United States

Background
Tobacco use is a risk factor for head and neck squamous cell carcinomas (HNSCC) and is associated with poorer treatment outcomes. Patients who continue smoking after a cancer diagnosis are more likely to have tumor recurrence. Rural populations have higher tobacco use rates and higher observed incidence rates of tobacco-associated cancers. The goal is to identify smoking cessation barriers to improve treatment outcomes and overall survival for rural patients. 

Methods
Patients with a head and neck cancer diagnosis who were receiving care within the University of Rochester Medical system were consented. They completed a quantitative RedCap survey and/or a qualitative semi-structured interview. Head and neck cancer providers were also interviewed, and together, the responses were coded for themes related to cessation barriers and possible interventions. 

Results
The qualitative analysis identified a patient theme of self-determinism and support for smoking cessation. This includes both emotional support and information on external cessation resources. Patients made comments such as “There are people that can decide to quit and that&#39;s it. And there are people that need encouragement, right? There are people that need strength outside of themselves.” 

Providers identified a theme of developing standardized smoking cessation care. They spoke at length of the benefits of team members such as nurse navigators and dedicated smoking cessation staff. 

Quantitatively, rural patients were more likely to be smokers when compared to urban patients. Only 10% of interviewed rural patients (n=19) were likely to join a smoking cessation program if convinced by their PCP, whereas 38% of urban patients (n=29) could be convinced by their PCP (p&lt;0.04). 

Discussion
Rural patients are less likely to respond favorably when counselled by their PCP. However, they value support from medical professionals. Cancer providers value a dedicated team member to deploy a standardized workflow for cessation counseling. Together, the qualitative and quantitative data both favor additional non-PCP team members when convincing rural patients to quit smoking. One novel solution, the “Rochester Model,” utilizes medical students to provide bedside smoking cessation to smoking patients. Preliminary results suggest that students are as effective as nurses in providing counseling when assessing smoking outcomes 1-, 3-, and 6-months post treatment. 

Conclusion
Non-PCP care members are essential to engaging rural smokers in cessation programs. Medical students are a possible new demographic of counselors. Further investigation is needed to assess their efficacy when counseling rural HNC patients.

AMA Research Challenge 2023

Barriers to Smoking Cessation for Rural Head and Neck Cancer Patients

Background
Tobacco use is a risk factor for head and neck squamous cell carcinomas (HNSCC) and is associated with poorer treatment outcomes. Patients who continue smoking after a cancer diagnosis are more likely to have tumor recurrence. Rural populations have higher tobacco use rates and higher observed incidence rates of tobacco-associated cancers. The goal is to identify smoking cessation barriers to improve treatment outcomes and overall survival for rural patients. 

Methods
Patients with a head and neck cancer diagnosis who were receiving care within the University of Rochester Medical system were consented. They completed a quantitative RedCap survey and/or a qualitative semi-structured interview. Head and neck cancer providers were also interviewed, and together, the responses were coded for themes related to cessation barriers and possible interventions. 

Results
The qualitative analysis identified a patient theme of self-determinism and support for smoking cessation. This includes both emotional support and information on external cessation resources. Patients made comments such as “There are people that can decide to quit and that's it. And there are people that need encouragement, right? There are people that need strength outside of themselves.” 

Providers identified a theme of developing standardized smoking cessation care. They spoke at length of the benefits of team members such as nurse navigators and dedicated smoking cessation staff. 

Quantitatively, rural patients were more likely to be smokers when compared to urban patients. Only 10% of interviewed rural patients (n=19) were likely to join a smoking cessation program if convinced by their PCP, whereas 38% of urban patients (n=29) could be convinced by their PCP (p<0.04). 

Discussion
Rural patients are less likely to respond favorably when counselled by their PCP. However, they value support from medical professionals. Cancer providers value a dedicated team member to deploy a standardized workflow for cessation counseling. Together, the qualitative and quantitative data both favor additional non-PCP team members when convincing rural patients to quit smoking. One novel solution, the “Rochester Model,” utilizes medical students to provide bedside smoking cessation to smoking patients. Preliminary results suggest that students are as effective as nurses in providing counseling when assessing smoking outcomes 1-, 3-, and 6-months post treatment. 

