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**Abstract:**



Bladder Cancer Knowledge in an Underserved, Highly Afflicted Population

Background
Kidney transplantation is a lifesaving treatment for patients with end-stage renal failure. However, the success of kidney transplantation is hindered by chronic kidney graft rejection. On average, transplanted kidneys last 9 years due to chronic rejection, requiring patients to undergo dialysis or re-transplantation. While advances have reduced the rates of acute rejection, little is known about preventing chronic rejection. In mice and humans, chronic rejection is characterized by a persistent T cell infiltrate. The cytokine IL-15 is elevated in renal graft rejection. However, it is unknown whether IL-15 signaling supports graft-specific T cells that drive chronic rejection. I hypothesize that IL-15 signaling is required for the long-term survival of graft-specific T cells, and that disrupting IL-15 signaling can prevent chronic rejection.

Methods
We transplanted MHC-mismatched kidneys (Balb/c.OVA x B6) to recipient mice (B6) followed by injection of OVA-specific CD8 T cells (OT-I cells). OT-I cells allow for tracking immune response in kidney grafts. Recipient native kidneys were removed during transplantation. Kidney grafts underwent analysis via flow cytometry, immunofluorescence, and histology.

The Cre-loxP system was used for temporal genetic deletion of CD122 or CD215. Anti-CD122 blocking antibody was administered intravenously to transplant mice. Graft rejection was monitored by signs of uremia (lethargy, decreased mobility, ruffled hair), serum creatinine, or death.

Results
We found evidence that IL-15 signaling was taking place in kidney grafts, with cells expressing CD215, a chaperone protein for IL-15, and CD8 T cells expressing CD122, a receptor subunit for sensing IL-15. Using a combination of conditional knockouts of CD215 and CD122, we found that genetic deletion of either CD215 or CD122 significantly reduced graft-specific CD8 T cells. Given the importance of IL-15 signaling, we treated transplant mice with anti-CD122 antibody, which significantly reduced graft-specific CD8 T cells, decreased graft infiltration and fibrosis, and prevented graft rejection.

Conclusion
IL-15 is a key component in the survival and function of graft-specific T cells and, ultimately, graft failure. Disrupting IL-15 signaling with anti-CD122 blocking antibody could serve as a potential approach to the prevention of chronic rejection.

Disrupting the Survival of Pathogenic T cells to Ensure the Survival of Kidney Transplants

Background:
Acute kidney injury is associated with significant morbidity and mortality. Estimation of volume status plays a major role in the differentiation of acute kidney injury. Invasive right heart catheterization has been traditionally used to guide management. We examined whether a simple bedside ultrasound assessment of intra-abdominal organ congestion can address this question and help differentiate acute kidney injury.
Methods:
A prospective single-center study included patients with cardiorenal, hepatorenal, acute tubular necrosis (ATN), and volume depletion acute kidney injury (AKI). Arrhythmias and body mass index (BMI)>30 were exclusions. Clinical data were obtained via chart review and urine microscopy was performed on all the patients. Inferior vena cava diameter (IVC); hepatic vein, portal vein and renal vein patterns; and Renal Resistive Indices (RRI) were obtained on three consecutive days via Logic e BT-12 ultrasound. Sonographers underwent training for eight hours and completed five ultrasound assessments prior to the study. Sonographers were also blinded from clinical diagnoses. We used analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables.
Results:
A total of 81 AKI subjects were included, 34% with volume depletion, 19% cardiorenal, 35% ATN, 6% hepatorenal, and 3% other. The IVC diameters on the day of diagnosis in ATN, volume depletion, and cardiorenal were 2, 1.87, and 2.34 cm respectively (p=0.05). Diminished or reversed systolic hepatic duplex was seen in only 2 patients with volume depletion(p=0.002), and both these patients had moderate tricuspid regurgitation and elevated pulmonary arterial pressures on echocardiogram explaining the deviation. Similar hepatic duplex findings were noted on day 2 and day 3. The portal vein was continuous in 62.1% ATN, 60.7% volume depletion, and 31.3% cardiorenal patients (p=0.09). In comparison to patients in the cardiorenal group, portal pulsatility in the volume depletion arm was almost always less than 50% (p=0.49). Renal venous flow was continuous in 18.8% of the cardiorenal patients(p=0.18). Quality assessment was performed and estimated concordance with the expert review was 96.6, 94.4, 95.5, and 75.6 percent in IVC, hepatic vein, portal vein, and renal vein interpretations respectively.
Conclusion:
Based on our results, we propose that the Hepatic vein, IVC, and marked portal pulsatility(>50%) can help differentiate volume depletion from cardiorenal syndrome. This noninvasive bedside tool in addition to urine sediment can help differentiate acute kidney injury and future trials will examine management.

