United States

Background
Antisocial Personality Disorder (ASPD) is one of the most stigmatized psychiatric diagnoses in the public sphere, contrasting with Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD), which are among the least stigmatized. ASPD stigma extends to healthcare, where many providers hold negative attitudes towards patients with ASPD, affecting their willingness to work with this population. Understanding whether medicine perpetuates this stigma is crucial for early intervention in medical training. Given the role of language in perpetuating stigma, as evident in studies on Opioid Use Disorder, this study explored how language contributes to negative attitudes about ASPD in healthcare, an area largely overlooked in stigma research, Psychiatry, and medical education. It aimed to assess medical education resources for stigmatizing language and compare how they reflect public stigma patterns, where ASPD is more stigmatized than MDD and GAD.

Methods
Seven widely used medical education resources were analyzed for their depiction of ASPD, MDD, and GAD. Since many medical students favor third-party resources for studying and board exams, the analysis included Boards and Beyond, AMBOSS, First Aid, First Aid for Psychiatry Clerkship, and APA, as well as in-house materials from Warren Alpert Medical School and the DSM-5. The analysis focused on two stigma components identified by Phelan and Link: labeling and status loss, particularly through clinical pessimism. Fisher&#39;s Exact Test compared ASPD to MDD and GAD across labeling, treatment difficulty, and treatment omission.

Results
The analysis revealed significant stigma toward ASPD, with 85.7% (n=6) of the materials using labels like &quot;bad,&quot; &quot;manipulative,&quot; and &quot;deceitful.&quot; Notably, &quot;bad&quot; was used as a mnemonic. In contrast, none of the materials for MDD or GAD employed such labels (p = 0.046). Regarding status loss, 42.9% (n=3) of ASPD materials emphasized treatment difficulty, compared to none for MDD or GAD (p = 0.031). Additionally, 71.4% (n=5) of ASPD resources omitted information on available treatments, while 42.9% (n=3) did so for MDD and GAD. Although the difference in treatment omission was not statistically significant (p = 1.0), the trend still reflects a bias.

Conclusion
The findings suggest that medical education promotes ASPD stigma, mirroring the disproportionate stigma seen in the general public. The use of stigmatizing language indicates that medical education may perpetuate negative attitudes among healthcare providers. Addressing this stigma is crucial to improving care and outcomes for individuals with ASPD. Further research is needed to explore causality and develop strategies to reduce stigma in medical training.

AMA Research Challenge 2024 

Stigma in Psychiatry Education: A Comparative Analysis of ASPD, MDD, and GAD

## Welcome to EMNLP 2024! 
We are excited to welcome you to one of the most prominent conferences in the field of Natural Language Processing. This year, EMNLP 2024 is being held in a hybrid format,
offering both virtual and in-person participation in beautiful Miami. Due to a record-breaking number of submissions, we've expanded the total number of accepted papers to accommodate more cutting-edge research from around the globe.
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EMNLP 2024

EMNLP 2024 will take place in Miami, Florida from Nov 12th to Nov 16th, 2024, at the Hyatt Regency Miami Hote and on Underline for remote participants.

Background
Antisocial Personality Disorder (ASPD) is one of the most stigmatized psychiatric diagnoses in the public sphere, contrasting with Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD), which are among the least stigmatized. ASPD stigma extends to healthcare, where many providers hold negative attitudes towards patients with ASPD, affecting their willingness to work with this population. Understanding whether medicine perpetuates this stigma is crucial for early intervention in medical training. Given the role of language in perpetuating stigma, as evident in studies on Opioid Use Disorder, this study explored how language contributes to negative attitudes about ASPD in healthcare, an area largely overlooked in stigma research, Psychiatry, and medical education. It aimed to assess medical education resources for stigmatizing language and compare how they reflect public stigma patterns, where ASPD is more stigmatized than MDD and GAD.

