Background: While the impact of social and environmental exposure on cardiovascular risks is often reported individually, the combined effect is poorly understood. 
Objectives: We aim to study the association between a combination of social and environmental determinants of health and the incremental impact of environmental factors on cardiovascular disease (CVD) and risk factors prevalence.
Methods: Utilizing the 2022 Environmental Justice Index (EJI), socio-environmental EJI ranks were divided into quartiles, Q1-Q4 (Q1: the least, Q4: the most vulnerable census tracts). Age-adjusted rate ratios (RR) of health measures reported in the Prevention Population-Level Analysis and Community Estimates (PLACES) data were compared between quartiles using multivariable Poisson regression. A second regression model was used to assess the independent effect of environmental burden and social vulnerability. 
Results: The prevalence of CVD and other adverse health measures increased with EJI and EBM quartiles. Q4-EJI was associated with a higher rate of coronary artery disease (CAD) (RR: 1.684, 95%CI: .660-1.708, p<0.001) and stroke (RR: 2.112, 95%CI:2.078-2.147, p<0.001) compared with Q1-EJI. Similarly, the risk of CAD (RR:1.143, 95% CI:1.127–1.159, p<0.001) and stroke (RR:1.118, 95% CI:1.102-1.135, p<0.001) was significantly higher in Q4 than in Q1-EBM. Similar results were observed for chronic kidney disease, hypertension, diabetes, obesity, high cholesterol, lack of health insurance, sleep < 7 hours, no leisure time physical activity, and impaired mental and physical health > 14 days.
Conclusion: The prevalence of CVD and its risk factors is higher in areas with increased social and environmental adversities, and environmental exposure plays an important role independent of social factors.


The Impact of Environmental Injustice on Cardiovascular Diseases and Risk Factors in the United States

Background
This case presented with symptomatic anemia shortly after being diagnosed in NOV/2021 with Invasive Ductal Carcinoma in the left breast T4N2M0. She had chest pain, dry cough, epigastric pain, nausea and generalized fatiguability 3 weeks prior, no past medical history, but significant positive family history for non-Hodgkin Lymphoma. However, finding compatible blood units was very challenging and transfusion dependency was developed. The main approach is to reach clinical stability when she can receive the first cycle of neoadjuvant chemotherapy.

Methods
A complete blood profile, hemolysis indicators, Hb electrophoresis, CT scan of the abdomen was required to evaluate the case and bone marrow aspiration, biopsy, and immunohistochemistry study. Numerous PRBC units were given to support the patient under close monitoring with oral prednisolone, cyclophosphamide, and IVIg.
Result
She shows a hemolytic pattern with hemoglobin level at 6.3g/dl, with mild neutrophilia, normal platelets, reticulocytosis, indirect hyperbilirubinemia, positive direct Coomb’s test and high serum ferritin at 1045ng/L . However, the haptoglobin was not detected, MCV was normal, LDH level was not elevated at 170 U/L, normal vitamin B12, liver enzymes, urea and electrolytes and uric acid,. Her blood group was A+, the HB electrophoresis showed HbA 97.5%, HbA2 2.5% and CT scan of abdomen revealed mild hepatosplenomegaly. The peripheral blood film shows Anisocytosis, neutrophilia and normal platelet, and bone marrow biopsy showed no malignant infiltration. An immunohistochemistry study shows that the malignant cells are positive for CK (Creatine kinase) and Mammaglobin while they are negative for LCA, CD20, CD3 and GCDFP15.

Conclusion 
Autoimmune hemolytic anemia (AIHA) is recognized relatively rare with solid tumors as a paraneoplastic syndrome. However, in this case due to her family history, lymphoma must be excluded by bone marrow biopsy and immunohistochemistry study. Patient did respond well to prednisolone nevertheless complicated by diabetes mellitus and gouty arthritis and received numerous units of packed red blood cells, her anemia was corrected and patient was fit to

A case report of autoimmune hemolytic anemia in a newly diagnosed patient with breast cancer Challenging transfusion dependency that interferes with neoadjuvant chemotherapy

