United States

Low back pain (LBP) is the leading cause of disability worldwide, affecting 600 million people. Chronic low back pain (cLBP) impacts 10–13% of the population. Forty percent is discogenic in origin. Due to aging, increased lifespan, and obesity, individuals are outliving or overburdening their intervertebral discs.
 
Traditional treatments focus on symptoms. Conservative management, including rehabilitation and medications, has limited efficacy and carries risks such as opioid dependence. Percutaneous non-biologic therapies, like epidural steroid injections, provide only short-term relief and may be chondrotoxic and tenotoxic. Surgical interventions pose additional risks, including prolonged recovery, permanent loss of spinal flexibility, accelerated degenerative disc disease, and inconsistent outcomes. None of these approaches halt or reverse disc degeneration.
 
The pathogenesis of intervertebral disc disease is multifactorial, involving complex cellular and biochemical changes. Orthobiologic therapies, are natural therapies such as platelet-rich plasma (PRP), aim to target these biological pathways. However, their adoption is hindered by skepticism, lack of standardization, limited high-quality research, and cost barriers. Despite these challenges, patient interest in orthobiologics continues to grow, largely driven by word-of-mouth, peer experiences, and a preference for natural or holistic treatments. 
 
Further, primary care physicians (PCPs) serve as the initial point of contact for many patients with dLBP. Research indicates that clinicians who provide comprehensive education—explaining the science, treatment options, risks, costs, and supporting evidence—can positively impact patient decision-making and adherence. This study aims to explore current data related to the treatment of chronic discogenic low back pain as it relates to patient outcomes and further how this impacts primary care referrals for pain management.


AMA Research Challenge 2025 

Orthobiologics and Discogenic Low Back Pain: A Systematic Review

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poster

Background
Retroperitoneal sarcoma (RPS) is a rare malignancy. Because surgical margin status is strongly associated with local recurrence and prognosis, frontline extended surgery, an aggressive resection strategy, was introduced. While controversial, frontline extended surgery has been increasingly adopted, but most outcome data come from high-volume centers, limiting generalizability. This study aimed to evaluate surgical trends and outcomes for RPS at the population level in the US.

Methods
We identified primary RPS cases treated with curative-intent surgery in the SEER 17
database. Patients were grouped by year of diagnosis: 2000–2005, 2006–2011, and 2012–2017. The primary outcomes were 5-year overall survival (OS) and disease-specific survival (DSS). Kaplan-Meier curves and multivariate Cox regression were used to assess prognostic factors. Propensity score matching (PSM) was utilized to adjust for baseline differences in comparing survival of radical versus standard surgery. As all data were de-identified and publicly accessible, this study was exempt from institutional review board process.

Results
A significant increase in radical surgery was observed over time (68.3% to 77.2%,
p=0.035), and period 2012-2017 demonstrated a significant higher odds ratio of radical surgery (OR 1.49, 95% CI 1.01–2.21, p = 0.044) after adjusting patients’ baseline characteristics. However, Cox regression analysis demonstrated no significant improvement in survival in patients with RPS. (p1 vs. p2: HR 0.82, 95% CI 0.62–1.07, p = 0.14, p3 vs. p1: HR 0.80, 95% CI 0.61–1.05, p = 0.11). After PSM, radical surgery did not confer a significant OS or DSS benefit (OS: HR = 1.22, 95% CI 0.82–1.62, p = 0.17; DSS: HR = 1.25, 95% CI 0.92–1.69, p = 0.15) in cox regression analysis and was not associated with higher 30-day mortality (OR 1.37, 95% CI 0.43–4.38, p=0.59) in logistic regression analysis.

Conclusion
The adoption of radical surgery for RPS has increased. Yet population-level analysis
revealed no significant survival improvement over recent period, contrasting prior findings of high-volume center studies. Survival advantage was not observed in radical surgery group. However, radical surgery group demonstrated comparable perioperative mortality to standard surgery group, supporting its safety.


Population-Based Trends in Radical Surgery and Survival for Retroperitoneal Sarcoma

Background: Diabetes mellitus (DM) and osteoarthritis (OA) are two prevalent chronic conditions that significantly burden the U.S. healthcare system. Although historically studied independently, this paper suggests potential molecular, inflammatory, and metabolic links between the two. Obesity, age, and systemic inflammation are among the shared risk factors. Understanding their overlap could help develop more targeted treatment strategies and mitigate overall disease burden and incidence. 

