United States

The COVID-19 pandemic has revealed significant secondary complications affecting musculoskeletal (MSK) health, especially in patients with pre-existing conditions. This review synthesizes data from clinical and experimental studies on key MSK biomarkers, including cartilage oligomeric matrix protein (COMP), hyaluronic acid (HA), osteocalcin, alkaline phosphatase (ALP), procollagen type I N-terminal peptide (PINP), osteopontin (OPN), matrix metalloproteinases (MMP-3 and MMP-9), myostatin, IGF-1, follistatin, and creatine kinase. COVID-19 is associated with decreased COMP and osteocalcin levels, indicating cartilage degradation and impaired bone formation, alongside elevated HA, ALP, PINP, OPN, and MMPs, reflecting increased joint inflammation, bone remodeling, and tissue breakdown. Changes in myostatin, IGF-1, follistatin, and creatine kinase levels have been showen to be linked with COVID-19 related sarcopenia. These biomarker alterations provide insight into the underlying mechanisms of MSK damage in COVID-19 patients and highlight the potential for using these markers in early diagnosis and management of post-COVID musculoskeletal disorders. Further longitudinal research is essential to develop targeted therapies aimed at mitigating long-term MSK complications in affected individuals.

2025 AMA Research Challenge – Member Premier Access

Understanding Musculoskeletal Complications in COVID-19 Through Biomarkers

Congratulations to all the researchers who have qualified for the AMA Research Challenge virtual poster symposium and semifinals!

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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).

•In 2025, it is estimated that there will be 84,870 new cases of bladder
cancer and an estimated 17,420 people will die of this disease.
•Bladder cancer is associated with significant renal-related mortality.
•Patients with muscle invasive bladder cancer (MIBC) scheduled for radical
cystectomy (RC) have reported baseline CKD prevalence rates of
approximately 37%. Studies have shown higher CKD stages post-RC
increases all cause mortality.
•This can be attributed to chemotherapy-associated nephrotoxicity, acute
kidney injury (AKI), chronic kidney disease (CKD) with possible dialysis
dependence.
•Older adults are particularly vulnerable due to age-related declines in renal
function, comorbidities, and higher prevalence rates.
•In our study we plan to evaluate the burden and trends of renal function
decline in bladder cancer patients using national database.
•Using the CDC WONDER Database, this study aimed to evaluate renal-
related events as a cause of death in bladder cancer patients, with a focus
on demographic trends and the preferred place of death (PPOD) in the
United States.

The Impact of Declining Renal Function on Bladder Cancer in the U.S. (1999-2023): A Regression Analysis Using the CDC WONDER Database

Introduction: The diagnostic yield of endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) can approach 72-95% in mediastinal and hilar lymph nodes. However, these percentages refer to the final diagnosis made by the pathologist after the procedure is completed. Rapid On-Site Evaluation (ROSE) is used during the procedure to obtain a preliminary pathology report. When performed on FNA samples, ROSE is frequently non-diagnostic, compelling the bronchoscopist to sample additional lymph nodes or switch modalities to navigational bronchoscopy for direct sampling of the lesion. Here, we investigate the utility of performing intranodal forceps biopsies under EBUS guidance to improve the diagnostic accuracy of ROSE. 



Methods: 58 adult patients with mediastinal or hilar lymphadenopathy were included in this single-center retrospective study with procedure dates between February 2021 and January 2023. A single bronchoscopist performed all procedures. After identification of the pathologic lymph node(s), EBUS-FNA sampling was performed, with samples being evaluated by ROSE. If these specimens were non-diagnostic, then intranodal forceps biopsy was attempted. When successful, forceps biopsies underwent ROSE as well. The diagnostic sensitivity for biopsy ROSE was calculated using the final pathology reports as the “gold standard” for diagnosis. 



Results: In our 58 patients, 65 lymph nodes and nodules underwent forceps biopsy. 83% (54/65) of the lymph nodes sampled had ROSE performed on both FNA and the biopsy, the majority of which were performed due to non-diagnostic ROSE. Of these, 18 (38%) had a positive biopsy ROSE. In one patient, there was a false positive with ROSE of the biopsy being read as “lesional cells”, but the final pathology had a diagnosis of “reactive cells.” When used as an add-on procedure for negative FNA ROSE, intranodal forceps biopsies had a sensitivity of 61.5%, specificity of 87.5%, positive predictive value of 94.1%, and negative predictive value of 41.2%. No complications were attributed to the intranodal forceps biopsies. 