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**Abstract:**



Risk of Lupus Death According to Rural Urban Residence

Background:
Creutzfeldt-Jakob Disease (CJD) is a neurodegenerative process that manifests as a rapidly progressive dementia with a usual poor prognosis within 12 months. CJD can be further grouped into three main categories: sporadic (sCJD), genetic (gCJD), and acquired (aCJD). The worldwide incidence is around 1.5 to 2.0 per million person-years and about 85-95% of CJD can be attributed to sporadic CJD. The presentation of this disease can vary and therefore requires a criterion to make this consideration carefully. For sporadic CJD to meet the criteria for “probable,” it must have 3 main criteria: (1) Clinical findings of a neuropsychiatric disorder with a positive positive Real Time Quaking Induced Conversion (RT-QuiC) test or rapid dementia plus at least two of the following symptoms: myoclonus, visual or cerebellar abnormalities, pyramidal/extrapyramidal signs, and akinetic mutism, (2) a typical EEG findings of periodic sharp wave complexes, positive 14-3-3 CSF assay in disease duration of less than 2 years, or high signal in caudate/putamen regions on MRI brain scan or at least two cortical regions either on DWI or FLAIR, and (3) exclusion of other causes in diagnostic workup.

Case Presentation:
We report the case of a 61-year-old woman with a past medical history of hypothyroidism, psoriasis, and hypertension that presented for acute onset, rapidly progressive cognitive decline that was 1 month in duration. The patient’s clinical presentation of rapid cognitive decline, subtle cerebellar and upper motor neuron findings (e.g. pseudobulbar affect, slow speech), and MRI brain findings of cortical ribboning and restricted diffusion in the caudate nucleus was most consistent with probable sporadic CJD. Cerebral spinal fluid analysis revealed a positive Real Time Quaking Induced Conversion (RT-QuiC) test, t-tau protein of 18531 pg/mL (0-1149 pg/mL), and 14-3-3 gamma protein of 61440 Au/mL (<30-1999 Au/mL). An EEG revealed pseudo periodic triphasic sharp wave complexes over the left frontotemporal regions. Additional laboratory findings were obtained to rule out mimickers such as autoimmune encephalitis, Hashimoto’s encephalopathy, and CNS vasculitis. Upon receiving diagnosis, the patient’s condition rapidly worsened and died after 1 month possibly due to respiratory arrest.

Discussion:
This patient had an “atypical” presentation due to absence of hallmark symptoms such as myoclonus, however, the rapid course of the disease was consistent with the nature and course of sCJD. Definitive diagnosis of CJD requires neuropathological evaluation of brain tissue via immunohistochemistry or protease-resistant PrP/scrapie-associated proteins on Western blot via autopsy post-mortem. The patient presented in this report did not have an autopsy, however, with information gathered based on criteria from Center of Disease and Control, we have high clinical suspicion that this patient had probable sporadic CJD. There is no current FDA approved treatment that is available to treat this disease.


A Rare Case of Probable Sporadic Creutzfeldt-Jakob Disease

Background
Coronary artery disease (CAD) is the leading cause of death in the United States. In Hawaii, three of every ten deaths are due to CAD. Access to cardiac catheterization centers (CCC) is crucial for reducing morbidity and mortality, but most CCCs are concentrated in the capital, Honolulu. No prior studies have assessed the distribution of CCCs in relation to the demand and capacity for catheterization services in Hawaii using Geographic Information Systems (GIS). This study analyzed both current demand vs. capacity for CCCs, as well as projected optimal CCC locations based on time and distance considerations on the island of Oahu. 

Methods
GIS is a powerful tool with which location-allocation problems may be addressed. Data from the Hawaii Department of Health was implemented to estimate the number of patients in need of CCCs. Patients were then randomly distributed across residential areas in the location-allocation model. Using network analysis in GIS, residents’ travel time from their homes to the nearest CCCs was approximated. Travel time and demand vs. capacity maps were created to enable assessment of the accessibility of CCCs in each region and to highlight areas with unmet demand.

Results
Time-to-care analysis showed significant time burdens for patients in certain areas of Oahu. Under optimal traffic conditions, it took >60 minutes for patients in West Oahu and the North Shore, and >40 minutes for patients in Northeast Oahu to reach the nearest CCCs. Analysis of the demand vs. capacity of CCCs revealed the CCC in Central Oahu, which serves many of the patients with significant time burdens, exceeded its annual capacity by more than 985 patients. Meanwhile, all CCCs in South Oahu had significantly higher capacity than demand. To best decrease time burdens and mitigate capacity concerns for the greatest number of patients, an additional CCC should be established in West Oahu.