Methods: A structured literature review was conducted using the PubMed database, focusing on publications from 2015 to 2022. Articles were selected based on relevance to shared risk factors and mechanisms between DM and OA, including obesity, inflammation, and cellular aging. Key search terms included “diabetes,” “osteoarthritis,” “oxidative stress,” “cytokines,” and “obesity.” Studies focusing on U.S. populations and exploring various molecular pathways were selected. Data were organized in an Excel sheet and analyzed for thematic overlap.

Results: A total of 22 studies were included in the final review. Findings indicate that individuals with DM have a significantly higher risk of developing OA and vice versa. Common mechanisms involve mitochondrial dysfunction, chronic inflammation, and disruptions in lipid metabolism. Pro-inflammatory cytokines such as IL-1β, IL-6, and TNF-α were frequently elevated in both diseases, contributing to joint cartilage degradation and insulin resistance. Obesity exacerbates this cycle by increasing adipokines and placing mechanical stress on weight-bearing joints. Furthermore, oxidative stress and advanced glycation end products (AGEs) were identified as contributors to tissue damage in both DM and OA. There was an imbalance between pro-inflammatory (IL-1β) and anti-inflammatory (IL-10) cytokines noted to be central to the pathology of both conditions.

Conclusion: There is a significant overlap between diabetes and osteoarthritis, both in clinical presentation and pathophysiological mechanisms. Chronic inflammation, mitochondrial dysfunction, and lipid dysregulation are shared pathways that link the two diseases. These findings highlight the need for integrated approaches in treatment and prevention, especially in obese and aging populations. Future research should focus on anti-inflammatory interventions, including IL-1β inhibitors and IL-10 modulation, as potential dual therapies for both OA and diabetes.


The overlap of Diabetes and Osteoarthritis in American Populations

Dysbiosis, an imbalance in gut microbiota, has emerged as a critical factor in the development and progression of neurological disorders. The gut-brain axis (GBA), a bidirectional communication network between the gastrointestinal tract and the central nervous system (CNS), facilitates neural, endocrine, and immune interactions. Dysbiosis disrupts this axis, contributing to increased gut permeability, systemic inflammation, and neuroinflammation—key factors implicated in conditions such as Attention-Deficit Hyperactivity Disorder (ADHD). Recent research highlights the role of specific gut microbiota in modulating neuroinflammatory pathways and neurotransmitter systems, such as serotonin, dopamine, and glutamate. Alterations in microbial composition can exacerbate disease progression by influencing neuronal health and immune responses. Emerging therapeutic strategies targeting gut dysbiosis, including dietary modifications, probiotics, and fecal microbiota transplantation (FMT), show promise in restoring microbiota balance and mitigating neurological symptoms. This review synthesizes current knowledge on the impact of dysbiosis on neurological health, emphasizing the need for personalized interventions and standardized methodologies. By unraveling the mechanisms linking gut microbiota to brain function, we aim to inform therapeutic approaches that harness the gut-brain axis for treating neurological disorders, specifically ADHD.

Gut Dysbiosis and ADHD: Decoding the Microbiota-Gut-Brain Axis in Neurodevelopmental Health

