Background:
Creutzfeldt-Jakob Disease (CJD) is a neurodegenerative process that manifests as a rapidly progressive dementia with a usual poor prognosis within 12 months. CJD can be further grouped into three main categories: sporadic (sCJD), genetic (gCJD), and acquired (aCJD). The worldwide incidence is around 1.5 to 2.0 per million person-years and about 85-95% of CJD can be attributed to sporadic CJD. The presentation of this disease can vary and therefore requires a criterion to make this consideration carefully. For sporadic CJD to meet the criteria for “probable,” it must have 3 main criteria: (1) Clinical findings of a neuropsychiatric disorder with a positive positive Real Time Quaking Induced Conversion (RT-QuiC) test or rapid dementia plus at least two of the following symptoms: myoclonus, visual or cerebellar abnormalities, pyramidal/extrapyramidal signs, and akinetic mutism, (2) a typical EEG findings of periodic sharp wave complexes, positive 14-3-3 CSF assay in disease duration of less than 2 years, or high signal in caudate/putamen regions on MRI brain scan or at least two cortical regions either on DWI or FLAIR, and (3) exclusion of other causes in diagnostic workup.

Case Presentation:
We report the case of a 61-year-old woman with a past medical history of hypothyroidism, psoriasis, and hypertension that presented for acute onset, rapidly progressive cognitive decline that was 1 month in duration. The patient’s clinical presentation of rapid cognitive decline, subtle cerebellar and upper motor neuron findings (e.g. pseudobulbar affect, slow speech), and MRI brain findings of cortical ribboning and restricted diffusion in the caudate nucleus was most consistent with probable sporadic CJD. Cerebral spinal fluid analysis revealed a positive Real Time Quaking Induced Conversion (RT-QuiC) test, t-tau protein of 18531 pg/mL (0-1149 pg/mL), and 14-3-3 gamma protein of 61440 Au/mL (<30-1999 Au/mL). An EEG revealed pseudo periodic triphasic sharp wave complexes over the left frontotemporal regions. Additional laboratory findings were obtained to rule out mimickers such as autoimmune encephalitis, Hashimoto’s encephalopathy, and CNS vasculitis. Upon receiving diagnosis, the patient’s condition rapidly worsened and died after 1 month possibly due to respiratory arrest.

Discussion:
This patient had an “atypical” presentation due to absence of hallmark symptoms such as myoclonus, however, the rapid course of the disease was consistent with the nature and course of sCJD. Definitive diagnosis of CJD requires neuropathological evaluation of brain tissue via immunohistochemistry or protease-resistant PrP/scrapie-associated proteins on Western blot via autopsy post-mortem. The patient presented in this report did not have an autopsy, however, with information gathered based on criteria from Center of Disease and Control, we have high clinical suspicion that this patient had probable sporadic CJD. There is no current FDA approved treatment that is available to treat this disease.


