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Trends in Marketplace Insurance Since the Passage of the Affordable Care Act (NHIS)
No full textAuthors: Julianna Vecchio, Bo Zhou, and Usha Sambamoorthi Background: In 2014, private insurance marketplaces (i.e., health exchanges) were established under the Affordable Care Act, allowing eligible individuals to purchase health insurance if they cannot obtain coverage through their employer or public programs. Analyzing enrollment trends in exchanges is important to evaluate policy effectiveness, and disparities in healthcare access. Objective: To analyze national trends in health exchanges enrollment and examine subgroup differences over a nine-year period (2014-2022) using data from the National Health Interview Survey (NHIS). Methods: This quasi-experimental study analyzed data from adults aged 26-65 years collected through the NHIS in 2014 (N = 15,183) and 2022 (N = 11,632). Unadjusted national trends and subgroup differences in health exchanges enrollment were assessed across variables such as age, race and ethnicity, sex, social determinants of health (education, poverty status, marital status, region), and past medical history using Rao-Scott chi-square tests. To account for confounding variables, multivariable logistic regressions were conducted to determine national trends. Results: Enrollment in health exchanges increased from 4.79 million (4.4%) in 2014 to 9.75 million (8.6%) in 2022, with all subgroups experiencing increases. Large gains were experienced by Hispanics (+6.8), unemployed (+27.6), poor(+17.5), ages 60-64 years(+6.3), and poor health (+7.8). After adjusting for other variables, adults in 2022 were significantly more likely to enroll in health exchanges compared to those in 2014 (AOR = 2.42, 95% CI = 2.04, 2.88; p < 0.001). Conclusion: Private market insurance places have become a more prominent and accessible option for obtaining health insurance. Larger gains among vulnerable subgroups indicate that health exchanges are effectively reaching populations that have had barriers to accessing private health insurance
A Case of Delayed LINX Device Erosion in Barrett’s Esophagus
No full textBackground: The LINX™ Reflux Management System (Ethicon) is a magnetic sphincter augmentation device designed to treat gastroesophageal reflux disease (GERD) by enhancing lower esophageal sphincter function. Patient selection criteria include adequate esophageal motility, body mass index (BMI) <35 kg/m², no prior foregut surgery, hiatal hernia ≤3 cm, and absence of Barrett’s esophagus. Device erosion, a rare complication occurring in 0-2% of cases, typically presents within four years and may cause dysphagia, chest pain, or weight loss. Case Presentation: A 56-year-old woman with a history of GERD and Barrett’s esophagus presented with worsening reflux symptoms and progressive dysphagia. She had undergone Nissen fundoplication in 2008 and placement of a 17-bead LINX device in 2018 after recurrence of GERD symptoms. Over two years, she developed escalating regurgitation, dysphagia to solids, abdominal bloating, epigastric pain, nocturnal reflux, and a dry cough. Despite high-dose proton pump inhibitor (PPI) therapy, symptoms persisted. Esophagogastroduodenoscopy (EGD) in 2023 revealed LA Grade C esophagitis, a 3 cm Barrett’s esophagus, an 8 cm hiatal hernia, and gastritis. Treatment with Dexlansoprazole failed to relieve symptoms, which now included early satiety and chest pain. Follow-up EGD in August of 2024 demonstrated persistent Barrett’s esophagus and intraluminal magnetic beads, indicating device erosion. The patient underwent robotic removal of the LINX device with esophageal repair. She was advanced from a liquid to solid diet postoperatively. At follow-up, she reported intermittent dysphagia and mild reflux managed with daily Dexlansoprazole, with plans for continued EGD surveillance. Discussion: This case highlights a delayed LINX device erosion occurring six years post-implantation, a rare but important complication. Most erosions occur within four years and are often linked to smaller devices no longer on the market. This case underscores the importance of long-term follow-up, as complications may manifest much later than expected. The patient’s history of Barrett’s esophagus, a large hiatal hernia, and previous foregut surgery likely contributed to mucosal vulnerability and device erosion. These factors are contraindications for LINX placement, emphasizing the need for strict adherence to patient selection criteria. Device erosions often present with non-acute symptoms such as dysphagia or GERD recurrence rather than life-threatening events. Robotic-assisted removal remains a safe and effective solution, enabling precise esophageal repair. Long-term monitoring remains essential, particularly in patients with Barrett’s esophagus, to manage reflux symptoms, assess mucosal integrity, and prevent complications. This case emphasizes the importance of vigilance in managing GERD patients with complex surgical histories and recognizing LINX-related complications
