United States

Background
Texas is home to nearly 7 million people without broadband access, representing a large population unable to utilize telehealth services. Extending internet access thereby promotes health equity. Link Health is a Boston-based digital health program addressing this issue through a satellite program in Houston. Link Health helps disseminate information about federal programs such as the ACP and Lifeline, which connect eligible participants to low-cost broadband internet.

Methods
Link Health enrolls participants in-person and digitally. Ambassadors facilitate in-person enrollments through health centers and community events, discussing eligibility and applications for ACP and Lifeline. A Google Form collects participant’s demographic data. Participants are transferred to the FCC National Verifier site to complete enrollment. Digital sign-ups are completed via Link Health’s webpage or by responding to SMS messages with program information from remote ambassadors. Here, we compare enrollment across Houston and Boston to understand the populations served.

Results
Data collected in or after July 2023 were included. During this time, 800 participants were enrolled (402 in Boston; 398 in Houston). A greater proportion of participants enrolled in person in Boston (56%) than in Houston (47.2%). Proportionally more enrollees in Houston preferred to speak English (70.4%) than Spanish (28.9%) than in Boston, where the language split was more equal: 49.5% preferred English and 40.9% Spanish. A breakdown of language by sign-up method revealed a higher proportion of Spanish speakers enroll in-person rather than digitally: 78.3% of Spanish speakers in Houston and 74.4% in Boston versus 34% of English speakers in Houston and 50.2% in Boston. Racial composition of enrollees was similar across cities but not sign-up method: in Boston, 23.3% of enrollees were Black, 52.2% were Hispanic, and 14.4% were White. In Houston, 28.6% of enrollees were Black, 49.7% were Hispanic, and 13.8% were White. Across both cities in-person enrollees were 37% Black or African American, 68% Hispanic and 33% White. 

Conclusion
The Link Health Digital Equity Program has major implications in closing the digital divide beyond Boston. The disconnected population in Texas can benefit from the continuation of federal programs like the ACP and Lifeline which facilitate access to telehealth services. Maintaining in-person resources is essential to equitably serve these populations, many of whom speak Spanish and are Hispanic.

AMA Research Challenge 2024 

Assessing the Impact of Pilot Community-based Digital Equity Program in Houston

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Abstract Title
Prenatal Exposure to Tetrachloroethylene and Adverse Birth Outcomes: Systematic Review & Meta- Analysis
Background
Tetrachloroethylene (PCE) is a chemical widely used in dry cleaning, metal degreasing, and textile processing. Occupational activities and improper waste management may lead to PCE contamination in indoor air and/or drinking water. Several studies have assessed associations between prenatal exposure to PCE and adverse birth outcomes, but a comprehensive review is needed to establish the strength and quality of these results. The aim of this study was to synthesize evidence and meta-analyze the associations between prenatal exposure to PCE and specific adverse birth outcomes: spontaneous abortions, stillbirths, CNS defects, oral cleft defects, neural tube defects, birthweight, preterm birth, and small-for-gestational-age.
Methods
Search Methods
Six electronic databases were searched to identify relevant studies with no restrictions on date, publication type or geographic location. Reference lists of included studies were also hand searched.
Selection Criteria
Studies were included if they were observational studies that statistically quantified the association between PCE and the adverse birth outcomes of interest. Participants included pregnant women with infants exposed to PCE in the antenatal period. Comparator groups were unexposed. Studies in which effects of PCE were not disaggregated were excluded.
Data Collection and Analysis
Main results and study characteristics were extracted from each relevant study. Critical appraisal was performed using the Newcastle–Ottawa Scale (NOS) for case-control and cohort studies and the Agency for Healthcare Research and Quality (AHRQ) for cross-sectional studies. Risk ratios were calculated for each outcome using David Wilson’s Online Effect Size Calculator. Effect sizes were then pooled using random effects meta-analyses. Subgroup analyses by exposure pathway, country, and study design were also conducted when possible. Sensitivity to risk of bias was also conducted where possible.
Results
Eighteen studies were included. Risk of bias was high in one, moderate in seven, and low in ten studies. Meta-analyses found that prenatal PCE exposure correlated significantly with any adverse birth outcome (RR=1.16, p=0.049, I2=60%) and spontaneous abortions (RR=1.38, p < 0.01, I2=1.7%). While elevated risk ratios were found for PCE exposure and other outcomes (any congenital anomaly, stillbirths, CNS defects, oral cleft defects, neural tube defects, low birthweight, preterm birth, and small-for-gestational- age), they were not significant.
Conclusion

