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**Abstract:**

Background 
The exponential growth of biomedical literature, especially in urology, with 1.3M new citations added to MEDLINE in 2023, makes it difficult for clinicians to stay updated and conduct literature reviews and meta-analyses. Artificial intelligence, specifically through a technique called sentiment analysis, can help by facilitating the rapid extraction and summarization of insights from study data. Sentiment analysis uses large language models (such as GPT-4) to classify texts based on sentiment (i.e. tone expressed). This study tests GPT-4 in conducting sentiment analysis of literature about a common urology topic — the utilization of radiotherapy versus prostatectomy as treatment for localized prostate cancer — by comparing GPT-classified sentiments of studies to human-classified sentiments. 

Methods 
A PubMed literature search using MeSH keywords for prostate cancer, prostatectomy, and radiotherapy, yielded 29 relevant studies. Abstracts were reviewed by the research team, with members independently assigning a sentiment of prostatectomy-preferred, radiotherapy-preferred, or neutral. 
GPT-4 was then provided three abstracts that were human-classified as prostatectomy-preferred, radiotherapy-preferred, and neutral. This provided GPT-4 a baseline for sentiment classification. The model subsequently classified the remaining 26 abstracts by sentiment. It was prompted five separate times to ensure consistency. 
GPT-4 sentiment classification results were compared to human-classified sentiments (reference, gold standard answers) through accuracy, precision, recall, and F1 score metrics to gauge model performance. 

Results 
GPT-4 had 80.8% (21/26) accuracy in classifying sentiments compared to manual, human classified sentiments, correctly categorizing 3 radiotherapy-preferred, 7 prostatectomy-preferred, and 11 neutral abstracts. GPT-4 had 76.5% recall, 82.8% precision, and an F1 score of 79.5% (F1 scores range between 0-1, with 75% being an approximate cutoff for “good”). 

Conclusion 
GPT-4 is capable of fairly accurate (80.8%) sentiment analysis, even for specialized domains like urology. Its mistakes were limited to differentiating between neutral and polarized (radiotherapy-preferred or prostatectomy-preferred) sentiments. Mis-categorization of neutrality can be due to lack of specific words deemed neutral, as opposed to positive and negative. Thus, GPT-4 has promise to rapidly parse through large numbers of studies and capture overall sentiment, which may be useful for clinicians. 


Leveraging AI in urologic literature: GPT-4 for sentiment analysis on the utilization of radiotherapy versus prostatectomy in prostate cancer as an upfront treatment

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**Abstract:**

Background: Downward trends in inflation-adjusted Medicare reimbursement to hand surgeons have been reported, likely to offset increasing costs associated with the aging population. Less is known regarding Medicaid reimbursement to physicians, but generally Medicaid reimbursement rates are thought to be lower than Medicare. Given the ability for each state to set rates for a given procedure, discrepancies exist in Medicaid reimbursements between states. This study compared Medicaid and Medicare rates for common hand surgery procedures to determine national and state differences in reimbursement.

Methods: Medicare rates for 26 commonly billed hand procedures, based on prior reimbursement studies, were obtained from the Center for Medicare & Medicaid fee schedule database. Corresponding work RVUs for each procedure were also collected here. Medicaid rates were found at states’ Medicaid online fee schedule website. State rates were compared to corresponding Medicare rates using mean values and dollar differences. These dollar differences were also divided by work RVUs. Each states’ reimbursement values were also adjusted using the Medicare Wage Index to account for regional wage differences. Variability between states and between procedures was analyzed using percentages as a function of Medicare reimbursement and by coefficient of variation values. Coefficient of variation values were calculated by dividing the standard deviation by the mean for each procedure, and values further from zero indicate higher variability within a dataset.

