United States

Objectives: The rise in popularity of electronic cigarettes (e-cigarettes) among U.S. adolescents in the past decade is cause for concern due to the device’s novelty and potential long-term health effects. In response to the concerns, a federal Tobacco 21 law (T21) was passed to raise the minimum age for purchasing tobacco products and e-cigarettes from 18 to 21. This study aims to determine the effectiveness of this federal legislation in reducing e-cigarette usage rates among middle and high school students.

Methods: This study utilized data from both the 2019 and 2020 National Youth Tobacco Survey (NYTS) to examine changes in vaping among 54,575,023 middle and high school students after passage of the federal T21. Odds ratios and logistic regression models were used to assess the association between vaping prevalence rates and the policy change while controlling for perceived harm and addictiveness of e-cigarettes. 

Results: Following the implementation of the federal T21 in December 2019, adolescents were significantly less likely to use e-cigarettes, with the odds of current use reduced by 29% (OR=0.71, with CI [0.58-0.86] and p-value=.001). During the same period, there was an increase in both perceived harm and addictiveness from 71% to 79% and 61% to 66%, respectively. Perceived harm was associated with lower e-cigarette use (OR=0.27 with CI [.25 to .30] and p-value &lt;.0001) whereas perceived addictiveness had a positive association with use (OR=1.12 with CI [1.01 to 1.24] and p-value= .033). 

Conclusions: Federal legislation such as increasing the minimum age of sale of tobacco and nicotine products is an effective strategy in reducing and preventing tobacco and e-cigarette use among adolescents. 


AMA Research Challenge 2025 

Evaluating the Impact of the Federal Tobacco 21 Legislation on Adolescent E-Cigarette Use and Risk Perceptions 

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AMA Research Challenge 2024 

Join the AMA Research Challenge poster symposium and semifinals to explore top research posters and score posters in the semifinals (an AMA member exclusive opportunity).

Objectives: The rise in popularity of electronic cigarettes (e-cigarettes) among U.S. adolescents in the past decade is cause for concern due to the device’s novelty and potential long-term health effects. In response to the concerns, a federal Tobacco 21 law (T21) was passed to raise the minimum age for purchasing tobacco products and e-cigarettes from 18 to 21. This study aims to determine the effectiveness of this federal legislation in reducing e-cigarette usage rates among middle and high school students.

Methods: This study utilized data from both the 2019 and 2020 National Youth Tobacco Survey (NYTS) to examine changes in vaping among 54,575,023 middle and high school students after passage of the federal T21. Odds ratios and logistic regression models were used to assess the association between vaping prevalence rates and the policy change while controlling for perceived harm and addictiveness of e-cigarettes. 

Results: Following the implementation of the federal T21 in December 2019, adolescents were significantly less likely to use e-cigarettes, with the odds of current use reduced by 29% (OR=0.71, with CI [0.58-0.86] and p-value=.001). During the same period, there was an increase in both perceived harm and addictiveness from 71% to 79% and 61% to 66%, respectively. Perceived harm was associated with lower e-cigarette use (OR=0.27 with CI [.25 to .30] and p-value <.0001) whereas perceived addictiveness had a positive association with use (OR=1.12 with CI [1.01 to 1.24] and p-value= .033). 

Conclusions: Federal legislation such as increasing the minimum age of sale of tobacco and nicotine products is an effective strategy in reducing and preventing tobacco and e-cigarette use among adolescents. 


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Background: Spanish-speaking patients face persistent barriers to health information due to limited availability and poor readability of online Spanish-language educational resources. Generative artificial intelligence (AI) presents a promising solution to address this gap. This study modeled a practical, scalable AI intervention to generate accessible Spanish-language orthopedic educational materials that institutions can readily adopt to address language disparities.

Methods: We conducted a cross-sectional analysis of the 203 U.S. academic orthopedic institutions listed on the 2024 ERAS directory to assess the availability of Spanish-language patient resources on each institution’s website. We then modeled an AI intervention using 30 articles from [Institution]’s orthopedic patient library using ChatGPT-4o, as currently no Spanish resources are available, with the goal of improving readability and translation quality. Prompt development was performed using proven prompt engineering strategies including context/persona building, few-shot prompting, structured chain prompting, and iterative testing until satisfactory outputs were achieved. Readability was assessed using validated readability tests in both languages. A modified DISCERN tool scored by two Spanish-speaking orthopedic surgeons assessed content and translation quality. Scores before and after ChatGPT intervention were compared with paired t-tests while correlation between changes in reading grade level and quality was assessed with Pearson’s correlation (p<0.05).

