United States

Background
Thoracic epidural analgesia (TEA) is widely regarded as the gold standard for postoperative pain control in patients undergoing abdominal surgery. While its benefits over systemic opioids and other analgesic modalities are well-documented, gaps remain in existing literature regarding outcome stratification based on modifiable factors of TEA. This study aimed to evaluate the effectiveness of TEA for postoperative pain control and assess how modifiable factors influence pain scores and opioid use after abdominal surgery.
Methods
Approval was obtained from the Saint Louis University Institutional Review Board to conduct this single-center retrospective chart review. Records were identified for a total of 176 adult patients who underwent abdominal surgery and received preoperative placement of a thoracic epidural between 2020 and 2022. Data on patient demographic information, procedural information regarding epidural placement, and post-surgical outcomes were collected through review of the electronic medical record system. Primary outcomes included patient-reported pain scores and adjunct opioid usage. Data were analyzed using t-tests, one-way ANOVA, and simple linear regression.
Results
Patients who did not require initiation of patient-controlled analgesia (PCA) postoperatively, indicating a successful epidural, reported significantly lower pain scores during epidural use (p = 0.009) and required significantly less adjunct opioids (total MME: p &lt; 0.001; average daily MME: p = 0.003). Administering epidural bupivacaine alone, compared with hydromorphone + bupivacaine, was associated with significantly higher pain scores at 24 hours, during the epidural period, and over the length of hospital stay (p = 0.014, 0.021, 0.023, respectively). Epidurals placed at T9–T10, compared with those placed at T12-L1, were associated with significantly lower pain scores at the three time points studied (p = 0.019, 0.009, 0.008), as well as lower daily adjunct opioid use (p = 0.046).
Conclusion
TEA is effective in controlling postoperative pain and reducing opioid consumption following abdominal surgery. The combination of a local anesthetic with an opioid, particularly hydromorphone, yields better analgesic outcomes than local anesthetic alone. Additionally, higher thoracic placement levels, especially T9–T10, are associated with improved pain control, underscoring the importance of accurate catheter placement. These findings highlight modifiable factors that can enhance TEA efficacy and inform future initiatives to optimize perioperative pain management.


AMA Research Challenge 2025 

Pain Control and Opioid Use After Abdominal Surgery: How Thoracic Epidural Variables Shape Outcomes

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Background
Thoracic epidural analgesia (TEA) is widely regarded as the gold standard for postoperative pain control in patients undergoing abdominal surgery. While its benefits over systemic opioids and other analgesic modalities are well-documented, gaps remain in existing literature regarding outcome stratification based on modifiable factors of TEA. This study aimed to evaluate the effectiveness of TEA for postoperative pain control and assess how modifiable factors influence pain scores and opioid use after abdominal surgery.
Methods
Approval was obtained from the Saint Louis University Institutional Review Board to conduct this single-center retrospective chart review. Records were identified for a total of 176 adult patients who underwent abdominal surgery and received preoperative placement of a thoracic epidural between 2020 and 2022. Data on patient demographic information, procedural information regarding epidural placement, and post-surgical outcomes were collected through review of the electronic medical record system. Primary outcomes included patient-reported pain scores and adjunct opioid usage. Data were analyzed using t-tests, one-way ANOVA, and simple linear regression.
Results
Patients who did not require initiation of patient-controlled analgesia (PCA) postoperatively, indicating a successful epidural, reported significantly lower pain scores during epidural use (p = 0.009) and required significantly less adjunct opioids (total MME: p < 0.001; average daily MME: p = 0.003). Administering epidural bupivacaine alone, compared with hydromorphone + bupivacaine, was associated with significantly higher pain scores at 24 hours, during the epidural period, and over the length of hospital stay (p = 0.014, 0.021, 0.023, respectively). Epidurals placed at T9–T10, compared with those placed at T12-L1, were associated with significantly lower pain scores at the three time points studied (p = 0.019, 0.009, 0.008), as well as lower daily adjunct opioid use (p = 0.046).
Conclusion
TEA is effective in controlling postoperative pain and reducing opioid consumption following abdominal surgery. The combination of a local anesthetic with an opioid, particularly hydromorphone, yields better analgesic outcomes than local anesthetic alone. Additionally, higher thoracic placement levels, especially T9–T10, are associated with improved pain control, underscoring the importance of accurate catheter placement. These findings highlight modifiable factors that can enhance TEA efficacy and inform future initiatives to optimize perioperative pain management.