A pragmatic study utilizing bedside ultrasound to replace invasive interventions.

Background
Hypertension is the number one preventable risk factor for all-cause mortality, affecting up to 45% of the adult population worldwide. In the era of the growing influence of artificial intelligence (AI), reliance on online platforms for medical information is more than ever before, resulting in concerns surrounding the accuracy of the available information. This study aims to assess the accuracy of text-generating AI using ChatGPT in answering patients’ frequently asked questions about hypertension and its complications.
methods
To assess the accuracy of the information offered by ChatGPT on hypertension and secondary complications, this nonhuman-subject qualitative study was designed. Frequently asked questions were gathered by study staff from professional platforms, including the American Heart Association. These questions were then reviewed by two physicians experienced in treating hypertension, and a final set of questions was established. Each question was put through the ChatGPT three times, and the majority- response to each question was evaluated against the national guidelines by study staff who graduate physicians in internal medicine. A board-certified internal medicine physician with over 8 years of experience then reviewed all questions and categorized responses in one of the following 3 classes: Responses were classified into three categories by accuracy: appropriate (in line with clinical recommendations), inappropriate (contain errors), or unreliable (inconsistent). Descriptive statistical analysis was performed to compare ChatGPT responses against the standard and assessed them for accuracy and reproducibility.
Results
Of the total of 130 questions initially proposed, a total of 100 questions were deemed appropriate and were selected for the purpose of this study. When assessed against acceptable standard responses, ChatGPT responses were found to be appropriate in 91.5% of cases, inappropriate in 0.5%, and unreliable in 8%. Notably, out of 300 responses, 4% were irreproducible, meaning that they could not be consistently reproduced across multiple ChatGPT runs.
Conclusion
ChatGPT demonstrated promising accuracy in answering frequently asked questions related to hypertension. These findings highlight the potential for AI chatbots, such as ChatGPT, in offering valuable

information to patients regarding hypertension. Further research and refinement are needed to ensure the reliability and broader applicability of ChatGPT in the medical field.

Assessing the Accuracy and Reproducibility of Artificial Intelligence Chatbot in Answering Frequently Asked Questions Regarding Hypertension and its Associated Complications