Results: Of the 203 institutions included in our search, 142 (70%) provided patient educational resources in English on their websites. Of these 142 institutions, only 17 (12%) provided Spanish-language resources. The cumulative average reading grade level of our model’s original articles was 10.7±2.3 in English and 10.1±1.7 in Spanish (“original” Spanish articles were approximated with Google Translate). ChatGPT significantly reduced the reading level in both languages, achieving an average of 6.9±1.5 in English (p<0.01) and 6.8±1.2 in Spanish (p<0.01). ChatGPT-generated Spanish articles demonstrated improvement in DISCERN content quality scores according to Grader 1 (p<0.05), and noninferiority according to Grader 2 (p=0.37). The quality of translation was scored significantly higher by both graders for ChatGPT content (p<0.05). No significant negative correlation was observed between improvements in readability and content quality scores for either grader (Grader 1: r=0.34, p=0.23; Grader 2: r=0.12, p=0.67).

Conclusion: Our model demonstrates the effectiveness of AI for enhancing the accessibility, readability, and quality of online Spanish-language education materials, representing a cost-effective and practical approach institutions may implement in real-time to address language barriers and promote equity in patient education. 


Prompt engineering for health equity: A modeled AI intervention to improve online Spanish-language orthopedic patient resources

Background
Sudden cardiac death (SCD) remains a leading cause of death in the United States. Although implantable cardioverter defibrillators (ICDs) reduce mortality, appropriate therapies are delivered in only 3-5% of sudden cardiac arrests (SCAs) annually, highlighting the need for improved risk identification for SCD and sustained ventricular tachycardia (VT). Cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) is prognostic for ischemic cardiomyopathy (ICM) and SCD; however, the recent PROFID trial found that gross scar parameters lacked predictive value. Radiomics enables granular scar characterization from LGE images. Additionally, a deep-learning artificial intelligence electrocardiogram (AI-ECG) risk estimator (AIRE) trained on millions of ECGs predicts cardiac events. In smaller cohorts, functional principal component decomposition (FPCD) produces more interpretable scalar features from ECG waveforms. This study aimed to develop and validate machine learning models to improve VT/SCD risk stratification and guide ICD selection.
Methods
Left ventricular LGE images from 455 patients with ICM and LVEF 4-49% were analyzed using Pyradiomics to extract ~2,000 scar and myocardial features. Principal component analysis (PCA) was used for dimensionality reduction, and LASSO logistic regression identified PCA components most associated with the primary outcome of sustained VT or SCD. 12-lead ECGs were processed using FPCD to extract scalar parameters characterizing the voltage-time curves, and predictive features were selected via LASSO. Identified predictors were combined with clinical data (LV ejection fraction [LVEF] and LGE) in a model and evaluated using area under the receiver operating characteristic (AUROC) curves with bootstrapping.
Results
Among 455 patients with ICM, 59 experienced either SCD or sustained VT; 115 received ICD implants. The combined model demonstrated high predictive accuracy with an AUROC of 0.83 (95% CI: 0.78-0.88). The radiomics-based principal component most associated with VT/SCD was “Contrast,” and higher values were linked to highly heterogeneous LGE signal intensity and increased arrhythmic risk. In parallel, the FPCD analysis of ECGs demonstrated that parameters based on leads aVF and V3 had the best association with VT/SCD. A positive R wave in V3 was associated with the primary outcome. Notably, in the subgroup with LVEF 36-49%, using a model of LVEF, AI-ECG, and CMR radiomics to predict the primary outcome had an AUROC of 0.94 (95% CI: 0.90-0.97). 
Conclusion
Integrating radiomics from LGE images and 12-lead ECG features with LVEF in this model enhances risk stratification in VT/SCD and may fill a critical gap for patients with ICM and LVEF 36-49% who lack established primary prevention ICD indications.


