United States

Background:
Wilson’s disease (WD) is an autosomal recessive disorder characterized by copper accumulation in the liver, brain, and other tissues. Neurological features usually include tremors, dystonia, and parkinsonism. Central pontine myelinolysis (CPM) is rarely reported in WD and is typically associated with rapid correction of hyponatremia or fulminant liver failure. Early recognition of CPM as a presenting sign of WD is crucial for timely intervention.
Case Presentation:
A 19-year-old male presented with a history of chronic liver disease of unclear etiology, later developing melena and acute flaccid quadriparesis. Neurological examination revealed proximal weakness, diminished reflexes, and hypophonia with preserved sensation. MRI brain demonstrated symmetric T2 hyperintensities in the central pons consistent with CPM. Slit-lamp examination showed Kayser–Fleischer rings, serum ceruloplasmin was low (8 mg/dL), and 24-hour urinary copper excretion was elevated. Liver function tests revealed mildly deranged transaminases. A diagnosis of WD with hepatic and neurological involvement was established, and the patient was started on zinc acetate, D-penicillamine, and supportive care.
Discussion:
This case highlights CPM as a rare initial neurological manifestation of WD. While commonly associated with osmotic shifts, CPM may also arise from copper-induced neurotoxicity and hepatic dysfunction. The acute motor presentation mimicked peripheral neuropathy but was centrally mediated. Recognition of this atypical presentation can prevent diagnostic delays and facilitate early initiation of chelation therapy.

AMA Research Challenge 2025 

Wilson’s Disease Presenting with Acute Flaccid Paraparesis: A Rare Neurological Manifestation

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Background
Thoracic epidural analgesia (TEA) is widely regarded as the gold standard for postoperative pain control in patients undergoing abdominal surgery. While its benefits over systemic opioids and other analgesic modalities are well-documented, gaps remain in existing literature regarding outcome stratification based on modifiable factors of TEA. This study aimed to evaluate the effectiveness of TEA for postoperative pain control and assess how modifiable factors influence pain scores and opioid use after abdominal surgery.
Methods
Approval was obtained from the Saint Louis University Institutional Review Board to conduct this single-center retrospective chart review. Records were identified for a total of 176 adult patients who underwent abdominal surgery and received preoperative placement of a thoracic epidural between 2020 and 2022. Data on patient demographic information, procedural information regarding epidural placement, and post-surgical outcomes were collected through review of the electronic medical record system. Primary outcomes included patient-reported pain scores and adjunct opioid usage. Data were analyzed using t-tests, one-way ANOVA, and simple linear regression.
Results
Patients who did not require initiation of patient-controlled analgesia (PCA) postoperatively, indicating a successful epidural, reported significantly lower pain scores during epidural use (p = 0.009) and required significantly less adjunct opioids (total MME: p < 0.001; average daily MME: p = 0.003). Administering epidural bupivacaine alone, compared with hydromorphone + bupivacaine, was associated with significantly higher pain scores at 24 hours, during the epidural period, and over the length of hospital stay (p = 0.014, 0.021, 0.023, respectively). Epidurals placed at T9–T10, compared with those placed at T12-L1, were associated with significantly lower pain scores at the three time points studied (p = 0.019, 0.009, 0.008), as well as lower daily adjunct opioid use (p = 0.046).
Conclusion
TEA is effective in controlling postoperative pain and reducing opioid consumption following abdominal surgery. The combination of a local anesthetic with an opioid, particularly hydromorphone, yields better analgesic outcomes than local anesthetic alone. Additionally, higher thoracic placement levels, especially T9–T10, are associated with improved pain control, underscoring the importance of accurate catheter placement. These findings highlight modifiable factors that can enhance TEA efficacy and inform future initiatives to optimize perioperative pain management.


