United States

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




AMA Research Challenge 2025 

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


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

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

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

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


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

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


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

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


Cracking the ABCG8 Code: The Mystery of Hemolytic Anemia

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

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

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

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

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

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

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

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

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

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

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

Stroke by the Book, Dissection in the Shadows: A Case of TNK in a Silent Type A Aortic Catastrophe

Background
Neuropsychiatric systemic lupus erythematosus (NPSLE)—also known as lupus cerebritis—is a severe manifestation of systemic lupus erythematosus (SLE) that affects the central nervous system. Its clinical spectrum ranges from mild symptoms, such as headache and cognitive dysfunction, to severe complications like seizures, psychosis, and stroke. Reported prevalence varies widely (37%–95%) depending on diagnostic criteria. This case report describes a rare instance of NPSLE complicated by supra-refractory status epilepticus (SRSE), successfully treated with complete remission—an outcome rarely reported.
Major central nervous system involvement in SLE is associated with significantly higher mortality, particularly in cases of treatment-resistant seizures such as SRSE. SRSE carries a mortality rate approximately four times that of standard status epilepticus, and when compounded by NPSLE, overall mortality may exceed 50%.¹ ² Given these risks, maintaining a high index of clinical suspicion and initiating early, targeted therapy—after excluding non-SLE causes—is critical.

Case Presentation
A 23-year-old woman with SLE complicated by class V lupus nephritis on dialysis and an unclear treatment history presented with status epilepticus and hypertensive emergency. Infectious and other non-SLE causes were swiftly ruled out. Prompt brain MRI revealed high signal intensity in the parietal and frontal lobe gyri and subcortical white matter of the bilateral cerebellum, consistent with NPSLE. Her clinical course was further complicated by SRSE, significantly increasing the risk of mortality.
Aggressive disease-specific treatment was initiated given the high associated mortality. This included high-dose corticosteroids, mycophenolate mofetil, plasma exchange, and multiple antiepileptic drugs. The patient gradually improved and ultimately achieved complete remission. She was discharged seizure-free and without neurological deficits.

Discussion
This case illustrates a rare but treatable presentation of NPSLE-induced SRSE. Early recognition and prompt multimodal intervention were key to the favorable outcome. Burst suppression with antiepileptic therapy controlled SRSE, while prompt immunosuppression and plasma exchange dampened B-cell activation and inflammatory cytokines such as interleukin-6. This case underscores the importance of early diagnosis due to a high index of suspicion, exclusion of alternative causes, and immediate initiation of immunosuppressive therapy to improve survival and outcomes in life-threatening NPSLE.

Neuroimmunologic Thunderstorm: Super-Refractory Status Epilepticus in Neuropsychiatric Systemic Lupus Erythematosus

Abstract Title: 
Why aren’t Women Choosing Orthopaedic Surgery? Barriers to Gender Diversity in Orthopaedics as Perceived by Current U.S Medical Students

Background:
Orthopaedic surgical residencies are among the least gender diverse, trailing behind other surgical specialties with only 15% of trainees identifying as female, compared to urology (25%), neurosurgery (18%), and otolaryngology (36%). While research detailing the extent of the gender gap in orthopaedic surgery exists, there is a lack of diversity in representation from allopathic, osteopathic, and LGBTQ+ students regarding barriers experienced during specialty consideration. Our goal was to investigate their perceived barriers. 

Methods:
An anonymous 27-question RedCap survey was distributed by 81 U.S. medical schools (20 osteopathic, 61 allopathic). This assessed students’ perceptions of factors like patient care, practice duties, training, and life outside of medicine. Anecdotal experiences were welcomed with open text boxes. 

Results:
245 total responses were collected. 177 (69%) self-identified as female, 69 (27%) as male, 5 (2%) as non-binary, and 2 (<1%) chose not to disclose. Orthopaedics was the top choice for 24% (60/254) of students, 26% (65/254) were previously interested, and 37% (95/254) were never interested. More females considered ‘physical strength required’ and ‘culture of specialty’ as negative aspects of orthopaedic surgery, while more males identified both as positive. Open responses cited access to research and mentorship as a barrier for 18% (23/130) of which 69% (16/23) were female. 

Conclusion:
Our results highlight the persistent diversity gap within orthopaedics, despite evidence that students identifying as male and female are both equally concerned about the toll a career in orthopaedics could have on their future family planning. This study additionally revealed specific barriers that diverse medical students face influencing their career plans – most notably access to research and mentorship. Furthermore, these data suggest that orthopaedics as a field is no longer the limiting factor, and instead diverse medical students are self-selecting away from the field based on their perceived barriers elucidated above. We recommend more expansive and inclusive efforts to further narrow the gender and diversity gap within the field – specifically by improving access to shadowing and mentorship for students in their preclinical training. 