Results: Medicaid reimbursement was lower than Medicare for 22 of the 26 procedures included in the analysis. On average, Medicaid rates were 18% lower than Medicare, a difference that increased to 29% when accounting for wage differences. Average dollar differences by procedure ranged from $205 less to $110 more for Medicaid. Dollar differences per RVU ranged from $38 less to $48 more for Medicaid. State Medicaid rates ranged from 30% to 158% of Medicare. Variability was low among Medicare procedures, with a coefficient of variation of 0.06. Medicaid variability between states ranged from 0.26-0.57 for unadjusted data and 0.36-0.67 for wage-adjusted data.

Conclusion: On average, Medicaid reimbursement is substantially lower than Medicare for common hand surgery procedures. There was wide variability in Medicaid rates, both between states and procedures. Adjustment for wage differences increased the percent difference and variability, suggesting a lack of objective metrics used to set Medicaid prices. Hand surgeons should be aware of variable prices between states and advocate for policy that fairly reimburses them while promoting better access to care for this vulnerable population.

Medicaid Reimbursement to Hand Surgeons is 18% Less than Medicare and Highly Variable, Ranging from 30-158% of Average Medicare Rates by State

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**Abstract:**

Eating disorders (ED) are a group of psychiatric conditions that impair both physical health and psychosocial functioning. Anorexia nervosa (AN) is an ED characterized by an inability to maintain an adequate, healthy body weight, along with persistent disturbances in eating behavior and body image. AN is a disorder with considerable morbidity and mortality, with a weighted annual mortality rate of 5 per 1,000 person-years. Although AN can resolve acutely, many patients relapse soon after weight-restoring treatment and more than half of patients with AN show signs of the disorder for years. We believe that aberrant processing of social information is a key component that contributes to the development and maintenance of the disease. We hypothesized that a more negative view of both self and social environment in adolescent AN patients and increased sensitivity to negative social interaction contribute to the pathology of AN. The project followed a cohort of adolescents receiving treatment for AN as well as matched healthy controls (HC) recruited from two clinical sites: Children’s Medical Center Plano and Children’s Hospital of Pennsylvania. Clinical status assessments at baseline, 3 months, and 6 months were assessed through percent expected body weight (%EBW), responses on the 13-point abbreviated eating disorder examination questionnaire (EDEQ-13) and the 25-point abbreviated Revised Child Anxiety and Depression Scale (RCADS-25). Social self-report questionnaires at the three timepoints included an abbreviated 14-point Internal Personal Situational Attribution Questionnaire (IPSAQ), the Rosenberg Trait Self-Esteem Scale (RSES), and the Social Reward Questionnaire (SRQ). AN adolescents had significantly lower %EBW compared to HC (M = 80.28, M = 101.77, p <0.0001). Total EDEQ-13 scores at baseline were also significantly higher in the AN group compared to HC (M = 2.95, M = 1.40, p = 0.0003). The RSES score was significantly lower in the AN group compared to HC (M = 22.22, M = 30.62, p = 0.0038) and of the five subscale scores of the SRQ, the AN group had significantly higher scores for prosocial interactions compared to HC (M = 28.67, M = 26.39, p = 0.0362). Responses to these selected social questionnaires suggest that AN adolescents have lower global self-esteem and a tendency towards self-blame in negative social scenarios compared to their HC. Additionally, the AN group had a significantly higher SRQ prosocial interactions sub-scale score when compared to their healthy counterparts, reflecting a value of fairness and equality in social interactions.

Self-concept and Social Processing in Adolescents with Eating Disorders

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**Abstract:**

Background
Mobile low-dose computed tomography (LDCT) lung cancer screenings (LCS) are part of an outreach program in rural Appalachia to detect early malignancy in areas with limited healthcare access. While the primary goal is to screen for lung cancer, LDCT LCS can identify calcium deposits in coronary arteries and can prompt risk modification strategies for prevention of cardiovascular disease (CVD) events. There is no clear guidance for follow-up regarding CAC or prevention of associated CVD risk in patients undergoing LDCT LCS. The aim of this study was to determine how many patients with no known CVD had the presence of CAC on LDCT LCS. Secondary objectives were to determine if patients with CAC scores ≥100 received appropriate CVD risk reduction follow-up, and if initiation of statin or aspirin therapy occurred within 3 months after LDCT LCS. 

