United States

Background
Advance care planning (ACP) is associated with important positive outcomes, including higher satisfaction with care and lower surrogate distress. However, engagement in ACP is low among Latinx older adults. This is the first study to use community-based participatory research (CBPR)—a method known to reduce health disparities—to identify ACP barriers/facilitators and design community-based ACP events.

Methods
In partnership with community-based organizations, clinicians, and local government in San Francisco (SF), we formed a Latinx Community Committee (N=13 community members) to lead this project from 9/2020-8/2021. We recruited Latinx-identifying, Spanish- or English-speaking older adults (age≥55), caregivers, and community leaders for focus groups. We conducted 6 focus groups in English and Spanish assessing ACP barriers/facilitators and analyzed data using thematic analysis. Based on focus group findings, we designed and implemented community-based ACP events that incorporated new (e.g., artwork used for messaging/advertising, testimonials from patients/physicians) and existing (e.g., Prepare for Your Care) culturally appropriate ACP materials, and targeted Latinx LGBTQI+, intergenerational, and older adult populations. We advertised events through various channels (e.g., flyers, phone calls, radio, social media) in SF Latinx communities. Using a validated survey at the events, we assessed acceptability (i.e., comfort attending, willingness to recommend to others) and pre- vs post-event readiness to engage in ACP (4-point scale; 4=most ready) with Wilcoxon signed rank tests.

Results
Focus groups included 10 older adults, 8 caregivers, and 10 community leaders. Themes highlighted the importance (e.g., means of advocacy), barriers (e.g., how to start ACP conversation), and facilitators (e.g., trusted community spaces) of ACP in the Latinx community. Ninety-seven people attended 5 pilot events; they were 59.4 (SD 19.2) years old, 81.7% Latinx, 5.6% Black, 64.8% Spanish-speaking, 32.4% sexual/gender minorities. Overall ACP readiness increased from 2.62/4 (SD 0.97) to 2.95 (SD 0.93; P=0.05). Specifically, participants’ readiness to document their wishes for medical care in writing increased significantly (P=0.003). Most people were comfortable attending events (85%) and would recommend them to others (90%).

Conclusion
This study describes a feasible, acceptable, and effective CBPR ACP intervention. Co-developed community events represent a promising approach to reducing disparities in ACP among the Latinx population.


AMA Research Challenge 2022

“Advocating for what we need”: A Community-Based Participatory Research Approach to Advance Care Planning in the San Francisco Latinx Elder Community

Welcome to the largest national, multi-specialty research event **featuring research from 750 medical students, residents and fellows, and international medical graduates.**


#### Event Details
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Ricardo Correa, MD, EdD
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

### Sponsor
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Register to explore research in a variety of topics. AMA members get exclusive access to score posters in the semifinals.

**Please use the link below to register for free if you have not already done so:**

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Registration Is Required

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


poster

Background: Adverse Childhood Experiences (ACEs) are events or actions experienced by a child before the age of 18 that fall within three categories: abuse, neglect, and household dysfunction. Standardized ACE scores can be calculated and have been proven to significantly affect future health outcomes. However, resiliency, defined as “the capacity to adapt successfully to challenges that threaten function, survival, or future development” has shown to be a protective factor against ACE-associated mental and physical health outcomes. A medical student led initiative was developed in collaboration with a local charter school as a near peer mentoring program for high school student with traditionally high ACE scores. The purpose was to foster positive relationships while developing social and emotional skills to promote resiliency with the intent to mitigate high ACE scores.

Methods Twenty-five high school students from the local charter school were identified and assigned to an individual near peer medical student mentor for a year-long mentoring relationship. The mentoring pair met monthly for one hour via a virtual video platform approved by the charter school. Monthly materials were provided to each medical student mentor to help facilitate the mentoring meetings.

Results Survey results show the goal of creating positive longitudinal relationships was achieved. Before the mentoring program, 55% of the charter school students felt that had someone to reach out to for support compared to 78% during the mentoring program. 78% felt they could contact their mentor for anything, 89% felt their mentor was a safe person to talk to, and 100% stated they felt their mentor was a reliable person in their life.