Pain Control and Opioid Use After Abdominal Surgery: How Thoracic Epidural Variables Shape Outcomes

Current methods for diagnosing acute cellular rejection (ACR) in heart transplant patients rely on manual histopathological analysis, which is time-consuming, subjective, and prone to variability. This project aims to develop an AI- driven approach to assist pathologists and streamline detection in myocardial biopsies, which would enable faster, more accurate, and objective identification from ACR, and the potential to apply the model’s ability to detect other diseases based on lymphocytic infiltration in the future. Methods including using ImageJ’s Trainable Weka Segmentation to analyze biopsy samples following heart transplant stained with H&E and standardized with a similar lymphocyte size. The primary task for the model was to identify clusters of lymphocytes, defined as ‘a cluster of over 3 blue-staining naked nuclei’. Classes included red for lymphocyte clusters, and green for ‘not-lymphocyte-clusters’. Model will be tested across new images to analyze the accuracy of detection. Preliminary outcomes include training across 7 samples, and 9 iterations of development for the model. Next steps include testing the model across 7-10 new biopsy slides, and comparing the identification across areas of manually-identified lymphocytic infiltration (the current gold standard).

AI-Driven Detection of Acute Cellular Rejection in Post-Heart Transplant Allograft Patients

Background: Traumatic brain injury (TBI) causes substantial morbidity and long-term neuropsychiatric sequelae. Bacterial meningitis may worsen outcomes after TBI, yet its mental-health impact is undercharacterized. This study examined 90-day neuropsychiatric outcomes following post-traumatic meningitis. 

Methods: We performed a retrospective cohort study using the TriNetX Global Collaborative Network. Two propensity-matched cohorts were assembled: severe TBI with subsequent bacterial meningitis and severe TBI without meningitis (2,977 patients each). Outcomes included post-concussional syndrome, amnesia, altered mental status, depressive episodes, anxiety disorders, and non-psychotic mental disorders. We estimated risks, risk ratios, and odds ratios, and generated Kaplan–Meier survival curves and instance-based frequency analyses. 

Results: Compared with TBI without meningitis, post-traumatic meningitis was associated with higher risk of amnesia (RR 2.65), altered mental status (RR 5.32), depressive episodes (RR 2.12), and anxiety (RR 2.05). Post-concussional syndrome risk was lower (RR 0.41). No difference was observed for non-psychotic mental disorders. Kaplan–Meier analyses showed significantly lower symptom-free probabilities for most outcomes. 

Conclusion: Post-traumatic bacterial meningitis substantially increases early neuropsychiatric complications after severe TBI, highlighting the need for proactive psychiatric evaluation, neurocognitive monitoring, and tailored rehabilitation in this high-risk population. Findings support early infection prevention and integrated neurocritical care pathways implementation.


Post Traumatic Meningitis Outcomes and Incidences on Mental Health

Background 
Postpartum musculoskeletal (MSK) pain is a common morbidity associated with biomechanical, hormonal, and caregiving demands. While most research focuses on pain within the first 6 months postpartum, chronic MSK pain is underexplored. Sarcopenic obesity, characterized by excess adiposity with low muscle mass, has been linked to chronic pain in older adults but is poorly studied in postpartum women. This study used real-world data to assess whether sarcopenic obesity increases the risk of persistent MSK pain following childbirth. 


Methods 
A retrospective cohort study was conducted using the TriNetX database to identify women aged 18–45 with documented deliveries. Two cohorts were formed based on the presence or absence of sarcopenic obesity diagnosed prior to pregnancy. The primary outcome was MSK pain up to 5 years postpartum. Propensity score matching was used to adjust for clinical and demographic factors. Kaplan–Meier survival curves and log-rank tests were used to assess time to event. A sensitivity analysis excluded those with MSK pain prior to delivery. 


Results 
After matching, 1,202 women were included in each group. MSK pain occurred in 66.1% of women with sarcopenic obesity versus 52.1% of controls (p<.001; OR=1.80, 95% CI 1.53–2.12; log-rank p<.001). In the sensitivity analysis, 40.7% of 91 women with sarcopenic obesity experienced MSK pain vs. 18.8% of 96 controls (p=.001; OR=2.97, 95% CI 1.53–5.75; log-rank p=0.058). 


