United States

Background:

The United States Preventive Services Task Force recommends colorectal cancer (CRC) screening for all average-risk adults aged 45 years and up1. Fecal Immunochemical Tests (FIT) and FIT/DNA (Cologuard) test are the two most widely used non-invasive tests used for this screening. In the event of a positive test, a diagnostic colonoscopy is recommended within three months of the positive result. As the Covid-19 pandemic continues, hospitals have implemented policies that include strict screening guidelines before procedures such as colonoscopies. The effect of these guidelines and restrictions on elective procedures such as colonoscopy on the interval between a positive non-invasive screening test (NIST) and diagnostic colonoscopy (DC) is not clear.
Study aim: to quantify the interval between a positive NIST (FIT, FIT/DNA) and DC, and to compare these findings to non-pandemic findings from the previous year. 


Methods:
In this retrospective, time-trend analysis, we identified patients within a major hospital system in Indiana who had a positive NIST between January 1, 2019 and June 30. After our original query, we noticed FIT/DNA tests were not coded into the EMR before June 10, 2020, and had to use data from campus-based public and private hospitals to supplement for this time period. Once identified, chart review was performed to determine if/when a patient underwent DC . If a patient’s chart did not show evidence of a DC, we examined the EMR notes to discern whether, when, or why colonoscopy was / was not completed. We measured the interval between NIST result and DC by quarter, comparing results between corresponding times during 2019 and 2020 as well as the first two quarters of 2021. We also measured and compared the proportion of patients with a positive non-invasive test who had not had colonoscopy by 60, 90, and 180 days. 


Results:
Of the 1,379 patients reviewed, 930 (68%) underwent subsequent colonoscopy in the 30-month study timeframe. Colonoscopy completion rates were 72% for the FIT/DNA group, and 47% for the FIT group over the 30-month timeframe. Of the 293 persons who did not elect to have a subsequent colonoscopy, 21 (7.2%) reported that the pandemic kept them from undergoing the procedure. Concern for acquiring COVID-19 from the colonoscopy site was the most common reason for declining colonoscopy in this group, having been mentioned by 8 of the 21 individuals. Other reasons included waiting to get a COVID vaccine before undergoing a procedure or issues with completing required COVID screening before the procedure. Only two individuals (0.7%) were found to have delayed colonoscopy due to a recent COVID infection. The proportion of patients completing a colonoscopy within 90 days of a positive NIST were 83%, 79%, and 83% for 2019, 2020, and 2021, respectively.


Conclusion/Impact:

Overall, the rate of DCs following a positive NIST test did not appear to be significantly affected by the COVID-19 pandemic. Concern of contracting COVID-19 was a more common reason for delay when compared to actual COVID infection. A study evaluating the rate of COVID infection following a colonoscopy procedure may be useful to address the validity of these concerns, the results of which could alleviate (or exacerbate) this issue in the setting of future outbreaks. When compared to Cologuard, patients who had a positive FIT test were more likely to wait longer for a DC. This discrepancy suggests the relationship between providers and their use of FIT vs. Cologuard should be further probed. In addition, studying patient perceptions of both screening procedures may identity reasons for delay.

1. US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965–1977. doi:10.1001/jama.2021.6238


AMA Research Challenge 2022

Interval Between A Positive Non-invasive Colorectal Cancer Screening Test and Colonoscopy: A Time-trend Analysis During the SARS-CoV2 Pandemic

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Background
This study sought to describe the levels of depression and anxiety experienced by English and Spanish-speaking patients undergoing radiation therapy for breast cancer. We aimed to describe the impact of different variables to better understand and quantify potential gaps.

Methods
Eligibility criteria included English and Spanish-speaking females, ages 18 or older, undergoing radiation therapy treatment for a breast cancer at Boston Medical Center. Surveys were completed before delivery of radiation therapy. Survey included sociodemographic questions along with the standardized PHQ-4 questionnaire, which uses a maximum total score of 12, to assess anxiety and depression. Results were analyzed using a least means square procedure.