Conclusion
Non-PCP care members are essential to engaging rural smokers in cessation programs. Medical students are a possible new demographic of counselors. Further investigation is needed to assess their efficacy when counseling rural HNC patients.

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Background: SARS-CoV-2 or (CoV2) utilizes the receptor binding domain (RBD) of its surface SPIKE protein to infect human cells that express ACE2 receptor. Infected persons can be asymptomatic or progress to a potentially fatal pneumonia-associated illness. Antibodies that prevent SPIKE/RBD/ACE2 interaction can result from infection or vaccination. However, their quantity, function, and cross-reactive protection requires serological testing. We obtained 50 deidentified serum samples, and were blinded to CoV2 vaccination (Vax+; Vax-) or CoV2 positive test (CoV2+; CoV2-). Serum IgG antibodies to SPIKE and RBD were quantified and efficacy in preventing CoV2 infection in vitro determined. We hypothesized that high titer RBD IgG would be efficient at preventing viral infection and be effective against a later CoV2 variant.

Methods: ELISA was used to quantify SPIKE and RBD antibodies in sera. Neutralizing capability of antibodies was determined by mixing sera with a firefly luciferase lentivirus psuedotyped with Wuhan CoV2 SPIKE. The mixture was applied to ACE2 expressing cells and luciferase activity used to calculate infection rates. Samples were unblinded to determine correlation between in vitro results and CoV2 exposure or vaccination. Cross-protection was determined by repeating neutralization assays with the Omicron BA.2 variant.

Results Thirteen participants reported no CoV2 vaccine or CoV2 positive test (Vax-/CoV2-) yet 7 had anti-SPIKE and -RBD titers and neutralizing function suggesting prior asymptomatic CoV2 infection. The remaining 37 participants reported Vax-/CoV2+ (n=8), Vax+/CoV2- (n=27), or Vax+/CoV2+ (n=2). Titers to RBD were comparatively lower than titers to SPIKE in most patient samples. Average RBD antibody titers were higher for the Vax+/CoV2- group (1:2600) versus Vax-/CoV2+ cohort (1:900). Highest RBD antibody titers were found in Vax+/CoV2+ patients (1:5400). Finally, sera with RBD titer ≥1:2700 and neutralization capacity had equal neutralizing function on Omicron BA.2, a variant with 28 amino acid changes in SPIKE and 16 in the critical RBD region.

Conclusion High-titer RBD sera correlated with greater viral neutralization activity highlighting the functional importance of this domain in infection. High-titer anti-RBD IgG to the initial Wuhan CoV2 virus also provided potent neutralization activity against the BA.2 variant despite 16 amino acid changes in its RBD region. This information could be used in future vaccination efforts and passive immunization, as well as provide a greater level of confidence to healthcare workers, first responders, and other high-risk populations regardless of the CoV2 strain. Serial immune studies in high risk populations could provide indications for booster vaccines.

Functional Serologic Testing and Cross Reactivity of Serum Antibodies to SARS-CoV-2 SPIKE Protein

Background
Screen time is defined as time spent watching television, playing video games, or using electronic devices with a screen. Levels of screen time have increased in the pediatric population with some individuals consuming over 7 hours per day. In the literature, screen time has been shown to have effects on neuropsychiatric health and development, but there are limited comprehensive studies. The aim of this study was to determine the effects of screen time on mental health and neurodevelopment in the child and adolescent population in North America.

Methods
We conducted an umbrella review to assess the psychological effects of screen time on health outcomes in children and adolescents. We searched PubMed and Google Scholar for systematic reviews or meta-analyses published within the last 10 years. Studies were included in our initial search if they had the words “screen-time” with “meta-analysis” or “systematic review”. A total of 15 systematic reviews were found. These were narrowed down to 4 total systematic reviews that specifically addressed the child and adolescent population as well as outcomes regarding depression, anxiety, sleep disruption, language development, and academic development. Effect sizes were collected.

