United States

Background
Pacemaker malfunction is a rare occurrence in modern times. However, programming features in a pacemaker can give the impression of pacemaker malfunction. Even though there may not be a device malfunction that would require replacement, some of these programming features can alarm the medical service.

Case Presentation
A 33-year-old male with history of idiopathic ventricular fibrillation (VF) arrests and tachycardia-bradycardia syndrome status post Boston Scientific dual chamber ICD presented with presyncopal episodes. As part of ischemic evaluation, he underwent an exercise stress test. Interestingly, his EKG revealed wide complex beats during sinus tachycardia at 180 beats/min.

In our patient, pacer spikes are visualized prior to a widened QRS complex confirming pacemaker mediated ventricular pacing. Review of the patient’s electrogram displayed an episode of atrial sensing occurring at 340 ms with a subsequent absence of ventricular sensing leading to a ventricular paced beat. Device settings were modified to allow generation of the next atrial current more quickly to overcome the need for ICD mediated ventricular pacing: the post-ventricular atrial refractory period (PVARP) threshold was lowered from 240-350 ms to 240-280 ms and paced/sensed AV delay thresholds were lowered from 220-280 ms to 200-250 ms. These adjustments led to appropriate recognition of native ventricular complexes by the pacemaker and resolution of his ventricular pacing during sinus tachycardia.

Discussion
Inappropriate pacing by a permanent pacemaker during episodes of tachycardia can be a sign of device malfunction and can lead to clinically dangerous arrhythmias. However, this finding is often a result of programming features of the device which should be investigated and modified appropriately. In our patient, given the young age and the fast ventricular rates, many of the ventricular complexes fell in the refractory period of the device leading to functional under sensing and consequent over pacing. An understanding of pacemaker functioning can lead to resolution of the issue and prevent unnecessary procedures.

AMA Research Challenge 2025 

Why is the pacemaker pacing when the patient’s own heart rate is 180/min?

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poster

Background
EFFC is a rare dermatologic condition of unknown etiology first reported by Kitamura in 1960. It presents with hyperpigmentation, well-demarcated erythema, telangiectasias, and follicular papules on the lateral aspects of the face. This patient is unique as he is the first reported case of EFFC in an African American patient or Fitzpatrick V-VI skin type.
Case Presentation
A 20-year-old healthy African American male presented with an asymptomatic hyperpigmented eruption on his bilateral cheeks. The eruption had been present for 6 years, and he had no significant personal or family history. On his bilateral cheeks, there were hyperpigmented plaques with multiple follicularly based hyperkeratotic papules (Figure, A, B, C). Prior treatments included tretinoin 0.025% cream and benzoyl peroxide 5% cleanser without improvement. Based on his clinical findings, the patient was diagnosed with Erythromelanosis follicularis faciei et colli (EFFC). The features of erythema, reddish-brown hyperpigmentation, and follicular papules on the cheeks are consistent with this diagnosis. He was recommended to start tretinoin 0.05% cream nightly and hydroquinone 4% cream twice daily to areas of hyperpigmentation along with strict photoprotection.
Discussion
To date, there have been less than 50 published case reports with the condition exclusively reported in the Asian and Caucasian population. At the time of this publication, 54% of published cases are Asian and 46% of cases are Caucasian. Proposed mechanisms for EFFC include autonomic nerve dysfunction, autosomal recessive inheritance, and sporadic mutations. Histopathology of EFFC shows hyperkeratosis, increased pigmentation of the basal membrane, follicular plugging, dilated blood vessels in the upper dermis, follicular dilatation, and perivascular and periadnexal inflammatory infiltrates. Dermatoscopic findings include a red-brown background color with gray-blue dots and granules present in interfollicular and perifollicular areas. Other dermatoscopic features include whitish scale and several follicular keratotic plugs, with white rosettes and telangiectasia occurring occasionally. Reported treatments of EFFC include topical metronidazole, retinoids, ammonium lactate, hydroquinone, tacalcitol, oral isotretinoin, salicylic acid peels, pulsed dye laser, glycolic acid peels, and Q-switch Nd: YAG laser. All of these treatments require long-term and consistent use which make compliance challenging and lead to poor therapeutic outcomes. As there is much unknown regarding EFFC, further research must be done to determine potential etiologies and efficacious treatments for this condition.