Conclusion The near peer mentoring program had a positive impact on fostering positive relationships and resiliency skills with students who have high ACE scores. The program’s virtual connecting allows for a high degree of flexibility and its use of standardized resources eases training. However, a virtual platform can at times limit relational depth, and the impact of the program is dependent on medical student engagement. As such, this program is easily adoptable to environments with community engagement focused on efforts to mitigate ACES among high school learners.

A Medical Student Near Peer Mentoring Program in Character Education Designed to Mitigate Adverse Childhood Experiences in High School Students

Abstract Title: A Systematic Review on Women’s Health in Abortion Legalized vs. Abortion Prohibited Nations
Background: On June 24, 2022, the US Supreme Court overturned the landmark 1973 Roe v. Wade decision that affirmed the constitutional right to abortion. This study compares trends in women’s health and unmet contraceptive needs between abortion legalized and prohibited nations, as of July 20, 2022.
Methods: A systematic review of data obtained from literature searches in Cochrane library, EMBASE, Medline, Guttmacher Institute, United Nations Children’s Fund (UNICEF) and World Health Organization (WHO) databases.
Results: Among 195 nations in the world, 16 each were grouped into two categories. Group one included 16 nations where abortion is legalized, and group two included 16 nations where abortion is prohibited, with exceptions only in cases to save the pregnant person’s life. The mean adolescent birth rate per 1000 women aged 15-19 years was 13.7 (range, 3.53- 51.8) in abortion legal group compared to 77.9 (range, 49.5-142.8) in abortion illegal group. Further, while 50% of unintended pregnancies ended in abortion in abortion legalized nations, only 38.5% were terminated in abortion illegal countries. In addition, it was observed that there was a 12% to 74% unmet need for contraceptive and abortive services among abortion prohibited nations. The mean maternal age at first birth was 27 years in abortion legal group compared to 21 years in abortion illegal group. The mean maternal mortality rate per 100,000 live births was 43 among abortion legal group while it was 263.8 among abortion illegal group. Overall, average female literacy rate was 96.8% in abortion legal group compared to 68.8% in abortion illegal group. It was also noted that the average adolescent birth rates were as low as 0.29 in nations having established unrestricted abortion laws that date back to 1960.
Conclusion: The high adolescent birth and maternal mortality rates alongside lower female literacy rates in abortion prohibited nations raises serious concerns about women’s health and restricted opportunities for higher education. Further research is needed to evaluate if liberalizing abortion policies would help improve women’s health and literacy.

A Systematic Review on Women’s Health in Abortion Legalized vs. Abortion Prohibited Nations

Title: Analysis of Blood Pressure Readings Among the Unsheltered Population of Miami-Dade County
Background: Hypertension (HTN) can lead to adverse cardiovascular sequelae without appropriate management. People experiencing homelessness (PEH) are at increased risk of acute and chronic diseases, yet have poor access to HTN monitoring. Little is known about prevalence of HTN among unsheltered PEH. Our objective is to assess baseline HTN characteristics in the unsheltered PEH population of Miami-Dade County. 
Methods: Blood Pressure (BP) measurements were obtained by in-person clinic “street runs” where medical providers meet with unsheltered PEH in non-clinical environments such as overpasses and encampments. Vitals were recorded in RedCap electronic medical record system. Centers for Disease Control National Health and Nutrition Examination Survey (NHANES) 2017 – 2020 pre-pandemic data set represented the general population. Descriptive statistics and independent sample t-test comparisons were performed using SPSS v26. 
Results: BP was reported in 145 interactions – participant mean age 56.2 years (SD 10.5), 79.8% Male. The total average systolic BP (SBP) 140.14 (SD 22.28), diastolic BP (DBP) 87.99 (SD 12.74). Average visit 1 (N = 94) SBP 141.10 (SD 22.82), DBP 88.46 (SD 13.24). Average visit 2 (N= 22) SBP 145.45 (SD 21.69), DBP 89.82 (SD 12.45). No significant difference was found between visits 1 and 2. Elevated BP at two visits established formal HTN diagnosis, as defined by American College of Cardiology criteria. NHANES average SBP 119.81 (SD 19.38), DBP 71.61 (SD 12.02). NHANES data compared to average Visit 1 BP showed PEH to have significantly higher SBP (p<0.0001), DBP (p<0.0001). Age and gender stratification furthered internal validation. The average BP measurements of unsheltered PEH at clinic was in American Heart Association’s HTN Stage 2 category. 
Conclusion: BP of the PEH surveyed were higher than in the general population and within pathological staging criteria for HTN. Steady results from multiple visits suggest compounding factors beyond access to care: polysubstance use disorder, smoking, poor and unbalanced nutrition, chronic stress of being unsheltered. Future studies comparing unsheltered vs sheltered PEH could elucidate more information on risks and management of this deadly and preventable disease.