A Rare Case of Probable Sporadic Creutzfeldt-Jakob Disease

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

Introduction: Left ventricular assist devices (LVADs) are a therapy for the management of end-stage heart failure. LVADs are typically managed with long-term therapeutic anticoagulation with warfarin to prevent thrombotic complications. Direct oral anticoagulants (DOACs) are easier to manage than warfarin for other medical conditions requiring therapeutic anticoagulation. There is limited data regarding DOAC safety in patients with LVADs.
Hypothesis: There is no significant difference in outcomes for patients with LVAD when on DOAC compared to warfarin.
Methods: In a single-center retrospective analysis from February 2019 to May 2023, patients with LVAD who were switched to the DOAC apixaban (due to warfarin complications or compliance problems) were compared to patients who remained on warfarin. Overall survival, number of hospitalizations, bleeding, and thrombotic complications were compared within/between groups.
Results: 72 patients were included. DOAC group vs warfarin group: n=12 vs 60, mean age = 52.5 vs 54.2 years; Male 75% vs 81.7%; black 66.7%; vs58.3%. For DOAC group, 10 out of 12 were on warfarin prior to DOAC. Of these 10, incidence rates for bleeding-related admissions were 4.2 per 1000 days on initial warfarin and 0.76 per 1000 days after switching to DOAC. Relative risk reduction of bleeding-related admissions decreased by 81.9%. In the DOAC group, thrombosis-related admissions on initial warfarin were 0, compared to 1 after switching to DOAC. When comparing DOAC and warfarin groups, there were no statistically significant differences in bleeding or thrombotic complications (HR = 0.61; 95%CI= 0.21 to 1.46; HR= 0.74;95%CI= 0.02 to 6.08, respectively) or mortality (HR = 0.44; 95%CI: 0.01 to 3.12). Incidence rates for bleeding-related admissions were 0.98 per 1000 days and 1.59 per 1000 days, for DOAC and Warfarin, respectively. Incidence rates for thrombotic-related admissions were 0.16 per 1000 days and 0.22 per 1000 days, for DOAC and Warfarin, respectively.
Conclusions: There was no statistically significant difference in bleeding, thrombotic events, or mortality in LVAD patients receiving DOAC compared to Warfarin. Switching to DOAC improved bleeding rates in LVAD patients who suffered bleeding complications with Warfarin.

Apixaban versus Warfarin for LVAD Anticoagulation

Objective: Salivary gland tumors are a heterogenous group of lesions with variable pathology and clinical outcomes. Most published data is derived from studies conducted at tertiary care centers. Our study analyzed the experience from a community setting to determine significant differences, if any, in pathological distribution and clinical outcomes compared to the existing literature.

Methods: We performed a retrospective analysis of all salivary gland tumors that presented to a large community practice over a 20-year period. Retrospective chart analysis was performed for demographics, clinical presentation, imaging, cytology, histopathology, and clinical outcome data.

Results: Of 806 patients, the parotid gland was the most common site in 683 patients (84.7%), followed by submandibular in 78 (9.7%) and sublingual in 45 (5.6%). 203 patients were managed conservatively without definitive diagnosis or lost to follow up. A total of 495 patients underwent surgical intervention within the community practice. 26 patients underwent surgical excision at an outside hospital. 82 patients were determined to have a benign diagnosis based on FNA or excisional biopsy alone. Final histopathology was benign in 505 cases (83.7%), while 98 tumors (16.3%) received a diagnosis of primary or secondary malignancy. For the parotid gland, pleomorphic adenoma (155) and Warthin’s tumor (155) were the most common benign diagnoses, while mucoepidermoid carcinoma (13), adenocarcinoma (8), and acinic cell carcinoma (8) were the most common primary malignancies. 

Conclusions: We found a higher rate of benign tumor pathology compared to the existing literature. While the outcome data on surgical treatment of benign tumors is comparable to the existing literature, the same conclusion cannot be drawn for malignant tumors, given relatively small numbers in our series and likely disparity in the complexity of the surgical cases in tertiary care centers.

Salivary Gland Tumors: A Twenty-Year Review from a Single Community Practice

Background:
Prolonged walking can occur in various settings, ranging from amusement and national parks to marathon races. When performed in hot climates, prolonged walking can induce ExerciseInduced Purpura (EIP), a form of small-vessel vasculitis that primarily affects the lower extremities. Purpura in adults typically indicates an underlying platelet disorder or multi-system disease requiring urgent attention. We seek to raise awareness of EIP, a benign condition, among primary care health professionals.

Case Presentation:
A 55-year-old post-menopausal woman from Europe with a sedentary lifestyle traveled to Las Vegas for vacation. She noticed a purpuric rash with mild soreness and edema on her lower extremities, extending from the ankles to the mid-legs. There was no prior history of petechial rashes or bruisability. She drank a few glasses of wine daily and denied recent consumption of raw fish or meat. The only change was prolonged walking for four consecutive days with a daily step count of 20-30 thousand, as documented on a lifestyle device. Sneakers and ankle-socks
were worn throughout. She was afebrile and the physical exam was unremarkable apart from the lower-extremity, palpable petechial and purpuric rash. Areas covered by socks were spared. Based on her history of prolonged walking, coupled with the absence of systemic symptoms, a presumptive diagnosis of EIP was made. The patient recovered with supportive treatment.

