United States

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.

AMA Research Challenge 2025 

Parental Perspectives on HPV Vaccination in Rural East Texas

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Background
Cardiovascular disease remains the leading cause of death in the United States, primarily due to the unsuccessful recovery of cardiac tissue from oxygen-deprived injuries. The severity of these insults varies among individuals and is often influenced by genetic factors. Despite extensive research, the specific genes involved in hypoxic response still remain unclear. Therefore, this study aims to characterize gene expression variability in response to the hypoxic event, since identifying these genetic markers will be crucial for early intervention in populations at high risk for oxygen-related cardiac complications.

Methods
Hypoxic stress was induced on two genetically distinct mice strains: hypoxia-sensitive (CD1) and hypoxia-resistant (C57BL/6J). We then performed a microarray on cardiac tissue samples from these mice to quantify the expression patterns of coding and non-coding (lncRNAs) genes. Using correlational and enrichment analysis methods, we compared the differential gene expression patterns between the two mice strains. Previous studies have reported limited success in identifying hypoxia-associated genetic markers, thus justifying our study’s emphasis on non-coding RNA profiles.

Results
Our data revealed that the most significant lncRNA differential expression patterns are involved in energy metabolism and conservation. This specifically included “protein secretion” and “oxidation-reduction processes” according to GeneOntology (GO) term descriptions. In the “regulation in protein secretion” GO Term, we discovered that the lncRNA XR_001783868.2 exhibited a 28% increase in expression in response to hypoxia. This lncRNA overlaps with the coding gene Fhip1a/FAM160A1 and may play a role in regulating its gene expression in response to hypoxia.

Conclusion
lncRNAs associated with heightened sensitivity to hypoxia may serve as genetic markers for identifying individuals at increased risk of cardiovascular-related mortality, supporting the development of preventive and targeted treatment strategies.

A Search for Long-noncoding RNAs (lncRNAs) as Genetic Markers for Hypoxia Sensitivity in Mus Musculus

Background
Somatic mutations in an MLK family member, Mixed Lineage Kinase 4 (MLK4), have been reported to activate its kinase activity in colorectal cancers (CRCs). Analysis of the TCGA (The Cancer Genome Atlas) database revealed that increased MLK4 expression correlates with poor overall survival in colon cancers. Novel MLK4 inhibitors are being developed using various computational techniques and in vitro models to target different types of cancers. We aim to evaluate the effects of CEP-1347, a pan-MLK inhibitor, on MLK4 expression, apoptosis, and tumorigenesis in colon cancer cells.

Methods
Colon cancer cell line, HCT 116 cells were treated with CEP-1347 (500nM) every 24 hours for two days and untreated and DMSO (Dimethyl Sulfoxide) treated cells were used as controls. Cell extracts were primarily incubated with MLK4 antibody, and a western blot analysis was performed. Apoptosis was assessed by measuring Bax, Bcl-2, PARP, and caspase-3 expression using western blot analysis. Additionally, we conducted a wound healing assay on HCT 116 cells treated with CEP-1347(500nM) and cell migration evaluated every 24 hours for 7 days with untreated and DMSO treated cells as controls.

Results
The western blot analysis showed significantly reduced MLK4 expression in cells treated with CEP-1347 (p < 0.05). Our apoptosis assay demonstrated a significantly increased Bax/Bcl-2 ratio (p < 0.0005) alongside other apoptotic markers like cleaved PARP (p < 0.0005) and cleaved caspase-3 (p < 0.005) in CEP-1347 treated cells when compared to control or DMSO treated cells. The cell migration assay showed delayed wound closure in CEP-1347-treated cells, with control cells achieving full closure by day 5, whereas treated cells retained ~10% of the initial wound area by day 6.

Conclusion
Our results demonstrate that CEP-1347 effectively inhibits MLK4 kinase activity in colon cancer cells, leading to increased apoptosis and reduced migratory potential. These findings suggest that MLK4 inhibition may be a promising therapeutic strategy for treating intractable colon cancers unresponsive to current therapeutic approaches and warrant further investigation.

MLKs Inhibitor CEP-1347 Suppresses Tumorigenic Potential and Survival of Colon Cancer Cells

Background
Postoperative pain contributes to opioid use. Physicians struggle to limit the prescription of opioids post-operatively and upon discharge. The side effect of respiratory depression is concerning in obese patients, particularly those undergoing bariatric surgery, because they often suffer from sleep apnea and other restrictive lung diseases. This research studies the effects of a novel multimedia program delivered via a tablet device on pain-related outcomes in patients recovering from bariatric surgery. 

