United States

Title
Comparative Effects of Statins and Fibrates on the Onset of Diabetic Retinopathy in Type 2 Diabetes

Background
Diabetic retinopathy (DR) is a common complication of type 2 diabetes mellitus (T2DM) and a leading cause of vision loss in working-age adults. Management often requires invasive, costly procedures to preserve vision and while lipid-lowering drugs (LLDs), particularly statins and fibrates, have shown promise in slowing DR progression, their role in disease onset remains unclear. This study evaluated the association between statin or fibrate therapy and DR onset to assess their prophylactic potential. 
Methods
This retrospective cohort study used de-identified electronic health records from 152 healthcare organizations via the TriNetX Global Network. Patients with T2DM and no prior ocular complications, diagnosed at least 10 years prior, were assigned to fibrate-only (n = 7,004) or statin-only (n = 463,588) cohorts. Drug exposure required two records: one within 6 months and one at least 1 year after diagnosis. After propensity score matching on demographic characteristics, retinal vascular and non-diabetic retinopathy conditions, and serum HDL, LDL, triglycerides, and HbA1c, each cohort included 6,691 patients. Outcomes included diagnosis of nonproliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), or need for antiVEGF injections or retinal laser. Patients with outcomes prior to cohort entry were excluded.

Results
Fibrate therapy was associated with lower risk of DR across all stages: 55.1% reduction in mild NPDR (RR = 0.449; 95% CI: 0.359, 0.561; p &lt; 0.001), 68.7% in moderate (RR = 0.313; 95% CI: 0.202, 0.486; p &lt; 0.001), 65.3% in severe (RR = 0.357; 95% CI: 0.174, 0.735; p &lt; 0.004), and 67.6% in PDR (RR = 0.324; 95% CI: 0.203, 0.517; p &lt; 0.001). Onset was also delayed: mild (log-rank x2 = 25.238; p &lt; 0.001), moderate (log-rank x2 = 17.419; p &lt; 0.001), severe (log-rank x2 = 5.140; p &lt; 0.024), and PDR (log-rank x2 = 15.125; p &lt; 0.001).
Fibrate users had a 66.7% reduced risk of retinal laser (RR = 0.333; 95% CI: 0.212, 0.524; p &lt; 0.001) and longer time-to-event (log-rank x2 = 14.372; p &lt; 0.001). No difference was found in antiVEGF injection risk. 

Conclusion
Fibrate therapy was associated with reduced risk and delayed onset of DR in patients with T2DM compared to statin therapy. These findings support a potential role for fibrates in DR prophylaxis.


AMA Research Challenge 2025 

The Comparative Effects of Statins and Fibrates on the Onset of Diabetic Retinopathy in Type 2 Diabetes

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Title
Comparative Effects of Statins and Fibrates on the Onset of Diabetic Retinopathy in Type 2 Diabetes

Background
Diabetic retinopathy (DR) is a common complication of type 2 diabetes mellitus (T2DM) and a leading cause of vision loss in working-age adults. Management often requires invasive, costly procedures to preserve vision and while lipid-lowering drugs (LLDs), particularly statins and fibrates, have shown promise in slowing DR progression, their role in disease onset remains unclear. This study evaluated the association between statin or fibrate therapy and DR onset to assess their prophylactic potential. 
Methods
This retrospective cohort study used de-identified electronic health records from 152 healthcare organizations via the TriNetX Global Network. Patients with T2DM and no prior ocular complications, diagnosed at least 10 years prior, were assigned to fibrate-only (n = 7,004) or statin-only (n = 463,588) cohorts. Drug exposure required two records: one within 6 months and one at least 1 year after diagnosis. After propensity score matching on demographic characteristics, retinal vascular and non-diabetic retinopathy conditions, and serum HDL, LDL, triglycerides, and HbA1c, each cohort included 6,691 patients. Outcomes included diagnosis of nonproliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), or need for antiVEGF injections or retinal laser. Patients with outcomes prior to cohort entry were excluded.

