United States



Background:
Bioprosthetic valve degeneration, particularly involving the Trifecta surgical aortic valve, has become an increasingly recognized clinical challenge due to its propensity for early structural valve deterioration and failure. Severe aortic regurgitation (AR) resulting from immobile or flail valve leaflets often presents with complex hemodynamic consequences, including functional mitral stenosis—a condition also known as pseudo-mitral stenosis. This phenomenon occurs when the regurgitant aortic jet impinges upon the anterior mitral leaflet, restricting its motion and creating an obstruction to diastolic mitral inflow. Clinically, this manifests as an Austin Flint murmur and may mimic organic mitral valve disease, complicating diagnosis. Distinguishing functional mitral stenosis from intrinsic mitral pathology is critical because the treatment focus should be on correcting the primary aortic valve lesion. Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has emerged as a less invasive, effective alternative to redo surgical valve replacement in patients with degenerated bioprosthetic valves who are at elevated surgical risk.
Case Presentation:
We report the case of an 84-year-old male with a history of a Trifecta bioprosthetic aortic valve replacement who presented with progressive exertional dyspnea, orthopnea, and acute hypoxic respiratory failure. Initial transthoracic and transesophageal echocardiography revealed severe eccentric AR due to an immobile bioprosthetic leaflet, accompanied by severe functional mitral stenosis characterized by a markedly elevated mean mitral valve gradient of 17 mmHg and reduced mitral valve area, despite structurally normal mitral leaflets. Right and left heart catheterization demonstrated elevated left atrial and pulmonary pressures, consistent with the dual-valve pathology. The patient’s comorbidities—including chronic kidney disease, severe obstructive sleep apnea, prior cerebrovascular accident with residual deficits, and frailty—rendered him high-risk for conventional redo surgery. After multidisciplinary evaluation, the patient underwent a transfemoral ViV-TAVR using a 23 mm Edwards SAPIEN Ultra valve with prophylactic coronary protection. Post-procedure imaging confirmed successful valve deployment with complete resolution of aortic regurgitation and significant reduction in mitral valve gradient to 6 mmHg. Mitral valve mobility and effective valve area improved, demonstrating reversal of functional mitral stenosis.
Discussion:
This case highlights the intricate pathophysiology of functional mitral stenosis secondary to severe AR caused by bioprosthetic valve degeneration. The findings underscore the importance of thorough echocardiographic and hemodynamic evaluation to differentiate pseudo-mitral stenosis from primary mitral valve disease. Correction of the aortic valve pathology alone can restore mitral valve function, obviating the need for direct mitral intervention. ViV-TAVR offers a safe and effective minimally invasive treatment option for high-risk patients with complex dual-valve dysfunction. Comprehensive pre-procedural imaging, including transthoracic and transesophageal echocardiography and computed tomography, is essential for accurate diagnosis and procedural planning, especially to mitigate risks such as coronary obstruction. This case adds to the growing evidence supporting ViV-TAVR in managing complex valvular heart disease and emphasizes the clinical relevance of recognizing the Austin Flint phenomenon in patients with severe aortic insufficiency.



AMA Research Challenge 2025 

Double Trouble, One Solution: Valve-in-Valve TAVR Corrects Both Aortic and Mitral Valve in a Complex Dual-Valve Pathology