poster

Current methods for diagnosing acute cellular rejection (ACR) in heart transplant patients rely on manual histopathological analysis, which is time-consuming, subjective, and prone to variability. This project aims to develop an AI- driven approach to assist pathologists and streamline detection in myocardial biopsies, which would enable faster, more accurate, and objective identification from ACR, and the potential to apply the model’s ability to detect other diseases based on lymphocytic infiltration in the future. Methods including using ImageJ’s Trainable Weka Segmentation to analyze biopsy samples following heart transplant stained with H&E and standardized with a similar lymphocyte size. The primary task for the model was to identify clusters of lymphocytes, defined as ‘a cluster of over 3 blue-staining naked nuclei’. Classes included red for lymphocyte clusters, and green for ‘not-lymphocyte-clusters’. Model will be tested across new images to analyze the accuracy of detection. Preliminary outcomes include training across 7 samples, and 9 iterations of development for the model. Next steps include testing the model across 7-10 new biopsy slides, and comparing the identification across areas of manually-identified lymphocytic infiltration (the current gold standard).

AI-Driven Detection of Acute Cellular Rejection in Post-Heart Transplant Allograft Patients

Background: Traumatic brain injury (TBI) causes substantial morbidity and long-term neuropsychiatric sequelae. Bacterial meningitis may worsen outcomes after TBI, yet its mental-health impact is undercharacterized. This study examined 90-day neuropsychiatric outcomes following post-traumatic meningitis. 

Methods: We performed a retrospective cohort study using the TriNetX Global Collaborative Network. Two propensity-matched cohorts were assembled: severe TBI with subsequent bacterial meningitis and severe TBI without meningitis (2,977 patients each). Outcomes included post-concussional syndrome, amnesia, altered mental status, depressive episodes, anxiety disorders, and non-psychotic mental disorders. We estimated risks, risk ratios, and odds ratios, and generated Kaplan–Meier survival curves and instance-based frequency analyses. 

Results: Compared with TBI without meningitis, post-traumatic meningitis was associated with higher risk of amnesia (RR 2.65), altered mental status (RR 5.32), depressive episodes (RR 2.12), and anxiety (RR 2.05). Post-concussional syndrome risk was lower (RR 0.41). No difference was observed for non-psychotic mental disorders. Kaplan–Meier analyses showed significantly lower symptom-free probabilities for most outcomes. 

Conclusion: Post-traumatic bacterial meningitis substantially increases early neuropsychiatric complications after severe TBI, highlighting the need for proactive psychiatric evaluation, neurocognitive monitoring, and tailored rehabilitation in this high-risk population. Findings support early infection prevention and integrated neurocritical care pathways implementation.


Post Traumatic Meningitis Outcomes and Incidences on Mental Health

Background 
Postpartum musculoskeletal (MSK) pain is a common morbidity associated with biomechanical, hormonal, and caregiving demands. While most research focuses on pain within the first 6 months postpartum, chronic MSK pain is underexplored. Sarcopenic obesity, characterized by excess adiposity with low muscle mass, has been linked to chronic pain in older adults but is poorly studied in postpartum women. This study used real-world data to assess whether sarcopenic obesity increases the risk of persistent MSK pain following childbirth. 


Methods 
A retrospective cohort study was conducted using the TriNetX database to identify women aged 18–45 with documented deliveries. Two cohorts were formed based on the presence or absence of sarcopenic obesity diagnosed prior to pregnancy. The primary outcome was MSK pain up to 5 years postpartum. Propensity score matching was used to adjust for clinical and demographic factors. Kaplan–Meier survival curves and log-rank tests were used to assess time to event. A sensitivity analysis excluded those with MSK pain prior to delivery. 