Results
Fibrate therapy was associated with lower risk of DR across all stages: 55.1% reduction in mild NPDR (RR = 0.449; 95% CI: 0.359, 0.561; p < 0.001), 68.7% in moderate (RR = 0.313; 95% CI: 0.202, 0.486; p < 0.001), 65.3% in severe (RR = 0.357; 95% CI: 0.174, 0.735; p < 0.004), and 67.6% in PDR (RR = 0.324; 95% CI: 0.203, 0.517; p < 0.001). Onset was also delayed: mild (log-rank x2 = 25.238; p < 0.001), moderate (log-rank x2 = 17.419; p < 0.001), severe (log-rank x2 = 5.140; p < 0.024), and PDR (log-rank x2 = 15.125; p < 0.001).
Fibrate users had a 66.7% reduced risk of retinal laser (RR = 0.333; 95% CI: 0.212, 0.524; p < 0.001) and longer time-to-event (log-rank x2 = 14.372; p < 0.001). No difference was found in antiVEGF injection risk. 

Conclusion
Fibrate therapy was associated with reduced risk and delayed onset of DR in patients with T2DM compared to statin therapy. These findings support a potential role for fibrates in DR prophylaxis.


poster

Background
Acinetobacter baumannii is an opportunistic nosocomial pathogen of concern due to its increasing pan-drug resistance and growing recognition in its involvement in necrotizing fasciitis (NF), a severe soft tissue infection with high morbidity if left untreated. Some NF associated strains of A. baumannii (NFAb) exhibit an ability to survive within human macrophages. However, the macrophage response to intracellular infection by these strains is not well understood. Understanding the macrophage transcriptional response to NFAb infection may help us uncover new immune evasion mechanisms and inform future therapies.

Methods
Human monocyte-derived THP-1 macrophages were infected with two NFAb strains (NFAb1 and NFAb2) or the reference strain ATCC 19606T at a MOI of 100. After 2 hours of infection and 2 hours of colistin protection assay, intracellular bacteria were quantified and total macrophage RNA was collected and subjected to RNA-sequencing (RNA-seq). Differential gene expression analysis was performed using the DESeq2 package in R and gene ontology analysis was used to evaluate enriched immune pathways.

Results
RNA-seq identified distinct transcriptional signatures in response to infection with NFAb strains compared to the reference strain. Pro-inflammatory genes like TNF, CCL4 and IL1B were upregulated in response to NFAb infection, indicating heightened immune activation. Genes related to immune regulation and signaling like CX3CR1 and GPRIN3 were downregulated across all strains. This may indicate disruption of communication pathways. Genes involved in microtubule associated proteins and intracellular trafficking were upregulated as well, suggesting a role for macrophage phagocytosis in intracellular bacterial infection.

Conclusion
This study sheds light on the transcriptional responses of human macrophages to A. baumannii infection, especially in the context of NF. Responses to NFAb strains were characterized by altered signaling regulation and increased inflammation, suggesting NFAb strains may survive intracellularly by triggering and modulating host immune pathways. Understanding of these mechanisms may provide us with novel targets for future therapeutic interventions against multidrug resistant A. baumannii infections.

Evaluation of Innate Immune Transcriptional Responses in the Context of Intracellular Infection by Necrotizing Fasciitis-associated Acinetobacter baumannii

Background
Immunotherapy has revolutionized cancer treatment, with FDA approvals and NCCN guidelines
incorporating immune checkpoint inhibitors across over 20 malignancies. Despite its growing
use and preference over chemotherapy, data on immunotherapy-related complications leading to
hospital readmissions remain limited. No large retrospective cohort study has yet addressed this
gap
Methods
We conducted a retrospective cohort study using the 2022 Nationwide Readmissions Database
(NRD). Index admissions involving inpatient immunotherapy were identified using ICD-10 code
Z51.12, and 90-day all-cause readmissions were tracked. Survey-weighted logistic, linear, and
Cox proportional hazards models were used to compare baseline characteristics and identify
predictors of 90-day readmission
Results
A total of 2,394 weighted admissions met criteria as index immunotherapy admissions, with a
90-day readmission rate of 41.06% (95% CI: 36.7–47.2%). There were 983 weighted 90-day
readmissions. Mean index LOS was 10.1 days, with a cumulative LOS of 24,222 days. The
average total hospital charge for index admissions was $692,011, and the mean cost was
$161,506, yielding a total cost burden of ~$379 million. Among readmitted patients (n ≈ 961
weighted), mean LOS was 8.7 days (8,510 total days), with a mean cost of $114,195 and
cumulative cost burden of ~$110 million.
© 2025 American Medical Association. All rights reserved.
Primary payer distribution differed between groups (p = 0.0002): Medicare was most common
among index admissions (51.7%), while Medicaid was more prevalent in readmissions (16.1%
vs. 7.1%). Most care occurred in urban teaching hospitals (95.3% vs. 98.0%). Discharge
disposition varied slightly (p = 0.047), with most patients discharged home; transfers and home
health use were more common in readmissions.Multivariable Cox regression identified the
following significant predictors of 90-day readmission: younger age (HR=0.983, p=0.000), self-
pay status (HR=2.82), Addison’s disease (HR=4.58), hyperthyroidism (HR=5.59), Crohn’s
disease (HR=7.13), COPD (HR=2.00), and others.Top non-cancer, non-chemotherapy
readmission diagnoses included neutropenia (79.1), sepsis (55.1), immune effector therapy
complications (32.5), COVID-19 (32.1), infusion complications (23.4), anemia of chronic
disease (21.8), ABO incompatibility (10.4), AKI (9.0), transplant complications (8.6), and
bacteremia (8.4)
Conclusion
Inpatient immunotherapy is associated with a high 90-day readmission rate and substantial
healthcare costs. Readmission risk is influenced by insurance type and specific comorbidities,
offering targets for intervention to reduce preventable hospitalizations in this expanding
population

