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  Beyond IVIG: Diagnostic Reclassification and Rituximab Response in Relapsing CIDP

  Samah Abdalla and Anacleto Diaz

  Publication Date: 5-8-2026

  Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated neuropathy with a wide range of clinical presentations. Early disease may resemble other acquired neuropathies, leading to diagnostic uncertainty. We describe a case of relapsing, treatment-refractory CIDP that initially presented as a painful lumbosacral syndrome and later demonstrated sustained clinical improvement with B-cell-directed therapy.

  A 69-year-old man with a history of type 2 diabetes mellitus presented with severe unilateral lumbosacral and buttock pain followed by progressive proximal leg weakness and weight loss, without clear sensory deficits or muscle atrophy. MRI of the brain and lumbar spine revealed no acute abnormalities, cauda equina pathology, or structural etiology to explain his symptoms, aside from stable multilevel degenerative changes. Electrodiagnostic testing showed a predominantly axonal polyradiculoneuropathy with limited demyelinating features. Cerebrospinal fluid (CSF) analysis was unremarkable. The patient was given a presumptive diagnosis of diabetic lumbosacral radiculoplexus neuropathy and treated with conservative management and rehabilitation. He later developed progressive neck and shoulder pain with radiation into the upper extremities, followed by distal sensory symptoms, gait instability, generalized weakness, and areflexia. Repeat electrodiagnostic studies demonstrated a diffuse acq

  This case highlights the evolving presentation of CIDP and underscores the importance of maintaining a high index of suspicion and continually reassessing initial diagnostic labels in relapsing neuropathies. While first-line therapies for CIDP include high-dose corticosteroids, intravenous immunoglobulin, and plasma exchange, rituximab may serve as an effective treatment option in severe, treatment-resistant cases.

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  Post-HSV NMDAR Encephalitis: A Case of Biphasic Neuroinflammation

  Esam Abobaker and Philip McCarthy

  Publication Date: 5-8-2026

  Herpes simplex virus (HSV) encephalitis is the leading cause of sporadic viral encephalitis and remains associated with substantial morbidity despite appropriate antiviral therapy. Increasing data support a secondary immune-mediated encephalitis occurring after HSV infection, most commonly associated with antibodies against the N-methyl-D-aspartate receptor (NMDA-R). This post-infectious process is uncommon and frequently underrecognized, particularly in adults, creating a diagnostic gap when patients develop delayed neurologic deterioration after apparent virologic resolution. Failure to identify this biphasic disease course can result in delayed immunotherapy and prolonged neurologic injury.

  We present a detailed case report of autoimmune NMDA-R encephalitis following HSV encephalitis. Clinical data were obtained through comprehensive chart review, including neurologic examinations, serial neuroimaging, cerebrospinal fluid (CSF) analyses, electroencephalography, and treatment response. Diagnostic reassessment focused on predefined clinical inflection points, including recurrent encephalopathy and inflammatory CSF profiles, prompting evaluation for secondary autoimmune encephalitis. A focused review of contemporary literature was performed to contextualize diagnostic and therapeutic decision-making.

  A 66-year-old female presented with acute encephalopathy and confusion. Brain MRI demonstrated asymmetric diffusion restriction with corresponding ADC hypointensity in the inferior medial left temporal lobe. CSF analysis confirmed HSV encephalitis, and she completed intravenous acyclovir therapy. Her course was complicated by focal status epilepticus requiring multiple antiseizure medications. Despite virologic treatment and seizure control, she developed progressive cognitive and functional decline approximately 4 weeks later, representing a critical clinical inflection point described in post-HSV autoimmune encephalitis cohorts (Armangue et al., 2015; Prüss et al., 2018). Repeat CSF demonstrated elevated protein, mild pleocytosis, and intrathecal IgG synthesis. Autoimmune encephalitis testing returned positive for NMDA-R antibodies, establishing the diagnosis. She was treated with high-dose intravenous methylprednisolone followed by plasma exchange, resulting in clinical stabilization, consistent with report

  This case highlights a critical diagnostic gap in the evaluation of delayed encephalopathy following HSV encephalitis. Recognition of clinical inflection points and early consideration of autoimmune mechanisms are essential to avoid misattribution to viral relapse or seizure-related encephalopathy. Contemporary evidence supports early immunotherapy to improve neurologic outcomes (Graus et al., 2016; Abboud et al., 2023). Increased awareness of post-HSV NMDA-R encephalitis is necessary to refine diagnostic pathways and optimize patient care.

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  When Iron Deficiency Becomes Life-Threatening: A Pediatric Case of Non-Compaction Cardiomyopathy

  Lauren Ahmann

  Publication Date: 5-8-2026

  There is well-established evidence linking iron deficiency to impaired brain development, with potential consequences including developmental delay and stroke. In contrast, the relationship between iron deficiency and cardiac function remains less clearly defined. Severe iron deficiency has been associated with cardiac electrophysiological abnormalities, such as QT and QTc prolongation, as well as impaired myocardial function, including dilated cardiomyopathy. These findings suggest that patients with severe iron deficiency may be at increased risk for life-threatening arrhythmias or other cardiac events. However, to date, there are no studies or case reports demonstrating a direct association between severe iron deficiency and cardiac arrest or cardiomyopathy, particularly in pediatric patients. This critical gap in the literature underscores the importance of this case report.

  The patient is a previously healthy 5-year-old female who presented to the emergency department in cardiorespiratory arrest in the setting of severe iron deficiency anemia. She was reportedly a picky eater whose diet consisted primarily of chicken nuggets, fries, and processed snacks. She had received limited medical care throughout her life and was minimally vaccinated. On presentation, her hemoglobin was profoundly low at 1.5 g/dL, with a normal white blood cell and platelet count. Head computed tomography was unremarkable. Chest radiography showed marked cardiomegaly. An echocardiogram revealed severe systolic dysfunction with an ejection fraction of 17% and evidence of left ventricular non-compaction. Subsequently, a brain MRI demonstrated multiple small right-sided embolic infarcts, and MRA of the brain revealed possible stenosis of the A1 segment. On the day of discharge, she was additionally found to have a small, non-occlusive thrombus in the left femoral vein.

  The paucity of literature examining the relationship between iron deficiency and cardiac function highlights an opportunity to expand current knowledge. As pediatricians, it is essential to broaden our understanding of iron deficiency and recognize the diverse ways it may impact the children we serve. Further exploration of this potential association may help identify conditions for which iron-deficient children are at increased risk. Equally important, however, is the continued emphasis on prevention of iron deficiency via family education and early intervention.