Conclusion 
Pre-pregnancy sarcopenic obesity was associated with significantly increased risk of persistent postpartum MSK pain. These findings highlight it as a potential modifiable risk factor requiring further research. 



Sarcopenic Obesity and the Risk of Persistent Postpartum Musculoskeletal Pain: A TriNetX Based Study

Title: Pennsylvania’s 30-Day Rule and Involuntary Commitment: A Case Review of Commonwealth v. Gibson

Background: Involuntary psychiatric commitment laws balance protecting individual liberties while ensuring safety. Pennsylvania’s Mental Health Procedures Act (MHPA) of 1976 requires “clear and convincing evidence” that an individual poses a “clear and present danger” to themselves or others within the past 30 days for long-term involuntary commitment under Section 304. This 30-day dangerousness standard can pose a challenge for psychiatrists who base risk assessments on longer-term clinical history. The 1981 Pennsylvania Supreme Court case Commonwealth ex rel. Gibson v. DiGiacinto highlights the differences between legal criteria and psychiatric judgment.

Case Presentation: Russell Gibson had a documented history of paranoid schizophrenia, medication non-adherence, psychosis, prior violent behavior, and failed community treatment. Multiple clinicians concluded he posed a danger to himself and others. However, legal review of his case focused on the absence of a specific overt act or threat within the 30 days preceding the commitment hearing. In 1978, the Pennsylvania Superior Court agreed with expert opinion. However, in 1981, The Pennsylvania Supreme Court ruled that despite psychiatric testimony, no legal criteria for involuntary commitment were met without recent behavior fitting the 30-day dangerousness standard. The Supreme Court decision emphasized reliance on recent behavioral evidence over clinical risk assessments extending beyond 30 days.

Discussion: This case illustrates the disconnect between clinical psychiatric evaluations, which incorporate long-term behavioral patterns and risk factors, and the MHPA’s 30-day dangerousness standard required by law. Psychiatric testimony assesses risk through multiple factors including past violence, psychiatric history, and medication adherence. Research supports that individuals with psychosis, paranoia, and history of violence are significantly more likely to commit future violent acts. Moreover, studies suggest that in cases involving severe mental illness, repeat involuntary commitment can be predicted up to 64 to 70 days ahead, exceeding the statutory timeframe. The MHPA’s narrow window may limit the effectiveness of psychiatric testimony in legal decisions, potentially undermining patient safety and clinical judgment. This clinical case vignette emphasizes the need for clinicians to understand legal constraints on risk assessment and invites consideration of legal reform to update Pennsylvania’s 30-day dangerousness standard with evidence-based psychiatric risk evaluations.

Pennsylvania’s 30-Day Rule and Involuntary Commitment: A Case Review of Commonwealth v. Gibson

Background:
Community-engaged learning allows an immersive, context-specific experience for medical students to appreciate the impact of social drivers of health (SDOH) (1-4). Community organizations (COs) and community partners are important stakeholders in these learning experiences as they are directly and indirectly impacted by the work of students. Despite the critical role COs play, their perspectives are not traditionally incorporated in curriculum development. In contrast, co-designed curriculum incorporates the knowledge and expertise of COs to produce a practical, context-specific curriculum with shared ownership. We partnered with COs to co-design a revised community-engaged learning curriculum. 


Methods:
Representatives from COs, medical students, residents, and faculty members were recruited to be part of a SDOH curriculum co-design team. Five co-design sessions were held between January to March 2025. Aligned with co-design methodology, participants shared their experiences with the current community-engaged learning curriculum and ideas for improvement, practicality, and sustainability within the community. Summative transcriptions of our co-design sessions underwent rapid qualitative analysis to identify group priorities, and specific revisions were proposed back to the team for further discussion. A finalized curriculum was made with the team and is planned for implementation in the upcoming academic school year. 


