United States

ABSTRACT
Soldiers on the battlefield are affected by heavy body armor and excessive march load. It is well known, but the long-term effects of this extra weight on the musculoskeletal system of military veterans, specifically the lumbar spine, are unclear. In Iraq and Afghanistan, most body armors weighed over 33 pounds (15 kg). These armors were 3 times heavier than those used in Vietnam. Chiropractors at the Fargo VA Hospital are seeing more young veterans with non-traumatic lower back pain. This article presents a perspective on the impact of body armor weight and excessive carry load on lumbosacral disc herniation with radicular pain in military veterans.
This study is a retrospective case series. We used a convenient sampling method. We selected the first 10 military veterans who came to a Fargo VA chiropractor in late fall 2023. Each veteran filled out a VA Form 10-5345 to give us permission
to access their electronic health records. All 10 veterans also completed a survey. The survey asked about their active combat status, the type and weight of their body armor, how long they wore the armor each day, how much weight they
carried, and their opinion on the cause of their lower back pain (service related or not). The Fargo VA does not require an institutional review board for a case series.
This study found that military veterans experience lower back pain at an average age of 35 years. This is at least 5 years earlier than non-service men. Lower back pain with disc herniation typically occurs at the L4-L5 and L5-S1 disc levels. All 10 veterans in the study believe that their lower back pain is related to their service. Sixty percent of the participants in the study have a service-connected disability because of back pain.
For military veterans, onset of lower back pain from a disc herniation at a young age may be linked to carrying heavy
body armor and loads. However, the small sample size of this case series limits causal relationship inferences.

AMA Research Challenge 2024 

Body Armor and Lumbar Disc Herniation in Young Military Veterans:
A Case Series

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Background
Physical and occupational therapy has grown significantly from 1965 to 2023. Despite this growth, challenges related to Medicare and accessibility remain for both professions, impacting their ability to serve all populations effectively. This research aims to investigate the distribution of physical and occupational therapists at the county, state, and national levels. The project seeks to identify factors contributing to disparities in therapist distribution and explore the consequences of underserved areas lacking sufficient resources in these fields.
Methods
The data utilized in this research study were sourced from the Centers for Medicare & Medicaid Services (CMS) for 2023. The number of physical and occupational therapists enrolled in Medicare was analyzed nationally and statewide via proportion tests. Pearson regression models compared the relationship between physical and occupational therapists in the United States and Ohio. The trend in practicing rehabilitation therapists was explored by graduation year.
Results
Approximately 229,740/364,720 (63.0%) of rehabilitation therapists were physical therapists nationally. However, 74,836/86,373 (86.6%) of rehabilitation therapists enrolled in Medicare were physical therapists (P<0.001). Additionally, on a state level, there were significantly fewer counties in Ohio that had at least one occupational therapist (P<0.05). There was a significant relationship between physical therapists and occupational therapists nationally (P<0.001, R=0.95) and in Ohio (P<0.001, R=0.89). The number of graduating physical therapists who practice in Ohio has increased significantly faster than occupational therapists (P<0.01).
Conclusion
When comparing physical and occupational therapists, there is a significant disparity in the number of these healthcare professionals registered with Medicare. The lower enrollment rate of occupational therapists in Medicare contributes to reduced accessibility to their services within the healthcare system. This limitation hinders certain populations from receiving assistance with their daily tasks. In contrast, the availability of physical therapists is increasing, potentially improving accessibility to their services with Medicare.

Trends and Impacts of Medicare Enrollment Among Physical and Occupational Therapists

Background: Conflicts of interest pose a significant risk to the integrity of clinical research. As a part of the Sunshine Act, the Open Payments Program was established to provide transparency in financial relationships between industry partners and physicians. Previous research indicates considerable disparities between industry payments self-reported by plastic surgeon authors and those disclosed by their industry partners. The goal of this study was to determine if the Sunshine Act enhances transparency regarding authors’ conflicts of interest for readers of peer-reviewed plastic surgery journals.

Methods: Articles from the Aesthetic Surgery Journal and Plastic and Reconstructive Surgery published between 2017 and 2022 were reviewed. Self-reported disclosures for plastic surgeon authors were aggregated and compared against the Open Payments database using Python scripts. 

Results: 8,040 articles were reviewed. After filtering, 1,469 unique plastic surgeons and 5,987 authorships were identified. A total of 11,593 discrepancies were found, with 82% of authors having at least one discrepancy. Average total payments for authors with discrepancies were greater than for authors without discrepancies ($106,928 vs. $6,501; p<0.001). A discrepancy in self-reporting was more likely to be identified for a senior author (p<0.001). 

