Introduction:
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rapidly developing mucocutaneous reactions, existing as a spectrum based on skin involvement, generally triggered by medications. SJS/TEN-like systemic lupus erythematosus (SLE) is described in
several case reports, although it remains uncommon. It presents as a diagnostic conundrum given that this bullous rash is not typically seen with lupus. Here, we describe a case of SLE masquerading as SJS.

Case Presentation:
A 25-year-old male with mixed connective tissue disease (MCTD) and
attention-deficit/hyperactivity disorder presented with a diffuse rash and oral mucosal involvement after a sore throat and fever. He had recently started Modafinil. Upon examination, he appeared ill, with a generalized maculopapular rash. Lab-work revealed thrombocytopenia, normocytic anemia, acute kidney injury (AKI), and transaminitis. Rheumatology was consulted, and initially recommended monitoring off Modafinil, with further
work-up, including a skin biopsy (as rash appeared atypical for that seen in MCTD or lupus). Other consultants were also involved, including Dermatology, Nephrology, and Hematology-Oncology. Patient underwent a kidney biopsy and was started on IV Methylprednisolone 150 mg for three days, followed by Prednisone.
Interestingly, skin biopsy findings indicated features of SJS (separation of the necrotic epidermis from the dermis, perivascular lymphocytic infiltrate); however, there were also atypical features (mixed-cell infiltrate with neutrophils). The sample was then sent out for a second opinion. The patient developed respiratory failure and pulmonary edema, necessitating intubation and transfer to the Intensive Care Unit for pressor support due to cardiogenic shock [echocardiogram showed an ejection fraction of less than 30%]. Given clinical deterioration with
worsening cytopenias, transaminitis, AKI, hypocomplementemia, positive antinuclear-antibody, and double-stranded DNA (dsDNA), he was switched to IV Methylprednisolone 1 gram for three days, followed by a steroid taper. Elevated triglycerides (765 mg/dl) and ferritin (15,084 ng/ml) raised concerns for HLH, leading to the initiation of Rituximab (literature has shown use off-label
for SLE, and benefit in certain viral-induced HLH). Kidney biopsy revealed acute tubular necrosis and Class 1 lupus nephritis. Ultimately, direct
immunofluorescence of skin biopsy showed granular deposition of immunoglobulins and complement consistent with SLE.

The patient was also started on continuous renal replacement therapy. After receiving intravenous immunoglobulin (IVIG) for four days and Cefepime for Escherichia coli and Klebsiella bacteremia, he was weaned off pressors. Improvements were seen in complements, dsDNA, C-reactive protein, ferritin, and cytopenias. By discharge, dialysis was no longer needed, and he was started on Hydroxychloroquine, Prednisone taper, Atovaquone, and Spironolactone.

Discussion:
This case highlights the diagnostic and therapeutic challenges of managing lupus-associated SJS/TEN. Initial biopsy findings were consistent with SJS, but atypical cells and subsequent immunofluorescence confirmed SLE. Key clinical indicators—hypocomplementemia, elevated dsDNA, and steroid-responsive cytopenias—pointed to an SJS/TEN-like lupus. Management was further complicated by conflicting reports on the use of steroids in SJS/TEN and the development of HLH, requiring an aggressive treatment approach. Differentiating SJS/TEN-like SLE from drug-induced SJS/TEN is crucial for appropriate management and
prognosis.

Unmasking the Rash: Unveiling the Mystery Behind a Curious Skin Reaction

Introduction
Reduction of overdose deaths by community naloxone education and distribution programs is well-established. The efficacy of teaching bystanders additional first aid measures is less clear. AHA recommends lay rescuers provide hands-only CPR for all unconscious patients with abnormal breathing as delaying CPR greatly worsens outcomes and bystanders may withhold chest compressions feeling for a pulse or worrying about rescue breaths. However, the WHO recommends CPR with rescue breathing for suspected overdose because the hypoxic etiology requires oxygenation. Other organizations recommend lay providers check a pulse to determine treatment since apnea with a pulse is more common in overdoses, particularly witnessed ones. The purpose of this study is to compare patient outcomes after community programs teach these varying strategies.