Erythromelanosis follicularis faciei et colli in an African American Male

Introduction 
Cytokeratin 7 (CK7) is commonly expressed in tumors of the lung, ovary, endometrium, and breast, but is rarely observed in the gastrointestinal epithelium. Therefore, colorectal carcinomas with a CK7+/CK20+ phenotype represent a minority, accounting for approximately 15.3% of cases. In addition, microsatellite-stable (MSS) tumors harboring BRAF V600E mutations are typically CK7-positive and are associated with a poor prognosis. Here, we report a rare case of colorectal carcinoma with hepatic and pulmonary metastases, analyzed from the perspective of multiple gene mutations.

Case Presentation 
A 59-year-old female presented to the emergency department of the previous hospital with abdominal pain. On the same day, abdominal CT scan with contrast revealed a 6.3 cm mass in the cecum, along with adjacent pericecal lymphadenopathy. On day 5, a liver biopsy guided by ultrasound showed tumor cells that were diffusely positive for CK7 and focally positive for CK20 and CDX2. Molecular testing revealed a BRAF V600E mutation, with wild type KRAS, MSS, and TP53 R273C. On day 47, a contrast enhanced chest CT scan revealed multiple pulmonary nodules consistent with pulmonary metastases. On day 52, she was referred to our clinic for the treatment of stage IV colon cancer (cT3N1M1c) with
metastases to the liver and lungs. Due to worsening abdominal pain, she underwent a colectomy on day 65. Although she completed 10 cycles of modified FOLFOX therapy (5-FU, leucovorin and oxaliplatin), her serum carcinoembryonic antigen (CEA) levels increased from 54.7 to 275.1. We changed her treatment regimen to FOLFIRI (5-FU, leucovorin, and irinotecan) combined with panitumumab. However, her condition deteriorated after just one cycle, and the treatment was discontinued, and she subsequently passed away.

Discussion
This case represents a rare molecular subtype of colon cancer with CK7 positive, CK20 positive, BRAF V600E mutation, and MSS. These types of tumors are said to arise via the serrated neoplasia pathway rather than the conventional adenoma–carcinoma sequence, and they often acquire TP53 mutations as the late stage, which contributes to tumor progression. These features are consistent with previous studies; however, detailed reports describing the clinical course of colorectal cancer with this phenotype remain limited. Additionally, tumors with this phenotype are associated with poor prognosis and limited response to standard chemotherapy as this patient died. Given the recent advances in targeted therapy such as encorafenib and cetuximab, early molecular profiling is essential to guide personalized treatment in such uncommon colorectal cancer subtypes.

Colorectal Cancer with CK7+/CK20+, BRAF Mutation, and MSS: A Distinct Molecular Phenotype with Poor Prognosis

Background:
Mycobacterium bovis (M. bovis) is a rare zoonotic pathogen most often acquired through the consumption of unpasteurized dairy products or direct contact with infected animals. Central nervous system (CNS) involvement is exceptionally uncommon, particularly in immunocompetent individuals. Diagnosis is particularly challenging due to its clinical and radiographic similarity to Mycobacterium tuberculosis, compounded by the prolonged time required for definitive culture-
based identification. In this report, we present a rare case of M. bovis meningoencephalitis in an immunocompetent adult.

