United States

Background
Reconstructing large segmental tibial defects remains challenging for surgeons. When defects are extensive and involve soft tissue loss, the vascularized free fibular flap (VFFF) offers advantages, including shorter treatment duration and single-site harvest of bone and soft tissue. This study reviews long-term outcomes of VFFF in the reconstruction of segmental tibial defects performed by a single surgeon at our institution.
Methods
The surgical case log of the senior author was reviewed for all adult patients who underwent VFFF reconstruction for tibial defects between 2007 and 2023. Electronic health records were used to collect demographic, clinical, and surgical data, including age, sex, race, comorbidities, etiology of injury, defect size, ankle joint involvement, need for soft tissue coverage, fixation method, and duration of external fixation.
Outcomes included ED visits; unplanned readmissions and reoperations; pin site infections; flap fractures; time to and achievement of full weight-bearing; ambulation without aids; NRS pain scores; time to return to work/avocation; flap success rate; conversion to amputation; and long-term donor/recipient site complications.
Results
Fifteen patients (80% male, mean age 41.4) met inclusion criteria. Most cases resulted from high-energy trauma complicated by nonunion and infection; three cases (20%) involved oncologic resection, and one case involved primary chronic osteomyelitis. The average tibial defect size was 10.91 cm (SD = 2.25), and ankle arthrodesis was performed in 4 patients (27%).
Soft tissue reconstruction was required in 13 patients (87%), with an average defect size of 117 cm² (SD = 40.84). A VFFF skin paddle was used in 11 patients; 3 (20%) required an additional ALT flap. Fixation methods included internal or external fixation, with or without subsequent conversion to a Taylor spatial frame.
The mean number of unplanned reoperations was 1.13. Pin site infections and flap fractures occurred in 3 patients each (20%). Full weight-bearing was achieved in 73% of patients, and 47% were able to ambulate without mobility aids, including orthotic braces. The mean NRS pain score at final follow-up was 1.64 (SD = 2.73), and time to return to work averaged 1.55 years (SD = 1.28). Flap success rate was 93%, with one additional patient electing amputation.
Recipient site complications included lymphedema (N = 3), venous stasis (N = 1), and foot drop (N = 1). Donor site complications included one case of claw toe, which was surgically corrected.
Conclusion
Our study demonstrates that VFFF is an effective option for reconstructing large segmental tibial defects with associated soft tissue loss, achieving an 93% flap success rate and an acceptable complication profile.


AMA Research Challenge 2025 

Long-Term Outcomes of the Vascularized Free Fibula Flap in the Reconstruction of Large Segmental Tibial Defects: A Retrospective Review

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CD38 is an ideal molecular imaging target for multiple myeloma. It is relatively specific for plasma cells and the target of first line therapeutic antibodies, Daratumumab and Isatuximab. Here, we have added a lipid tail to a peptide-based radiotracer that targets CD38 in order to template self-assembly into a polyvalent nanofiber with excellent affinity for CD38. In vitro, the nanofiber outcompetes the monomer for uptake by CD38+ MOLP2 cells. Additionally, these nanofibers can be used to encapsulate and deliver small molecule therapeutics.

CD38-avid Nanofibers for Molecular Imaging of Multiple Myeloma

Abstract: 
Background: 
Primary pulmonary lymphoma (PPL) is a rare form of non-Hodgkin lymphoma (NHL) originating in the lungs, accounting for less than 1% of all NHL cases and under 0.5–1% of primary lung malignancies. Among its subtypes, primary pulmonary follicular lymphoma is particularly uncommon and may present diagnostic challenges due to its nonspecific respiratory symptoms. 
Aim: 
To highlight the clinical presentation, diagnostic workup, and therapeutic approach in a rare case of primary pulmonary follicular lymphoma, with emphasis on bilateral pleural effusion as the initial manifestation. 
Case 
Presentation: 
A 74-year-old male presented with progressive shortness of breath over several weeks without constitutional symptoms or prior pulmonary disease. Imaging revealed bilateral pleural effusions. Initial thoracentesis and cytology were non-diagnostic. Due to worsening symptoms, repeat 
thoracentesis was performed. Flow cytometry and FISH analysis of pleural fluid revealed monoclonal B-cell population positive for lambda CD10, BCL2, BCL6, and t(14;18)/IGH-BCL2 translocation—findings consistent with follicular lymphoma. 
Conclusion: 
This case underscores the importance of considering PPL in the differential diagnosis of unexplained pleural effusions. Despite initial negative cytology, advanced diagnostic tools such as flow cytometry and molecular studies are critical in reaching a definitive diagnosis. Early identification and targeted treatment are essential to optimize patient outcomes in rare presentations of NHL. 


