North Texas Research Forum 2025

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  2025 North Texas GME Research Forum Program

  HCA Healthcare

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  2025 Oral Presentations & Keynote

  HCA Healthcare and Kimberly Washington

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  2025 Poster Presentations - In Person

  HCA Healthcare

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  2025 Poster Sessions - Virtual Poster Hall

  HCA Health

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  A Case of Biopsy-Proven Atopic Dermatitis Perpetuated by Psychosomatic Factors

  Henry Lim, Jamie Y. Choe, Marshall Hall, Arianne Felicitas, Christian Scheufele, Garrett Furth, Michael Carletti, and Stephen Weis

  Introduction: Psychodermatology is an interdisciplinary branch of psychosomatic medicine that addresses interactions between the psyche and skin. Stress is often a key exacerbating factor and highlights the bidirectional relationship between psychological factors and skin disorders. Atopic dermatitis (AD) is a chronic skin condition affecting pediatric and adult populations with an estimated global prevalence of approximately 2.6%, or approximately 204 million people. AD classically presents with a red, scaly, pruritic rash. Here, we present a case of biopsy-proven AD induced by stress-associated behaviors related to patient-identified obsessive-compulsive habits. Case Presentation: A 61-year-old female presented for persistent itching and white discoloration in the interdigital spaces of her feet. She had seen multiple clinicians without improvement and failed oral and topical antifungal trials. Dermatologic history was significant for chronic AD on bilateral elbows and knees and managed with clobetasol 0.05% ointment. Self-reported allergies included over thirteen foods and medications. On physical exam, there were white scaly plaques between the interdigital spaces of the right and left feet. Clinical examination suggested tinea pedis. Histopathology demonstrated epidermal hyperplasia with mild spongiosis, hyperkeratosis, and focal parakeratosis. Periodic acid-Schiff stain was negative for hyphae. This was consistent with AD and secondary lichen simplex chronicus. After obtaining biopsy results, further questioning revealed the patient developed an abscess between her buttocks 8-years ago requiring drainage and hospitalization for methicillin-resistant staphylococcus aureus. She feared developing another infection and followed a strict hygiene regimen that involved bathing 2-hours twice per day. Bathing habits involved close skin inspection while scrubbing with soap. The patient disclosed she was self-diagnosed with obsessive-compulsive disorder and stated her children agreed her behavior was extreme. Recommended behavior modification therapy included decreasing scrubbing and replacing rubbing behaviors with a new habit of applying petroleum jelly. Hydrocortisone 2.5% cream was prescribed. On 6-week follow-up, the patient reported improved pruritus but continued bathing 4-hours daily. Learning Points: Our case demonstrates an atypical presentation of AD complicated by psychiatric factors perpetuating dermatologic symptoms. In this case, skin biopsy provided a clue to diagnosis. Patient workup should include a thorough assessment of medical and social history, psychological state, and inquiry into living habitus and/or environment. While this patient’s presenting symptoms slowly improved, her disease process stems from underlying stress-associated behaviors. An interdisciplinary care team may be optimal for long-term management of psychocutaneous disorders with the goal of halting perpetuation of the disease cycle.

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  A Case of Life Threatening Hemorrhage After in Office Drainage of Suspected Bartholin Gland Cyst

  Rebecca Johnson, Sandra Zhi, Megan Khuu, and Robert Boccaccio

  Introduction: Labial masses are common in OBGYN clinics. They are benign the vast majority of times. Common causes are Bartholin cysts, epidermal inclusion cysts, labial warts, sebaceous cyst. We report a case of a 33 year old who presented for what appeared to be a benign Bartholin gland cyst but resulted in massive hemorrhage, exam under anesthesia, massive transfusion, and embolization. Case Summary: A 33 year old patient presents for a painless, non-enlarging labial mass that has been present for 3 weeks. History and physical exam were consistent with a commonly encountered condition, Bartholin gland cyst. Routine incision and drainage of this mass led to massive hemorrhage. The patient was emergently transferred to the operating room for an exam under anesthesia. The patient lost approximately 2 liters of blood in 15 minutes during transit to the operating room. Bleeding was controlled intraoperatively and the mass was found to be an arteriovenous malformation. The patient was stabilized and transferred to the ICU. Subsequently she underwent pudendal artery embolization with interventional radiology. Conclusion: Arteriovenous malformations (AVMs) are a grouping of poorly formed arteries and veins that connect to each other without a capillary bed. The prevalence of AVMs is rare and occur in less than 1% of the population, and pelvic AVMs account for 2% of those instances. Pelvic AVMs can present with pelvic pain, abdominal pain, abnormal vaginal bleeding, tenesmus, etc, although 20% are asymptomatic and they do not become symptomatic until they grow into other tissues. The majority of Pelvic AVMs occur in the context of congenital conditions such as Hereditary hemorrhagic telangiectasia, Cowden syndrome from PTEN mutations, Parkes Weber syndrome, Familial Capillary Malformation-Arteriovenous Malformation syndrome, and Wyburn-Mason syndrome. Visualization of AVMs can be achieve through Computed tomography with arteriography, Magnetic resonance imaging with contrast, or even doppler ultrasound. The gold standard of imaging is catheter angiography, though it is reserved for specific cases due to its invasiveness. Most vulvar AVM cases reported are in premenarchal girls with one report in a postmenopausal patient marked by pruritus over the lesion. Overall, proper history taking, physical exam and noting of concerning features are necessary to determine the need for imaging or ultrasound.

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  A Case of Meningitis with Pyogenic Ventriculitis

  Shterna Frand, Matthew Gutzmer, Melissa Jaworski, Calan Teel, and Premal Patel

  Bacterial meningitis and subsequent pyogenic ventriculitis in patients with complex medical histories and prior cranial surgeries presents significant diagnostic and management challenges. While typical signs of infection such as fever and leukocytosis may be present, secondary complications including seizure, respiratory failure, and pyogenic ventriculitis can complicate the clinical course. This case illustrates the need for comprehensive evaluation and tailored intervention in immunocompromised patients presenting with atypical infection. The case involved a 63-year-old female with a prior craniotomy and multiple comorbidities, presenting to the Emergency Department with acute encephalopathy and suspected bacterial meningitis. Upon transfer to the ICU following acute onset seizure with subsequent respiratory failure, the patient underwent diagnostic workup including lumbar puncture continuous electroencephalography (cEEG), and MRI. Management was initiated with broad-spectrum antibiotics (ceftriaxone, vancomycin) and supportive care. Diagnostic testing revealed bacterial meningitis with positive blood cultures & MRI evidence of pyogenic ventriculitis. After intubation and initial seizure management, the patient showed clinical improvement with IV antibiotics, levetiracetam, and supportive care. ABG normalization and clinical improvement led to successful extubation and discharge by hospital day 9. Follow-up therapy included home-administered ceftriaxone. This case underscores the importance of rapid intervention in bacterial meningitis & its complications, particularly for patients with prior neurological surgeries. Continuous monitoring, early neurologic consultation, early neurosurgical evaluation, and timely antimicrobial therapy can mitigate complications and support positive outcomes. The insights gained reinforce the need for vigilance in managing similar high-risk cases in critical care settings.

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  A Case of Neutrophilic Dermatosis of the Dorsal Hands with Post-Traumatic Onset

  Marshall Hall, Kristina Kafle, Henry Lim, Christian Scheufele, Garrett Furth, Michael Carletti, and Stephen Weis

  Background Sweet Syndrome is an acute, febrile neutrophilic dermatosis that is characterized by painful red lesions, fever, and neutrophilia with histological findings of dermal neutrophilic infiltrate. Neutrophilic Dermatosis of the Dorsal Hands is a localized variant of Sweet Syndrome. Neutrophilic Dermatosis of the Dorsal Hands presents with focused lesions on the dorsal hands, most commonly between the index finger and thumb, typically with fewer systemic manifestations. This condition presents significant diagnostic challenges as it can mimic infectious processes, potentially leading to delayed appropriate treatment. Case Information A 64-year-old male presented to the emergency department with wounds on the bilateral hands. He reported injuring his right hand three weeks prior to presentation that then progressively enlarged over two weeks. The patient noticed the onset of a wound on his left hand despite no injury or trauma. One week before hospital admission, the patient was prescribed trimethoprim-sulfamethoxazole and clindamycin. Despite antimicrobial treatment his wounds continued to worsen. The patient reported that he had occasional fevers but denied other systemic symptoms. In the hospital he was given IV antibiotics and initial work-up complete blood count and complete metabolic panel were performed without clinically significant findings. X-ray of the hands showed soft tissue swelling with polyarticular degenerative joint disease. Blood and wound cultures showed no growth. Due to the atypical presentation dermatology was consulted. Physical exam showed edematous red plaques with overlying hemorrhagic crust extending from the thumb to the dorsal hands bilaterally. Clinically, the presentation was consistent with neutrophilic dermatosis of the dorsal hands, however, to confirm the diagnosis and rule out infection biopsies were performed. The biopsies showed a neutrophilic infiltrate with spongiosis and eosinophils without fungal or atypical mycobacterial growth on cultures which confirmed the diagnosis. The patient was initiated on topical fluocinonide ointment twice daily under occlusion at the time of the biopsy. The patient reported significant improvement in pain within 1 day of receiving treatment. Learning Points Neutrophilic Dermatosis of the Dorsal Hands requires high degree of clinical suspicion. The condition can have multiple etiologies, including drug-induced, paraneoplastic, and idiopathic causes. It is essential in neutrophilic conditions to rule out infection. Early recognition and appropriate diagnosis can prevent unnecessary antibiotic and surgical interventions. This case demonstrates a key diagnostic criterion of Neutrophilic Dermatosis of the Dorsal Hands – rapid improvement within 24 hours of appropriate therapy – while providing valuable insight into the variable progression and healing stages of this condition.

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  A Case of Severe Synodic Stenosis in a Patient with Granalomatosis with Polyangitis Requiring Tracheostomy

  Yousuf Sherwani and Mohan Sengodan

  Granulomatosis with polyangiitis (GPA) is characterized by vasculitis of small and medium sized blood vessels and granulomatous lesions of the upper respiratory tract. A rare condition associated with GPA, subglottic stenosis, presents in about 20% of cases on inpatient GPA. Symptoms such as stridor, hoarseness, dyspnea and dysphagia are hall marks of subglottic stenosis. Here we present the case of a male patient with life threatening subglottic stenosis that required tracheostomy.