Analysis of Blood Pressure Readings Among the Unsheltered Population of Miami-Dade County

Background: Moderators of now-banned r/nonewnormal described its aims as the “free exchange of ideas and debate”, but it often hosted topics such as vaccine misinformation and questioning COVID-19 death report legitimacy. Previous studies on Reddit vaccine sentiment found that conglomerates of COVID-19 related subreddits had overall positive sentiment. However, no study analyzed specific characteristics of individual misinformation and information subreddits, such as r/nonewnormal and r/Coronavirus, respectively.

Methods: This study analyzed Reddit comments from 7/2020-6/2021 that are publicly available at http://files.pushshift.io/reddit/comments/ for similarity and topic analyses using Rstudio. For subreddit similarity, we counted distinct users commenting on a subreddit 10 or more times, to ensure consistent engagement. Subreddits were ranked by overlapping users with r/nonewnormal and r/Coronavirus to determine similarity. The 50 most popular subreddits overall were excluded because they target broad topics (e.g. r/news) that users engage, regardless of interests. Topic popularity in both subreddits was determined by incidence of the words “vaccine”, “lockdown”, “mask”, and “quarantine”. Word aliases were also counted (e.g. Vax for vaccine).

Results: The most similar subreddits to r/nonewnormal serially were r/LockdownSkepticism, r/Coronavirus, r/conspiracy, r/Conservative, and r/PoliticalCompassMemes. For r/Coronavirus the most similar serially were r/nottheonion, r/insanepeoplefacebook, r/PoliticalHumor, r/technology, and r/trashy. The topic analysis showed that in r/nonewnormal the difference in incidence of “vaccine” (+19,175) and “mask” (+7346) increased from 7/2020-6/2021 while “quarantine” (+263) and “lockdown” (+1608) stayed similar. In r/Coronavirus, “vaccine” (+16,907) increased from 7/2020-3/2021 then decreased through 7/2021 (-14,083) while “quarantine” (-2792), “mask” (-33,894), and “lockdown” (-4573) decreased from 7/2020-6/2021.

Conclusion: Similarity analysis showed that users of r/nonewnormal were likely to engage with other subreddits related to COVID-19, COVID-19 misinformation, and conspiracies. r/conservative’s presence contrasted with r/Coronavirus’s liberal-leaning similar subreddits r/nottheonion and r/PoliticalHumor. Pew Research surveys reflect this as liberal Americans believed the pandemic was serious more than conservatives. “Vaccine” became more popular over time, likely, because of 12/2020 vaccine rollouts sparking discussions. “Quarantine” and “lockdown” likely decreased overtime as CDC guidelines decreased quarantine times and statewide lockdowns lessened overall. The incongruent “mask” incidence causation is unclear. This study shows, as activity mirrors previous survey results, online activity can reflect interests, sentiment, and overall activity of specific corresponding populations.

Analysis of COVID-19 Information and Misinformation Subreddits

BACKGROUND: School safety is of growing interest with weapon carrying at the center. Weapon carrying in school causes physical injury and death among students and staff, and psychological trauma among those who witness the display or use of such weapons. Factors such as age, gender, mental and psychological status, bully victimization, family characteristics, poverty, and neighborhood crime have been associated with weapon carrying into schools. My main objective is to determine the prevalence of weapon carrying among US high school students and examine the association between bully victimization and weapon carrying in school.