Primary Pulmonary Follicular Lymphoma Presenting with Bilateral Pleural Effusion: A 
Rare Case Report

Introduction
Social determinants of health (SDOH), including socioeconomic status, access to healthcare, and institutional policies, significantly impact the management of chronic conditions such as epilepsy. Financial instability can limit access to essential medications or a medical marijuana card, forcing patients to seek alternative treatments without physician oversight. Patients with limited financial resources often rely on cannabis to manage symptoms, yet institutional regulations and insurance policies create barriers to its use during hospitalization and safe continuation after discharge. This case highlights how a patient’s financial instability, housing situation, and hospital policies on cannabis administration influenced epilepsy management and overall care.

Case Presentation
A 26-year-old male with a history of chronic bipolar disorder, prior traumatic brain injury (TBI) with intracranial hypertension, and epilepsy presented in status epilepticus with incontinence, tongue biting, and postictal confusion. Emergency medical services (EMS) witnessed an additional seizure and administered midazolam en route to the hospital. The patient had a history of medication nonadherence and long-term cannabis use for seizure control. Upon arrival, he had severe metabolic acidosis (ABG: 6.81/38, bicarbonate: 6) and leukocytosis (WBC: 23). He was intubated for airway protection and treated with lorazepam, bicarbonate infusion, and levetiracetam. The patient was admitted to the intensive care unit (ICU) for further management, where he was transitioned to IV valproate sodium and continuous EEG monitoring. His EEG showed encephalopathy, likely influenced by sedation.
Two days later, after extubation and transfer to the neurology unit, the patient expressed a strong desire to leave the hospital, stating that when sober, he became violent. He admitted to daily cannabis use but lacked the financial means to obtain a medical cannabis card. Institutional policies prohibited smoking or self-administering edibles, preventing him from using his preferred method of seizure control. After extensive discussion with hospital administration and the chief medical officer, oral dronabinol was introduced at 2.5 mg up to four times daily as a compromise to ensure his continued hospitalization and neurological evaluation.
The patient was discharged on divalproex but reported severe nausea and vomiting, leading to self-discontinuation after two doses. He had previously discontinued levetiracetam due to mood instability. His epilepsy was strongly influenced by stress, and he cited financial hardship and an unstable living environment as factors worsening his condition. Outpatient MRI showed no acute intracranial abnormalities.
Discussion
This case illustrates how institutional policies can inadvertently create barriers for patients from disadvantaged backgrounds. The patient’s inability to afford a medical cannabis card restricted his ability to self-administer cannabis per hospital guidelines, potentially leading to premature discharge and inadequate seizure management. Hospitals’ restrictive policies on cannabis use, even when legally prescribed, disproportionately impact patients with financial limitations, housing instability, or difficulty accessing traditional pharmaceutical treatments.

Conclusion
Equitable healthcare policies must consider patients' reliance on alternative therapies, like cannabis, particularly for those facing financial or social barriers. Implementing hospital protocols for supervised medical cannabis administration could help mitigate disparities in care, ensuring patients receive comprehensive treatment without disruption due to institutional restrictions.

Rethinking hospital policies that restrict relief in patients who rely on cannabis

The anterior spinal artery (ASA) supplies the vascular distribution to the anterior ⅔ of the spinal cord. This distribution contains many crucial afferent and efferent tracts, including the spinothalamic tracts and corticospinal tracts. Compromise of this tissue can cause extreme morbidity and even mortality. 

Perfusion to neural tissue is the difference between mean arterial pressure (MAP) and intrathecal pressure. The importance of maintaining MAP goals for treating spinal cord ischemia is well documented. However, reducing intrathecal pressure via cerebrospinal fluid (CSF) drainage may also help restore and maintain adequate cord perfusion. CSF diversion is well-documented to improve spinal cord perfusion during aortic surgery, and mounting evidence demonstrates its utility following spinal cord injury. However, there have been very few reports detailing the efficacy of CSF diversion via lumbar drainage in spinal cord ischemia unrelated to aortic surgery or traumatic spinal cord injury.