Conclusions: Plastic surgeon authors continue to underreport their financial relationships, and the lack of oversight continues to be problematic. Plastic surgery journals may consider automated systems to assess self-reporting accuracy.

How accurate are financial self-disclosures in Plastic Surgery journals?

Background
LGBTQ+ young adults experience disproportionately higher rates of mental health disorders and homelessness related to family and community rejection. A nonprofit organization providing emergency shelter for LGBTQ+ individuals aged 18-24 was partnered with, to address mental health literacy through educational interventions. The objective of this study was to assess mental health and barriers to accessing mental health care to better understand and meet the mental health needs of this population. 

Methods
Four LGBTQ+ identifying individuals experiencing homelessness were interviewed after participating in a single-session mental health education intervention. Interviewees were asked a series of open-ended questions regarding their mental health experiences, their LGBTQ+ identity, and their healthcare experiences. All interviews were recorded, transcribed, and coded individually using RAPID Analysis Process. Codes were analyzed as a group using a grounded theory approach.

Results
Participants cited that their mental health was impacted by their situation, the people around them, and a lack of access to healthcare. Participants stated that their LGBTQ+ identity contributed to feelings of isolation, difficulty trusting others, sexualization and sexual assault, and poor mental health due to interpersonal and systemic homophobia and transphobia. Three participants stated that they found it difficult to discuss their mental health with others. When asked about their relationship with healthcare systems, participants discussed cultural stigma against LGBTQ+ individuals in healthcare settings, a desire for gender-affirming interactions in healthcare, and a hope for a change in perspective amongst a new generation of healthcare providers. Participants stated that the mental health interventions provided tools in mindfulness, communication, and emotional regulation, and fostered community with their peers.

Conclusion
Investigating the intersection of mental health and LGBTQ+ identity showed that personal discrimination from family and friends, systemic transphobia, isolation, and sexualization and sexual assault due to gender identity all contributed negatively to participants’ mental health. Participants’ lack of comfort with reaching out to others for help with their mental health puts this community in a dangerous intersection of heightened mental health stressors and decreased social support. Additionally, participants’ responses indicate a lack of access to general, mental, and gender-affirming healthcare for this community. Increasing access to affordable and consistent care, as well as ensuring gender-affirming and culturally competent interactions in healthcare settings, will help this population better meet their health needs. Conducting interactive mental health educational interventions may further help this population connect with potential support systems and learn tools for managing mental wellness.


Fostering Mental Health in LGBTQ+ Young Adults

Background: Rheumatic diseases are frequently linked to a reduced quality of life (QoL), particularly as disease severity escalates. Patients with rheumatic conditions often have higher rates of depression and anxiety, conditions which can diminish QoL and hinder medication adherence. Suboptimal medication adherence to disease-modifying antirheumatic drugs agents can allow disease progression, exacerbating both QoL and mental health. However, the relationship between rheumatic diseases and mental health disorders remains unclear.


Methods: This retrospective case-control study examined the association between rheumatic diseases—specifically rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriatic arthritis (PsA), and ankylosing spondylitis (AS)—and mental health disorders (anxiety and depression) in patients treated within the authors' health system. Patients over 18 years old between September 28, 2010, and May 1, 2024 were identified using Epic’s SlicerDicer tool. Rheumatic diseases and mental health disorders were identified using ICD-10 codes. Odds ratios (OR) and 95% confidence intervals were calculated via multivariable logistic regression, adjusting for sex and age using IBM SPSS Statistics 29.0.2.


Results: Of the 3,305,015 patients screened, 1.0% had RA, 0.3% had SLE, 0.2% had PsA, and 0.1% had AS. Anxiety was identified in 12.3% patients, and depression in 11.9%. Adjusting for age and sex, patients with diagnosis codes for RA, SLE, PsA, and AS had a statistically significant increase in the odds for anxiety (ORs ranging from 1.99 to 2.40 ), depression (ORs ranging from 2.07 to 2.67), and concomitant anxiety and depression (ORs ranging from 2.37 to 3.09), with all p-values < 0.001. Subgroup analysis of patients seen specifically at our outpatient rheumatology clinics revealed associations between SLE and anxiety, depression, and concomitant anxiety and depression (ORs 1.42, 1.38, 1.49, respectively, all p-values <0.001). PsA and AS were linked to depression (ORs 1.18, p=0.008 and 1.32, p=0.003, respectively) and concomitant anxiety and depression (ORs 1.17, p=0.034 and 1.40, p=0.004, respectively). The lower ORs in this subgroup are likely due to underreporting of ICD-10 codes for depression and anxiety, as these patients may receive mental health care outside of the health system.


