United States

Background
Syphilis, colloquially termed “the Great Imitator,” is a sexually transmitted infection caused by the spirochete treponema pallidum. Syphilis occurs in multiple stages. Tertiary syphilis occurs years after inoculation, presents with chronic granulomas, cardiovascular, and neurologic manifestations. Syphilitic hepatitis is a rare and often missed diagnosis in patients who have syphilis and who are often co-infected with HIV or hepatitis B.
Case Presentation 
The diagnosis is made by both clinical presentations and positive serological markers, characteristic transaminitis, with no other alternative cause of hepatobiliary injury identified. Here, we highlight a case of an undomiciled 40-year-old male with HIV (on Genvoya) and chronic hepatitis B, who presented with tachycardia to 107. Physical examination was remarkable for a diffusely spread rash with erythema on the bilateral lower extremities, a small purulent boil on the right shin, left index finger and dry, itchy, distinct raised purple lesions on the scalp, eyebrows, upper and lower extremities, back, and shoulders. Laboratory findings were remarkable for a severely elevated alkaline phosphatase, mild transaminitis, and elevated total bilirubin, with negative pertinent imaging including a right upper quadrant sonogram, CT scan of the abdomen, and MRCP. Extensive additional work-up revealed elevated VDRL titers. Both a skin and liver biopsy were completed. Immunohistochemical stain of shave biopsy of a verrucous plaque on the scalp vertex and an excoriated papule of the left neck highlighted numerous spirochetes. Liver biopsy revealed hepatocellular necrosis with moderate mixed inflammation involving the portal tract and periportal hepatocytes, with immunohistochemical marker for spirochetes negative for organisms. However, given the patient’s clinical history of secondary syphilis involving the skin and lab abnormalities, it raised the differential diagnosis of syphilitic hepatitis.
Diagnosis
With our case report and extensive research of the literature, we hope to shed light on the importance of certain infections, even those in decline, on the differential. Additionally, contemplation of coexisting infections often helps to contribute to diagnoses not otherwise common. Because of how rarely seen syphilitic hepatitis is, it is often a missed diagnosis, but we are hopeful our case report helps physicians with patients with similar presentations, especially patients with otherwise unexplained high alkaline phosphatase levels.


AMA Research Challenge 2022

The Great Masquerader: A Case of Syphilitic Hepatitis

Welcome to the largest national, multi-specialty research event **featuring research from 750 medical students, residents and fellows, and international medical graduates.**


#### Event Details
The 2022 American Medical Association Research Challenge includes a poster symposium hall and a semifinals hall with the top scored research. Log in at any time throughout the event to:
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Ricardo Correa, MD, EdD
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Stephanie Strohbeen, MD
 
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


poster

Impacts of Wind Speeds on Wildfire specific PM2.5 Levels in Orange County and Butte County: A Comparative Observational Study

Background: The COVID-19 pandemic has affected society's quality of life worldwide. Everyday aspects of life have been obliged to change, allowing individuals a safer lifestyle revolving around COVID-19. Once vaccines against COVID-19 were introduced, daily practices were expected to remit to normalcy. In this study, we aimed to identify if vaccination influenced the way of living of vaccinated individuals.
Methods: A questionnaire containing sociodemographic inquiries was administered via QR Code at the Universidad Central del Caribe (UCC) vaccination clinics and social media platforms to assess the quality of life (QoL) before the pandemic (BP), during the pandemic before vaccination (DPBV), and after vaccination (AV) against COVID-19. The study ran from January 2022 to May 2022.
Results: Participant recruitment reached 203 participants, 138 identified as female and 55 as male, all aged 21 and older. Participants received the following vaccines: 69.5% received Pfizer- BioNTech, 25.6% received Moderna, 3.4% received a combination of Pfizer-BioNTech/Moderna, and 1.5% received Johnson&Johnson. We analyzed that DPBV, 60% of participants did not visit food establishments (P < .001). Likewise, 62.3% did not visit malls (P < .001). However, there was a statistical difference AV with 67.5% of participants visiting food establishments (P < .001) and 74.2% visiting malls 1-2 times per week (P < .001). Regarding feeling of safety, while spending time with vaccinated or non-vaccinated people, we observed that 72.8% felt assured about hanging around vaccinated people, and 19.9% did not feel safe spending time with non-vaccinated people (P < .001). Concerning safety attending public events: 9.3% of participants said they felt safe DPBV, while 33.7% said they felt secure AV (P < .001).
Conclusion: The COVID-19 vaccine positively impacted the QoL of Puerto Ricans participating in the study. The statistical analysis indicates an increase in the measured daily activities amongst individuals post-vaccination compared to pre-vaccination in several variables, such as visits to food establishments, malls, and public events.

