United States

Abstract Title
What defines a ‘goals of care’ conversation for surgeons? 

Background
In the age of increased patient autonomy, “shared-decision making” and patient-focused approaches to treatment plans, there is increasing interest in how goals are discussed in clinical practice. Many studies analyze how physicians approach end-of-life and informed consent conversations with their patients. However, little is known about what constitutes a ‘goals of care’ (GOC) conversation for surgeons and their attitudes around these conversations. We aimed to evaluate attending surgeon attitudes, definitions, practices, and beliefs regarding ‘goals of care’ conversations. 

Methods
A 20-30 question Qualtrics survey was distributed by email to attending surgeons from the departments of surgery including general surgery, cardiothoracic, colorectal, minimally invasive, oncology, transplant, pediatric, plastic and reconstructive, and urology at Washington University in St. Louis School of Medicine (WUSM) with a combination of Likert-type, multiple choice, and free-text questions about GOC. Fifty-two surgeons completed the survey. All responses were anonymous and securely stored on the WUSM Box platform. Analysis was done using IBM SBSS software. To expand upon our qualitative data, seven survey participants were interviewed. Interviews were conducted over Zoom by the same interviewer. Interviews were transcribed and analyzed using NVivo. 


Results
Of the 39 surgeons that responded to the question of whether it is important to ask a patient about their goals, all 39 responded that it was important, with 25 (64.1%) responding it is “extremely important.” Yet, 11 of 39 respondents (28.2%) reported not asking patients about their goals before obtaining surgical consent with 30% of these respondents reporting the reason as “irrelevant to treatment.” The most common factors considered when having a GOC conversation were prognosis, diagnosis, and what the available treatments for the patient were. Only 12 of 38 surgeons (31.6%) considered their own comfort with the operative options when conducting a GOC conversation. When asked to define goals of care in their own words, many responded that it signifies discussing what a patient’s desired outcome is. In addition, despite 100% of respondents viewing GOC conversations as important, 22 of 39 respondents (56.4%) had not received any formal education on how to conduct GOC conversations. 

Conclusion
Despite surgeons acknowledging the importance of GOC conversations, many do not ask patients about goals consistently. Further, GOC conversations appear to be context dependent. Finally, many do not receive formal education regarding GOC and conducting GOC conversations. 


AMA Research Challenge 2025 

Goals of Care Discussions in Surgery: Defining them, conducting them, and learning from them

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Background:
Glomerular diseases are commonly classified based on immune complex and complement deposition patterns. While classical and alternative complement pathways are well studied, the role of the lectin pathway (LP) in glomerular disease pathogenesis remains underexplored. Previous observations at our institute revealed C4d deposition in 20% of C3 glomerulonephritis (C3GN) and 50% of dense deposit disease (DDD), prompting further investigation into LP activation across various glomerular pathologies.
Methods:
In this prospective study (2020–2021), 39 consecutive kidney biopsies (native and transplant) with glomerular pathology were analyzed. Light microscopy (LM), IF, and electron microscopy (EM) were used for diagnosis. Routine immunofluorescence (IF) findings guided selection for additional immunofluorescent staining with C5b-9, C4d, MASP, MBL, and ficolin on OCT blocks stored at –80°C.
Results:
Lectin pathway activation was observed in 75% of membranous nephropathy (MN) cases, with higher prevalence in primary MN (72%). Early-stage MN showed stronger LP activation (80%) compared to late-stage disease. IgG4 predominance (16%) and co-dominance (58%) were frequently associated with LP activation. No correlation was found between LP activation and anti-PLA2R status. C3 tissue deposition was present in 75% of secondary and 28% of primary MN cases. In secondary MN, C3 tissue positivity correlated with low serum C3 in 75% of cases; this correlation was absent in primary MN.
IgA nephropathy (IgAN) showed no deposition of lectin pathway markers, although all cases exhibited strong C5b-9 deposition. C3 was deposited in 50% of IgAN cases without correlation to serum C3 levels. C4d was positive in 25% of IgAN. In complement-mediated MPGN, strong C3 and C5b-9 deposits were observed along capillary walls and mesangium, but no lectin pathway proteins were detected.
Other glomerular diseases including MPGN, FSGS, non-proliferative glomerulopathies, diabetic nephropathy, amyloidosis, chronic active antibody-mediated rejection (AMR), acute tubular injury (ATI), and thrombotic microangiopathy (TMA) showed no evidence of complement activation via the lectin pathway.
Conclusion:
Our study demonstrates consistent activation of the lectin pathway in primary membranous nephropathy, particularly in early stages, and links it to IgG4 deposition. LP activation is variable in secondary MN and lupus nephritis, but absent in IgAN, MPGN, FSGS, and other glomerulopathies. These findings suggest a potential pathogenic role for the lectin pathway in MN and underscore the therapeutic potential of complement-targeted interventions tailored to specific pathways.