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  Albuterol: An Often-Forgotten Cause of Lactic Acidosis

  Sania Moonnumackel, Sameera Muqueet, and Machaiah Madhrira

  Introduction Lactic acid (LA) is a commonly used biomarker and is often indicative of severity of disease in critically ill patients. Lactic acidosis which is defined as LA > 4.0 can be divided into two categories: Type A which is the more common type is caused by systemic tissue hypoperfusion most likely due to shock and Type B which is caused by impairment of cellular metabolism and or decreased clearance of LA. An important cause of Type B lactic acidosis is medications including acetaminophen, anti-retroviral drugs, antibiotics and beta-adrenergic agonists including albuterol. Often patients with severe lactic acidosis are given fluid boluses however this may worsen their condition of type B lactic acidosis. Case presentation A 39-year-old female with past medical history of Factor V Leiden, prior PE/DVTs, Seizure disorder, HTN, anxiety, HLD presented with chief complaints of shortness of breath. The patient was intubated for anaphylactic reaction to contrast in ED at 12:30 am, overnight patient had quick respiratory status recovery and was extubated at 8:45 am the same day. On Physical exam at 8:40 am, the patient was noted to have tachypnea and was unable to speak or eat due to shortness of breath. Patient was treated with albuterol nebulization. Labs from 9:05 am showed a Ph of 7.27 and a Bicarb of 13 despite patients PCO2 being 31.7. This prompted a lactic acid check which revealed a severe lactic acidosis of 11. Following this, the frequency of albuterol administration was decreased. LA was rechecked with repeat lactic coming down to 4.5 after frequency of albuterol was decreased. Discussion There are several proposed mechanisms to explain albuterol induced LA. One mechanism is thought to be due to the stimulating effect B-agonists have on glycolysis which in turn makes more pyruvate. B agonists also have a stimulating effect on lipolysis which makes more free fatty acids and in turn inhibits pyruvate dehydrogenase causing excess pyruvate to be channeled into lactic acid production. In the case of albuterol induced lactic acid, albuterol administration may inadvertently worsen respiratory distress as the body tries to compensate for the metabolic acidosis. Albuterol is a commonly used medication in asthma and COPD exacerbations, however, its ability to cause lactic acidosis by creating a hyperadrenergic state which shifts the Krebs cycle is often overlooked.

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  A Match Made In Heaven: The Heart And The Kidney, A case report on Uremic Pericardial Effusion With Complete Resolution Post Transplant

  Sania Moonnumackel, Victor DelPrincipe, Vivek Bhupathi, Srinivasan Rajaganapathy, Anand Karthik, and Machaiah Madhrira

  Introduction: Pericardial effusion resulting from uremic pericarditis is a complication associated with chronic kidney disease (CKD). In patients with advanced CKD or End Stage renal disease (ESRD) renal transplant is the definitive treatment to improve long term outcomes. However, the presence of a large pericardial effusion poses a risk of hemodynamic compromise during transplant surgery. Options of stabilizing the patient with aggressive dialysis, pericardiocentesis or pericardial window can be considered. Here we present a case of a patient with advanced CKD who underwent pre-emptive kidney transplant and in three months had complete resolution of a large pericardial effusion noted pre-operatively. Case Presentation: A 48-year-old African American male with advanced CKD stage V secondary to Focal segmental glomerulosclerosis (FSGS) presented for pre-emptive deceased donor renal transplant. During his pre-operative testing, apart from severe azotemia, he was noted to have a CXR with severely enlarged cardiac silhouette. An echocardiogram revealed a large pericardial effusion without signs of hemodynamic compromise. The patient underwent a successful renal transplantation without any perioperative complications. Post transplantation patient’s renal functions normalized in a week with a serum creatinine of 1.2mg/dl. A follow up Echocardiogram done 3 months later revealed complete resolution of pericardial effusion. Learning Points: The literature is scant of cases describing resolution of pericardial effusion following a kidney transplant. This uniqueness adds interest to this case. In a Retrospective chart review of ESRD patients undergoing evaluation for renal transplant moderate to large pericardial effusions were noted with a prevalence of 1.9 %. This case highlights the fact that complete and rapid resolution of uremic pericardial effusion following a kidney transplant is possible. The presence of uremic pericardial effusion should not be a barrier to timely transplantation.

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  Anti-PD-1 Monoclonal Antibody Induced Diabetic Ketoacidosis in Melanoma

  Boney Lapsiwala, Jacqueline Bekhit, Indira Tata, and Vibhuti Veeranna

  Background: Immune checkpoint inhibitors (ICIs), including pembrolizumab, are increasingly used in cancer therapy, particularly for melanoma. While effective, these agents are associated with various immune-related adverse events (IRAEs), including endocrine disorders like diabetic ketoacidosis (DKA). This report aims to contribute to the understanding of pembrolizumab-induced DKA, especially in patients with pre-existing prediabetes. Case Presentation: A 78-year-old male with a history of melanoma, prediabetes, and other comorbidities developed DKA after 1.5 years of pembrolizumab treatment. He presented with symptoms of weakness, thirst, dry mouth, and diarrhea, alongside severe hyperglycemia and metabolic acidosis. Diagnostic workup confirmed DKA, and his clinical improvement followed intensive management including intravenous fluids, insulin therapy, and electrolyte replacement. Endocrinology evaluation suggested pembrolizumab-induced insulin-dependent diabetes due to low C-peptide levels. Discussion: Pembrolizumab, a PD-1 inhibitor, may trigger DKA in patients through mechanisms potentially involving autoimmune destruction of pancreatic beta cells. This case underscores the need for awareness of this rare but serious side effect. Regular glucose monitoring and early intervention are crucial in managing patients on ICIs to prevent and address such complications. Conclusions: This case highlights the occurrence of DKA in a patient receiving pembrolizumab for melanoma, emphasizing the importance of monitoring glucose levels and prediabetes status in patients undergoing ICI therapy. Further research is needed to better understand the pathophysiology of pembrolizumab-induced diabetes and to develop preventive guidelines for this adverse effect.

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  An Unusual Case of Indolent Systemic Mastocytosis: Diagnostic Insights in the Absence of Classic Systemic Symptoms

  Henry Lim, Jonah Gutierrez, Rafael do Valle, Reem Ayoub, Marshall Hall, Christian Scheufele, Garrett Furth, Michael Carletti, and Stephen Weis

  Introduction: Mastocytosis is a disorder characterized by an abnormal clonal accumulation and subsequent activation of mast cells within one or more organs. It is generally classified as either cutaneous, with or without systemic involvement, or systemic without cutaneous disease based on major and minor criterion. Indolent systemic mastocytosis (ISM) is a subclass of systemic mastocytosis with generally good prognosis. While the etiology of ISM is not completely understood, those who are affected typically have the KIT D816V mast cell receptor mutation. Given that ISM is mast cell mediated, patients predominantly present with a wide range of symptoms related to mast cell degranulation, including flushing, anaphylaxis, gastrointestinal disturbances, and bone pain that can cause disruption to quality of life. Case Presentation A 61-year-old Caucasian female presented for the evaluation of a pruritic rash on her trunk and extremities. The rash had persisted for 43 years and she described ongoing pruritus significantly impacting daily activities, particularly bathing with warm water, which made the itching unbearable. She also experienced episodes of brain fog predating menopause There was no history of angioedema, asthma, wheezing, abdominal symptoms, or bone pain. Her daughter was also affected by a similar condition. Dermatologic examination revealed innumerable reddish-brown macules and patches on the trunk and extremities, most concentrated on the lower legs. These lesions formed wheals when stroked firmly. A skin biopsy revealed abnormally increased mast cell concentration in the dermis. Laboratory studies showed elevated serum tryptase, low total protein, low globulin, and high albumin/globulin ratio. A bone marrow biopsy revealed multifocal dense mast cell infiltrates with absent iron stores. Genetic testing was negative for mutations in KIT D816V. The patient met criteria for ISM and her symptoms were managed by varying degrees with Omalizumab, Montelukast, Cetirizine, and topical Clobetasol. She continues to have flares to this date. Learning Points Cutaneous mastocytosis can reliably be diagnosed clinically using Darier’s sign, in which rubbing a lesion induces wheal formation due to mast cell degranulation. Additionally, while virtually all ISM cases are linked to the KIT D816V mutation, this patient’s genetic testing was negative for the mutation, suggesting an alternative disease mechanism. Recent advancements in therapy offer new treatment options, providing hope for patients who, like this one, have endured over 40 years of limited therapeutic success. ISM, though carrying a favorable prognosis, can significantly impact quality of life through persistent symptoms.

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  A Rare Case of Cutaneous Vulvar Leiomyoma Complicated by Postoperative Hematoma Formation

  Ariel Moskowitz and Kimberly Udell

  Leiomyomas are benign, well-circumscribed, monoclonal smooth muscle tumors. While leiomyoma of the uterus are exceedingly common, soft tissue leiomyomas are rare and often misdiagnosed. While excisional therapy is the mainstay of treatment, wide vulvar excisions can cause significant discomfort and disfigurement of the vulva. Here we present a unique case of a vulvar hematoma excision complicated by hematoma formation. A 39-year-old female presented to the ambulatory gynecology clinic with a 4-month history of an enlarging vulvar mass. On exam, a 4-cm mass was seen arising from the right upper labium. Office biopsy showed a well-circumscribed spindle cell lesion without nuclear atypia that stained diffusely positive for SMA, supportive of leiomyoma. The patient returned 6 months after her initial presentation and reported enlargement of the mass. She also reported that the mass had become painful and interfered with urination. Options of expectant versus surgical management of the vulvar mass were discussed and the patient elected for surgical excision. The patient was taken to the operating room where the vulvar mass was excised. Approximately 4 hours postoperatively, the patient reported worsening vulvar pain and swelling. On bedside exam, the right vulva was enlarged, tense and tender and there was concern for expanding vulvar hematoma. Patient was advised that the return to the operation room for re-exploration and evacuation of presumed hematoma. A significant amount of clot was noted and subsequently evacuated. A venous plexus with multiple feeder vessels was noted to be the culprit of the bleeding and was cauterized to achieve hemostasis. The patient was kept overnight for observation with no further hematoma formation and was discharged home on POD1. Vulvar leiomyomas are exceedingly rare tumors with only 160 documented cases in the literature. Due to the low incidence of these tumors, no standardized diagnostic or treatment algorithms. While surgical excision remains the mainstay of treatment, the approaches used are often varied and provider dependent. This case is unique as it was complicated by postoperative hematoma formation. The vulvar tissue is highly vascularized and capable of tissue expansion contributing to large hematoma formation. Reports such as this can help determine a standardized surgical approach for vulvar leiomyomas to help prevent similar operative complications. Additionally, this study helps elucidate the need for nonoperative approaches to vulvar fibroids in patients who are not surgical candidates.

