United States

Background: Cytokine Release Syndrome (CRS) is an acute inflammatory response syndrome marked by fever and/or multiorgan dysfunction and increased inflammatory cytokine release. CRS is generally observed in patients receiving CAR-T cell therapy, bispecific T cell engager therapy, or haploidentical hematopoietic cell transplantation. We present an intriguing case of Grade-3 CRS in a patient who recently contracted COVID-19 and was taking pembrolizumab.

Case Presentation: A 67-year-old man presented to the hospital with complaints of nausea, vomiting, diarrhea, and fever for two weeks. His family reported intermittent confusion, anorexia, and weight loss before hospital admission. Medical history was significant for metastatic renal cell carcinoma on pembrolizumab with axitinib for one year, CKD stage 3A, hypertension, left-sided nephrectomy, and recent COVID-19 infection four weeks ago. Physical examination revealed fever, tachycardia, tachypnea, and delirium. He was initially treated for severe sepsis with broad-spectrum antibiotic therapy but subsequently transferred to ICU for hypotension, and worsening delirium. Workup showed negative blood culture, urine culture, fungal culture, CSF culture, MRI brain, autoimmune connective tissue cascade, and paraneoplastic panel, albeit CRP was elevated to 239.3 mg/L. Due to worsening delirium, hypotension, and recent immunotherapy, there was clinical suspicion of CRS. Interleukin-6 level testing was ordered, and an elevated level of 1088 pg/mL was confirmed. He was given IV methyl prednisone 1 mg/kg on Day 7 of hospital admission, which improved his hypotension and minimal improvement in delirium. On Day 11, a one-time dose of tocilizumab was administered, and rapid resolution of delirium along with significant clinical improvement. After discharge, the oncology team discontinued pembrolizumab and started second-line therapy with cabozantinib.

Discussion: CRS is a frequently observed phenomenon in patients receiving CAR T-cell therapy and bispecific antibody therapies, often presenting with high fever, multiorgan failure, and elevated serum IL6 levels. Pembrolizumab is an immune checkpoint inhibitor (CPI), and several cases of CRS are reported in patients receiving this treatment. COVID-19 vaccination in patients receiving CPI therapy has been attributed to causing CRS-like symptoms in several reports. We observed a unique phenomenon in our patient who was receiving pembrolizumab for one year without side effects and presented with acute CRS after COVID-19 infection. Our literature review identified one other case of a patient presenting with acute COVID-19 infection, CRS symptoms, and colitis while receiving nivolumab/ipilimumab therapy. However, our patient had a delayed onset of CRS. Incidence of CRS is rare but has high mortality and requires prompt identification and treatment.

AMA Research Challenge 2024 

Post COVID Cytokine Release Syndrome in a Renal Cell Cancer Patient on Pembrolizumab Therapy

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AMA Research Challenge 2022

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AMA would like to thank Laurel Road for sponsoring a $10,000 grand prize for the winner of the AMA Research Challenge. Laurel Road is not involved in winner selection process. The winner will be announced on February 20, 2025 during the AMA Research Challenge finals. Payment of the grand prize will be directly from Laurel Road. See the AMA Research Challenge Official Rules for terms and conditions.

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Background: Patients with bicuspid aortic valve (BAV) experience valvular complications at an accelerated rate. While BAV is generally regarded as a benign anatomical variant, recent histological and cardiac imaging studies suggest significant hemodynamic instability in even asymptomatic BAV patients.

Case Presentation: A previously healthy 59-year-old man was referred for new-onset difficult-to-control hypertension. Echocardiography revealed a mildly calcified but well-functioning bicuspid aortic valve (BAV) and there were signs of chronically elevated left-sided heart pressures, though the patient denied any symptoms and exercise stress testing was normal. Over the next 2 years he failed multiple antihypertensive drug regimens despite proper compliance. He eventually presented to the hospital with profound hypotension and was found to have infective endocarditis complicated by a perivalvular abscess requiring mechanical aortic valve replacement (AVR). Prior to AVR, he struggled to maintain blood pressure on a 3-drug regimen and his response to atenolol reflected that of elderly patients with isolated systolic hypertension from age-related aortic stiffening. Following AVR, a dramatic improvement was observed in the patient’s blood pressure, now responsive to nebivolol monotherapy at half the previous dose, and he has remained stable at 1, 3, and 6-month follow up.