Lectin Pathway Activation in Glomerular Diseases: A Prospective Analysis of Native and Transplant Kidney Biopsies

Objective: Pediatric asthma exacerbations are common emergencies seen in the emergency department (ED), with a high potential for decompensation. While it is known that substance use disorder (SUD) complicates management of pediatrics in the ED, little is known about how they influence outcomes in asthma exacerbations. This study aims to assess how a coexisting SUD diagnosis influences clinical outcomes in pediatric ED visits for asthma exacerbation.

Methods: We queried the deidentified TriNetX database to identify patients aged 11–21 who presented to the ED with asthma exacerbation between 01/01/2010 and 01/01/2025 (n=75,167). Patients with a documented SUD diagnosis within the last 1 year (n=5,712) were compared to patients who have never been diagnosed with SUD (n=69,455). Propensity score matching (PSM) was performed (1:1) based on age, sex, race, ethnicity, and common pediatric comorbidities. Risk ratios (RR) with 95% confidence intervals (CI) and p-values (<0.05 significant) were used to compare outcomes.

Results: After PSM (5,703 per cohort), within 0–1 day of ED presentation, adolescents with SUD were more likely to receive systemic corticosteroids (RR=1.23 [1.19–1.27]), inhaled beta-agonists (RR=1.32 [1.29–1.36]), and magnesium sulfate (RR=1.94 [1.72–2.19]; all p<0.001). They more frequently underwent chest X-ray (RR=1.46 [1.39–1.53]) and blood gas analysis (RR=2.33 [1.97–2.76]) and required CPAP (RR=2.40 [1.68–3.41]), sedation (RR=1.53 [1.31–1.77]), inpatient (RR=1.80 [1.56–2.07]), and ICU care (RR=1.47 [1.19–1.82]; all p<0.001). From 1 day to 1 month post-presentation, SUD patients showed higher risks of repeat asthma exacerbation (RR=1.43 [1.29–1.59]), ED revisits (RR=1.55 [1.41–1.69]), ICU admission (RR=2.07 [1.52–2.83]), acute respiratory failure (RR=2.12 [1.56–2.86]), pneumonia (RR=1.75 [1.33–2.31]), and SDOH code documentation (RR=1.79 [1.28–2.50]; all p<0.001).

Conclusion: Pediatric patients with SUD experience significantly greater resource utilization during ED visits for asthma exacerbations, including increased admissions, interventions, and diagnostic testing. These findings highlight the urgent need for integrated, multidisciplinary care strategies that address the complex medical and behavioral health needs of this vulnerable population.