Machine Learning Predicts Ventricular Tachycardia and Sudden Cardiac Death in Ischemic Heart Disease

Background
Pediatric atopic dermatitis (AD) has been linked to later metabolic dysfunction, including obesity, dyslipidemia, etc. Systemic type-2-cytokine blockade with dupilumab may confer long-term protective metabolic effects in AD patients, but longitudinal studies in children receiving modern biologic therapy compared to topicals remain scarce. We compare short and long-term incidences of 23 metabolic disorders in pediatric AD managed with dupilumab, high-potency corticosteroids (HPCS), low/medium-potency corticosteroids (LMCS), topical calcineurin inhibitors (TCI), targeted non-steroidal topicals (crisaborole or ruxolitinib), or no therapy.

Methods
We queried the TriNetX Global Network for patients <18 years carrying ICD-10 code L20 for AD. The index date was the first prescription or AD-related encounter, and baseline was the 12 months prior. Cohort sizes were: dupilumab 12,871; untreated 144,655; HPCS 45,992; LMCS 514,970; TCI 40,814; targeted topicals 9,408; any topical 634,356. Each comparator was 1:1 propensity-score matched to the dupilumab cohort on age, sex, race/ethnicity, and baseline metabolic diagnoses. All standardized mean differences were <0.01.

Outcomes were assessed at 6 months, 1, 3, and 5 years, and any time after index. Logistic regression provided odds ratios (OR) with 95% confidence intervals (CI); Kaplan-Meier curves, log-rank tests, and proportional-hazards diagnostics provided time-to-event differences. Two-sided p<.05 signified significance. Analyses were conducted in R 4.3 and TriNetX; de-identified data rendered our study IRB-exempt.

Results
Within 1 year of treatment-onset, dupilumab showed numerically higher—but frequently non-significant odds for metabolic dysfunction compared with topicals (e.g., overweight/obesity OR 1.225, 95% CI 0.857-1.751 at 6 months vs TCI). 

However, ~30 months post-index, Kaplan-Meier curves diverged; dupilumab seemed to confer a protective metabolic effect versus all comparators. By 5 years, dupilumab exhibited lower risk for nearly all metabolic outcomes. Versus the aggregated topical cohort, for example, 5-year ORs were 0.417 for overweight/obesity, 0.435 for dyslipidemia, 0.605 for elevated glucose, and 0.554 for acanthosis nigricans (all p<.001). This protective association continued beyond 5 years.

Protective associations were similar against HPCS, LMCS, and TCI, and modestly attenuated against targeted non-steroidal topicals. No comparator showed excess late metabolic risk relative to dupilumab.

Conclusion
Our analysis with this large real-world pediatric cohort suggests dupilumab may increase early metabolic dysfunction (frequently without statistical significance), while conferring pronounced long-term protective metabolic effects compared with topical-only management or no therapy, supporting the hypothesis that sustained interleukin-4/13 inhibition may favorably alter metabolic risk trajectories in pediatric AD. Prospective studies adjusting for disease severity and further mechanistic studies may help confirm this causality and elucidate the underlying mechanisms.

Metabolic Outcomes in Pediatric Atopic Dermatitis Treated with Dupilumab versus Topical Agents: a Retrospective Cohort Study

Background
Acupuncture has been practiced for thousands of years as a modality of Traditional Chinese Medicine. A greater emphasis on Complementary and Alternative Medicine (CAM) has led to enhanced adoption of acupuncture in Western medicine. While traditional acupuncture relies on surface landmarks and empirical knowledge, modern imaging techniques offer the opportunity to more precisely understand the proximity of critical neurovascular structures to needled sites. Peripheral nerves are particularly vulnerable to inadvertent injury at acupoints underlying nerves are superficial to dense osseo-ligamentous structures. Despite these risks, there is limited data quantifying the spatial relationships between acupuncture needles and adjacent nerves. Ultrasound imaging provides a non-invasive, real-time method for visualizing both acupuncture needle placement and underlying anatomical structures. Accordingly, this study aims to map the relative distance between inserted acupuncture needles and nearby peripheral nerves at selected acupoints, providing an evidence-based framework for safer clinical practice.
Methods
Ultrasonography was utilized in a physician-led acupuncture clinic to assess the distance of the acupuncture needle to nerves (NTN) at two specific acupoints (ACPs): Pericardium 6 (PC 6) and Kidney 3 (KI 3). These two points were selected because of their high clinical significance, relationship to underlying nervous structures, and ease of visualization via ultrasound. With informed consent from patients attending their scheduled acupuncture appointments, a physician, trained and board certified in medical acupuncture, located the selected ACP. Ultrasonography was performed to identify the underlying nerves. The site was then cleaned, and an acupuncture needle was inserted to achieve de qi by the physician. Ultrasonography was performed at the site again to identify the location of the needle. The NTN distance is measured and recorded. 
Results
The data collection and analysis are currently ongoing, and no results are yet available. 
Conclusion
This study demonstrates the value of ultrasound in visualizing anatomical structures relevant to acupuncture practice. By mapping the spatial relationships between acupuncture needles and underlying peripheral nerves, this work contributes to a growing body of evidence aimed at improving the safety and anatomical precision of acupuncture treatments. Although data collection and analysis are ongoing, preliminary findings are expected to inform clinical decision-making and guide safer needling practices, particularly in regions where nerves lie superficially. Limitations include the variability in individual anatomical presentations and the technical challenges of standardizing needle insertion depth and angle. Future work will benefit from larger sample sizes and functional outcome data to further refine anatomical risk mapping in acupuncture.