Discussion: Hemodynamic instability and ascending aorta (AAo) stiffness are intimately associated with BAV, regardless of age, valvular function, aortic diameter, or atherosclerotic plaque burden. While the exact etiology of AAo stiffening in BAV patients has not been confirmed, recent histological studies suggest a similar–but
accelerated–mechanical stress-induced phenotypic shift in vascular smooth muscle cells (VSMCs) which has previously been implicated in thoracic aortic disease and age-related aortic stiffening. Reactive deposition of extracellular matrix initially serves to dampen mechanical stress and maintain homeostasis; however this ultimately increases pulse wave velocity (PWV) and central systolic pressure, perpetuating a feedforward loop of maladaptive stiffening and increased myocardial demand. Supporting these findings are recent strain imaging studies revealing subclinical diastolic dysfunction associated with aortic stiffness in asymptomatic BAV patients. Consensus guidelines for BAV surveillance currently address aortic aneurysm detection but fail to address its likely precursor–loss of AAo distensibility due to the intrinsic hemodynamic abnormalities of BAVs. Strain imaging offers immense value for this application but is not yet widely available in clinical practice. In the meantime, assessment of PWV on doppler echocardiography may be a valuable surrogate for aortic stiffness in
BAV patients.

Resolution of Hypertension Following Replacement of a “Well-Functioning” Bicuspid Aortic Valve

Background
Adverse childhood experiences (ACEs) are traumatic events like abuse or neglect that are associated with dangerous behaviors like violence and substance abuse during adulthood. ACEs contribute to the development of chronic non-communicable diseases like cardiovascular diseases, diabetes, and mental health disorders, which collectively account for over 70% of global deaths yearly. Research on ACEs has been limited in low-to-middle-income countries, like Honduras, which is ranked 5th globally in violence and 131st out of 191 in healthcare. The lack of studies on the driving factors behind violence and health disparities in Honduras has hindered the understanding of the relationship between ACES, violence, and health outcomes. Thus, this cross-sectional study aims to assess the impact of ACEs on violence and poor health outcomes amongst Honduran university students. 

Methods
This cross-sectional study comprised randomly selected students from Universidad Nacional Autónoma de Honduras which participated in a baseline eligibility screening survey followed by three self-administered Spanish questionnaires completed from 11/01/2023 to 11/05/2023. Questionnaires included ACEs, Maudsley Violence Questionnaire (MVQ), and Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) questionnaires. The sample size of 287 Honduran University students comprised 101 males (SD=2.6) and 186 females (SD=2.6) with ages between 17-33 (M=21; SD=2.7). The relationship between ACEs and MVQ was assessed through correlation analyses (Pearson r). The relationship between ACEs or MVQ and TAPS was assessed using Spearman correlations (rho). The statistical significance was set at p<0.05.

Results
Participants completed the ACEs questionnaire, reporting experiencing 0 ACEs (14.2%), 1 ACE (12.8%), 2 ACEs (13.2%), 3 ACEs (20.2%), 4 ACEs (16.3%), 5 ACEs (9.75%), and 6+ ACEs (13.2%).

A positive correlation was observed between the number of ACEs and MVQ macho (Pearson’s r=0.16, P=0.0083). Tobacco usage showed a positive correlation with MVQ macho (rho=0.19) and total scores (rho=0.19, p-value=0.0015).
Drug usage was positively correlated with ACEs total (rho=0.12, p-value=0.0491), MVQ macho (rho=0.09, p-value=0.1327), MVQ acceptance (rho=0.12, p-value=0.0486), and MVQ total (rho=0.19, p-value=0.0014).

Medication usage showed positive correlations with total ACEs (rho=0.22, p-value=0.0001), MVQ macho (rho=0.17, p-value=0.0041), MVQ acceptance (rho=0.22, p-value=0.0002), and MVQ total (rho=0.19, p-value=0.0011).