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  A Rare Case of Right sided May-Thurner Syndrome Diagnosis and Treatment

  Sania Moonnumackel, Akhil Gade, Anand Karthik, and Machaiah Madhrira

  Introduction: May-Thurner Syndrome (MTS) is a phenomenon commonly described as acquired stenosis of the left common iliac vein secondary to compression by the right common iliac artery. Right sided MTS is a rare syndrome that can happen due to a left sided inferior vena cava (IVC) and abdominal aorta with a high bifurcation which results in the right common iliac vein being compressed by the left internal iliac artery. It is a rare presentation of this condition which can commonly be missed and management guidelines are less defined compared to classic MTS. Case Report: A 63-year- old female with past medical history significant for hypertension, hyperlipidemia and coronary artery disease presented with five days of worsening right lower extremity (RLE) pain and swelling. Ultrasound of RLE showed extensive deep vein thrombosis (DVT) proximal to distal femoral vein, popliteal, posterior tibial and peroneal vein. She denied history of any reversible etiologies that could have caused clot formation such as prolonged travel, immobilization, usage of hormonal replacements, blood disorders, or malignancies. As the patient continued to have pain with the extent of clot burden the decision was made to perform mechanical thrombectomy. Using ultrasound guidance, a 16F catheter was placed in the right popliteal vein. The venogram revealed an extensive clot burden in the right femoral and external iliac veins, with an incidental finding of 80% stenosis in the right external iliac vein. Mechanical thrombectomy was performed, followed by intravascular ultrasound (IVUS) to assess vessel sizing and evaluate the compression. A 16mm x 60mm Wallstent was placed and post-dilated with a 14mm x 40mm XXL balloon. IVUS was performed to confirm optimal stent placement Discussion: The diagnosis of MTS requires a higher level of suspicion based on diagnostic testing. MTS should be suspected with unilateral lower extremity swelling, unprovoked DVT. Magnetic resonance venography (MRV) and computed tomography venography (CTV) are important to evaluate the central venous system for any stenosis or external compression. However, Venography with IVUS is the gold standard for visualizing the compression of iliac veins and establishing the diagnosis of MTS. Treatment of MTS is dependent on severity of symptoms, presentation and whether the patient has developed DVT. For asymptomatic and patients with mild symptoms conservative management with compression stocking can be followed. However, for moderate to severe symptoms endovascular treatment with stenting is recommended.

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  A Retrospective Cross-Sectional Study of GLP-1 Agonist Effects on Outcomes after Total Knee Arthroplasty

  McKenna Box, Troy B. Puga, Neil J. Werthmann, Andrew M. Jen, Yingxian Liu, and John T. Riehl

  Objective: Total knee arthroplasty (TKA) is one of the most common elective orthopaedic surgeries. In addition, there are rising rates of obesity and diabetes and, with it, medications to treat them. This retrospective cross-sectional analysis aims to examine the outcomes of patients who underwent TKA and were on a Glucagon-like peptide-1 agonist (GLP-1a) at the time of surgery Methods: This study analyzes a database using CPT and ICD-10 codes to identify patients having primary TKA for knee osteoarthritis. Patients were divided into two groups based on GLP-1a use at TKA. Control variables included sex, age, BMI, smoking status, ECI, and type 2 diabetes. Primary outcomes included surgical site infection (SSI) within 90 and 365 days, medical complications within 30 days, 90-day readmissions, implant complications, revision TKA, in-hospital mortality or discharge to hospice within 365 days, and initial hospital stay length. A sub-analysis focused on diabetic and non-diabetic populations and compared those taking semaglutide, dulaglutide, or liraglutide with non-GLP-1a users. Results: Results: 26,157 patients met inclusion criteria; 914 were on GLP-1a (668 diabetic, 246 non-diabetic). GLP-1a users were younger and had a higher BMI in both groups (p < 0.001 for diabetics, p = 0.001 for non-diabetics). Logistic regression showed GLP-1a use correlated with a 10% reduction in hospital stay (p < 0.0001) and 45% lower odds of 1-year implant complications (p = 0.0195). Among diabetics, GLP-1a use did not affect 30, 90, or 365-day outcomes. Non-diabetics using GLP-1a showed increased rates of 30-day AKI (p = 0.001), medical complications (p = 0.002), and 1-year readmissions (p = 0.007), but lower rates of 1-year revision TKA (p = 0.016). Dulaglutide increased AKI and medical complications (p < 0.01) and semaglutide was linked to higher 1-year readmissions (p = 0.0008). Conclusions: The results of this retrospective cross-sectional analysis suggest GLP-1a use is associated with reduced hospital length of stay and lower odds of implant complications in all patients. Non-diabetic GLP-1a users demonstrated increased rates of certain short-term complications and readmissions. These findings indicate that GLP-1a can be beneficial in arthroplasty patients, but they are not without potential risks and individualized care should be taken in patients on GLP-1a undergoing surgery.

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  Assessing the Effectiveness of a Rapid Response Training Course

  Nasima Mehraban, Caroline Brooke, Vivek Punjabi, and Veeranna Vibhuti

  Introduction: Rapid response teams are crucial in healthcare settings for managing clinical emergencies. To enhance the preparedness of interns in handling such situations, we developed a rapid response training course. This study aimed to evaluate the course's effectiveness by examining changes in residents' self-reported confidence levels before and after completing the training. Methods: A group of interns participated in five simulated rapid response scenarios. Before the training, participants rated their confidence level on a scale from 1 (not confident in running a rapid response) to 10 (very confident). Following the training, they reassessed their confidence level. Pre- and post-training ratings were compared to evaluate the impact of the course on their confidence in managing rapid responses. Results: Pre-training confidence scores ranged from 2 to 7, with an average score of 4.5. Post-training scores ranged from 6 to 8, with an average score of 7.2. The majority of participants (approximately 85%) reported an improvement in their confidence, with scores increasing by 1 to 3 points on the scale. Notable changes in individual scores included increases of up to 6 points, demonstrating significant progress in confidence after the training. Conclusion: The rapid response training course significantly improved residents' self-reported confidence in managing clinical emergencies. These results suggest that the course effectively enhances preparedness for rapid response situations. Further research is needed to assess the retention of skills and performance in real clinical settings

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  Assessment of Patient Satisfaction Through the Introduction of a Post-Procedure Pamphlet in an Outpatient Clinic

  Mohammad Rashik, James Aston, and Sajid Surve

  This quality improvement project aimed to create a patient pamphlet for the Osteopathic Manipulative Medicine (OMM) clinic at the University of North Texas Health Science Center. The pamphlet provides important post-procedure information for patients who undergo treatments like joint injections, platelet-rich plasma therapy, prolotherapy, hydrodissection, botulinum toxin injection, and nerve blocks. These procedures can lead to potential side effects, some of which patients may not be aware of. To address this, the pamphlet includes information on common symptoms, their causes, recommended next steps, and guidance on when to contact the OMM clinic or visit the Emergency Department. The pamphlet was developed based on a literature review examining the side effects of various procedures like joint injections, nerve blocks, and orthobiologic treatments. It is currently awaiting final approval. Once approved, the pamphlet will be distributed to patients who undergo procedures at the OMM clinic for 30 days. During this time, clinic staff will track which patients receive the pamphlet. After the 30-day period, patients who received the pamphlet will be contacted by phone to evaluate its effectiveness and their level of satisfaction. A satisfaction survey will be created, consisting of 10 to 15 questions using a 0 to 10 scale to measure the pamphlet’s accuracy, simplicity, and helpfulness. The survey will also compare patients' post-procedure satisfaction before and after receiving the pamphlet. Patient data will be anonymized and coded to prevent bias in the survey results. The survey results will be statistically analyzed to determine whether the pamphlet has led to significant improvements in patient satisfaction. Based on these findings, a decision will be made about whether the pamphlet should be implemented as a permanent resource for the OMM clinic.

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  A Standardized Surgical Protocol for Placenta Accreta Spectrum Disorder at an Accreta Center of Excellence

  Ana Adams, Monica Rodriguez, Kate Hansen, Aysu Erdemir, and Robert Cohen

  Introduction Placenta Accreta Spectrum Disorder (PASD) refers to a spectrum of abnormal invasion of the placenta into the uterus during pregnancy. PASD ranges in severity from involvement through the endometrial layer of the uterus to complete invasion involving other pelvic structures. This abnormal invasion can result in significant postpartum hemorrhage, often requiring large-volume transfusions, about six units of packed red blood cells on average. The maternal mortality rate associated with PASD is approximately 4-7%. The Society for Maternal-Fetal Medicine (SMFM) recommends that pregnancies complicated by PASD be delivered in hospitals with dedicated interdisciplinary teams, referred to as “Accreta Centers of Excellence.” The management of PASD requires readily accessible blood products with the capability to activate massive transfusion protocols (MTP). Methods This outline details the standardized protocol for performing cesarean hysterectomies for PASD, utilized at a large community hospital with an established interdisciplinary team dedicated to reducing morbidity and mortality. The team is comprised of obstetricians with expertise in PASD, maternal-fetal medicine specialists, anesthesiologists, interventional radiologists, urologists, and critical care physicians. The protocol consists of preoperative considerations, necessary equipment, day-of-surgery planning, surgical setup, the use of intravascular balloons, surgical techniques, and postoperative considerations. Additionally, it includes digital media to further illustrate the required equipment and surgical approach. Conclusion Established through the experience of managing over 200 PASD cases spanning over twelve years, this protocol serves as a comprehensive guide for performing cesarean hysterectomy in PASD. It is intended to be shared with other institutions to promote knowledge sharing and foster collaboration to potentially improve surgical outcomes and the standardization of care.

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  Atypical Presentation of CD4+ Small/Medium T-cell Lymphoproliferative Disorder

  Rafael do Valle, Reem Ayoub, Marshall Hall, Henry Lim, Christian Scheufele, Garrett Furth, Michael Carletti, and Stepehen E. Weis

  Introduction: Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (PCSM-LPD) is a rare cutaneous disorder that until 2016, was classified as a primary cutaneous lymphoma. PCSM-LPD histopathologically consists of a localized proliferation of small to medium-sized T lymphocytes. Clinically there is minimal to no systemic involvement. It typically presents as an asymptomatic, solitary red-purple nodule, papule, or plaque on the face. PCSM-LPD has an indolent course and an excellent prognosis. It is important to recognize PCSM-LPD as a distinct entity from primary cutaneous lymphoma to avoid treatments with side effects. Case Presentation: A 68-year-old female with a history of insulin-dependent type 2 diabetes mellitus complicated by diabetic neuropathy, major depressive disorder, gastroesophageal reflux, and essential hypertension presented with a two-month history of progressively increasing, small, itchy bumps on the right cheek. On examination, there were scattered, non-tender, pink, non-scaly papules limited to her right cheek. A punch biopsy revealed a nodular infiltrate of small regular appearing CD4+/CD3+ lymphocytes with a T-cell receptor gamma gene arrangement, most consistent with PCSM-LPD. At follow-up, it was noted that her lesions had improved around the biopsy site. She was subsequently treated with intralesional triamcinolone injections and is currently pending follow-up. Learning Points: PCSM-LPD is a rare cutaneous disease with an undetermined malignant potential. Despite its uncertain malignant potential, PCSM-LPD typically follows a benign course with an excellent prognosis. PCSM-LPD most commonly presents as a solitary asymptomatic lesion. However, in some cases, multiple lesions may appear. In other instances, they can be pruritic. Due to its routinely benign course aggressive treatment or extensive diagnostic work-up is not recommended. PCSM-LPD is an indolent disease with no long-term risk of secondary lymphomas. For this reason, imaging modalities and bone marrow evaluations are low-yield. Conservative management including local treatment modalities and clinical observation can be used with a high degree of success and should be considered before invasive or systemic treatments.