Methods
Patients scheduled for vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) surgery were randomized into an experimental (A) and control group (B). Group A received an iPad programmed with an educational video and four applications. Group B received the standard entertainment options. Pain scores, opioid medication use, and BMI were monitored inpatient and at follow-up visits. Tablet usage time in Group A was monitored, and both groups completed exit surveys about the interventions. Candidates were screened until 48 subjects were enrolled, 23 in Group A and 25 in Group B (control). All patients received an intraoperative transversus abdominis block and an oral regimen including acetaminophen, celecoxib, and tramadol; patients were discharged on tramadol 50-100 mg every 6 hours as needed for 28 days.

Results
• Question 1: mean response was 1.88/4 with a standard deviation of 1.05 (p = 0.721). 
• Question 2: 3/17 patients stated that the usage of the tablet helped with pain (p = 1.000). 7/17 stated that the usage of the tablet helped with anxiety (p = 1.000). 4/17 stated that it helped with sleep (p = 0.738). 6/17 stated that it helped with mood (p = 0.494). 4/17 endorsed it helping with unpleasant thoughts (p = 1.000). 
• Question 3: 5/17 stated that the tablet helped with less pain medication use. 12/17 stated that it did not (p = 0.197). 
• Question 4: 16 responded yes and 1 responded no (p = 1.000).
• Question 5: 8 responded yes and 9 responded no (p = 0.014). 
• Question 6: the mean was 2.0/4.0 with a standard deviation of 1.41, and the range was 0-3 (p = 0.211). 

Conclusion
Multimedia helped with all the areas queried, including crucial postoperative factors such as pain, anxiety, and sleep. The limitation of this study was the inability to control the multimedia resources that patients brought to the hospital on their own. All patients found multimedia to be at least “probably” helpful in the postoperative setting, with the control group continuing to use similar approaches at home.


A Digital Media Program for Postoperative Pain: A Survey of Bariatric Surgery Patients

Background
Immune checkpoint inhibitors (ICI) are first-line treatments for many advanced solid tumors. Patients with type 2 diabetes mellitus (T2DM) have decreased response rates to ICI, and poor glycemic control is associated with worse outcomes in cancer patients. Further adjunctive therapies to enhance ICI efficacy are needed.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have emerged as effective antihyperglycemic medications with concomitant cardiovascular benefits. SGLT2i are now approved in patients with T2DM and congestive heart failure (CHF). Pre-clinical studies suggest SGLT2i may help slow tumor growth in-vitro and in-vivo; however, there is a lack of clinical data regarding SGLT2i use in patients with advanced malignancy receiving ICI.

Methods
We performed a retrospective, matched cohort study of patients with stage IV malignancy and T2DM or CHF, who were treated with ICI using Epic Cosmos dataset (2013–2024). Ten solid tumor types, five ICI, and three SGLT2i were analyzed. Among 6,674 patients treated with ICI, 573 had at least one overlapping cycle of ICI and SGLT2i. 1:1 propensity score matching was conducted to balance baseline covariates, including cancer type, comorbidities, age at diagnosis, and sex. Kaplan-Meier curves were generated to examine survival differences, and Cox proportional hazards models were used to estimate hazard ratios (HR). The primary outcome was overall survival (OS) for the entire matched cohort and sub-groups by cancer, ICI, and SGLT2i types.

Results
Patients who received ICI and SGLT2i had significantly improved OS compared to those who received ICI alone (HR = 0.67, 95% CI: 0.57-0.78). Among cancer types, significant improvements in survival were observed in patients with renal cell carcinoma (RCC, HR = 0.58, 95% CI: 0.41–0.84) and non-small cell lung cancer (NSCLC, HR = 0.59, 95% CI: 0.42–0.84). Among ICI types, ipilimumab + nivolumab (HR = 0.50, 95% CI: 0.27-0.93) and pembrolizumab (HR = 0.58, 95% CI: 0.45-0.77) showed a significant improvement in survival when used with SGLT2i. There was no statistically significant difference in OS amongst the three SGLT2i types.

Conclusion
We observed encouraging improvements in OS in patients with T2DM or CHF receiving SGLT2i in addition to ICI across multiple solid tumor types. Patients with RCC and NSCLC derived the greatest benefit. Patients treated with either ipilimumab + nivolumab or pembrolizumab had the best responses to therapy. SGLT2i may be beneficial as adjunctive therapies in patients with advanced malignancy receiving ICI. Further prospective studies are needed to validate our observations and determine potential underlying mechanisms.


