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  The Masquerade or What's in This Skin; A Case of Cutaneous Sarcoidosis

  Daniel Emrick and Anacleto Diaz

  Publication Date: 5-9-2025

  First described in 1877 by Jonathan Hutchinson, sarcoidosis affects approximately 150,000 to 200,000 patients in America and is characterized by the presence of non-caseating granulomas. The exact cause remains poorly understood. In the United States, risk is greater in African-American patients and in greater predominance in women compared to men. It can affect any organ system, though it most frequently begins in the lungs. Cutaneous sarcoidosis can be seen in approximately one third of cases. Cutaneous forms can be nonspecific as in erythema nodosum, or specific with granulomatous infiltration. Cutaneous sarcoidosis is a particularly challenging diagnosis, as a single patient can have a variety of lesions in terms of appearance, each of which may appear resemble countless other pathologies including; lichen planus, psoriasis, fungal infection, or cutaneous T-cell lymphoma

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  Quality Improvement Project on Strengthening the Treatment of Pediatric Overweight/Obesity

  Kristen Erwin, Lyn Mattathil, Maria Correa Roldan, Grace Tsaloff, Swetha Gogu, Emily Abele, Michael Kennett, Elizabeth Parker, and Miranda Hillard

  Publication Date: 5-9-2025

  In 2023, The American Academy of Pediatrics released guidelines on the treatment of childhood overweight and obesity. In partnership with the AAP Institute for Healthy Childhood Weight, Corewell Health West Pediatric residency clinic conducted a quality improvement project to implement these guidelines with a focus on lifestyle therapy.

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  Erector Spinae Plane Block for Refractory Shingles Pain

  Patrick Fewins, Justin Winkler, and Jordan Johnson

  Publication Date: 5-9-2025

  Herpes zoster (shingles) results from the reactivation of the varicella-zoster virus from the dorsal root ganglion, which can result in severe and debilitating pain. It is recommended for providers to implement a multimodal pain control regimen while limiting opiates, given the known deleterious side effects, including addiction potential, delirium, and respiratory depression. One such method is regional anesthesia. A recent ACEP policy states that ultrasound-guided nerve blocks (USGNBs) are not only within the scope of practice for emergency medicine physicians (EPs), but also are a "core component" of multimodal pain control. We present a case of an 81-year-old patient with severe acute herpetic neuralgia refractory to conventional measures, who experienced significant pain relief from an erector spinae plane block (ESPB) without requiring opiate medications.

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  Prophylactic Antibiotics in a Penetrating Traumatic Brain Injury

  Kevin FitzGerald and Jose Morillas

  Publication Date: 5-9-2025

  Traumatic brain injury and antibiotic prophylaxis recommendations lack clear guidance on which agents should be utilized. Some institutions recommend cefazolin or clindamycin monotherapy vs possible addition of metronidazole if organic material was present at the time of injury. This case helps highlight potential organisms that should be considered for coverage in a traumatic brain injury. The goal would be to continue to evaluate an outline for appropriate antibiotic guidance for penetrating traumatic brain injuries.

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  Stroke in Adolescent Patient Requiring IR Intervention: A Case Report

  Alyssa Gill, Carina Grain, Todd Chassee, and Christine Knight

  Publication Date: 5-9-2025

  Strokes are rare in pediatric patients, as 75% of stroke patients are 65 years or older. Risk factors for stroke in children are the same as in adults, including hypertension, obesity, and dyslipidemia; however, congenital heart disease and hematologic conditions like sickle cell disease are more common causes for pediatric strokes. Approximately 80% of pediatric cases have an identified cause, but this case report describes a 12 year-old female who had an ischemic stroke of an unknown etiology.

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  Resident Work Hour Correlation with Wellness Scores: Do Less Hours Make Happier Residents?

