United States

Background
Resident-led code status discussions are common in teaching hospitals, yet trainees often lack formal training to navigate these complex conversations effectively. Prior studies show that patients frequently hold unrealistic expectations about resuscitation and are more likely to opt for a do-not-resuscitate (DNR) status when provided with education that supports informed decision-making. Moreover, DNR orders have been associated with the inappropriate withholding of peri-arrest interventions. This study aims to assess internal medicine (IM) residents’ comfort, self-reported practices, and observations related to code status conversations to identify educational gaps and inform targeted training.
Methods
We designed and administered a survey to all residents in our IM program, collecting demographic information, including training level. Residents rated their comfort and knowledge of code status, resuscitation components, and expected outcomes on a 5-point Likert scale. Additional items addressed the frequency, depth, and barriers to discussions; patient-related factors, documentation practices, observations regarding peri-arrest interventions for DNR patients, and conflicting code statuses.
Results
Of 115 residents, 51 responded; 49% were interns. Over 90% expressed comfort discussing code status, but only 72% felt knowledgeable about the expected outcomes of in-hospital cardiac arrest. Discussions occurred most frequently on hospital (74.4%) and ICU admissions (60.5%), but less often during ICU transfers. Major barriers included limited time and patient anxiety. Only 44% reported consistently documenting their conversations. Although over 90% of residents felt familiar with code status components, fewer than half routinely discussed all interventions in the full code bundle. Patient acuity strongly influenced the level of detail of conversations. Of note, 40% of residents reported that ICU transfer, intubation, or vasopressors were ‘always’ or ‘often’ withheld for DNR patients. Additionally, 65% had encountered conflicting code status orders on multiple occasions.
Conclusion
These findings reveal significant knowledge gaps and inconsistencies in how code status conversations and decisions are approached. While residents are having code status conversations more frequently than documented, there is considerable variation based on the stage of care and interventions discussed. Documentation was lacking, and DNR orders were frequently misinterpreted. Moreover, patients’ requests for incompatible interventions underscore persistent misunderstandings. Targeted education is critical to ensure that residents engage in informed, comprehensive, and patient-centered code status conversations. Improving training in this area will enhance decision-making, align care with both clinical standards and patient values, and ultimately improve patient outcomes.

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Resident Approaches to Code Status Discussions – Perspectives and Practices

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Assessing Mental Health Outcomes After Ketamine Use in Orthopedic Surgery Patients
Edward Arenas1,2, Anthony Albornoz1,2, Tegshjargal Baasansukh1,2, Elizabeth Beyene3, Mekdem Bisrat3, Miriam Michael3,4 
1Howard University College of Medicine, Washington, DC, USA
2Howard University Department of Anesthesiology, Washington, DC, USA
3Department of Internal Medicine, Howard University College of Medicine, Washington, USA
4Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, USA 
Abstract

Background: Ketamine, a dissociative anesthetic with analgesic and neuropsychiatric properties, has shown promise in treating depression and PTSD. While its use in orthopedic surgery is well established for pain control, its potential impact on psychiatric outcomes in the perioperative period remains underexplored.

Objectives: To assess the association between intraoperative ketamine use and postoperative psychiatric outcomes—specifically depressive episodes, PTSD, and opioid-related disorders—among pediatric, adult, and elderly orthopedic surgery patients.

Methods: A retrospective cohort study was conducted using the TriNetX US Collaborative Network database. Patients undergoing orthopedic surgery between June 4, 2002, and June 4, 2022, were stratified into pediatric (≤18 years), adult (18–60 years), and elderly (≥60 years) cohorts. Patients were grouped based on intraoperative ketamine exposure and matched 1:1 using propensity scores for age, sex, race, and ethnicity. Psychiatric outcomes were assessed at 3 and 6 months postoperatively, focusing on depressive episodes, PTSD, opioid-related disorders, and other mental health conditions. Risk ratios (RR), odds ratios (OR), and risk differences (RD) were calculated, with p-values <0.05 considered statistically significant.

Results: A total of 45,732 patients were analyzed across all age groups. Ketamine exposure was significantly associated with reduced incidence of depressive episodes and PTSD in all cohorts at both 3 and 6 months. Opioid-related disorders were also significantly reduced at 6 months among adult and elderly patients. No significant increases in psychosis, substance use, or sleep disorders were observed in ketamine-exposed patients.