Results
Screen time in children and adolescents was found to have significant associations with several neuropsychiatric variables, including risk of depression (odds ratio 1.12, 95% confidence interval 1.03-1.22) and decreased sleep duration (2.283 [2.132-2.445]). Additionally, the meta-analyses studied show a negative association between screen time and language skills (n = 38, r = -0.14 [−0.18 to −0.10], OR 0.599 [0.515-0.694]), and no association with academic performance (d = -0.29 [−0.65 to 0.08], OR 0.591 [0.308-1.156]). 

Conclusion
There is an association between increased screen time and some adverse neuropsychiatric outcomes, including risk of depression, decreased sleep duration, anxiety, and lower language skills. Furthermore, the literature has even demonstrated a dose-response relationship for some outcomes. For example, participants with high screen time were more likely to have depression than their low screen time counterparts. These findings are increasingly important as technology becomes more prevalent and suggest that recommendations to limit screen time may mitigate adverse neuropsychiatric outcomes. Limitations of this umbrella review include the cross-sectional design of the meta-analyses and the accuracy of screen time reporting.


The Association of Screentime With Neuropsychiatric Health in the Pediatric Population: An Umbrella Review

Introduction. There are racial differences in how adverse childhood experiences (ACEs) affect depression which is experienced by 25% of cancer survivors. While previous studies have examined association between ACEs and depression in general population, studies focusing on cancer survivors are lacking. This study assessed the association between ACEs and history of depression among cancer survivors in different race groups.

Methods. This study was a cross-sectional analysis of the 2020 Behavioral Risk Factor Surveillance System among 19,241 cancer survivors. The ACE category (zero, one, two-three, ≥four) included questions assessing exposure to eight types of adverse childhood experiences before age 18 years. The outcome is self-reported history of depression. Three weighted multivariable logistic regression models were used to examine the association between ACE and depression for each race group: Non-Hispanic White (NHW), Non-Hispanic Black (NHB) and Hispanics, adjusting for age, sex, smoking status, income, education, marital status, body mass index, health status.

Results. In this sample, 41%, 22%, 21% and 16% reported having experienced zero, one, two-three, and >=4 ACEs respectively. Majority of survivors were NHW (82.5%) while 6.2%, 6.4% and 4.9% were NHB, Hispanics, and Others respectively. Personal history of depression was reported by 21% of survey respondents. Among survivors experiencing >=4 ACEs, depression was reported by 46.9 % of NHW, 55.2% of NHB and 50.6% of Hispanics. In the adjusted models, among NHW survivors with 1 ACE (aOR: 1.7, 95% CI. 1.3– 2.2), 2-3 ACEs (aOR: 1.9, 95% CI. 1.5– 2.4), or >=4 ACES (aOR: 4.2, 95% CI. 3.3– 5.5) had higher odds of depression compared with those with zero ACEs. Among NHB, survivors with >=4 ACEs had higher odds of depression (aOR: 2.5, 95% CI. 1.2– 5.0) compared with those with zero ACEs; no significant difference was observed for survivors with 1 or 2-3 ACEs. Similarly, among Hispanics, survivors with >=4 ACEs had higher odds of depression (aOR: 11.3, 95% CI. 5.4– 23.8) compared with those with zero ACEs whiles no significant difference was observed for survivors with 1 or 2-3 ACEs.

Conclusion. Cancer survivors with ACEs may represent an important targeted prevention group to reduce risk of depression. While there is a relationship between all categories of ACE and depression among NHW cancer survivors, only those with >=4 ACEs had association with depression among NHB and Hispanics. Variation by race warrants additional studies regarding potential for selective prevention and identification of resilient, cultural, and healthcare access factors.

Keywords. adverse childhood experiences, depression, cancer survivors, racial disparities


Racial disparities in the association between adverse childhood experiences and history of self-reported depression among cancer survivors

Background The US has a severe shortage of psychiatry workforce. In 2021, one in three Americans lived in Mental Health Professional Shortage Area (MHPSAs). Telehealth has long been advocated as a promising delivery model to mitigate the psychiatry workforce shortage but is limited by broadband access. This study identified counties without either psychiatrists or broadband coverage, described their characteristics, and examined their mental health outcomes.