Healthcare Utilization and Predictors of Readmission After Immunotherapy in a National Cohort


Background:
Pulsed-field ablation (PFA) for atrial fibrillation (AF) offers several advantages compared to thermal ablation, however direct comparisons of patient-reported outcomes after PFA and radiofrequency ablation (RFA) are limited. This study aimed to assess patient experience following PFA or RFA in AF ablation performed under general anesthesia.

Methods:
A retrospective study across a single integrated health system was conducted on consecutive patients who underwent PFA or RFA for AF under general anesthesia from March 2024-December 2024. Data were collected from electronic medical records. Primary endpoints included postprocedural pain complaints and scores, need for post-procedure analgesic medication, and frequency of emergency department (ED) visits for procedure-related concerns.

Results:
Two hundred patients (100 PFA and 100 RFA) were analyzed (age 73.2 ±9.2y, 38% female). Patients undergoing RFA had a significantly higher rate of ED visits compared to those who underwent PFA (17% vs. 6%, p <.05). The most common complaints prompting RFA ED visits were shortness of breath (29% of RFA ED visits), palpitations (23% of RFA ED visits), dizziness (18% of RFA ED visits), and other (30% of RFA ED visits). There were no statistically significant differences in postprocedural pain scores (RFA 1.70 vs. PFA 1.57, p = 0.61), requests for analgesic medications in the recovery area (RFA 36% vs. PFA 27%, p = 0.26), nor encounters made to the care team within 4 weeks following the procedure (RFA 57% vs. PFA 44%, p = 0.20).

Conclusion:
In this retrospective study, patients undergoing PFA for AF under general anesthesia experienced fewer ED visits for procedure-related issues compared to those undergoing RFA. While these clinical endpoints potentially suggest improved procedural recovery with PFA compared to RFA, larger prospective studies using patient-reported outcome measures are warranted.

Patient Experience Following Pulsed Field Ablation Compared to Radiofrequency Ablation for Atrial Fibrillation

Impact of Treatment Modality on Local Recurrence for Immunosuppressed Patients with cSCC

Background
Prior literature has established that the immune system plays a significant role in the
development and progression of non-melanoma skin cancers (NMSC), with studies
demonstrating that immunosuppressed patients experience increased rates of local tumor recurrence, tumor metastasis, and mortality post-treatment of cutaneous squamous cell carcinoma (cSCC) compared to non-immunosuppressed patients. The worsened clinical outcomes in immunocompromised patients with cSCC necessitates further investigation into optimal treatment approaches for this population to reduce tumor morbidity and mortality. For this project, we evaluated the impact of host immunosuppression on clinical outcomes for patients with cSCC undergoing electrodessication and curettage (EDC), Mohs micrographic surgery (Mohs), and wide local excision (WLE).