METHODS: A nationally representative sample of high school students from the 2019 YRBSS data was utilized for this cross-sectional study (n= 13,677). Logistic regression was used to assess if bully victimization predicts the odds of weapon carrying, adjusting for age, sex, grade, and sexual identity. A stratified analysis using age groups was also carried out to determine the odds of weapon carrying among younger adolescents (15 years and younger) and older adolescents (older than 15 years).

RESULTS: In the final sample of 11,921 students, the prevalence of weapon carrying was 2.4%. 19.5% of the adolescents in the sample reported being bullied in school. Those who were bullied had 3.06 times greater odds of weapon carrying to school than those who were not bullied (aOR= 3.06; 95% CI 2.38,3.91]. These odds were lower among those aged
15 years and below (aOR= 2.05, 95% CI 1.33, 3.1) and higher among those greater than 15 years (OR= 3.45,95% CI 2.58, 4.6).

CONCLUSION: With about 16 million students in US high schools, the prevalence of weapon carrying suggests that about 368,000 students carry weapons to school. The results suggest that victims of bullying are more likely to carry weapons to school. Interventions to improve school safety should also focus on reducing bullying in schools. Particular attention should be paid to older adolescents who are victims of bullying.

Bully Victimization as a Predictor of Weapon Carrying in US High Schools: Is Age a Factor?

Background:
Bluelining is an outgrowth of redlining that is defined as overly aggressive policing while under-serving marginalized communities that results in space, place, and race consolidation. This zoning impacts health in various ways, such as higher levels of exposure to environmental toxins, inhabitation of food deserts resulting in malnutrition, higher rates of cancer incidence and death, and exposure to and transmission of infectious diseases for incarcerated individuals. Bluelining may contribute to toxic stress outcomes such as heart disease, substance use disorders, anxiety/depression, and auto-immune diseases. 

Bluelining research is scarce; thus this series fosters opportunities to educate providers, encourage advocacy, and support community healing. We hypothesize that participating in an advocacy workshop would increase awareness of bluelining as well as impart a base of knowledge on how to apply trauma-informed care (TIC) and Alternative Policing Response Models (APRM) to bluelining interventions. ​The objective was for students, physicians, educators, and community members to advocate for improvements to policy that perpetuate bluelining by investing in Alternative Police Response Models for Louisville, KY. 

Methods:
Recruitment ULSOM AMA/KMA listserv, University of Louisville-wide listservs, community flyers, social media, eventbrite, and email campaigns. Total attendees= 37 attendees. Sample size= 20.
Event structure
· Zoom and Facebook Live​
· Panelists – (6 Louisville Metro Councilmembers, Kentucky State Representative, Police Officer, and Law Professor). ​
· Overview of bluelining, how to advocate, open discussion and polling, and break out groups to contribute to a policy memo outline
Metrics De-identified pre/post surveys and demographics via QR code linked to QualtricsXM. IRB 22.089
Analysis: 2-tailed Fischer’s Exact Test and Wilcoxon Signed Rank. Statistical significance set at p<0.05. SPSS version 27.0 or SAS 9.4.

Results: Participants showed prior knowledge of bluelining, advocacy, and social determinants of health definitions.​ Statistically significant increase in ability for participants to advocate for legislative change and discuss bluelining as a social determinant of health. ​Statistically significant improvement in participants' confidence discussing and advocating for bluelining as a social determinant of health.​ The event encouraged confidence in advocating for public health policy. 
Conclusion:
This data demonstrates need and applicability for additional education and advocacy involving bluelining through the lens of TIC and APRMs.​

Caged Bird: Bluelining and Medicine Advocacy Workshop

Background

China has the largest population of older people and the largest number of Parkinson’s disease (PD) cases in a single country, but little is known about the determinants of PD in the Chinese population. Previous studies have reported different incidence rates of PD in Asian compared with Western populations, but few studies have assessed the determinants of PD in Asian populations. Prospective studies, conducted in Western populations, have also reported discrepant results for the associations of cardiovascular disease (CVD) risk factors with PD, with inverse associations with smoking, but positive associations with other CVD risk factors. Thus, the objectives of this study were to compare the risks of Parkinson's disease among those with versus those without prior stroke or heart disease at baseline in a prospective study of 0.5 million adults in China, and to examine associations of cardiovascular disease risk factors (cigarette smoking, hypertension, diabetes, obesity) with risk of PD.