Background: Adrenal myelolipomas are benign, lipid-filled masses containing elements of interspersed myeloid cells and comprise approximately 3-6% of all adrenal masses. Epidemiologically, adrenal myelolipomas affect both sexes equally and are often discovered in middle age. These masses are typically unilateral and variable in size, with macroscopic fat as a diagnostic feature on imaging. Notably, patients with congenital adrenal hyperplasia (CAH) are more likely to present with large bilateral myelolipomas, and, as such, patients presenting with these features should be evaluated for concurrent CAH.
Case presentation: In this report, a 34-year-old male presented to the emergency department following an alleged assault on his abdomen. During his trauma evaluation, he received a CT scan of the abdomen, demonstrating large bilateral adrenal incidentalomas with pathognomonic features of macroscopic fat (Hounsfield unit -90 to -120) consistent with adrenal myelolipomas. The left and right adrenal masses were reported at 20 cm and 14 cm, respectively. On further questioning, he endorsed a past medical history of CAH and noncompliance with glucocorticoid and mineralocorticoid therapy associated with a chronic history of abdominal discomfort. On physical exam, palpable bilateral abdominal masses at the levels of adrenals were appreciated. This patient received appropriate lab and imaging to confirm the diagnosis of bilateral adrenal myelolipomas. He successfully underwent bilateral open adrenalectomy, is currently on maintenance glucocorticoid and fludrocortisone therapy, and is doing well one year post-operation.
Discussion: Adrenal myelolipomas are benign masses of mature adipocytes and scattered myeloid cells. They are the second most common benign adrenal masses following adrenal adenomas. While they are usually found unilaterally and incidentally, they can present bilaterally and symptomatically, especially in CAH, a group of genetic enzyme deficiencies involving steroidogenesis. There are three working hypotheses explaining adrenal myelolipoma's prevalence in CAH: 1) Increased adrenocorticotropic hormone (ACTH) leads to constitutive stimulation of the adrenal cortices, resulting in hyperplasia 2) Stress, infection, and trauma induce metaplastic transformation of the reticuloendothelial cells in the adrenal gland and 3) Granulocyte stimulating factor recruiting mesenchymal stem cells and circulating bone marrow which adrenocortical adipocytes are derived from.
The size and presence or severity of symptoms are essential in guiding management. Larger masses (> 4 cm) more commonly present with mass effects and possible complications of hemorrhage and, therefore, are surgically excised. Smaller masses and asymptomatic cases can be followed yearly with imaging. For masses larger than 10 cm, as in this patient, midline laparotomy is preferred to the laparoscopic surgical approach.

Large Bilateral Adrenal Myelolipomas in a 34-year old Male with Congenital Adrenal Hyperplasia

Background:
Pregnant people face higher morbidity and mortality from influenza (flu) and COVID-19 infection than non-pregnant counterparts. Despite high vaccine efficacy, only 50% of eligible pregnant people received flu vaccine before or during pregnancy and 22% completed COVID vaccination series (including boosters) as of January 2022 and December 2022, respectively.

Objective:
Qualitatively assess how providers and nurses recommend flu and COVID vaccines during prenatal visits in obstetric practices that participated in a flu vaccine communication randomized control trial (RCT) in Rochester, NY and Los Angeles, CA.

Methods:
34 obstetric practices (21 in NY, 13 in CA) participated in an RCT to increase flu vaccination rates. 16 intervention sites received a total of 60 minutes of online training on flu morbidity, vaccine effectiveness, motivational interviewing, discussing protection of the infant, and using presumptive recommendations (“you are due for a flu vaccine”). At the end of the study, provider and nurse participants received a REDCap survey with open ended questions about how they recommend flu and COVID vaccinations during prenatal visits. Data collection occurred from July - October 2022. Investigators applied content analysis to code qualitative data into themes. Results were stratified according to study arm.

Results:
The survey response rate was 46% (124/271); and 44% (104/239) of providers and 59% (19/32) of nurses participated. For flu vaccination, increased risk of flu during pregnancy was the most common theme noted in both study arms. Intervention sites more frequently described using presumptive recommendations (14% intervention, 3% control) and normalized vaccinating (“we recommend flu vaccine for all prenatal patients”, 30% intervention, 23% control) to encourage flu vaccination. Presumptive recommendation for COVID vaccination was infrequent and occurred exclusively in intervention sites (6%). Respondents from intervention sites more often mentioned protection of the baby when discussing COVID vaccination (46% intervention, 38% control).

Conclusion:
In a qualitative analysis of flu and COVID vaccine discussions for practices that participated in a flu vaccine communication RCT, participants in intervention sites more often used presumptive recommendations and normalized vaccinating, in addition to using skills taught for flu vaccination while discussing COVID vaccination. Next steps include formally testing similar interventions to increase COVID vaccination rates for pregnant people.


Provider and nurse recommendations for Influenza and COVID-19 vaccination in obstetric practices: a qualitative analysis

Background: Testicular infarction is a rare complication of epididymitis. We present a case of testicular infarction to highlight this complication and the role of ultrasound in aiding diagnosis to guide management.