Improved survival with sodium-glucose cotransporter-2 inhibitors and immune checkpoint inhibitors in metastatic solid tumors

Introduction
The purpose of this study is to examine return to recreation outcomes in patients following surgical treatment of malignant musculoskeletal tumors and identify which sports and activities to which patients are able to return.

Methods
On October 31st, 2024, a systematic review of the literature was conducted utilizing Pubmed, Cochrane, and Embase (OVID) databases. Abstracts and titles were screened by two independent reviewers for studies that investigated return to sport, activity, or recreation after a musculoskeletal tumor resection.

Results
Across 8 studies (6 case series, 1 cohort, 1 cross sectional), a total of 223 patients (119 males, 86 females) underwent surgical resection of a malignant musculoskeletal tumor and were considered in follow-up evaluations of physical activity. Of the 223 patients, 66% (147/223) participated in some level of recreational physical activity post-operatively. Eight patients over a total of two studies returned to sport at their competitive level, with competitive sports including soccer and dancing. Across 5 studies, the most common post-surgery sport was cycling (n=37, 12.5%). Average follow-up duration ranged from 85 days to 230 months. A variety of surgical techniques were utilized over the 8 studies, including intra-articular and extra-articular surgery, rotationplasty, arthrodesis, graft, and megaprosthesis.

Conclusion
While upper limb tumor resections may have better return to sport at a higher level of activity than lower limb tumor resections, overall return to sport at any level is approximately 66%. Post-surgery activity scale is lower than pre-surgery activity scale, with the most common sport after surgical resection becoming cycling. However, the lack of quality data in current literature makes it difficult to allow for evidence-based decision-making on return to sport after resection of malignant musculoskeletal tumors. Further studies are necessary to evaluate return to sport based on age, tumor diagnosis, surgery type, and pre and post-activity levels after both upper and lower extremity malignant musculoskeletal tumor resections.

Return to Recreation after Surgery for Malignant Musculoskeletal Tumors: A Systematic Review

Background:
Glucagon-like peptide-1 receptor agonists (GLP-1) are increasingly prescribed for diabetes and obesity, yet their long-term effects on bone health remain unclear. Clinical trials commonly report neutral or protective effects of GLP-1s on bone mineral density (BMD) but seldom consider dietary intake or nutritional status in their analysis. Given the appetite-suppressing effects of GLP-1s, users may have inadequate intake of nutrients essential for bone health. Consequently, findings from GLP-1 users with normal BMD may be misleading, as patients may still suffer from underlying nutrient deficiencies or reduced muscle strength, both of which contribute to future skeletal fragility. This study aimed to develop a more comprehensive profile of bone health in GLP-1 users by examining dietary intake, serum biomarkers, grip strength, and BMD.
Methods:
Data were obtained from the 1999-2020 National Health and Nutrition Examination Survey. Nutrient intake was assessed using 24-hour dietary recalls and compared to the recommended daily value (DV). Serum markers, including total calcium, phosphorus, and 25-hydroxyvitamin D, were analyzed to identify subclinical deficiencies. Muscular strength was assessed via handgrip dynamometry, stratified by age and sex, and categorized into percentiles based on population reference standards. Femur and lumbar spine dual-energy x-ray absorptiometry (DEXA) scans were used to assess BMD and evaluate associations with nutrient intake, serum biomarkers, and grip strength. 
Results
Among GLP-1 users (n=150), intake of bone supporting nutrients was suboptimal with vitamin D (18% of DV), vitamin E (47% of DV) and potassium (49% of DV) below recommended levels. Serum vitamin D deficiency (<20 ng/ml) was observed in 33% of users, 64% of whom were female. In grip strength analysis (n=29), 29% of female GLP-1 users were below the age-and sex-adjusted 20th percentile compared to 13% of males. Median lumbar spine BMD increased with age in males from 0.97 g/cm2 (IQR: 0.93-1.07 g/cm2 n=4) in 40-49 year olds to 1.21 g/cm2 (IQR: 1.19-1.27 g/cm2 n=9) in 60-69 year olds while remaining stable with age (range: 1.01–1.10 g/cm2) in females. 
Conclusion
This study developed a comprehensive profile of bone health in GLP-1 users, showing that despite increased BMD in males and stable BMD in females, many individuals, particularly women, had vitamin deficiencies, reduced grip strength, and other indicators of skeletal vulnerability. Patients on GLP-1s would likely benefit from more comprehensive monitoring of bone health, not only through traditional imaging studies, but also regular assessment of nutritional status, serum testing, and monitoring for functional status changes.