Substance Use Disorder and Emergent Asthma Exacerbation in Adolescents

Title
Advanced Lung Adenocarcinoma in a Non-Smoker: Unravelling Diagnostic Challenges with Immunohistochemistry and Atypical Marker Profiles
Introduction
Lung adenocarcinoma is the most common subtype of non-small cell lung cancer (NSCLC), increasingly diagnosed in non-smokers. In these patients, vague symptoms and misleading tumor markers often delay diagnosis. Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9), commonly associated with gastrointestinal malignancies, may be elevated in lung cancer, complicating workup. This case illustrates how immunohistochemistry (IHC) enabled diagnostic clarity in a non-smoker with metastatic disease and atypical biochemical features.
________________________________________
Case Presentation
A 75-year-old non-smoking male presented with fatigue, anorexia, weight loss, and a chronic cough. Laboratory evaluation revealed elevated CEA (60.4 ng/mL) and CA 19-9 (763.3 U/mL). PET-CT showed a right middle lobe lung mass with mediastinal lymphadenopathy and liver metastases.
Due to elevated GI tumor markers and liver involvement, a gastrointestinal primary was initially suspected. Liver lesion biopsy revealed poorly differentiated carcinoma. IHC showed strong positivity for CK7, TTF-1, NAPSIN-A, and CK19; focal positivity for CDX2; and negativity for CK20 and HepPar1 — confirming primary lung adenocarcinoma. The patient received Pemetrexed and Carboplatin. Molecular testing was not completed before therapy. He deteriorated and was transitioned to palliative care.
________________________________________
Discussion
This case highlights how tumor marker elevation and metastatic pattern can obscure the diagnosis of lung adenocarcinoma, particularly in non-smokers. CA 19-9 and focal CDX2 positivity initially suggested gastrointestinal origin. However, robust expression of TTF-1 and NAPSIN-A confirmed pulmonary origin, emphasizing the diagnostic utility of IHC in metastatic disease of uncertain origin.
Focal CDX2 staining has been documented in poorly differentiated lung adenocarcinomas, and its presence should not outweigh the significance of lung-specific markers. The reliance on tumor markers alone risks misclassification, especially when imaging patterns are nonspecific.
Moreover, non-smokers frequently harbor actionable driver mutations like EGFR or ALK. Unfortunately, molecular profiling was delayed, precluding timely personalized therapy. This reflects a common clinical gap where real-world constraints limit access to targeted options. The case underscores the value of integrating molecular diagnostics early, particularly in patients likely to benefit from targeted agents.
________________________________________
Conclusion
When clinical and biochemical indicators are incongruent, comprehensive IHC can guide accurate diagnosis. In advanced lung adenocarcinoma, especially in non-smokers, early molecular profiling is essential. This case exemplifies the importance of timely, integrated diagnostics to inform optimal, individualized care.

Reference #1: Travis WD, Brambilla E, Burke AP, et al. WHO Classification of Tumours of the Lung, Pleura, Thymus and Heart. 4th ed. IARC; 2015.

Reference #2: Lindeman NI, Cagle PT, Aisner DL, et al. Updated molecular testing guideline for lung cancer patients. Arch Pathol Lab Med. 
2018;142(3):321–346. doi:10.5858/arpa.2017-0388-CP
Reference #3: Saad RS, Ghorab Z, Khalifa MA, et al. CDX2 as a marker in the differential diagnosis of gastrointestinal adenocarcinomas. 
Am J Clin Pathol.2004;121(3):351–359. doi:10.1309/Y6A14HCKUJYHCEHJ


Advanced Lung Adenocarcinoma in Non-Smoker: Unraveling Diagnostic Challenges with Immunohistochemistry and Atypical Marker Profiles

Background
Long-duration spaceflight exposes astronauts to immense physical and psychological stress, potentially impairing neurocircuitry and motor coordination. Recent literature has revealed decreased density in several white matter tracts associated with motor control and coordination alongside well-established deficits in coordinative function post-spaceflight. Virtual reality (VR) could potentially be used to monitor and enhance neurocognitive resilience in space environments. This project involved conducting a literature review, creating a study design, and submitting a NASA grant to fund a VR training program that will be implemented during a future space mission in October 2025.
Methods
We have designed and implemented a VR training program with several games capturing pupillometry, eye tracking, and body kinematic data to test various aspects of cognitive control and psychomotor function. Performance data will be collected by the REACT Neuro VR System through biometric sensors and task analytics. Evaluation will involve outcome measures including ocular dynamics, oculo-motor coordination, accuracy, and reaction time, to compare baseline assessments with post-spaceflight outcomes. Overall task performance will be based on the number of difficulty levels successfully passed. Additionally, astronauts will undergo specialized MRI imaging to quantify white matter changes and associate them with VR metrics.
Results
Preliminary activities include literature synthesis and grant preparation, building a robust framework for this project. Anticipated results, as demonstrated in a test cohort of Air Force C-17 pilots earlier this year, include detection of early psychomotor decline after high-altitude flight and new evidence for the use of VR training to preserve motor coordination and strength in the astronaut population.
Conclusion
This VR analysis program provides a new method for neurocognitive monitoring during spaceflight. It may also support the role of neuroplasticity in psychomotor changes observed after spaceflight. Limitations include small participant sample sizes and delays between spaceflight and MRI imaging, while future directions involve scaling this program to larger cohorts and integrating more neurofeedback metrics. After demonstrating REACT Neuro’s potential to track and rehabilitate coordinative and cognitive deficits in astronauts, we see incredible potential for translating these techniques to patients with similar ailments in the general population.

