United States

Background:
Heart failure (HF) is a complex medical condition associated with high hospital readmission rates, placing a significant burden on hospital resources. Attempts to improve outcomes and quality of life for these patients have led to significant advances in patient care in terms of medical therapies and risk reduction measures. However, the increased complexity of treating HF associated with these advances has also made healthcare navigation and patient compliance more difficult. For patients hospitalized with heart failure, goal-directed medical therapy (GDMT) leads to improved patient outcomes and reduces rehospitalizations, thus reducing the cost of care. Inadequate GDMT translates to a 29% excess mortality risk over just a 2-year period of follow-up. While patient compliance encompasses a large realm of social determinant factors, the consistent prescription of GDMT by physicians is the first step. 

Methods:
We analyzed prescription rates of patients hospitalized between 2/1/2024 – 5/1/2024 with HF with reduced ejection fraction (HFrEF). This included 54 patients who were pre-educational interventions and 80 patients who were post-educational interventions. The Quality Improvement (QI) project intervention included an in-person presentation as well as an email sent to all internal medicine residents with a succinct one-pager and full PowerPoint presentation. It additionally involved the creation of an HF order set hard-coded into the hospital’s electronic medical record. This included but was not limited to a list of GDMT medications (angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) or angiotensin receptor/neprilysin inhibitor (ARNI), beta blockers (BB), mineralocorticoid receptor antagonist (MRA)), daily weights, ins and outs, a therapeutic diet, elevation of the bed, cardiac rehabilitation referral, and other useful lab work. Of note, sodium-glucose cotransporter 2 (SGLT-2) inhibitors were excluded as part of GDMT as they are not on the formulary at our institution.

Results: 
After the QI project intervention, beta blocker prescription rates rose from 77.8% to 92.5%. Angiotensin receptor blocker prescription rates changed from 81.5% to 76.3%. Mineralocorticoid receptor antagonist prescription rates rose from 46.3% to 57.5%. 

Conclusion: 
This project demonstrated that educational sessions as well as HF order sets can improve GDMT prescription rates. However, our results also indicate the need for continued improvements. Repeat educational sessions as well as improvement of order sets with the incorporation of heart failure coordinators and care management consults are starting points to continue optimizing GDMT rates.

AMA Research Challenge 2024 

Optimization of GDMT prescription rates for patients with HFrEF following educational interventions

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AMA Research Challenge 2022

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Background: Early detection has been the historical strategy for improving outcomes in patients diagnosed with melanoma. Since the 1960s, physicians have focused on interventions to educate the public about the nature of melanoma and the importance of sun protection and regular skin cancer screening. Despite these efforts, publications have highlighted the rapid increase in melanoma incidence over the past four decades with minimal changes in the mortality rates. In fact, the recent drop in melanoma mortality has been widely attributed to the introduction of newer medications such as molecular and immune checkpoint therapies approved in the mid 2010’s. However, the impact of ongoing public efforts remains unknown. We thus set out to more closely examine the dynamics of melanoma mortality in the “pre-therapeutic era” and test the hypothesis that death rates have been unwavering. To accomplish this, we characterized and modeled mortality trends between 1969-2014 in both the U.S. and Australia. 

Methods: We performed a differential time series analysis based on population-ascertained mortality rates (total, male, and female) from the United States (SEER) and Australia (Cancer Australia). To this end, we calculated the first derivative of yearly mortality rates between 1969-2014 and analyzed trends using linear regression. Melanoma mortality rates were then modeled using a second-order polynomial regression and compared to mortality trajectories of 10 other cancers. 

Results: Melanoma mortality rates have been significantly decelerating since the 1970s in both the U.S. (p<0.0001) and Australia (p=0.0021). Zero acceleration occurred around 2001 (95% CI: 1996, 2008) for the U.S. and 2004 (95% CI: 1999, 2011) for Australia. The male mortality rates decelerated 3-4 times faster than females in both countries, though the absolute male mortality rates were much higher. Melanoma mortality followed a quadratic function (R2>0.9). Compared to total U.S. cancer death rates and mortality among ten other cancer types, melanoma showed a similar quadratic distribution albeit with a later inflection point (1986 vs. 2001) and broader focal width. 

