United States

Background
Normal pressure hydrocephalus (NPH) is commonly treated with ventriculoperitoneal shunting, though shunt revisions remain a frequent complication and wound dehiscence, albeit rare, may lead to full revision surgery. The Valve-Agnostic Cranial Implant (VACI, “InvisiShunt®” Longeviti, Inc.), is designed to countersink ventriculoperitoneal shunt valves, to reduce dehiscence and the need for revision. These were first implanted in 2019 and offer a low-profile alternative to traditional subgaleal shunt placement. However, only one prior clinical trial report of its use exists to date (n=25). This case series of twenty-five patients seeks to add to the existing literature on VACI efficacy in NPH patients.
Methods
Twenty-five patients diagnosed with NPH underwent implantation of the VACI (InvisiShunt®), at a mean age of 76.4 ± 10.1 years. This case series was conducted at Hoag Medical Center, Newport Beach, CA, USA, from November 2022 to March 2023. Follow-up ranged from 4 to 24 months. Patient demographics, comorbidities, preoperative symptoms, surgical details, postoperative outcomes, and complications were collected and analyzed.
Results
No intraoperative complications occurred. Six patients demonstrated either altered mental status, abdominal pain, or generalized weakness, unrelated to the implant. There were no infections reported within the 30-day post-operative period and up to 24 months of follow-up. There was one incidence of wound dehiscence that necessitated full revision surgery. Patients underwent an average of 2.3 ± 1.4 reprogramming events. Post-operative outcomes included improvements in gait disturbance (n=18; 72.0%) and urinary incontinence (n=9; 36.0%), and cognitive disturbances (n=8; 32%).
Conclusion
Our findings support the potential of VACI as a viable and safe low-profile alternative to traditional subgaleal shunt valve placement for NPH treatment, with no increase in morbidity. Further research with extended follow-up is needed to confirm these preliminary results and evaluate long-term efficacy.

AMA Research Challenge 2025 

Valve-Agnostic Cranial Implant (InvisiShunt®) in Normal Pressure Hydrocephalus Ventriculoperitoneal Shunting: A Case Series

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Objectives:
• Recognize histiocytoid Sweet syndrome (HSS) as a potential dermatologic manifestation of MDS and AML.
• Assess the role of hypomethylating agents (decitabine and azacitidine) in triggering HSS.

Introduction:
Sweet syndrome (SS) is an acute febrile neutrophilic dermatosis, and its histiocytoid variant (HSS) is a rare, yet increasingly recognized form characterized as an infiltrate of immature myeloid cells that resemble histiocytes. Common triggers of HSS discussed in literature include underlying hematologic malignancies, especially MDS, as well as certain drugs, including hypomethylating agents [1, 2, 3, 4]. These cases mainly focus on the initial presentation of HSS but to our information, no published case reports have described occurrence and recurrence of HSS by two distinct hypomethylating agents.
We present a case of elderly female patient with MDS with progression to AML who initially presented with biopsy-diagnosed HSS and had recurrence of HSS after initiation of Azacitadine. Recognizing this rare syndrome and its common triggers can have significant diagnostic and therapeutic implications.

Case Presentation:
An 83-year-old woman with a history of DCIS and newly diagnosed MDS-EB-2, who had completed her first cycle of decitabine one week earlier, presented with a painful ulcerative lesion on the left lower extremity along with widespread purple papules and plaques. A skin punch biopsy demonstrated histiocytic and neutrophilic inflammation consistent with the diagnosis of Histiocytoid Sweet syndrome. Patient was initially treated with topical steroids with improvement of her dermatologic symptoms. Of note, during this time, patient did not receive any additional Decitabine therapy and had lab findings significant for 28% blasts, consistent with progression of disease to AML. Given new diagnosis AML, patient was started on Azacitidine (and Venotoclax) with recurrence and worsening of her rash requiring topical and oral steroids.