Results
60 participants completed surveys, with a total distress mean (DM) of 3.32 (SD= 3.55). English-speaking patients comprised 70% (n=42) of the sample and had a DM of 3.40. Spanish-speaking patients comprised 30% (n=18) with a DM of 3.11. Sociodemographic characteristics included: race -- 27% White (n=16), 46% Black (n=28), 27% other (n=16); ethnicity -- 67% non-Hispanic (n=40), 33% Hispanic (n=20); marital status -- 37% never married (n=22), 33% married (n=20), 30% divorced/ separated/widowed (n=18); education level -- 20% < High school (n=12), 60% high school/associate’s (n=36), 20% bachelor’s/master’s/doctorate (n=12); and longest residence -- 60% US (n=36), 40% foreign country (n=24). Additional variables surrounding social determinants of health included housing and food insecurity. 

Conclusion
Our study showed a higher baseline DM among English-speaking patients in comparison to Spanish-speaking patients. Most of our patient population was English-speaking, though approximately one third Spanish-speaking. Participants were also primarily Black, non-Hispanic, never married, had a high school or associate level education, and had their longest residence in the US. Although the majority did not report housing or food insecurity, both had increasing DM with increased insecurity, with statistically significant results. This study provides insight into a patient population that has historically been understudied, particularly Black and Hispanic patients, that comprise ~29% of the US population, but make up less than 10% of participants in cancer clinical trials. In addition, as the number of Spanish-speakers in the US continues to increase, it will be important to understand and address potential differences in cancer care.

A Comparative Assessment of Depression and Anxiety in English-Speaking and Spanish-Speaking Breast Cancer Patients Undergoing Radiation Therapy

Background: Black mothers have worse birth outcomes than White mothers. Historic medical abuses and systemic racism render a sense of mistrust between Black birthing individuals towards their obstetric healthcare providers and may result in Black birthing people seeking medical advice from doulas outside their traditional practice scope. Objective: The objective of this study was to create a structured collaborative curriculum between community doulas and academic obstetric providers to address common prenatal and postpartum pregnancy complications that disproportionately affect Black birthing people. 
Study Design: The collaborative training session was a two-hour session jointly developed by the founding director of Homeland Heart Nashville Birth and Wellness Collective, a Vanderbilt Maternal-Fetal Medicine Specialist, and a Vanderbilt Certified Nurse midwife. On the day of the collaborative training, the doulas (n=12) took a pretest to assess their knowledge of postpartum warning signs, preeclampsia, breastfeeding, and GDM. After the didactic session, the doulas were given a post-test. The scores were averaged across the four pre and post-assessment topics. We calculated students' t-tests between the pre-and post-assessment. A p-value of < 0 .05 was considered significant. 
Results: All twelve participants identified as Black female birth workers. The mean score correct of the pretest results was 55.25±13.36%. The initial percent correct for post-birth warning signs, hypertension in pregnancy, and gestational diabetes mellitus/ breastfeeding sections were 37.5±19.55 %, 72.9±16.72 %, and 75±18.46%, respectively. The post-test mean score of correct answers rose to 91.92 ± 4.66% (p< 0.01). The percent correct per section increased to 92.7±9.91 %, 81.3±11.31 %, and 100±0 %, respectively. The student T-test calculated P-value from the pre-and post-test mean was < 0.01.
Conclusion: An educational framework that leverages community and academic partnerships between doulas and obstetric providers can bridge the gap to improve doulas’ knowledge and holds promise to improve Black birthing outcomes.

Collaborative Education as a Conduit to Build Trust and Skills in Black Birth Workers

Background
Covid-19 infection poses higher risks if contracted during pregnancy. Yet, COVID-19 vaccination rates in those who desire future fertility are low. Misinformation about COVID-19 vaccination leading to to female infertility has been common on social media. The objective of this study was to characterize the prevalence and content of misinformation about infertility and the COVID-19 vaccine on Twitter. 

Methods
Tweets were obtained from the COVID-19-TweetIDs dataset at two key points in the COVID-19 vaccine discourse (July 2021 and December 2021). All relevant tweets contained at least one word related to COVID19 vaccination and one word related to fertility and were analyzed for factuality. Descriptive statistics on followers, verification status, engagement, and common words and hashtags were obtained. ANOVA or Chi-square tests were utilized to examine differences between the factual and misinformation groups. A p value of <0.05 was considered statistically significant. Sentiment analysis was conducted to categorize tweets as positive, neutral, or negative.