Results 
After matching, 1,202 women were included in each group. MSK pain occurred in 66.1% of women with sarcopenic obesity versus 52.1% of controls (p<.001; OR=1.80, 95% CI 1.53–2.12; log-rank p<.001). In the sensitivity analysis, 40.7% of 91 women with sarcopenic obesity experienced MSK pain vs. 18.8% of 96 controls (p=.001; OR=2.97, 95% CI 1.53–5.75; log-rank p=0.058). 


Conclusion 
Pre-pregnancy sarcopenic obesity was associated with significantly increased risk of persistent postpartum MSK pain. These findings highlight it as a potential modifiable risk factor requiring further research. 



Sarcopenic Obesity and the Risk of Persistent Postpartum Musculoskeletal Pain: A TriNetX Based Study

Background: Patients with bone metastases bear poor prognosis. For surgically indicated patients, orthopedic interventions range from long-term reconstruction to short-term palliative stabilization. For both the patient and the orthopedic oncologist, survival estimates are crucial to guide decision making into which surgical intervention is best. To improve existing survival models, new methods of differentiating survival are needed. Despite the known contribution of cytokines and chemokines in the development and progression of bone metastases, few studies have examined the relationship between the concentrations of these immune signatures and survival in this population. The objective of this study was to examine the prognostic value of immune signatures in patients treated surgically for bone metastases.

Methods: A 35-plex cytokine panel was performed on serum from 173 patients prior to surgical intervention for bone metastases. Univariable analyses were performed between overall survival (OS) from time of surgery with lymph node and visceral metastases, solitary versus multiple bone metastases, and each serum marker using Cox proportional hazards models. Logistic regression models for three-month survival were used to assess the short-term prognostic capabilities of circulating cytokines and chemokines.

Results: The median age at surgery was 63 years (IQR 54 – 69). 58% of patients were female. The most common primary malignancies were lung (23.7%), breast (18.5%), and renal (17.9%). Concentrations of circulating cytokines and chemokines were not significantly associated with 3-month survival or OS. Median survival was 1.1 years (IQR 0.70, 1.4). Patients with lymph node (hazard ratio [HR] 2.05, 95% confidence interval [CI] 1.45, 2.88; p < 0.001) or visceral metastases (HR 2.04, 95% CI 1.41, 2.95; p <0.001) had significantly shorter OS. Having multiple bone metastases was not associated with worse OS (HR 1.40, 95% CI 0.96, 2.03; p = 0.08).

Conclusion: Patients with bone metastases have poor prognosis overall, with lymph node and visceral metastases associating with shorter survival. Our analyses did not reveal associations between concentrations of circulating cytokines and chemokines with survival. We hypothesize this is due to the redundant function of our immune system’s cytokines and chemokines, rendering individual markers non-prognostic. Future work is needed elucidate the clinical impact these immune markers hold in the setting of bone metastases.

Can Circulating Immune Signatures Predict Post-Op Survival in Patients with Bone Metastases?

Background
Perinatal hypoxic brain injury, commonly referred to as hypoxic-ischemic encephalopathy (HIE), is a birth complication with high rates of morbidity and mortality. Despite ongoing research, there is still significant variation in methods of describing and diagnosing affected infants, which has also contributed to variation in treatment. In this systematic review, we aimed to describe the variability in terminology and subsequent impact on diagnosis, description, and treatment of perinatal hypoxic brain injury as demonstrated by relevant studies published between 2000 and 2024.

Methods
Initial searches of EMBASE and MEDLINE databases returned 1073 results. Studies were excluded if they were not in English, were secondary analyses, included data from an already-included research collaboration, used animal models, focused on non-infant populations, or lacked clearly defined inclusion/exclusion criteria. Ultimately, 245 studies published between 2000 and 2024 were reviewed for study design, country of origin, terminology used, and inclusion/exclusion criteria.