Discussion:
This case highlights several important and underrecognized aspects of histiocytoid Sweet syndrome (HSS) in myeloid malignancies. HSS is most often triggered by underlying hematologic disease, such as MDS or AML, and by certain chemotherapy agents. While decitabine and azacitidine have both been linked to Sweet syndrome, we found no prior reports of sequential HSS flares from two different hypomethylating agents in the same patient.
Our patient first developed biopsy-proven HSS shortly after receiving decitabine and during progression of MDS to AML. The timing suggests that both the progression of her leukemia and exposure to decitabine may have played a role. It remains unclear whether worsening hematologic disease itself increases the risk of HSS, or whether drug exposure simply unmasks the underlying inflammatory response.
The second episode, following initiation of azacitidine, is also notable. While azacitidine-induced Sweet syndrome has been documented, recurrence with another hypomethylating agent has not been reported. Our case suggests that in some patients, the broader class of hypomethylating agents may predispose to recurrence of HSS, especially when underlying disease is active.
Overall, this case adds to the limited literature on drug-induced HSS and raises important clinical questions: Does disease progression increase susceptibility to Sweet syndrome? Should clinicians be cautious about recurrence of Sweet syndrome when re-exposing patients to similar hypomethylating agents? Answering these questions will require further study, but awareness of this potential complication is key to early recognition and treatment.

Sweet Troubles in AML: Sequential Histiocytoid Sweet Syndrome Triggered by Hypomethylating Therapy

Background
Acute appendicitis is a common condition that classically occurs with periumbilical pain that radiates to the right lower quadrant, accompanied by nausea, vomiting, fever, and decreased oral intake. But in patients with complex abdominal surgical history, anatomical defects can lead to atypical presentations. Here, we have acute appendicitis in an 82-year-old male with a prior Whipple procedure and cholecystectomy, who presented without "typical" appendicitis symptoms.

Case Presentation
An 82-year-old man with a history of pancreatic cancer (status post-Whipple procedure), prostate cancer, and cholecystectomy was seen from a referral hospital with five days of fevers and progressively worsening intake. He complained of no abdominal pain aside from a chronic, years-long, postoperative gassy distress. Leukocytosis (WBC 20,000) and positive blood cultures for Klebsiella were found upon initial presentation to our hospital. His abdominal ultrasound was normal as well. However, CT imaging, which was only ordered once he got to VAMC, found a dilated appendix that was suspicious for an acute appendicitis. Due to his surgical history, the appendix was possibly seen to be in an ectopic location, posterior to his liver. It was deemed he was not an optimal candidate for surgery due to his age and history of prior abdominal operations. Nonoperative treatment with IV antibiotics was initiated subsequently. Over the course of a week, he came with clinical improvement with resolution of leukocytosis and was discharged in stable condition.

Discussion
This case illustrates the diagnostic challenge of appendicitis in patients with altered surgical anatomy. Classic migratory pain to the right lower quadrant is a reliable predictor of appendicitis, but this patient lacked this presentation due to post-surgical anatomical change, as well as his abdominal pain presenting as a years-long, chronic, non-specific bloating pain. As a learning point, one must have a high index of suspicion for appendicitis in elderly patients with extensive surgical history with ambiguous systemic symptoms, and manage appropriately. Initial imaging is crucial to avoid delayed diagnosis and appropriate guiding treatment.


Atypical Presentation of Acute Appendicitis in an 82-Year-Old Man with Complex Surgical History

Background
Angelman Syndrome (AS) is a rare neurogenetic disorder caused by maternal UBE3A dysfunction, resulting in intellectual disability, hypotonia, ataxia, epilepsy, and language impairment. Antisense oligonucleotide (ASO) therapy is an investigational approach that aims to restore UBE3A expression by reactivating the normally silenced paternal allele. Early trials suggest intrathecal ASO infusions are generally well tolerated, but pediatric neurological complications remain underreported. We present a case of transient cauda equina radiculopathy after intrathecal ASO infusion in a child with AS and Autism Spectrum Disorder (ASD), emphasizing diagnostic and management challenges in nonverbal children with developmental delays.