Discussion:
Typically affecting healthy females in their 50s, EIP has been labeled in multiple contexts in the literature as Disney Rash, golfer’s rash/vasculitis, hikers’ dermatitis/purpura, jogger’s petechiae, sport-induced vasculitis, marathon runner’s vasculitis, and exercise-induced vasculitis (EIV). Initial cases of EIV are documented in the early 2000’s dermatology literature, exhibiting a common presentation of pruritic and burning lower extremity rash after prolonged walking in
warm climates. These clinical findings are often coupled with a histopathological analysis of small vessel leukocytoclastic vasculitis. Prior studies have suggested that the vasculitis is driven by cytokine release and circulating immune complex deposition. Potential EIV risk factors include chronic venous disease and lipedema due to an impairment in venous return and heat regulation. EIV is commonly misdiagnosed for stasis dermatitis, cellulitis, and systemic vasculitis. To avoid this, patients with bilateral lower extremity purpura after prolonged walking in warm weather should raise clinical suspicion for a diagnosis of benign EIV or EIP. Increased
awareness and knowledge of EIV/EIP is critical for preventing unnecessary diagnostic work-up, improper empirical treatment, or hospitalization.

Disney to Las Vegas: Benign Lower Extremity Purpura Following Prolonged Walking

**Scoring is only possible in the semifinals hall**

**Abstract:**



The role of the triglyceride-glucose index (TyG) in obesity and its progression to Type 2 diabetes

Various growth factors have been shown to affect the proliferation, migration, and adhesion of keratinocytes in the face of wound healing. The expression of wound repair genes is suspected to be regulated by circadian rhythm. How wound repair functions over the course of a circadian rhythm has yet to be fully described. Moreover, much is unknown about the impact of bacteria on the circadian expression of wound healing genes. Here, we intend to use periodontal disease as a model to describe the effect of a septic environment on expression of wound healing genes by epithelial cells. Furthermore, we aim to demonstrate that stimulation of epithelial cells with pathogenic bacteria alters the circadian patterns of wound repair gene expression. In the experiment, OKF4 cells were seeded, and artificial wounds were created in each well. The cells were challenged with pathogenic oral bacteria, and cell lysates were collected at T=0, T=8, and T=22 hours. PCR quantified gene expression levels. Microscopically, increased cell spreading was observed after T=22 hours in the wounded cells. Impaired cell spreading was observed in the wells challenged with pathogenic bacteria. The expression of EGF and FGF-7 appeared to follow a circadian rhythm. The presence of pathogenic bacteria downregulated the expression of genes involved in keratinocyte migration. These findings support the hypothesis that genes involved in wound healing follow a circadian rhythm and are altered in the face of infection. Continued research into this topic can lead to the development of therapies targeted towards restoring the expression of genes that aid in wound repair complicated by a septic environment or overlying infection. Further elucidating the circadian pattern of expression of these genes can also result in optimization of the timing that therapies are administered to maximize their therapeutic effect thereby improving patient outcomes. 


Altered Wound Healing Response after Challenge with Pathogenic Bacterium

Infertility impacts 1 in 4 female physicians which is twice a s high in comparison to the women in the general population. As the proportion of women in the medical workforce
continues to rise, it becomes crucial to address reproductive health issues for female physicians. This study aims to a s s e s s medical students' knowledge of fertility, risk factors for infertility, and available treatment options.