We describe the use of CSF diversion through a lumbar drain in the treatment of ASA syndrome in a 72-year-old female.


Cerebrospinal Fluid Drainage for the Treatment of Anterior Spinal Artery Syndrome 

Background:
Dysferlinopathy encompasses a group of rare autosomal recessive muscular dystrophies caused by mutations in the DYSF gene, which encodes dysferlin, a protein critical for muscle membrane repair. The main clinical phenotypes include Miyoshi muscular dystrophy and limb-girdle muscular dystrophy type 2B, with a prevalence ranging from 1 in 14,000 to 1 in 2 million individuals. These disorders typically present with progressive proximal and/or distal muscle weakness. No disease-modifying treatments currently exist, and management remains supportive. While certain medications may exacerbate underlying muscle pathology, the interaction between psychiatric medications and genetic myopathies is underrecognized.

Objective: 
To describe a case of dysferlinopathy unmasked and worsened in the setting of atypical antipsychotic therapy, highlighting the importance of considering medication-related muscle toxicity in genetically susceptible individuals.

Case Presentation: 
A 23-year-old male with schizophrenia residing in a psychiatric facility presented with progressive muscle weakness and difficulty ambulating over one year. His symptoms coincided with initiation of monthly paliperidone palmitate. Neurologic examination revealed decreased muscle bulk, bilateral proximal upper extremity weakness (MRC 3/5), proximal lower extremity weakness (MRC 3/5), and hyporeflexia. Laboratory evaluation showed creatine kinase 6,100 U/L, AST 90 U/L, and ALT 150 U/L. Aldolase was within normal range. ANA, ANCA, SSA, SSB, anti-RNP, and anti-Jo antibodies were negative. ESR, CRP, TSH, and T4 were normal. Urinalysis, Hepatitis A/B/C, and HIV tests were negative. Testicular ultrasound and chest X-ray showed no evidence of malignancy. MRI of the lumbar spine demonstrated severe atrophy of the lumbosacral erector spinae muscles. Genetic testing confirmed a pathogenic DYSF mutation, consistent with dysferlinopathy. Muscle biopsy of the right thigh revealed marked fiber size variability, necrosis, regeneration, and increased connective tissue. Paliperidone palmitate was discontinued, and the patient received intravenous methylprednisolone, resulting in significant improvement in muscle strength and reduction of CK levels. He was discharged on aripiprazole and quetiapine with neurology follow-up.

Discussion:
This case highlights the potential for antipsychotic medications, particularly paliperidone palmitate, to exacerbate underlying neuromuscular disorders such as dysferlinopathy. Although antipsychotic-induced myopathy is rare, proposed mechanisms include mitochondrial dysfunction, oxidative stress, and metabolic derangements. The temporal relationship between drug initiation, symptom progression, and improvement following discontinuation supports a drug-induced exacerbation superimposed on a genetic vulnerability. Early recognition and medication adjustment, combined with supportive therapy including corticosteroids, may facilitate meaningful recovery.

Conclusion:
Clinicians should maintain a high index of suspicion for medication-induced worsening in patients presenting with unexplained weakness or elevated CK, particularly those on neuroleptics. This case underscores the need for careful psychopharmacologic management in individuals with known or potential neuromuscular disorders and calls for further research into safe psychiatric treatment strategies for patients with genetic muscle diseases.

The Mind-Muscle Mismatch: Dysferlinopathy Exacerbated By
Paliperidone

Abstract Title: 
Hypochlorous Acid as Adjunctive Therapy in Recalcitrant Postsurgical Endophthalmitis

Background:
Endophthalmitis is an intraocular infection after ocular surgery, optimally managed with urgent and aggressive treatment in order to prevent irreversible vision loss. Topical fortified antibiotics, intravitreal antibiotics, and systemic antibiotics are conventional treatments. Hypochlorous acid (HOCl), an anti-inflammatory and antimicrobial agent, has shown promise in the management of surface ocular disease but is largely unexplored in the management of intraocular infection. There is a need for adjunctive therapies in the management of recalcitrant endophthalmitis. The present report aims to evaluate the clinical utility of HOCl as an adjuvant in two instances and recommends it for use both in treatment and prophylaxis.

