United States

Background
There is a higher burden of diabetes related lower extremity amputation in the Lower Rio Grande Valley area of Texas compared to the Texas average. Hispanics have a higher proportion of this complication in the region. Yet, there is a dearth of research on factors associated with the risk of diabetes associated amputation in Hispanic populations. This study evaluates factors associated with diabetic related amputations in Hispanic patients with diabetic foot ulcer in the Rio Grande Valley area of Texas.

Methods
Our study was a retrospective study using patients’ medical records. Subjects were categorized based on whether they had at least one amputation (outcome) during the period of analyses. Baseline demographic, lifestyle, and metabolic characteristics of participants were determined. Characteristics of interest were insulin use, neuropathy, nephropathy, peripheral arterial disease, hypertension, history of cerebrovascular accident, smoking status, osteomyelitis, previous history of diabetic foot ulcer, previous history of amputation, hyperlipidemia, and glycated hemoglobin levels. Chi-square tests were used to analyze the association between these characteristics and amputation status. Logistic regression modeling was used to estimate the odds ratios for amputation and their 95% confidence intervals by each of the independent variables. We adjusted for age and gender in our multivariable analyses. Statistical analyses were carried out using Stata software.

Results
This study included 120 subjects, all of whom had diabetic foot ulcer. Sixty (50%) of the study subjects had diabetic foot amputation and the rest did not. The variables found to be significantly associated with amputation were peripheral arterial disease (p = 0.006), osteomyelitis (p &lt; 0.0001), previous history of amputation (p &lt; 0.0001), and hyperlipidemia (p = 0.013). However, previous diabetic ulcer, neuropathy, nephropathy, hypertension, smoking status, the use of insulin, retinopathy, and levels of hemoglobin A1c were not significantly associated with amputation.

Conclusion
Diabetic foot amputations have untold effects on the lives of affected individuals, and the broader society. Thus, factors promoting this event should be readily prevented and managed. In the studied population, peripheral arterial disease, osteomyelitis, previous amputation, and hyperlipidemia were significantly linked to diabetic foot amputations. Hence, while more research is required, medical professionals should actively seek out and adequately manage diabetic Hispanic patients with these risk factors to prevent this complication.

AMA Research Challenge 2023

Factors associated with diabetic foot amputations in Hispanic patients in Rio Grande Valley, Texas.

Background
There is a higher burden of diabetes related lower extremity amputation in the Lower Rio Grande Valley area of Texas compared to the Texas average. Hispanics have a higher proportion of this complication in the region. Yet, there is a dearth of research on factors associated with the risk of diabetes associated amputation in Hispanic populations. This study evaluates factors associated with diabetic related amputations in Hispanic patients with diabetic foot ulcer in the Rio Grande Valley area of Texas.

Methods
Our study was a retrospective study using patients’ medical records. Subjects were categorized based on whether they had at least one amputation (outcome) during the period of analyses. Baseline demographic, lifestyle, and metabolic characteristics of participants were determined. Characteristics of interest were insulin use, neuropathy, nephropathy, peripheral arterial disease, hypertension, history of cerebrovascular accident, smoking status, osteomyelitis, previous history of diabetic foot ulcer, previous history of amputation, hyperlipidemia, and glycated hemoglobin levels. Chi-square tests were used to analyze the association between these characteristics and amputation status. Logistic regression modeling was used to estimate the odds ratios for amputation and their 95% confidence intervals by each of the independent variables. We adjusted for age and gender in our multivariable analyses. Statistical analyses were carried out using Stata software.

Results
This study included 120 subjects, all of whom had diabetic foot ulcer. Sixty (50%) of the study subjects had diabetic foot amputation and the rest did not. The variables found to be significantly associated with amputation were peripheral arterial disease (p = 0.006), osteomyelitis (p < 0.0001), previous history of amputation (p < 0.0001), and hyperlipidemia (p = 0.013). However, previous diabetic ulcer, neuropathy, nephropathy, hypertension, smoking status, the use of insulin, retinopathy, and levels of hemoglobin A1c were not significantly associated with amputation.