Results
Overall, 11,436 tweets from Timeframe 1, and 5,982 tweets from Timeframe 2 were reviewed (n = 17,418). Misinformation tweets were 29.9% in July 2021 to 45.1% in December 2021. Accounts sharing factual information were more frequently verified users (p<0.001) and had increased follower counts (p<0.001). Engagement was similar in both factual and misinformation groups. Sentiment analysis revealed that factual tweets were more likely positive and misinformation tweets more often negative (p<0.001). 

Conclusion
Misinformation about the COVID-19 vaccine and fertility a serious problem on social media, and may limit vaccine uptake in people desiring future pregnancy. To combat misinformation, it is imperative to identify and denounce the misinformed content. Physicians must be aware of online misinformation to adequately address vaccine hesitancy in patients who are pregnant or trying to conceive. Twitter accounts sharing factual information were more likely to be verified, highlighting the need for more physicians’ accounts to be verified. Physicians can play an important role in fighting misinformation both in the office and online.

COVID-19 Vaccine Information and Infertility Tweets: Insights on a Misinformation Pandemic

Background: 
Anticipating a desire for at-home services during COVID-19, the authors hypothesized that there would be an increase in preference for medical abortions (“pill” abortion, at-home method) over surgical abortions (vacuum aspiration, in-patient setting) for first trimester voluntary terminations. There is limited information on the effects of the pandemic on a patient’s preference between medical or surgical abortion. Such research would allow healthcare professionals and policy-makers to understand factors that patients evaluate when choosing a pregnancy termination procedure.

Methods: 
One of nine independent abortion clinics in Southeastern Michigan took part in the study. Retrospective, deidentified data regarding the count and type of first trimester abortions was collected. Inclusion criteria included first trimester medical and surgical abortions performed January 1, 2019 through December 31, 2020. In 2019, there was 2,221 first trimester abortions, with 1,519 surgical and 702 medical cases; in 2020, there was 2,482 first trimester abortions, with 1,503 surgical and 979 medical. A negative binomial statistical model compared the number of medical abortions by calendar year. A logistic regression time-period variable assessed for chronological trends over the 24-month period. Each calendar year was divided into quartile periods of three consecutive months. Analysis focused on Quarter 1 and Quarter 2, based on a Michigan executive order issued in March of 2020.

Results: 
Data showed that medical abortions increased from 702 in 2019 to 979 in 2020 (p-value=0.00499). Time-period variable analysis was statistically significant (p-value=0.00824), implying a significant chronological increase across the 24-months. There was no significant increase in medical abortions in Quarter 1 from 2019 to 2020 (185 vs 215, p-value=0.79). There were 175 medical abortions in Quarter 2 of 2019 compared to 294 in Quarter 2 of 2020 (p-value=0.00067).

Conclusion: 
Understanding medical abortion trends allows clinicians to better serve their patients - potentially prioritizing telemedicine and holistic at-home care. Expanding medical abortion access via telemedicine could assist clinics/patients in overcoming various barriers, including clinic costs and distance/transportation.

Acknowledgements: 
Protocol was determined IRB-exempt. This research did not receive any grants from any funding agencies or study sponsors.

Medical abortion trends during COVID-19 at an independent clinic in Detroit, Michigan

Background
On May 2nd, 2022, a leaked majority draft opinion revealed the Supreme Court's intention to overturn Roe v. Wade, thereby threatening abortion access in at least 26 states. On June 24, SCOTUS issued their ruling taking away the constitutional right to abortion. As physicians’ key interest groups, medical societies often leverage their power to advocate for policies to improve the health of our patients and colleagues alike. This study aims to describe which medical societies made statements advocating for abortion access following both the leaked opinion and the final decision overturning Roe v. Wade. 
Methods
The study included 130 U.S.-based medical societies from the AMA House of Delegates, Council of Medical Specialty Societies, CREOG, and other Ob/Gyn societies. Study authors (SF, ML) reviewed websites and social media profiles of medical societies to determine whether they made statements within 2 weeks post-leak (May 2-16) and post-SCOTUS decision (June 24-July 8). Outcomes included whether a statement was posted, the latency from event to statement, and whether statements contained the word “abortion.” 
Results
Within 2 weeks of the leaked draft opinion, only 13.1% (n=17) of societies made a statement. The average time from leak to statement was 2.4 days. Most statements [82.4%, (n=14)] used the word “abortion.” 
In the 2 weeks following the SCOTUS decision, 38.5% (n=50) of societies made a statement. Of those, 14% (n=7 of the 50) only joined collective statements. The average time from leak to statement was 3.2 days. Many statements [70%, (n=35)] used the word “abortion.” Significantly more societies made a statement in the 2 weeks following the SCOTUS decision (z = 4.6793, p < .00001). 
Discussion
After the leaked opinion indicated a likely overturning of Roe, when statements would likely have had maximal impact, few medical societies affirmed the importance of abortion access. Although significantly more spoke up once Roe v. Wade was officially overturned, the majority of societies (over 60%) remained silent. Medical societies have a responsibility to advocate for abortion access, and many missed the opportunity to influence policymakers and stand in solidarity with our patients and colleagues.