Case Presentation: 26-year-old male, with recent admission for left epididymitis secondary to Multiple Drug Resistant Enterobacter, presented to the emergency department with a two-day history of progressively worsening left scrotal pain and swelling. Physical examination revealed left scrotal erythema and tenderness. Scrotal ultrasound demonstrated asymmetric enlargement and heterogeneous appearance of the left testicle consistent with left scrotal edema. The left testicle showed peripheral hypervascularity without intrinsic flow on color and spectral Doppler interrogation compatible with testicular infarction. In contrast, the right testicle was homogenous and with normal arterial and venous spectral Doppler flow. Management included intravenous antibiotic and urology consultation with subsequent partial orchiectomy. Patient’s hospital course was complicated by wound dehiscence and residual necrotic tissue requiring scrotal debridement and washout. After transition to oral antibiotics, he was discharged with outpatient follow-up with urology.

Discussion: Ultrasound with color flow Doppler is the primary method to diagnose testicular infarction secondary to epididymitis. Characteristics of testicular infarction include asymmetrically decreased or absent intrinsic testicular blood flow with or without increased peripheral flow. Although understanding of the pathophysiology of testicular infarction is evolving, arterial and venous insufficiency are suspected. Risk of global testicular infarction is low due to the testes receiving blood supply from the testicular, the deferential and cremasteric arteries. Persistent clinical symptoms and worsening imaging findings can warrant surgical intervention. In addition to spectral and color doppler, there is expanding utilization of contrast- enhanced sonography (CEUS) to increase sensitivity for testicular infarction. Testicular infarction is a rare but important diagnosis to consider in the setting of epididymitis that has management implications to prevent morbidity.

Treatment Failure of Epididymitis leads to Testicular Infarction

Background: Estimated Glomerular Filtration Rate (eGFR) is the standard method for determining kidney function and chronic kidney disease (CKD) stage classification. In the Spina Bifida (SB) population, eGFR estimates from a creatinine-based equation may not accurately represent kidney function due to the lower muscle mass in this population. We hypothesized that estimating equations utilizing Cystatin-C (CysC) would yield different CKD classifications than Creatinine (Cr) – based equations for the adult SB population. 

Methods: We conducted a retrospective chart review of all patients seen in an adult urology clinic with a diagnosis of spina bifida from 2004-2021 that were managed in our urology clinic with creatinine and cystatin C values available. All patients were > 18 years old. A cross-sectional study of patients with a CysC and concurrent Cr measurement was performed; the most recent lab values were utilized if multiple existed. Three adult eGFR equations were utilized. Patients were staged based on CKD classification (GFR > 90, GFR 60-90, GFR <60). A Chi-square test was conducted to determine the difference in CKD classification based on each equation.

Results: A total of 105 SB patients (63% female) were included in cross-sectional analysis. The mean age was 33 ± 6.5 years. Medical comorbidities including diabetes (12.4%), hypertension (28.6%), obesity (34.2%) were noted. Table 1 shows the difference in eGFR and CKD classifications between equations. On Chi-square analysis, CKD classifications were significantly different by the type of equation used (p = 0.007). Pair-wise comparison showed that significance was driven by the difference between cystatin C and creatinine equations (p = 0.002) and the cystatin C and combined equations (p = 0.05). 

Conclusion: In an adult SB population, CysC-based equations result in lower eGFRs and different CKD classifications. Determining an appropriate eGFR measurement is essential to assessing and managing renal function in these medically complex patients.

Variability in Cystatin C and Creatinine-Based equations for Chronic Kidney Disease Staging in Adult Spina Bifida Patients

Background: Nocturia, or frequent night-time urination, significantly impacts patients’ sleep, quality of life, and health. Both age and biological sex contribute to nocturia. The water-regulatory hormone arginine vasopressin (AVP) controls urine production. AVP binds to arginine vasopressin receptor 2 (AVPR), a G-protein-coupled receptor, in various organs, including the kidney and bladder. Desmopressin, an AVPR2-specific agonist, is a mainstay treatment for nocturia, but its mechanism of action in the bladder is not fully understood. A better understanding of vasopressin signaling in the bladder is crucial for refining treatment options. The fruit bat Carollia perspicillata have CNS anatomy more closely resembling humans and primates and can be kept in captivity for well over ten years, making it an attractive translational model to study aging, including nocturia. We aim (1) to identify commercial antibodies recognizing AVPRs in a novel animal model for nocturia, the fruit bat C. perspicillata (2) to develop an assay to precisely quantify arginine vasopressin receptor levels in bat bladder.