Methods

During an average of 11.5 years of follow-up of 503,497 middle-aged participants in the China Kadoorie Biobank study, 603 incident cases were hospitalized with a diagnosis of PD. Cox proportional hazards models were used to assess associations of history of heart disease or stroke with PD in all participants, and of cardiovascular disease risk factors with PD in a subset without prior cardiovascular disease.

Results

In this population, the incidence rate of PD (mean [SD] age of cases, 61 [10] years) was 13.3 (95% confidence interval: 12.3–14.4) per 100,000 person-years. Incidence increased with age, and was higher in men than in women, and in urban than in rural residents. Prior stroke was associated with about twofold higher risk of PD (hazard ratio 1.94; 1.39–2.69). After adjustment for confounders in those without prior cardiovascular disease, a 5 kg/m2 higher body mass index was associated with 17% (1.17; 1.03–1.34: P = 0.019) higher risk of PD, but neither hypertension, diabetes, nor current cigarette smoking was significantly associated with PD.

Conclusion

Prior stroke and adiposity were each associated with higher risks of PD, but none of the other cardiovascular disease risk factors were significantly associated with PD in this population.

Cardiovascular risk factors and Parkinson's disease in 500,000 Chinese adults

Background
Through the American Medical Association-Medical Student Section (AMA MSS), medical students have advocated for policies related to a variety of challenges we face in healthcare. These policies are reviewed by the AMA MSS to decide the organization's level of support which then has an impact on the direction of healthcare in the country. This project is a novel analysis of both policy proposed and the resulting decisions from the AMA MSS which reflects the opinion and sociopolitical stance of medical student members in the organization.

Methods
Two authors reviewed 2208 AMA MSS policy proposals submitted between 1999-2021 and categorized them based on keywords within the title and resolved clauses. A third author settled any disputes. Policies were categorized as related to race, gender inequality, LGBTQIA+, reproductive health, immigration, socioeconomic status, medical education, pediatrics, AMA infrastructure, or Other. We categorized potential decisions as either positive, neutral or negative outcomes. Statistical analysis was performed using IBM SPSS Statistics Version 28.

Results
Linear regression revealed a positive correlation between policies proposed per year and time (R²= 0.63). A qualitative assessment demonstrated that past 2015 there was an increase in positive outcomes for proposals related to race, reproductive health, and AMA infrastructure. The average positive outcome rate of policies related to race, reproductive health, LGBTQIA+, and AMA infrastructure was significantly higher than the average positive outcome rate of all the proposals based on students t-test (p<0.05). Past 2015 there has been a qualitative increase in neutral outcomes over all topics. 

Conclusion
The results showed a consistent increase in policies proposed per year over the past two decades, suggesting greater student involvement. The greater amount of neutral outcomes since 2015 could indicate more indecision in the AMA possibly due to the increased complexity of issues the AMA now wants to address. This increase in neutral decisions may warrant expert consultation. Policies on race, reproductive health, LGBTQIA+ and AMA infrastructure showed a greater percentage of positive outcomes indicating a correlation between the topic and its approval rate but further analysis would need to determine a cause for this.

Changes in Approval Rate of AMA Policies by Topic

Background
Home rapid antigen tests (RATs) are widely available, partially due to government distribution programs. Time-sensitive clinical decisions about provision of ambulatory COVID-19 care can depend on the results of these studies, which are often more readily accessible than clinician-performed tests. It is assumed that the two are similarly accurate. However, few studies of self-test RAT accuracy exist. Here, we compare the accuracy of patient-performed and clinician-performed BinaxNOW RATs using PCR as a gold standard.