Methods
Seven widely used medical education resources were analyzed for their depiction of ASPD, MDD, and GAD. Since many medical students favor third-party resources for studying and board exams, the analysis included Boards and Beyond, AMBOSS, First Aid, First Aid for Psychiatry Clerkship, and APA, as well as in-house materials from Warren Alpert Medical School and the DSM-5. The analysis focused on two stigma components identified by Phelan and Link: labeling and status loss, particularly through clinical pessimism. Fisher's Exact Test compared ASPD to MDD and GAD across labeling, treatment difficulty, and treatment omission.

Results
The analysis revealed significant stigma toward ASPD, with 85.7% (n=6) of the materials using labels like "bad," "manipulative," and "deceitful." Notably, "bad" was used as a mnemonic. In contrast, none of the materials for MDD or GAD employed such labels (p = 0.046). Regarding status loss, 42.9% (n=3) of ASPD materials emphasized treatment difficulty, compared to none for MDD or GAD (p = 0.031). Additionally, 71.4% (n=5) of ASPD resources omitted information on available treatments, while 42.9% (n=3) did so for MDD and GAD. Although the difference in treatment omission was not statistically significant (p = 1.0), the trend still reflects a bias.

Conclusion
The findings suggest that medical education promotes ASPD stigma, mirroring the disproportionate stigma seen in the general public. The use of stigmatizing language indicates that medical education may perpetuate negative attitudes among healthcare providers. Addressing this stigma is crucial to improving care and outcomes for individuals with ASPD. Further research is needed to explore causality and develop strategies to reduce stigma in medical training.

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ChatGPT and other large language models (LLM) present a promising avenue for enhancing medical education due to its advanced text comprehension and generation capabilities. Motivated by the skyrocketing use of ChatGPT and the lack of curricular mention or discussion on how to best utilize LLMs in medical school, this study investigates the integration of ChatGPT into medical education through a single-session workshop.
Methods
Fifty-nine students from the Emory School of Medicine, 80% first- and second-year medical students and 20% physician assistant students, voluntarily participated in a ChatGPT workshop—a one hour session with learning objectives to understand the framework and construction of a LLM (ChatGPT) and develop comfort in using ChatGPT within medical contexts by generating relevant responses to medical queries in simulated scenarios. Thirty minutes was allocated toward a lecture style presentation and another thirty minutes to hands-on use of ChatGPT. Surveys administered before, immediately after, and eight weeks post-workshop assessed participants' comfort with and likelihood of using ChatGPT, as well as their perceptions of its utility in their future medical careers, ranked on a Likert scale.
Results
ChatGPT usage rose from “never used” and “rare” usage for 76% of participants to usage at least one time per week for 82% of participants at 8 weeks post-workshop, with 23% using ChatGPT four or more days per week. Survey results revealed a significant increase in participants' comfort with using ChatGPT immediately after the workshop, with this improvement persisting at the eight-week follow-up (p<0.05). Moreover, participants reported a significantly higher likelihood of utilizing ChatGPT in their future medical practice after attending the workshop (p<0.05) with the greatest proportion of individuals, 64%, using ChatGPT for explanations of pathophysiology.
Conclusion
This workshop highlights the effectiveness and need of education and training in fostering understanding and utilization of AI technologies like ChatGPT. Despite initial hesitancy, participants demonstrated increased comfort and willingness to incorporate ChatGPT into their medical education and practice. The study underscores the potential of integrating ChatGPT into medical curricula to enhance learning experiences, promote interdisciplinary collaboration, and foster critical thinking skills among students. Additionally, it emphasizes the need for further research to explore the long-term impact and ethical considerations of integrating AI technologies into medical education. Overall, integrating ChatGPT into medical education holds significant implications for the future of healthcare training and practice.

Integrating ChatGPT into Medical Education: A Workshop-Based Approach

Background
Clinical simulations have an important role in medical education, allowing students to gain realistic clinical experience in a didactic manner to improve patient interaction and clinical reasoning skills. However, access to simulations is often limited by resources including physical space in simulation centers and time with standardized patients. ChatGPT is a large language model (LLM) artificial intelligence software that is freely accessible online, that has garnered significant attention in the medical community for its ability to generate relatively accurate medical information. We evaluated the ability of ChatGPT to create high-fidelity virtual clinical simulations and provide simulated patient information and feedback across several clinical scenarios.