Case Presentation:
Two patients with postsurgical endophthalmitis unresponsive to conventional therapy received adjunctive HOCl 0.01% (Avenova, NovaBay Pharmaceuticals) as part of their treatment regimen.
Case 1: Endophthalmitis after pterygium surgery by the PERFECT technique in a pseudophakic patient.
Case 2: Infection after pars plana vitrectomy in a povidone-iodine-allergic patient, with preoperative use of chlorhexidine.
Both patients had severely impaired vision in spite of antibiotic therapy. HOCl was applied topically off-label. Outcomes were monitored by visual acuity, intraocular pressure, slit lamp evaluation, and B-scan ultrasonography. Final visual acuity was the primary outcome.

Discussion:
Both patients had rapid response to HOCl, with resolution of infection within days and restoration of preoperative visual acuity. In the pterygium case, inflammation was severe, yet there was no recurrence at two years, and the patient achieved excellent cosmetic results. These findings are a testimony to the strength of the PERFECT technique and challenge the necessity for steroids after uncomplicated pterygium surgery. HOCl not only halted the progress of disease but also minimized risk of retinal complications. Therefore, HOCl seems to be a promising adjunct in the treatment of endophthalmitis and, as such, an excellent antiseptic choice in preoperative preparation of patients.

To our knowledge, this is the first report that describes HOCl usage in treating postsurgical infectious endophthalmitis.


Hypochlorous Acid as Adjunctive Therapy in Recalcitrant Postsurgical Endophthalmitis

Years of evidence and community accounts consistently highlight pervasive stigmatization against people experiencing homelessness (PEH) within the healthcare system. This stigma often results in healthcare providers excluding unhoused individuals from basic health services and dismissing their health concerns. Consequently, many unhoused individuals rely on emergency rooms as their primary source of care. Recognizing this issue, there is growing support for comprehensive training programs for physicians to provide trauma-informed care to unhoused individuals. This study aims to investigate the specific needs of the community regarding such a program. The study population comprises a group of (number of participants) unhoused individuals who frequent Recovery Cafe Indy in Indianapolis, a social support system for those in recovery. A needs assessment survey was conducted and analyzed to gather insights into their specific requirements. The results of this survey were used as a basis for support for the implementation of trauma-informed care training for physicians working with unhoused individuals. This survey found that unhoused folks strongly wanted to increase trauma-informed care training in their physicians and such training would increase their willingness to take care of their health. Trauma-informed care training for healthcare populations would greatly increase the quality of care given by physicians to unhoused populations. This could allow unhoused individuals to feel a sense of health security that may allow them to further their journey to recovery. Providing enhanced access to basic health services, particularly with a focus on trauma-informed care, would empower individuals to seek regular medical assistance confidently, thereby potentially reducing emergency room visits and alleviating financial burdens on hospitals.


Assessing the Need for Trauma‐Informed Care Training for Healthcare
Professionals Serving the Unhoused Population

Background
The Community Homeless Interprofessional Program (CHIP) serves as a vital resource for providing healthcare education and resources to underserved populations, particularly those experiencing homelessness in the Detroit metropolitan area. This interprofessional, student-run free walk-in clinic was developed in collaboration between health profession students and faculty of pharmacy, medicine, social work, law, and physical therapy within Wayne State University to help address social and health determinants of individuals experiencing homelessness. This project seeks to innovate by developing a comprehensive strategy to quantify and understand food insecurity within CHIP’s patient population, with a particular focus on the impact of the new United States Department of Agriculture (USDA) Able-Bodied Adult Without Dependents (ABAWD) work requirements. With these efforts, CHIP aims to create a more informed and responsive care model that can be integrated into medical education and training.

Methods
The study collected and analyzed survey data from CHIP’s patient population to quantify the prevalence and severity of food insecurity and determine the percentage of patients subject to ABAWD work requirements under the new USDA guidelines. All patients seen at CHIP were screened for food insecurity using a homegrown survey between October 2024 and July 2025 and referred to the appropriate resources. Descriptive statistics were used. WSU IRB determined this research to be exempted. 

Results
Preliminary analysis reveals a complex relationship between food insecurity and homelessness among CHIP clients, emphasizing the significant impacts of nutritional deficiencies on this vulnerable population.