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  Accuracy of AI-Assisted Citation Generation in Emergency Medicine Publications

  Victoria L. Aquilino, Justin Romero, Stacy Whipple, Michelle A. Padley, and Lindsey Ouellette

  Publication Date: 5-8-2026

  The rapid expansion of artificial intelligence (AI) in academic research has improved efficiency and accessibility, particularly in literature review and citation generation. AI-driven tools embedded within large language models are increasingly used to identify, synthesize, and cite scholarly sources. Despite their convenience, concerns persist regarding the accuracy and reliability of AI-generated references. In emergency medicine, where evidence-based practice and scholarly rigor are essential, inaccurate citations may undermine research credibility and propagate misinformation. Prior studies have documented fabricated, incomplete, or misattributed references generated by AI; however, the prevalence and characteristics of these inaccuracies within emergency medicine remain poorly defined. Systematic evaluation of citation accuracy is therefore critical to guiding responsible AI use.

  We will conduct a cross-sectional analysis of randomly selected research articles and systematic reviews published in the August 2025 issues of Annals of Emergency Medicine and Prehospital Emergency Care. All citations within selected articles will be cross-referenced with the cited source to assess accuracy. Errors will be categorized by type and severity using a predefined classification scale. Eligible publications will be assigned numeric identifiers, and a random number generator will select four original research articles and two review articles. Three medical students will evaluate citations, with the principal investigator reviewing a random subset. An additional 10-20% of citations will be assessed by emergency medicine physicians and residents to evaluate inter-rater reliability. Primary outcomes include citation accuracy and error severity; secondary outcomes include inter-rater reliability (κ) and clinician assessment of the classification system.

  From the August issues of Annals of Emergency Medicine: Volume 86 (9) and Prehospital Emergency Care: Volume 29 (20) 29 articles total met inclusion criteria. Three systematic reviews formed an additional subset. From these groups, six articles were selected from the main set and one from the systematic review subset. One article was used as a pilot to establish rater consensus guidelines and excluded from analysis. The final evaluation included six articles comprising 237 unique citations. Student raters were assigned 122 and 115 citations, respectively, with the PI reviewing three overlapping articles (137 citations). Nineteen citations with errors were identified, which consists of 8% of all citations. There were 4 incidents of initial non-consensus identified, one flagged by a single reviewer. The total non-zero review scores (with overlap) were 28. Error type counts were as follows: -Existence errors (5): 1 -Accuracy errors (4): 17 -Obsolete errors (3): 3 -Relevance errors (2): 6 -Assembly errors (1): 1A

  Given the wide availability and growing prevalence of Al-assisted citation tools, it's important to take a measured approach when utilizing them for scholarly publications, and that authors need to verify citations to ensure academic credibility and integrity, as well as prevent propagation of inaccurate and misleading references.

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  Temporal Patterns of Concussions, Soft Tissue, and Joint Injuries in the NFC North: Insights from the 2025-2026 NFL Season

  Victoria Aquilino, Lena Wuensch, Brian Tani, Natalie Dunn, Adam Haddad, Terry Griggs, Humza Salim, and Allison Tenfelde

  Publication Date: 5-8-2026

  Injuries have profound consequences in the National Football League (NFL), impacting overall team performance and players on an individual level. Roster availability drives team success, alters strategy, and increases the reliance on backup players. Beyond their large-scale toll, injuries can greatly influence the trajectory of a player's career, have profound psychological impacts, and influence contract negotiations. By examining injury patterns across the NFC North during the 2025-2026 season, this study seeks to contextualize seasonal trends, highlighting when concussions, soft tissue, and joint injuries most commonly occur.

  Injury reports and injured reserve lists from NFC North teams (Lions, Bears, Packers, and Vikings) during the 2025-2026 NFL season were compiled. Injuries were recorded by player, position, and week of initial occurrence. Each injury was counted once at onset; repeated listings of the same injury across consecutive weeks were excluded to avoid overrepresentation. Injuries were required to be officially reported on the NFL weekly injury report or injured reserve list. Soft tissue injuries included muscle strains and non-rupture tendon injuries (e.g., hamstring, calf, quadriceps, groin). Joint injuries included articular, ligamentous, tendon rupture, and bony pathology (e.g., knee, ankle, shoulder, elbow). Non-injury-related absences were excluded. Temporal patterns were assessed by dividing the season into early (Weeks 1-6), mid (Weeks 7-12), and late season including playoffs (Weeks 13-18 and postseason). Injury frequencies were analyzed to describe temporal patterns across the season.

  Across the NFC North during the 2025-2026 season, 388 injuries were reported on weekly injury reports and injured reserve lists, including 30 concussions, 138 soft tissue injuries, and 220 joint injuries. Early season injuries (Weeks 1-6) totaled 115, consisting of 7 concussions (6.1%), 38 soft tissue injuries (33.0%), and 70 joint injuries (60.9%). During mid-season (Weeks 7-12), injury burden increased to 136 injuries, with joint injuries comprising the majority (n=96, 70.6%), alongside 31 soft tissue injuries (22.8%) and 9 concussions (6.6%). Late season and postseason play (Weeks 13-18 and playoffs) demonstrated the highest injury burden (n=137), including 27 soft tissue injuries (19.7%), with a sustained predominance of joint injuries (n=96, 70.1%) and a higher proportion of concussions (n=14, 10.2%). Soft tissue injuries declined progressively across the season, whereas joint injuries increased from early to mid-season and remained elevated through late-season play, reflecting shifts in injury patterns.

  Injuries across the NFC North demonstrated clear temporal variation throughout the 2025-2026 NFL season. Soft tissue injuries were more common early, while joint injuries increased through mid-season and remained predominant during late-season and postseason play. Concussion incidence also rose late in the season. These findings highlight the utility of publicly reported injury data for identifying season-long injury trends and may support future studies evaluating mechanisms and prevention strategies.

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  Anesthetic Considerations for Cesarean Delivery in the Setting of Newly Diagnosed Intracranial Mass

  Heather Asuncion, Riley McDaniel, and Marc Korn

  Publication Date: 5-8-2026

  The diagnosis of intracranial tumors during pregnancy presents significant challenges for anesthetic and obstetric management. Gestational meningiomas account for approximately 15% of intracranial tumors in reproductive-age women.1 Pregnancy-related hormonal and hemodynamic changes may accelerate tumor growth and worsen neurologic symptoms, increasing maternal and fetal risk.1-3 Management requires careful evaluation of multiple factors. While neuraxial anesthesia is commonly used in obstetrics, it has traditionally been contraindicated in patients with elevated intracranial pressure, whereas general anesthesia carries risks related to airway management and uterine effects.3,4 Evidence guiding anesthetic choice remains limited and largely based on case reports.3-7 Currently, no standardized guidelines exist to define when neuraxial anesthesia is considered "safe" in these patients.

  A 32-year-old gravida 1 para 0 woman at 36 weeks' gestation presented to the emergency department after a witnessed seizure occurring during sleep. She had no prior seizure history and a medical history notable only for Sjögren syndrome. Neuroimaging revealed a large right parasagittal intracranial mass measuring approximately 6 cm with associated midline shift, concerning for meningioma. The patient remained neurologically intact and asymptomatic following the single seizure episode and was started on levetiracetam. Neurology, neurosurgery, maternal-fetal medicine, obstetrics, and anesthesiology were consulted.

