United States

Abstract Title
Isolating abductor hallucis and tibialis posterior activation for targeted foot arch strengthening
Jadah Eshenaur D.O.’28, Jackson Watson D.O.’28, Shane McClinton P.T., D.P.T., Ph.D. OCS, FAAOMPT, CSCS
Background
The abductor hallucis (AbdH) and tibialis posterior (TP) contribute to foot arch strength(1,3) and are often the target of foot strengthening programs.(2,4,5) However, strategies to isolate AbdH and TP while minimizing activation of compensatory muscles such as the flexor hallucis longus, flexor digitorum longus, and tibialis anterior have not been identified. This preliminary study aims to provide clinical guidance for isolating and strengthening the AbdH and TP.
Methods
Surface and fine-wire electromyography (EMG) measured muscle activity in 10 subjects during different foot strengthening exercises. EMG data was normalized to each muscle’s peak dynamic activity across all exercise conditions. Radar plots were constructed to identify exercises with optimal TP and AbdH activation.
Results
AbdH demonstrated its highest activation during the unilateral heel raise while TP had its highest activation with the plantar flexion inversion exercise. Exercises that yielded the highest activation for both AbdH and TP with minimal compensatory muscle activation included the plantar flexion inversion towel sweep (PITS), short foot (SF) in sitting, and walking. Exercises with the highest overall activation of both AbdH and TP, regardless of compensation, included the unilateral heel raise, SF hop, and unilateral stance SF.
Conclusion
When initiating foot training, seated PITS and SF exercises, and walking will optimize AbdH and TP recruitment while minimizing compensatory muscle activation. The next logical progression would be the unilateral stance SF before progressing to the unilateral heel raise and hopping exercises which demonstrated the highest activation, but with more compensatory muscle recruitment.
References
1. Fiolkowski, P., Brunt, D., Bishop, M., Woo, R., &amp; Horodyski, M. (2003). Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. The Journal of Foot and Ankle Surgery, 42(6), 327–333. https://doi.org/10.1053/j.jfas.2003.10.003
2. Osborne, J., Menz, H. B., Whittaker, G. A., &amp; Landorf, K. B. (2023). Development of a foot and ankle strengthening program for the treatment of plantar heel pain: a Delphi consensus study. Journal of Foot and Ankle Research, 16(1). https://doi.org/10.1186/s13047-023-00668-2
3. Jung, D.-Y., Koh, E.-K., &amp; Kwon, O.-Y. (2011). Effect of foot orthoses and short-foot exercise on the cross-sectional area of the abductor hallucis muscle in subjects with pes planus: A randomized controlled trial1. Journal of Back and Musculoskeletal Rehabilitation, 24(4), 225–231. https://doi.org/10.3233/bmr-2011-0299
Ridge, S. T., Myrer, J. W., Olsen, M. T., Jurgensmeier, K., &amp; Johnson, A. W. (2017).
Reliability of doming and toe flexion testing to quantify foot muscle strength. Journal of Foot and Ankle Research, 10(1). https://doi.org/10.1186/s13047-017-0237-y
4. Ridge, S. T., Olsen, M. T., Bruening, D. A., Jurgensmeier, K., Griffin, D., Davis, I. S., &amp;
Wayne Johnson, A. (2018). Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles. Medicine &amp; Science in Sports &amp; Exercise, 51(1), 1.
https://doi.org/10.1249/mss.0000000000001751


2025 AMA Research Challenge – Member Premier Access

Isolating abductor hallucis and tibialis posterior activation for targeted foot arch strengthening

