United States

Abstract Title: Time to Hemorrhage Response After Implementation of an Obstetric
Hemorrhage Bundle
Background: Obstetric hemorrhage (OBH) is a leading cause of maternal mortality on day of birth. Alarmingly, but not surprisingly, maternal mortality tracks closely with racial disparities, with patients from underserved backgrounds at a greater risk for death during pregnancy and childbirth. Despite several effective uterotonic interventions available for postpartum bleeding, the rate of OBH per 10,000 births has seen a sharp increase, from 4.3 in 1993 to 21.1 in 2014. OBH “bundles” that standardize hemorrhage recognition and response have been shown to reduce OBH rates, however the mechanisms for reduction in morbidity are unclear. Imprecise estimate of blood loss leading to delayed provider response to hemorrhage has been theorized as a contributing factor for the rise in hemorrhage rates. This is the first study to compare the time delay of uterotonic interventions for OBH before and after the implementation of an OBH bundle.
Methods: We performed a retrospective study of 7276 deliveries before and after
implementation of an OBH bundle which includes risk assessment tools and quantitative blood loss measurement. A random sample of deliveries from January to December 2016 was selected for the pre-intervention group. All deliveries from January 2018 to December 2019 were included in the post-intervention group. The primary outcome was time from delivery to first dose of oxytocin; secondary outcome was the number of uterotonic interventions utilized. Groups were compared using Student’s t-tests and chisquared tests.
Results: Of the 7276 deliveries, 1944 (27%) occurred pre-intervention and 5332 (73%) occurred post-intervention. After bundle implementation, average oxytocin time delay decreased from 8.3 minutes to 5.9 minutes (p &lt;0.01). The frequency of second line uterotonic interventions increased from 16% to 18% post-intervention (p &lt;0.05).
Conclusion: This is the first study to investigate how implementation of standard OBH treatment drives clinical decision making such as medication administration. Implementation of this OBH bundle was associated with more prompt delivery of uterotonic interventions. Future studies should explore the effect of OBH bundle protocols on hemorrhage-related outcomes.

AMA Research Challenge 2022

Time to Hemorrhage Response After Implementation of a Obstetric Hemorrhage Bundle

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Ricardo Correa, MD, EdD
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Abstract Title: Time to Hemorrhage Response After Implementation of an Obstetric
Hemorrhage Bundle
Background: Obstetric hemorrhage (OBH) is a leading cause of maternal mortality on day of birth. Alarmingly, but not surprisingly, maternal mortality tracks closely with racial disparities, with patients from underserved backgrounds at a greater risk for death during pregnancy and childbirth. Despite several effective uterotonic interventions available for postpartum bleeding, the rate of OBH per 10,000 births has seen a sharp increase, from 4.3 in 1993 to 21.1 in 2014. OBH “bundles” that standardize hemorrhage recognition and response have been shown to reduce OBH rates, however the mechanisms for reduction in morbidity are unclear. Imprecise estimate of blood loss leading to delayed provider response to hemorrhage has been theorized as a contributing factor for the rise in hemorrhage rates. This is the first study to compare the time delay of uterotonic interventions for OBH before and after the implementation of an OBH bundle.
Methods: We performed a retrospective study of 7276 deliveries before and after
implementation of an OBH bundle which includes risk assessment tools and quantitative blood loss measurement. A random sample of deliveries from January to December 2016 was selected for the pre-intervention group. All deliveries from January 2018 to December 2019 were included in the post-intervention group. The primary outcome was time from delivery to first dose of oxytocin; secondary outcome was the number of uterotonic interventions utilized. Groups were compared using Student’s t-tests and chisquared tests.
Results: Of the 7276 deliveries, 1944 (27%) occurred pre-intervention and 5332 (73%) occurred post-intervention. After bundle implementation, average oxytocin time delay decreased from 8.3 minutes to 5.9 minutes (p <0.01). The frequency of second line uterotonic interventions increased from 16% to 18% post-intervention (p <0.05).
Conclusion: This is the first study to investigate how implementation of standard OBH treatment drives clinical decision making such as medication administration. Implementation of this OBH bundle was associated with more prompt delivery of uterotonic interventions. Future studies should explore the effect of OBH bundle protocols on hemorrhage-related outcomes.