Methods
A literature review was conducted. Studies that did not specify recommendations for actions in addition to naloxone training or include measurement of patient outcomes were excluded. Twelve studies met the criteria for inclusion. Two studies described programs that recommended naloxone and CPR, while the remainder recommended naloxone and rescue breathing.

Results
After completing training programs recommending CPR, participants responded to 45 overdoses, with successful reversal 97.5% of the time (95% CI: 0.149-1.802). After programs recommending rescue breathing, participants responded to 1751 overdoses, with successful reversal 95.4% of the time (95% CI: 0.68-1.229). This information was usually obtained through voluntary self-reporting or interviewing when participants returned for naloxone refills. Numerous participants were lost to follow-up in all studies. “Reversal” was inconsistently defined but generally meant arousal and normal breathing. All patients received naloxone (dosing not recorded). Most studies did not record whether patients also received CPR and/or rescue breathing or whether this was associated with successful reversal. The published studies have significant deficiencies including limited measurement of outcomes, small sample sizes, and potential confounding variables.

Conclusion
The currently available scientific literature related to this topic is insufficient to make recommendations about how overdose response education should be structured. Further research is clearly needed.

We Taught How to Use Naloxone: Now What?

Background: Sex disparities in cardiovascular disorders are well documented, but data on in-hospital outcomes for Complete Heart Block (CHB) remain scarce. Using a national readmissions database, we assessed the association of sex with the outcomes of CHB cases.
Methods: We examined the 2016-2020 Nationwide Readmission Database (NRD) to identify patients with a principal diagnosis of CHB. Men were used as our control group, while women comprised our cohort. The primary outcome was mortality. Secondary outcomes included odds of mechanical ventilation use, all cause 30-day readmission, length of stay (LOS) and total hospitalization charges (THC). Multivariate linear and logistic regression models were used to adjust for confounders.
Results: Among the patients with CHB (N = 175,257), 45% were Female. A Female sex was associated with higher odds of mortality (adjusted OR [aOR] 1.42, 95% CI 1.3 – 1.55, p<0.001) compared to male patients with CHB. Additionally, female sex was associated with a higher likelihood of mechanical ventilation use (aOR 1.1, 95% CI 1.03 – 1.2, p=0.004), all cause 30-day readmission (aOR 1.08, 95% CI 1.03 – 1.13, p=0.004), longer LOS (4.13 days vs 3.86 days, p<0.001) and lower THC ($89,908 vs. $94,590, p=0.002) compared to male patients with CHB. 
Conclusions: Among patients with CHB, female sex was associated with higher odds of mortality and non-fatal adverse events compared to male patients. 


Sex-Based Differences in Hospitalization Outcomes for Complete Heart Block: A Population-Based Study 


Medical education is an evolving process that continues to incorporate various modes of delivery to enrich medical students’ learning. Film is a unique medium that has been shown to be an effective teaching method in educating students about patient socioeconomic factors and clinical interactions. Although film is established as an effective teaching tool, there is little to no data regarding film’s effectiveness in improving medical students’ awareness and understanding of governmental healthcare policies. The aim of this study was to determine if medical students’ understanding of disability healthcare policy was significantly influenced after viewing the film Crip Camp. Medical students watched the film Crip Camp and engaged in peer-facilitated discussion of the film. Prior to the screening, participants completed a Likert scale and yes/no survey questionnaire to assess their baseline awareness of disability policy. Following the screening, students completed the survey again. The pre- and post-survey groups were compared for statistical significance using the Mann-Whitney U test. Furthermore, a One-Way Chi-Square analysis test was conducted. In total, 18 participants responded to the surveys given at the film screening. There was a statistically significant difference between pre- and post-survey answers regarding Question 1: “Do you think that the government is doing enough in 2024 to provide services for individuals with disabilities?”(U = 420, z = 8.81, p < 0.01). Furthermore, most students who answered “Mostly not” to the previous question, also indicated “Yes” regarding Question 2: “Do you think that the state of Michigan should establish opt-in in-patient facilities for those with severe disabilities?” (ꭓ² = 5.0294, df = 2, a = 0.05). The data suggests that there was a significant difference in participants’ understanding of disability healthcare policy after viewing Crip Camp. The number of students that answered “I don’t know” to Question 1 decreased from 8 to 3. Thus, it can be inferred that the film influenced the students’ understanding because they took a stance on Question 1 post-screening. Following the screening, significantly more students selected “Mostly not” for Question 1 and “Yes” for Question 2. Hence, it can be inferred that the students became more inclined to support the government establishing opt-in services for individuals with disabilities. The scope of future studies could aim to assess students’ knowledge on health policy, and whether our screenings impact their future approach to care.