Abstract Title
Isolating abductor hallucis and tibialis posterior activation for targeted foot arch strengthening
Jadah Eshenaur D.O.’28, Jackson Watson D.O.’28, Shane McClinton P.T., D.P.T., Ph.D. OCS, FAAOMPT, CSCS
Background
The abductor hallucis (AbdH) and tibialis posterior (TP) contribute to foot arch strength(1,3) and are often the target of foot strengthening programs.(2,4,5) However, strategies to isolate AbdH and TP while minimizing activation of compensatory muscles such as the flexor hallucis longus, flexor digitorum longus, and tibialis anterior have not been identified. This preliminary study aims to provide clinical guidance for isolating and strengthening the AbdH and TP.
Methods
Surface and fine-wire electromyography (EMG) measured muscle activity in 10 subjects during different foot strengthening exercises. EMG data was normalized to each muscle’s peak dynamic activity across all exercise conditions. Radar plots were constructed to identify exercises with optimal TP and AbdH activation.
Results
AbdH demonstrated its highest activation during the unilateral heel raise while TP had its highest activation with the plantar flexion inversion exercise. Exercises that yielded the highest activation for both AbdH and TP with minimal compensatory muscle activation included the plantar flexion inversion towel sweep (PITS), short foot (SF) in sitting, and walking. Exercises with the highest overall activation of both AbdH and TP, regardless of compensation, included the unilateral heel raise, SF hop, and unilateral stance SF.
Conclusion
When initiating foot training, seated PITS and SF exercises, and walking will optimize AbdH and TP recruitment while minimizing compensatory muscle activation. The next logical progression would be the unilateral stance SF before progressing to the unilateral heel raise and hopping exercises which demonstrated the highest activation, but with more compensatory muscle recruitment.
References
1. Fiolkowski, P., Brunt, D., Bishop, M., Woo, R., & Horodyski, M. (2003). Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. The Journal of Foot and Ankle Surgery, 42(6), 327–333. https://doi.org/10.1053/j.jfas.2003.10.003
2. Osborne, J., Menz, H. B., Whittaker, G. A., & Landorf, K. B. (2023). Development of a foot and ankle strengthening program for the treatment of plantar heel pain: a Delphi consensus study. Journal of Foot and Ankle Research, 16(1). https://doi.org/10.1186/s13047-023-00668-2
3. Jung, D.-Y., Koh, E.-K., & Kwon, O.-Y. (2011). Effect of foot orthoses and short-foot exercise on the cross-sectional area of the abductor hallucis muscle in subjects with pes planus: A randomized controlled trial1. Journal of Back and Musculoskeletal Rehabilitation, 24(4), 225–231. https://doi.org/10.3233/bmr-2011-0299
Ridge, S. T., Myrer, J. W., Olsen, M. T., Jurgensmeier, K., & Johnson, A. W. (2017).
Reliability of doming and toe flexion testing to quantify foot muscle strength. Journal of Foot and Ankle Research, 10(1). https://doi.org/10.1186/s13047-017-0237-y
4. Ridge, S. T., Olsen, M. T., Bruening, D. A., Jurgensmeier, K., Griffin, D., Davis, I. S., &
Wayne Johnson, A. (2018). Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles. Medicine & Science in Sports & Exercise, 51(1), 1.
https://doi.org/10.1249/mss.0000000000001751


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Background
Postoperative nausea and vomiting (PONV) is a common adverse event during the perioperative period. It leads to delayed recovery, patient dissatisfaction, and increased hospital costs. This study aims to identify optimal antiemetic use in laparoscopic surgery to prevent hospitalization due to postoperative nausea and vomiting.

Methods
A retrospective chart review was conducted over a 28-month period (January 2022 to April 2024) analyzing patients who underwent either a laparoscopic hysterectomy or a robotic prostatectomy at IU Health University Hospital. Demographic data, surgery duration and time of discharge were collected for every case. Antiemetic administration was recorded, including specific agent, dosage, frequency, and timing. Exclusion criteria included patients who received scopolamine patches, aprepitant, or total IV anesthetic. To minimize selection bias, only patients who received intraoperative dexamethasone were included. A total of 522 cases met the initial inclusion criteria, with 470 cases included after applying the exclusion criteria. 

Results 
In the intraoperative setting, all 470 cases received at least one dose of both dexamethasone and ondansetron. Promethazine was administered intraoperatively in 1.49% (n=7) of cases, droperidol in 4.04% (n=19), and haloperidol in 0.43% (n=2). A total of 28 patients received additional intraoperative antiemetics beyond the standard dexamethasone and ondansetron regimen, of whom 3 patients required hospitalization for PONV. 

Postoperatively, 34.9% of patients received at least one rescue antiemetic dose prior to discharge (n=164). On average, these patients received 1.47 doses of antiemetic medication postoperatively. Ondansetron was the most frequently administered antiemetic in this subset, used in 48.8% of cases, followed by haloperidol (33.5%), promethazine (25.1%), droperidol (1.2%), and prochlorperazine (1.2%). 