Results
This systematic review included 245 studies from 6 continents and 49 countries. Of these, 138 (56.3%) studies were single center prospective, and 89 (36.3%) studies were multi-center prospective with the remaining 11 (6.5%) studies being retrospective. The total number of injured infants included per study ranged from 4 to 3095 (mean 105). There was considerable variation in the primary term used to describe the hypoxic injury (59.2% HIE, 30.6% asphyxia, 8.6% neonatal encephalopathy, 0.8% asphyxia encephalopathy) with 66.5% of studies including a secondary term. Inclusion criteria varied notably. Though the actual values used for cutoffs varied, commonly used criteria were minimum gestational age (89.4% of studies), need for resuscitation (57.6%), cord pH (56.3%), and modified Sarnat scoring (55.9%). There were varying categories of exclusion criteria including congenital anomalies (73.5%), postnatal age >6 hours at enrollment (26.5%), chromosomal abnormalities (25.7%), metabolic abnormalities (17.1%), congenital infection (16.3%), and imminent death (12.7%).

Conclusion
The goal of this systematic review was to demonstrate the significant variation in description, definition, and management of perinatal hypoxic brain injury. Primary terminology and inclusion criteria notably varied across studies. Our findings highlight a critical gap in consensus as far as primary terminology and inclusion criteria, leading to confusion and ambiguity in both clinical and research settings. Future efforts should focus on standardizing definitions along with inclusion and exclusion criteria in order to allow for greater generalizability, targeted research, and enhanced clinical care of patients with this diagnosis.

Defining Perinatal Hypoxic Brain Injury: A Systematic Review of Variability in Diagnosis and Terminology

Background
Infective endocarditis (IE) stems from bacterial adhesions to vascular endothelium or valve leaflets, and if untreated can result in pseudoaneurysm (PSA) or abscess formation in the aortic root. Risk factors for IE include congenital heart defect, injection drug use, and prosthetic valves. PSA/abscess can increase the risk for conduction abnormalities and systemic embolization, along with additional procedural challenges. This study aims to evaluate the differences in procedural choice and surgical outcomes of patients with aortic valve endocarditis with and without PSA or abscess. 

Methods
From 2019-2025, 110 patients at a single institution underwent surgical management of aortic valve IE. Patients were grouped based on the presence or absence of aortic root PSA/abscess intraoperatively, (PSA/abscess group n=57, No PSA/abscess group n=53). Data were analyzed using R statistical analysis software: continuous variables were compared using the Wilcoxon-Mann-Whitney test, categorical variables were compared using the Chi-squared test or Fisher’s exact test and Kaplan-Meier survival analysis was performed using the survival package. A p-value of less than 0.05 was considered statistically significant. 

Results
The PSA/abscess group had a significantly higher rate of prior myocardial infarction compared to the no PSA/abscess group (35.1% vs. 17.0% respectively, p=0.031). The PSA/abscess group had a higher rate of positive cultures for coagulase negative staph (17.9%) than the no PSA/abscess group (1.9%, p=0.003). The groups had no other significant differences in pre-operative characteristics. Operative results showed the PSA/abscess group more frequently underwent Bentall (43.9%) and commando (17.5%) procedures compared to the no PSA/abscess group (13.2%, 1.9%, p=<0.001). Peri-operative outcomes of median cardiopulmonary and cross clamp times, new hemodialysis requirement, post-operative pacemaker placement, prolonged inotrope need, and ICU length of stay were all significantly higher in the PSA/abscess group. There was no difference in in-hospital mortality between groups (p=0.061). Median follow-up of the cohort was 311 days (66, 890). There were no significant differences between the groups in valve-related reinterventions, ventricular function, recurrent IE or all-cause mortality. 

Conclusion
Management of IE with aortic root PSA/abscess remains a common challenge compared to IE without PSA/abscess. Patients with PSA/abscess more commonly experienced peri-operative hemodialysis requirement, permanent pacemaker placement, prolonged inotrope need, and longer ICU length of stay. There were no significant differences between groups in survival or repeat endocarditis during follow-up, although there was a trend towards increased risk of in-hospital mortality in the PSA/abscess group. Larger studies are needed to better elucidate perioperative risk associated with both complicated and uncomplicated aortic valve endocarditis.

