United States

Abstract Title
Adverse Childhood Experiences and Temporal Discounting in Older Adults

Background
Traumatic events experienced in the first 18 years of life, known as adverse childhood experiences (ACEs), are associated with an increased burden of chronic disease. ACEs have been shown to impact brain regions associated with impulsivity and may play an important role in an individual’s ability to delay reward. Temporal discounting is the tendency to prefer more immediate rewards over delayed gratification, and higher discounting has been implicated in poor chronic disease management. To better understand how adversity early in life could complicate chronic disease management, we examined the association between ACEs and temporal discounting in older adults. We hypothesized that a higher total number of ACEs will have a greater effect on future temporal discounting.

Methods
We conducted a cross-sectional analysis of self-reported ACEs and temporal discounting using previous cohort data in the Rush Alzheimer’s Disease Center on 834 participants 65 years and older (mean age 80, 86% white, 12.4% African American, 76% female). ACEs were measured with a 16-item trauma questionnaire and summed into a total ACE score (composite measure z- score) and five categories (principal component analysis): family separation/problems, emotional neglect, financial need, parental violence, and parental intimidation. Small scale (α) and large scale (A) temporal discounting was measured at baseline and assessed via a standard preference elicitation protocol of a 7-question binary choice task between smaller immediate versus larger delayed rewards. Cross-sectional analysis was conducted using R Statistical Software, ANOVA, and Poisson regression.

Results 
Higher total ACE scores were significantly associated with steeper temporal discounting: A (β = 0.077, SE = 0.028, p = 0.006) and α (β = 0.0022, SE = 0.0010, p &lt; 0.001). Among ACE categories, parental violence showed the strongest effects on both A (β = 0.090, SE = 0.027, p = 0.001) and α (β = 0.0022, SE = 0.00070, p = 0.002) and was dose-dependent with a 14.8% (A; p-value &lt; 0.001) and 15.4% (α; p-value = 0.001) increase in discounting per unit of parental violence. Race was also associated with discounting, while years of higher education, male sex, and high global cognition had protective effects.

Conclusion
These findings suggest that ACEs, particularly parental violence, are associated with diminished ability to delay gratification in later life. This supports the hypothesis that early adversity has a significant and dose-dependent effect on temporal discounting. Further studies are warranted to further explore these implications on health behaviors and chronic disease management and to inform interventions.

AMA Research Challenge 2025 

Adverse Childhood Experiences and Temporal Discounting in Older Adults

### Welcome to CogSci Conference 2025!

The 47th Annual Meeting of the Cognitive Science Society was a hybrid meeting held in San Francisco. 

<div style="position:relative;padding-top:0;width:900px;height:500px;"><iframe style="position:absolute;border:none;width:100%;height:100%;left:0;top:0;" src="https://online.fliphtml5.com/ebtyf/amvr/"  seamless="seamless" scrolling="no" frameborder="0" allowtransparency="true" allowfullscreen="true" ></iframe></div>

#### About

The Cognitive Science Society brings together researchers from around the world who hold a common goal: understanding the nature of the human mind. The mission of the Society is to promote Cognitive Science as a discipline, and to foster scientific interchange among researchers in various areas of study, including Artificial Intelligence, Linguistics, Anthropology, Psychology, Neuroscience, Philosophy, and Education.

The Society is a non-profit professional organization and its activities include sponsoring an annual conference and publishing the journals Cognitive Science and TopiCS.

#### Our History 

* **Society Creation**<br>
The Society was incorporated as a 501(c)(3) non-profit professional organization in Massachusetts in 1979. The organizing committee included Roger Schank, Allan Collins, Donald Norman, and a number of other scholars from psychology, linguistics, computer science, and philosophy. 
<br><br>
* **Conference Creation**<br>
The first conference on cognitive science was held at La Jolla, California in August, 1979, and has occurred annually since then. The proceedings of each conference are published, and those from most years are available through Lawrence Erlbaum Associates, Inc. The annual proceedings of the Cognitive Science Conference represent a major source of information on new work and new ideas in the scientific study of thinking. In 1990, the Society, with help from an anonymous donor, established the David Marr Prize for the best student paper at each annual meeting.
<br><br>
* **Journal Creation**<br>
The Journal, Cognitive Science, began publication in 1976, and is now published by Wiley-Blackwell. The Executive Editor is currently Richard P. Cooper of Birkbeck, University of London, and there are 18 Associate Editors and a 30-member editorial board. It serves as the premier outlet for research reports that intersect two or more disciplines. Copyrights for articles published in the journal are held by the Society. The Governing Board of the Cognitive Science Society voted in late 2006 to found a new journal, Topics in Cognitive Science (topiCS). The Editor in Chief is Wayne Gray, Cognitive Science Department, Rensselaer Polytechnic Institute. The journal seeks to fill a niche not occupied by Cognitive Science Journal or other cognitive science journals. Membership in the Society includes a subscription to Cognitive Science and TopiCS. Copyrights for articles published in the journal are held by the Society.
<br><br>