Results:

Our co-design team included 14 CO representatives, 4 medical students, 1 resident, and 5 medical school faculty. 

Group priorities included:
1) creating sessions to develop skills in cultural humility and community trust-building prior to working with the community 
2) developing longitudinal partnerships between COs and students to develop a meaningful and tailored educational experience 
3) assessing students’ growth in understanding and appreciation of SDOH 

Our revised curriculum incorporates these priorities in three areas: 
1) Pre-clinical foundational years: Students first learn SDOH concepts, undergo empathy skills training, and simulate response to community needs through case-based discussion and exposure to lived experience narratives. Students are also paired with a CO to begin formulating a longitudinal community project. 
2) Clinical years: Students participate in a required community clerkship where they work with COs on longitudinal community projects. 
3) Fourth year: Students reflect on experiences with community and patients to state the impact of this curriculum on personal and professional growth. 


Conclusion:
Partnering with the community in designing an SDOH community-engaged learning curriculum provides stronger alignment between medical institutions and COs to broaden social impact, enhance transformative learning around SDOH, and more effectively address community needs.


References:
1. Harding D, Uppal S, Meiring S, Golding B, Dutta N, Parekh R. Community-engaged primary care medical education. Clin Teach. 2023;20(3):e13573. doi:10.1111/tct.13573 

2. Bamdas JAM, Averkiou P, Jacomino M. Service-Learning Programs and Projects for Medical Students Engaged With the Community. Cureus. 2022;14(6):e26279. Published 2022 Jun 24. doi:10.7759/cureus.26279 

3. Teherani A, Nikjoo A, den Boer A, Tong MS, Desai A. Community-engaged sustainable health care education. Clin Teach. 2021;18(1):62-68. doi:10.1111/tct.13234 

4. Gimpel N, Kindratt T, Dawson A, Pagels P. Community action research track: Community-based participatory research and service-learning experiences for medical students. Perspect Med Educ. 2018;7(2):139-143. doi:10.1007/s40037-017-0397-2

Co-Designing a Social Determinants of Health Medical School Curriculum in Partnership with Community Organizations

Background: High-quality multiple-choice questions (MCQs) are essential for medical education and licensing exams such as the USMLE Step 1. However, faculty face increasing time constraints and cognitive burden in creating psychometrically sound items aligned with both curriculum and national standards. Generative AI, such as GPT-4o, offers the potential to automate this process, yet no published studies have rigorously compared AI-generated items with faculty-authored questions using blinded expert evaluation and psychometric analysis.
Methods: We conducted a randomized controlled study involving preclinical medical students at a U.S. medical school (2024–2025). Using a structured prompt framework and NBME-aligned rubric, GPT-4o generated 20 USMLE Step 1-style MCQs based on six faculty lectures. Two faculty content experts independently authored 20 matched questions from the same lectures. All questions were evaluated using a standardized 12-point rubric by a blinded national assessment expert. Ten students per course (N=20) completed both AI and faculty questions in randomized order. Student accuracy, response time, and source attribution were recorded. Item-level point-biserial correlations and distractor analysis were conducted.
Results: AI-generated items scored similarly to faculty-authored questions on expert review (mean rubric scores: 11.1 vs. 11.4 out of 12, p=0.3). Student performance did not differ significantly between AI and faculty items (mean accuracy difference: 1.5 points, p=0.8). Point-biserial correlations for correct answers and distractors were equivalent. Students were unable to reliably distinguish between AI and faculty-authored questions (AI: 70%, Faculty: 60%, p=0.5). Notably, performance on AI-generated questions correlated more strongly with final course grades (r=0.665, p=0.001) than faculty-written items (r=0.152, p=0.522). AI-generated explanations were shorter and rated lower in reasoning accuracy. GPT-4o required under 2 minutes to generate 10 questions; faculty required ~3 hours.
Conclusion: GPT-4o, when guided by structured prompts and institutional lecture content, can generate USMLE Step 1-style questions that match faculty-authored items in quality, psychometric performance, and student usability. These findings support scalable integration of generative AI into medical assessment workflows, with implications for faculty efficiency, curricular alignment, and learner preparation. While AI-generated questions matched faculty in structure and performance, their explanations consistently lacked depth and nuance, highlighting a critical area where human oversight remains essential. The custom GPT-4o profile used in this study is publicly available, and we encourage others to adapt it and generate NBME-style questions directly from lecture content.