Case Presentation
The patient was a 9-year-old male with a history of AS, ASD, and a tonic-clonic seizure. At baseline, he was nonverbal, used fewer than five words or signs, and had inconsistent verbal comprehension. He ambulated independently with a wide-based gait and climbed stairs with one hand. He exhibited hypotonia, required assistance with dressing, and lacked bladder control. Four weeks after intrathecal ASO infusion in a clinical trial, he developed progressive unsteadiness, difficulty climbing stairs, and behavioral changes including irritability, clinginess, and movement anxiety. No trauma, seizure activity, or regression were reported. The exam showed symmetrical facial movements, intact cranial nerves, wide-based gait, normal reflexes, and no focal deficits. Imaging revealed mild diffuse enhancement of multiple cauda equina rootlets on lumbar spine MRI, consistent with radiculopathy. Brain MRI and X-rays were unremarkable. Lumbar puncture showed no pleocytosis, and autoimmune and cytokine panels were negative. Differential diagnoses considered included post-infectious cerebellar inflammation, unwitnessed injury, and UBE3A progression. All were ruled out clinically and radiographically. Initial management with steroids and benzodiazepines was ineffective and gabapentin provided temporary relief. A course of intravenous immunoglobulin (IVIG) with continued gabapentin led to gradual resolution of symptoms and return to baseline.

Discussion
This case illustrates cauda equina radiculopathy as a rare potential complication of intrathecal ASO therapy. Preclinical data suggest repeated ASO infusions may provoke spinal immune activation, leading to inflammation and nerve root compression. Other mechanisms include procedural trauma, direct neurotoxicity, or hypersensitivity. In nonverbal children, behavioral changes such as irritability or clinginess may indicate neurologic complications. Due to communication barriers, clinicians should maintain a high index of suspicion following intrathecal procedures. Early recognition and evaluation, including imaging and labs, support timely intervention to prevent irreversible outcomes such as bladder dysfunction or paralysis. This case underscores the importance of behavioral monitoring in nonverbal patients as early indicators of neurologic injury.

Cauda Equina Radiculopathy After Intrathecal ASO Infusion in an Adolescent with
Angelman Syndrome

Background :
Herpes simplex virus (HSV) esophagitis is an uncommon condition, typically occurring in immunocompromised individuals. It presents with inflammation and ulceration of esophageal mucosa. Both HSV-1 and HSV-2 can be implicated. Prompt diagnosis and treatment are essential to prevent complications. 

Case Presentation :
We report a case of a 57-year-old female with a history of mixed connective tissue disorder and Raynaud’s phenomenon, currently on corticosteroid therapy. She presented with a two-month history of progressive dysphagia to both solids and liquids, odynophagia, and significant weight loss. Physical examination revealed pallor. Laboratory investigations showed anemia (Hb: 8.5 g/dL), leukopenia (TLC: 2800/mm³), and thrombocytopenia (Platelets: 110,000/mm³). Upper gastrointestinal endoscopy revealed superficial ulcers with exudates throughout the esophagus. Histopathological examination of biopsy samples showed characteristic features of HSV infection, including multinucleated giant cells, ground-glass nuclei, nuclear molding, and intranuclear inclusions with perinuclear halo. A diagnosis of HSV esophagitis was confirmed. The patient was treated with oral acyclovir 800 mg QID for 21 days, resulting in clinical improvement and endoscopic healing of esophageal ulcers. 

Discussion:
HSV esophagitis should be considered in immunocompromised patients presenting with odynophagia, dysphagia, and weight loss. Diagnosis is established through endoscopy and histopathological confirmation. Early initiation of antiviral therapy is effective and leads to favorable outcomes. This case highlights the importance of maintaining a high index of suspicion for HSV esophagitis in at-risk populations.


A Case of Herpes Simplex Esophagitis

Background 
The CDC reports that 15% of Americans live in rural areas (population <50,000). Rural residents are generally older, have higher rates of chronic illnesses like osteoarthritis, and experience more musculoskeletal injuries than urban populations. Unfortunately, local access to both urgent and elective orthopaedic care in these areas remains limited. 

Despite residency program expansion, the shortage of rural orthopaedic surgeons persists. From 2013 to 2018, the total number of orthopaedic surgeons grew by 1.9%, but the proportion practicing in rural areas declined by 0.9%. Little data exists on why orthopaedic residents aren’t choosing rural practice despite the clear need. 

This study aims to explore orthopaedic surgery residents’ views on rural practice and the key factors influencing their decisions, providing insights for educators and healthcare leaders addressing rural orthopaedic care gaps. 