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BACKGROUND: 
Delirium is categorized by acute changes in attention, cognition, and awareness that are not explained by pre-existing medical conditions. Its etiology remains poorly understood. Delirium occurs in around 21-25% of older patients after elective surgery. Delirium is associated with increased risk for post-discharge mortality, dementia, long-term cognitive decline, and other poor outcomes. This study focuses on a previously identified neurodegenerative marker that is associated with delirium. APOe4 has been found to increase the risk for delirium, but not all patients with the APOe4 allele experienced delirium. This suggests that mechanisms underlying delirium are multifactorial. Recent literature has suggested that chronic conditions are associated with the onset and progression of neurodegenerative diseases. It is not known whether the combination of chronic conditions and APOe4 infers a greater risk for delirium than either variable alone.
OBJECTIVE: 
Question: What is the association between APOe4 and postoperative delirium after considering presence of chronic conditions?
Hypothesis: Both chronic conditions and APOe4 will be associated with postoperative delirium.
METHODS: 
This is a secondary analysis of data from 2001-2014 at the University of California, San Francisco. The inclusion criteria are:
- >= 65 year old
- Major elective noncardiac surgery requiring anesthesia
- Expected to remain in the hospital postoperatively for more than 48 hrs.
- None were delirious at admission
The study included 351 elective surgery patients. Each patient is interviewed by the same research assistant preoperatively and postoperatively. Data collected from each patient include:
- APOe4 allele status
- Medical history
- The measured outcome, delirium status (Confusion Assessment Method)
148 of the patients analyzed in this study were also included in a prior study (Leung et al., 2007) investigating the risk of postoperative delirium in older patients undergoing noncardiac elective surgery.
RESULTS: 
30.2% of patients in this sample were over the age of 75. 15.4% of patients had at least one APOe4 allele, while 84.6% did not. 28.5% of patients had a Charlson Comorbidity Index (CCI) > 1, while 71.5% had a CCI of 0 or 1. 32.8% of patients had postoperative delirium. There is an association between higher number of comorbidities and postoperative delirium (OR = 1.70, CI = 1.03 - 2.82). After controlling for confounding variables (comorbidities and age), the association between APOe4 and postoperative delirium (OR = 0.50, CI = 0.21 - 1.23) was not statistically significant. This indicates that increased comorbidities and increased age have a greater impact on postoperative delirium than APOe4 in this cohort.
DISCUSSION: 
Increased comorbidities are associated with postoperative delirium in non-cardiac elective surgery patients over age 65. This relationship can be used to inform clinical recommendations and aid in determining preventable risk.

The Combined Impact of Chronic Illness and Presence of Genetic Disposition for
Dementia on Incident Postoperative Delirium among Older Elective Surgery Patients

Abstract Title: Psychiatric Care in the Pediatric Emergency Department 
Authors: Priyanka Kaushal, Lisa Gorham, Cedric Bruges, James Rudloff, Viani Dickey, Cynthia Rogers, & George Hoganson

Background: Due to surging demand for pediatric psychiatric services, emergency departments (EDs) are increasingly utilized by parents and community physicians to address psychiatric concerns. Further research is needed to understand the expectations of families seeking ED care for their children and barriers to community psychiatric services. We hypothesized that most families seek services in the ED due to unmet needs in the community and that there would be a mismatch of expectations between care sought and care received. 

Methods: Parents of children presenting with psychiatric complaints at the St. Louis Children’s Hospital ED completed a survey about their child. We extracted patient demographics, diagnoses, length of stay (LOS), and disposition from the medical record. Our primary outcomes were parent-reported goals for treatment and barriers to care outside of the ED as well as risk factors for being admitted. 

Results: We included 151 children in the final cohort (52% female, mean age 13.3 years, 66% White, 23% Black). The most common diagnoses were suicidal ideation/attempt (54.3%), depression (27.8%), ADHD (19.2%), aggression (17.9%), anxiety (11.9%), and self-harm (9.3%). Parent-reported reason(s) for ED visits included seeking overnight hospitalization (59%), medication changes (42%), a diagnosis (42%), counseling (36%), and intensive outpatient therapy (36%). Commonly reported barrier(s) to treatment outside of the ED included long wait lists for providers (36%), providers not accepting new patients (24%), and insurance issues (14%). The median LOS in the ED was 18.33 hours (range: 2.7 to 167.7 hours). Males, on average, had a longer LOS (t=-2.05, df=103, p=0.04). 28% of children got admitted, 15% were transferred to another psychiatric facility, and 57% were discharged. Of those families who sought inpatient care, only 61% were admitted/transferred. Across all subjects, having a diagnosis of depression (X2=31.99, df=1, p<0.001) and being older (OR 1.45, 95% CI 1.25-1.71, p<0.001) made children more likely to be admitted. 

Conclusion: The gap between families seeking inpatient care and actual admissions underscores the need for better outpatient access. By identifying barriers to care and mismatched expectations, this study helps inform policies to better support families in need.

