. 

Methods: A comprehensive review of 167 animated films from seven major studios was conducted. Characters who wore corrective eyewear and had at least one line of dialogue were included. Traits were evaluated by five independent reviewers, and statistical comparisons were performed using Fisher’s exact and two-sample proportion tests. 

Results: Among the 167 films, only 39% featured at least one character wearing glasses, totaling 121 characters from 66 films. Glasses-wearing characters were significantly more likely to be supporting (91%) than main characters (9%). Among children with glasses, the most frequent traits were socially awkward (52%) and weak (36%), both significantly more common than in Ó 2025 American Medical Association. All rights reserved. other age groups (p = 0.001 and p = 0.006). In contrast, children with glasses were least likely to be portrayed as mature (8%) or authoritative (8%; p < 0.001 and p = 0.002). Elderly spectacle-wearing characters were significantly more likely to be portrayed as mature (59% vs. 31%; p = 0.026), with a trend toward authority (50% vs. 30%; p = 0.087). Intelligence was a common trait across all age groups (~41%) but did not differ significantly by age (p > 0.8). 

Conclusion: Younger characters with glasses are commonly portrayed as socially awkward and weak, while older spectacle wearers are depicted as mature and authoritative. The relative scarcity and marginalization of glasses-wearing characters in animated films may limit positive identification for children who wear glasses. These age-dependent portrayals may reinforce stereotypes about spectacle wearers and influence how children perceive themselves and others who wear glasses.

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