Methods
A retrospective review of mobile LDCT LCS from September 2021 to December 2022 was conducted in one large, tertiary health-system. Adult patients with no previous CVD history were included. CT images were obtained at 100 kVp with a slice thickness of 3 mm. Agatston CAC scoring was completed retroactively. Descriptive statistics and chi-square analyses were utilized.

Results
A total of 526 LDCT LCS were included. Over 54% of patients had coronary calcification on LDCT lung screening. 161 patients (30.6%) had a CAC score of ≥100 and 75 patients (14.3%) had a CAC score ≥400. Of patients with a CAC score ≥100, only 7.5% received referrals for follow-up and 9.3% had additional cardiac testing. Of those with a CAC score ≥100 not already on a statin (45.3%), only 8.2% were initiated on statin therapy within 3 months after LDCT LCS. Of those with a CAC score ≥100 not already on aspirin therapy (63.3%), only 5.9% were initiated on aspirin therapy within 3 months after LDCT LCS. Aspirin and statin initiations were dependent on calcium score (p<0.01).

Conclusion
In patients with no CVD history, CAC was frequently identified on mobile LDCT LCS in rural communities. Calcium scoring from LDCT lung screenings allowed for simultaneous assessment of lung cancer and CVD risk. Despite high CAC scores, there was limited initiation of cardiovascular disease prevention measures and follow-up, likely indicating missed opportunities for early intervention. Awareness of CAC score utility, follow-up for identified coronary calcification, and consideration of primary prevention medications when indicated, would be beneficial in patients undergoing LDCT lung cancer screenings, especially in rural areas with limited resources.

Cardiovascular Risk Reduction Strategies After Coronary Artery Calcium Scoring on Mobile CT Lung Screenings in Rural Appalachia

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**Abstract:**

Purpose
Telehealth has become a mainstay of modern healthcare, post-COVID-19 pandemic era. Telehealth has increased access to healthcare providers across various regions, potentially reducing access disparities. Currently no studies exist evaluating the impact of telehealth on access equity in thoracic surgery. This paper aims to assess if telehealth increases access to thoracic oncologic surgery in disadvantaged communities.

Methods
A retrospective single institution review of thoracic surgery patients with an oncologic indication from March 2018 to November 2022 was conducted. Patients were stratified into office or telehealth groups based on the type of their first preoperative consultation visit. Patients being assessed for esophageal malignancy or mediastinal staging alone were excluded. Demographic data included age, sex, location by county, and state. Primary outcomes were median Area Deprivation Index (ADI) for state deciles and national percentiles for in-office and telehealth patients. The Area Deprivation Index (ADI) is a ranking of socioeconomic disadvantaged neighborhoods at the state or national level with consideration for factors such as income, education, employment status, and housing. Mann-Whitney U tests were used to analyze the ADI difference between groups. 

Results
759 patients met inclusion criteria, including 376 in office and 383 telemedicine. All telemedicine visits were audio only and conducted over the phone. There were no demographic differences between groups based on age (p=0.3) or sex (p=0.9). There was a total of 62 unique counties represented among all patients in this cohort. The majority of patients resided in Oregon (628/759, 82.74%) and Washington (108/759, 14.23%). Median ADI for national percentiles and state deciles can be seen in Table 1. The median ADI of telehealth patients was significantly higher than that of in office patients (34 v. 32, p<0.01). Similar results for telemedicine and in-office patients were found when evaluating Oregon specific ADIs (5 v 6, p<0.01). There was no difference in State ADIs for patients from Washington (p = 0.156).

Conclusions
Overall, patients in the telemedicine group had a higher disadvantaged rating than their in-office counterparts nationally and in Oregon. Telemedicine improves access to thoracic surgeons for patients from socioeconomically disadvantaged neighborhoods, addressing the unequal distribution of physicians and healthcare systems in these areas. Further studies should be conducted to evaluate the role of telehealth in increasing health equity in thoracic surgical cancer care.