Why Aren’t Women Choosing Orthopaedic Surgery? Barriers to Gender Diversity in Orthopaedics as Perceived by Current US Medical Students

Objectives: The rise in popularity of electronic cigarettes (e-cigarettes) among U.S. adolescents in the past decade is cause for concern due to the device’s novelty and potential long-term health effects. In response to the concerns, a federal Tobacco 21 law (T21) was passed to raise the minimum age for purchasing tobacco products and e-cigarettes from 18 to 21. This study aims to determine the effectiveness of this federal legislation in reducing e-cigarette usage rates among middle and high school students.

Methods: This study utilized data from both the 2019 and 2020 National Youth Tobacco Survey (NYTS) to examine changes in vaping among 54,575,023 middle and high school students after passage of the federal T21. Odds ratios and logistic regression models were used to assess the association between vaping prevalence rates and the policy change while controlling for perceived harm and addictiveness of e-cigarettes. 

Results: Following the implementation of the federal T21 in December 2019, adolescents were significantly less likely to use e-cigarettes, with the odds of current use reduced by 29% (OR=0.71, with CI [0.58-0.86] and p-value=.001). During the same period, there was an increase in both perceived harm and addictiveness from 71% to 79% and 61% to 66%, respectively. Perceived harm was associated with lower e-cigarette use (OR=0.27 with CI [.25 to .30] and p-value <.0001) whereas perceived addictiveness had a positive association with use (OR=1.12 with CI [1.01 to 1.24] and p-value= .033). 

Conclusions: Federal legislation such as increasing the minimum age of sale of tobacco and nicotine products is an effective strategy in reducing and preventing tobacco and e-cigarette use among adolescents. 


Evaluating the Impact of the Federal Tobacco 21 Legislation on Adolescent E-Cigarette Use and Risk Perceptions 

The global rise in obesity has led to a parallel increase in type 2 diabetes mellitus (T2DM), a chronic disease with significant morbidity and economic burden. While bariatric surgery is widely accepted as an effective treatment for obesity and established T2DM, its potential role as a preventive intervention in high-risk obese individuals remains underexplored. Emerging evidence suggests that early metabolic surgery, particularly in prediabetic patients, may significantly reduce the progression to T2DM by improving insulin sensitivity, enhancing beta-cell function, and promoting long-term glycemic stability. This project aims to explore the preventative benefits of early bariatric surgery through a comprehensive review of current literature. Articles from Embase and Pubmed spanning from early 2015 to the most recent clinical trials were collected following a systematic approach using the Prisma Protocol guidelines. Different modalities of bariatric surgery and how the procedure affected patients’ metabolic comorbidities were reviewed. By compiling and analyzing available data, this project seeks to determine whether earlier surgical intervention offers meaningful benefits in reducing T2DM risk. Bariatric surgery can be effective in managing and even reversing T2DM; however, the optimal timing of surgery for maximum preventive benefit is still under investigation. It was concluded that bariatric surgery significantly increased life expectancy in patients with T2DM compared with patients who managed their T2DM with pharmacologic agents alone. There is strong evidence of its benefits even when T2DM is already well established. By shifting the focus from treatment to prevention, this research highlights the clinical and public health value of earlier surgical referral for obese patients at high risk for T2DM.

Early Bariatric Surgery in the Prevention of Type 2 Diabetes Mellitus in Obese Individuals

Background
The increasing convenience of access to online information may lead to patient consumption of incomplete or misleading information about ocular problems. The purpose of this study is to evaluate the quality and accuracy of videos on glaucoma treatment options.
Methods
A search of “glaucoma” and “eye pressure” combined with “treatment” or “cure” was performed for Facebook (FB) and YouTube (YT) videos. YT videos with at least 25,000 views and 25 views per day and top FB videos with at least 1,000 views were included. Videos were evaluated using a modified Currency, Relevance, Authority, Accuracy, and Criteria (CRAAP) metric.
Results
74 YT and 19 FB videos were included. Of the YT videos, 74% defined glaucoma, 65% discussed untreated disease course, 64% stated treatment goals, 84% described treatment options, 17% discussed treatment risks, and 15% contained misinformation. Of the FB videos, 66% defined glaucoma, 47% discussed untreated disease course, 34% stated treatment goals, 68% described treatment options, 0% discussed treatment risks, and 18% contained misinformation. Higher accuracy and increased quantity was seen for educational videos containing “glaucoma treatment” on both platforms.
Conclusion
Commonly utilized YT and FB videos may lack important information and/or promote misinformation.


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

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