Conclusion: Patients with rheumatic disease face significantly increased incidence of depression and anxiety, negatively impacting QoL and medication adherence. It is essential to frequently screen these patients for mental health conditions to ensure comprehensive care.

Associations between Rheumatic Diseases and Mental Health Disorders

Abstract Title:
Outcomes and Quality of Life with Severe Obesity After Life Threatening Respiratory Illness

Background:
A body mass index (BMI) of ≥ 35 kg/m2 is traditionally considered a contraindication to extracorporeal support. We evaluated outcomes and quality of life (QoL) associated with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in patients with BMI ≥ 35 kg/m2.

Methods:
We conducted a multi-institution retrospective analysis of patients requiring VV ECMO between May 2020 and December 2021. Patients were ≥ 18 years of age who fulfilled clinical criteria for extracorporeal support. Data on survival, discharge, decannulation, tracheostomy, and extubation times were collected. Statistical analysis involved t-tests, chi-square tests, Kaplan-Meier survival plots, time-to-event models, and multiple linear regressions. Cox proportional hazards models adjusted for confounders. A Short-Form Health Survey (SF-12) provided physical and mental scores in both cohorts of patients. The relationship between outcomes and quality of life (QoL) were assessed using generalized linear and mixed models.

Results:
A total of 181 patients were studied, 80 of whom had a BMI ≥ 35 kg/m2. The median age was 43.5 (±13.5) years, with 59.7% Male and 97.2% White. Patients with a BMI ≥ 35 kg/m2 had a significantly shorter time to discharge (HR: 1.97, 95% CI: 1.16 3.36, p = 0.013) and a lower likelihood of death following discharge compared to those with BMI < 35 kg/m2 (HR: 0.169, 95% CI: 0.036-0.799, p = 0.025). Higher BMI patients also had higher survival rates at discharge (78.8% vs. 63.4%, p = 0.037). Time to decannulation and extubation did not differ significantly between cohorts. SF-12 physical and mental scores demonstrated that patients with a BMI ≥ 35 kg/m2 did not show a significant difference in physical or mental scores when compared to patients with BMI < 35 kg/m2 (42.5 (+/-10.3) vs. 41.9 (+/-10.9), p = 0.822), (51.8 (+/-11.2) vs. 53.2 (+/-9.81), p = 0.582).

Conclusions:
Patients with BMI ≥ 35 kg/m2 do not have worse outcomes from ECMO and report similar QoL metrics as patients with BMI < 35. These findings suggest the fact that BMI ≥ 35 kg/m2 should not be used as a contraindication to ECMO candidacy. Further prospective studies necessitate investigation to better characterize this relationship.

Outcomes and Quality of Life with Severe Obesity After Life Threatening Respiratory Illness

Introduction: 
Mpox is a rare but potentially serious viral disease with a fatality rate of about 11% and is endemic to the Central and West African countries. Vaccination plays a crucial role in controlling and preventing the spread of the disease. However, due to limited resources and challenges in vaccine distribution, designing effective vaccination strategies becomes essential to optimize cost-effectiveness. In this study, we propose a game-theoretic model to evaluate different vaccination strategies for managing Mpox outbreaks via voluntary vaccination.

Methods: 
The game-theoretic model is designed to simulate interactions between different stakeholders involved in controlling the spread of Mpox. We created an epidemiological compartmental model that incorporates various parameters based on literature data to simulate the spread of monkeypox in three equilibria scenarios- disease free, fully endemic and semi-endemic (with disease existing only among humans)

Results: 
Our simulation model demonstrated that the effectiveness of vaccination strategies
depends on the collaboration and decision-making strategies of the involved parties. The existence of semi-endemic equilibrium has severe implications should the MPX virus mutate to increase viral fitness in humans. We find that MPX is controllable and can be eradicated in a semi-endemic equilibrium by vaccination. However, in a fully endemic equilibrium, MPX cannot be eradicated by vaccination alone.