#### Code of Conduct

By attending the CogSci 2025 Conference, you are required to adhere to the society’s **[Code of Conduct](https://drive.google.com/file/d/1ChPuihLy6jE_BWqfO7J2KKgX35JW2zsM/view?usp=sharing)**.
<br><br>


You need to log in with the email address you registered with. 

Login credentials were sent to you from Underline -  subject line "Welcome to the CogSci 2025 Conference". Please be sure to check your spam/promotional inbox  if you do not see an email confirmation right away.





Please log in to join this event.

To access the site, please register [**here**](https://cognitivesciencesociety.org/registration/).

If you are registered and feel like you are seeing this message by mistake, please make sure you are logged in with the same email that you registered with. 

Please register!

CogSci 2025

The 47th Annual Meeting of the Cognitive Science Society presents the latest research across cognitive science and highlights the theme of Cognition in Context.

Abstract Title
Adverse Childhood Experiences and Temporal Discounting in Older Adults

Background
Traumatic events experienced in the first 18 years of life, known as adverse childhood experiences (ACEs), are associated with an increased burden of chronic disease. ACEs have been shown to impact brain regions associated with impulsivity and may play an important role in an individual’s ability to delay reward. Temporal discounting is the tendency to prefer more immediate rewards over delayed gratification, and higher discounting has been implicated in poor chronic disease management. To better understand how adversity early in life could complicate chronic disease management, we examined the association between ACEs and temporal discounting in older adults. We hypothesized that a higher total number of ACEs will have a greater effect on future temporal discounting.

Methods
We conducted a cross-sectional analysis of self-reported ACEs and temporal discounting using previous cohort data in the Rush Alzheimer’s Disease Center on 834 participants 65 years and older (mean age 80, 86% white, 12.4% African American, 76% female). ACEs were measured with a 16-item trauma questionnaire and summed into a total ACE score (composite measure z- score) and five categories (principal component analysis): family separation/problems, emotional neglect, financial need, parental violence, and parental intimidation. Small scale (α) and large scale (A) temporal discounting was measured at baseline and assessed via a standard preference elicitation protocol of a 7-question binary choice task between smaller immediate versus larger delayed rewards. Cross-sectional analysis was conducted using R Statistical Software, ANOVA, and Poisson regression.

Results 
Higher total ACE scores were significantly associated with steeper temporal discounting: A (β = 0.077, SE = 0.028, p = 0.006) and α (β = 0.0022, SE = 0.0010, p < 0.001). Among ACE categories, parental violence showed the strongest effects on both A (β = 0.090, SE = 0.027, p = 0.001) and α (β = 0.0022, SE = 0.00070, p = 0.002) and was dose-dependent with a 14.8% (A; p-value < 0.001) and 15.4% (α; p-value = 0.001) increase in discounting per unit of parental violence. Race was also associated with discounting, while years of higher education, male sex, and high global cognition had protective effects.

Conclusion
These findings suggest that ACEs, particularly parental violence, are associated with diminished ability to delay gratification in later life. This supports the hypothesis that early adversity has a significant and dose-dependent effect on temporal discounting. Further studies are warranted to further explore these implications on health behaviors and chronic disease management and to inform interventions.

poster

Congratulations to all the researchers who have qualified for the AMA Research Challenge virtual poster symposium and semifinals!

Welcome to the **largest national, multi-specialty research event** featuring research from nearly 1,000 medical students, residents, fellows, and international medical graduates across six topic areas - basic science, clinical and translational research, clinical vignettes, health systems science, medical education, and public health and health policy.