Assessing Medical Students' Understanding of Fertility and Infertility: Implications for Physician Well-being and Reproductive Health

Background
The purpose of this research is to test the clinical validity of a computerized version of the Trail Making Test (TMT) in an acute rehabilitation center for predicting concurrent inpatient disability. The TMT is a widely used neuropsychological assessment that has been shown to predict brain damage. Despite its value and efficacy in testing cognitive function, the TMT is limited to patients who have intact manual dexterity because it requires using a pen. Individuals with conditions that limit manual use (e.g. bone fracture, paralysis, burns, etc.) cannot take the test. Although there are adapted TMTs to include these populations, not many of these tests still involve visual interaction. Assessment of executive function using the Computer-Assisted TMT (CTMT) has already shown to be feasible in rehabilitation patients with intact manual dexterity. This study tested the Computer-Assisted TMT (CTMT) in rehabilitation patients who lack motor hand use.
Methods
This cross-sectional study was conducted in an acute rehabilitation hospital setting with patients (n = 37) who lack hand usability with either hand. Because patients with brain illness may have slower speech, the CTMT scores were corrected for maximal oral speech rate. Participants were tested in their hospital rooms over two sessions of the CTMT to evaluate test-retest reliability. Test-retest reliability was evaluated with Pearson correlation.
Results
50 patients were approached to be in the study, and 37 of them consented to participate. Out of the 37 participants, 33 participants were able to complete one round of testing and 17 participants were able to complete both rounds of testing. Time for CTMT completion was corrected by the maximal speech production rate (diadochokinesis or DDK). Since DDK rate has shown to be modulated by age, we also corrected people 47 years and older by a factor of 0.9316, which is based on previous research. The CMT versions had excellent test-retest reliability (r = 0.93 for CTMT-A, r = 0.83 for CTMT-B, and r =0.92 for CTMT-3).
Conclusion
The results of this study could help to determine if the CTMT can reliably predict concurrent physical disability and inform new forms of cognitive rehabilitation.


The Validation of a Computer-Assisted Trail Making Test in Acute Rehabilitation Inpatients with Manual Disability

Background: Cognitive impairment encompasses a broad range of degenerative conditions that affect an individual's memory, attention, language, perception, and problem-solving skills. While significant strides have been made in the assessment of cognitive impairment once it has already overtly manifested, researchers are becoming more interested in identifying subclinical signs of impairment using the Dual Task Paradigm. Dual tasking most often involves the performance of a motor and cognitive task simultaneously; poor dual task performance has been widely associated with cognitive impairment. The development of novel technologies offers the ability to assess dual task performance in increasingly precise ways. 
This systematic literature review is the first to comprehensively investigate how studies so far have used novel technologies to assess dual task performance as a function of cognitive impairment. With no effective cure, and mild cognitive impairment having a high conversion rate to dementia, this field holds significant potential for enabling tailored interventions, monitoring and preventing disease progression, and better overall care.

Methods: 1775 papers from 4 databases were found between January 2010-July 2023 using targeted key-word search. Following title, abstract, and full-paper screening, 142 studies were included in this review. Studies were stratified based on their objectives, type of DT (motor-cognitive, motor-motor, etc.), technology, what technologies measured as a marker of DT performance/CI, and how effective they were in fulfilling their objectives. 

Results: Counting backwards was the most widely used cognitive task (52%) as they increase cognitive load, thereby enhancing DT impairments to a greater degree. Since 2010, sensors have been the only technology used every year (2010-2023). By 2022, sensors were used in over twice as many studies as any other technology, due to their innumerable uses and ability to measure fine motor discrepancies at high precision. A future area of study gaining traction is the use of multiple technologies simultaneously for a more robust assessment of DT performance. Additionally, researchers have successfully applied AI/machine learning to DT performance metrics to predict the presence and degree of CI in patients (some with over 90% accuracy rate!). 

Conclusion: This comprehensive review has identified several study designs and technologies that offer the possibility of diagnosing subclinical cognitive impairment earlier and more precisely. These methods can be easily and cost-effectively incorporated into clinical practice.