Multimodal Assessment of Bone Health in GLP-1 Agonist Users

Background
Effective prognostic communication is fundamental for informed, goal-concordant decision-making in critical illness. Prior research identified variability in how physicians convey prognosis, yet little is known about how that variability in language influences surrogate understanding. This study described physician prognostic language patterns and evaluated their impact on surrogate understanding.

Methods
This mixed-methods secondary analysis used data from a multicenter randomized clinical trial assessing a decision aid for surrogates of patients receiving prolonged mechanical ventilation (i.e., ≥ 10 days). Physician-estimated and surrogate-perceived one-year survival were measured on a 100-point scale before and after unstructured, audio-recorded, physician-surrogate meetings. We included cases with a ≥ 20-point discrepancy between physician estimate and surrogate perception of the physician estimate (i.e., “misunderstanding”) before the family meeting. The hybrid inductive-deductive codebook focused on physician prognostic language patterns, such as probabilistic and non-probabilistic language. Coders dual-coded
20% of physician-surrogate meeting transcripts in NVivo (Cohen’s kappa 0.89); remaining transcripts were single coded. Median percent coverage (MPC) describes the proportion of transcript content occupied by each code. Linear regression models evaluated associations between prognostic language patterns and change in misunderstanding, adjusting for baseline misunderstanding, health literacy, and study arm.

Results
Among 75 meetings with initial misunderstanding, pre-meeting physician prognostic estimates (mean 42.1; SD 26.7) were lower than surrogate perceptions (68.8; 30.1). Post-meeting, 57.3% of surrogates (n=43) demonstrated persistent misunderstanding. Prognostic communication occupied a median 23.3% of transcript content. Non-probabilistic language (MPC 18.6%) was more common than probabilistic language (5.2%). The most common sub-types were best- or worst-case scenarios (5.3%; e.g., "Best case, she walks again; worst case, she doesn't
improve"), general statements (3.2%; e.g., "His body’s still got a lot to fight through"), and opinions (3.0%; e.g., "I don’t think he’s gonna die here"). Numeric estimates were nearly absent (0.0%). Individual framing predominated (17.6%) over population-level statements (3.9%). Beta coefficients for modeled prognostic language patterns ranged from –0.74 to +0.90, with 95% confidence intervals overlapping zero in all cases. No prognostic language pattern was significantly associated with post-meeting understanding (p-values > 0.025 in bivariate analysis).

Conclusion
Surrogates in this cohort perceived physicians as more optimistic than they were, and most continued to misunderstand prognosis – suggesting current prognostic communication practices inadequately support comprehension. Physicians conveyed prognostic information in less than one-quarter of the conversation, using primarily individualized, non-probabilistic language. As no single behavior predicted understanding, further analysis of communication quality and variability within categories may inform strategies to improve clarity.

Prognostic Communication in Critical Illness: Language Patterns and Surrogate
Misunderstanding

Robotic Prostatectomy (RP) is the predominant surgical approach for localized prostate cancer in the United States and over 50% of RP are performed as ambulatory or same-day discharge encounters. Current literature supports that RP performed in the outpatient setting are as effective and have no increase in complications compared to those performed inpatient and cost nearly 20% less than those performed inpatient. However, in 2022, the Centers for Medicare and Medicaid Services (CMS) removed robot-assisted radical prostatectomies from the list of covered procedures for ambulatory surgery centers (ASC).

In 2021, an independent multi-specialty physician group performed RP in both a freestanding ASC and in an affiliated hospital. This study compares the clinical and pathological factors, operative metrics, and postoperative outcomes between RP performed by this physician group in an ASC and in a hospital.

This is a retrospective study of consecutive RP cases performed by two high-volume robotic surgeons at an ASC or a hospital between May 2021 and December 2021. Data on demographics (age, body mass index), clinical and pathological variables (prostate specific antigen, grade group, prostate volume, pathological stage), and operative metrics (American Society of Anesthesiologists (ASA) classification, estimated blood loss, operative time) were collected. Outcomes and complications were defined by recovery time, total length of stay, adverse events, and Clavien-Dindo classification. Analysis involved the use of descriptive statistics, t-tests for continuous variables, and Chi-Square analysis and Fisher’s tests for categorical variables.

40 ASC cases and 50 hospital cases were identified. There were no significant differences in mean age, BMI, PSA, prostate volume, and final pathological stage between groups. The hospital group had higher grade group classification. There were no significant differences in ASA classification, estimated blood loss, operative time, or complications between groups. 

RP performed in an ASC demonstrated outcomes comparable to those performed in a hospital. These findings are consistent with published evidence that outpatient RP are safe and cost- effective, supporting reconsideration of current CMS reimbursement policies that restrict access to ambulatory surgical care for prostate cancer.