Methods 
A 22-question survey was created in REDCap. Questions captured basic individual demographic information, information about the participant’s training program, future practice plans, interest in rural practice, and reasons for or against practice in rural areas. Interested orthopaedic surgery residency Program Directors (PD) at various institutions were identified through the Collaborative Orthopaedic Education Research Group’s (COERG) database. A letter of invitation to participate was sent to the program directors at interested institutions. 

Of the 29 program directors expressing interest in the study, 16 (55.17%) confirmed they had forwarded the survey to their trainees. Demographics were compared by responses to interest in future rural practice: yes, no, and maybe (have or haven't considered rural practice). 


Results 
107 orthopaedic surgery residents (25 women, 82 men) of a total of 404 (response rate 26.7%) completed the survey. Results are shown in Table 1. Only 6 respondents (5.6%) plan to practice in rural areas, with 3 planning full-time rural practice. Thirty-two (30%) reported no interest in rural practice. 
There were no significant differences in rural practice interest based on gender or parental status. However, residents from hometowns with populations under 50,000 were more likely to consider rural practice. 
The main reasons for choosing rural practice were growing up in rural areas, proximity to family, and recreational opportunities. Reasons against it included limited recreation, family preferences, and personal wellbeing (Table 2). 


Conclusion 
Given the prevalence of orthopaedic conditions among those living in rural America, there is a need for more orthopaedic surgeons to practice in these areas. Addressing this issue is complex and will require collaboration at all levels- including medical schools, local community leaders, orthopaedic surgeons, and professional associations.

The Future of Rural Orthopaedic Practice: A COERG Resident Survey

Introduction:
Residency salaries are typically standardized within institutional programs, yet the cost of living (COL) varies widely across the United States. These regional disparities can affect the surplus income that residents have available for personal use, a factor that students may consider. This study aims to analyze the relationship between PGY-2 salaries and the COL across physical medicine and rehabilitation (PM&R) programs in the United States. 
Methods:
PGY-2 salary data were primarily obtained from the 2024-2025 academic year (n=107), with a small proportion from 2023-2024 and 2025-2026 (n=3 for both), from program websites (n = 113). The annual COL for 2025 was obtained using the Massachusetts Institute of Technology (MIT) Living Wage calculator based on the program county. The surplus income and percentages were calculated using the salary and COL. Correlation and regression analyses were conducted to assess the relationship between salary, COL, and surplus income. The programs were grouped by the U.S. Census geographic regions for subgroup analyses. ANOVA and effect sizes were calculated for regional effects. 
Results:
The average PGY-2 salaries, COL, surplus income, and surplus percentages were $70,766, $50,113, $20,653, and 29% respectively. Correlation analysis revealed a moderate positive association between salary and COL (r=0.58), moderately negative association between surplus percentage and COL (r= -0.64), and a weak positive association between surplus percentage and salary (r=0.25). Regression found that COL was a significant predictor of surplus income (adjusted R2 = 0.54, p<0.0001), with the West showing a significantly lower adjusted surplus compared to the Southeast (p<0.0001). Surplus percentage across U.S. regions was significantly different (F(4,108) = 6.65, p<0.0001, n2 = 0.2), with geographic region having a large effect on cost-adjusted surplus income. 
Conclusion:
PM&R PGY-2 salaries, COL, surplus income, and surplus percentages varied significantly geographically across the U.S. Although salaries moderately correlate with COL, they do not provide equitable surplus income for residents.

Geographic Variations in ACGME PGY-2 PM&R Residency Program Salaries Compared to Cost of Living