  This case highlights the importance of individualized anesthetic decision-making in cesarean delivery for patients with intracranial pathology. Although neuraxial anesthesia is traditionally discouraged in this setting, it may be an option that can be considered in carefully selected pregnant patients with stable neurologic status, reassuring imaging, and multidisciplinary planning.3,4,6,7 Identifying clinical and radiographic features which predict acceptable patient risk remains a potential area of future research that would help guide clinical decision making.

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  When Back Pain Isn't Just Back Pain: Spinal Epidural Abscess in an Unhoused Woman with IV Drug Use History

  Ahmad Ayyad and Tom Peterson

  Publication Date: 5-8-2026

  Spinal epidural abscess (SEA) is a rare but potentially devastating spinal infection in which delayed diagnosis can lead to permanent neurologic injury or death. Back pain is common and often nonspecific, while fever and focal neurologic deficits may be absent early, making SEA easy to miss in emergency department (ED) patients with seemingly benign presentations. Intravenous drug use (IVDU) is a major risk factor, yet reliance on "red flag" symptoms and reassuring examinations can contribute to diagnostic anchoring and delay.

  A 38-year-old unhoused woman with prior intravenous heroin use and chronic low back pain presented four times over 10 days to three EDs for worsening back pain. Initial visits showed normal vitals, intact neurologic exams, no spinal tenderness, and unremarkable labs; she was repeatedly diagnosed with musculoskeletal pain, and inflammatory markers were not obtained. On the fourth visit, she arrived in septic shock with leukocytosis, lactic acidosis, pulmonary nodules concerning for septic emboli, and positive blood cultures for Staphylococcus aureus; MRI revealed an extensive cervical to lumbar dorsal spinal epidural abscess.

  This case illustrates how SEA in a patient with IVDU can be repeatedly overlooked when clinicians rely on normal neurologic examinations and the absence of classic red flags to exclude serious spinal infection. It underscores the importance of recognizing IVDU as a persistent high-risk feature, obtaining inflammatory markers, and maintaining a low threshold for contrast-enhanced MRI in high-risk patients with recurrent back pain, even when early findings are reassuring. Earlier consideration of SEA might have limited disease extent and preserved neurosurgical options.

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  Temporal Trends in Racial and Gender Diversity in the Most Highly Decorated Craniofacial Plastic Surgeons

  Caroline E. Baker, Atawef Ayesh, Shems Hamdan, John A. Girotto, and Anna R. Carlson

  Publication Date: 5-8-2026

  Although the demographic composition of medical students and graduate medical trainees has become increasingly diverse, leadership positions and markers of professional distinction have historically lagged in comprehensive representation. Prior literature suggests that women and underrepresented racial and ethnic groups experience progressive attrition at higher levels of professional advancement in plastic surgery such as conference presentation acceptances, fellowship applicants, and institutional division leadership. In this project, we aim to examine whether these disparities persist across national academic leadership roles within craniofacial plastic surgery and how they have evolved over time.

  Leadership positions were examined from 2016-2025 and stratified into three tiers by selectivity (tier 1 being most selective and tier 3 being least). Tier 1 consisted of craniofacial journal editors-in-chief and national professional society presidents. Tier 2 consisted of professional award and research grant award recipients. Tier 3 consisted of journal editorial board and professional society board positions. Race and gender were recorded for craniofacial plastic surgeons in each role using institutional biographies stating race and/or gender/pronouns, name origins, and accompanying online images. Where no information was available or ambiguous, the "Unknown" race and gender designations were used. Racial and gender distributions were compared using chi-square and Fisher's exact tests within and between early (2016-2020) and late (2021-2025) time periods within tiers with significance for p-values less than 0.05.

  Over all tiers, 83.6% of leadership positions were held by men, 16.4% by women, and 0% by transgender, non-binary, and other gender groups. Positions were filled by White surgeons in 57.2% of cases, 30.0% Asian, 6.0% Middle Eastern or North African, 4.1% Hispanic/Latinx, 1.7% African American/Black, and 1.0% combined for Unknown Race, Other Race, American Indian or Alaskan Native, and Hawaiian Native or Pacific Islander. Gender and race imbalances (compared to male and White) were observed in both early and late time periods for all tiers (all p< 0.001). Pairwise comparisons demonstrated persistent underrepresentation of gender and racial/ethnic minorities across time periods in all tiers (p>0.05 for change over time).

  Despite increasing diversity in the medical training pipeline, the most highly decorated positions in craniofacial plastic surgery remain disproportionately occupied by White male surgeons. These disparities persist across levels of selectivity and time, suggesting that gains in trainee diversity have not yet translated into equivalent representation in roles of power and recognition within the specialty. Continued attention to promotion pathways, mentorship, and selection processes may promote a more equitable distribution in the field's most influential positions.

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  A Temporal Analysis of Plastic Surgery Training Capacity and Associated Factors: 2010-2025

  Caroline E. Baker, Lasya P. Marla, Riley McDaniel, Parker Martinez, and Ronald D. Ford

  Publication Date: 5-8-2026

  Recent decades have witnessed substantial shifts in the plastic surgery (PS) residency model. Through the 1990s, PS training required 5 years in general surgery followed by 2-3 years in fellowship-the independent route. In 1995, the integrated model, a direct 6-year pathway into PS, gained legitimacy from the American Board of Plastic Surgery, and American Council for Graduate Medical Education (ACGME) accreditation followed in 2012. In this project, we aim to characterize trends in plastic surgery residency by training model and evaluate relationships between structural, geographic, and economic factors and training capacity from 2010-2025.

  This is a cross-sectional observational study. PS residency quotas were obtained from the National Residency Matching Program (NRMP) yearly match reports (integrated programs) and the San Franscisco Match (independent) from 2010-2025. Institutional factors analyzed were training models offered (NRMP), initial accreditation year (ACGME), sponsorship type, state and U.S. region, urbanicity (2023 Rural-Urban Continuum Codes), number of programs in the state, state graduate medical education per capita (2023 AAMC State Physician Workforce Data Report), and state percentage of private insurance holders and median income (2023 U.S. Census data). Sources are listed or publicly available information. Univariate analysis was conducted via Kruskal-Wallis and Spearman tests. Multivariable linear regression was used to identify independent factors associated with annual capacity change with significance at p< 0.05.

  From 2010-2025, PS residency capacity increased by 20.3% (107 positions). In 2010, there were 73 institutions offering 73 integrated and 93 independent spots. In 2025, there were 104 institutions offering 221 integrated spots and 52 independent. Over the time period, there were 72 newly accredited programs and 34 dissolutions. Institutions were most likely to offer both independent and integrated programs (45.5%), be private (52.7%), and be located in large metropolitan areas (median RUCC: 1.0 [IQR 1.0-2.0]) in the South (34.5%). Institutions offering an integrated training model only were associated with program expansion (p=0.046). No other structural, geographic, or state-level economic factor was independently associated with growth in whole-group or subgroup analysis by program type (all p>0.05).