Film as a Teaching Tool: Enhancing Medical Students' Understanding of Disability Healthcare Policy


Background: Caregiving and caregiving intensity is associated with increased depressive symptoms among caregivers. Nonetheless, more research is needed to examine the relationship between caregiving intensity and depressive symptoms among care recipients. 

Methods: Using data from the seventh wave of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE)(n=550), we assessed the association between depressive symptoms in care recipients and the source of care for ADL disability in Older Mexican Americans age 75+. Depressive symptoms were measured using the Center for Epidemiological Studies Depression (CESD) scale. Caregivers were asked to name all sources of ADL care for care recipients, including the caregiver, the care recipient, another family, and other non-family. We used regression models controlling for the care recipient and caregiver characteristics, as well as the care recipient’s health. 

Results: The average CESD score of care recipients was 11.12. Care recipients' mean age was 87 years old, 68% were women, and 52% were born in the U.S. Caregivers reported sources of care included the care recipient (73%), the caregiver (32%), another family (13%) and other non-family(21%). Care recipients who provided care for themselves had significantly fewer depressive symptoms (-3.16), while those who reported non-family as sources of care had significantly higher depressive symptoms (3.33), even when controlling for the level of disability. Depressive symptoms were higher for females than males and among those that had fewer than seven years of education.

Conclusion: The source and amount of attention the care recipients receive are crucial in determining the risk of developing depressive symptoms.


Depressive Symptoms in Older Mexican Americans and the Role of Disability Care

Supernumerary breast tissue is ectopic breast tissue that communicates with the breast skin, nipple or areola. Approximately 5.6% of the population exhibits supplementary breast tissue. To date, the National Comprehensive Cancer Network does not provide monitoring and management guidelines for ectopic breast DCIS. 

This report describes a woman in her 60’s with a left supernumerary nipple positioned at the inframammary fold with a recently discovered 2-cm palpable anomaly that was confirmed as an intraductal papilloma on histology. Upon surgical excision of the mass, pathology revealed a low grade ductal carcinoma in situ, estrogen receptor positive and progesterone receptor positive. The patient’s case was presented at a multidisciplinary tumor board. She was ultimately recommended for radiation therapy, followed by anti-hormone therapy.


Presentation of Ductal Carcinoma In Situ in a Supernumerary Nipple

A 56-year-old woman with a past medical history of alcohol-associated cirrhosis presented for hematochezia. She was hypotensive. A computed tomography (CT) angiogram scan of the abdomen and pelvis revealed a conglomeration of severe right lower quadrant (RLQ) varices extending to the right colon wall. The prevalence of colonic varices (CV) is likely underestimated. While gastrointestinal bleeding from colonic varices is rare, there is a potential risk of death in severe cases. Currently, there are no specific guidelines for managing colonic varices. The management choice is based on the etiology, severity of bleeding, and distribution of the varices.

Massive Lower Gastrointestinal Bleeding From Colonic Varices In a Patient With Cirrhosis

Background 

Tumor cells in the tumor microenvironment (TME) are known to upregulate endoplasmic reticulum (ER) stress as a survival mechanism and ER stress transmission to the mitochondria is associated with tumorigenesis. We studied the mitochondrial unfolded protein response (mtUPR) associated Lon protease 1 (LONP1) in tumor cells undergoing ER stress. Our hypothesis is LONP1 inhibition during ER stress promotes immunogenic cell death (ICD) in melanoma cells.