Persistent Racial and Ethnic Disparities in Aortic Aneurysm and Dissection Mortality in the 
United States, 2018-2023: A Population-Level Analysis Using CDC WONDER 
Background: 
Aortic aneurysm and dissection (AAD) are life-threatening vascular conditions requiring rapid diagnosis and treatment to prevent mortality. While technological advancements in care have improved outcomes overall, access to these resources remains unequal. Prior studies have documented racial disparities in cardiovascular outcomes, but data specifically examining mortality trends in AAD remain limited. This study evaluates racial and ethnic disparities in AAD mortality in the United States from 2018 to 2023, reflecting broader structural barriers in healthcare access. 
Methods: 
We extracted mortality data for aortic aneurysm and dissection (ICD-10 I71) from the CDC WONDER Underlying Cause of Death database for 2018–2023. Age-adjusted mortality rates (AAMR) per 100,000 population were calculated using the direct method, standardized to the 2000 U.S. standard population. Mortality rates were stratified by race/ethnicity using CDC defined categories: American Indian/Alaska Native, Asian, Black/African American, Native 
Hawaiian/Pacific Islander, White, and Multiracial. Trends were analyzed descriptively using CDC WONDER query tools. 
Results: 
From 2018 to 2023, there were 59,300 AAD-related deaths nationwide, with an overall AAMR of 2.5 per 100,000. Black or African American individuals experienced the highest AAMR at 2.8 per 100,000, increasing from 2.8 in 2018 to 2.9 in 2023. White individuals accounted for the largest absolute number of deaths (n=49,508) with a stable AAMR of 2.4 per 100,000. American Indian/Alaska Native populations showed a notable rise in AAMR from 1.1 to 1.4 per 100,000 over the study period. Asian individuals maintained a stable rate of 1.6 per 100,000. Native Hawaiian/Pacific Islander populations had limited data but demonstrated a high cumulative AAMR of 2.8 per 100,000. Multiracial individuals had the lowest AAMR at 1.5 per 100,000. 
Conclusion: 
Racial and ethnic disparities in AAD mortality persist in the United States, with Black and American Indian/Alaska Native populations bearing disproportionate mortality burdens. These findings highlight the urgent need for targeted interventions addressing systemic inequities in emergency vascular care, including access to timely diagnosis, specialized surgical care, and broader social determinants of health.

Persistent Racial and Ethnic Disparities in Aortic Aneurysm and Dissection Mortality in the United States, 2018-2023: A Population-Level Analysis Using CDC WONDER

Background
After undergoing major surgery, 7-15% of patients experience postoperative complications, with a mortality rate of up to 5%. Since the total number of major surgeries continues to increase, improving postoperative outcomes has become a priority for advancing patient health and reducing medical costs. One method to reduce complications and length of hospital stay is by increasing preoperative cardiovascular fitness (CVF). Increased CVF may allow an individual to better tolerate other physical stresses, such as major surgery. This study aims to explore how preoperative CVF, self-reported by patients as the Exercise Vital Sign (EVS), relates to postoperative outcomes in patients undergoing mixed-major abdominal surgeries (ventral hernia repair, cholecystectomy, appendectomy, and colonic resection). It is hypothesized that patients who report higher levels of preoperative cardiovascular exercise will experience fewer postoperative complications compared to lower levels of reported preoperative cardiovascular exercise.

Methods
Data was gathered from 14254 de-identified patients who underwent major abdominal surgeries using data from a major hospital system. Exercise Vital Sign was evaluated at three thresholds: 0, 75, and 150 minutes of cardiovascular exercise per week. Postoperative outcomes, including complications (hematoma, abscess, infection, and internal bleeding), emergency department visits, critical care admissions, infusion therapy, and general health management, were identified via CPT codes. A multinomial logistic regression was performed. Comorbidities (cancer, diabetes, obesity, and hypertension) and length of stay were controlled for. 

Results
The results show a significant association between increased exercise and lower predicted probabilities of life-threatening CPT categories, particularly as weekly exercise increased from 0 to 75 minutes in patients with one or less comorbidities. Higher risk patients, those with multiple comorbidities, showed the greatest benefit as weekly exercise increased from 75 to 150 minutes per week with the risk of complication dropping from 0.11 at 75 minutes to nearly 0 at 150 minutes. All patient profiles showed a shift away from life-threatening care towards preventive care.

Conclusion
Modest levels of exercise were significantly associated with a sharp reduction in life-threatening postoperative outcomes across all patient profiles. Most patients benefitted by achieving 75 minutes of cardiovascular exercise per week; moreover, higher risk patients had additional benefits of achieving 150 minutes of cardiovascular exercise per week. Thus, preoperative exercise counseling could be an effective, low-cost intervention to reduce postoperative complications. Future policies could incentivize physical activity promotion as part of surgical quality improvement initiatives and integration of collecting exercise data in routine healthcare visits.