Overall, prenatal exposure to PCE is significantly associated with higher risk of any adverse birth outcome and spontaneous abortions. This highlights the importance of minimizing PCE through policy measures and monitoring of water and air samples. Future research should address limitations in the evidence base and potential biological mechanisms.

Association between Prenatal Exposure to Tetrachloroethylene and Adverse Birth Outcomes: Systematic Review and Meta-Analysis

Background
Previous studies reported a reduction in cardiac catheterization laboratory activations for ST-Elevation Myocardial Infarctions in the US1 and Spain2 during the early COVID-19 pandemic. We analyzed the long-term relationship between regional COVID burden and acute myocardial infarction (AMI) incidence across the US.

Methods
Monthly ACS data was drawn from the de-identified Vizient database of clinical data. Patients diagnosed with AMI (defined by ICD-10 code I.21) were drawn from 20 US hospital systems from January 2019 to June 2023. COVID-19 data were drawn from the de-identified New York Times github database of COVID-19 data. Monthly positive COVID-19 cases were drawn at the state level and then grouped within the West, Midwestern, Northeastern, Mid-Atlantic, and Southern regions. March 1, 2020 was identified as the beginning of the “after COVID” (AC) period and any prior data were identified as the “before COVID” (BC) period (January 2019 to February 2020). Spearman’s ρ assessed the association between statewide COVID-19 cases and AMI diagnoses, and was repeated with a one-month delay applied to AMI diagnoses to account for the potential lag time between COVID-19 burden and corresponding behavioral modifications. A mixed linear model with random intercepts corrected for time as a continuous variable estimated the percent change in STEMI activations in the BC versus adjusted AC (aAC) period (March 2020 to April 2021).

Results
The mean monthly AMI diagnoses was 6581.86 (SD=362.43) in the BC period and 6654.79 (SD=725.76) in the AC period. No states demonstrated a negative association between monthly COVID-19 and AMI diagnoses with all sites (ρ=0.33; 95%CI=0.016-0.59), Colorado (ρ=0.48; 95%CI=0.18-0.7), Massachusetts (ρ=0.4; 95%CI=0.09-0.64), New Hampshire (ρ=0.11; 95%CI=0.1-0.65), and Pennsylvania (ρ=0.46; 95%CI=0.15-0.68) revealing positive associations. With a one-month delay applied to ACS diagnoses, Colorado (ρ=0.53; 95%CI=0.24-0.74), Massachusetts (ρ=0.34; 95%CI=0.02-0.60), and Pennsylvania (ρ=0.37; 95%CI=0.05-0.63) demonstrated positive associations. In the mixed linear model, the percent change of regional and statewide AMI diagnoses in the aAC period was negative in the first three months compared to the BC period, albeit not reaching statistical significance.

Conclusions
No negative association was found between monthly statewide or aggregate COVID-19 burden and AMI diagnoses among, even with a one-month delay applied to AMI diagnoses. Contradicting previous studies, there was no observed reduction in AMI diagnoses across hospital systems after the start of the COVID-19 pandemic. This may reflect psychosocial factors such sedentarism, social distancing, or increased ED visits for chest pain; however, studies with more precise regional data are required to validate these results.