The Use of Novel Technologies in Assessing Dual Task Performance as a Function of Cognitive Impairment: A Systematic Literature Review

A venous air embolism occurs when gas enters a venous structure that is under negative pressure. This arises most frequently through central venous catheterization. We report the case of a man in his 70s who underwent computed tomography (CT) guided biopsy of a 14 millimeter nodule in the left upper lobe of the lung. This procedure was complicated by an anterior left-sided pneumothorax as well as pulmonary hemorrhage due to nicking of the left superior pulmonary vein. This nicking is believed to have introduced an air embolism, which then circulated to the heart as visualized on CT. The patient required bilevel positive airway pressure (BiPAP) for about twelve hours, as well as placement of a thoracostomy tube for three days. Following the event an echocardiogram and CT head were performed in order to track the air embolism, however the embolism was not visualized. The patient continued to have pleuritic chest pain and hemoptysis at the time of discharge, and was followed closely outpatient by pulmonology.

Introduction of air embolism during a lung biopsy - a case report

Background
Dietary recall assessments are important clinical tools used by Registered Dietitians (RDs) for assessing eating habits, malnutrition and obesity risk, and health status. Current methods of dietary recall assessment pose barriers to accurately assessing the nutritional intake of older adults due to age-related increases in risk for cognitive decline and more complex health histories. Voice-assistant systems (VAS) are emerging technologies that have been shown to improve the health of older adults. Our study explored the challenges older adults face with dietary recall and whether VAS integration could improve current dietary recall methods from the perspective of RDs.

Methods
This qualitative study utilized semi-structured interviews and demographic questionnaires. We included participants that actively practiced as licensed RDs and were ≥ 22 years of age (n=20). Interviews were conducted over Zoom. RD perspectives were recorded through audio recordings that were professionally transcribed. Transcriptions were inductively analyzed and codified through Dedoose to generate common themes. Qualitative themes included significance of current methods of dietary recall, barriers and facilitators of current methods of dietary recall, and barriers and facilitators of VAS dietary recall.

Results
Of the 20 interviewees, ages ranged from 22-65+ years, of which 9 (45%) were 22-34, 8 (40%) were 35-64, and 3 (15%) were ≥ 65 years. Most of the RDs identified as being female (95%), white (85%), and not of Hispanic, Latino/a/x, or Spanish origin (90%). RDs believed the implementation of VAS had the potential to improve dietary recall assessments of older adults. RDs reported challenges of current dietary recall methods among older adults, such as memory and hearing (65% of participants) and properly reporting serving sizes (45% of participants). RDs reported that VAS dietary recall may be beneficial due to convenience of real-time data collection (80% of participants), more efficient use of time during clinical visits (65% of participants), and ease of accurately reporting meals (85% of participants). However, RDs reported low technology literacy in older adults as a barrier to VAS implementation (70% of participants).

Conclusion
Our qualitative study provides a framework on how VAS can better meet the needs of both older adults and clinical RDs in managing and assessing dietary intake. Future VAS technologies can improve dietary recall methods by incorporating probing cues to enhance real- time data collection, providing clinicians accessibility to patient responses, and including questions that enable collection of data points related to food intake, such as accurate intake times and food-related symptoms.

Underline digital video library

A Rare Case of Probable Sporadic Creutzfeldt-Jakob Disease

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

Apixaban versus Warfarin for LVAD Anticoagulation

Salivary Gland Tumors: A Twenty-Year Review from a Single Community Practice

Disney to Las Vegas: Benign Lower Extremity Purpura Following Prolonged Walking

The role of the triglyceride-glucose index (TyG) in obesity and its progression to Type 2 diabetes

Altered Wound Healing Response after Challenge with Pathogenic Bacterium

Assessing Medical Students' Understanding of Fertility and Infertility: Implications for Physician Well-being and Reproductive Health

The Validation of a Computer-Assisted Trail Making Test in Acute Rehabilitation Inpatients with Manual Disability

The Use of Novel Technologies in Assessing Dual Task Performance as a Function of Cognitive Impairment: A Systematic Literature Review

Introduction of air embolism during a lung biopsy - a case report

Understanding the Feasibility of Voice-assistant Systems to Advance Dietary Recall Methods

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