  Samuel Girian, Elizabeth Bushong, Beatrice Lucchesi, Matthew Fahrenkopf, Ronald Ford, and Megan Sommers

  Publication Date: 5-9-2025

  Long work hours have been reported to negatively impact resident wellness, which can influence work, personal life, and even patient care. Due to these concerns, the Accreditation Council for Graduate Medical Education (ACGME) implemented 80-hour per week work restrictions with the goal of improving resident wellbeing and patient safety. However, the efficacy of these guidelines is debated, and some studies suggest they might lead to impaired resident education. Annually, the ACGME conducts resident wellness surveys to evaluate factors such as burnout, mood, and work environment. This study aims to assess whether ACGME work hour restrictions accomplished their goal of improving resident wellbeing and offer direction for future wellness interventions. It is hypothesized that increased work hours correspond to decreased wellness survey scores.

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  Improving Vitamin D Testing and Supplementation in Intestinal Failure Patients at Helen Devos Children's Hospital Outpatient Pediatric Gastroenterology Clinic

  Swetha Gogu, Lucy Frey, and Vanessa Cardenas-Kimball

  Publication Date: 5-9-2025

  Intestinal failure (IF) is a condition that results from obstruction, dysmotility, surgical resection, congenital defect, or disease-associated loss of absorption and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balances. Vitamin D deficiency is one of the most common micronutrient deficiencies among children with IF, and there are no published guidelines for monitoring, repleting, and maintaining vitamin D levels within this population. This quality improvement initiative is looking at our pediatric gastroenterology department's Vitamin D monitoring protocol in IF patients to assess how we can improve our practice protocols and patient care. We conducted a quality improvement (QI) initiative with the aim to increase compliance with following our Vitamin D monitoring and supplementation protocol to at least 90% in children with IF.

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  Obstetric Anesthesia Management of Emergent Cesarean Delivery with Complex Cardiac History and Neuraxial Contraindications: A Case Study

  Antonio Gonzales, Andrew Harris, and Laurie Chalifoux

  Publication Date: 5-9-2025

  Cardiovascular disease is a leading cause of maternal morbidity and mortality globally. Patients with acute cardiac conditions such as atrial fibrillation (afib) with rapid ventricular response (RVR) benefit from multidisciplinary care at specialized Maternal Care Centers before delivery. Sustained afib with RVR poses risks, such as maternal hemodynamic instability, heart failure, thromboembolism, need for emergency interventions, and fetal distress. Treatment must be tailored to mitigate morbidity. For hemodynamically stable patients, rate control with beta-blockers or digoxin is preferred. Direct current cardioversion (DCCV) in pregnancy is possible, but carries risks of fetal distress, necessitating post-procedure fetal monitoring. Sedation for DCCV requires careful titration to respiratory depression and aspiration.

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  Preliminary Data: Improving Mental Health Processes, Workflows, and Responses

  Tamara Paola Gonzalez Copo, Jeffrey Haus, Erica Guldensky, and Nicholas Beam

  Publication Date: 5-9-2025

  Mental health problems contribute to global burdens of disease and pediatric patients are not exempt.1 Despite this high burden, significant variability exists in how hospitals manage acute pediatric mental health. Research has demonstrated that verbal de-escalation and agitation focused medications allow for reduction in use of physical restraints.2 Additionally, lethal means counseling has demonstrated reduction in firearm deaths when performed.3 Finally, the use of routine screening labs has been shown to have no change in ED management. This study sought to assess these common areas of variability in pediatric mental care to establish institutional baselines. This baseline data will provide information that will be used to make targeted quality improvements to improve care for children ages 12-18 years presenting to the ED for an acute mental health concern.

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  Dog Bite-Induced Open Lunate Dislocation Precipitating Acute Carpal Tunnel Syndrome: An Unusual Mechanism

  Joseph Gorvetzian and Stephen Duquette

  Publication Date: 5-9-2025

  Lunate and perilunate dislocations are relatively rare but serious injuries of the wrist. Lunate dislocations entail significant disruption of the robust stabilizing ligamentous structures of the carpus, whereby the lunate dislocates from its articulation with the distal radius. Such disruption is precipitated almost exclusively by high-energy traumatic mechanisms, such as falls from significant height or high-speed motor vehicle accidents. Despite the gravity of these injuries, they can present with relatively subtle initial features on physical and radiographic examination and thus a high index of suspicion is required to mitigate significant morbidity associated with missed or delayed diagnosis. Here we present a case of lunate dislocation with acute carpal tunnel syndrome induced by a dog attack, a heretofore undescribed mechanism.