Quality of Life After COVID-19 Vaccination in an Adult Hispanic Cohort

ABSTRACT 

Addisonian Crisis Exacerbation Secondary to COVID-19 Infection
Taylor L. Brewer, OMS III, Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL.; Hayley P. Nichols, OMS III, Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL.; Jordan S. Nolan, OMS III, Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL.; Heath W. Shelton, M.S., OMS III, Alabama College of Osteopathic Medicine, Dothan, AL.; Daniel C. Burnes, M.D., Crestwood Medical Center, Huntsville, AL. 

Addisonian Crisis, or adrenal crisis, is an uncommon condition characterized by severe hypotension, hypoglycemia, and hyperkalemia. If not treated promptly this condition can lead to organ failure or shock. It typically presents in patients who have had a prior diagnosis of Addison’s disease, or primary adrenal insufficiency (PAI). Manifestations of primary adrenal insufficiency include hyperpigmentation of skin, fatigue, nausea, vomiting, hypoglycemia, and hypotension. In this particular case a 55-year-old male with a past medical history significant for atrial fibrillation, hypothyroidism, and Addison’s disease was found unresponsive in his home. Upon presentation to the hospital the patient’s labs and vitals revealed an anion gap metabolic acidosis, fever of 103.2 degrees, altered mental status, an extremely hypotensive blood pressure of 69/49 mmHg, and was positive for COVID-19. He was given a bolus of normal saline IV fluids, ceftriaxone, ampicillin, and acyclovir as a prophylactic treatment regimen for possible meningitis that was later ruled out with a negative lumbar puncture. Cardizem was also initiated to combat tachycardia secondary to atrial fibrillation. Upon investigation into this patient’s prior hospitalizations, the electronic medical record revealed a previous diagnosis of primary adrenal insufficiency. At that time, IV hydrocortisone and fludrocortisone were initiated, followed by a rapid recovery and subsequent discharge from the hospital within 48 hours of admission. Since he was asymptomatic, COVID-19 directed therapy was never initiated. Upon discharge, fludrocortisone was reincorporated into the patient’s home medications. The purpose of this case report is to discuss an atypical presentation of Addison’s disease in a patient presenting in a crisis state due to COVID-19 infection.


Addisonian Crisis Exacerbation Secondary to COVID-19 Infection

Hyposmia from chronic rhinosinusitis: Is a vitamin D3 derivative the cure?

Background: 
Autoimmune disease (AID) affects over 23 million Americans and is a leading cause of death among young and middle-aged women. Unfortunately, no cure exists for AID. Current therapies have limited efficacy and severe side effects, therefor new therapeutics utilizing the body’s immunoregulatory mechanisms are needed.
This study investigates CUE-401, an injectable fusion protein of cytokines IL-2 and TGF𝛽, designed to accomplish this by increasing regulatory immune cells known as Tregs. Previous studies demonstrated IL-2 and TGF𝛽 together induce new Tregs from naïve CD4+T-cells, whereas IL-2 alone expands existing Tregs. However, therapeutic use of these cytokines is limited by IL-2’s short half-life and TGF𝛽’s off-target effects. CUE-401 is designed to overcome these two challenges by fusing modified IL-2 and TGF𝛽 to an FC backbone.

Methods
Several in-vitro pilot assays using T-lymphocytes from a transgenic mouse model of autoimmune gastritis (TxA23) were completed to investigate this new molecule. First, naïve CD4+T-cells were co-cultured with CUE-401 and tested for Treg induction. Next, Foxp3+Tregs were isolated and co-cultured with titrating doses of CUE-401. Finally, proinflammatory cytokines released from mature T-cells co-cultured with CUE-401 were measured.
CUE-401 was then tested in-vivo with TxA23 mice modeling an environment of AID. A subcutaneous injection of CUE-401was given to TxA23 mice, then blood and lymphoid tissue was examined 7 days post-injection for cellular classification.