Background: Congenital pulmonary airway malformations (CPAMs) are abnormalities of lung development in the fetus, leading to cyst formation. While initially considered rare (1 in 25,000–35,000 births), recent data from local registries indicate a higher prevalence. CPAMs can lead to complications depending on lesion size and type. The in-utero course is unpredictable, although most lesions resolve, while others enlarge, resulting in adverse outcomes like nonimmune hydrops fetalis. In utero treatment strategies include resection, drainage, shunting, and corticosteroids, though clinical management remains challenging due to the lack of reliable predictive features. Genetic variants, particularly in the RAS/MAPK pathway (e.g., KRAS), are implicated in CPAM lesions in adults, but have not been studied in fetal or neonatal contexts. We hypothesize that underlying pathogenic/likely pathogenic variants contribute to more severe prenatal and neonatal outcomes, thus serving as potential diagnostic biomarkers.
Methods: To test this hypothesis, 30 CPAM samples from the UCSF Pathology Department were sequenced using the UCSF 500 Cancer Gene Panel to identify pathogenic/likely pathogenic (P/LP) variants. Additionally, maternal, fetal, and neonatal records were reviewed for variables including CPAM size, type (e.g. presence of cysts), prenatal course, and neonatal outcomes. The presence of a composite of adverse perinatal outcomes was compared across groups using chi-square.
Results: Samples were stratified into three groups based on the presence and type of variant: CPAM lesions with KRAS variants (N=4), other non-KRAS variants (N=4), and no variants detected by the panel test (N=22). Adverse perinatal outcomes were more common in those with KRAS variants as compared to non-KRAS or no variants, including: nonimmune hydrops in 75%, 0%, and 36%; in utero intervention in 100%; 0%, and 14%; preterm birth in 100%, 0%, and 9%; neonatal symptoms in 100%, 50%, and 41%; NICU admission in 100%, 75%, and 45%; and death in 50%, 25%, and 5%, respectively. An adverse perinatal outcome occurred in 100%, 75%, and 41% (p=0.059). NICU admissions were excluded from this calculation because many infants with CPAM are admitted to the NICU solely for observation, even when asymptomatic.
Conclusion: In this cohort, the presence of a KRAS variant in CPAM cases was associated with a poor prognosis and more adverse prenatal and neonatal outcomes. Further research is needed to clarify the role of genetic variants in CPAM outcomes and whether there is a role for prenatal genetic testing with amniocentesis to predict prognosis and optimize prenatal management.

Genomic Variants and Perinatal Outcomes in Congenital Pulmonary Airway Malformation (CPAMs)

Background
Older adults with cancer are living longer, but there is a lack of research aimed at understanding their experience with cancer including their unique concerns and how they manage symptoms. Self-management strategies (SMS), historically studied in other chronic diseases, are a promising approach for empowering patients with cancer and reducing their symptom burden. Consequently, we conducted a secondary analysis of audio-recorded primary palliative care visits with oncology infusion room nurses to characterize the concerns and self-management strategies of older patients with advanced cancer.

Methods
We conducted a cluster-randomized controlled trial of an oncology nurse-led primary palliative care intervention for patients with advanced solid tumor cancer receiving care at 17 community oncology clinics in Pennsylvania from 2016-2020. All visits were led by oncology infusion room nurses trained to address palliative care needs. Of 672 patients enrolled, 336 were randomized to the intervention arm, of this group, 179 were age 60 or older and the focus of this analysis. Audio-recorded initial study visits (N=179) were transcribed using TranscribeMe, Inc. We conducted a qualitative descriptive content analysis using mixed inductive and deductive methods. All transcripts were reviewed by two coders with disagreements resolved by consensus.

Results
Patients were a mean age of 72+/-8 years, 51% (92/179) female, and primarily white (175/179, 98%), they were most frequently diagnosed with lung cancer (71/179, 40%) followed by gastrointestinal (28/179, 16%) and hepatobiliary cancers (27/179, 15%). Of the 24 patient concerns identified, the most frequent patient concerns were physical in nature with fatigue being the most common (78%, 140/179), followed by pain (54%, 96/179), and loss of appetite (53%, 94/179). Outside of physical symptoms, the most common patient concerns were feelings of anxiety (47%, 84/179), physical functional limitations (45%, 81/179), depressed mood (36%, 65/179), and changes to self-concept (32%, 58/179). Only one patient had no concerns. On average, patients had 5 concerns per visit. Of the 19 SMS identified, patients most frequently used supportive medications (64%, 115/179) followed by relationship with family (62%, 111/179), positive thinking (50%, 90/179), and following a nutrition plan (48%, 86/179). Patients were using or planning to use an average of five SMS. 

Conclusion
More than half of older adults with advanced cancer had physical, emotional, and functional concerns. Older adults are already using a variety of strategies to cope with their advanced cancer. This knowledge can be leveraged in future supportive oncology interventions.

Patient Concerns and Self-Management Strategies Among Older Adults with Advanced Cancer

Stick to the Script: 
Large Language Model (LLM) Performance on the Hinting Task Highlights the Role of Language in Theory of Mind

 Alexander Schemmer, A.B., Ryan Partlan, M.S., Jiefei Li, M.P.S., Amir H Nikzad, M.D., Sunny X. Tang, M.D.