Of the 470 cases, nine hysterectomy and nine prostatectomy patients were admitted due to complications related to nausea and vomiting. These patients had a longer mean anesthesia duration though it is not statistically significant. (hysterectomy 3.71 hours vs 2.91 hours, prostatectomy 3.9 hours vs 3.69 hours). Severe PONV hysterectomy patients were younger (39.22 vs. 41.85 years) and had a higher BMI (34.16 vs. 33.82) compared to the study population. In contrast, PONV prostatectomy patients were older (69.11 vs. 65.01 years)** and had a lower BMI (27.61 vs. 29.03)**. 
** Statistically Significant (p<0.05)

The severe PONV group received on average 2.60 doses of antiemetics in the postoperative setting compared to 0.48 doses in the study population. The average length of stay for the severe PONV hysterectomy patients was 27.41 hours, compared to 3.22 hours in the overall study population. For the severe PONV prostatectomy patients, the average length of stay was 67.96 hours, compared to 23.52 hours in the study population.

Conclusion
Intraoperative administration of dexamethasone and ondansetron in laparoscopic surgical cases was highly effective in preventing PONV. Ondansetron, haloperidol, and promethazine were the most used rescue antiemetics, despite evidence suggesting limited efficacy with repeated ondansetron dosing. There was no definitive correlation identified between the use of additional intraoperative antiemetics and PONV incidence, likely due to the small sample size in this subgroup. The length of anesthesia positively correlated with increased risk of PONV in both hysterectomy and prostatectomy groups. Further investigation into prevention of PONV remains crucial for patient outcomes and hospital resource management, as the patients in this group experienced significantly longer hospital stays compared to the overall study population.

Trends in Antiemetic Administration and Clinical Efficacy for Postoperative Nausea and Vomiting in Laparoscopic Surgeries

Background Chronic idiopathic constipation (CIC) is one of the most common, debilitating digestive conditions that affects 0.7%-29.7% of children worldwide.1 Gold standard treatment for CIC is a structured bowel management program (BMP) which contains a clean out followed by a laxative or enema trial to find individualized dosages resulting in daily bowel movements and no fecal accidents. Proper management is essential to prevent further sequelae like the formation of a megarectosigmoid and social and/or psychological impact. This study aimed to evaluate the success rate of the BMP for patients with CIC at our institution and to identify factors that contribute to these outcomes.
Methods A retrospective review of 51 patients presenting for BMP to WVU Children’s Hospital was conducted. Patients were divided into groups based on their diagnosis: CIC, neurogenic bowel, Hirschsprung disease, and anorectal malformation. Patient’s demographics, treatment course, number of missed appointments and socioeconomic circumstances were collected. Failure was defined as occurrence of fecal accidents, fecal impaction, noncompliance, or loss to follow up. Statistical analysis was performed using JMP Student Edition 18. 
Results Among the 51 patients, 63% had CIC, 24% had neurogenic bowel, 10% had anorectal malformation, and 4% had Hirschsprung disease. In the group with CIC, 81% participated in a BMP. Failure rate was 31% due to loss to follow up (3), noncompliance (4), and in only one case fecal accidents. In the remaining, who did not participate, inability to comply was the primary reason. The majority of those who failed BMP were covered by public insurance (p=0.04). Among those who failed due to loss to follow up or noncompliance, 86% were covered by public insurance and lived in areas with 0 grocery stores within a 10-minute walk and an average of 1.5 stores in a 10-minute drive.
Conclusion The difference in insurance types between groups indicates a potential socioeconomic disparity between outcome populations. Beyond these disparities, compliance-related issues were overwhelmingly responsible for failure and inability to participate in BMP, indicating a critical role in the initiation and continuation of a successful BMP. Given that CIC requires a high level of support and attention from caregivers and retains stigmas surrounding treatment, a prospective study to identify contributing factors leading to noncompliance has been initiated. The future goal is to improve adherence to the BMP and mitigate the noncompliance-related barriers that contribute to the treatment outcome.


The effect of socioeconomic factors on the outcomes of pediatric patients treated at our institution for colorectal problems.

Background:
Kambo, a traditional Amazonian frog secretion ritual, has gained international popularity as an alternative intervention for psychological and physical complaints, but systematic evidence regarding its effects and the predictors of positive outcomes is lacking.