Conclusion: Intraoperative ketamine use during orthopedic surgery was associated with improved psychiatric outcomes, including reduced depression, PTSD, and opioid-related disorders across age groups, with no evidence of increased psychiatric morbidity. These findings support ketamine’s potential role as a perioperative adjunct to optimize both physical and mental health recovery following orthopedic procedures.

Assessing Mental Health Outcomes After Ketamine Use in Orthopedic Surgery Patients

Background: Female reproductive aging remains a significant challenge in reproductive medicine and is characterized by a decline in oocyte quantity and quality, as well as uterine and cervical dysfunction, all of which contribute to infertility, pregnancy complications, and congenital defects. As maternal age continues to rise worldwide, there is a pressing need to prevent age-associated infertility and pregnancy complications. The molecular mechanisms underlying female reproductive aging are complex and not yet fully understood. We have recently demonstrated that the Spag17 gene is a key regulator of female reproductive aging. To better understand its mechanism of action, the objective of this research was to investigate the effects of Spag17 loss of function in stromal cells from cervical tissue at the molecular level.

Methods: Stromal cells and cervical tissue were isolated from wild-type and Spag17 knockout mice and used to assess the activation of molecules involved in profibrotic, inflammatory, and senescence signaling pathways by immunofluorescence and immunohistochemistry. Image analysis was conducted using Zen 10 and ImageJ software. Statistical analysis was performed using GraphPad Prism 10.

Results: Profibrotic signaling markers such as SMAD2/3 for the TGF-β pathway, YAP1 for the Hippo pathway, procollagen as a marker of collagen synthesis, and ASMA as a myofibroblast marker, were found constitutively activated in knockout cells. Additionally, a higher number of infiltrating immune cells (CD45⁺ and F4/80⁺) were observed in knockout cervical samples. Activation of these molecules led to the nuclear translocation and activation of the senescence-associated proteins P16, P21, and P53, as evidenced by increased nuclear-to-cytoplasmic ratios.

Conclusions: Our results reveal that Spag17 influences female reproductive aging by regulating the activation of profibrotic, inflammatory, and senescence-related molecular signaling pathways.

Female reproductive aging is associated with loss of Spag17 gene function

Objective: Tears of the gluteus medius tendon are a well-recognized cause of lateral hip pain and gait dysfunction, especially in older adults. Although surgical repair has demonstrated favorable clinical outcomes, persistent challenges such as gap formation, suture pull through, and inadequate healing continue to contribute to repair failure. BioBrace is a bioinductive scaffold composed of collagen and PLLA microfilaments designed to provide early mechanical support while facilitating tissue regeneration. This study aims to biomechanically evaluate the effectiveness of BioBrace augmentation in gluteus medius tendon repair using a cadaveric model.
Methods: Twelve fresh-frozen human cadaveric hips from six matched pairs will be used in this controlled biomechanical study. Specimens will be randomized to receive either standard double-row suture anchor repair or BioBrace-augmented repair. All constructs will utilize ConMed Revo anchors and Hi-Fi sutures in a standardized suture bridge configuration. In the augmentation group, a 40 × 60 × 3 mm BioBrace
scaffold will be secured medially and laterally within the construct. Biomechanical testing will consist of cyclic tensile loading (10–125 N for 150 cycles) followed by load-to-failure testing using a servohydraulic testing system. Outcome measures will include gap formation, ultimate failure load, linear stiffness, and failure mode. Statistical analysis will be performed using paired t-tests or Wilcoxon signed-rank tests based on data distribution.
Results: While results are currently pending, this study has secured $50,000 in funding and testing is actively underway. Based on prior biomechanical research in rotator cuff repair, we hypothesize that BioBrace augmentation will result in reduced gap formation, higher ultimate load to failure, and increased construct stiffness when compared to non-augmented repairs. The collagen matrix and PLLA
reinforcement of the scaffold are designed to both distribute force and provide early mechanical strength, which may reduce the incidence of suture pull through, a common failure mode in tendon repair. Using a matched-pair design will help minimize inter-specimen variability, strengthening the internal validity of our biomechanical comparisons. If the hypotheses are confirmed, this study will offer
the first cadaveric biomechanical evidence supporting the use of BioBrace in gluteus medius repairs. These data may justify future translational or clinical studies and support incorporation of biologic scaffolds in technically demanding abductor tendon reconstructions.
Conclusion: This study represents a critical step in evaluating the mechanical benefits of BioBrace augmentation for gluteus medius tendon repair. With dedicated funding and testing in progress, we anticipate our results will support the integration of bioinductive scaffolds into the surgical armamentarium for managing complex abductor tendon tears.

