United States


Background
Emphysematous pyelonephritis (EPN) is a life-threatening necrotizing infection of the renal parenchyma and surrounding tissues. It is most commonly seen in patients with uncontrolled diabetes and obstructive uropathy. Rapid diagnosis and timely radiologic intervention are essential to prevent progression to sepsis or death.

Case Presentation
A 67-year-old woman with poorly controlled diabetes and recent history of nephrolithiasis presented to the emergency department with fever, chills, altered mental status, and right flank pain. She was febrile, hypotensive, and tachycardic on arrival. Laboratory studies showed leukocytosis, acute kidney injury, and hyperglycemia. Urinalysis revealed pyuria and bacteriuria.
Initial ultrasound showed a markedly echogenic right kidney with poor corticomedullary differentiation and dirty shadowing, raising concern for gas formation. Non-contrast CT confirmed the diagnosis of emphysematous pyelonephritis, demonstrating parenchymal destruction and extensive gas within the renal collecting system and perinephric space.
Given the patient’s instability and imaging findings, she was admitted to the ICU and started on broad-spectrum IV antibiotics. Urology was consulted, and interventional radiology performed emergent image-guided percutaneous nephrostomy and drainage catheter placement. Cultures grew E. coli. Over the following days, the patient’s hemodynamics improved, and nephrectomy was avoided.

Discussion
This case highlights the importance of early imaging in patients with sepsis and risk factors for EPN, such as diabetes and obstructive uropathy. Although nephrectomy has historically been the treatment of choice, image-guided drainage has emerged as a kidney-sparing alternative, particularly in critically ill patients. Ultrasound can provide initial clues, but CT is the diagnostic gold standard. Multidisciplinary collaboration between critical care, urology, and interventional radiology is essential for optimal outcomes.

AMA Research Challenge 2025 

Emphysematous Pyelonephritis in a Critically Ill Patient: Prompt Diagnosis and Image-Guided Drainage to Avoid Nephrectomy


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Background: Prostate cancer (PC) growth is driven by androgen receptor (AR) signaling, and AR-targeted therapies extend survival in many patients. However, advanced tumors develop resistance to these therapies via various mechanisms like adopting basal-like or stem cell–like (SCL) transcriptional programs, which are less dependent on AR and linked to aggressive, treatment-resistant disease. As 30-40% of PCs are basal-like, identifying underlying mechanisms in which these PCs become basal or SCL is vital for treating aggressive PCs. CREB5, a transcription factor, has been implicated in the progression of breast, colorectal, and prostate cancers. However, while these studies independently point to CREB5 as a key factor of tumor progression, the underlying transcriptional regulatory role of CREB5 in PC remains elusive.

Methods:
We analyzed RNA-sequencing data from 701 patient tumors (n=208, Stand Up To Cancer; n=493, TCGA) to assess correlations between CREB5 expression, AR activity, and basal and SCL gene signatures. In an AR-positive PC cell line (LNCaP), rapid immunoprecipitation mass spectrometry of endogenous protein (RIME) and chromatin immunoprecipitation (ChIP) assays determined CREB5’s protein interactions and its binding to regulatory DNA elements. Functional impact on tumor progression was evaluated by measuring three-dimensional tumorsphere formation in vitro, and assessing tumor growth in mouse xenografts with CREB5 overexpressed in the LNCaP cell line.

Results:
High CREB5 expression inversely correlated with AR signaling and positively correlated with basal-like and SCL transcriptional programs in both primary and castration-resistant PCs. We found that CREB5 protein interacted with AP-1 factors, which have previously been implicated in stem cell features, therapy resistance, and metastasis. CREB5 also bound to regulatory elements of several AP-1 factors,  suggesting a complex mechanistic role in regulating activity of numerous AP-1 genes. Functionally, cells overexpressing CREB5 formed significantly more tumorspheres and produced larger tumors in vivo, demonstrating its association with enhanced stemness and aggressive growth in PC.

Conclusion:
Altogether, this study indicates that CREB5 enhances PC tumor progression through genes that are associated with SCL transcriptional programs. Therefore, CREB5 may act as a pivotal regulator of differentiation in PC. As CREB5 was associated with AP-1 family members, this may be a mechanism of such tumor progression. Altogether, increased CREB5 may lead to specific mechanisms of therapy response, and future therapeutic strategies may consider antagonizing CREB5 interactions with AP-1 complexes to mitigate tumor progression in deadly PCs.