Methods:
In a prospective, observational study, 50 Kambo-naive adults underwent three supervised Kambo sessions within 30 days. Validated self-report scales measured change in depressive symptoms (IDSSR), fatigue (MFI), mindfulness (MAAS), subjective happiness (SHS), and psychological well-being (Ryff, binary responder definition) from baseline to 3-month follow-up. Predictors included demographic, health history, and session-level variables (e.g., ritual elements, acute reactions). Missing predictor data were imputed by Multivariate Imputation by Chained Equations (MICE). Lasso regression and Random Forests were used for prediction, with validation via bootstrapping and cross-validation.

Results:
Across 3 months, Kambo was associated with a group-level decrease in depressive symptoms (IDSSR) and increases in mindfulness (MAAS), subjective happiness (SHS), psychological well-being (Ryff), and fatigue (MFI) scores. Lasso regression models achieved moderate-to-high predictive performance (mean bootstrapped R²: IDSSR=0.78; MFI=0.63; MAAS=0.70; SHS=0.75), and Random Forests performed similarly (mean R² 0.93–0.94). For binary well-being response, both logistic regression and Random Forest achieved near-perfect discrimination (AUROC ≥0.99). Baseline symptom severity was the most consistent predictor of z-score change. Session-level features, such as fainting, vomiting, and Sananga or Rapeh use, contributed modestly for some outcomes, especially depression and fatigue, while demographic and health history variables showed inconsistent effects.

Conclusions:
In this exploratory analysis, both baseline psychometric scores and select session features predicted change in psychological outcomes after Kambo, with the largest effect seen for baseline symptom severity. Group-level z–score changes indicated improvement across most scales, but increased fatigue was observed. These findings are hypothesis-generating and limited by the lack of a control group, possible regression to the mean, and unmeasured confounding. Future controlled studies are needed to confirm these results and clarify which factors most influence response to Kambo.


Psychological Outcomes of Human Participants in the Kambo ritual: Using Machine Learning to inform Predictors of Participant, Ritual, and Session-Level Factors in a Prospective Observational Study

Background
Myocardial infarction can lead to a host of complications; however, the occurrence of refractory ventricular tachycardia particularly comes with a poor prognosis. Managing refractory VT becomes significantly challenging in the absence of electrophysiology services. Use of Impella CP for cardiac support before ablation has the potential to be an effective bridge. We aim to document a unique instance of Impella CP-assisted hemodynamic stabilization of a patient suffering from delayed refractory ventricular tachycardia following a STEMI.

Case Presentation
A 70-year-old male patient with a history of hypertension, prediabetes, and GERD presented to a rural hospital with STEMI, where he received tPA before being transferred to a tertiary hospital. Angiography revealed 100% occlusion of the RCA and 99% stenosis of the proximal ramus intermedius. Percutaneous coronary intervention and transluminal coronary angioplasty were performed.
While in ICU, the patient developed atrial fibrillation with a rapid ventricular rate and was treated with an amiodarone drip, later converted to the oral form. He was readmitted to the ICU on day 4 in view of a non-sustained VT and hypotension, which progressed to cardiogenic shock. With multiple pressors and IV amiodarone, temporary rhythm control was established.
However, on day 9, the patient had a cardiac arrest secondary to ventricular fibrillation, requiring about 12 minutes of CPR. He received amiodarone and lidocaine during the code, followed by return of spontaneous circulation, but continued to have intermittent nonsustained VT with The patient experienced an increased frequency of arrhythmias and eventually developed pulseless ventricular tachycardia (VT), which required intermittent brief CPR and cardioversion, despite the ongoing administration of amiodarone and the addition of lidocaine. He had a brief response after starting procainamide but eventually worsened with more frequent nonsustained VT episodes along with hemodynamic decompensation and escalating pressor requirements.
In the absence of an electrophysiologist, an Impella CP device was inserted for mechanical circulatory support. This intervention stabilized the patient and provided a critical bridge to definitive care. The patient was successfully transferred to a higher level of care without any ventricular arrhythmia episodes during transport.

Discussion
This case showcases the utility of temporary mechanical support using Impella CP in stabilizing patients with refractory, unstable arrhythmias. This approach enables patients to achieve hemodynamic stability before definitive treatment can be provided, extending the window for intervention and improving the likelihood of a favorable outcome.