  PS residency training capacity has expanded substantially since 2010. Large-scale contributing factors likely include U.S. population growth and increased procedural demand particularly for minimally invasive and gender affirming procedures. Interestingly, PS training capacity appears to be expanding along the existing academic infrastructure rather than according to economic or geographical factors. Thus, despite national emphasis on equitable workforce distribution, training expansion appears not to correlate with commonly cited need-based metrics.

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  Exploring the Distribution and Gaps of Applicant-relevant Information Between Platforms for Plastic Surgery Residency Programs

  Caroline Baker, Lasya Marla, Annie Hoang-Pham, and Ronald Ford

  Publication Date: 5-8-2026

  As plastic surgery grows tremendously as a field, so does its applicant pool, sustaining the specialty's highly competitive match. Historically, applicants have been able to virtually gauge fit for a residency program by exploring its website. Today, social media makes information even more accessible. We aimed to assess the distribution and remaining gaps in applicant-relevant information between plastic surgery residency program websites and social media to provide a holistic picture of program information transparency.

  This is a cross-sectional observational study examining plastic surgery residency program websites and social media (Instagram and Facebook) accounts across nine informational domains: program mission, educational resources, curriculum, resident identification, faculty identification, clinical workload (e.g. duty hours, case volume), wellness initiatives, away rotations, and interviews. Jaccard similarity coefficients were used to quantify the overlap in content between the two platforms, and McNemar's tests were performed to assess the differences in content per domain.

  A total of 130 plastic surgery residency programs were analyzed (91 integrated, 39 independent). A mean of 46.5% of information was available on program websites, 37.0% on social media, and 64.5% combined (median Jaccard: 0.29). Across domains, resident information was most accessible (94.0% combined) while clinical workload was least prevalent (18.0%). Whereas faculty information, mission statement, and interview details were more likely to appear on program websites, wellness content and program resources were significantly more common on social media (all p< 0.001). No significant platform differences were found for resident information, clinical workload, or curriculum (all p>0.05).

  Together, plastic surgery residency program websites and social media provide approximately two-thirds of applicant-relevant information and less than half alone. Social media was much more likely to emphasize wellness (e.g. team bonding, personal activities) and resources (e.g. simulation labs, educational facilities), which may serve to humanize programs and increase applicant interest. However, critical gaps remain in transparency particularly regarding clinical workload. Making program information accessible allows applicants to better align their priorities with

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  Guideline for Precedex Use in Comfort Care Settings at Corewell Health West: A Quality Initiative

  Trinity Bauer-Wojnar, Kristin Inger, and Gretchen Roe

  Publication Date: 5-8-2026

  In the setting of palliative medicine, the control of agitation, anxiety, and pain are essential to improving patients' symptomatology and quality of life. Dexmedetomidine, or Precedex, is an anesthetic agent that has recently been used more frequently for uncontrolled agitation, anxiety, or pain in palliative patients. While Precedex is shown to have clinical utility in the palliative setting, many palliative providers and nursing staff are unfamiliar with the dosing guidelines for this medication in the setting of palliative medicine, as the established dosing guidelines were created for its use in procedural settings for anesthesia. The aim of our quality initiative was to establish an institutional clinical guideline for Precedex use in inpatient palliative medicine at Corewell Health West.

  We met with the inpatient and outpatient pharmacy teams, palliative medicine providers, and nursing leadership to establish the current institutional practices and knowledge surrounding the use of Precedex for palliative medicine patients. We performed a literature search of Pubmed, utilizing the search terms "(Palliative) and (Dexmedetomidine or Precedex)" over the past 5 years. We excluded results related to pediatrics, anesthesia, critical care, and procedural sedation.

  Based on our meetings with nursing leadership and palliative medicine providers, we discovered that providers and staff felt they had limited comfortability with administering Precedex for palliative medicine patients. Based on our meetings with palliative pharmacy teams, we discovered that there is not currently an order set for Precedex in the setting of comfort care. We utilized a broad review of the literature to create a clinical guideline for Precedex administration in the setting of comfort care. This protocol encompasses Precedex mechanism of action, clinical utility, side effects, and dosing guidelines for different routes of administration.

  Patient comfort is a mainstay of palliative medicine. Recently, Precedex has been used increasingly often to provide sedation in the setting of comfort care. Our initiative established a clinical guideline for Precedex use in the setting of inpatient palliative medicine at Corewell Health West. Based on our quality initiative, our next steps will be to distribute the clinical guideline and seek feedback on its clinical utility in inpatient palliative medicine.

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  A Novel Case of West Nile Virus Rhombencephalitis Complicated by Obstructive Hydrocephalus

  Ryan Bean, Justin Huynh, Shayna Marsia, Samantha Cencer, and Nicholas Lannen

  Publication Date: 5-8-2026

  West Nile Virus (WNV) is a ssRNA arbovirus endemic to the United States that is known to cause neuroinvasive disease such as meningitis, encephalitis, and flaccid paralysis, typically detected through WNV-specific antibodies. However, obstructive hydrocephalus and the diagnostic pitfalls that chronic B cell depleting therapy generate in this disease have not been clearly described in the literature.

  We report what proved to be a diagnostically challenging case of WNV rhombencephalitis complicated by obstructive hydrocephalus in a patient with multiple sclerosis on long term ocrelizumab. A 44-year-old female with PPMS on ocrelizumab, presented with acute onset of fever, fatigue, confusion, and worsening weakness. Encephalopathy progressed despite empiric antibiotics requiring intubation, with EEG demonstrating focal status epilepticus, resolving with ASMs.

  Development of severe rhombencephalitis with obstructive hydrocephalus represents an extremely rare manifestation of WNV infection. Prior reports of similar MRI findings in the thalami and posterior fossa, suggesting a predilection for subcortical structures, but no cases of obstructive hydrocephalus readily exist in the literature. Furthermore, its occurrence in the setting of B cell depleting immunotherapy illustrates the limitations of traditional antibody testing in this patient population and highlights the early adoption of metagenomic NGS for accurate management.

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  A Case of Superior Mesentery Artery Syndrome in a Patient with Duchenne Muscular Dystrophy

  Katherine Bekker, Katie McCarthy, and Christopher Benner

  Publication Date: 5-8-2026

  This case illustrates the multifactorial nature of medically complex pediatric patients with Duchenne Muscular Dystrophy (DMD) and their risk of malnutrition, leading to rare complications like superior mesentery artery syndrome (SMAS). This case is particularly notable due to significant barriers to accessing healthcare, including inability to obtain sufficient enteric feeds, inconsistent transportation, and incarceration of the primary guardian one month following SMAS resolution. Malnutrition in pediatric patients is complex, particularly when potential neglect is involved; however, this family also faced barriers to care, and it is unclear if the initial weight loss leading to SMAS was directly related to intentional neglect. Furthermore, this case highlights the impacts changes in guardianship may have on medically complex children, suggesting a need for better coordinated care.