Methods
We prompted ChatGPT to generate seven clinical scenarios (fractured arm/intimate partner violence, acute appendicitis, aortic dissection, acetaminophen overdose, acute seizure/metastatic lung cancer, COPD exacerbation, and tension pneumothorax) and create interactive simulations including simulated patient history, physical exam discoveries, lab findings, and imaging descriptions. Each scenario was concluded with feedback and repeated in triplicate to assess consistency. Simulation scenarios were graded for fidelity, evaluated by accuracy, realism, and consistency on a 5-point Likert scale (1-2 = poor, 2-3 = low, 3-4 = moderate, 4-5 = high) by three independent physicians holding the academic rank of Full Professor. A one-sample Wilcoxon signed-rank test was used to assess simulation performance based on a threshold criteria of greater than three out of five points. Fleiss’ Kappa was used to assess interrater reliability. All hypothesis testing was performed using a significance level of p<0.05.

Results
Of the seven simulations evaluated, four were rated high fidelity, two were rated borderline high fidelity, and one was rated moderate fidelity regarding simulation accuracy, realism, and consistency. The mean overall score was 4.0, indicating overall high accuracy, realism, and consistency, significantly higher than hypothesized threshold of 3.0 (p < 0.001). There was a high degree of interrater agreement (ordinal weighted Fleiss κ, 0.763; 95%CI: 0.25-1.0, p<0.05).

Conclusion
Overall, ChatGPT was able to consistently generate accurate and consistent virtual clinical simulations. Our study highlights a framework for a novel use case of LLMs in medical education and demonstrates its utility in providing increased accessibility to simulations for medical students. Although LLMs have known limitations in information accuracy, with the rapid advancement of artificial intelligence technology and advent LLMs that can be trained on specific resources, the use of LLMs such as ChatGPT for further simulation-based medical education represents a promising frontier for medical education.

Evaluating the Utility of a Large Language Model in Simulation-Based Medical Education

Background
Implicit bias, or unconscious attitudes towards minoritized groups, among healthcare providers can contribute to disparities in care, health status, and mortality for minoritized patients. One approach to mitigating the negative effects of these biases on patient care is by implementing anti-racism/anti-bias training into medical education. 

Methods
Rising third year medical students participated in a student-led implicit bias and microaggression training program, including experiential learning through standardized patient (SP) encounters and self-reflection via student-led debrief sessions. The SP encounters simulated instances of xenophobia and perceived language barriers in a hospital setting, in which students were expected to address microaggressions in real time utilizing the VITALS (Validate, Inquire, Take time, Assume the best, Leave opportunities, Speak up for others) framework. Participants completed surveys on attitudes regarding implicit bias prior to participating in the program (T1), after the VITALS video presentation (T2), and after the SP encounter and debrief sessions (T3); surveys were adapted from the VITALS study. 

Results
200 students participated in the program of which 135 linked survey sets were collected for all three time points for data analysis. Results showed that from T1 to T3, there were significant improvements in empathy with targets of bias, comfort in sharing experiences and knowledge and skills to counteract microaggressions. There were no differences by race/ethnicity, language exposure, or religious adherence.

Conclusion
Our implicit bias training, equipped students with the tools and practice needed to interrupt microaggressions in the clinical setting and helped improve their understanding and likelihood of engaging in anti-racism allyship.

Efficacy of Standardized Patient Encounters to Reinforce Implicit Bias Training in the Clinical Setting

Background
In recent years, active learning methods have gained attention for improving material retention and teamwork, especially in education. Despite such benefits, learner engagement remains a challenge, prompting exploration into innovative solutions like game-based instruction. By using game principles, educators can sustain learner interest and encourage participation. Building on these principles, the Texas Health Presbyterian Dallas Internal Medicine Residency program implemented a “House Cup” system where points were awarded for educational activities to promote friendly competition and active learning.