Conclusion: While EBUS-FNA is an excellent diagnostic tool, false-negative preliminary results on ROSE frequently occur. Our study shows that intra-nodal forceps biopsy can be performed safely and effectively on a wide array of mediastinal lymph node stations, and that it can improve the immediate diagnostic yield of ROSE. In our experience, the use of intranodal forceps biopsy as an add-on procedure for negative FNA ROSE reduced the need for additional procedures in over one-third of cases. Further studies are recommended to generalize these findings as well as investigate the overall meaningful clinical benefits of intranodal forceps biopsy.

Using Endobronchial Ultrasound-Guided Forceps Biopsy to Improve Yield of Rapid On-Site Examination During Bronchoscopy

Abstract Title
The Impact of Anesthesia-Induced Intraoperative Hypotension on Hemostasis during Holmium Laser Enucleation of the Prostate

Background
Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms (LUTS) in men. Holmium laser enucleation of the prostate (HoLEP) has emerged as a superior option for patients with hemostatic concerns. Intraoperative hypotension (IOH) during general anesthesia is a phenomenon whereby general anesthetics reduce a patient’s blood pressure (BP) and is commonly defined as a >20% reduction from baseline. Existing literature on the relationship between IOH and postoperative blood loss is sparse in urology but has been proposed in plastic surgery literature. This study aims to address this critical knowledge gap by investigating the effect of IOH during HoLEP on post-operative hematuria.

Methods
A retrospective analysis was conducted of all patients who underwent HoLEP by a single surgeon from 1/1/2024 to 12/31/2024. The primary comparison group was the incidence of clinically significant hematuria (CSH). Groups with and without CSH were matched by preoperative prostate volume as determined by preoperative imaging using coarsened exact matching. Mean baseline systolic BP (SBP) within 1 year before HoLEP, highest SBP during the first half of the procedure (the “enucleation phase”), and highest SBP during the second half (the “hemostasis and morcellation phase”) were recorded. Patients were considered to have IOH if highest SBP was at least 20% below the mean baseline. Perioperative characteristics were compared using the Wilcoxon Rank Sum test for continuous variables and either the Chi-squared or Fisher’s exact test for categorical variables.

Results
Out of 182 HoLEPs in the study period there were 26 included in each group after matching. Baseline characteristics were similar. The CSH cohort had a greater incidence of IOH during the hemostasis and morcellation phase (21 vs 0%, p=0.022). The CSH cohort also demonstrated greater length of stay and incidence of ED visits and readmissions.

Conclusion
Patients with IOH throughout the hemostasis and morcellation phase of HoLEP appeared more likely to progress to CSH. Considering IOH role when identifying bleeding vessels and obtaining hemostasis is critical to improving patient safety. Thus, it may be prudent to optimize blood pressure during the hemostasis and morcellation phase of the procedure in order to minimize risk of CSH.

Intraoperative Hypotension and Postoperative Risk of Bleeding in Hemostasis during Holmium Laser Enucleation of the Prostate 

This case report describes myeloperoxidase-anti-neutrophil cytoplasmic antibody
associated vasculitis with kidney involvement in a patient with relapsing
polychondritis, which was successfully treated with Avacopan. Although
relapsing polychondritis has been associated with anti-neutrophil cytoplasmic
antibody-associated vasculitis, overlap can result in severe organ involvement,
particularly renal damage progressing to end-stage kidney disease. This case
presents a unique opportunity to evaluate the potential role of Avacopan as an
alternative therapeutic option in managing myeloperoxidase-anti-neutrophil
cytoplasmic antibody-associated vasculitis in the context of relapsing polychondritis highlighting a positive renal response despite treatment challenges.