Case Presentation:
A previously healthy 35-year-old butcher presented with three weeks of progressive fatigue, malaise, and intermittent headaches, followed by acute unresponsiveness and urinary incontinence. He remained afebrile throughout his hospitalization. Neurologic examination revealed somnolence, orientation to self only, impaired attention, and poor abstract reasoning. Notable findings included left horizontal gaze nystagmus, pronator drift of the right upper extremity, right Achilles hyperreflexia, and a positive Babinski sign on the right. Laboratory studies showed hyponatremia (Na 125 mmol/L) with inappropriately concentrated urine, consistent with SIADH. Cerebrospinal fluid (CSF) analysis revealed elevated protein (270 mg/dL), lymphocytic pleocytosis (WBC 107/μL), and hypoglycorrhachia (glucose 11 mg/dL). Brain MRI showed multiple rim-enhancing lesions, leptomeningeal enhancement, an acute right basal ganglia infarct, and mild communicating hydrocephalus. Spinal MRI demonstrated focal cord signal abnormalities and leptomeningeal enhancement. A positive QuantiFERON-TB Gold test raised suspicion for CNS tuberculosis, although CT imaging revealed no pulmonary or abdominal involvement. Given the overlapping neuroradiologic features of CNS tuberculosis and neurocysticercosis, the initial differential diagnosis included both possibilities. Empiric RIPE therapy (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol) was started. Three months later, CSF cultures grew M. bovis, confirming the diagnosis. The regimen was modified to Isoniazid, Rifampin, Ethambutol, and Moxifloxacin for seven months due to the intrinsic pyrazinamide resistance of M. bovis. Despite appropriate therapy, the patient exhibited persistent cognitive impairment and physical disability, requiring assistance with mobility. He was referred to inpatient rehabilitation for ongoing neurologic recovery and functional support.

Discussion:
This case highlights the zoonotic potential of M. bovis and the importance of considering it in patients with CNS disease and relevant exposure history. Its clinical similarity to M. tuberculosis underscores the need for timely diagnosis and appropriate treatment to minimize neurologic compromise.

Mycobacterium bovis in an Immunocompetent Patient: A Rare Intruder of the CNS

Background 
Research experience during medical school is widely recognized as a valuable component of medical education and an increasingly emphasized metric for increased competitiveness for residency applications. In 2021, 41% of program directors (PD) said meaningful research participation will be more important in offering interviews with USMLE Step 1 transitioning to pass/fail. This has resulted in a research arms race among medical students, with NRMP data showing a 50% increase in the number of research items for applicants between 2014 and 2024. While this trend continues to rise, it has led to concerns regarding the quality of research, its translatability, and scholarly impact. We aim to quantify the impact of medical student research and to provide updated patterns and trends in medical student research across a span of 20 years. 

Methods 
We conducted a bibliometric analysis of PubMed-indexed articles (2003–2023) authored by U.S. and international medical students and residents, identified using standardized affiliation-based queries. Filters limited results to original research and reviews across medical and surgical specialties. Duplicate entries were removed to create mutually exclusive cohorts. Research impact was assessed using NIH iCite metrics, including citation counts and Relative Citation Ratio (RCR), a field-and-time-normalized measure of article influence. Article metadata was manually extracted. Summary statistics were calculated to compare output and scholarly influence between cohorts. 

Results 
From 2003-2023 medical student authorship yielded 1001 exclusive publications and residents yielded 1930. Medical student–driven publications received more citations on average (20.65 vs. 16.97) and had a higher median RCR (0.98 vs. 0.87) compared to resident-driven publications (p<0.05). Of the medical student-driven articles, 31% were cited in clinical documents whereas only 11% were never cited. Surgical specialties accounted for nearly twice as many publications as medical specialties; however, both received comparable citations per publication (median = 13.00 vs. 13.50, p=0.71). U.S. medical student publications outperformed international counterparts, generating more citations (13.10 vs. 9.00) and a higher median RCR (1.16 vs. 0.77, p<0.05). 

Conclusion 
In recent decades, medical student research output has grown substantially, demonstrating a stronger emphasis on scholarly activity in medical education. Our bibliometric analysis demonstrates that medical students contribute impactful research that is frequently cited and built upon. With research becoming an integral part of residency competitiveness, these findings underscore the importance of student-led scholarship and supporting mentored research opportunities.

The Science Before the Scrubs: A Bibliometric Analysis of Medical Student-Driven Research (2003-2023)

Background
Non-communicable diseases and injuries are now the leading causes of disability-adjusted life years globally. Plastic and reconstructive surgery (PRS) can address up to 66% of surgical disease burden, yet only 41% of U.S. residency programs offer global surgery education. This gap, coupled with ethical tensions between local and visiting surgeons on topics like scope of practice and informed consent, underscores the need for culturally sensitive, stakeholder-informed training models.