Outcomes of Surgical Management of Aortic Valve Endocarditis With and Without
Pseudoaneurysm

Title:
Double Trouble, One Solution: Valve-in-Valve TAVR Corrects Both Aortic and Mitral Valve in a Complex Dual-Valve Pathology

Background:
Bioprosthetic valve degeneration, particularly involving the Trifecta surgical aortic valve, has become an increasingly recognized clinical challenge due to its propensity for early structural valve deterioration and failure. Severe aortic regurgitation (AR) resulting from immobile or flail valve leaflets often presents with complex hemodynamic consequences, including functional mitral stenosis—a condition also known as pseudo-mitral stenosis. This phenomenon occurs when the regurgitant aortic jet impinges upon the anterior mitral leaflet, restricting its motion and creating an obstruction to diastolic mitral inflow. Clinically, this manifests as an Austin Flint murmur and may mimic organic mitral valve disease, complicating diagnosis. Distinguishing functional mitral stenosis from intrinsic mitral pathology is critical because the treatment focus should be on correcting the primary aortic valve lesion. Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has emerged as a less invasive, effective alternative to redo surgical valve replacement in patients with degenerated bioprosthetic valves who are at elevated surgical risk.
Case Presentation:
We report the case of an 84-year-old male with a history of a Trifecta bioprosthetic aortic valve replacement who presented with progressive exertional dyspnea, orthopnea, and acute hypoxic respiratory failure. Initial transthoracic and transesophageal echocardiography revealed severe eccentric AR due to an immobile bioprosthetic leaflet, accompanied by severe functional mitral stenosis characterized by a markedly elevated mean mitral valve gradient of 17 mmHg and reduced mitral valve area, despite structurally normal mitral leaflets. Right and left heart catheterization demonstrated elevated left atrial and pulmonary pressures, consistent with the dual-valve pathology. The patient’s comorbidities—including chronic kidney disease, severe obstructive sleep apnea, prior cerebrovascular accident with residual deficits, and frailty—rendered him high-risk for conventional redo surgery. After multidisciplinary evaluation, the patient underwent a transfemoral ViV-TAVR using a 23 mm Edwards SAPIEN Ultra valve with prophylactic coronary protection. Post-procedure imaging confirmed successful valve deployment with complete resolution of aortic regurgitation and significant reduction in mitral valve gradient to 6 mmHg. Mitral valve mobility and effective valve area improved, demonstrating reversal of functional mitral stenosis.
Discussion:
This case highlights the intricate pathophysiology of functional mitral stenosis secondary to severe AR caused by bioprosthetic valve degeneration. The findings underscore the importance of thorough echocardiographic and hemodynamic evaluation to differentiate pseudo-mitral stenosis from primary mitral valve disease. Correction of the aortic valve pathology alone can restore mitral valve function, obviating the need for direct mitral intervention. ViV-TAVR offers a safe and effective minimally invasive treatment option for high-risk patients with complex dual-valve dysfunction. Comprehensive pre-procedural imaging, including transthoracic and transesophageal echocardiography and computed tomography, is essential for accurate diagnosis and procedural planning, especially to mitigate risks such as coronary obstruction. This case adds to the growing evidence supporting ViV-TAVR in managing complex valvular heart disease and emphasizes the clinical relevance of recognizing the Austin Flint phenomenon in patients with severe aortic insufficiency.