Anatomical Risk Mapping of Peripheral Nerves in Acupuncture via Ultrasound

Background
Idiopathic Intracranial Hypertension (IIH) is characterized by elevated intracranial pressure, papilledema, and often transverse sinus stenosis, in the absence of imaging or cerebrospinal fluid (CSF) abnormalities. Current treatments focus primarily on medical management, weight loss, and dural venous sinus stenting. However, inspired by arachnoid granulation function, a novel endovascular device may show significant potential in improving IIH management. The eShunt System is a transdural shunt deployed via the inferior petrosal sinus (IPS) to drain CSF from the cerebellopontine angle cistern (CPAC) into the internal jugular vein. Although it has shown promising results in patients with normal pressure hydrocephalus, the implant’s applicability in IIH remains undefined. This study aims to characterize the morphometrics of cisternal, venous, and skull base anatomy in adult patients with IIH-associated dural venous sinus stenosis and evaluate them against minimum required dimensions for safe deployment of the eShunt implant.

Methods
High-resolution T1-weighted Gadolinium-enhanced brain MRIs of IIH patients post-venous sinus stenting at Tufts Medical Center (Boston, MA) were retrospectively analyzed to measure CPAC depth, IPS diameter, IPS angle, and cerebellar tonsillar descent; pertinent history and demographics were also assessed.

Results
Sixty adult patients (ages 18-77, 50 females) were included. Median CPAC depth was 4.5 mm and 4.4 mm, while median IPS diameter was 4.1 mm and 3.8 mm, for right and left sides, respectively. CPAC depth trended higher in older (P=0.05) and male (P=0.07) patients, but not significantly. Transverse sinus stenting did not significantly affect cistern dimensions (P=0.8). Endovascular placement of the eShunt implant was possible with stringent (CPAC depth >5mm and IPS diameter >2mm), moderate (CPAC depth >4mm and IPS diameter >2mm), and permissive (CPAC depth >3mm and IPS diameter >2mm) feasibility criteria in 55%, 65%, and 78% of analyzed patients, respectively. Interestingly, CPAC depth was found to be inversely correlated with cerebellar tonsillar descent (P<0.01); patients with Chiari I diagnoses tended to have small CPA cisterns. On excluding 26 patients with tonsillar descent below the foramen magnum, eShunt eligibility rose to 62%, 76%, and 91%, under stringent, moderate, and permissive criteria, respectively. Thus, cerebellar tonsillar position emerges as another predictive factor for eShunt eligibility.

Conclusion
A significant proportion of patients with IIH currently treated with dural venous stenting may be suitable candidates for the eShunt implant. Its biomechanical potential for ICP reduction, minimally invasive endovascular deployment, and lack of anti-coagulant and anti-platelet requirements, warrant further clinical investigation of its role in IIH management.