Methods This cross-sectional analysis of all US counties employed public data in 2020. We used psychiatrist data from the Health Resources and Services Administration’s Area Health Resources Files, county socio-demographic characteristics from the American Community Survey, county-level measurements of broadband coverage from the Department of Commerce, and mental health outcomes from the County Health Rankings. We first identified counties without psychiatrists or broadband coverage in 2020 before performing a multivariate logistic regression to assess characteristics of those counties. The regression included state fixed effects, controlling for county level covariates: health insurance, unemployment, educational attainment, racial/ethnicity composition, household income, rurality (defined as the 2013 USDA rural-urban continuum codes of 8 or 9), and MHPSA designation. We used chi-squared tests to compare percent of adults with a history of depression, frequent mental distress, and drug overdose deaths and completed suicides per 100,000 population between counties without psychiatrists or broadband and other counties.


Results
We found that 596 (19%) counties were without psychiatrists or broadband, representing 10.5 million residents. Our regression results indicated that these counties were more likely to be rural (adjusted odds ratio [AOR]=3.048, p<0.01), have higher unemployment rates (AOR=1.122, p<0.01) and uninsurance rates (AOR=1.031, p<0.01), and lower proportion of population with bachelor’s degrees (AOR=0.919, p<0.01), but were not associated with MHPSA designation. 

Counties without psychiatrists or broadband had higher percentages of adults with a history of depression (22.4% vs 18.9%, p<0.01), frequent mental distress (16.5% vs 13.8%, p<0.01), drug overdose mortality (40.9 vs 11.1 per 100,000, p<0.01), and completed suicides (88.1 vs 11.3 per 100,000, p<0.01) compared to other counties. 


Conclusion: Despite the recent expansion of telehealth services, continued gaps in both broadband coverage and the psychiatrist workforce exist and are associated worse mental health outcomes, highlighting the need for further policy interventions to improve digital equity and access to psychiatric care, especially by targeting predominately rural counties and counties with lower socio-economic status.

Lacking Both Psychiatry Workforce and Broadband Coverage and Association with Mental Health Outcomes

Background 
Research has demonstrated that regularly measuring and monitoring SUD patients during treatment enhances outpatient mental health outcomes. (Lambert et al., 2003). Systematically monitoring patient progress in treatment for substance abuse can sustain individualized care. (Cacciola et al., 2013). However, consensus on which tool to adapt for SUD treatment outcomes and monitoring remains hindered by the diversity of 
outcome criteria proposed for SUD treatment (Alves et al., 2017). This study aims to identify, examine, and compare existing tools for measuring SUD treatment outcomes, considering their characteristics, benefits, limitations, utility, and cost-effectiveness. 

Methods 
Thirteen measurement tools used for SUD were identified through PubMed and Addictions Drug and Alcohol Institute Library searches. Tools analyzed include WHO- QOL, WHO-QOL-BREF, ARC, BARC-10, PHQ-9, TEA, OCVAS, BAM, COWS, ASI-5, ASI-Lite, CAGE-AID and AUDIT. Domains covered by these tools were categorized into Substance Use, Social, Physical Health, Mental Health and Economic. We performed a qualitative analysis of differences between these tools based on their coverage of the above domains, question length and format, administration time, scoring/analysis, and frequency of administration. 

Results 
Our results demonstrated that many of the identified SUD outcome measurement tools covered varying domains. Of all the tools analyzed, 38% covered all 5 domains while 3 tools focused solely on the Substance Use domain. The most commonly covered domains were “Substance Use” and “Mental Health” each represented by 9 tools, followed by “Social”, “Physical Health” and “Economic” domains, each represented by 8 tools. Question structure varied, with Likert scaling being most common. The number of 
questions ranged from 1 to 200, and the time required for completion variedfrom under 1 minute to 75 minutes. Scoring methods included summation, averaging, formulaic scoring, and floor vs ceiling scoring. Frequency of administration varied across settings. 

Conclusion 
Lack of consensus and standardization in measurement tools for SUD poses significant challenges in assessing, monitoring and treating SUD. Absence of standardized tools hinders treatment outcome comparisons, evaluation of intervention effectiveness, and evidence-based decisions. It also impedes the development of uniform guidelines, which may result in suboptimal care. The burden caused by this lack of standardization and overall consensus emphasizes the urgent need for collaboration and agreement in the field of SUD measurement tools. Such consensus could provide great improvement to assessment, treatment and overall outcomes of those affected.