Conclusion: Deaths due to melanoma have been decelerating for the past five decades, reaching an inflection point around 2001 prior to the advent of modern therapies. These findings suggest that mitigating campaigns had already taken afoot in both the U.S. and Australia.

Differential Time Series Analysis Shows Deceleration in Melanoma Mortality Prior to the Widespread Use of Highly Effective Therapies

Background
In the wake of COVID-19, a vaccine outreach program was designed in 2021. A component of this study involved assessing patients' attitudes toward receiving additional vaccinations in dermatology offices. The survey data showed high degrees of satisfaction with vaccines administered at the dermatology office, and 90.9% of patients stated they would receive other vaccines at their dermatology clinic if recommended and available. It is important to note that less than half of patients in the cohort who received COVID-19 vaccines (48.2%) had been vaccinated with a shingles (varicella zoster virus) vaccine despite being age-eligible. Patients view physicians as a trusted source of information regarding vaccines. We believe that after physician-directed education, patients may be more willing to receive a shingles vaccine. We sought to test this hypothesis, by collecting survey data to evaluate shingles vaccination rates and patients’ perspectives among individuals seen in a multipractice dermatology group. 
Methods
Patients who were eligible for vaccination and being seen by a resident physician were identified upon intake. The patients were surveyed before and after education about the shingles vaccine was provided. Education included resident-administered verbal education following the Center for Disease Control's vaccine information sheet. Survey data was recorded anonymously and is therefore IRB exempt. A total of 62 subjects were surveyed, and 59 surveys were completed.
Results
Only 24% of subjects had received the vaccine, despite being eligible to receive it. The most cited reason (27.8%) for being unvaccinated was that subjects had never been offered to receive it. Of the unvaccinated respondents, 53% initially indicated considering vaccination, and this increased to 69% post-education (p-value= 0.06). 88% of subjects who were unvaccinated and changed from “not considering” to “considering” vaccination attributed their decision to the educational materials.
Conclusion
We see vaccine availability as a major barrier to unvaccinated individuals. Provider directed education can mitigate vaccine hesitancy, as demonstrated in a 2022 study which showed the efficacy of physician recommendations in reducing COVID-19 vaccine hesitancy. This study is limited by population size, and a greater difference would likely be shown if performed on a larger scale. We believe these results will nonetheless inform and provide support for the valuable role that dermatology practices can play in improving public health, specifically when it comes to shingles vaccination rates.

The Impact of Education in Reducing Shingles Vaccine Hesitancy in Dermatology

Background 
Burn injuries are a major public health concern and in the US alone, making up about 500,000 ED visits per year. While most of these burn injuries are minor, the ones that do require hospital admission are often directed towards specialized burn centers. These burn centers, which provide optimal burn care, involve a team of healthcare workers from many different specialties including highly trained burn surgeons along with other rehabilitation services. EMS official guidelines concerning pre-hospital management of burn patients state that patients should be transported to either the nearest emergency department, or if protocols allow, directly to a burn center. With the emergence of more specialized burn centers, pre-hospital providers must triage their patients to an appropriate destination. And despite the prevalence of burns, less than 1% of all EMS calls from 2020-2023 in North Carolina were burn related. Such a low occurrence means that pre-hospital providers have minimal experience with this population of patients. The pre-hospital transport destination, burn center or local hospital, depends on the burn classification. Burn classifications are highly dependent on the clinical examination, which is subjective especially for providers without specialty training in burns. 
Methods 
In this retrospective study, all emergency response calls categorized as burn-related were analyzed using the NC Continuum Database from 2020-2023. A total of 3467 transports were evaluated. Based on the chief complaint, the determination was made, according to the American Burn Association and UNC Jaycee Burn Center criteria, whether the patient should have been transferred to a burn center, or local hospital. If there was not enough data to determine this information, the record was categorized as unknown. 
Results 
Of the patients we determined as needing specialized care from a burn center (n=246), 68% were not transported appropriately, while only 32% were. Of the patients who we determined that local hospital care was appropriate (n=111), 14% were transported inappropriately to a burn center. Less than 2% of charts reported percentage of total body surface area (TBSA) of burn within the chief complaint. We classified 2868 number of transports as “unknown” due to lack of fully descriptive criteria that would allow us to correctly categorize the transport decision. 
Conclusion 
The lack of appropriate triage and destination for burn patients can negatively impact patient outcomes. This highlights the need for a standardized approach to pre-hospital burn management which can be facilitated by further education of EMS providers.