Appelmans Protocol: a directed evolution method to naturally evolve bacteriophages for an expanded host range
No full textPoster Highlight: College of Biomedical and Translational Science, RAD 2025 Award Winning Posters & Oral PresentationsAntibiotic-resistant microbes kill around 5 million people worldwide per year, and deaths due to resistant microbes are anticipated to surpass cancer deaths by 2050. Compounding the problem, developing new antibiotics is costly, time-consuming, and quickly undermined by new drug resistance, leading to the urgent necessity for alternative therapeutics. According to the CDC, of particular concern are the so-called ESKAPE pathogens: Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa, and Enterococcus faecium. These pathogens are increasingly resistant to antibiotics and can cause life-threatening infections. One promising alternative treatment option is bacteriophage therapy. Bacteriophages, or simply “phages,” are viruses that specifically infect bacteria in a highly host-specific manner, often infecting only certain strains within a bacterial species. Therefore, to fully employ bacteriophage as an alternative means of treatment, a group of bacteriophages must be isolated and assembled with infectivity towards a broad range of strains within the species. The phages can be naturally evolved to improve infectivity using Appelmans Protocol. Appelmans Protocol broadens the phage host range (i.e., how many strains a phage can infect) through tail fiber recombination between 2 or more phages¹. Thus, the protocol allows naturally evolved phages entry into the bacterial cell in a previously inaccessible way. Natural recombination and evolution are encouraged using a phage cocktail with 60% activity in bacterial strains against resistant strains from that same panel¹. When lysis is observed in resistant strain wells, it is assumed that this is due to the recombination of the phages. The recombined phages from the pool are tested against the bacterial strains again until the phages can infect at dilutions up to 10-7 across all strains being tested¹. In our experiment, phages for the cocktail were isolated on Pseudomonas aeruginosa strain 14203 and could not infect the other P. aeruginosa strains (PSA 7, 11, 12, 18, and 22). Following Appelmans Protocol with some modifications, the phages were iteratively tested against the resistant bacteria until they were able to infect all strains used. The recombined phages are now considered “mother” phages which can be used in a new cocktail to treat a previously resistant bacterial infection. 1. Burrowes, B. H., Molineux, I.J., & Fralick, J. A. (2019). Directed in vitro evolution of therapeutic bacteriophages: The Appelmans Protocol. Viruses, 11(3), 241. 10.3390/v1103024
Bridging the Gap: Assessing Optimal Medical Therapy for Acute Coronary Syndrome in Guatemala
No full textPURPOSE: Acute coronary syndrome (ACS) remains the leading cause of death worldwide, with acute myocardial infarction (MI) being the top cause of mortality in Guatemala. Despite its burden, there is no national policy or established standard of care for ACS management in the country. Optimal medical therapy (OMT) has been shown to reduce the risk of adverse cardiovascular outcomes. This study aimed to assess the percentage of ACS patients in Guatemala receiving OMT during hospitalization and at discharge. METHODS: This was an observational, multicenter, prospective study conducted across six public hospitals within Guatemala's National Health System, representing six out of the eight geographic regions of the country. A total of 109 adult ACS patients admitted between February 2020 and January 2021 were included. OMT at admission was defined as the combined use of aspirin, P2Y12 inhibitors, heparin or enoxaparin, and fibrinolytic therapy, according to the 2017 European guidelines for ST- segment elevation myocardial infarction (STEMI) and the 2020 European guidelines for non ST-segment elevation myocardial infarction (NSTEMI). OMT at discharge was defined by the prescription of aspirin, P2Y12 inhibitors and statins. Prescription of angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACE inhibitors/ARBs), β-blockers or angiotensin receptor-neprilysin inhibitors (ARNIs) in patients with reduced left ventricular ejection fraction (rLVEF), was also regarded as OMT at discharge. A p-value < 0.05 was considered statistically significant. RESULTS: At hospital admission, OMT was prescribed in 8.3% of cases, with STEMI patients receiving it less frequently (6.8%) compared to NSTEMI patients (14.3%) (p=0.26). Among patients with rLVEF, one-third of STEMI patients were prescribed ARNI, and two-thirds of NSTEMI patients received beta-blockers at discharge. Overall, 78% of patients with rLVEF and 83% of those with preserved LVEF received OMT at discharge. Availability of medications varied by hospital and geographical location. Public hospitals primarily provided ACE inhibitors/ARBs, aspirin, P2Y12 inhibitors, and enoxaparin, while statins and beta-blockers were more commonly available through patient expense or donation. CONCLUSION: The rates of in-hospital and discharge OMT for ACS patients in Guatemala were suboptimal, highlighting significant gaps in adherence to current guidelines. This study represents the first high-quality registry of ACS care in the country and underscores the need for national strategies to improve ACS management, address medication accessibility, and implement standardized care protocols