Generative AI as a Medical Educator: GPT-4o Matches Faculty in Writing Step 1-Style Questions

Background
Texas is experiencing a severe health crisis as Galveston County has the second-highest rate of drug overdose fatalities. Limited access to education about life-saving intervention worsens circumstances for unhoused individuals. Despite interventions such as naloxone – an opioid antagonist that reverses overdoses – becoming more accessible, low health literacy and drug use stigma continue to impede effective use. This project aims to evaluate naloxone literacy among the unhoused in Galveston and assess the impact of targeted educational and street distribution interventions on awareness and utilization.

Methods
From July 2025 to May 2026, participants will be recruited via convenience sampling during biweekly outreach in partnership with the Street Medicine Interest Group and receive care kit compensation. Student volunteers will be trained on proper naloxone use and sensitive surveying. The intervention contains three phases: (1) baseline health literacy assessment asking the questions (“Do you know what naloxone is?” & “Do you know how to use naloxone?”) and post-round interviews of student volunteers, (2) distribution of naloxone kits with culturally sensitive educational materials and referrals to local substance abuse treatment resources, and (3) follow-up surveys and focus group interviews to evaluate changes in knowledge and attitudes. Each participant will be assigned a unique identifier (UID) to classify responses anonymously to assess longitudinal tracking of changes in knowledge and engagement across study phases.

Results
We anticipate enrolling a maximum of 100 unhoused participants over the study period. Outcome variables include quantitative data: the number of participants who can correctly identify naloxone, describe how to administer it, and the accepted distribution rate. Qualitative data includes: volunteer focus groups feedback on stigma, system-level barriers, and the cultural relevance of harm reduction education materials. Survey data was analyzed with descriptive statistics to summarize baseline health literacy, naloxone knowledge, and distribution rates. Pre- and post-intervention surveys are compared using paired t-tests with a significance threshold of p≤ 0.05 applied.
Conclusion
Phase 1 of this project shows that while 72% of the unhoused could identify naloxone, a majority (60%) of those surveyed did not know how to use the drug. Thus, this study offers a scalable, community based model for increasing naloxone access among vulnerable populations through street medicine outreach and peer-driven education. Findings will inform future harm reduction strategies and guide sustainable partnerships between medical institutions and underserved communities to address the ongoing opioid crisis in Texas and beyond.

Assessing Naloxone Literacy Among the Unhoused in Galveston, TX

Background: Biologic therapies such as dupilumab have significantly improved outcomes for patients with atopic dermatitis (AD), but access is often delayed by insurance authorization processes. It remains unclear whether patients with higher disease burden are more likely to experience these delays.

Objective: To determine whether clinical burden—defined by age, comorbidities, and prior treatment history— is associated with prolonged insurance approval delays for dupilumab among patients with AD.

Methods: We conducted a retrospective chart review of 140 patients with AD who submitted insurance authorization requests for dupilumab between 2017-2025 from UTHealth/UTPhysicians in Houston. Dupilumab delay was defined as the number of days between prior authorization submission and approval. To better capture real-world variation in insurance processing times, delay was categorized into four bins: 0–14 days (rapid approval), 15–30 days (moderate delay), 31–60 days (prolonged delay), and >60 days (significant delay). These thresholds were selected
with 30 days representing a typical benchmark for standard prior authorization review and >60 days suggesting more substantial administrative or insurance-related barriers. To assess potential delays related to off-label prescribing, we flagged patients under the FDA-approved age thresholds at the time of prescription. Age cutoffs were based on official approval dates for adolescents (March 2019), children aged 6–11 (May 2020), and children under 6 (June 2022). Measures of clinical burden included patient age, number of documented comorbidities, and
number of prior medications attempted. Bivariate analyses using chi-square tests evaluated associations between delay and individual burden variables.