Psychiatric Care in the Pediatric Emergency Department

Background: Androgen deprivation therapy (ADT) is a key treatment for patients with advanced prostate cancer. With longer durations of ADT, patients face an increased risk of cardiometabolic side effects. This study aimed to assess body composition, cardiometabolic risk, and overall survival in patients with advanced prostate cancer on long-term ADT. 
Methods: We performed a retrospective analysis of body composition, cardiometabolic risk, and outcomes in patients with locally advanced or metastatic prostate cancer treated with at least 6 months of intensified ADT at the UVA Comprehensive Cancer Center between 2015 and 2023. Patients included had baseline imaging within 9 months prior to ADT initiation and follow-up imaging around 1 year. Body composition was assessed at the L3 vertebral level using automated CT analysis (Comp2Comp). Cardiovascular risk was estimated using the American Heart Association PREVENT™ calculator. Overall survival was analyzed using the Kaplan-Meier method. 
Results: A total of 56 men were included, with a median age of 72 years (IQR 64.3 72.0). Fourteen (25%) had stage IVA disease and 42 (75%) had stage IVB disease. Twelve (21.4%) were classified as having castrate-resistant disease. At baseline, many had independent cardiovascular risk factors including hypertension (73.2%), hyperlipidemia (30.6%), and diabetes (21.4%). Nineteen of 49 (38.8%) had a predicted 10-year cardiovascular disease risk >20%. Fifteen of 55 (27.3%) had sarcopenic obesity, defined as a skeletal muscle index two standard deviations below a healthy U.S. reference, with expansion of subcutaneous and visceral fat. After a median of 13 months on ADT, most patients (32/39, 82%) showed selective loss of muscle mass without significant fat loss. The median skeletal muscle area (SMA) decrease was 10.52 cm² (P < 0.0001). Lower muscle mass correlated with increased cardiovascular risk score (R = -0.32, P = 0.026). A higher cardiovascular risk estimate was associated with lower overall survival (median OS 21.2 months for high risk vs. 49.9 months for intermediate risk, P = 0.0164). 
Conclusions: This study highlights elevated baseline cardiovascular risk and a body composition profile consistent with sarcopenic obesity in elderly men with prostate cancer. Long-term ADT-induced muscle loss may worsen cardiometabolic health and is associated with reduced overall survival.

Effect of long-term androgen deprivation therapy on body composition, cardiometabolic risk and overall survival in patients with advanced prostate cancer

Abstract Title
Adverse Childhood Experiences and Temporal Discounting in Older Adults

Background
Traumatic events experienced in the first 18 years of life, known as adverse childhood experiences (ACEs), are associated with an increased burden of chronic disease. ACEs have been shown to impact brain regions associated with impulsivity and may play an important role in an individual’s ability to delay reward. Temporal discounting is the tendency to prefer more immediate rewards over delayed gratification, and higher discounting has been implicated in poor chronic disease management. To better understand how adversity early in life could complicate chronic disease management, we examined the association between ACEs and temporal discounting in older adults. We hypothesized that a higher total number of ACEs will have a greater effect on future temporal discounting.

Methods
We conducted a cross-sectional analysis of self-reported ACEs and temporal discounting using previous cohort data in the Rush Alzheimer’s Disease Center on 834 participants 65 years and older (mean age 80, 86% white, 12.4% African American, 76% female). ACEs were measured with a 16-item trauma questionnaire and summed into a total ACE score (composite measure z- score) and five categories (principal component analysis): family separation/problems, emotional neglect, financial need, parental violence, and parental intimidation. Small scale (α) and large scale (A) temporal discounting was measured at baseline and assessed via a standard preference elicitation protocol of a 7-question binary choice task between smaller immediate versus larger delayed rewards. Cross-sectional analysis was conducted using R Statistical Software, ANOVA, and Poisson regression.

Results 
Higher total ACE scores were significantly associated with steeper temporal discounting: A (β = 0.077, SE = 0.028, p = 0.006) and α (β = 0.0022, SE = 0.0010, p < 0.001). Among ACE categories, parental violence showed the strongest effects on both A (β = 0.090, SE = 0.027, p = 0.001) and α (β = 0.0022, SE = 0.00070, p = 0.002) and was dose-dependent with a 14.8% (A; p-value < 0.001) and 15.4% (α; p-value = 0.001) increase in discounting per unit of parental violence. Race was also associated with discounting, while years of higher education, male sex, and high global cognition had protective effects.

Conclusion
These findings suggest that ACEs, particularly parental violence, are associated with diminished ability to delay gratification in later life. This supports the hypothesis that early adversity has a significant and dose-dependent effect on temporal discounting. Further studies are warranted to further explore these implications on health behaviors and chronic disease management and to inform interventions.