#### Access the Event
Use the buttons below or navigation menu to access the event. 

[![](https://assets.underline.io/markdown_image/1/image/d4076f2146939317a29eb9f69c53ad41.png)](https://underline.io/events/506/sessions?searchGroup=all)
[![](https://assets.underline.io/markdown_image/1/image/6bcee0b523a4874c4292ca0415d88dde.png)](https://underline.io/events/506/posters?searchGroup=all)

#### Event Details
The 2025 AMA Research Challenge includes the following symposium halls:
* **Semifinals hall:** Features research from 54 medical students, residents and international medical graduates that received top scores during first round scoring. 
* **Poster symposium hall:** Features research from nearly 1,000 medical students, residents and international medical graduates categorized by topics and subtopics.

**Here’s how to participate:**
* **View posters and presentations** on a variety of topics and specialties
* **Score posters in the semifinals** to help decide the top five finalists (AMA member exclusive opportunity)
* **Connect with presenters** and provide feedback to help advance their research
* **New this year: Watch live poster presentations** by topic area and engage directly with researchers

At the conclusion of this event, the AMA announced the top five finalists who advanced to the AMA Research Challenge final round, presented their research to an elite panel of judges, and competed to win a $10,000 grand prize presented by Laurel Road.

**Addison Shenk, a fourth-year medical student from Edward Via Virginia College of Osteopathic Medicine, was the winner of the 2025 AMA Research Challenge and was awarded the grand prize of $10,000, presented by Laurel Road.**

#### A message from Dr. Bobby Mukkamala, AMA President
<div style="position: relative; width: 100%; padding-bottom: 56.25%; height: 0; overflow: hidden;">
  <iframe 
    src="https://underline.io/embed/136894-ama-video?t=0"
    title="AMA Welcome Video"
    allowfullscreen
    style="position: absolute; top: 0; left: 0; width: 100%; height: 100%; border: 0;">
  </iframe>
</div>


#### Recognized Institutions
In 2025, 1,400 abstracts were submitted across six topic areas representing 174 medical schools and more than 150 residency and health care institutions. [See if your institution is represented this year!](https://drive.google.com/file/d/1eFrTqCmCeobx9pr5drJK2hllvsIpFNOY/view?usp=drive_link)

#### Grand Prize Sponsor
AMA would like to thank Laurel Road, a brand of KeyBank, for sponsoring a $10,000 grand prize for the winner of the AMA Research Challenge. Laurel Road and KeyBank are not involved in winner selection process. The winner will be announced during the AMA Research Challenge final round. Payment of the grand prize will be directly from Laurel Road/KeyBank. See the [AMA Research Challenge Official Rules for terms and conditions](https://www.ama-assn.org/system/files/research-challenge-official-rules.pdf).

[![](https://assets.underline.io/uploads/markdown_image/1/image/611e331d4a0eba0920f240cfc04b4d77.png)](https://www.laurelroad.com/)

#### Code of Conduct
<html>
AMA has a code of conduct for its meetings – we ask all attendees to adhere to this code to participate in this year’s meeting. Please read and <a href="https://www.ama-assn.org/about/code-conduct" target="_blank">learn more here</a> about your conduct requirements.
<br><br>
	</html>
	

#### Semifinals Judges

You need to log in with the email address you registered with. Access credentials have been sent to your email. 

Please be sure to check your spam and other email folders if you do not see an email confirmation right away.

Need help? Contact us at <support@underline.io>.

Please log in to explore this event.

If you have used the AMA Research Challenge platform previously, please click the ‘Log-in’ button below. If you do not remember your password, please click “forgot password” and follow prompts to reset your password. After resetting your password, please refresh your webpage to access the platform. 

Register to explore research in a variety of topics. AMA members get exclusive access to score posters in the semifinals. 

**Please use [this link here](https://www.ama-assn.org/member-benefits/events/ama-research-challenge) to register for free. **

Registration Is Required

Join the AMA Research Challenge poster symposium and semifinals to explore top research posters and score posters in the semifinals (an AMA member exclusive opportunity).


