United States

Background
The Coronaviridae family, including SARS-CoV-2 responsible for COVID-19, leads to a severe inflammatory respiratory infection with varying clinical outcomes. With an ever-changing virus epidemiology and COVID-19 vaccines playing a crucial role in prevention, trust issues and vaccine hesitancy persist. This systematic review and meta-analysis aim to examine the link between clinical outcomes and vaccination status in COVID-19-infected individuals to address knowledge gaps. By evaluating the impact of vaccination on disease course, this study seeks to provide clear insights into the preventive potential and effectiveness of COVID-19 vaccines, contributing to better public health policies and strategies in combatting this infectious disease.

Methods
We conducted a meta-analysis to assess COVID-19 vaccination effectiveness in North America. PRISMA guidelines were followed for English studies published between March 17, 2020, and July 10, 2022. Studies comparing vaccinated and unvaccinated groups in terms of COVID-19 outcomes were considered. Primary outcomes were incidence, hospitalization, ICU admission rates, mortality rate and mechanical ventilation need. Data were extracted and pooled using a random-effects model. Bias assessed with Joanna Briggs Institute criteria. A snowball search complemented PubMed, Cochrane, and Google Scholar searches. Pooled proportion estimates and risk ratios were calculated with 95% confidence intervals. 

Results
The meta-analysis included 14 articles with a total of 24,164,227 COVID-19 patients. The results showed that unvaccinated patients with COVID-19 infection were 2.36 times more likely to contract COVID-19 compared to vaccinated patients (p = 0.02). Additionally, unvaccinated patients were six times more likely to be admitted to the ICU (p &lt; 0.0001), 3.37 times more likely to be hospitalized (p &lt; 0.0001), and 6.44 times more likely to require mechanical ventilation (p &lt; 0.0001) compared to vaccinated patients. Lastly, the OR for COVID-19 mortality was 2.46 (95% CI: 1.71 to 3.53; p &lt; 0.0001), indicating unvaccinated patients were 2.46 times more likely to die from COVID-19.


Conclusion
In conclusion, this meta-analysis provides robust evidence that COVID-19 vaccination significantly reduces the incidence of infection, hospitalization rates, ICU admissions, mechanical ventilation requirements, and mortality among COVID-19-infected individuals in North America. The findings highlight the importance of widespread vaccination campaigns to enhance public health and control the spread of COVID-19. Efforts to address vaccine hesitancy and promote vaccination acceptance are crucial for maximizing the benefits of vaccination and minimizing the impact of the pandemic. Further research on the effectiveness of different vaccine types and their protection against emerging variants is warranted to guide vaccination strategies effectively.



AMA Research Challenge 2023

Unlocking the Power of COVID-19 Vaccines: A Meta-Analysis Reveals Impact on Patient Outcomes in North America

Background
The Coronaviridae family, including SARS-CoV-2 responsible for COVID-19, leads to a severe inflammatory respiratory infection with varying clinical outcomes. With an ever-changing virus epidemiology and COVID-19 vaccines playing a crucial role in prevention, trust issues and vaccine hesitancy persist. This systematic review and meta-analysis aim to examine the link between clinical outcomes and vaccination status in COVID-19-infected individuals to address knowledge gaps. By evaluating the impact of vaccination on disease course, this study seeks to provide clear insights into the preventive potential and effectiveness of COVID-19 vaccines, contributing to better public health policies and strategies in combatting this infectious disease.

Methods
We conducted a meta-analysis to assess COVID-19 vaccination effectiveness in North America. PRISMA guidelines were followed for English studies published between March 17, 2020, and July 10, 2022. Studies comparing vaccinated and unvaccinated groups in terms of COVID-19 outcomes were considered. Primary outcomes were incidence, hospitalization, ICU admission rates, mortality rate and mechanical ventilation need. Data were extracted and pooled using a random-effects model. Bias assessed with Joanna Briggs Institute criteria. A snowball search complemented PubMed, Cochrane, and Google Scholar searches. Pooled proportion estimates and risk ratios were calculated with 95% confidence intervals. 