Conclusion
This study identified a significant positive correlation between ACEs scores, MVQ scores, and TAPS scores. Over 80% of participants reported experiencing one ACE, aligning with research suggesting higher ACE scores in marginalized populations. The novelty of this research in Honduras offers insights that can inform national programs aimed at violence reduction and public health initiatives focused on preventing childhood trauma.

A Cross-Sectional Assessment of the Effects of Adverse Childhood Experiences (ACEs) on the Prevalence of Violence and Substance Abuse in Honduran University Students

Background
Female to male (FTM) and non-binary individuals assigned female at birth (transmasculine and non-binary people, or TMNB) who retain their assigned female at birth (AFAB) reproductive anatomy are recommended to have regular preventive screenings to evaluate for the risk of cervical cancer. However, evidence currently suggests that many TMNB persons have had negative experiences with pelvic exams that make them wary of visiting their current physician or of trying to find another provider. There is a need to evaluate the present barriers to care and how they can be addressed to make preventive gynecological care more accessible for this community.
Methods
We conducted a qualitative review of current literature on the TMNB OB-GYN experience and guidelines for conducting preventive reproductive care for the TMNB population.
Results
We identified several barriers to Pap smear access for the TMNB population, such as: anti-transgender discrimination within the healthcare workplace; gender dysphoria associated with the Pap smear procedure; feminine-coded environmental visuals and language in office spaces and educational materials; and insurance barriers. Some solutions were found, including developing coping strategies, administration of self-performed exams, improved healthcare professional education on the needs of the transgender population, and gender-inclusive language and visuals.
Conclusion
We recommend that the solutions recommended in the literature be implemented in both active clinics and in medical schools to enhance the accessibility of and minimize or eliminate negative experiences associated with preventive reproductive care for the transgender community.

Access to Pap smears for transgender persons assigned female at birth: a review of barriers to care and possible solutions

Background and Objectives:
Elective surgery cancellations can lead to increased costs, reduced resource utilization, and patient and surgeon dissatisfaction. The reasons for why these cancellations occur remain poorly understood, hindering interventions to prevent their occurrence. Understanding these factors is necessary to implement effective strategies to reduce cancellation rates and improve surgical care delivery. This study aimed to identify the reasons for elective surgery cancellation and how these reasons can be efficiently addressed to reduce cancellation rates.

Methods & Study Design
The study focused on the General Surgery outpatient service at Grady Memorial Hospital, affiliated with Morehouse School of Medicine. We compiled a list of all requested elective surgical cases and documented the number of cases completed versus those canceled and the reasons for cancellations. Data collection occurred from July 1, 2023, to December 29, 2023. Following the appointment of a pre-procedure coordinator, a second set of data was collected from January 1, 2024, to April 22, 2024.

The reasons for cancellations were categorized into patient-related factors (e.g., no-shows, call-in cancellations, non-adherence to NPO status, failure to stop anticoagulation, unexpected illness), surgeon-related factors, missed preoperative anesthesia visits, financial clearance issues, and unknown reasons. We applied a one-sample chi-square goodness-of-fit test to calculate the chi-square statistic for data analysis. Additionally, we conducted a cost analysis to estimate the missed revenue based on average CMS reimbursements for the respective procedures. Using the collected dataset, we extrapolated the potential missed revenue over the course of a year if current trends continued.

Results
During the first five months of the study, 48 elective cases were canceled, representing approximately 30% of the scheduled elective cases. Most of these cancellations (60%) were due to missed pre-anesthesia testing or appointments (PAT) and other patient-related factors.

Following the appointment of a surgery center scheduler to assist with elective cases, there were no missed PAT appointments during the second data collection period in 2024. However, patient-related factors still accounted for most cancellations in 2024, constituting 69.2%.

Cancellations were also categorized as "intervenable" versus "non-intervenable" to evaluate the impact of system-wide deficits. Notably, 66% of the canceled cases were due to "intervenable" reasons, such as patients not showing up for scheduled pre-anesthesia testing because they were unaware of the appointments.