***This is an ongoing study. 31/40 patients have completed the protocol are included in this preliminary abstract.

Abstract Title
A Comparison of Push-off and Gait Strength following Open Haglund’s Resection vs. Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy

Background
The gold standard for surgical treatment of insertional Achilles tendinopathy (IAT) is the open midline Achilles tendon splitting Haglund’s resection (OH). However, the percutaneous Zadek osteotomy (ZO) is a safe and effective alternative intervention. Retrospective studies have compared patient-reported outcomes and radiographic findings between ZO and OH; however, data on post-operative strength remain limited. Accordingly, the current prospective study evaluated the postoperative push-off and gait strength following OH vs ZO for IAT.
Methods
Thirty-one patients >18 years of age who underwent unilateral OH (N=17) or ZO (N=14) for IAT with ≥1-year follow-up met the inclusion criteria; patients with prior midfoot/hindfoot surgery, recent lower extremity surgery, neuromuscular conditions were excluded. Static plantarflexion/dorsiflexion strength were assessed in seated and supine positions. Standing strength was evaluated by unilateral and bilateral calf raises performed on pressure plates. Single-leg balancing was timed. Finally, vertical and anterior ground reaction forces at toe off were captured during gait. The mean difference between operative/non-operative limbs was calculated for each measurement and reported as percentage of body weight (%BW).
Results
In patients who underwent OH, a significant decrease in lower anterior ground reaction force of the operative limb was observed (0.00950.013, p=0.007). Also, following OH, patients demonstrated a decrease in unilateral vertical ground reaction force when compared to the non-operative limb (0.0210.035, p=0.02). Interestingly, following OH patients balanced on their operative limb a mean 8.311.7 seconds longer in comparison to their non-operative limb (p=0.01). No significant differences were observed in the ZO cohort.
Conclusion
Statistically significant decreases in operative limb strength during unilateral calf raise and forward propulsion was observed following OH for IAT. Meanwhile, no such loss of strength was observed following ZO. While both procedures are safe and effective surgical options for managing IAT, these preliminary findings suggest ZO may allow for preserved post-operative strength relative to OH.

Strength Analysis of Open Haglund's Resection & Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy

Background: Aerobic exercise induces a range of complex molecular adaptations in skeletal muscle. However, a complete understanding of the specific transcriptional changes following exercise warrants further research. Methods: This study aimed to identify gene expression patterns following acute aerobic exercise by analyzing Gene Expression Omnibus (GEO) datasets. We performed a comparative analysis of transcriptional profiles of related genes in two independent studies, focusing on both established and novel genes involved in muscle physiology. Results: Our analysis revealed ten consistently upregulated and eight downregulated genes across both datasets. The upregulated genes were predominantly associated with mitochondrial function and cellular respiration, including MDH1, ATP5MC1, ATP5IB, and ATP5F1A. Conversely, downregulated genes such as YTHDC1, CDK5RAP2, and PALS2 were implicated in vascular structure and cellular organization. Importantly, our findings also revealed novel exercise-responsive genes not previously characterized in this context. Among these, MRPL41 and VEGF were significantly upregulated and are associated with p53-mediated apoptotic signaling and fatty acid metabolism, respectively. Novel downregulated genes included LIMCH1, CMYA5, and FOXJ3, which are putatively involved in cytoskeletal dynamics and muscle fiber type specification. Conclusions: These findings enhance our understanding of the transcriptional landscape of skeletal muscle following acute aerobic exercise and identify novel molecular targets for further investigation in the fields of exercise physiology and metabolic health.

Transcriptional Signatures of Aerobic Exercise-Induced Muscle Adaptations in Healthy Young Humans

Background: Neonates with severe forms of congenital heart disease (CHD) such as hypoplastic left heart syndrome (HLHS) are at increased risk of delayed brain development and brain injury. Disorders of the placenta have been linked to brain abnormalities in this population, but mechanisms by which the placenta increases this risk are unknown. We hypothesize that placental pathologies impact the development of cerebral autoregulation (CAR), leading to higher risk of brain injury and delayed brain development. Placental vascular malperfusion lesions may be most likely to exert deleterious effects on cerebral hemodynamics. The purpose of this study was to compare the percentage of time spent with impaired CAR during the early postnatal period in neonates with HLHS and healthy placenta versus those with histopathologic lesions of the placenta. 