Background / Objective:

Theory of Mind (ToM)—the ability to reason about others’ mental states—is impaired in schizophrenia spectrum disorders (SSD), contributing to poorer social functioning and quality of life. While disorganized speech and pragmatic comprehension deficits characterize schizophrenia, their relationship to ToM deficits remains unclear, limiting targeted interventions.

No current language-based interventions specifically address ToM deficits in schizophrenia. However, two non-clinical domains offer promising models: Konstantin Stanislavski’s "script analysis" in modern acting, which enhances inductive reasoning and subtextual understanding through textual analysis; and Large Language Models (LLMs), which produce contextually relevant responses by modeling deep semantic relationships among words.

This study investigates whether ToM deficits in SSD reflect impaired semantic modeling—difficulty aligning language with underlying intention. To test this, we administered the Hinting Task (Corcoran et al., 1995)—a validated ToM measure using narrative vignettes with indirect speech—to individuals with SSD, healthy controls (HC), and three high-performing LLMs (GPT-4o, Claude, LLaMA). We hypothesized that semantic alignment—measured via cosine similarity between prompt and response embeddings—would predict successful ToM inference in humans and LLMs.

Methods:

Participants included 36 individuals with SSD, 38 HC, and three groups of 30 simulated responses from GPT-4o, Claude, and LLaMA. Each completed the 10-item Hinting Task, scored from 0–2 (maximum total = 20). Semantic alignment was calculated using cosine similarity between sentence embeddings (sentence transformer model embeddings) of each participant’s responses and their corresponding prompts. Group comparisons and accuracy-based differences were analyzed via t-tests.

Results:

LLMs achieved exceptional performance (GPT: 19.6 ± 0.6; Claude: 19.5 ± 0.7), significantly surpassing HC (17.5 ± 2.1) and SSD (13.6 ± 4.3). Cosine similarity mirrored this performance, with pooled LLM responses demonstrating significantly higher semantic alignment than pooled human responses (p < .001, d = 1.56). Within HC and SSD, accurate responses exhibited significantly greater semantic alignment than inaccurate ones (HC: p < .001, d = 0.79; SSD: p < .001, d = 0.58). No significant semantic alignment differences emerged between correct human responses and those generated by GPT or Claude.

Discussion / Conclusion:

Findings support the hypothesis that impaired semantic modeling is closely linked to Theory of Mind deficits in schizophrenia. The association between semantic similarity and ToM accuracy highlights the potential of language-based therapeutic approaches inspired by Stanislavski’s methods and LLM semantic modeling strategies. Future research should explore whether specific training modules targeting semantic comprehension, drawing on these approaches, can effectively enhance ToM abilities and improve social functioning outcomes in individuals with schizophrenia spectrum disorders.

Stick to the Script: Large Language Model (LLM) Performance on the Hinting Task Highlights the Role of Language in Theory of Mind

An Unusual Case of Post-Coital Takotsubo Syndrome in a Female Patient on Venlafaxine 
Takotsubo cardiomyopathy is characterized by new EKG changes of ST elevation, T wave inversions or cardiac troponin elevation; left-ventricular dysfunction and apical-ballooning in the absence of obstructive coronary artery disease; and reversible LV dysfunction. (Mayo Clinic criteria). The syndrome was first recognized in Japan and named Takotsubo, meaning octopus- catching pot. Although precise mechanisms are unclear, takotsubo syndrome is often triggered by sudden or overwhelming physical or emotional stress, with attendant catecholamine excess. Generally, negative stressors have induced stress cardiomyopathy, but there are rare instances of positive experiences also eliciting it. We present a rare case of Takotsubo syndrome in a female, with no prior cardiac history, thirty minutes after sexual intercourse. Temporal association does not prove causality, but our report suggests that Takotsubo may follow either a negative or positive event. Sexual activity is associated with a catecholamine surge of dopamine and noradrenaline. Our patient was on venlafaxine, which may synergistically trigger catecholamine excess alongside sexual intercourse. 
A 47-year-old female with depression on venlafaxine presented with sudden onset of chest tightness after sexual intercourse. On admission, blood pressure was elevated at 170/100, and heart rate elevated at 90- 100’s. An electrocardiogram demonstrated T-wave inversions in V2-5 and a CT angiogram excluded pulmonary embolism. Cardiac troponin levels rose from .099 to .646 to .74 ng/ml. She was suspected of having NSTEMI. She received aspirin, nitroglycerin drip, heparin drip, metoprolol, and atorvastatin. Subsequent cardiac catheterization showed normal coronary arteries. The left ventriculogram demonstrated normal left-ventricular function, apical ballooning, and left-ventricular akinesis. The rest of her hospitalization was uneventful, and she was discharged in good condition on nifedipine and atorvastatin. 
We compiled six total patients with post-coital takotsubo syndrome. All were female, average age of 53.8 years (range 47-61). All presented with chest pain or dyspnea, and one presented in cardiac arrest. One took atomoxetine (selective-norepinephrine-reuptake-inhibitor) for ADHD. Ours is the youngest and had two possible triggers – venlafaxine (serotonin-noradrenaline- reuptake- inhibitor) and sexual intercourse. Her elevated blood pressure and heart rate may reflect sympathetic or catecholamine excess. Venlafaxine has had reported associations with Takotsubo syndrome through a postulated catecholamine excess. Rarer complications of sexual intercourse include cardiocerebral infarction and coronary artery dissection. 
This case reminds the provider to include takotsubo syndrome in the differential of acute coronary syndromes in patients presenting post-coital or who are on venlafaxine. Takotsubo syndrome may follow positive or negative stressors, with an underlying catecholamine basis. 
 