Conclusion
Diabetic foot amputations have untold effects on the lives of affected individuals, and the broader society. Thus, factors promoting this event should be readily prevented and managed. In the studied population, peripheral arterial disease, osteomyelitis, previous amputation, and hyperlipidemia were significantly linked to diabetic foot amputations. Hence, while more research is required, medical professionals should actively seek out and adequately manage diabetic Hispanic patients with these risk factors to prevent this complication.

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Background
The bi-directional relationship between depression and prescription opioids is well-established. Evidence shows that adults with depression and non-cancer pain are more likely to remain on opioids and are at risk for opioid use disorder. In contrast, less is known about persistent opioid use and change in anxiety. Among chronic pain patients, opioid users are at higher risk for developing anxiety symptoms compared to those receiving other forms of pain management. However, it is unknown if continued use leads to worsening anxiety when compared to quitting. This study aims to determine if persistent opioid use is a risk factor for developing or worsening generalized anxiety disorder (GAD).

Methods
This prospective cohort study involved non-cancer pain patients (n=361) 18-70 years old starting a period of 30 to 90-day opioid use. Patients from Saint Louis University’s medical practice and the Henry Ford Health System self-administered web surveys or participated in telephone interviews. Difference in difference (D.I.D) analysis determined if change in opioid use was associated with change in GAD-7 scores. Outcome measures included mean GAD-7 score, change in GAD-7 score between baseline and 6 months, and threshold change from a GAD-7 score<10 before and after adjusting for age, race, gender, depression, PTSD, anhedonia, substance use disorder, smoking, and alcohol use.

Results
At baseline, those who persistently used opioids had significantly higher GAD scores [6.4 (±5.9)] compared to those who quit [4.7 (±5.3)]. However, there was no significant difference in GAD score at 6 months between persistent users [5.3 (±5.5)] and quitters [5.2 (±5.8)]. The crude D-I-D analysis revealed no differences in GAD score change from baseline to 6 months between the groups (D.I.D = -1.58; 95% CI: -3.38, -0.23). An adjusted analysis revealed similarly insignificant results (D.I.D = -1.16; 95% CI: -2.94,0.62). Furthermore, among patients with negative GAD (score<10) at baseline, there was no significant difference in risk of GAD (score>=10) at 6 months, whether they persisted or not [crude RR = 1.10; 95% CI: 0.55,2.20); adjusted RR = 1.01 95% CI: 0.53,1.93)].

Conclusion
Patients who persisted vs. quit opioid use at 6 months did not differ in association with worsening or new-onset GAD. However, the results reveal a trend for persistent opioid users to have lower 6-month GAD scores. Additional analysis with a larger sample is needed to determine the characteristics of patients who persist yet experience a decrease in GAD symptoms compared to those who experience constant or worsening GAD.