Virtual Reality Training for Neurocognitive Monitoring in Astronauts

Introduction:
Thalassemia trait generally has minimal clinical impact, but physiologic changes during pregnancy may increase the risk of anemia, transfusion, and hypertensive disorders. Prior evidence is limited and often conflicting. This study evaluated pregnancy outcomes among women with thalassemia trait using a large, multicenter database.
Methods:
We conducted a retrospective cohort study using data from the TriNetX US Collaborative Network. Females aged 18–45 with ICD-10 codes indicating pregnancy (Z33.1, O00–O9A, Z34, Z3A) were included. Patients with pregnancy and coexisting thalassemia minor (D56.3) formed the thalassemia cohort (n = 19,369), while those without a thalassemia diagnosis (D56) comprised the control cohort (n = 5,471,214). Propensity score matching (1:1) balanced age, race/ethnicity, and comorbidities including obesity, smoking, hypertension, and type 2 diabetes. The index event was defined as the earliest date meeting criteria for both pregnancy and thalassemia minor (exposed) or pregnancy alone (controls). Outcomes within one year included anemia, blood transfusion, preeclampsia/eclampsia, cesarean section, venous thromboembolism (VTE), heart failure, preterm delivery, intrauterine growth restriction (IUGR), and intrauterine fetal demise (IUFD). Risk ratios (RR) with 95% confidence intervals (CI) were calculated.
Results:
After matching, 38,488 patients (19,244 per cohort) were analyzed. Thalassemia trait was associated with increased risks of anemia (RR 3.09, 95% CI 2.94–3.25), transfusion (RR 1.65, 95% CI 1.41–1.94), preeclampsia/eclampsia (RR 1.57, 95% CI 1.49–1.65), cesarean delivery (RR 1.47, 95% CI 1.38–1.56), preterm delivery (RR 1.39, 95% CI 1.26–1.53), and IUGR (RR 1.96, 95% CI 1.72–2.23), all p < 0.001. VTE risk was also higher (RR 2.05, 95% CI 1.40–3.01, p < 0.001).
Conclusion:
Thalassemia trait in pregnancy was associated with greater rates of anemia, transfusion, and adverse maternal and fetal outcomes. These findings highlight the need for tailored peripartum care and close multidisciplinary monitoring in this population.

Pregnancy Outcomes in Women with Thalassemia Trait: A Multi-Center Cohort Study

Background
Hexapod external fixators are used for fracture treatment, deformity correction, and limb lengthening. Although they are very powerful tools, they pose several challenges including their size, pin track infections, and patient physical and mental discomfort.. Therefore, any intervention minimizing the time spent in the frame is desirable. 
In the setting of fractures, controlled micro-motion has demonstrated greater circumferential callus formation and greater mechanical strength compared to rigid fixation. Historically, controlled “accordion” motion at the fracture or osteotomy site has been utilized to promote healing. We have utilized an automated hexapod to provide ongoing mechanical stimulation during deformity correction and/or lengthening. We report on the early results in this case series.
Methods
We queried an IRB approved database for all patients who underwent deformity correction or lengthening with a hexapod external fixator from May 2020 to June 2025. Demographic data as well as treatment parameters were recorded. 
Results
Seven patients were included in our study. Two of these patients had double level osteotomies, totaling nine corrections for this study. Three patients had lengthening ranging from 1.0 - 3.7 cm. The mean time in the external fixator was 190.3 days. Ultimately seven out of seven osteotomies healed with 2 additional osteotomies still in treatment. There was one patient with an unplanned return to the operating room for inadequate frame stability and early conversion to internal fixation. 
Conclusion
The use of HEF with automated mechanical stimulation has potential to assist with healing and bony union. It is difficult to compare results with the existing literature, but these encouraging findings warrant further research to refine these methods and compare its efficacy against alternative techniques. 