Methods
We studied a retrospective cohort (n=1693) to assess differences in two-year local recurrence (LR) risk. Within the group, 163 (9.6%) were immunocompromised. Tumors (n = 2322) included 288 (12.4%) from immunosuppressed patients, 972 (41.8%) on the head, 1337 (57.6%) welldifferentiated, and 28 (1.2%) with perineural invasion. Most tumors were treated with EDC (1121, 48.3%), followed by Mohs (667, 28.7%), and WLE (534, 23.0%). Multivariable Fine and Gray sub distribution hazard regression models were used to compare local recurrence by immunosuppression status and treatment type, adjusted for high-risk tumor locations, perineural invasion, sex, age, tumor diameter, keratoacanthoma status, and tumor differentiation.

Results
Immunosuppressed patients had higher LR compared to immunocompetent controls with 3% recurrence in immunocompetent patients and 9% recurrence in the immunosuppressed cohort. For immunocompetent patients, Mohs treatment resulted in 1% LR, WLE in 3%, and EDC in 4%. For immunocompromised patients, Mohs treatment resulted in 7% LR, WLE in 6%, and EDC in 11%. Of note, the subgroup analysis for LR following WLE in immunosuppressed patients was the only group to not be statistically significant.

Conclusion
Given the higher likelihood of tumor recurrence among the immunosuppressed population, investigation into optimal treatment strategy to reduce such risk is important. Odds of tumor recurrence, after adjusting for baseline differences in tumor and patient factors, indicate Mohs and WLE may be effective treatment options for immunosuppressed patients with cutaneous squamous cell carcinoma while suggesting that EDC may not be an appropriate treatment modality.

Impact of Treatment Modality on Local Recurrence for Immunosuppressed Patients with cSCC

Abstract Title
Improving Chronic Pain Management among Older Adults through Primary Care Innovation – A Patient-Centered Goal Approach 
Background
Opioid-related deaths among Oklahomans aged 65 and older increased by 61%, from 7.4 to 11.9 deaths per 100,000 between 2017-2019 and 2020-2022. To improve non-cancer chronic pain and opioid management among older adults, the Oklahoma Primary Healthcare Improvement Cooperative implemented a multi-faceted, person-centered, scalable chronic pain management program in 31 Oklahoma primary care practices from January 2022 to September 2023, using a 3-stage, modified stepped-wedge design (Reducing Inappropriate Opioid Use in Seniors in Oklahoma (RISE-OK) Study). As part of the quality improvement intervention, participants set personalized goals related to chronic pain management, and goal achievement was measured as a secondary outcome. This study aimed to assess how effectively older adults involved in a primary care–based intervention achieve their personalized pain management goals to improve chronic pain and reduce opioid use.
Methods
Of the 270 enrolled participants (≥ 60 years), 267 set goals for pain management. Participants were asked how chronic pain impacted their daily lives and what they hoped to achieve with pain management. Participants also identified barriers to achieving their goals and created action plans to address these barriers. Two investigators independently qualitatively coded participant goals, barriers, and action plans, categorizing them into themes; any differences in coding were resolved through group consensus. Most participants rated their goal attainment between 3 and 12 months, depending on their wave, using a 3-category scale.
Results
Participants had an average age of 70 years, were 62% female, and 81% white, non-Hispanic. Most primary care practices (57%) were small, with 1-5 clinicians, and located in rural communities (53%). Participant goals prioritized physical activity (36%), obtaining a specific health care service (12%), doing recreational activities (e.g., travel, hobbies, attending events) (12%), controlling other symptoms (e.g., fatigue, constipation, insomnia) (9%), and reducing medications (7%). Other goals included performing self-care activities (6%), continuing to work (5%), and socializing with family/friends (3%). 24% of participants attained their goals as expected, 22% attained their goals better than expected, and 53% did not attain their goals.
Conclusion
Older adults set diverse personalized goals for chronic pain management, prioritized mobility and meaningful life activities, and nearly half met their goals. Implementing patient-centered goal setting in chronic pain care encourages clinicians to align treatment recommendations with what matters most to patients, potentially improving adherence to care and functional and quality of life outcomes for older adults with chronic pain.




Improving Chronic Pain Management among Older Adults through Primary Care Innovation – A Patient-Centered Goal Approach


Background
This study examines the extent to which preoperative osteoporosis predicts dysphagia after cervical spine surgery. Osteoporosis has been associated with increased surgical risk and poorer outcomes in spine procedures, but its relationship with postoperative swallowing difficulties remains underexplored.