Results
The meta-analysis included 14 articles with a total of 24,164,227 COVID-19 patients. The results showed that unvaccinated patients with COVID-19 infection were 2.36 times more likely to contract COVID-19 compared to vaccinated patients (p = 0.02). Additionally, unvaccinated patients were six times more likely to be admitted to the ICU (p < 0.0001), 3.37 times more likely to be hospitalized (p < 0.0001), and 6.44 times more likely to require mechanical ventilation (p < 0.0001) compared to vaccinated patients. Lastly, the OR for COVID-19 mortality was 2.46 (95% CI: 1.71 to 3.53; p < 0.0001), indicating unvaccinated patients were 2.46 times more likely to die from COVID-19.


Conclusion
In conclusion, this meta-analysis provides robust evidence that COVID-19 vaccination significantly reduces the incidence of infection, hospitalization rates, ICU admissions, mechanical ventilation requirements, and mortality among COVID-19-infected individuals in North America. The findings highlight the importance of widespread vaccination campaigns to enhance public health and control the spread of COVID-19. Efforts to address vaccine hesitancy and promote vaccination acceptance are crucial for maximizing the benefits of vaccination and minimizing the impact of the pandemic. Further research on the effectiveness of different vaccine types and their protection against emerging variants is warranted to guide vaccination strategies effectively.

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Background
Mpox is an infectious disease characterized by a painful rash. It is caused by the monkeypox virus, which spreads through direct contact with skin or bodily fluids. The United States has been experiencing an outbreak of mpox since May 17th, 2022, which has disproportionately affected men who have sex with men (MSM).
When the outbreak began, there were two mpox vaccines already approved for use, and the federal government already had 36,000 doses of one such vaccine (Jynneos) in stockpile. However, by June 28th, 2022, only 9,000 doses of Jynneos had been released, which was widely critiqued as inadequate.
Little has been previously published about the sentiments of MSM during this time period. This research project thus sought to better understand the perspectives and experiences of MSM seeking a mpox vaccine in June–July 2022 as told in their own words.
Methods
41 conversations were conducted with gay or bisexual men via phone or instant messaging between July 12th and July 15th, 2022. Participants were recruited from Instagram, the author’s personal social circle, or from friends of friends. Individuals were nearly all in their 20s and 30s, and nearly all came from urban areas, including New York City, Los Angeles, San Francisco, Chicago, Boston, Austin, Houston, Seattle, Minneapolis and Atlanta.
Results
At time of interview, 12 of 41 (29%) respondents had been able to access a first dose of the mpox vaccine. Those able to get vaccinated attributed their success to luck or word of mouth, having free time to wait in lines, and getting vaccinated in Canada.
Of the 29 respondents not yet vaccinated, 28 (97%) said they had been trying without success. Twelve of these respondents were then asked about their overall feeling towards the situation; the most common response was “frustrated” (4 respondents), followed by “afraid”, “annoyed as fuck”, “awful”, “hilarious”, “hopeless”, “messy”, “panicked”, and “pathetic” (1 respondent each). The most common hurdles experienced included a lack of appointments, restrictive eligibility criteria, clinics running out of doses or closing early without advance warning, websites crashing, and no information available from public health authorities.
Conclusion
The early mpox rollout in the United States was slow and beset with widespread logistical failures, leaving the MSM community frustrated and anxious. Future public health vaccination campaigns should emphasize the rapid acquisition and distribution of vaccines, as well as improved communication from health authorities.

Delays, disarray and disparities in early United States mpox vaccine rollout, June–July 2022

Our study addressed COVID-19 vaccine knowledge and attitudes among medical students at the University of New England College of Osteopathic Medicine (UNECOM). Medical students recruited to complete an anonymous online survey assessed backgrounds, experiences, knowledge, and attitudes toward the COVID-19 vaccine. The correlation analysis utilized gender, physical health rating, close connection to someone with COVID-19, and work in the medical field during March 2020 as potential factors affecting students' attitudes. Respondents included 139 medical students aged 20-39 years old, with 99.3% having received at least one dose of the COVID-19 vaccine under institutional mandate. Every student obtained vaccine information from any combination of medical professionals, scientific journals, or review articles. Almost all correctly identified the components of the vaccine, its benefits, and its potential side effects. We found that 85% of medical students expressed little hesitancy toward receiving the vaccine; about 90% of participants supported a vaccine mandate for students. The marked enthusiasm expressed by UNECOM medical students to receive the vaccine contrasts surveys conducted before any vaccine mandate, although students' accurate knowledge of the vaccine and its potential benefits may have influenced acceptance. Overall, consideration of societal and individual implications is paramount. Access to scientifically validated information is essential when implementing public health policy at both institutional and federal levels.




