In February, we reported on a cheating scandal that resulted in U.S. Medical Licensing Examination (USMLE) scores being invalidated for hundreds of Nepali test takers, some of whom later filed a class action lawsuit. In this report, we follow up on what has happened since.
Nearly a year ago, the USMLE program found a pattern of suspicious results, and after an investigation, invalidated the scores for 832 Nepali test takers. Some had scores for just one step invalidated while others had all three, putting their careers and visa status in limbo.
One of the people who had all three scores invalidated — Latika Giri, MBBS, a Nepali medical graduate who lives in Kathmandu, Nepal — quickly launched a class action lawsuit against the National Board of Medical Examiners (NBME), which co-runs the USMLE. Her legal team also filed a preliminary injunction to restore score validity, which was denied by Judge Christopher R. Cooper.
A few weeks later, the plaintiffs amended and refiled their complaint, alleging discrimination based on national origin and demanding $80 million in damages, at which point Swechha Shrestha, MD — who holds Nepali citizenship but lives in Nevada and had her step 3 score invalidated — joined the suit.
The latest legal filings date back to June and July, when NBME filed a motion to dismiss and the plaintiffs subsequently filed an opposition to that motion, as well as other exhibits and replies. Some of those documents reveal new information on the scope of the case. Notably, most people — 618 out of 832 — only had one step’s score invalidated, while 202 had two invalidated. Just 12 people, including Giri, had their scores from all three steps flagged.
Meanwhile, the USMLE had given the people whose scores were invalidated three options on how to proceed: they could either retake the exams at no cost (though if they failed they will be barred from the USMLE for 3 years), they could request that the USMLE reconsider their score invalidation, or they could do nothing and have their score remain listed as “Score Not Available” and also be barred from the exam for 3 years. According to exhibits filed in the court documents, Giri and Shrestha both requested that the USMLE reconsider their invalidated scores, which remain listed as “Score Not Available” until a decision is reached.
A spokesperson for the USMLE told MedPage Today that “a majority of examinees chose to retake their invalidated exams in 2024” and that validation exams have been offered for all three steps with more dates available in 2025 and 2026.
However, the organization said it will not be sharing the score outcomes for these validating exams. The spokesperson also said that “multiple steps have been implemented to mitigate the potential for problematic examinee behaviors, and where direct evidence of misconduct has been obtained specific to an individual, those individuals have been routed to the program’s process for adjudicating allegations of irregular behavior,” though they didn’t give any details about the safeguards.
Bryan Carmody, MD, who runs the popular medical education blog, “The Sheriff of Sodium,” and has been following the scandal closely, told MedPage Today that it makes sense that most people chose to retake the exam and that passing it a second time answers the question of whether they were knowledgeable enough to be a doctor.
Carmody also explained that the Electronic Residency Application Service (ERAS) displays an applicant’s most recent USMLE score most prominently, though the invalidated score on their USMLE transcript could still impact these candidates’ chances of matching into a U.S. residency.
“So if an applicant failed Step 1 and then passed it, all that ERAS shows in the easily accessible part … is USMLE Step 1: pass,” he said, adding that to see their USMLE transcript, which includes an applicant’s complete examination history, another click is required. Carmody suspects that most programs will indeed look at the transcript, but he’s confident that not all programs will. He also thinks the NBME has lessons to learn from this ordeal.
“I think if their announcement had been phrased in a different way, there wouldn’t have been a lawsuit against them,” Carmody said. At the same time, he noted that publicly announcing the findings of an internal cheating investigation was helpful for the organization’s reputation so that people in the field know that they are policing the test.
“Their whole business really stands on their reputation for offering a test that’s fair and reproducible and whose results mean something that’s useful in the world of medical licensure and residency selection,” he said.
Neither the NBME nor the plaintiff’s legal teams responded to MedPage Today’s request for comment. As of press time, no meetings regarding the case are on the public court calendar and the district court did not reply to MedPage Today’s questions about an anticipated timeline.