Methods
A prospectively collected multi-institutional quality registry was retrospectively reviewed. Patients undergoing cervical surgery were categorized based on preoperative osteoporosis, and correlations with preoperative and postoperative Eating Assessment Tool-10 (EAT-10) dysphagia questionnaire scores were assessed. Mixed-effects logistic regressions were performed to assess the impact of preoperative osteoporosis on the incidence of dysphagia.

Results
Of the 2,001 patients that met inclusion criteria, 110 (5.5%) reported preoperative osteoporosis. Patients experiencing preoperative osteoporosis demonstrated a higher incidence of dysphagia at baseline (29% vs. 15%, p<0.001), 1 month (69% vs. 55%, p=0.032), and 12 months follow up (38% vs. 25%, p=0.014) but not at 3 months follow up (30% vs. 29%, p=0.7). Additionally, patients with preoperative osteoporosis experienced significantly more severe dysphagia at baseline (3.864 ± 7.422 vs. 1.678 ± 4.875, p=<0.001), 1 month (8.516 ± 8.602 vs. 6.246 ± 7.682, p=0.032), and 12 months (4.338 ± 7.296 vs. 2.537 ± 5.061, p=0.014). Further stratification revealed that preoperative osteoporosis did not impact incidence of dysphasia in patients without baseline dysphasia at 1 month (p=0.2), 3 months (p>0.9), or 12 months (p=0.14). Multivariable analyses with baseline dysphagia as a fixed effect demonstrated that osteoporosis is not an independent predictor of postoperative dysphagia at 1 month (OR=1.58, p=0.2), 3 months (OR=0.61, p=0.095), or 12 months (OR=1.05, p=0.9). Exclusion of the patient subset with baseline dysphasia reflected similar results in post-hoc multivariable analyses.

Conclusion
While patients with osteoporosis have higher rates of postoperative dysphagia at baseline, 1-month, and 12-month follow-up, preoperative osteoporosis did not independently predict dysphasia following cervical surgery. The increased rate of postoperative dysphagia in patients with preoperative osteoporosis may be attributed to comorbid conditions (coronary artery disease, chronic pulmonary disease, etc.) more prevalent in osteoporosis patients. Neurosurgeons may benefit from knowing this information to guide preoperative patient decision-making to undergo surgery in patients with osteoporosis.


The Impact of Preoperative Osteoporosis on Postoperative Dysphagia Following Cervical Spine Surgery

Background
Degenerative Vitreous Syndrome (DVS) is a well-documented, age-related condition characterized by vitreous liquefaction and collagen aggregation, leading to the development of symptomatic floaters that project shadows onto the retina and cause dynamic entoptic disturbances. Although Snellen visual acuity is typically preserved, an increasing body of evidence indicates that floaters, especially when central, can significantly impair functional vision. Despite this, DVS is often dismissed as benign and untreatable, even though OCT and ultrasound demonstrate posterior vitreous opacities. While observation and YAG vitreolysis are options, pars plana vitrectomy (PPV) is a definitive method for floater removal. Advances in small-gauge vitrectomy has resulted in improved safety profiles and shorter recovery times. Still, data on outcomes and patient satisfaction remains sparse. This study evaluates the safety, efficacy, and patient-reported results of small-gauge PPV for symptomatic DVS.
Methods
We conducted a retrospective case series involving 53 eyes treated with 25-gauge PPV by the same vitreoretinal surgeon. By design, the study focused on evaluating surgical outcomes in patients selected based on functional impairment attributable to vitreoretinal pathology. All procedures employed high-speed vitrectomy, triamcinolone-assisted vitreous visualization, complete posterior vitreous removal, and fluid-air exchange to optimize vitreous clearance and reduce residual collagen debris. Preoperative counseling emphasized the risks, benefits, and shared decision-making. Postoperative outcomes included anatomic assessments, complication tracking, and structured interviews regarding visual improvement and satisfaction.
Results
Among the 53 eyes treated, 91% (48/53) had preoperative posterior vitreous detachment (PVD), with the remainder undergoing intraoperative induction. Fifteen percent (8/53) of cases were combined with cataract extraction and intraocular lens implantation. No cases of retinal tear, detachment, endophthalmitis, or hypotony occurred. Postoperative epiretinal membranes (ERM) developed in 5.6% (3/53) of eyes, two of which required surgical peeling. Mean follow-up was 4.8 months. At final evaluation, 98.2% (52/53) of patients reported complete resolution of floaters; one patient noted a mild residual floater. Patient satisfaction was consistently high, with many describing restored “continuously clear vision” and expressing interest in surgery for the fellow eye.
Conclusion
Small-gauge vitrectomy is a safe and highly effective intervention for patients suffering from symptomatic floaters due to DVS. With careful surgical technique, patient-centered evaluation, and shared decision-making, PPV can offer dramatic improvements in visual function with minimal risk. These findings challenge traditional clinical reluctance to offer vitrectomy for floaters and underscore the need for more comprehensive assessment tools to better capture the true impact of DVS on patients and guide appropriate treatment options.