Association between Regional COVID-19 Burden and Acute Myocardial Infarctions in the United States

Background
Nepal has the highest mortality rate from chronic lung diseases globally. The World Bank reports that over 30 percent of Nepalese patients currently use tobacco products. Yet, the smoking epidemic is still under-researched in Nepal. This research seeks to understand the Nepalese peoples’ attitudes towards smoking, in order to develop sustainable, culturally appropriate smoking cessation programs in Nepal.

Methods
Participants were recruited from outpatient multispecialty clinics at the Tribhuvan University Teaching Hospital in July 2023. Participants (n= 250) met eligibility requirements if they were 18+ years of age and had used a tobacco product in the last 15 years. Participation was voluntary and both verbal and written consent was obtained. The 46-question survey was administered verbally using interpreters and answers were entered into data management application Qualtrics. Data analysis was conducted using R statistical analysis software, and results are reported as numbers and proportions. 

Results
Participants included 231 (92.4%) males, 18 (7.2%) females, and one participant who identified with neither (0.4%). Of the participants, 36 were 18-24 years old (14.4%), 82 were 25-39 (32.8%), 64 were 40-54 (25.6%), and 68 were 55-89 (27.2%). Approximately 69% of participants were married, and 17% did not attend any formal schooling. Peer pressure by friends or family (friends smoking by 78%, and family smoking by 21%) was given as a reason for smoking initiation, and curiosity was selected by 48% of participants. The most prevalent reason for delaying smoking initiation was lack of peer pressure (friends do not smoke (66.8%). Continued smoking was attributed to killing time (22.4%), energy and euphoria (21.2%), and dealing with anger and anxiety (18.8%) as the most popular reasons. The large number of male participants supports previous results that men are three times as likely to smoke as women. Social pressures were the most dominant factors that accounted for smoking initiation. Similarly, lack of social pressures resulted in delayed smoking initiation. Friends smoking was not offered as an option for continued smoking. Participants continuation reasoning points to stress and boredom as contributing factors.

Conclusion
The results of our cross-sectional study suggest a potential for public health interventions to reduce social pressure to smoke or introduce measures to replace the habit and decrease stress.

Attitudes Around Smoking Initiation and Cessation in Kathmandu, Nepal

Background: Refugee families (both adults and children) face numerous health inequalities, barriers, and disparities to accessing healthcare services and oftentimes present with complex medical and social needs unfamiliar to healthcare providers. It is therefore critical to analyze these health issues and healthcare requirements amongst this minoritized population. This study examines barriers to care and acculturation among refugee and underserved families with children in Roanoke, Virginia. This study aims to add to needs-assessments to enhance pediatric refugee healthcare models in Roanoke and similar resettlement areas.
Methods: A 10-item questionnaire in 2023 and an 18-item questionnaire in 2024 were administered to attendees at community events for refugee and immigrant children in Roanoke City. The survey included questions about healthcare barriers including language interpretation needs and difficulty scheduling medical appointments as well as acculturation topics, including perceived familial safety and usage of resettlement resource aid. The questionnaires were adapted from screening tools, including the Accountable Health Communities Screening Tool and the Hispanic Community Health Study Acculturation Questionnaire.
Results: 149 respondents completed the questionnaires across both years. 62.9% (2023) and 79.5% (2024) identified Spanish as their preferred language. 13.9% (2023) and 54.1% (2024) found obtaining personal transportation to medical appointments challenging. 65.8% (2024) of families did not use any local resettlement resources and 41.0% (2024) reported significant familial support during these periods. 97.2% (2024) were provided with a language interpreter during clinic and hospital visits, and 91.2% (2024) preferred a human interpreter for translation in these settings.
Conclusion: Personal transportation may not be feasible for families with financial constraints, preventing access to medical care. Familial support systems were shown to positively impact the acculturation process for these families, and there is an opportunity for community outreach to increase awareness of unused local resources to aid in resettlement. Language interpreter use may improve patient ease and understanding during medical visits. Further analysis of healthcare needs within this community emphasizes the importance of advocating for resources that assist in equitable healthcare delivery and acculturation in similar-sized resettlement communities.