  A 14-year-old male with a known history of DMD, steroid dependence, developmental delay, and severe protein-calorie malnutrition presented to the emergency department for evaluation of worsening bilious emesis, abdominal pain, and persistent constipation over the previous 24 hours. He was hemodynamically stable, but weighed 22.1 kg after significant weight loss. Physical exam was notable for abdominal tenderness without distention. The patient was started on IV fluid bolus and IV ondansetron for symptom control. Labs were notable for leukocytosis (WBC 12.1 x10⁹/L) with neutrophilic predominance, hypokalemia (K⁺ 2.4 mmol/L), decreased bicarbonate (19 mmol/L), and an elevated anion gap (26). Liver enzymes were mildly elevated, though the lactate was within normal limits. Computed tomography (CT) of the abdomen and pelvis demonstrated significant gastric distention with radiographic features consistent with SMAS. Additional findings included compression of the left renal vein.

  This case underscores the complex interplay of neuromuscular disease, nutritional challenges, and multidisciplinary coordination in managing medically fragile pediatric patients. This patient's experience illustrates the profound impacts social determinants of health have on disease trajectory, treatment adherence, and outcomes. Coordinated multidisciplinary care and proactive social support are critical to optimizing outcomes in similarly vulnerable populations, decreasing the risk of fractured medical care that may accompany placement disruption or loss of resources.

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  When Myotonia Mimics Malignant Hyperthermia: Proactive Peripartum Anesthetic Planning in Congenital Myotonic Dystrophy Type 1

  Kalyan Bobba, Kayla Doughty, and Laurie Chalifoux

  Publication Date: 5-8-2026

  Congenital myotonic dystrophy type 1 (CMD1) is a rare autosomal dominant neuromuscular disorder, with an incidence of 2-28 per 100,000 live births. Expansion of CTG repeats in the DMPK gene results in dysfunctional myotonin protein kinase, leading to impaired structural integrity and function of cardiac and skeletal muscle and neurons. Clinically, CMD1 is characterized by myotonia, cataracts, and cardiac conduction abnormalities. These multisystem features pose significant anesthetic risk in the peripartum period such as preeclampsia and postpartum hemorrhage. However, due to the rarity, heterogeneity, and complexity of CMD1, there is no consensus regarding optimal peripartum anesthetic management. This case underscores the value of proactive, multidisciplinary anesthetic planning to mitigate risk and guide safe obstetric anesthesia care in patients with CMD1.

  A 31-year-old G1P0 woman with CMD1 and a history of nonischemic cardiomyopathy was referred for anesthesiology consultation at 29 weeks and 4 days gestation. Her symptoms included intermittent hand and tongue myotonia, neck and lower extremity weakness, often exacerbated by cold temperatures. She was fully ambulatory and an active runner. A transthoracic echocardiogram performed in 2024 demonstrated a left ventricular ejection fraction of 60-65%, mild mitral valve prolapse, and normal right ventricular size and function, representing significant improvement from prior nonischemic cardiomyopathy. Electrocardiography showed sinus bradycardia at 53 beats per minute. Following multidisciplinary review, a comprehensive peripartum anesthetic plan addressing medication selection and delivery considerations was established at 29 weeks and 4 days gestation.

  This case highlights the importance of having a pre-determined plan for complex obstetric patients to ensure consistent evidence-based care, especially for a rare clinical disease process which requires emergent care. General anesthesia poses unique risks in pregnancy, and is often emergent for fetal concerns. Furthermore, MH presents similarly to CMD1, so a non MH-triggering anesthetic may be prudent to avoid diagnostic dilemma. The complexity of this case shows the need for patient-centered planning to drive safe pharmacological and procedural decision making.

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  Diagnosis of Maternal and Fetal Myotonic Dystrophy Following Fetal Ultrasound

  Victoria Bright, Inara Ismailova, and Erin Fricke

  Publication Date: 5-8-2026

  Historically, myotonic dystrophy, type 1 (DM1), was thought to occur in 5-20 per 100,000 births, but recent studies suggest that the incidence may be as high as 1 per 2,100 births. Congenital DM1 (cDM1) has a variable reported incidence and is often the first familial diagnosis. cDM1 is often diagnosed in the neonatal period. There are certain ultrasound findings that support this diagnosis, such as fetal talipes and polyhydramnios, but none are pathognomonic. This case emphasizes how maternal and fetal diagnoses can coincide and that efficient diagnoses inform care for both patients.

  This case reviews a 29-year-old G1P0 who initially presented to the Maternal Fetal Medicine (MFM) for fetal ultrasounds due to suspected bilateral talipes, first noted at 20 weeks gestation. At her 25-week ultrasound, no fetal flexion or extension of legs was noted. Subsequently, a 29-week ultrasound demonstrated the bilateral lower extremities fixed in an extended "pike" position with minimal fetal movement. No other significant ultrasound findings were noted at that time. The patient also reported her own muscular symptoms, including muscle stiffness and gait difference, and the "Gowers's maneuver" was noted in the office. The patient was urgently referred to a medical geneticist. Her myotonia gene panel demonstrated >200 repeats in one copy of her DMPK gene, consistent with DM1. Following maternal diagnosis, the patient underwent amniocentesis for fetal genetic testing, which revealed an expanded DMPK allele with approximately 1710 repeats, consistent with cDM1.

  During pregnancy, the patient connected with multiple subspecialists. She continued following with MFM and planned for a delivery at a regional birthing center for maternal intrapartum cardiac monitoring and neonatal acute care services. She was ultimately scheduled for an amnioreduction followed by an induction of labor secondary to polyhydramnios at 37 weeks 2 days gestation. Fetal status was reassuring during labor, and her delivery was uncomplicated. The neonatal ICU was present at delivery. The umbilical cord was immediately clamped and cut due to nonreassuring neonatal status. APGARs were 3 and 5 at 1 and 5 minutes, respectively, due to poor tone and minimal reactivity. The baby was intubated during initial resuscitation and admitted to the neonatal ICU for 60 days, requiring extensive multidisciplinary care. They were ultimately discharged with oxygen support but without a tracheostomy. Both the patient and baby continue to follow with subspecialists routinely.

  This case supports second- and third-trimester ultrasound findings associated with cDM1, while exemplifying how fetal findings can expedite the often delayed maternal diagnosis. Further, it demonstrates the importance of expeditious diagnosis to establish surveillance and management of maternal and neonatal complications.

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  Thyroid Storm Masquerading as Serotonin Syndrome: A Pediatric Case Report

  Brad Burns, Kelsie Hendrick, and Christian Kolacki

  Publication Date: 5-8-2026

  Thyroid storm is a rare, life-threatening endocrine emergency representing the most severe form of thyrotoxicosis, with mortality reported up to 10-30%. Pediatric thyroid storm is exceedingly uncommon and diagnostically challenging, particularly when presentation overlaps with toxicologic syndromes. This case describes a 15-year-old female whose initial presentation suggested sertraline overdose and serotonin syndrome, but whose course ultimately revealed thyroid storm.