Ethnic Disparities in Pediatric Retinoblastoma: A Retrospective Cohort Analysis of The United States Cancer Registry Database
Full text linkRetinoblastoma (Rb) is a rare eye cancer that primarily affects children under age 5. Although the overall survival for Rb is high, ethnic and sex differences in Rb incidence and outcomes within the last decade exist as a gap in the literature. This project explores ethnic disparities in the prevalence and outcome of pediatric Rb in the United States using data from the Surveillance, Epidemiology, and End Results (SEER) Program. Cases of pediatric Rb were identified from the SEER 22 database, including 20 geographic regions, during 2000-2021. Overall, the findings of this project further reinforce the early onset of the disease, predominance of unilateral cases, and frequent use of enucleation as a treatment modality in unilateral cases. Continued surveillance of Rb incidence trends and a focus on equitable healthcare across the diverse patient population is critical in optimizing outcomes for all affected individuals
Leveling Up Medical Education: How Gamified Learning Boosts Student Confidence and Academic Preparedness
No full textPurpose: Traditional medical school curricula utilize didactics as a primary learning method. Our study investigates how to leverage pedagogical techniques to engage students and enhance material retention and exam outcomes. The central research question we are investigating is: How does active learning–including collaborative, integrative, and inquiry-based learning–compare to traditional didactics in terms of student performance, retention, and confidence in the material? This topic is significant because integrating innovative learning techniques can reduce inequities in learning outcomes by providing alternative methods to engage with the material. This study provides measurable reforms in a medical curriculum that can be integrated to improve student outcomes. We aim to demonstrate that embedding creative learning approaches with student collaboration and integrated material from peer-reviewed research enhances academic performance. Our research contributes to existing medical education knowledge by supporting integrative approaches to improve learning outcomes. Methods: This pilot project involved 240 second-year medical students at the Texas College of Osteopathic Medicine (TCOM). A learning activity was generated by four medical students who had previously completed the course with the objective of incorporating first- and second-order review questions that would be high-yield for both in-house and board examinations. The bingo-style game included 30 questions and was delivered live and in person. Students were provided a copy of the game, including 41 supplemental questions. Students were presented with a post-game survey utilizing a Likert scale and free response to gather feedback. Results: From a focus group survey gathering feedback on the Cardiology 2nd-year course, eight responses were obtained for questions specific to the Cardiology Bingo activity. Of these responses, the majority of students (62.5%) agreed or strongly agreed that the Cardiology Bingo activity allowed them to assess their understanding of critical, high-yield facts. Half of the students (50%) agreed or strongly agreed that the supplemental questions from the Cardiology Bingo activity were helpful in their exam preparation. In the free-response portion of the survey, students reported that the activity enhanced their learning, reinforced high-yield material, and was enjoyable to participate in. Students also reported that the supplemental questions were a valuable resource for assessing their understanding of the material, and some expressed a preference for higher-order questions. Conclusions: The Cardiology Bingo study demonstrates that integrating active learning approaches can enhance student understanding and support academic success. Among the survey participants, 62.5% reported improved understanding, and 50% found the additional practice items beneficial for exam preparation. More research into integrating active learning practices is needed to extrapolate conclusions further