Delayed Refractory VT Storm Post Myocardial Ischemia and Use of Impella for Hemodynamic Stabilization—A Case Report

Ogilvie Syndrome in an HIV-Positive Young Male with Nutcracker Phenomenon: A Rare Dual Diagnosis
Background
Acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, is a rare condition characterized by massive colonic dilation without mechanical obstruction. It is typically associated with postoperative states, severe illnesses, or advanced age. We report a rare presentation of Ogilvie syndrome in a young, ambulatory male with well-controlled HIV, highlighting the importance of broadening diagnostic considerations beyond traditional risk profiles.
Case Presentation:
A 37-year-old African American male with well-controlled HIV (CD4 1414 cells/mm³; HIV-1 RNA 197 copies/mL) presented with three weeks of progressive abdominal distention, diffuse discomfort, intermittent nausea, and urinary retention. He denied fever, recent hospitalization, or surgery. Physical examination revealed a tense, tympanic abdomen. Laboratory values were within normal limits. CT imaging demonstrated marked colonic dilation without obstruction and incidentally revealed compression of the left renal vein between the aorta and superior mesenteric artery—consistent with the Nutcracker phenomenon. Flexible sigmoidoscopy confirmed the absence of mechanical obstruction. Conservative management—including bowel rest, decompression via a rectal tube, and supportive care—resulted in full resolution by hospital day 7, without the need for neostigmine or surgery.
Discussion:
This case illustrates an atypical presentation of Ogilvie syndrome in a young, HIV-positive individual without typical hospitalization factors. While his HIV was well-controlled, HIV-associated subclinical autonomic dysfunction may have contributed to colonic dysmotility. The coincidental presence of Nutcracker anatomy, although radiologically striking, was not clinically relevant due to absence of hematuria or renal impairment. This emphasizes the importance of correlating imaging findings with the clinical picture and avoiding diagnostic anchoring based on incidental findings. Clinicians should consider functional bowel obstruction in younger patients, including those with HIV, and recognize that conservative treatment can be highly effective when initiated promptly.

Ogilvie Syndrome in an HIV-Positive Young Male with Nutcracker Phenomenon: A Rare Dual Diagnosis

Background: In traditional U.S. medical education, preclinical training offers limited exposure to community-based experiences during a critical formative period of career discernment. The absence of early experiential learning may result in missed opportunities to cultivate motivation and sustained enthusiasm to practicing medicine. 
Objective: This observational study aimed to understand the perspectives of preclinical students on their volunteer experiences with the Mobile Health Initiative (MHI), focusing on its perceived impact and role in enhancing their medical education.
Methods: A survey was disseminated to all MHI volunteers to assess the program’s impact on student engagement and future practice intentions. Seventy-six percent of volunteers (n=49) reported participating during their preclinical years. 
Results: Students defined meaningful experiences as providing healthcare to underserved populations, utilizing cultural understanding to bridge care gaps, and fostering community connections. There was a significant increase in the feeling of connectedness with their community, which helped students rediscover their purpose for pursuing a career in medicine. Some highlights from the survey responses centered on an increased sense of fulfillment and learning to communicate compassionately. In addition, many respondents detailed how MHI events improved their clinical skills through these hands-on experiences and enhanced their clinical judgment in resource-limited settings. 
Conclusion: We identified four main themes that defined meaningful experiences for medical student volunteers: 1) Community Engagement and Connection, 2) Hands-On Clinical Skills Development, 3) Health Equity and Access, and 4) Emotional Fulfillment. There is a strong need for community-based, service-learning programs, such as MHI, to enhance traditional medical education.