Medical Students' Attitudes and Knowledge on the COVID-19 Vaccine and Mandate

Background
The reimbursement landscape for infectious diseases is constantly evolving. In recent years, there have been significant changes in Medicare reimbursement for infectious disease procedures. These changes have had a major impact on infectious disease specialists, who may be disproportionately affected by changes in reimbursement in certain regions, which could have implications for access to care. Previous research has not examined these fluctuations especially in different geographic regions. Thus, our study analyzed Medicare reimbursement changes from 2013 to 2023 for all U.S. states and territories. We also explored the relationship between these changes and select social determinants of health (SDOH).
Methods
Medicare Administrative Contractor codes for the top 50 infectious disease procedures were used to identify states using the Centers for Medicare and Medicaid Services’ Physician Fee Schedule. Each price was adjusted for inflation using the consumer price index and weighted using an index of codes. A total percent change was generated for each state or territory. State-based data for various SDOH were used to calculate a correlation coefficient with geographic changes in
reimbursement (statistical significance factored with α of 0.05).
Results
From 2013 to 2023, the inflation-adjusted Medicare reimbursement for the top-grossing infectious disease procedures for U.S. states and territories decreased by a mean and median of 24.8% and 25.0%, respectively. The greatest total decrease was experienced by Illinois (-29.0%), Wyoming (-26.8%), Kansas (-26.8%), and Wisconsin (-26.6%). Massachusetts (-22.5%), New York (-22.3%), Washington (-19.8%), and Puerto Rico (-14.2%) were states that had the lowest change over the ten-year period. Some of the top grossing procedures (Current Procedural Terminology code) and their yearly percent change included critical care for the first 30-74 minutes of instance(99291, -197.2%), debridement of subcutaneous tissue for the first 20 cm2 or less(11042, -197.0%), transitional care management with high medical decision complexity(99496, -197.0%), and removal of central venous catheter without subcutaneous port or pump (36589, -197.0%).
Conclusion
Our findings suggest that over the past ten years, Medicare reimbursement for infectious disease procedures has decreased in many regions of the United States. These findings have important implications for access to care. Decreased reimbursement may make it more difficult for infectious disease specialists to provide care in certain regions, which could lead to longer wait times and decreased
access to care for patients. Policymakers should consider and develop strategies to address these geographic disparities. This could include providing financial assistance to infectious disease practices or expanding access to telehealth services.

The Impact of Geography on Medicare Reimbursement for Infectious Diseases: A 10-Year Analysis

Background: America is in the midst of an epidemic of sexually transmitted infections (STI). Between 2020-2021, the CDC reported a 32% increase in the incidence of primary/secondary (early) syphilis with underserved and marginalized communities predominantly affected. Treponemal central nervous system (CNS) invasion is estimated to occur in approximately 25-60% of cases, however, the current standard of care for early syphilis does not achieve CNS clearance. This raises concern for a preventable burden of neurologic morbidity secondary to treponemal CNS persistence and subsequent neurosyphilis. Our central hypothesis is that individuals with history of syphilis infection will experience greater odds of neurologic morbidity relative to their uninfected counterparts. 

Methods: An FQHC-based, preliminary 10-year retrospective analysis (01/2013-12/31/2022) of deidentified electronic medical records (EMR) was undertaken in summer of 2023. The exposure of interest consisted of grouped ICD-10 codes representative of early syphilis infection with neurologic outcomes defined as ICD-10 diagnoses reflective of the principle clinical manifestations of neurosyphilis. Unadjusted, bivariate analysis was performed for preliminary assessment of exposure-outcome association.

Results: 3,711,053 EMR from an academic health system were included in final analysis. 5,981 patients were found to have a diagnosis of syphilis. Patients with syphilis exposure had significantly higher odds for stroke (OR = 5.14; 95%CI = 4.71-5.61), dementia (OR = 20.68 ; 95%CI = 19.27–22.19 ), sensorineural hearing loss (OR= 5.75; 95% CI= 5.07-6.2), and blindness (OR= 15.74 ; 95%CI = 14.31-16.54) relative to unexposed patients. 