Results 
In-vitro studies revealed CUE-401’s ability to functionally induce and expand Tregs, while also suppressing effector cells. Naïve T-cells co-cultured with CUE-401 demonstrated significant Treg induction, while endogenous Tregs co-cultured with CUE-401 experienced significant expansion in a dose dependent manner. Effector cells co-cultured with CUE-401 released significantly less proinflammatory cytokines, revealing the molecule’s immunosuppressive capabilities.
Similarly, our in-vivo experiment revealed CUE-401 induced/expands Tregs, as tissue from mice treated with CUE-401 had significantly higher proportions of Tregs compared to untreated mice. Furthermore, CUE-401 also demonstrated immunosuppressive capabilities in-vivo by decreasing the proliferative index of disease mediating effector cells. 

Conclusion
Unlike current therapies for autoimmunity, CUE-401 acts directly on T-cells in-vivo to suppress autoreactivity by increasing Tregs and suppressing disease mediating effector cells. This unique mechanism of action may hold the key to a curative treatment for autoimmune disease.


Injectable Fusion Protein Expands Horizon of Autoimmune Disease Therapy

Background
COVID-19 vaccine production shed light on using mRNA vaccines to prevent chronic illness. Moderna recently announced their quest to manufacture an mRNA vaccine against HIV, a chronic illness affecting approximately 38 million people worldwide. In order to develop an HIV vaccine, two properties are essential: antibody dependent cellular cytotoxicity and long-lived antibody response. Multiple somatic hypermutations and long complementarity determining regions pose challenges to this. Key vaccine trials and a reflection on lessons learned for future vaccine development are discussed.

Methods
One study described an mRNA-LNP vaccine encoding clade C HIV-1 Env 1086C and tested tier 1, 2, and 3 neutralization capability. A second compared a gp160 mRNA vaccine with a SOSIP gp140 mRNA vaccine and SOSIP gp140 protein vaccine. SOSIPs are trimers that resemble HIV virions with a more soluble form due to the additions of a disulfide bond (SOS) and point substitution (IP). A third experiment compared an mRNA vaccine encoding HIV-1 Gag, Pol, and Nef proteins to another mRNA vaccine with an additional 1-methyl-3’-pseudouridylyl modified vector. Subjects were boosted with a poxvirus booster carrying the same antigen. A fourth experiment compared the efficacy of a trivalent versus tetravalent adjuvanted protein vaccine. The final experiment analyzed the efficacy of an mRNA vaccine that co-expressed HIV-1 426c.3dg Env and SIVmac239 Gag proteins.

Results
The first study failed to produce recall antibody response and recommended that future trials use next-generation SOSIPs. The second study incorporated SOSIPs but did not produce significant recall antibody responses. The third study showed promising results with vaccination with a poxvirus booster. The fourth study showed a higher antibody response and enhanced recall in tetravalent vaccines and is currently undergoing further testing. The final trial showed a 79% reduction in per-exposure risk for vaccinated subjects as compared to controls.

Conclusion
mRNA vaccines have a marked advantage compared to other vaccines – there are less manufacturing challenges and decreased cost. Incorporating several boosters, particularly utilizing different mechanisms and vehicles, shows promising results. The COVID-19 vaccine rollout provides a layout for arranging international rollout. Communities must be engaged early on and support the diversity and flexibility necessary in HIV vaccine development.

Lessons Learned from HIV mRNA Vaccine Development in the Age of COVID-19 Vaccines

Background: The Omicron Variant of Concern (VOC) recently originating from South Africa possesses a striking arrangement of mutations that distinguishes it from prior VOCs and which promotes greatly enhanced transmissibility and evasion from humoral immunity.

Methods: To better understand how these mutations have contributed to the “fourth wave” of the pandemic, we assessed 20 Omicron mutant isolates from South Africa against the immunogenetic profile of the South African population. Mutations contributing to innate immune evasion, antibody evasion, and T cell evasion were identified using the VaxiJenv2.0 and NetMHCpan immunoinformatic platforms were catalogued. 

Results: We characterized an unprecedented number of mutations predicted to cause evasion from innate and adaptive immune elements, including mutations occurring in immunodominant epitopes specific for the South African population. These findings suggest that Omicron’s success stems from its ability to simultaneously evade multiple arms of the immune system at the population level. 

Conclusion: We report that SARS-CoV variant Omicron appears to have evolved a comprehensive constellation of mutations, enabling it to escape all three arms of the immune system at once. We theorize that this mutational profile is a consequence of slowly adapting on a population with endemic HIV/AIDS, providing the virus the immunological opportunity to evolve more fastidiously on its host.


