Texas Medical Center

Colovaginal fistula often presents subtly but can be diagnosed through careful history and physical examination making it a key condition for clinicians to recognize in older adults with a previous hysterectomy. In this case, a 79-year-old woman with a past medical history of Cesarean-section and hysterectomy presented to her primary care physician with a sensation of fluid in the abdomen, foul-smelling discharge, and vaginal flatus persisting for several weeks. Based on the history and physical exam, the patient received timely low anterior resection of a colovaginal fistulous connection. Colovaginal fistula can present with non-specific symptoms that can be diagnosed through careful history and physical examination leading to early intervention and quality of life preserving care.

For decades, researchers have explored the therapeutic potential of the vagus nerve through vagus nerve stimulation (VNS). Initially developed for epilepsy, VNS has since been applied to treat resistant depression, stroke recovery, and inflammatory conditions. Transcutaneous VNS (tVNS) now offers a noninvasive alternative, fueling clinical trials in disorders ranging from rheumatoid arthritis and migraines to long COVID-19. Mechanistic studies suggest that afferent and efferent vagal fibers modulate immune responses, mood regulation, and neurotransmitter systems. The SPARC initiative has accelerated mapping of vagal circuits, enabling more precise approaches to stimulation. Despite progress, the results remain mixed: while some patients experience lasting symptom relief, others respond no better than to placebo. Depression studies, in particular, highlight both the promise and the complexity of VNS, as inflammation, motivation circuits, and gut–brain signaling emerge as key modulators. Next-generation closed-loop devices and circuit-specific targeting may improve efficacy and reduce adverse effects. VNS research thus lies at the intersection of neuromodulation, psychiatry, and immunology—offering hope for hard-to-treat conditions, yet demanding rigorous trials to separate myths from medicine. In this article, we review the current clinical and experimental applications of tVNS, analyze its mixed efficacy across psychiatric, immunological, and neurological disorders, and highlight the mechanistic insights, stimulation parameters, and emerging technologies that may shape next-generation therapies.

These consensus guidelines by the American Clinical Neurophysiology Society (ACNS) describe best practices for performing intraoperative Electrocorticography (ioECoG) using subdural or depth electrodes for adult and pediatric population. A group of ACNS members was convened to develop technical standards for performing ioECoG. PubMed searches were performed to identify pertinent peer-reviewed literature. Sections were assigned to individual authors based on expertise. Consensus was achieved during subsequent group discussions to develop evidence-based recommendations to the extent possible. Communication between the neurosurgical and the neurophysiology teams is essential in verifying and documenting the location of the contacts. Most authors recommend ioECoG recordings of at least 5 and up to 30 minutes in duration to allow for sufficient observation of interictal activity. The anesthesia should be adjusted to allow continuous EEG activity and to minimize the effect on the ioECoG recording during general anesthesia or awake surgery. The surgical procedure and technical report should separate ioECoG recordings to define the irritative zone from ioECoG findings during functional mapping. The neurophysiology physician's physical presence in the operating room is required in the definition of the services. These consensus guidelines by the ACNS describe best practices for performing intraoperative ECoG based on published literature and expert consensus.

The intestinal microbiome influences health and disease. Its composition is affected by host genetics and environmental exposures. Understanding host genetic effects is critical but challenging in humans, due to the difficulty of detecting, mapping and interpreting them. To address this, we analyse host genetic effects in four cohorts of outbred laboratory rats exposed to distinct but controlled environments. We show that polygenic host genetic effects are consistent across cohort environments. We identify three replicated microbiome-associated loci, one of which involves the sialyltransferase gene St6galnac1 and Paraprevotella. We find a similar association in a human cohort, between ST6GAL1 and Paraprevotella, both of which have been linked with immune and infectious diseases. Moreover, we find indirect (i.e. social) genetic effects on microbiome phenotypes, which substantially increase the total genetic variance. Finally, we identify a novel mechanism whereby indirect genetic effects can contribute to “missing heritability”.