Methodology: In this single center observational cohort study, we analyzed time synchronized vital sign data in neonates with HLHS born at ≥35 weeks' gestation. CAR was determined in the early postnatal and pre-operative time period using the temporal relationship between mean arterial blood pressure (MAP) and regional cerebral oxygen saturation (rSO₂). To assess intact versus impaired CAR, we used a rolling calculation of the Cerebral Oximetry Index (COx), a dynamic correlation in which values >0.3 were considered impaired CAR in accordance with prior studies. Placental pathologic diagnoses were made using Amsterdam guidelines. We used a student's t-test to determine differences between mean time spent with impaired CAR in HLHS neonates with normal versus abnormal placentas. In subgroup analyses, we compared those with normal placentas to neonates with vascular malperfusion lesions of the placenta. 

Results: In our cohort of 26 neonates with HLHS, we analyzed an average of 86 hours of continuous monitoring (range 18-153). There was a total of 18 (69%) patients with evidence of placental pathology and 8 (31%) with normal placentas. COx showed a wide range in time spent with impaired CAR between subjects (range 0-35%, Fig 1). Mean time spent with impaired CAR in those with normal placentas was significantly less than those with placental histopathology (3.0 ± 1.8% vs. 8.4 ± 9.0%; p=0.02, Fig 2). In exploratory subgroup analyses, those with vascular malperfusion lesions of the placenta had similar time spent with impaired CAR (8.8 ± 6.5%; n=5) to those with normal placentas (p=0.12). 

Conclusion: In neonates with severe forms of CHD such as HLHS, placental histopathologies may increase the risk of brain injury through disrupted development of CAR.

Placental Effects on Early Postnatal Cerebral Autoregulation in Neonates with Hypoplastic Left Heart Syndrome

Background
Transfusion during cardiac surgery is independently associated with adverse outcomes, yet no tool currently provides a validated estimate of transfusion-free aortic repair. We developed and validated a point-based clinical tool to predict the likelihood of bloodless proximal thoracic aortic aneurysm (TAA) repair and support personalized surgical planning.

Methods
We retrospectively analyzed 1,074 patients who underwent open proximal TAA repair between 2012 and 2023 at a single academic center. Bloodless operation was defined as complete avoidance of allogeneic blood products throughout hospitalization. Predictive factors were identified via multivariable logistic regression with internal cross-validation. For risk score model development, the sample was randomly divided into 4/5 training and 1/5 validation cohorts. Model performance was assessed using area under the curve (AUC), Brier score, and F-score. A point system was derived from model coefficients. Observed and predicted probabilities in the validation cohort were compared to assess accuracy.

Results
Of 1,074 patients, 668 (62.2%) received transfusion, while 406 (37.8%) achieved bloodless repair. Eight independent predictors of bloodless surgery (p<0.05) were incorporated into the scoring system: body surface area (BSA) (OR=2.429), hypertension (OR=0.679), reoperation (OR=0.526), heart failure (OR=0.617), preoperative hemoglobin (OR=1.134), extent of repair (OR=0.729), concomitant procedure (OR=0.404), and hypothermic temperature (OR=1.095). The model demonstrated strong discrimination (AUC = 0.761), calibration (Brier = 0.192), and positive predictive value (F-score = 0.758). In the point system, BSA > 1.9 m² and hemoglobin > 13.1 g/dL (8 points each) conferred the greatest positive influence, while extensive repair involving both proximal and distal extension (-8 points) conferred the greatest negative influence. Possible point totals range from -34 to 16, while observed totals in our validation cohort range from -34 to 13. The point system accurately stratified patients into three probability tiers for bloodless repair, with strong alignment between predicted and observed rates; the “unlikely” group was the most congruent.

Conclusion
This is the first validated, clinically applicable scoring tool to predict bloodless proximal TAA repair. It offers a novel, actionable framework for risk stratification in patients where transfusion avoidance is paramount, such as Jehovah’s Witnesses or those at high risk for transfusion-related complications, and may support surgical decision-making, resource allocation, and patient counseling in cardiac surgery.


Predicting Bloodless Aortic Aneurysm Repair: A Validated Scoring Tool


Background 
Coronary artery calcification, particularly in the form of calcified nodules (CN), presents a significant challenge in percutaneous coronary intervention (PCI), especially in patients with end-stage renal disease (ESRD) and acute coronary syndromes. We report a case of a 67-year-old woman with ESRD on hemodialysis, prior right coronary artery stent, and hypertension who presented with acute dyspnea and mild chest discomfort. She was hypoxic, requiring BiPAP support. Laboratory tests revealed a BNP of 1736.9 pg/mL and troponin of 580 ng/L. Chest X-ray showed pulmonary edema, and ECG demonstrated nonspecific ST changes. Initial management included IV heparin and urgent hemodialysis.