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  Challenges of Surgical Wound Care with Idiopathic Calciphylaxis: A Case Report

  Ellie Gschwendtner, Samuel Girian, Humza Mirza, Timothy Burton, Patricia Pentiak, Amy Spencer, and Alistair Chapman

  Publication Date: 5-9-2025

  Calciphylaxis is a poorly understood and notoriously difficult to treat rare condition characterized by calcium deposition within small blood vessels of subcutaneous fat and skin. The calcium deposits cause narrowing of the lumen and occlusion which further leads to ischemic necrosis and chronic, painful skin lesions. Although typically associated with end stage renal disease (ESRD) or hyperparathyroidism (hyperPTH), idiopathic cases are rarely reported. Surgical management of wounds caused by idiopathic calciphylaxis presents complex challenges for both diagnosis and wound care.

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  Multidisciplinary Management of Pheochromocytoma in Cardiovascular Patients: A Two-Case Report

  David Han and Gerald Wright

  Publication Date: 5-9-2025

  Pheochromocytoma is a tumor of the adrenal medulla that results in overproduction of catecholamines. Adrenalectomy with a preoperative administration of alpha blockers is the standard treatment; however, perioperative management can be challenging for cases with underlying cardiovascular disease. This report presents two unique, complementary cases: one case required a simultaneous coronary artery bypass grafting (CABG) and adrenalectomy, and the other was complicated by hypertrophic cardiomyopathy (HCM). These cases highlight the critical role of multidisciplinary coordination in optimizing outcomes for patients with complex cardiovascular and surgical challenges.

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  No T1N0M0 <5cm >"Oncocytic Renal Neoplasms" Developed Distant Metastases: Longterm Follow-up in Two Health Systems

  Andrew Harris, Danly Omil-Lima, Shivaram Cumarasamy, Michael Lesgart, Sabrina Noyes, Alexander Kutikov, Andres Correa, and Brian Lane

  Publication Date: 5-9-2025

  The 2022 WHO guidelines advise against diagnosing oncocytoma based solely on needle biopsy due to limited sampling and its similarities with malignant tumors. As a result, localized renal masses are now classified as "oncocytic renal neoplasm (ORN), not further classified," which has significant implications for clinical practice. Patients eligible for active surveillance (AS) no longer receive pathology reports indicating a benign diagnosis, leading to uncertainty in management. Additionally, the limited long-term data on ORN and the emergence of new entities within this category have raised concerns. This study aims to address these issues by providing extended follow-up on patients diagnosed with ORN from two institutions to assess the risk of metastasis.

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  Using Large Bore Catheter Aspiration to Retrieve a Projectile Fragment Free Floating between the Right Atrium and IVC: Case Presentation with Review of Literature

  Zoee Harris, Samy Behairy, and Nathan Kauffmann

  Publication Date: 5-9-2025

  Foreign bodies pose many risks to the patient, including but not limited to infection, obstruction, and soft tissue damage. Successful retrieval of the foreign body is important in preventing these potential consequences. Minimally invasive techniques for retrieval utilized by interventional radiologists have traditionally been the use of snares, endoscopic baskets, forceps, or retrieval nets. This exhibit explores the employment of a suction thrombectomy catheter to retrieve a metallic foreign body that remained free in the bloodstream post-migration from its entry point.

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  Primary Umbilical Hernia Repair: Does Suture Type Matter?

  Kristen Hawes, Alex Finn, Tien Hua, Madison Mangione, Elizabeth Martin, Steven Kuselias, Giuseppe Zambito, and Amy Banks-Venegoni

  Publication Date: 5-9-2025

  Umbilical hernias are a common surgical pathology, with an estimated prevalence in 23-50 percent of people. Small umbilical hernias, especially those 1 cm or less, are generally treated with open primary suture repair. The estimated risk of recurrence following primary umbilical repair is 4.9 to 27 percent. A variety of suture types and repair techniques are used for primary umbilical hernia repair with little evidence to suggest which suture and technique provides the lowest risk of recurrence. There has also been very little data on absorbable repairs, yet most midline laparotomies are closed as such. The primary goal of our study is to evaluate recurrence rates between primary repairs with braided and monofilament suture. We will also analyze monofilament permanent vs. absorbable repairs. We hypothesize that the braided suture will show a lower recurrence rate.