Conclusion
GIS analysis showed that the current CCCs on Oahu are not positioned to optimize patient outcomes. Patients in areas with significant time-to-CCC burdens likely face worse outcomes when they need emergent catheterization. This disparity could be remedied with the addition of CCCs closer to these regions, particularly in West Oahu. Looking forward, this model may be applied to other healthcare resources, such as emergency departments, to analyze current demand and geographical distributions and to influence future resource allocation. GIS has the power to improve healthcare efficiency, thus enhancing clinical outcomes.

GIS Analysis of Cardiac Catheterization Centers on the Island of Oahu


Background:
Mobile health (mHealth) is a rapidly evolving technological field determined to assist healthcare professionals and users in monitoring their health status through biometrics collected on internet of things (IoTs). Recent advancements in IoTs increase user access to protected/personal health information (PHI) and streamline data analysis for healthcare professionals to perform occupational responsibilities. While IoTs involve gathering individual health data, which some may see as violating the rights of privacy and security, implementing effective policies and regulations can ensure that confidentiality is maintained. Although the utilization of IoTs in healthcare is evolving rapidly, there is still limited exploration regarding how it can benefit individuals in high-risk occupations, such as first responders, who are frequently exposed to dangerous conditions.

Methods:
To explore this knowledge gap, our team has performed a literature review on the development of mHealth & IoTs in high-exposure occupations. High-exposure occupations were defined as those who experienced increased trauma, environmental hazards, chemicals, and stress (e.g., emergency medicine, firefighters, police officers, etc.). We reviewed previous implementations of IoTs in high-exposure occupations, evaluated statistics of work-related illnesses/injuries that were identified as preventable, and recognized challenges of IoTs utilization in such occupations.

Results:
Our literature review concluded there is a significant opportunity for the current utilization of IoTs in physician-patient relationships to expand toward such careers. Implementing non-obstructive wearable devices in high-exposure careers while abiding by the Health Information Technology for Economic and Clinical Health (HITECH) Act can minimize work-related mortalities, improve situational awareness, aid in the early detection of occupational illnesses/injuries, and facilitate safer working conditions. The Swiss cheese model developed by James Reason supports these claims through the addition of another systemic barrier to reduce unnecessary risk. Such an idea could be promoted by real-time monitoring and analysis of biometric data (heart rate, electrocardiogram, pulse oximetry, etc.) and environmental data for the user and a potential third-party analyst. The third-party analyst would interpret live biometrics for the users of the IoTs and send an alert if any abnormalities were identified compared to baseline measurements.

Conclusion:
mHealth and IoTs have become common since the COVID-19 pandemic and increased development encourages further utilization. Implementation of non-obstructive wearable devices in high-exposure occupations is one such way. Here we present a solution to promote work-related safety for preventable illnesses/injuries. Our literature review establishes an opportunity for the expansion of mHealth and IoTs to high-exposure occupations to promote overall safety.

IoTs Expansion and their Opportunity to Promote Safety in High-Exposure Occupations

Background
One in four adults in the United States live with a disability, making interactions between patients with disabilities and healthcare professionals inevitable. Despite this, numerous studies demonstrate that healthcare professionals lack confidence in providing equitable care to disabled patients. Several calls have been issued for improved anti-ableist and disability-specific healthcare education. However, there is a dearth of disability-focused continuing medication education (CME). Therefore, the aim of this study was to explore and assess patient-facing employees’ (1) willingness to participate in disability health training, and (2) self-perceived changes in confidence and attitudes towards patients with disabilities after completion of a disability-focused educational module termed the ADEPT-CARE protocol.

Methods
All patient-facing employees in our healthcare system were invited to voluntarily participate in the ADEPT-CARE module. The CME module of ADEPT-CARE consisted of a fifteen-minute video describing the protocol, which is a nine-step mnemonic for performing an equitable and comprehensive history and physical exam for a disabled patient, and a ten-minute ADEPT-CARE “in-action” standardized patient scenario. Voluntary pre- and post- module surveys assessed participants’ confidence and attitudes towards patients with disabilities on a 4-point Likert scale and included elements from Iezzoni et. al. and the Disability Attitudes in Health Care Scale. Descriptive statistics were used to analyze survey results. 

Results
Of the 14,410 patient-facing employees who were invited to participate in the training, 13,164 (91%) voluntarily completed the ADEPT-CARE module, and 1,542 (11.7%) completed the pre- and post-survey. Participants were most likely to be nurses, work in a non-surgical specialty, and have no prior training on disability. Completion of the module resulted in an increase in participants’ likelihood to agree that understanding their patients with disabilities was valuable (95.3% vs 98.2%, p<0.0001). Nearly all participants agreed that the ADEPT-CARE module improved their knowledge of disability health (n = 1,425, n = 94.6%), made sense (n = 1,472, 96.6%), increased their confidence in caring for patients with disabilities (n = 1,396, 93.1%), and will help them take better care of patients with disabilities (n = 1,463, 96.5%).