References 
Athanassopoulos P, Y-Hassan S. A case report: 'happy heart' syndrome in a patient treated with atomoxetine for attention deficit hyperactivity disorder. Eur Heart J Case Rep. 2019 Dec;3(4):1- 5. doi: 10.1093/ehjcr/ytz151. Epub 2019 Sep 30.PMID: 31911993; PMCID: PMC6939811. 
Tomcsányi J, Marosi A, Arabadzisz K, Zsoldos A, Bózsik B. Tako-tsubo syndrome associated with sexual intercourse. Int J Cardiol. 2007 Oct 18;121(3):e28-9. doi: 10.1016/j.ijcard.2007.06.131. Epub 2007 Sep 19. PMID: 17884207. 
Recurrent Sexual Intercourse-Associated Takotsubo Cardiomyopathy, Ishak, M. et al. Heart, Lung and Circulation, Volume 32, S174. 
Madias JE. Follow-up of a patient who had suffered a "heart breaking pleasure"-triggered Takotsubo syndrome. Int J Cardiol. 2016 Nov 1;222:1057. doi: 10.1016/j.ijcard.2016.01.067. Epub 2016 Mar 31. PMID: 27038689. 
Mathew B, Villarreal D. Two unusual cases of Takotsubo cardiomyopathy presenting with sudden cardiac death. Am J Med Sci. 2009 Jun;337(6):473-5. doi: 10.1097/MAJ.0b013e3181956f49. PMID: 19390432. 
Liu G, Khalid U, Birnbaum Y, Hamzeh IR. A heartbreaking pleasure. Int J Cardiol. 2016 Feb 1;204:177-8. doi: 10.1016/j.ijcard.2015.11.115. Epub 2015 Nov 19. PMID: 26666345. 
SG, Faulx M, Kapadia SR, Griffin BP, Desai MY. Characteristics and Outcomes of Patients With Takotsubo Syndrome: Incremental Prognostic Value of Baseline Left Ventricular Systolic Function. J Am Heart Assoc. 2020 Aug 18;9(16):e016537. doi: 10.1161/JAHA.120.016537. Epub 2020 Aug 5. PMID: 32755253; PMCID: PMC7660826. 
Pastore C, White M, Henry M, Filler L. Simultaneous Cardiocerebral Infarction Associated with Postcoital Activity. J Emerg Med. 2023 Dec;65(6):e554-e558. doi: 10.1016/j.jemermed.2023.08.008. Epub 2023 Aug 25. PMID: 37852811. 
Möller J, Ahlbom A, Hulting J, Diderichsen F, de Faire U, Reuterwall C, Hallqvist J. Sexual activity as a trigger of myocardial infarction. A case-crossover analysis in the Stockholm Heart Epidemiology Programme (SHEEP). Heart. 2001 Oct;86(4):387-90. doi: 10.1136/heart.86.4.387. PMID: 11559674; PMCID: PMC1729949. 
Finocchiaro G, Westaby J, Behr ER, Papadakis M, Sharma S, Sheppard MN. Association of Sexual Intercourse With Sudden Cardiac Death in Young Individuals in the United Kingdom. JAMA Cardiol. 2022 Mar 1;7(3):358- 359. doi: 10.1001/jamacardio.2021.5532. PMID: 35019956; PMCID: PMC8756354. 
Madias JE. Venlafaxine and takotsubo syndrome: Can we learn more from published patient cases? Int J Cardiol. 2016 Dec 15;225:73-74. doi: 10.1016/j.ijcard.2016.09.133. Epub 2016 Oct 1. PMID: 27716552. 
Woronow D, Suggs C, Levin RL, Diak IL, Kortepeter C. Takotsubo Common Pathways and SNRI Medications. JACC Heart Fail. 2018 Apr;6(4):347-348. doi: 10.1016/j.jchf.2017.12.011. PMID: 29598939. 