Discussion:
Using the game-theoretical approach in conjunction with our mathematical model yielded insight into the complex dynamics in disease spread and prevention. Our model quantified the costs and benefits of getting the smallpox vaccine (85% effective in preventing MPX) and presented a sensitivity analysis to identify parameters that created the greatest change in controlling Mpox outbreaks. As cases of MPX become increasingly reported among humans, we hope that the
models may serve as a predictive tool to better study the spread of MPX. We also showed a potential existence of the semi-endemic equilibrium, in which there is no infection in the squirrel population and the disease still persists in the human population. As evidenced in recent outbreaks in countries without a disease reservoir, a careful understanding of the semi-endemic
equilibrium is needed when making decisions on optimal vaccination and preventative measures.

A game-theoretic model of Monkeypox to assess vaccination strategies

Abstract Title: 
Challenges and Opportunities for Gun Safety Education in the Pediatric Emergency Department

Background:
Firearm injuries are the leading cause of death among children and teens in the United States. Firearm safety education is critical, as improper storage is a significant risk factor for injury. Although a combination of education material and safety devices provided to parents has shown to be effective in preventing gun injuries, attempts at implementing such an intervention in clinical settings faces multiple barriers. This study aims to evaluate the implementation of a gun safety education intervention in the Pediatric Emergency Department of Robert Wood Johnson University Hospital.

Methods:
A gun safety education program based on BeSMART guidelines in coordination with Robert Wood Johnson University Hospital staff was developed and implemented for mainly nurses, residents, and attendings to perform with parents of pediatric emergency department patients in non-life threatening situations. Participating parents watched an educational video, completed an in-hospital survey to assess baseline beliefs and practices, received a brochure, and were offered free gun locks. Follow-up telephone surveys assessed parents’ changes in beliefs and behaviors regarding firearm storage. The intervention was then evaluated, after multiple iterations, through feedback from ED staff to identify implementation challenges and areas for improvement.

Results:
Over one hundred gun locks were distributed yet overall participant survey completion was minimal. Feedback from twelve pediatric emergency department staff including nurses, attendings, and residents in charge of conducting the in hospital education revealed that gun safety education was conducted infrequently due to prioritization of acutely ill patients, forgetting the workflow, and time constraints. Key suggestions included involving non-clinician staff and integrating the education into the registration or discharge processes.

Conclusion: 
While there is interest in practical gun safety measures among parents, the emergency department presents challenges for consistent education from clinical staff due to high workload and limited time. Future efforts should focus on alternative settings, such as outpatient clinics or involve non-clinician staff for successful rollout of firearm safety interventions. Such efforts should be made in coordination with representa

Challenges and Opportunities for Gun Safety Education in the Pediatric Emergency Department

Background
The WHO reports that elderly people have the highest risk of death or serious injury arising from a fall (WHO, 2021). This study utilized the 2020 National Inpatient Sample (NIS) database from the Healthcare Cost and Utilization Project to determine which diagnostic conditions were most likely to be seen in elderly fall patients. 

Methods
The 2020 NIS database was used to identify the ICD-10 diagnostic codes in elderly patients that were associated with a fall code. Analyses used the first 3 digits of the diagnostic code. 

Results
Analyses revealed that 4.7% of the in-patient sample (6,471,165 patients) had a diagnostic fall code. We referred to these patients as falls patients (FPs). The incidence of falls increased dramatically with age, as 7.6% of patients >50 years of age (YOA) and 12.2% of patients >70 YOA were FPs. Moreover, 90.6% of the FPs were >50 YOA. As expected, 90.2% of the FPs also had a code for a musculoskeletal disorder or injury. Interestingly, 26.2% of FPs >50 YOA were associated with dementia or a neurodegenerative disorder resulting in dementia. The most common diagnostic categories seen in FPs >50 YOA were Circulatory (88.6% of patients), Psychiatric (55.6%), Neural (48.1%), and Heme/Immune diagnoses (47.1%). Interestingly, 73.1% of FPs >50 YOA had either a Psychiatric or Neural code. The highest percentage of Circulatory codes seen in FPs >50 YOA were Hypertension (44.1%), Atrial fibrillation (26.4%), Chronic heart disease (26.2%), Hypertensive chronic heart/kidney disease (22.7%), Heart failure (22.0%), and Hypotension (10.5%). The highest percentage of Psychiatric codes seen in FPs >50 YOA were Dementias (22.4%), Depression (15.8%), Anxiety (15.6%), Nicotine dependence (12.5%), and Alcohol abuse (8.2%). The highest percentage of Neural codes seen in FPs >50 YOA were Metabolic encephalopathy (12.3%), Chronic pain (11.3%), Insomnia (10.8%), Epilepsy (4.91%), Alzheimer’s (4.4%), and Parkinson’s (3.42%). 