Methods: Total protein was isolated from mouse and bat kidney, liver, and bladder by homogenization in RIPA buffer with a homemade bead mill and centrifugation. 10 µg protein each, as measured by BCA assay, was electrophoresed with size standards in gels and electroblotted onto membranes. AVP1aR and AVP2R proteins were detected with commercial 1° antibodies followed by fluorescent 2° antibodies, while total protein was detected with Fast Green. Fluorescence was measured by scanning (Odyssey M, Li-Cor) and quantitated with Fiji/ImageJ software.
The mouse bladder was dissected, pinned flat and fixed overnight in a 4% w/v formaldehyde buffer. The sample was permeabilized with a blocking solution for a few hours. The same sample was then incubated with 1° commercial antibody AVP1aR for 12hrs and washed in a solution. Next the sample was incubated with 2° immunofluorescent antibody and washed again. The tissue sample was mounted and visualized with confocal microscope.

Results: AVPR2 were detected in the kidney and liver of both mouse and bat at the same expected apparent molecular masses of ~44 kDa. In the bladder of both species, the predominant apparent molecular masses were ~80 kDa, indicating dimerization, a common phenomenon with G-protein-coupled receptors. Relative protein levels were similar in the kidney and liver.
AVPR1A proteins were detected throughout the detrusor muscle of the mouse using confocal microscopy at 20x magnification.

Discussions/Conclusions: Commercial antibodies against human and rodent AVPRs recognize the orthologous proteins from the fruit bat C. perspicillata. The sizes of AVPR1A and AVPR2 proteins observed for bats match those for mice and those reported in the literature, indicating the specificity of the antibodies. AVPR1A and AVPR2 are expressed in bat kidney and bladder, the organs responsible for urine production, and are known in humans to be involved in nocturia. The fruit bat, C. perspicillata, is thus a tractable model for studies of vasopressin signaling in nocturia. Our next step will be to determine the cellular location of AVPRs and to measure their levels in the kidney and bladder of young and old bats.

Vasopressin Receptors in Bat: A Novel Animal Model for Nocturia

Pancreaticoduodenectomy (PD) is a complex procedure with a high postoperative morbidity rate. Postoperative complications include pancreatic leak, intra-abdominal abscess, postpancreatectomy hemorrhage (PPH), and others. One of the most feared complications is PPH. This is a case of a patient status post robotic-assisted laparoscopic PD who suffered Gastroduodenal Artery (GDA) stump blowout leading to PPH and cardiac arrest. The Common Hepatic Artery (CHA) was subsequently embolized to control the PPH. This is the first report in existing literature to report embolization of CHA as a method of PPH management in the setting of a replaced left hepatic artery.

Coil embolization of Common Hepatic Artery as management of postpancreatectomy hemorrhage following Pancreaticoduodenectomy 


