Drew Barron Kraus

Background: Carnitine palmitoyltransferase II (CPT II) deficiency is an autosomal recessive disorder of long-chain fatty acid oxidation; its myopathic form is an important inherited cause of recurrent exertional rhabdomyolysis, myoglobinuria, and myalgia. Diagnosis can be challenging because supportive findings are often intermittent or nondiagnostic and may be obscured by coexisting acquired precipitants. Symptomatic heterozygous carriers of pathogenic CPT2 variants have also been described, adding further complexity to attribution. Case Description: A 49-year-old man with hypertension, chronic kidney disease, prior anabolic-androgenic steroid (AAS) use, ongoing supratherapeutic exogenous testosterone therapy, and prior alcohol use disorder presented repeatedly to multiple emergency departments (EDs) with symptomatic rhabdomyolysis initially attributed to heavy exercise and strenuous labor and managed with supportive care. Recurrent creatine kinase (CK) elevation, acute kidney injury, and concurrent cardiac abnormalities prompted broader etiologic evaluation. An Invitae genetic and metabolic myopathy panel identified a heterozygous pathogenic CPT2 c.338C>T (p.Ser113Leu) variant; whole genome sequencing did not identify a second pathogenic CPT2 allele, and the acylcarnitine profile was within reference range. He underwent neuromuscular, metabolic dietetics, and clinical genomics evaluation and was counseled on fasting avoidance, hydration, exertional modification, and emergency planning. Recurrent episodes continued after initiation of a high-carbohydrate, low-fat diet with adjunctive medium-chain triglyceride (MCT) and L-carnitine supplementation, though adherence to multidisciplinary recommendations was incomplete. Conclusions: This case illustrates how a single heterozygous pathogenic CPT2 variant in a classically autosomal recessive disorder is best interpreted as a biologically plausible but unconfirmed contributor, particularly when overlapping acquired precipitants and a nondiagnostic biochemical profile leave attribution unresolved. Clinicians should maintain suspicion for a contributing metabolic myopathy when recurrent rhabdomyolysis is incompletely explained by acquired triggers, even when routine biochemical screening is unrevealing. Recurrence may persist despite longitudinal multidisciplinary care.

Purpose: This study assessed the association between holding an additional graduate degree beyond a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) and residency match outcomes. Specifically, the authors examined graduate degree attainment trends among residency applicants and evaluated whether graduate degree holders experience lower match rates than non-holders. Methods: A retrospective, observational analysis was conducted using publicly available data from the National Resident Matching Program's Charting Outcomes in the Match reports (2016-2024). The 10 specialties with the highest applicant volumes were analyzed, encompassing 80 136 matched and 6820 unmatched U.S. MD and DO senior applicants. Trends in graduate degree attainment were evaluated using linear regression models. Match rates were stratified by graduate degree status and compared using two-proportion z-tests based on aggregated matched and unmatched counts for each specialty and overall. Results: From 2016 to 2024, the proportion of graduate degree holders entering the match increased significantly for MD (15.77% to 18.29%, P = .0008) and DO (19.93% to 23.31%, P = .0151) applicants. Across all 10 specialties, graduate degree holders matched at lower rates than non-holders. Among MD applicants, graduate degree holders matched at 92.57% compared with 94.12% for non-graduates (P < .0001), with specialty-specific differences ranging from 0.22% in Psychiatry to 4.61% in Anesthesiology; five specialties demonstrated statistically significant disparities. Among DO applicants, graduate degree holders matched at 84.54% compared with 88.64% for non-graduates (P < .0001), with specialty-specific differences ranging from 1.44% in Family Medicine to 10.48% in Obstetrics and Gynecology; five specialties also reached statistical significance. Conclusions: The proportion of graduate degree holders in the residency match is increasing, and these applicants experience lower match rates than non-holders. These findings challenge the assumption that additional graduate education provides a competitive advantage and underscore the need for further research into the applicant-level factors contributing to these disparities.