Burns: Destination Evaluation for Patients Transported by EMS ​

Objective: Hispanic immigrant populations vary greatly regarding demographic and economic factors based on their country of origin. Understanding the factors that influence healthcare disparities in the United States is essential to creating sustainable change in the healthcare system, and it begins with understanding the unique differences between the communities experiencing these disparities. Studies on emergency room utilization from non-native immigrants are limited in the current literature. This study sought to use country of origin as a predictor of emergency room usage from four Hispanic countries to demonstrate the disparities within the Hispanic community.

Methods: This cross-sectional study used the 2020 Medical Expenditure Panel Survey that collects information on utilization and expenditure of emergency room (ER) among foreign-born Hispanic adults aged 18 and above (N=1,838). We examined the association between four countries of origin and two outcomes, including the number of ER visits per person and average cost per visit. Survey-weighted multivariable regression models were conducted to evaluate how average cost varied by country of origin while considering demographics and socioeconomic factors including but not limited to insurance status, region, and language spoken.

Results: The results show that Dominicans spent $474.84 more than Mexicans per emergency room visit (p = .044). Dominicans spent the most out of the four countries, costing a total of $534.13 (p = .053). Average expenditures per emergency room visit for Mexicans were negatively associated with speaking a language other than English or Spanish and having a master’s degree (p = .029 and p = .003, respectively). For Puerto Ricans, average expenditures were negatively associated with low incomes (p = .044). Additionally, the average spending for Dominicans was negatively associated with living in the Midwest and positively related to having a doctorate degree (p = .006 and p = .022, respectively). No variables were identified as a strong predictor of average emergency room expenditures for Cubans.

Conclusion: Unexpected costs that arise with emergency room visits can be taxing on individuals and their families, especially those experiencing financial distress to begin with. This study demonstrates intra-group disparities in emergency room costs among Hispanic populations from four countries. However, very few variables could predict the reason for these observed findings, which are largely misunderstood. Understanding the reasons for the increased costs accompanying specific populations when they receive emergency services is vital in guiding treatment and ensuring that patients are treated equitably. More research needs to be done on hispanic immigrants that recognizes country of origin as a contributing factor to the health care they receive in the United States. With more awareness of the disparities present between Hispanic immigrant populations, extra precautions can be taken to ensure patients are not being undertreated or overtreated and erase the gap in associated costs.

Cross-sectional Study of Emergency Room Visits Among Hispanic Immigrants by Country of Origin

Introduction
Reduction of overdose deaths by community naloxone education and distribution programs is well-established. The efficacy of teaching bystanders additional first aid measures is less clear. AHA recommends lay rescuers provide hands-only CPR for all unconscious patients with abnormal breathing as delaying CPR greatly worsens outcomes and bystanders may withhold chest compressions feeling for a pulse or worrying about rescue breaths. However, the WHO recommends CPR with rescue breathing for suspected overdose because the hypoxic etiology requires oxygenation. Other organizations recommend lay providers check a pulse to determine treatment since apnea with a pulse is more common in overdoses, particularly witnessed ones. The purpose of this study is to compare patient outcomes after community programs teach these varying strategies.

Methods
A literature review was conducted. Studies that did not specify recommendations for actions in addition to naloxone training or include measurement of patient outcomes were excluded. Twelve studies met the criteria for inclusion. Two studies described programs that recommended naloxone and CPR, while the remainder recommended naloxone and rescue breathing.

