While PD-1 inhibitors have revolutionized the treatment of metastatic NSCLC and the drugs are overall well tolerated, a small percentage of patients develop immune mediated liver injury due to reactive cytotoxic T lymphocytes as the reactivated T cells attack other tissues, including the liver. Generally, this has been seen consistently across the entire drug class, not specific to single agents. We present a rare case of immune mediated liver toxicity specific to Pembrolizumab that was subsequently not observed with Nivolumab, despite both drugs having identical mechanisms of actions. Patient has had multiple serial labs and imaging studies showing no progression of her disease, stable on Nivolumab. This case highlights the need for further investigation regarding the mechanism of Immune mediated liver toxicity/ injury that may be specific to single agents and not necessarily a drug class.

Background: Remediation in medical school should be a time-limited, and highly structured process that addresses student deficiencies and allows them to prove content competency before progressing in the curriculum. In this study, we analyze the use of a comprehensive end-of semester final examination in the remediation process for pre-clinical students at Kirk Kerkorian School of Medicine (KSOM). Faculty time utilized is analyzed and compared with the previously employed remediation process. Methods: Administered to all students at the end of each semester is a comprehensive examination consisting of a sufficient number of faculty-selected questions relating to each organ system covered with a 75% passing threshold. A student must also demonstrate competency of any failed system examination content to remediate successfully. The performance of those who did not exhibit competency was analyzed to identify areas of deficiency then an individualized exam would then be administered. The total remediation time spent by faculties and students was then analyzed. Results: KSOM Class of 2024 results showed that faculty were able to yield significant savings in time spent on remediation. Faculty spent 45 total remediation hours for the Class of 2024, compared to 400 hours remediating using the paper-based assignment method for the Class of 2021. With the transition to comprehensive end-of-semester final examinations, a total of 355 hours were saved. Furthermore, faculty used an average 1.07 hours/student with end-of-semester comprehensive examinations. The saved time allows faculty to work on improving the overall curriculum for all students rather than focusing on a limited number of students. Conclusion:Utilizing comprehensive end-of-semester final examinations notably decreased the amount of faculty time spent per semester on remediation. Further evaluation is required to evaluate long-term effectiveness on content competency and would further be strengthened by a multi-institutional comparison.

surgical evaluation as the case was not amenable to endovascular intervention. General surgery, surgical oncology, and vascular teams concluded that intraoperative mortality associated with reconstruction would approach 100%. The patient was then evaluated by palliative and hospice teams, and she was discharged with home hospice services two days after admission. (Figure ) Discussion: Our case emphasizes that in patients presenting with FBRBR and sepsis, clinicians should have a high suspicion of DCFs, especially in the setting of a history of PUD, abdominal surgery and radiotherapy, and recent excessive NSAID use.[2683] Figure 1. Axial (A) and coronal (B) views of an enhanced abdominal CTA scan demonstrating locules of gas within the inferior vena cava (yellow asterixis) with communication with the duodenal lumen (yellow arrow) suggestive of a duodenocaval fistula.

Upper gastrointestinal hemorrhage is an uncommon but can be a lethal presentation of a pseudoaneurysm because a rupture is associated with a 40%-80% mortality rate. We report a rare case of left gastric artery pseudoaneurysm secondary to peptic ulcer disease presenting as an upper gastrointestinal hemorrhage.

BackgroundThe ability to provide performance insights of various United States Medical Licensing Examination (USMLE) Step 1 assessments is of great importance to medical educators. Two custom pre-clerkship assessments used at the Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas (KSOM) are National Board of Medical Examiners (NBME)-derived end-of-semester final examinations and subject examinations. The authors sought to determine if performance on these custom assessments can provide feedback on a medical student's readiness to undertake the USMLE Step 1 examination. MethodologyDeidentified student performance data were provided by institutional databases for the KSOM graduating class of 2023 (N = 60). Pearson correlation analyses were utilized to evaluate the strength of the correlation between USMLE Step 1 performance and NBME subject examinations versus NBME end-of-semester final examinations. ResultsThe results indicated that the NBME end-of-semester final examinations have a statistically higher correlation to the USMLE Step 1 score than the majority of the individual NBME subject examinations. However, the mean NBME subject examination score (Semester 1: r = 0.53, p < 0.05; Semester 2: r = 0.58, p < 0.05) demonstrated significantly higher correlation to the USMLE Step 1 performance than the NBME endof-semester final examination score for both Semesters 1 and 2 (Semester 1: r = 0.50, p < 0.05; Semester 2: r = 0.48, p < 0.05). ConclusionsThese results showed that the mean of the NBME subject examination score was a better metric to assess readiness for the USMLE Step 1 than the NBME end-of-semester final examinations. However, each NBME end-of-semester final examination score showed a better correlation than the majority of the NBME subject examinations.