Conclusion: Syphilis infection was associated with significantly increased odds of neurologic morbidity across all representative outcome measures queried. These data are concerning as they suggest a clinically significant limitation to the current standard of care for early syphilis. We plan to more rigorously evaluate our hypothesis in a follow-up study that will utilize regression analysis to determine the independent effect of syphilis exposure adjusting for multiple confounders.


An Imitation Game: Syphilis Infection and Increased Odds of Neurologic Morbidity

Instagram is the most downloaded app globally, with billions of active users. Instagram has evolved to encompass several categories of posts, including advertisements. Users below the age of 24 make up 38.6% of total Instagram users, and the United States Preventive Services Task Force recommends counseling patients about decreasing the risk of skin cancer by minimizing exposure to ultraviolet radiations, especially for ages 6 months to 24 years. Users are more likely to connect with advertisements in which they feel represented; therefore, it is important that the sun protection (SP) advertisements on the application are inclusive of all races and genders. The purpose of our study was to analyze the quality of advertisements on the Instagram profiles of common SP brands. The thirty most recent product-related posts on Instagram profiles of common SP brands were analyzed. Results revealed Fitzpatrick skin types IV-VI are poorly represented in the Instagram posts of SP brands, totaling only 35.5% of featured people. Additionally, only 19% of the total posts including males. There is a documented misconception amongst people of color that the use of SP to prevent skin cancer and photoaging is unnecessary. Additionally, there is a greater incidence of skin cancer in males, which may be attributed to less SP use than females. With advertisements expanding to easily accessible applications like Instagram, it would be beneficial to determine avenues to improve representation within these advertisements to promote patient compliance with SP products.

Instagram Advertisements for Sun Protection Products: A Spectrum to be Broadened

Background
Psoriasis is a multisystem inflammatory disease associated with increased cardiovascular risk. Prior studies have shown a paradoxically lower mortality in AMI (acute myocardial infarction) despite higher comorbidities in psoriasis patients. The lower age of AMI patients with psoriasis may explain this paradox. Our study looked for possible additional explanations.

Methods
The Nationwide Inpatient Sample (NIS) is the largest US inpatient database cataloging over 7 million hospitalizations annually. This retrospective study analyzed this database from January 2016 to December 2019. Appropriate ICD-10 codes identified both AMI patients and AMI- psoriasis subset. Chi–square testing and multivariable binary logistic regression were used for analysis.

Results
Amongst 2.55 million AMI patients, 15,520 had psoriasis in addition. At baseline, AMI patients with psoriasis had significantly higher rates of smoking (31% vs 25%), alcohol use (1.39% vs 1%), diabetes (43% vs 41%), hypertension (47% vs 44%), dyslipidemia (71% vs 66%), prior CAD (83% vs 80%), COPD (25% vs 22%) and thyroid disease (14% vs 13%). Psoriasis patients had significantly lower age (64.9 vs 66.9 years).

A higher percentage of AMI patients with psoriasis were White compared to AMI patients without psoriasis (80% to 71%); and the converse for African Americans (4% to 11%). These racial differences were statistically significant.

Comparing outcomes, psoriasis patients had significantly higher rates of CABG (11% vs 7%), length of stay (4.5 versus 4.4 days) and hospital costs ($ 103,247 vs $ 99,094). Notably, psoriasis patients had significantly lower in-hospital mortality (2.74% vs 4.93%). The adjusted odds ratio was 0.70 (95% CI 0.56- 0.88). The p-values for all above-mentioned metrics were between 0.00 and 0.02.

Conclusion
A possible explanation for this mortality paradox was the lower age of incidence for AMI in patients with psoriasis (68 years versus 73 years in a 2020 German study). In our dataset, the difference in mean age of incidence between the two groups was only 2 years (64.9 years versus 66.9 years). One striking confound between the two groups is racial demographics. The data shows a statistically significant increase in percentage of white psoriasis patients having AMI than minority groups. If healthcare access/standard of care is different for these two groups, then this would provide an explanation for this paradox and show that this is not pathological issue but rather a sociological one. With growing concerns about equal opportunity access to healthcare, this paradox warrants further study and has potential to demonstrate opportunities for improvement.