Methods
Surgeons in Humanitarian Alliance for Reconstruction, Research and Education (SHARE), founded in 2019, aims to increase access to PRS care in low- and middle-income countries while prioritizing local surgeon leadership in Africa. This study assesses the impact of SHARE’s curriculum on the knowledge, attitudes, and confidence of UMass PRS residents regarding global surgery. Residents completed pre- and post-exposure surveys. 

Results
Residents reported unanimous agreement with understanding ethical problems (mean=5.0 on a 5-point Likert scale), but limited prior experience and moderate confidence in delivering culturally competent care. There was strong interest in improving these skills. 

Conclusion
Preliminary findings suggest UMass residents are eager to engage in global surgery education and build cultural competence. SHARE’s curriculum may serve as an effective model to fill existing gaps in global health training. It could be scalable to other programs aiming to prepare ethically grounded, globally competent surgeons.

SHARE-ing the World: Mandatory Global Surgery Education for Plastic Surgery Residents at UMass

Background
Point-of-care ultrasound (POCUS) is rapidly becoming a fundamental aspect of patient care due to its real-time diagnostic and procedural guidance. Despite this, barriers such as limited curricular integration, lack of accessible and affordable training models, and paucity of ultrasound-trained faculty limit opportunities for preclinical medical students to obtain meaningful experience with ultrasound. Early exposure to ultrasound in medical training leads to increased knowledge of anatomy and basic sciences, improved ultrasound knowledge and performance in clinical clerkships and residency, and improved comprehension of POCUS exams and procedures.
In this study, we evaluate the effectiveness of a low-cost, homemade phantom model for teaching ultrasound-guided IV insertion to preclinical medical students and measure the impact on participants’ reported ultrasound proficiency, clinical preparedness, and interest in POCUS.

Methods
In the Fall of 2024, the Ultrasound is For Everyone (USIFE) club at the Boston University Chobanian and Avedisian School of Medicine held an ultrasound-guided IV insertion workshop for MS1s, led by MS2s and MS4s. Phantom models were created using gelatin, Metamucil, and blue dye to simulate tissue, while long balloons filled with red-dyed corn syrup mimicked veins. The workshop covered ultrasound identification of neurovascular structures and demonstrated ultrasound-guided IV insertion, followed by supervised practice.
Participants (n = 23) completed pre- and post-surveys, which included Likert-scale items and open-ended questions, assessing their confidence, clinical preparedness, and career interests. Quantitative data were analyzed using Wilcoxon Signed Rank tests and paired t-tests; qualitative responses underwent inductive thematic analysis.

Results
Participants reported a significant increase in confidence in distinguishing neurovascular structures on ultrasound (p<0.001) and performing ultrasound-guided IV insertion on both phantom models and patients (both p<0.001). Participants also reported feeling more prepared to use ultrasound during clinical rotations (p<0.001), and interest in pursuing medical specialties that frequently use POCUS increased significantly (p = 0.023). Qualitative feedback emphasized the value of hands-on learning in building clinical skills, heightened interest in learning ultrasound, and enhanced understanding of the clinical applications of ultrasound.

Conclusion
Homemade phantom models offer an affordable, effective solution for introducing ultrasound-guided procedures in early medical education. Our findings show that even a single, student-led workshop can significantly boost preclinical students’ confidence and preparedness for clinical ultrasound use and ability to discern neurovascular anatomy on ultrasound. While further study is needed to evaluate long-term skill retention and clinical transferability, these findings support wider adoption of similar low-cost POCUS training methods in preclinical medical education.

A Student-Created Phantom Model for Affordable Early Ultrasound Exposure in Medical Education

Background
Food insecurity and limited nutritional education exacerbate health disparities in underserved communities, contributing to higher risks of long-term chronic illness and diminished health outcomes. YES Prep West Secondary school serves an economically disadvantaged student population, providing a key opportunity to address these challenges within the local community. Current studies have shown that when implemented together in a year-long program, the involvement of interactive activities significantly improves the effectiveness of dietary intervention, compared to didactic knowledge alone. Nourish, a weekly nutrition and cooking after-school program designed by a Registered Dietitian and medical students, aims to increase food accessibility and empower students to make healthier dietary choices, develop practical cooking skills, and sustainably improve health literacy. 