A Case Series of Automated Mechanical Stimulation in a Hexapod External Fixator

Background 
Ultrasound education is essential in medical training, but students often struggle to mentally convert 2D images into 3D structures. To address this, we developed a 3D-printed model with defined geometric features, encapsulated it in ballistic gel to simulate soft tissue, and provided it alongside an unencapsulated version for tactile reference. 

Methods 
First-year medical students were divided into experimental and control groups over eight academic blocks. Experimental groups had access to the models, while controls used traditional resources. Test scores assessing 3D spatial understanding were collected before, during, and after their ultrasound curriculum. Model use was voluntary, and engagement was not tracked. 

Results 
Test score analysis showed no significant difference between groups. We hypothesize that low model usage contributed to these results. 

Conclusion 
3D-printed models may enhance ultrasound education but likely require structured integration and mandatory use to demonstrate measurable benefits. Future studies should incorporate usage tracking and curriculum-based implementation. 


Evaluating 3D-Printed Models for Enhancing Spatial Visualization in Ultrasound Imaging

Background
The San Antonio Refugee Health Clinic provides free care to over 1,300 refugees annually. From January to April 2024, 25 patients presented with diabetes-related issues; 40% had HbA1c levels above 7% (uncontrolled diabetes), 30% above 6.5% (diabetes), and 30% above 5.8% (prediabetes). Diabetes progression carries severe risks, including cardiovascular disease, myonecrosis, and liver disease. Refugees often face barriers such as lack of insurance, language difficulties, and limited transportation, complicating chronic disease management. Given the high diabetes prevalence and limited literature on refugee health, this project assessed diabetes knowledge and self-management confidence.

Methods
Starting in October 2024, patients with diabetes completed a survey while waiting to see their provider. The survey assessed diabetes knowledge and self-management confidence using targeted questions and a 5-point Likert scale. Patients then received instruction and a glucometer for at-home blood sugar monitoring.

Results
By December 2024, eight Pashto-speaking patients from Afghanistan completed the initial survey. The average knowledge score was 68.75% (SD = 16.54), with a median of 75% and a range of 50%. The most challenging topics were understanding lifestyle changes versus medication, with 50% answering incorrectly, and diabetes pathophysiology, with 37.5% answering incorrectly. Self-management confidence was high, averaging 4.1/5 (SD = 1.05) with a median of 4.5/5.

Conclusion
Although refugee patients reported high confidence in managing diabetes, they demonstrated limited knowledge of key concepts such as diabetes pathophysiology and the importance of lifestyle changes. This underscores the need for culturally and linguistically tailored educational interventions to improve diabetes outcomes. We will monitor our intervention’s long-term impact through a follow-up knowledge assessment and HbA1c tracking.


Enhancing Diabetes Care and Self-Management in Refugee Patients: A Quality Improvement Initiative

Background
Hereditary Hemochromatosis (HH), particularly due to HFE C282Y homozygosity, leads to progressive iron overload due to increased intestinal absorption. In individuals assigned female at birth, cyclic menstrual blood loss after onset of menses may delay the clinical manifestation of hereditary hemochromatosis. In cisgender males, however, this manifests earlier and more severely due to the absence of any mechanisms of blood loss. 

This case review presents the hypothetical case of Finley, a 30-year-old transmasculine patient with a history of heavy menstrual bleeding and iron supplementation, who rapidly develops clinical iron overload after initiating testosterone therapy. The case examines how the interaction between testosterone, erythropoietin, and iron metabolism can unmask a latent genetic condition. Additionally, it highlights the need for proper history taking before the initiation of gender-affirming hormone therapy, proactive iron monitoring and supplementation reassessment during gender-affirming care, especially in patients with known or potential genetic risk.