  A 15-year-old female with autism, depression, and ADHD presented after ingestion of 125 mg of sertraline, with tachycardia, tachypnea, hypertension, and hallucinations, and was treated for presumed serotonin syndrome with benzodiazepines. Despite largely unremarkable initial laboratory studies and sinus tachycardia on ECG, she remained hemodynamically unstable. In the PICU, she was diaphoretic, tachycardic, tachypneic, afebrile, with decreased GCS and an enlarged thyroid, and detailed history revealed six months of diarrhea, heat intolerance, weight loss, and unexplained tachycardia with family history of autoimmunity.

  Thyroid storm should remain on the differential for pediatric patients with unexplained tachycardia, altered mental status, and gastrointestinal symptoms, even when an apparent toxic ingestion is reported. Careful history and physical examination, particularly evaluation for chronic hyperthyroid symptoms and goiter, were pivotal in correcting the initial misdiagnosis in this case. Early endocrinology involvement and prompt institution of guideline-consistent multimodal therapy can lead to rapid stabilization and improved outcomes in pediatric thyroid storm.

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  Capnocytophaga Meningitis: A Rare Cause of Bacterial Central Nervous System Infection

  Hannah Campbell, John Parent, and Ghaleb Khirfan

  Publication Date: 5-8-2026

  Capnocytophaga species is a slow-growing gram-negative bacilli that colonizes the saliva of canines. Human infections caused by this organism are most commonly seen as sequela of dog bites in immunocompromised or asplenic patients. Meningitis due to capnocytophaga is rarely documented. In a review of literature from 2019, only 37 cases of meningitis due capnocytophaga canimorsus were highlighted. Because of its slow-growing nature, delayed diagnosis is common, and even more delayed if it is not suspected in patients without classic risk factors or a clear history of animal bite. This case highlights an atypical presentation of Capnocytophaga meningitis in an immunocompetent patient and highlights the diagnostic challenges posed by this rare infection.

  A 70-year-old female with hypothyroidism and history of tobacco use presented to the emergency room after being found unresponsive in her home. She had been feeling general malaise for three days prior to presentation and fever for one day but did not endorse any other symptoms. On presentation, she was incoherent, not responsive to verbal stimuli but protecting airway, with a GCS of 11. Meningitic coverage antibiotics were started. Lumbar puncture was performed which was suspicious for bacterial infection with cerebral spinal fluid protein of 260 mg/dL with glucose of 39. Imaging was unremarkable. Other initial labs were suggestive of rhabdomyolysis and significant for a procalcitonin of 23.7.

  This case is a rare presentation of Capnocytophaga canimorsus meningitis in an immunocompetent patient. Due to the organism's slow growth and frequent delays in species identification, diagnosis may be prolonged and blood cultures initially nondiagnostic. Early initiation and maintenance of broad-spectrum antimicrobial therapy is critical when this pathogen is suspected, particularly in patients with canine exposure and severe sepsis. Increased awareness of this diagnosis may facilitate earlier recognition and improve outcomes.

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  Comparison of Thumb Metacarpophalangeal Joint Arthrodesis Techniques by Outcome: A Systematic Review

  Noah Carson, Reddy Swetha, Rachel Weber, Samuel Girian, and Matthew Fahrenkopf

  Publication Date: 5-8-2026

  The ultimate role of the thumb metacarpophalangeal joint (MCPJ) is grip stabilization and instability can be debilitating1. Arthrodesis is a well-established surgical technique sacrificing motion for return of stability2. Multiple arthrodesis techniques are described, however, no consensus among hand surgeons exists for which technique is best3. This study aims to examine available literature from the most recent decade to summarize the documented efficacy and safety of thumb MCPJ arthrodesis methods.

  A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Databases searched include Pubmed, Google Scholar, and Cochrane Library using Boolean expression: ("thumb MCPJ" OR "thumb metacarpophalangeal joint") AND (arthrodesis OR fusion) AND (technique* OR method*) AND (outcome* OR compar*), retrieving studies documenting thumb MCPJ arthrodesis technique outcomes. Studies examining outcomes between at least two techniques in adults were included. Excluded studies did not meet these criteria. Primary outcomes (fusion rates), and secondary outcomes (patient-reported and/or functional outcomes), were extracted by two independent reviewers. Articles were evaluated for risk of bias (ROB) using design-appropriate assessment tools; those demonstrating high ROB were excluded.

  The primary search yielded 15 studies. After exclusion criteria and ROB assessment, 9 were included in the final synthesis of results. Of these, 2 studies were retrospective cohort studies, 2 were retrospective case series, and 5 were retrospective chart reviews. Most were conducted in the United States [n=5, 55.5%], France [n=3, 33.3%], and Canada [n=1, 11.1%]. The average sample size was 54.6 patients, average follow-up duration was 45.3 days, and typical patient age was 55.1 years. Heterogeneity in outcome measures precluded meta-analysis. However, 3 studies found K-wire arthrodesis consistently safe and effective. Tension band wiring had greater numbers of hardware complications in 2 articles with one article citing higher union rates compared to screw fixation. Open arthrodesis techniques remain more reliable than minimally invasive in one study, and union rates may benefit from autologous bone grafting in another. Plate and screw technique may provide excellent alignment but less consistent union rates.

  K-wire methods for thumb MCP arthrodesis are widely efficacious and low risk across patient populations and indications. Other techniques lack consistency in terms of union and hardware complications. Further research is needed to directly assess each technique and compare outcomes across arthrodesis methods.

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  Lyme Carditis Presenting with Atypical Rash and Complete Heart Block

  Lucas Chalfoun, Lucas Rich, and Michael P. Brunner

  Publication Date: 5-8-2026

  Lyme carditis is an important and reversible manifestation of Borrelia burgdorferi infection that most commonly presents with atrioventricular (AV) conduction abnormalities. Early recognition is essential to prevent unnecessary pacemaker implantation; however, diagnosis may be delayed when dermatologic findings are atypical. We report a case of Lyme carditis presenting with complete heart block and an unusual rash morphology.

  A previously healthy 52-year-old female presented with one week of fatigue, dyspnea on exertion, and lightheadedness. Electrocardiogram demonstrated hemodynamically stable complete heart block with a ventricular escape rhythm of 46 beats per minute. Physical examination revealed a flat, macular, purple rash approximately 5 cm in length on the right posterior flank, lacking the classic "bull's-eye" appearance of erythema migrans. Six weeks earlier, she experienced transient fever and headache and later provided images of an ulcerated rash at the same location. She did not recall a tick bite but reported outdoor gardening activity.

  This case highlights the diagnostic challenge posed by non-classic erythema migrans presentations, including macular or ulcerated lesions that may be misinterpreted. Awareness of the broad dermatologic spectrum of Lyme disease is critical, as prompt empiric antibiotic therapy can lead to resolution of high-grade AV block and avoidance of unnecessary permanent pacemaker implantation.