Methods
Nutritional knowledge quizzes and behavioral surveys were distributed at baseline (September 2024), mid-program (December 2024), post-program (May 2025), and sustainability follow-up at the start of the next school year (September 2025). A subsection of the surveys focused on fiber, assessing students’ ability to identify high-fiber foods (e.g., fruits, vegetables, whole grains) and their frequency of incorporating these foods into meals and snacks. Students were assigned a fiber identification score (0–5) and a fiber consumption score (0–9 as a sum of three frequency items: fruits, vegetables, whole grains), respectively. Paired t-tests were used to analyze changes in survey responses over time.

Results
At baseline, students (n=25) demonstrated an average fiber identification score of 47% and consumption score of 35%, indicating some difficulty recognizing high-fiber foods and infrequent incorporation into meals. By December 2024, identification improved significantly, with a +26.4 percentage-point (pp) increase in correct responses, and self-reported consumption of fiber (fruits, vegetables, and whole grains) rose by +18.7 pp (p<0.05). At the May 2025 endpoint, students maintained their gains in identifying fiber sources (+30.4 pp from baseline) and demonstrated an increase in high-fiber food consumption (+26.6 pp from baseline) (p<0.05). At the September 2025 follow-up, students retained knowledge gains (+29.6 pp from baseline) and reported continued incorporation of high-fiber foods (+28.4 pp from baseline), suggesting sustained behavior change even after structured programming ended (p<0.05).

Conclusion
Nourish significantly improves students’ ability to both identify and incorporate high-fiber foods, with gains sustained beyond the completion of the program. These findings highlight the efficacy of targeted community-based interventions in addressing health disparities and empowering youth toward sustainable wellness.

Sustained Impact of an After-School Culinary Program on Youth Health Literacy and Behaviors

Background: Hypoglossal nerve stimulation (HGNS) is an effective therapy for Obstructive Sleep Apnea (OSA) in patients intolerant to CPAP. However, concerns about its efficacy in patients with elevated body mass index (BMI) have led to restrictive insurance coverage, often using a threshold of 32 kg/m². This creates a critical treatment gap for a significant patient population. This systematic review and meta-analysis aimed to evaluate how a BMI ≥32 kg/m² influences HGNS surgical outcomes, challenging the evidence basis for current BMI-based restrictions.

Methods: Following PRISMA guidelines, a systematic literature search was conducted across PubMed, Embase, and Scopus for studies published between January 2014 and April 2025. Eligible studies included prospective/retrospective cohorts or case-control studies that reported HGNS outcomes in adult OSA patients, stratified by a BMI of 32 kg/m². Data on study design, patient demographics, and postoperative outcomes were extracted. A random-effects meta-analysis was performed on qualifying studies to estimate the pooled odds ratio (OR) for treatment success, primarily defined by the Sher criteria, comparing patients with BMI ≥32 kg/m² to those below this threshold.

Results: Seven studies comprising 1,572 patients were included in the qualitative synthesis, with four studies (n=1,507) qualifying for the meta-analysis. While individual study findings were mixed, the meta-analysis revealed that patients with a BMI ≥32 kg/m² had a trend toward reduced odds of achieving surgical success (pooled OR = 0.87, 95% CI: 0.68–1.11), though this result was not statistically significant. Notably, many patients in the higher BMI groups who did not meet formal success criteria still experienced clinically meaningful reductions in Apnea-Hypopnea Index (AHI) and reported high rates of satisfaction and subjective improvement on validated scales like the Epworth Sleepiness Scale and the Clinical Global Impression Index scale.

Conclusion: The assertion that a BMI ≥32 kg/m² uniformly predicts HGNS failure is not supported by this meta-analysis. The lack of statistical significance, coupled with consistent reports of objective and subjective benefits, suggests that many patients with elevated BMI derive substantial value from HGNS. These findings challenge the rigid application of BMI-based cutoffs in payer policies and advocate for a more individualized, patient-centered approach to determining HGNS candidacy, which could expand access for a population with limited treatment alternatives.