Case Presentation 
Cardiac catheterization revealed a chronic total occlusion of the proximal left circumflex artery with a prominent, heavily calcified nodule, along with a patent RCA stent. Elevated pulmonary capillary wedge pressure (28 mmHg, V wave 36 mmHg) and TEE confirmed secondary mitral regurgitation. Due to the presence of a calcified nodule—a known cause of stent underexpansion and poor outcomes—PCI was planned using advanced calcium modification strategies. Intravascular ultrasound (IVUS) was used to assess lesion morphology. Rotational atherectomy with a 1.5 mm burr debulked the lesion, followed by intravascular lithotripsy (IVL) using a 4 × 12 mm balloon (100 pulses) to fracture residual calcium. A 4 × 28 mm Megatron drug-eluting stent was deployed with optimal expansion. The patient was successfully weaned off BiPAP after dialysis and discharged on optimized heart failure therapy.

Discussion 
This case underscores the complexity of managing CNs in ESRD patients with NSTEMI and pulmonary edema. CNs are particularly resistant to conventional balloon angioplasty. A combination of IVUS-guided assessment, rotational atherectomy, and IVL enabled effective modification of both superficial and deep calcium, achieving optimal stent expansion. The strategy aligns with findings from the Disrupt CAD III trial, which demonstrated >92% success rates with IVL in severely calcified lesions. Such techniques are particularly valuable in ESRD, where vascular calcification is often severe and multifocal.


IVUS-Guided PCI Using Rotational Atherectomy and Lithotripsy for a Calcified Coronary Nodule in ESRD Presenting with NSTEMI and Pulmonary Edema

Background 
Percutaneous endoscopic gastrostomy (PEG) is frequently utilized to provide long-term enteral nutrition for patients with impaired swallowing ability. Most PEG-related complications are considered minor, such as peristomal wound infections, tube dislodgement, and leakage. Entero-colo-cutaneous fistulas are rare (0.5%-3%) but represent serious complications following PEG tube placement, particularly in patients with altered gastrointestinal anatomy. Here, we present the case of a 51-year-old female with the formation of an entero-colo-cutaneous fistula after PEG tube insertion post Roux-en-Y procedure. 

Case Presentation 
A 51-year-old woman with a medical history significant for resected anaplastic oligodendroglioma diagnosed approximately 12 years prior, refractory epilepsy, and tracheostomy dependence, previously underwent Roux-en-Y gastric bypass surgery for morbid obesity. Postoperatively, she developed chronic dysphagia, necessitating placement of a percutaneous endoscopic gastrostomy (PEG) tube for long-term enteral nutrition. Five months following PEG placement, the patient exhibited intolerance to enteral feeding. Abdominal computed tomography (CT) revealed malposition of the PEG tube, which had traversed the colon, leading to the development of an entero-colo-cutaneous fistula. The PEG was subsequently removed, and enteral nutrition was continued via a Dobhoff tube. Given her surgically altered anatomy and poor candidacy for re-intervention, PEG replacement was deferred. Although the cutaneous fistula opening closed externally, serial imaging demonstrated a persistent and progressively enlarging fistulous tract between the small intestine and colon. Medical management included acid suppression therapy to reduce gastric secretions and calorically restricted tube feeds to manage obesity-related comorbidities. 

Discussion 
Entero-colo-cutaneous fistulas are rare following PEG tube placement but are more frequently observed in patients with prior Roux-en-Y gastric bypass, primarily due to intra-abdominal adhesions that increase colonic fixation and the risk of inadvertent colonic injury during tube insertion. Additionally, gradual internal migration of the PEG tube’s internal bumper toward the jejunal limb may contribute to the development and persistence of the fistulous tract over time. Diagnosis of such fistulas can be particularly challenging as many patients remain asymptomatic for an extended period, with symptoms typically emerging only after tube dislodgement or attempted replacement. In the present case, the patient exhibited intolerance to enteral feeds five months post-PEG placement, without classic signs such as feculent vomiting or diarrhea, underscoring the variability in clinical presentation. This case emphasizes the need for heightened clinical suspicion in patients with prior gastric surgery, especially Roux-en-Y gastric bypass. Conservative management, consisting of PEG tube removal and initiation of alternative enteral nutrition, is considered for clinically stable patients. However, surgical intervention is required in cases complicated by sepsis, peritonitis, or a high-output fistula.