technical paper

Impacts of Wind Speeds on Wildfire specific PM2.5 Levels in Orange County and Butte County: A Comparative Observational Study

Background: The COVID-19 pandemic has affected society's quality of life worldwide. Everyday aspects of life have been obliged to change, allowing individuals a safer lifestyle revolving around COVID-19. Once vaccines against COVID-19 were introduced, daily practices were expected to remit to normalcy. In this study, we aimed to identify if vaccination influenced the way of living of vaccinated individuals.
Methods: A questionnaire containing sociodemographic inquiries was administered via QR Code at the Universidad Central del Caribe (UCC) vaccination clinics and social media platforms to assess the quality of life (QoL) before the pandemic (BP), during the pandemic before vaccination (DPBV), and after vaccination (AV) against COVID-19. The study ran from January 2022 to May 2022.
Results: Participant recruitment reached 203 participants, 138 identified as female and 55 as male, all aged 21 and older. Participants received the following vaccines: 69.5% received Pfizer- BioNTech, 25.6% received Moderna, 3.4% received a combination of Pfizer-BioNTech/Moderna, and 1.5% received Johnson&Johnson. We analyzed that DPBV, 60% of participants did not visit food establishments (P < .001). Likewise, 62.3% did not visit malls (P < .001). However, there was a statistical difference AV with 67.5% of participants visiting food establishments (P < .001) and 74.2% visiting malls 1-2 times per week (P < .001). Regarding feeling of safety, while spending time with vaccinated or non-vaccinated people, we observed that 72.8% felt assured about hanging around vaccinated people, and 19.9% did not feel safe spending time with non-vaccinated people (P < .001). Concerning safety attending public events: 9.3% of participants said they felt safe DPBV, while 33.7% said they felt secure AV (P < .001).
Conclusion: The COVID-19 vaccine positively impacted the QoL of Puerto Ricans participating in the study. The statistical analysis indicates an increase in the measured daily activities amongst individuals post-vaccination compared to pre-vaccination in several variables, such as visits to food establishments, malls, and public events.

Quality of Life After COVID-19 Vaccination in an Adult Hispanic Cohort

Abstract Title: Tissue Anchoring Nanomedicine Alleviates Osteoarthritis Knee Model in Mice

Background 
Osteoarthritis (OA) is the most common joint disorder in the United States. The CDC estimates more than 32.5 million US adults suffer from clinical OA. According to the AAOS evidence-based guidelines, intraarticular anti-inflammatory therapy is the first line treatment for knee OA. Currently available therapies have critical shortcomings, primarily the inability to modify pathophysiological disease progression limiting treatment solely to palliative care. Further, rapid clearance of these drugs from the joint space limits therapeutic potential and results in systemic side effects. Given the established anti-inflammatory potential and readily modifiable structure of nanoparticle fullerene (C60), we attempt to develop a more precise treatment for knee OA.
Methods
We have previously developed a targeted C60 nanoparticle composed of a C60 cage with a conjugated cFLFLF peptide (cFLFLF-C60) that binds specifically to formyl peptide receptor-1, a receptor abundantly expressed on activated macrophages. Using Raw 264.7 macrophages, Lipopolysaccharide, and the Cy5 fluorophore integrated in the cFLFLF peptide, the nanoparticle’s preferential binding was evaluated, and anti-inflammatory efficacy analyzed by PCR. Ten to 12-week-old Balb/c mice underwent destabilization of middle meniscus (DMM) surgery to induce OA, with seven mice receiving a cFLFLF-C60 injection and six serving as control (injected with saline). IVIS imaging was then used to evaluate the functionalized-C60’s distribution 2 weeks post-injection. After 6 weeks, the mice were sacrificed, and the knee joints scanned and analyzed by microCT as well as sectioned and stained for histological analysis.
Results
The cFLFLF-C60 demonstrated preferential binding to LPS-stimulated macrophages versus non-inflammed macrophages. IVIS imaging revealed significant retention within the injured knee joint compared to fluorophore-labeled saline. MicroCT analysis revealed that compared to control mice joints, cFLFLF-C60 effectively attenuated OA morphological changes (subchondral sclerosis, osteophyte formation) and restored trabeculae morphological parameters back to those of sham group (trabeculae number, spacing, and connectivity density). Histologic analysis revealed improved OARSI grading and tidemark measurements in the cFLFLF-C60 cohort.
Conclusion
cFLFLF-C60 preferentially anchors to activated macrophages, leading to significantly increased joint space retention. The pathophysiological changes that define OA were attenuated by intra-articular injection of cFLFLF-C60 as confirmed by microCT and histological analysis.