Double Trouble, One Solution: Valve-in-Valve TAVR Corrects Both Aortic and Mitral Valve in a Complex Dual-Valve Pathology



Abstract Title 

Hepatosplenomegaly in Syphilis: An Unusual Association in Adults 

Background 

Hepatosplenomegaly is an uncommon manifestation of syphilis in adults; although, it is well recognized in pediatric population. Syphilitic hepatitis commonly presents with rash, abdominal pain, hepatomegaly, fatigue, and jaundice. It is less commonly associated with splenomegaly. We describe a case of a young female who was found to have hepatosplenomegaly and was diagnosed with syphilis of unclear duration on further evaluation. She was noted to have complete resolution of hepatosplenomegaly after completing the treatment for syphilis with no major adverse outcomes. 

Case Presentation 

A 28-year-old female with medical history significant for orolabial and genital Herpes simplex virus presents with 1-week history of macular palmar lesions of the right hand and a pruritic rash to bilateral upper extremities and abdomen. She also has associated sore throat, fever, nasal congestion, right upper quadrant abdominal pain and malaise ongoing for the same duration. Vitals were stable except mild tachycardia. Physical exam revealed posterior oropharyngeal erythema and a rash involving abdomen, bilateral palms, and upper extremities. Lab work revealed leukopenia with white cell count of 3.6 K/uL, hemoglobin 11.2 g/dL, and platelet count 189 K/uL. Liver enzymes were elevated with alkaline phosphatase 409 U/L, aspartate transaminase 162 U/L, and alanine transaminase 279 U/L. Ultrasound (US) abdomen was significant for hepatosplenomegaly. Evaluation for chlamydia, gonorrhea, group A streptococcus, COVID-19, influenza, respiratory syncytial virus, human immunodeficiency virus, hepatitis A, hepatitis B, hepatitis C, infectious mononucleosis, tuberculosis, toxoplasma, bartonella, and histoplasma were negative. The Treponema pallidum agglutination assay resulted reactive with rapid plasma reagin titer of 1:64. She was treated for early syphilis and prescribed doxycycline for 14 days. She was also referred to infectious diseases and hematology/oncology. An ultrasound guided liver biopsy revealed mild portal and lobular inflammation. After the course of doxycycline, liver enzymes trended down along with resolution of the right upper quadrant pain. Three months later, repeat rapid plasma reagin titer improved to 1:2, liver enzymes normalized, and computed tomography of the abdomen and pelvis revealed complete resolution of hepatosplenomegaly. 



Discussion 

Antibiotics are effective in most cases of syphilitic hepatitis; however, some cases that do not respond to antibiotics can lead to liver failure. Spontaneous resolution of hepatomegaly has also been described. This case demonstrates a rare association of hepatosplenomegaly with syphilis in adults and the importance of considering syphilis in the differential diagnoses of hepatomegaly/hepatitis. It also highlights the value of timely diagnosis resulting in successful treatment with good outcomes.

Hepatosplenomegaly in Syphilis: An Unusual Association in Adults

Abstract Title: Cracking the Code Early: Type I PPB as the First Sign of DICER1 Syndrome in Infancy

Background
The DICER1 gene encodes an endoribonuclease essential for microRNA (miRNA) processing, a key element of post-transcriptional gene regulation. Germline mutations in DICER1 cause a rare autosomal dominant tumor predisposition syndrome, predisposing individuals—primarily children and young adults—to a spectrum of neoplasms. Tumorigenesis typically involves a germline loss-of-function mutation followed by a somatic “hotspot” mutation in the RNase IIIb domain, impairing miRNA maturation and dysregulating gene expression.

Pleuropulmonary blastoma (PPB) is a hallmark tumor of this syndrome and often represents the initial clinical manifestation. PPB progresses histologically from cystic (Type I) to solid (Type III) forms, with earlier stages associated with better outcomes. DICER1-associated tumors may show primitive mesenchymal features and various differentiations, including rhabdomyoblastic or cartilaginous elements. Due to the syndrome’s multi-organ involvement—including the lungs, kidneys, thyroid, ovaries, and brain—early detection and genetic testing are vital in initiating timely treatment and identifying at-risk family members, including asymptomatic carriers.