Background:
In September 2021, a task force of kidney experts recommended a new eGFR formula without a race term to replace the previous race-based CKD-EPI formula. Existing studies have not assessed the effect of the new formula on the timeliness of chronic kidney disease (CKD) patients’ first nephrology clinic visit, a factor which has been shown to be associated with slowed progression and reduced costs of CKD. In this study we aimed to examine changes in the racial disparity between Black and non-Black patients in the timeliness of CKD patients’ first nephrology clinic visit before and after the implementation of the new race-free eGFR formula.
Methods:
We included adults seen at any of Indiana University Health’s 17 nephrology clinics between April 1st, 2021, and March 15th, 2023 for CKD or low GFR, excluding inpatient referrals and those who had previously seen an IU Health nephrologist. We conducted a multivariate linear regression with covariates including sex, self-reported race, age, timeframe, BMI, and an interaction term between race and timeframe, with timeframe defined as before or after implementation of the new formula on April 1st, 2022. Timeliness of care was defined as receiving care earlier in CKD progression (i.e., higher eGFR). All eGFR values shown are ml/min/1.73m2.
Results:
On average, throughout the entire study period, eGFR was 13.0 (95%CI: 10.3, 15.7) higher for female than male patients, 6.7 (95%CI: 2.4, 10.9) higher for non-Black than Black patients, and 5.9 (95%CI: 0.3, 11.4) higher for patients seen after the formula change than patients seen before the change. Each additional year of life reduced eGFR at time of first visit by -0.3 (95%CI: -0.4, -0.2). Our analysis found no evidence that the gap in eGFR at time of first visit between Black and non-Black patients changed significantly after the formula change (-3.7, 95%CI: -10.1, 2.7).
Conclusion:
The removal of the race term from the eGFR formula aimed to address systemic racial disparities in the diagnosis and treatment of CKD. Our results indicate that it instead led to earlier consultation with a nephrologist for all patients, as evidenced by a higher mean eGFR at the time of first clinic visit after the formula change. Despite this general trend, Black patients continued to have a lower mean eGFR at the time of first clinic visit than non-Black patients after the formula change, indicating a persistent delay in the involvement of outpatient nephrology for Black CKD patients.


Impact of race-free estimated Glomerular Filtration Rate (eGFR) on racial disparity in receiving timely outpatient nephrology care

Morgagni hernias are a rare type of diaphragmatic hernias usually presenting as a congenital defect within the diaphragm at the foramen of Morgagni with a prevalence of 2-3% [1,6]. Although rare, these hernias are usually seen in infancy or early childhood but are uncommon within adulthood. Due to the location of the foramen of Morgagni, abdominal contents herniate anteriorly within the chest with the majority in the right chest (91%) and less commonly in the left (5%) or bilateral chests (4%) [5]. Patients often present with pulmonary symptoms including chest discomfort, shortness of breath, or pneumonia [6, 9]. Although most cases are found incidentally, due to the concern for incarceration these hernias are recommended for surgical repair [4]. Approaches for repair include laparotomy, thoracotomy, open thoracoabdominal approach, laparoscopy, video-assisted thoracoscopy (VATs) [2]. However, there seems to be very limited reports of a combined laparoscopic and VATs approach for the repair of a diaphragmatic hernia. Here we present a case of 76-year-old male who presented to our emergency department with shortness of breath, chest tightness and pain with oral intake found to have a Morgagni hernia with herniation of the omentum, small bowel, and colon into the left hemithorax. Using a combined laparoscopic and VATs approach, we were able to successfully repair his hernia with minimal complications demonstrating the combined approach as a safe and viable option.

Underline digital video library

Bladder Cancer Knowledge in an Underserved, Highly Afflicted Population

Disrupting the Survival of Pathogenic T cells to Ensure the Survival of Kidney Transplants

A pragmatic study utilizing bedside ultrasound to replace invasive interventions.

Assessing the Accuracy and Reproducibility of Artificial Intelligence Chatbot in Answering Frequently Asked Questions Regarding Hypertension and its Associated Complications

Large Bilateral Adrenal Myelolipomas in a 34-year old Male with Congenital Adrenal Hyperplasia

Provider and nurse recommendations for Influenza and COVID-19 vaccination in obstetric practices: a qualitative analysis

Treatment Failure of Epididymitis leads to Testicular Infarction

Variability in Cystatin C and Creatinine-Based equations for Chronic Kidney Disease Staging in Adult Spina Bifida Patients

Vasopressin Receptors in Bat: A Novel Animal Model for Nocturia

Coil embolization of Common Hepatic Artery as management of postpancreatectomy hemorrhage following Pancreaticoduodenectomy

Impact of race-free estimated Glomerular Filtration Rate (eGFR) on racial disparity in receiving timely outpatient nephrology care

Combined Video-Assisted Thoracoscopic and Laparoscopic Approach to a Morgagni Hernia Repair

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