Barriers in Access to Medical Care amongst Underserved Minoritized Families in Southwest Virginia

Abstract Title
Black and White Menthol Smokers’ Perceptions of the FDA’s Proposed Ban on Menthol Cigarettes 

Background
Menthol as a characterizing flavor in cigarettes is a critical public health issue due, in large part, to targeted tobacco industry marketing that has led to Black adults disproportionately using a product that is more addictive and harder to quit. Recent estimates indicate that 81% of Black adults who smoke and 34%-51% of adults who smoke in other racial/ethnic minority groups use menthol cigarettes. In April 2022, FDA announced its commitment to advance a product standard banning menthol in cigarettes and prohibiting characterizing flavors other than tobacco in cigars. To-date, no federal menthol cigarette or flavored cigar (MC/FC) product standards (commonly called ‘bans’) have been enacted, despite evidence that these actions could potentially improve public health and promote smoking cessation.

Methods
Study participants were registered workers on Amazon’s Mechanical Turk (MTurk) who opted into the study between July 2023 and January 2024. Eligible participants (n=3,200) completed a survey assessing perceptions and perceived impacts of the FDA’s proposed product standard limiting characterizing flavors in MC/FC. Eligible participants were African American/Black or White adults (> 21 years of age) who had been menthol cigarette smokers for at least one year and were using a computer with a United States IP address.

Results
There was no difference in favor/opposition to the proposed MC/FC ban with 37.2% of Black and 34.5% of White adults who smoke menthol cigarettes stating that they were in favor of the ban (p=0.13). Notably, while overall endorsement of beliefs that menthol cigarettes are more addictive, harmful, and harder to quit than non-menthol cigarettes was low overall, Black participants in this study were more likely than White participants to endorse these beliefs. A greater proportion of Black adults also demonstrated support for the FDA's proposed rationale for the product standard. Both groups were concerned that a MC/FC ban would lead to increased policing and victimization in their community (95.3% overall) and other vulnerable communities (90.9% overall).

Conclusion
Our research has produced several key findings, including identification of factors associated with support of or opposition to the ban, racial differences in perceptions of the proposed ban, determination of specific concerns related to the impact of the ban, and participant intentions for future tobacco use or cessation following the ban. This data will serve to inform the FDA’s policies on menthol flavoring and assist public health researchers in planning for best smoking cessation practices in anticipation of the proposed policy shift.



Black and White Menthol Smokers’ Perceptions of the FDA’s Proposed Ban on Menthol Cigarettes

Abstract Title
Breathing Easier: A Breath of Fresh Air in Albuterol Education

Background
Inadequate inhaler technique among patients with COPD remains a pervasive issue, with multiple studies demonstrating the alarming number of patients misinformed about proper inhaler techniques, leading to significant morbidity and impaired quality of life. Current literature has shown that up to 50% of patients utilizing albuterol have improper handling techniques. These findings underscore the critical need for effective educational interventions, considering that proper albuterol use has been correlated with decreased mortality in patients diagnosed with COPD.

Methods
In 2023, the Luke Society clinic partnered with the University of Texas Medical Branch (UTMB) School of Respiratory Care and embarked on a targeted educational program to bolster albuterol technique knowledge among patients with pulmonary conditions. The initiative aims to minimize improper albuterol techniques and ultimately decrease emergency visits stemming from COPD or asthma exacerbations. Our approach involves a thorough education tutorial on the proper
albuterol inhaler technique facilitated by the School of Health Professions (SHP) Respiratory Care faculty and Respiratory Therapy (RT) student volunteers. The RT faculty initially vets the patient’s knowledge of albuterol use and then teaches the proper technique.

Results
Over the last year, this interprofessional initiative has improved proper inhaler technique among our patient population, which primarily comprises individuals with low literacy levels and those facing homelessness. The results of this partnership highlight the importance of tailoring educational strategies to meet the unique needs of Galveston’s underserved community.