Rachael Robertson is a writer on the MedPage Today enterprise and investigative team, also covering OB/GYN news. Her print, data, and audio stories have appeared in Everyday Health, Gizmodo, the Bronx Times, and multiple podcasts. Follow

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The holidays came with a side of flu for many Americans, with 40 states reporting high or very high levels of illness last week, according to the latest government health data.
“A lot of flu out there,” said the CDC’s Carrie Reed, PhD.
There are a number of bugs that cause fever, cough, sore throat, and other flu-like symptoms. One is COVID-19. Another is RSV, or respiratory syncytial virus, which is a common cause of cold-like symptoms but can be dangerous for infants and the elderly.
The most recent CDC hospitalization data and other indicators show that the flu virus is trending higher than the other germs, Reed said. Several seasonal flu strains are driving cases, with no dominant one, she added.
Pediatric hospitals have been busy since November with RSV, but “influenza has now joined the party,” said Jason Newland, MD, an infectious diseases specialist at Nationwide Children’s Hospital in Columbus, Ohio.
“Now we’re really starting to roll,” he added. “Our hospitals are busy.”
One indicator of flu activity is the percentage of doctor’s office visits driven by flu-like symptoms. That level last week was about equal to the peak of last winter’s respiratory virus season, which occurred at the same time of year. Reed noted that most people avoid medical appointments over the holidays if they can help it, so the data in late December might be skewed by people who came down with sudden illnesses.
Last week’s flu activity was particularly intense in the South, Southwest, and western U.S. The states reporting lesser amounts of suffering were mostly in the northern Great Plains and in New England.
So far this season, the CDC estimates, there have been at least 5.3 million flu illnesses, 63,000 hospitalizations, and 2,700 deaths, including at least 11 children. It’s not clear whether this winter respiratory virus season will be any worse than others. So far, it seems relatively typical, at least for kids, Newland said.
The CDC also has been keeping its eye on a rise of illnesses from norovirus, with 91 outbreaks reported early in December.
Investigators also are closely watching the type A H5N1 version of bird flu. The CDC says 66 human U.S. cases of that were reported last year, but none of them in the last week.
The cases are “fairly sporadic” and the overall risk to the public remains low, Reed said. Almost all have been traced to direct contact with infected animals, with no proof of spread between people.

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“CBD is known for its soothing and anti-inflammatory properties, which makes it your period’s perfect partner in crime.”
“… a CBD coating for the days when period pain is cramping your style.”
These are a few examples of the way Anne’s Daye Ltd., dba Tampon Innovations, a U.K. firm with a manufacturing plant in Bulgaria, marketed tampons infused with cannabinoids to American customers.
But while menstruation can be annoying or even painful, selling tampons to U.S. consumers containing unauthorized substances like CBD is not a good solution, the FDA said.
The agency recently sent a warning letter to the company’s CEO, Valentina Milanova, noting that an inspection of the Bulgarian plant last July “determined that your firm manufactures cannabinoid (CBD)-coated tampons (‘CBD Daye Tampons’).”
Daye tampons are cleared for insertion into the vagina to absorb menstrual discharge. “However, your firm’s labeling and promotion of the device provides evidence that the device is intended for relief of period-related pain, which would constitute a major change or modification to its intended use, for which your firm lacks clearance or approval,” the FDA wrote.