Medical Society Statements on Abortion Rights at SCOTUS Leaked Draft Opinion vs Final Decision on Dobbs v. Jackson Women’s Health Organization

Background
Since the start of the COVID-19 pandemic in 2020, patterns of trauma and injury have changed. The immediate lockdown period showed fewer ED visits but a higher proportion of severe injury. The objective of this study is to compare the incidence of eye-related injuries presenting at a single institution occurring in 2019 versus 2020. 

Methods
A retrospective study was conducted on 824 patients presenting to the ED from 01/01/2019 through 12/31/2020 at a freestanding Level 1 Trauma Center in the Midwest. Patients were >18 years old with any sort of ophthalmic trauma. Patients were organized by age, ethnicity, and gender. De-identified data from the Trauma Registry Database was filtered based on ICD codes relating the manner of injury, including the overarching categories of superficial, laceration, fracture, ocular trauma, and burns. 

Results
The number of distinct patients seen for eye-related traumas was 378 in 2019 and 446 in 2020. Most of the change from 2019 to 2020 arose from increases in lacerations and fractures, with lacerations increasing 24.5% and fractures increasing 27.0%. The number of fractures reported in each 3-month season following the initial March 2020 lockdown was 27.4-44.9% higher than the corresponding seasons in 2019. Superficial injuries marginally increased, while ocular trauma injuries decreased by 10.2%.

Demographically, the proportion of female patients compared to male patients increased from 2019 to 2020. There were increases in incidence across all age groups: 25.7% for age 18-30, 9.6% for age 31-50, 13.9% for age 51-65, and 25.7% for age >65. The proportion of ophthalmic trauma patients identified by self-reported race remained stable from 2019 to 2020, with approximately ⅓ patients identifying as Black/AA and ⅔ identifying as White.

Conclusion
Eye-related traumas increased during the initial COVID-19 wave through the end of 2020. We specifically found an increase in severe eye injuries including lacerations and fractures, although ocular traumas such as ruptured globes decreased. The drastic change in lifestyle mandated by COVID-19 lockdowns likely contributed to these changes, with more people sustaining injuries while completing home projects and a concurrent rise of intimate partner violence.

Changes in Incidence of Eye-Related Injuries from 2019 to 2020

Healthcare disparities in the United States lead to nearly $35 billion in excess health expenditures annually and can include increased risks of surgical complications and mortality among at-risk patients. However, these disparities have yet to be clearly elucidated within the field of orthopedic surgery. Moreover, minority populations receive poor trauma care and increased complications after spine surgical & joint replacement surgeries. This study aims to highlight the current disparities in orthopedics and provide strategies to decrease these discrepancies to provide equitable medical care. To accomplish this, we conducted a systematic review of the clinical, functional, and quality of life measures in relation to healthcare disparities in the field of orthopedics. Using the recommendations outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we screened studies in language, race, transportation, and orthopedic trauma coverage and extracted current data to synthesize strategies to reduce disparities. Preliminary analysis indicates lack of access to reliable and robust public transit infrastructure interrupts the continuity of care and produces worse health outcomes, specifically in Hispanic populations. Additionally, disparities based on language demonstrate a difference in the outcomes of their care. With regards to trauma coverage, uninsured and minority populations experienced more iatrogenic complications, had an increased risk of major adverse events, longer wait times, and lower chances of undergoing surgery resulting in more major adverse events. These results underscore the need for educational interventions to improve patient follow-up care in orthopedic settings.