CREB5 Regulates Stem Cell-like Transcriptional Programs to Boost Tumor Formation in Prostate Cancer

Background: Fertility typically returns after kidney transplantation; however, pregnancy in this population remains high-risk. Although most result in live births, rates of fetal complications including preterm birth, low birth weight, fetal growth restriction (FGR), and cesarean delivery are significantly elevated, especially among individuals of advanced maternal age. Pregnant kidney transplant recipients also experience higher rates of preexisting hypertension and pre-eclampsia compared to the general obstetric population. Furthermore, pregnancy following solid organ transplantation may increase the risk of graft dysfunction or rejection due to immunologic complications. Limited data exists on pregnancy outcomes in this group. This study provides a descriptive statistical analysis of a small cohort of women who became pregnant following kidney transplantation.

Methods: Data were collected from 17 women who became pregnant after renal transplantation (5.9% White, 41.2% Black, 47.1% Hispanic, 5.9% Asian). Participants lived in areas with limited neighborhood resources (mean Area Deprivation Index = 75%, SD = 20.8). The average time from transplant to delivery was 8.2 years. Exploratory descriptive statistics and correlation analyses were performed to examine risk factors and outcomes before and after transplant, as well as pre/peri/post pregnancy, in relation to medical and social determinants of health.

Results: Relevant significant positive correlations were found between Body Mass Index (BMI) at the time of transplant and during the first and second trimesters, and serum creatinine levels measured one month before pregnancy, at conception, and at the end of the first trimester. Additionally, longer duration on dialysis prior to transplant was associated with lower neighborhood resource access.

Conclusions: This exploratory study provides insights into a unique sample of women who pursued pregnancy following renal transplant at a large urban public medical center. Findings of this study provide insights into relevant risk factors and considerations for optimizing pregnancy and graft outcomes in this high-risk population.

 Pregnancy Outcomes in Kidney Transplant Recipients at an Urban Academic Medical Center


Background: Fluoroscopy has become essential in orthopedic surgery, particularly with the rise of minimally invasive surgery (MIS) techniques. Despite its advantages, it raises concerns about radiation exposure to both patients and surgical staff. This study evaluated fluoroscopy time and radiation dose associated with open versus MIS bunion correction, comparing the modified Lapidus procedure (open) and the MIS distal transverse osteotomy. Additionally, we compared these procedures to historical controls of common orthopedic surgeries to understand relative exposure risk. It was hypothesized that MIS procedures would be associated with increased radiation exposure and fluoroscopy time however compared to historically controls, both procedures would be significantly less.

Methods: A retrospective review was conducted for patients who underwent a bunion correction between January 2021 and June 2025 by one of two fellowship-trained foot and ankle surgeons at a single academic institution. A total of 294 patients met inclusion criteria. Of these, 258 patients underwent a MIS distal transverse osteotomy and 36 underwent a modified Lapidus procedure. Fluoroscopy time (minutes) and radiation dose (mGy) were compared between groups. Historical controls utilized were intramedullary tibial nailing and distal radius plating.

Results: A mean fluoroscopy time of 2.13±1.27 (range, 0.06-7.05) minutes and radiation dose of 2.02±1.30 (range, 0.05-7.52) mGy was observed in the MIS distal transverse osteotomy cohort. An average fluoroscopy time of 1.63±1.83 (range, 0.08-7.70) minutes and a radiation dose of 1.31±1.43 (range, 0.07-5.98) mGy was observed in the modified Lapidus cohort. There was no significant difference in fluoroscopy time (p=0.123), but the MIS group demonstrated a higher radiation dose (p=0.007). Compared to other orthopedic procedures, the MIS cohort showed significantly lower radiation doses than intramedullary tibial nailing, which requires an average dose of 137.00±111.00 (range, 41.00-378.00) mGy (p=<0.001) and distal radius plating, which requires an average dose of 17.00±10.00 (range, 3.30-26.00) mGy (p=0.007). 

Conclusion: MIS distal transverse osteotomies result in higher radiation exposure than open modified Lapidus procedures, though both remain substantially below levels seen in other orthopedic surgeries. Despite MIS distal transverse osteotomies generating an average radiation dose of 2.02 mGy per case, surgeons receive only 0.50% of the dose; thus, nearly 1,980 procedures would be required to exceed the 20.00 mGy annual occupational limit. Over a 30 year career, performing 50 such cases annually would increase lifetime cancer risk by 0.075%. These findings suggest that concerns about radiation exposure should not deter providers from performing MIS distal transverse osteotomies for bunion correction.