How well do HbA1c, OGTT, and FPG identify prediabetes/diabetes in youth <18 years-of-age
No full textThe incidence of type 2 diabetes (T2D) in youth is increasing. To improve outcomes, diabetes must be diagnosed early, and effective and affordable treatment implemented. Since children with type 1 diabetes become symptomatic at time of diagnosis, routine population screening is not an effective strategy for diagnosis. Diabetes-related antibody screening may be considered in children who have an affected 1st-degree relative. The American Diabetes Association (ADA) recommends risk-based screening for T2D in children who are overweight or obese and have additional risk factors. Recommended screening methods include fasting plasma glucose (FPG), oral glucose tolerance testing (OGTT), and hemoglobin A1c (HbA1c). While the HbA1c test is convenient and readily available, the ADA acknowledges studies have raised concerns about the sensitivity and specificity of HbA1c in children. Although considered to be the “gold standard” for the diagnosis of diabetes, the OGTT is less convenient and relatively more expensive. The FPG identifies baseline glucose levels, which may not adequately characterize the pathophysiology of diabetes. In adults, a diagnostic approach using more than one test is often used. The present study explores the association between the HbA1c, OGTT, and FPG to help inform clinicians about the most reliable way of screening overweight or obese children for prediabetes/diabetes. Utilizing retrospective data from 510 children, our preliminary results suggest significant differences exist in these three screening methods
The Effects of Empaglifozin on FosB expression in the PVN and SON in a Rat Model of HFpEF
No full textPurpose: Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome characterized by diastolic dysfunction and widespread comorbidities such as hypertension, obesity, and diabetes. HFpEF lacks well-established therapeutic interventions, leading to significant morbidity and mortality. Emerging evidence highlights a potential role for central nervous system pathways in regulating cardiovascular dysfunction in HFpEF. Neural circuits in the paraventricular nucleus (PVN) and supraoptic nucleus (SON) are key regulators of sympathetic outflow and fluid balance, both of which are dysregulated in HFpEF. Additionally, empagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor originally developed for type 2 diabetes, has demonstrated benefits in reducing cardiovascular events and improving quality of life in HFpEF patients, regardless of diabetes status. However, the underlying mechanisms remain poorly understood. This study investigates neuronal activation in the PVN and SON in a rat model of HFpEF and evaluates whether empagliflozin modulates neural activity in these regions, potentially elucidating its mechanism of action in HFpEF. Methods: We used male and female Dahl salt-sensitive rats (3-6 mos), a specific rat strain that develops hypertension (which can lead to HFpEF) when put on a high salt diet. Male rats were divided into three groups: control (normal diet), high salt diet (8% NaCl, HS), and high salt diet plus empagliflozin (10 mg/kg/day, HS+Empa). HS rats developed hypertension and cardiac remodeling characteristic of HFpEF by 8 weeks. Transthoracic echocardiograms were performed on the rats to track development of HFpEF. After 8 weeks, animals were sacrificed, and brain tissue was collected. Immunohistochemistry for Delta-FosB, a marker of neuronal activation, was performed to quantify neuronal activation in the PVN and SON. Comparisons of Delta-FosB positive cell counts were made between the three groups. Results: The total sample size included 9 total rats, 5 of which were HS+Empa, 4 control, and 1 HS. The average cell counts for the controls were 54 in the SON and 83 in the PVN. The controls had the highest cell count averages in the SON (54), suggesting baseline neuronal activity. In contrast, HS rats showed moderate increased activity in the SON (18), but the highest counts in the PVN (123), indicating increased neuronal activation linked to HFpEF. HS+Empa rats had the lowest counts in both regions (12 for SON and 61 for PVN), suggesting reduced neuronal excitation. The standard errors for the SON and PVN respectively for the empagliflozin treated rats were 7.58 and 35.08, for the control rats 14.32 and 55.43, and no standard error was noted for the high salt rats since there was only one rat. Conclusions: This study shows location-specific neuronal activation in HFpEF, with increased PVN activity in HS rats and higher SON activity in controls. Empagliflozin reduced activation in both regions, potentially lowering sympathetic tone and restoring homeostasis. These findings suggest a principal mechanism for cardiovascular benefits of empagliflozin in HFpEF
Thyrotoxicosis Induced Heart Failure in Hashimoto’s Patient