Biomechanical Evaluation of BioBrace Augmentation in Gluteus Medius Tendon Repair: A Cadaveric Study

Background
Acanthamoeba keratitis (AK) is a rare but serious eye infection caused by the opportunistic protozoan pathogen Acanthamoeba castellanii. AK can also lead to disseminated disease and encephalopathy in immunocompromised individuals. First-line treatment is has a prolonged schedule, due to weak antiamoebal medicines and limited therapeutic options; and sometimes, even with pharmacological intervention, surgery may be needed and patients can still lose their sight. New effective treatments are needed. Protein kinases make up a significant portion of the A. castellanii proteome, suggesting that protein kinase inhibitors (PKIs), already developed for other indications like cancer and autoimmune diseases, may be viable for repurposing if selective against pathogen targets.
Methods
PKIs were obtained from AOBIOUS (Gloucester, MA) and reconstituted in DMSO. These compounds were screened in vitro against A. castellanii (Neff strain, ATCC 30100) cultured in YPG media in 96-well plates. Trophocidal activity was quantified using a Resazurin fluorescence. Protein alignments were performed via UniProt to assess sequence identity between known human tyrosine kinases and putative kinases in A. castellanii.
Results
Initial screening at 20 μM revealed multiple PKIs with inhibitory activity against A. castellanii trophozoites. Dose-response curves demonstrated micromolar EC50 values for compounds TUN-00048 and TUN-00055. Sequence alignment showed approximately 27% identity between two putative A. castellanii tyrosine kinases and the human Abl1/Abl2 kinases, the known targets of the active PKIs.
Conclusion
These preliminary findings support the potential utility of repurposing PKIs as therapeutic agents against AK. Continuing studies will expand the compound library and will clone and express A. castellanii tyrosine kinases for detailed structure-activity relationship and profiling for selectivity for amoebal kinases over patient kinases. Such work could lay the foundation for novel, targeted therapies for this difficult-to-treat infection.

PKIdnapped: Hijacking Cancer Drugs to Fight Acanthamoeba

Background
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is an adult-onset disorder caused by somatic mutations in the UBA1 gene. It primarily affects older men and is characterized by systemic inflammation and hematologic abnormalities. Despite growing interest in VEXAS, the literature remains limited to case reports and small series, with no comprehensive synthesis of U.S. cases to date. This scoping review addresses this gap by describing the clinical features, diagnostic pathways, treatment outcomes, and management strategies in U.S. patients, offering key insights for clinicians.

Methods
We searched PubMed, Web of Science, and CINAHL through April 2025 to identify case reports and series of U.S. patients diagnosed with VEXAS syndrome. Articles were eligible if they reported a UBA1 mutation consistent with VEXAS syndrome and included sufficient clinical detail for data extraction. Non-U.S. cases, reviews, commentaries, and abstracts without full reports were excluded.

Results
Of 194 citations screened, 105 underwent full-text review, and 31 articles met inclusion criteria, describing 43 unique male patients. The median reported age at diagnosis was 66 years. The p.Met41Leu variant was identified in 25/43 patients (58%), making it the most common UBA1 mutation. Macrocytic anemia was reported in 41/43 patients (95%), and bone marrow vacuolization in all cases. Cutaneous findings were noted in 38/43 patients (88%), including Sweet syndrome or neutrophilic dermatoses in 18/43 (42%) and histiocytoid variants in 5 cases. These were often misclassified as lupus or vasculitis, causing diagnostic delays of 1-3 years. Other features included fever, chondritis, and inflammatory arthritis. Myelodysplastic syndrome was diagnosed in about half of patients. All patients were treated with corticosteroids, and among the 31 with tapering data, 24/31 (77%) experienced symptom flares when prednisone was reduced below 20-30 mg daily. Immunosuppressants and biologics showed limited benefit.