“Our inspection and review of your website determined that the CBD Daye Tampon is adulterated … because your firm does not have an approved application for premarket approval … or an approved application for an investigational device exemption,” said the letter, which was signed by Michael Hoffmann, director of the FDA’s Office of GastroRenal, ObGyn, General Hospital, and Urology Devices.
“The CBD Daye Tampon is also misbranded … because your firm introduced or delivered for introduction into interstate commerce for commercial distribution this device with major changes or modifications to the intended use without submitting a new premarket notification to FDA,” the letter continued. “The device is further misbranded because your firm did not notify FDA regarding changes and modifications in the device that could significantly affect the safety or effectiveness of the device.”
The warning letter discussed a series of back-and-forth communication between the company and the FDA.
“FDA evaluated the regulatory decision form that you provided the investigator to support not needing a 510(k) for the CBD Coated Daye Tampons and found the assessment was inadequate because the CBD coating raises significant concerns regarding safety and effectiveness of the devices due to the potential for local and systemic exposure of CBD, potential adverse events (e.g., reproductive/developmental toxicity) associated with CBD, and potential effects due to the uncertainty of the potency and quality of the CBD (e.g., psychoactive effects from possible contaminants like Delta-9-tetrahydrocannabinol),” it said.
Daye appears to have heeded the FDA’s warning. A visitor to the company website on Friday was asked what country they were browsing from, and upon answering “United States,” was directed to a product list that did not include CBD-infused tampons. A page for the tampons on Walmart’s website also has disappeared.
The tampons, however, were not the only Daye product the FDA had an issue with. Agency officials also warned the company against marketing its vaginal microbiome screening kit to U.S. customers.
“Our inspection and review of your website determined that the Vaginal Microbiome Screening Kit is adulterated … because your firm does not have an approved application for premarket approval … or an approved application for an investigational device exemption,” the FDA said in its warning letter.
The kit is also misbranded because “your firm did not notify the agency of its intent to introduce the device into commercial distribution,” the letter continued. “Your firm’s promotion of the Vaginal Microbiome Screening Kit provides evidence that the device is intended for diagnosing yeast infections, BV [bacterial vaginosis], STIs [sexually transmitted infections], fertility implications, and other gynecological health complications, indications for which your firm lacks clearance or approval.”
“The FDA evaluated the regulatory decision form you provided to the investigator to support that the Vaginal Microbiome Screening Kit is a general wellness device,” it said, adding that the company’s reasoning was inadequate “because your firm markets the device with diagnostic claims that are outside the scope of a general wellness device as described in the FDA guidance document ‘General Wellness: Policy for Low Risk Devices;’ therefore, your device would need to be submitted for premarket review by the FDA.”
The company appears to have partially heeded the FDA’s warning on the test kit. A listing for that product on Amazon’s website — which the agency specifically complained about in its letter — has disappeared. However, the product is still available on Daye’s site for U.S. consumers at a price of $125, along with an offer of a 30-minute “sexual and reproductive coach consultation” for $55.

Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow

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People who died with sporadic Creutzfeldt-Jakob disease were more likely to have been prescribed antidepressants before neurologic symptoms started, a retrospective study in Austria showed.
Compared with controls in the general population, patients with sporadic Creutzfeldt-Jakob disease had higher odds of being prescribed selective serotonin reuptake inhibitors (SSRIs) in the year preceding disease onset (18.6% vs 8.2%, OR 2.86; 95% CI 1.63-4.95, P

Professional guidelines recommend LMWH and DOACs over UFH for the majority of patients hospitalized for acute PE.Yet physicians expressed general indifference toward anticoagulation choice, or the belief that the choice of in-hospital anticoagulation ultimately did not matter.Misperceptions include the idea that UFH users are less prone to bleeding, and that UFH is a stronger anticoagulant.

Despite guidelines recommending other anticoagulants for people hospitalized with acute pulmonary embolism (PE), old habits and misconceptions have kept unfractionated heparin (UFH) the initial choice for many physicians in the U.S., according to one report.
Based on interviews with several dozen physicians spanning various geographic locations and practice settings, investigators found that several common themes underlie the persistent use of UFH over low-molecular-weight heparins (LMWHs) or direct oral anticoagulants (DOACs).
First and foremost, “both emergency medicine physicians and hospitalists routinely referred to inertia carried over from training (generally when discussing a habit of using UFH in patients admitted with PE). This inertia was, at least in part, due to a general indifference toward anticoagulation choice,” reported Lauren Westafer, DO, MPH, MS, of University of Massachusetts Chan Medical School-Baystate in Springfield, and colleagues.
“Adoption of new practice patterns requires awareness of clinical guidelines and data,” they noted in JAMA Network Open.
In pulmonary embolism, systemic anticoagulation is the cornerstone treatment. Unless a specific contraindication exists, professional guidelines recommend LMWH and DOACs over UFH for the majority of patients hospitalized for acute PE who are treated with parenteral anticoagulation. The reason: these alternatives achieve therapeutic anticoagulation more quickly and consistently and are associated with fewer bleeding complications.
As such, the view that came up again and again in the qualitative study, that the choice of in-hospital anticoagulation ultimately did not matter, is not backed by the literature, Westafer and colleagues stressed.
The group had previously reported a steady climb in the proportion of U.S. patients with acute PE initially treated with UFH, increasing from 41.9% in 2011 to 56.3% in 2020.
The group detailed other themes that arose from their interviews with physicians about anticoagulation in acute PE:They have been used to using UFH for decadesHospitalists reported rarely switching patients started on UFH to LMWH or a DOAC until the patient was nearing discharge due to reasons like convenience, timing of transitions, and the desire to reduce the number of anticoagulation transitions.Some institutions have an unwritten institutional culture of using a UFH-dominant approachThe short half-life of UFH was more reassuring to physicians fearing decompensation and/or bleeding from the PEA misperception that UFH was stronger than other anticoagulants because of its “quick on, quick off” and its IV administration
In an invited commentary, Brandon Maughan, MD, MHS, of Oregon Health and Science University in Portland, and colleagues highlighted that another common misperception — that LMWH is contraindicated to patients undergoing catheter-directed treatment — was cited as part of physicians’ reasoning that upfront UFH would offer the patient more flexibility to change the anticoagulant in downstream care.
“Guidelines recommend continuing anticoagulation during catheter-directed interventions, although there remains heterogeneity in clinical practice regarding choice of anticoagulant and monitoring during catheter-directed thrombolytic infusion. Parenteral anticoagulation with either UFH or LMWH is not a contraindication to systemic thrombolysis,” the editorialists clarified.
“Another important misconception is that no steps can be taken to reverse LMWH,” Maughan and colleagues continued. “Protamine achieves partial (approximately 60%) reversal of LMWH, and guidelines recommend protamine for management of life-threatening bleeding associated with either UFH or LMWH. DOACs may be reversed with prothrombin complex concentrates or specific reversal agents.”
All in all, they said, the present findings “suggest widespread misunderstanding of the pharmacology and guideline-recommended use of heparins in acute PE.”
“Addressing these misconceptions and changing clinical practice will require a multifaceted approach, including pragmatic trials of anticoagulation effectiveness and safety in clinical settings, targeted educational programs from professional societies, and adoption of evidence-based policies by institutional quality committees. Ongoing emergency care research using implementation science frameworks should be conducted to modernize anticoagulation choices and improve outcomes for patients with PE,” the editorialists wrote.
For their qualitative study, Westafer’s group relied on semistructured interviews with 46 participants in emergency medicine (54.3%), hospital medicine (37.0%), interventional cardiology and interventional radiology (8.7%). Participants were invited to a 30-minute interview on Zoom software and received a $25 Amazon gift card.
Median age was 43 years. Men accounted for 71.7% of the participating cohort. By race, the group was 60% white and 32% Asian. The small group included individuals spanning the spectrum of practice patterns and geographic settings in the U.S.
Chief among the study’s caveats was its limited sample and the possibility that participants may have chosen what they said during interviews with some degree of social desirability bias.

Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures
The study was funded in part by the Baystate Medical Center Research Pilot Award Program and Vanderbilt Faculty Research Scholars Program.Westafer reported receiving grants from the National Heart, Lung, and Blood Institute and Baystate Medical Center.Co-authors reported relationships with Pfizer, Bristol-Myers Squib, Janssen, Anthos, Bayer, the Anticoagulation Forum Board of Directors, Boston Scientific Consulting, AstraZeneca, Sanofi, and Abbott Vascular.Maughan reported receiving grants from the National Academy of Medicine, the American Heart Association, and the Collins Medical Trust.

Primary Source
JAMA Network Open
Source Reference: Stubblefield WB, et al “Factors in initial anticoagulation choice in hospitalized patients with pulmonary embolism” JAMA Netw Open 2025; DOI: 10.1001/jamanetworkopen.2024.52877.

Secondary Source
JAMA Network Open
Source Reference: Maughan BC, et al “Evidence-based anticoagulation choice for acute pulmonary embolism” JAMA Netw Open 2025; DOI: 10.1001/jamanetworkopen.2024.52850.