Radiation Exposure and Safety in Minimally Invasive Foot and Ankle Surgery: A Comparative Analysis Between Minimally Invasive and Open Bunion Correction

Optimizing the Value of Knee Injections: Comparative Analysis of Hyaluronic Acid and Corticosteroids 

Background:
In the U.S., approximately half the total population will develop knee osteoarthritis. Among them, nearly 50% of patients pursue intra-articular injections prior to total knee arthroplasty. Despite widespread use, the comparative value between corticosteroids (CS) and high molecular weight hyaluronic acid (HMW-HA) injections remains uncertain. This study evaluates each through cost analysis and prospective patient-reported outcomes. We hypothesize that CS injections will demonstrate superior value compared to HMW-HA. 

Methods:
Patients receiving CS or HMW-HA injections were recruited. Time-driven activity-based costing categorized total costs into direct variable labor (DVL), direct variable supply (DVS), direct fixed (DF), and indirect. Patient-reported outcomes were assessed using PROMIS Pain Interference (PROMIS-PI), PROMIS Physical Function (PROMIS-PF), and KOOS-JR at baseline, 3, and 6 months. Score changes from baseline to 3 months were multiplied by average duration of benefit to estimate quality-adjusted life years (QALYPI, QALYPF, QALYK). Total cost was divided by each QALY to determine Value. Lower cost per QALY indicates greater cost-effectiveness. 



Results:
Twelve patients received CS, 11 received HMW-HA. Average total cost was significantly lower for CS ($124.58) than HMW-HA ($604.19, p < 0.001). DVL costs were similar (CS: $13.41; HMW-HA: $13.06, p = 0.84). DVS costs differed significantly (CS: $10.61; HMW-HA: $367.14, p < 0.001). DF (CS: $33.52; HMW-HA: $74.66, p = 0.09) and indirect costs (CS: $67.04; HMW-HA: $149.32, p = 0.009) were higher for HMW-HA. 

QALYs were not significantly different: QALYPI (CS: 0.60; HMW-HA: 0.59), QALYPF (CS: 1; HMW-HA: 0.36), QALYK (CS: 2.59; HMW-HA: 1.77). 

Value measures favored CS: 
ValuePI: CS $206.21 vs. HMW-HA $1,022.47 
ValuePF: CS $124.58 vs. HMW-HA $1,661.51 
ValueKOOS: CS $48.09 vs. HMW-HA $348.46 

Conclusion:
CS injections were significantly less costly, mainly due to lower supply costs, and showed similar clinical benefit to HMW-HA at 3 months. CS demonstrated greater cost-effectiveness across all PROMs. 

A limitation is short follow-up, though both injections typically provide around 3 months of benefit. Some evidence suggests effects may last longer. Continued follow-up may be valuable. 

These findings highlight the importance of evaluating both outcomes and cost to determine treatment value.

Optimizing the Value of Knee Injections: Comparative Analysis of Hyaluronic Acid and Corticosteroids​

Background: 
Kawasaki Disease (KD) is an acute, self-limited medium vessel vasculitis of unknown etiology that is the leading cause of acquired heart disease in children in developed countries. Kawasaki disease primarily affects infants and young children, primarily those under the age of 5 years old. The odds of recurrences after the fifth year following recurrence are 4%. We present a case of recurrent KD presenting 8 years following the patient's initial diagnosis at 4 months. 
Case Presentation: 
An 8-year-old male patient with a history of Kawasaki Disease at 4 months presented initially to the ED with 6 days of fever, malaise, bilateral conjunctival injection and one day of bilateral joint pain. There was a recent history of mild viral illness among household contacts. On examination, bilateral erythema of the hands and feet were also noted. The patient also presented with bilateral testicles visualized in the superior inguinal canal on ultrasound. Upon admission, crusting of the oral mucosa, bilateral joint effusion, and unilateral cervical lymphadenopathy were also noted. An echocardiogram demonstrated a mildly distended left anterior descending artery. The patient was diagnosed with KD and subsequently treated with aspirin 325 mg four times a day, IVIG, and methylprednisolone 30 mg twice a day. The patient then experienced significant improvement in appetite, appearance, and decreased neck, joint, and eye pain over the next three days. However, the patient was only followed up 17 days later by pediatrics with no cardiology or urology follow-up 6 months after discharge. 
Discussion: 
In patients whose initial KD occurred at a younger age, there is an increased risk of recurrence. Patients less than <6 months and >9 years old are at an increased risk for diagnosis taking over 12 days. While this patient was quickly treated, delayed diagnosis of KD can result in treatment resistance due to the clinical progression of the disease. KD should be considered in the setting of prolonged fever even at extreme ages of presentation. Furthermore, this case highlights the need for cardiac follow-up for patients with recurrent KD, especially in the setting of recurrence where cardiovascular consequences can be devastating. Those who are >6 years of age are at an increased risk for cardiovascular sequelae compared to those <3 years of age. Thus, the suspicion of cardiac complications must remain high after discharge, and adequate follow-up should be established prior to discharge.