Avacopan in the Treatment of Relapsing Polychondritis with p-ANCA Associated Vasculitis


A Novel Method for Curriculum Evaluation: A Cognitive Diagnostic Modeling Approach 

Background 

Integrating basic science education with clinical application in the pre-clerkship years has been shown to strengthen knowledge retention and improve clinical performance later on. In 2017, the University of Toledo College of Medicine and Life Sciences launched a new competency-based curriculum called “Rocket Medicine.” This redesign emphasized early clinical exposure and a more seamless connection between foundational sciences and clinical skills. The transition created an opportunity to compare student mastery of these areas using the DINA model under both the traditional Legacy curriculum and Rocket Medicine. To assess this, we examined retention of foundational science knowledge and student proficiency across key domains, including Diagnosis, Management, Prevention, and Foundation. 

Methods 

The Deterministic Input, Noisy “And” Gate (DINA) model, a type of Cognitive Diagnostic Assessment (CDA), was used to evaluate students’ content mastery based on their performance on NBME subject exams. We applied the DINA model to calculate percentage content mastery across four core skills: Diagnosis, Management, Prevention, and Foundation. Data were collected from all required core clerkships for students in both the Legacy curriculum and the redesigned Rocket Medicine curriculum between academic years 2017 and 2024. To perform the analysis, we built a question-by-content Q-matrix using NBME item analysis reports. Differences in performance between the two curricula were tested using one-way ANOVA and two-sample t-tests, with significance set at P < 0.05. Each medical school cohort included approximately 175 students. 

Results 

Overall, students in the Rocket Medicine curriculum demonstrated higher content mastery across the four core skills (Diagnosis, Management, Prevention, and Foundation) compared to those in the Legacy curriculum. This trend was seen in most clerkships, including significant gains in Diagnosis for internal medicine (95% vs. 81%, p < 0.05), Management for pediatrics, and all four skills in OBGYN. 

Prevention consistently emerged as the lowest mastered skill across both curricula and clerkships. Within Rocket Medicine students, Prevention was significantly lower than Diagnosis in internal medicine (75% vs. 95%, p < 0.05) and lower than other skills in pediatrics, neurology, psychiatry, and surgery (all p < 0.05). 

An exception to these trends was noted in emergency medicine, where Legacy students showed higher overall mastery, likely due to small cohort sizes before becoming a required clerkship. No significant differences were observed between curricula in family medicine. 

Conclusion 

The DINA model revealed higher overall content mastery with Rocket Medicine. However, Prevention remained a consistent gap, highlighting a key area for curriculum refinement and targeted improvement.

A Novel Method for Curriculum Evaluation: A Cognitive Diagnostic Modeling Approach

Background/Objective: 
In fast-paced clinical settings like labor and delivery, quick access to accurate, evidence-based guidance is critical. Traditional methods of sharing protocols can be inefficient, especially for trainees managing complex scenarios. Advances in artificial intelligence (AI) and large language models (LLMs) offer the potential to transform how critical clinical decision-making tools are disseminated, making them more accessible, responsive, and integrated into real-time learning. Our objective was to develop our own chatbot to facilitate quick retrieval and enhanced learning. 

Methods: 
The AI chatbot was developed by IUSM researchers using Microsoft Copilot Studio and made accessible via Microsoft Teams. The AI chatbot was built on a retrieval-augmented generation (RAG) framework, leveraging a fine-tuned LLM. The base LLM was augmented with domain-specific documents, including IUSM protocols – developed by the Maternal-Fetal Medicine division - which incorporate evidence-based practices and provide a consistent management strategy for OB conditions. The RAG architecture was configured to retrieve contextually relevant documents from the collection of protocols in response to user queries.

Results:
The chatbot retrieves information from the protocols based on a user’s query and generates a relevant answer with reference to the sources. Upon testing the chatbot, we learned that the chatbot was unable to retrieve information from figures, flowcharts, and diagrams. Therefore, figures were manually annotated and narrated, enabling the model to process and retrieve relevant visual information during inference. With other adjustments, the chatbot is able to read all aspects of the protocols and synthesize accurate answers to clinical questions.

Conclusion and Potential Impact: 
We optimized an RAG model AI chatbot for clinical education, demonstrating that existing educational material can be used to activate a chatbot to serve clinical needs with sufficient oversight to ensure clinical accuracy. Future directions include evaluating its impact on clinical decision making and student perception of the learning environment once the chatbot is more uniformly adopted. 