Tissue Anchoring Nanomedicine Alleviates Osteoarthritis Knee Model in Mice

Background: There have been a few recent studies that attempt to describe the insertional anatomy of the triceps brachii muscle onto the tip of the olecranon process of the ulna. Despite the findings from these studies, the detailed complexity of this insertional footprint continues to challenge surgeons as evidenced by continued reports of triceps-associated complications following elbow procedures including tendon rupture and triceps insufficiency. The purpose of this study is to provide a more detailed understanding of the three-dimensional footprint of the triceps brachii at its olecranon insertion at the elbow.
Methods: To perform this basic science study, 22 cadaveric elbows were dissected leaving only the distal insertion of the triceps intact. The insertion was defined and probed with a three-dimensional digitizer to create a digital three-dimensional footprint allowing width, height, and surface area of the footprint to be recorded relative to the bare area. Additionally, the insertional soft tissues of tendon versus muscle along with the shape of the footprints were qualitatively described. An alpha of 0.05 was used for all statistical analysis.
Results: We found the mean width and surface area of the lateral segment to be greater in males than in females (30.07 mm vs. 24.37 mm, p=0.0339 and 282.1 mm vs. 211. 56 mm, p= 0.0181, respectively). No other statistically significant differences between the sexes were noted. In all specimens, the triceps insertional footprint was “crescent-shaped” and consisted of three regions: central tendon, medial muscular extension, and lateral muscular extension.
Conclusion: The distinction between muscles and tendons is particularly important for surgical decision making. These findings better detailing the complexity of the insertional anatomy of the triceps brachii muscle help explain the importance of avoiding these muscular structures during triceps-off approaches and provides the framework for future clinical studies.


Triceps Brachii Insertional Footprint: Under-estimated Complexity

*Purpose: The rate of living donor kidney transplants (LDKTs) performed has declined overall regardless of race. Studies show that web-based tools increase access to living organ donation (LOD). Kidney transplant candidates (KTCs) may be reluctant to ask potential donors directly. Donor app was designed to help KTCs identify potential living donors by creating social media postings about their need for transplant. The purpose of this study is to evaluate the feasibility of using Donor app in improving awareness about LOD and rates of LDKT.
*Methods: Single-center prospective pilot study of 53 adult KTCs without potential donors was conducted using Donor app. KTCs were required to have access to social media account(s) including Facebook, Messenger, Email and/or Twitter. Based on KTC preference, postings were shared on as many platforms as desired. KTCs were allowed to have donor Champion(s) that will post their own story on social media about their relationship with KTC to advocate for donation. Demographics, clinical characteristics, donor referrals and transplant outcomes were compared between KTCs who used the Donor app with 1:1 matched historic controls from our waitlist.
*Results: 47 KTCs posted their stories using the Donor app. Median age 48 yrs (Interquartile range [IQR]: 41.5-58.5 yrs); median time on waitlist 511 days (IQR: 107-777 days), with 54% AA (n=25). Total views on all platforms and patients were 8501. 67 donor referrals came on behalf of 21/47 KTCs (44%) with a median of 6 days (IQR: 1-23 days) from posting to 1st donor inquiry; 6/21 (28%) had at least 1 donor Champion. KTCs with at least 1 donor referral were also likely to have at least 1 donor Champion (p=0.009), use of multiple social media outlets for posting their story (p=0.02), and had significantly higher views vs. ones with no referrals (487 vs. 71 views/KTC respectively; p=0.003). To date, 2 underwent transplants (1 LDKT; 1 deceased direct donation) and 4 have approved living donors pending the scheduling of transplant. Another 4 KTC’s have living donors still in evaluation. None of the matched controls had any living donor referrals (p=0.01).
*Conclusions: The Donor app can significantly increase awareness & rate of LOD, including in AA. Transplant programs should consider this technology as adjunct support for KTCs who otherwise have no prospects for potential living kidney donation.