Addressing the Inequities in Thoracic Surgery: How Telemedicine is Levelling the Playing Field

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**Abstract:**

Introduction/Objective
The sinus of Valsalva is the most proximal section of the ascending aorta near the aortic root. Sinus of Valsalva aneurysms (SOVA) is a rare congenital or acquired condition of the aortic root. Ruptured SOVA typically involves another chamber of the heart. Free wall rupture of the SOVA is normally associated with sudden death due to tamponade. We report a case of blunt trauma resulting in the rupture of the non-coronary sinuses of Valsalva, which was successfully repaired.

Case Presentation
The patient is a 47-year-old male with a past medical history of left thoracotomy and sternotomy for penetrating trauma who recently sustained blunt chest trauma at work. The patient was transferred from an outside hospital due to concern for thoracic aortic injury with active extravasation into the pericardium. Upon arrival, the patient complained of a brief loss of consciousness, chest pain, and shortness of breath. On the primary survey, the patient required BiPAP and esmolol drip. 
Transthoracic echocardiogram (figure 1A) and chest CTA (figure 1B) revealed a rupture of the sinus of Valsalva.
Figure 1A: The transthoracic echocardiograph reveals a rupture of the sinus of Valsalva. The rupture is near the aortic root's non-coronary cusp (NCC). Also visible are the right ventricle (RV), left ventricular outflow tract (LVOT), right coronary cusp (RCC), and ascending aorta.
Figure 1B: Axial view of chest CT showing disruption of the non-coronary cusp (NCC) with contained posterior hematoma within the mediastinum. The left coronary cusp (LCC) and right coronary cusp (RCC) are visualized.
The patient underwent a redo sternotomy, revealing a rupture of the left and non-coronary aortic root sinuses. He received a biological aortic root and valve replacement. After a prolonged hospital course, he was discharged home and resumed all normal activities upon outpatient follow-up.

Discussion
A literature search did not identify any reports of long-term survival following emergency surgical intervention for traumatic, free rupture of the Sinuses of Valsalva. We identified reports of non-traumatic ruptures of the SOVA into the pericardium causing tamponade. The unique feature of this case was the acute traumatic cause of the rupture, the distinct CT and TTE findings, and the successful aortic valve replacement. The history of sternotomy for penetrating trauma possibly contributed to the patient’s survival.

Conclusion
Traumatic free wall ruptured sinus of Valsalva into the mediastinum can show specific radiological findings; rapid surgical correction should ensue.

Successful Repair of a Ruptured Sinus of Valsalva Following Blunt Chest Traumatic Injury

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**Abstract:**

Background
Encephalitis (inflammation of the brain) is primarily divided into Autoimmune Encephalitis (AE) and Infectious Encephalitis (IE). Encephalitis poses a substantial burden on the U.S. healthcare system with an annual prevalence of 5-10 patients per 100,000 individuals and an inpatient mortality of nearly 10% [1-3]. Additionally, most patients are discharged with sequelae of impaired cognitive function [4]. Previous studies suggest both autoimmune (e.g. multiple sclerosis) and infectious (e.g. SARS-CoV-2) condition severity is associated with Vitamin D (VitD), where it can modify disease activity or where hypovitaminosis is a causal risk [5-6]. VitD supplementation, an extremely accessible and cost-effective intervention, in some cases resulted in disease prevention and risk reduction [5,6]. Despite these findings, the relationship between VitD and both autoimmune- and infection-mediated encephalitis is unknown. We sought to assess this relationship between VitD and clinical measures and outcomes in patients with encephalitis. 