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  The Role of Inspiratory Muscle Training in Reducing COPD-Related Hospital Readmissions: A Literature Review

  Hussein Hazime, Humza Bhatti, Keith Sims, Heba Fardoun, and mike Eldirani

  Publication Date: 5-9-2025

  Chronic obstructive pulmonary disease (COPD) is a leading cause of hospital readmissions, contributing to increased healthcare costs and reduced patient quality of life (Gosselink et al., 2011). Many COPD patients struggle with persistent dyspnea and frequent exacerbations, often requiring hospitalization. Inspiratory Muscle Training (IMT) has been shown to improve respiratory muscle strength, reduce breathlessness, and enhance exercise tolerance, making it a promising tool in pulmonary rehabilitation (Beaumont et al., 2018). However, despite these well-documented benefits, there is limited research examining whether IMT can actively reduce hospital readmission rates (Charususin et al., 2018). This literature review explores whether IMT could serve as an effective intervention to prevent recurrent hospitalizations in COPD patients.

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  Etanercept Use in the Management of Pediatric Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Case Report

  Rana Hegazi, Emmy Grinstead, and Charlyne Cuyar Cruz

  Publication Date: 5-9-2025

  Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immune-mediated, dermatologic emergencies associated with high morbidity and mortality. Current therapeutic guidelines involve discontinuing offending agents and management of symptoms with supportive care. Growing evidence suggests that the use of TNF-alpha inhibitors, such as etanercept, early in the disease course may improve patient outcomes by inhibiting disease progression. We present the case of a 14-year-old young man diagnosed with SJS/TEN, presumed to be triggered by a preceding viral infection vs Group A Strep pharyngitis.

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  Unmasking the Uncommon: A Rare Case of Pediatric Infective Endocarditis Misdiagnosed as a Viral Illness

  Lyanette Irizarry-Leon, Angela Zamarripa, and Lindsey Ouellette

  Publication Date: 5-9-2025

  Infective endocarditis (IE) is an infection of the endocardium and/or heart valves that involves thrombus formation (vegetation), which may damage the endocardial tissue and/or valves. Diagnosing infective endocarditis (IE) in children can be challenging because its clinical presentation is often nonspecific, meaning symptoms can mimic other common illnesses like the flu, making it difficult to distinguish and requiring a high level of suspicion, especially in children without known heart defects.

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  Squamous Cell Carcinoma Arising from a Tailgut Cyst: A Case Report Highlighting the Challenges of Diagnosis and Treatment

  Jacob Kalkman and Roxanne Kyriakakis

  Publication Date: 5-9-2025

  Tailgut cysts (TGCs) are rare lesions caused by incomplete regression of the embryologic hindgut. These lesions are typically benign and incidentally noted on imaging studies. They may, however, cause mass-effect symptoms and do have the potential for malignant transformation. Squamous cell carcinoma (SCC) arising from a TGC is an extremely rare diagnosis. To date, only five prior case reports have been published. The gold standard of treatment is surgical resection with adjuvant radiation and chemotherapy on a case-by-case basis. The scarcity of the disease presents challenges when making treatment plans given the lack of clinical trials to guide therapy selection. As a result, we are dependent upon case studies to elucidate the optimal management plan. The goal of this study is to provide an additional data point regarding the treatment of SCC arising from a TGC.

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  A Calculated Approach: Neuraxial Anesthesia in a High-Risk Parturient with Aortic Stenosis

  Adam Kapp, Kalyan Bobba, and Paul Jaklitsch

  Publication Date: 5-9-2025

  Neuraxial anesthesia is traditionally avoided in patients with severe aortic stenosis due to the risk of catastrophic hypotension from reduced sympathetic tone, leading to decreased preload, contractility, heart rate, and cardiac output. These challenges are typically better managed under general anesthesia with vasopressor and inotropic support. However, general anesthesia poses unique risks in severely obese patients, including difficult airway management, increased aspiration risk, and impaired respiratory mechanics. In pregnant patients, both maternal and fetal considerations are paramount and the anesthetic approach requires careful planning. This case highlights the successful use of a combined spinal-epidural technique in a parturient with aortic stenosis and class IV obesity, demonstrating how neuraxial anesthesia can be safely performed with meticulous hemodynamic optimization.