Conclusions
U.S. cases of VEXAS syndrome consistently reveal a pattern of relapsing inflammation, diagnostic delays, and prolonged corticosteroid use, underscoring the need for more effective treatments and earlier diagnosis. Most steroid-sparing agents provided limited benefit, though some targeted therapies showed improvement in selected patients. Earlier recognition may be supported by awareness of hallmark features like cutaneous inflammation, macrocytic anemia, and cytopenias in older males, leading to timely diagnoses and better outcomes. Genetic testing for UBA1 mutations should be considered for early diagnosis and to guide targeted therapies.

Clinical Characteristics and Reported Cases of VEXAS Syndrome in the United States: A Scoping Review

Empowering Diabetics Through Structured Blood Glucose Logging: A Community-Based Quality Improvement Initiative
Background
Diabetes affects over 537 million adults globally, with projections rising to 783 million by 2045. In underserved communities like East Trenton, glycemic control remains a major challenge due to low health literacy, limited access to glucometers, and lack of patient engagement. Many patients on insulin or sulfonylureas are not routinely tracking blood glucose levels, leading to delayed therapeutic adjustments and increased risk of complications.

Objective
To increase the proportion of diabetic patients on hypoglycemic agents (insulin or sulfonylureas) maintaining structured blood glucose logs from a baseline of 25–30% in August 2023 to at least 75% by May 2024.

Methods
This resident-led QI initiative was conducted at East Trenton Clinic from August 2023 to May 2024. Patients on insulin or sulfonylureas were identified and educated on the frequency and timing of glucose monitoring based on ADA guidelines. A standardized logbook template was distributed. During follow-up visits, providers reviewed logs, reinforced lifestyle counseling, and made timely medication adjustments. Focused walk-in visits were also arranged for patients with poor glycemic control. Barriers such as cost, literacy, and documentation format were addressed iteratively.

Results
By May 2024, over 75% of target patients had begun maintaining structured glucose logs. Patient engagement improved, with many reporting increased understanding of their disease and actively participating in their care. Clinic teams were able to identify trends earlier, allowing for prompt medication changes. Despite improvements, challenges included financial constraints, literacy issues, and time limitations during routine visits.

Conclusions
This QI initiative demonstrated that structured glucose logging can significantly improve patient engagement and glycemic monitoring in underserved populations. Empowering patients with the tools and education to manage their diabetes fosters more timely clinical decision-making. Future efforts will focus on integrating log templates into the EHR, expanding focused diabetes visits, and tracking corresponding improvements in HbA1c.


Empowering Diabetics Through Structured Blood Glucose Logging: A Community-Based Quality Improvement Initiative

Abstract Title: 
Avoiding the scalpel: Implementation of radiologic and clinical markers to reduce the need for biopsy in tumefactive MS

Background:
Tumefactive multiple sclerosis (TMS) is a rare subtype of MS characterized by large (>2 cm) demyelinating lesions that often mimic brain tumors or abscesses. Symptoms can range from visual changes, aphasia, cognitive changes, paresthesia, incontinence, etc—often raising concern for malignancy, stroke, or infection.
TMS affects approximately 1–3 per 1,000 MS cases, typically in young adults aged 20–40. Lesions are often enhancing, edematous, and radiographically similar to lymphoma, glioma, or abscess, frequently leading to brain-biopsy for diagnosis. However, emerging literature highlights distinct imaging and clinical patterns that may allow for confident, noninvasive diagnosis—potentially avoiding unnecessary procedures and reducing patient risk.

Methods:
This study retrospectively reviewed four patients (2018–2025) who presented to a metropolitan emergency department, were ultimately diagnosed with TMS, and are now followed at the same MS specialty clinic. For each case the presenting symptoms, early diagnostic impressions, MRI findings (lesion size, enhancement pattern, ring-like features, mass effect, midline shift, diffusion restriction), CSF results (glucose, cytology, oligoclonal bands), response to corticosteroids, and the input of a multidisciplinary tumor board were all compared to investigate possible patterns.