Background: Spontaneous rupture of an intercostal artery (ICA) is exceedingly rare. Secondary causes include trauma, iatrogenic injury, aneurysm rupture, or genetic conditions such as neurofibromatosis. This case report describes a 50-year-old woman presenting with acute right flank pain and hemodynamic instability secondary to spontaneous ICA rupture. Case Description: The patient was a 50-year-old female with a history of metastatic breast cancer complicated by pathological rib fractures and right hepatic vein thrombosis on long-term anticoagulation. She presented to the emergency department with acute right flank pain radiating to the shoulder and neck, exacerbated by inspiration. Computed tomography (CT) imaging ultimately revealed a right hemothorax and active ICA bleeding adjacent to a pre-existing pathological rib fracture. While in the emergency department, the patient developed hemorrhagic shock requiring blood transfusion and anticoagulation reversal. Transcatheter arterial embolization (TAE) achieved hemostasis; however, a persistent hemothorax required surgical management for hematoma evacuation. Post-operatively, the patient recovered well and was discharged on postoperative day one in stable condition. Conclusions: This case highlights the importance of early recognition of spontaneous ICA rupture in patients with malignancy, pathological fractures, and anticoagulation therapy. Progression to hemorrhagic shock underscores the need for prompt diagnosis and multidisciplinary management, including TAE and surgical intervention, to improve outcomes.

Purpose: This study investigates medical students’ opinions on the optimal timing for taking the emergency medicine (EM) clerkship and its effects on preparedness for subsequent clerkships and the USMLE (United States Medical Licensing Examination) Step 2 examination. Methods: A cross-sectional survey was conducted among third- and fourth-year students at the Mayo Clinic Alix School of Medicine. The survey collected opinions on the optimal timing for the EM clerkship and its impact on self-efficacy as well as perceived preparedness for future clerkships and the USMLE Step 2 examination. Results: Only 5% of third-year EM clerkship students felt they would have been more prepared in their fourth year. Conversely, 70% of fourth-year students believed they were more prepared than if they had taken it in their third year. Students were evenly split on if an earlier EM clerkship would have been helpful for subsequent clerkships. 88% of pre-USMLE Step 2 students found it helpful for Step 2, while 37% of post-USMLE Step 2 students felt it would have helped their preparedness. Additionally, 96% of students stated the EM clerkship increased their confidence in seeing patients. 43% of those who took the clerkship in their fourth year reported they would have considered EM as a specialty had they taken it earlier. Most students recommended taking the EM clerkship during the second 6 months of clerkships. Conclusion: There are mixed opinions among medical students regarding the helpfulness of taking the EM clerkship earlier for subsequent clerkships and USMLE Step 2 preparedness. However, the majority recommend taking the EM clerkship earlier. A significant proportion of participants would have considered EM as a specialty if they had taken the clerkship earlier. Furthermore, 96% reported increased self-efficacy. Therefore, encouraging students to take the EM clerkship earlier may increase self-confidence and allow for earlier career exploration.

Purpose: To use the All of Us database to investigate barriers to health care access for patients with meniscus tears and to examine how specific demographic, socioeconomic, and health‐related factors independently influence their health care utilization. Methods: The National Institutes of Health All of Us database was queried for patient data between March 2017 and March 2023 to form a cohort of patients with meniscal tears. Patients with meniscal tears were identified using Systematized Nomenclature of Medicine clinical terms. All patients with self‐reported meniscus tears were included, with no exclusion criteria to ensure a diverse representation of underrepresented individuals. Patient responses to the “Healthcare Access and Utilization Survey” were analyzed across 4 domains: “delayed care,” “could not afford care,” “skipped medication,” and “have not seen a provider in over one year.” Results: In total, 5,671 survey respondents with meniscal tears were included for analysis from a population of 436,000 eligible records. Among them, 27.7% reported delayed care, 23.9% were unable to afford care, 11.8% skipped medication, and 2.0% had not seen a provider in over a year. Patients with annual incomes under $50,000 were more likely to delay care (odds ratio [OR], 1.41; P < .001), be unable to afford care (OR, 1.73; P < .001), or skip medications (OR, 1.79; P < .001). Younger age than the cohort mean of 65.4 years, female sex, and poor physical and mental health were associated with impaired access in at least 1 care domain. Conclusions: Over one‐fourth of patients with a diagnosis of meniscus tear who responded to the All of Us “Healthcare Access and Utilization Survey” reported difficulties with access to care across 4 domains, with those of low income, younger age, female sex, and poor mental or physical health experiencing significant barriers to care. Clinical Relevance: This research can inform strategies for equitable treatment of meniscal injuries by highlighting disparities in orthopaedic care access and utilization.