Enhancing early medical education through mobile health care: An observational survey of medical student volunteers

Background:
Self-directed learning (SDL) is increasingly emphasized in undergraduate medical education and is a requirement of LCME Standard 6.3 and AAMC Entrustable Professional Activity (EPA) 7. These standards expect students to develop competencies in identifying knowledge gaps, acquiring and appraising information, and implementing feedback. SDL is inherently active and student-driven, relying heavily on learners’ motivation, self-regulation, and engagement. While prior studies highlight generally positive attitudes toward SDL, mixed findings persist regarding student preparedness and motivation for lifelong learning. One area lacking in the literature is the concept of “buy-in”—students’ belief in the value and relevance of SDL to their development. Buy-in, as used in educational research, refers to commitment and acceptance of pedagogical approaches and is known to correlate with greater engagement and behavior change. This study investigates the extent of medical student buy-in toward SDL at the end of their pre-clinical training and whether exposure to SDL practices leads to meaningful implementation in clinical practice.
Methods:
A cross-sectional survey was administered to second-year medical students at Virginia Commonwealth University after completing their pre-clinical curriculum. The survey, adapted from validated instruments, measured SDL buy-in using the Exposure–Persuasion–Identification–Commitment (EPIC) framework across each SDL activity defined by EPA 7. We analyzed the percentage of students endorsing each EPIC stage, performed one-way ANOVAs to assess differences by gender, race, ethnicity, and age, and developed a serial mediation model to examine the pathway from exposure to implementation.
Results:
Students reported high exposure to tasks involving identifying knowledge gaps and appraising medical information, and lower exposure to reflection and incorporating feedback. Tasks requiring information acquisition and source evaluation showed greater progression through the EPIC model compared to those requiring metacognition. No significant differences in EPIC stages were observed across demographic variables. The serial mediation analysis revealed a significant pathway from exposure to implementation, mediated by persuasion, identification, and commitment (p<0.05).
Conclusion:
Buy-in to SDL varies across competencies, with lower engagement in reflection and feedback utilization—critical yet underemphasized aspects of SDL. These findings suggest a need to enhance exposure to these components in the pre-clinical curriculum. Moreover, the observed mediation effect supports the idea that structured exposure to SDL practices fosters deeper commitment and implementation, reinforcing the importance of intentional SDL design to prepare students for clinical learning and lifelong self-improvement.

From Exposure to Implementation: Investigating Buy-In to Self-Directed Learning Among Second Year Medical Students

Background
Diaper dermatitis is a prevalent form of irritant contact dermatitis which disproportionately affects pediatric patients of color, yet disparities in incidence, diagnosis, and management remain under-explored. This study investigates racial and ethnic inequities contributing to these disparities, such as diagnostic challenges due to atypical presentation, socioeconomic barriers limiting access to timely care, and variations in cultural practices. Additionally, the research emphasizes how systemic inequities and healthcare access issues exacerbate the public health burden of diaper dermatitis among children from racially and ethnically diverse backgrounds. By building on existing literature, this study aims to illuminate diaper dermatitis not only as a dermatological issue but also as a significant public health concern that requires targeted interventions.

Methods
A comprehensive literature search was conducted using PubMed and Google Scholar. Keywords included “diaper dermatitis,” “contact dermatitis,” “pediatric health disparities,” “skin of color,” and “racial inequities in dermatology.” Inclusion criteria encompassed peer-reviewed studies published in English from 2014 to 2025, focusing on epidemiology, pathophysiology, diagnostic challenges, and management strategies highlighting racial disparities and access to care. Articles addressing socioeconomic determinants and cultural factors were prioritized to provide contextually rich insights. Relevant findings were systematically synthesized according to AMA citation guidelines.

Results
From 2010 to 2021, 184,097 diaper dermatitis cases were reported in California children aged 0–3, with 53,678 requiring inpatient care. Prevalence (per 1,000) was highest in Black patients (9.56) compared to White (5.93, p < 0.001), Hispanic (6.67, p < 0.001), and Asian/Pacific Islander patients (2.49, p < 0.001). Black children were disproportionately diagnosed in emergency departments, indicating delayed care linked to diaper need and systemic barriers. Atypical presentations in skin of color, such as less apparent erythema, and limited access to patch testing compounded challenges.

Conclusion
This study underscores significant racial and ethnic disparities in diaper dermatitis especially in Black and Hispanic children. These findings highlight the need for tailored diagnostics, preventative resources, and culturally competent care through multidisciplinary public health and education initiatives. Furthermore, addressing this inequity necessitates enhanced clinical awareness and increased availability of culturally sensitive care in medicine. Future research should examine the impact of socioeconomic interventions and community-based initiatives, which are essential for mitigating these disparities and improving health outcomes for pediatric patients of color.