Results
After completing training programs recommending CPR, participants responded to 45 overdoses, with successful reversal 97.5% of the time (95% CI: 0.149-1.802). After programs recommending rescue breathing, participants responded to 1751 overdoses, with successful reversal 95.4% of the time (95% CI: 0.68-1.229). This information was usually obtained through voluntary self-reporting or interviewing when participants returned for naloxone refills. Numerous participants were lost to follow-up in all studies. “Reversal” was inconsistently defined but generally meant arousal and normal breathing. All patients received naloxone (dosing not recorded). Most studies did not record whether patients also received CPR and/or rescue breathing or whether this was associated with successful reversal. The published studies have significant deficiencies including limited measurement of outcomes, small sample sizes, and potential confounding variables.

Conclusion
The currently available scientific literature related to this topic is insufficient to make recommendations about how overdose response education should be structured. Further research is clearly needed.

We Taught How to Use Naloxone: Now What?

Background: Cigarette smoking during pregnancy is associated with increased infant mortality, low birth weight, and other poor outcomes. Pregnant patients who try to quit smoking are increasingly turning to electronic cigarettes (e-cigarettes), as they believe it is safer for the fetus. However, little is known about the relative safety of e-cigarettes as compared to cigarettes during pregnancy.
We evaluated whether e-cigarette use during pregnancy was associated with fewer infant health complications, lower toxicant biomarker levels, and better birth outcomes compared to cigarette smoking. We examined toxicant levels at delivery, birth outcomes, and health at 3-months postpartum of infants born to women who exclusively used e-cigarettes, only cigarettes, and those who used both during pregnancy.
Our objective is to understand the role of e-cigarettes in reducing infant health complications, improve physician counseling regarding e-cigarette safety, and evaluate e-cigarettes as a harm-reduction tool for pregnant patients who smoke.

Methods: This prospective cohort study followed n=179 (n=100 exclusive cigarette, n=40 dual use, and n=39 exclusive e-cigarette) pregnant women. At birth, neonatal urine and cord blood were analyzed for the tobacco metabolite NNAL; volatile organic compounds benzene, acrylamide, acrolein, acrylonitrile; and nicotine metabolite (cotinine) levels. Birth outcomes, such as APGAR score, gestational age, and weight were collected from medical charts. 3-month postpartum surveys assessed infant health complications, such as infection, hospitalizations, and respiratory problems. Kruskal Wallis and Chi-square tests were conducted using SPSS statistical software.

Results: Infants of women who exclusively smoked cigarettes had the highest mean NNAL level at birth (30.32, SD=43.39), followed by those who dual used (17.24, SD=15.90), and those who used e-cigarettes (2, SD= .77, p=0.004). Similarly, infants of women who exclusively smoked cigarettes and who dual used had the highest mean acrylonitrile values (22.74, SD= 34.32, and 23.06, SD=22.97, respectively), while those born to exclusive e-cigarette users had the lowest (18.16, SD=56.91, p=0.008). No differences were observed in cotinine levels, birth outcomes, or 3-month postpartum health complications across the groups.

Conclusion: Exclusive maternal e-cigarette use during pregnancy correlates with lower infant NNAL and acrylonitrile levels at birth. However, exclusive e-cigarette use during pregnancy does not reduce rates of adverse 3-month health outcomes or poor birth outcomes. Further research is needed to determine whether these infants achieve age-appropriate developmental milestones in motor, social, and cognitive domains. Our results suggest e-cigarettes are not clinically safer than cigarettes during pregnancy, and physicians should counsel patients on alternative forms of nicotine replacement therapy to support smoking cessation.

Impact of E-Cigarette vs. Cigarette Use During Pregnancy on Infant Health

Background
Cryptosporidiosis, a gastrointestinal infection caused by Cryptosporidium spp., is an emerging public health concern, typically manifesting as self-limiting watery diarrhea in immunocompetent individuals, sometimes treated with nitazoxanide or other antiparasitics. In patients experiencing immunocompromisation, such as those with AIDS or solid organ transplantation (SOT), risk of infection is known to be higher and symptoms are more severe, but first-line medicines are less effective. Risk, presentation, and effective management among those with inflammatory bowel disease (IBD) is not known. This population is frequently treated with immunosuppressive therapy, and symptoms of cryptosporidiosis can be mistaken as an IBD flare. This study aims to systematically review and map the intersection of cryptosporidiosis and IBD to assess disease risk, diagnostic delays, and effective pharmaceutical interventions to inform better patient care.