Methods 

To simulate the TME, we used murine B16 melanoma cells that were treated with thapsigargin, a compound known to induce ER stress. Then, some cells were co-treated with both thapsigargin and CDDO-Me, a pharmacological inhibitor of LONP1. RT-PCR was used to assess potential targets associated with mt-UPR. TIMER is a database we used to assess the clinical significance of LONP1 in skin cutaneous melanoma patients. MitoProbe DIOC assay was used to assess mitochondrial membrane potential. Annexin V/PI assay was used to determine the proportion of apoptotic cells. Calreticulin exposure assay was used to determine the expression level of cell-surface calreticulin. CellTiter-Glo assay was used to determine both the intracellular and extracellular concentrations of ATP.

Results

RT-PCR showed that Lonp1 is expressed in response to ER stress. TIMER showed that expression of LONP1 is negatively correlated with the infiltration of cytotoxic CD8+ T cells, CD4+ T cells and activated NK cells. MitoProbe DIOC assay of co-treated cells showed the lowest mitochondrial membrane potential. Annexin V/PI assay of those cells showed an increase in apoptosis versus all other conditions. Calreticulin exposure assay of co-treated cells showed an increase in cell-surface calreticulin exposure versus all other conditions. CellTiterGlo assay showed both decreased intracellular ATP and increased extracellular ATP in cotreated cells only.

Conclusion

B16 melanoma cells undergoing ER stress in the absence of LONP1 function showed higher cell-surface calreticulin, higher extracellular ATP release, increased entry into late apoptosis and their mitochondrial membrane potential was significantly reduced. We conclude that inhibition of LONP1 in the presence of ER stress induced ICD in our cells, suggesting LONP1 as a potential target for cancer immunotherapy.

Inhibiting LONP1 Promotes Immunogenic Cell Death in Melanoma Cells Undergoing Endoplasmic Reticulum Stress

Abstract Title:
Outcomes and Quality of Life with Severe Obesity After Life Threatening Respiratory Illness

Background:
A body mass index (BMI) of ≥ 35 kg/m2 is traditionally considered a contraindication to extracorporeal support. We evaluated outcomes and quality of life (QoL) associated with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in patients with BMI ≥ 35 kg/m2.

Methods:
We conducted a multi-institution retrospective analysis of patients requiring VV ECMO between May 2020 and December 2021. Patients were ≥ 18 years of age who fulfilled clinical criteria for extracorporeal support. Data on survival, discharge, decannulation, tracheostomy, and extubation times were collected. Statistical analysis involved t-tests, chi-square tests, Kaplan-Meier survival plots, time-to-event models, and multiple linear regressions. Cox proportional hazards models adjusted for confounders. A Short-Form Health Survey (SF-12) provided physical and mental scores in both cohorts of patients. The relationship between outcomes and quality of life (QoL) were assessed using generalized linear and mixed models.

Results:
A total of 181 patients were studied, 80 of whom had a BMI ≥ 35 kg/m2. The median age was 43.5 (±13.5) years, with 59.7% Male and 97.2% White. Patients with a BMI ≥ 35 kg/m2 had a significantly shorter time to discharge (HR: 1.97, 95% CI: 1.16 3.36, p = 0.013) and a lower likelihood of death following discharge compared to those with BMI < 35 kg/m2 (HR: 0.169, 95% CI: 0.036-0.799, p = 0.025). Higher BMI patients also had higher survival rates at discharge (78.8% vs. 63.4%, p = 0.037). Time to decannulation and extubation did not differ significantly between cohorts. SF-12 physical and mental scores demonstrated that patients with a BMI ≥ 35 kg/m2 did not show a significant difference in physical or mental scores when compared to patients with BMI < 35 kg/m2 (42.5 (+/-10.3) vs. 41.9 (+/-10.9), p = 0.822), (51.8 (+/-11.2) vs. 53.2 (+/-9.81), p = 0.582).

Conclusions:
Patients with BMI ≥ 35 kg/m2 do not have worse outcomes from ECMO and report similar QoL metrics as patients with BMI < 35. These findings suggest the fact that BMI ≥ 35 kg/m2 should not be used as a contraindication to ECMO candidacy. Further prospective studies necessitate investigation to better characterize this relationship.