Rash Beyond Redness: The Intersection of Contact Dermatitis and Diaper Use in Children of Color

Background: Medical schools have equal representation of men and women, yet surgical specialties, like orthopaedics and neurosurgery, have far less women. Addressing sex disparities among spine surgeons may promote more effective spine care in the United States (US). 
Methods: The Medicare Provider Utilization and Payment Dataset was used to identify neurosurgical and orthopaedic surgeons performing ACDF surgery from 2013-2021. The dataset was linked to the Medicare National Downloadable File to determine hospital affiliations and medical training. All hospitals included were queried to determine association with residency or fellowship training programs. This retrospective cross-sectional study measured the total representation of female spine surgeons performing ACDF, their procedural volumes, and reimbursements compared to male cervical spine surgeons.
Results: There were 2,492 surgeons who performed at least eleven ACDFs over the study period accounting for 139,456 total cases. Of this, there were 58 female spine surgeons (2.3%) who performed 2,733 cases (2.0%). The percentage of female surgeons increased from 0% (0/1,124) in 2013 to 1.8% (12/651) in 2021 (p<0.001). The average volume of ACDFs performed by females (16.83.6) was similar compared to males (17.27.6; p=0.712). Mean standardized reimbursement by Medicare for ACDFs was $1,304, with no difference between female and male surgeons during the study period (p=0.145). There were no significant differences in the beneficiary demographics between male and female surgeons, except for in 2021 where female surgeons saw a higher proportion of female patients (56.8 vs 55.0%, p=0.043).
Conclusions: Despite some progress observed over the study period, profound sex disparities persist among spine surgeons performing ACDF. Strategies are needed to increase the number of female medical students and residents interested in spine surgery.

Sex Disparities in Medicare Reimbursement, Case Volume and Practice Characteristics Among Cervical Spine Surgeons in the United States

Abstract Title
Suicide in Haiti: Perceptions, Associated Factors, and Research Gaps: a Narrative Review

Background
Suicide is a major global health concern, disproportionately affecting low- and middle-income countries (LMICs) where research remains limited. Although global suicide rates have declined
in recent decades, rates in Haiti have changed minimally. Haiti's sociocultural complexity and limited mortality data obscure understanding of suicide risk factors and perceptions. Known
global risk factors—such as depression, hopelessness, trauma, and stigma—may interact differently in local contexts. This review examines the current state of empirical research on
suicide in Haiti, exploring both perceptions and psychosocial risk factors, to inform future prevention strategies.

Methods
A systematic search of 15 databases identified peer-reviewed, English-language studies containing data on suicide or suicidal ideation in Haiti. Search terms included variations of
"Haiti" and "suicide." Studies were included if they reported Haiti-specific data on suicide and met inclusion criteria. Data extracted included participant demographics, study region, methods, and findings on suicide-related perceptions or risk factors.

Results
Ten studies met inclusion criteria. Samples included rural and urban populations, adolescents, adults, pregnant individuals, health care workers, and those with psychiatric or medical
diagnoses. Four studies used qualitative methods; of the seven studies that included quantitative methods, four used data from the Violence Against Children in Haiti survey and
three used culturally adapted Beck Depression Inventory surveys. Common themes included the cultural idiom reflechi twòp ("thinking too much"), which was strongly associated with suicidal ideation, namely 7.7 times more likely (95% CI, 1.03–58.04). Community members often cited poverty, shame, and Voodoo-related beliefs as causes of suicide, while health care workers favored psychiatric explanations. Perceived shame from unplanned pregnancy, HIV status, and sexual orientation were also prominent. Suicidal ideation was associated with depression, as was social support absence, alcohol use, and experiences of emotional, physical, and sexual violence -- females who experienced all three forms of violence had the highest odds of suicidal ideation (adjusted OR, 15.09; 95% CI, 6.10–37.33, p < 0.001). Protective factors were rare: one was the belief that women should tolerate violence to preserve family unity. 

Conclusion
Empirical studies on suicide in Haiti are limited and regionally narrow. Cultural and social perceptions—such as reflechi twòp and stigma related to sexuality, illness, and gender—shape
suicide risk in ways not captured by universal models. Integrating culturally specific constructs and community support systems into screening, safety planning, and interventions is essential. Further research is needed across diverse Haitian populations and languages to build effective, context-sensitive suicide prevention strategies.

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