Results:
Presenting symptoms included visual field deficits, aphasia, dysarthria, cognitive decline, loss of motor control, rapid-onset-weakness, and hemiparesis. All four patients were initially suspected of neoplasm (specifically low-grade-glioma). One patient underwent open craniotomy/biopsy after imaging revealed an incompletely enhancing lesion with moderate vasogenic edema, mild mass effect, notable midline shift, and CSF studies were negative for oligoclonal bands. However, this patient returned to the ED following discharge with worsening headaches; subsequent imaging demonstrated lesion expansion and increased edema.

Of the remaining three patients, two were scheduled for biopsy but deferred following tumor board reassessment. The fourth was diagnosed with TD relatively quickly compared to other cohort members. Shared features among these non-biopsied patients included open/incomplete ring enhancement without necrosis, minimal or no mass effect or midline shift, presence of oligoclonal bands, and clinical/radiographic improvement with corticosteroids.
All four patients have since stabilized or improved on immunotherapy

.Conclusion:
While brain-biopsy remains necessary in select cases, specific imaging and CSF features—alongside steroid responsiveness—may support noninvasive diagnosis of tumefactive demyelination. In this cohort, pattern recognition enabled safe avoidance of biopsy in most cases. These findings may inform evolving diagnostic strategies in neurology and neuro-surgery/oncology, improving care for patients with atypical demyelinating lesions.

Avoiding the scalpel: Implementation of radiologic and clinical markers to reduce the need for biopsy in tumefactive MS

Background: The rise of ChatGPT and similar large language models (LLMs) transformed how medical and dental students accessed information and engaged in learning. This technological shift presented a challenge for educators, necessitating curriculum and policy adjustments. While existing literature has focused on how educators should integrate artificial intelligence tools into curricula, less attention has been placed on the perspectives and actual practices of students themselves. This study aimed to bridge that gap by investigating the usage of and attitudes towards LLMs, centering primarily on OpenAI’s GPT, among medical and dental students at a US allopathic medical school, thereby informing more effective educational strategies.
Methods: A cross-sectional survey was distributed via email to all medical and dental students at a single university, with responses collected through Qualtrics. The survey included multiple-choice, Likert scale, and free-text questions, and remained open for two months. Quantitative data were analyzed descriptively, and inductive thematic analysis was performed on free-text responses.
Results: A total of 160 students completed the survey. Of these, 88% reported using large language models, with 89% preferring OpenAI’s free version of ChatGPT. Overall, 73% of students used these models to supplement their medical/dental education or research. Common uses included quick information retrieval (82%), assistance with school assignments (56%), tutoring (30%), and research assistance/literature reviews (26%). Most students (81%) felt that integrating AI technologies is necessary to keep pace with medical advances but emphasized the need for proper training on the use of artificial intelligence. Thematic analysis revealed a strong student preference for open discussions that promote LLMs as beneficial tools when used appropriately, rather than restrictive bans or negative framings, which some felt could foster irresponsible or covert use. Concerning usage patterns were also identified: 16% of respondents reported not fact-checking LLM-generated information, and most students indicated they do not cite AI tools as sources.
Conclusion: Medical and dental students have integrated ChatGPT and similar large language models into their education. Their widespread adoption, driven by perceived usefulness and efficiency, underscores a critical need for structured educational interventions. The usage patterns identified, including inconsistent fact-checking and lack of citation, highlight significant risks to academic integrity and patient safety as students transition into clinical roles. Students believe educators must develop and implement curricula focused on responsible and effective AI usage, advocating for transparent guidance that embraces AI’s potential rather than discouraging its use. Equipping future clinicians with tools and knowledge will be essential for navigating AI responsibly in both academics and clinical practice.

Navigating the Artificial Intelligence Era: Student Perspectives and Usage Patterns of Large Language Models in Medical and Dental Education