An Unusual Case of Post-Coital Takotsubo Syndrome in a Female Patient on Venlafaxine

Background:
Nonalcoholic steatohepatitis (NASH), sarcoidosis, and hypothyroidism are often associated with immune dysregulation and may coexist in complex clinical scenarios. Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory condition affecting multiple organs—including the pancreas, thyroid, and hepatobiliary system—and can mimic malignancy or other autoimmune disorders. Recognizing multisystem IgG4-RD is critical for timely diagnosis and treatment.
Case Presentation:
A 56-year-old female with known NASH, hypothyroidism, and sarcoidosis presented with gastrointestinal discomfort, right shoulder pain, and intolerance to L-ornithine L-aspartate (Microliv Forte). Lab studies revealed elevated liver enzymes, vitamin D deficiency, low folic acid, and prediabetes (HbA1c 6.0%). TSH was elevated, but anti-TPO antibodies were negative. Imaging showed hepatomegaly with fatty infiltration, cholelithiasis, and a 1 cm ill-defined lesion in the pancreatic head/uncinate process with upstream ductal dilatation on MRCP—raising concern for malignancy. EUS revealed two small pancreatic cysts without a discrete mass or lymphadenopathy.
Further workup showed elevated IgG4 (136 mg/dL) and complement C4, with normal CA 19-9 and negative autoantibodies (dsDNA, RF, anti-TPO, celiac serologies). Bone density testing showed osteopenia. In the context of elevated IgG4 and thyroid dysfunction without TPO antibodies, IgG4-related thyroid disease (IgG4-RTD) was considered. The constellation of findings suggests possible systemic IgG4-RD with pancreatic and hepatobiliary involvement.
Discussion:
This case underscores the need to consider IgG4-RD in patients with overlapping metabolic and autoimmune disorders who develop atypical pancreatic or hepatobiliary findings. IgG4-RD can resemble malignancy or other inflammatory conditions, making diagnosis challenging. A combination of serology, imaging, and histopathology is essential. Early recognition is vital, as corticosteroids are highly effective in preventing irreversible organ damage. The MITIGATE trial has shown promising results using B-cell depletion therapies like inebilizumab. Additionally, hypothyroidism has been shown to increase the risk of metabolic-associated steatotic liver disease (MASLD), with a 1.7-fold higher risk independent of other metabolic factors.



Beyond NASH, Sarcoidosis, Hypothyroidism, and Pancreatic Lesions: A Case Highlighting the Overlap Between Autoimmune, Metabolic, and IgG4-Related Pathology


Background
Microscopic polyangiitis (MPA) is a pauci-immune small-vessel vasculitis associated with MPO-ANCA positivity, characterized by necrotizing small-vessel inflammation. Though lung and kidney involvement is most common, systemic symptoms may precede or overshadow the classic features, thereby complicating the diagnostic process. As the incidence is low and symptoms often vague, MPA can mimic infection, malignancy, or other autoimmune conditions. Early identification is key to preventing irreversible organ damage.