Examining Strengths and Limitations of Treatment Outcome Measurement Tools for Substance Use Disorders

Background: Lung transplants from donors with hepatitis C (HCV D+) have excellent outcomes, but these organ offers are often not even considered or, if considered, continue to be declined. We evaluated whether (1) being listed to consider and (2) accepting HCV D+ offers provided a survival benefit to lung transplant candidates.
Methods: Using the Scientific Registry of Transplant Recipients, we identified all adult (≥18 years) lung transplant candidates 2016-2021 and compared waitlist mortality between candidates listed as willing vs. not willing to consider HCV D+ offers using Fine Gray competing risk regression. Among those who were listed as willing to consider HCV D+ offers, we then identified all candidates offered an HCV D+ lung that was later accepted and followed them from offer decision until death or end-of-study. We estimated adjusted mortality risk of accepting vs. declining an HCV D+ lung offer using propensity-weighted Cox regression.
Results: From 2016-2021, we identified 21,007 lung transplant candidates, 33.8% of whom were willing to consider HCV D+ offers. Candidates willing to consider HCV D+ offers had a 17% lower risk of waitlist mortality (subhazard ratio 0.83, 95%CI 0.75-0.91, p<0.001) than candidates not willing to consider HCV D+ offers overall, and a 24% lower risk of mortality after adjusting for candidate characteristics (subhazard ratio 0.76, 95%CI 0.69-0.84, p<0.001). Over the same period, 665 HCV D+ lung offers were accepted after being declined a total of 2,562 times. HCV D+ offer acceptance vs. decline was associated with a 20% lower risk of mortality (adjusted hazard ratio 0.80, 95% CI 0.66-0.96, p=0.02). Among candidates who declined HCV D+ offers, 66.1% eventually received a lung transplant from a donor without HCV, 12.4% received a different HCV D+ lung transplant, 14.8% were removed from the waitlist, 5.0% died, and 1.8% remained on the waitlist at three years after initial HCV D+ offer decline. 
Conclusion: Considering vs. not consider HCV D+ lung offers was associated with a 24% lower risk of waitlist mortality, while accepting vs. declining an HCV D+ lung offer was associated with a 20% lower risk of mortality. Centers and candidates should consider accepting suitable HCV D+ lung offers to optimize outcomes, as it could mean the difference between excellent survival and waiting for a supposedly “better” offer that might never come.

To Decline or Not To Decline: Consequences of Decision-Making 
Regarding Lung Offers from Donors with Hepatitis C

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

**Abstract:**



Bladder Cancer Knowledge in an Underserved, Highly Afflicted Population

Background
The Missouri Board of Registration for the Healing Arts (“the Board”) publishes information on all physicians who have been disciplined by the Board, as well as information on the medical schools, board certifications, and business locations of all active physicians. However, this information has not been publicly analyzed through formal research. Such analyses would help patients and other stakeholders contextualize disciplinary information. With this objective in mind, this study analyzed the characteristics and context of physician discipline in Missouri from the year 2000 to 2022.

Methods
Information on the disciplined physicians was collected using the Board’s published disciplinary action list and the Missouri Division of Professional Registration’s licensee search tool. IBM SPSS Statistics was used to calculate the frequencies of different types and reasons for discipline, the median time between license issuance and discipline, the median time between revocation and reinstatement, and the discipline rates among various physician subgroups.

Results
Less severe disciplinary actions were more common than more severe actions. Inappropriate prescribing practices were the most common reason for discipline. Tax delinquency was also a common reason for discipline, although tax-related discipline has declined in recent years. The median time between license issuance and discipline was 17.5 years, and the median time between license revocation and reinstatement was eight months. Physicians in surgical specialties tended to have higher rates of discipline, while physicians in specialties with limited patient interaction (pathology, radiology) tended to have lower rates of discipline. Osteopathic physicians were subjected to discipline at higher rates than allopathic physicians. Discipline rates by county were generally unreliable due to small sample size.