Racial Differences May Explain The Psoriasis Mortality Paradox in Acute Myocardial Infarction: A Nationwide Inpatient Sample Analysis

Background. Dermatillomania (skin picking disorder) is a psychodermatologic disorder consisting of compulsive picking leading to chronic mechanical damage to skin integrity. Secondary to this damage come possibilities of infection and poor mental health as recurring open wounds and visible scabs form triggers in individuals with this condition. Likely to be largely under-reported, the American Journal of Psychiatry estimates that dermatillomania occurs in upwards of 1 in 20 patients. A trending nutraceutical, N-acetyl cysteine (NAC), shows promise as it encourages rapid regeneration of tissue without scarring. As a cysteine donor, NAC replenishes glutathione reductase, which serves as a safeguard against reactive oxygen species (ROS), thereby averting further cellular damage. Whether utilized as a high-dose systemic therapy or applied topically, NAC exhibits a large therapeutic index providing patients with a safe and potentially effective nutraceutical treatment option. Moreover, a comprehensive biopsychosocial approach can be provided through the social cognitive theory (SCT) framework which bolsters the self-efficacy and behavioral capacity of an individual to form positive health behaviors. Improving SCT constructs like reciprocal determinism, individuals’ perceptions, social interactions (family/peers), and environmental factors (stressors, UV radiation), will provide better patient support. 

Methods. A preliminary search was performed on all freely available PubMed articles from the past decade that discussed “n-acetyl cysteine wound healing”. A total of 76 articles were acquired. Articles that did not fall under the topics of dermatology, plastic surgery, medical treatments or did not review the use of NAC directly were omitted from our study. Finally, 19 articles detailing NAC’s effectiveness in reducing wound margins and scarring were identified for use in this study. 

Results. Findings show the pro-wound healing properties of NAC, including its ability to promote re-epithelialization, cell proliferation, enhance angiogenesis, and inhibit fibroblast migration. Moreover, NAC boosts antioxidant enzymes (glutathione reductase and superoxide dismutase) to slow ROS-mediated DNA damage. 

Conclusion. By eliminating "pick-able" scabs and accelerating healing, NAC may reduce triggers for patients with dermatillomania and associated risk of infection for other skin excoriations. Therefore, we recommend the integration of NAC as an essential treatment for this specific population as it can abate triggers that exacerbate skin injury and infection in patients with dermatillomania. Furthermore, integrating the SCT framework to deliver psychosocial support may bolster patients’ self-esteem, reducing associated costs to treat future exacerbations and related complications. We have created SCAR-PROOF: a novel, multi-pronged biopsychosocial intervention aimed at supporting dermatillomania management and recovery for our target patient population.

SCAR-PROOF: A Novel Social Cognitive Approach to Prevent Skin Injury & Infection for Dermatillomania

Background: Windham Aging was created to analyze, primarily, ways for senior residents to age in place; a November 2022 report concluded that one of the barriers is lack of primary care professionals. The current physician workforce is aging into retirement with 48% of PCPs in Windham County being over 60 years old. Previous literature reported the following themes among primary care professionals as factors in determining retention and recruitment: financial, social, lifestyle, and community. 

Methods: This research study aimed to identify strategies to enhance the recruitment of primary care professionals in rural areas of Vermont. The study team conducted interviews with family medicine residents and Doctor of Nursing Practice (DNP) students. Using a qualitative, inductive approach, the team identified key themes that could impact the recruitment of primary care professionals in rural Vermont, including a 5-point scale on previously identified factors affecting recruitment. 

Results: Trainees (n=13) ranked housing, political association, community factors, and access to schools as most important. Qualitative analysis revealed that trainees’ financial incentives weigh less heavily than previous rural clinical experience and interest in living in a rural setting. 

Conclusion: Recruitment of rural practitioners in Vermont is largely influenced by personal preferences regarding community attributes and exposure to rural clinical training experience.