Adverse Childhood Experiences and Temporal Discounting in Older Adults


***This is an ongoing study. 31/40 patients have completed the protocol are included in this preliminary abstract.

Abstract Title
A Comparison of Push-off and Gait Strength following Open Haglund’s Resection vs. Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy

Background
The gold standard for surgical treatment of insertional Achilles tendinopathy (IAT) is the open midline Achilles tendon splitting Haglund’s resection (OH). However, the percutaneous Zadek osteotomy (ZO) is a safe and effective alternative intervention. Retrospective studies have compared patient-reported outcomes and radiographic findings between ZO and OH; however, data on post-operative strength remain limited. Accordingly, the current prospective study evaluated the postoperative push-off and gait strength following OH vs ZO for IAT.
Methods
Thirty-one patients >18 years of age who underwent unilateral OH (N=17) or ZO (N=14) for IAT with ≥1-year follow-up met the inclusion criteria; patients with prior midfoot/hindfoot surgery, recent lower extremity surgery, neuromuscular conditions were excluded. Static plantarflexion/dorsiflexion strength were assessed in seated and supine positions. Standing strength was evaluated by unilateral and bilateral calf raises performed on pressure plates. Single-leg balancing was timed. Finally, vertical and anterior ground reaction forces at toe off were captured during gait. The mean difference between operative/non-operative limbs was calculated for each measurement and reported as percentage of body weight (%BW).
Results
In patients who underwent OH, a significant decrease in lower anterior ground reaction force of the operative limb was observed (0.00950.013, p=0.007). Also, following OH, patients demonstrated a decrease in unilateral vertical ground reaction force when compared to the non-operative limb (0.0210.035, p=0.02). Interestingly, following OH patients balanced on their operative limb a mean 8.311.7 seconds longer in comparison to their non-operative limb (p=0.01). No significant differences were observed in the ZO cohort.
Conclusion
Statistically significant decreases in operative limb strength during unilateral calf raise and forward propulsion was observed following OH for IAT. Meanwhile, no such loss of strength was observed following ZO. While both procedures are safe and effective surgical options for managing IAT, these preliminary findings suggest ZO may allow for preserved post-operative strength relative to OH.

Strength Analysis of Open Haglund's Resection & Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy

Drug-Induced Liver Injury (DILI) often has delayed identification due to the latency and idiosyncratic nature of the injury. The treatment for DILI is removal of the offending agent and supportive care with consideration that ALT and AST can downtrend quickly whereas Alkaline Phosphatase may increase for months after. 
Our patient is a 22 year old male who presents with 5 days of abdominal pain and diarrhea accompanied by pale stools, dark urine, generalized pruritus, and scleral icterus. His liver enzymes were all elevated, and his R score was 2.2 suggestive of a mixed pattern of both hepatocellular and cholestatic liver injury. Initial workup tested for viral hepatitis, Wilson’s disease, alpha-1 antitrypsin deficiency, and hereditary hemochromatosis. The patient denied any new medications, supplements, or drug use other than natural cannabinoids. An autoimmune liver panel ruled out PBC/PSC, and Stool Studies were unrevealing for acute GI illness. The patient was sexually active with multiple partners, but STI work-up only showed a resolved syphilis infection.
Despite this negative laboratory work up, abdominal ultrasound revealed coarse echogenicity suggestive of hepatic inflammation and MRCP was significant for mild hepatomegaly. Finally, liver biopsy revealed mixed inflammatory infiltrate reflecting a likely drug-induced liver injury. Upon more thorough medical reconciliation, dispense reports from an out-of-city urgent care showed amoxicillin prescribed 2 months prior, and the patient ultimately revealed a history of strep throat treated with a full course of antibiotics which he had forgotten about. 
The patient’s presentation was consistent with this diagnosis but history and labs were originally unrevealing as the injury occurred months prior and symptoms manifested separately. This case demonstrates the importance of obtaining a detailed medication history and inquiring into older infections, as DILI can have a delayed presentation several months after the offending agent is removed and patients often do not recall certain medications until specifically prompted. It also exhibits the relative utility of liver biopsy in diagnosing otherwise vague presentations when noninvasive workup is inconclusive. This patient’s ALT and AST downtrended over time, but his Alkaline Phosphatase continued to increase even months after amoxicillin use. This variability in liver enzyme trends is due to cholestatic injury having a more protracted course because bile duct injury takes months to heal whereas hepatocellular injury can resolve within days.

Diagnostic Challenges of Amoxicillin Induced Liver Injury

Background: Pathogenic variants in SCN2A, a gene encoding the voltage-gated sodium channel (Nav1.2), contribute to a spectrum of epilepsy and neurodevelopmental disorders. The recurrent 16p11.2 duplication is a copy number variant risk loci commonly associated with developmental delays affecting speech and motor functions, with increased seizure risk. 