Mutational Analysis of SARS-CoV-2 Variant Omicron Reveals Profound Immunogenetic Adaptations: A Lesson on Antigenic Drift

Abstract Title: Applying Illness Scripts Theory to Climate Health Equity: Design and Pilot Evaluation of a Multi-Residency Educational Symposium
Background: Defining climate change is key to understanding its long-lasting impacts and the urgency for action. Climate change encompasses the natural and primarily human-driven processes resulting in vast changes to the environment which indirectly and directly impact human health and disease, disproportionately affecting vulnerable populations. While climate change continues to be touted as a public health crisis, much of the ground-level work for tackling the issue remains. Medical education is key to amplifying efforts for change and resulting in a paradigm shift in human health and disease. As physicians, we can bring about sustainability in these efforts by redesigning medical education to seamlessly implement the processes and impacts of climate change in the common framework of “illness scripts” which are used to teach and learn about various medical conditions. 
Methods: The purpose of this study was to pilot an educational intervention and evaluate its effectiveness aimed at incorporating the use of newly adapted illness scripts for common medical conditions with a climate health and equity lens. The intervention was a multi-residency half-day symposium for Family Medicine and Emergency Medicine residents in San Diego, CA developed via the collective expertise of Primary Care, Emergency Medicine, Pediatric, and OBGYN physicians. The symposium consisted of interactive breakout sessions focused on the climate health impacts on various cardiac, respiratory, obstetric, and mental health conditions followed by large group sessions centered on health advocacy.
Results: The symposium was attended by 92 resident and faculty physicians, of which 46 completed the pre-intervention survey and 29 completed the post-intervention survey. Survey participants reported a statistically significant difference in their knowledge and skills pre- and post-attendance of the symposium (p-value <0.001).
Conclusion: A multi-residency symposium leveraging the collective expertise of local physicians and the application of illness scripts is a potential educational strategy to educate physicians about climate health. While the concept of integration of climate health into medical education is not novel, the use of illness scripts, which are known to improve clinical reasoning and application of new knowledge to clinical problems, to accomplish this has not been studied or implemented to the best of our knowledge.

Applying Illness Scripts Theory to Climate Health Equity: 
Design and Pilot Evaluation of a Multi-Residency Educational Symposium

Association of Statins with the Onset and Progression of Non-Alcoholic Fatty Liver Disease in Veterans with Diabetes: A Retrospective Propensity Score-Matched Cohort Study

Background
This review aims to establish the current trends in the management of mallet finger injuries. Practices vary widely from institution to institution as there is no clear-cut guideline on which intervention is preferred. Case studies and past literature reviews from 2015 onwards were analyzed to assess for a general trend in the treatment of mallet finger injury as well as to analyze associated risks with each approach. It was found that surgical intervention, with closed reduction percutaneous k-wire fixation as the most utilized method, is generally favored in most circumstances due to compliance issues associated with splinting and a better degree of improvement in extensor lag as compared to non-operative intervention.

Case Presentation
Upon review of the literature, it was found that operative intervention of the closed mallet finger injury resulted in a shorter immobilization period of 4.9 weeks compared to splinting which had a much longer immobilization average of 9.5 weeks. The mean extension lag was significantly better in patients in surgical treatment groups as compared to conservative treatment groups and also had a better extension of the DIP joint by 11.7 º. Specifically, the conservatively treated group had an extensor lag of 13.8º while the surgically treated group had an extensor lag of 2.1º. Within operative intervention, K-wire (Kirschner Wire) was a popular choice among surgeons because of the minimally invasive fixation achieved with closed reduction.

Discussion
Overall, surgical intervention with K-wire pinning seems to be the predominating trend when considering treatment for mallet finger injuries. Surgical intervention is preferred by surgeons for all cases of mallet finger regardless of the degree of articular surface involved because of the ease of patient compliance, cosmetic reasons, and quicker restoration of function for the patient. Operative intervention was also shown to present with decreased extensor lag delay, higher patient comfort levels as compared to patients who underwent non-surgical interventions, and also avoids the prospect of having to revisit the injury if it failed conservative intervention via splinting.

Next from AMA Research Challenge 2022

Impacts of Wind Speeds on Wildfire specific PM2.5 Levels in Orange County and Butte County: A Comparative Observational Study

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