Methods
Residents were evenly distributed into six teams. Points were earned based on criteria including: number of admissions on call days, attendance at lectures, Medical Knowledge Self Assessment Program (MKSAP) review, and the number of procedures performed. Data from January through March of 2022, 2023, and 2024 was collected. Surveys were utilized to gather information on the time spent on MKSAP preparation before and after implementation. Qualitative variables were analyzed with chi-square tests; quantitative variables with ANOVA or Kruskal-Wallis. Statistical significance was determined at an alpha level of 0.05.

Results
Prior to the “House Cup” system (pre-group), there was an average of 5.30 admissions (± 1.15). Following implementation (post-group), admissions rose to an average of 7.87 (± 1.68). Lecture attendance remained stable, with a median of 83 (IQR: 70.75-93) in the pre-group and 85 (IQR: 77-93) in the post-group. MKSAP questions completion and review time in the post-group (mode 51+ questions, 4-5 hours) increased compared to the pre-group (mode 0 questions, 0-1 hours). Number of procedures performed in 2024 (54) surpassed both 2022 (7) and 2023 (16).

Conclusion
Our aim was to assess the impact of game-based learning techniques on material retention, engagement, and teamwork within resident education. Integrating game-based learning into educational activities led to increased participation in call day admissions, lecture attendance, MKSAP review, and number of procedures performed. Implementing game-based learning resulted in improved performance across all metrics except lecture attendance, which was already high. These promising results benefit our residency program and offer insights for others seeking to incentivize and motivate residents


Level Up: Exploring the Effectiveness of Game Based Learning in Graduate Medical Education

Abstract Title: Association Between Utilization of Gender-Affirming Care and Insurance Payer, State, and State Policy

Background: Gender-affirming surgery/hormone therapy (GAS/GAHT) play an essential role in improving quality of life for many transgender and gender-diverse (TGD) individuals. Despite increased demand for GAS/GAHT, TGD individuals face many obstacles to care. We investigated the association between utilization rates of GAS/GAHT and insurance payer, state, and state-level nondiscrimination policies, which prohibit health plans from precluding care based on gender identity or expression. With the disparate legislative climate, it is imperative for stakeholders to understand how these factors influence national utilization rates of GAS/GAHT.

Methods: We retrospectively analyzed a cohort of TGD individuals of all ages to characterize GAS/GAHT utilization between 2010-2020 using the PearlDiver-Mariner Database, which contains all-payer claims for 151 million patients in all 50 states and DC. We used binary logistic regressions to evaluate associations between insurance payers (private, Medicaid, Medicare) and GAS/GAHT, while testing for effect modification by individual states. Furthermore, we designed a difference-in-differences analysis to compare GAS/GAHT utilization among those who did and did not live in states that passed policies prohibiting healthcare access discrimination by insurance payers.

Results: 77,366 individuals were included in the study. The distribution of insurance payers was as follows: 77% private, 16% Medicaid, 7% Medicare. GAS/GAHT utilization was highest among the privately insured and lowest among the Medicare subgroups. Individuals covered by Medicaid (OR=0.78,95% CI=0.73-0.83) or Medicare (OR=0.69,95% CI=0.63-0.75) were less likely to undergo GAS compared to the privately insured. Similar differences in GAHT utilization were observed. Effect modification by state was evident in both outcomes. For example, differences in GAHT utilization rates by insurance payers were smaller among those living in Illinois (38% private, 37% Medicaid, 33% Medicare) compared to Idaho (35% private, 15% Medicaid, 23% Medicare). Quasi-experimental analysis suggested that nondiscrimination policies were associated with increased national all-payer treatment utilization, especially GAS, which more than doubled after implementation.

Conclusion: Our study highlights three main findings: 1) Across all states, individuals covered by Medicaid/Medicare received GAS/GAHT less often compared to the privately insured, 2) Some individual states had minimal insurance payer discrepancies in GAS/GAHT utilization, and 3) While these insurance payer differences in utilization remain at the national level, individuals living in states that implemented nondiscrimination policies experienced an increase in GAS/GAHT post-implementation. Overall, nondiscrimination policies implemented in 21 states and DC increased GAS/GAHT utilization, but challenges at the insurance payer and individual state level continue to threaten TGD individuals’ healthcare and lives.