Conclusion
The ongoing challenges of enhancing albuterol technique awareness necessitate our continued interprofessional collaboration with SHP Respiratory Care. Future initiatives include developing accessible educational materials, such as pamphlets, to support patients in reinforcing proper technique between clinic visits.

Breathing Easier: A Breath of Fresh Air in Albuterol Education

This research project focuses on examining the integration of artificial intelligence (AI) into urologic practice, highlighting both its promising advancements and the substantial ethical, legal, and regulatory challenges it poses. The study emphasizes the urgent need for an adaptable regulatory framework to ensure the safe and effective deployment of AI technologies in urology. Our participation involved conducting a multifaceted investigation, consisting of a literature review, the development and administration of a comprehensive survey, and in-depth interviews with key stakeholders within the urology community. Through these phases, we evaluated the level of awareness among urologists and patients regarding AI’s risks and complexities, including patient safety, privacy concerns, and regulatory intricacies. By elucidating these issues and capturing nuanced insights into the implications of regulation and implementation of these emerging technologies, our research seeks to empower the urology community in shaping the future of AI integration in healthcare. Ultimately, our goal is to influence responsible AI adoption, foster collaboration between stakeholders, and contribute to the refinement of regulatory frameworks in urology practice.

Bridging Perspectives: Examining the Landscape of AI in Urology

Abstract Title
Bridging the Gap: Examining the Healthcare Limitations due to Latina Physician Shortage
Background
According to 2022 data, women make up 37.6% of the U.S. physician population. However, Hispanic women represent only 2.4% of medical professionals, facing significant disparities across specialties. This study examines existing literature addressing these disparities among Latina and Hispanic women physicians, focusing on key challenges contributing to their scarcity in various specialties. Addressing these issues is essential for overcoming systemic barriers and promoting diversity in medicine.
Methods
A comprehensive literature review used databases like Still OneSearch, DynaMed, Google Scholar, and PubMed. It searched for articles on "Latina physicians in specialties," "Latino or Hispanic physician underrepresentation," and "Latinas in Medicine." Filters were applied to select peer-reviewed sources published from 2018 to 2023. Studies were cited in AMA format, highlighting key findings on the underrepresentation of Latina women in medical specialties.
Results
Hispanic provider representation remains significantly low (6.9%) compared to their US population (19.1%). This underrepresentation is more pronounced among Hispanic women, who make up less than 3% of practicing physicians, medical school faculty, and matriculants as of 2019. Recent data shows a 4.5% increase in Hispanic medical matriculants between 2022 - 2023. However, barriers like discrimination, burnout, and imposter syndrome lead to higher attrition, hindering progression into residency and beyond.
Studies highlight the importance of Hispanic representation in medicine for cultural concordance and addressing implicit biases. Spanish-speaking Hispanic providers show improved outcomes in chronic disease control and patient adherence. Notably, 35.6% of Hispanic women physicians are proficient in Spanish, enhancing healthcare for Hispanic patients. The representation of Hispanic physicians varies across specialties, with primary care having the highest numbers and geriatric medicine the highest relative value at 9.4%. Studies on Hispanic women in specialties are scarce and often combine women and ethnic minorities. A 2021 study in plastic surgery from 2015-2019 showed 42.7% female but only 6.6% Hispanic representation.
Conclusion
Studies on Hispanic patient care highlight improved language proficiency, cultural empathy, and patient outcomes demonstrated by Hispanic providers. The underrepresentation of Latina physicians highlights broader issues in recruitment, inadequate support, and limited advancement opportunities within medical education and professional systems. The recent U.S. Supreme Court decision restricting race or ethnicity considerations in admissions exacerbates challenges in enhancing Latino representation in medicine, particularly in specialty fields. A lack of research on Hispanic women in specialty medicine leaves a significant gap in equitable representation and underutilized opportunities to improve healthcare outcomes for Hispanic communities.