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  A Unique Case of Small Bowel Arteriovenous Malformations in the Setting of Immune Thrombocytopenic Purpura

  Austin Moore, Evan Chen, and Hassan Ahmed

  Arteriovenous malformations (AVM) are a common cause of gastrointestinal (GI) bleeding and often require intervention for definitive treatment. The diagnosis and management of this disease process becomes complicated when combined with an immunologic coagulation disorder. There is very limited literature describing management techniques for patients with these coinciding diseases. This unique case describes a 65-year-old male with a history of AVMs of the small bowel as well as immune thrombocytopenic purpura (ITP). Previously he had undergone multiple medical interventions for management of his ITP, including steroids and intravenous immunoglobulin therapy. He had also undergone multiple imaging and endoscopic interventions to control spontaneous hemorrhages from AVMs in his G.I. tract. Having concurrent AVMs of the G.I. tract as well as ITP caused him to face multiple instances of G.I. hemorrhage throughout his life, instances which had increased in frequency over the last year. The decision was made to pursue surgical intervention. We performed an exploratory laparotomy with the use of intraoperative small bowel endoscopy to locate portions of bowel with with evidence of active or recent bleeding from AVMs. Two small bowel resections were carried out in these areas, each with a primary anastomosis. Preoperatively it was decided the best course of action to concurrently treat this patient’s ITP was a splenectomy, which was simultaneously performed during this operation. Due to this patient’s increase in instances of G.I. hemorrhage, he had developed chronic anemia requiring numerous blood transfusions despite being on appropriate medical therapy to attempt to control his ITP. This proved to be a unique case where a combination of methods of surgical management were employed to offer this patient a better quality of life. These efforts required extensive coordination and communication with the gastroenterology team to offer this patient thorough evaluation prior to and during surgical intervention to properly isolate areas of bleeding within his bowel that could be resected. From this case, it was important to obtain the most benefit out of a single operation by addressing two different disease processes in the same procedure, in this case by performing a small bowel resection for his AVMs and a splenectomy to definitively treat his ITP.

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  A Vaping Nightmare: Sudden Death Provoked by Vaping in the Setting of Pectus Excavatum

  Anoop Gala, Nga Van, Grace Rustom, Danielle Ford, and Phuc Nguyen

  Pectus excavatum (PE), characterized by an inward depression of the sternum, is the most common congenital chest wall abnormality. It has been rarely linked to cardiac abnormalities, such as arrhythmias and sudden cardiac arrest (SCA). In addition, emerging research suggests that vaping is a cardiovascular risk factor that has the potential to destabilize cardiac rhythm and promote arrhythmias. There is a lack of FDA oversight and long-term research on the effects of vaping. The rising popularity of vaping among youth, coupled with misconceptions about its safety, underscores the urgent need to understand the potential interactions vaping has in precipitating fatal arrhythmias and SCA. This is especially crucial in higher-risk populations, such as those with chest wall deformities like PE. CASE PRESENTATION A 20-year-old Arabic man with a known diagnosis of PE and no family history of SCD presented after experiencing an out-of-hospital cardiac arrest due to ventricular fibrillation (VF). His medical history included daily vaping and infrequent marijuana use. Additionally, he reported a significant tobacco history, beginning with occasional cigarette use at age 11 and escalating to 1-2 packs per day from ages 17-19. He was found unresponsive in his car, surrounded by multiple vaping devices. On arrival of emergency services, he was pulseless, with the initial rhythm indicating VF. After two rounds of cardiopulmonary resuscitation (CPR) and successful defibrillation, return of spontaneous circulation (ROSC) was achieved. He was intubated at the scene and subsequently transferred to the intensive care unit (ICU) for further management. Initial diagnostic workup, including brain imaging, computed tomography (CT) of the chest, spine, abdomen, and pelvis showed no acute abnormalities except for left lower lobe consolidation. The electrocardiogram (EKG) displayed sinus rhythm with a QTc of 484 ms. Urine toxicology tests were negative. A transthoracic echocardiogram (TTE) revealed mildly reduced systolic function of the left ventricle with an ejection fraction (EF) of 40–45% and septal wall hypokinesis. The patient was successfully extubated and gradually regained neurological function over the following days. Telemetry monitoring during the hospital course did not reveal any significant tachyarrhythmias. A cardiac MRI identified the PE as a chest wall abnormality causing geometric distortion on the right side of the heart, but no signs of arrhythmogenic right ventricular cardiomyopathy were observed. Coronary angiography showed no significant coronary artery disease or aortic stenosis. A corrective surgical plan for the PE and placement of an implantable cardiac device were coordinated between the electrophysiology and cardiothoracic surgery teams to prevent further episodes of cardiac arrest. DISCUSSION PE has been associated with an increased risk of arrhythmias due to mechanical compression of the heart. Individuals with PE may experience arrhythmias such as ventricular tachycardia and atrial fibrillation, though the exact mechanisms remain unclear. Additionally, recent research has raised concerns about the potential link between vaping and arrhythmias, attributable to various mechanisms, including the effects of nicotine and other chemicals on the cardiovascular system. In our case, the patient’s history of vaping and subsequent cardiac arrest from ventricular fibrillation highlights the importance of considering both PE-related arrhythmias and potential cardiovascular risks associated with vaping. While arrhythmias in patients with isolated PE are relatively rare, the combination of PE and vaping may increase the risk significantly. Further research is needed to elucidate the precise mechanisms and prevalence of arrhythmias in these populations, but surveillance in cardiac health is crucial, especially in individuals with these risk factors.

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  Body Dysmorphic Disorder Presenting as Alopecia Anxiety: A Case Report

  Henry Lim, Paige Loux, Arianne Felicitas, Marshall Hall, Christian Scheufele, Garrett Furth, Michael Carletti, and Stephen Weis

  Background: Body dysmorphic disorder (BDD) involves a preoccupation with a nonexistent or insignificant physical defect that causes clinically significant distress and impacts a patient's daily functioning. We present a case of a patient with body dysmorphia that manifested as anxiety about hair loss. Case Information: A 48-year-old otherwise healthy female presented to the dermatology clinic with the chief complaint of 8 months of hair loss. She had been seen previously by 2 other dermatologists. She brought 28 pages of paperwork to her first appointment detailing previous work-up, including four separate skin punch biopsies consistent with androgenetic, non-cicatricial (non-scarring) alopecia. Other lab work was largely unremarkable. This patient counted each hair she lost, reporting about 100 strands daily. This was severely distressing, and she was losing sleep worrying that her hair loss would scar, sleeping only 4 hours the night before her first appointment. She sees a therapist regularly and feels they have a therapeutic relationship. Despite multiple biopsies suggesting non-scarring alopecia, and a normal appearance of the hair and scalp, this patient continued to worry that she may have scarring alopecia, and she continued to request more biopsies. The patient was scheduled for close interval follow ups to monitor her condition and regularly address concerns. Despite this, she continued to call the office and presented for multiple emergency work-in visits without clinical change. She presented to yet another Dermatologists office and underwent an additional scalp biopsy. The result was limited by the superficial nature of the sample. It was read as likely an acneiform or folliculitis-like process, however an inflammatory condition such as frontal fibrosing alopecia could not be ruled out. The report recommended correlating the findings clinically, but the patient has anchored on this statement, disregarding prior work-up and the clinically reassuring picture. Conclusions: The prevalence of Body Dysmorphic Disorder (BDD) is estimated to be between 11-13% among dermatology patients. In many cases, the imperfection of concern is imperceptible to other people. Consequently, patients may lack sympathy from their family and friends, leading to social friction and isolation. Studies indicate that individuals with BDD are more likely to experience suicidal thoughts and to make suicide attempts compared to healthy individuals and patients with eating disorders, OCD, or anxiety disorders. Thus, it is imperative for clinicians to assess for signs of psychiatric distress and evaluate risk of harm to self or others.

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  Bradycardia in a Renal Transplant Patient Receiving Rabbit Antithymocyte Globulin

  John Mathew, Victor DelPrincipe, Seline Haci, Karthik Anand, and Rangina Farhad

  Rabbit antithymocyte globulin (rATG) is widely used for induction and treatment of acute T-cell mediated rejection in renal transplant patients. Bradycardia is reported as a rare side effect of this medication (citation). With the increasing number of transplanted kidneys in today's world, there is greater need to understand the adverse effects of these drugs in transplant recipients.. Here we report a case of symptomatic bradycardia in a renal transplant patient receiving rATG for acute T-cell mediated rejection.

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  Bridging Knowledge and Practice: Exploring the Medical City Arlington Internal Medicine Handbook

  Laura Montoya, Evangelista Ezenduka, Shivani Agarwal, Mike Nguyen, Fatima Safi, Nikhil Madhav, Dallin Beus, George Yeung, and Hayan Kundi

  Internal medicine residents face a wide range of challenging medical conditions during their training and need to be equipped with both the knowledge and flexibility to handle whatever comes their way. As part of a collaborative initiative, we present the Medical City Arlington Internal Medicine Handbook, a practical resource built by residents, for residents. This handbook brings together practical insights, evidence-based practices, and specialized clinical expertise, all with the goal of enhancing the diagnostic and treatment skills of internal medicine practitioners. It covers a broad spectrum of conditions, from common ailments to rare and complex diseases, and provides in-depth management strategies, treatment guidelines, and diagnostic tools. The handbook is organized into sections covering key areas like cardiology, pulmonology, gastroenterology, endocrinology, infectious diseases, and rheumatology, with each chapter providing concise, evidence-backed recommendations. What makes this handbook special is its collaborative nature. Residents from multiple hospitals contributed their knowledge and experiences, creating a resource that not only helps residents expand their own expertise but also gives them a chance to be part of something that will guide future residents. In today’s fast-moving healthcare environment, where medical conditions are becoming increasingly complex, this handbook is designed to help residents make faster, more accurate clinical decisions. Ultimately, this collaborative effort strives to foster a culture of continuous learning, teamwork, and excellence in patient care.

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  Bucks Traction in the Emergency Departments (ED) in North Texas Division (NTXD)

  Mason Poffenbarger, Neil Werthmann, Cody Beltran, Hannah Affleck, Kristen Payne, Caleb Shin, Hans Drawbert, Hayley Buehler, James Drinan, Sanjay Sharma, Diona Johnson, John T. Riehl, and Adam Green

  Implementing Buck’s traction for elderly hip fracture patients in the emergency department (ED) is often inefficient, leading to prolonged setup times, increased staff workload, and delays in patient care, ultimately impacting ED length of stay (LOS). This quality improvement project aims to streamline the process by establishing a standardized storage system for traction equipment, optimizing bed compatibility, developing a clear workflow flowchart, and providing targeted staff training. By improving organization and efficiency, we anticipate a reduction in setup time, enhanced workflow, and decreased ED LOS for hip fracture patients. Measuring pre- and post-intervention times will ensure continuous refinement, ultimately leading to improved patient outcomes and overall ED efficiency.