Methods
373 adult encephalitis patient charts from 03-31-2013 to 03-31-2023 were reviewed from the Texas Medical Center/Greater Houston area. VitD levels, demographics, physical exam findings, treatments, imaging findings, diagnostics, and outcome variables were collected. VitD values were trichotomized into “Deficient”, “Insufficient”, and “Sufficient” [7]. 

Results 
Chi Square Tests of Independence analysis revealed significant associations between VitD Status and Disposition (p = 0.01), Cause of Death (p < 0.001), and # Rituximab therapies (p = 0.006). Additionally, statistically significant associations existed between low VitD levels (VitD Deficiency and Insufficiency) and immunocompromised state (p = 0.008), poorer outcomes referencing the Glasgow Outcome Scale (GOS) (p = 0.014), Hospital Readmission (p < 0.001), severe comorbid conditions referencing the Charlson Comorbidity Score (p = 0.032), and Mortality (p < 0.001). Binary Regression analysis revealed confounds; African-American patients and those receiving mechanical ventilation had poorer outcomes based on the GOS (p = 0.008, 0.048).

Conclusion 
Our study provides evidence that VitD status has a significant relationship with AE and IE clinical measures and outcomes post-hospitalization. However, we were limited by lack of VitD documentation; ~10% of study patients had documented measurements taken during their hospital stay. This illuminates the need for clinicians to 1) collect VitD data for all AE/IE patients and 2) consider VitD supplementation, an accessible and cost-effective intervention, for AE/IE patients. Future studies, currently being pursued, include incorporating 300 additional AE/IE patients from the Johns Hopkins medical system to further define the relationship between VitD status with clinical outcomes. 



1. Graus F, Titulaer MJ, Balu R, Benseler S, Bien CG, Cellucci T, Cortese I, Dale RC, Gelfand JM, Geschwind M, Glaser CA, Honnorat J, Höftberger R, Iizuka T, Irani SR, Lancaster E, Leypoldt F, Prüss H, Rae-Grant A, Reindl M, Rosenfeld MR, Rostásy K, Saiz A, Venkatesan A, Vincent A, Wandinger KP, Waters P, Dalmau J. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol. 2016 Apr;15(4):391-404. doi: 10.1016/S1474-4422(15)00401-9. 
2. Ellul M, Solomon T. Acute encephalitis - diagnosis and management. Clin Med (Lond). 2018 Mar;18(2):155-159. doi: 10.7861/clinmedicine.
3. Hansen MA, Samannodi MS, Hasbun R. Predicting Inpatient Mortality Among Encephalitis Patients: A Novel Admission Risk Score. Open Forum Infect Dis. 2020 Oct 7;7(11):ofaa471. doi: 10.1093/ofid/ofaa471.
4. Kvam KA, Stahl JP, Chow FC, Soldatos A, Tattevin P, Sejvar J, Mailles A. Outcome and Sequelae of Infectious Encephalitis. J Clin Neurol. 2024 Jan;20(1):23-36. doi: 10.3988/jcn.2023.0240. PMID: 38179629; PMCID: PMC10782093.
5. Sintzel MB, Rametta M, Reder AT. Vitamin D and Multiple Sclerosis: A Comprehensive Review. Neurol Ther. 2018 Jun;7(1):59-85. doi: 10.1007/s40120-017-0086-4. Epub 2017 Dec 14. PMID: 29243029; PMCID: PMC5990512.
6. Xu Y, Baylink DJ, Chen CS, Reeves ME, Xiao J, Lacy C, Lau E, Cao H. The importance of vitamin d metabolism as a potential prophylactic, immunoregulatory and neuroprotective treatment for COVID-19. J Transl Med. 2020 Aug 26;18(1):322. doi: 10.1186/s12967-020-02488-5. PMID: 32847594; PMCID: PMC7447609.
7. Holick MF. Vitamin D status: measurement, interpretation, and clinical application. Ann Epidemiol. 2009 Feb;19(2):73-8. doi: 10.1016/j.annepidem.2007.12.001. Epub 2008 Mar 10. PMID: 18329892; PMCID: PMC2665033.