For the first data set, the calculated chi-square value (χ²) was 18.750, greater than the critical value of 15.09 for a degree of freedom (df) of 5, with p = 0.002. The chi-square value for the second data set was 28.462, exceeding the critical value of 11.34 for a degree of freedom (df) of 3, with p < 0.001. 


Conclusions
Since the calculated chi-square values exceed the critical values in both instances, we reject the null hypothesis (H₀), which posits that the observed proportions of surgery cancellations due to different factors are consistent with the expected proportions. This indicates that the observed proportions of surgery cancellations due to multiple dependent factors are inconsistent with the expected proportions, and the findings are statistically significant, not attributable to random chance.

The reasons for surgery cancellations differ significantly from the expected patterns based on the sample data. However, there remains a gap in the system for keeping patients informed about their pre-operative appointments and the overall pre-operative process after scheduling elective surgery. A dedicated outpatient surgery coordinator could help bridge this gap by facilitating more frequent and direct communication between patients and providers, potentially increasing the number of completed scheduled surgeries. Nonetheless, non-intervenable reasons for cancellations, such as unannounced no-shows and new onset medical conditions, will persist as challenges in elective surgery care due to their unpredictable nature and lack of easily identifiable solutions.

Analyzing Factors Contributing to Elective Surgery Cancellations: A One-Sample Chi-Square Test Approach

Background: 
Recent studies indicate an association between pancreatitis and cardiovascular disease. However, research regarding the association between atrial fibrillation (AF) and acute pancreatitis (AP) is limited. To address this gap and test our hypothesis that AF exacerbates mortality and clinical outcomes in patients with AP, we conducted a retrospective cohort study using the extensive multi-institutional research network, TriNetX.

Methods: 
De-identified patient data from the US Collaborative Network in TriNetX was used to assess the risk of all-cause mortality in AP patients with AF compared to those without AF within 30 days of the index event from January 1, 2010 to July 6, 2024. Secondary outcomes included critical care services, acute kidney injury (AKI), deep vein thrombosis (DVT), acute respiratory distress syndrome (ARDS), hemorrhage, systemic inflammatory response syndrome (SIRS), and severe sepsis within 30 days of the index event. Analyses were performed before and after propensity score matching, with risks expressed as odds ratios (OR) with 95% confidence intervals (95% CI), and Kaplan-Meier curves were generated for outcomes.

Results: 
A total of 267,429 patients with AP were identified, of whom 44,621 had a diagnosis of AF. Patients in the AP with AF cohort, predominantly older males of White and Native Hawaiian or Other Pacific Islander ethnicity, presented with higher comorbidity burdens compared to the non-AF cohort before propensity score matching. After matching, the AF cohort exhibited increased risks of all-cause mortality (OR, 1.24; 95% CI 1.18-1.3), AKI (OR, 1.17; 95% CI 1.14-1.2), DVT (OR, 1.33; 95% CI 1.27-1.39), hemorrhage (OR, 1.06; 95% CI 1.01-1.11), ARDS (OR, 1.4; 95% CI 1.27-1.54), SIRS (OR, 1.12; 95% CI 1.03-1.22), severe sepsis (OR, 1.3; 95% CI 1.25-1.35,), and requiring critical care services (OR, 1.19; 95% CI 1.16-1.23) compared to the non-AF cohort. Kaplan-Meier survival analysis demonstrated significantly lower 30-day survival probabilities for all-cause mortality, ICU level of care, AKI, DVT, and hemmorrhage in the AF cohort compared to patients without AF, while similar survival probabilities were observed for ARDS and SIRS between the two cohorts.

Conclusion: 
Our results suggest that AF significantly increases the risk of mortality in patients with AP, even after accounting for confounding etiological, comorbid, and pharmacological factors. Patients with AP and AF are also at greater risk of worse clinical outcomes.