No full textBackground: Thyrotoxicosis is a condition that describes an overproduction of Thyroxine (T4) levels and low TSH levels, leading to symptoms of tachycardia and hypertension. These symptoms are generally exclusive to cases of hyperthyroidism. Case Presentation: A 49-year-old male with no significant past medical history presented with palpitations and was found to be tachycardic (170 bpm) and have atrial fibrillation with rapid ventricular response. Vitals included a blood pressure of 110/80, respiratory rate of 18 breaths/min, and oxygen saturation of 100% on room air. Laboratory evaluation revealed a suppressed TSH (<0.1 µIU/mL) and elevated free T4 (40 ng/dL), indicating thyroid toxicosis. His complete blood count and comprehensive metabolic panel were unremarkable. Patient was treated with propranolol (20 mg b.i.d.) and antithyroid therapy with methimazole (20 mg) which stabilized his arrhythmia. The patient displayed initial improvement with vitals normalizing, however, dyspnea worsened on day two, resulting in the need for supplemental oxygen. On re-evaluation of the patient, 1+ pitting edema bilaterally to the lower extremities was found. To further evaluate the dyspnea-related symptoms and concern for heart failure, proBNP levels were recorded and found to be at 5000 pg/mL — suggesting heart failure. An echocardiogram was subsequently done and revealed normal diastolic function. The patient had no evidence of ischemic-related symptoms so the cause of the tachycardia was attributed to thyrotoxicosis. Further evaluation revealed elevated anti-TPO, anti-thyroid receptor antibodies, and anti-thyroglobulin antibodies. Thyroid ultrasound demonstrated a diffuse uptake pattern indicating that the thyroid gland was uniformly affected and no focal nodule was present. This is consistent with Hashimoto’s thyroiditis in a thyrotoxic phase. The patient saw improvement after beginning treatment with diuresis (IV furosemide 40 mg) and guideline-directed medical therapy for HFrEF, including beta-blockers and renin-angiotensin system inhibitors. Conclusion: Typically, thyrotoxicosis is seen in a hyperthyroid state. However, this case illustrates thyrotoxicosis as a symptom of Hashimoto thyroiditis and as a potential cause of atrial fibrillation and heart failure. This emphasizes the importance of thyroid screening when patients present with heart failure-related symptoms
Natural History of Troponin I elevation in pediatric emergency room patients
No full textThe use of troponin I (TnI) is common in pediatric emergency rooms as a screening for cardiac injury/ischemia. We hypothesize that in pediatric patients presenting to a local ER, the natural history of trivially elevated troponin is normal without cardiac sequelae as evident by subsequent cardiac testing. Additionally, we hypothesized there exists a cut-off troponin value with good sensitivity and specificity for associated abnormal cardiac testing. We conducted a single-center retrospective study of patients who were presented to Cook Children’s ER 2022-2023 with an abnormal troponin level. Patients without elevated troponin or follow-up cardiac testing were excluded. Each patient’s hospital course was captured and collected. We compared patients with normal (normal EKG + ECHO) versus abnormal (abnormal EKG + ECHO) cardiac findings using chi-square and independent t-tests. Receiver operating curve analysis to determine discriminatory ability of troponin. Sensitivity and specificity were determined using Youden’s J statistic. Sub-groups were compared by independent t-test and Chi-square, where appropriate, and p < 0.05 was considered significant. There were 465 patients who met inclusion criteria for analysis, of which 38 had abnormal cardiac testing and 427 had normal testing. There were no differences in age, sex, prior cardiac disease, or size (Table). Patients with abnormal cardiac testing had significantly higher troponin (5.4 ± 11.0 vs. 0.47 ± 2.0, p < 0.001) and BNP levels (356 ± 1189 vs 2113 ± 4003, p < 0.001). Abnormal cardiac testing group also experienced significantly higher rates of hospital admission, ICU admission, inotropic support, and ECMO support. ROC analysis demonstrated good discriminatory ability for troponin to detect patients with subsequent abnormal cardiac testing (area under curve = 0.84, p < 0.001). Point of best sensitivity and specificity was a troponin value of 0.2 – sensitivity 76.3% and specificity 81%. A troponin < 0.2 yielded a negative predictive value of 98% for abnormal cardiac testing. Patients with troponin < 0.2 experienced hospital admission 68.1% of the time, ICU admission 29.4%, inotrope use 14.8%, ECMO use 1.1%. Troponin levels at ER presentation has good discriminatory ability for associated abnormal cardiac testing. Low troponin levels (< 0.2) have high negative predictive value, though many pediatric patients with TnI < 0.2 still experienced a hospital admission. This data could guide ER triage and resource use