Vitamin D Status in Autoimmune and Infectious Encephalitis

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**Abstract:**

Background
Historically, women are underrepresented in the field of orthopedic surgery. To evaluate progress in this area, it is important to assess not only representation but also activity at high profile orthopedic conferences in the field.
Methods
Poster presentations from the 2023 and 2024 AAOS annual meetings were identified via the AAOS ePoster archive. First, second and last authors were recorded for each poster that met inclusion criteria. For each author included in the data, gender was determined and recorded. In addition gender, degree title (as listed on the AAOS website) was recorded, including authors’ AAOS membership status if listed. The Elsevier database, Scopus, was used to determine each authors’ academic influence at the time of data collection. H-indexes, an author specific metric that evaluates scientific output based on publications and citations, were recorded for each author.
Results
Chi-squared analysis for independence revealed a statistically significant difference in distribution of authorship positions by sex (P=0.03). Using a student's T-test, H-index for male first authors (M = 9, SD = 8) were found to be significantly higher than that for female first authors (M = 5, SD = 6), P < .001. Similar trends were observed for second authors (male: M = 10, SD = 8; female: M = 8, SD = 7), P < .001, and senior authors (male: M = 27, SD = 19; female: M = 17, SD = 18), P < .001. There was also a statistically significant difference in the proportion of male and female authors between the two years (P=0.03). Finally, there was an increase in the proportion of female authors from 14.3% in 2023 to 16.3% in 2024.
Conclusion
In our analysis of the two most recent AAOS summit authorship data, male authors dominate all authorship positions—first author, second author, and senior author. This disparity is most pronounced in the senior author role, where only 9.6% of senior authors are female. These findings further underscore a persistent gender imbalance in authorship positions at the AAOS annual meeting. Additionally, male authors generally have higher citation impacts than their female counterparts across all author positions. An increase in the proportion of female authors from 14.3% in 2023 to 16.3% in 2024 indicates a positive trend toward greater female representation in orthopedic presentations at the AAOS annual meeting. This significant increase suggests ongoing efforts to promote gender diversity in the field, which remains predominantly male.

Representation of Female Authorship to Evaluate Gender Diversity in Orthopedics

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**Abstract:**

Cataracts are a significant cause of vision loss. Modern treatment of cataracts involve surgical fragmentation, removal, and replacement of the clouded intraocular lens. Femtosecond laser-assisted pretreatment is a recent advancement that is thought to enhance the precision, efficiency, and safety of cataract surgery. In this study, Cumulative Dissipated Energy (CDE) and intraoperative time in cataract surgeries with and without femtosecond laser pretreatment were observed. 700 eyes in 541 patient charts over a 38-day period were included in this retrospective analysis. We conclude that femtosecond laser pretreatment significantly reduces average effective phacoemulsification time (EPT) by 12% and average intraoperative time by 7% as compared to non-femtosecond laser assisted (conventional) cataract surgery, supporting current data on its efficacy.

A Retrospective Analysis of Cumulative Dissipated Energy during Phacoemulsification and Operative Time in Cataract Surgery with and without Femtosecond Laser-Assistance

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**Abstract:**

Appropriate use of radiological studies is of utmost importance in medical practice, guiding care and reimbursement. The American College of Radiology Appropriateness Criteria (ACR-AC) is a free, online evidence-based resource dedicated to supporting practitioners with radiology decision-making. However, this resource has historically been underutilized by physicians and medical students, with those groups often opting to use alternative resources such as UpToDate
(UTD). Increasing awareness and user-friendliness of the ACR-AC within medical education is necessary to integrate regular use of this resource in practice. This study seeks to investigate medical student performance with and perception of the ACR-AC and UpToDate when presented with radiology decision-making cases.