Case Description: Following a normal pregnancy, neonatal and early developmental period, this female patient was noted to have delayed developmental milestones and failure to thrive at 8 months of age. By 19 months of age, she began experiencing both focal and generalized seizures occurring up to 4 times daily over a 2-month period, ultimately leading to hospitalization. An EEG performed at this time demonstrated epileptiform discharges in the right central, right temporal, and left temporal head regions. Antiepileptic therapies were initiated, with lack of response to phenobarbital and oxcarbazepine, with intolerable side effects to lacosamide. At 20 months of age, regression of skills with worsening language and motor delays and recurrent hand flapping, prompted a titration of previous medications and initiation of clobazam. A brain MRI at this time demonstrated delayed myelination for age without other notable findings. Exam findings at this time included round hypotonic facies, coarse facial features, hypertelorism, arched eyebrows and long eyelashes. 

Results: Seizures persisted and were pharmacoresistant in nature, thus exome sequencing with concurrent chromosomal microarray analysis were initiated at age 20-months. Testing resulted with an interstitial duplication of 565kb of DNA at 16p11.2 (29635211_30199713)x3 and a pathogenic variant in SCN2A c.2557C>T (R853W).
The patient is now 3-years-old and continues to experience focal seizures, reflux, global developmental delay, and self-injurious behavior. A repeat brain MRI revealed progressive volume loss within the supratentorial brain. 

Discussion: This is the first reported case of patient with co-occurring16p11.2 duplication and a heterozygous SCN2A pathogenic variant. It is suspected that much of this patient’s phenotype is caused by the SCN2A variant. As a neurodevelopmental risk loci, the 16p11.2 duplication may increase this patient’s risk for more severe developmental delays, autism, or additional seizures types. Seizure control and early intervention therapies continue to be the mainstays of intervention to improve developmental outcomes, as to date there are no targeted anti-epileptic medications or other precision therapies for SCN2A-DEE.


First Reported Case of Concurrent 16p11.2 Duplication and SCN2A R853W Variant in a Patient with Pharmacoresistant Epilepsy and Developmental Delay

Cocaine and ethanol co-use, the most prevalent polysubstance disorder, occurs in 74% of users. Ethanol potentiates cocaine’s sympathomimetic effects through cocaethylene, a metabolite with a half-life 2-3 times longer. The resulting combination amplifies excitotoxicity, oxidative stress, and neuroinflammation, compounding cerebrovascular risk, including ischemic and hemorrhagic strokes or transient ischemic attacks (TIAs). Cocaine-induced vasospasm, endothelial dysfunction, and hypertensive fluctuations may also provoke temporary neurological deficits, including visual field disturbances. Homonymous hemianopia, typically caused by post-chiasmal pathology (e.g., stroke, intracranial hemorrhage, or mass effect), is conventionally considered irreversible, though exceedingly rare cases of recovery have been reported.

Herein, a 65-year-old male with alcohol use disorder, type II diabetes, hypertension, hyperlipidemia, and hypothyroidism presented for an inpatient detoxification after escalating to 24 beers daily for two weeks, with intermittent cocaine use. He appeared disheveled, depressed and displayed psychomotor retardation but had no tremors or previous seizures. Laboratory studies revealed macrocytic anemia, mild transaminitis, and an ammonia level of 51 μmol/L, with negative toxicology for other substances. Two days post-admission, he developed severe cognitive impairment (MMSE 13/30), inconsistent with alcohol withdrawal given the absence of autonomic instability or hallucinations. A clock drawing test (CDT) revealed right-sided number crowding. Non-contrast CT ruled out acute intracranial pathology but showed chronic ischemic changes. By day four, cognition improved (MMSE 24/30), and CDT normalized.

This case presents a rare, reversible homonymous visual disturbance likely related to cocaine and ethanol-induced cerebral vasospasm in the setting of preexisting cerebrovascular disease. Although the precise mechanism remains unclear, transient visual deficits in polysubstance users may reflect TIAs triggered by drug-induced vasospasm, particularly in patients with underlying small vessel disease. Similar visual disturbances were reported by Burggraaf-Sánchez de las Matas et al., who described a 36-year-old man presenting with bilateral peripapillary hemorrhages and profound vision loss due to alcohol and cocaine use. Toxic-ischemic optic neuropathy hemorrhages resolved within three weeks, and visual acuity (20/20 OU) recovered fully; however, central scotomas persisted, indicating only partial reversibility. Altogether, these cases suggest that combined toxic and vascular insults can result in acute but variably reversible visual sequelae. Future studies may explore advanced neuroimaging correlates, the role of vascular imaging in polysubstance users with transient deficits, and the utility of early cognitive screening tools such as the CDT in detecting subtle visual field changes.