Atrial Fibrillation and the Risk of Adverse Events and Mortality in Adults with Acute Pancreatitis: A Propensity-Score Matched Analysis

Introduction: Obesity is associated with a number of comorbidities which deteriorate health status and are costly to manage. We are interested in assessing the cost-effectiveness of the two most common bariatric procedures, the sleeve gastrectomy, and roux-en-y gastric bypass (RYGB) for reducing comorbidity rates and costs. With the entry of new weight-loss medications to market, this long-term data will serve as a benchmark to compare therapies as outcome data become available.

Methods: A meta-analysis was submitted to PROSPERO and performed utilizing Ovid Medline. A total of 53 articles were identified which met quality and inclusion criteria. Data were extracted for a total of 113,762 patients. Utility values, procedural and annual comorbidity cost data were extracted from literature and adjusted for inflation. A cost-utility analysis model was constructed for each of these data trends, to a maximal of 20-years post-operatively.

Results: At 10 years post-RYGB or sleeve, patients had significant and sustained BMI decreases of 15.9 and 11.1 points respectively as compared to 1.3 points for mixed medical/diet control. RYGB data at 20 years, demonstrated a sustained decrease of 17.8 points, compared to control at 1.9. At 10 years RYGB patients had a 12.3% reduction in DM, sleeve a 10.5% reduction, compared to a 12.8% increase in the control group. At 12 years, DM prevalence in RYGB was decreased by 14.9% whereas the control group had increased by 16.1%. At 10 years there was a net-positive cost of $946 for RYGB and $7,623 for sleeve, with QALY gain of 1.04 and 0.74 and ICER of $909/QALY and $10,262/QALY respectively. BMI and DM data were available for RYGB at 12 years, where a net cost-savings for RYGB of $6,129 per patient and 1.28 utility gain was observed.

Conclusion: While bariatric surgery may be viewed as having a high initial cost, this study demonstrates that these procedures are not only cost-effective, they are cost sparing. At 10 years this study demonstrates ICER at $909/QALY for RYGB and $10,262/QALY for sleeve gastrectomy, qualifying them as extremely cost-effective procedures. At the 12-year mark, RYGB was cost negative with a net savings of $6,129 per patient. In addition to these cost-savings, both procedures demonstrate a major reduction in type 2 diabetes and BMI, which cannot be overstated for the unquantified subjective impact on quality of life. Future work will include addition of other comorbidities and the impact of complications of both medical and surgical therapy.


Cost Utility Analysis of Long-Term Outcomes of Bariatric Surgery as Compared to Medical Therapy for Obesity Management

Abstract Title:
Enhancing Continuity of Care in Outpatient Setting: A Quality Improvement Initiative

Background:
Continuity of care is the process of ensuring high-quality care over time through a continuous, long-term relationship between patients and physicians. When patients receive consistent care from the same healthcare provider, it enhances the provider’s understanding of the patient’s medical history and preferences, leading to better communication, enhanced trust, thus fostering strong doctor-patient relationships. This continuity was documented to reduce healthcare costs, improve medication adherence and patient satisfaction. Residency programs in internal medicine are required to create a continuous relationship between residents and a panel of patients. However, maintaining continuity can be challenging due to limited time and availability of residents, as well as scheduling issues. 

Methods:
We aimed to improve continuity of care by at least 50% at Federally Qualified Health Center (FQHC) of our hospital during the period of September to December 2023. Interventions include: 1. Educating residents on the importance of continuity of care through presentations and posters. 2. Preparing the annual resident schedule in advance to facilitate appropriate follow-up scheduling. 3. Confirming patient availability to ensure clinic visits on agreed dates. 4. Coordinating with support staff involved in setting up appointments by providing them access to the annual resident schedule. 

Results:
During the specified period, a total of 313 patients were seen in the clinic who met the inclusion criteria, with 184 (58.8%) of them being females. The mean age of the group was 48.9 (14.8) years. Out of 151 patients in the pre-intervention group, 13.9% (21) were followed by the same physician during their visits. This figure increased to 26.5% (43 among the 162 patients) in the post-intervention group. This disparity was statistically significant, with a p-value of 0.006. There were no notable differences in gender or age between the two groups (p-value > 0.05). Resident survey: All the residents (100%) emphasized the extreme importance of continuity of care. 68% of the residents have observed patients requesting to be seen by the same physician during their clinic visits. When asked how they would perceive patient satisfaction levels post-intervention, 75% of them found that patients were more satisfied.