Evidence on the Safety, Efficacy, and Patient Satisfaction of Pars Plana Vitrectomy for Symptomatic Floaters in Degenerative Vitreous Syndrome

Introduction: Mutations in the ABCG8 gene are classically associated with sitosterolemia, a rare autosomal recessive disorder characterized by excessive intestinal absorption and decreased biliary excretion of plant sterols. With only 100 cases of sitosterolemia worldwide, hemolytic anemia has an estimated occurrence of 6.8%. Stomatocytosis, macrothrombocytopenia, and increased osmotic fragility of RBC were described, hypothetically caused by the abnormal incorporation of plant sterols into RBC and platelet membranes due to elevated plasma levels, altering membrane composition
Case Presentation: A 32-year-old Yemeni woman with IBS in remission, presented with worsening fatigue, dizziness, headaches, and regular menstrual cycles with moderate flow. On initial evaluation:
Microcytic anemia with beta-thalassemia trait. Iron deficiency was excluded.
Peripheral blood smear showed teardrop cells, schistocytes, elliptocytes, basophilic stippling and giant platelets with high mean platelet volume. 
Undetectable haptoglobin, high LDH and reticulocyte count, but negative Direct Coombs and moderately increased osmotic fragility.
Abdominal ultrasonography showed moderate splenomegaly. 
Anemia persisted despite folic acid, iron and corticosteroids oral treatment. A comprehensive hereditary HA panel identified a heterozygous mutation in the ABCG8 gene. Transient improvement was achieved with intravenous iron infusions and 2 cycles of intravenous immunoglobulin. Her hemoglobin declined accompanied by worsening exertional dyspnea and palpitations when she was pregnant. Following uneventful delivery, the patient's hemoglobin stabilized at 9 g/dL. Postpartum PBS showed a few tear drops and schistocytes, hypo and polychromasia, micro and anisocytosis. She remains on oral folate and iron and is monitored outpatient.
Discussion: To our knowledge, this is the first documented case of a heterozygous ABCG8 mutation presenting without any of the characteristic clinical features of sitosterolemia. The presence of a heterozygous ABCG8 mutation raises suspicion for a genetic contribution to this patient’s hemolytic anemia, especially in the absence of other identifiable causes. A definitive link cannot be established without further studies, but this mutation remains the most likely contributor.
Conclusion: This case highlights the need to consider rare genetic mutations in unexplained anemia and the importance of ongoing research in such presentations, particularly in treatment-resistant cases where anemia does not respond to ongoing steroid therapy.


Cracking the ABCG8 Code: The Mystery of Hemolytic Anemia

Background
Statins are important for cardiovascular disease prevention, yet muscle toxicity leading to myopathy is a common adverse effect.¹ Statin-induced myopathy presents as muscle pain or weakness with elevated creatine kinase in the context of statin therapy. Our objectives were to: 1) Recognize the typical incidence and duration of statin myopathy. 2) Describe the utility of SLCO1B1 genetic testing as a personalized medicine tool to predict statin myopathy.

Case Presentation
A 73-year-old female was initiated on statin therapy in 2012. She developed leg pain and weakness after starting pravastatin, which persisted despite trials of atorvastatin and an unknown third statin, prompting discontinuation. Despite statin cessation, her lower extremity weakness progressed to involve her shoulders, upper arms, and core. Physical therapy provided mild strength improvement. Trials of methylprednisolone, hydroxychloroquine, and prednisone were discontinued due to side effects. Examination in January 2025 revealed weakness in the left proximal upper limb and bilateral hip flexors, with intact distal and proximal strength elsewhere. MRI of the thighs demonstrated diffuse fatty infiltration and asymmetric muscle edema. Serologic testing revealed an ANA titer of 1:1280 (cytoplasmic pattern), elevated Anti-SSA antibodies (107.68 units/mL), and myositis-specific antibodies were negative. Quadriceps biopsy demonstrated frequent atrophic fibers with mixed myopathic and neurogenic changes, along with scattered T lymphocyte infiltration. 