Transient Homonymous Hemianopia in Cocaine and Ethanol Co-Use: A Case of Vasospam-Induced Transient Ischemic Attack

Background: Despite progress in Zambia’s HIV response, the disease still poses a significant health burden on the country. In 2021, Zambia had the 7th highest adult HIV prevalence worldwide at 10.8%, with over 15,000 new infections occurring among youth aged 15-24. The progression of HIV to AIDS has devastating consequences, especially among young people. Between 2005 and 2015, there was a 45% increase in AIDS-related deaths among youth aged 15-19, and AIDS ranks as the second leading cause of death among young women in Africa. Anti-retroviral therapy (ART) is an effective treatment that suppresses HIV viral load by interfering with the viral replication cycle; however, youth living with HIV (YLHIV) in Zambia face significant barriers to antiretroviral therapy (ART) adherence, including stigma and substance use. In 2019, an estimated 65,000 adolescents in Zambia were living with HIV, with only about 60% on ART. Furthermore, 46% of YLHIV in Zambia reported missing a recent clinic appointment. This care deficit leaves most YLHIV virally non-suppressed, making them vulnerable to opportunistic infections and life-threatening complications.

Methods: This study utilized qualitative analysis of focus group discussions (FGDs) among YLHIV (ages 18–24) receiving care at Kanyama First Level Hospital (KFLH) and Matero Urban Health Centre (MUHC) in Lusaka, Zambia. FGDs assessed participants’ experiences of ART adherence, substance use, and HIV self-management. There were six FGDs conducted, three among female participants and three among males. Participants were eligible based on <80% medication adherence in the previous month, combined with substance use during the same period.

Results: FGDs revealed stigma and substance use as major barriers to ART adherence among YLHIV. Participants faced stigma from healthcare providers, family, and friends. Fear of disclosure led adolescents to hide their status, avoid taking medication in public, or disengage from care. Additionally, substance use with alcohol, cannabis, and amphetamines was found to worsen mental health and disrupt medication routines, leading to increased viral replication. 

Conclusion: Non-adherence to ART can be attributed to several intersectional factors, most notably stigma and substance use. To address these barriers, the next phase of the project will utilize FGD findings to design a culturally sensitive mobile health (mHealth) motivational text messaging (MTM) intervention. The intervention aims to improve ART adherence and health outcomes while reducing stigma, addressing substance use, and protecting privacy. Participants will receive motivational text messages reminding them to take their medications, attend clinic appointments, and reduce their substance use.

Stigma and Substance Use as Barriers to ART Adherence Among
Youth Living with HIV in Zambia

Assessing the Perceptions of Osteopathic Medical Students’ beliefs since Transitions in the USMLE step 1 and COMLEX level 1 examinations to Pass/Fail
Student Author: Milo Taylor
Mentor: Robert Goldsteen
Objective: since the transition of the USMLE step 1 and COMLEX level 1 examinations to pass/fail in 2022, there has been very little research into the impact of this transition on osteopathic medical students. The goal of this study is to investigate the impact of the transitions of these exams to pass/fail on osteopathic student well-being depending on their intended specialty. 
Methods: A Qualtrics survey was administered to students at the Burrell College of Osteopathic Medicine. This survey included a free response question asking what specialty the student intended to pursue. Then the perceived stress scale 10 (PSS-10) was administered. The responses were divided into four groups based on how competitive the intended specialty was. The PSS-10 score averages were calculated for each group and compared. 
Results: the most competitive group had a PSS-10 mean score of 20.29, the intermediate group had a mean PSS-10 score of 21.29, the least competitive group had a mean PSS-10 score of 21, and the undecided group had a mean PSS-10 score of 20.33. 
Conclusion: There was very little difference in stress levels between the four groups, and therefore intended specialty seemed to not have any effect on stress levels. This possibly confirms our hypothesis that there would be no difference in stress levels between the groups because the pressure of obtaining a high numerical score on these exams has been eliminated. While this preliminary data suggests that the NBOME and NBME may have succeeded in improving student well-being with the decision to make these exams pass/fail, further research must be done to investigate the effects of this transition. 




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The Combined Impact of Chronic Illness and Presence of Genetic Disposition for Dementia on Incident Postoperative Delirium among Older Elective Surgery Patients

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Double Trouble, One Solution: Valve-in-Valve TAVR Corrects Both Aortic and Mitral Valve in a Complex Dual-Valve Pathology