An Endovascular Approach for Idiopathic Intracranial Hypertension: Assessing Feasibility of the eShunt Implant using Morphometric Analysis

Background:
Macular edema (ME) is an ocular condition resulting from the accumulation of fluid in the central, most visually important part of the retina, typically as a complication of a retinal or inflammatory disease. Traditionally, laser photocoagulation or intravitreal injections of corticosteroids or anti-vascular endothelial growth factor agents are used to treat ME. However, these treatment options may have a wide array of undesirable side effects or limitations in their usage. In ophthalmology, topical NSAIDs are already largely used for their potent inhibition of inflammatory processes and treatment of postoperative ME. The overall diversity of NSAID agents, their mechanism of action, and risk profile make them a viable alternative option for intravitreal administration. This study sought to present a narrative synthesis and meta-analysis on the efficacy and safety of intravitreal injections of NSAIDs for the treatment of macular edema. 
Methods
A systematic search was conducted in the PubMed, Embase, Springer, and Cochrane Library databases, with search terms such as ('cystoid macular edema' OR 'cme' OR 'macular edema' OR 'macula cystoid edema') AND ('intravitreal injection' OR 'intraocular injection' OR 'intra-ocular injection') AND ('non-steroid anti-inflammatory agent' OR 'nsaid' OR 'non-steroidal anti-inflammatory drug' OR 'diclofenac' OR 'ketorolac' OR 'bromfenac' OR 'nepafenac' OR 'flurbiprofen') in KEYWORDS and FULL-TEXT on April 4, 2025. Relevant randomized and non-randomized clinical trials and observational studies were included if they involved intravitreal NSAID administration. Risk of bias and certainty were assessed. Data was extracted and evaluated using either narrative synthesis or meta-analysis, depending on the available data. Studies missing data for average best-corrected visual acuity and central macular thickness (CMT) were excluded from the meta-analysis. 
Results
Eight total studies, including six randomized and two nonrandomized trials, reporting 313 subjects and 340 eyes were included. All eight studies validated the safety of intravitreal NSAID agents. Two studies indicated intraocular pressure (IOP) reduction following administration, while others reported no significant IOP changes. Meta-analysis of 110 eyes found nonsignificant functional visual recovery (p=0.07), while meta-analysis of 130 eyes revealed significant reductions in CMT and anatomical improvement (p=0.04). Risk of bias and certainty assessment suggested potential effects of publication bias in the results. 
Conclusion
Intravitreal NSAID treatments for ME were not associated with any adverse reactions. Comparatively, they show insignificant functional gain but significant structural improvement. Although there is uncertain evidence of their efficacy, intravitreal NSAIDs present a viable alternative to current treatment methods and require further investigation in ME management.

Intravitreal Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for the Treatment of Macular Edema: A Systematic Review and Meta-Analysis

The global rise in obesity has led to a parallel increase in type 2 diabetes mellitus (T2DM), a chronic disease with significant morbidity and economic burden. While bariatric surgery is widely accepted as an effective treatment for obesity and established T2DM, its potential role as a preventive intervention in high-risk obese individuals remains underexplored. Emerging evidence suggests that early metabolic surgery, particularly in prediabetic patients, may significantly reduce the progression to T2DM by improving insulin sensitivity, enhancing beta-cell function, and promoting long-term glycemic stability. This project aims to explore the preventative benefits of early bariatric surgery through a comprehensive review of current literature. Articles from Embase and Pubmed spanning from early 2015 to the most recent clinical trials were collected following a systematic approach using the Prisma Protocol guidelines. Different modalities of bariatric surgery and how the procedure affected patients’ metabolic comorbidities were reviewed. By compiling and analyzing available data, this project seeks to determine whether earlier surgical intervention offers meaningful benefits in reducing T2DM risk. Bariatric surgery can be effective in managing and even reversing T2DM; however, the optimal timing of surgery for maximum preventive benefit is still under investigation. It was concluded that bariatric surgery significantly increased life expectancy in patients with T2DM compared with patients who managed their T2DM with pharmacologic agents alone. There is strong evidence of its benefits even when T2DM is already well established. By shifting the focus from treatment to prevention, this research highlights the clinical and public health value of earlier surgical referral for obese patients at high risk for T2DM.

Early Bariatric Surgery in the Prevention of Type 2 Diabetes Mellitus in Obese Individuals

Background
The increasing convenience of access to online information may lead to patient consumption of incomplete or misleading information about ocular problems. The purpose of this study is to evaluate the quality and accuracy of videos on glaucoma treatment options.
Methods
A search of “glaucoma” and “eye pressure” combined with “treatment” or “cure” was performed for Facebook (FB) and YouTube (YT) videos. YT videos with at least 25,000 views and 25 views per day and top FB videos with at least 1,000 views were included. Videos were evaluated using a modified Currency, Relevance, Authority, Accuracy, and Criteria (CRAAP) metric.
Results
74 YT and 19 FB videos were included. Of the YT videos, 74% defined glaucoma, 65% discussed untreated disease course, 64% stated treatment goals, 84% described treatment options, 17% discussed treatment risks, and 15% contained misinformation. Of the FB videos, 66% defined glaucoma, 47% discussed untreated disease course, 34% stated treatment goals, 68% described treatment options, 0% discussed treatment risks, and 18% contained misinformation. Higher accuracy and increased quantity was seen for educational videos containing “glaucoma treatment” on both platforms.
Conclusion
Commonly utilized YT and FB videos may lack important information and/or promote misinformation.