Recruitment of Primary Care Professionals in Rural VT

Background: Chronic disease appointment deferral was a potent problem throughout the pandemic. Additionally, literature shows poorer health for non-English-speaking patients. This study aims to bridge the existing gap in research for this patient population while assessing the state of primary care during the pandemic via chronic disease appointments.
Methods: The Larry A. Green Center launched a series of national surveys (n > 500) with a unique series of questions to obtain temporal, pressing information surrounding primary care’s response to the pandemic. We analyzed changes based on clinic perception of chronic disease appointment incidence using two of these surveys. We further stratified the data by the proportion of non-English speaking patients in each clinic and used Chi-square analysis to analyze significance.
Results: In October 2021, clinics with less English-speaking patients had a greater decrease in stable chronic disease appointments and a larger increase in unstable chronic disease appointments: Among clinics reporting ≥ 90% English speakers (n = 336), 36% (n = 121, p = 0.03) reported less stable chronic disease visits, and 30% (n = 99, p =0.01) reported more visits for unstable chronic disease. In clinics with ≤ 80% English-speaking patients (n = 239), 47% (n = 110, p = 0.03) reported a decrease in stable chronic disease appointments, and 40% (n = 97, p = 0.01) reported an increase in unstable chronic disease appointments. 
In March 2023, the clinics with the least English-speaking patients had a higher incidence of reporting a detrimental change in the stability of their patients’ chronic conditions: 32% (n = 273) of all total clinics, 29% (n = 125) of clinics with ≥ 90% English-speaking patients, 39% (n = 74) of clinics with 81 to 90% English-speaking patients, 42% (n = 48) of clinics with 50-80% English-speaking patients, and 49% (n = 26) of clinics with ≤ 50% English-speaking patients reported a transition from stable to unstable chronic disease due to lack of access to care (p = 0.001). 
Conclusion:
These findings suggest a clinician-reported transition of chronic conditions from stable to unstable, raising concern surrounding deferred care during the pandemic. This emphasizes the need for programs to improve accessibility to clinic visits. Furthermore, additional emphasis should be placed on clinics serving non-English speaking patients, as our study reveals higher rates of care deferral in this population.

Navigating the Deferral Dilemma: Understanding Access to Chronic Disease Care for Non-English Speakers and Overall

Background: Primary care physicians are the principal clinicians treating addiction medicine in the U.S., yet chronically lag behind the demand for substance abuse care. Current literature has detailed worsening substance abuse and addiction with the onset of COVID-19, especially among minority individuals. Our study works to understand low-income individuals from the perspective of primary care, for which current literature is lacking. 
Methods: The Larry Green Center gathered perception data surrounding many pandemic-related impacts on primary care using the weekly "Quick COVID-19 Primary Care" surveys. This study selected six nationwide surveys (n=582-1472) in 2020, 2021, & 2023. Each survey was selected based on their inclusion of addiction medicine questions and was analyzed using descriptive statistics. Surveys were stratified by income with significance testing via Chi-Square analysis (p<0.05). 
Results: Polled primary care clinics revealed an increased perception of addiction during all stages of COVID-19 compared to pre-pandemic levels. Three surveys in 2020 revealed that 31-39% of clinics reported more addiction. A marked increase occurred in December 2021 with 48% of clinics reporting more addiction. No data existed for 2022; however, 41% of clinics reported more addiction in March 2023, demonstrating persistent elevation. After stratification to income, roughly 26% of clinics reporting more addiction served 10-19% of low-income patients. This proportion was consistent for clinics with 20-49% low-income patients, which comprised approximately 25% of all clinics reporting more addiction. Clinics reporting more addiction over the fielded surveys were nearly twice as likely (~48%) to serve the highest proportion of low-income patients (>50% low income). All findings were significant at p<0.05. 
Conclusion: Perception data collected from primary care clinics during COVID-19 suggest a worsening addiction epidemic that disproportionately affected lower-income patients. Chronically underfunded primary care clinics need greater financial resources to tackle systemic stressors beyond COVID-19 that will continue to exacerbate the addiction epidemic in the U.S. Training primary care physicians in addiction medicine, eliminating barriers to addiction care, and targeting low-income patient populations may help to mitigate the current trend of addiction in the U.S.

Next from AMA Research Challenge 2023

Delays, disarray and disparities in early United States mpox vaccine rollout, June–July 2022