A Case of Kawasaki Disease Recurring 8 years later with Cardiac Complications

Dominic Theodore, MS; Nita Bhatt, MD, MPH Department of Psychiatry, Boonshoft School of Medicine, Wright State University
Background
Cochlear implants are widely used to restore hearing in individuals with severe sensorineural hearing loss. However, their placement in individuals with psychotic disorders presents unique challenges. Historically, psychosis was considered a contraindication to cochlear implantation due to concerns about exacerbating hallucinations and delusions. While research suggests that cochlear implants can improve quality of life, there remains a lack of formal guidelines for their use in individuals with schizophrenia or high-risk psychotic disorders. This case highlights the complex interplay between auditory rehabilitation and psychiatric symptomatology.
Case Presentation
A 47-year-old male with schizophrenia and post-traumatic stress disorder (PTSD) was admitted for competency restoration following legal issues related to delusional beliefs and impaired judgment. His psychiatric history included multiple hospitalizations and persistent auditory hallucinations. He had profound hearing loss secondary to childhood encephalitis, with a cochlear implant placed in 2015. Upon admission, the patient exhibited disorganized thoughts, paranoia, and auditory hallucinations directly involving his cochlear implant. He reported experiencing command hallucinations perceived as broadcasts through the device, as well as delusions that it had been modified into a "Neurolink" system to control his thoughts.
During hospitalization, the patient was treated with olanzapine and haloperidol, leading to some improvement in disorganized behavior and hallucinations. However, paranoid delusions related to surveillance and external control persisted. His case underscores the difficulty in distinguishing auditory hallucinations from implant-related perceptual experiences, further complicating treatment and competency restoration efforts.
Discussion
This case highlights the complexities of treating psychosis in individuals with cochlear implants. While hearing restoration can reduce the social isolation that exacerbates psychosis, it may also introduce distressing experiences in patients predisposed to paranoia or delusions. The absence of formal guidelines for screening or managing psychotic symptoms in cochlear implant candidates raises ethical and clinical concerns. Prior research suggests that cochlear implants are not an absolute contraindication in psychosis, yet careful consideration must be given to patient selection and psychiatric stability. Future research and standardized protocols are needed to optimize care for this unique patient population and to balance the benefits of auditory rehabilitation with the risks of exacerbating psychotic symptoms.

Development of Psychotic Symptoms Involving a Cochlear Implant

BACKGROUND Concurrent infective endocarditis (IE) and end-stage liver disease present significant perioperative challenges due to overlapping clinical risks.
CASE SUMMARY A 53-year-old man presented with decompensated cirrhosis and IE characterized by severe aortic regurgitation and vegetation extending into the aortomitral curtain. He underwent a complex, yet successful, simultaneous orthotopic liver transplantation and cardiac surgery, which included double valve replacement and reconstruction of the aortomitral curtain using a patch repair.
DISCUSSION Simultaneous cardiac and liver surgery is rarely performed because of overlapping risks of morbidity. This case illustrates the feasibility and potential benefit of a multidisciplinary, single-stage approach in select high-risk
patients.
TAKE-HOME MESSAGE Concurrent orthotopic liver transplant surgery and double valve replacement with aortic-mitral curtain patch reconstruction for IE can be feasible in very select cases, with successful outcomes hinging on close
multidisciplinary collaborations.

Simultaneous cardiac surgery for infective endocarditis and liver transplantation in end stage liver disease