Results: Of the 140 patients reviewed, 120 had complete data available for analysis. There was a statistically significant association between age group and approval delay (χ² = 44.31, p < 0.0001). Patients aged 65 and older experienced significantly longer approval times (p = 0.0002), suggesting that Medicare-related processes may contribute to treatment delays. Although younger age was initially associated with longer delays, stratification by FDA label status revealed no difference in delay between on-label and off-label prescriptions (p = 1.00), indicating
that off-label use did not account for the observed age-related disparities. There was no significant association between comorbidities and delay (χ² = 8.02, p = 0.0907). In contrast, the number of prior medications attempted was strongly associated with delay (χ² = 42.26, p < 0.0001), with patients who had tried 0–1 treatments experiencing disproportionately longer delays compared to those with 2–3 or 4+ medications.

Conclusion: Age and prior treatment history were significantly associated with dupilumab approval delays in patients with atopic dermatitis. Older adults, especially those ≥65, experienced longer delays, likely reflecting Medicare-related barriers. Patients with fewer prior treatments also faced greater delays, while comorbidities and off-label status were not associated. These findings suggest that systemic and insurance-related factors, rather than clinical severity, contribute most to treatment access delays. Ongoing multi-institutional efforts aim to further investigate structural obstacles and guide the development of policy and clinical approaches that promote more equitable access to care.

Insurance Delays in Atopic Dermatitis are Driven by Age and Treatment History

Background: Bleeding events post electric cardioversion in anticoagulated patients are rarely reported. ¹⁻² Current guidelines recommend anticoagulation for at least 3 weeks prior to and 4 weeks after cardioversion for atrial fibrillation of >48-hour duration. ¹ Our case highlights a rare occurrence of cardiac tamponade in an anticoagulated patient who underwent elective cardioversion. 

Case presentation: A 73-year-old man with ALS-related chronic respiratory failure and ventilator dependence presented from his facility with sudden-onset palpitations. Other relevant medical history includes prior pulmonary embolism (on reduced dose apixaban) and depression. Initial EKG revealed atrial flutter with rapid ventricular rate (RVR) and 2:1 conduction pattern. He underwent successful electrical cardioversion after inadequate response to medical management. 

Within hours of the procedure, the patient developed hypotension accompanied by a notable decline in hemoglobin levels. A transthoracic echocardiogram demonstrated a moderate-sized pericardial effusion with early signs of tamponade. An emergent pericardiocentesis was performed, yielding 430 mL of hemorrhagic fluid. Cytological studies showed no evidence of malignancy. Hemodynamic stability was restored following the procedure. 

A multidisciplinary discussion held after this event led to the permanent discontinuation of anticoagulants from the patient’s medication regimen. 

Discussion: Multiple trials present evidence of safety and efficacy (in preventing thromboembolic events) of DOACs and VKAs for peri-cardioversion anticoagulation. ¹ Our case represents a rare but life-threatening complication of cardiac tamponade following cardioversion. There is very sparse literature describing similar cases; one case report by Jessuran et al describes tamponade following electrical cardioversion, though asbestos-related subclinical pericarditis served as a significant confounding factor in their case. ³ 

Clinicians must be vigilant of subtle risk factors for hemorrhagic complications, which may not be fully captured by the current guidelines. Individual risk assessments with careful monitoring and/or stopping anticoagulation indefinitely can prevent unfavorable outcomes in such patients.

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Pain Control and Opioid Use After Abdominal Surgery: How Thoracic Epidural Variables Shape Outcomes

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