Entero-Colo-Cutaneous Fistula Following PEG Placement in a Post-Gastric Bypass Patient: A Rare and Challenging Complication

Background: DiGeorge Syndrome is a relatively common genetic disorder, the cardinal features of which are often remembered by the acronym, ‘CATCH-22.’ While this acronym helps highlight the medical morbidities and genetic bases of the syndrome, it tends to ignore its profound psychiatric burden. The current literature posits that approximately 70% of affected individuals have a lifetime prevalence of at least one psychiatric condition, with over one-third developing psychosis by early adulthood, making DiGeorge Syndrome the most significant risk factor for developing schizophrenia, second only to having a monozygotic twin or both parents diagnosed with schizophrenia. 

Case Presentation: We present the case of a 21-year-old female with a known diagnosis of DiGeorge Syndrome who presented with marked conceptual disorganization, delusions of reference and grandeur, pronounced grandiosity, and auditory hallucinations. The patient appeared disheveled, with an inappropriate affect, significant distractibility, and agitation, which complicated the clinical assessment. She reported her mood to be 'very bad' and endorsed ongoing suicidal ideation with intent. The patient had a complex psychiatric history with multiple psychiatric hospitalizations dating back to early adolescence, frequently complicated by medication non-adherence. The most recent hospitalization occurred one month prior, following a psychotic episode with imminent concerns for suicidal and homicidal ideation. Following a thorough psychiatric evaluation and collateral information, a diagnosis of Schizoaffective Disorder, current episode Bipolar, was established. Due to the complex presentation, the patient was started on a regimen of Olanzapine/samidorphan 200 mg and Quetiapine 300 mg. Despite this aggressive pharmacologic approach, there was limited improvement after two weeks. Therefore, given the urgency, Paliperidone Palmitate 1.5 ml was added as an augmentation agent. Additionally, her Olanzapine/samidorphan dose was increased to twice daily, and her nighttime Quetiapine dose was doubled to address the imminent risk to herself and others. Clozapine was considered unsuitable due to concerns about medication adherence and current medical morbidities. 

Discussion: DiGeorge Syndrome is the most significant molecular risk factor for schizophrenia-spectrum disorders, believed to be linked to COMT gene mutations. Psychosis in DiGeorge tends to appear early, be complex, and resistant to treatment. Its comorbidities, like hypocalcemia, disabilities, and metabolic disturbances, 
complicate care. Research shows psychosis often develops gradually, with 20-60% showing sub-threshold symptoms, allowing early intervention. With this case report, the authors aim to highlight the complex psychiatric challenges of DiGeorge and recommend comprehensive screening for early sub-threshold symptoms to enable timely intervention.

More Than CATCH-22: Probing the Profound Psychiatric Burden of DiGeorge Syndrome

Abstract Title
What defines a ‘goals of care’ conversation for surgeons? 

Background
In the age of increased patient autonomy, “shared-decision making” and patient-focused approaches to treatment plans, there is increasing interest in how goals are discussed in clinical practice. Many studies analyze how physicians approach end-of-life and informed consent conversations with their patients. However, little is known about what constitutes a ‘goals of care’ (GOC) conversation for surgeons and their attitudes around these conversations. We aimed to evaluate attending surgeon attitudes, definitions, practices, and beliefs regarding ‘goals of care’ conversations. 

Methods
A 20-30 question Qualtrics survey was distributed by email to attending surgeons from the departments of surgery including general surgery, cardiothoracic, colorectal, minimally invasive, oncology, transplant, pediatric, plastic and reconstructive, and urology at Washington University in St. Louis School of Medicine (WUSM) with a combination of Likert-type, multiple choice, and free-text questions about GOC. Fifty-two surgeons completed the survey. All responses were anonymous and securely stored on the WUSM Box platform. Analysis was done using IBM SBSS software. To expand upon our qualitative data, seven survey participants were interviewed. Interviews were conducted over Zoom by the same interviewer. Interviews were transcribed and analyzed using NVivo. 