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  Fluoroscopic Findings of Colonic Interposition Dysfunction in Esophageal Atresia: An Adult Case of Dysphagia

  Alexandra Charron

  Publication Date: 5-8-2026

  Esophageal atresia (EA) is a congenital disorder that results in discontinuity of the esophagus, with an estimated global incidence of approximately 3 in 10,000 live births. The most common surgical intervention is primary anastomosis of the proximal and distal segments of the esophagus. However, there are situations when primary anastomosis is not possible due to a long gap between the proximal and distal esophageal segments. One surgical solution for these cases is esophageal replacement with other portions of the gastrointestinal tract, such as the stomach, jejunum, or colon. We present a case of a late complication in an adult patient with a history of esophageal atresia, who previously underwent surgical repair with colonic interposition.

  The patient is a 41-year-old with a history of neonatal EA repaired with colonic interposition, who presented to an outpatient gastroenterology clinic with chronic dysphagia. The patient reported several years of progressively worsening difficulty with swallowing and globus sensation. An esophagram was ordered to investigate the shape of the patient's esophagus/colonic conduit and to evaluate for potential narrowings or dysmotility. Fluoroscopic esophagram with barium contrast demonstrated a tortuous and dilated colonic conduit with significant stasis of barium.

  Late complications of EA treated with colonic interposition are becoming increasingly relevant as this unique patient population is surviving through adulthood. Colonic interposition has fallen out of favor due to higher rates of graft dysfunction, including delayed emptying and stasis, with a large portion of patients requiring conduit revision. Fluoroscopic examination is useful for characterizing conduit pathology in adult EA patients presenting with dysphagia and can guide next steps for management, including endoscopic intervention versus surgical revision.

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  Outcomes of Operative Versus Nonoperative Management of Ankle Fractures in Patients with Diabetes Mellitus: A Systematic Review

  Eric Chen, Chase Wahl, Deb Ovik, and Allison Tenfelde

  Publication Date: 5-8-2026

  Ankle fractures present as significant clinical challenges to diabetic populations, with fracture rates increased 1.24 fold in diabetic patients compared to nondiabetic patients. Additionally, there are substantially more soft tissue complications and delayed bone healing following ankle fractures, resulting in increased risks of nonunion, wounds, Charcot arthropathy, and amputation. While operative fixation is often recommended to restore ankle stability, some sources outline surgical and postoperative risks, and suggest a higher complication rate in diabetic patients treated with surgical treatment compared to conservative management. Due to these concerns, the optimal treatment strategy for diabetic ankle fractures remains elusive. This systematic review aims to evaluate and compare clinical outcomes of surgical versus nonsurgical management of diabetic ankle fractures.

  A systematic review was conducted in accordance with PRISMA guidelines. A comprehensive literature search of PubMed Library databases was performed to identify studies evaluating ankle fractures in ambulatory, adult patients (≥18 years) with diabetes mellitus. Search terms included "diabetes", "ankle fracture", "operative", "nonoperative". Studies comparing surgical and/or nonsurgical management of ankle fractures in diabetic patients and reporting clinical outcomes were included. Case reports, pediatric studies, studies focused solely on healthy patient populations, and studies focused on non-ankle fractures were omitted. Outcomes of interest included complication rates, need for revision surgery, and functional outcomes. Study quality for retrospective chart review studies were assessed using the Newcastle-Ottawa Scale.

  The literature search identified two comparative studies consisting of 101 ambulatory, diabetic adult patients (≥18 years) with ankle fractures. The complication rates however varied by treatment approach and patient selection. In a cohort involving closed, displaced diabetic ankle fractures (n = 28), nonoperative treatment was associated with 21 fold complication rates when compared to operative treatment (75% vs 12.5%, OR 21.0, P = .004). Complications included loss of reduction/malunion, new-onset Charcot arthropathy, cast ulcer, unplanned operation, and deep infection. Additionally, delayed surgery after failed nonoperative treatment led to 100% complication rates compared to 12.5% with immediate ORIF (p = 0.005). In a separate cohort of closed, mixed-stability diabetic ankle fractures (n = 73), the study primarily evaluated early protected weightbearing protocol. Complications were low, with 2 in the nonoperative group (n = 25) and 12 in the operative group (n = 48), most commonly wound dehiscence (18.8%).

  Diabetic patients with ankle fractures experience elevated risks regardless of treatment modality, yet evidence guiding optimal management remains limited. Available comparative data suggest improved outcomes with operative fixation in displaced fractures, while outcomes appear similar between operative and nonoperative approaches in selected mixed-stability fractures. Given the heterogeneity of fracture patterns and risk profiles, further high-quality, comparative studies are needed to define evidence-based treatment strategies for this high-risk population.

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  Exercise-Associated Transient Global Amnesia with Characteristic Hippocampal MRI Findings

  Nicholas Christians, Luke Witvliet, Danielle Cadoret, and Andrew Nash

  Publication Date: 5-8-2026

  Transient global amnesia (TGA) is a self-limiting neurological syndrome characterized by anterograde amnesia, mild retrograde amnesia, and confusion lasting less than 24 hours.1 The incidence of TGA is 3.4 to 10.4 per 100,000 people, most commonly affecting individuals aged 51 to 80 without gender predilection.2 Recurrence rates are 2.9 to 23.8% and is associated with a younger age at first episode and migraine history.1,3 Radiographically, TGA classically manifests as punctate unilateral foci of restricted diffusion in the CA1 field of the hippocampus on diffusion-weighted MRI, most prominent 24 to 48 hours after symptom onset.2 While the pathogenesis is not fully understood, it is associated with extreme temperatures, emotional distress, and strenuous activity.4 TGA has also been linked to iatrogenic causes including coronary angiography, cerebral angiography, and general anesthesia.

  A 65-year-old female with a past medical history including type 2 diabetes mellitus, hypertension, hyperlipidemia, and hypothyroidism, presented to the emergency department as a stroke code for confusion and amnesia. Further assessment demonstrated isolated anterograde amnesia characterized by repetitive questioning. The patient's last known normal was the morning of symptom onset. Later in the day, after returning from a workout, she began experiencing confusion and disorientation. She was unable to recall events from the previous day or earlier in the week and her husband stated that she repeatedly asked questions regarding her whereabouts and activities. No vision loss, slurred speech, focal sensory or motor deficits, ataxia, vertigo, word-finding difficulties, or loss of consciousness were reported. Ten years prior, the patient experienced an episode of similar confusion and amnesia following head trauma.

  This case demonstrates TGA with a characteristic clinical presentation and MRI findings. Although TGA has a relatively recognizable presentation, it remains a diagnosis of exclusion. Imaging findings are subtle yet can be critical to confirm the diagnosis. Clinicians and radiologists should maintain suspicion for TGA, and understand how specific brain imaging can clinch the diagnosis for this self limited condition, avoiding more extensive workup. Overall, the prognosis for TGA patients is good, with no increased stroke risk or established need for ongoing treatment.