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In early 2024, we reported new research that suggested Alzheimer’s disease may be transmissible under rare conditions. The study fueled debates in the Alzheimer’s research community, which we discuss in this follow-up story.
Five U.K. patients treated with human growth hormone from cadaveric pituitary glands when they were children later developed early dementia or other changes consistent with Alzheimer’s disease, John Collinge, MD, of University College London, and co-authors said in Nature Medicine in January 2024.
Four of these patients were between ages 38 and 49 when their cognitive symptoms started; the fifth was 55. Two had biomarker changes that supported a possible Alzheimer’s diagnosis. Two did not have molecular biomarker testing but showed progressive brain atrophy on imaging. One had Alzheimer’s pathology detected at autopsy.
The findings did not mean that Alzheimer’s could be transmitted between people during daily activities or routine medical care, Collinge emphasized. “The patients we have described were given a specific and long-discontinued medical treatment, which involved injecting patients with material now known to have been contaminated with disease-related proteins,” he stated when the study was published.
“However, the recognition of transmission of amyloid-beta pathology in these rare situations should lead us to review measures to prevent accidental transmission via other medical or surgical procedures, in order to prevent such cases occurring in the future,” he said.
Was This Alzheimer’s Disease?
The findings fueled discussions almost immediately on the global networking website AlzForum. Several experts said it seemed likely that Alzheimer’s pathology could be transmitted iatrogenically.
Six months later, a group of researchers including neurologist Avindra Nath, MD, of the National Institute of Neurological Disorders and Stroke, published a perspective article in Alzheimer’s & Dementia stating that the cases did not provide evidence that Alzheimer’s disease was transmitted by cadaveric growth hormone.
“Contrary to the title of the paper that suggests that these patients developed Alzheimer’s disease, a description of the patients and their findings suggests that most of them did not meet criteria for Alzheimer’s,” Nath said.
“Each individual had different clinical manifestations and course of illness,” he told MedPage Today.
“There were alternative explanations for their clinical findings, and they lacked laboratory support of Alzheimer’s disease, except for one individual,” Nath continued. “And the presence of Alzheimer’s-like pathology in a single individual could very well be by chance alone.”
The presentations of the cases were highly variable and not consistent clinically or pathologically with probable or definite Alzheimer’s disease, Nath and co-authors argued.
“In people with progressive cognitive decline, the diagnosis of Alzheimer’s disease requires a demonstration of amyloid and tau pathology, or amyloid and tau biomarkers,” they wrote. “Extensive tau pathology is not demonstrated, and some also lack amyloid beta pathology.”
“If the findings of this paper were to be correct, it would have important public health ramifications,” Nath noted. “Hence, it is critical that there be a high bar for making such conclusions.”
Surveillance Continues
More than 50 years ago, pioneering studies showed that neurodegenerative diseases like kuru and Creutzfeldt-Jakob disease were transmissible. In 1982, Stanley Prusiner, MD, of the University of California San Francisco, demonstrated that a single misfolded protein, or prion, was sufficient to do so. Prusiner later received the Nobel Prize in Physiology or Medicine for this work.
Since then, there’s been growing concern that other neurodegenerative diseases could be transmitted, Nath said.
“There have been several studies in which there has been iatrogenic transmission of Creutzfeldt-Jakob disease by exposure to brain tissue,” he observed.
Between 1959 and 1985, cadaver-derived human growth hormone was used around the world to treat young patients for pituitary insufficiency. The product was withdrawn after some patients received prion-contaminated cadaveric growth hormone and subsequently died of Creutzfeldt-Jakob disease.
In 2015, Collinge and co-authors reported that some of the U.K. patients who died of iatrogenic Creutzfeldt-Jakob disease had amyloid-beta pathology at autopsy. Whether they also had Alzheimer’s symptoms wasn’t known because Creutzfeldt-Jakob, a universally fatal prion disease that progresses rapidly, may have masked any symptoms.
In the U.S., nearly 7,700 children were treated with pituitary human growth hormone under the National Hormone and Pituitary Program (NHPP) from 1963 to 1985. In 1977, the NHPP started a safer purification method and later fully switched to recombinant human growth hormone.
“The NIH in collaboration with the CDC has been overseeing the surveillance of the approximately 7,700 individuals who received cadaveric human growth hormone in the United States in the 1960s, 1970s, and early 1980s through the NHPP,” Nath said. “We are currently evaluating all deaths in the NHPP cohort — 1,480 to date — to determine whether there is a signal for an increase in Alzheimer’s disease.”
The cohort also is being monitored for other neurodegenerative diseases, he added. To date, there’s been no conclusive evidence for other diseases except possible cerebral amyloid angiopathy, he said.
Despite the questions raised by Nath and colleagues, Collinge maintains that his 2024 paper is sound. “With the greatest of respect to these authors, we are describing a new condition, iatrogenic Alzheimer’s disease,” he told MedPage Today.
“Just as iatrogenic Creutzfeldt-Jakob disease has different clinical and pathologic features to sporadic Creutzfeldt-Jakob disease, we would expect differences with classical Alzheimer’s disease,” Collinge said. “The full phenotypic range of iatrogenic Alzheimer’s disease — which has an acquired, rather than sporadic, etiology — will emerge and be better understood as more cases are reported.”

Judy George covers neurology and neuroscience news for MedPage Today, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more. Follow

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