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  Cannabis Induced 2nd Degree AV Block

  Shivani Gandhi, Vineeth Lekkala, Muhammad Suleman, and Anvitha Manduva

  Cannabis use, both medical and non-medical, has seen a marked increase following the growing trend of legalization. While the immediate effects of cannabis on mental and physiological states are well-documented, its potential impact on the cardiovascular system remains an area of growing concern. Cannabis-induced arrhythmias, particularly atrioventricular (AV) block, are rare but potentially life-threatening events that can present in young, otherwise healthy individuals (Heckle et al., 2018). This case highlights the importance of recognizing cannabis as a potential contributing factor in the development of AV block.

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  Case Report: Left Internal Mammary Artery (LIMA)/Coronary Steal Syndrome (CSS) in Severe Coronary Artery Disease and End-Stage Renal Disease

  Fahed Alsayed, Muhannad Badran, Sara Khasawneh, and Mohan Sengodan

  Background: LIMA/coronary steal syndrome is a rare but significant complication in patients with severe coronary artery disease (CAD) who have undergone coronary artery bypass grafting (CABG) and concurrently have high-flow arteriovenous (AV) fistulas for hemodialysis. The left internal mammary artery (LIMA) is a preferred conduit for CABG due to its long-term patency and ability to sustain myocardial perfusion. However, in patients with end-stage renal disease (ESRD) requiring hemodialysis, excessive AV fistula flow can divert blood away from the LIMA graft, leading to myocardial ischemia despite graft patency. Early recognition and appropriate intervention are essential to prevent further deterioration of cardiac function.

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  Case Report of Neurosyphilis

  Caroline Finnerty, Elizabeth Diaz, and Teena Mathew

  This is the case of a 29 year old female who initially presented with generalized joint aches noted to have neurosyphilis. Because of her delayed treatment, this case presents interesting findings that we classically no longer see in syphilis cases due to early detection and treatment. The case looks at the early symptoms as well as late symptoms if syphilis is left untreated. The patient was ultimately treated with IV penicillin with improvement of her symptoms.

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  Challenges in Public Health: The Diagnosis and Treatment of Crusted Scabies

  Marshall Hall, Alyssa Forsyth, Wenquin Du, Michael Carletti, and Stephen Weis

  Introduction: Common scabies is a parasitic dermatologic condition that often presents as an extremely pruritic rash. A rare and highly contagious variant of common scabies is crusted scabies, formerly known as Norwegian scabies. While infection with common scabies typically involves 10 to 20 mites, individuals with crusted scabies are burdened with thousands to millions of mites. Crusted scabies is characterized clinically by hyperkeratotic papules and plaques, most commonly on the palms and soles. Due to the variety of presentations seen in scabies, it can be difficult to diagnose. Case presentations: We present 4 cases of crusted scabies. An 89-year-old male with a history of dementia presented with a two-month history of a generalized pruritic rash. A 22-year-old male with a history of trisomy 21 presented with a 10-month history of mildly pruritic rash on the hands. A 54-year-old female with a history of trisomy 21 and cutaneous T-cell lymphoma presented with a three-week history of a generalized pruritic rash. Lastly, a 5-year-old male with acute lymphoblastic leukemia with a minimally pruritic rash on his hands and elbows that had spread to the genitals. The patients were diagnosed with skin scrapings or biopsy showing scabies mites. These patients were all treated with extended courses of oral and topical anti-parasitic medications. Discussion/Conclusion: Crusted scabies poses a significant challenge to public health as a severe variant of scabies associated with high morbidity and mortality. It is most commonly seen in persons who are immunosuppressed, have an underlying neurologic disorder, or are immobile. Patients may present with skin eruption and pruritus. Patients can also present with severe illness such as erythroderma, which poses a risk for hypothermia, acute respiratory distress syndrome, sepsis, and high-output heart failure. Scabies-related mortality in crusted scabies is high. Management of crusted scabies is different than for other types of scabies because the patient is infested with large numbers of mites. Patients may also have an altered immune response. Treatment of crusted scabies requires a combination of oral and topical treatments. Lastly, the large number of mites in crusted scabies requires more rigorous evaluation and treatment of contacts than other types of scabies. This is necessary to prevent or limit scabies outbreaks and re-infection. As many patients with crusted scabies live in congregate facilities, this requires prompt evaluation of contacts with treatment of cases and public health treatment of asymptomatic residents, staff, and visitors.

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  Clinical Evaluation and Management of Terra Firma-Forme Dermatosis: Insights from Two Diverse Cases

  Henry Lim, Rafael do Valle, Reem Ayoub, Marshall Hall, Michael Carletti, and Stephen Weis

  Terra Firma-Forme Dermatosis (TFFD), also known as Duncan’s dirty dermatosis is a benign, asymptomatic dermatologic condition characterized by well-demarcated brown patches to hyperkeratotic papules or plaques. It most commonly affects the neck, trunk, and face but can appear on other body regions. A key diagnostic feature is that these lesions persist despite routine washing with soap and water but can be removed by forcibly wiping the affected area with 70% isopropyl alcohol, revealing normal underlying skin. The exact etiology of TFFD remains unknown, though it is thought to involve abnormal keratinization or delayed desquamation. This condition is often underdiagnosed or misdiagnosed as dermatitis neglecta, acanthosis nigricans, or other hyperpigmented disorders, leading to unnecessary interventions or patient distress. Increased awareness of TFFD can prevent misdiagnosis and ensure proper management.

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  Coexisting Type A and B Aortic Dissection with Extension to Carotid Arteries Resulting in Acute Ischemic Stroke

  Dung Nguyen, Jilpa Shah, and Amnah Andrabi

  Coexisting Type A and B aortic dissection with extension to carotid arteries resulting in acute ischemic stroke Abstract Background: Acute aortic dissection (AAD) is a rare cause of ischemic stroke. Additionally, it is even rarer to have a combined type A and type B aortic dissection. ADD is a high-mortality disease that can lead to immediate decompensation and can be masked by stroke-like symptoms, which can result in delayed or missed diagnosis. We report a patient with acute ischemic stroke (AIS) with subsequent combined type A and type B aortic dissection. Case Report: A 47-year-old man was admitted to the hospital for nonspecific chest discomfort with associated symptoms of nausea and vomiting. The patient had a long history of uncontrolled hypertension (HTN) and stage IV chronic kidney disease (CKD) due to poor adherence to medications and previous history of pulmonary embolism. The initial physical assessment was unremarkable. Initially, high sensitivity troponin I levels were 72 with an upward trend to 191. B-type natriuretic peptide (BNP) was 32.8. Lipase was 28. Creatinine and blood urea nitrogen (BUN) were 5.01 and 36. D-dimer was 40181. Electrocardiogram (EKG) showed normal sinus rhythm with nonspecific ST changes in the inferior leads 2 and aVF and precordial leads. Given the medical history of CKD, a lung ventilation/perfusion scan (V/Q scan) showed a low probability of pulmonary emboli (PE). The next day, the rapid response team (code RRT) was called. The patient was found to have seizure-like activity and right-sided weakness. Brain attack magnetic resonance image (MRI), MRA head and neck, and CTA neck and aortic dissection were evaluated. Results were significant for acute infarcts in the left posterior frontal lobe cortex and right cerebellum with type A and B aortic dissection extending from the aortic root to the pericardium left common carotid and common femoral arteries. Acute aortic dissection (AAD) complicated with acute ischemic stroke (AIS) was considered, thrombolytics were withheld, and the patient was transferred to a specialized heart center for emergent cardiovascular surgical treatment. Conclusion: Initial ADD diagnosis can be missed in clinically stable patients lacking the typical tearing chest pain and back pain; subsequently, neurological symptoms can, in rare cases, mask an underlying AAD. This case highlights the need for clinicians to consider AAD in the differential diagnosis of acute ischemic stroke, particularly in patients with elevated D-dimer levels and risk factors such as hypertension and chronic kidney disease.

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  Comparison of Fibula Plating versus Fibula Nailing: A Systematic Review with Meta-analysis of All Current Comparative Literature

  Troy Puga, McKenna Box, Charles Marchese, Alan Lam, Sam Stegelmann, and John Riehl

  Introduction Ankle fracture surgeries are common orthopaedic procedures. Fibular fixation is often an important component in restoring ankle stability. Fibular intramedullary nailing (fIMN) has gained recent interest as an alternative technique to fibular plating. This systematic review and meta-analysis was performed to compare the outcomes of fibular nailing versus fibular plating for all current available literature. Methods A PRISMA-compliant systematic review was conducted across MEDLINE/Pubmed, Cochrane, and Embase databases for cohort and clinical trial studies comparing outcomes of fibular nailing and fibular plating of ankle fractures. Demographics and results of the studies were extracted from the articles. Outcomes of interest extracted included operative time, functional outcomes scores, hardware/loss of reduction, malunion/nonunion, re-operations, and wound complications. Meta-analysis of included studies used odds ratios and standardized mean difference when appropriate. Results Nine studies were included in this systematic review. Eight studies were then used for meta-analysis comparison. fIMN showed equivalent operating times to fibular plating. fIMN had equivalent outcomes when compared with fibular plating for hardware failure/loss of reduction, Olerud and Molander Ankle Score, malunion/nonunion, and re-operations. Fibular nailing showed a decrease in wound complications (OR: 0.35 [0.18,0.66] (p = 0.001)) when compared with fibular plating. Conclusion fIMN showed equivalent outcomes and decreased wound complications compared to fibular plating. fIMN is a safe and effective alternative treatment method that can be used by surgeons to treat distal fibula fractures.