Methods
All adult patients between February 12, 2022 and May 18, 2022 at a free state testing site in Baltimore, USA, were offered enrollment. Demographic and symptom status were recorded. 3 samples were obtained from each participant: clinicians sampled bilateral nares for PCR and RAT, after which participants self-tested using identical RATs. Sensitivity and specificity were compared using Chi-square. 

Results
625 patients participated. 60.6% were female, 58.6% were white, 98.2% were English speaking, and median age was 34 (IQR: 28, 48.5). 34.1% were symptomatic and 14.9% were PCR positive by PCR. Clinician and self-performed RATs had similar sensitivity (88.2% [95% CI: 80.1%, 93.2%] vs 83.9% [95% CI: 75.1%, 90.0%] P= 0.40) and specificity (99.6% [95% CI: 98.5%, 99.9%] vs 99.8% [95% CI: 98.8%, 100%] P= 0.57). In symptomatic patients, self-test had a sensitivity of 94.5% (95% CI: 86.6-98.5) and specificity of 62.5% (95% CI: 24.5-91.5). For asymptomatic patients, self-test had a sensitivity of 66.7% (95% CI: 29.9-92.5) and specificity of 100% (95% CI: 29.2-100.0). These were similar to clinical PCR as well. 

Conclusion
Clinician-performed and self-performed RATs had similarly high accuracy. The high observed sensitivity of home RATs supports their continued usage in ambulatory decision-making to identify eligible candidates for COVID-19 therapeutics. Their accessibility is key, since federal policy now states that patients are treatment eligible for a maximum of 7 days. Self-performed RATs reduce barriers including time needed to search for and then attend clinician appointments, and allow patients to play a larger role in their own care. Low false positive rates mitigate concerns about poor technique or contamination, and ensure that treatment is appropriate. Our study supports continued use of home RATs for clinical decision making.

Comparison of Accuracy of Self-Test and Clinical Rapid Antigen Testing for Coronavirus-19 (COVID-19)

Background
Non-urgent use of the emergency department (ED) is costly for patients. It can lead to increased healthcare spending and ED overcrowding and negatively affect primary care physician (PCP)-patient relationships. We aim to evaluate the association between perceived medical urgency, PCP coverage (whether a patient has a PCP), and patient descriptive characteristics with utilization of the ED for non-urgent clinical care.

Methods
Adult ED patients were stratified to preventable and non-preventable ED visits according to their emergency severity index (ESI) at the UC Irvine ED. A REDCap questionnaire was used to assess descriptive information, self-perceived medical urgency, and PCP Coverage. Chi-Square tests at a 5% significance level were performed to examine differences between race, native language, self-perceived medical urgency, and PCP coverage between preventable and non-preventable ED visits. 

Results
Study participants included 348 adult patients (52% female), of which 160 (46%) were preventable visits (ESI 4-5). There were more preventable visits among Black patients compared to non-Black patients (69.6% vs 30.4%, p=0.028) and the preventable group had less native English speakers than the non-preventable group (38.8% vs 61.2%, p=0.035). Compared to patients in the non-preventable ED visit group, patients in the preventable group are more likely to agree that they could have been seen and treated effectively by a PCP (p=0.003). Fewer patients in the preventable group have a PCP that they can see regularly and make an appointment with compared to the non-preventable group (40.3% vs 59.7%, p=0.004). 

Conclusion
Our results indicate that Black patients and non-native English speakers were overrepresented in preventable ED visits compared to their counterparts, suggesting these patients may be more vulnerable to the plethora of negative consequences associated with utilizing the ED for non-emergent medical services. In addition, our study also revealed that patients in the preventable ED visit group were less likely to have a PCP, even though they were more likely to agree that a PCP could manage their symptoms. Future interventions are needed to address this lack of PCP coverage among preventable ED patients to reduce patient financial burden, ED overcrowding, and overall healthcare spending.

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A Medical Student Near Peer Mentoring Program in Character Education Designed to Mitigate Adverse Childhood Experiences in High School Students

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