Quality Analysis of YouTube and Facebook Videos for Glaucoma Treatment Options

Background: Complementary health approaches (CHAs) are increasingly integrated into whole-person care strategies aimed at enhancing well-being across a range of clinical settings. While patient engagement with CHAs is shaped by multiple cognitive and behavioral factors, emerging research suggests that subconscious processes may play a critical role. Subconscious connectedness—defined as the extent to which an individual’s conscious mind interacts with non-conscious mental processes in daily life—offers a novel cognitive dimension relevant to health behavior. Despite its theoretical relevance, little is known about how
subconscious connectedness influences CHA use, satisfaction, and expectations. This study examined whether levels of subconscious connectedness, as measured by the Thought Impact Scale (TIS), are associated with CHA engagement and beliefs in a nationally representative sample of U.S. adults.

Methods: We conducted a cross-sectional online survey of 3,022 U.S. adults in 2024 using quota sampling aligned with U.S. Census benchmarks to ensure demographic
representativeness. Subconscious connectedness (SC) was measured via the 17-item Thought Impact Scale (TIS) and categorized into quartiles. Outcomes included past-year use of complementary health approaches (CHAs), self-reported favorability of prior CHA experiences, and expected benefit from CHA modalities not previously used. CHA engagement was assessed both overall and by category (nutritional, physical, psychological, system based, and combined psychological/physical) as well as by individual modality. Multivariate logistic
regression models estimated adjusted odds ratios (AORs) for each outcome, controlling for demographic, socioeconomic, and health-related variables.

Results: Higher levels of subconscious connectedness were significantly associated with greater engagement in complementary health approaches. Compared to the lowest TIS quartile, participants in the highest quartile had increased odds of past-year CHA use (AOR = 3.62, 95% CI: 2.14-6.14), favorable CHA experiences (AOR = 2.20, 95% CI: 1.32-3.68), and high expectations of benefit from modalities not yet tried (AOR = 2.54, 95% CI: 2.00-3.21). A clear dose-response pattern was observed, with odds of CHA engagement increasing progressively across TIS quartiles. These associations held across CHA categories—nutritional, physical, psychological, system based, and combined psychological/physical—with the strongest effects
seen for psychologically oriented modalities.

Conclusion: Subconscious connectedness is positively associated with CHA utilization, satisfaction, and expectations among U.S. adults. These findings support the inclusion of subconscious cognitive traits in behavioral health models and suggest opportunities for improving patient-centered care strategies through cognitive profiling.

High Subconscious Connectedness is Associated with Greater Use, More Favorable Experience, and Higher Expectations of Complementary Health Approaches in the U.S. Adult Population

Intro: Our study examines the rate of Emergency Department (ED) visits for asthma in Mariposa County and its relationship to days unhealthy to sensitive groups, median air quality index (AQI), and Ozone (O3) days.

Methods: Annual AQI reports for each county from 2015 to 2022 were obtained from the United States Environmental Protection Agency website. The yearly age-adjusted asthma ED visit rate from the California Health and Human Services Open Data Portal website. California’s entirely rural counties were
determined by the Public Policy Institute of California’s Rural California Fact Sheet. Counties with incomplete data sets were excluded. Variables were plotted on Microsoft Excel, and linear regression was calculated with an R2 of 0.15 used to define significance.

Results: The yearly age-adjusted asthma ED visit rate was trended from 2015 to 2022, showing a decrease in visits from 2019 to 2021 with a subsequent increase from 2021 to 2022. There is no meaningful correlation between annual age adjusted ED visit rate and days unhealthy for sensitive groups, R2=0.05.

Conclusion: Further studies are required to examine the numerous socioeconomic and environmental factors related to rural asthma ED visits in California.

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