Background: Frailty, a state of reduced physiological reserve, is associated with mortality, morbidity, and poor quality of life in older cancer survivors. Understanding disparities in longitudinal frailty transitions is essential to identify subgroups in need of interventions. We described disparities in one-year frailty phenotype transitions among older cancer survivors by socioeconomic status (SES), hypothesizing that those with less education and lower wealth would experience worse frailty outcomes than their counterparts.
Methods: We conducted a cohort study using rounds 1-9 (2011-19) of the National Health and Aging Trends Study (NHATS), a nationally-representative cohort of older Medicare beneficiaries. We included 1303 older adults (≥65 years) with a self-reported cancer history in round 1. SES was measured by educational attainment (≥high school [HS] diploma vs. <HS) and wealth quartiles (financial assets minus debts). Frailty was assessed using the frailty phenotype, based on five indicators: shrinking, weakness, exhaustion, slowness, and low physical activity. Participants with 0 indicators were classified as robust, those with 1-2 as prefrail, and those with 3-5 as frail. Pooling nine years of data, we estimated one-year transitional probabilities across the frailty phenotype states and death using multistate Markov models stratified by education and wealth. Models adjusted for age, gender, race, and ethnicity and accounted for the NHATS survey design using survey sampling weights.
Results: Median wealth was $95,800 (IQR: $3,750, $339,250) and 75% had a HS diploma. Survivors without a HS diploma were less likely to remain robust (42% vs. 58%), more likely to stay frail (48% vs. 37%), and more likely to transition to poorer frailty states (e.g. robust to prefrail, robust to frail, robust to death, and prefrail to frail) after one year than those with a HS diploma. Survivors in lower wealth quartiles were less likely to remain robust than those in the highest quartile (Q1: 50%, Q2: 52%, Q3: 54%, Q4: 63%) and were more likely to transition to poorer frailty states.
Conclusion: Cancer survivors with lower SES measured by education and wealth experienced poorer frailty transitions than their counterparts. Disentangling the mechanisms behind these disparities is crucial for developing interventions to improve frailty outcomes in this population.

Socioeconomic Disparities in Frailty State Transitions Among Older Cancer Survivors

Background: 
Anaplasma phagocytophilum causes human granulocytic anaplasmosis (HGA). It spreads by tick bites, much like several other tick-borne diseases. Like ehrlichiosis and Lyme disease, anaplasmosis can cause nonspecific flu-like symptoms like fever, headache, myalgia, and leukopenia. However, HGA causes rash in only 6–10% of cases, less than Lyme disease and ehrlichiosis. Vasculitic presentations are exceedingly rare and are more common in equine granulocytic anaplasmosis (EGA) than in HGA. We report HGA in an elderly woman who presented with a petechial rash, proteinuria, and evidence of systemic inflammation, which initially mimicked vasculitis and posed a diagnostic challenge.

Case Presentation:
A 73-year-old woman with hypertension and hyperlipidemia presented with generalized weakness, fatigue, and a diffuse, flattened, circular rash involving the torso and extremities, sparing the palms and soles, for one week, and fever for one day. She reported a tick bite sustained approximately one month prior while gardening. She sustained a fall due to weakness and loss of balance and was brought to the emergency department. On admission, she was febrile (100.8°F), had bilateral lower extremity edema and a diffuse rash. Laboratory evaluation revealed significant thrombocytopenia (platelets 26 K/μL), leukopenia (WBC 3.4 K/μL), hyponatremia (Na 125 mmol/L), elevated AST (110 U/L), and hypoalbuminemia (2.6 g/dL). A urinalysis showed proteinuria (UPCR 1.22). Nephrology was consulted since vasculitis was suspected. Serologic workup showed positive ANA, elevated CRP (14.4 mg/L), RF (49 IU/mL), and elevated IgA (469 mg/dL), but ANCA panels were negative. A punch biopsy was obtained. IV steroids were initiated due to worsening cytopenias, resulting in rapid hematologic improvement. PCR testing confirmed Anaplasma phagocytophilum infection, establishing the diagnosis of HGA. Other tick-borne infections and viral panels were negative, even though EBV IgM and IgG were elevated. The patient’s rash was later suspected to represent a secondary immune-mediated vasculitic response to Anaplasma infection. She improved clinically with doxycycline and adjunctive corticosteroids. Outpatient follow-up was arranged.

Discussion:
This case highlights the diagnostic challenges posed by Anaplasma phagocytophilum infection, particularly when initial findings mimic autoimmune disease. The combination of cytopenias, rash, positive ANA, and proteinuria initially pointed toward systemic vasculitis. However, confirmation of Anaplasma phagocytophilum by PCR and rapid improvement with doxycycline and steroids supported an infectious etiology with a secondary immune-mediated component. To avoid delays in initiation of appropriate treatment, clinicians should maintain high suspicion for tick-borne diseases, even in the presence of autoimmune markers.


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