Discussion
Statin myopathy affects ~27.8% of users and commonly leads to medication intolerance.2 Simvastatin 40 mg has the highest incidence (50%), while fluvastatin XL 80 mg and rosuvastatin 10 mg are lowest (8% and 10.8% respectively). Symptoms typically resolve within 2.3 months of cessation, unlike this patient’s prolonged course.3 Statins regulate cholesterol metabolism by inhibiting HMG-CoA reductase after entering hepatocytes through OATP1B1 transporters encoded by the SLCO1B1 gene.1 The study SLCO1B1 Genotype Informed Statin Therapy found that ~15% of patients have the variant SCLO1B1, which results in increased systemic statin concentration and myopathy risk.4 Individuals could use an over-the-counter test called Statin Smart to determine if they had a genetic predisposition to myopathy; though data reporting has been criticized as inaccurately high.5 Providers may order SLCO1B1 testing, though insurance coverage is inconsistent. While this patient’s inflammatory myopathy was likely statin-induced and potentially preventable with genetic screening, she might also possess an inherent predisposition to myopathy. Perhaps in the future, personalized medicine will be more accessible, helping patients better understand their risk of medication side effects like statin myopathy.

Statin Myopathy: Understanding Its Incidence and the Utility of Personalized Medicine to Predict It

Background:
Acute ischemic stroke is a time-sensitive emergency, with thrombolysis guided by strict American Heart Association/American Stroke Association (AHA/ASA) protocols emphasizing door-to-needle metrics. Tenecteplase (TNK) is widely accepted as an alternative to alteplase in eligible patients. However, Type A aortic dissection remains an absolute contraindication to thrombolytics due to risk of hemorrhage or hemodynamic collapse. This report describes a rare case of silent aortic dissection in a young woman treated with TNK for presumed MCA syndrome, highlighting the challenges of protocol adherence, diagnostic uncertainty, and the need to reevaluate stroke pathways for atypical presentations.

Case Presentation:
A 45-year-old woman with hypertension was found unresponsive after a witnessed seizure. EMS administered midazolam, and upon arrival she was somnolent with a GCS 6, leftward gaze deviation, right hemiplegia, and global aphasia (NIHSS 19). Non-contrast head CT was negative, and with a last known well time under 4.5 hours, she met criteria for TNK, which was administered.

Within 30 minutes, she became hypotensive and unresponsive. Bedside ultrasound confirmed tamponade physiology; emergent pericardiocentesis and 1 g tranexamic acid (TXA) were administered to reverse TNK. CTA revealed extensive Stanford Type A aortic dissection involving arch vessels. She underwent ascending aortic grafting.

Postoperative MRI revealed multifocal infarcts in bilateral cerebral and cerebellar hemispheres, basal ganglia, thalami, and watershed zones, consistent with embolic and hypoperfusion etiologies. Despite aggressive care, she was transitioned to hospice.

Discussion:
This case underscores the difficulty of diagnosing painless aortic dissection presenting as isolated stroke without typical features such as chest pain or pulse deficits. This is particularly rare in younger patients, as aortic dissections commonly affect men over 50. Subtle or silent dissections account for approximately 6.4% of cases and carry increased mortality.

AHA/ASA guidelines contraindicate thrombolysis in dissection, but without suspicion, screening via CTA is not routine and would delay reperfusion therapy. While alteplase use in dissection-related strokes is reported, literature on TNK with successful TXA reversal is extremely limited. MRI confirmed true infarction, supporting the decision to thrombolyse. In hindsight, dissection-related hypoperfusion likely outweighed any benefit of thrombolysis.

Future stroke pathways may consider optional chest imaging in atypical presentations. However, indiscriminate imaging risks compromising treatment times. The balance between speed and diagnostic breadth remains delicate. This case illustrates the tension between guideline adherence and diagnostic uncertainty. Despite catastrophic outcome, thrombolysis was appropriate. It highlights the limitations of current protocols in detecting rare but fatal mimics and underscores the need for flexible, real-time clinical judgment.

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