Using social media to increase live organ donation for kidney transplant candidates: Single-center study using Donor App

Background:
Boston Medical Center (BMC) is a safety net hospital that serves a diverse patient population with various socio-demographic backgrounds. It is crucial to understand whether such factors serve as barriers to care. Previous studies have investigated disparities among specific populations, such as African Americans, and have used the accounts of cancer survivors or oncologists, but few studies have addressed barriers that encompass multiple minority populations in a safety net hospital. This study investigates disparities in care regarding clinical trial discussion and enrollment in lung cancer patients. 

Methods:
1,121 patients with a diagnosis of lung cancer between January 2015 to December 2020 at BMC were included in this study. Electronic medical records were searched for keywords “clinical trial” or “enroll”, or by filtering oncology notes for “research encounter.” Each chart was reviewed for one of three categories: 1) clinical trial discussed and patient enrolled, 2) clinical trial discussed but patient not enrolled, 3) clinical trial not discussed. Socio-demographic variables such as age, gender, race, ethnicity, city, primary language, median household income, insurance, and education level were also collected. SPSS version 26.0 was used for chi-squared and t-test statistical analysis. 

Results: 
Of 1,121 patients, 50.4% were of minority race, 16.9% did not speak English, 8% were Hispanic, 70.6% had an education of high school or below, and 70.6% belonged to a lower median house-hold income (<$84,000). Clinical trial was discussed in 141 patients (12.6%) and of those, 22 (15.6%) were enrolled. Although clinical trial enrollement has been historically low at BMC, we enrolled more African American patients (50%). When looking at age, clinical trial discussions were conducted more with younger patients (68.19 vs 71.37, p=0.001). There was no significant difference in clinical trial discussion or enrollment between gender, race, ethnicity, primary language, median household income, insurance, or education level. 

Conclusion:
Overall, BMC’s clinical trial discussion and enrollment rate were found to be similar across various socio-demographic factors. The only difference identified was clinical trials were discussed more with younger populations. This indicates that patients presenting with lung cancer to BMC experience minimal disparities in care regarding clinical trial discussion and enrollment.

Disparities in Lung Cancer Clinical Trial Discussion and Enrollment at a Safety Net Hospital

Background
Syphilis, colloquially termed “the Great Imitator,” is a sexually transmitted infection caused by the spirochete treponema pallidum. Syphilis occurs in multiple stages. Tertiary syphilis occurs years after inoculation, presents with chronic granulomas, cardiovascular, and neurologic manifestations. Syphilitic hepatitis is a rare and often missed diagnosis in patients who have syphilis and who are often co-infected with HIV or hepatitis B.
Case Presentation 
The diagnosis is made by both clinical presentations and positive serological markers, characteristic transaminitis, with no other alternative cause of hepatobiliary injury identified. Here, we highlight a case of an undomiciled 40-year-old male with HIV (on Genvoya) and chronic hepatitis B, who presented with tachycardia to 107. Physical examination was remarkable for a diffusely spread rash with erythema on the bilateral lower extremities, a small purulent boil on the right shin, left index finger and dry, itchy, distinct raised purple lesions on the scalp, eyebrows, upper and lower extremities, back, and shoulders. Laboratory findings were remarkable for a severely elevated alkaline phosphatase, mild transaminitis, and elevated total bilirubin, with negative pertinent imaging including a right upper quadrant sonogram, CT scan of the abdomen, and MRCP. Extensive additional work-up revealed elevated VDRL titers. Both a skin and liver biopsy were completed. Immunohistochemical stain of shave biopsy of a verrucous plaque on the scalp vertex and an excoriated papule of the left neck highlighted numerous spirochetes. Liver biopsy revealed hepatocellular necrosis with moderate mixed inflammation involving the portal tract and periportal hepatocytes, with immunohistochemical marker for spirochetes negative for organisms. However, given the patient’s clinical history of secondary syphilis involving the skin and lab abnormalities, it raised the differential diagnosis of syphilitic hepatitis.
Diagnosis
With our case report and extensive research of the literature, we hope to shed light on the importance of certain infections, even those in decline, on the differential. Additionally, contemplation of coexisting infections often helps to contribute to diagnoses not otherwise common. Because of how rarely seen syphilitic hepatitis is, it is often a missed diagnosis, but we are hopeful our case report helps physicians with patients with similar presentations, especially patients with otherwise unexplained high alkaline phosphatase levels.