ABSTRACTIntroductionLearning health systems leverage clinical data and knowledge to advance healthcare quality. Effective training in informatics concepts and tools is essential for medical trainees to become health system experts and contributors to positive organizational change. The objective of this study is to summarize characteristics of existing clinical informatics training programs and map these to recommended Learning Health System informatics competencies. We aim to answer the following research questions: (1) How are academic medical institutions implementing informatics education initiatives for medical trainees? (2) Are these initiatives implementing recommended informatics competencies? and (3) How effective are these initiatives according to established health professions education evaluation frameworks?MethodsWe searched for literature in the databases Embase, Ovid Medline, and Web of Science. Three researchers independently screened study titles and abstracts. Inclusion criteria were (a) studies with medical students and/or postgraduate medical professionals in the study sample, (b) in an academic medical setting, and (c) describing a clinical informatics curriculum initiative.ResultsWe included a total of 27 studies for analysis. Most curricula (n = 16) had the objective of basic informatics knowledge acquisition. Instruction delivery for most (n = 17) included a combination of didactic and practical components. The most common evaluation tool was student self‐reported confidence and self‐efficacy. All but three of the studies integrated the recommended informatics competency of demonstrating knowledge of clinical information systems such as Electronic Health Records. Most studies (n = 12) reported outcomes related to the Kirkpatrick Level II of Learning.ConclusionGaps remain in the context of leveraging education to pursue Learning Health System endeavors of clinical research, quality improvement, and achieving organizational‐level results. Further research on recent education initiatives targeting undergraduate and graduate medical trainees is needed to elevate the rate of clinical informatics education implementation, while simultaneously advocating for standardization in the design and evaluation of these initiatives.

Stroke is a leading cause of disability worldwide, often resulting in persistent motor, cognitive, and emotional impairments. While the hippocampus and amygdala play critical roles in post-stroke behavioral changes, specific neuronal alterations and prolonged glial responses within these regions across different stroke types remain unclear. This study investigates the behavioral, neuronal, and glial effects of subarachnoid hemorrhage (SAH), transient middle cerebral artery occlusion (tMCAO), and photothrombotic stimulation (PTS) in mice. SAH and tMCAO models exhibited significant motor deficits, spatial and recognition memory impairments, and increased anxiety- and depressive-like behaviors, whereas the PTS model showed similar motor and cognitive impairments but lacked affective (anxiety- and depressive-like) behavioral changes. Immunohistochemical analysis revealed increased overlap of tyrosine hydroxylase (TH, a dopaminergic marker) process with NeuN (a neuronal marker) in the dentate gyrus (DG) of SAH and tMCAO mice, highlighting region-specific vulnerability to ischemic damage in the hippocampus. In the amygdala, elevated overlap of TH+ process with NeuN in SAH and tMCAO mice suggests enhanced dopaminergic involvement in emotional dysregulation. In contrast, the PTS model did not exhibit any changes in overlap of TH+ process with NeuN in either the hippocampus or amygdala, consistent with the absence of affective behavioral deficits. Additionally, SAH and tMCAO models exhibited persistent astrocytic and microglial activation in the amygdala, characterized by increased intensity and density without significant morphological changes, indicative of a chronic inflammatory response. The PTS model also showed increased microglial intensity and density without overt morphological changes, suggesting a more moderate, possibly subclinical inflammatory response. These findings highlight the differential effects of stroke models on behavior, neuronal populations, and glial responses in limbic regions. The pronounced dopaminergic and glial alterations in SAH and tMCAO may underlie post-stroke emotional and cognitive disturbances.