Optimization of a RAG Model Chatbot for Obstetric Medical Education

Introduction: Adequate sleep during childhood is important for learning, memory formation, and physical and mental well-being. In 2019, around 79,000 individuals passed away due to drug use. Insufficient sleep has been found to decrease positive emotions. Many drugs that are commonly abused - opioids, cocaine, or nicotine - flood the reward pathway with dopamine, reproducing positive emotions.

Research Questions: Is there an association between childhood sleep inadequacy and deaths from substance use in early adulthood? Are there differences in the types of drugs that are more likely to be used? 

Methods: This project was a correlational study using secondary data across all 50 states and the District of Columbia. Correlational testing was performed at a 95% Confidence Interval, and p-values < 0.05 were considered significant. The correlations between sleep inadequacy and 5 outcomes were explored: total substance abuse, alcohol use, amphetamine use, opioid use, and cocaine use. Data analyses were conducted using SAS Software 9.4, and maps were generated using Tableau. 

Results: West Virginia had the highest prevalence of substance use deaths for total substance use, cocaine use, amphetamine use, and opioid use. New Mexico had the highest prevalence of deaths from alcohol use. Mississippi had the lowest percentage of children meeting sleep guidelines, and Utah had the highest percentage of children meeting sleep guidelines. Total substance use, amphetamine use, opioid use, and cocaine use were positively correlated with less sleep during childhood, and Alcohol use was negatively correlated. Deaths from opioid use in early adulthood were significantly correlated with less sleep during childhood (p = 0.0132). 

Conclusions: Chronic sleep deprivation may dysregulate neurobiological pathways in the brain, potentially increasing susceptibility to opioid misuse later in life. Prevention and treatment services for sleep disorders and substance abuse are not equitable and accessible across all states and the District of Columbia.

Associations of Childhood Sleep Insufficiency to Substance Use Among U.S. Adults

Background
Acute myocardial infarction (AMI) is a leading contributor to cardiovascular mortality. Prior research suggests that areas with high social vulnerability, defined as those having worse social conditions such as low socioeconomic status (SES), have higher rates of AMI. Kentucky ranks fourth in the nation for cardiovascular disease, including AMI, and has elevated levels of social vulnerability. However, few studies have examined the link between social vulnerability and AMI-related outcomes in Kentucky. The purpose of our study is to examine the association of county-level social vulnerability index (SVI) with AMI hospitalization and mortality rates in Kentucky from 2016 to 2020. 

Methods
AMI hospitalization and mortality data for adults ≥35 years old were presented as five-year age-adjusted rates per 100,000 population and obtained from the Centers for Disease Control and Prevention (CDC). County-level scores for SVI overall and by its four subcategory themes (i.e., socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation) were also obtained from the CDC and categorized into quartiles, with Q1 representing the least socially vulnerable counties and Q4 the most. To examine the association between SVI overall and by its four themes with the study outcomes, we fit unadjusted and adjusted linear regression models. Beta coefficients and p-values were computed to assess the overall association between each independent variable in regression models; p-values ≤ 0.05 were considered statistically significant.

Results
Compared to the least vulnerable counties (Q1), the most vulnerable counties (Q4) on the overall SVI measure had higher age-adjusted AMI hospitalization rates (Q1= 389.2 per 100,000 vs Q4=519.4; p=0.001). In linear regression models simultaneously adjusting for the four subcategory themes, counties with high vulnerability on the socioeconomic status theme had increased AMI hospitalization rates (Q1= 404.3 vs Q4=505.0; p=0.008), while counties with high vulnerability on the racial and ethnic minority status theme (indicating a greater proportion of racial and ethnic minorities) had lower AMI hospitalization (Q1= 404.3 vs Q4=229.7; p <.0001) and mortality rates (Q1= 138.9 vs Q4=71.7; p=0.038). 

Conclusion
County-level interventions targeting overall social vulnerability and low SES may reduce poor AMI outcomes in the state. Counties with a larger proportion of racial and ethnic minorities may have lower AMI hospitalization and mortality rates because these counties are more likely to be urban and therefore may have better access to healthcare resources. Nonetheless, this unexpected finding warrants further investigation.