Persistent Opioid Use and the Development of Generalized Anxiety Disorder

Background
Crohn’s disease (CD) and ulcerative colitis (UC) are inflammatory disorders of the GI tract that may cause symptoms leading to the alteration of dietary intake to control symptoms. There are recommended diets for treatment of inflammatory bowel disease (IBD), but many diets have low-quality evidence for efficacy. However, in an effort to relieve symptoms, patients or families may self-restrict certain foods, leading to the development of restrictive eating behaviors.
In 2013, avoidant-restrictive food intake disorder (ARFID) was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to identify patients who actively restrict food intake leading to insufficient caloric/nutritional intake and causing at least one of the following complications: weight loss, nutritional deficiency, dependence on nutritional supplements, or psychosocial impairment. 
As ARFID is a relatively new diagnosis, the prevalence of this diagnosis in chronic disease states has not been well-characterized. A recent adult study measured the prevalence of ARFID in an adult IBD population, examined nutritional risk in the context of ARFID risk, and identified risk factors for ARFID in IBD patients. 28/161 (17%) patients had a positive ARFID risk score, as measured by the Nine-item ARFID Screening tool (NIAS).
Currently, there are no studies evaluating the prevalence of ARFID in pediatric patients with IBD. We estimate that the prevalence is high based on anecdotal food avoidances, particularly during a flare of symptoms. We also hypothesize that patients who have high ARFID risk scores may be more at risk for nutrition deficiencies. 
Methods
This is a prospective, observational cohort study of pediatric patients (age 0-17) with inflammatory bowel disease. Fifty patients will be enrolled. Participants complete surveys about eating behaviors and nutritional status after scheduled clinic visits. Study outcomes measured are ARFID risk score (calculated by the NIAS) and nutritional status (height and weight velocity z-scores, mid-upper arm circumference z-scores). 
Results
Based on recent guidelines, a positive ARFID risk score is defined as a score that meets at least one of the following criteria: ≥10 in the picky eating sub-score, ≥9 in the appetite sub-score, ≥10 in the fear sub-score, ≥24 in the total NIAS score Preliminary results suggest a prevalence of ARFID in participants based off a positive ARFID screen to be 21% (8/38 patients), compared to the estimated prevalence of ARFID in community pediatric populations of 2%.
Conclusion
We anticipate that the results of this study can help clinicians address nutritional deficiencies in pediatric IBD patients before it becomes detrimental to patients’ well-being. With the knowledge that pediatric IBD patients are more at risk of ARFID, their needs can be predicted by clinicians and dietitians to ensure proper care of patients.

Evaluating the Prevalence of Avoidant Restrictive Food Intake Disorder in Pediatric Patients with Inflammatory Bowel Disease

Background
Routine hepatic ultrasonography is the most used clinical imaging study in diagnosing chronic liver diseases (CLDs), including assessing hepatic steatosis, a common presentation of CLDs. However, data remain lacking on the performance of hepatic ultrasonography in assessing steatosis and factors that may impact the quality of its performance. This study evaluated the association of hepatic ultrasonography for the assessment of hepatic steatosis with histological hepatic steatosis and other related factors.
Methods
A single-center retrospective study of 188 patients with various CLDs, regular follow-ups, and liver biopsy at the UCIMC Liver Clinic.
Results
The mean age±SD was 57±13 years old. 93 patients were male (49.5%), and 44 (23.4%) had a BMI ≥ 30. Chronic hepatitis C (CHC, 20.8%) and B (17.5%), and non-alcoholic fatty liver disease (NAFLD, 29.0%) were the main CLDs. In this cohort, 89/187 (47.6%) patients had biopsy-proven hepatic steatosis (i.e., ≥ 5% of hepatocytes), 129/188 (68.6%) had ultrasonographic reports of hepatic steatosis, and 67/184 (36.4%) had ultrasonographic reports of hepatomegaly (i.e., ≥ 16.5 cm). The sensitivity and specificity of hepatic ultrasonography for assessing hepatic steatosis, compared to histological steatosis ≥ 5% (gold standard), was 85.4% (76/89 patients) and 46.9% (46/98 patients), respectively. Chi-square analysis showed that hepatic steatosis on ultrasonography was significantly associated with biopsy-proven hepatic steatosis (76/128, 59.4%, p<.01). Hepatic steatosis on ultrasonography was also significantly associated with age ≥ 65 years old (48/129, 37.2%, p=.02), histological evidence of ballooning degeneration (57/86, 66.3%, p<.01), Mallory-Denk bodies (20/60, 33.3%, p<.01), and portal/periportal fibrosis (66/98, 67.3%, p<.03). The frequency of hepatic steatosis diagnosed on ultrasonography was higher in those with NAFLD (45/92, 48.9%) than those with CHC (25/92, 27.2%) or CHB (22/92, 23.9%), but the difference was not significant (p=.08). Ultrasonographic-diagnosed hepatic steatosis was not significantly associated with BMI ≥ 30 (31/129, 24%, p=.76), elevated AST or ALT to ≥ 35 IU/L for males or ≥ 25 IU/L for females (90/111, 81.1%, p=.06 or 84/111, 75.7%, p=.77, respectively). In multivariate analysis, ultrasonographic-diagnosed hepatic steatosis was significantly associated with the presence of ballooning degeneration (95% CI: 1.25-20.72; p=.02) and portal/periportal fibrosis (95% CI: 1.29-11.14; p=.02) on liver biopsy, but not biopsy-proven hepatic steatosis (95% CI: 0.17-1.94; p=.37) or hepatomegaly on ultrasonography (95% CI: 0.71-7.33; p=.17).
Conclusion
Routine hepatic ultrasonography has good sensitivity, but low specificity in the assessment of hepatic steatosis. Histological hepatocytic ballooning degeneration and portal/periportal fibrosis were independently associated with hepatic steatosis detected by ultrasonography.