Case Presentation
A 1-month-old male presented to his primary care physician with respiratory distress. Chest X-ray identified a left lower lung mass, prompting PICU admission and subsequent lobectomy. Postoperative recovery was smooth. Pathologic review raised suspicion for Type I PPB, with some inconclusive areas suggesting early Type II. Referral to the International PPB/DICER1 Registry confirmed Type I PPB. Genetic testing via next-generation sequencing revealed pathogenic DICER1 variants: c.3630del in exon 21 and c.5438A>G in exon 25, confirming a diagnosis of DICER1 tumor predisposition syndrome. The patient continues to be followed by pediatric oncology and genetics. Plans are underway for long-term surveillance and genetic counseling for first-degree relatives.

Discussion
This case highlights the importance of recognizing hereditary cancer syndromes like DICER1. This patient was diagnosed unusually early at 1 month—well before the typical 2–3 years for Type I PPB—it underscores the need for timely imaging in infants with unexplained respiratory symptoms. Early detection is key, as lower-grade lesions may be cured with surgery before progressing to more aggressive types.

The discovery of pathogenic DICER1 mutations transformed the clinical focus to lifelong surveillance for associated tumors and risk assessment for relatives. Although targeted therapies are lacking, identifying DICER1 syndrome early allows for multidisciplinary care that can improve outcomes and reduce morbidity. For clinicians, maintaining a high index of suspicion for DICER1 syndrome in the presence of early-onset, cystic, or rare tumors is key to improving outcomes and reducing the burden of undiagnosed familial cancer syndromes.

Cracking the Code Early: Type I PPB as the First Sign of DICER1 Syndrome in Infancy

Background: Each year, ~50,000 applicants register for the National Resident Matching Program, ~9% of whom are lesbian, gay, bisexual, or queer (LGBQ). These students face high rates of mistreatment and discrimination within and beyond medical school, as anti-LGBTQ+ legislation has been increasingly introduced across the country. 
Methods: Data from the Electronic Residency Application Service and Graduation Questionnaire included 151,772 applicants from 2017-2024. Each U.S. state was categorized using the Human Rights Campaign’s State Equality Index (SEI), an annual assessment of law and policy impacting LGBTQ+ equality, from states with strong, broad legal protections (SEI 1) to those without fundamental protections (SEI 4). To assess applicant behavior in relation to state policy environments, the proportion of applications submitted by each applicant to states in each SEI Tier were calculated. For example, if a student applied to 5 programs, 2 of which were in SEI 1, the proportion of SEI 1 applications would be 0.4. 
Results: LGBQ residency applicants submitted more of their applications to programs in states with strong legal protections for their community (SEI 1 and 2) than their non-LGBQ peers and submitted fewer of their applications to states without fundamental protections or with active bans (SEI 3 and 4). 
LGBQ applicants submitted a higher proportion of applications (Mean: 0.46, SD: 0.23) to states in SEI Tier 1 than non-LGBQ applicants (Mean: 0.40, SD: 0.24), t(144897) = -27.15, p = 0.0000, and a higher proportion of applications (Mean: 0.22, SD: 0.19) to states in SEI Tier 2 than non-LGBQ applicants (Mean: 0.20, SD: 0.19), t(144897) = -14.46, p = 0.0000.
LGBQ applicants submitted a lower proportion of applications (Mean: 0.12, SD: 0.16) to states in SEI Tier 3 than non-LGBQ applicants (Mean: 0.14, SD: 0.17), t(144897) = 12.24, p = 0.0000, and a lower proportion of their applications (Mean: 0.20, SD: 0.18) to states in SEI Tier 4 than non-LGBQ applicants (Mean: 0.26, SD: 0.22), t(144897) = 32.4209, p = 0.0000.
Summary: 
Our findings indicate that, from 2017-2024, LGBQ residency applicants submitted higher proportions of their applications to programs in states with strong legislative protections for their community when compared to their non-LGBQ peers. If anti-LGBTQ+ legislation continues to escalate, residency programs in states with weaker protections may see a decline in applications from this community, possibly creating less diverse residency programs and limiting chances for LGBTQ+ patients in these states to receive care from a physician who shares their identity.

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