Conclusion
As expected Circulatory codes were common in the FPs >50 YOA, as the incidence of these diagnoses increases dramatically with age. It was, however, surprising to see the high incidence (73.1%) of Psychiatric and Neural codes in the FPs >50 YOA, particularly codes relating to dementias. It is important to note that it was impossible in this study to determine if any falls occurred in the hospital, although we presume that most falls occurred outside of the hospital and may have been associated with hospital admission. Studies like this may help to develop fall prevention strategies by isolating specific diagnostic patient profiles in the elderly.

Diagnostic codes associated with falls, a focus on psychiatric and neural diagnoses in the elderly in-patient sample

Abstract Title: 
Financial Conflicts of Interest of Physicians Followed by Leading Medical Journals on X (Twitter)
Background
Social media platforms like X (Twitter) have become important for disseminating medical research. However, financial conflicts of interest (FCOIs) among physicians on these platforms may influence content. This study aimed to assess FCOIs among physicians followed by top medical journals on X.

Methods
We identified US physicians followed on X by The New England Journal of Medicine, The Lancet, and JAMA. Using the Open Payments database, we analyzed general payments, research payments, and ownership interests received by these physicians from 2014-2021. We also examined payments to editorial board members and analyzed a subset of posts from physicians with FCOIs. We analyzed the posts using named-entity-recognition, topic modeling, and sentiment analysis. 

Results
Of 253 US physicians followed, 54.9% received general payments totaling $19.2 million. Specialists received significantly higher median payments than primary care physicians ($540 vs $0, p=0.0003). Among editorial board members with X accounts followed by their journals, 73.3% received general payments.When compared to general payments, only 9.5% of physicians received research payments. Analysis of physicians’ X activity showed those with FCOIs had significantly more followers than those without (64,490 vs 17,724, p=0.044). Topic modeling of Posts from physicians with FCOIs revealed frequent discussion of industry-related topics. Physicians with declared financial conflicts of interest tend to include academic links in their tweets slightly more often (20.93%) compared to those without FCOI (19.07%). Subspecialities of internal medicine and surgery tended to share more academic sources. Physicians with FCOIs tend to discuss more specific medical topics (e.g medical education, FDA and regulations, vaccines) compared to those without FCOIs, who often have "other" as their most common topic.The average sentiment scores vary between -0.037 and 0.576, with most scores being positive.

Conclusion
A majority of physicians followed by top medical journals on X have FCOIs, with some receiving substantial payments. This raises concerns about potential bias in social media content from these influential voices. Greater transparency is needed regarding FCOIs on social media platforms used for medical information dissemination. Medical journals should consider implementing policies for disclosing FCOIs when interacting with or promoting content from physicians on social media. Physicians should also provide reference to their FCOIs to avoid the appearance of bias and maintain public trust.


Financial Conflicts of Interest Among Physicians Followed by the Leading General Medical Journals on X

Objective: It is unclear if Medicare Advantage (MA) benefit design may influence when MA beneficiaries receive elective treatments such as spinal fusion surgery. We characterize the impact of MA insurance status on the timing of spinal fusion surgeries across calendar years.

Study Design: Cross-sectional event study.

Methods: Using the national sample of Medicare beneficiaries from 2016-19, we identified 175,181 Medicare beneficiaries who received a spinal fusion surgery from November through February each year. We conducted a descriptive analysis and a series of event study difference-in-difference linear regressions to answer our research questions. 

Results: Among Medicare enrollees who received spinal fusion surgeries between November and February, 2,460 (2.0%) beneficiaries in Traditional Medicare (TM) at the time of surgery and 1,978 (3.8%) beneficiaries in MA at the time of surgery switched plans from one calendar year to the next. Among all spinal fusion surgeries received by Medicare enrollees and controlling for confounders, beneficiaries enrolled in MA are 1.6 percentage points (95% CI [-2.2%, -1.0%]; P<0.001) less likely to have been at the beginning of the calendar year compared to TM surgeries. 

Conclusions: The budgetary impact of enrollees switching between MA and TM plans to gain access to spinal fusion surgery is likely low. MA enrollees may be accelerating care at the end of the calendar year due to benefit design differences between MA and TM, such as annual spending caps or out-of-pocket maximums. Dual beneficiaries are not subject to this incentive structure, providing further evidence that the benefit design of MA may be driving the timing of surgery.

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Body Armor and Lumbar Disc Herniation in Young Military Veterans: A Case Series

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