Body Mass Index and Hypoglossal Nerve Stimulation Outcomes: A Systematic Review and Meta-Analysis

Background
Non-alcoholic fatty liver disease (NAFLD) and type 2 Diabetes Mellitus are the major causes of significant mortality and morbidity. NAFLD and type 2 diabetes have common risk factors. SGLT-2 inhibitors are believed to have a beneficial effect on liver fat in patients with NAFLD and type 2 diabetes. However, there are limited data available on this aspect of empagliflozin use. Thus, we aimed to compare the impact of empagliflozin on liver fat reduction in type 2 diabetes and NAFLD.
Methods
A comprehensive search of databases like PubMed, Google Scholar, and Cochrane Library was done. In the end, a detailed analysis was performed on a total of 6 finalized studies, all of which were randomized controlled trials. This comprehensive analysis consisted of a cohort of 806 Individuals.
Results
Participants in the Empagliflozin group had an average change of -29.57 (SD = 19), while those in the placebo group showed a smaller improvement of -16.41 (SD = 24.1). The standardized mean difference (SMD) was -0.60, with a 95% CI, Z = 2.48, P = 0.01. AST studies showed a statistically significant benefit of empagliflozin over placebo with an SMD of -0.41 (95% CI: -0.66 to -0.16, p = 0.001). Heterogeneity among the studies was low (I² = 34%). The SMD is -0.43 with a 95% CI and a p-value of 0.03, indicating a statistically significant effect favoring empagliflozin. The heterogeneity is low (I² = 0%, P = 0.37). The results for 30 % liver fat reduction show an odds ratio of 14.08 with a 95% CI of 2.74 to 72.48. The test for overall effect is statistically significant (p = 0.002).
Conclusion
The analysis found that with the use of empagliflozin, different variables significantly decreased. These include Liver Steatosis (CAP) Score, AST, MRI-PDFF, 30% LVEF Reduction, and liver fat content (LFC).
Keywords: 
Empagliflozin, NAFLD, Type 2 diabetes, liver fat reduction


Empagliflozin and liver fat reduction in T2DM & NAFLD

Introduction: Smoking is a major modifiable risk factor for age-related macular degeneration (AMD), but its influence on disease progression after early dry AMD is uncertain. The purpose of this study is to quantify the association between smoking and progression from early or intermediate nonexudative AMD to (1) advanced nonexudative AMD and (2) exudative AMD. 
Method: Retrospective cohort study using de-identified electronic health records from the TriNetX US Collaborative Network (68 health care organizations). Smokers were identified by nicotine dependence ICD 10 codes or varenicline prescriptions; nonsmokers had no such records. Propensity score matching (1:1) for age, sex, race/ethnicity, diabetes, hypertension, and obesity yielded balanced cohorts of 8,978 smokers and 8,978 nonsmokers—incident diagnosis of advanced nonexudative AMD or exudative AMD captured by ICD-10 codes. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.
Results: Among 22 490 adults aged ≥50 years with early or intermediate non exudative AMD (11,225 smokers [mean (SD) age, 73.1 (8.9) years; 52.5% female] and 11,265 nonsmokers [73.1 (9.1) years; 52.8% female]), smoking was associated with a higher risk of progression to advanced non exudative AMD (580/11225 [5.2%] vs 486/11265 [4.3%]; risk difference, 0.9%; RR 1.20; 95% CI, 1.07 1.35). Among 19,766 patients without prior exudative AMD (9,702 smokers, 10,064 nonsmokers), progression to exudative AMD occurred in 710/9702 (7.3%) vs 678/10,064 (6.7%); risk difference, 0.6%; RR 1.09; 95% CI, 0.98- 1.20.
Conclusions: Smoking was independently associated with a modest but statistically significant 20% relative increase in risk of progression to advanced nonexudative AMD, whereas its association with exudative AMD progression was not substantial. These findings reinforce smoking cessation as a key preventive strategy for patients with early dry AMD and refine risk stratification in clinical practice.


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