Association of Ultrasonographic Assessment of Hepatic Steatosis with the Presence Of Histological Steatosis and the Related Factors

There is very sparse data about prevalence
and outcome of gastric intestinal
metaplasia (GIM) in children. Our aim is to
review clinical and endoscopic findings in
children with GIM diagnosed by gastric
biopsy (bx) undergoing
esophagogastroduodenoscopy (EGD) for
various indications at our institution; also
review and compare above findings in
patients with repeat EGD in patients with
GIM.

Gastric Intestinal Metaplasia (GIM) in Children-How Common It Is And What Happens to It-A Pilot Project

Background:
Gastric cancer is among the top five cancer-burden in the United States and worldwide. The aim of our study is to investigate the racial variations in gastric carcinoma among individuals aged 50 years and above.

Methods:
We conducted a retrospective study using the SEER database, 17 registries, Nov 2021 Sub (2000- 2019) to identify individuals diagnosed with gastric cancer of 50 years and above age group. Age adjustment was done using the 2000 US population as a standard population. We collected racial/ethnic information related to incidence and incidence-based mortality of stomach cancer in our desired age groups.

Results:
This study included a total population of 109,352 patients of 50 years and above age with stomach cancer, out of which 71.6% were white, 12.9% were black, 14.2% were Asian or Pacific Islanders (API), and 0.9% were 1 American 1 Indian/ 1 Alaskan native (AI/AN). Based on incidence, all-cause mortality was 79.2% in white population, 78.9% in black, 71.5% in API and 82.8% in AI/AN. The incidence rate among white, black, API, and AI/AN were 20.6, 35, 36.3, and 21.3 per 100,000 population respectively, whereas the incidence-based mortality among the above races were 16.4, 28.9, 26.7, and 18.7 per 100,000 standard population. According to race, the incidence in white was 71.6% with incidence-based mortality of 79.2%. In Black incidence was 12.9% with incidence-based mortality of 78.9%. In American Indian incidence was 0.9% and incidence-based mortality was 82.8% and for Asian
incidence was 14.2% and incidence-based mortality of 71.5%.

Conclusion:
Our study outlines the racial disparities in the incidence and mortality of gastric carcinoma among individuals with gastric carcinoma among individuals aged 50 years and above. Although, gastric carcinoma is diagnosed mostly in the white population followed by Asian or Pacific islanders, black and then American Indians. The incidence rate and incidence-based mortality rates were highest among
Asian/Pacific Islanders and Black compared to that of white and American Indian/Alaskan natives. These findings help to address the disparities through interventions and healthcare policies targeted to improve gastric cancer incidence and outcomes across a diverse racial or ethnic population in the United
States. Further research is warranted to explore the underlying factors contributing to the racial disparities in gastric cancer.

Racial Disparities in Incidence and Mortality of Gastric Carcinoma of Individuals
Aged 50 Years and Above: A Population-Based Analysis

**Scoring is only possible in the semifinals hall**

**Abstract:**



A Retrospective Cohort Study: Utility of Fecal Occult Blood Test in the Acute Hospital Setting and Its Clinical Impacts

Association Between Mucosa-Associated Lymphoid Tissue (MALT) Surgery and Inflammatory Bowel Disease (IBD): A Systematic Review

Association Between Mucosa-Associated Lymphoid Tissue (MALT)
Surgery and Inflammatory Bowel Disease (IBD): A Systematic Review