Conclusion:
Our project resulted in increasing in the continuity of care from 13.9% to 26.5%, which was statistically significant. A physician-led, team-based approach to healthcare along with targeted interventions can facilitate continuity of care, reducing fragmentation of care and improving patient health care quality and patients’ satisfaction.


Enhancing Continuity of Care in Outpatient Setting: A Quality Improvement Initiative

Background
The extreme scarcity of donor hearts limits the availability of heart transplantation. Patients from vulnerable communities are disproportionately impacted. Social determinants of health (SDoH) are often quantified using place-based disadvantage indices. In this study, we apply place-based disadvantage indices and evaluate their relationship with heart transplant waitlist outcomes. 
Methods
We studied all adult heart-only transplant candidates initially listed between January 1, 2019 and December 31, 2022. Four indicies were compared: SVM, SVI, ADI, and DCI. Covariates included demographic characteristics, VADs, total artificial heart, and initial status (1-6).
The primary event of interest was heart transplantation. Candidate death or removal from the waitlist due to deterioration served as a competing event. For each index, we performed a competing risk regression with indices split by decile (categorical variable) and all covariates. We also performed competing risk regressions stratified by the transplant center where each candidate was waitlisted.
Results
Our final study cohort included 16,639 adult heart transplant candidates. Candidates in the 10th SVM decile were significantly less likely to receive transplantation than candidates in the 1st decile (sub-HR=0.84, p<0.001). Candidates in the 4th, 7th, and 9th SVI decile were significantly less likely to be transplanted (9th: sub-HR=0.82, p=0.034). Candidates in the 4th through 10th ADI decile were significantly less likely to be transplanted (10th: sub-HR=0.73, p<0.001). Candidates in the 3rd and 10th DCI decile were less likely to receive a transplant (10th: sub-HR=0.87, p=0.006).
When stratifying by transplant center, we found that SVM decile did not significantly predict a candidate’s likelihood of receiving a transplant. For SVI, candidates in every SVI decile (2nd – 10th) were significantly less likely to receive a transplant than candidates in the 1st SVI decile (10th decile: sub-HR = 0.79, p=0.035). For ADI, candidates in the 9th decile were significantly less likely to receive a transplant than patients in the 1st ADI decile (sub-HR = 0.86, p=0.025). For DCI, candidates in the 3rd decile were significantly less likely to receive a transplant than patients in the 1st DCI decile (sub-HR = 0.91, p=0.048).
Conclusion
All four indices showed an association with a candidate’s likelihood of transplantation, with significant variability between the indices. These findings highlight the relationship between neighborhood vulnerability and access to transplant, and the importance of investigating more deeply how best to correct for this obstacle to equitable distribution in the forthcoming continuous distribution heart allocation framework.

Evaluating Place-Based Disadvantage Indices in Heart Transplantation

Background: Although safety net coverage programs like Medicaid exist to fund health care for low-income patients, the administrative burden of the lengthy application limits uptake by eligible individuals. Therefore, many patients do not attempt to enroll until they become ill, which is common among uninsured adults diagnosed with cancer. Further, key groups, including many non-citizen immigrants (~8% of the US population), are not eligible for Medicaid, and must be covered by local charity care programs. The literature reports worse cancer outcomes for those with Medicaid, but reasons for this are unclear. The delays in enrollment for patients with uncertain coverage at the time of diagnosis – those in limbo – are understudied and may explain some of this persisting disparity. 

Objective: We estimated the patient and health system burdens for those with uncertain coverage status at the time of cancer diagnosis at Parkland Health, the main provider of cancer treatment for the uninsured in Dallas, Texas. 

Methods: We assembled the electronic health record financial encounter data of patients with an incident cancer diagnosis in the Parkland tumor registry, diagnosed from 2010 – 2022. We defined patients as being “in limbo” if they had self-pay, pending, or missing insurance plans at the date of diagnosis. We also included patients whose coverage verification date occurred after diagnosis date, since coverage programs can apply retroactively for 90 days. We used plan verification dates to identify when limbo status resolved. We used coarsened exact matching to balance across age, race, Spanish-language preference, Charlson, and screenable cancer type, then multivariate regression to compare patients that were in limbo to those that had established coverage before cancer diagnosis. 