Methods
Finley is homozygous for the HFE C282Y mutation but does not have a diagnosis of hemochromatosis due to lack of clinical presentation. His ongoing heavy menstrual blood loss has functioned as a natural compensatory mechanism, keeping serum iron and ferritin levels low despite his genetic predisposition to iron overload. 

Finley visits an endocrinologist to initiate gender affirming care and begin testosterone therapy in his transition to a transgender man. Upon standard medical history taking, his endocrinologist inquires about any prescription medications to which Finley denies. Finley does not disclose his use of over-the-counter iron supplements as he does not perceive this information to be clinically significant. 

Finley initiates medical transition through testosterone therapy of 100 mg IM administered once a week. Follow-ups are scheduled with his endocrinologist for 3, 6 and 10 months. 

Results
Finley’s blood panels at his 10-month follow-up visit show ferritin, TSAT, hematocrit, ALT and AST values elevated well above the reference ranges. The hepatic ultrasound early signs of hepatic steatosis. DNA analysis of the HFE gene showed HFE C282Y homozygosity, consistent with a diagnosis of HH. 

Conclusion
This scenario emphasizes the critical need for comprehensive pre-treatment evaluation in transgender patients initiating hormonal therapy, including detailed menstrual, supplementation, and family histories. Standard history-taking procedures may fail to elicit pertinent information, such as long-term iron supplementation, emphasizing the need for specific and directed questioning. Routine monitoring of iron indices and liver function should be considered, particularly in patients with known risk factors or suggestive clinical histories.

Testosterone Therapy in a Transgender Man with C282Y Hemochromatosis, Heavy Menses, and Prior Iron Supplementation: A Hypothetical Case Study

Pre-eclampsia affects 2–8% of pregnancies globally and remains a major contributor to maternal morbidity and mortality, particularly in low- and middle-income countries where healthcare access and resources are limited. The condition is characterized by defective extravillous trophoblast invasion into the maternal spiral arteries, leading to impaired placental perfusion and systemic endothelial dysfunction. Established risk factors include nulliparity, chronic hypertension, extremes of maternal age, obesity, and low socioeconomic status. Exposure to high-altitude has also been proposed as a potential risk factor, though findings across regions have been inconsistent and underexplored in population-level studies. This study aimed to evaluate the association between altitude—treated as a continuous variable—and the risk of pre-eclampsia in Ecuador, while accounting for sociodemographic and healthcare-related factors.

We conducted a nationwide epidemiological study using publicly available maternal health records from Ecuador’s National Institute of Statistics and Census (INEC) from 2021 to 2023. Altitudes were geospatially mapped to maternal residential addresses and verified against national elevation data. Generalized additive models (GAMs) with cubic splines were used to assess potential non-linear associations between altitude and pre-eclampsia risk. Models were fitted using Restricted Maximum Likelihood (REML) and adjusted for key confounders including maternal age, ethnicity, funding model, type of care, and residential setting.

In adjusted models, altitude was not significantly associated with an increased risk of pre-eclampsia. However, pre-eclampsia risk was significantly elevated among women at the extremes of maternal age (p<0.001) and among those receiving publicly funded care (p<0.001), underscoring the influence of socioeconomic disparities. Ethnicity also emerged as a significant determinant of pre-eclampsia risk, though no interaction effect was observed between ethnicity and altitude.

These findings suggest that in Ecuador, altitude alone may not be an independent driver of pre-eclampsia risk. The absence of a measurable altitude effect may reflect unique demographic, genetic, and environmental characteristics specific to the region. Given the persistent burden of pre-eclampsia and its ties to social determinants of health, further multi-regional studies incorporating both environmental and socioeconomic factors are needed to clarify contextual risk drivers. Such evidence can inform targeted screening strategies and guide more equitable allocation of maternal health resources, especially in geographically and economically diverse settings.



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