Outcomes and Quality of Life with Severe Obesity After Life Threatening Respiratory Illness


Background: Andersen-Tawil Syndrome (ATS) is an autosomal dominant channelopathy classified as long QT syndrome (LQTS) type 7, Characterized by periodic paralysis, ventricular ectopy/arrhythmia, and dysmorphic features. According to different authors, prolonged QTc is not always present, and thus it should be reclassified. However, no studies have found the correlation to life-threatening arrhythmias (LTAs) and prolong QTc. This study compared the likelihood of LTAs like VT and VF in ATS patients with prolonged QTc intervals against those with normal QTc.

Methods: To enable a meta-analysis, we searched literature reviews of reported cases or cohort studies with ATS between 1994 and 2024. Cases were selected if they presented a cardiologic affection. Prolong QTc interval was defined as QTc 440 msec in females and 460 msec for males. Each variable was calculated using the validated percentage. Numerical variables are expressed as mean and SD. Categorical variables are expressed as percentages. Student’s t-test was used for numerical variables. Categorical variables were analyzed using chi-square. Values of p <0.05 were considered statistically significant.

Results: 209 cardiologic-affected cases with ATS that provided information regarding the QTc interval were included. Of these, only 45.5% evidenced a prolonged QTc with a mean of 490  37 msec. ATS Probands were more likely to present a prolonged QTc than affected family members (51% vs. 29% respectively [p = 0.008]). Patients with prolonged QTc presented lower odds of a U wave than those with normal QTc (43% vs. 75%, respectively [p = 0.004]). Although there was no statistical significance when comparing LTAs in patients with prolonged QTc to normal QTc, LTAs were similar in both groups. VT episodes were more likely present with prolonged QTc than normal QTc (79% vs. 72%). However, episodes of sustained VT were more commonly present in cases with prolonged QTc than normal QTc (20% vs. 12%). Torsade de points and VF were more likely present in patients with a prolonged QTc interval than normal QTc (6% vs. 3% and 14% vs. 13%, respectively). Non-fatal cardiac arrest was slightly more common in cases with prolonged QTc than normal QTc (13% vs. 9%). Both prolonged and normal QTc had the same percentage of SCD (3%).

Conclusion: Although ATS has been classified as a long QT syndrome, prolongation is not always present. Patients with prolonged QTc demonstrated only a slightly increased percentage of developing LTAs compared to those with normal QTc. 


Long QT type 7 (Andersen Tawil Syndrome): Is the QTc prolongation associated with higher odds of developing life-threatening arrhythmias or cardiac arrest?

Background: Patients may seek gender-affirming orchiectomy and scrotectomy (GAOS) to alleviate dysphoria related to the scrotum and testes, while allowing for penetrative intercourse, if desired. However, techniques and outcomes of scrotectomy in this specific setting have not been described to date. Here we discuss our initial experience with GAOS as an option for patients who do not necessarily desire other gender-affirming genital surgeries.

Methods: All patients who had undergone GAOS procedures from 2021 to 2022 at our institution were reviewed. The World Professional Association for Transgender Health (WPATH) criteria for surgical treatment were met for all patients preoperatively. In addition, patients were counseled on the irreversibility of the procedure and its implications, including sterility and the impact on future surgical options such as vaginoplasty. Patients were offered a choice of two approaches depending on their surgical goals: excision of a majority of scrotal tissue and primary closure of the perineal wound, or excision of all rugated skin with mons and groin (Y-flap) advancement. Preoperative demographic data, baseline sexual function, intraoperative findings, and postoperative outcomes were collected. Patient-reported outcomes (PROs) derived from the PROMIS ® Sexual Function questionnaires were sent to all patients postoperatively and collected.

Results: Five patients underwent GAOS during the study period. Median age was 29 years and median preoperative duration on hormones was 16 months. All patients reported dysphoria related to the scrotum and testes, and wished to preserve the phallus. Three of the five patients elected for primary closure, while two desired Y-flap perineoplasty. Median operative time was 152 min and median resected scrotal area was 96 cm2; all patients were discharged home the same day. At median follow up of 97 days, all patients reported satisfaction with the surgical outcome. One patient who had Y-flap experienced wound dehiscence requiring operative revision. Three of five patients completed detailed questionnaires regarding resolution of dysphoria and preservation of sexual function. All patients who experienced postoperative complications reported being sexually active with the ability to achieve erection and orgasm within the last thirty days of the survey collection, and no change to their libido. Further patient follow-up is being collected.