The Great Masquerader: A Case of Syphilitic Hepatitis

Abstract Title: Applying Illness Scripts Theory to Climate Health Equity: Design and Pilot Evaluation of a Multi-Residency Educational Symposium
Background: Defining climate change is key to understanding its long-lasting impacts and the urgency for action. Climate change encompasses the natural and primarily human-driven processes resulting in vast changes to the environment which indirectly and directly impact human health and disease, disproportionately affecting vulnerable populations. While climate change continues to be touted as a public health crisis, much of the ground-level work for tackling the issue remains. Medical education is key to amplifying efforts for change and resulting in a paradigm shift in human health and disease. As physicians, we can bring about sustainability in these efforts by redesigning medical education to seamlessly implement the processes and impacts of climate change in the common framework of “illness scripts” which are used to teach and learn about various medical conditions. 
Methods: The purpose of this study was to pilot an educational intervention and evaluate its effectiveness aimed at incorporating the use of newly adapted illness scripts for common medical conditions with a climate health and equity lens. The intervention was a multi-residency half-day symposium for Family Medicine and Emergency Medicine residents in San Diego, CA developed via the collective expertise of Primary Care, Emergency Medicine, Pediatric, and OBGYN physicians. The symposium consisted of interactive breakout sessions focused on the climate health impacts on various cardiac, respiratory, obstetric, and mental health conditions followed by large group sessions centered on health advocacy.
Results: The symposium was attended by 92 resident and faculty physicians, of which 46 completed the pre-intervention survey and 29 completed the post-intervention survey. Survey participants reported a statistically significant difference in their knowledge and skills pre- and post-attendance of the symposium (p-value <0.001).
Conclusion: A multi-residency symposium leveraging the collective expertise of local physicians and the application of illness scripts is a potential educational strategy to educate physicians about climate health. While the concept of integration of climate health into medical education is not novel, the use of illness scripts, which are known to improve clinical reasoning and application of new knowledge to clinical problems, to accomplish this has not been studied or implemented to the best of our knowledge.

Applying Illness Scripts Theory to Climate Health Equity: 
Design and Pilot Evaluation of a Multi-Residency Educational Symposium

Association of Statins with the Onset and Progression of Non-Alcoholic Fatty Liver Disease in Veterans with Diabetes: A Retrospective Propensity Score-Matched Cohort Study

Background
This review aims to establish the current trends in the management of mallet finger injuries. Practices vary widely from institution to institution as there is no clear-cut guideline on which intervention is preferred. Case studies and past literature reviews from 2015 onwards were analyzed to assess for a general trend in the treatment of mallet finger injury as well as to analyze associated risks with each approach. It was found that surgical intervention, with closed reduction percutaneous k-wire fixation as the most utilized method, is generally favored in most circumstances due to compliance issues associated with splinting and a better degree of improvement in extensor lag as compared to non-operative intervention.

Case Presentation
Upon review of the literature, it was found that operative intervention of the closed mallet finger injury resulted in a shorter immobilization period of 4.9 weeks compared to splinting which had a much longer immobilization average of 9.5 weeks. The mean extension lag was significantly better in patients in surgical treatment groups as compared to conservative treatment groups and also had a better extension of the DIP joint by 11.7 º. Specifically, the conservatively treated group had an extensor lag of 13.8º while the surgically treated group had an extensor lag of 2.1º. Within operative intervention, K-wire (Kirschner Wire) was a popular choice among surgeons because of the minimally invasive fixation achieved with closed reduction.

Discussion
Overall, surgical intervention with K-wire pinning seems to be the predominating trend when considering treatment for mallet finger injuries. Surgical intervention is preferred by surgeons for all cases of mallet finger regardless of the degree of articular surface involved because of the ease of patient compliance, cosmetic reasons, and quicker restoration of function for the patient. Operative intervention was also shown to present with decreased extensor lag delay, higher patient comfort levels as compared to patients who underwent non-surgical interventions, and also avoids the prospect of having to revisit the injury if it failed conservative intervention via splinting.

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Time to Hemorrhage Response After Implementation of a Obstetric Hemorrhage Bundle

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