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  Cryptococcal Meningitis in a Patient with Multiple Sclerosis on Fingolimod

  Syed Hassan Amir and Teena Mathew

  Background: There are a host of pathogens that thrive only when the host is weakened enough to be susceptible – Cryptococcus is one such organism that causes fatal meningitis, primarily in HIV patients. Those immunocompromised by other means are also susceptible. Among them, patients with multiple sclerosis (MS) pose a significant challenge as what may initially be considered an MS flare could mask a serious underlying infection. Objective: This case study discusses an MS patient on Fingolimod, an immunosuppressant, that likely made them vulnerable to cryptococcal meningitis. Pathogenesis: Cryptococci are encapsulated yeast that enter the body via inhalation of spores from sources such as bird droppings. They travel to the lungs and colonize it – in some hosts, they may form latent granulomas; while in susceptible hosts, they spread hematogenously, eventually crossing the blood-brain barrier to infect the brain. Case Presentation: A 58-year-old Caucasian female with PMHx MS presented with a change in her mental status. She displayed odd behaviors -- a case in point where she took an unusual driving route that culminated in a motor vehicle collision. On presentation, CBC and CMP were unremarkable. Alcohol/ammonia levels and urine drug screen were all negative. CT head showed no hemorrhage, but possible ischemic changes in basal ganglia. MRI confirmed an abnormal signal of the basal ganglia, midbrain and left meningeal enhancement. A lumbar puncture showed elevated WBC with lymphocytic pleocytosis, elevated protein, and low glucose. CSF studies were positive for cryptococcus antigen with an elevated cryptococcus CSF titer. CSF fungal cultures returned negative. Patient was started on induction therapy with liposomal Amphotericin B alongside Flucytosine. A repeat lumbar puncture confirmed normal opening pressure. The patient was transitioned to Fluconazole for consolidation therapy prior to discharge. Discussion: Besides HIV patients with CD4 counts of less than 100 cells/microL, CM may also occur in patients immunosuppressed by other means, such as in this case with Fingolimod. The immunosuppressant nhibits S1P receptors and thus prevents lymphocytes from leaving lymphatic tissue. Further research could delineate the relationship between lymphocytes and immunity against cryptococcus. Future studies could also help to elucidate whether MS patients are more susceptible to CM than the general population infected by the disease, while exploring possibilities of whether certain immunosuppressants put MS patients at a higher risk of infection. Conclusion: Cryptococcal meningitis should therefore be considered as part of a differential for an MS patient on immunosuppressants presenting with neurological symptoms.

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  Culture Negative Endocarditis Masquerading as Idiopathic Leukocytoclastic Vasculitis

  Sania Moonnumackel, Manish Pandey, Randy Nguyen, Reuben Abreu, Seline Haci, Neelima Paladugu, and Machaiah Madhrira

  Background: Infective endocarditis (IE) is a challenging disease to diagnose often presenting with heterogeneous features. Blood cultures are the gold standard for diagnosing endocarditis, but it is important to know that up to 20 % of cases of infective endocarditis have negative blood cultures. Leukocytoclastic vasculitis (LCV) is a small vessel vasculitis and is idiopathic in 50% of cases. LCV is a rare but possible presentation of Infective endocarditis. Hence IE should be part of the differential diagnosis when LCV is diagnosed. Case summary: A 53-year-old male patient presenting right lower extremity pain and vesiculobullous lesions over bilateral upper and lower extremities. He is diagnosed with severe peripheral arterial disease (PAD) and leukocytoclastic vasculitis (LCV). For leukocytoclastic vasculitis, a causative factor could not be determined, hence, the patient was diagnosed with idiopathic LCV and was started on IV steroids. Simultaneously, the patient was determined to need bilateral AKAs for severe PAD. However, a preoperative transthoracic TTE) revealed a large vegetation on the mitral valve. Transesophageal echo (TEE) confirmed the presence of a large 2 cm X 1cm mass on the atrial aspect of the posterior leaflet The patient was presumptively diagnosed with culture negative endocarditis and empiric treatment with IV Vancomycin and IV cefepime was started. Cardiothoracic surgery was consulted for possible surgical removal of the vegetation, but the patient was deemed very high risk for mitral valve replacement. Consequently, the patient was treated with long term Antibiotics. Learning Points: Negative blood cultures increase the mortality rate in IE, a potentially lethal disease process. Adding a rare presentation of leukocytoclastic vasculitis to this mixture creates an even more challenging clinical picture. In culture-negative acute native valve endocarditis, empiric dual therapy with Vancomycin and cefepime for six weeks is appropriate as it covers organisms such as S. aureus, beta-hemolytic streptococci, and aerobic Gram-negative bacilli. Also, serologies for Coxiella Burnetii, Bartonella spp., brucella, legionella, and mycoplasma may be tested. Classical lesions seen in IE include Osler's nodes and Janeway lesions that histologically show septic emboli with inflammatory reactions. It is important to remember that patients presenting with LCV have also been diagnosed with infective endocarditis. Treating a patient with steroids or immunosuppressives (management of idiopathic LCV) can be detrimental to the treatment of an already highly morbid condition such as endocarditis. Therefore, it is important to keep an infectious cause such as IE in one's differential diagnosis while managing vasculitis.

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  Current Trends in School Nursing for Diabetes & Dermatology

  Ali Al-Nahi, Jeffrey Dickerson, Enith Espinosa Palmett, Shterna Frand, Garrett Furth, Matthew Gutzmer, Marshall Hall, Sana Khan, Shana-Kay Lambert-Johnson, Henry Lim, Kelly Mofor, Lakshmi Morla, Ali Nazim, Rui Zhang, Christian Scheufele, Zara Soomro, Michele McCarroll, Taylor Pickering, Jasmine Silva, Brina Gonzalez, Devika Adusumilli, Sherri Morgan, and Nischal Pokhrel

  Background: School nurses are on the front lines of assessing, identifying and treating school-age children with a number of health complications. Implementing nursing services in schools has previously demonstrated improved medical care costs for students, less productivity loss for parents, and less productivity loss for teachers. As a result, nursing services in schools provide a cost-beneficial investment of public money, and warrant both financial support from policy makers as well as educational support from local healthcare services. Aim Statement: This quality improvement project addressed the targeted continuing education gap topics of Dermatology and Diabetes management in school age children. Methods: Residents from emergency medicine, family medicine, internal medicine, general surgery, and dermatology delivered synchronous and asynchronous lectures throughout the academic year 2024-2025 at local Medical City Healthcare hospitals in North Texas. Results: Approximately n=1,500 nurses from 18 different school districts within the North Texas Division of Medical City Healthcare attended/will attend the voluntary sessions. Self-reported data from pre and post session surveys regarding knowledge and treatment were collected. To-date: RNs, n=688; LPNs, n=34; CNA, MA, Clinic/Health Aides, n=65; Social Worker, n=1; Others, n=3 completed the surveys. At the end of this learning event, 96.4% attendees specified a change in clinical practice they will implement based on knowledge gained. In addition, attendees reported an average “increase in knowledge” rating of 4.81 on 5-point Likert scale. Conclusion: By educating nurses on common school age medical problems, we seek to continue to improve both nursing confidence in primary management of these conditions as well as increase the overall participation from the community in these educational sessions.

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  Curtain-like Vision Loss: A Case Report on Semaglutide and its Effects on Vision

  Sereena Jivraj, Jonathan Eledge, Amenda Khoei, and Amnah Andrabi

  Background: Semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-RA), was introduced and approved by the United States Food and Drug Administration (FDA) for the management of type 2 diabetes in 2017. Since then, the medication has garnered much more attention for its ability to aid with weight loss. Until recently, the most significant side effects of semaglutide noted were mostly gastrointestinal symptoms such as nausea, vomiting, and diarrhea due to the drug’s mechanism of action of delayed gastric emptying. However, a singular cohort study from Harvard Medical School in conjunction with Massachusetts Eye and Ear of 16,827 patients recently suggested a possible risk of semaglutide and non-arteritic anterior ischemic optic neuropathy (NAION), a form of vision loss resulting from loss of blood flow to the optic nerve. Case Description: Here we report one case of semaglutide-associated vision loss in a middle-aged woman whose symptoms began roughly 2 months after discontinuing semaglutide due to intractable nausea. A 50-year-old woman with a past medical history of migraines, primary immune deficiency, asthma, and endometriosis presented with a recent diagnosis of Idiopathic Intracranial Hypertension and worsening symptoms. She stated that over the past two days, her right eye vision had gotten worse and reported being unable to see in the lower half of her visual field. Her headache was described as a pressure sensation radiating between her ears. On exam, the patient had horizontal nystagmus, difficulty converging, sluggish pupils, and difficulty visualizing anything below the level of the ceiling in her right eye. Left eye vision changes were not appreciable. Conclusion: Although causality has not been confirmed, there appears to be a correlation of semaglutide use with NAION, as observed in the study at Harvard Medical School and Massachusetts Eye and Ear, as well as in our patient. Therefore, further studies are recommended to assess the long-term risks associated with semaglutide, including NAION and other vision changes.

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  Development and Validation of an Accurate and Precise Skin Color Scale

  Henry Lim, Christina Guo, Reem Ayoub, Rafael do Valle, Kristina Kafle, Ysabelle Martinez, Dana Olsen, Marshall Hall, Christian Scheufele, Michael Carletti, and Stephen Weis

  Introduction: Utilization of the Fitzpatrick scale to describe skin color does not adequately account for variations in pigmentation that are reflective of skin color characteristics of persons from diverse racial and ethnic backgrounds. This study aims to create a better way to describe skin color. Methods: We developed an 11-point color scale. This Skin Color Scale (SCS) was reproduced onto a physical card that could be placed onto a research participant’s inner arms for independent scale interpretation. Participants and two investigators selected the best matching scale interpretation value for each arm. Self-acquired and investigator assessed Fitzpatrick scores were taken. These readings were compared to objective measurements by two separate spectrophotometers. Results: SCS rating between participant vs. Investigators #1 and #2 showed significant positive correlation on the right arm (n=440, t=47.73, 39.335, p= < 2e-16) and the left arm (n=440, t= 43.427, 39.695, p= < 2e-16). Participants SCS rating using colorimeter #1 and #2 showed a significant inverse relationship with Melanin Index (MI) (t= -25.93, -21.59; p= < 2e-16). As well participants SCS rating showed a significant positive correlation with Luminosity values for colorimeter #1 and colorimeter #2 (t=30.27, 28.219; p=

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  Disseminated Fusarium Infection to Lung, Liver, and Brain in an Acute Promyelocytic Leukemia (APML) patient; a case report

  Lane F. Smith, Alexandria Goyer, Ali Al-Nahi, Neil Bhangoo, Yi Lei, Zara Soomro, Amy Nguyen-Pham, and Tasaduq Mir

  Background: Disseminated fusarium, primarily affecting immunocompromised individuals, is associated with persistent fevers, rash, and lung involvement. Despite interventions, mortality rate remains high, exceeding 75% for disseminated disease. There are only 26 documented cases worldwide between 1974 and 2022 with CNS involvement. This case highlights a rare presentation of disseminated fusarium infection involving the lungs, liver, and brain in a 53-year-old male with acute promyelocytic leukemia (APL), highlighting critical diagnostic and therapeutic challenges. Case Presentation: A 53-year-old male with a history of APL with PML/RARA fusion t (15,17) after chemotherapy presented with persistent fevers, rash, encephalopathy, and severe sepsis while undergoing rehabilitation. Initial blood cultures were negative and urine culture was positive for multi-drug resistant enterobacter, for which meropenem was initiated. CT of the chest and abdomen revealed bilateral pulmonary nodules, liver cystic lesions, and signs of cholecystitis. Liver biopsy confirmed fusarium species, prompting treatment with voriconazole monotherapy. Despite surgical intervention and aggressive therapy, the patient experienced worsening respiratory failure, neurological decline, and ultimately transitioned to hospice care where they subsequently passed away. Treatment Approach: Disseminated fusariosis predominantly affects immunocompromised patients, presenting with prolonged febrile illness and cutaneous lesions. MRI head was performed due to acute encephalopathy and showed punctate acute versus subacute infarct in the posterior right cerebellum, small multifocal regions of periventricular/subependymal irregularities and trace fluid within fourth ventricle which correlates to ventriculitis. Infectious disease team added amphotericin B and decreased the voriconazole dose due to worsening of encephalopathy and hallucinations. The case demonstrated resistance to standard therapy, necessitating combination antifungal treatment. Patient’s hospital course was also complicated by gangrenous cholecystitis, which required surgical intervention and additional antibiotics for intra-abdominal infection. Conclusion: This case underscores the critical need for proactive diagnostics with a presentation of immunocompromised status, persistent fevers, disseminated rash, respiratory distress and encephalopathy. Tailored early antifungal regimens and preventative measures are crucial for high-risk patients. The efficacy of combination therapies and advanced imaging techniques in monitoring fusariosis progression, particularly with rare organ involvement such as the liver and brain, should be investigated.