Association Between Utilization of Gender-Affirming Care and Insurance Payer, State, and State Policy

Abstract Title
Analyzing Recruitment Methods to Increase Diversity in Biobank Collections

Background
Biospecimen collection has played an integral role in research by storing valuable data and tissue samples from both patients with diseases, such as cancer and HIV, as well as healthy control specimens for comparison. The results of these studies shed light on the pathogenic processes of diseases, provide risk stratification, validate new diagnostic tools, and develop targeted pharmacotherapies. Including diverse samples from various races, ethnicities, and backgrounds is essential to increase the generalizability of the results of these studies. Traditional university research participants are typically recruited from the student body and surrounding area, which may not accurately represent the demographics of the local population. Our objective was to create a tissue bank from healthy individual blood samples that is representative of the San Antonio, Texas population for use in future research and analyze traditional university research recruitment methods.

Methods
Traditional methods of university recruitment at UT Health San Antonio using campus fliers, posters, emails, and class announcements were implemented. 311 individuals were screened and a total of 101 participants were enrolled. Participants self-reported a medical history without significant health conditions and provided basic demographic information. Tissue samples were acquired from blood draws and then allocated for storage in the repository. Participant demographic data was compared to the 2020 U.S. Census San Antonio population using the chi-squared test. 

Results
There was a statistically significant difference (p < 0.05) from the expected San Antonio demographics and the recruited participants of racial groups (“White/Caucasian”, “Black or African American”, “Asian”, “Native Hawaiian and Other Pacific Islander”, and “Other”) and ethnic groups (“Hispanic/Latino” and “Not Hispanic or Latino”) except for “American Indian/Alaskan Native” (Expected: 2, Actual 2). There was an overrepresentation of participants who identified as “White/Caucasian” (Expected: 61, Enrolled: 78), “Asian” (Expected: 5, Enrolled: 14), and “Not Hispanic or Latino” (Expected: 37, Enrolled: 58). There was an underrepresentation of those who identified as “Black or African American” (Expected: 10, Enrolled: 3) and “Hispanic/Latino” (Expected: 64, Actual 42). Most participants reported “White/Caucasian” (83%).

Conclusion
Advertising research opportunities in universities is an effective way of increasing enrollment at the cost of diversity. The consequences of utilizing tissue samples from a limited demographic could have significant impacts for minorities. To increase the recruitment of the underrepresented, researchers suggest the use of social media, radio advertisements, health fairs, flea markets, churches, community centers, and translated fliers.

Analyzing Recruitment Methods to Increase Diversity in Biobank Collections

Introduction and Background: The need for cultural competency in healthcare is more critical than ever, as healthcare systems must effectively meet the needs of diverse populations. A significant gap exists in providing culturally competent hair care, particularly for patients with textured or curly hair. Currently, BUMC-P lacks inclusive hair care options for these patients, impacting their overall care experience. Inspired by the University of Iowa's successful initiative to develop equitable hair care options for hospitalized patients, this project aims to bridge that gap. Our goal is to enhance patient inclusion by addressing unique hygiene needs and elevating resident cultural competency, ultimately leading to more inclusive and respectful patient care.

Methods/Approach: 72 hair and 72 beard kits were created that included hair oil, wide-toothed combs, satin bonnets, and single-blade razors. Kits were modeled after the University of Iowa initiative. Each kit includes a QR code with which patients complete a patient satisfaction survey. RNs will distribute kits on select BUMC-P inpatient floors to patients with a BMAT score of 4. Survey data will be reviewed at 6 intervals. Kits will be built by residents accompanied by interactive educational sessions on culturally-sensitive healthcare. Pre and post surveys will be used to assess resident cultural competency.

Results: This quality improvement project is ongoing. By providing culturally appropriate hair and skin care products for hospitalized patients, we aim to increase patient inclusion, which may in turn increase patient satisfaction, a key metric in Medicare reimbursement. We anticipate that collaborating with trainees on the design and necessity of these hair and beard kits, trainees will forge personal connections with patients that will improve cultural sensitivity and promote trainee well-being.