Results
Of the 39 surgeons that responded to the question of whether it is important to ask a patient about their goals, all 39 responded that it was important, with 25 (64.1%) responding it is “extremely important.” Yet, 11 of 39 respondents (28.2%) reported not asking patients about their goals before obtaining surgical consent with 30% of these respondents reporting the reason as “irrelevant to treatment.” The most common factors considered when having a GOC conversation were prognosis, diagnosis, and what the available treatments for the patient were. Only 12 of 38 surgeons (31.6%) considered their own comfort with the operative options when conducting a GOC conversation. When asked to define goals of care in their own words, many responded that it signifies discussing what a patient’s desired outcome is. In addition, despite 100% of respondents viewing GOC conversations as important, 22 of 39 respondents (56.4%) had not received any formal education on how to conduct GOC conversations. 

Conclusion
Despite surgeons acknowledging the importance of GOC conversations, many do not ask patients about goals consistently. Further, GOC conversations appear to be context dependent. Finally, many do not receive formal education regarding GOC and conducting GOC conversations. 


Goals of Care Discussions in Surgery: Defining them, conducting them, and learning from them

Background 
Ultrasound education is essential in medical training, but students often struggle to mentally convert 2D images into 3D structures. To address this, we developed a 3D-printed model with defined geometric features, encapsulated it in ballistic gel to simulate soft tissue, and provided it alongside an unencapsulated version for tactile reference. 

Methods 
First-year medical students were divided into experimental and control groups over eight academic blocks. Experimental groups had access to the models, while controls used traditional resources. Test scores assessing 3D spatial understanding were collected before, during, and after their ultrasound curriculum. Model use was voluntary, and engagement was not tracked. 

Results 
Test score analysis showed no significant difference between groups. We hypothesize that low model usage contributed to these results. 

Conclusion 
3D-printed models may enhance ultrasound education but likely require structured integration and mandatory use to demonstrate measurable benefits. Future studies should incorporate usage tracking and curriculum-based implementation. 


Evaluating 3D-Printed Models for Enhancing Spatial Visualization in Ultrasound Imaging

Background
The San Antonio Refugee Health Clinic provides free care to over 1,300 refugees annually. From January to April 2024, 25 patients presented with diabetes-related issues; 40% had HbA1c levels above 7% (uncontrolled diabetes), 30% above 6.5% (diabetes), and 30% above 5.8% (prediabetes). Diabetes progression carries severe risks, including cardiovascular disease, myonecrosis, and liver disease. Refugees often face barriers such as lack of insurance, language difficulties, and limited transportation, complicating chronic disease management. Given the high diabetes prevalence and limited literature on refugee health, this project assessed diabetes knowledge and self-management confidence.

Methods
Starting in October 2024, patients with diabetes completed a survey while waiting to see their provider. The survey assessed diabetes knowledge and self-management confidence using targeted questions and a 5-point Likert scale. Patients then received instruction and a glucometer for at-home blood sugar monitoring.

Results
By December 2024, eight Pashto-speaking patients from Afghanistan completed the initial survey. The average knowledge score was 68.75% (SD = 16.54), with a median of 75% and a range of 50%. The most challenging topics were understanding lifestyle changes versus medication, with 50% answering incorrectly, and diabetes pathophysiology, with 37.5% answering incorrectly. Self-management confidence was high, averaging 4.1/5 (SD = 1.05) with a median of 4.5/5.

Conclusion
Although refugee patients reported high confidence in managing diabetes, they demonstrated limited knowledge of key concepts such as diabetes pathophysiology and the importance of lifestyle changes. This underscores the need for culturally and linguistically tailored educational interventions to improve diabetes outcomes. We will monitor our intervention’s long-term impact through a follow-up knowledge assessment and HbA1c tracking.


Premium content

Next from AMA Research Challenge 2025

Strength Analysis of Open Haglund's Resection & Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy

Similar lecture

A Normative Model of Delay Discounting Across the Lifespan: Tradeoffs Between Mortality, Fertility, and Parenting

Stay up to date with the latest Underline news!

PRESENTATIONS

CONFERENCES

COMPANY

RESOURCES