Conclusion
The results will inform the development of tailored interventions to address food insecurity and related health disparities within CHIP’s population. By integrating these insights into medical education and clinical practice, the project aligns with broader goals to optimize learning processes and improve patient outcomes, ultimately enhancing the scope and quality of care provided to underserved populations.

Evaluating Food Insecurity in the Setting of an Interprofessional Student-Run Free Clinic

Background: The purpose of this quality improvement study is to gain a deeper understanding of the metrics that influence patient satisfaction and identify which metrics correlate with decreased patient satisfaction scores at a family medicine outpatient residency clinic. Resident physicians work under the guidance of experienced attending physicians to refine their physician skills as they progress through their training. Patient satisfaction ratings can help physicians assess how their patients feel after their appointments and identify areas where patients would like to see improvement. Our goal is to develop initiatives that enhance patient interactions, improve our quality of care, and help train our residents to become effective family physicians.

Methods: An optional, anonymous, post-visit survey was offered to eligible adult patients for three weeks. The survey questions directly assessed five patient satisfaction metrics: continuity of care, trust, communication, confidence in managing healthcare needs at home, and access to resources. These metrics correlate with physician skills that our clinic values in effective family doctors.

Results: The average patient satisfaction rating for the clinic was 9.81 out of 10. 90.5% of patients reported they could not be more satisfied with the care they received. 60.3% of patients who saw attending physicians reported perceived continuity of care, while only 37.5% of patients who saw resident physicians reported the same. While a similar percentage of patients denied confidence in managing healthcare at home and access to resources, patients who denied access to resources were five times as likely to report lower satisfaction ratings. There was a strong correlation between the number of patient satisfaction metrics denied and lower patient satisfaction ratings for third-year residents and attendings; however, this correlation was weaker for second-year residents and inverted for first-year residents.

Conclusion: There was no significant difference in average patient satisfaction ratings between residents and attending physicians; however, the percentage of patients who could not be more satisfied with their care increased from PGY-1 to PGY-3, with third-year residents exceeding attending physicians in this regard. Patients trusted their physicians at all levels of training. Attending physicians had better perceived continuity of care with their patients. Although continuity of care was the most frequently denied patient satisfaction metric at our clinic, it did
not correlate with lower patient satisfaction ratings. The patient satisfaction metric that most significantly correlated with lower patient satisfaction ratings was access to resources.

Analysis of patient satisfaction metrics between family medicine residents and attending physicians

Background: Liver cancer is the sixth leading cause of cancer death in the United States (US), and is one of 13 different types of cancer related to obesity. Access to healthy food is a modifiable factor that reduces liver cancer morbidity and mortality risk, but residing in areas with no grocery store and greater access to unhealthy food options (i.e. food swamps) reduces healthy food access. Georgia ranks ninth in the US with low access to key food resources, with over 80% of Georgia counties having significantly high food swamp scores. The association between food swamps and liver cancer in Georgia is poorly elucidated, so we examined the county-level relationship between food swamps and liver cancer mortality in Georgia. 

Methods: We performed a cross-sectional (ecological) analysis using 2010 – 2020 data from the US Department of Agriculture Food Environment Atlas, US Census, and Centers for Disease and Control (CDC) Wonder database. A total of 86 rural Georgia counties were analyzed with complete information on food environment scores and liver cancer mortality. The ratio of fast food and convenience stores to grocery stores and farmer’s markets defined food swamps. Higher scores indicated greater access to unhealthy food resources. An age-adjusted, mixed-effects regression model was run for the association of food swamp scores with liver cancer mortality rates. 

Results: Rural Georgia counties with high liver cancer mortality rates had higher poverty rates (20.4 vs. 16.3), and food swamp scores (28.9 vs. 27.6) compared to counties with low mortality rates (p - value < 0.05). There were 50% increased odds of having high liver cancer mortality rates among Georgia counties with high food swamp scores vs. low food swamp scores (AOR = 1.50; 95% CI: 0.48 - 4.65) in fully adjusted models.  

Conclusions: We found a nonsignificant higher association between high food swamp scores and liver cancer mortality. Future steps include utilizing Georgia Cancer Center patient-level data to further elucidate the potential association between food swamps and liver cancer outcomes. New policy and governmental action should be prioritized regarding healthy food access for rural Georgia counties to combat obesity and cancer-related outcomes especially among disenfranchised populations.

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