Examining the Association between County-Level Social Vulnerability and Acute Myocardial Infarction Hospitalizations and Mortality in Kentucky

Background 
The challenges that people with disabilities experience within emergency settings are uniquely complex. Disruptions in routine, painful procedures, and confusion can be especially agitating for this population – making the need for adequate sedation, pain management, and communication paramount. Anatomical and physiological differences and communication barriers can further complicate emergency visits. There is a lack of research evaluating current nationwide emergency medical service protocols for treating patients with various disabilities. This paper serves to initiate discussion regarding current practices and identifies potential areas for improvement. It also considers the expansion of such protocols into emergency departments, peri-operative care, and routine care. 

Methods 
The 30 existing statewide protocols were analyzed for the presence or absence of disability protocols within four categories: autism spectrum disorder, intellectual disability, orthopedic impairment, and/or speech/language impairments. Physiological differences and communication barriers were also outlined to contextualize challenges faced within each category. Behavioral health emergency protocols were analyzed to serve as a comparison, as these may be the only guidance available in the absence of disability protocols despite their lack of appropriateness. Within each protocol, special attention was paid to standing orders regarding medical guidance and behavioral guidance. Broadly, the authors define medical guidance as pharmacological management, and behavioral guidance as any communication or de-escalation techniques. Lastly, the availability of emergency care plans was also noted. 

Results 
We found that while most available statewide protocols have existing protocols for behavioral health emergencies, the majority did not have existing protocols for patients with disabilities. Within behavioral health protocols, adequate sedation and appropriate communication techniques were almost always addressed. Of note, the states that did not provide medical guidance for these patients only provided basic life support guidelines statewide, not advanced life support. Only two states provided the option for emergency care plans, either for medically complex patients or patients with disabilities. 


Conclusion 
There is currently a lack of appropriate guidance for providing emergency care to patients with disabilities, but documented plans for these patients could increase both provider and patient comfort. Given the unique challenges in providing adequate sedation, pain management, and communication for patients with disabilities, it would be sensible if more protocols were put in place to provide guidance in these areas. Similar protocols and guidelines may also be beneficial in emergency departments, peri-operative settings, and routine care as the need for appropriate sedation and communication for patients with disabilities is still relevant in these settings.

Analyzing Existing Protocols for Patients with Disabilities 
in the Emergency Setting  

Human papillomavirus (HPV) is a common sexually transmitted infection in the United States, with certain strains linked to multiple cancers. Although HPV vaccination effectively reduces cancer risk, uptake remains low, particularly in rural areas. This study aimed to assess parental attitudes and barriers toward HPV vaccination in rural East Texas. An Institutional Review Board–approved, bilingual, English and Spanish, anonymous 20-item survey was administered to parents at a pediatric clinic. The survey assessed demographics, vaccine knowledge, beliefs, and sources of information. Responses were analyzed by comparing parents who vaccinated their children (WV) with those who did not (WDV). A total of 49 parents completed the survey (WV=29; WDV=19). Significant differences were observed in perceptions of vaccine safety (p=0.001), understanding the purpose of the vaccine (p=0.02), comfort in requesting the HPV vaccine from providers (p=0.01), and perceived importance of youth vaccination (p=0.02). No differences were found by age, gender, race/ethnicity, education, or employment. Healthcare providers were the most common source of HPV information for both groups. WDV parents often declined vaccination due to a perceived lack of need and limited knowledge, while WV parents cited concerns about cost, insurance, and side effects. Both groups prioritized learning about vaccine effectiveness and side effects. Educational pamphlets were preferred across groups, though WV parents also valued provider discussions and personal testimonials. These findings suggest that provider-led education emphasizing safety, cancer prevention benefits, and early vaccination may increase uptake. Despite limitations of a small, single-site sample, the results highlight strategies to address HPV vaccine hesitancy in rural populations.

Next from 2025 AMA Research Challenge – Member Premier Access

The Impact of Declining Renal Function on Bladder Cancer in the U.S. (1999-2023): A Regression Analysis Using the CDC WONDER Database