Conclusion
Physicians most often face discipline in the middle of their careers. The prescribing habits of disciplined physicians may contribute to drug misuse. Recent legal requirements to discipline physicians for tax delinquency appear to be effective. Frequent patient interaction and procedure-heavy specialties appear to be risk factors for discipline. Osteopathic physicians and medical schools are associated with higher rates of discipline compared to their allopathic counterparts, although further research is needed to identify the reasons for this pattern.

Disciplinary Patterns for Missouri Physicians 2000-2022

Background
With the increased acceptance of transgender individuals, so has the number of gender-affirmation surgeries. Transgender individuals face elevated depression rates, leading to an increase in suicide ideation and attempts. This study evaluates the risk of suicide or self-harm associated with gender affirmation procedures.

Methods
This retrospective study utilized de-identified patient data from the TriNetX database, involving 56 US healthcare organizations and over 90 million patients. The study involved three cohorts: Cohort A, adults aged 18-60 who had gender-affirming surgery and an emergency visit (N=1,501); Cohort B, control group of adults with emergency visits but no gender-affirming surgery (N=15,608,363); and Cohort C, control group of adults with emergency visits, tubal ligation or vasectomy, but no gender-affirming surgery (N=142,093). Propensity matching was applied to Cohorts A and C. Data from February 4, 2003, to February 4, 2023, was analyzed to examine suicide attempts, death, self-harm, and PTSD within five years of the index event. A secondary analysis with pharyngitis controls was conducted to validate Cohort C.

Results
Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who didn’t (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p<0.0001). Compared to the tubal ligation/vasectomy controls, the risk was 5.03-fold higher before propensity matching and remained significant at 4.71-fold after matching (3.50% vs. 0.74%, RR 95% CI 2.46-9.024, p<0.0001) for the gender affirmation patients with similar results with the pharyngitis controls.

Conclusion
Gender-affirming surgery is significantly associated with elevated suicide attempt risks, underlining the necessity for comprehensive post-procedure psychiatric support.

Risk of Suicide and Self-Harm following Gender-Affirmation Surgery

Background
We present a Quality Improvement study on a community exercise program to determine if attending community walking events provides participants sense of comfort to exercise individually. We define comfort with exercise as experiencing increased motivation and support to exercise. This study was conducted through Walk With A Future Doc Lake County, whose goal is to help promote behavioral changes that can help community members live healthier lifestyles by addressing the racial and socioeconomic disparities within cardiovascular health.

Methods
Before this event, we identified a healthcare professional available to speak at the event or virtually, located a local walking trail for the one-hour walk, and contacted Roberti Community House to gauge community interest. We organized a pre-walk meeting with members and asked participants to complete a survey indicating their agreement with statements regarding comfort with exercise on a scale of 1 (Strongly Disagree) - 5 (Strongly Agree). After completing that survey, participants watched a video created by a healthcare professional. Volunteers and participants then completed a one-hour walk with breaks for stretching and hydration. After the walking event, participants completed an additional survey indicating their agreement with statements regarding comfort with exercising on a scale of 1 (Strongly Disagree) - 5 (Strongly Agree). 

Results
After attending the community event, members felt more comfortable exercising independently. The community members reported their comfort with individual exercise following the walk as 2.81 out of 5, their motivation to exercise as 4.13 out of 5, their understanding of the health benefits of exercising as a 4.69 out of 5, the encouragement to attend community events in the future as a 4.56 out of 5, and the support they felt from the event to stay active as a 4.31 out of 5. 


Conclusion
Members of the Roberti Community House experienced how community engagement and education can encourage individuals to make healthier lifestyle changes in the future. Members learned where the local walking trail was, how to stretch before and after walking, and connect with community members. This increased community involvement and support has been missing since the COVID-19 pandemic. Our current goal is to follow up with the Roberti Community House every two months, schedule events 3-4 times yearly, and maintain a relationship with Rosalind Franklin University of Medicine and Science. Some challenges during the study were finding a healthcare professional, communicating with adults who speak a language other than English, and publicizing the event.



Next from AMA Research Challenge 2023

Functional Serologic Testing and Cross Reactivity of Serum Antibodies to SARS-CoV-2 SPIKE Protein