Methods
A protocol for a scoping review was developed, following the Joanna Briggs Institute (JBI) methodology. We used PCC (Problem, Concept, Context) framework, where IBD is the Problem and cryptosporidiosis is the Concept. Context is broad to include all clinical reports (randomized and non-randomized control trials, case studies, and observational studies). Inclusion criteria encompass clinical cases across all age groups, both with and without the use of immunomodulators, including patients initially diagnosed with either cryptosporidiosis or IBD. 

Results
A MEDLINE (PubMed) search conducted January 19, 2024 yielded 308,023 results for IBD and 11,307 results for cryptosporidiosis. Systematic reviews for cryptosporidiosis were found on epidemiology and risk factors for AIDS, SOT, and poor water hygiene, but none regarding IBD. Combined query of IBD and cryptosporidiosis retrieved 91 results. An instrument was developed via the Qualtrics platform for comprehensive and homogenous data extraction. Our protocol is registered with Open Science Framework (https://osf.io/j47mb) and has been submitted for peer review, currently awaiting managing editor’s decision. 

Conclusion
This scoping review seeks to address the literature gap by systematically mapping the comorbidity of cryptosporidiosis and IBD. The next steps involve integrating reviewer feedback and adapting our search strategy for additional databases. By enhancing our understanding of the intersection between cryptosporidiosis and IBD, this research has the potential to drive changes in clinical practice, improve patient outcomes, and inform future research directions in the field of gastroenterology and infectious diseases.

Mapping the Intersection of Cryptosporidiosis and Inflammatory Bowel Disease: A Scoping Review Protocol

Surgical site infections (SSIs) are a challenging complication that involves multifactorial measures to effectively prevent the occurrence of SSIs in low- and middle- income countries (LMICs). Chlorhexidine is a broad-spectrum antimicrobial agent that is widely used in surgical antiseptic solutions in order to prevent SSIs, however the use of chlorhexidine is not used in all global surgery settings, especially in LMICs, due to factors such as availability and cost. This systematic review aims to explore the effectiveness of chlorhexidine compared to other surgical antiseptic preparations in preventing SSIs in LMICs. On November 24, 2023, PubMed, Scopus, Cochrane and EBSCO, which were accessed via Rocky Vista University’s overarching database search tool, were searched using Boolean search terms. Information and data from 12 articles were selected to be included in this review, and the included articles were a combination of various clinical trials, study protocols, surveys and commentaries. Overall, there was conflicting information between the included articles, with some articles such as the FALCON trial concluding that there is no significant difference between the use of chlorhexidine compared to other antiseptic surgical preparations, and others stating that chlorhexidine is more effective. Due to the limited amount of included articles that were data from true clinical trials, this review reveals the need for more clinical trials to be done comparing the cost effectiveness, availability and local acceptance of CHX implementation in global surgery protocols, especially for LMICs. Further research could then lead to a more standardized, evidence-based approach to the reduction of SSIs in global surgery, thus improving surgical outcomes in LMICs.

Effectiveness of Chlorhexidine Compared to Other Antiseptic Solutions in Preventing Surgical Site Infections in Low- and Middle- Income Countries: A Systematic Review

Introduction: Breast cancer is the most common non-skin cancer in women in the United States. Minority groups such as Hispanics and Blacks generally have worse outcomes compared to the general population even after accounting for potential confounders. We hypothesize that stage at diagnosis modifies the magnitude of the disparities in survival seen in different racial/ethnic groups. 

Objective: To assess if breast cancer survival is associated with race/ethnicity defined as Non-Hispanic Whites (NHW), Non-Hispanic Blacks (NHB), Hispanic Whites (HW), and Hispanic Blacks (HB), and whether this association is modified by stage at diagnosis.