Results: We identified 17,468 adults newly diagnosed with cancer, 80% of whom were < age 65, 55% female, 73% Hispanic and/or Black, and 30% were Spanish-language preferring. The most common cancer types were GI/colorectal (19%), breast (17%), and lung (9%); 23% were advanced stage at diagnosis and 13% died within 180 days of diagnosis. 52.1% were already enrolled in Medicaid/charity care, but one-third (35%) were in limbo at diagnosis, which lasted for a median 31 days (IQR 13 – 126). Over half (55%) of patients in limbo resolved to Medicaid or charity care. Patients who experienced limbo had a median of 596 financial account notes in the first year after diagnosis, 121 more than the comparison group (95% CI 86.7 - 156.1) and began treatment 10 days later (95% CI 7.7 - 12.7). They also had a median of 1 ED visit in the year after diagnosis, 0.2 more than patients never in limbo (95% CI 0.11 - 0.26). 

Conclusions: The administrative burden of enrolling into coverage programs for the uninsured may impose direct and indirect costs on patients and safety-net health systems and may contribute to worse cancer care outcomes. A more comprehensive accounting of the effects of administrative burdens might suggest ways to redesign coverage enrollment for the uninsured to improve care and reduce costs.

Impacts of the administrative burden of establishing healthcare coverage for the uninsured​

Background: The catastrophic Crowdstrike patch failure of July 19, 2024, exposed criticalvulnerabilities in global healthcare systems, stemming from a memory safety issue in C++ code. This null pointer error, a common pitfall in languages without automatic memorymanagement, led to system-wide failures in Microsoft-based environments while GNU/Linux and Apple systems remained unaffected. This event underscores the urgent need for robust,quantum-resistant cryptographic solutions in healthcare IT infrastructure.

Methods: We developed a protocol for building and benchmarking National Institute of Standards and Technology (NIST)-endorsed classical and post-quantum encryption algorithmson-premesis, using consumer grade Linux computers to prioritize viability for underservedregions & underfunded institutions. We compiled OpenSSL with Open Quantum Safe (OQS) Clibrary to enable post-quantum encryption development that allowed the same level of accessas Crowdstrike's faulty driver code while allowing for bindings with numerous memory safeprogramming languages. Our focus on post-quantum Key Encapsulation Mechanism (KEM) encryption reflects the ubiqutious protection that these protocols provide to securecommunication and knowledge-work as well as the relative ease of hybridization with classicalencryption protocols like Elliptical Curve Diffie-Hellman (ECDH). Following on-devicecompilation and installation of the encryption binaries, we built and executed an evaluationscript with OpenSSL's native toolkit for twenty-four NIST-endorsed KEM protocols consisting ofclassical, quantum, and hybrid KEM implementations. We evaluated the KEMs on the numberand rate of key generations (keygen), key encapsulation (encap) rate, and key decapsulations(decap) and rated their NIST post-quantum security level according to NIST advancedencryption standard (AES) exaustic key search levels.

Results: We successfully benchmarked all 24 KEM protocols, producing an examplepublic/private key pair following the evaluation. The 24 KEM protocols are evenly split acrossNIST security levels 1, 3, and 5, with 8 protocols at each.We made all relevant code, regulatoryinformation, and the example cryptographic key pairs available on the Qompass AI Github page.We released them under the GNU Affero General Public License (AGPL) to maintain the freeavailability of these encryption tools to benefit communities.Conclusion: Out of the evaluated KEMs, we propose hybrid combinations of ECDH and Kyber for most acute adoption of enhanced encryption protocols due to the layered security of nascentpost-quantum encryption with established efficient classical protocols. Currently, Google Chrome implements Kyber768/X25519 hybrid encryption as part of its Transport Layer Security (TLS), offering a familiar and accessible platform to perform institutional assessements.

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