Conclusion: GAOS is a well tolerated procedure that can reasonably address dysphoria related to the scrotum and testes. Further and longer-term study of this emerging procedure is warranted.

Scrotectomy as Genital Gender-Affirming Surgery: Novel Surgical Technique and Patient-Reported Outcomes

Abstract Title
Atrial Fibrillation Presenting as Renal Infarction
Background
Renal infarction is caused by occlusion of renal artery or its branches, due to emboli from cardiac sources or in situ thrombosis. It presents as sudden flank or abdominal pain, with labs showing elevated LDH, hematuria, proteinuria. Prompt diagnosis is crucial to initiate timely revascularization therapies.

Case Presentation
A 78-year-old male with past medical history of hypertension, diabetes mellitus, hyperlipidemia, COPD, meningioma presented to the emergency department with complaints of pain in the left flank and umbilical region which started gradually over the past few days and was described as dull and non-radiating. Physical evaluation revealed stable vital signs with hypertension, chronic normocytic anemia, irregularly irregular pulse, Left costovertebral angle (CVA) tenderness, bilateral chronic hand tremors. No focal neurological deficits. Denies fever, nausea, vomiting, diarrhea, constipation, anorexia, alcohol use, changes with meal, similar pain, incontinence, dysuria, hematuria, changes with urine output, urinary frequency, chest pains, palpitations, syncope, orthopnea, PND, edema. Initial Diagnostic workup included negative troponin, COVID-19/flu/RSV tests, and a chest X-ray showing mediastinal widening. Further investigations with a CT angiography chest ruled out aortic aneurysm or dissection but noted a region of low density in the left kidney parenchyma suggestive of multiple cortical infarcts. Urinalysis was positive for microscopic blood and 1 RBC. An EKG demonstrated new-onset atrial fibrillation (Afib). Cardiology consulted recommended to start anticoagulation therapy for atrial fibrillation and electrophysiology with no immediate plan for cardioversion. Later, CTAP with and without contrast show findings consistent with multiple acute renal infarcts (ARI) in the left kidney. Urology was consulted and determined no surgical intervention was indicated, recommending anticoagulation to prevent further complications from kidney infarcts. The patient was educated about his condition and discharged with appropriate outpatient follow-up.

Discussion
ARI is potentially serious medical condition but its clinical presentation of is often
nonspecific, leading to delays in diagnosis and treatment. Autopsy studies suggest the incidence of renal infarction is 14 per 1000, or 1.4%. Other retrospective studies of ER admissions found an incidence of 0.004% to 0.007%. In our case, the patient's abdominal pain with no previous history of arrhythmias prompted further evaluation, revealing new-onset AFib on EKG and subsequent diagnosis of renal infarction on imaging. Afib can cause thrombotic complication to any body part, most commonly being ischemic stroke. Clinicians should suspect other systemic embolization phenomena in patients with Afib.


Underline digital video library

Unmasking the Rash: Unveiling the Mystery Behind a Curious Skin Reaction

We Taught How to Use Naloxone: Now What?

Sex-Based Differences in Hospitalization Outcomes for Complete Heart Block: A Population-Based Study

Film as a Teaching Tool: Enhancing Medical Students' Understanding of Disability Healthcare Policy

Depressive Symptoms in Older Mexican Americans and the Role of Disability Care

Presentation of Ductal Carcinoma In Situ in a Supernumerary Nipple

Massive Lower Gastrointestinal Bleeding From Colonic Varices In a Patient With Cirrhosis

Inhibiting LONP1 Promotes Immunogenic Cell Death in Melanoma Cells Undergoing Endoplasmic Reticulum Stress

Outcomes and Quality of Life with Severe Obesity After Life Threatening Respiratory Illness

Long QT type 7 (Andersen Tawil Syndrome): Is the QTc prolongation associated with higher odds of developing life-threatening arrhythmias or cardiac arrest?

Scrotectomy as Genital Gender-Affirming Surgery: Novel Surgical Technique and Patient-Reported Outcomes

Atrial Fibrillation Presenting as Renal Infarction: A Case Report

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