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  Effective Communication in the Pronunciation of Brain Death

  Sumanth Reddy, Artur Amirkhanyan, Jeremiah Avarana, Praneetha Arge, and Alicia Lay

  Background: Clinical brain death determination requires both technical proficiency and sensitive communication with families. However, residents often report inadequate training and confidence in performing and discussing these examinations. This study evaluated an educational intervention combining didactic training and simulation to improve residents’ competence in brain death protocols and family communication. Methods: A mixed-methods cohort study was conducted with resident physicians. Participants completed a pre-intervention questionnaire assessing baseline knowledge, experience, and confidence in brain death determination and communication. An educational session reviewed clinical criteria, examination protocols, and communication strategies. Residents then engaged in an in-person simulation with standardized actors portraying grieving family members, while others observed live video recordings of these interactions. Post-simulation debriefs and a repeat questionnaire evaluated changes in confidence and preparedness. Results: Of 15 initial participants (8 PGY-1, 5 PGY-2, 2 PGY-3), 67% reported prior didactic training, yet 67% (n=10) had never performed a brain death examination, and 47% (n=7) lacked confidence in doing so. All participants agreed that increased exposure to brain death protocols would improve their preparedness. Post-intervention, 5 residents (4 PGY-1, 1 PGY-2) completed follow-up assessments, with 100% strongly agreeing they felt confident communicating brain death to families. Conclusion: Simulation-based training demonstrated preliminary potential to enhance resident confidence in discussing and performing brain death examinations, particularly among junior trainees. However, low post-intervention response rates (33% of initial cohort) limited statistical significance. These findings underscore the need for structured training in this high-stakes clinical task

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  Effect of a Durable Medical Equipment Template on a Family Medicine Clinic

  Zara Soomro, Ali Al-Nahi, Neil Bhangoo, Yi Lei, John Nguyen, Sahar Elchehabi, Austin Driskill, Priyanka Reddy, Dylan Huynh, Jonathan Choi, Dante Paredes, and Tasaduq H. Mir

  Background Patients rely on durable medical equipment (DME) to maintain their independence, however supplying and ordering DME for patients is challenging due to lack of a clear workflow, inadequate documentation, and differing coverage criteria, which has led to delays in patients receiving their DME. Current criteria to order DME include the following items: equipment description, quantity, length of need (estimate), diagnosis, recent height and weight, name, date of birth, home address, insurance company and member ID. The objective of this quality improvement project is to provide a clear and concise template for providers to use in ordering DME. Methods The DME Template development team consisted of PGY-2 and PGY-3 residents at Medical City Fort Worth (MCFW) Family Medicine Residency program. The DME Template is a comprehensive guidebook that contains a guide to how to order DME through NextGen EMR via appropriate documentation for the History of present illness, review of systems, physical exam and assessment and plan sections. A pre-survey consisting of Likert Scale questions was distributed amongst the residents and faculty members of the HSC Family Medicine Clinic, gauging the current comfortability of the DME ordering process. The DME Template document was then distributed to the residents and faculty staff via e-mail, Microsoft Teams, and QR code. A post-survey consisting of Likert Scale questions 3-5 months after the document distribution was then sent to the same residents and faculty members. Results from the pre and post-surveys created by HCA Healthcare will be analyzed via chi squared analysis. Results Results will depend on the final survey, which will be completed in February 2025. Discussion Amidst evolving challenges in ordering DME for patients, we hope that our study reveals that the implementation of the DME guidebook will help providers by increasing confidence in proper documentation during face to face encounters for DME approval. We plan to eventually incorporate these standardized templates into Next Gen EMR for ease of use.

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  Effects of Rideshare Services on Alcohol Related Motor Vehicle Collision (MVC) Outcomes

  David Bassa, Morgan Johnson, Devika Pavuluri, and Michael Truitt

  BACKGROUND: In 2022, The National Highway Traffic Safety Administration (NHTSA) reported over 42,000 motor vehicle collisions (MVCs) deaths with 31% of MVC deaths secondary to alcohol (AR-MVCs). In 2010, rideshare services (RSS) were introduced to the market providing a new method of transportation with the potential to reduce the incidence of driving under the influence (DUI). We analyzed the NHTSA database to evaluate trends in alcohol related MVC deaths (AR-MVC Deaths) since the initiation of ride share services. METHODS: Fatality Analysis Reporting System (FARS) source from the NHTSA was used to obtain data from years 2009 and 2022 from 50 states, the District of Columbia and Puerto Rico. SPSS software was used to run non-parametric assessments of variance to explore the association between drivers under the influence of alcohol and fatal crashes. The VEHICLE data files for the years 2009 and 2022 were used to explore the trends in alcohol related crashes. Uniform Crime Reporting Program (UCR) source from the Federal Bureau of Investigation (FBI) was used to obtain data to compare number of DUIs RESULTS: There are more than 5 billion reported RSS per year. Between the years of 2009 and 2022, the DUI arrests rates decreased from 32.95% to 16.61% respectively. In 2009, the total number of AR-MVC deaths was 22.8%. In 2022, the number of AR-Deaths was 17.2%. AR-MVC deaths decreased 5.6% (p<.001). From the FARS data tables, the highest percentage of alcohol-related crashes were observed was between 12:00 am to 2:59 am during both the years 2009 (65%) and 2022 (55%). CONCLUSIONS: Since the initiation of rideshare services, there has been a statistically significant decrease in alcohol related MVC fatalities from 22.8% in 2009 to 17.2% percent in 2022 (p<.001). In addition, there has been a decrease in the number of DUIs. This may represent the positive effect of rideshare services on preventing alcohol related MVC mortality.

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  Efficacy of Osteopathic Manipulative Treatment in Post-Stroke Recovery Patients

  Elizabeth White, Dakota Dalton, Alexis Walker, Patrick Vu, and Christopher Medina

  Each year, an estimated 795,000 adults in the United States have a stroke, making it the fifth leading cause of death and the tenth leading cause of adult disability. Current literature addresses the use of osteopathic manipulative treatment (OMT) for pain and physical limitations in the post-acute outpatient setting. However, stroke patients can benefit additionally from rehabilitation in the subacute hospital setting as demonstrated by this case study. A 53-year-old Caucasian female presented to the emergency department with a history of slurred speech and right-sided weakness secondary to a left middle cerebral artery (MCA) stroke. Head computed tomography angiogram (CTA) demonstrated moderate stenosis of the distal M1 segment of the left MCA. The inpatient osteopathic manipulative medicine team was consulted on day three of admission for total body pain related to positional changes, muscle contractures and chronic rheumatoid arthritis. Following six sessions of osteopathic manipulative treatment (OMT), the patient reported improvement of pain in all treated regions as well as increased motor function in the paralyzed right side. Over the course of treatment, the patient experienced decreased need for assistance with activities of daily living and ambulation. OMT was performed in both the neurological intensive care unit and the inpatient rehab facility for a total of fourteen treatments over thirty-six days. Treatment included indirect techniques for diagnosed somatic dysfunctions and surrounding structures and improved physical restrictions bilaterally. This case demonstrates that in conjunction with evidence-based physical and occupational therapies, subacute stroke OMT increases biomechanical functionality as demonstrated by the increased functionality of both the paralyzed extremities and the newly dominant side.

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  Exploring the Link Between COVID-19 and Transverse Myelitis: A Case Report

  Sara Sanghera, Trivianne Franklin, Veeranna Vibhuti, and Danielle Ford

  Transverse myelitis (TM) is a rare inflammatory syndrome of the spinal cord that is often attributed to immune-mediated responses which lead to demyelination and the resultant varying degrees of motor, sensory, and autonomic dysfunction. While COVID-19 virus itself is known to present with anosmia, ageusia and Guillian Barre syndrome, a few rare cases of COVID-virus related TM have been reported. This case presents a 61-year-old female experiencing bilateral lower extremity weakness with brisk to absent reflexes. Onset of the symptoms was of 3 days origin, and she was tested positive for COVID-19. Patient did not have upper extremity symptoms but had new presentation of urine retention. MRI scan of C-spine showed extensive intramedullary cord lesion consistent with transverse myelitis with extensive demyelination extending to thoracic spine. Upon further workup from blood and CSF fluid studies, other viral or bacterial etiologies and autoimmune causes were ruled out. Patient was treated with IV glucocorticoids and a course of IVIG. After a few weeks course at a skilled rehab facility, she made partial but significant progress to the weakness. As more cases now continue to be reported, COVID-19 associated TM should be increasingly considered in the differential diagnosis. A greater understanding the mechanism behind COVID-19 related development of TM would allow for tailored management strategies, and in-turn better patient outcomes.

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  Facial Hair and Infection: A Beardly Question with a Bald Spot in the Literature

  Kyle O'Connor, Samuel Stegelmann, Hans Drawbert, Edwin Dudoussat, and John T. Riehl

  Background: Upholding a sterile environment in orthopedic surgery is vital to minimize surgical site infections (SSIs). Among personal protective equipment, beard covers for surgical staff with facial hair have been recommended as a measure to prevent contamination. However, their effectiveness in reducing SSIs remains uncertain, especially in orthopedic procedures that often involve high-risk implants and extended exposure of surgical fields. This systematic review assesses the current evidence on the role of beard covers in infection prevention during surgery. Methods: Using PRISMA guidelines, databases were searched for studies investigating facial hair, beard covers, and infection risk. Eligible studies included comparative studies, laboratory experiments, and consensus statements. Quality was assessed using MINORS and CASP tools, while certainty of evidence was graded using GRADE criteria. Results: 617 studies were extracted from databases and eight met inclusion criteria. Clinical studies did not demonstrate a statistically significant difference in SSI rates between uncovered bearded surgeons, uncovered clean-shaven surgeons, or with the use of beard covers. Laboratory studies provided mixed results on bacterial shedding associated with facial hair. A consensus statement highlighted insufficient evidence to recommend beard covers as standard practice. Conclusions: The current evidence is equivocal when determining the role for beard covers for SSI reduction in orthopedic surgery. Given the lack of evidence-based data, further high-quality research is needed to justify the routine use of beard covers in infection prevention and operating room protocols.