Methods
First-year osteopathic medical students were presented with a clinical case and utilized either UpToDate or ACR to assist in determining the most appropriate imaging modality for the case. Following the case, students were surveyed to assess their familiarity with each resource, its effectiveness in establishing a differential diagnosis, ease of selecting the appropriate imaging, perceived usefulness, impact on confidence in imaging selection, and likelihood of future utilization. The accuracy of their decisions was also evaluated based on which resource they used. 

Results
Our survey had 82 respondents for the UTD group, and 83 respondents for the ACR group. The results showed that more students have used UTD over ACR coming into the study (20% vs 8%, p=0.01). The students also more strongly agreed that UTD was more helpful in establishing a differential diagnosis for the cases (56.1% vs 49.4%, p= 0.04). However, students found that ACR was easier to use as a resource for determining the appropriate imaging modality (3.9 vs 4.2, p=0.02). The accuracy of the tests showed a trent towards significance with case one showing 92.1% correct vs 82.6% with UTD (p=0.06) and 84.9% vs 75.6% on case two (p=0.13). 

Conclusion
The awareness of imagining resources among first year medical students is generally low. Following a case presentation, students more strongly agreed that UTD is a more helpful resource in establishing a differential diagnosis. However, students found that ACR was easier to use to determine the appropriate imaging modality. The results also showed a trend towards significance with students making more accurate decisions utilizing ACR over UTD.

Comparing ACR Appropriateness Criteria and UpToDate in Medical Student Radiology Decision Making

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**Abstract:**

Background
Interstitial lung disease serves as an umbrella term to cover over 100 conditions causing scarring and inflammation of the lungs. Common offending agents include autoimmune disease such as lupus and rheumatoid arthritis, pneumoconiosis such as asbestosis, hypersensitivity pneumonitis, or adverse reactions to medications. Nitrofurantoin is one such medication that can cause pulmonary injury, with about 1 in 5000 having acute hypersensitivity presenting an average of 9 days after initiation, while chronic pneumonitis reactions take 6 months to several years. Risk factors include age over 60, pre-existing lung conditions and renal impairment. Commonly used to treat uncomplicated lower urinary tract infections, we present the case of a patient that is unique for developing lung toxicity while on this medication outside of the expected timeframe of this manifestation.

Case Presentation
An 86-year-old female with past medical history significant for hypertension, hypothyroidism, CKD stage 2, presented to the emergency department with exertional dyspnea and fatigue for 3 weeks. For 4 months leading up to this admission, the patient had been on daily UTI prophylaxis with nitrofurantoin. She is a former smoker with a 50-pack year and quit 3 years ago. Pertinent labs include positive ANA, RF and anti-CCRP antibodies. 2D Echo was unremarkable. CT chest was significant for diffuse dense ground glass opacities with scattered areas of consolidation worse at the peripheries. There was no evidence of honeycombing, traction bronchiectasis or pleural effusion. Pulmonology was consulted and a bronchoscopy was performed. BAL studies were negative for Aspergillus, PCP, Histoplasma, Blastomyces. The clinical history, CT imaging findings and further workup results were suggestive of nitrofurantoin lung toxicity. Nitrofurantoin was discontinued and patient was started on steroid taper of oral prednisone, 2L/min O2 supplementation to maintain SPO2>90% with plan for repeat CT chest in 6 weeks.

Discussion
As the 5-year survival rate for ILD is 48.1%, identifying the cause is key for overall prognosis. In our patient with infectious and cardiogenic causes ruled out, autoimmune work up was positive. It’s not unusual to have positive antibodies in nitrofurantoin toxicity, including RF and ANA having been reported. It would be unusual to develop acute RA- related lung disease at her age without any other systemic symptoms or signs. Improved function and imaging on repeat follow-up will confirm, with this case serving to illustrate the high index of clinical suspicion needed by the provider to implement timely interventions in cases that present in an atypical fashion.