Conclusion
Healthcare professionals were willing to participate in voluntary training on disability. ADEPT-CARE was understood by a wide range of professionals and staff, and completing the training led to significant changes in participants’ self-perceived confidence and attitudes towards disabled patients. ADEPT-CARE has the potential to be a valuable teaching tool across other health systems to directly counter ableism in healthcare.

Improving Health Care Delivery for Patients with Disabilities: Implementing ADEPT-CARE Amongst Patient-Facing Employees at an Academic Medical Center

Numerous Recurrent Venous Thromboembolisms in the Setting of Severe Obesity and Anticoagulation: A Case Report

Learning Objective:
Identify Wernicke encephalopathy and copper deficiency as potential causes of neurologic abnormalities.
Case:
Wernicke encephalopathy is a potential consequence of heavy alcohol use. It classically presents with disorientation, ocular motor dysfunction, and ataxia. However, other medical complications may muddle this clinical picture. A 26-year-old previously healthy female presented with several months of worsening bilateral lower extremity weakness. She had multiple shots of hard liquor daily for several years and a low appetite for the past month following a friend’s death. Her last drink was three days before admission. On admission, vital signs were stable except for mild tachycardia. The patient was completely disoriented and unable to ambulate due to unsteadiness. She had an abnormal finger-to-nose test, bilateral vertical nystagmus, and stocking-glove pattern neuropathy. She also had leukopenia, normocytic anemia, and low serum thiamine, folate, and copper. HIV, RPR, vitamin B12 level, methylmalonic acid, urine drug screen, and lumbar puncture were all unremarkable. MRI brain was negative for mamillary body or thalamic changes. She was empirically treated for Wernicke encephalopathy using IV thiamine 500 mg TID for 2 days, then 200 mg daily for 5 days. After completing this, she was discharged with oral thiamine and folate supplementation for alcohol use disorder and gabapentin for neuropathy. She was instructed to purchase over-the-counter copper supplements for her copper deficiency. The patient made a full recovery other than she did not remember being hospitalized during a follow-up phone visit.
Discussion:
This patient’s neurological status was initially attributed to Wernicke encephalopathy given her disorientation, vertical nystagmus, and positive finger-to-nose test. However, she incidentally had low serum copper, which can be treated with oral supplements or cocoa. Copper deficiency is not classically associated with heavy alcohol use, though there has been literature hinting towards some association. Low copper can lead to leukopenia, normocytic anemia, and stocking-glove pattern neuropathy, all of which were present in this patient. She also lacked the contrast enhancement of the thalamus and mamillary bodies that is present in patients with Wernicke encephalopathy, which suggests that her clinical presentation was not solely from Wernicke encephalopathy. This case illustrates that although Wernicke encephalopathy is usually in the differential diagnosis of patients with neurologic abnormalities in the setting of heavy alcohol use, copper deficiency should also be included. Properly managing patients with such a complex clinical picture is essential to improve their neurologic status, avoid irreversible complications such as Korsakoff psychosis, and treat reversible vitamin and mineral deficiencies.

Mineral Mining: A Confounding Case of Wernicke Encephalopathy

Analyzing the Quality of Reporting of AI Studies for Hip Fracture Detection

Background
The choroid, due to its rich vascular supply, is the most commonly affected ocular site for metastatic diseases. 
Most common cancers that result in choroidal metastasis are breast cancer (46-47% of cases) and lung cancer (21-29%). 
The most common type of lung cancer responsible for metastatic spread to choroid is adenocarcinoma. Small-cell lung cancer is a rare cause of choroidal metastasis.

Case Presentation
A 69-year-old male with history of COPD and heavy tobacco smoking initially presented with right-sided blurred vision and flashes of light. In the oncologist’s office, the patient was also found to have dyspnea, fatigue, anorexia and significant unintentional weight loss.
Fundus examination revealed irregular creamy white lesion and sub retinal fluid. 
The optical coherence tomography (OCT), ultrasound and fluorescein angiography of right eye showed vitreous detachment and a 10 mm x 10 mm x 3 mm irregular choroidal mass consistent with amelanotic metastatic choroidal disease.
CT scan of the chest W/WO contrast revealed a 5 cm x 4 cm right lower lobe mass, multiple bilateral pleural-based nodules, left lobe satellite nodules, subcarinal and anterior tracheal lymphadenopathy. CT scan of the abdomen and pelvis were negative for metastatic disease.
CT-guided biopsy of the right lower lobe mass showed high-grade tumor cells and immunohistochemistry showed positive staining for synaptophysin, CD56, TTF-1, and AE1/AE3 consistent with small-cell lung cancer.