Case Presentation
A 48-year-old woman with hypertension, type 2 diabetes mellitus, and a history of post-surgical pulmonary embolism presented to the ED with progressive dyspnea, dry cough, fatigue, subjective fever, abdominal pain and dark urine over three weeks. On presentation, she was febrile (38.5°C) and hypoxic with an oxygen saturation of 93% on room air and bibasilar rhonchi. She was empirically treated with ceftriaxone and azithromycin for community-acquired pneumonia. 
On hospital day 3, she developed submandibular swelling, a facial rash, and exacerbation of a chronic symmetric pruritic, hyperpigmented rash on her dorsal forearms. These findings prompted consideration of autoimmune and systemic inflammatory etiologies. Chest CT revealed multifocal bilateral nodular opacities and a small left pleural effusion. Thoracentesis performed on hospital day 5 showed exudative fluid with lymphocytic predominance and gram-positive cocci on gram stain with no growth on culture. Due to concern for a complicated parapneumonic effusion, ceftriaxone was continued for 14 days. 
Despite fluid resuscitation, her serum creatinine continued increasing (peak 3.2); her abdominal pain and fatigue persisted. Urinalysis revealed nephrotic-range proteinuria and macroscopic hematuria, prompting nephrology consultation for glomerulonephritis workup. Her autoimmune panel displayed a positive direct Coombs test indicating IgG-mediated hemolytic anemia, MPO-ANCA positivity, and weakly positive rheumatoid factor, anti-dsDNA, anti-cardiolipin IgA, and β2-glycoprotein IgA. IV methylprednisolone was initiated, and renal biopsy revealed pauci-immune crescentic glomerulonephritis consistent with microscopic polyangiitis. Rituximab was initiated for induction therapy. The patient demonstrated marked clinical improvement and was weaned off oxygen prior to discharge on hospital day 14. After one month on rituximab and prednisone, her creatinine levels normalized and respiratory symptoms resolved.

Discussion
This case highlights the diagnostic challenges of MPA, particularly when systemic features such as hypoxia, abdominal pain, cutaneous findings, and glandular swelling obscure classic presentations of pulmonary-renal vasculitis. It underscores the importance of maintaining a high index of suspicion for vasculitis in patients with pulmonary infiltrates, rash, and unexplained kidney injury. Prompt and accurate distinction between infectious and autoimmune etiologies is critical to avoid delays in initiating appropriate treatment.


From Cough to Crescents: Microscopic Polyangiitis Uncovered Through Systemic Cues

Background
People with disabilities (PWD) face numerous barriers to equitable healthcare, despite utilizing the healthcare system at three times the rate of people without disabilities. In 2005, the Surgeon General identified the lack of provider training as one major barrier to high-value care for PWD, citing disability awareness education for healthcare providers as a key solution. Nevertheless, a 2017 survey found that only 52% of medical schools provided a disability awareness program, with significantly fewer reporting an experiential component or the incorporation of disability community input. As the disabled population continues to grow, it is increasingly important to implement and evaluate disability curricula for medical trainees to close this gap. 

Methods
A four-week, full-time (118.5 contact hours) elective course for third- and fourth-year medical students was developed by faculty with disabilities at Washington University, in partnership with disability-centered community groups. The course simultaneously aims to: (1) increase knowledge about conceptual frameworks of disability and community support services, (2) enhance skills in accommodating patient needs and adapting clinical assessments, and (3) change attitudes through engagement with PWD sharing their lived experiences. Attitudes and perceived self-competence were assessed via completion of identical pre- and post-intervention surveys consisting of Likert-type items adapted from the validated Medical Student Attitudes toward People with Disabilities (MSA-PWD) instrument, as well as open-ended feedback questions administered at course-end. Knowledge was assessed dichotomously using students’ scores on course assessments.

Results
Across seven cohorts of students enrolled in the course from January 2023 – September 2025, 41 students completed the pre- and post-intervention surveys. Wilcoxon signed-rank tests, conducted to compare mean pre-intervention and post-intervention scores, indicated significant increases in positive attitudes towards PWD, comfort interacting with PWD, and perceived self-competence in caring for PWD (all: W=0, p<0.001), regardless of whether or not students had prior personal or professional experience working with PWD. Exam scores demonstrated that all students achieved competency on course assessments. Qualitative feedback revealed themes focused on attitudinal change and appreciation of experiential coursework and non-clinical interactions with disability communities.

Conclusion
This disability elective represents a novel experiential curriculum that has demonstrated the ability to effectively educate medical students about disability-inclusive health and positively change attitudes toward PWD. Future work will develop and evaluate expanded disability-focused content for undergraduate medical education, with the goal of implementing a longitudinal curriculum to ensure that medical trainees become healthcare professionals who are equipped to provide high-value care to PWD and chronic illnesses.

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