Comparison of Same-Day Discharge Robotic-Assisted Radical Prostatectomy in Ambulatory Surgery Center vs. Hospital Setting

Introduction:

Myonecrosis is a rare but serious complication of diabetes, particularly in patients with end-stage kidney disease (ESKD), characterized by ischemic necrosis of skeletal muscles. Its diagnosis is often delayed due to overlapping presentations with cellulitis or deep vein thrombosis. Treatment is traditionally limited to supportive measures such as rest and pain control, which remains the cornerstone. The role of corticosteroids remains controversial in this condition as its effectiveness and utility is not widely understood. This case highlights the unconventional use of corticosteroids in managing refractory diabetic myonecrosis, emphasizing their potential in mitigating inflammation and promoting recovery.

Case Report:

We present a 31-year-old woman with ESKD on hemodialysis and a history of type 1 diabetes, who presented with recurrent, debilitating pain and swelling in the right lower extremity. Despite a comprehensive workup, including MRI and a muscle biopsy confirming myonecrosis, the patient’s symptoms persisted despite conventional supportive care. Following a multidisciplinary discussion, corticosteroid therapy was initiated, resulting in dramatic symptom resolution within 48 hours. The patient experienced significant pain reduction, improved mobility, and decreased swelling, allowing for discharge on a tapering steroid regimen. Notably, a subsequent recurrence of myonecrosis in a different muscle group also responded favorably to corticosteroid treatment, further underscoring its therapeutic potential in managing patients with this condition.

Discussion/Conclusion:

This case underscores the importance of considering corticosteroids as an adjunctive therapy in refractory diabetic myonecrosis, particularly in patients who fail to respond to standard care. A detailed workup, a high degree of suspicion, distinct clinical findings, and imaging such as MRI along with muscle biopsy can accurately diagnose this condition. While corticosteroids are not routinely used due to potential risks, their dramatic effect in this patient highlights the need for further research to better understand their role and refine treatment strategies. By expanding the therapeutic approach to diabetic myonecrosis, this case provides valuable insights for improving outcomes in this rare and challenging condition. This case opens the door for exploring corticosteroids as adjunctive therapy in similar diabetic patients with ESKD and refractory myonecrosis.

Steroids for Diabetic Myonecrosis in ESRD: An Unconventional Treatment with Unexpected Success

Background
The pelvic exam is used in the evaluation of many gynecologic complaints. Providers across all specialties should be able to perform this exam with an emphasis on consent, patient comfort, and accuracy. The OB/GYN clerkship is an important time for medical students to develop the technique and interpersonal skills necessary to perform pelvic exams on patients assigned female at birth. Graduating students should be able to independently perform these examinations accurately and sensitively; however, students report limited exposure in the clinical setting.
Methods
This was a prospective, mixed-methods study of medical students and OB/GYN preceptors at a large academic center in NYC between June 2024 and March 2025. The authors developed surveys using a modified Delphi process and refined them through cognitive interviews. Students logged the number of pelvic exams they performed and completed a survey at the end of the 5-week clerkship. Preceptors were surveyed via email. Quantitative analysis included descriptive statistics and nonparametric tests. Qualitative data from open-ended survey responses were analyzed inductively to identify key themes.
Results
Among 93 student respondents (91.2% response rate), the average number of exams performed per student was 4.25 speculum and 2.17 bimanual exams. Students at the academic center performed significantly fewer exams than those at the community hospital. Over half of students (51.6%) did not perform any bimanual exams. Cisgender male students performed fewer speculum exams than cisgender female students. Students reported increased confidence and reduced anxiety with pelvic exams after the clerkship. Simulation and gynecologic teaching associate sessions were rated as helpful, but students emphasized the need for real clinical opportunities. Among 89 preceptor respondents (52.0% response rate), barriers to student participation included patient preference, exam complexity, time constraints, and institutional climate. Preceptors at the academic center cited time constraints and institutional climate as barriers more often than those at the community hospital.
Conclusion
Despite improved confidence by the end of the OB/GYN clerkship, many students perform few pelvic exams in the clinical setting. Preceptor behavior, institutional policies, and clinical environment significantly impact student opportunity. To ensure all students meet pelvic exam learning objectives, institutions should supplement clinical training with simulation, improve preceptor engagement, and clearly communicate policies around student participation and patient consent.

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A Search for Long-noncoding RNAs (lncRNAs) as Genetic Markers for Hypoxia Sensitivity in Mus Musculus

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