Discussion/Conclusions: The Inclusive Hair, Inclusive Care project aims to improve patient sense of inclusion, provider-patient relationships, and resident cultural competency.


The Inclusive Hair, Inclusive Care Project: Enhancing Patient Inclusion and Resident Cultural Competency Through Inclusive Hygiene Products


Background:
Conjunctivitis is a familiar presentation in a pediatrician’s office, but sometimes the cause is less common. Ranging from viral, bacterial, allergic, and nonimmune etiologies, it is our job to take a detailed history and perform a thorough physical exam to determine the best therapy possible while preserving antibiotic stewardship and improving our patients’ outcomes.

Case Presentation:
An 18 year old female presented to clinic for evaluation of worsening right eye redness, swelling, and blurred vision over the span of two weeks. Yellowish drainage in the morning caused her eye to “crust shut”, and though she used warm compresses to wipe it away, the drainage returned quickly. She had rhinorrhea with congestion, but denied fevers. Lubricating eye drops had not been helpful in alleviating her symptoms, and eye movement caused pain as well. When asking about social history, she admitted to being sexually active with inconsistent use of condoms. She did have vaginal discharge. She was afebrile, and physical exam was notable for significant conjunctival injection with copious purulent drainage and mild swelling around her eye. A urine GC/Chlamydia and pregnancy test were ordered along with a culture from the affected eye. The patient was started on ofloxacin 0.3% solution and amoxicillin/clavulanate 875-125 mg while waiting for confirmatory diagnosis and evaluation by an ophthalmologist. Her urine was positive for Gonorrhea the following day, and eventually her eye culture revealed Group A S. pyogenes and beta lactamase negative N. gonorrhoeae. The ophthalmologist agreed on continuing her ofloxacin 0.3% solution while stopping amoxicillin/clavulanate, and going to her pediatrician’s office to receive Rocephin 1000 mg intramuscularly. The patient’s symptoms vastly improved after her antibiotic therapies were completed, and was recommended to follow up with ophthalmology to monitor for any vision changes.

Discussion:
There are different causes for conjunctivitis, viral being the most common in children, however there are cases of conjunctivitis that providers must address in a timely fashion to prevent blindness. Gonococcal conjunctivitis is a severe condition that requires urgent evaluation and treatment by an ophthalmologist due to concerns for corneal perforation leading to scarring and blindness. It is most commonly seen in neonates due to maternal infections, however pediatricians cannot forget that N. gonorrhoeae is the most common cause for bacterial conjunctivitis in sexually active teenagers and adults. Even though this patient was only being seen for conjunctivitis, one must never forget to ask about sexual history for this very reason.

An Unexpected Diagnosis of Conjunctivitis in an 18 Year Old Female

Unveiling Trends and Disparities: A Comprehensive Analysis of Adolescent Births in California - Navigating the Challenges and Prioritizing Adolecent Maternal Health

Background: The adolescent birth rate in the United States, measured as births per 1,000 females aged 15 to 19 years, has steadily declined since 1991, reaching a historic low of 16.7 per 1,000 females in 2019. Despite this positive trend, teenage pregnancy continues to pose significant social and health challenges, manifesting in heightened rates of maternal high school dropout, birth complications, infant mortality, adolescent incarceration, and chronic childhood medical conditions. This study aims to examine recent trends in teen birth prevalence, identifying associated risk factors and disparities in the state of California.

Methods: Conducted as a retrospective cohort study, we analyzed 372,352 teen births out of the 5,137,376 resident live births (7.25%) documented in the California Birth Statistical Master Files (BSMF) spanning from 2007 to 2016. Age at birth was categorized as 15 to 19 years, with a reference category of 20 to 29 years. The study investigated various birth outcomes, including low birth weight (LBW), very low birth weight (VLBW), preterm birth (PTB), very preterm birth (VPTB), small-for-gestational-age birth (SGA), large-for-gestational-age birth (LGA), and cesarean delivery (CD). Utilizing descriptive analysis, simple linear regression, and multivariate logistic regression (MLR), we calculated adjusted odds ratios (AORs) with 95% confidence intervals (CIs) to explore associations. The MLR analysis specifically delved into predictors of teen pregnancy, referencing mothers aged 20 to 29 years.