Current Strategies for Decreasing Disparities in Orthopaedic Care: A Systematic Review

Background: Coronavirus (COVID-19) is transmissible via aerosolized particles (0.07-0.09μm). Healthcare workers are at risk when treating COVID+ patients; therefore, it is imperative to find ways to protect frontline staff. Patients who need emergency procedures or those that involve the aerodigestive tract may place staff at high risk of COVID transmission, as COVID status may not be known. Power drills operate at faster rpm and require irrigation in order to cool down the bone. This study investigated particle generation during maxillofacial trauma repairs using power and self-drilling techniques at different distances from the operating table during open reduction and internal fixation (ORIF). In doing so, we aim to find ways to mitigate the risk of contracting airborne diseases such as COVID-19. 

Methods: Two cadaveric specimens in a simulated operating room underwent ORIF of midface and mandible fractures via intraoral incisions as well as maxillomandibular fixation (MMF) using hybrid arch bars. For both simulated ZMC and parasymphyseal mandible fractures, ORIF was performed utilizing self-drilling screws and a power drill. Real-time aerosol concentration was measured throughout each procedure using 3 particle counters placed 0.45, 1.68, and 3.81 m (1.5, 5.5, and 12.5 feet, respectively) from the operative site.

Results: There was a significant decrease in particle concentration in all procedures at 1.68 m compared to 0.45 m (P < 0.001). At all three distances away from the operative site, there was significantly less aerosolized particle generation when using self-drilling techniques compared to power drilling for ORIF (P < 0.01).

Conclusion: Based on our study, self drilling techniques, unlike power drills, operate at lower rpm and do not require irrigation, therefore generating fewer particles and mitigating aerosol spread. Using self-drills and maintaining physical distancing protocols in the OR significantly reduce the number of aerosolized particles, which can decrease the risk of COVID-19 infection to the surgical team. While we have become more adept with the rise of multiple vaccines and more PPE, there is still uncertainty with the long term effects of COVID, and mitigation efforts are still critical. Furthermore, this and future studies will help us prepare for future pandemics and helping other at-risk populations, such as those at risk of tuberculosis.

Quantifying Aerosol Generation in Maxillofacial Trauma Repair Techniques

Background: Recent studies in large databases characterize child abuse and investigate the utility of clinical decision tools to detect physical abuse. This study characterizes risk factors preceding a diagnosis of physical abuse (NAT) in the pediatric trauma population to explore the potential of administrative databases in detecting physical abuse.
Methods: The Maryland Health Services Cost Review Commission (HSCRC) public-use data was queried for patients aged 0-19 to balance the number of patient records with the constraints of the database. Suspected physical abuse, confirmed physical abuse, and trauma were outcomes identified using ICD10 codes. Using logistic regression, odds ratios for each diagnostic code were identified unadjusted and adjusted for age, sex, race, ethnicity, year of encounter, and payer. Significance equals p<.05 after Bonferroni/Holm adjustment. Analysis was conducted in R (R Core Team, 2022).
Results: We identified 2,230 patients diagnosed with confirmed or suspected physical abuse totaling 10,546 encounters prior to NAT diagnosis. We identified 396,575 pediatric trauma patients totaling 606,146 encounters. The regression model comparing diagnostic codes of confirmed or suspected NAT with pediatric trauma yielded hundreds of statistically significant diagnostic codes. We report only the diagnoses with the highest frequency in the confirmed or suspected NAT population adjusted for demographic characteristics.
Conclusion: We identify known risk factors and findings associated with the child abuse population, such as racial disparities, psychiatric conditions, and congenital conditions. Several hundred statistically significant diagnoses were identified, demonstrating the limited immediate clinical utility of any single diagnostic code. We identified diagnostic codes such as cough, asthma, and visual pathologies that increase the odds of NAT but are poorly characterized in the literature. A large number of statistically significant diagnoses presents an opportunity to use machine learning in the child abuse population to assist clinicians in diagnosing and identifying NAT.

Identifying Risk Factors Preceding Non-Accidental Trauma Among Pediatric Trauma Patients in the HSCRC dataset

Socio-demographic Characteristics of Childhood Asthma and its Association With Substance Abuse – US Cross-Sectional Survey Study

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A Comparative Assessment of Depression and Anxiety in English-Speaking and Spanish-Speaking Breast Cancer Patients Undergoing Radiation Therapy

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