Discussion
Lung cancer is a very uncommon cause of choroidal metastasis. Among all lung neoplasms, adenocarcinoma of the lung is the most common type which account for choroidal metastasis. 
SCLC is rarely reported to have spread to choroid. Most patients with SCLC with intraocular metastasis also had evidence of spread to bones and abdominal organs. Our patient did not show metastasis to solid organs or bones, but had widespread metastatic lesions in the thoracic cavity. Treatment of metastatic SCLC includes systemic therapy and local therapy. Systemic therapy includes chemotherapy with platinum-based regimens and target therapy e.g. atezolizumab or durvalumabc etc. Local radiotherapy also helps increase tumor response rate significantly.


Unilateral Choroidal Metastases as An Unusual Presentation for Small Cell Lung Cancer


Background
Emergency department (ED) visits for preventable dental conditions are substantially increasing. 

Methods
A retrospective chart review of prospectively maintained data was used. We reviewed 275 children who presented to the ED between July 2019 and January 2021. The inclusion criteria were children under the age of 18 years with odontogenic pain, demographics, insurance status, primary diagnosis, services provided in the ED, prescriptions given, total ED length of stay, and disposition. We classified these visits as necessary and unnecessary based on the treatment given. Data were analyzed using chi-square and student t-test.

Results
Among these patients, 52% were males with ages 9.3±4.7 years and a median of 9 years old. The primary diagnoses were dental caries (27%), tooth pain (26%), tooth infections (17%), traumatic tooth fracture (11%), and others comprising cavities, gingivitis, and oral mucosal infections (19%). Most patients were under Medicaid-managed care (67%), followed by those without insurance (17%). After ED evaluation, 70% of patients received non-steroidal anti-inflammatory drugs (NSAIDs), 55% had dental referrals, 28% had OMFS referrals, and 27% received antibiotics. This cohort was subdivided into necessary versus unnecessary ED visitation––with the majority of patients having tooth pain (17% vs. 33%) and dental caries (21% vs. 31%) that required NSAIDs (35% vs. 34%) and home discharge (98% vs. 99%).

Conclusion
The cost of 1 ED visit in New York City averages from 1400$ to 1600$, so avoiding these 155 unnecessary ED visits, about 250,000$ could be saved. Dental pain is highly prevalent among children, with a substantial increase in ED visits for atraumatic dental problems. The fact is that dental conditions can be treated more effectively in a dental clinic due to the availability of definitive care and the likelihood of continuity of care than in a hospital. Multiple strategies are required to reduce this usage and relieve the healthcare system pressure. Reducing barriers like lack of insurance, sociocultural deterrents, and language barriers improves access to optimal dental care. Efforts should be made to raise dental health awareness and improve access and utilization of oral health care services. These will benefit the patient and decrease the reliance on hospital ED for non-traumatic dental issues.


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The Impact of Environmental Injustice on Cardiovascular Diseases and Risk Factors in the United States

A case report of autoimmune hemolytic anemia in a newly diagnosed patient with breast cancer Challenging transfusion dependency that interferes with neoadjuvant chemotherapy

Risk of Lupus Death According to Rural Urban Residence

A Rare Case of Probable Sporadic Creutzfeldt-Jakob Disease

GIS Analysis of Cardiac Catheterization Centers on the Island of Oahu

IoTs Expansion and their Opportunity to Promote Safety in High-Exposure Occupations

Improving Health Care Delivery for Patients with Disabilities: Implementing ADEPT-CARE Amongst Patient-Facing Employees at an Academic Medical Center

Numerous Recurrent Venous Thromboembolisms in the Setting of Severe Obesity and Anticoagulation: A Case Report

Mineral Mining: A Confounding Case of Wernicke Encephalopathy

Analyzing the Quality of Reporting of AI Studies for Hip Fracture Detection

Unilateral Choroidal Metastases as An Unusual Presentation for Small Cell Lung Cancer

An Audit of Dental Visits in the Pediatric Emergency Department of a Community Teaching Hospital

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