Background: Although low-energy pelvic fractures seldom present with significant hemorrhage, early recognition of at-risk patients is essential. We aimed to identify predictors of blood use in this cohort.
Methods: A 5-year retrospective chart review was performed. Low energy mechanism was defined as falls of ≤ 5 feet. Fracture pattern was assigned using the AO/OTA system as A, B or C. Primary outcome was the need for ≥ 2 units of packed red blood cells (PRBC) in the first 48 hours. Bivariable analysis and logistic regression analysis were performed. A p-value ≤0.05 was considered significant.
Results: 350 patients were included with median age 88 (interquartile range [IQR] 85-92) and median Injury Severity Score (ISS) 5 (IQR 4-8). 346 (99%) had type A fractures. 17 (5%) required ≥2U PRBC/48 hours. In-hospital mortality rate was 4%. Factors associated with blood transfusion were systolic blood pressure (SBP) < 100 mmHg at any time in the emergency department (ED), trauma team activation, Abdomen-Abbreviated Injury Score and contrast extravasation on computed tomographic (CT) scan. By logistic regression, SBP< 100 mmHg (odds ratio [OR] 16.3, 95% confidence interval [CI] 5.33-40.2) and contrast extravasation (OR 4.29, 95% CI 1.11-15.3) were predictors. Both need for 2U PRBC (4/17 [24%] vs 9/332 [3%], p=0.002) and any SBP < 100 mmHg in the ED (6/41 [15%] vs 7/307 [2%], p=0.001) were associated with mortality.
Conclusion: Contrast extravasation on CT and hypotension in the ED predicted the need for transfusion of ≥ 2U of PRBC in patients with low energy pelvic fractures.

Hypotension in the Emergency Department and Contrast Dye Extravasation Predict Blood Transfusion in Low-Energy Pelvic Fractures

Background
Phenytoin has demonstrated improved wound healing, as well as analgesic and antibacterial properties. These effects occur through a variety of mechanisms, including increased collagen deposition, neovascularization, and fibroblast proliferation secondary to an up-regulation in platelet-derived growth factor expression. Systemic absorption of phenytoin is negligible when administered topically. Since the application of phenytoin in wound care is relatively uncommon, a systematic review may provide meaningful insights for clinicians and researchers alike.

Methods
Cochrane Library, Pubmed, Pubmed Central, and Medline were searched to find all relevant studies. Secondary hand searching was done using the references listed in other relevant papers. Irrelevant papers were removed while screening titles and abstracts. Selected randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) were assessed for quality using a revised tool for assessing risk of bias in randomized trials (RoB 2), and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) respectively. Data regarding the type of wounds studied, interventions, sample size, outcome measures, and reported adverse effects were collected and analyzed. 

Results
A total of 17 RCTs and 8 NRCTs were included. The wounds under study were predominantly of a single etiology; diabetic foot ulcers, decubitus ulcers, oral biopsy wounds, sutured episiotomies, leprotic ulcers, excisional wounds, fistulotomies, burns, abscess cavities, and traumatic wounds. A minority investigated wounds of multiple etiologies. Phenytoin was most often compared to inert controls such as normal saline, but there were trials with several other comparators including honey, silver sulfadiazine, Edinburgh University solution of lime, framycetin, and Aloe vera. The sample sizes of the included studies varied between 20 wounds to 200 wounds, with a median of 62 wounds. Phenytoin was found to hasten wound healing in the majority of trials. In addition, granulation tissue proliferation was improved, greater analgesic effects were produced, and there was an inhibition of bacterial contaminants as well as a reduction in wound discharge, slough, and exudates. Adverse effects were uncommon, minimal in severity, and transient in duration. The most common adverse effect observed was a burning sensation at the time of application.

Conclusion
Our review suggests that phenytoin may be a potentially beneficial adjunct to standard wound care. The topical administration of phenytoin can most likely be considered safe in most patients. We believe further study is warranted to investigate the optimal dose, frequency, and vehicle for application as well as the effects of phenytoin on other types of post-operative wounds.

Next from AMA Research Challenge 2023

Persistent Opioid Use and the Development of Generalized Anxiety Disorder