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  Income is a Better Predictor of Knowledge and Positive Perceptions of Positional Plagiocephaly than Education Level

  Brittney Collins, Hanna Pfershy, Caroline Baker, Kyle Knapp, John Girotto, Anna Carlson, and Aditi Kanth

  Publication Date: 5-8-2026

  Positional Plagiocephaly (PP) is the acquired deformation of an infant's skull due to consistent external pressures, such as frequently lying in the same position. Literature continues to debate the best management for PP, however some methods such as helmet molding are currently widely used. Due to the use of protective helmets in children at risk of accidental head injuries, such as those with Autism Spectrum Disorder (ASD), children with PP seen wearing molding helmets may be assumed to have cognitive or developmental delays. Demographic factors may play a role in a person's perception of molding helmets. This study aims to understand the relationship between income and education level on a person's understanding of positional plagiocephaly and their perceptions of children in molding helmets.

  A compensated online survey was distributed through Amazon Mechanical Turk (MTurk) to individuals in the United States who were over age 18. Income and highest education level were gathered, among other demographic data. Participants were asked about their knowledge of positional plagiocephaly, perceptions of infants in molding helmets, personal history with the condition, and any decisions made in their own children's PP management. Descriptive and Chi-Square analysis were performed with Bonferroni multiplicity adjustments applied to p-values.

  Compared to all other income levels, participants making over $200k knew that babies in helmets did not have a "brain problem" (100%, p< 0.0001) but instead a "skull problem" (87.5%, p< 0.0001). They did not think children in helmets were clumsy (0%, p=0.0019) or autistic (0%, p< 0.0001). They knew that babies get PP between 0-6 months (93.8%, p=0.0005), the flat spot can go away on its own (100%, p< 0.0001), and that it does not affect brain growth (93.8%, p< 0.0001). Those with a Bachelor's degree were the most likely education level to think that babies in helmets had a skull problem, however this was only 31%(p=0.0004). About 10% of overall participants thought babies in helmets were autistic, and 20% thought babies in helmets were clumsy. Education level was not a statistically significant predictor. Both those with doctorate and high school level degrees incorrectly thought that children get positional plagiocephaly after age 6 months (73%, 71%, p=0.0008).

  The results of this survey show that there are varying perceptions of babies in helmets and oftentimes incorrect beliefs regarding positional plagiocephaly across all demographics. However, this study also supports that income level is a better predictor of correctness compared to the highest level of education pursued.

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  Multifactorial Causes of an SJS-like Acute Skin Reaction

  Alexander Cooke

  Publication Date: 5-8-2026

  Acute rashes vary widely in presentation and severity, with many being mild while others like Stevens-Johnson Syndrome (SJS) are true dermatologic emergencies. Rashes can have a variety of causes, including drugs, infection, and autoimmune disorders. While supportive care is a mainstay of all acute rashes, differentiating types of reactions can allow for more directed treatment, and in the case of multifactorial skin pathologies, can help determine how different factors affect presentation. We present a case of acute rash initially concerning for SJS but found to have multifactorial contributions due to a complex clinical course. The patient is a 74 y.o. female with a history of paroxysmal Afib, COPD, DVT, and diastolic heart failure who presented to an outside hospital after a fall. As an outpatient she had received separate courses azithromycin and doxycycline for bronchitis.

  She was found to be hypotensive and hypothermic and was admitted to the ICU. Due to left leg swelling and history of DVT, CT was obtained and found an extensive left iliac vein DVT and reduced caliber of the IVC. A pelvic hematoma was also observed, likely related to her fall. She completed thrombectomy and continued on IV heparin. She had a complex ICU course with worsening of the hematoma requiring multiple transfusions and increasing pressor requirements along with abdominal pain, fever, and rash. Erythema and warmth were noted on the lower abdomen, buttocks, groin, and bilateral lower extremities. Oral lesions were not noted. Abdominal CT showed acute pancreatitis with complex fluid collection and stable pelvic hematoma. She received vancomycin, cefepime, metronidazole, and piperacillin-tazobactam during the admission. She transferred to the floor and was noted to have significant lower extremity edema due to extensive fluid resuscitation in the ICU.

  In contrast, this patient lacked mucosal erosions and had multiple contributors to her dermatitis in addition to antibiotic exposure. Her pelvic hematoma led to extravasation of blood that migrated to dependent areas that correlated to the most severe wounds. She also had edema from fluid resuscitation and a superimposed fungal infection. The multifactorial nature of her dermatitis required a varied treatment approach, with diuresis and antifungals playing roles that would not have existed if SJS were the primary diagnosis.

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  Pharmacological Management of Delirium in Older Adults with Isolated Hip Fractures

  Angela Rose David, Patrick Renner, Laura Krech, and Guibin Li

  Publication Date: 5-8-2026

  Isolated hip fractures (IHF) are a significant cause of morbidity and mortality among geriatric trauma patients due to diminishing age-related bone density. While surgical fixation of fractures is associated with greater survival, the inpatient stay confers additional risks on this population, particularly the potential for hospital-acquired delirium. Due to various physiological factors, polypharmacy, and comorbidities, geriatric patients are at an especially high risk. The objective of this study is to analyze medication use for delirium management in older adults with IHF during hospitalization. The primary aim is to compare hospital length of stay, mortality, readmission rates, and hospice engagement among delirium patients with and without dementia, and all sustained IHF. Secondary aims include characterization of inpatient medication use and QTc changes among these cohorts.

  This retrospective study was determined to be as a quality improvement project by the CHW IRB. Patients 65 years of age and older who were admitted to Butterworth Hospital with isolated hip fractures between January 1, 2018, and October 20, 2024, were included in the project. Among 2,121 patients, 68 patients had a diagnosis of delirium. Electronic medical records were reviewed by the project team, and data points were uploaded to a secure REDCap for analysis. Numeric outcomes were expressed as mean ± standard deviation or median.

  68 geriatric patients with delirium met inclusion criteria, with a mean age of 85.2 years (range 67-99) and 57.4% were female. The mean length of stay was 7.8 days. The most frequent comorbidities were functional dependence (70.1%), hypertension (65.7%), hyperlipidemia (59.7%), osteoporosis (53.7%), and dementia (37.3%). Antipsychotics were used in 48.5% of patients, benzodiazepines in 22.1%, antihistamines in 16.2%, and opioid analgesics in 86.8%. Among antipsychotics, the most used agents were olanzapine (17.6% of patients), quetiapine (13.2%), and haloperidol (11.8%). Opioid analgesics included oxycodone (86.8%), fentanyl (58.8%), morphine (50.0%), and hydromorphone (35.3%). The mean QTc prior to administration of these medications was 456 ± 30 milliseconds, with a mean post-medication QTc of 463 ± 56 milliseconds. Unplanned ICU admissions were the most common hospital event at 13.2%. Readmission rates were 11.8% at 30 days; in-hospital mortality was 1.5%.

  The results of this initial analysis demonstrate that the use of antipsychotics and analgesics was prevalent among geriatric trauma patients who had a diagnosis of delirium while admitted for IHF. Unfortunately, the use of antipsychotics and subsequent long QTc are common among elderly patients with dementia, highlighting the need for more stringent measures regarding medication selection and ECG monitoring in this population. Future studies should address comprehensive assessments aimed at limiting the use of these agents in the geriatric population.