Atypical Presentation of Nitrofurantoin-Induced Pulmonary Toxicity

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**Abstract:**

• Abstract Title 
• A Fatal case of Diffuse Large B Cell Lymphoma Presenting with Bilateral Necrotic Renal Masses. 
• Background 
• A 48-year-old woman with a history of chronic inflammatory demyelinating polyneuropathy presented to the hospital for failure to thrive. She experienced rapid decompensation during two consecutive hospitalizations; No diagnosis was able to be elucidated prior to patient expiring. 
• Case Presentation 
• A 48-year-old female with questionable past medical history of SLE and chronic inflammatory demyelinating polyneuropathy (CIDP), treated with weekly intravenous immunoglobulins (IVIG), presents to the hospital due to difficulty with activities of daily living, including eating and bathing. Family endorsed a thirty-pound weight loss with progressive dysphagia. CT Head showed right tentorium cerebellar lesion and CT abdomen and pelvis showed necrotic bilateral adrenal masses. Left retroperitoneal lymph node biopsy showed a benign reactive lymph node. Completed a Positron emission tomography (PET) scan depicting intensely avid bilateral adrenal masses with retroperitoneal and pelvic lymphadenopathy. 
• Three weeks after discharge, she presented back to hospital with worsening lethargy, microcytic anemia with hemoglobin of 6.9, hypotensive due to adrenal crisis responsive to fluids and stress dose steroids. New diffuse lower extremities purpuric lesions noted, for which biopsy showed leukocytoclastic vasculitis. Admitted to Medical Intensive Care Unit for worsening hyponatremia after fluid resuscitation and was started on 2% hypertonic saline. She was downgraded after resolution of hyponatremia and hypotension. She was again upgraded due to worsening fevers to 103F and started on broad spectrum antimicrobials: meropenem, vancomycin and fluconazole. Flow cytometry studies were negative. A large filling defect in the suprarenal inferior vena cava was noted and was started on apixaban. Despite all measures, the patient ultimately developed worsening hypoxic respiratory failure, was converted to comfort care measures and ultimately expired. 
• Pathology indicated Diffuse Large B-Cell Lymphoma returned after the patient expired. Initial differential diagnoses for this patient included lymphoma with negative biopsy due to steroid use as outpatient, Castleman disease, Rosai Dorfman disease or unspecified autoimmune disease. 
• Discussion 
• This case involves a young woman with controlled neurologic disease and multiple rheumatologic diagnoses. She presented with bilateral necrotic adrenal masses leading to adrenal insufficiency, which complicated her condition. Despite undergoing biopsy, no single diagnosis or syndrome was initially identified to explain the constellation of symptoms, and 
• unfortunately, the patient passed away from acute hypoxic respiratory failure. Diagnosis was limited by unusual symptom presentation and negative first biopsy. 



Underline digital video library

Leveraging AI in urologic literature: GPT-4 for sentiment analysis on the utilization of radiotherapy versus prostatectomy in prostate cancer as an upfront treatment

Medicaid Reimbursement to Hand Surgeons is 18% Less than Medicare and Highly Variable, Ranging from 30-158% of Average Medicare Rates by State

Self-concept and Social Processing in Adolescents with Eating Disorders

Cardiovascular Risk Reduction Strategies After Coronary Artery Calcium Scoring on Mobile CT Lung Screenings in Rural Appalachia

Addressing the Inequities in Thoracic Surgery: How Telemedicine is Levelling the Playing Field

Successful Repair of a Ruptured Sinus of Valsalva Following Blunt Chest Traumatic Injury

Vitamin D Status in Autoimmune and Infectious Encephalitis

Representation of Female Authorship to Evaluate Gender Diversity in Orthopedics

A Retrospective Analysis of Cumulative Dissipated Energy during Phacoemulsification and Operative Time in Cataract Surgery with and without Femtosecond Laser-Assistance

Comparing ACR Appropriateness Criteria and UpToDate in Medical Student Radiology Decision Making

Atypical Presentation of Nitrofurantoin-Induced Pulmonary Toxicity

A Fatal case of Diffuse Large B Cell Lymphoma Presenting with Bilateral Necrotic Renal Masses

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