Introduction Labor trafficking is a widespread yet underreported form of exploitation that disproportionately affects migrant populations. Migrants often face coercion, deception, and abuse across various labor sectors, and these circumstances are often exacerbated by structural inequalities and legal protections. There is a pressing need to synthesize existing knowledge and integrate stakeholders’ perspectives to inform future prevention and policies. Objective This study examines the scope, nature, and thematic trends in the literature on labor trafficking among migrant populations and augments these findings with qualitative insights from stakeholders working directly with trafficked migrant populations. Methods A scoping review was conducted following A scoping review was conducted according to the PRISMA guidelines. Nineteen peer-reviewed empirical studies published between 2014 and 2024 were analyzed across four databases. In parallel, 17 semi-structured interviews were conducted with service providers, researchers, and advocates experienced in labor trafficking. Structural violence theory guided the thematic analysis using Quirkos software. Results Seven major themes emerged: (1) informal recruitment networks, (2) hazardous and exploitative working conditions, (3) psychological and physical coercion, (4) economic and structural vulnerability, (5) gender-based vulnerabilities, (6) inadequate legal protections and enforcement gaps, and (7) mental health impacts. The qualitative data highlight the lived realities and systemic challenges trafficked migrants face and help validate and enrich the findings from the scoping review. Conclusion Labor trafficking among migrants is driven by economic, legal, and social vulnerabilities. Comprehensive, survivor-centered policies are urgently needed: reforms to recruitment practices, expanded mental health support, and stronger legal frameworks. The study findings call for cross-sectoral collaboration and the integration of migrant voices in program and policy design to combat trafficking for labor exploitation.

Disclosure: S.I. Alqaisi: None. E. Lopez Hidalgo: None. A. Chunduru: None. P.R. Orlander: None.Background: Succinate dehydrogenase mutations are particularly associated with rare hereditary autosomal dominant conditions linked to a higher risk of malignant tumors and multifocal paragangliomas. Here we present a case of a patient with recurrent pheochromocytoma associated with SDHD mutation. Clinical Case: A 43-year-old man with a history of bilateral pheochromocytoma at the age of 8, status post-resection, and prior glioma of the carotid artery and vocal cord treated with chemotherapy and radiation, presented to the hospital with episodes of vomiting, abdominal discomfort, and diarrhea. Previous genetic testing had confirmed SDHD-associated hereditary paraganglioma and pheochromocytoma syndrome given family history of similar diagnosis. An abdominopelvic CT scan revealed a left adrenal gland measuring 4.7 cm transversely by 2.96 cm anteroposterior, with a 4.3 cm mass in the longitudinal dimension. Laboratory testing showed elevated serum normetanephrine (1327 pg/mL, normal <148 pg/mL), low serum-free metanephrines (<25 pg/mL, normal <57 pg/mL), and elevated total metanephrines (1327 pg/mL, normal <205 pg/mL). Urine catecholamine testing revealed elevated norepinephrine (498 mcg/24 hours, normal 15-100 mcg/24 hours) and dopamine (1940 mcg/24 hours, normal 52-480 mcg/24 hours) but normal epinephrine levels (<7 mcg/24 hours, normal 2-24 mcg/24 hours). An iodine meta-iodobenzylguanidine (MIBG) scan demonstrated increased tracer uptake in the 4 cm left adrenal mass, consistent with a neuroendocrine tumor, and a 7 × 6 × 5 cm mediastinal mass with radiotracer uptake suggestive of metastasis or another etiology. The patient developed hypertension, for which doxazosin was initiated. He also experienced tachycardia, requiring metoprolol administration before the procedure. The patient underwent laparoscopic left adrenalectomy, and histological examination confirmed a 4.4 cm pheochromocytoma. Cardiothoracic surgery and radiation oncology teams were consulted for the mediastinal mass; however, no immediate treatment was indicated. Outpatient follow-up was planned for further evaluation and management of the mediastinal mass. Conclusion: Recurrent pheochromocytomas are uncommon; however, they are most frequently observed in the context of SDHD mutations, which confer an increased predisposition to the development of paragangliomas and other neuroendocrine tumors, as demonstrated in this patient. These findings underscore the importance of genetic testing and close surveillance in patients with a history of pheochromocytoma, particularly those with a family history of similar diagnoses, to enable early detection and management of recurrence or associated tumors.Presentation: Saturday, July 12, 2025