Methods: A historical cohort, including breast cancer cases in Hispanic and non-Hispanic black and white women was assembled using the Surveillance, Epidemiology, and End Results (SEER) Database 2000-2019. Kaplan-Meier survival functions for each race/ethnicity were compared using the log rank test. Using multivariable Cox regression analysis, hazard ratios for cancer mortality for each race/ethnicity group were estimated while testing for the interaction between race/ethnicity and stage at diagnosis (localized, regional, and distant) and controlling for potential confounders.

Results: The study included 820,748 women 20 years or older with primary breast cancer. The 95-percentile survival time was 27, 25, 19 and 14 months for NHW, HW, HB and NHB respectively. As compared to NHW, HR (95%CI) in localized tumors were: NHB 1.57(1.50-1.65); HB 1.43(1.02-2.01); HW 1.05(0.99-1.11); In regional tumors NHB 1.50(1.45-1.54); HB 1.39(1.12-1.71); HW 1.11(1.07-1.15) and in distant tumors NHB 1.36(1.31-1.42); HB 1.16(0.89-1.50); HW 1.36(1.31-1.42). 

Discussion/Conclusions: The study found that the association between race/ethnicity and breast cancer survival is indeed modified by stage at diagnosis. Compared to NHW, both HB and NHB have worse survival, and such differences in survival decrease as the stage at diagnosis is more advanced. Disparities in survival between HW and NHW are only evident in non-local tumors. Further research should clarify the role of biological vs. social factors in these disparities.

The Effect of Stage at Diagnosis on the Association Between Race/Ethnicity and Survival in Patients with Primary Breast Cancer

Background
The CDC recommends that all children follow the primary immunization series vaccination schedule to prevent vaccine-preventable diseases. The treatment for acute lymphoblastic leukemia (ALL) targets lymphocytes, which are cells that play a role in memory retention for vaccine immunity. The purpose of this experiment is to determine whether there is loss of vaccine immunity in children treated for ALL and whether there is a difference between the high- risk ALL protocols and standard-risk ALL protocols. Understanding loss of immunity in children treated for ALL can help to establish reimmunization guidelines in order to protect survivors from vaccine-preventable diseases.

Methods 
This retrospective study consisted of chart reviews of 45 pediatric patients who are ALL survivors at Children's Hospital of Richmond. The results of hepatitis B, varicella, MMR, and Dtap titers drawn from these patients were compared to the general population using a one- proportion z-test. The ALL group was then divided into high-risk protocol and standard-risk protocol groups. Titers and lymphocyte enumeration panels were then compared between the two groups using a two-proportion z-test.

Results
The results of this study showed that there was a significantly higher percentage of negative hepatitis B, varicella, MMR, and Dtap titers for the ALL group than in the general pediatric population (p<.01). However, there was no significant difference between children treated with high-risk protocols and standard-risk protocols (p = .42). The standard-risk group had 44% negative titers while the high-risk group had 53%. Additionally, the standard-risk group had 78% abnormal lymphocyte enumeration panel while the high-risk group had 86%.

Conclusion
This study showed that children treated with chemotherapy for ALL lose immunity against vaccine preventable diseases and require reimmunization to protect them from future infection. Additionally, there is no significant statistical difference in immunity between the children treated with high-risk protocols vs standard-risk protocols. However, the percentage of negative titers and abnormal lymphocyte enumeration panels in the high-risk group was greater than the standard-risk group, so there may be some clinical significance. Therefore, routine revaccinations should be implemented after chemotherapy and children treated with high-risk protocols may require more follow-ups and precautions. Limitations of this study include small sample size and possible revaccinations at outside hospital systems. Future studies will look at the rate of lymphocyte recovery in standard vs high-risk protocol groups to further assess impacts of chemotherapy protocols on immunity.

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Differential Time Series Analysis Shows Deceleration in Melanoma Mortality Prior to the Widespread Use of Highly Effective Therapies

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