Bridging the Gap: Examining the Healthcare Limitations due to Latina Physician Shortage

Background
Regulatory bodies such as the Joint Commission, have required health systems to screen patients for health-related social needs (HRSNs) to address social determinants of health (SDH), which influence individual and community health outcomes. Key screenings include housing instability, food insecurity, and transportation instability. 
Despite these efforts, there remains a gap in understanding the interconnections between various HRSNs. Addressing this gap is crucial for developing comprehensive interventions that target multiple SDH. This study aims to characterize the associations between key HRSNs. 

Methods
This prospective cross-sectional study at an adult urban primary care clinic from October 2021 through October 2023 saw volunteers screen patients for HRSNs: food insecurity; unemployment; less than high school education; housing instability; difficulty affording medications; and lack of access to transportation, utilities, phone, and medicine or any healthcare. Binary logistic regression determined associations between demographic factors: race, ethnicity, gender, and age and the HRSNs examined. Pearson correlation coefficients assessed linear relationships between HRSNs.

Results
Volunteers screened 2153 patients identifying 49.34% with at least one HRSN. Binary logistic regression revealed no significant association between HRSNs and patient age (p=0.260), race (p=0.889, p=0.875), Hispanic ethnicity (p=0.652), gender (p=0.319).
Pearson correlation coefficients identified significant associations: strong between food insecurity and difficulty affording utilities (r=0.447); moderate between food insecurity and difficulty accessing transportation (r=0.22), phone (r=0.286), and medicine or any healthcare (r=0.313). Housing insecurity correlated with transportation issues (r=0.200) and difficulty affording utilities with difficulty accessing medicine or any healthcare (r=0.306). A strong correlation was found between difficulty accessing medicine or any healthcare and affording medications (r=0.694).

Conclusion
Our results reveal significant relationships among HRSNs, indicating interconnected challenges. Food insecurity positively correlates with 4 HRSNs, all of which can impact a patient’s overall health. Although studies that examine screening for food insecurity have not shown improved outcomes, interventions addressing SDH through housing or income support have proven beneficial. Targeted interventions for the HRSNs experienced by food insecure patients may prove valuable. 
Other associations support the need for comprehensive interventions. The link between medicine/healthcare access and affordability as well as housing instability and transportation issues underscores the interconnected challenges and the importance of integrated solutions. These findings suggest that HRSNs rarely exist in isolation, illustrating the need for multi-faceted interventions to effectively meet needs and improve outcomes of vulnerable populations.



Characterization of Interactions Between Health-Related Social Needs

Background
University-sponsored mobile health vans are a popular method of supporting individuals with significant barriers to receiving healthcare by tailoring services to the community’s needs. Their main challenges are longevity and sustainability. Departure of an established van program from a community without other programming in place can have negative effects on the neighborhood’s health. These weaknesses must be addressed prior to developing this program.

Methods
Eight qualitative interviews were conducted with key informants to provide a deeper understanding of mobile health financing and operations sustainability. These interviews focused on the programs at five reputed university-affiliated mobile health vans in different stages of sustainability. Participants were identified through snowball sampling. All interviews were recorded using Zoom. Transcripts were coded and analyzed using NVIVO. 

Results
Four emerging themes of funding, affiliation, sustainability, and community focus were identified. A series of recommendation questions were developed from the specific findings of each theme and compiled into a guide. The main downfalls of mobile health vans stem from inconsistent funding and universities not being fully committed to communities. Vans can sidestep most limiting factors they run into by having preemptive plans in place and a clear mission statement that the university can stay grounded to. 

Conclusion
University-sponsored mobile health vans have potential if they are created with the community at the center of their intentions. The recommendations developed from this qualitative analysis will help to create a sustainability and implementation guide for university-sponsored mobile health vans and secure support for communities in need.

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Association between Prenatal Exposure to Tetrachloroethylene and Adverse Birth Outcomes: Systematic Review and Meta-Analysis

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