Background
Gender differences in academic medicine are well established globally, including underrepresentation and decreased scholarly influence among women authors. In ophthalmology, previous research has demonstrated that women publish fewer articles and garner fewer citations than men. Yet, few investigations have specifically investigated gender authorship trends in the highest impact ophthalmology journals, or contrasted these findings with the gender composition of practicing U.S. ophthalmologists. Elucidating these patterns is critical to determining disparities.
Methods
Two leading ophthalmology journals, Ophthalmology and JAMA Ophthalmology, were analyzed for authorship trends. Original research articles published from 2019 to 2023 were reviewed. Authorship order was examined by gender for first, second, and last authors (n=11,801 authors, 1,098 articles). A chi-square test was used to assess gender differences across years. The difference between the percentage of authors and the percentage of physicians in the workforce was calculated using a one-sample proportion test with all percentages acquired from the AAMC US Physician Workforce Data Dashboard. Yearly authorship differences between the years were calculated using analysis of variance, and trends were analyzed with linear regression.
Results
In both journals, significant gender differences were observed in first, second, and last authorship (p<0.001). For Ophthalmology, females comprised 35.82%, 39.21%, and 28.21% of the first, second, and last authors respectively, while in JAMA Ophthalmology, females made up 39.75%, 42.47%, and 33.06% of the same. Compared to the 2022 U.S. ophthalmology workforce, where women comprised 28% of practicing physicians, female authors were 
significantly overrepresented as first and second authors across both journals (p<0.001). No significant yearly authorship differences were found, but there was a downward trend in female second authorship (p=0.04). 
Conclusion
Women continue to be underrepresented in the population of ophthalmologists in the United States. This disparity is apparent in the gender differences observed in two of the leading ophthalmology journals. However, authorship analyses in these journals show that women are overrepresented as first and second authors. Further research is warranted to explore contributing factors such as differences in productivity, mentorship opportunities, or greater pressure to establish scholarly credibility.


Beyond the Lens: Examining Gender Gaps in Ophthalmology Research Authorship

Background
Imposter Phenomenon (IP) is the experience of self-doubt in one’s own abilities and failure to internalize success despite achievements. Originally described by Suzanne Imes and Pauline Rose Clance as they observed successful women in the 1970s, the term has since expanded to all individuals who minimize their achievements and perceive their abilities as frauds. This is a common phenomenon seen in the healthcare field, particularly among medical students, affecting their academic performance and leading to burnout. While there are various factors that contribute to the development of self-undermining behavior, one proposed factor is Adverse Childhood Experiences (ACE), which refers to the negative childhood experiences that can have a lasting impact on a person later in life. While there is much research conducted on ACE and IP separately, there are few studies that link the two subjects, and no study has focused on the population of medical students.

Methods
We conducted a 30-question survey-based study that included demographic questions and validated questionnaires assessing IP and ACE. The ACE questionnaire was developed by the U.S. Centers for Disease Control and Prevention and Kaiser Permanente and the Clance IP questionnaire was created by Clance. The survey was distributed to first- and second-year medical students at Burrell COM. Based on a total population of 391 students, the ideal sample size was calculated to be 78 participants.

Results
We collected a total of 103 surveys. The demographic data showed that the majority of the respondents were between the ages of 20 and 35, identified as Caucasian, and identified as female. The ACE and IP scores were analyzed using the paired t-test. It showed a p-value of < 0.01 and a correlation coefficient (R) value of 0.221.

Conclusion
There is a statistically significant relationship between higher ACE scores and higher Clance IP scores in first- and second-year medical students at Burrell COM, although the positive correlation is weak. This result suggests that the adverse experiences from childhood may influence the psychological well-being of medical students. However, our research was limited due to the small sample size and the use of a single institutional population, limiting the generalizability. Further research needs to be done to identify additional contributing factors to IP. We hope this study can contribute to identifying the roots of medical student burnout and encourage more support for their mental health throughout medical training.

Determining the Correlation Between Adverse Childhood Experiences (ACE) and Imposter Phenomenon (IP) Experienced in Medical Students from Burrell College of Osteopathic Medicine

Background:
Physician involvement in advocacy and health policy is crucial for advancing patient care, population health, and increased access to equitable care. Medical students and trainees often do not receive formal training or accessible resources to learn about the legislative process and to take action. To address this gap, we have created a guide to help medical students and other trainees learn about the legislative process and how to testify at the Rhode Island State House.

Program Description: 
The Rhode Island Health Advocacy and Testimony Guide is a student-made resource created to provide medical students and other medical trainees with a basic understanding of the Rhode Island legislative process. It contains information on how to engage with the State House through written and verbal testimony and how to follow the outcomes of the bills that trainees testify on through time.

Discussion: 
The guide strives to increase student engagement with testimony at the Rhode Island State House, to increase student knowledge about the process of tracking bills as they develop through the Rhode Island legislature, as well as to increase student and trainee confidence with providing written and verbal testimony. This resource will hopefully increase the amount of trainees that testify at the State House as well as to increase discussion of bills being heard and the implications that those bills have on patient care.

Future Directions: 
Future directions of this project include evaluating student confidence in providing testimony, integrating more bill advocacy education into the medical student curriculum, as well as adapting the resource for other medical schools to be able to use as a model.

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