Understanding the Association between Preoperative Exercise Level and Post-Operative Outcomes of Mixed-Major Abdominal Surgery


Abstract Title: Barriers to Breast Cancer Screening Adherence Among African American Women in Michigan 
Author’s: Miranda Goodson B.S., Whitney Bowyer B.S., Anna Lundh B.S., Dr. Laura Benjamins M.D. 

Background 
African American (AA) women have lower adherence to breast cancer screening guidelines, which may contribute to delayed diagnoses and reduced survival rates. The importance of examining studies focused on the experiences of Black women within urban healthcare networks is essential to understanding the links between demographics, socioeconomic status (SES), and breast cancer outcomes. 

Methods 
A systematic literature search was conducted using Ovid Medline. The search string included terms such as “Black or African American,” “Breast Neoplasms,” and “Treatment Outcomes.” Inclusion criteria for the articles focused on studies published from 2014 to 2024 and included cohort studies, case-control studies, and other observational studies. The search yielded 24 articles which were reviewed and assessed for racial disparities and treatment outcomes within this population. 

Results 
Six articles reviewed the prevalence of triple-negative breast cancer, finding that AA women are affected at higher rates. Five articles highlighted SES disadvantages leading to worse health outcomes by limiting access to preventative care services and delaying diagnosis. The historical discrimination of AA patients in healthcare has also fostered hesitation towards seeking these services. Differences in lived experiences contributed largely to lower-quality care. Five studies examined implicit bias and mistrust in the physician-patient relationship, contributing to a compounded delay in diagnosis. The studies reported that physicians with high implicit bias often conducted shorter visits and were less engaged with AA patients. This can extend to decisions regarding preventative care, leading to fewer referrals for genetic and critical screenings compared to other patients. 

Conclusion 
This initial review highlighted how health disparities impact breast cancer screening, treatment and survival rates among Black women. In the next research phase, the attitudes toward mammogram screening will be explored by directly surveying patients. 



Barriers to Breast Cancer Screening Adherence Among African American Women in Michigan

Asthma is a chronic respiratory condition characterized by difficulty breathing, wheezing, and coughing. According to the United States Centers for Disease Control and Prevention (CDC), around 6 million children in the US have asthma. The asthma hospitalization rate for pediatric patients has been shown to be significantly higher in certain racial/ethnic groups. Socio-environmental factors play a role in the perpetuation of healthcare disparities and inequities across racial groups. Despite global clinical advances in asthma management and exacerbation prevention, asthma disproportionately affects Black and Hispanic/Latino children as compared to their White peers. This study aimed to examine racial and ethnic disparities in pediatric asthma hospital admissions and readmissions

We conducted a retrospective analysis using electronic medical record data from Loma Linda University Children’s Hospital (LLUCH). Variables examined included admission and discharge dates, date of birth, sex, and race/ethnicity. The target population was pediatric patients admitted to LLUCH in 2023 with a diagnosis of moderate persistent or severe persistent asthma. Patients were assigned to one of three racial/ethnic groups: Black, White, or Latino. Outcome variables were (1) asthma hospital admissions and (2) asthma readmissions. We conducted statistical analysis by calculating summary statistics and examining differences across racial/ethnic groups using chi-square analysis.

Out of 140 total admissions, 40 were Black, 80 were Latino, and 20 were White. When comparing the proportion of admissions to the expected proportion based on regional demographics, pairwise chi-square analyses revealed significantly higher asthma admission rates among Black children compared to White and Latino children (p < 0.01), and among Latino children compared to White children (p < 0.01). There was also a significantly higher asthma readmission rate among Black children compared to White children (p = 0.03), and among Latino children compared to White children (p = 0.05), with no significant difference between Black and Latino children (p = 0.32)

This study demonstrated continued disparities in pediatric asthma care. Our findings demonstrate that Black and Latino children have significantly more asthma admissions and readmissions as compared to White children. Speculative reasoning for why these racial/ethnic inequities exist include provider biases and limited geographical access to providers for follow-up. Limitations of this study include the small sample size within a single hospital system and that chance of misclassification of race/ethnicity, both of which could introduce bias into the results. Future steps include a QI project to promote asthma follow-up of Black and Latino patients with primary care providers and/or specialists 


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Sweet Troubles in AML: Sequential Histiocytoid Sweet Syndrome Triggered by Hypomethylating Therapy

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