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  A Rare Case of a Neuroendocrine Tumor Metastasizing to the Breast

  Danielle Katz, Aryana Sharrak, Mariam Khan, Jessica Thompson, and Mathew Chung

  Publication Date: 5-9-2025

  Neuroendocrine tumors (NET) frequently originate in the GI tract and lung tissue. They often metastasize to the liver and lymph nodes. Tumors of the GI tract will most commonly metastasize to the liver through drainage from the portal venous system. When these do metastasize, enterochromaffin cells in NETs secrete serotonin which can lead to symptoms such as flushing, diarrhea, and sequela of right sided heart disease. These tumors can be misdiagnosed, particularly when they present in infrequent locations such as breast tissue. Prompt and accurate diagnosis of NETs is essential in guiding proper management. Here, we present a rare case of a GI tract NET primary metastasizing to the breast.

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  Familial Campomelic Dysplasia due to SOX9 Mosaicism and In Vitro Fertilization with Preimplantation Genetic Testing

  Saheli Kokoruda, Vivian Romero, Marcos Cordoba, and Renee Zolynsky

  Publication Date: 5-9-2025

  Campomelic dysplasia (CD) is a rare, skeletal dysplasia that is often lethal. CD is characterized by bowing, shortening of the long bones, distinctive facies, and clubfeet. Other findings include laryngotracheomalacia with respiratory compromise. CD is an autosomal dominant disorder caused by heterozygous SOX9 pathogenic variants that are typically de novo. This case report describes a fetus affected with familial CD, inherited from a mother with confirmed SOX9 somatic mosaicism. The couple then pursued IVF with preimplantation genetic testing for their future pregnancy. An unaffected embryo was transferred, resulting in a healthy pregnancy. There is limited literature on familial CD due to SOX9 mosaicism and preimplantation genetic testing. We explore the implications of mosaicism, as well as the role of genetic and reproductive technologies in mitigating recurrence risk.

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  Assessing Safety and Tolerability in Bee Venom Immunotherapy: Conventional vs. 1-day Ultra Rush Protocol

  Connor Kuipers, Kaylee Gwyn, and Ted Kelbel

  Publication Date: 5-9-2025

  Venom immunotherapy (VIT) is a potentially lifesaving treatment for patients with anaphylaxis to Hymenoptera. Research comparing the safety and tolerability of the conventional weekly build-up protocol with single day ultra-rush protocol is limited.

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  Evaluating the Effectiveness of Regular Physical Examinations in Post-Treatment Breast Cancer Surveillance

  Anna Levine, Jessica Thompson, G Paul Wright, Luke Terrian, Kelsey Lawrence, and Daniel Dishay

  Publication Date: 5-9-2025

  Current post-treatment surveillance for breast cancer survivors, as outlined by the National Comprehensive Cancer Network, consists of regular history and physical examinations every four to six months for five years then annually thereafter. Given the time commitment and expenses that accompany frequent in-person visits, the primary objective of this study was to assess the yield of routine clinical exams in disease recurrence recognition, with a secondary objective of comparing the effectiveness of clinical exam in identifying metachronous primary breast malignancies versus other modes of detection.

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  Toxic Erythema of Chemotherapy in Enfortumab Vedotin Limited to the Lower Extremities: Another Form of Pseudocellulitis

  Karissa Libson, Lily Kauffman, Kalyn Hoffman, Catherine Chung, and Benjamin Kaffenberger

  Publication Date: 5-9-2025

  Pseudocellulitis describes conditions which mimic cellulitis but is not caused by infection and is typically a sterile inflammatory process. Enfortumab vedotin (EV) is an antibody drug conjugate used as a second or third line therapy to treat urothelial carcinoma. Toxic erythema of chemotherapy is the umbrella term for cutaneous toxicities caused by chemotherapeutic agents. Adverse skin reactions have been reported in almost half of patients taking EV ranging from severe cutaneous adverse reactions (SCARs) due to idiosyncratic hypersensitivity reactions to toxic erythema of chemotherapy resulting from off-target direct cutaneous toxicity.