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  Fibrillary Glomerulonephritis Associated with Hepatitis C: A Case Report of Progression to End-Stage Renal Disease

  Boney Lapsiwala, Karthik Kasireddy, Marisha Sharma, Mayank Singh, Vaishnavi Singh, and Victor Canela

  A Case of DNAJB9 with rapid renal progression to End-Stage Renal Disease in a patient with previously treated HCV Background Fibrillary glomerulonephritis (FGN) is a rare and progressive kidney disease, accounting for 0.5% to 1.4% of native kidney biopsies. It is characterized by non-amyloid fibrillar deposits in the extracellular matrix. Although historically regarded as idiopathic, recent studies have revealed associations with autoimmune diseases, malignancies, and Hepatitis C virus (HCV) infection. DNAJB9, a proteomic marker identified through mass spectrometry, has been consistently found in FGN cases, regardless of congophilia. This case illustrates FGN in a patient with a history of successfully treated Hepatitis C, with rapid progression to end-stage renal disease (ESRD). Case Presentation A 54-year-old female with a medical history of successfully treated Hepatitis C (using Glecaprevir and Pibrentasvir), cerebrovascular accident (CVA), coronary artery disease (CAD), decompensated cirrhosis, and chronic kidney disease (CKD) presented with encephalopathy. Upon admission, her vital signs were stable (blood pressure 118/64 mmHg, heart rate 73 bpm, respiratory rate 22 breaths/min, oxygen saturation 99% on room air). Physical examination revealed an obese abdomen with significant ascites but no asterixis, tremor, or skin lesions. Laboratory results showed acute kidney injury (serum creatinine 9.24 mg/dL, blood urea nitrogen 103 mg/dL, ammonia 106 µmol/L), with preserved synthetic liver function (INR 1.2). Urinalysis was negative for microscopic hematuria. During a previous admission, the patient's serum creatinine level was 5.9 mg/dL, highlighting a rapid decline in renal function. Serological tests were negative for hepatitis B, C, HIV, autoimmune markers, and monoclonal spikes. Imaging showed no evidence of hydronephrosis. The etiology of CKD was believed to be multifactorial but her current presentation prompted further diagnostic biopsy. A renal biopsy showed immune deposits with a fibrillary substructure on electron microscopy, while immunohistochemistry confirmed the presence of DNAJB9, solidifying the diagnosis of FGN. Light microscopy revealed over 40% of moderate tubular atrophy and, interstitial fibrosis, and mild non-specific inflammation. Immunofluorescence microscopy was negative for IgG, IgA, IgM, C1q, albumin, fibrinogen, and kappa/lambda light chains. The patient met indications for renal replacement therapy and was started on hemodialysis. She underwent paracentesis with albumin infusion as needed. No renal recovery was observed. Discussion This case illustrates a patient with previously treated hepatitis C and worsening renal function. We suspect this pathologic process had been ongoing for months but by the time the biopsy was done the damage was irreversible. The patient's history of treated HCV points out the risk of renal involvement and GN developing later on despite on successful HCV treatment. Conclusion FGN should be considered in the differential diagnosis for any patients with rapidly declining renal function, even in the absence of typical signs of glomerulonephritis. DNAJB9 serves as a novel diagnostic marker for FGN. Prior Hepatitis C infection continues to be a significant risk factor for FGN and renal disease progression.

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  Follicular Occlusion Syndrome: Diagnosis, Management, and Emerging Insights

  Henry Lim, Reem Ayoub, Rafael do Valle, Marshall Hall, Michael Carletti, and Stephen Weis

  Follicular Occlusion Syndromes (FOS) are rare chronic relapsing skin disorders characterized by abnormal follicular hyperkeratinization, plugging, and inflammation. FOS are more commonly discussed as a ‘triad’ or ‘tetrad’ based on the patient’s clinical presentation. The triad includes hidradenitis suppurativa, acne conglobata, and dissecting cellulitis of the scalp. The tetrad in addition to the triad includes a history of pilonidal cysts. These disorders have a considerably negative effect on quality of life due to chronic pain, psychological distress, and body image concerns. Delayed or misdiagnosis can exacerbate patient outcomes, heightening the importance of timely identification and multidisciplinary treatment. We present two previously unrecognized cases of FOS to raise awareness to improve management.

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  From Deposition to Infection, A Rare Case of Osteomyelitis in Tumor Calcinosis

  Munazzah Kaleem, Alexander Newell, Wendy Phillips, and Saravanan Balamuthusamy

  Background/Intro Tumor calcinosis is a rare disease, and its association with greater trochanteric pain syndrome, abscess formation, and Osteomyelitis has not been well studied. Case presentation A 63-year-old woman with a known history of tumor calcinosis presents with right hip pain for 5 days. She woke up with a pain that was constant, alleviated with resting and getting worse with exertion and rolling on that side. She reports a t-max of 101F. Ct scan revealed a 9 x 4 x 11cm rim enhancing right great trochanteric collection and/ or severe bursitis. Orthopedic surgery evaluated the patient and, had low suspicion of infection. They also discussed the IR-guided aspiration but it was ultimately deferred and she was discharged home on a Medrol dose pack for possible inflammation. The patient presented again 2 days later with drainage from the site. WBC count was significant at 32.9 and a repeat CT scan showed a right lateral hip soft tissue abscess of 3.6 x 3.0 x 8.4 soft tissue fluid collection with a thick, mildly enhancing rim, an overlying cutaneous defect, and sinus transit. MRI showed osteomyelitis of the lateral aspect of the right greater trochanter. Wound culture grew MSSA. The patient was started on antibiotics which resolved the symptoms and was discharged home on long-term IV antibiotics. Pt has a history of tumor calcinosis resection in 2018 with mild removal of muscle mass on the right hip joint. Which was complicated by mRSA and Klebsiella at that time and the patient fully recovered after 8 months long treatment. Discussion Recurrent multifocal osteomyelitis has been reported earlier in patients with tumor calcinosis, but no association between tumor calcinosis and episodes of osteomyelitis years after surgery has been reported so far. Teaching/Learning Points Patients with tumor calcinosis can often present with osteomyelitis which can be overseen as bursitis.

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  Hearts Hidden Message: Right Ventricular Thrombus Reveals Esophageal Adenocarcinoma

  Devika Adusumilli, Seline Haci, Jafri Imran, Arman Vaghefi, Mehdi Khalafi, Ikponmwosa Iyamu, and Sarvanan Balamuthusamy

  Introduction Right ventricular thrombi are uncommon, usually found with concurrent pulmonary emboli and associated with significant mortality. They often originate from deep vein thrombi but may also be due to primary intracardiac processes . A right ventricular thrombus can be an unexpected marker for underlying malignancies, including esophageal cancer. This occurs due to the hypercoagulable state often induced by malignancy. Here we report a presentation where the identification of a right ventricular thrombus led to the diagnosis of esophageal cancer. Case Presentation Our patient is a 57-year old male with no past medical history who experienced an episode of dizziness . On admission vitals and physical examination were within normal limits. Electrocardiogram showed normal sinus rhythm, white blood cell count of 31, elevated troponins at 187. Echocardiogram was ordered as part of syncope /presyncope evaluation to rule out any structural/functional abnormalities.On transthoracic echocardiogram, there was a hypoechoic, irregularly shaped, partially mobile structure partially adherent to the free wall of the right ventricle, measuring 35 x 12.6mm. A computed tomography scan was done to rule out pulmonary embolism. This revealed no evidence of pulmonary embolism but incidentally patchy consolidative opacities of the left lower and upper lung lobes, mediastinal hilar lymphadenopathy, numerous hepatic hypodensities, lytic lesions of the thoracic spine,and an esophageal junction mass. Endoscopy revealed a gastro esophageal junction mass. Biopsy revealed moderate to poorly differentiated adenocarcinoma.The decision was made to percutaneously aspirate the right ventricular mass as it was highly mobile and large , placing it at high risk for embolization and related complications.Pathology of the specimen confirmed it to be a thrombus . Patient was not a surgical candidate as per surgical oncology consultation due to extensive metastatic disease. Learning Points There is no literature to show cases wherein a right ventricular thrombus led to the discovery of malignancy.A right ventricular thrombus is dangerous because of the risk of embolization. The thrombus can potentially break off and travel to the pulmonary arteries, causing a pulmonary embolism or impair the right ventricle’s ability. The discovery of a right ventricular thrombus in an otherwise unexplained clinical context should prompt a thorough evaluation. A hypercoagulable or prothrombotic state of malignancy occurs due to the ability of tumor cells to activate the coagulation system. Future studies assessing the best advanced therapy for a right ventricular thrombus are necessary.

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  Hematometra in a Pre-Menopausal Patient: A Case Report of Idiopathic Cervical Occlusion

  Sandra Zhi, Claire Middleton, Chrystal Stallworth, Mindy Beth Luck, and Nicole Tenzel

  Introduction: Hematometra is a blood collection caused by a structural blockage of the vagina or cervix. Most cases of hematometra and/or hematocolpos occur in a relatively rare condition of imperforate hymen or Mullerian anomalies in children or adolescent patients. Case: We present a case of a 46 year old G2P2002 with a past surgical history of two C-sections with increasingly severe pelvic pain and abnormal uterine bleeding for the prior five years since her last Cesarean delivery. A large hematometra was found on CT imaging. Pelvic exam showed no vaginal abnormalities and a discolored, pale cervix. Digital pressure led to an incidental rupture of the hematometra and 150ccs of dark red blood were expelled from the cervix. After the incidental rupture, the patient reported a sudden relief of pelvic pain. Discussion: In this case report, we present an unusual case of spontaneous hematometra and background on acquired causes of hematometra and hematocolpos. A case of hematocolpos or hematometra would be unexpected in this patient as she has no history of vaginal deliveries or cervical procedures. We explore the various causes of hematometra and hematocolpos, seek an understanding of the potential etiology behind this patient’s presentation and present a discussion of the adequate follow up as well as considerations of how to best manage this condition. Teaching Points: 1. Most cases of hematocolpos are congenital due to imperforate hymen or secondary to cervical surgery or trauma. 2. Evaluations of hematocolpos include a proper history and physical exam, pelvic exam, and possible Computed Tomography imaging or Transvaginal Ultrasound. 3. Consider providing an antibiotic course in the case of a ruptured hematometra prior to discharge.