Results: While the teenage pregnancy rate exhibited a linear decline (p < 0.001) from 40.1 in 2007 to 15.8 in 2016 (per 1,000 females), certain maternal characteristics witnessed an increase over time. Adjusted odds ratios revealed that women with less than a high school education and those with a high school diploma had a 9.0-fold and 3.3-fold higher prevalence of teen births, respectively, compared to women with some college or an associate degree. Hispanic women were twice as likely to experience teen births compared to White women. Teen mothers were nearly 50% more likely to rely on Medi-Cal (public health insurance) and 46% more likely not to receive first-trimester prenatal care. Importantly, they were 43% more likely to be underweight.

Conclusion: Our findings emphasize the need to address racial and ethnic disparities and improve birth outcomes among adolescent births. Policymakers should prioritize ensuring pregnant adolescents have access to high-quality maternal health services, encompassing both pre and postnatal care, to safeguard the health of both mothers and infants in the years ahead.

Unveiling Trends and Disparities: A Comprehensive Analysis of Adolescent Births in California

Abstract Title
A Heart Under Siege: The Uncommon Tale of Salmonella Endocarditis 
Background
Infective endocarditis (IE) is an infection of the innermost layer of the heart, typically caused by bacteremia localized with platelets, fibrin, and inflammatory cells that form a vegetation on a heart valve. It is generally caused by gram-positive bacteria such as Staphylococcus aureus, Streptococci viridians, Enterococci, and coagulase-negative Staphylococci, with gram-negative pathogens accounting for a small fraction of IE cases. This case report highlights the presentation, diagnostic work-up, treatment, and outcome of a patient with the rare condition of Salmonella infective endocarditis.

Case Presentation
A 59-year-old male presented to the emergency department with decreased appetite, weakness, and altered mental status. He was initially diagnosed with pneumonia and Salmonella bacteremia and started on an antibiotic regimen. His hospital course was further complicated by a CT scan revealing a splenic abscess and a brain MRI showing multiple cerebral infarctions, both caused by septic emboli. Interventional radiology and neurology were consulted for these complications. A transesophageal echocardiogram (TEE) showed a 1.0 cm mitral valve vegetation. Infectious disease was consulted for antibiotic recommendations to manage the bacteremia while the patient awaited mitral valve replacement, as recommended by cardiothoracic surgery.
The patient, with a significant past medical history of heart failure, diabetes, hypertension, and 30-year smoking, initially presented with tachypnea, marked leukocytosis, and elevated lactic acid levels. Blood cultures revealed Salmonella non-typhi, prompting a switch to Ceftriaxone. The patient developed encephalopathy and altered mentation, with a brain MRI showing multiple tiny infarcts. A diagnosis of Salmonella infective endocarditis with septic embolization was confirmed via TEE.
A multidisciplinary approach involving interventional radiology, infectious diseases, neurology, and cardiothoracic surgery led to the decision for mitral valve replacement and concurrent coronary artery bypass grafting. Postoperatively, the patient developed atrial fibrillation, managed with an amiodarone drip and eventual cardioversion. He was discharged with an anticoagulant and follow-up plan.
At follow-up visits, the patient was stable, compliant with medications, and reported no new symptoms. His INR was closely monitored, and he was educated on the importance of medication adherence following mitral valve replacement. He was referred to occupational and physical therapy, as well as neurology, for his history of cerebral infarctions.

Discussion
This case underscores the importance of clinical suspicion, immediate symptom treatment, interdisciplinary collaboration, and tailored therapeutic interventions in managing rare cases of infective endocarditis. This report serves as a guide for clinicians encountering similar pathologies, highlighting the critical role of prompt microbiological investigations and tailored treatment regimens in improving patient outcomes.



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